25th Edition

ON PATIENT CARE Answers You Need From Experts You Trust

INSIDE: Practical guidance on more than 100 questions about clinical care.

Ron Melton, OD

Randall Thomas, OD, MPH A supplement to

Patrick Vollmer, OD

Supported by an unrestricted grant from Bausch + Lomb FROM THE AUTHORS

CLINICAL PERSPECTIVES Your Questions—Answered ON PATIENT CARE Last year, you spoke up about eyecare issues that matter to you most. We listened, and address your most pressing questions in this year’s installment. Section I: Strategies for Success See the practice of Page 3 optometry through the of three experts. elcome to the 25th edition of what is colloquially known as “The Drug Section II: Guide,” even though it no longer bears a name limited to drug therapy. Anterior Segment Care Ron Melton, OD The big change in the 2020 edition was the expansion into other clinical W Page 29 Randall Thomas, OD, MPH areas beyond drugs and a change of name to reflect that.

The cancelling or postponment of live meetings that began in March 2020 severely Section III: Patrick Vollmer, OD A Supplement to truncated our personal appearances over the past year, and we had to default to PosteriorSupported by anSegment unrestricted grant from Bausch + Lomb Care doing most of our educational programs virtually. While we found this to be much Page 46 less dynamic and enjoyable, the silver lining was your numerous questions, which were captured electronically. Supported by an So this year, in large part, we are answering your verbatim questions across unrestricted grant from Bausch + Lomb the spectrum of clinical patient care. It is a time-honored reality that when one attendee asks a question, it’s highly likely that many others had the same question in mind. Thus, in that spirit, we are answering those questions for the benefit of all optometrists. Prior to this outpouring of electronic questions, we had to assume that we understood your needs, and so we wrote from that perspective. Now that we know with certainty the questions that you have, we can be more exacting in answering your clinically related quandaries. Randall K. Thomas, One interesting development occurred last year, validating what we have been OD, MPH, FAAO saying all along about dry . Since 1998, when loteprednol came to market as Lotemax, the notion that “inflammation” was foundational in the care of patients with dry had not yet been realized. Finally, in 2020, the FDA acknowledged the role of loteprednol in dry eye disease treatment by approving a 0.25% rendition with that specific indication. This governmental formal recognition in no way modifies our clinical care, but it does underscore what we have known for about 20 years: suppression of ocular surface inflammation is indeed foundational to caring for patients with dry Ron Melton, OD, FAAO eye disease. ’Bout time! Last year, we comprehensively discussed the impact of hydroxychloroquine on retinal tissues; in like manner, this year we discuss giant cell arteritis—a condition never to be missed—among other topics pertinent to high-quality patient care. We hope you enjoy our responses to your many questions and that this knowledge will serve to further enhance your patient care. Remember, treat your patients in the manner in which you would like to be treated. Patrick M. Vollmer, OD, FAAO

With our best wishes, Drs. Melton, Thomas and Vollmer

Disclosure: Drs. Melton and Thomas are consultants to, but have no financial interests in the following companies: Bausch + Lomb and Icare. Dr. Vollmer has no financial interests in any company. A PEER-REVIEWED Note: The authors present unapproved and “off-label” uses of specific drugs in this publication. SUPPLEMENT

2 REVIEW OF OPTOMETRY JUNE 15, 2021 SECTION I: STRATEGIES FOR SUCCESS

Your First Five Years Practicing in your formative years is exhilarating, exhausting, but most of all— rewarding.

By Patrick Vollmer, OD that doesn’t know exactly what I can your chair. The same holds true for do for their patients. This realization patients coming to you who have pre- lmost five years ago, I graduat- can only come through a high-level diagnosed their condition. Don’t be ed from my residency program commitment to integrating yourself thrown off by an outside diagnosis. Ain Columbia, SC. Several into the medical community. months later I purchased a private, PRESCRIBE (LOTS AND LOTS one-doctor practice... in a small town DON’T REFER OUT OF) I’d never heard of until days before I NON-SURGICAL CASES Corticosteroids are the greatest drug started, and with business knowledge Your referrals from local medical we have access to in our armamentari- I thought I needed but didn’t have. professionals will be short-lived if you um. I prescribe oral or topical Looking back, I think I was able to refer all of these cases to ophthalmol- every day in my clinic, multiple times “succeed” through sheer ignorance ogy. Barring extreme cases, there is a day. Once you have identified that about the fact that I may have not no reason to refer out any case that your patient’s condition is inflamma- succeeded! In my experience, if you does not need to have surgical care— tory (it almost always is), it is critical own a private practice, committing to ever. Additionally, patients will not be to dose them appropriately with cor- a high level of patient care will make pleased when, after you take their co- ticosteroids. For example, I will dose up for your lack of business knowl- pay, you tell them that you cannot be marginal corneal infiltrates Q1H for edge in the interim. any assistance to their case. In a small one day, Q2H for one day and QID town, you have a handful of chances for four days. I will treat mild cases of KNOW YOUR MEDICAL to make a lasting impression, which iritis in a similar manner. The point COMMUNITY will endure for better or worse. is, don’t dose hesitantly with topical I think new graduates should all or oral steroids. Rid the patient of in- strongly consider private practice. DO YOUR OWN THINKING flammation, and dose early and often. When you own your own clinic, you Medical professionals will often refer can build your vision from the ground their patients with ocular emergencies REFUSE TO FAIL up. I made up for my lack of business to your clinics with a presumptive di- The first few years in practice is a experience with a relentless work ethic agnosis already in hand. I have found strange time. Initially, patients can’t and an understanding that things take that these “diagnoses” are oftentimes always tell if you are the doctor, the time to fall into place. However, there incorrect. However, it is crucial that tech or the intern. One “positive” as- are ways to make these things fall into you do your own thinking and not pect of being young is that patients as- place faster. One of the best decisions let external opinions influence your sume that you must know everything that I made early on in my career was management decisions. Ultimately, since you just graduated! This is likely to integrate with the medical commu- you are responsible for the patient in true, despite your inexperience. Don’t nity at large. I went to every medical office in my community many times REFRACTIONIST OR DOCTOR? over to introduce, then reintroduce STRATEGIES FOR SUCCESS myself. Almost every physician has • A new world of vision testing and eye wear sales is dawning now that my personal cell phone number or refractions and prescription fulfillment are being offered online. knows how to get in touch with me » Visibly » My Eyelab » Warby Parker immediately through our after-hours » EyeNetra » Smart Vision Labs » Digital line. » My Vision POD » Vmax Vision Optometrics Hanging an “open” sign on your door and waiting for patients to come • These developments may not be a negative for practices to you is not helpful and undermines and patients. your self-worth. This goes double for medical and emergent cases. In year • ODs: expand your scope of patient care services to protect your future! five, I don’t think there is one physi- • The AOA is aggressively fighting for optometry: Join the AOA! cian, PA, NP or RN in my community

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The first week I was in practice, we saw 33 patients total. I typically will now see 25 to 35 a day and about one-third of all of these patients are emergency patients. Don’t let discour- agement get the best of you and don’t fall prey to worthless measurements like “gross revenue per patient.” If you concern yourself with providing extraordinarily high-level care, your numbers will take care of themselves and your patients will honor and re- spect your clinical prowess. One day Fig. 1. Herpes zoster ophthalmicus. you’ll appreciate these early years and be afraid to take on the hard cases: feel comfortable with this, make sure the undeniable struggle that accompa- the treatments are almost always they have a method to reach you after nies your initial startup efforts. Be the straightforward. Connect with your hours. best doctor you can be and let the rest patients on a deeper level and make On the days you are not busy (and fall in place. sure that they know you are there for there will be those days), refuse to What now follows are several inter- them. My emergency colleagues have sit idle and wait for more patients esting cases I’d like to share. my direct cell phone number, and no to come in. You must get out in one has ever abused this privilege dur- your community and connect if you Case 1. Herpes Zoster Ophthalmicus: ing my time at my clinic. If you don’t want patients to walk in your door. All ODs should be able to rattle off the three antiviral schedules to treat DON’T LET YOUR PATIENTS GO TO AN ER! shingles: ast year, we begged our colleagues to let your patients know to call • Acyclovir: 800mg 5x a day for Lyour office if they developed a “medical eye emergency,” and there is 10 to 14 days a ton of good will and resultant practice growth in doing so. A new study • Valacyclovir: 1000mg TID for further defines the need for eye patients to see an eye doctor. Check out 10 to 14 days these quotes: • Famciclovir: 500mg TID for 10 • “Most ocular conditions that present in emergency departments aren’t to 14 days urgent, and can be treated in an outpatient facility. Even if patients were Make sure to ask about adequate to seek treatment in an ER, new research reports that the personnel in kidney function every time before these facilities are not usually equipped to measure important ocular vital starting patients on any of the above signs, including visual acuity (VA) and (IOP).” antivirals. Compromised kidney • “Most common ocular diagnoses that presented emergently involved the or . They included , corneal abrasion, corneal function will alter dosing schedules. ulcer, meibomian gland dysfunction, dry eye, , punctate epithe- Check with their nephrologist prior to lial erosion and or epidemic .” starting treatment. • “ER doctors measured VA and IOP in about 41% and 17% of patients, Treatment: This patient was started respectively.” on valacyclovir 1000mg TID for 14 • “VA measurement agreement between ER personnel and ophthalmol- days and oral 30mg for ogists was just under 12%. The agreement between IOP testing was worse, one week, then 20mg for one week with the two groups coming to the same conclusion less than 1% of the (Figure 1). Keep in mind, this patient time. Diagnosis agreement occurred in about half the cases.” was not diabetic. With HZO, I like • “In terms of symptoms, patients present eye pain, irritation, foreign to use Maxitrol ointment to the facial body sensation, dryness, light sensitivity or a combination of these signs. lesions QID and Pred Forte 1% QID It’s critical that the standard workup of ocular cases include an accurate assessment of VA and IOP.” if the is involved. If there is a If we truly care for the people who entrust us with their eye care, we concomitant inflammatory iritis, a need to let them know to never seek eye care at an ER; rather, “call our cycloplegic will have to be initiated office, and we can help you.” This is so reassuring to our patients, and as well. Don’t forget that these cases these types of situations are rare. will often “get worse” before they

1. Tang VD, Safi M, Mahavongtrakul A, et al. Ocular anterior segment pathology in the emergency department: get better—a key point that you and a five-year study. Eye Contact . 2021;47(4):203-7. your patient will want to understand. 2. Cole J. ERs Unequipped to manage ocular conditions. Review of optometry. 2020:157(12):5. Viruses run their course.

4 REVIEW OF OPTOMETRY JUNE 15, 2021 thromboembolism. Above 3, and their risk of bleeding rises considerably. Treatment: This patient was tak- ing too much warfarin, causing an elevated INR. Their posterior segment was unremarkable on dilation. We comanaged with their primary care physician to ensure the patient was Fig. 2A. A four-year-old child was hit in the eye with a metal coat hanger (left). Five properly dosed, and the hemorrhages days later, there was complete resolution (right). resolved less than a month later.

Case 4. Ocular Allergy: These cases can manifest with various presenta- tions from mild to dramatic (Figure 4). They present with little to no pain at all and itching can be a hallmark. Treatment: I treat almost all of these cases with oral and topical steroids. The poison ivy case (Figure Fig. 2B. A 20-year-old female was scratched in the eye by a dog (left). A week later, she was 90% improved. 4D) was treated with 20mg oral pred- nisone for one week, Lotemax SM Case 2. Lesions: These cases (Figures idiopathic. We call them “Halloween QID ophthalmic drops to the affected 2A and B) are always fun because eyes” in my clinic: they look scary to eye, children’s Benadryl as directed the treatment is so straightforward, our patients, but they always self- and I’ve never had a case that didn’t resolve. This case (Figure 3) highlights A resolve completely. Don’t let dramatic the importance of knowing our appearances throw you off and don’t patients’ current medications. In this even consider referring these cases. case, warfarin was the antagonist. Pa- Treatment: Once I identify the extent of the lesion and make sure the B eye is void of foreign bodies in the up- per and lower lids, I immediately start therapy. For me, I cycloplege these pa- tients every time. You can guarantee that there will be a traumatic iritis. I keep in my clinic and always place a drop into the affected eye. C At this point, I will use an antibiotic ointment and firmly tape the patient’s eye tightly shut. In some instances, I prescribe an oral antibiotic for cover- age. The important thing to know is STRATEGIES FOR SUCCESS that I will not see these patients back D in the next 48 hours. They will have my direct cell phone number to reach Fig. 3. A 73-year-old male on me with any complications, but I have warfarin presented with a dramatic found it to be superior to keep the subconjunctival hemorrhage (top). His eye taped closed. The patient will not international normalized ratio (INR) be instilling any drops on their own. was over 6! Three weeks later, the They simply leave their eye alone. hemorrhages resolved (bottom). Fig. 4. Examples of ocular allergy. Not to be confused with preseptal cellulitis, Case 3. Subconjunctival Hemor- tients on warfarin should have an INR these presentations had an explosive and painless onset. In the bottom photo, rhages: In almost every case, subcon- between 2 and 3. Lower than 2, and attention is drawn to the periocular area junctival hemorrhages are benign and they are at risk for stroke and venous (poison ivy).

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eye was one of my patients who is a nurse practitioner. In the morning she presented a unilateral . Initially, the lesion looked like a small abrasion, but she could not remember trauma or previous trauma in the past. At the time, her cornea did not have a staining pattern obvious for herpes simplex (HSK). I let Fig. 5. Herpes simplex (blister lesions). Fig. 6. Herpetic dendrite discovered with The case had no corneal involvement. topical steroids in a period of eight hours. her know we were going to place her on a Q2H and to come back in and ice packs. The other cases were lesions in the periocular area. Don’t the evening for a second look. treated in an identical manner aside confuse these lesions for bacteria! The HSK cases are worsened by topical from the children’s Benadryl—I used treatments are identical to zoster, with steroids. Sure enough, a small dendrite the adult dose in those cases. As with the dosages halved: was present at her evening follow- any presenting inflammatory case, it’s • Acyclovir: 400mg five times a up just eight hours later. Steroids critical to hammer the inflammation day for 10 to 14 days were discontinued, and the patient early and often. • Valacyclovir: 500mg TID for was started on valacyclovir. Three 10 to 14 days days later, the cornea was void of Case 5. Herpes Simplex: Herpes sim- • Famciclovir: 250mg TID for dendrites. This case illustrates the plex remains one of my favorite pa- 10 to 14 days importance of occasional ambiguity thologies to treat. These cases should Treatment: Two of these cases were and vital follow-up care. never be referred out and rarely treated with valacyclovir for 10 days comanaged with primary care. Sim- and went to resolution quickly. Figure Dr. Vollmer can be reached at plex can often present as ‘blister like’ 5 was interesting in that the affected [email protected].

THE DIAGNOSTIC CHALLENGES OF THE SOLO PRACTITIONER t is a fact that “failure to diagnose” is by far the most common reason that optometrists are successfully sued. ISolo practitioners in general have about a 20% misdiagnosis rate. “We found that groups of all sizes outper- formed individual subspecialists on cases in their own subspecialty.” We find this shocking. The old saying, “two heads are better than one,” appears to be scientifically sound. “We found that collective diagnosis by groups was associated with improved accuracy over individual diagnosis. Given the few proven strategies to address the high prevalence of misdiagnosis, these results suggest that collective intelligence merits further study in a real-world clinical setting.” This article states the obvious: “Diagnostic accuracy is largely a function of knowledge and experience. A grow- ing literature suggests that diagnostic error is common and can lead, not unexpectedly, to harm.” “The diagnostic accuracy of aggregated opinion, which they refer to as ‘collective intelligence’, improved as the number of contributors increased, although the rate of accuracy began to plateau at two to three contributors. Group diagnoses also appeared to be more accurate than those of individual specialists solving cases within their specialty.” A summary statement might read like this: “Attention, solo practitioners—seek to bring on and partner with another colleague. The science is clear that collaborative assessments enhance patient care. The optometric profes- sion is becoming more and more medically oriented day by day. As the public learns they can seek optometric care for all sorts of diverse conditions, our collective duty is to become increasingly astute diagnosticians. For example (and this could just as easily apply to optometric care), “A well-appearing 14-month-old girl was referred for the evaluation of recurrent left subconjunctival hemorrhage with increasing frequency since seven months of age. Multiple prior office visits with referring ophthalmologists during which eyes were dilated showed normal results.” “This patient presented to several outside ophthalmologists with recurrent subconjunctival hemorrhage, but the possibility of an orbital mass was not considered because of a lack of proptosis or other ocular abnormalities.” My goodness, such a history is just not normal, and a high index of suspicion should have prompted deeper diagnostic intervention. When something is plainly out of the ordinary, extraordinary investigation is merited! None of us have all the answers, but putting two heads together may very well enhance patient care!

1. Barnett ML, Boddupalli D, Nundy S, et al. Comparative accuracy of diagnosis by collective intelligence of multiple physicians vs individual physicians. JAMA. 2019;2(3):e190096. 2. Harrie RP, Levin AM, Owen L. Recurrent subconjunctival hemorrhage in a child with an orbital mass. JAMA Ophthalmol. 2021;139(1):125-6.

6 REVIEW OF OPTOMETRY JUNE 15, 2021 Prescribing for Eye Disease: An Expert Q&A Settle in as we tackle 75 (!) clinical questions from the trenches in this section alone.

Is it still best to use non- tis is marked, we would go straight to A Q generic Pred Forte to treat (Durezol) and not even iritis? I had a pharmacist who risk pharmacy modification. Coupons recently changed my prescrip- are also available for Durezol. The tion to a generic and they said way we practice is to use Durezol for it was the exact same thing. severe iritis and , and we B A The literature has been consis- use loteprednol for everything else. tent and clear for many years that the generic versions are not as For dermatitis, clinically effective as the original Pred Q when would you use oral Forte. However, this is not terribly vs. topical steroids? C critical since even the generics, when If the erythematous, scratchy, properly shaken and properly used, A dry, scaly area of dermatitis is perform reasonably well. superficial and localized, our choice is The good news is that there are 0.1% cream. However, coupons available that allow patients if a patient has a broader or more under age 65 with a commercial drug erythematous expression, such as with D plan to get the “real deal” for $50, a poison ivy encounter, then we which is a fair price. Just Google would generally prescribe 40mg of “Pred Forte coupons.” Now, if the iri- oral prednisone for about three days.

LOW-DOSE ATROPINE AND OCULAR BIOMETRICS Fig. 1. Photos A and B are before “Low-concentrations of atropine (0.05%, 0.025% and 0.01%) have no clini- treatment for eyelid dermatitis. Photos cal effect on corneal or lens power. Antimyopic effects of low-concentration C and D are after. atropine act mainly on reducing axial length elongation, and therefore could reduce the risk of subsequent complications.” Is it safe if triamcinolone Li FF, Kam KW, Zhang Y, et al. Differential effects on ocular biometrics by 0.05%, 0.025%, and Q 0.01% atropine: low-concentration atropine for myopia progression study. Ophthalmology. 2020 cream gets into the eye? Dec;127(12):1603-1611. Yes. Kenalog is a brand name A for triamcinolone. It is routinely SUNSHINE: injected into the eye by THE ENEMY OF MYOPIA specialists to help resolve inflamma- Time spent outdoors is correlated with tory diseases. We’ve never had a single a decreased risk of myopia onset. “If a child has two parents with myopia, the issue from the triamcinolone cream hereditary genetic effects increase the getting onto the ocular surface. child’s chances of developing myopia to approximately 60% if time spent STRATEGIES FOR SUCCESS outdoors is low. More time spent out- doors, approximately fourteen hours per week (or two hours per school day), can nearly neutralize that genetic This is a teenager who appeared risk for the child to approximately 20%, to be considerably myopic by the the same chance as a child without appearance of his eyeglasses. Is any parents with myopia.” It is thought there a connection? Highly probable! that “the protective effect relates primarily to myopia onset while questions remain about a similar effect on myopia progression.” It is odd that simply getting away from the gravity of “the screen,” to go outside and play can have so many positive benefits. Fig. 2. This is a case of contact Zadnik K. Myopia prevention: here comes the sun. Ophthalmology. 2020 Nov;127(11):1470-1. blepharodermatitis where we would prescribe 0.1% triamcinolone cream.

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With contact dermatitis Q cases, do you usually ascertain what the antigen is? What recommendations do you provide to reduce recurrences? What if there is no discernible/ known trigger found? We try to. Most of the time the Fig. 3. These are two more presentations of periocular contact dermatitis. A offending agent/substance can be determined via a good history. Any opinion on OTC 1% Exposure to poison ivy or other NON-OPHTHALMIC STEROID Q potentially noxious vegetable matter OINTMENT/CREAM/LOTION cream for contact dermatitis rather than is common. Various cosmetics, • Triamcinolone, a moderate triamcinolone? especially fingernail polish, are potency steroid A Yes. Inflammation can be another common cause. If a specific • Available in cream, ointment undertreated, but is rarely trigger cannot be identified, just ask and lotion (0.5%, 0.1%, 0.025%) over-treated. We always hit it hard to the patient to be keenly attentive • Our favorite: the 0.1% cream do our best to quell the inflammatory should there be another episode. process, thus limiting tissue damage to Source: Drug Facts and Comparisons the fullest extent possible. While OTC Can Lotemax ointment be 1% hydrocortisone cream can indeed Q used on periocular skin work on some mild cases, we would tissues similar to triamcinolone? rather prescribe our tried-and-true, Certainly, but Lotemax highly effective triamcinolone. A ointment is just much more expensive. Any time nocturnal PEDIATRIC EYE FROM HAND SANITIZERS suppression of inflammation of the globe is needed, Lotemax 0.5% OVID can cause bodily injury preservative-free ointment is the Cin a wide variety of ways. One prime choice. In situations where dry of the (relatively) least important eye disease patients would prefer not assaults comes in the form of children’s eyes. Of course, to eye having to deal with eye drops by day, doctors these types of are we use this ointment at bedtime (relatively) very important. We are Monday, Wednesday and Friday for all aware in one way or another that two weeks, then just Monday and the Goldmann tonometer “tattoo” Friday for two more weeks. On rare can result from not fully drying the occasions, such ointment supplemen- alcohol off the tonometer prism tip before applanating the cornea! tation may be needed for stubborn Alcohol-based hand sanitizers (ABHS) have always been around, but cases of anterior uveitis and in some COVID precautions brought them front and center just over a year ago. cases of recurrent corneal erosion. In fact, such reported exposures went from 1.3% in 2019 to 10% in 2020. Most cases were of no clinical significance, but there are a few reported serious corneal and conjunctival injuries. Most such encounters occurred in Q Instead of triamcinolone, stores or malls where these dispensers tend to be at children’s eye level. can Protopic be used? Immediate rinsing/dilution with water is appropriate first aid. Most of the A The patient in Figure 4 teaches ABHS solutions contain 80% ethanol or 75% isopropanol. Keep in mind two facts: fingernail polish is a that ethanol is widely used in corneal and refractive surgeries to facilitate very common cause of contact epithelial debridement, but these are 20% concentrations and are applied dermatitis, and the patient made the for up to 30 seconds. Note, however, that there is no permanent scarring mistake of seeing a doctor who to these alcohol toxicities. obviously had the same thought you We treat most such ABHS encounters with a preservative-free artificial had. The tacrolimus 0.1% (Protopic) tear, but if there was any significant microtrauma to the tissues, we would did not work, and once she was prescribe an antibiotic/steroid, such as Zylet (Bausch + Lomb) or generic placed on our beloved 0.1% triam- Maxitrol QID for four days. cinolone cream, she was restored to Colby K. Unintended consequences of hand sanitizer use in the coronavirus disease 2019 pandemic. JAMA Ophthalmol. 2021;139(3):352. normal in three days. You have just got to cherish the wonderful benefits

8 REVIEW OF OPTOMETRY JUNE 15, 2021 In our experience, when treated conditions, however. Keep in mind A authoritatively, episcleritis that most all cases of episcleritis are uncommonly becomes recurrent. At idiopathic. We do still ask the patient the first recurrence, we would send a about the presence of any current note to the patient’s primary care medical conditions at the initial provider and give them specific presentation, but we rarely pursue a guidance as to what conditions may diagnostic workup then. be associated with episcleritis, such as Fig. 4. This patient first sought care rheumatoid arthritis, systemic lupus Are topical steroids more for her eyelid contact dermatitis from erythematosus, Wegener’s granuloma- Q effective in treating a dermatologist. Note that she would tosis, syphilis and gout. We could not have sought a second opinion if the episcleritis than oral NSAIDs? initial treatment had worked! We still order testing for these conditions Or could they be used as an have no idea why doctors are reluctant to ourselves, but involving the PCP is alternative? prescribe steroids—it’s frustrating. Once more appropriate in our opinion; they Topical steroids are key in we had the patient using our tried, true do need our professional guidance as A treating episcleritis. For and trusted 0.1% triamcinolone cream, she to these commonly associated advanced cases, we use Durezol; for was almost back to normal in three days. But there is more to this story: be attentive to her fingernail polish, a highly EPISCLERITIS UP CLOSE common cause of contact dermatitis to the (which was news to her). • Inflammation of the superficial • Recurrence is common We educated the patient to try a more • Systemic associations: RA, SLE, hypoallergenic brand of polish. Attentive, • Usually sectoral, benign, idiopathic Wegener’s granulomatosis, effective healthcare is what we all seek. • Occurs mostly in young adults syphilis, gout • Two types: simple and nodular • Tx: artificial tears, cold of corticosteroid suppression of compresses, topical inflammation. The patient was • Chief complaint is eye redness; decongestants, topical steroids advised to either stop using fingernail mild discomfort is the rule polish, or perhaps try another brand.

Why use Lotemax gel and Q not drops, when gel produces blurry vision in some patients? There may be some confusion A here with nomenclature. The Lotemax eye drops—Lotemax gel and Lotemax SM—are indeed viscous liquids (gel drops) that lose their viscosity after several blinks over a couple of

minutes. The STRATEGIES FOR SUCCESS Lotemax oint- ment, like all ointments, will severely blur vision for minutes.

What is your steroid of Q choice for recurrent episcleritis, and after how many recurrences do you go to a low-dose maintenance steroid Here are several images of episcleritis; the top two show before and after corticosteroid suppression. like Alrex?

REVIEW OF OPTOMETRY JUNE 15, 2021 9 SECTION I: STRATEGIES FOR SUCCESS

mild to moderate cases, we use sclerotic, we would think that any preservatives in these bottles would Lotemax SM. Using NSAIDs is like such drug would be less effective. inactivate the COVID-19 virus. We using a squirt gun on a house fire in Only one investigational drug works have seen no studies addressing this. the setting of acute, prominent ocular to reduce sclerosis. For those presby- As always, we would be vigilant to inflammation. Oral NSAIDs are opic drugs that work via a quasi- not contact the patient with the useful in but are way under- pinhole effect, patient age might not dropper tip, and if we did, then we powered in suppressing episcleral be as critical. You will definitely hear would discard the bottle (in a known, inflammatory disease. There is no much more about these medical active COVID patient). Probably a alternative to a steroid; only clinical interventions in the next year or two. good and sufficiently hygienic efficacy gives us choices—FML or technique would be sufficiently Alrex vs. Durezol, as an example. What is your opinion, cautionary. Q given COVID-19 concerns, Do you hesitate to use regarding reuse of conventional Is there much risk for Q steroids in a pregnant bottles for administering Q clostridium difficile infec- patient presenting with inflam- diagnostic drops in the exam tion when using doxycycline as matory eye disease (e.g., room? For example, mydriatics a primary treatment for MGD? episcleritis, dry eye)? or cycloplegics. Clostridium difficile superinfec- When oral prednisone is The question might be re- A tion is rarely seen with doxycy- A indicated for severe inflamma- A phrased as to whether the cline! We personally have never tory diseases, we always consult the patient’s obstetrician. Working together collegially best serves patient FACTS ABOUT “SULFUR” ALLERGY care. For topical eye drops, we ere’s something we all need to know regarding the concept of sulfur typically do not consult; we do what Hallergy. “The term ‘sulfur allergy’ is misleading and dangerous, and is prudent to diminish systemic should not be used. An allergy to a sulfonamide antibiotic may imply absorption. We direct the patient to cross-reactivity with other sulfonamide antibiotics, but does not imply cross-reactivity with non-antibiotic sulfonamides or other drugs containing do gentle eyelid closure for three sulfhydryl or sulfate groups. Allergy to sulfonamides also does not imply minutes, or we use punctal plugs, or cross-reactivity with sulfite preservatives, sulfates or elemental sulfur.” we prescribe an ointment formulation “The term ‘sulfonamide’ applies to a sulfone group connected to since ointments are known to have amine group. All antibiotics sulfonamides are arylamines. A review of all very minimal systemic absorption. available relevant studies concluded that the dogma of cross-reactivity between sulfonyl arylamines and other sulfonamide drugs cannot be sup- If my patient is allergic to ported by the evidence. In patients who have had an allergic reaction to Q sulfa, can I prescribe one drug or allergic reactions to other drugs—even if entirely unrelated— Maxitrol? occur more commonly.” Maxitrol contains neomycin, “Sulfur is a natural element and it exists in many forms. There are many A polymyxin b sulfate and substances which have names stemming from ‘sulfur’ such as sulfites (preservatives in food and drugs) and sulfates (common compounds . Sulfa-based medi- found in drugs, soaps and cosmetics). Some patients who have suffered cines do not share a cross-allergenicity from hypersensitivity reactions to a sulfonamide antibiotics are unfortu- with sulfates, so yes is the answer. nately labeled ‘sulfa allergic.’ This term creates confusion for the patient and often for health profes- Do these drops under sionals. Many patients believe that having been ‘sulfa allergic’ means they Q development for presby- are also at risk for adverse reactions or allergies from sulfites, sulfates and opia reverse early even elemental sulfur, and they attempt to avoid them.” already in progress? So, such medicines as polymyxin B sulfate or trimethoprim sulfate are This is a topic of keen impor- perfectly fine to use in patients who claim to be allergic to sulfa drugs. A tance. Research is ongoing. The carbonic anhydrase inhibitors also have a sulfa moiety, but they do not share a cross-allergenicity with sulfa drugs. Based on limited knowledge, we “The commonly used canister type of metered dose inhalers do not would theorize that perhaps starting contain sulfites, but several do contain sulfate salts and some patients when the patient first presents with need to be reassured that sulfates are inactive and do not cross-react presbyopic complaints would be the with sulfites.” optimum time to consider such a therapeutic intervention. As the 1. Smith WB, Katelaris CH. ‘Sulfur allergy’ label is misleading. Australian Prescriber, 2008;31:8-10. lenticular nucleus becomes more 2. Annals of Allergy, September 1987.

10 REVIEW OF OPTOMETRY JUNE 15, 2021 experienced this in any of our patients. Most antibiotics hold the GARDENING AS A CAUSE OF CORNEAL EDEMA potential to set the stage for C. diff. infection, though this is an uncom- • Acute onset corneal edema mon event. Clindamycin is an and blurred vision excellent alternative for those rare • Most usually unilateral— individuals who truly have an allergy rubbing face and eyes to penicillin, but it does carry an • History is critical to making the increased risk of C. diff. Interestingly, diagnosis of isolated corneal and as an aside, fecal transplantation edema has been shown to be highly effective Fig. 5. Similar to glaucomatocyclitic • Milkweed contains cardiac in treating some of these complicated crisis, this post-herpetic keratouveitis glycosides, which can alter cases. with elevated IOP was quieted with endothelial enzymes, largely a (and with oral sparing epithelial tissues! For varicella zoster viral valacyclovir 500mg daily for a month). • Onset of symptoms after Q Note the pancorneal leukocytic (VZV) keratitis, would exposure: 12 to 24 hours infiltration. Maxitrol and oral antiviral work? • Tx is topical steroid therapy— A The keratitis (or keratouveitis) QID for four days, then BID for as a concurrent or secondary rate an antibiotic/steroid combination. two days expression of herpes zoster (shingles) The oral antiviral nicely eliminates the Venkateswaran N, Tonk RS, Berrocal A. Cor- is one exclusively of inflammation, active virus, and a topical steroid neal edema in a gardener. JAMA Ophthalmol. 2020;138(9):998-99. therefore there is no need to incorpo- nicely suppresses the associated inflammation. RISK OF UVEITIS RECURRENCE 100% suppressed. These are those • Acute uveitis = less than three Q What is your go-to in-of- “steroid for life” patients (similar to months fice “cocktail” for breaking those with corneal transplant and posterior synechiae? Is it stromal herpetic disease) who may • Chronic uveitis = more than need to use a drop of steroid a day three months extremely important to break them sooner rather than later? indefinitely. There are also some mild, • Risk factors for recurrence of Synechial formation in some “smoldering” cases that do not chronic anterior uveitis are: A cases of iridocyclitis can be require long-term steroids. Every case » Longer duration of problematic. Sometimes synechia can is individualized. inflammation be broken (“unglued”) in the office, » Younger age sometimes only after a few days of Is there any reason you intensive topical corticosteroid Q would need to taper oral » Bilateral uveitis therapy, and, depending upon severity prednisone for an ocular acute » Prior or and length of time it has gone on, they inflammatory response? Or is it surgery may never be completely broken. We fine to stop the 40 mg daily » Juvenile idiopathic arthritis often prescribe 1% atropine to be dose after four days? used QID and 2.5% or 10% phenyl- Many such cases can be » Spondyloarthropathy A (ankylosing spondylitis, ephrine BID. This is done concur- successfully stopped after a few psoriatic arthritis or reactive rently with hourly (while awake) days, and some may take months of a STRATEGIES FOR SUCCESS arthritis) instillation of Durezol (which, because slow taper. As with any medical it is an emulsion does not have to be treatment, the goal is to treat effec- » Presence of keratic precipitates and synechiae shaken). We see these patients back tively and then try to stop the about every three days, then less often medicine as soon as possible. So, if • “Patients with these factors as the condition improves. after a week to ten days of acute should be managed taking into treatment the medicine is stopped or account the higher probability tapered, and if the condition returns, of a longer disease course.” Can a patient with multiple Q episodes of uveitis have a that is a clear indication a more protracted course of therapy is Sobrin L, Pistilli M, Dreger K, et al. Systemic im- low-grade AC reaction? munosuppressive therapy for eye diseases Cohort Absolutely. These are common required. It’s all (to some degree) trial Study Research Group. Factors predictive of A remission of chronic anterior uveitis. Ophthalmol- patients, and in spite of the best and error. It is the “art” of practicing ogy. 2020; 127(6):826-34. of care, some uveitis cases cannot be medicine!

REVIEW OF OPTOMETRY JUNE 15, 2021 11 SECTION I: STRATEGIES FOR SUCCESS

With conjunctivitis, I was QUOTABLE Q taught that mucopurulent discharge inactivates Polytrim. True or false? While the Xa inhibitors Xarelto (rivaroxaban) and Bacteria synthesize folic acid A from para-aminobenzoic acid Eliquis (apixaban) are steadily replacing Coumadin and are a component of mucopuru- (warfarin), there are still plenty of patients on lent discharge, but not to any warfarin, so it is incumbent upon us to be cognizant clinically significant degree. Recall that both sodium sulfacetamide and of the INR, which is the blood-derived laboratory trimethoprim work along the measure of coagulative status. metabolic pathway inhibiting the production of folic acid, but trim- treatment can vary wildly from patient improving in just in a couple of days; ethoprim is not a sulfa-based drug. to patient. A common scenario might however, we are not perfect, and So, false. look something like this: valacyclovir should your eye worsen, please give us 500mg once daily for a couple of a call.” This statement is also months. At the same time, we would documented in our medical record. use Lotemax SM QID for one to two weeks, then BID for two months, then What is the cost of new every day for six months, then every Q anticoagulant drugs as other day for another six months, but compared with warfarin? this gives a flavor for the long-term These new anticoagulants are suppression of this secondary inflam- A indeed considerably more mation that can be associated with expensive than warfarin, but this has herpetic eye disease. to be viewed in two distinct ways. If the patient has good insurance, cost of Please review when you the newer drugs is likely not to be an Q would not want to use issue. With warfarin, there are the Fig. 6. Copious mucopurulent discharge steroids during inflammation/ requisite monthly laboratory checks with mildly injected eye. infection situations or when you to monitor the patient’s international would delay the steroids. normalized ratio (INR). Once the time How long do you use a The prime contraindication for and lab expenses are calculated, the Q topical steroid with the A using steroids is the evidence of cost of the newer medicines is not all systemic antiviral for stromal acute epithelial herpetic simplex that different. Eliquis (apixaban) and herpetic disease? disease. Always consider any unilat- Xarelto (rivaroxaban) are far more This is a largely unanswerable eral red eye as possibly herpetic in effective and convenient in that there A question because the length of origin. Otherwise, that’s about it. is less side effect potential with other Here is the key to therapeutic patient drugs and there are no dietary INR: INTERNATIONAL care: if you are just not sure exactly restrictions. These newer drugs NORMALIZED RATIO what is going on, treat with a (known as Xa factor inhibitors) combination antibiotic/steroid and interfere with the blood coagulation • A universally accepted mea- sure of “coagulability”(clotting) then call the patient a few days later cascade and do not affect platelet behavior of blood in patients to check on them. If the condition function. Just a reminder: aspirin taking Coumadin (warfarin). were to ultimately turn out to be works on platelet function, but is not herpetic, it’s no problem at all. Just an anticoagulant per se. • An INR of 1 is a normal, physi- discontinue the initial medicine and ological clotting behavior. start the more appropriate medicine; For foreign body sensa- • Target anticoaguable profile it is truly that simple. We have Q tion, instead of sweeping is an INR generally between 2 medically treated thousands of the superior cul-de-sac, have and 3. patients over the decades, and have you tried one of the instruments • The higher the INR > 3, the thin- only had to modify our treatment a to double-evert the lid? ner the blood, thus increasing handful of times. We tell every patient You can know we have done risk of bleeding and hemor- we medically treat something like this: A this many, many times, but the rhagic stroke. “This medicine should have you fulcrum “flip” is at the top of the

12 REVIEW OF OPTOMETRY JUNE 15, 2021 but she had a vitreous hemor- ASPIRIN FOR PRIMARY AMOXICILLIN/CLAVULANIC rhage and acute iritis but no RD. ACID (AUGMENTIN) PREVENTION: NOT SO I put her on Pred Forte, and • Clavulanic GREAT cyclopleged and referred her to acid enables “Aspirin confers an 11% rela- a retina specialist, who didn’t do amoxicillin to tive reduction in cardiovascular anything except monitor her. be bactericidal disease risk and a relative 43% Would you have managed the against common increase in the risk for major patient differently? gram positive pathogens bleeding, and only patients with Yes, we would have kept the very high cardiovascular disease • Useful in treating soft tissue A patient in our care, and we risk and low bleeding risk would infections gain a net benefit for aspirin would have monitored her ourselves! • Cannot use if patient is allergic therapy.” Our profession needs to develop the to penicillin “This study confirms that confidence to manage more and more most patients do not benefit of these types of situations. Your care • Tx: 250, 500 and 875 (generic) from primary preventive aspirin.” was just perfect. or 1000mg (branded only) tablet “Even among patients with q12 hours for seven to 10 days favorable benefit/harm balance, Is oral prednisone an • Can be taken with meals the probability of benefit is tiny, Q appropriate treatment for about four per 1,000.” a ? As we try to keep current with KEFLEX No. A chalazion is a ball of all common aspects of human (CEPHALEXIN) A granulomatous scar tissue most medicine, we pass these find- • Children >2 months ings on to our optometric phy- commonly resulting from a previously • For skin and soft sician colleagues. untreated or undertreated bacterial infection of a single (or multiple) tissue infections, Annals of Internal Medicine, October 2019 (as may be given every reported in NEJM Journal Watch, October meibomian gland. Intralesional 2019). 12 hours steroid injection can be helpful in some of these cases, but in-office Weight (lbs) Dose (250 mg/5ml) excision and curettage is still a commonly needed intervention. It is 11 ¼ tsp just difficult to get a high enough 22 ½ tsp concentration of the steroid via the 33 ¾ tsp oral route. 44 1 tsp (250mg cap) A contact lens wearer had 66 1 ½ tsp Q some dust blow in his eyes. 88+ 2 tsp (500mg cap) He slept in his contact lenses that night, and the next day he OVERVIEW OF PENICILLIN had a bacterial conjunctivitis in “ALLERGY” both eyes. His lids were so Fig. 7. After instilling proparacaine, • “Severe anaphylactic reactions swollen that his eyes were moisten the tip of the cotton swab with to oral amoxicillin are rare.” an ointment for lubrication. Have the barely visible. What is the best patient look down and insert the cotton way to treat the lid edema? The • “IgE-mediated penicillin allergy STRATEGIES FOR SUCCESS swab. Gently sweep the entire cul-de-sac lids were not painful. Homatro- (the real deal) wanes over time, back and forth two to three times. pine TID? Oral prednisone? with 80% of patients becoming Cold compresses and 40mg of tolerant after a decade. Cross- reactivity between penicillin tarsal plate, yet the recesses on up to A PO prednisone for two days is and cephalosporin drugs occurs the cul-de-sac remain blinded. Only a what we would typically advise. There in about 2% of cases.” sweep of the cul-de-sac can remove is no need for since there foreign material remotely located in is no intraocular inflammation. Use • “Many patients report they are allergic to penicillin but the cul-de-sac (see Figure 7). an antibiotic/steroid combination few have clinically significant every two hours for a couple of days, reactions.” I saw a patient who had a then QID for four days. Threaten the Q bungee cord accident in patient with severe trauma if he ever Blumenthal KG, Shenoy ES. Am I allergic to penicillin? JAMA. 2019; 321(2):216. one eye. Her vision was good, sleeps in his contact lenses again!

REVIEW OF OPTOMETRY JUNE 15, 2021 13 SECTION I: STRATEGIES FORThe SUCCESS 2020 ARMOR Update This long-running study of bacterial susceptibility to antibiotics helps which agents are most formidable and which are weakest.

prescribe 250mg for children; 500mg You are the doctor and you have the ALLERGIC REACTIONS TO he Antibiotic Resistance Moni- acin, gatifloxacin and trimethoprim for small adults; 875mg for most position of authority (and responsibil- CEPHALOSPORINS toring in Ocular Microorgan- showed slightly diminished effective- adults and 1,000mg for a large ity) to write for any medication within isms (ARMOR) study—a ness against gram-positive species. • 19 of “more than a million” person.T Augmentin is to be taken your state’s prescriptive authority. massive and ongoing effort regarding • Ciprofloxacin remains the most patients experienced allergic twice daily and is best taken with a Tobramycin is a good drug, as is reactions. antibiotic resistance—was recently effective drug against Pseudomonas. meal to minimize the potential for Vigamox; we would have written for updated in the May 2020 issue of • About 30% of Staph. aureus • “Almost 66,000 patients who stomach upset. non-substitutable besifloxacin based JAMA Ophthalmology. isolates and half of Staph. epidermi- received cephalosporins had pre- on scientific research (see ARMOR The researchers tested more than dis isolates were methicillin resistant, viously documented allergies to A 70-year-old male pre- study data below). penicillin and 3,300 had previous 6,000 isolates of Staphylococcus and this was especially observed in Q sented with an inferior reports of cephalosporin aller- aureus, coagulase-negative staphylo- patients older than 80. secondary to poor What contraindications to gies.” cocci (CoNS), Streptococcus pneu- • Older patients were more likely This Pseudomonas lower lid coverage. I prescribed Q oral prednisone do we moniae, Pseudomonas aeruginosa to have resistance than children. treatment with • “Cross reactivity between Vigamox, but the insurance need to be aware of? With its cephalosporins and penicillin and Haemophilus influenzae col- However, even pediatric patients cycloplegics. company denied it as: “This 40mg a day dosage, do you has long been a concern; how- lected between 2009 and 2018. did show notable levels of antibiotic ever, in recent studies, almost all drugHere is arenot the approved latest findings: for this prescriberesistance. 10mg QID? We would Keep in mind penicillin-allergic patients have diagnosis.”• Vancomycin The remained pharmacist robust at for prescribe• Of the methicillin-resistantto take four 10mg iso- and thus may received cephalosporins safely.” leastall gram-positive called, but species. substituted tabslates, at75% one demonstrated time with breakfast.multi-drug clinical efficacy “Contraindications” should tobramycin.• Besifloxacin was roughly equiva- resistance. J. Allergy and Clinical Immunology. March 2015 (as Ah, the joy of working with a A probably be substituted with the reported by NEJM JournalWatch). lent to vancomycin—a constant find- • Azithromycin was, by far, the A pathologically over-bureaucra- term “concerns.” There are four ing within the study. least effective of the antibiotics tested. THE LATEST tized healthcare system! How does the circumstances where we would be Can you describe your • When the researchers calculated • Both P. aeruginosa and H. influ- AND IODINE Q pharmacy even know what the particularly attentive, and those gonioscopic criterion for the lowest drug concentrations that enzae isolates were found to have low diagnosis is? At any rate, prescribing would be with patients with diabetes, • Seafood when photoiridotomy is indi- inhibited the growth of 90% of levels of resistance. “off-label” is totally routine, and is peptic ulcer disease, possible tubercu- by various cated prior to dilation? indicated isolates, they found that Overall, there was little deviation If the angle is so narrow that done thousands of times each day. losis and pregnancy. In all four such Therefore, tobramycin, ciprofloxacin, moxiflox- from the data published in 2015. A there is some appositional food is the use iridocorneal contact, then there are 2020 ARMOR SURVEILLANCE DATA: two options: go ahead and do routine MIC COMPARISONS FOR STUDY ISOLATES • Allergy dilation (usually with 1% 90 media and 2.5% phenylephrine) or perform S. aureus MRSA CoNS MRCoNS iodine, the laser photoiridotomy. Regarding 2015 2020 2015 2020 2015 2020 2015 2020 chemicals. (n=1169) (n=2189) (n=493) (n=765) (n=992) (n=1765) (n=493) (n=871) the diagnostic challenge of pupillary • “The current Besifloxacin* 0.25 1 2 2 0.25 2 4 4 dilation, it is best to do this in the gests Vancomycin 1 1 1 1 2 2 2 2 morning so that if angle-closure does an allergen; occur, timely and unhurried LPI could Trimethoprim* 2 4 2 2 32 >128 >128 >256 thyroid be done (or arranged for) in the Moxifloxacin* 1 4 1 16 1 16 32 32 normal afternoon. Gatifloxacin 2 4 16 16 2 16 32 32 and does Ofloxacin 8 >8 >8 16 8 >8 >8 32 complexity Q Can you go over when you Ciprofloxacin 8 128 256 256 8 64 64 64 antigenicity.” might modify your oral Tobramycin* 1 128 >265 256 4 16 16 32 • “There dosing for children, very heavy- Azithromycin >512 >512 >512 >512 >512 >512 >512 >512 ports set patients or 90-pound elderly * Denotes the four antibiotics we use most routinely, given their proven efficacy and ary to patients? Do you have any relatively low resistance profile. of povidone–iodine.”

pearls for weight adjustment? As a reminder, the lower the MIC90, the more potent the anticipated efficacy. 1. Bellchambers Generally speaking, small CoNS = coagulase-negative Staph. species, of which the majority are Staph. epidermidis. surgery A bodies need less medicine and self-reported Sources: Asbell PA, et al. JAMA Ophthalmol. 2015;133(12):1445-1454. Refract Surg. large bodies may need more. For Asbell PA, et al. JAMA Ophthalmol. Published Online April 9, 2020. example, Augmentin (amoxicillin with clavulanic acid) is an excellent While these ARMOR data are in vitro, we can still glean some clinical guidance. It is antibiotic with its forte being in the well understood that fortified vancomycin (which has to be compounded) is the gold standard when treating suspected gram-positive corneal infection. Note that these gram-positive arena. It comes as comparisons are based on MIC (minimum inhibitory concentration) at which 90% of REVIEW OF 250mg, 500mg tablets, 875mg and the bacteria are eradicated. Based on these comparative data, besifloxacin shows very 1,000mg tablets. This gives one many similar performance to vancomycin, which is why we prescribe this unique suspension options. For example, one could when treating severe conjunctivitis or keratitis.

14 REVIEW OF OPTOMETRY JUNE 15, 2021 cian first. If the patient is pregnant, A NOVEL FLUOROQUINOLONE: certainly we would do as we always PREDNISONE POINTERS BESIFLOXACIN do—call and have a conversation • Most commonly Rx’d systemic • A unique bi-halogenated with her obstetrician. For all of these corticosteroid quinolone patients, we put our heads together • Common initial dosage: 40mg • New chemical entity: an with the proper physician to come up to 60mg 8-chloro-fluoroquinolone with the best formulation to maxi- • Available generically in both • Not used systemically; mally and safely provide patient care. tablets and DosePaks relatively resistance-proof • Questions to ask before • FDA-approved Q Can you explain prescrib- prescribing: medication: ing oral steroids again? » Diabetic? bacterial What size tablets and how » Peptic ulcer disease? conjunctivitis many times per day? » Tuberculosis? There are two common ways to » Pregnant? • FDA-approved A treatment protocol: prescribe oral prednisone. First This is the TID for seven days is with a variety of dose packs: classic 4mg • 4mg dose-pack (starting with six Medrol • Pediatric approval: tablets (24mg) on day one, and then dose-pack. ages one and older follow with five, four, three, two and Note that • Preserved with one tablet on day six). the initial 0.01% BAK (Durasite vehicle) • 5mg dose-pack (starting with six starting dose • Marketed as Besivance 0.6% tablets [30mg total] and tapering as is only 24mg, and such a ophthalmic suspension by above). Bausch + Lomb slow taper • 10mg dose-pack (starting with over six days six tablets [60mg total] on day one, is rarely—if ever—warranted. We cases, we would call the physician and then tapering at 10mg per day as typically write for 10mg tablets relevant to our specific concern, and above). (easy math!) and, for example, chat about our need to use oral Or simply prescribe 10mg tablets have the patient take four tablets prednisone. (with customized dosing) for four days. We have them take What we have learned from • For example, take four tablets per all four tablets at one time with the specialty physicians: regarding day for four days or take four tablets breakfast. There is no need to diabetes mellitus, patients with type for three days, and then two tablets taper if oral prednisone is used 1 diabetes know how to administer for three more days. for less than one week. their insulin on a “sliding scale,” so they should be able to easily adjust their dosing. For patients with type 2 or adult-onset diabetes, we have been told that these patients are out of control from time to time anyway, so having transient hyperglycemia for a few days is not a major concern.

For peptic ulcer disease, our gastro- STRATEGIES FOR SUCCESS enterology friends advise us to have the patient purchase over-the-counter Pepcid or Prilosec (20mg tablets of omeprazole), and to take that medi- cine once daily while taking the oral prednisone. If the patient has been in an environment where tuberculosis is common, such as third world coun- tries or some nursing homes, then the possibility of TB must be considered, and that is why we would chat with the patient’s primary care physi-

REVIEW OF OPTOMETRY JUNE 15, 2021 15 SECTION I: STRATEGIES FOR SUCCESS

40mg for four to seven days is the most common dosage we prescribe; PAIN MANAGEMENT IN THE SETTING OF SHINGLES but, as with all prescribing, every ain is a common accompaniment to acute shingles. Oral antivirals patient’s condition is unique and Pand oral prednisone are very helpful in reducing viral replication and therefore individualization of care is reducing secondary inflammation (and its resultant pain) respectively. the order of the day. Occasionally, oral opioids are needed for only a few days. Studies have At 60mg or 80mg per day dosing, shown that alternating oral ibuprofen and oral acetaminophen QID can we generally divide the medicine in be roughly equivalent to hydrocodone/acetaminophen (Vicodin/Lortab). Sometimes doctors prescribe gabapentin or pregabalin (Lyrica) for acute half. For example, for 60mg per day, pain relief, but such use has shown to be unhelpful. To wit, these drugs our sig would be #3, 10mg tablets are only approved for the management of post-herpetic neuralgia: “Both with breakfast and #3, 10mg tablets gabapentin and pregabalin are approved for managing post-herpetic neu- with lunch. Obviously, with 80mg ralgia, but both are used often for acute zoster pain, for which studies have per day, the number of 10mg tablets shown no benefit.” would be #4 tablets BID, prefer- Most shingles patients do not require supplemental oral prednisone or ably with breakfast and lunch. A supplemental analgesia (other than acetaminophen); however, for patients few people get some jitters or have with more advanced disease—particularly older patients— 40mg to 60mg difficulty sleeping with higher doses of oral prednisone for a week may well be in order. Keep in mind that early of prednisone, so we typically try intervention with an oral antiviral quickly subdues the disease process such that oral prednisone and/or oral analgesics may not be needed at all. to avoid “after-lunchtime” dosing. Having prescribed this medicine well JAMA Internal Medicine, March 2019 (as presented in NEJM Journal Watch, April 2019). over 200 times, we have not had any significant issues, so take heart.

Are we managing the Q “high” dose oral predni- sone with taper ourselves, or referring to the PCP? Our prescribing style varies. A Sometimes we prescribe This gentleman presented acutely with a one-day history of redness in his ourselves; sometimes we ask the right eye. This is a typical case of first (ophthalmic) division shingles. He has a concurrent/secondary mostly temporal episcleritis, but minimal discomfort. patient’s PCP or specialist to do so. He was treated with oral famciclovir 500mg TID for a week along with Durezol Our job is to make the right diagnosis, Q2hours for two days, then QID one time a week. initiate the right therapy and then pass the patient (along with a succinct letter detailing the situation and Should we consider using How do you treat second- diagnosis) onto the PCP, internist or Q trifluridine ophthalmic Q ary iritis with HSV disease? rheumatologist, depending upon the solution for treating ocular Just treating the primary unique situation. We often do initial herpes? Or [should] the oral A infection is hugely helpful in tapering (within the first week or treatment always be the first improving iritis signs and symptoms, two), but if long-term tapering is instance? In which cases should and good cycloplegia such as with needed, we generally ask the medical the drops be used? cyclopentolate 1% QID or atropine providers to handle this. It should be stressed that only in 1% BID should be all that is needed. A a severe case (which we have yet Is the dosage of oral to see) would oral and topical Does Shingrix reduce the Q antiviral the same for kids? treatments concurrently be indicated. Q risk of herpes simplex Dosing is different and needs We cannot think of a case in which we keratitis? A to be weight-adjusted. would use topical therapy; perhaps in Since herpes simplex and herpes Table 1 on the next page a patient with dysphasia (difficulty A zoster are cousins of sorts, one nicely provides guidance. swallowing). would think this would be the case. Keep in mind that of the However, Shingrix vaccine only three oral antivirals, only What dosage of antivirals actively intercedes against herpes acyclovir comes as a Q do you use for HSV? zoster (shingles). It’s a two-dose liquid at 200mg/cc (or We almost always use valacyclo- vaccine, as are most of the COVID per tsp). A vir 500mg TID for one week. vaccines.

16 REVIEW OF OPTOMETRY JUNE 15, 2021 TABLE 1. TREATMENT AND PROPHYLACTIC DOSAGES FOR ACYCLOVIR IN CHILDREN Treatment Dose Prophylactic Dose Age Thrice Daily Twice Daily Infants (up to 18 months) 100mg (2.5 ml) 100mg (2.5 ml) Toddlers (18 months to three years) 200mg (5 ml) 200mg (5 ml) Young children (three to five years) 300mg (7.5 ml) 300mg (7.5 ml) Older children (six years and older) 400mg (10 ml) 400mg (10 ml) Source: Ophthalmology, October 2012

This chart nicely guides proper dosing of the oral suspension of acyclovir.

Fig. 8. This case of shingles is more What are the oral treat- antiviral? Generally speaking, if the Q disseminated than the common isolated ment options for shingles? patient is over age 60 and the presen- dermatome in that it appears that While shingles expression can tation is moderate to severe (or if there both first and second dermatomes are A range from mild to severe, the is considerable pain), then we would afflicted. Also, the patient exhibited antiviral dosage is the same for most prescribe 40mg or 60mg oral predni- more lesions just below her neck. She did all cases. We usually prescribe sone per day for a week. When we use well with only oral antiviral therapy. valacyclovir at 1000mg TID for one prednisone for less than that, there is week, but sometimes for 10 days. no requirement to taper. If the patient is over 65, we gener- Practical dosing is breakfast, mid- If cost is of the antiviral is critical, ally use generic famciclovir, as it seems afternoon and at bedtime. The more acyclovir is always less expensive, but to be better tolerated in this popula- challenging question would be: when it has to be used five times a day, so tion than acyclovir or valacyclovir. do we concurrently prescribe oral the dosing is a bit burdensome (about The usual dosage is 500mg TID for prednisone along with the oral every three and a half hours). seven to 10 days.

STAMP OUT SHINGLES began in 1996 and became more Shingrix Replaces Zostavax effective after the two-dose This painful, debilitating experience regimen started in 2006.” • Shingrix can have serious consequences for is the Kong CL, Thompson RR, Porco TC, et al. Incidence the cornea in particular, but also rate of herpes zoster ophthalmicus: a retrospective second the skin around the eyelids. Newer cohort study from 1994 through 2018. Ophthalmol- vaccine ogy. 2020 Mar; 127(3):324-30. vaccines in use now will lessen the to be incidence some years hence, but The Latest on Shingles FDA- for now it remains an ongoing risk approved to many. • Mean age of event: 52. to help • Patients who have had HZO prevent Incidence: Herpes Zoster shingles. Ophthalmicus should be examined “within several weeks before and after • Approved for people ages 50 • Shingles occurs in one-third of vaccination against herpes and older. adults. zoster” because they may be at • A non-live vaccine (Zostavax is STRATEGIES FOR SUCCESS • Of these, about 15% involve the risk for recurrent eye disease. live, attenuated). ophthalmic division; of these • We should “recommend about half will afflict the globe. strongly” that patients over 50 • Administered in 2 IM doses • Rate is increasing in ages 35 to 55. get Shingrix. (initially then two to six months later). • “Given the shift in HZO burden • Our advocacy could “play an toward middle-aged individuals, important role in increasing • About 90% effective and it is crucial for clinicians to vaccination rates.” maintained over four years. support vaccination efforts for • About 10% of people have a • If the last Zostavax vaccine individuals 50 years of age and reaction to Shingrix, more after was at least five years ago, older.” the second dose. can have Shingrix. • “Varicella (chicken pox) Policy Statement. Recommendations for Herpes Zoster Vaccine for Patients 50 Years of Age and • Marketed by GlaxoSmithKline. vaccination (Varivax) of children Older Ophthalmology. Nov. 2018

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Any of the “90-D” type lenses good, honest, forthright communica- A are excellent for retinal viewing. tion (a face-to-face discussion) is We generally prefer the Volk Super critical. At the very least, the “associ- 66, but any of these similar lenses ate” should keep these patients perform well. We continue to rely “in-house” so that they can be heavily on the binocular indirect internally referred to you or another ophthalmoscope (BIO), as we feel we optometric colleague. can get to the peripheral retina more effectively with that instrumentation. Orbital inflammatory Q pseudotumor: how do you Is scleral depression know you are not dealing with Q standard of care? Years an inflammatory malignancy ago, I remember a lecturer without at least doing blood saying it must be performed and work to rule out lymphomas? documented as a “CYA.” I See the slide below regarding a would love to hear it is not A diagnosis of this disorder. Note considered necessary. Thanks! that orbital inflammatory disease Retina subspecialists are the occurs over a few days. Malignancies Fig. 9. Examples of HSV epithelial A masters of scleral depression take weeks or months to manifest keratitis. and are most likely the ones doing the themselves. lion’s share of these procedures. A Do topical antivirals have a study in IOVS from 2013 offers an Regarding idiopathic Q role in herpes simplex updated perspective that we greatly Q orbital inflammatory disease any more? appreciate. disease, is your first line for a Certainly, but only minimally. • “An examination using a 28 definitive diagnosis like that a A The oral antivirals are equally diopter lens with scleral depression did CT scan? Would you ever try effective, less toxic and less expensive not provide any additional benefit to using steroid eye drops before- than topical therapies. an examination without depression hand? during indirect .” The diagnosis is usually very For chemical burns of the • “In many areas around the world A straightforward, but an urgent Q cornea and/or conjunctiva, ophthalmologists have progressively CT scan can quickly seal the diagno- does Lotemax ointment work shifted from indirect ophthalmos- sis. Since we are going to make the even during the day? If the copy with 28 diopter-type lenses to diagnosis before starting treatment, no cornea is still intact, is it true that new fundus lenses at the to eyedrops are needed—only oral the burn won’t be as bad as when improve the comfort of the patient prednisone. the corneal epithelium is off? without scleral depression.” A Yes, you are correct, although IDIOPATHIC ORBITAL we would be more inclined to Q How do you handle an INFLAMMATORY DISEASE use the less expensive Maxitrol associate OD who isn’t (ORBITAL PSEUDOTUMOR) ophthalmic ointment. Toxic chemicals comfortable with medical optom- • Usually acute onset, unilateral, are also bactericidal, but having an etry and typically refers most red eye antibiotic drug along with the steroid glaucoma patients and other might be a better course of action, conditions within our scope? • Chemosis, lid edema and even during the day—as well as at This is more in the realm of erythema bedtime. Your second observation is A practice management, but since • Proptosis, EOM dysfunction and generally correct, because this would you asked, we’ll take a crack at it. are possible be a mild chemical burn if the First of all, this topic should have • Systemic association rare if epithelium is still intact. come up in the interview and initial unilateral office visits. After four years of intense • VA, exophthalmometry, IOP, CT What type of lens would clinical training, how could an or MRI Q you use to view the fundus optometrist not be comfortable with with the slit lamp instead of these conditions? There is ample • Treatment is oral prednisone, high dose (1mg/kg/d initially) binocular indirect ophthalmos- continuing education readily available with taper copy with scleral depression? to help address such concerns. Last,

18 REVIEW OF OPTOMETRY JUNE 15, 2021 When using the pulse-style management is pretty much straight Q dosing of Lotemax for dry eyedrop dependent, DED (dry eye eye, what does the literature say disease) is much more complex and about cataract formation? most always involves a multifaceted To our knowledge, there is not a approach. It has been our experience A single case report of cataract that if a steroid fails to suppress ocular formation associated with the use of surface inflammation, any and all Fig. 10. Idiopathic orbital inflammatory loteprednol. This is because intrinsic other non-steroidal medicines will also disease. Note hemorrhagic chemosis— no itching—and has been there about ocular esterases preclude the accumu- fail, and that just makes common four days. CT scan did show orbital lation of sufficient and prolonged pharmacologic sense. inflammation. A consult was done with steroid concentration. Even with the the primary care practitioner because ketone-based steroids like predniso- What are your thoughts on of the need to treat with 60mg of oral lone, dexamethasone and diflupred- Q Lotemax compared to IPL prednisone over one week. nate, such occurrences are rare. or LipiFlow? There are no studies of which Is it understood why the A we are aware that have re- Q aqueous-based preserva- searched this. IPL, LipiFlow, tive-free artificial tears did TearCare, iLux and other similar nothing to alleviate symptoms? devices do get more to the primary We assume it is because the problem of meibomian gland dysfunc- A preponderance of dry eye results tion, so if these were able to restore a from deficiencies in the lipid layer—at more robust lipid layer, then there least that would make sense. would be no more hyperosmolarity and therefore minimal opportunity for Do you use meibomian secondary inflammation to occur. Fig. 11. Non-itching, acute “hemorrhagic” Q gland treatments that Lotemax SM very effectively and chemosis indicative of orbital warm and express the glands? safely suppresses ocular surface inflammation. What are your thoughts? inflammation, so a study of this nature We are just now getting into would really be comparing apples to A that technology, but our results oranges. are quite promising—our preliminary data look really good. Studies to date Are you using autologous show that such technology performs Q serum for dry eye? considerably better than warm soaks We’ve had only moderate or warming masks. A success with autologous serum eyedrops over the years. With the Fig. 12. Photo shows complete restoration to normal one week later. How often do you come advent of Regener-Eyes, we have Q across dry eye patients found this drop to work better than who respond poorly to lotepre- autologous serum tears. Since it is Treating these inflamma- dnol? commercially available, it is much Q tory periorbital tumors No contact lens manufactured more convenient for patients. scares me a little. How can I be A works for every patient, and no STRATEGIES FOR SUCCESS more comfortable treating with medicine performs ideally for every Do you ever use Restasis or a steroid first-line vs. an oral patient. Our success rate is about 80 Q Xiidra, or just loteprednol? antibiotic? to 85%. One must bear in mind that Reports in the literature and our The “key of keys” in medicine is no single approach can meet the needs A vast clinical experiences have A making the proper diagnosis. of all patients. We guide our patients found neither Restasis (Allergan) nor Review the teaching slide, do a good to use a top-quality, lipid-based Xiidra (Novartis) to be all that “Review of Systems” and get an artificial tear such as Soothe XP effective in the care of patients with urgent CT scan. Radiologists can be (Bausch + Lomb) or Systane Complete dry eye. There are multiple peer- immensely helpful in these types of (Alcon), plus warm soaks, blinking reviewed articles that fully support the cases. Once you have a solid diagno- exercises and so on, in addition to use of loteprednol for suppressing the sis, you can then be more confident anti-inflammatory eyedrops to address attendant inflammation in DED. Why with the proper therapy. their condition. While glaucoma make medical eye care expensive—and

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relatively ineffective—when rock solid suspension; Inveltys, a 1% concentra- efficacious approaches are readily JAMA INTERNAL MEDICINE tion product; and Eysuvis, which is a ON RESTASIS available? As we have said until we 0.25% product. While there is some are blue in the face, if we all read the Restasis has never been approved bureaucratic uniqueness to each of in the EU, Australia or New Zealand prestigious eye journals monthly, none “due to insufficient evidence of effi- these products, such as FDA-approved of this would be surprising! cacy.” indications (which have zero bearing While there is no universally ap- on our clinical practice), these prod- Schwartz LM, Woloshin S. A Clear-eyed view of plicable algorithm to properly treat restasis and chronic dry eye disease. JAMA Intern ucts all perform very similarly because dry eye disease, loteprednol is the ap- Med. 2018 Feb 1;178(2):181-2. they are all loteprednol! proach we most commonly use, and Inveltys is approved for twice-daily if this did not work, we would not be form of flattery, so the loteprednol administration with an indication for doing it. molecule is meritorious of imitation! postoperative care. It requires minimal Now, let’s try to put this increas- shaking before instillation. Eysuvis What is the difference ingly complicated array of loteprednol is a 0.2% ophthalmic suspension Q between Inveltys and products into perspective. The original and uniquely indicated for up to two Lotemax SM? product was Lotemax ophthalmic weeks of QID treatment for DED. Actually, an update to your suspension. Because of the unique Like Inveltys, Eysuvis requires very A question might be, “What is the chemistry of this suspension, the minimal shaking. difference between Inveltys, Eysuvis bottle does not state “shake well” Since these products are all lotepre- (both Kala Pharmaceuticals), and but rather “shake vigorously.” As a dnol etabonate, we just marvel at the Lotemax SM (Bausch + Lomb)?” “runny” liquid, an improved formula- various “indications” that are granted These are all different, yet similar tion was sought to make it less runny, them by the FDA. Our vast experi- formulations of loteprednol, which to have a longer ocular surface resi- ence clearly shows that all of these came to market as Lotemax 0.5% dency time, and to eliminate the need products can be used in any clinical suspension in 1998. Loteprednol is the to be shaken. Thus was born Lotemax situation when suppression of ocular only ester-based ophthalmic cortico- gel 0.5% drops. Further enhance- surface tissue inflammation is needed. steroid, which provides a greatly ment of the formulation resulted in a Hopefully, as learned doctors, this enhanced safety profile while main- smaller particle size to enhance clinical just makes common sense. Focus on taining good therapeutic efficacy. As performance. This also allowed for providing your patients the ultimate is often said, imitation is the highest actually decreasing the concentration in clinical care and don’t let a federal from 0.5% to 0.38%. Neither the bureaucracy alter your sound clinical ANTIBIOTIC USE IN URGENT Lotemax gel drop nor the Lotemax judgment. CARE CENTERS SM require shaking before use—other • “Patients with viral upper than once to make sure the medicine What are you using in respiratory infections were actually gets positioned up into the Q place of for treated with unnecessary dropper tip. pain management with abra- antibiotics almost half the Back to the beginning: Bausch + sions? We keep atropine on the time.” Lomb also made available its 0.2% shelf to treat iritis, since phar- • “Despite proven harms of formulation of loteprednol, known as macies do not have homatro- unnecessary antibiotic use, Alrex. This is also a suspension, very pine, but we are undecided in the battle to limit unnecessary much like the Lotemax 0.5%. Alrex’s our practice about its use for prescriptions rages on.” forte is in treating allergic conjuncti- pain management. My partner • “Likelihood of antibiotic vitis, but it can be used off-label, like wants to have the local phar- prescription use was uniformly all loteprednol formulations, in a wide macy stock scopolamine. What higher in urgent care centers range of inflammatory conditions. are your thoughts? than in hospital-associated Because of the high chemo-techni- You are correct regarding the emergency departments (25%) cal challenges of getting loteprednol A pain relief from therapeutic or medical offices (17%).” into liquid form, Bausch + Lomb cycloplegia. As best we can determine, • “The booming market in urgent was able to maintain brand name 5% homatropine and scopolamine are care centers has opened exclusivity for over 20 years. Now no longer manufactured. However, another gigantic front in the that other companies have been able even 1% cyclopentolate or atropine antibiotic wars.” to manufacture loteprednol formula- performs similarly to homatropine. JAMA Int Med, July 2018 (as reported in NEJM tions, we have three other renditions We commonly instill a couple of Journal Watch, July 2018). of loteprednol available: generic 0.5% drops of one of these cycloplegic

20 REVIEW OF OPTOMETRY JUNE 15, 2021 capsules over-the-counter and as 40mg “Doxycycline has a low affinity THE TETRACYCLINES capsules by prescription—nicely for calcium binding. Gastrointestinal • Tetracycline, doxycycline, suppresses gastric acid secretion. absorption of minocycline and doxy- minocycline Either an H2 receptor blocker or a PPI cycline is not significantly affected by • Doxycycline most commonly can protect the stomach mucosal food or dairy products.” used lining from the potentially toxic effects of high-dose prednisone. Only very • Advantages over tetracycline: For treating recurrent rarely have we found it necessary to Q corneal erosions, do you • Maintenance dose 20mg to co-administer one of these “GI start with doxycycline 100mg 100mg daily protective” medicines, because of the orally and Lotemax four times • Can be taken without meals short duration of their use. We do, daily for one month and then • Contraindicated in pregnancy, however, prescribe prednisone to be continue to use ointments at nursing mothers, under age taken with breakfast. Further, with night during this month? Then, eight; photosensitivity warning these higher dosages, we divide the can these be stopped without dosing such that half is taken with • Indications in primary eye care recurrence? breakfast and the other half with We tend to use doxycycline • Meibomianitis (chronic lunch. When appropriate, verbal A 50mg once daily for a month, inspissated glands) consultation with the patient’s along with Lotemax SM QID daily for • Adult inclusion conjunctivitis primary care provider is initiated. two weeks, then BID for two more (chlamydia) weeks, along with GenTeal gel (Alcon) • Recurrent corneal erosion If my patient has moderate at bedtime for two months. Our hope Q meibomian gland dysfunc- for the patient is that this regimen is agents while the patient is in the office, tion associated with rosacea, curative. We have about 80% to 90% since it may take a day or two to get would you start with 20mg of success with this medical approach. the prescription. Thankfully, you keep Periostat (doxycycline hyclate) Anterior stromal micropuncture is yet atropine in your office, and like the twice daily or 50mg once daily, another very viable approach. cyclopentolate, you can instill a drop and for how long? or two in the office depending upon Because of the expense of If a patient has severe dry the severity of the condition. Also, A Periostat, we typically prescribe Q eye secondary to both topical NSAIDs can be of some help in 50mg doxycycline once daily (prefer- meibomian gland dysfunction dampening ocular surface pain (such ably taken with breakfast) for three to and decreased tear film with as your referenced abrasion), so while six months for such patients. Periostat corneal punctate staining, can I instilling a drop or two of an NSAID is a 20mg BID version of doxycycline, still use Lotemax with the can help, applying a bandage contact so both of these two approaches are doxycycline? lens does a world of good for pain clinically sound. We prefer once-daily Yes, indeed! We would use amelioration. vs. BID dosing. Doxycycline comes in A doxycycline 50mg for two both hyclate and monohydrate forms. months, LotemaxSM QID for two When prescribing higher While not a major deciding factor, we weeks, then BID for one month. Use a Q dosages of oral steroids prefer the monohydrate form because lipid-based artificial tear in between (60mg to 80mg or more per it tends to be a bit more GI-friendly. use of the Lotemax as often as day), what do you recommend But cost is always a concern and often practical (two to four times a day). for an H2 blocker, since Zantac steers our prescribing. Of course, STRATEGIES FOR SUCCESS has been removed from the knowing cost before prescribing is I live in a very sunny market due to a contaminant always a challenge. Q location. Is a 50mg once- linked to cancer? daily doxycycline prescription Zantac (ranitidine) has indeed Any problem using doxycy- going to cause photosensitivity? A been removed from the market. Q cline with concurrent Although uncommon, some However, H2 blockers such as calcium supplements or milk? A patients may experience some Tagamet (cimetadine) 200mg per day Here is the wisdom stated in photosensitivity, especially those with and Pepcid (famotidine) 20mg, or a A Drug Facts and Comparisons: fair complexions. Therefore, we would proton pump inhibitor such as OTC “Food decreases absorption of advise such patients to be aware of Prilosec (omeprazole), Prevacid tetracyclines, except doxycycline and this possibility and advise them to (lansoprazole) or Nexium (esomepra- minocycline; these two agents may be wear a hat or long-sleeve shirts during zole)—which is available as 20mg taken without regard to food.” this active treatment.

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Getting Adenovirus Under Control The topic of Betadine gets the prize for generating the most questions.

nsurprisingly, there was keen The Betadine wash is interest in the treatment of Q amazing! When I was in UCOVID-19 viral conjuncti- the Army, I used to use it all vitis. Let us not lose perspective that the time on the basic trainees most all ocular infections are indeed who would spread it like adenoviral, and the literature tells wildfire. They were miserable us that corona viral conjunctivitis is right after I did it, but then uncommon. Keep in mind the horse within the next two days they vs. zebra dichotomy. were thanking me. There is no question that what Is treatment for pink eye A you say is true. We do not Q related to COVID-19? know your exact protocol, but we do From all indications, we would use proparacaine before instilling the A use the exact same protocol as 5% Betadine and also instill a drop we do for adenoviral (EKC) infec- of an NSAID, which can dampen This shows how simple it is to collect a tions. See “Povidone-Iodine 5% tear sample using the Quidel QuickVue ocular surface pain. These approach- Ophthalmic Solution” on adjacent Adenoviral test when supplemental info es do indeed help with the comfort page. is needed. No anesthesia is necessary. (or less irritation).

Do you foresee an in- BETADINE AND COVID-19 Q crease in the proportion e have long appreciated the many virtues of povidone iodine in the of doctors using Betadine with Wcare of our patients with viral epidemic keratoconjunctivitis. Now red eyes of suspected viral with the new, uninvited guest of COVID in our midst, it has been discov- nature in their practice in a ered that Betadine is even effective against this menace. “post-COVID world” with Here are two quotes from an article, titled “Povidone Iodine concern that some of the Mouthwash, Gargle, and Nasal Spray to Reduce Nasopharyngeal Viral infections could in fact be from Load in Patients With COVID-19: A Randomized Clinical Trial,” that will COVID-19? bring you up to speed regarding the many virtues of dilute povidone This is certainly a prudent iodine: A approach, since the COVID-19 “Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is pri- virus can cause a clinical conjunctivitis marily transmitted person-to-person through the aerosolization of drop- identical to adenovirus. Of course, a lets containing contaminated nasopharyngeal secretions. Povidone iodine careful history of smell/taste loss, fever (PI) solutions with concentrations as low as 0.5% rapidly inactivate SARS- or other constitutional problems will CoV-2 in vitro with contact times as short as 15 seconds. We investigated help identify a more specific cause. whether nasopharyngeal application of PI could reduce the viral load in People with adenoviral conjunctivitis patients with nonsevere coronavirus disease 2019 (COVID-19) symptoms.” pretty much only have an isolated eye “Discussion: Nasopharyngeal decolonization may reduce the carriage of infection. We do know that Betadine infectious SARS-CoV-2 in adults with mild to moderate COVID-19. Thyroid dysfunction occurred in 42% of the patients exposed to PI, with sponta- is effective against both viruses. neous resolution upon treatment discontinuation, as previously reported. The QuickVue (formerly RPS Ad- Strengths of this study include assessment of viral titer to deter- eno Detector) adenoviral in-office test mine whether the virus was viable and, thus, potentially transmissible. by Quidel only detects adenovirus, Limitations include the small number of patients in the single-centered not COVID. (Go to quideleyehealth. design. These data call for a larger clinical trial to confirm the benefit of com for more information.) So, a PI in limiting the excretion and resulting human-to-human transmission of negative test only tells you that the SARS-CoV-2, using lower PI concentrations to minimize adverse effects.” red eye is probably not adenoviral, Guenezan J, Garcia M, Strasters D, et al. Povidone iodine mouthwash, gargle, and nasal spray to reduce because these tests are not as sensitive nasopharyngeal viral load in patients with COVID-19: a randomized clinical trial. JAMA Otolaryngol Head as would be ideal; the red eye could be Neck Surg. 2021 Apr 1; 147(4):400-1. from any number of causes.

22 REVIEW OF OPTOMETRY JUNE 15, 2021 INSIGHTS FROM LITERATURE • Effectively kills bacteria that are Betadine and Iodine Allergy resistant to topical antibiotics. By now, we as • Seafood allergy is caused by a profession • “Dilute PI solution is widely various protein allergens. Thus, an know Betadine available, easy to make, allergy to seafood is not a contra- pretty well, inexpensive and has been indication to the use of betadine. studied extensively.” given its • Allergy to iodinated contrast breadth of Koerner JC, George MJ, Meyer DR, et al. media is not related to the iodine, use. Still, there Povidone-iodine concentration and dosing in cataract surgery. Surv Ophthalmol. 2018 Nov- but to other intrinsic chemicals. are always Dec;63(6):862-8. new rev- • “Current literature suggests that elations from Preventing Eye Infections iodine itself is not an allergen; it is journal articles and clinical practice. (Intravitreal Injections) required for thyroid function and other normal biological processes • Kill time for Betadine (povidone Povidone-Iodine 5% and does not have the complexity iodine) 15 to 120 seconds—at any Ophthalmic Solution necessary for antigenicity.” concentration! • Broad spectrum microbicide. • There are currently no reports of • Anaphylaxis to iodine does not anaphylaxis secondary to topical • Indicated for “irrigation of the exist! ocular surface.” ophthalmic use of P-I. • “Topical moxifloxacin .5% J Cataract Refract Surg. 2020; 46(5):795-96. • “Off label” use: Tx adenoviral had no additional effect on keratoconjunctivitis. reducing conjunctival bacterial Intranasal Betadine and COVID-19 counts beyond the effect of 5% • “P-I nasal antiseptic solutions at • No reports in clinical trials of povidone iodine alone.” adverse reactions. concentrations as low as 0.5% rap- • “Preinjection antibiotics either idly inactivate SARS-CoV-2 at con- • Marketed as Betadine 5% before the day of injection or tact times as short as 15 seconds.” ophthalmic prep solution (30ml immediately prior to injection are • Virus transmission pathway: opaque bottle) by Alcon. not generally recommended.” “Infection of ciliated cells of the Our Clinical Protocol • Gentamicin was vastly more upper airway within the nose as effective than fluoroquinolones. the dominant site of infection, • Anesthetize with proparacaine. followed by subsequent aspiration Wykoff CC, Flynn HW Jr, Rosenfeld PJ. Prophylaxis • Instill one or two drops of NSAID. for endophthalmitis following intravitreal injection: and seeding of the lungs.” antisepsis and antibiotics. Am J Ophthalmol. 2011 • Instill several drops Betadine 5% Nov; 152(5):717-9.e2. • Perhaps betadine has another in eye(s); close eye(s). role in addition to its effect on Antibiotic Use and adenoviral ocular infection. • Swab or rub excess over lid margin. Intravitreal Injections Frank S, Brown SM, Capriotti JA, et al. In vitro efficacy of a povidone-iodine nasal antiseptic for rapid inactivation • After 60 to 90 seconds, irrigate • Preoperative and postoperative of SARS-CoV-2. JAMA Otolaryngol Head Neck Surg. with sterile saline. antibiotics might have a 2020 Sep 17; 146(11):1–5. negative impact on the safety • Instill one or two drops of NSAID. of the procedure because, with Betadine for Ophthalmia • Rx steroid QID for four days. repeated injections, patients Neonatorum Prophylaxis develop ocular surface bacteria • “A controlled clinical trial compar- Insights Into Betadine Use that are antibiotic-resistant. ing erythromycin 0.5% povidone- STRATEGIES FOR SUCCESS • 5% Betadine works well on the • Topical antibiotics before the iodine 2.5% and silver nitrate 1% ocular surface. day of injection did not reduce demonstrated that povidone- • Betadine is a broad spectrum conjunctival bacterial counts iodine was more effective than antimicrobicide. more than the immediate pre- the other agents for preventing injection use of povidone-iodine. infectious conjunctivitis, including • “Brief application of povidone chlamydial conjunctivitis.” iodine (PI), 5 to 10%, to the • In spite of this knowledgae, 27% ocular surface is commonly used of surveyed retina specialists • “We believe povidone-iodine world wide since the ’80s.” continue to use pre-injection would be a suitable and perhaps preferable alternative • Toxicity is concentration and antibiotics and 63% use post- to azithromycin for ophthalmia duration dependent. injection antibiotics. neonatorum prophylaxis.” • It is preoperative standard-of- Brucker AJ. Antibiotic prophylaxis may have negative effect on safety of intravitreal injections. Keenan J et al. Research Letters. Archives of Ophthal- care. Ocular Surgery News. 2013 June 25. mology. January 2010

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How quickly do I need to any necrotic superficial ulcerative Q start Betadine after a red debris and then perform a Betadine eye develops to be most treatment prior to starting intensive effective? topical antibiotics. Just like in treating shingles A with oral antivirals, you want How do you prepare (clean to catch the patient as early in the Q and sterilize) your Fluress active (replicative) phase as possible. bottles for the Betadine? If a shingles or EKC patient comes in Rinse thoroughly with tap seven to 10 days or so after the A water, allow these bottles to condition began, the effectiveness—if air-dry then pour in the desired Here is a patient who waited too long any—of these interventions will be amount of the leftover Betadine once to present; what you now see is purely minimal. After all, your body’s the 30ml bottle has been opened. inflammatory membrane formation. The infectious window is closed and all that intrinsic healing responses are kicking Think about this: do you have to be can or needs to be done is hammer the in trying to help the body heal itself. concerned with contamination or eye with topical steroids, e.g., every two sterility?! hours for two days, then QID for a week, What is your take on using then BID for another week or two. Q steroids to treat infiltrates For adenoviral infection, if in EKC? Would you say the use Q patient is allergic to Can you use Betadine for of steroids is controversial in iodine, would treatment just be Q EKC treatment after the the available literature? the steroid? patient has developed subepi- The first part of your question See “The Latest on Betadine thelial infiltrates? A is answered in the next Q&A. A and Iodine Allergy” in the box A No. Once the infectious phase The second part—if it is controver- on the previous page. is over, all that’s left is the sial—we could not explain it. Having subsequent inflammation (see above prescribed a steroid in this setting For children with pharyn- photo). At this stage, if the infiltrates numerous times, we know it per- Q goconjunctival fever (PCF) are visually problematic, then we forms beautifully. or adenovirus, do you have typically prescribe Lotemax SM to be parents keep them home from used QID for two to four weeks, then What steroid do you use for school? TID for two to four weeks, then BID Q EKC after Betadine wash? If we don’t, the school will! for two to four weeks, then Q day for The cheapest one you can get. A Since PCF is caused by less two to four weeks, blindly trying to A You are only going to use it virulent serotypes of adenovirus, we use the least amount of drug to QID for about four days. Once the just treat the patient with Alrex QID neutralize the antigen antibody active viruses are killed via the for about four days. The body heals reaction which is causing the Betadine, the secondary inflammation these less virulent serotypes quickly. subepithelial infiltrates. Do remember subsides quickly with the steroid. that these are indeed subepithelial, so Up to what age group are there should be no epithelial fluores- Why has Betadine not Q you treating patients with cein staining. If the subepithelial Q become a standard treat- Betadine? infiltrates are not visually bother- ment for antibiotic-resistant From birth to 100-plus. See some, do nothing; they will go away bacterial ulcers and other A “Betadine for Ophthalmia with time. The intensity and duration vision-threatening corneal Neonatorum Prophylaxis” in the box of problematic SEIs are variable. infections? Antibiotics, when on the previous page. effective, certainly have fewer Do we have to be careful adverse reactions, but would a What are your thoughts Q with Betadine treatment if simple in-office Betadine Q about using hypochlorous the patient has existing ocular treatment not be an effective acid in the eye for EKC vs. surface disease? in-office cure at presentation? Betadine? A In the setting of a miserable A Your point is well taken (and A Academically, this would be a human being, the baseline appreciated). We are not sure, better choice, but our success ocular surface is relatively irrelevant. but there may be an issue with with hypochlorous acid has been less That can be addressed once the viral corneal penetration. It certainly than ideal. For now, we are devoted beast has been cleared. would seem meritorious to debulk to our tried-and-true Betadine.

24 REVIEW OF OPTOMETRY JUNE 15, 2021 Smartphone Use in Eye Care ike all technologies, there is im- “Currently, most smartphone apps provement over time. For now, do not have the evidence to claim Lthe usefulness of smartphones is scientific validation for integration limited in developed countries, but can into clinical practice; however, the be relatively more helpful in develop- Peek Acuity and the D-Eye apps both ing countries via telemedicine use. have research suggesting that they Google Play has nearly 300 may be useful clinical adjuncts moving ophthalmic-based apps and the Apple forward. Indeed, the D-Eye app can “A clinician will find looking for App Store has about 170. serve as an excellent replacement of a suitable and validated app very dif- “iPhone add-ons such as the Cell direct ophthalmoscopy on the inpa- ficult. App store rating systems have Scope, EyeGo, D-Eye and PEEK are tient wards, given its high accessibility low user uptake and are inherently examples of devices that, in conjunc- and ease of use when compared to the biased and unregulated.” tion with the high-resolution camera direct ophthalmoscope, which has had There is no doubt that smartphone of a smartphone, are capable of taking ongoing issues with user proficiency.” apps have the potential to augment high-quality images of the anterior Having had the honor of training some portions of our clinical care and posterior segments of the eye, family medicine residents during their going forward. The extent of such will even in inexperienced hands.” ophthalmology rotations, not a single only be known in the years ahead. We Since compliance and adherence is- one possessed clinical competence in have no doubt that “refraction” will sues with eyedrop applications plague direct ophthalmoscopy until this rota- be one aspect of these advances. the care of glaucoma, smartphone “re- tion midway through their residencies. Hogarty DT, Hogarty JP, Hewitt AW. Smartphone use minder systems” could be beneficial to (Opinion: this should be a part of core in ophthalmology: What is their place in clinical prac- forgetful patients. training during medical school!) tice? Surv Ophthalmol. 2020 Mar-Apr; 65(2):250-62.

FACTS ON FEMTO Femto Not a Factor for Patients • Postoperative complications were lower in conventional • “There were no statistically While there is a lot of hype and phacoemulsification cataract significant differences between discussion regarding the “benefits” surgery. (and increased revenue) from femtosecond laser assisted cata-

femtosecond-assisted cataract sur- ract surgery and manual cataract 1. Popovic M, Campos-Möller X, Schlenker MB, gery, the consensus of the literature surgery in terms of patient- et al. Efficacy and safety of femtosecond laser- assisted cataract surgery compared with manual opines that such extra expense to important visual and refractive cataract surgery: a meta-analysis of 14,567 eyes. the patient does not meet the clini- outcomes and overall complica- Ophthalmology. 2016 Oct; 123(10):2113-26. cal return on investment. Knowl- tions.”1 2. Manning S, Barry P, Henry Y, et al. Femtosecond edge gleaned from the literature is laser-assisted cataract surgery versus standard • “Femtosecond laser-assisted phacoemulsification cataract surgery. J Cataract so enlightening. These four studies Refract Surg. 2016 Dec; 42(12):1779-90. cataract surgery did not yield all corroborate each other. better visual or refractive Femto’s Only Difference: Femto vs. Traditional Phaco: outcomes than conventional Higher Cost Virtually Identical phacoemulsification cataract surgery. Intraoperative complica- • “Postoperatively, there was no • The results of this large study tions were similar and low in both statistically significant difference STRATEGIES FOR SUCCESS “found that phaco is as good as groups. Postoperative complica- found between eyes undergoing femto in terms of vision, patient- tions were lower in conventional femto and eyes undergoing stan- reported health and safety out- phacoemulsification cataract dard extraction with respect to comes at three months.” surgery.”2 refractive and visual outcomes.” • These findings have been consis- • Femtosecond laser-assisted cata- • To us, this is an unnecessary tent with other similar studies. ract surgery did not yield better “techno-interruption” that only serves to increase cost to our • Our take: the costs associated visual or refractive outcomes patients. with femto rarely justify its use. than conventional phacoemulsifi- cation cataract surgery. Berk TA, Schlenker MB, Campos-Möller X, et al. Day AC, Burr JM, Bennett K, et al; FACT group. Visual and refractive outcomes in manual versus Femtosecond laser-assisted cataract surgery ver- femtosecond laser-assisted cataract surgery: a sus phacoemulsification cataract surgery (FACT): • Intraoperative complications were single-center retrospective cohort analysis of 1838 A Randomized Noninferiority Trial. Ophthalmology. similar and low in both groups. 2020 Aug; 127(8):1012-9. eyes. Ophthalmology. 2018 Aug; 125(8):1172-80.

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Are Topical Antibiotics Needed After Oculofacial Surgery? his question is especially cant allergic contact dermatitis in the antibiotic ointment and prescribe relevant for doctors who periocular area has been reported to it for postoperative use, but these Tcomanage such patients. Here be lower, and a large meta-analysis decisions are not based on sound are key findings from a recent study: was unable to conclude the rela- evidence, if any.” • “This study of 400 patients tive effect of topical antibiotic vs. • In summary, “Patients with found that topical antibiotic oint- non-antibiotic ointment on this periocular wound infections gener- ment application following oculofa- complication. In the present study, ally improve and experience minimal cial plastic surgery procedures barely this complication was encountered sequelae. […] Such infections are outperformed non-antibacterial rarely in both the placebo and the not only rare, but also when they do OTC lubricating ointment. The vast antibiotic cohorts.” occur, they are easy to treat, unlike majority of oculoplastic surgeons • “A cost analysis was performed intraocular or intracranial infections do indeed prescribe antibacterial antibiotic versus bland petrolatum by comparison.” ointments, although postoperative therapy and found that the health- Our take on these findings is that infections are exceedingly rare, even care system could save $8 to $10 in spite of clinical evidence, human with non-antibacterial ointments.” million annually if all dermatologists beings are creatures of habit, and • “Many topical antibiotics are switched to bland ointment after new evidence minimally alters clini- associated with drug allergies, and surgery.” cal behavior. Sound familiar? patch testing has identified neomy- An invited commentary candidly Ashraf DC, Idowu OO, Wang Q, et al The role of cin allergy in 11.6% and bacitracin shared how most of us likely behave: topical antibiotic prophylaxis in oculofacial plastic allergy in 9.1% of the population. • “Admittedly, I often dress surgery: a randomized controlled study. Ophthal- Notably, the rate of clinically signifi- abrasions of my own body with mology. 2020 Dec; 127(12):1747-54.

FLOPPY EYELID SYNDROME HELP FOR PATIENTS WITH COLOR VISION DEFICIENCY hile Wthere are no major breakthroughs for genetically Notice the unilateral of the left eye, and the classic red, velvety programmed appearance of the palpebral conjunctiva photoreceptor upon simply raising the left upper lid. deficiencies, there are con- trast-enhanc- ing eyeglass Top photo: Simply lenses. These do not represent miraculous interventions, raising the right but many patients do find subjective benefit, and there- upper lid resulted fore, these lenses are meritorious of our investigation. An example of a floppy eyelid. in spontaneous These technologies have recently come to our attention, eversion, which is and we feel that they could be helpful to the subset of pathognomonic for patients who are afflicted with the challenges of com- floppy lid syndrome. promised color vision function. For information on these spectacle lenses, we encourage you to examine the Bottom photo: website: www.glassesforthecolorblind.com Note the eyelid and ptosis in this Historically, X-Chrome and other color-enhancing con- Eyelash ptosis can often be seen prior patient with floppy tact lenses have been helpful for those with color vision to the clinical development of floppy lid syndrome. deficiencies; however, these “Color My World” lenses eyelid syndrome. appear to be more beneficial.

26 REVIEW OF OPTOMETRY JUNE 15, 2021 Clinical Cases

Insect in the eye: This bicyclist was struck in the eye by an unknown “bug.” The heavy, ropy, mucoid discharge is more compatible with an acute allergic response. Note the inferior chemosis. After removing the “goop,” we prescribed an antibiotic- steroid, such as Zylet or generic Maxitrol, QID for four days.

Steroid responder: This 34-year-old gentleman had seen a community The reason Maxitrol was replaced by TobraDex was patent expiration. If TobraDex optometrist who properly diagnosed were as cost-effective as Maxitrol, we would embrace TobraDex, but the difference superior limbic keratopathy, but rather in price often is greater than $100 and these two medicines perform identically. than take the time and effort to have Obviously, we would prefer tobramycin over a combination of neomycin and formulated 0.5% silver nitrate (AgNO3) polymyxin-B but, again, cost is typically a major concern for the patient. ophthalmic solution, he was prescribed two different ketone-based corticoste- roids respectively. Still miserable, he sought a third opinion. His entering IOPs were 54mm Hg and 56mm Hg, and as can be easily seen, his superior bulbar conjunctivae stained heavily with lissamine green vital dye. The corticosteroids were dis- continued, and he was prescribed 0.5% timolol (he had already spent over $200 for the steroids). A compounding A B pharmacy was found, and he brought the bottle in four days later when it was applied. Upon return in one week, as can be

seen, the staining was completely gone STRATEGIES FOR SUCCESS and IOPs were 15mm Hg and 16mm Hg. The individual was advised that he was a “steroid responder” and should never ever use steroids again. He was told to use a lipid-based artificial tear QID for a month and then return for the second C D application (since he had already pur- Unusual skin infection: (A) This lady presented with an unusual skin infection to chased the bottle). her left lower lid. A pledget of proparacaine was applied for 30 seconds, and then He continues to do well and to use necrotic tissues were debrided. (B) Maxitrol ointment was applied. (C,D) The eye the artificial tears at least BID. This was patched. man will become a patient for life The patient did fine via a telephone call three days later because she no-showed because he knows where to come for for her pre-appointed follow-up visit. Taking care of and managing patients is an attentive, competent and compassion- enduring challenge. ate care.

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Clinical Cases

A classic case of superior limbic kerato- Note that the inferior bulbar conjunctiva conjunctivitis. While lissamine green dye is completely normal, but downgaze can certainly more quantitatively assess reveals classic superior limbic the condition, at least in this case it is not keratoconjunctivitis and the lissamine Nonspecific limbal inflammation required to seal the diagnosis. green uptake in the left eye. could be a phlyctenule. Regardless of the exact diagnosis, it is clearly inflammatory and merits the use of a topical corticosteroid.

Eyes in primary gaze appear healthy. Upon downgaze, the diagnosis of SLK is obvious, thus emphasizing the necessity of lifting the eyelids to search for the cause of his presenting symptoms.

FACTS ABOUT SUPERIOR LIMBIC KERATOCONJUNCTIVITIS • Both sexes affected, women more than men • Main symptoms: distressingly irritated eyes • Dry eyes common These eroding calcific bodies caused this EKC presents as a unilateral or companion finding patient’s foreign body sensation. bilateral inferior palpebral follicular • Symptoms disproportionate conjunctivitis with epithelial and to clinical findings subepithelial keratitis. • Spontaneous exacerbations and remissions • 25% to 40% have some thyroid dysfunction • Treatment can be difficult. Several options:

0.5% AgNO3, optimum lubrication, pressure patching, therapeutic soft Capillary microhemangiomas can develop over time and can bleed spontaneously. lenses, surgical resection, These present no threat to vision, but patients can see this blood in their eye. The cryotherapy diagnosis is made, the patient is reassured and Lotemax SM is prescribed QID for four days. In our experience, this is all it takes.

28 REVIEW OF OPTOMETRY JUNE 15, 2021 SECTION II: ANTERIOR SEGMENT CARE

Practical Pearls for Managing Dry Eye Disease Control the inflammation and you’ll fast-forward symptomatic control.

ry eye has got to be the most time are needed for diagnosis. All common condition we en- other assessments are superfluous. Dcounter in practice. Because Keep it simple—it is! there are so many patients, some • Since the vast majority of clinicians overthink their approach. dry eye disease results from lipid Here are some of our best tips, suit- deficiency, always try a standard able for most patients. bottle of a lipid-based artificial tear • Diagnosis is heavily symptom- first. If there is a clinically signifi- guided. cant amount of punctate epithelial • Only history, a slit lamp exami- erosion, then perhaps a preservative- nation of the ocular surface with a free formulation could be used vital dye, assessing the tear meniscus initially along with something like As can be readily seen, this dry eye height and the tear film breakup GenTeal Gel (Alcon) lubricant at patient has a scant lacrimal lake.

bedtime. Follow back up with your HOW BEST TO HANDLE DED INFLAMMATION? patient in about a month to assess ecent reports of Novartis’s withdrawal of Xiidra from the drug approval progress and to modify the treat- Rprocess in Europe for a dry eye indication highlight the importance of ment plan as needed. matching a medication with the disease process at hand:1,2 • If none of your rational thera- “The European Medicines Agency (EMA) disclosed on June 16, peutic interventions alter the symp- 2020, that Novartis has withdrawn its marketing application seek- toms, then consider “neuropathic ing approval of Xiidra (lifitegrast) to treat moderate to severe DED pain” as the etiology. No eye doctor in adults who have had an inadequate response to treatment with can successfully “treat” this somato- artificial tears.” sensory neurological disease. These “Based on a review of the data, the agency stated that its provi- are relatively rare patients, but they sional opinion was that Xiidra could not have been authorized for are out there, so be attentive to these the dry eye indication Novartis was seeking, as the drug’s benefit recalcitrant patients. A second opin- did not outweigh its risks.” “The EMA said the effectiveness of Xiidra had not been demon- ion may be in order. strated across different symptoms of dry eye disease. Specifically, • The focus of managing dry eye the Agency noted that while some effect was seen with Xiidra in disease is attending to foundational terms of reducing eye dryness, the benefit was not clinically signifi- meibomian gland dysfunction. While cant.” meibography is optional, practically In detailed research from the Dartmouth School of Medicine, such similar speaking, it is desirable; however, observations were found regarding Restasis. keep in mind that there is a high Both Xiidra and Restasis are touted as having anti-inflammatory proper- probability of meibomian gland ties, and such is true. anti-inflammatory drugs (NSAIDs) also disease accompanying and/or caus-

have anti-inflammatory properties, but why don’t we use any of these to ing dry eye. ANTERIOR SEGMENT CARE treat iritis, episcleritis and countless others? The answer is because we We recommend starting with this believe they don’t possess sufficient anti-inflammatory activity to be clini- approach: use your golf club spud to cally helpful. scrape back and forth three or four This same reasoning could be applied to the treatment of DED. There are times along the top of the eyelids numerous and consistent peer-reviewed articles fully supporting the vir- tues of using topical corticosteroids to address the suppression of dry eye where the orifices of the meibomian disease-associated inflammation, at least short-term. Nothing compares to glands are. No anesthesia is required a topical steroid when inflammation suppression is the goal. Obviously, we for this maneuver. Of note, there is think an ester-based corticosteroid such as loteprednol would be the wisest no CPT for it either. Then, guide the choice in the comprehensive care of DED. patient to use very warm compresses

1. Novartis pulls dry eye drug Xiidra’s bid for approval in Europe. Reuters, June 27, 2020. for at least five minutes, and then to 2. Novartis pulls EU filing seeking approval of Xiidra for dry-eye disease. FirstWord Pharma, June 26, 2020. perform gentle to moderate eye- lid massage. The LipiFlow device

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(Bausch + Lomb) can be purchased PERSPECTIVE ON SERUM TEARS IN THE (with a coupon) for $25 to $35. In MANAGEMENT OF DRY EYE DISEASE our experience, nothing out there to rom time to time the American Academy of Ophthalmology conducts treat dry eye symptoms is more ef- F“ophthalmic technology assessment” exhaustive reviews on a wide ficacious and less expensive. Studies number of ophthalmically associated technologies. A recent such review have shown that after one month discussed “autologous serum-based eyedrops for the treatment of ocular of corticosteroid suppression, the surface disease.” Herein, we share the key findings of their research: inflammation is subdued.1 Once this • Such therapy can cost several hundred dollars for a two- to three- month supply. major pathological component is • “There were no randomized controlled studies found in the peer- conquered, there is no reason to use reviewed literature.” suboptimal, highly expensive topical • “The available evidence supports the effectiveness of topical medicines twice daily for years. So, autologous serum eyedrops.” for less than $70, treatment of the • They “suggest that this treatment is a reasonable option in refractory inflammatory aspect of dry eye dis- cases of dry eyes or nonhealing epithelial defects.” ease is done—so simple, so patient- We certainly concur with these studious observations. With absolutely centric, so scientifically sound! no scientific substantiation, it is our opinion that such patients might However, no single approach benefit from a trial of the commercialized biologic eyedrop, Regener- works effectively for all patients, Eyes, prior to embarking on the more complex and expensive approach of blood-derived serum tears. (It should not have to be said, but we have and sometimes deviation from our zero direct or indirect financial relationship with the manufacturer of approach is needed to achieve and Regener-Eyes.) to maintain patient comfort. We do It has been our experience that these eye drops work similarly to autol- have several patients who require ogous serum and can play a very beneficial role in treating dry eye dis- once-daily loteprednol, as that is the ease. We encourage you to visit their website mydryeyes.org to become least anti-inflammatory effect that more familiar with this “biologic” agent. keeps them comfortable. The company recently began an incentive program that provides addi- We have never had a patient devel- tional bottles based on your volume prescribed or stocked. op at this dosing Regener-Eyes for DED schedule. For perspective, many patients are using once-daily prednis- • First in class “biologic” eye drop olone acetate chronically for stromal • Contains numerous anti- herpetic disease, corneal transplant inflammatory cytokines and growth rejection suppression or chronic factors from placental-derived tissue anterior uveitis. This approach • Hyaluronic acid for lubrication to inflammation control is time- • Enhances the lipid layer honored. Think about this. Which is safer, loteprednol or ? • Helps the body to regenerate itself Such chronic low-dose inflammatory • Available in a 2.5ml sterile bottle suppression may be required for a • See mydryeyes.org subset of patients in a very safe and cost-effective manner. (Johnson & Johnson Vision Care), of its efficacy, enhanced safety pro- • Cyclosporine 2.0 is upon us. TearCare (SightSciences) and iLux file and lower cost. Authoritative journal articles have (Alcon) are technologies to perform Just as in glaucoma patient care, questioned the patient benefit of such in-office procedures. cost is a major deterrent to patient Restasis.2 It is now well recognized • It is well understood that “in- compliance. The cost of prescription that the vast majority of patients flammation” of the ocular surface is drugs such as Restasis (Allergan) with dry eye disease have some commonly present in the setting of and Xiidra (Novartis), and even degree of meibomian gland dysfunc- dry eye disease. So, the next ques- OTC artificial tears, can put an tion, and patient-centric interven- tion is fundamental: which drug class undue burden on the patient. Now, tions include aggressive use of warm best addresses the “inflammatory” let’s put this into clinically relevant, soaks (compresses), mechanical component? It should be profoundly patient-centric perspective. The vast debridement of the meibomian gland obvious that the answer is a topical majority of dry eye patients develop orifices and mechanical expression. corticosteroid. Objectively, the “pick symptoms before the age of 65, i.e., Note that all renditions of cyclospo- of the litter” is loteprednol because while of working age. Lotemax SM rine are indicated to “increase tear

30 REVIEW OF OPTOMETRY JUNE 15, 2021 production.” Without a physiologi- 9.2% of patients, whereas the 0.09% tive and objective analysis. The De- cal lipid layer, the addition of tears is concentration did this in 16.6% of cember 2, 2019 issue of The Medical minimally effective. patients. As with the 0.05% formula- Letter stated that Cequa “appears to With Restasis (0.05% cyclospo- tion, about 25% of patients using the be similar in efficacy” to Restasis.4 It rine) now being generically available, 0.09% drop experienced instillation- says further the “addition of topical there’s a market opportunity for a site pain vs. 4.3% with vehicle.3 corticosteroids in the first month [of newer brand-name cyclosporine, As we have asserted for over 20 treatment] may be helpful.” In our Cequa, a 0.09% solution, available years, if the goal is to reduce ocular opinion, that is because our experi- from Sun Ophthalmics, a division surface inflammation, a month-long ence and the peer-reviewed literature of Sun Pharma. It is thought that its course of loteprednol is optimally ef- have confirmed that a one-month nanomicellar formulation might be fective and vastly less expensive than course of loteprednol suppresses the an improvement over its predecessor. other brand-name products. ocular surface inflammation!1 The data show modest gains. The The Medical Letter is a highly We all need to practice based on FDA trials found vehicle-increased prestigious publication and is similar science and medical literature, not Schirmer results of 10mm or more in to Consumer Reports in its exhaus- commercial marketing; it is really

USING STEROIDS FOR and effective anti-inflammatory TBUT, corneal and conjunctival DRY EYE AND BEYOND therapy.”1 fluorescein staining, lid margin abnormality, meibum quality, • The study used the loteprednol The scientific literature and FDA expressibility, ocular irritation QID for two weeks, and approvals are finally catching up symptoms and MGD stage. with the approach we have used (unsurprisingly) none of Lee H, Chung B, Kim KS, Seo KY, Choi BJ, Kim for over 20 years! the hundreds of patients TI. Effects of topical loteprednol etabonate on experienced an IOP increase tear cytokines and clinical outcomes in moder- 1 ate and severe meibomian gland dysfunction: Loteprednol Approved greater than 5mm Hg. randomized clinical trial. Am J Ophthalmol. 2014 for Dry Eye 1. Guttman Krader C. Investigational topical Dec;158(6):1172-83. corticosteroid demonstrates efficacy for dry eye. • October 2020 Ophthalmology Times. May 18, 2020. marked the Corticosteroids for Dry Eye Disease first FDA- Loteprednol’s Effect on Dry Eye approved Disease and Inflammation • This study compared PF steroid Refresh Optive to PF 0.1% • Using 0.5% loteprednol QID treatment for dexamethasone—each used QID. DED. Though for one month was sufficient • There was no difference in a 0.25% ophthalmic suspension to control ocular surface untreated and AT–treated at the formulation, only two or three inflammation. two-week mark. shakes are necessary. • “No cases showing a significant • After two weeks of steroid • Unique mucus-penetrating increase of IOP were detected.” treatment, signs and symptoms nanoparticle formulation • “Pflugfelder and associates “significantly” improved. enhances tear film residency reported no clinically significant time. changes in IOP in any patient • “Our study shows that corticosteroids can mitigate the • Approved for up to two weeks of who received topical loteprednol adverse effects of low-humidity QID therapy. four times daily for one month.” environmental stress on the ocular ANTERIOR SEGMENT CARE • Can be “re-pulsed” as needed • Summary: Loteprednol surface in individuals with DED.” over time. can provide greater anti- inflammatory effects and clinical • “This suggests that the • “Adverse events and IOP benefits through reduction of increased irritation and ocular increases were comparable ocular surface inflammation surface epithelial disease that to those seen with vehicle” in without serious adverse events. develops following a desiccating clinical trials. environmental challenge is • Compared with eyelid scrubs attributable to inflammation • Marketed by Kala with warm compresses alone, that can be modulated by a Pharmaceuticals as Eysuvis. additional application of topical corticosteroid.” 0.5% loteprednol significantly • Eysuvis studies show that Moore QL, De Paiva CS, Pflugfelder SC. Effects “results indicate that LE 0.25% decreased inflammation. There of dry eye therapies on environmentally induced was noticeably improved ocular surface disease. Am J Ophthalmol. 2015 suspension is a rapid-acting, safe Jul;160(1):135-42.e1.

REVIEW OF OPTOMETRY JUNE 15, 2021 31 SECTION II: ANTERIOR SEGMENT CARE

pretty evident, but one has to read in tion,” and adhere to time-honored, order to be able to separate knowl- scientifically sound patient care. It is DRY EYE DISEASE: IT’S ALL edge from salesmanship. very straightforward. ABOUT THE SYMPTOMS • Although there is controversy • A recent literature review comes Patients suffering from dry eye 5 over the impact of omega-3 essential to the following conclusions: consistently tell us—in day-to- fatty acids in the care of patients –“Recognition of the role of day practice and in what they with dry eye disease, the vast major- inflammation in dry eye has been a report to researchers—that what ity of optometrists (as surveyed in crucial factor in facilitating dry eye matters most is how they feel. our lecture audiences) subscribe to treatment. Inflammation plays a their benefit, and so do we. We start significant role in dry eye, promoting Patient Priorities all of our patients on fish oil at about ocular surface disruption and symp- • “The three most important 2000mg/day. By the way, this dosing toms of irritation.” questions pertained to is well below the levels that affect –“Pretreatment with Lotemax effectiveness of patient blood coagulation based on conver- induction two weeks before the ini- education, environmental sations we have had with cardiolo- tiation of cyclosporine-A can provide modifications and topical gists. more rapid relief of dry eye signs and anti-inflammatory eye drops.” • On the following page, we have symptoms and greater efficacy than laid out a rational, cost-effective, pa- cyclosporine-A and artificial tears • Patient interest on “education tient-centric and literature-supported alone.” was top ranked by all approach to diagnosing and manag- –“The inflammatory nature of dry subgroups.” ing patients with dry eye disease. eye has been widely accepted; thus, • “The three most important Beware of industry-driven “educa- the direction for treatment research outcomes were ocular burning and stinging, ocular discomfort and ocular pain.” JAMA INTERNAL MEDICINE ON RESTASIS • There was little interest in • A fundamental question: “Does Restasis work?” “signs,” as patient-centric • Restasis has never been approved in the EU, Australia or New Zealand “due outcomes (symptoms) were to insufficient evidence of efficacy.” deemed the most relevant to patients.

• “Although Canada approved Restasis, its National Technology Assessment Saldanha IJ, Petris R, Han G, et al. Research Unit, unconvinced of meaningful benefit, recommended Canada not pay for questions and outcomes prioritized by patients with dry eye. JAMA Ophthalmol. 2018 it.” Oct 1;136(10):1170-19. • “Clinicians typically do not learn about new products from regulatory documents; they learn from commercially-sponsored, promotional Keep it Simple efforts, such as detailing visits and events where food and beverages are • “The most important metric provided.” when treating DED is patient symptoms.” (Our take: We • It is so challenging to separate science from spin; these regulatory have been stressing this in documents greatly illuminate reality and truth. our collective lectures for Schwartz LM, Woloshin S. A clear-eyed view of restasis and chronic dry eye disease. JAMA Intern Med. 2018 over a decade.) Feb 1;178(2):181-2. • “Your patient is not really MITIGATING SIDE EFFECTS OF RESTASIS AND XIIDRA interested in corneal clearance or the slope of tear • It is well established that these two drugs can have numerous side osmolarity decline. All they effects. know is how they feel and • “A short tapering course of Lotemax Gel is helpful in initiating therapy how well they see.” with either Xiidra or Restasis. The steroid gives extremely fast (same • “Symptoms direct treatment. day) relief from dry eye symptoms and usually masks the stinging that Ultimately, symptoms can accompany the initiation of therapy with either agent. I usually determine the success of our give Lotemax four times a day for two weeks, then twice a day for two interventions.” weeks.” White DE. It is still the symptoms: patients care about how they see and feel. Ocular McDonald MB, Fumuso PW. Counseling our dry eye patients: How to enhance compliance with lifitegrast or Surgery News, April 25, 2020. cyclosporine. Ocular Surgery News. 2018 May 31. 2018.

32 REVIEW OF OPTOMETRY JUNE 15, 2021 is geared toward the reduction of plugs and continuing a lipid-based patients out there for which you have inflammatory cytokines.” artificial tear. We start all patients on tried everything without success. Our take: Let’s take a moment a premium-quality fish oil at 2000mg This new product may be helpful to here to engage logical thought. per day from the outset. For the some of these more severely afflicted When treating inflammatory eye most part, treating dry eye disease is patients. For now, we simply suggest conditions, we never use an NSAID, straightforward; don’t make complex you explore the Regener-Eyes website cyclosporine or lifitegrast; we use what is simple. (mydryeyes.com) and then use your a steroid! Studies have shown that • Regener-Eyes may have a role best judgment. By next year, we will loteprednol QID for four weeks elim- as an additive therapy in patients have a much more definitive under- inates this inflammatory component, recalcitrant to steroid therapy. We standing of its role in patient care. so any eyedrop following this course have some early and limited experi- 1. Lee H, Chung B, Kim KS, et al. Effects of topical of therapy will do just fine, because ence with this nonmedical (biologic) loteprednol etabonate on tear cytokines and clinical outcomes in moderate and severe meibomian gland the targeted inflammation has been eyedrop. It is in the same universe as dysfunction: randomized clinical trial. Am J Ophthalmol. conquered. autologous serum tears, but contains 2014 Dec;158(6):1172-83.e1. 2. Seitzman GD, Lietman TM. Dry Eye Research—Still So, the intelligent, cost-effective, numerous biological cytokines and Regressing? Ophthalmology. 2019;126(2):192-94. scientifically sound approach is growth factors. We have seen no 3. Goldberg DF, Malhotra RP, Schechter BA, et al. A Phase 3, randomized, double-masked study of OTX-101 to prescribe Lotemax SM (with a conclusive studies, but anecdotally ophthalmic solution 0.09% in the treatment of dry eye disease. Ophthalmology. 2019;126(9):1230-37. coupon) QID for two weeks, then at this time, we feel Regener-Eyes 4. Drugs for common eye disorders. Med Lett Drugs BID for two more weeks (or a similar may have merit. It is very expensive Ther. 2019;1586. 5. Hessen M. Cyclosporine Shoot-out: How Do They approach). Now consider punctal (about $200 a bottle), but there are Match Up? Rev Optom. 2019 May 15;156(5):58-65. 42-9.

OUR DRY EYE MANAGEMENT ALGORITHM All therapy—dry eye included—should be individualized to the patient. That said, here is our usual approach to symptomatic dry eye management.

TWO WEEKS TWO WEEKS INDEFINITELY

Lipid-Based Artificial Tear Lipid-Based Artificial Tear Lipid-Based Artificial Tear Four to six times a day as needed Three to four times a day as needed Two to four times a day as needed

Lotemax SM Gel 0.38%* Lotemax SM Gel 0.38% Discontinue Lotemax SM Gel 0.38% Four times a day Two times a day If symptoms breakthrough or (Consider punctal plugs if needed) continue, then pulse-dose Lotemax SM gel drops four times a day for one week, or consider loteprednol once daily as needed. ANTERIOR SEGMENT CARE The risk of increased IOP with loteprednol is uncommon at high dosage and rare at low dosage. Our experience has been that if an increase in IOP is going to occur, it will do so at the initial one-month follow-up, and not later.

Omega-3 essential fatty acids (derived from fish and/or flaxseed oil) Can be initiated at any stage, based on clinical judgment.

*Alternatively, instill loteprednol ointment daily at bedtime for two weeks, then M-W-F for two weeks. Loteprednol therapy for inflammation due to DED is considered an “off-label” use.

While there is no algorithm for treating DED, this approach is the one we most commonly use (because it is relatively inexpensive and it works about 80% of the time). We all should be attentive to the great benefit of punctal plugs (but only after suppressing the ocular surface inflammation first).

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BEWARE POTENTIAL HAZARDS OF FISH OIL! DOXYCYCLINE’S ROLE IN OSD • In the setting of heart disease, there is either no This tetracycline agent exhibits multiple anti- benefit or potential harm. inflammatory properties that can aid management of dry eye: • “Not all fish oils are created equal, and most OTC fish oils should be avoided.” • Inhibits T-cell activation and chemotaxis. • “These findings suggest a lack of fish oil effect • Downregulates pro-inflammatory cytokines, on cardiovascular benefits. The study’s higher including tissue necrosis factor alpha and incidence of atrial fibrillation among fish oil users interleukin 1 beta. […] warrants caution and further exploration. Given • Inhibits matrix metalloproteinases that have been their lack of clinical benefit and possible risk for pathologically activated. harm, fish oils should not be recommended.” • May kill fibroblasts responsible for scar tissue 1. Curfman G. Do omega-3 fatty acids benefit health? JAMA. 2020 8;324(22):2280-1. development.

2. Kalstad AA, Myhre PL, Laake K, et al; OMEMI Investigators. Effects of n-3 Fatty Batra R, Tailor R, Mohamed S. Ocular surface disease exacerbated glaucoma: acid supplements in elderly patients after myocardial infarction: a randomized, optimizing the ocular surface improves intraocular pressure control. J Glaucoma. controlled trial. Circulation. 2021 Feb 9;143(6):528-39. 2014 Jan;23(1):56-60.

DIAGNOSTIC PRIORITIES interpret conflicting test results? baseline conjunctival staining Ultimately, how do we arrive of all the dry eye parameters. New technology often is vital to at the best treatment, […] one Conjunctival staining needs par- diagnostic assessment in eye care— that is efficient, value-based and ticular attention when evaluating just look at OCT. However, some effective. We know the more patients for dry eye.” tools only add incrementally to our complex the treatment protocol, understanding or may even unnec- the greater the likelihood for • Our take: This further supports essarily complicate matters. noncompliance. our perspective that DED diagno- sis is very straightforward without Be Wary of Managing DED • “Arguably, the most plausible the need for superfluous ancillary by the Numbers approach is a return to the basics. tests. We all need to appreciate I think most would agree that a • There is so much marketing push the usefulness of lissamine green good history, a little fluorescein dye in our DED evaluations. for point-of-care devices, one and a careful biomicroscopic can be lured into thinking they Karakus S, Agrawal D, Hindman HB, et al. Effects evaluation is all we really need.” of Prolonged Reading on Dry Eye. Ophthalmology. are critical to the DED diagnostic DePaolis MD. Get back to the basics with dry eye. 2018 Oct;125(10):1500-05. evaluation. Primary Care Optometry News, May 2017. • Here’s a reality check: “Substan- Rose Bengal or tial differences in characteristics DED Testing to Dye For Lissamine Green? and physical properties of the • “Of all the available dry eye tests, • “Lissamine green may be consid- tear film, such as levels of inflam- corneal fluorescein staining is ered the most underappreciated mation, pH, osmolarity, volume reportedly the most commonly of the diagnostic dyes. Consider- and stability, also exist between performed and the conjunctival ing that rose bengal burns and night (sleeping) and day (wak- lissamine green is the least com- stings, it’s surprising that more monly used test.” ing), and over the course of the practitioners haven’t already day itself.” • “This could be due to ease/dif- turned to lissamine green as a Guillon M, Shah S. Rationale for 24-hour management ficulty of access to these dyes standard diagnostic tool.” of dry eye disease: A review. Cont Lens Anterior Eye. 2019 Apr;42(2):147-54. or perhaps lack of knowledge or Abelson, M, Ingerman, A. The dye-namics of dry-eye awareness regarding the signifi- diagnosis. Review of Ophthalmology, November 2005. An Enlightened Perspective on cance of each.” Dry Eye Disease • “The degree of baseline conjunc- • “First, we are better equipped tival staining was a significant than ever to manage dry eye. predictor of the worsening in Second, there is the potential corneal staining after sustained reading.” for more confusion than ever. Does every patient need every • “Subjective symptoms showed diagnostic test? How should we the strongest correlation with

34 REVIEW OF OPTOMETRY JUNE 15, 2021 ODs KEEP IT SIMPLE WHEN IT COMES TO DIAGNOSTIC TESTS FOR DRY EYE EVALUATION

n January 2021, Review Which of these diagnostic tests do you use? of Optometry reported, in I n Never n In dry eye patients/suspects only n Always an article titled “Dry Eye in Weighted Optometry: Trends, Habits and 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Avg. Hang-ups,” some of the results Fluorescein 62.3 36.7 2.36

of a reader survey. Tear break-up time 6.1 61.4 32.5 2.27

A total of 215 optometrists Blink assessment 11.6 54.9 33.5 2.22

in the United States shared Dry eye questionnaires 31.6 44.2 24.2 1.93 their impressions of DED Lissamine green 46.5 49.8 1.57 prevalence, diagnostic testing, Schirmer’s test 61.4 37.7 1.40 treatment habits and challeng- es they encounter managing Meibography 67.9 27.9 4.2 1.36 the condition. Reflex tearing 65.6 32.6 1.36 Interestingly, the survey Rose bengal 71.6 27.9 1.29 found most ODs primarily rely Tear film osmolarity 76.8 20.9 1.26 on simple diagnostic tests and Anterior segment OCT 80.5 15.3 4.2 1.24 familiar treatments, as finan- MMP-9 testing 78.6 20.5 1.22 cial pressures keep them from Interferometry 85.6 12.5 1.16 advancing their care. Although there is no short- age of ways to assess pro- In what percentage of your dry eye patients do you use each of the following spective dry eye patients, the methods to manage their condition? n 0% n 1-25% n 26-50% n 51-75% n 76-100% Weighted most popular choices were 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Avg. cost-effective and simple Artificial tears 3.7 9.8 22.8 62.8 4.43 ones, which might come as a surprise to some. Education on screen time 3.3 9.3 16.7 26.1 44.6 4.00 In fact, the No. 1 testing At-home lid hygiene 9.8 20.5 32.1 37.6 3.98

method in the survey was flu- OFA supplements 5.1 26.5 24.7 26.1 17.6 3.25 orescein staining, with about Topical cyclosporine 2.55 37% of individuals reporting 7.4 46.1 31.2 14.4 this was always their first Topical steroid 10.2 44.2 28.4 14.9 2.55 choice in their dry eye diag- In-office lid procedures 27.0 37.7 17.7 12.6 5.0 2.31 nostic toolbox. Topical lifitegrast 20.0 45.1 22.8 10.7 2.28 Furthermore, no high-tech tools were in the top five. Punctal plugs 28.9 51.6 15.8 3.7 1.94 Meibography ranked No. 7 in Oral doxycycline 33.0 51.2 14.0 1.85 popularity, and tear osmolarity came in at No. 10. Which diagnostic tests do you consider the most clinically valuable? These findings echo what 0% 10% 20% 30% 40% 50% 60% 70% we have been telling clinicians Fluorescein 71.6

for years: there is no reason ANTERIOR SEGMENT CARE Tear break-up time 69.8 in the world to complicate dry eye diagnosis for you and Dry eye questionnaires 46.1 your patients. Keep diagnosis Meibography 26.1 simple and cost-effective. Blink assessment 22.3 The figures to the right rep- Lissamine green 15.8 resent some of the findings Tear film osmolarity 14.9 from the reader survey. Take a MMP-9 testing 7.4 look and see for yourself what Schirmer’s test 5.6 your colleagues reported to Interferometry 3.3 Review of Optometry. Anterior segment OCT 2.3 The results speak for them- 1.9 Rose bengal selves. Enough said. Reflex tearing 1.4

REVIEW OF OPTOMETRY JUNE 15, 2021 35 SECTION II: ANTERIOR SEGMENT CARE

Meibomian Glands and the Golf Club Spud Help improve patient comfort while they’re in your chair.

t is well established that meibo- Here are a few more pearls that your therapeutic approaches are mian gland orifice stenosis or can help your dry eye patients: working. Iocclusion is a focal pathology • Flush the rose bengal and begin No device that generates a nu- interfering with meibum secretion, using lissamine green. These two meric value significantly contributes which in turn diminishes the quality dyes do the exact same thing, but the to the diagnostic assessment. Keep and quantity of the oily layer of the lissamine green is much more gentle what is simple, simple. Above and tear film. on the ocular surface tissues. beyond the basic steps and interven- Years ago, we learned from the • Always try a lipid-based artifi- tions aforementioned, a therapeutic legendary Donald Korb, OD, that cial tear, as opposed to an aqueous- trial of loteprednol QID for two simply scraping along the top of the based artificial tear. Remember, the weeks is critical to suppressing the eyelid margins can physically/me- focal dysfunction of the precorneal inflammation that is known to ac- chanically open these orifices, thus tear film is centered upon the func- company clinically significant dry enhancing the lipid layer of the tear tionality of the lipid layer. eye disease. All other prescription film. This is an incredibly helpful • Discuss with your patient the eyedrops pale in comparison to the maneuver, yet it was either omitted importance of deliberate blinking therapeutic efficacy of corticoste- from the therapeutic options, or not and/or blinking exercises. We recom- roid suppression, and loteprednol is done often enough to merit mention. mend a forced closure for five sec- much less expensive, particularly if This is just plain sad. In our opinion, onds, which is to be repeated several coupons are used. this should be at the very top of the times over the span of one minute. Following a two-week course of list. There is no CPT code because Doing this one-minute exercise from corticosteroid suppression therapy, this maneuver is such a “nothing” time to time throughout the day can permanent punctal occlusion should procedure. It requires no anesthesia, be very helpful. be strongly considered, using the is simple and is extremely helpful. • Take full advantage of the slit plug of your preference. We suppose it is just not as “sexy” lamp by generally assessing the Dry eye is a chronic medical as so many other, more expensive height/volume of the lacrimal lake. condition that is not helped by our procedures that generate revenue. Conduct a tear film breakup time societal requirement to face all sorts We want to take this opportunity test, as this metric is uniformly of screens for multiple hours daily. to once again highlight the great endorsed as critical to qualifying and People need to look away and do benefit of decapitating the meibo- quantifying assessment of dry eye blinking exercises multiple times mian gland orifices. For all patients disease. throughout the day. Only with with dry eye disease, this should be • Forget all questionnaires: simply unrelenting disciplined “personal done or at least considered at every ask the patient, on a scale of one to hygiene” of blinking, artificial tear office visit. It takes 10 to 15 seconds 10, how their eyes feel. Then, at the use, a humidified sleeping environ- per eyelid to do, and patients feel first month’s follow-up visit, ask the ment and other sensible protective better right away—sort of like an question again. This ever-so-simple measures can we hope to properly eyelid massage. approach quickly lets you know how manage dry eye disease.

MG SCRAPING IN TREATING DRY EYE “In the future, the health and maintenance of the MCJ [mucocutaneous junction] and keratinized lid margin may be considered integral to routine eye care. This shift in our culture will involve improvements in our observa- tion skills and also the willingness to incorporate novel techniques such as debridement-scaling of the MCJ and keratinized lid margin in our clinical practice.”

Korb DR, Blackie CA. Debridement-scaling: a new procedure that increases meibomian gland function and reduces dry eye symptoms. Cornea. 2013 Dec;32(12):1554-7.

36 REVIEW OF OPTOMETRY JUNE 15, 2021 A “One-Two” Attack on MGD You and your patient each have duties to perform to ensure optimum results. n dental care, the standard behavior is to see a hygienist DRY EYE AND MEIBOMIAN GLAND DYSFUNCTION Ievery six months for an in-office ne of the basic fundamental maneuvers procedure, but then the patient is to Oin dry eye care is addressing meibomian brush and floss regularly to maintain gland dysfunction. This is done through dental and gingival hygiene. In a proper moist heat application followed by similar manner, many people have massage and cleansing of the meibomian in-office meibomian gland treatments gland orifices. There are three main tech- such as TearCare or other similar nologies for in-office procedures: TearCare, interventions to heat and express the LipiFlow and iLux. meibomian glands. Current in-home, self-treatments with However, as with dental hygiene, warm soaks are suboptimal for addressing these MGD patients need to main- meibomian gland dysfunction; however, a tain glandular hygiene. Self-admin- new technology, EverTears (www.thermamedx.com), can be effectively used by the patient at home. It is a high temperature, soft/moist applicator istered treatments have historically that rapidly heats the eyelids to the optimum temperature levels and after been “warm soaks,” but these and only two minutes of heating the eyelids can be massaged and cleansed by all sorts of masks have been subop- the patient him/herself using this simple handheld device. EverTears stands timal. EverTears is a highly sophis- in stark contrast to all other at-home, self-administered approaches, which ticated new technology that rapidly typically require longer application times. It is always gratifying when new heats the meibomian glands to an technologies raise the level of patient care. It is our impression that the new optimum temperature and maintains EverTears applicators do just this. this level of heat such that easy five- minute per eyelid home treatments help maintain meibomian gland The challenge of rejuvenating One last pearl: prior to perform- function. meibomian gland function seems un- ing any of the various in-office MGD Not everyone is able to afford relenting in our quest to conquer dry treatments to warm and express the these in-office procedures, yet these eye disease. These two technologies glands, always use your golf club same people can be benefitted by are available to help us in this thera- spud to gently scrap along the tops self-treatments at home with the peutic endeavor. We encourage you of the lids to mechanically open the EverTears technology. In practical to research these to see if they could meibomian gland orifices; such a reality, some help is better than no play a role in your untiring efforts to simple maneuver can enhance the help. help your dry eye patients. efficacy of heat treatments.

CRAB LICE INFECTION • Phthirus pubis (crab louse) eyelid infestation

• Uncommon form of blepharitis ANTERIOR SEGMENT CARE • Symptoms: intense itching (pruritus) • Signs: nits (louse egg cases) and reddish sanguinofecal debris at base of classic slit lamp findings • Treatment: – Forceps to remove lice at slit lamp Crab lice: four are seen in this image (there were 11 total). Note the sanguino-fecal discharge at the posterior aspect of these lice.

– Standard lid scrubs and aggressive ointment to lid margins BID for seven days • Consult with primary care physician

REVIEW OF OPTOMETRY JUNE 15, 2021 37 SECTION II: ANTERIOR SEGMENT CARE

Sparse Evidence for Need of “Blue-Blockers” ast year, we shared an ar- screens by eliminating blue ticle documenting the lack light. There is little evidence, Lof benefit of “yellow-tinted however, that blocking blue lenses.” There are now numerous light with spectacles, espe- articles shattering the myth of benefit cially ones with antireflective of blue-blocking spectacle lenses. coatings designed for that An excellent review article by Drs. purpose, provides much ben- Morrison and Yuhas in the January efit to the patient. A recent 15, 2021 issue of Review of Optom- study found that eliminating etry succinctly documents the lack of blue light from a computer significant benefit of blue-blocking screen does no more to re- light: duce strain and fatigue than • “Unfortunately, marketing simply dimming the screen.” and soft science have muddied our This further underscores conversations about screen time and how worthless “blue-block- blue light exposure.” er” lenses are. Yet, the desire • “Unlike even higher energy ultra- to “sell” is not abated by violet light, visible blue light can pass scientific knowledge. One through the cornea and crystalline study found the following: lens to reach the retina.” “Blue-blocking lenses did • “The preponderance of evidence not alter signs or symptoms suggests that sunlight exposure is not of with computer a risk factor for AMD.” use relative to standard clear • “If sunlight exposure is not clear- lenses. Clinician advocacy ly linked to AMD, then light emitted type had no bearing on clini- from screens is not likely to damage cal outcomes.”1 the retina either. The reason is that Our summary: Unneces- light emitted from personal elec- sary screen time can set the tronic devices is substantially dimmer stage for myopia, asthenopia, than sunlight.” obesity and ocular surface • “Simply put, the light emitted drying, but blocking blue from screens of personal electronic light is the very least of these devices is not bright enough to dam- concerns. Let’s focus on guid- age the retina. A recent publication ing patients to look away for investigating the theoretical blue 20 seconds every 20 minutes light hazard of using screens con- and to blink more often, not cluded that light from screens poses selling them an “add-on” a minimal risk to damage the retina with minimal to no benefit. because they are so dim.” (O‘Hagan Here are just two examples of messages our 1. Singh S, Downie LE, Anderson AJ. Do JB, et al. Eye [Lond]. 2016.) blue-blocking lenses reduce eye strain patients are receiving in which retail interests • “Some doctors may be inclined from extended screen time? A double- promote “protective” technology in the absence masked, randomized controlled trial. Am J to manage the negative effects of Ophthalmol. 2021 Feb 12;226:243-51. of scientific support.

FUNCTION OVER FASHION Often-forgotten, these “moisture-retaining,” side- shield eyeglasses can be a real help in recalcitrant DED. They will not win any fashion contests, but are very practical for select patients.

38 REVIEW OF OPTOMETRY JUNE 15, 2021 Don’t Overcomplicate Allergy Management llergy is so simple. We use a topical antihistamine/ Amast cell stabilizer once daily (twice daily as needed) if there is symptomatic itching and the conjunctival tissues are quiet. If there is conjunctival injection/eyelid edema/excessive mucoid discharge, go straight to 0.38% loteprednol (Lotemax SM), 0.2% loteprednol (Alrex), 0.25% loteprednol (Eysuvis) or 1% loteprednol (Inveltys). We would use any of the lotepred- nol formulations QID for three days, Classic ocular allergy with chemosis and moderate bulbar conjunctival injection. then BID for one week. If itching persists beyond this initial treatment, Regarding pregnancy, a recent ion that the ester-based loteprednol then we prescribe an antihistamine/ study notes that “the use of topical would be even safer. The authors of mast cell stabilizer as above. If the ophthalmic corticosteroids in preg- this article state: “Information for allergic reaction is acute and severe, nant women with allergic conjunc- the safety of ophthalmic corticoste- then use aggressive cold compresses tivitis was not associated with any roids in pregnant women may help along with one of the loteprednols. increase in congenital abnormalities, reduce anxiety regarding their use in There is obviously more to the ex- preterm birth or low birth weight.”1 those with .” pression of allergy, but these simple, The steroids studied were conducted 1. Hashimoto Y, Michihata N, Yamana H, et al. Ophthalmic straightforward interventions will during the first trimester, and only corticosteroids in pregnant women with allergic con- junctivitis and adverse neonatal outcomes: propensity almost always carry the day. with ketone steroids. It is our opin- score analyses. Am J Ophthalmol. 2020 Dec;220:91-101. Thoughts on “Sulfur Allergy” Concerns ere’s something we all need ed that the dogma of cross-reactivity having been ‘sulfa allergic’ means to know regarding the con- between sulfonyl arylamines and they are also at risk for adverse cept of sulfur allergy, from other sulfonamide drugs cannot be reactions or allergies from sulfites, H 1 the pharmacology literature. supported by the evidence. In patients sulfates and even elemental sulfur, • “The term ‘sulfur allergy’ is who have had an allergic reaction to and they attempt to avoid them.” misleading and dangerous, and one drug, allergic reactions to other So, such medicines as polymyxin should not be used. An allergy to a drugs—even if entirely unrelated— B sulfate or trimethoprim sulfate are sulfonamide antibiotic may imply occur more commonly.” perfectly fine to use in patients who cross-reactivity with other sulfon- • “Sulfur is a natural element and claim to be allergic to sulfa drugs.

amide antibiotics, but does not imply it exists in many forms. There are The carbonic anhydrase inhibitors ANTERIOR SEGMENT CARE cross-reactivity with non-antibiotic many substances which have names also have a sulfa moiety, but they do sulfonamides or other drugs con- stemming from ‘sulfur’ such as sul- not share a cross-allergenicity with taining sulfhydryl or sulfate groups. fites (preservatives in food and drugs) sulfa drugs. Allergy to sulfonamides also does and sulfates (common compounds • “The commonly used canister not imply cross-reactivity with sulfite found in drugs, soaps and cosmet- type of metered dose inhalers do not preservatives, sulfates or elemental ics). Some patients who have suffered contain sulfites, but several do con- sulfur.” from hypersensitivity reactions to a tain sulfate salts and some patients • “The term ‘sulfonamide’ applies sulfonamide antibiotic are unfortu- need to be reassured that sulfates are to a sulfone group connected to an nately labeled ‘sulfa allergic.’” inactive and do not cross-react with amine group. All antibiotic sulfon- This term creates confusion for the sulfites.”

amides are arylamines. A review of patient and often for health profes- 1. Smith WB, Katelaris CH. ’Sulfur allergy’ label is all available relevant studies conclud- sionals. Many patients believe that misleading. Aust Prescr 2008;31:8-10

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Acute White Lesions in the Peripheral Cornea: Infectious or Inflammatory? Don’t let unfounded fears about steroids make it harder than it should be.

he answer to this question is, staining defect roughly the same size have consistently observed that round “almost always inflamma- of the underlying stromal infiltrate. or oval defects at or near the limbus Ttory.” There are many triggers Any time a round or oval whit- are part of inflammatory processes of leukocytic chemotaxis into the ish lesion can be seen at or near the due to the anatomic proximity of peripheral cornea. If these cumulative limbus, it is almost invariably a sterile, abundant humeral immunity (antibod- concentrations of leukocytic infiltrates leukocytic infiltrate that merits sup- ies) and cellular immunity (leukocytes) remain in the anterior stroma for a pression with a topical steroid. This at the highly vascularized limbus. few days, a small, retrograde epithelial strategy rapidly enables the corneal ep- Since there’s s a sliver of a chance breakdown can occur that will stain ithelium to repopulate or the epithelial of secondary opportunistic bacterial minimally with vital dyes, whereas defect would endure for many days infection, we always prescribe an an infectious corneal ulcer will have a until innate resolution occurred. We antibiotic-steroid combo drug, such as Zylet (tobramycin 3% with 0.5% CORNEAL INFILTRATES loteprednol, Bausch + Lomb), generic • Chemotactically attracted leukocytes Maxitrol (neomycin, polymyxin-B, migrate into the subepithelial tissues. 0.1% dexamethasone) or generic To- braDex (tobramycin 0.3% with 0.1% • If they are numerous enough or present long dexamethasone). For clinical, practical enough, epithelial compromise can occur, which will manifest as a relatively small perspective, recall that generic Maxi- fluorescein staining defect. trol is the least expensive, followed by Zylet at around $35 (with a coupon). • At the stage depicted in this rendering (to the right), the bulbar The most expensive agent is generic conjunctiva is usually mildly injected. TobraDex, which costs about $80 • A topical antibiotic/steroid combination drug used QID for one week to $90. All of these drugs are clinical is the appropriate treatment. equivalents and perform identically. We know of two cases in which such peripheral corneal lesions were mistakenly identified as “corneal ulcers,” were treated with topical anti- biotics and did not improve—because leukocytic infiltrates do not respond to any antibiotic! In each case, the patient sought out another doctor (which was one of us). We added a topical steroid and the cornea cleared Classic subepithelial corneal Carefully observe the dense anterior within two to three days. infiltrates from an untreated case of stromal infiltration that occupies about Also, given the highly remote EKC. These do not stain with a vital one-third of the stroma and goes up chance that dye because they are subepithelial. If about halfway. This is always evidence vision is significantly compromised, of a sterile leukocytic infiltrate, and a could manifest as a peripheral mar- then one could rationally consider combination antibiotic/steroid such as ginal ulcer, we always follow-up with loteprednol QID for one month, until Zylet or generic Maxitrol is ideal. Use the patient in a couple of days. “time” decreases the viral antigenic the medicine about every two hours It is critically important that we load to below a symptomatic for one or two days, then QID for collectively understand the difference four or five more days. If there is any threshold. between inflammation and infection, associated blepharitis, then address that. and realize that, almost without ex- ception, steroid suppression is crucial to achieve enhanced patient care.

40 REVIEW OF OPTOMETRY JUNE 15, 2021 MANAGING MICROCYSTIC CORNEAL EDEMA his condition is generally seen in two circumstances: with acute intra- Tocular pressure rises—usually above 50mm Hg—and as a response to marked corneal inflammation such as with herpes zoster ophthalmicus. The former is treated with IOP-lowering medicines of timolol and/or brimonidine (or in the combination Combigan). Note that prostaglandins are not nearly as fast-acting as are timolol and brimonidine. The latter condition is treated with a topical corticosteroid to suppress the epithelial tissue inflammation. Glaucoma Drugs that Can Cause Corneal Edema • Both CAIs and netarsudil (Rhopressa) can alter endothelial function resulting in For pterygia, we initiate treatment with corneal microcystic “reticular” epithelial Lotemax SM QID for a week, and then edema, particularly after endothelial surgical BID for two more weeks. At the start of procedures. the second week, we ask the patient to use a lipid-based artificial tear QID and • Not all cases of corneal edema have to continue the artificial tear at least endothelial dysfunction. BID indefinitely. If there is a significant • It may take days to a few months after dry eye component, then we would also consider a punctal plug to the ipsilateral therapy initiation for corneal edema to lower eyelid. manifest. • Such iatrogenic edema is rare, but be attentive to the possibility should corneal edema be a presentation. Chen TC, Jurkunas U, Chodosh J. A Patient with glaucoma with corneal edema. JAMA Ophthalmol. 2020 Aug 1;138(8):917-8.

Milkweed and Endotheliopathy • Exposure to milkweed sap can cause endothelial toxicity in a white eye with no epithelial damage. • This cardenolide can penetrate the epithelium. When reaching the endothelium, it interferes with ATPase (sodium-potassium pump) resulting in corneal edema. • Treatment is a topical steroid for four to six days. • “The value of a through history cannot be overstated.” Rostami B, Lalezary M. The Horticulturist With Blurry Vision. Eyenet, August 2019.

Gardening as a Cause of Corneal Edema In the images above, a child’s fingernail ANTERIOR SEGMENT CARE scraped across dad’s cornea, resulting in • Acute onset corneal edema and blurred vision. a clear-cut abrasion. Note the roughened, • Most usually unilateral—rubbing face and eyes. abraded tissues at 3 o’clock. These need to be debrided to ensure clear, • History is critical to making the diagnosis of isolated corneal edema. neat margins to maximize healing. This • Milkweed plants contain cardiac glycosides which can alter endothelial was not done, and in the bottom image, enzymes, largely sparing epithelial tissues! healing was retarded. Also in that image, note the ghosting of the subepithelial • Onset of symptoms after exposure: 12 to 24 hours. tissues as well as in the middle image. Here, we would prescribe any steroid or • Tx is topical steroid therapy, QID for four days, then BID for two days. combination antibiotic-steroid for four Venkateswaran N, Tonk RS, Berrocal A. Corneal edema in a gardener. JAMA Ophthalmol. 2020; to six days to reduce any subtle scarring. 138(9):998-9. The patient fully recovered crisp 20/20 vision in just a few days.

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The Telltale Signs of Vernal Conjunctivitis hile puberty often ushers in a plethora of challenges, it is com- Wmonly the cure for the aggravating disease of vernal conjunc- tivitis. This clinical entity is largely a disease of children, especially—but not exclusively—black males. There is itching and redness to the eyes with this condition, but the distinguishing feature is the “gelatinization” of por- Limbal “gelatinization” and Horner-Trantas dots are classic signs of VKC. tions of the corneal limbus. Within these gelatinized tissues will be seen they may be under the care of an al- QID for one week, then BID for two the classic Horner-Trantas dots, es- lergist as well. weeks. It is our hope at that point to pecially when aided with fluorescein Our usual approach in treating be able to switch the patient to an dye. There is usually a copious, stringy/ cases of vernal conjunctivitis is to antihistamine/mast-cell stabilizer BID ropy mucoid discharge present as well. prescribe Lotemax SM to be used for several weeks to several months This is not to be confused with the mu- Q2hrs for two to three days, then as needed. copurulent discharge that is seen with bacterial infections. Patients are also FAST FACTS ON VERNAL DISEASE likely to complain of . • Common in young African and Asian males in hot, dry climates. Left untreated, or in more severe cases, there can be an immune- • Like Thygeson’s SPK and SLK, it can be chronic with episodes of acute mediated “shield” ulcer. These rare exacerbations. complications are treated with an • Characterized by ropy mucoid discharge, itching and redness; papillary antibiotic-steroid combination eye hyperplasia of superior tarsus and limbus. “Shield” corneal ulcers can drop. However, only a straight occur in untreated cases. steroid like Lotemax SM (Bausch + • History of asthma, eczema and hay fever seen in half of patients Lomb) is needed for initial suppres- sion of these relatively uncommon • Tx: Loteprednol for two to three weeks, then convert to antihistamine presentations of ocular allergy. Many BID PRN long-term. Also, lipid-based artificial tears PRN. of these patients also have atopy, so —Survey Ophthalmol. May/June 2019 The 2020 ARMOR Update This long-running study of bacterial susceptibility to antibiotics helps us understand which agents are most formidable and which are weakest.

he Antibiotic Resistance Mon- moniae, Pseudomonas aeruginosa inhibited the growth of 90% of itoring in Ocular Microor- and Haemophilus influenzae col- indicated isolates, they found that Tganisms (ARMOR) study—a lected between 2009 and 2018. tobramycin, ciprofloxacin, moxiflox- massive and ongoing effort regarding Here are the latest findings: acin, gatifloxacin and trimethoprim antibiotic resistance—was recently • Vancomycin remained robust for showed slightly diminished effective- updated in the May 2020 issue of all gram-positive species. ness against gram-positive species. JAMA Ophthalmology. • Besifloxacin was roughly equiva- • Ciprofloxacin remains the most The researchers tested more than lent to vancomycin—a constant effective drug against Pseudomonas. 6,000 isolates of Staphylococcus finding within the study. • About 30% of Staph. aureus aureus, coagulase-negative staphylo- • When the researchers calculated isolates and half of Staph. epidermi- cocci (CoNS), Streptococcus pneu- the lowest drug concentrations that dis isolates were methicillin-resistant,

42 REVIEW OF OPTOMETRY JUNE 15, 2021 2020 ARMOR SURVEILLANCE DATA: MIC90 COMPARISONS FOR STUDY ISOLATES S. aureus MRSA CoNS MRCoNS 2015 2020 2015 2020 2015 2020 2015 2020 (n=1169) (n=2189) (n=493) (n=765) (n=992) (n=1765) (n=493) (n=871) Besifloxacin* 0.25 1 2 2 0.25 2 4 4 Vancomycin 1 1 1 1 2 2 2 2 Trimethoprim* 2 4 2 2 32 >128 >128 >256 Moxifloxacin* 1 4 1 16 1 16 32 32 This Pseudomonas ulcer was treated Gatifloxacin 2 4 16 16 2 16 32 32 with Besivance and cycloplegics. Ofloxacin 8 >8 >8 16 8 >8 >8 32 Ciprofloxacin 8 128 256 256 8 64 64 64 and this was especially observed in Tobramycin* 1 128 >265 256 4 16 16 32 patients older than 80. Azithromycin >512 >512 >512 >512 >512 >512 >512 >512 • Older patients were more likely *Denotes the four antibiotics we use most routinely, given their proven efficacy and to have resistance than children. relatively low resistance profile.

However, even pediatric patients As a reminder, the lower the MIC90, the more potent the anticipated efficacy. did show notable levels of antibiotic CoNS = coagulase-negative Staph. species, of which the majority are Staph. epidermidis. resistance. Sources: Asbell PA, et al. JAMA Ophthalmol. 2015;133(12):1445-54. • Of the methicillin-resistant iso- Asbell PA, et al. JAMA Ophthalmol. Published Online April 9, 2020. lates, 75% demonstrated multi-drug resistance. • Both P. aeruginosa and H. in- from the data published in 2015. • Azithromycin was, by far, the fluenzae isolates were found to have Keep in mind this is an in vitro study least effective of the antibiotics low levels of resistance. and thus may not perfectly reflect the tested. Overall, there was little deviation clinical efficacy of these drugs.

ORAL DOXYCYCLINE AND PTERYGIAL ANGIOGENESIS FACTS ABOUT CEPHALEXIN (KEFLEX) • UV light is a known trigger for • Cephalexin—a first-generation pterygenesis and cephalosporin progression. • Effective against most gram- • Doxycycline (and positive pathogens corticosteroids) • Some earlier-generation can inhibit cephalosporins share less than neovascularization. 1% cross-allergenicity to PCN • Perhaps • Usual management can dosage: ANTERIOR SEGMENT CARE be augmented 500mg BID with 50mg P.O. once a week doxycycline daily • Useful in soft for many weeks or tissue Staph. many months after infections, (or concurrent with) such as topical loteprednol internal QID for one month, the BID for two months. hordeola, preseptal Di Girolamo N, Wakefield D, Coroneo MT. Doxycycline’s and ocular angiogenesis. Ophthalmology. 2011 Apr;118(4):789-90; author reply 790-1. cellulitis and others Di Girolamo N, Chui J, Coroneo MT, et al. Pathogenesis of pterygia: role of cytokines, growth factors, and matrix metalloproteinases. Prog Retin Eye Res. 2004 Mar;23(2):195-228.

REVIEW OF OPTOMETRY JUNE 15, 2021 43 SECTION II: ANTERIOR SEGMENT CARE

Merits of the “Look Up, Look Down” Manuever Use this method to evaluate the symptomatic red eye.

here are times when asking the patient to look down (while you hold the eyelid Tup) can reveal the often missed or misdiagnosed superior limbic keratoconjunctivitis (SLK). Conversely, having the patient look up while you hold down the lower eyelid can reveal the giant follicles indicative of chlamydial infection, which is another often missed or Classic presentation of SLK. Lissamine In upgaze, with the lower eyelid being misdiagnosed condition. dye nicely highlights the keratinized pulled down, the pathognomonic The treatment of chlamydial infec- epithelial tissues of the superior bulbar expression of “giant” follicles is easily tion is 1000mg of oral azithromycin conjunctiva. appreciated. taken all at once. A brief letter to the patient’s primary care provider of sexual partners. Such cases often the doctors we are! There are times is most appropriate so that a genital involve tedious (and sometimes awk- when having these hard conversa- examination can be performed, and ward) conversations, but we must tions is just part of our responsibility to facilitate medical examination “man up” or “woman up” and be in providing good patient care.

ANTIMICROBIAL RESISTANCE A MEDICAL APPROACH TO RECURRENT EROSION • Staph. Epi. most common pathogen Two studies shed light on the appropriate use of doxycycline in conjunction with other therapies to manage RCE: • 97% of all isolates were sensitive to gentamicin • 100mg doxycycline per day for one month and Lotemax QID for one month. • Fluoroquinolone resistance ranged from 32% to 40% • Curative in most cases. • “The high prevalence of fluoro- • Combination therapy with oral doxycycline (50mg two times a day) for quinolone-resistant organisms two months along with a topical corticosteroid three times a day for among ocular and nasal flora in our two to three weeks produced rapid resolution of cases of recalcitrant patient population raises concern recurrent corneal erosion.1 with regards to the usefulness of • Therapy with a combination of medications that inhibit topical fluoroquinolones as the metalloproteinase-9 prevented further recurrence of RCE cases that best first-line agent in the setting were unresponsive to conventional therapies. No recurrence was of ophthalmic prophylaxis and for observed during an average follow-up period.1 empiric use in acute ophthalmic • Pain resolved and epithelial defects healed within two to 10 days after infectious processes.” 1 initiation of therapy. Alabiad CR, Miller D, Schiffman JC, et al. Antimicrobial resistance profiles of ocular and nasal flora in patients • Treatment may avoid the risks of scarring or as seen in undergoing intravitreal injections. Am J Ophthalmol. 2011 ASP, or induced as seen in PK.2 Dec;152(6):999-1004.e2. • At least a 70% short-term relapse-free rate, as well as a subjective NEWER FLUOROQUINOLONE: improvement in symptoms and decrease in number of recurrences in BESIFLOXACIN the majority of patients.2 • New chemical entity: an 8-chloro- 2 • Long-term follow-up needed to confirm treatment efficacy. fluoroquinolone 1. Dursun D, Kim MC, Solomon A, Pflugfelder SC, Treatment of recalcitrant recurrent corneal erosions with inhibitors of matrix metalloproteinase-9, doxycycline and corticosteroids. Am J Ophthalmol. 2001;132(1):8-13. • Not used systemically; relatively 2. Wang L, Tsang H, Coroneo M. Treatment of recurrent corneal erosion syndrome using the combination of resistance-proof oral doxycycline and topical corticosteroid. Clin Exp Ophthalmol. 2008;36(1):8-12.

44 REVIEW OF OPTOMETRY JUNE 15, 2021 QUESTIONS COLLEAGUES OXYMETAZOLINE 0.1% AND PTOSIS ASK… • Afrin nasal spray = 0.05% oxymetazoline Q “Do you recommend a specific probiotic when • To help with acquired ptosis you prescribe doxycycline? I • Alpha agonist to stimulate muller know it has a low risk profile, muscle but a few patients of mine have • Used once daily as needed developed Clostridium difficile (C. Diff infection). • Provides about 0.5mm to 0.7mm of lid rise A As usual, we consulted • Approved down to age 13 authoritative literature to • Duration of effect is not yet known gain an answer: “Comparison of findings from the American • Marked as Upneeq (single-use vial) by RVL Pharmaceuticals College of Gastroenterology, the • Only available via RVL Pharmacy (www.upneeq.com) association for professionals in Slonim CB, Foster S, Jaros M, et al. Association of oxymetazoline hydrochloride, 0.1%, solution administration infection control and epidemiolo- with visual field in acquired ptosis: a pooled analysis of 2 randomized clinical trials. JAMA Ophthalmol. 2020 Nov gy, and the European Society of 1;138(11):1168-75. Clinical Microbiology and Infectious Diseases does not rec- Here is a young woman ommend probiotic prophylaxis who sustained severe when antibiotics are prescribed, itching to her eyes and citing insufficient evidence.”1 eyelids. She rubbed her eyelids to the point she created a contusion/ Our take: Rarely have we ever abrasion. Cold compresses recommended concurrent use of and an antibiotic/steroid a probiotic with any oral antibi- ointment were prescribed. otic. For patients with a history She did not return for of Clostridium difficile infection, follow-up. we would consult with their pri- mary care practitioner prior to prescribing any antibiotic. ADDITIONAL WARNINGS REGARDING Q “What pain regimen do ORAL FLUOROQUINOLONES you employ when patients lthough these have been in common use for many years now, their full have significant post-herpetic Aclinical profile continues to change. Here’s the latest from the CDC: neuralgia? • “During the past 10 years, the FDA has issued several warnings about A From a lecture we attend- potentially disabling adverse effects associated with their use, beginning ed on opioid medicines, with tendinopathy and tendon rupture. In July, 2018, the FDA strengthened we learned from an esteemed its warning that fluoroquinolones can affect glucose homeostasis adversely, pain management expert that particularly in elders and patients with diabetes who take oral hypoglycemic alternating ibuprofen 400mg agents.” ANTERIOR SEGMENT CARE QID with 500mg of acetamino- • “Now, in its most recent update, the FDA has highlighted another rec- phen QID is slightly more effec- ognized, much less common yet more serious adverse effect of fluoroquino- tive than the standard 5mg lones—aortic rupture and tearing. Fluoroquinolones up-regulate cellular matrix hydrocodone/acetaminophen metalloproteinases, resulting in fewer collagen fibrils of types I and III col- drugs, so we have heeded this lagen, which comprise the majority of collagen in both Achilles tendons and instruction. However, most of the the aorta, serving as a likely mechanism for those adverse events. Recently time we direct these patients to published studies demonstrated similar excess risks for aortic dissection a neurologist or a pain manage- and Achilles tendon rupture with fluoroquinolones, at about 2.5- to 3-fold ment clinic. compared with controlled populations.” (About half of these aortic ruptures

1. Goldenberg JZ, Mertz D, Johnston BC. occurred within the first three weeks of fluoroquinolone therapy.) Probiotics to prevent Clostridium Difficile infec- tion in patients receiving antibiotics. JAMA. U.S. Food and Drug Administration. Drug Safety Communication: FDA warns about increased risk of 2018;320(5):499-500. ruptures or tears in the aorta blood vessel with fluoroquinolone antibiotics in certain patients. www. fda.gove/DrugSafety/ucm628753.htm. December 20, 2018.

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Glaucoma Care: Take the Pressure off Novices and seasoned pros alike have many questions about how to proceed. Here’s our time-honored advice.

Do we factor nocturnal A similar question amplifies the Q coverage of IOP-lowering NOCTURNAL EFFICACY above query: meds (given the known noctur- • “Alpha agonists and beta- Q In a patient with small nal IOP spike) in our decision blockers have reduced, or even discs and IOP of 32mm Hg, making about prescribing? lack, IOP lowering during the is there any consideration or Yes, we do, but in a somewhat nocturnal period.” concern about vascular occlu- A conditional manner. Only the sion? If the patient had systemic • All prostaglandins reduce noc- prostaglandins express a theorized hypertension, would that turnal IOP, but with a “reduced benefit during the nocturnal period; influence your decision to treat? magnitude” as compared to however, the impact during sleep is Blood pressure is rarely a diurnal efficacy. A reduced at night compared to diurnal deciding factor in our decision efficacy. Given this reality, such • CAIs might reduce IOP about making, with the exception of low consideration is weighted for those 15% around the clock, but BID diastolic BP. Let us digress for a patients whom we deem to have a dorzolamide “failed to reduce moment: there is sort of a dynamic high risk for glaucoma progression. IOP versus baseline at any of tug-o-war taking place; high IOP All other glaucoma medicines bring the nighttime measurements.” presses against the head little or no clinically significant Mansouri K, Tanna AP, De Moraes CG, et al. and its vascular supply. If the BP is Review of the measurement and management reduction to nocturnal IOP. of 24-hour intraocular pressure in patients low and the IOP relatively high, then with glaucoma. Surv Ophthalmol. 2020 Mar- there can be suboptimal vascular Apr;65(2):171-186. Do you start to worry supply (known as the ocular perfusion Q about vein occlusion at pressure) to the optic nerve head. some point with IOP above 30? IOP and retinal vein occlusion, there More infrequently, if there is low First of all, “worry” might is no evidence of a “causal” relation- cerebrospinal pressure, then the effect A better be replaced with “con- ship. We would be much more of the IOP is somewhat exaggerated. cern”—and no, we do not. While interested in the IOP-glaucomatous Once cerebrospinal fluid pressure there is an association with increased relationship. can be noninvasively measured, we

Melgarejo JD, Lee JH, Petitto M, et al. Glaucomatous THE BP/IOP CONNECTION optic neuropathy associated with nocturnal dip in blood Diastolic BP, Ocular Perfusion pressure: findings from the Maracaibo Aging Study. Pressure and Glaucoma IOP is influenced by many things, Ophthalmology. 2018 Jun;125(6):807-814. including two other fluid forces: • OPP = diastolic BP – IOP blood pressure and cerebrospinal Blood Pressure and Glaucoma • Theory: OPP <50mm Hg is a risk fluid pressure. Since BP is far more factor for glaucoma and glau- • Low blood pressure is associated accessible to doctors and patients, coma progression. with the incidence and progression let’s focus on that with a look at of glaucoma. Examples: three important studies: • “Calcium channel blockers can • DBP of 65 and IOP of 15mm Hg. • DBP of 85 and IOP of 35mm Hg. Nocturnal Dip in Blood Pressure cause sudden and extreme reduc- tion in blood flow.” • These two patients may be at • The role of BP in glaucoma patho- equal risk because they have the genesis is critical. • “Nocturnal diastolic blood pressure dip may have a greater impact on same theorized OPP of 50mm Hg. • Extreme dipping (~20% of people) VF progression in NTG eyes than • Take-home message: begin to portends higher risk for glaucoma, nocturnal systolic blood pressure check BP on your glaucoma and especially in normotensive patients. dip. Spontaneous or drug-induced glaucoma suspect patients, espe- • Antihypertensive medications need excessive nocturnal DBP dip should cially those with lower IOPs. morning administration! be avoided.” Quaid P, Simpson T, Freddo T. Relationship be- tween diastolic perfusion pressure and progressive • The relationship between IOP and Kwon J, Jo YH, Jeong D, et al. Baseline systolic versus optic neuropathy as determined by Heidelberg reti- diastolic blood pressure dip and subsequent visual field POAG is weak with lower levels of nal tomography topographic change analysis. Invest progression in normal-tension glaucoma. Ophthalmology. Ophthalmol Vis Sci. 2013 Jan 28;54(1):789-98. intraocular pressure. 2019 Jul;126(7):967-79.

46 REVIEW OF OPTOMETRY JUNE 15, 2021 FACTS ABOUT FIELDS • “Macular glaucoma as measured by central defects are seen on the 24-2. the 10-2 VF is a strong, frequently Your choice of testing protocol can unmeasured, explanatory variable We recommend suppressing the urge change the results you get. While it’s in vision-related QOL.” important to know the differences, all to micromanage visual field testing. Blumberg DM, De Moraes CG, Prager AJ, et al. Associa- Along with our subspecialty col- have great clinical value regardless. tion between undetected 10-2 visual field damage and vision-related quality of life in patients with glaucoma. leagues, we continue to do a 24-2 24-2 vs. 10-2 JAMA Ophthalmol. 2017 1;135(7):742-7. SITA Fast for most of our primary • 50% of all ganglion cells are within glaucoma assessments. Assessing Glaucoma with 10-2 8º of fixation. However, we would consider doing Visual Fields • 90% of the visual cortex involves a 10-2 when one or more of the cen- • Central VF loss can also occur in 10° of central VF. tral 24-2 test spots are defective. We early disease. • 24-2 does not sufficiently sample would only do such additional testing • 30% of all RGCs serve the central 8º. the central VF. in the context of the comprehensive • Using only 24-2 “may underes- • 24-2 has only four central test glaucoma evaluation. Remember, timate the extent, location, and points. observation and study of the optic implication of VF loss.” • 10-2 has 44 central test points. nerve head is the only component of • Macular damage can occur early in • Routine 10-2 testing isn’t practical. this evaluation that we would “micro- glaucoma. • Do a 10-2 only when one or two manage”! anticipate that this metric will become artificial tear in our lab coat pockets. pull down our lower eyelid and bring a part of the comprehensive glaucoma We slide our chair up beside the the bottle to about an inch above our workup. Most doctors will prescribe patient and raise their chair high eye and gently squeeze the bottle. We for patients with IOP over 30mm Hg, enough to give them a bird’s eye view. hear so much chatter about how but careful monitoring of a trustwor- We then tilt our head back, and with patients are so poor at instilling thy patient is also a rational option. our face looking up at the ceiling, we eyedrops, but we think this weak link

Q Which visual field test is ODs WELL-POSITIONED TO TACKLE PATIENT NON-ADHERENCE your preferred one at ven the best medication in the world is worthless if the patient won’t initial testing: 24-2 or 10-2? Etake it. Glaucoma patients especially need careful instruction and fre- While there is a fair amount of quent “pep talks.” From a public health perspective, this is why optometry A discussion regarding macular should play a much larger role in glaucoma patient care. We can and do ganglion cell complex attenuation as spend more time with our patients! an early sign of glaucoma, we (and the vast majority of glaucoma Challenges of Glaucoma Drop Adherence subspecialists) still perform a SITA • “Approximately half of patients with glaucoma do not take their medi- Fast Humphrey 24-2 test as our gold cines as prescribed.” standard. If there were considerable • There are significant projected shortages in the ophthalmologist work- paracentral on the 24-2, we force and expected increases in the number of people with glaucoma. would consider performing a 10-2. • “In one short study of 279 video-recorded patient visits in which a new Do keep in mind our strong admo- medication was prescribed, less than one third of patients received any nition to not micromanage any indi- education or counseling about their glaucoma or treatment.” POSTERIOR SEGMENT CARE Newman-Casey PA, Salman M, Lee PP, et al. Cost-Utility Analysis of Glaucoma Medication Adherence. vidual component of the multifaceted, Ophthalmology. 2020 May;127(5):589-98. comprehensive glaucoma evaluation; visual field testing is only one compo- Physician Communication and Glaucoma Adherence nent. Rather, look at the overall “big • “The issue of nonadherence is multifactorial and includes inadequate picture,” and do not obsess over a communication between doctors and patients, resulting in significant single aspect of the workup. costs associated with enhanced disease progression.” • “Surprisingly, a very few studies on glaucoma medication or surgery ad- Is there a procedure to tell dressed the concept of adherence. However, adherence is discussed in Q patients how to instill drops? studies which consider psychological aspects of patients or communica- We do not “tell” patients how tion issues between doctors and patients.” A to instill drops; we show them! Meier-Gibbons F, Berlin MS, Töteberg-Harms M. Influence of new treatment modalities on adherence in glaucoma. Curr Opin Ophthalmol. 2019 Mar;30(2):104-9. We keep a sample bottle of an

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ANGLE CLOSURE MANAGEMENT PIGMENT DISPERSION SYNDROME OPTIONS (PIGMENTARY GLAUCOMA) • 500mg of acetazolamide in tablet form. • Predominately affects young, myopic men. • Brimonidine, q15min x 2 doses. • About 50% of cases progress to • A beta-blocker, q15min x 2 doses. pigmentary glaucoma. • Pilocarpine 2% once above steps • Concave rubs zonules causing completed. release of pigmentation particles. • Potent steroid q1h with associated inflammation. • Pigmented debris can overwhelm • YAG photoiridotomy once control achieved. trabecular meshwork. • reveals dense trabecular RISK OF DEVELOPING PIGMENTARY GLAUCOMA pigment band. “The risk of developing pigmentary glaucoma from pigment dispersion • Iris retroillumination defects are syndrome was 10% at five years and 15% at 15 years. Young, myopic hallmark finding. men were most likely [affected]. An IOP greater than 21mm Hg at initial exam was associated with an increased risk of conversion.” • Laser photoiridotomy is helpful with PDS, but plays little or no role once Siddiqui Y, Ten Hulzen RD, Cameron JD, Hodge DO, Johnson DH. What is the risk of developing pigmentary glaucoma from pigment dispersion syndrome? Am J Ophthalmol. 2003 Jun;135(6):794-9. pigmentary glaucoma has occurred.

in the glaucoma chain of care could be greatly strengthened if only doctors SEEING THE LIGHT • Initial IOP was on average 3.4mm would take the 30 seconds to demon- Hg higher than the IOP at the time he merits of selective laser tra- strate proper instillation technique. of the second treatment. Tbeculoplasty (SLT) continue to be revealed by research, as well as • Repeat SLT can have a longer Q How do you determine clinical practice. Still, it should be duration of effect than the initial target IOP? viewed as just one piece of a com- one. There are a number of ways to prehensive, lifelong glaucoma man- • “Additional SLT maintained drop- A go about this, and a number of agement program. free IOP control in 67% of eyes 18 factors go into this decision-making months later.” gymnastic act. Such factors include LiGHT Study the health and age of the patient, the • Three-year study on laser treat- Garg A, Vickerstaff V, Nathwani N, et al. Laser in ment in glaucoma and OHT. Glaucoma and Ocular Hypertension Trial Study Group. degree of glaucomatous damage, and Efficacy of Repeat Selective Laser Trabeculoplasty in the baseline IOP. So, in one sense this • 16% of patients were on a cal- Medication-Naive Open-Angle Glaucoma and Ocular cium channel blocker. Hypertension during the LiGHT Trial. Ophthalmology. is an unanswerable question. How- 2020 Apr;127(4):467-46. ever, shooting from the hip, for • SLT was initial Tx in “treatment- naïve” patients. moderate glaucoma, aim for IOP of “Real World” Effectiveness of • 75% of patients drop-free at less than 18mm Hg, and for more SLT advanced glaucoma, aim for less than three years. • “Most patients initially respond 14 to 15mm Hg. Remember that • 75% only required one treat- to SLT, but the majority failed individualization of patient care is a ment. within one year.” requirement, and as doctors, we are • Further treatment was initiated constantly required to think. when IOP exceeded 4mm Hg • Treatment success was 70%, above target. 45% and 27% at six, 12 and 24 Gazzard G, Konstantakopoulou E, Garway-Heath D, et al If a glaucoma suspect is on LiGHT Trial Study Group. Selective laser trabeculoplasty months post-SLT. Q an oral beta blocker, how versus eye drops for first-line treatment of ocular • Success was best in patients hypertension and glaucoma (LiGHT): a multicen- effective is it in controlling IOP? tre randomised controlled trial. Lancet. 2019 Apr with higher baseline IOPs. 13;393(10180):1505-1516. We have seen no studies directly • Mean initial decrease in IOP was A addressing this topic, but it is Follow-up on LIGHT 3 to 4mm Hg. our opinion that there would be some • At 18 months, only 25% of initially Khawaja AP, Campbell JH, Kirby N, et al. UK Glaucoma IOP reduction. This is why we advise Real-World Data Consortium. Real-world outcomes of treated patients required a second our glaucoma or glaucoma suspect selective laser trabeculoplasty in the United Kingdom. laser treatment. Ophthalmology. 2020 Jun;127(6):748-57. patients who are taking an oral beta

48 REVIEW OF OPTOMETRY JUNE 15, 2021 blocker to allow us to re-measure their IOP if they ever stop these QUOTABLE medicines. Think about this: a drop of beta blocker in one eye can cause a “Glaucoma clinics are currently under colossal strain, much reduced but measurable effect in the non-treated fellow eye. That partly due to aging populations, but mainly because being true, it certainly stands to they’re increasingly being sent people who have pharmacological reasoning that an been referred ‘just in case’ but who in truth have oral beta blocker would also have some measurable effect on IOP. healthy eyes and don’t need to be there.” Jones PR, Lindfield D, Crabb DP. Doing what comes naturally. The Ophthalmologist. 2019. 34(6):15-8. Why wouldn’t an optic Q nerve head hemorrhage in What’s known is that nerve ecchymosis) and subconjunctival someone you thought you had A head hemorrhages are indeed hemorrhages generally last about a treated correctly and had common in patients with glaucoma, week or two, and then are resorbed. It managed, alert you to probable and these hemorrhages simply come could just be that many/most of our spike/IOP fluctuation that and go (via hemolysis). Remember glaucoma patients have these, just not needed tighter control? that bruises (subcutaneous vascular when we are seeing them.

OPTIC DISC ASSESSMENT • “We found glaucoma, higher PRINCIPLES AND PEARLS blood pressure and diabetes to be associated with risk of RVO.” echnologies like OCT have done Klein BE, Meuer SM, Knudtson MD, et al. The rela- Twonders for the glaucoma evalu- tionship of optic disk cupping to retinal vein occlu- ation, but that doesn’t free us from sion: the Beaver Dam Eye Study. Am J Ophthalmol. 2006 May;141(5):859-62. our duty to fully understand what the optic nerve head is telling us. Two other key principles came out 2 Perspectives on Disc of another important study: Hemorrhages Size and Glaucoma • There is poor agreement between “Patients show structural glaucoma- It’s been 45 years since Bengtsson slit-lamp ophthalmoscopy, HRT tous progression before and after articulated some basic principles of and OCT in classifying disk size as the event of a disc hemorrhage disc size in a seminal 1976 paper:1 small, average or large. without significant differences. This • Normal small discs have small • Jonas proposed that in routine suggests that a disc hemorrhage cups. practice, the clinician conduct “a is an on-going structural progres- • Normal large discs have large quick, crude estimate of whether sion in glaucoma and may not be a cups. the disk in question is average- discrete event that leads to subse- • Average disc diameter is 1.5mm. sized (medium), smaller-than- average, or larger-than-average.” quent progression.” Disc Mean Upper Chung E, Demetriades AM, Christos PJ, et al. 1. Bengtsson B. The variation and covariation of Structural glaucomatous progression before and Diameter C/D Limit cup and disc diameters. Acta Ophthalmol 1976; after occurrence of an optic disc haemorrhage. Br J Small 1.0mm to 1.3mm 0.35 0.55 54:804-818. Ophthalmol. 2015 Jan;99(1):21-5. Medium 1.4mm to 1.7mm 0.45 0.65 2. Barkana Y, Harizman N, Gerber et al. Measure- Large 1.8mm to 2.0mm 0.55 0.75 ments of optic disk size with HRT II, Stratus OCT, and funduscopy are not interchangeable. Am J Ophthalmol. 2006 Sep;142(3):375-80. Once thought rare, optic disc hem- Implications for glaucoma diagnosis orrhages occur in most glaucoma POSTERIOR SEGMENT CARE and management: patients. It has been proposed that • A high ratio may not be patho- Optic Disc Cup Association with IOP fluctuations represent a key risk logic. Retinal Vein Occlusion factor for glaucoma progression; • C/Ds for large discs change by a • “Persons with incident RVO were however, there is no clear evidence smaller amount. more likely to be older, have high- to support this concept. er IOP and have had definite or International Glaucoma Review of the World Glau- • C/D changes caused by glau- coma Association. 2008. Vol. 10. coma occur more slowly in large probable glaucoma at baseline.” discs than in small discs (baseline • “Persons with larger optic cups While a variety of opinions regard- photos of large discs especially and higher C/D ratios at baseline ing disc hemorrhages exist, we important. were more likely to develop RVO.” believe the latter article squares • C/D asymmetry is not always • “In multivariate models, IOP was with most of the literature and our not related to vein occlusion.” pathological. observation over the decades.

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IOP OVER 24-HOUR CYCLE We typically give the patient the balance of the pilocarpine bottle to use • “Measuring IOP over a 24-hour period has shown nearly two-thirds of about four times a day (while awake) patients experienced peak IOP outside of regular clinic hours, with peak until laser photoiridotomy can be IOP most frequently occurring at night.” performed in a day or two. • “A combination of hydrostatic changes in the body and an elevation of episcleral venous pressure when the body is in a horizontal position Why do you do monocular contributes to a consistent IOP elevation in this position.” Q treatment? Why not start • “Two-thirds of patients experienced peak IOP outside of regular clinic both eyes? hours, with peak IOP most frequently occurring at night.” IOP is dynamic, and there are A diurnal fluctuations. So by • “We recommend obtaining multiple IOP pressure performing a monocular trial, we are measurements outside of office hours.” not faked out by physiologic IOP • The Icare Home device allows for self-measurement of reduction, thinking the reduction was IOP, and your contact lens technician can easily teach caused by the drug. In some cases, we most patients how to perform this technique. do in fact treat both eyes; for example Mansouri K, Tanna AP, De Moraes CG, et al. Review of the measurement and when IOP is above 40mm Hg. management of 24-hour intraocular pressure in patients with glaucoma. Surv Ophthalmol.2020;Mar-Apr;65(2)::171-86. In low-tension glaucoma, if Q you get minimal IOP Would it be so bad to add IOP. We instill each of these drops decrease from glaucoma drops, Q a topical antihistamine every 15 minutes for two doses. After do you prescribe anyway? once to three times daily to help about 30 to 60 minutes, we put in a Which one? the reaction to brimonidine? couple of drops of 2% pilocarpine, As the IOP is normal or low to The brimonidine “allergy” is which mechanically opens the angle. A begin with, one would expect a A more of a toxic/inflammatory response than a histamine-mediated • Third Tier: Combigan, Cosopt, process. Therefore, the only current OFF TO A GOOD START Simbrinza or Rocklatan. “treatment” is to simply stop the nitiating glaucoma therapy doesn’t brimonidine and move to another Ihave to be nerve-wracking for you • Fourth Tier: Pilocarpine oral CAI class of drugs. or your patient. Here’s our approach. (preferably methazolamide).

Would you use a prosta- Treatment Goals For POAG The Merits of Mono Q glandin in a patient with • Establish a target IOP below “The monocular trial of therapy is active rheumatoid arthritis which optic nerve damage is effective in accurately predicting without a history of iritis? unlikely to occur. the response of an untreated eye Prostaglandins rarely evoke • Maintain IOP at or below this to monotherapy with a prosta- A iritis or cystoid target with appropriate therapy. glandin analogue at all daytime in patients who have never had these • Monitor VFs and ONH appear- time points measured. There is disease processes before, but we ance to refine the adequacy of no requirement for patients to be would comfortably try a prostaglan- the target IOP. seen at the same time of day after din if such was clinically indicated. • Optimally balance the benefits of treatment has commenced. The therapy with any side effects. effect in the first eye predicts both To treat acute angle clo- • Educate and engage patients the likelihood and magnitude of an Q effect in the second eye at all time sure, after starting two in the management of their points during office hours and 250mg tablets of acetazolamide, disease. do you start to treat with drugs in negates the requirement for an the office, or is the patient using additional visit to check the thera- Our Glaucoma Medication Flow peutic effect when commencing drops after leaving the office? • First Tier: prostaglandin (generic therapy in the second eye.” It’s vital to keep samples of latanoprost or Vyzulta) or A King AJ, Rotchford AP. Validity of the monocular acetazolamide in your office, timolol. trial of intraocular pressure-lowering at dif- along with 0.5% timolol and 0.2% ferent time points in patients starting topical • Second Tier: topical CAI, glaucoma medication. JAMA Ophthalmol. 2016 Jul brimonidine, since these two eyedrops brimonidine or Rhopressa. 1;134(7):742-7. cause the most rapid reduction in

50 REVIEW OF OPTOMETRY JUNE 15, 2021 relatively muted effect from any ALERT ON TOPIRAMATE (TOPAMAX) eyedrop. That being said, we would first try Vyzulta to see if that achieved • Approved in 1996 for seizure disorders. target-range IOP. If further reduction • Mechanism of action is unknown. is needed, then we would • Because of a topiramate-associated risk for oral consider adding timolol, clefts, the FDA has now designated topiramate as and if even further a pregnancy category D drug. reduction is needed • Numerous reported cases of acute, bilateral, (assuming measurable simultaneous angle-closure glaucoma. effectiveness with both of these medi- • Onset usually within first two weeks of therapy. cines), we would • Most common presenting symptom: blurred vision. generally substitute • Exact mechanism of increased IOP is unknown. Insights from: the timolol for a combination • Tx: Stat consult with prescribing physician to medicine such as Combigan, or begin to reduce topiramate dosage; then aqueous Cosopt (generically). In most all cases, suppressants, oral CAI, cycloplegia (retracts ciliary IOP can be adequately controlled. body); no miotics. • IOP normalizes in one to four days, no laser How is laser photoiridoto- treatment indicated. Q my helpful with pigment dispersion syndrome if the patient has diffuse peripheral iris TOPAMAX AND VISION transillumination defects? Why • Uses: anticonvulsant, migraine prevention, bipolar disorder, obesity, wouldn’t a prostaglandin be OCD, IIH, neuropathic pain, essential tremor, post-herpetic neuralgia. indicated in pigmentary glau- • Topiramate is a sulfa derivative (like CAIs). coma, as it would increase • Idiosyncratic ciliochoroidal effusion is the most common ocular uveoscleral outflow since pig- side effect and most always results in a myopic shift with or without ment is blocking the meshwork? increased IOP. The posterior iris epithelial • This rare event usually occurs within two weeks of initiation (or A chafing is a progressive event. doubling) of dosing. Ideally, if laser photoiridotomy can be accomplished early in the process, the • First described in 2001; 70% of patients are female posterior chamber/anterior chamber • Tx: D/C the medicine; use PRN beta-blocker, brimonidine, or in pressures can be equalized, thus refractory case, oral prednisone or IV . Also, instill allowing the iris to move anteriorly cycloplegic agent and do not use pilocarpine. and halting further chafing. If, Abtahi MA, Abtahi SH, Fazel F, et al. Topiramate and the vision: a systematic review. Clin Ophthalmol. however, so much trabecular debris 2012;6:117-31. has already accumulated, causing increased IOP, laser photoiridotomy is within days or weeks of initiating There is a fair amount of relatively ineffective and ALT/SLT therapy or increasing the dose. You A discussion regarding the now becomes the laser procedure of could casually share with your patient necessity of checking IOP at the same choice. A prostaglandin would indeed that there’s a remote chance of such a time each day. At the risk of slipping POSTERIOR SEGMENT CARE be a reasonable initial choice for the side effect, but we tell every single one into counterproductive micromanage- reason you nicely pointed out. that we are real eye doctors and that, if ment, this concern is not a major one they ever have any kind of medical eye to us. Serial tonometry is done less If a patient has been on emergency, to call our office and we and less now that we know the highest Q Topamax for a while, can (or another OD) will get back to them. IOP for most patients is during the they still be at risk for ciliary This is very comforting and reassuring, sleep cycle. There may be some body effusion? Should we worry and it radically builds practices. wisdom in checking IOP at different about this in patients who have times of the day just to screen for peak been on Topamax for a while? When rechecking IOP, is it diurnal IOP. While your question has The risk of an iatrogenic event Q best to do it the same time a sound rationale, there is probably A (myopic shift, increased IOP) of day, and is serial tonometry not a need to check IOP near the same with topiramate most often occurs still beneficial? time of day.

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Note the very thin inferior retinal nerve fiber layer on the first two annual scans. Yet, at year three, the very obvious thinning is now markedly less thin. The quality scores are eight and nine, attesting to high-quality scans. This shows two important concepts: first, the so-called “objective” scanning devices are only relatively objective (compared with the highly subjective visual field test); and second, this is an excellent example of why one should never micromanage such scans.

Cupping may be suspi- and it highly correlates with floppy Absolutely. Our succinct letter Q cious, but what about the eyelid syndrome, but it’s less concern- A professionally explains the effect disc size? Shouldn’t this be part ing in glaucoma care. That is, we do of amlodipine (a calcium channel of the equation/documentation? not find the use of continuous positive blocker) on suppressed nocturnal Yes, your detailed characteriza- airway pressure (CPAP) machines a diastolic blood pressure and its A tion of the disc anatomy is significant factor in our overall care of detrimental effect on intraocular crucial. Small discs tend to have small glaucoma patients. These devices can pressure control. We ask for the cups, and large discs tend to have be a significant contributing factor in doctor’s consideration of either large cups. Keep in mind that cups dry eye disease, however. morning administration or switching generally concentric to the disc to a non-calcium channel blocker class margins are physiologic. Be especially Do you consult a glaucoma of drug. It is probably best that all attentive to superotemporal and Q patient or suspect’s PCP if blood pressure medications be taken inferotemporal erosions of the disc they’re on amlodipine to sug- with breakfast in caring for our rim. Regarding disc size, for goodness gest changing their medicine? patients with glaucoma. sake do not attempt to measure this with a reticule! Just note in your chart SYSTEMIC MEDICATIONS AND GLAUCOMA if the disc happens to be larger than • SSRIs: selective serotonin reuptake inhibitors. normal or smaller than normal. Be • SNRIs: serotonin-norepinephrine reuptake inhibitors. attentive, but keep it simple. • SSRIs (Prozac, Zoloft, Paxil and Lexapro) and SNRIs (Effexor, Cymbalta) showed a 30% protective effect. Which tonometer do you rely • Beta-blockers (mainly metoprolol) offered 20% protection. Q on for best IOP accuracy? Different studies show varied • Calcium channel blockers, mainly amlodipine (Norvasc), have a strong A results. Professor Goldmann’s harmful association with glaucoma. design remains the gold standard, but • Eye physicians need to be aware of these positive and negative more and more doctors are beginning influences on their patients with advancing and advanced glaucoma. Zheng W, Dryja TP, Wei Z, et al. Systemic medication associations with presumed advanced or uncon- to use the Icare tonometer. The notion trolled primary open-angle glaucoma. Ophthalmology. 2018 Jul;125(7):984-93. of single-use disposable probes as with the Icare tonometer was especially • Participants taking systemic beta-blockers had lower IOPs. (If a glaucoma popular as a result of the COVID patient or glaucoma suspect stops their beta-blocker, reassessment of their pandemic (which we hope is quickly IOP needs to be done.) becoming a bad memory by the time • Multiple longitudinal studies show no increased risk of POAG for individuals you read this). with diabetes. • IOP alone is a poor tool for identifying whether an individual has glaucoma. Are CPAP machines useful • Glaucoma diagnosis requires a careful assessment of all relevant risk factors, Q for POAG patients? an expert examination of the optic disk and an assessment of the visual field. Having sleep apnea is a poten- Foster PJ, Khawaja AP. The association of systemic medication and disease with intraocular pressure. A tially life-threatening condition, JAMA Ophthalmol. 2017 Mar 1; 135(3):203-04.

52 REVIEW OF OPTOMETRY JUNE 15, 2021 based solely on OCT findings would Q Does the patient need to DIAGNOSTIC ACCURACY OF be taking bimatoprost be naïve. That being said, generally INSTRUMENTS drops first to see its effect speaking, a 5µm reduction in RNFL before considering the Durysta thickness is regarded as clinically • “Differentiating between glau- intraocular implant? significant. coma suspects and normal sub- It would certainly seem jects presents a significant A necessary, and it would make Have you used ocular clinical challenge sense, so yes. Q perfusion pressure (OPP) because there as a factor in determining the is substantial What is the proper interval target IOP? overlap of clinical Q for repeating OCT for Only on rare occasions would characteristics be- patients with large/very large A we need to get this detailed tween the groups.” discs with cupping with normal since there are so many other more • The best approach to determin- imaging and no loss of retinal impactful parameters we would assess ing the status of a glau- nerve fiber layer thickness? first. That being said, blood pressure coma or glaucoma The answer would depend on should be taken on all glaucoma suspect patient is A central corneal thickness, patients, especially those with to comprehensively intraocular pressure and baseline normal-tension glaucoma, since low examine every single appearance of the optic nerve head. blood pressure can less effectively aspect of the glau- However, annual testing is standard perfuse the blood supply to the optic coma work-up. for most patients most of the time. nerve. • Further, do not micromanage or obsess over any Is there any reason to not What is the incidence of single parameter Q use anterior segment OCT Q macular edema with of the comprehen- measurement for central cor- prostaglandin treatment? sive evaluation, neal thickness (CCT)? It is exceedingly rare, and even except when No. Remember that CCT A then, most always the patient assessing the optic A measurements are not exact to has a history of cystoid macular nerve head. the millimeter. Just like with optic disc edema. Dabasia PL, Fidalgo BR, Edgar DF, et al. Diag- size, note that the cornea is thin nostic accuracy of technologies for glaucoma (<500µm), normal (500µm to 570µm) When you get a patient case-finding in a community setting. Ophthal- mology. 2015 Dec;122(12):2407-15. or thick (>575µm). Do not get into Q with parental family micromanaging this parameter. history of glaucoma, large optic Regarding the numeric ranges, we nerve cups but normal fields, Recent studies have shown that made them up, but they are scientifi- IOP and RNFL, do you start to A initial laser treatment can push cally sound generalizations. wonder if that is really just a the need for topical medications down family history of large cups and the road for a few years. Of course, What do you consider a the patient was misdiagnosed? laser treatment can be considered Q clinically relevant change Absolutely! Try to see other anywhere along the disease continu- in RNFL thickness when moni- A family members to authenticate um. Surely, new techniques and new toring a glaucoma suspect with your logical suspicions; this can be medicines will be invented over these clear visual fields, borderline very reassuring to the patient. It is decades. POSTERIOR SEGMENT CARE high IOPs (18 to 21mm Hg) and most important to evaluate siblings if good RNFL profile? How much possible. There are many people being When initiating monocular RNFL thinning/change would treated for a disease that they do not Q treatment, how much later you tolerate before recom- have! do you see the patient for an mending treatment? IOP check? Then, when you We never make any clinical With a 34-year-old patient, start the second eye, how much A judgments based solely on this Q would you potentially have later would you see them after one parameter. Depending upon them on glaucoma medicines that? several factors, some doctors wait for 50-plus years? Would an For prostaglandins, we wait a until the first repeatable visual field initial treatment with laser be A full three weeks to assess defect occurs before starting treat- indicated without starting efficacy. For all other topical medica- ment. To make a therapeutic decision drops? tions, we re-check in two weeks.

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Prostaglandins take longer to achieve their full therapeutic potential. If a GLAUCOMATOCYCLITIC good response occurs, we would then CRISIS: CASE EXAMPLE treat both eyes and see the patient • BVA: 20/20; 20/50 back in about three months. • normal; no APD • Conjunctiva quiet OS When do you think is the Q best time to send a glau- • Cornea: 2+ peripheral epithelial edema OS coma patient for a consult for laser procedures? Do you • Endothelium shows mild KP suggest treating first with • A/C: Grade 1 cell, trace flare medications and then sending • 4-mirror gonio: open without Slit lamp exam shows some keratic the patient to the specialist to synechiae precipitates on the endothelium as see if they would benefit, or • IOPs: 18, 56 well as prominent and pan-corneal have them assessed by the • ONHs: 0.25 OU; healthy rims sterile (leukocytic) infiltration of the anterior half of the cornea. specialist first? The laser procedures SLT and This is a straightforward case of Treatment was Durezol q2h glaucomatocyclitic crisis. A ALT are temporizing interven- for two days, then QID for one tions. Although the effectiveness is week, then BID for one week. Suppressing this idiopathic irido- highly variable, most patients achieve cylokeratitis is essential to quiet and maintain target IOP for two to the anterior segment tissues, thus five years. enabling the tissues to renormal- We hold that most people can be ize, hastening the renormalization properly trained to instill eyedrops of the intraocular pressure. (very much like contact lenses). We We also gave the patient a also hold that if a doctor takes the sample of Combigan to use BID time to attentively discuss the disease for three days to facilitate the IOP process, most patients can and will be drop secondary to steroid sup- adherent to their eyedrop therapy. It is pression of the inflamed tissues. imperative that patients truly under- stand the importance of their self-care. Who can do this better—a doctor seeing 40 to 80 patients per day, or Note the inferior microcystic edema. one seeing 25 to 30 per day? This is This is because the intraocular yet another reason why doctors of pressure went from the upper teens to The ptotic eye is almost always the optometry should be providing the the mid-50s in just a day or two. problematic eye. majority of glaucoma patient care. BRIMONIDINE TARTRATE What is the proper interval Q of repeating OCT for • Alpha-2 adrenergic agonist; TID FDA individuals who have large and approval. very large discs with cupping on • Acts by reducing aqueous production normal imaging and no loss of with some enhancement of uveoscleral RNFL? outflow. Here we are teetering on A “micromanagement!” Without • Reduces IOP similarly to timolol 0.5% more of a comprehensive understand- BID. ing of the patient, a well-focused • Side effects: fatigue and dry mouth are the most common; uveitis has answer cannot be given. How old is been reported; it may reduce systolic BP by 10mm Hg; causes less the patient? Is there a positive family tachyphylaxis or allergy than apraclonidine. history? What are the intraocular • Neuroprotective potential speculated but not confirmed. pressure readings? What is the central corneal thickness? So, we now provide • Alphagan (0.2%, Allergan) and generic, Alphagan P (0.15%, Allergan a poorly focused answer: annually. and generic) and Alphagan P (0.1%, Allergan)

54 REVIEW OF OPTOMETRY JUNE 15, 2021 Don’t Miss Giant Cell (Cranial) Arteritis

argely a disease of the elderly, Photo: Michael Trottini, OD fatigue, weight loss, night sweats, giant cell arteritis (GCA) can depression and low-grade fever. Lpresent in numerous ways. Just as with GCA, elevated CRP Most common is as an anterior isch- and ESR are most always seen. About emic optic neuropathy, but it’s also half of patients diagnosed with GCA possible for GCA to present with dip- have PMR, and about 20% of those lopia or retinal microvascular occlu- patients afflicted with PMR go on sive disease, such as central or branch to develop GCA. PMR occurs much retinal artery occlusion. Sometimes, more frequently than GCA. patients can present with a history of So, in working up patients suspect- transient, monocular vision loss. ed of having GCA, always ask about a As GCA can cause blindness, it is history of PMR—specifically morning A large, palpable, firm temporal artery is imperative that we be experts in this shoulder pain and stiffness. a good indicator of possible GCA. disease process. The following section In the setting of suspected GCA, will enable you to expertly assess and at the thrombocyte (platelet) count. it’s also important to begin replacing manage the ocular manifestations of Thrombocytosis > 400 is commonly temporal artery biopsy (TAB) with ul- this idiopathic vasculitis. seen in the setting of GCA. trasound (US) studies of the temporal “In GCA, temporal artery biopsy artery.3 OUR GUIDE TO EVALUATING may not be required with typical While the TAB conditionally GCA SUSPECTS disease features accompanied by char- endures as the gold standard with This is essentially a three-step process: acteristic ultrasound or MRI findings suspicion of GCA, its diagnostic (1) History. Classic symptoms of (of the temporal arteries),” one study dominance is being appropriately GCA include: new-onset headache in noted.2 challenged with noninvasive vascu- a person over age 50 (the older the In summary, since GCA has the lar US. Keep a few things in mind: person, the higher the risk); a history potential to be a blinding disease, patients with arteritic AION may of jaw claudication (virtually pathog- as doctors it is critical that we are have a history of episodes of transient nomonic for GCA); scalp tenderness; keenly attentive to any person who vision loss, whereas this is not seen in diplopia; general malaise; weight loss; presents with symptoms that could be the much more common nonarteritic and a history of polymyalgia rheu- compatible with cranial arteritis. As (vascular) form of AION. Also note matica. Women are more at risk than optometrists whose primary purpose that if this same demographic has a men. Race is minimally helpful, with is to enhance vision, interceding in history of transient monocular vision white patients perhaps at some greater this idiopathic arterial inflammatory loss, these patients may have carotid risk than others. disease in a timely manner can indeed atheromatous disease. If that is the (2) General physical examination preserve vision. case, an urgent carotid ultrasound (which is limited). Palpate the tem- study needs to be accomplished within poral arteries, hoping for a palpable POLYMYALGIA RHEUMATICA a day or two. pulse, and perform dilated ophthal- (PMR) AND GCA US evaluation of the cranial arteries moscopy to look for anterior ischemic These two idiopathic inflammatory should be done within a day or two optic neuropathy, or branch retinal vasculopathic disorders are thought of the initiation of high-dose steroids. POSTERIOR SEGMENT CARE artery occlusion or central retinal to be related in some as yet not fully Of course, a combined history (e.g., artery occlusion. understood manner. These diseases new-onset headache, malaise, jaw (3) Order laboratory (blood) stud- may even manifest across an inexact claudication, scalp tenderness) and ies. If equipment is available, perform spectrum. blood studies (CRP, ESR and CBC) temporal artery ultrasound. Blood- PMR typically presents in patients would guide one’s presumptive initia- work suggestive of GCA includes over age 50. These patients com- tion of high-dose oral prednisone. C-reactive protein (CRP) >2.45 and monly present acutely with bilateral Such corticosteroid vascular inflam- erythrocyte sedimentation rate (ESR) upper extremity pain, more exactly mation suppression does not negate >60.1 In both of these studies, the as shoulder pain and stiffness, most the validity of a TAB for a few days. higher the result, the greater the likeli- commonly upon awakening in the When performed properly in a timely hood of GCA. Also, order a complete morning. These patients often have manner, US is more sensitive and blood count (CBC) to look specifically constitutional symptoms such as specific than biopsy.

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Given that ultrasounds studies are are ophthalmic manifestations of other episode of transient visual loss, less expensive, less time-consuming systemic disease. Our duty is to assess developed an afferent pupillary defect and noninvasive, we anticipate the di- the patient, perform a timely state- and a visual field defect. agnostic pendulum will steadily swing of-the-art workup, initiate therapy if Our take: Our perception is that from TAB to US in the near future. indicated, and then get the patient to a another key consideration would be specialist for ongoing care. carotid atheromatous disease, so a THERAPY INTERVENTION IN Comanagement of arteritic AION carotid ultrasound should have been THE SETTING OF GCA with a neurologist is essential in GCA ordered. The sed rate alone was insuf- Since high-dose oral prednisone is the patients and suspects. Early steroid ficient. The doctor also should have primary therapeutic intervention in treatment is critical and may be re- obtained a C-reactive protein, and the setting of suspected or confirmed quired for several years in severe cases a CBC to look for thrombocytosis. GCA, we need to have a quick chat to avoid permanent vision loss. The low sed rate finding of 6 partially with the primary care provider of such From a medicolegal perspective, we caused the doctor to let his guard patients to ascertain any contraindica- can never miss this diagnosis! For the down. Don’t let that happen to you! tions to the use of high-dose predni- most part, keeping an attentive ear and Two other cases where vision sone. This is just one scenario in which a high index of suspicion will guide change was the only symptom were good doctor-to-doctor communication the clinician to perform an appropriate settled when OMIC could not find enhances patient care. workup. supportive defense experts. There is no firm rule as to what Our take: That is because these dosage is best: we generally initiate THE MEDICOLEGAL cases were so poorly handled that with 80mg per day, but if the patient ASPECT OF GCA there was no plausible defense. is small or large, we may reduce/in- The Ophthalmic Mutual Insurance Another case: The ophthalmologist crease the initial dosage accordingly. Company is a major insurer of oph- noted in an 81-year-old Once we have the laboratory and/or thalmologists. They published an ar- who presented with sudden vision radiological results (which will further ticle titled “Giant Cell Arteritis Claims loss, but the doctor did not work up confirm or refute our initial clinical are Costly and Difficult to Defend” in the cause. suspicion), we pass these patients on their Ophthalmic Risk Management “Ophthalmologists examining older to a rheumatologist or internist for Digest that shares some interesting patients, especially those with vision ongoing management. Then we see cases and insights.4 Following, we changes and headache, need to take these patients only to monitor any share some paraphrased content from a more active role in obtaining the visual deficits, especially if the patient this article that we feel have merit for history.” presented with AION, diplopia or all eye doctors. While this specific ar- All of us need to “document the arterial occlusion. ticle exclusively addresses ophthalmo- encounter and your decision-making The urgency of intervention is more logical care, these cases could just have process in the medical record.” acute if a patient presents with unilat- easily been optometric scenarios! Just to close out this brief section, eral vision loss resulting from AION First, we all need to be mindful that the median payment for missing GCA or arterial occlusion. Keep in mind varied and nonspecific constitutional was $335,000. The bottom line is: be that most cases of AION are indeed symptoms such as fatigue, malaise and attentive, obtain a proper history, con- nonarteritic and result from systemic a history of weight loss need to be ad- duct a thorough physical examination, hypertension, diabetic vasculopathy dressed along with the classic ocular- order proper laboratory tests, and if or simply age-related vascular disease. related symptoms and signs. “The indicated, start the patient on high- But we must always assume the ophthalmologist failed to elicit the dose prednisone (around 80mg per etiology to be giant cell arteritis until non-vision-related symptoms in ten of day) after consulting with the patient’s appropriate blood studies are done. the fifteen patients who were having PCP. Importantly, document all of Further, always check the blood them. Defense experts opined that this these steps in your medical record. pressure of all these patients. If inadequate history contributed to the 1. Buttgereit F, Matteson EL, Dejaco C. Polymyalgia the blood pressure is, for example, delay and diagnosis and was below rheumatica and giant cell arteritis. JAMA. 2020 Sep 210/100, the cause of the AION is the standard of care.” 8;324(10):993-94. 2. Ching J, Smith SM, Dasgupta B, et al. The role of heavily weighted toward hypertensive A 79-year-old patient presented vascular ultrasound in managing giant cell arteritis vasculopathy and not GCA; yet, we with . A sed rate was in ophthalmology. Surv Ophthalmol. 2020 Mar- must always rule out GCA. Keep in ordered, which was 6, and so a second Apr;65(2):218-26. 3. Pelton RW. Giant cell arteritis claims are costly and mind that visual compromise, diplopia sed rate was obtained, which was also difficult to defend. Ophthalmic Risk Management and retinal vascular occlusive disease 6. Six days later, the patient had an- Digest. 2015;25(3).

56 REVIEW OF OPTOMETRY JUNE 15, 2021 Dural Arteriovenous Malformations Keep alert for the “other” red eye. ot all red eyes are infectious or inflammatory! In the pho- DURAL AVM FACTS AND CLINICAL FEATURES Ntos to the right, take a careful • Usually US women ages 50 or older, often with HTN look at the pattern of the conjunctival injection. Such presentations can • Classic herald congestion within the cavern- syndrome: ous sinus, thus altering hemodynam- » mild to ics. Note there is also unilateral retinal moderate vasculature tortuosity on the ipsilater- proptosis al side. These patients need to be sent » dilation from the OD’s office to radiology in (tortuosity) of a non-emergent manner for definitive conjunctival evaluation. No eyedrops are needed. vessels A case reported in the January 2021 JAMA Ophthalmology ex- » mild to hibited ocular manifestation of a moderate systemic (neuro-ophthalmic) disease.1 conjunctival A 68-year-old woman presented to chemosis the emergency eye clinic with a three- » abducens week history of progressive left-eye nerve paresis redness and discomfort unresponsive to topical antibiotics or lubricants, as » venous stasis prescribed by her optometrist. The IOP was raised (26mm Hg) and was • DDx: Conjunctivitis, dysthyroid orbitopathy, orbital pseudotumor, true treated with a topical beta-blocker. orbital mass Otherwise, her condition was man- • Almost always spontaneous (not trauma associated) aged conservatively for presumed viral conjunctivitis. • Workup: comprehensive eye exam, MRI / MRA “She self-presented six days later • Natural history with intermittent visual blurring, » rarely affect mortality rates » rarely extraocular signs/symptoms mild eyelid swelling and conjunctival chemosis. The IOP remained raised at » rarely bleeding » often close spontaneously 24mm Hg. An inflammatory or aller- gic etiology was suspected; therefore • Patient is at risk for infrequent CRVO, rarely glaucoma topical corticosteroids and a prosta- glandin analog were also prescribed.” was made on the retinal microvascu- charge from the eye. So, always keep “One week later, at planned lature. in mind that infectious processes POSTERIOR SEGMENT CARE follow-up, the patient had dilated and There are several points to be seen have a discharge. Last, a much more tortuous bulbar blood vessels. Further here: (1) it is critically important to intensive history in this case would interrogation of the history revealed a take a good history and to make an have prompted all of the patient’s left-sided, nonspecific dull headache, accurate diagnosis; (2) if you do not doctors to arrive at the cavernous si- constant for the previous two months, adequately address the situation, the nus foci much earlier. Thankfully, this and an annoying ‘whooshing’ noise in patient will seek a second opinion patient did undergo neuroradiological the patient’s left ear.” elsewhere; and (3) the pattern of the intervention and had a fully successful While this case was obviously dif- conjunctival blood vessels in no way outcome. ferent because it is a different patient appears to be similar to that seen in The moral to this story is: give than the one shown here, the clinical typical infectious conjunctivitis. deep thought to the diagnosis and do presentation looked very similar to the Further, there was no palpable your very best to make an accurate images in these photos. No comment node on that left side and no dis- assessment.

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RED REFLEX IN INFANTS IS A Role of Vitamin D and Omega-3 CRITICAL OBSERVATION Fatty Acid Supplementation in AMD uring the course of routine prac- Dtice, there are many times a par- hile AREDS and AREDS2 ent is holding a “lap baby” while the doctor is examining an older child (or supplementation have a sig- parent). Our practice has always been Wnificant positive impact on to take a few seconds to retinoscope the progression of AMD, it is certainly or to use the direct ophthalmoscope desirable to further augment their to screen these infants and children efficacy. A recent trial of physiologic with a quick assessment of their red doses of vitamin D (2000 IU/day) and reflex. The yield of a positive finding one gram/day of omega-3 fatty acids is tiny, but so is the time expended! failed to provide any enhancement One case that comes quickly to to the effects of AREDS or AREDS2 mind is the one-year-old who had a supplementation. Some key findings: unilateral, dulled reflex. It turned out that the child was emmetropic in the • “These negative results of a large, red reflex eye and a +5.00D in the well-designed and well-conducted Advanced, soft, large, confluent macular drusen. dulled reflex eye. Amblyogenic aniso- clinical trial, performed by highly metropia was detected and early, experienced investigators, are dis- with vitamin D3 and marine omega-3 and appropriate treatment was initi- couraging. This is especially the case fatty acids for a median 5.3 years had ated, hopefully preventing permanent because the prior successes of AREDS no significant overall effect on AMD vision loss. Of course, other causes and AREDS2 have led to consider- incidence or progression.” of a dulled/absent reflex can be a able optimism that at least one and So, until some other interventions , retinoblastoma, possibly other common and highly dis- are discovered, we press on urging our chorioretinal coloboma, vitreous mass abling eye diseases can be substantially patients who smoke to try their best or other congenital abnormalities. reduced in severity, or even prevented, to quit, and to continue to take their As a recent study puts it: • “Large refractive errors may be by large but safe doses of commonly AREDS2 supplements daily. Surely, observed as changes in red reflex used and inexpensive vitamins and additional help will be forthcoming. because the passing of light through dietary supplements.” Christen WG, Cook NR, Manson JE, et al; VITAL Research the eye depends on the bending • “In conclusion, in this large Group. Effect of vitamin D and ω-3 fatty acid supple- (refraction) of light by the optical mentation on risk of age-related : randomized trial of initially healthy an ancillary study of the VITAL randomized clinical trial. media.” men and women, supplementation JAMA Ophthalmol. 2020 Dec 1;138(12):1280-9. • “Retinal changes that are restrict- ed to the peripheral retina and do not affect the central part that reflects LUTEIN-ZEAXANTHIN CONTENT OF FRUITS AND VEGETABLES the light will not be detected.” • “ size can be increased by Since a good number of our patients Fruit/Vegetable Micrograms/100g performing the test in a dark room are at risk for—or have—clinically Kale 21,900 or slightly deviating the angle of illu- significant macular degeneration Collard greens 16,300 mination may improve visualization and do not eat sufficient amounts of of the red reflex if the infant focuses these foods, we recommend that they Spinach (cooked) 12,600 directly on the light source.” augment their diet with Spinach (raw) 10,200 • “Not performing red reflex the AREDS2 vitamin/ Parsley (not dried) 10,200 screening will have a detrimental mineral supplement. Mustard greens 9,900 effect on ocular health and visual out- Preventive care is an Dill (not dried) 6,700 comes.” optimal approach Celery 3,600 • “Red reflex testing is not entirely to good health, and accurate, but it is a good enough, we want to do all we Scallions (raw) 2,100 cost-effective, simple screening tool.” can to preserve and Leeks (raw) 1,900 Checking the red reflex is just protect vision. Broccoli (raw) 1,900 another quick and simple public In addition to the more common Broccoli (cooked) 1,800 health service for our patients that capsules are these “chewables.” Always shows just how much we really care. keep in mind that a sizable minority of Mangles R, Holden JM, Beecher GR, et al. Carotenid content of fruits and vegetables: an Adams GGW. The enduring value of newborn Red patients do have difficulty swallowing evaluation of analytic data.” J Am Diet Assoc. Reflex Testing as a Screening Tool. JAMA Ophthalmol. large tablets and capsules. 1993;93:284-96. 2021 Jan 1;139(1):40-41.

58 REVIEW OF OPTOMETRY JUNE 15, 2021 Retinal Injury from Handheld Lasers

ike most technology, the two- edged sword metaphor holds Ltrue for handheld lasers. An excellent, comprehensive review on this topic was published in Survey of Ophthalmology March/April 2021, from which we share the following clinically relevant information. First things first: If you ever encoun- ter a male patient roughly between the ages of eight and 28 with unexplained unilateral decreased vision, do an at- torney cross examination–like history and obtain an SD-OCT. Approxi- mately half of these young males will deny any laser-associated activities; Laser-induced retinal lesion. Note the small, focal, yellowish foveal lesion. Note the focal defect from the laser injury. thus, the need for a penetrating his- tory! Most certainly, both sexes can imaged by SD-OCT revealed outer rance of our critical role as primary be involved, the age brackets can be segment macular abnormalities at the providers, or a political attack against expanded and there can be bilateral initial presentation.” our profession; either way, such exclu- vision loss, but we are speaking of • “The large majority of lasers sion is an egregious breach of profes- the most common scenarios. Vision were purchased through the Internet sional integrity. loss is generally mild, but in severe directly by children, indicative of the • “Unfortunately, some patients are bilateral cases be mindful of possible strong influence of online advertising mistakenly diagnosed with macular underlying psychiatric illness. Now, specifically designed to target the child dystrophies or posterior uveitis. Di- the details: consumer.” agnosis of retinal laser injury is often • “When exposures occurred in • “Medical professionals, including challenging due to lack of forthcoming children and young adults (age ≤ to 18 ophthalmologists, psychiatrists, and history of laser use, requiring evaluat- years), they were frequently associated primary care doctors need education ing physicians to recognize the clinical with play behavior (96.1%). Children and awareness of this entity to proper- and imaging findings indicative of who sustained retinal injury were typi- ly diagnose and prevent further vision laser injury.” cally exposed to lasers by their peers loss in patients with laser injuries.” • “Nonspecific foveal retinal pig- (81.0%). These presentations result in Our take: We continue to be ment epithelial changes and distinctive ‘unnecessary testing and misdiagnoses amazed at how optometrists—the yellow or gray lesions corresponding in these patients.’” primary eye/vision gatekeepers—are to outer retinal phototoxic damage • “Ninety-eight (98)% of patients’ ignored. This shows profound igno- on clinical examination was found in nearly half of all cases and should FOLLOW-UP AFTER INITIAL PVD EVENT raise suspicion for handheld laser . Visual acuity in patients POSTERIOR SEGMENT CARE • In a recent study, about 2% of patients with normal findings developed a with these more common macular subsequent retinal tear. findings was generally good.” • 45% of retinal breaks “were found more than six weeks after presentation.” In summary, handheld lasers can • At the Wills Eye Hospital Retina Service, “60% of patients in our study had be a source of retinal injury. It is the at least a four to six week follow-up. Most physicians in our practice do not mindful, judicious and attentive clini- routinely follow up patients beyond this timeframe.” cian with a high index of suspicion who can arrive at an accurate diagno- • Only about half of these subsequent events were symptomatic; therefore, sis. There is no effective treatment, but there may be a need to reevaluate acute PVD patients more frequently thankfully most all patients exhibit than is currently common practice. only minimal visual compromise. Uhr JH, Obeid A, Wibbelsman TD, et al. Delayed Retinal breaks and detachments after acute posterior Bhavsar KV, Michel Z, Greenwald M, Cunningham ET vitreous detachment. Ophthalmology. 2020 Apr;127(4):516-22. Jr,, Freund KB. Retinal injury from handheld lasers: a review. Surv Ophthalmol. 2021 Mar-Apr;66(2):231-60.

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