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VOL. 155 NO. 4 ■ APRIL 15, 2018

IN THE NEWS Hope For Noninvasive Hydrogel and overnight orthokeratology (OK) contact lens (CL) wear can ICP Monitoring increase tear fi lm osmolarity, a new study fi nds. Researchers observed osmo- Ultrasonography may one day help patients avoid a larity values in non-CL wearers and those who have worn hydrogel and overnight painful lumbar puncture. OK lenses for at least three years, and By Rebecca Hepp, Managing Editor found osmolarity was within normal limits Photos: Nate Lighthizer, OD in all groups, although it was signifi cantly linicians have long known lower in non-CL wearers compared with intracranial pressure (ICP) hydrogel and OK lens wearers. Osmolar- Cplays a critical role in idio- ity returns to baseline one month after pathic intracranial hypertension, discontinuation of CL wear. and “there has also been debate Nieto-Bona A, Nombela-Palomo M, Felipe-Márquez about its potential role in other G, Teus MA. Tear fi lm osmolarity in response to long- term orthokeratology treatment. Eye Contact Lens. disease states such as glaucoma,” 2018;44(2):85-90. says Nate Lighthizer, OD, an Researchers found day one post-op associate professor and assistant assessment with swept-source OCT dean of Clinical Care Services at provided better visualization of the Oklahoma College of Optom- macula than spectral-domain (SD) etry. “There is current thinking OCT in patients treated with pars plana now that perhaps glaucoma is a vitrectomy and gas tamponade. For two-pressure disease: the balance patients with rhegmatogenous retinal between intraocular pressure and detachment, SD-OCT provided good intracranial pressure. So better visualization on day one in 35.3% of eyes understanding the role ICP plays compared with 73.5% of eyes using Ultrasonography can reveal any number SS-OCT’s line scan protocol. In eyes with in many disease states may be a macular holes, the rates were 59.3% critical element in the future.” of issues, such as choroidal melanoma with SD-OCT and 88.9% with SS-OCT’s Unfortunately, the standard with overlying retinal detachment, top, line scan protocol. test for diagnosing elevated ICP, and optic nerve drusen, bottom. Recently, Ahn SJ, Park SH, Lee BR. Visualization of the macula lumbar puncture (LP), is invasive reseachers found measuring optic nerve in gas-fi lled eyes: Spectral domain optical coherence and painful.1 Recently, researchers sheath diameter with ultrasonograpy tomography versus swept-source optical coherence tomography. Retina. 2018;38(3):480-9. have sought noninvasive methods may be a noninvasive method of for dynamically monitoring ICP, monitoring ICP. Clinicians should endeavor to refer and think ultrasonography may be patients with orbital-fl oor trap-door the key.1 correlation between the ONSD blowout fractures with incarcerated Researchers in China used ul- and ICP values on admission, and tissue for surgery within eight days, according to new research. The study trasonography to measure the op- a strong correlation between the found ocular motility outcomes were tic nerve sheath diameter (ONSD) change in ONSD and ICP values signifi cantly better for patients who un- in 60 patients admitted for lumbar one month later. Post-treatment, derwent repair surgery within eight days puncture. After LP, the patients the elevated ICP and dilated of injury than those after eight days. were split into two groups, ONSD had returned to normal, 1 Yamanaka Y, Watanabe A, Sotozono C, Kinoshita S. those with elevated ICP between the researchers found. Impact of surgical timing of postoperative ocular motility in orbital blowout fractures. Br J Ophthalmol. 200mm H2O and 300mm H2O Other studies have highlighted 2018;102(3):398–403. and those above 300mm H2O. ultrasonography’s utility in The investigators noted a strong (continued on page 5)

REVIEW OF OPTOMETRY APRIL 15, 2018 3

003_ro0418_news.indd 3 3/30/18 4:38 PM News Review FDA Hits Opternative with Notice

he Food and Drug Admin- On-Line Opternative Eye Examina- The American Optometric Asso- istration (FDA) has advised tion Mobile Medical App device, ciation (AOA) is counting the FDA’s Tonline refraction company such as the commercial distribution action as “validation” of its 2016 Opternative that its services consti- of the device through your online complaint. “Despite the October tute a medical device and, as such, website.” 2017 FDA warning letter, Opterna- require “marketing clearance,” ac- “We responded promptly to tive has continued to market their cording to a letter the agency issued FDA’s warning letter from October device through 1-800 Contacts, etc. in October, but didn’t publicize until 2017, and we are working dili- until the fi ling was made public,” March. The letter indicates that the gently to voluntarily comply with says Clarke Newman, OD, AOA company, which was sending mar- all regulatory requirements,” says Federal Relations Committee chair. keting e-mails as of March 22, has a representative from Opternative. “We recognize our technol- been operating in violation of the “We continue to communicate with ogy and our new way of helping Federal Food, Drug, and Cosmetic the FDA on a regular basis to work patients get their prescriptions Act. In the letter, the FDA “requests through the regulatory medical renewed are viewed as disruptive to that Opternative, Inc. immediately device clearance process with our those who wish to prohibit emerg- cease activities that result in the outside experts.” ing technologies from entering the misbranding or adulteration of the The FDA’s letter also says that vision prescription renewal space,” the agency determined that the app said an Opternative representative. “is a device because it is intended Although the AOA has histori- for use in the diagnosis of disease cally opposed online refraction, a or other conditions or in the cure, spokesperson underscores that the mitigation, treatment, or prevention association supports technologies, of disease, or to affect the structure so long as they don’t interrupt the or any function of the body.” It patient-doctor relationship. also outlines how Opternative can submit for premarket approval Food and Drug Administration. Inspections, Compliance, Enforcement, and Criminal Investigations. Opternative Opternative just hit a roadblock with an and “whether the product may be Inc 10/30/17 Warning Letter. www.fda.gov/iceci/ FDA warning letter. legally marketed.” enforcementactions/warningletters/2017/ucm600029.htm. Clinical Acumen Boosts AI Accuracy lthough artifi cial intelligence sensus of the retina specialists as the study author Lily Peng, MD, PhD.1,2 (AI), and the machine learn- reference standard. Although reference cases are Aing algorithm that drives After adding the reference cases key to “teach” any deep learning it, shows promise as a screening “as a tuning dataset,” the inves- machine to properly screen for DR, tool for ocular pathology such as tigators looked at the area under creating those standards is time- diabetic retinopathy (DR), it’s not the curve (AUC), sensitivity and consuming. The researchers were perfect. But researchers at Google specifi city data between the manual happy to fi nd using just a small found using a small set of DR cases grading and the algorithm. With the subset of carefully adjudicated cases judged by ophthalmologists and new data, the algorithm improved could make a huge difference in the retina specialists can improve the its AUC from 0.934 to 0.986 when algorithm’s performance. algorithm’s accuracy.1 screening moderate or worse DR, a 1. Krause J, Gulshan V, Rahimy E, et al. Grader variability and The researchers had the clinicians boost that enabled the AI system to the importance of reference standards for evaluating machine and the algorithm grade retinal perform similarly to or even exceed learning models for diabetic retinopathy. Ophthalmology. March 12, 2018. [Epub ahead of print]. fundus images from DR screening US board-certifi ed ophthalmologists 2. Human adjudication of DR grading enhances machine programs and then chose the con- and retinal specialists, according to learning algorithm. Healio. March 14, 2018.

4 REVIEW OF OPTOMETRY APRIL 15, 2018

003_ro0418_news.indd 4 3/30/18 4:39 PM The doctor gave me six months… Monitoring ICP Sans LP (continued from page 3) OMG! measuring elevated ICP, and this study “adds further evidence for the sensitivity and specifi city of ultrasonography for this purpose,” according an editor’s note from Andrew G. Lee, MD, of Hous- ton Methodist Eye Associates in Houston, Texas. …to my Dr. Lee already uses the diagnostic tool in his practice to: dif- next visit! ferentiate diffi cult cases of pseu- dopapilledema vs. papilledema, follow patients with papilledema with residual post-treatment disc changes, evaluate those whose papilledema may no longer manifest ophthalmoscopically and * patients with cerebrospinal fl uid Six Full Months of shunts and follow patients who re- fuse or cannot undergo a standard LP for measuring ICP.2 Effective Dry Eye Relief Because of the strong correlation between ONSD and The Extend 180™ Long-Term Dissolvable Implant ICP values, and because the ICP decreased as the dilated ONSDs Featuring decreased, the researchers be- • Simple insertion technique lieve “ultrasonographic ONSD 3 sizes!sizes! measurements may be a useful, • No foreign body sensation noninvasive tool for dynamically evaluating ICP.”2 • Exceptionally reliable retention “It is exciting to see that other Indications measurements, such as ultrasound assessments of optic nerve sheath • Post-ocular surgery or seasonal dry eye diameter, potentially offer easier, less invasive ways to gain an • Contact lens intolerance understanding of a patient’s ICP,” • Dry eye associated with digital eye strain says Dr. Lighthizer. “Certainly, future research will only help to clarify this even more.” 1. Wang L, Chen L, Chen Y, et al. Ultrasonography assessments of optic nerve sheath diameter as a noninvasive and dynamic method of detecting changes in intracranial pressure. JAMA Ophthalmol. 2018;136(3):250-256. 1-866-906-8080 2. Lee AG. Correlation between noninvasive ultrasonography and dynamically monitored intracranial pressure. JAMA bvimedical.com Ophthalmol. 2018;136(3):256.

* 510(k) Summary K162361

003_ro0418_news.indd 5 3/30/18 4:39 PM News Review Stem Cells Reverse AMD Effects

linicians in the United Photo: Richard Trevino, OD surgery on 10 patients, but Kingdom recently they have chosen to report on Creported positive the 12-month follow-up of outcomes after treating two their fi rst two cases because patients with severe age-related the results have been so favor- macular degeneration (AMD) able,” says Dr. Trevino. “Both by implanting an engineered subjects experienced a dra- retinal pigment epithelium matic improvement in vision (RPE) patch made of a fully (fi ve to six lines on the ETDRS differentiated, human embry- chart) following the procedure onic stem cell (hESC)–derived despite neither patient receiv- RPE monolayer on a coated, ing anti-VEFG treatment.” synthetic basement membrane.1 Research shows an implanted stem cell patch The Phase 1 trial was “Until now, stem cell re- may provide visual improvement for patients with designed to fi rst investigate search for retinal disorders has severe AMD. the safety of the treatment, primarily involved the implan- and results showed no tumors tation of a suspension of retinal seems to support that notion.” caused by residual undifferentiated pigment epithelium cells,” says The researchers documented the embryonic stem cells spreading Richard Trevino, OD, director of survival of the implant with bio- from the patch. Serious compli- Residency Programs at the Rosen- microscopy and optical coherence cations following the procedure berg School of Optometry, Univer- tomography, and noted the patients were rare, the most serious being sity of the Incarnate Word. “The gained signifi cant visual acuity over a retinal detachment associated use of a patch is believed to im- 12 months of follow up.1 with proliferative vitreoretinopathy prove the viability of the implanted “The researchers have regula- (PVR), according to Dr. Trevino. cells, and the results of this study tory approval to perform this “The researchers admit that the implanted RPE cells may have contributed to the development OCT Reveals Ocular Changes in Astronauts of PVR. Only by performing the Researchers recently found that astronauts have disc edema-like changes in eye structure procedure on more patients will after returning to Earth from the International Space Station (ISS). the true risk be assessed.” The study looked at morphological changes in the optic nerve head and surrounding The researchers have a long way tissues in 15 astronauts after they completed a roughly six-month mission aboard the ISS. to go before proving the patch’s The results were compared with 43 healthy control patients with no history of exposure to full safety and effi cacy, how- microgravity in space. After analyzing optical coherence tomography (OCT) data for the as- ever. For one, “there is no control tronauts collected before and after the mission, the researchers found three major changes group, so it is unclear how the in eye structure. vision recovery experienced fol- Before the fl ight, the astronauts presented with recessed Bruch’s membrane openings lowing this intervention compares compared with the healthy controls. After the mission, their membrane openings were to the vision recovery that would deepened. Additionally, the astronauts showed a noteworthy increase of total retinal thick- occur following standard therapy ness near the optic nerve head rim margin, and the total number of eyes with choroidal folds for this disorder (anti-VEGF increased. therapy),” Dr. Trevio adds. “But While determining an exact cause of these changes was not within the study’s scope, the the prospect of having another results do point to long-term exposure to microgravity and space travel as a possibility. Be- treatment for this disorder that has yond that, the researchers believe the algorithms and methods used to determine structural the potential to improve vision is changes could be helpful in both future space travel studies and those here on Earth. very exciting.”

1. da Cruz L, Fynes K, Georgiadis O, et al. Phase 1 clinical Patel N, Pass A, Mason S, et al. Optical coherence tomography analysis of the optic nerve head and surrounding structures study of an embryonic stem cell–derived retinal pigment in long-duration international space station astronauts. JAMA Ophthalmol. 2018;136(2):193-200. epithelium patch in age-related macular degeneration. Nature Biotechnology. March 19, 2018. [Epub ahead of print].

6 REVIEW OF OPTOMETRY APRIL 15, 2018

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RP0118_Akon Zioptan.indd 1 12/19/17 2:42 PM News Review Scientists Discover a New ‘Organ,’ Label it “the Interstitium”

sing probe-based confo- spaces and hid them from exami- for movement of injurious agents, cal laser endomicroscopy nation for decades, the research- pro-fi brogenic signaling molecules, U(pCLE), researchers can ers said in the report. By viewing and tumor cells,” according to the now view living tissue at the the live tissue, Neil Theise, MD, study. “This raises the possibility microscopic level—leading to the a professor of pathology at New that direct sampling of the inter- recent discovery of fl uid-fi lled York University Langone School stitial fl uid could be a diagnostic spaces in the body’s connective of Medicine, and colleagues tool.” tissue. In a recently published found not a dense structure, but This fi nding, while potentially report, investigators are calling the an “open, fl uid-fi lled highway,” ground-breaking, raises more interconnected, fl uid-fi lled spaces that transports “interstitial” fl uid, questions than it answers. How- supported by a lattice of thick including lymph and drains into ever, it “allows us ask all kinds collagen “bundles” a new ‘organ,’ the lymphatic system.1 of questions we didn’t even know although further research and a Because the purported new to ask beforehand,” said Michael consensus is necessary before the ‘organ’ is in connective tissues all Nathanson, MD, chief of the label can become offi cial.1 over the body, the researchers hy- digestive diseases section at Yale Previous research used stan- pothesize several functions—and University School of Medicine, dard microscopic slides to explore possible dysfunctions. For one, who was not involved in the work this tissue layer, which, when they note the interstitium may act but observed the network of dark viewed on the slides, appeared to as a “shock absorber” for other fi bers in a 2011 study of his own.1 be “densely-packed barrier-like organs subject to “cycles of com- 1. Rettner R. Meet your interstitium, a newfound ‘organ.’ Live 2 2 Science. www.livescience.com/62128-interstitium-organ. walls of collagen.” pCLE reveals pression and distension.” And html?utm_source=notifi cation. March 27, 2018. Accessed a failing of this traditional scien- because it seems integral to lymph March 29, 2018. 2. Benias PC, Wells RG, Sackey-Aboagye B, et al. Structure and tifi c method, as the preparation movement throughout the body, it distribution of an unrecognized interstitium in human tissues. process collapsed the fl uid-fi lled may also be “a potential conduit Scientifi c Reports 2018;8:4947. Rare Corneal Dystrophy Gene ID’ed enome sequencing has GRHL2—that leads to dysfunction for further studies to under- lead researchers to identify tion in the endothelial barrier and, stand even more about the biologi- Gthe root cause of posterior ultimately, PPCD.1 cal processes leading to corneal polymorphous corneal dystrophy Using data from a large family dystrophies and to developing new (PPCD), a rare autosomal-dom- of Czech origin, the researchers treatments,” Neil Meemaduma, a inant form of corneal dystrophy mapped a locus for an autosomal- research manager with Fight for that affects the corneal endothe- dominant corneal endothelial Sight—which assisted in funding lium, according to a new study dystrophy. The whole-genome the research—said in a statement published in the March edition of sequencing identifi ed a unique on the organization’s website.2 ■ the American Journal of Human variant that causes the gene to 1 1. Liskova P, Dudakova L, Evans C, et al. Ectopic GRHL2 Genetics. Investigators from Uni- be expressed inappropriately in Expression Due to Non-coding Mutations Promotes Cell versity College London’s Institute corneal endothelial cells. State Transition and Causes Posterior Polymorphous Corneal Dystrophy 4. AJHG. 2018;102(3):447–59. of Ophthalmology and Moorfi elds “We are delighted that the 2. Omoniyi Y. Researchers discover a new genetic cause of Eye Hospital London have nailed results from this study led to the corneal dystrophy. Fight for Sight: The Eye Research Charity. www.fi ghtforsight.org.uk/news-and-views/articles/news/ down the precise variation to the discovery of a new genetic cause researchers-discover-a-new-genetic-cause-of-corneal- DNA—located on a gene called of PPCD. This will be the founda- dystrophy/. Accessed March 29, 2018.

8 REVIEW OF OPTOMETRY APRIL 15, 2018

0003_ro0418_news.indd03_ro0418_news.indd 8 33/30/18/30/18 4:394:39 PMPM BEAR IN MIND THE FORMULATION OF LOTEMAX® GEL

• ENGINEERED TO ADHERE TO THE OCULAR SURFACE1,2 • DOSE UNIFORMITY—EVERY DROP, EVERY TIME - Adaptive viscosity: Gel at rest, viscous liquid on the eye - No shaking required to resuspend drug2-4 - Drug-related blurred vision was rarely reported (0.25%, 2/813) • pH OF 6.5 CLOSE TO THAT OF HUMAN TEARS2 • ® ~70% LESS PRESERVATIVE than LOTEMAX SUSPENSION • CONTAINS 2 KNOWN MOISTURIZERS3 2,3,5 (loteprednol etabonate ophthalmic suspension) 0.5% - Glycerin and propylene glycol ~80% unrestricted managed care access on commercial plans* Indication LOTEMAX® GEL (loteprednol etabonate ophthalmic gel) 0.5% is indicated for the treatment of post-operative inﬂ ammation and pain following ocular surgery. Important Safety Information about LOTEMAX® GEL • LOTEMAX ® GEL is contraindicated in most viral diseases of the cornea and conjunctiva including epithelial herpes simplex keratitis (dendritic keratitis), vaccinia, and varicella, and also in mycobacterial infection of the eye and fungal diseases of ocular structures. • Prolonged use of corticosteroids may result in glaucoma with damage to the optic nerve, defects in visual acuity and fields of vision. If this product is used for 10 days or longer, IOP should be monitored. • Use of corticosteroids may result in posterior subcapsular cataract formation. • Use of steroids after cataract surgery may delay healing and increase the incidence of bleb formation and occurrence of perforations in those with diseases causing corneal and scleral thinning. The initial prescription and renewal of the medication order should be made by a physician only after examination of the patient with the aid of magnification, and where appropriate, fluorescein staining. • Prolonged use of corticosteroids may suppress the host response and thus increase the hazard of secondary ocular infection. In acute purulent conditions, steroids may mask infection or enhance existing infection. • Use of a corticosteroid medication in the treatment of patients with a history of herpes simplex requires great caution. Use of ocular steroids may prolong the course and exacerbate the severity of many viral infections of the eye (including herpes simplex). • Fungal infections of the cornea are particularly prone to develop coincidentally with long-term local steroid application. Fungus invasion must be considered in any persistent corneal ulceration where a steroid has been used or is in use. • Patients should not wear contact lenses when using LOTEMAX® GEL. • The most common ocular adverse drug reactions reported were anterior chamber inflammation (5%), eye pain (2%) and foreign body sensation (2%). Please see brief summary of Prescribing Information on adjacent page.

References: 1. Rajpal RK, Fong R, Comstock TL. Loteprednol etabonate ophthalmic gel 0.5% following cataract surgery: integrated analysis of two clinical studies. Adv Ther. 2013;30:907-923. 2. Coff ey MJ, Decory HH, Lane SS. Development of non-settling gel formulation of 0.5% loteprednol etabonate for anti-inﬂ ammatory use as an ophthalmic drop. Clin Ophthalmol. 2013;7:299-312. 3. LOTEMAX GEL [package insert]. Tampa, FL: Bausch & Lomb Incorporated. 4. Apt L, Henrick A, Silverman LM. Patient compliance with use of topical ophthalmic corticosteroid suspensions. Am J Ophthalmol. 1979;87(2):210-214. 5. LOTEMAX SUSPENSION [package insert]. Tampa, FL: Bausch & Lomb Incorporated. * Fingertip Formulary data 2017

RP0917_BL Lotemax.indd 1 8/25/17 9:47 PM BRIEF SUMMARY OF PRESCRIBING INFORMATION ossification) and teratogenic (increased incidence of meningocele, abnormal This Brief Summary does not include all the information needed to left common carotid artery, and limb flexures) when administered orally prescribe Lotemax Gel safely and effectively. See full prescribing to rabbits during organogenesis at a dose of 3 mg/kg/day (35 times information for Lotemax Gel. the maximum daily clinical dose), a dose which caused no maternal toxicity. The no-observed-effect-level (NOEL) for these effects was 0.5 mg/kg/day (6 times the maximum daily clinical dose). Oral treatment (loteprednol etabonate ophthalmic gel) 0.5% Lotemax of rats during organogenesis resulted in teratogenicity (absent innominate Rx only artery at ≥5 mg/kg/day doses, and cleft palate and umbilical hernia Initial Rx Approval: 1998 at ≥50 mg/kg/day) and embryotoxicity (increased post-implantation losses at 100 mg/kg/day and decreased fetal body weight and skeletal INDICATIONS AND USAGE ossification with ≥50 mg/kg/day). Treatment of rats with 0.5 mg/kg/day LOTEMAX is a corticosteroid indicated for the treatment of post-operative (6 times the maximum clinical dose) during organogenesis did not result inflammation and pain following ocular surgery. in any reproductive toxicity. Loteprednol etabonate was maternally toxic DOSAGE AND ADMINISTRATION (significantly reduced body weight gain during treatment) when administered Invert closed bottle and shake once to fill tip before instilling drops. to pregnant rats during organogenesis at doses of ≥5 mg/kg/day. Apply one to two drops of LOTEMAX into the conjunctival sac of the affected Oral exposure of female rats to 50 mg/kg/day of loteprednol etabonate from eye four times daily beginning the day after surgery and continuing the start of the fetal period through the end of lactation, a maternally toxic throughout the first 2 weeks of the post-operative period. treatment regimen (significantly decreased body weight gain), gave rise to decreased growth and survival, and retarded development in the offspring CONTRAINDICATIONS during lactation; the NOEL for these effects was 5 mg/kg/day. Loteprednol LOTEMAX, as with other ophthalmic corticosteroids, is contraindicated in etabonate had no effect on the duration of gestation or parturition when most viral diseases of the cornea and conjunctiva including epithelial herpes administered orally to pregnant rats at doses up to 50 mg/kg/day during the simplex keratitis (dendritic keratitis), vaccinia, and varicella, and also in fetal period. mycobacterial infection of the eye and fungal diseases of ocular structures. There are no adequate and well controlled studies in pregnant women. WARNINGS AND PRECAUTIONS LOTEMAX should be used during pregnancy only if the potential benefit Intraocular Pressure (IOP) Increase justifies the potential risk to the fetus. Prolonged use of corticosteroids may result in glaucoma with damage to the Nursing Mothers optic nerve, defects in visual acuity and fields of vision. Steroids should be It is not known whether topical ophthalmic administration of corticosteroids used with caution in the presence of glaucoma. If this product is used for 10 could result in sufficient systemic absorption to produce detectable quantities days or longer, intraocular pressure should be monitored. in human milk. Systemic steroids appear in human milk and could suppress Cataracts growth, interfere with endogenous corticosteroid production, or cause other Use of corticosteroids may result in posterior subcapsular cataract formation. untoward effects. Caution should be exercised when LOTEMAX is administered Delayed Healing to a nursing woman. The use of steroids after cataract surgery may delay healing and increase the Pediatric Use incidence of bleb formation. In those diseases causing thinning of the cornea Safety and effectiveness in pediatric patients have not been established. or sclera, perforations have been known to occur with the use of topical Geriatric Use steroids. The initial prescription and renewal of the medication order should No overall differences in safety and effectiveness have been observed be made by a physician only after examination of the patient with the aid between elderly and younger patients. of magnification such as slit lamp biomicroscopy and, where appropriate, NONCLINICAL TOXICOLOGY fluorescein staining. Carcinogenesis, Mutagenesis, Impairment Of Fertility Bacterial Infections Long-term animal studies have not been conducted to evaluate the Prolonged use of corticosteroids may suppress the host response and carcinogenic potential of loteprednol etabonate. Loteprednol etabonate was thus increase the hazard of secondary ocular infections. In acute purulent not genotoxic in vitro in the Ames test, the mouse lymphoma tk assay, or in conditions of the eye, steroids may mask infection or enhance existing a chromosome aberration test in human lymphocytes, or in vivo in the single infection. dose mouse micronucleus assay. Treatment of male and female rats with up Viral Infections to 50 mg/kg/day and 25 mg/kg/day of loteprednol etabonate, respectively, Employment of a corticosteroid medication in the treatment of patients with (600 and 300 times the maximum clinical dose, respectively) prior to and a history of herpes simplex requires great caution. Use of ocular steroids may during mating did not impair fertility in either gender. prolong the course and may exacerbate the severity of many viral infections PATIENT COUNSELING INFORMATION of the eye (including herpes simplex). Administration Fungal Infections Invert closed bottle and shake once to fill tip before instilling drops. Fungal infections of the cornea are particularly prone to develop Risk of Contamination coincidentally with long-term local steroid application. Fungus invasion must be considered in any persistent corneal ulceration where a steroid has been Patients should be advised not to allow the dropper tip to touch any surface, used or is in use. Fungal cultures should be taken when appropriate. as this may contaminate the gel. Contact Lens Wear Contact Lens Wear Patients should not wear contact lenses during their course of therapy with Patients should be advised not to wear contact lenses when using LOTEMAX. LOTEMAX. Risk of Secondary Infection ADVERSE REACTIONS If pain develops, redness, itching or inflammation becomes aggravated, the Adverse reactions associated with ophthalmic steroids include elevated patient should be advised to consult a physician. intraocular pressure, which may be associated with infrequent optic nerve damage, visual acuity and field defects, posterior subcapsular cataract Bausch + Lomb, a division of Valeant Pharmaceuticals North America LLC formation, delayed wound healing and secondary ocular infection from Bridgewater, NJ 08807 USA pathogens including herpes simplex, and perforation of the globe where US Patent No. 5,800,807 there is thinning of the cornea or sclera. ©Bausch & Lomb Incorporated The most common adverse drug reactions reported were anterior chamber inflammation (5%), eye pain (2%), and foreign body sensation (2%). Lotemax is a registered trademark of Bausch & Lomb Incorporated or its affiliates. USE IN SPECIFIC POPULATIONS Pregnancy LGX.0114.USA.16 Teratogenic Effects Based on 9269101/9269201 Revised: 08/2016 Loteprednol etabonate has been shown to be embryotoxic (delayed

RRP0917_BLP0917_BL LotemaxLotemax PI.inddPI.indd 1 88/25/17/25/17 9:479:47 PMPM Contents Review of Optometry April 15, 2018

11th Annual Pharmaceuticals Report KNOW YOUR SYSTEMIC MEDS: THE TOP

TO TRACK Here’s what you need to know about the ocular effects of the heavy-hitters. BY MEGAN HUNTER, OD, AND MICHELLE MARCINIAK, OD 1 PAGE 44

One Size Won’t Fit All: Treating Ocular Infection Knowing which antibiotic to choose and how to use it are critical when treating and beating ocular infection. BY TRACY OFFERDAHL-MCGOWAN, PharmD, AND GREG CALDWELL, OD PAGE 52 Sizing Up Anti-inflammatories in Dry Eye Disease A practical guide for optometrists applying these medications. BY VIN DANG, OD PAGE 62 Protocols and Pitfalls in Topical Steroid Use It’s always a balancing act between benefit and side effects. Here’s how to keep patients safe while treating with steroids. BY AARON BRONNER, OD, AND WALTER O. WHITLEY, OD, MBA PAGE 66

Proceed With Caution: Low Vision and Driving Here’s how you can navigate the complex interplay between DMV standards and the needs of your patients who

74 are visually impaired. By Mark E. Wilkinson, OD, and Khadija S. Shahid, OD, MPH

REVIEW OF OPTOMETRY APRIL 15, 2018 11

009_ro0418_toc.indd 11 4/3/18 9:40 AM Departments Review of Optometry April 15, 2018

3 News Review 14 Letters to the Editor 18 Through My Eyes Just Say Yes to (Some) Drugs BUSINESS OFFICES PAUL M. KARPECKI, OD 11 CAMPUS BLVD., SUITE 100 NEWTOWN SQUARE, PA 19073

20 Chairside CEO, INFORMATION SERVICES GROUP The Extinction of the Ink Pen MARC FERRARA MONTGOMERY VICKERS, OD (212) 274-7062 • [email protected]

PUBLISHER 22 Clinical Quandaries JAMES HENNE Taking the Floor on Fractures 22 (610) 492-1017 • [email protected] PAUL C. AJAMIAN, OD REGIONAL SALES MANAGER MICHELE BARRETT 24 Outlook (610) 492-1014 • [email protected] A Significant Proposal JACK PERSICO REGIONAL SALES MANAGER MICHAEL HOSTER (610) 492-1028 • [email protected] 26 Coding Connection No Sneaking Around this Code VICE PRESIDENT, OPERATIONS JOHN RUMPAKIS, OD, MBA CASEY FOSTER (610) 492-1007 • [email protected]

28 Focus on Refraction VICE PRESIDENT, CLINICAL CONTENT Fresnel Prism to the Rescue PAUL M. KARPECKI, OD, FAAO MARC B. TAUB, OD, MS, AND [email protected] PAUL HARRIS, OD PRODUCTION MANAGER SCOTT TOBIN 32 Retina Dilemmas (610) 492-1011 • [email protected] Hold ’em or Fold ’em? 28 SENIOR CIRCULATION MANAGER DIANA SHECHTMAN, OD, AND HAMILTON MAHER JAY M. HAYNIE, OD (212) 219-7870 • [email protected]

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86 Therapeutic Review CIRCULATION Take Your Lumps PO BOX 81 JOSEPH W. SOWKA, OD, AND CONGERS, NY 10920 ALAN G. KABAT, OD TEL: (TOLL FREE): (877) 529-1746 OUTSIDE US: (845) 267-3065 89 Glaucoma Grand Rounds 84 The Devil is in the Details JAMES L. FANELLI, OD

CEO, INFORMATION SERVICES GROUP 91 Advertisers Index MARC FERRARA 93 Surgical Minute SENIOR VICE PRESIDENT, OPERATIONS The MIGS Just Keep on Coming JEFF LEVITZ CHRISTOPHER KRUTHOFF, OD, VICE PRESIDENT, HUMAN RESOURCES WALTER O. WHITLEY, OD, MBA, AND TAMMY GARCIA

DEREK N. CUNNINGHAM, OD VICE PRESIDENT, CREATIVE SERVICES & PRODUCTION MONICA TETTAMANZI 94 Classifieds CORPORATE PRODUCTION DIRECTOR 97 Meetings & Conferences JOHN ANTHONY CAGGIANO VICE PRESIDENT, CIRCULATION 98 Diagnostic Quiz EMELDA BAREA There Will Be Blood 98 ANDREW S. GURWOOD, OD

12 REVIEW OF OPTOMETRY APRIL 15, 2018

009_ro0418_toc.indd 12 4/3/18 9:39 AM CONTRIBUTING EDITORS A. PAUL CHOUS, MA, OD, TACOMA, WASH. PAUL C. AJAMIAN, OD, ATLANTA ROBERT M. COLE, III, OD, BRIDGETON, NJ AARON BRONNER, OD, KENNEWICK, WASH. GLENN S. CORBIN, OD, WYOMISSING, PA. MILE BRUJIC, OD, BOWLING GREEN, OHIO ANTHONY S. DIECIDUE, OD, STROUDSBURG, PA. S. BARRY EIDEN, OD, DEREK N. CUNNINGHAM, OD, AUSTIN, TEXAS DEERFIELD, ILL. STEVEN FERRUCCI, OD, EPULVEDA ALIF MARK T. DUNBAR, OD, MIAMI S , C . MURRAY FINGERET, OD, EWLETT ARTHUR B. EPSTEIN, OD, PHOENIX H , NY IAN BEN GADDIE, OD, LOUISVILLE, KY. JAMES L. FANELLI, OD, WILMINGTON, NC PAUL HARRIS, OD, MEMPHIS, TN FRANK FONTANA, OD, ST. LOUIS MILTON HOM, OD, AZUSA, CALIF. GARY S. GERBER, OD, HAWTHORNE, NJ BLAIR B. LONSBERRY, MS, OD, MED, PORTLAND, ORE. ANDREW S. GURWOOD, OD, PHILADELPHIA THOMAS L. LEWIS, OD, PHD, PHILADELPHIA ALAN G. KABAT, OD, MEMPHIS, TENN. DOMINICK MAINO, OD, MED, CHICAGO DAVID KADING, OD, SEATTLE KELLY A. MALLOY, OD, PHILADELPHIA PAUL M. KARPECKI, OD, LEXINGTON, KY. RICHARD B. MANGAN, OD, LEXINGTON, KY. JEROME A. LEGERTON, OD, MBA, SAN DIEGO RON MELTON, OD, CHARLOTTE, NC JASON R. MILLER, OD, MBA, POWELL, OHIO PAMELA J. MILLER, OD, JD, HIGHLAND, CALIF. CHERYL G. MURPHY, OD, BABYLON, NY BRUCE MUCHNICK, OD, COATESVILLE, PA. CARLO J. PELINO, OD, JENKINTOWN, PA. MARC MYERS, OD, COATESVILLE, PA. JOSEPH PIZZIMENTI, OD, SAN ANTONIO, TEXAS WILLIAM B. POTTER, OD, FREEHOLD, NJ JOHN RUMPAKIS, OD, MBA, PORTLAND, ORE. CHRISTOPHER J. QUINN, OD, ISELIN, NJ DIANA L. SHECHTMAN, OD, FORT LAUDERDALE, FLA. MICHAEL C. RADOIU, OD, STAUNTON, VA. JEROME SHERMAN, OD, NEW YORK MOHAMMAD RAFIEETARY, OD, MEMPHIS, TN JOSEPH P. SHOVLIN, OD, SCRANTON, PA. JOHN L. SCHACHET, OD, ENGLEWOOD, COLO. JOSEPH W. SOWKA, OD, FORT LAUDERDALE, FLA. JACK SCHAEFFER, OD, BIRMINGHAM, ALA. MONTGOMERY VICKERS, OD, LEWISVILLE, TEXAS LEO P. SEMES, OD, BIRMINGHAM, ALA. WALTER O. WHITLEY, OD, MBA, VIRGINIA BEACH, VA. LEONID SKORIN, JR., OD, DO, ROCHESTER, MINN. JOSEPH W. SOWKA, OD, FORT LAUDERDALE, FLA. EDITORIAL REVIEW BOARD SRUTHI SRINIVASAN, PhD, BS OPTOM, WATERLOO, ONT. JEFFREY R. ANSHEL, OD, ENCINITAS, CALIF. BRAD M. SUTTON, OD, INDIANAPOLIS JILL AUTRY, OD, RPH, HOUSTON LORETTA B. SZCZOTKA, OD, PHD, CLEVELAND SHERRY J. BASS, OD, NEW YORK MARC TAUB, OD, MEMPHIS, TN EDWARD S. BENNETT, OD, ST. LOUIS TAMMY P. THAN, MS, OD, BIRMINGHAM, ALA. MARC R. BLOOMENSTEIN, OD, SCOTTSDALE, ARIZ. RANDALL THOMAS, OD, CONCORD, NC CHRIS J. CAKANAC, OD, MURRYSVILLE, PA. SARA WEIDMAYER, OD, ANN ARBOR, MI JERRY CAVALLERANO, OD, PHD, BOSTON KATHY C. WILLIAMS, OD, SEATTLE WALTER L. CHOATE, OD, MADISON, TENN. KAREN YEUNG, OD, LOS ANGELES BRIAN CHOU, OD, SAN DIEGO

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009_ro0418_toc.indd 13 4/3/18 9:39 AM Letters to the Editor

The February 2018 cover story, future surpluseses Today’sToday’ annual gradu- “How the Diploma Deluge is of optom- ation ratera of 1,900 will Reshaping Optometry,” presented etrists and eventuallyeventua produce a comments from educators and data shortages of workforceworkf of 76,000 from the Association of Schools ophthalmolo- practicingpract optom- and Colleges in Optometry gists. These etrists,etris a density (ASCO) to look at the impact of initial projec- ofof optometrists optometry’s expanded educational tions assumed perpe 1,000 nearly footprint. The feature generated no surplus of twicet today’s. criticism, praise and suggestions, optometrists existedxisted It has been some of which is addressed in the in 2012 despitee tthehe too easy, for following letters and our reply. fi ndings of its oownwn nana-- toot long, for tional survey ooff a 32% scschoolshools tto meet Accred- Behind the Drive “excess capacity.”ty.” iitationtation CouncilCouncil oon Optometric Kudos for your well researched The group thenh EdEducationi (A(ACOE)COE) accreditation and appreciated article. I believe constructed a complex model that standards, which are far less robust one cannot have a “deluge” of did include the 2012 optometry than medical and dental schools graduates without producing a “excess capacity,” but increased due to a lack of quantitative stan- surplus of optometrists, and that future eye care demands due to the dards for required student contacts this surplus was self-induced and is Affordable Care Act, the grow- by types/numbers during training. counterproductive to patient care. ing diabetes rate and child health —Kenneth J. Myers, PhD, OD This surplus was fi rst predicted in insurance plans. In this “unifi ed President, American Board of a 1995 Rand study and again by eye care market,” optometrists and Certifi cation in Medical an Abt. Associates study in 2000.1,2 ophthalmologists were assumed Optometry 1. Lee P, Jackson C, Rolles D. RAND, Estimating eye care pro- But both underestimated future interchangeable. The fi nal model’s vider supply and workforce requirements. www.rand.org/pubs/ surpluses because graduates have assumptions claimed: monograph_reports/MR516.html. 1995. 2. White A, White C, Doksum T. Workforce study of optom- since increased about 40%. 1. No increase in future ophthal- etrists. St. Louis, MO: Abt Associates Inc. American Optometric In 2011, the Lewin Group—with mologists or their productivity. Association. 2000. 3. American Optometric Association/Lewin Group. Eye Care AOA-appointed advisors—was 2. Optometry “excess capaci- Workforce Study: Supply and Demand Projections. Executive commissioned to survey how ties” will “fi ll” shortages of oph- Summary. April 25, 2014. optometrists practiced and to thalmologists. estimate the future supply of, and 3. Optometrists and ophthalmol- The Whole Truth demand for, eye care. Its 2012 sur- ogists have identical scopes of care Your recent article identifi es a vey found a 32% optometry sur- and considered interchangeable subject worthy of discussion by plus and its supply/demand model generic “eye care providers.” the profession in looking to plan in 2014 predicted greater future 4. A rate of 1.36 optometrists for the future. Unfortunately, the optometry surpluses but increasing provide the care equivalent of one article appears to be something ophthalmology shortages.3 Howev- ophthalmologist. written more for a deadline than er, Lewin’s fi ndings stated, “There These were, of course, implau- for a serious consideration of all would be an adequate supply of sible assumptions. the aspects. The effect of manda- eye care providers in the future,” The chief impetus for the “di- tory board passage for graduation which was egregiously mislead- ploma deluge” were Bureau of La- and its effect on graduation rate ing. Lewin buried the optometry bor Statistics reports claiming high was not even mentioned, nor was surplus within the surplus of “eye demand for optometrists that led the recalibration of the Optomet- care providers” and characterized the media to report optometry was ric Admission Test (OAT) during it as “an adequate supply of eye “hot.” But the primary source for the years across which the author care providers.” those forecasts were rosy projec- compares scores. While footnotes In 2014, Lewin next developed tions supplied by the AOA leader- are used to imply some vigorous optometry and ophthalmology sup- ship and bitterly resisted, over the research, all the data is not given. ply/demand projections and found years, by some staff offi cers. For classes that matriculated in

14 REVIEW OF OPTOMETRY APRIL 15, 2018

0014_ro0418_Letters.indd14_ro0418_Letters.indd 1414 33/30/18/30/18 4:414:41 PMPM 2017, the University of the Incar- Every year, administrators re- Center for Practice Excellence. It nate Word Rosenberg School of view the test to determine whether suffered from low pass rates before Optometry had an entering class it’s still a predictive indicator for that and its reputation was nega- GPA that was higher than four of schools. Before the 2009 test, tively impacted. When the school the six oldest institutions listed. they decided it was not. However, started requiring board passage, The entire article must be the adjustment was “not really a that changed drastically; in fact, viewed with suspicion as it shows change in the test, it’s a change in it infl uenced other schools in the the Arizona College of Optometry how many items the student needs South to embrace requiring board to have been established in 2017 to get correct in order to get to passage. A rising tide lifts all boats. and yet provides its pass rates on 300,” Dr. Damari explains. “It’s an Others wonder whether requir- licensing examinations. Once you adjustment, not a major rescal- ing students to pass a test that the realize the magnitude of that error ing.” There’s an ebb and fl ow to institution itself does not compose you begin to question everything all testing, he suggests. Once a test itself amounts to a violation of the else the article asserts. starts to mature, average scores go institution’s autonomy. After all, —Timothy A. Wingert, OD up and that’s how administrators the school issues a degree, not a Dean, University of the know it’s time to recalibrate the license. Incarnate Word test. In fact, educators are look- As our story noted, the numbers Rosenberg School of Optometry ing again to adjust the scoring. Dr. don’t tell all. Optometry schools’ Damari notes that “2008 was just standards clearly exist on a spec- Keeping Us Honest before one calibration and 2017 trum and, although they can be We thank the above readers and is probably going to end up being measured in a variety of ways, they others who reached out to com- right before another recalibration. can never really be ranked. There ment on the article. Several readers If anything, that’s an incredibly fair will always be some incongruity or pointed out that Midwestern Uni- comparison.” unique circumstance. Although we versity’s Arizona College of Op- The article also makes use of can quantify performance and use tometry’s fi rst class was in 2009, recently released statistics from data to predict success, we cannot 2017. We regret the error. The the National Board of Examin- not quantify human beings and, online version has been corrected. ers in Optometry revealing the ultimately, that’s what optometric Second, Table 3 of our article percentage of graduates who pass education must focus on: training compared the OAT scores of the boards. However, we did not actual human beings from a variety matriculating students from 2008 discuss a caveat to those numbers; of backgrounds, to become skilled, with those from 2017. Some read- that some schools require students dedicated, passionate doctors. ers pointed out, correctly, that the to pass part one or parts one and If it’s to thrive, optometric scoring was modifi ed in 2009. The two of the boards (nobody re- education must serve two masters, test is graded on a scale of 200 to quires passing part three) before it one from the idealistic world of 400. In 2009, adjustments were allows them to graduate. Although academia and one from the sober, made to reduce the average score— it does impact what that ultimate hard-nosed world of capitalism. which had crept up to 320—to board pass rate is, this really And while doing that may require 300. According to Association of raises a philosophical question. If schools to compromise from time Schools and Colleges of Optom- optometry schools exist to educate to time, the educational system’s etry President David Damari, OD, future optometrists, should they do infl uence over the future of optom- the changes included “changing the all they can to ensure their students etry is not absolute. The real future way raw scores (number of items success—and does “doing all they is in the hands of the students answered correctly) were converted can” include guaranteeing they can themselves, who—we hope our ar- to the standard scores reported.” pass the boards? ticle demonstrated—strive to grow He went on to explain that, “As Look at Southern College of the profession while preserving the the test ages—so to speak—the Optometry (SCO), which started legacy of their predecessors. average score goes up a little bit at requiring the national boards in —Bill Kekevian a time, for various reasons, espe- 1990, according to Lisa Wade, Senior Editor, cially in reading comprehension.” OD, director at SCO’s Hayes Review of Optometry

REVIEW OF OPTOMETRY APRIL 15, 2018 15

0014_ro0418_Letters.indd14_ro0418_Letters.indd 1515 33/30/18/30/18 4:414:41 PMPM Advertorial Don’t Hold Back

There are many good reasons to switch patients to silicone hydrogel—whether they’re wearing frequent replacement or 1-day lenses.

consider the fact that more than 75% of you ask most optometrists which lens material is their go-to for monthly contact lens wearers admit to napping in and two-week fi ts, the answer is overwhelmingly silicone hydrogel. Due their lenses and 28% admit to sleeping to its increased oxygen transmissibility, silicone hydrogel off ers patients If * in their lenses at least once a month. a healthier lens-wearing experience. Indeed, on average, ECPs fi t 91% Whether they are telling you about it or of their monthly and two-week contact lens wearers in silicone hydrogel lenses. This trying to hide from you, these patients is in stark contrast to how many 1-day patients they fi t in silicone hydrogel—they fi t need as much oxygen as they can get— only 30% of 1-day patients in silicone hydrogel. no matter how frequently they replace This begs the question: Why don’t doctors routinely fi t 1-day wearers in the same their lenses. material they prefer for frequent replacement wear? Unfortunately, the answer to Dr. Frogozo: I agree. We need to be this question remains a mystery, particularly in light of startling new research, which more realistic about how our patients are demonstrates that doctors’ lens prescribing patterns lag far behind their beliefs about wearing their lenses. The reality is that what’s best for patients. most patients don’t wear their lenses for We spoke with three optometrists for insight on this disconnect between beliefs just a few hours per day. Research shows and behavior. In the interviews that follow, these 1-day silicone hydrogel advocates that 1-day wearers in the U.S. habitually explain why they are committed to this material for 1-day fi ts and share advice on wear their contact lenses for at least how to always recommend the lens you trust the most. 15 hours per day, seven days per week. Before reaching for a 1-day hydrogel, ask yourself if hydrogel would be your fi rst choice for the patient if he or she Is hydrogel good enough for most The Practitioners 1-day lens wearers? was wearing a frequent replacement Melanie Frogozo lens. If the answer is no, then why would Dr. Rosinski: I strongly believe that OD, FAAO, FSLS you deprive the 1-day wearer of this silicone hydrogel 1-day lenses provide The Contact Lens same opportunity? better long-term eye health for my Institute of San Antonio What meaningful advantages does patients than hydrogel 1-day lenses. San Antonio, Texas Furthermore, 91% of my colleagues silicone hydrogel have in a 1-day lens? agree according to recent research. We Dr. Frogozo: I agree with 92% of also need to consider the increasing Ethan E. Huisman ECPs who say silicone hydrogel 1-day OD, FAAO demands of modern life. In this digital Elite Eye Care lenses are the best choice to safeguard era, patients are prone to dryness, West Des Moines, patients’ eye health related to contact discomfort and fl uctuating vision. Silicone Iowa lens wear. This same study shows hydrogel lenses outperform hydrogel in that 92% likewise believe that silicone terms of all-day comfort and eye health. hydrogel 1-day lenses provide the best Steve Rosinski benefi ts to their patients. In terms of Furthermore, we know from experience OD with frequent replacement lenses that Crozet Eye Care my own personal beliefs and how that increased oxygen permeability leads to Charlottesville, guides how I practice, I’m concerned that clinically meaningful outcomes. It has Virginia the hydrogel wearer will develop hypoxia an impact on corneal edema, limbal and eventually drop out of lens wear. hyperemia, neovascularization, refractive It’s a familiar story that we’ve seen play Dr. Huisman: I have a relatively young out when hydrogel was the go-to lens in error change, epithelial thinning, and patient population, so I’m very focused frequent replacement. more. With all this in mind, I would say on preserving ocular surface health for silicone hydrogel is an obvious choice 20, 30 or even 40 years or more. In my Dr. Huisman: Doctors want health, but for the health and comfort of 1-day practice, making compromises isn’t in the patients care about comfort. Silicone lens wearers. patient’s long-term best interests. Also, hydrogel 1-day lenses off er both.

RO0418_Coopervision.indd 2 3/28/18 11:44 AM with the current lenses, than the trial. A strong recommendation I shift the conversation focus from a doctor is all most patients need around preventative care. to hear. If you believe silicone hydrogel is a superior material, the patient will likely Dr. Frogozo: My practice believe it too. However, if you have a is primarily referral-based, patient who is already wearing a 1-day which means patients walk in lens in a hydrogel material and you want wearing many diff erent types Silicone hydrogel 1-day lenses are great to switch to silicone hydrogel, the lens of lenses. Despite this, I fi t my sphere for my younger patients because they’re trial can be a tipping point. In these patients almost exclusively in 1-day so easy to insert and remove—plus cases, I tell the patient that their current silicone hydrogel lenses. And, as the toric they’re extremely comfortable. My lenses are based on older technology, so parameters expand, I’m fi tting more patients aren’t rushing home from work I’m off ering them an opportunity to trial so they can take out their lenses. That’s and more astigmats in 1-day silicone something newer and healthier. a meaningful, practical advantage. hydrogel as well. Patients rarely object to my recommendation. I proactively Dr. Huisman: I agree. Trials are great Dr. Rosinski: The number one educate my patients on the need for but the conversation has to precede it. I advantage is ocular health. When oxygen in lens wear and advise them don’t want patients to think I’m making the clariti 1 day family of lenses was that silicone hydrogel is healthiest. a change for change’s sake. Eighty-two introduced, it was a no-brainer for percent of ECPs believe that silicone me to switch my 1-day patients. Dr. Rosinski: I go beyond generic, hydrogel should be the standard of Silicone hydrogel creates a highly traditional questioning. You won’t get care for 1-day contact lens patients “breathable” lens that promotes much information by asking, “how are and 87% say silicone hydrogel material whiter, brighter** eyes. your contacts?” Patients are likely to should be the fi rst choice of material for say, “FINE,” which in my view means daily disposable lenses. When patients How do you get patients on board “Feelings I’ve Not Expressed.” The more hear that from us, they’re more likely to with your decision to switch to pointed questions you ask, the more approach the lens trial with enthusiasm. a silicone hydrogel material— you are likely to discover something especially if they seem happy with to improve upon. Upgrading to silicone Dr. Rosinski: Trialing silicone hydrogel their current hydrogels? hydrogel doesn’t require a huge change 1-day lenses also helps strengthen our in mindset for a current 1-day wearer. relationships with patients. First, we Dr. Huisman: Patients are confi dent in make the recommendation and educate On the contrary, it’s an obvious choice your recommendation when you cite the patient on the benefi ts. Next, they because 1-day patients are already a specifi c reason for change. I educate take the lens for a test drive. Finally, health conscious. Moving to silicone them on the benefi ts and advantages when they return satisfi ed with the hydrogel is simply a logical next step. of silicone hydrogel generally and for comfort and vision of their new lenses, their case specifi cally. Quite oft en, Does the lens trial play a they’re more confi dent than ever in our my hydrogel patients have signs of signifi cant role in convincing knowledge and our commitment to neovascularization or hyperemia, so I 1-day wearers about the benefi ts providing the best possible care. take a photo of this and show it to the of silicone hydrogel? patient, explaining that this is the reason change is needed. In the event that the Dr. Frogozo: In my practice, the patient has no signs and is very happy conversation is usually more powerful

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* With higher oxygen permeability than hydrogel materials, silicone hydrogel contact lenses minimize or eliminate hypoxia-related signs and symptoms during lens wear. ** Data on ﬁ le; clariti® 1 day off ers whiter eyes than 1-DAY ACUVUE® MOIST®.

RO0418_Coopervision.indd 3 3/28/18 11:44 AM Through My Eyes

Just Say Yes to (Some) Drugs Don’t shy away from prescribing the right medications when your patients need them. By Paul M. Karpecki, OD, Chief Clinical Editor

ptometrists manage more gan) and Xiidra (lifitegrast, Shire) Many cases necessitate systemic anterior segment disease have made significant contributions therapy, and in today’s healthcare than anyone, and it’s critical to treating the underlying inflamma- system, a referral before treatment O 2 that we have the pharma knowledge tion of dry eye disease. Xiidra may leaves the patient vulnerable to to treat these patients appropriately. bring symptom improvement in as significant morbidity. Soft tissue This month’s annual pharmaceutical little as two weeks, and some stud- infections such as dacryocystitis, issue provides detailed advice to elevate ies of Restasis show improvement at hordeola, canaliculitis and preseptal your practice so you can give patients one month.3 cellulitis are just one category that much-needed relieve and recovery. I’d comes to mind (orbital cellulitis like to preface this article series with a Topical Steroids requires referral to an emergency few thoughts from my perspective as Don’t fear these drugs. For superficial room for intravenous antibiotics). both a clinician and an educator. punctate keratitis (SPK), few treat- Systemic medications are also ments are more effective.4 There are required to fully control chronic Antibiotics risks to withholding steroids when conditions such as ocular rosacea, Just because we haven’t seen a new managing inflammatory diseases multiple or repeat hordeola and antibiotic in a few years doesn’t such as corneal neovascularization, chalazia, and chronic ocular surface mean we should get complacent synechiae, persistent SPK, progressive disease. Severe allergies, derma- in drug selection. Drug resistance, dry eye, corneal haze and scarring. tological disorders and immune while steady, is incredibly high.1 At the same time, don’t be responses may require a short The most recent ARMOR study—a cavalier with steroids. Although the course of oral prednisone. One can- yearly review of over 3,000 ocular only absolute contraindication is not manage most cases of ocular isolates in the United States—found epithelial herpetic disease, there are herpes simplex virus without oral methicillin-resistant Staphylococ- times when you should apply cau- antivirals, and even over-the-counter cus is resistant to 30% to 40% of tion in their use. For example, be oral nonsteroidals can greatly aid a antibiotics; for coagulase-negative wary of steroids when treating an patient with a corneal abrasion. Staph., it’s nearly 50%. Because we early infectious keratitis (especially It’s nearly impossible to effective- don’t typically culture conjunctivitis without a confirmed diagnosis), an ly manage ocular disease without and it takes so long to get a culture abrasion or when using a bandage occasionally having to reach into for an infectious keratitis, we have contact lens. There still may be a the bag for an oral medication. Give to be knowledgeable and judicious role for steroids in such cases, but this hard-won legal right the recog- when treating empirically.1 Most exercise greater caution. Always nition—and use—it deserves. ■ bacteria are susceptible to newer check intraocular pressure within Note: Dr. Karpecki is a consultant agents such as Besivance (besifloxa- three to five weeks for any patient for many companies discussed here. cin, Bausch + Lomb).1 on a corticosteroid. To help ensure 1. Asbell PA, Sanfilippo CM, Pillar CM, et al. Antibiotic resistance the patient returns for the check, I among ocular pathogens in the United States: five-year results from the Dry Eye Drugs often provide no refills on steroid- Antibiotic Resistance Monitoring in Ocular Microorganisms (ARMOR) Surveillance Study. JAMA Ophthalmol. 2015;133(12):1445-54. Although artificial tears continue to containing drops in new patients. 2. Stern ME, Gao J, Schwalb TA, et al. Conjunctival T-cell subpopula- tions in Sjögren’s and non-Sjögren’s patients with dry eye. Invest advance with a number of new and Ophthalmol Vis Sci. 2002;43(8):2609-14. increasingly effective options, they Systemic Medications 3. Deveci H, Kobak S. The efficacy of topical 0.05 % cyclosporine A in patients with dry eye disease associated with Sjogren’s syndrome. Int still play a palliative role, with little An optometrist without access to Ophthalmol. 2014;34(5):1043-8. 4. Coursey TG, de Paiva CS. Managing Sjögren’s syndrome and value in addressing inflammation. systemic meds is in a difficult posi- non-Sjögren syndrome dry eye with anti-inflammatory therapy. Clin Both Restasis (cyclosporine, Aller- tion to effectively care for patients. Ophthalmol. 2014;8:1447-58.

18 REVIEW OF OPTOMETRY APRIL 15, 2018

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RO0418_Imprimis.indd 1 3/26/18 10:28 AM Chair Side

The Extinction of the Ink Pen …and other things. What’s in your pile of office junk you never use anymore? By Montgomery Vickers, OD

ow that we are all techno everything instead of actually doing their irides and how long they slept. post-pseudo-Millennials, I anything real. Have you noticed Confirmation calls. When Ncannot find an ink pen any- how soft their hands are these days? patients had one phone in the house, where. That’s right, people from the Quarterly soft contact lenses. two rings garnered an answer. Now South call it an ink pen. If you do What? You still have some patients everyone has a phone glued to their not call it an ink pen, you are either disposing of their lenses once every ear, but no one answers. a transplant from the North or pre- 90 days? That’s just two 90 packs of Lunchtime office hours. I blame tentious. Either way is fine by me. dailies lasting 22 years. myself for this one. I started clos- I do have a couple of ink pens that Bandage contact lenses. You ing the office for lunch in 2006. survived the Great Ink Pen Purge remember, the ones that were actu- This attracted patients like bears to created by the Feds in an attempt to ally studied and approved by the honey, and they all came to pick up protect patient records by making FDA for this use only. I’ll bet I know stuff as soon as I locked the door. it easier for any basement-dwelling what you really use. Elevator music. Once a staple of hacker get all of them with the Paper Snellen charts. OK, these every reception area, the soothing stroke of a key. Before, they had to are not extinct, but 100% of them orchestral versions of the Beatles’ break into my office and carry them are at the pediatrician’s office where White Album has given way to big out, which is way more effort than your patient’s kid “just had an eye TVs explaining progressive spectacle any hacker would expend. exam.” To be fair, they don’t need lenses to people wearing ear buds There are so many other things to see the pediatrician for a physical listening to orchestral versions of the that have become extinct in the new either because, well, they seemed Beatles’ White Album. frontier of optometry: healthy enough when we saw them. It’s OK, time marches on. The Pen lights. There may be a few Last-minute cancellations. I just next generation will look back holdouts who test every pupil every stuck this in here because I knew fondly on extinct stuff, too. Like time with a penlight, but most of us you’d laugh. ODs, if we don’t watch out. ■ know if anything’s messed up by the Shirt and tie. The last time I saw time we hit them with a slit lamp. this in the office was me passing by PD ruler. Why bother? ODs are a mirror. The staff and the patients always griping about not being absolutely loved it, so try it. paid for giving patients PDs. Folks, Being on time. Now that we have anything on the patient’s chart is 200 separate pretesting instruments, their information, not yours. If you we might see our 9am by 9pm, like to fight over releasing PDs, just but at least we’ll quit measuring them. You can’t give know the exact them what you don’t have. wavelength Trifocals. Now and then a patient color of wanders in who loves his version of “start, step and stumble,” but most aren’t very excited to have any lines on their glasses, much less two. Double segs. Another victim of the tech age where mechanics and electricians plug a gizmo in to reset

20 REVIEW OF OPTOMETRY APRIL 15, 2018

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RP0418_Keeler.indd 1 3/22/18 4:26 PM Clinical Quandaries

Taking the Floor on Fractures When a mishap puts an orbital floor fracture in your chair, know how to look past the gore and devise a plan. Edited by Paul C. Ajamian, OD Q A patient called me Sunday eve- need to send for emergency surgery. ning after being on the losing However, there are a few extenuat- end of a bar brawl Friday night. When ing circumstances. Young kids, for seen in the ER on Saturday, a CT scan example, can more easily present revealed an orbital floor fracture. He with entrapment and require imme- was told to see an eye doctor. How do diate surgery. “I usually see this in you examine this swollen eye and how kids under age 13,” adds Dr. Milite, do you know when surgery is in order? “as their bones are pliable and don’t A “First of all, don’t panic,” A 25-year-old male with orbital floor crack—they bend and snap back, says James Milite, MD, an fracture raises questions about the need causing tight EOM entrapments.” oculoplastic surgeon from Omni Eye for reconstructive surgery. This can lead to nausea, vomiting Services in Iselin, NJ. In many cases, and a decrease in blood pressure. the impact of the injury will make away from the midline. This might Since the fracture snaps closed the eye look worse than it is. “Take indicate a fracture of the cheek bone almost like a trap door, it might not a step back and take your time doing or cheek complex,” he says. Left seem significant on the scan, but a thorough exam,” he says. untreated, it could permanently pull these signs represent a potentially A comprehensive history is your the lower lid down or flatten the urgent case and require a rapid next step. You’ll want to know how malar region. referral to an oculoplastic surgeon. the injury happened and what struck Failure to refer could result in the eye. “Ask if there was any loss To Refer or Not to Refer? irreparable damage to the tightly of consciousness at the scene of the After examination, you should have entrapped muscle. incident; also find out if there have a sense of whether or not you have When choosing to treat these been any flashes, floaters or double a surgical candidate on your hands, cases with antibiotics or steroids, vision. Check their lateral gaze and says Dr. Milite. “You’re looking a few simple rules will suffice. downgaze, ability to open and close for either or both of the following: “Antibiotics are given due to theo- the mouth, and look for evidence of entrapment causing restriction of retical risk of infection, so a five-day decreased sensitivity in the distribu- extraocular muscles (EOMs) and course of prophylactic antibiotic tion of the maxillary division of the diplopia in functional fields, and can’t hurt,” says Dr. Milite. “If you trigeminal nerve,” says Dr. Milite. enophthalmos greater than 2mm.” have a patient with a moderate-size After ruling out head trauma and However, the degree of periorbital fracture and excessive swelling, an foreign bodies, conduct your typical edema often makes assessment of oral steroid will cut the window eye exam—acuities, confrontation globe position and motility difficult. down for edema resolution to fields, pupils and a careful anterior “It’s also important to look out unmask the development of enop- and posterior segment exam. “Make for signs of proptosis of the eye,” thalmos and help determine the need sure the retinal periphery is OK, adds Dr. Milite. “This is an indica- for repair.” and look out for corneal abrasions, tor of a retrobulbar hemorrhage.” Consult a specialist if in doubt. hyphema, iridodialysis, uveitis, cata- Though uncommon, it necessitates In this case, referral resulted in sur- ract, vitreous hemorrhage and retinal an urgent referral to an oculoplastic gery later that week. “Describe the detachment,” adds Dr. Milite. Also, specialist. All these patients require fracture, explain motility issues and examine the orbit. “This can be the CT imaging if not already obtained record everything,” Dr. Milite says. trickiest part due to the eye swell- prior to your exam. “If it’s a surgical candidate, ask what ing,” he says. “Observe if the globe Typically, if the primary injury is you can do to prepare the patient is sunken or displaced downward an orbital floor fracture, you won’t before sending them along.” ■

22 REVIEW OF OPTOMETRY APRIL 15, 2018

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1. Ketelson H, Rangarajan R. Pre-clinical evaluation of a novel phospholipid nanoemulsion based lubricant eye drops. Poster presented at: The Annual Meeting of the Association for Research in Vision and Ophthalmology (ARVO); May 7–11, 2017; Baltimore, Maryland, USA. 2. Data on fi le. Alcon; 2017. 3. Fernandez KB, Epstein SP, Raynor GS, et al. Modulation of HLA-DR in dry eye patients following 30 days of treatment with a lubricant eyedrop solution. Clin Ophthalmol. 2015;9:1137-1145. 4. Davitt WF, Bloomenstein M, Christensen M, Martin AE. Effi cacy in patients with dry eye after treatment with a new lubricant eye drop formulation. J Ocul Pharmacol Ther. 2010;26(4):347-353. 5. Korb D, Blackie C, Meadows D, Christensen M, Tudor M. Evaluation of extended tear stability by two emulsion based artifi cial tears. Poster presented at: 6th International Conference of the Tear Film and Ocular Surface: Basic Science and Clinical Relevance; September 22-25, 2010; Florence, Italy. 6. Lane S, Paugh J, Webb JR, Christensen MT. An evaluation of the in vivo retention time of a novel artifi cial tear as compared to a placebo control. Poster presented at: The Annual Meeting of the Association for Research in Vision and Ophthalmology (ARVO); May 3-7, 2009; Fort Lauderdale, FL. 7. Craig JP, Nichols KK, Akpek EK, et al. TFOS DEWS II defi nition and classifi cation report. Ocul Surf. 2017;15:276- 283. 8. Torkildsen G. The effects of lubricant eye drops on visual function as measured by the Inter-blink interval Visual Acuity Decay test. Clin Ophthalmol. 2009;3:501-506.

RO0418_Alcon Systane.indd 1 3/28/18 9:56 AM Outlook By Jack Persico, Editor-in-Chief PRINTED IN USA

FOUNDING EDITOR, FREDERICK BOGER 1891-1913

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SUBSCRIPTION INQUIRIES design, experts say. 1-877-529-1746 CONTINUING EDUCATION INQUIRIES ies, they say, come in three vari- Poof, one-third of your ‘facts’ just 1-800-825-4696 eties: lies, damn lies and sta- went up in smoke. EDITOR-IN-CHIEF • JACK PERSICO tistics. Cynical though it may It’s a scary proposition, but may (610) 492-1006 • [email protected] L sound, that rings true for anyone be for the best. Such a move would MANAGING EDITOR • REBECCA HEPP (610) 492-1005 • [email protected] whose profession revolves around cut a lot of noise out of the conver- SENIOR EDITOR • BILL KEKEVIAN numbers. Medicine, of course, is sation. Too many studies using P val- (610) 492-1003 • [email protected] rife with statistics: the incidence and ues in the 0.05 range are quoted and ASSOCIATE EDITOR • MICHAEL IANNUCCI (610) 492-1043 • [email protected] prevalence of diseases, the efficacy of promoted as gospel, in eye care and ASSOCIATE EDITOR • FRANCESCA CROZIER-FITZGERALD therapies, optimal dosing regimens, other disciplines. “Most claims sup- (610) 492-1021 • [email protected] adverse events, risk factors, survival ported with P values slightly below SPECIAL PROJECTS MANAGER • JILL HOFFMAN (610) 492-1037 • [email protected] rates—all are expressed in numeric 0.05 are probably false (i.e., the ART DIRECTOR • JARED ARAUJO terms, sometimes to a hundredth of a claimed associations and treatment (610) 492-1032 • [email protected] decimal point. Even quality of life, by effects do not exist),” the editorial DIRECTOR OF CE ADMINISTRATION • REGINA COMBS (212) 274-7160 • [email protected] its very name a qualitative measure, states. “Even among those claims

EDITORIAL BOARD gets quantified in health care. that are true, few are worth acting CHIEF CLINICAL EDITOR • PAUL M. KARPECKI, OD Do doctors rely too much on the on in medicine and health care.” ASSOCIATE CLINICAL EDITORS • JOSEPH P. SHOVLIN, OD; statistics in medical literature? The And yet, many of those claims ALAN G. KABAT, OD; CHRISTINE W. SINDT, OD people in charge of medicine and the are the lifeblood of medical practice DIRECTOR OPTOMETRIC PROGRAMS • ARTHUR EPSTEIN, OD CLINICAL & EDUCATION CONFERENCE ADVISOR people in charge of statistics think today. Health care would be better PAUL M. KARPECKI, OD so. An editorial in the Journal of off, says the editorial, “with fewer, CASE REPORTS COORDINATOR • ANDREW S. GURWOOD, OD the American Medical Association, larger, and more carefully conceived CLINICAL CODING EDITOR • JOHN RUMPAKIS, OD, MBA echoing the American Statistical and designed studies with sufficient CONSULTING EDITOR • FRANK FONTANA, OD Association, argues that probabilities power to pass these more demand- COLUMNISTS (expressed by the P value) “are misin- ing thresholds.” CHAIRSIDE • MONTGOMERY VICKERS, OD terpreted, overtrusted and misused.”1 Of course, this would be no CLINICAL QUANDARIES • PAUL C. AJAMIAN, OD Actually, it’s fairer to say that the panacea. Those with a vested inter- CODING CONNECTION • JOHN RUMPAKIS, OD CORNEA & CONTACT LENS Q+A • JOSEPH P. SHOVLIN, OD problem isn’t so much reliance on est, most notably for-profit entities DIAGNOSTIC QUIZ • ANDREW S. GURWOOD, OD statistics but rather the way in which more interested in finding a market- THE ESSENTIALS • BISANT A. LABIB, OD we ascribe validity to medical ‘facts’ ing angle rather than the purity of FOCUS ON REFRACTION • MARC TAUB, OD; that are expressed numerically. The truth, could just move the goalposts. PAUL HARRIS, OD GLAUCOMA GRAND ROUNDS • JAMES L. FANELLI, OD two groups seek to tighten that up “Selected study end points may NEURO CLINIC • MICHAEL TROTTINI, OD; by advocating for “lowering the become even less clinically relevant MICHAEL DELGIODICE, OD routine P value threshold for claim- because it is easier to reach lower OCULAR SURFACE REVIEW • PAUL M. KARPECKI, OD ing statistical significance from 0.05 P values with weak surrogate end RETINA QUIZ • MARK T. DUNBAR, OD REVIEW OF SYSTEMS • CARLO J. PELINO, OD; to 0.005 for new discoveries.” That points than with hard clinical out- JOSEPH J. PIZZIMENTI, OD means the likelihood of a random comes,” JAMA warns. SURGICAL MINUTE • DEREK N. CUNNINGHAM, OD; (rather than causative) association It’s not easy to think of scientific WALTER O. WHITLEY, OD, MBA THERAPEUTIC REVIEW • JOSEPH W. SOWKA, OD; in a study would drop from 5% to validity as a tunable instrument: turn ALAN G. KABAT, OD 0.5%, raising the bar for what gets the dial up and certainty goes down. THROUGH MY EYES • PAUL M. KARPECKI, OD called significant. This would “shift But this proposal reminds us that URGENT CARE • RICHARD B. MANGAN, OD about one-third of the statistically our facts are only as ‘real’ as our JOBSON MEDICAL INFORMATION LLC significant results of past biomedical methods—and motives—demand. ■

literature to the category of just ‘sug- 1. Ioannidis JP. The proposal to power P value thresholds to .005. gestive,’” the editorial states. JAMA. March 22, 2018 [Epub ahead of print.]

24 REVIEW OF OPTOMETRY APRIL 15, 2018

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RO0418_Haag Octopus.indd 1 3/26/18 2:11 PM Coding Connection

No Sneaking Around this Code Modifier -59 should be a last resort. Here’s how to use it wisely. By John Rumpakis, OD, MBA, Clinical Coding Editor onsider this scenario: A its proper application. Modifier -59 in the CPT definition, modi- patient comes in for a glau- is used to identify procedures/ser- fier -59 should only be used Ccoma workup after being vices, other than E/M services, that if no other modifier more identified as a suspect during last are not normally reported together, appropriately describes the week’s annual exam. During this but are appropriate under the cir- relationship of the two proce- follow-up office visit (9921X) cumstances. Documentation must dure codes.”3 you want to do: optical coherence support a different session, different tomography (OCT) optic nerve procedure or surgery, different site Limitations (92133), fundus photography or organ system, separate incision/ Modifier -59 should not be (92250), pachymetry (76514) and excision, separate lesion or separate appended to an E/M service. To threshold visual fields (92083). injury (or area of injury if exten- report a separate E/M service with sive) not ordinarily encountered or a non-E/M service performed on The Temptation performed on the same day by the the same date, use modifier -25.4 You know fundus photography same individual. Modifier -59 can You should never use modifier and OCT of the optic nerve are not be used appropriately in these situ- -59 to bypass a PTP edit unless allowed on the same date of service. ations (remember, the eye is con- you meet and document the proper However, you have heard certain sidered a single anatomic structure criteria required by any NCCI- modifiers, such as -59, can “over- and site):2,3 associated modifier. The use of ride” these rules on the claim form 1. “Modifier -59 is used appro- modifier -59 does not require a dif- so you can get paid for both ser- priately for different anatomic ferent diagnosis for each HCPCS/ vices. So what should you do? Let’s sites during the same encoun- CPT coded procedure; conversely, take a look. ter only when procedures different diagnoses are not adequate which are not ordinarily criteria for use of modifier -59. The Where to Start performed or encountered on HCPCS/CPT codes remain bundled The rules that govern situations the same day are performed unless the procedures are per- such as this one are the National on different organs, or differ- formed at different anatomic sites Correct Coding Initiative (NCCI) ent anatomic regions, or in or separate patient encounters.4 edits, which are found in CMS’s limited situations on different, NCCI Policy Manual For Medicare non-contiguous lesions in dif- Misuse Services, published yearly and ferent anatomic regions of the Modifier -59 is used inappropri- updated quarterly. These edits con- same organ.”3 ately if the basis for its use is simply trol the pairing of procedures on 2. “Another common use of that the narrative description of the the same date of service.1 modifier -59 is for surgi- two codes is different. Understanding these code pairing cal procedures, non-surgical One of the common misuses of rules and their context is crucial, therapeutic procedures or modifier -59 is related to the por- especially when applying a modi- diagnostic procedures that tion of the definition allowing its fier that will override a claim pair are performed during differ- use to describe a “different proce- denial. One of the most abused ent patient encounters on the dure or surgery.” The code descrip- modifiers is -59. same day and that cannot be tors of the two codes of a code described by one of the more pair edit usually represent different CMS Definition specific NCCI-associated procedures, even though they may To properly use a modifier, you modifiers—i.e., 24, 25, 27, be overlapping. The edit indicates must know both the definition and 57, 58, 78, 79 or 91. As noted that the two procedures should not

26 REVIEW OF OPTOMETRY APRIL 15, 2018

026_ro0418_coding.indd 26 3/30/18 4:51 PM be reported together if performed another in that a provider would For our case example, using at the same anatomic site and same use one technique or the other to modifier -59 on the fundus photog- patient encounter, as those pro- evaluate fundal disease. raphy code might get you paid, but cedures would not be considered As with most rules, a few excep- it is not appropriate. You must first “separate and distinct.” tions exist, and there are a limited establish proper medical necessity However, if the two procedures number of clinical conditions where for each procedure that you need to are performed at separate anatomic both techniques are medically perform. Remember, modifier -59 sites or at separate patient encoun- reasonable and necessary on the is a last resort and should be used ters on the same date of service, ipsilateral eye. In these situations, sparingly in clinical practice. ■ modifier -59 may be appended to both CPT codes may be reported Send questions and comments to indicate that they are different pro- appending modifier -59 to CPT [email protected]. cedures on that date of service. code 92250.”5 1. Centers for Medicare and Medicaid Services (CMS). Those limited number of clinical National Correct Coding Initiative Edits. www.cms.gov/ -59 in Your Office conditions must meet the definition Medicare/Coding/NationalCorrectCodInitEd/index.html. Accessed February 22, 2018. In ophthalmic practice, the most of medical necessity, i.e., patient 2. CMS. Modifier 59 Article. www.cms.gov/Medicare/ Coding/NationalCorrectCodInitEd/Downloads/modifier59. common combination with harm could be a result if the two pdf. Accessed February 22, 2018. which modifier -59 is improperly tests aren’t performed on the same 3. CMS. Proper Use of Modifier 59. www.cms.gov/ Outreach-and-Education/Medicare-Learning-Network-MLN/ used is CPT codes 92250 and date of service. This does not mean MLNMattersArticles/Downloads/SE1418.pdf. Accessed February 22, 2018. 92133/92134. The NCCI manual there is a wholesale acceptance 4. CMS. NCCI Policy Manual For Medicare Services – specifically states: “Fundus photog- of this code combination with Effective January 1, 2018:I-20, I-25, III-18, IV-23, V-29, VI-19, VII-20, VIII-26, IX-25, XI-12. XI-52, XII-21, XIII-10. raphy (92250) and scanning oph- modifier -59 just because the doctor www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd/ index.html. Accessed February 22, 2018. thalmic computerized diagnostic thinks it’s appropriate or because it 5. CMS. NCCI Policy Manual For Medicare Services – imaging (e.g., 92133, 92134) are is convenient for either the doctor Effective January 1, 2018:XI-12. www.cms.gov/Medicare/ Coding/NationalCorrectCodInitEd/index.html. Accessed generally mutually exclusive of one or the patient. February 22, 2018.

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026_ro0418_coding.indd 27 3/30/18 4:51 PM Focus on Refraction

Fresnel Prism to the Rescue Finding the perfect prism can take time and patience, but once it fits, it sticks. By Marc B. Taub, OD, MS, and Paul Harris, OD

hen we are called to complaint we encounter is double Case One see patients at a reha- vision. This occurs for a multitude One morning, a 44-year-old male bilitation facility, and of reasons, including muscle and reported that, several days prior, occasionally when nerve injury, and can be quite severe. he was pulling into a parking spot patientsW are scheduled for vision In these situations, the extent may at work, and when backing in, he therapy evaluations at Southern vary depending on the gaze and turned his head to get a better view College of Optometry, we truly do head position. In the short term, we and suddenly felt different. It turns not know what we are going to often use occlusion—either binasal out, he had a major aneurysm and encounter. Brain injury cases range or spot—to eliminate the double did something to the blood vessels from visual field and acuity loss to vision and evaluate the visual system and supply to his brainstem. Ever visual inattention to vague com- weeks later as the visual, and cogni- since, he had double vision. When plaints that something simply “feels tive and control systems come back he presented, he was wearing an eye off.” Of course, some patients are online. For comitant diplopia, we patch. Luckily, he was still operat- in such a state of decreased mental often investigate the use of prism ing at a high cognitive level, a cru- and physical capacity that they can- to attempt to restore single vision. cial aspect when considering the use not respond in a traditional manner. The two cases presented here dem- of Fresnel prism. Those are the most challenging, onstrate how the use of temporary Visual acuity, confrontation but can reap huge rewards for the Frensel prism can get your patients fields, pupils and eye movements patients in the long run. on the road to recovery quickly and were all normal. His primary Perhaps the most common effectively. complaint was the double vision, which he described as “vertical.” Upon visual inspection, the eyes appeared aligned. Cover testing at distance and near revealed a six prism diopter right hypertropia. The magnitude was not changed by altering his head posture or gaze. This was confirmed subjectively and objectively via cover test with loose prism. Not all patients suffering from brain injury double vision can obtain single vision so soon after, so we considered this a good opportunity to use temporary prism. However, the higher the prism strength, the more the visual acuity is degraded. Some patients are not willing or are unable to adjust to the degraded acuity. As his acuity without glasses was excel- These frames, fit binocularly with Fresnel prism, can be used to restore single vision lent, tried frames with plano lenses to patients such as the one in our first case. we had handy.

28 REVIEW OF OPTOMETRY APRIL 15, 2018

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RO0418_Xcel.indd 1 3/26/18 10:33 AM Focus on Refraction

may be out of the patient’s line of sight. On the other hand, if the magnitude of the diplopia is small, there is potential that the patient is indeed fusing some of the time. In this case, it was fortunately the latter. As with the first case, the patient was refractively normal. The double vision was intermittent, occurring 50% of the time without a recognizable pattern on the part of the patient or therapists. Cover testing showed a three diopter left hyperphoria. We grabbed our plano spectacles and Fresnel powers of one and two prism diopters from the kit. These frames are similar to the ones on page 28, but are only fit monocularly with Subjectively, the patient reported Fresnel prism. The other lens is plano. good fusion with the lower power but felt more comfortable with the The use of prism follows a pat- degraded vision, we tend to split higher one. We allowed him to sit tern we have presented over and the prism to even out the acuity with the prism on and questioned over in this column: less is typically decrease. Essentially, this brings him regarding the acuity difference. more. Over our careers, we have down both eyes equally instead of Since he was thrilled to not see dou- both found that patients need less penalizing one; lessening the visual ble, he was not fazed by the slight prism for fusion than measured on acuity in one eye would throw acuity difference. We ended up with the cover test or even as measured off the binocular system we are two prism diopters base down in with standard von Graefe or other working so hard to rehabilitate. If the right eye on the plano spectacles methods. Giving less prism than one eye has decreased acuity for and the patient was happy. measured also serves a therapeutic whatever reason, choosing not The therapists were ecstatic at role in leaving degrees of freedom to split the prism may be a better the improvement in skills several in which the system can operate. option. In that instance, we tend days later. He too will be re-evalu- With two base down over the to put the full amount of the prism ated in several days. We are hoping right eye and two base up over the or the bulk of it in front of the eye to either reduce or eliminate the left eye, the patient reported see- with the worse visual acuity or was prism if symptoms abated. ing single vision. We informed him turned all the time. Fresnel prisms can aid your that these were full-time glasses patient care regardless of whether and confirmed with the rehabilita- Case Two or not you treat patients with tion team that there were no visual Immediately following the previ- stroke or traumatic brain injury. restrictions. We checked back ous patient, a 63-year-old male If you are considering grinding several days later and the patient who suffered a head injury after in prism, the temporary prism can was still smiling. The rehab team a fall presented to the clinic. The help confirm the amount needed. In reported good progress on balance patient was in good spirits and some cases, the use of the prism has and hand-eye coordination activi- was joking around with me, which a therapeutic effect and the amount ties. He will follow up with the is always a good sign. Unlike the of prism can be reduced over time. vision rehab service at the college in patient described in case one, he This is especially true of patients in several weeks. was not wearing a patch, indicat- vision therapy. You may be wondering why we ing that either the magnitude of For some reason, optometrists chose to split the prism. With a the diplopia was especially high or seem afraid of prism. With the use patient who sees well, even though fairly low. If the magnitude of the of Fresnel prism, this fear should be he comprehends the potential for diplopia is large, one of the images eliminated. ■

30 REVIEW OF OPTOMETRY APRIL 15, 2018

028_ro0418_FOR.indd 30 3/30/18 4:54 PM ADVERTORIAL OPEN YOUR EYES TO A FRESH START: EYE HEALTH OF PATIENTS WHO SLEEP IN THEIR CONTACT LENSES

Reed Bro, OD

Optometrist Eye Care Center of Colorado Springs Colorado Springs, CO

Dr Reed Bro was compensated by Alcon for his participation in this advertorial. Sleeping in contact lenses that aren’t keratitis, and less than 0.04% with Unpredictable Busy Frequent Moms with approved for such use has been associated Work Schedules Professionals Travelers Young Kids presumed microbial keratitis and a loss of with discomfort, as well as with more serious visual acuity. eye health problems.1 Even so, a survey of Need immediate Eyes feel Travel too often Can’t see vision waking up strained looking to hassle with clearly getting My patients’ eye health is important to me contact lens wearers found that 64% of for shift at my mobile my lenses up throughout and my practice, but I also want to make those who sleep in their lenses for at least a devices the night sure that overnight lens wearers remain week at a time are not wearing extended/ 2 comfortable throughout the full overnight use lenses. A separate study ® recommended wearing period. AIR OPTIX found that about one-third of contact lens ® NIGHT & DAY AQUA contact lenses patients report wearing their lenses ® feature SmartShield Technology, a to bed.3 proprietary surface technology that In our practice, many patients want protects against the inherent hydrophobic extended-wear contact lenses because of properties of silicone.6,7 SmartShield® lifestyle demands, such as new moms, shift Technology acts as a protective barrier, workers and on-call physicians and nurses. limiting exposure of silicone on the surface One of my patients—a law student—spends of AIR OPTIX® contact lenses, and thereby endless hours studying in the school library helping to maintain excellent surface and sleeps for a few hours at a time, taking wettability and deposit resistance. With this naps when his schedule allows. He recently technology, my patients can experience complained of lens discomfort and frequent clear vision and consistent comfort from the redness, and his history revealed that he first day they put on their lenses, waking up often wore 2-week replacement lenses continuously and overnight for a week to these benefits for up to 30 days thereafter. at a time (for which his lenses were not approved). I explained that sleeping Since the health of my patients is very important to me, I’m concerned in lenses like his could cause the discomfort he was describing, and that it also that so many may be inappropriately wearing their contact lenses increased his risk of ulcerative keratitis, a serious condition that can lead to overnight. As their eye doctor, my job is to educate them and provide loss of vision, which is usually caused by a microbial infection. I switched him ® ® the best lenses to meet their needs. Thanks to the many benefits of to AIR OPTIX NIGH T & DAY AQUA contact lenses because, unlike some ® ® ® AIR OPTIX NIGHT overnight lenses that are available, I find that AIR OPTIX NIGHT & DAY ® & DAY AQUA AQUA contact lenses provide continuous comfort,4 and are specifically contact lenses, I can designed for continuous wear, even while napping and sleeping. The lenses provide comfort to are FDA approved for daily wear and up to 30 nights of continuous wear.* my overnight lens- AIR OPTIX® NIGHT & DAY® AQUA contact lenses are made from lotrafilcon wearing patients, A, a lens material with an established safety profile including a low rate ensuring that they of microbial keratitis.5 In a study of more than 6,000 lotrafilcon A see, look and feel wearers, only 0.18% of patients were diagnosed with presumed microbial their best.

Our passion is to help your patients see, look and feel their best.

*Extended wear for up to 30 continuous nights, as prescribed by an eye care practitioner Important information for AIR OPTIX® NIGHT & DAY® AQUA (lotrafilcon A) contact lenses: Indicated for vision correction for daily wear (worn only while awake) or extended wear (worn while awake and asleep) for up to 30 nights. Relevant Warnings: A corneal ulcer may develop rapidly and cause eye pain, redness or blurry vision as it progresses. If left untreated, a scar, and in rare cases loss of vision, may result. The risk of serious problems is greater for extended wear vs. daily wear and smoking increases this risk. A 1-year postmarketing study found 0.18% (18 out of 10,000) of wearers developed a severe corneal infection, with 0.04% (4 out of 10,000) of wearers experiencing a permanent reduction in vision by two or more rows of letters on an eye chart. Relevant Precautions: Not everyone can wear for 30 nights. Approximately 80% of wearers can wear the lenses for extended wear. About two-thirds of wearers achieve the full 30 nights continuous wear. Side Effects: In clinical trials, approximately 3-5% of wearers experience at least one episode of infiltrative keratitis, a localized inflammation of the cornea which may be accompanied by mild to severe pain and may require the use of antibiotic eye drops for up to one week. Other less serious side effects were conjunctivitis, lid irritation or lens discomfort including dryness, mild burning or stinging. Contraindications: Contact lenses should not be worn if you have: eye infection or inflammation (redness and/ or swelling); eye disease, injury or dryness that interferes with contact lens wear; systemic disease that may be affected by or impact lens wear; certain allergic conditions or using certain medications (eg. some eye medications). Additional Information: Lenses should be replaced every month. If removed before then, lenses should be cleaned and disinfected before wearing again. Always follow the eye care professional’s recommended lens wear, care and replacement schedule. Consult package insert for complete information, available without charge by calling (800) 241-5999 or go to myalcon.com.

References 1. Stapleton F, et al. The Incidence of Contact Lens-Related Microbial Keratitis in Australia. Opthalmology. 2008;115:1655-62. 2. Alcon data on file, 2012. 3. In a survey of 2,115 daily and extended wear contact lens patients. Alcon data on file, 2012. 4. Alcon data on file, 2012. 5. Schein OD, McNally JJ, Katz J, et al. The incidence of microbial keratitis among wearers of a 30-day silicone hydrogel extended-wear contact lens. Ophthalmology. 2005;112:2172-9. 6. Alcon data on file, 2012, 2013. 7. Epstein AB, et al. Surface and polymer chemistry: the quest for comfort. Rev Cornea Contact Lens. 2010;247:15-9.

RO0418_Alcon AOND.indd 1 3/26/18 10:24 AM Retina Dilemmas

Hold ’em or Fold ’em? Better treatment options for DME give us more flexibility, but also more responsibility. We need to use anti-VEGF prudently—if at all. By Diana Shechtman, OD, and Jay M. Haynie, OD

iabetic macular edema (DME) contributes sig- Dnificantly to vision loss in diabetes patients and is the most common cause of vision loss among young adults. Previously, these patients were subjected to focal or grid laser photocoagula- tion. Although this method was effective in reducing vision loss by 50%, it was ineffective in restor- Figs. 1 and 2. This patient’s center-involved DME (left) responded well to anti-VEGF (right). ing lost vision. All patients who participated in the original Early Classification of DME is now history includes hypertension and Treatment Diabetic Retinopathy based more on optical coherence 12 years of Type 2 diabetes. Her Study (ETDRS) had visual acuity of tomography (OCT) images than medication history included metfor- 204/0 or worse.1 funduscopy. The world of oph- min and glyburide for diabetes, and Fortunately, management of thalmology and retina in general is lisinopril for hypertension. Her best- DME has improved over the last moving away from the classifica- corrected visual acuity measured decade and has increased the poten- tion of clinically significant macular 20/40 in the right eye and 20/20 in tial of visual restoration with the edema (CSME), which primarily the left eye. The anterior segment approval of anti-VEGF compounds relied on funduscopic findings, exam was unremarkable, and she Lucentis (ranibizumab, Genentech) and more towards spectral-domain was phakic. Dilated examination and Eylea (aflibercept, Regeneron), OCT (SD-OCT) findings and reti- revealed moderate nonprolifera- and the off-label use of Avastin nal thickness. Now, DME is bro- tive diabetic retinopathy (NPDR) (bevacizumab, Genentech). Given ken down into “center involved” with multiple dot-blot hemorrhages the role inflammation plays in the (CI-DME) and “non-center and central macular thickening). development of DME, steroids have involved” (NCI-DME) cases based SD-OCT confirmed CI-DME also become an effective option on SD-OCT subfields. (Figure 1). in DME management. Ozurdex These advances have given She was treated with serial anti- (dexamethasone, Allergan) is a retina specialists and comanag- VEGF injections, variously using time-release intravitreal implant ing optometrists more options for bevacizumab and aflibercept. She that emits a low dose of dexameth- management of DME—but also responded well, achieving resolu- asone over 90 to 120 days. Another more room for doubt and debate tion of the edema and a recovery implant, Iluvien (fluocinolone ace- regarding whether, when and how in vision to 20/20 with stable OCT tonide, Alimera Sciences), the most to intervene. images (Figure 2). recent therapy approved to treat This case may seem straightfor- DME, has an efficacy of up to 36 A Tale of Two Patients ward, and the retinal referral was months. Focal or grid macular laser By Dr. Haynie considered both necessary and is also still used for clinically signifi- Case 1. A 51-year-old white unremarkable. Now let’s look at cant macular edema. female presented for an evaluation another case of DME and discuss The ways we detect and with a six-month history of blurred how the referral and management define DME have evolved, too. vision in the right eye. Her medical may differ.

32 REVIEW OF OPTOMETRY APRIL 15, 2018

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RO0418_MS Tech.indd 1 3/26/18 11:35 AM Retina Dilemmas

Fig. 3. Circinate lipid ring in case 2. Figs. 4 and 5. The macular edema (left) resolved without therapy at three months (right).

Case 2. This 68-year-old Native ones described above. The question edema on the ETDRS retinal thick- American female was referred for an of whether to treat or observe has ness OCT grid, but the increased evaluation of diabetic retinopathy become increasingly controversial. thickness is not confined to the cen- and macular edema. She reported DME is dynamic and, as Dr. Haynie tral area. In our practice, many cases that her vision had been stable with points out in case 2, may have the defined as CSME may still benefit no recent symptoms. Her medical potential for resolution without from focal laser. Yet, the manage- history included Type 2 diabetes of intervention. Hence, it is critical to ment of each case is assessed on an 12 years’ duration, hypertension and educate the patient about the impor- individual basis. cardiac arrhythmia. Medications tance of tight glycemic control. Studies such as the Diabetic included glargine and metformin Yet, many cases will progress Retinopathy Clinical Research for diabetes, and amlodipine, meto- and, if untreated, result in decreased Network’s Protocol V may in fact prolol and clopidogrel for hyperten- visual acuity. Thus, all five surgeons help us to better assess the efficacy sion. Entering best-corrected visual at my practice would agree with the of anti-VEGF therapy in cases acuity measured 20/25 in each management of case 1. In the pres- where the visual acuity is 20/25 or eye. Anterior segment evaluation ence of decreased visual acuity (i.e., better.2 This study compares three revealed grade 2 nuclear cataracts in <20/25) and CI-DME, anti-VEGF approaches to management in each eye. Dilated fundus examina- therapy is initiated at our practice. patients with center-involved DME tion revealed mild NPDR in each Patients are often treated for about but good visual acuity: (1) prompt eye with a circinate ring of lipid in three months. If further assistance use of laser plus deferred anti-VEGF, the temporal macula of the right is necessary, we’ll consider a steroid (2) observation plus deferred anti- eye (Figure 3). SD-OCT imaging implant such as Ozurdex or Iluvien. VEGF and (3) prompt use of anti- revealed NCI-DME with a normal Keep in mind that prior to the use of VEGF therapy. foveal contour and thickness. Iluvien, it is recommended to have Researchers hope the results will After a discussion of the available the patient on a steroid challenge to reveal how long anti-VEGF therapy treatment options, including serial minimize the potential of complica- can be deferred and the impact of anti-VEGF intravitreal injections, tions such as glaucoma. observation or laser treatment in she elected to observe rather than Case 2 may not be as straightfor- such cases. There is still debate as treat. After three months, the NCI- ward. In cases of NCI-DME with to the prompt use of anti-VEGF: DME resolved and her vision was good visual acuity, we may observe does the benefit justify accepting the maintained at 20/25 in the right eye but still evaluate for the presence known risks, and what is the opti- (Figures 4 and 5). of CSME as defined by the ETDRS mal number of injections needed to (retinal thickening and hard, yellow maintain vision? Hopefully, Protocol How Our Practice Compares exudates within 500µm of the foveal V’s results will shed some light. ■

By Dr. Shechtman center and at least one disc area of 1. Early Treatment Diabetic Retinopathy Study Research Group. Early photo- Given that I practice in a retina thickening within one disc diameter coagulation for diabetic retinopathy. ETDRS report number 9. Ophthalmology. 1991 May;98(5 Suppl):766-85. clinic in South Florida, we are of the foveal center). These cases 2. Treatment for CI-DME in Eyes With Very Good VA Study (Protocol V). inundated with cases similar to the often show increased focal macular https://clinicaltrials.gov/ct2/show/NCT01909791. Accessed March 20, 2018.

34 REVIEW OF OPTOMETRY APRIL 15, 2018

032_ro0418_RD.indd 34 3/30/18 4:58 PM RO0418_Menicon.indd 1 3/26/18 2:21 PM FRONTLINE OCULAR SURFACE DISEASE CARE

A contemporary approach to dry eye using early detection and proactive intervention to slow the cascade of disease.

By Paul M. Karpecki, OD, FAAO; Lyndon Jones, PhD, FCOptom, FAAO; Kelly K. Nichols, OD, MPH, PhD, FAAO; Leslie O’Dell, OD, FAAO

ry eye, as we understand it today, is entirely different continuing education program, you don’t need expen- Dthan it was 20—or even 10— years ago. Of course, sive equipment to provide high-quality, comprehensive the disease itself has not changed, but our understand- ocular surface care. New technology makes it easier in ing of it has. As a result, we can now offer our patients higher-volume settings and in clinics that want to build a comfort, relief, improved ocular health, better vision and strong dry eye specialty presence, but by no means is this a quality of life that we struggled in vain to attain just a necessary. However, a current understanding of dry eye is few years ago. essential. This is what TFOS DEWS II offers. Thanks to tremendous amounts of clinical research and The following discussion breaks down these extensive the compilation of that research in the recently published reports into an easy-to-follow, ﬁ ve-step process. As you Tear Film and Ocular Surface Society (TFOS) Dry Eye will learn, a contemporary approach to dry eye involves Workshop (DEWS) II reports, anyone practicing optom- early detection and proactive intervention to slow the etry can make this specialty as fundamental to primary cascade of disease. This is in stark contrast to the old ap- care as a dilated fundus exam. As you’ll discover in this proach, when we would watch-and-wait for identiﬁ able

Release Date: April 15, 2018 Expiration Date: December 31, 2018 Goal Statement: Upon completing this educational activity, optometrists should have increased knowledge about research from the recent DEWS II report that redefines DED and further illuminates its pathophysiology, and new strategies for diagnosing and managing the disease and its inflammatory response in order to provide patients with the highest level of care. Faculty/Editorial Board: Lyndon Jones, PhD, FCOptom, FAAO; Paul M. Karpecki, OD, FAAO; Kelly Nichols, OD, MPH, PhD, FAAO; Leslie O’Dell, OD, FAAO Credit Statement: This course is COPE approved for 2 hours of CE credit. COPE ID is 56784-AS. Please check your state licensing board to see if this approval counts toward your CE requirement for relicensure. Joint-Sponsorship Statement: This continuing education course is joint sponsored by the University of Alabama School of Optometry. Disclosure Statement: Dr. Jones is a consultant for Alcon, CooperVision and J&J Vision; and a principal investigator for Alcon, Allergan, CooperVision, GL Chemtech, J&J Vision, Nature’s Way, Novartis, Santen and Shire Pharmaceuticals. Dr. Nichols is a consultant for Bruder Healthcare Company, InSite Vision, Parion Pharmaceuticals, SARcode Bioscience, Shire Pharmaceuticals, Sun Pharmaceuticals, Kala Pharmaceutical, Eleven Biotherapeutics, Science Based Health, Allergan, Santen Pharmaceutical. Dr. Karpecki is a consultant for Aerie Pharmaceuticals, Alcon, Abbott Medical Optics, Akorn, Allergan, Anthem Bausch + Lomb, Bio-Tissue, BlephEx, Beaver- Visitec, Bruder Healthcare, Cambium Pharma, Essilor, Eyes4Lives, Focus Labs, Glaukos, iCare USA, Imprimis Pharmaceuticals, J&J, Konan Medical, Maculogix, Oasis, Ocular Therapeutix, Oculus, OcuSoft, Regeneron, SightRisk, Reichert, Shire Pharmaceuticals, Science Based Health, Smart Vision Labs, TearScience, Topcon, TLC Vision, Vision Care Inc., Vmax and Visiometrics; a research grant principal investigator for Eleven BioTherapeutics, Fera Pharmaceuticals, Shire Pharmaceuticals; has received honoraria for the speaker’s bureaus of Glaukos and Oculus; is director/clinical advisor for Optometric Medical Solutions; and is on the board of directors for TearLab. Dr. O’Dell is a consultant to Eye Eco and Shire Pharmaceuticals; and is a speaker for Allergan, Shire and Genyzme. Supported by: An unrestricted educational grant from Shire.

Supported by an unrestricted Administered by Review of Optometry® educational grant from Approved Shire

0418_Shire_CE.indd 36 4/2/18 10:52 AM 2 CE Credits (COPE Approved)

signs of moderate to late-stage disease. Our current THE BIRTH OF A NEW DEFINITION approach to more advanced cases is also very differ- FOR DRY EYE ent today than it was a few years ago, because we now The revised defi nition of dry eye that was created have a better understanding of effective strategies to by TFOS in the TFOS DEWS II report states: “Dry quell disease and safeguard the ocular surface, lids eye is a multifactorial disease of the ocular surface and meibomian glands from further compromise. All characterized by a loss of homeostasis of the tear of this is good news for patients and great news for fi lm, and accompanied by ocular symptoms, in the doctors on the frontlines who encounter this com- which tear fi lm instability and hyperosmolarity, oc- plex disease all day, every day. ular surface infl ammation and damage, and neurosensory abnormalities play etiological roles.”1 STEP ONE: TRIAGE This defi nition is different from the original TFOS DEWS defi nition in meaningful ways.2 It was im- Dr. Karpecki: TFOS DEWS II lays out a very struc- portant to this subcommittee that the defi nition tured and methodical way of getting to the bottom has international relevance. A lot of time was spent 3 of dry eye disease. From a practical perspective, in talking about individual words and how they would most offi ces, this would begin when the patient fi rst translate in different languages. checks in at your offi ce. The recommendation of the Next, important terms were identifi ed. For ex- Diagnostic Committee is to begin with a set of tri- ample, it’s important that dry eye is recognized as a aging questions. Do you fi nd this helpful in terms of disease because this suggests that there must also practice fl ow and identifying dry eye? be diagnostic and management criteria, whereas a Dr. O’Dell: I fi nd it very helpful. The recommended syndrome might be viewed as simply a nuisance. triaging questions save a lot of time, error and over- “Multifactorial” is another important term that sight. puts dry eye into clearer perspective. However, the words the committee focused on most were “loss of Dr. Karpecki: Which questions do you fi nd most homeostasis.” This is new to the defi nition. It was in- useful? cluded because we know that there are things about Dr. O’Dell: I fi nd, “How long have your symptoms dry eye that we can’t yet grasp, but the term “loss of lasted and was there any triggering event?” the most homeostasis” is an umbrella term that accounts for benefi cial. Most times, a dry eye patient has a gradu- these unknowns. As such, this new defi nition may al onset of symptoms. They can’t say that everything not need to be changed for quite some time. went wrong on Sept 28th. But when you have a pa- The new defi nition also recognizes that symp- tient who can pick the exact day, you’re onto some- toms are important but don’t need to be specifi cally thing you may never have otherwise discovered. defi ned, since they present in many different ways Sometimes, you’ll fi nd that patients you thought had and affect comfort and/or vision to varying degrees. dry eye in fact have recurrent corneal erosion or epi- Finally, the latter part of the defi nition refl ects our current knowledge of the etiological pathways, but thelial basement membrane dystrophy. The other big leaves an opening for what we might learn in the fu- time-saver is, “Are the symptoms or any redness much ture. For example, neurosensory abnormalities were worse in one eye than the other?” Having this infor- included in the new defi nition as a direct result of a mation before you step into the exam room is incred- preponderance of new research in that area. ibly valuable.

Panel Participation in Tear Film and OcularSurface Society (TFOS) Dry Eye Workshop II (DEWS II) Report

Dr. Karpecki: TFOS Diagnostic Dr. Nichols: Co-chair of the TFOS Deﬁ - Methodology Subcommittee member nition and Classiﬁ cation Subcommittee and TFOS Global Ambassador and Steering Committee member

Dr. Jones: TFOS Treatment and Dr. O’Dell: TFOS Public Awareness and Management Subcommittee Chair and Education Subcommittee member and Steering Committee member TFOS Global Ambassador

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0418_Shire_CE.indd 37 4/2/18 10:52 AM Modernize Your Methods of Dry Eye Care* aren’t going to work well if you’ve got a patient whose ocular surface is damaged. We need to address the ocular surface before we start making other changes in contact lens wearers. Looking for meibomian gland dysfunction and Demodex is a great place to start in any symptomatic contact lens wearer. Always look for those two things before changing anything else. Then, if you still need to change the lens, the previous TFOS report on contact lens discomfort offers adequate evidence to support switching to a daily disposable modality.4 Dr. Karpecki: Moving on to medications, what role do glau- *Adapted and reprinted from Ocular Surface (2017) 544–579, Wolffsohn JS, Arita R, Chalmers, R, et al. TFOS coma drops play in terms of DEWS II diagnostic methodology report, p. 561, © 2017, with permission from Elsevier. being a risk factor for dry eye TFOS DEWS II TRIAGING QUESTIONS3 disease? • How severe is the eye discomfort? Dr. O’Dell: Topical glaucoma • Do you have any mouth dryness or swollen glands? therapy creates ocular surface • How long have your symptoms lasted and was there any triggering event? disease, so we need to screen • Is your vision affected and does it clear on blinking? these patients, whether or not • Are the symptoms or any redness much worse in one eye than the other? • Do the eyes itch, appear swollen or crusty, or have they given off any dis- they’re complaining about their charge? drops burning or end-of-the- • Do you wear contact lenses? day discomfort. Many patients • Have you been diagnosed with any general health conditions (including require multiple medications to recent respiratory infections) or are you taking any medications? control their disease, which increases their dry eye symptoms STEP TWO: RISK FACTOR exponentially. Fortunately, we are starting to see a ANALYSIS paradigm shift in the way we manage glaucoma, with Dr. Karpecki: The second step, after triaging ques- the introduction of alternative preservatives, preserva- tions, is risk factor analysis. Risk factors for dry eye tive-free options and fi rst-line surgical options includ- include the patient’s environment, smoking, medica- ing selective laser trabeculoplasty (SLT) and minimally tions, contact lens wear, ocular surgery and systemic invasive glaucoma surgery (MIGS). disease and others. Do any of these stand out as ar- Dr. Karpecki: Are you seeing dry eye at an earlier eas that require a change in approach? age? Dr. Jones: Depending on what study you’re read- Dr. O’Dell: Absolutely. Future research needs to ing, broadly speaking, roughly 50% of patients who take a closer look at what’s happening in the under-40 wear contact lenses complain of dryness and discom- crowd. Everyone is staring at screens, including young fort toward the end of the day. The problem is that children. Consider the effects of this over time. many practitioners are either numb to these com- Dr. Karpecki: Indeed, we’re starting to see those plaints or try to solve the issue by spending an inor- effects even now. We’re all familiar with the original dinate amount of time switching lens materials and Beaver Dam research, but when researchers looked solutions and fl ip-fl opping between different ones. at the participants’ offspring in the Beaver Dam Off- What we’re overlooking when we do this is that you spring Study (BOSS), they discovered that the inci- can have the best contact lens material and the best dence of dry eye in the patients between age 21 and contact lens solution in the world, but these strategies 34 was about 13%, which is about the same incidence

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0418_Shire_CE.indd 38 4/2/18 10:52 AM 6 DRY EYE IN THE BEAVER DAM II Sex, Gender, and Hormones Committee. First, to OFFSPRING STUDY* clarify terms, “sex” refers to your biological makeup, and “gender” relates to what the environment does DED prevalence is similar in both younger and older age groups. to infl uence your behavior. In both male and female patients, the level of hormones and androgens in 32.5 every part of the lacrimal system—from meibomian 26 glands to the lacrimal gland to the accessory glands— 25.6 is unique based on sex. In post-menopausal patients 19.5 19.9 especially, androgens play an enormous role. 17.4 16.5 13 13.2 12.3 10.9 11.2 9.7 10.2 STEP THREE: DIAGNOSTIC TESTS 6.5 Dr. Karpecki: Step three is diagnostic testing, which includes a symptomology screening question- 0 21-34 34-44 45-54 55-64 65-84 naire plus at least one of three diagnostic tests to * Paulsen AJ, Cruickshanks KJ, Fischer ME, et al. Dry eye in the beaver dam measure homeostasis. Do you rely heavily on a par- offspring study: Prevalence, risk factors, and health-related quality of life. Am J Ophthalmol. 2014 Apr;157(4):799-806. ticular dry eye questionnaire? Dr. Nichols: We tend to use the Ocular Surface Dis- ease Index (OSDI) because it provides a great bench- as their parents.5 That’s a pretty high number. Does it mark, and has excellent reliability and validity, and strike you as unrealistic? good sensitivity and specifi city.7 If you choose to ask Dr. Jones: It doesn’t surprise me at all. In our clinics more questions yourself, you don’t need a survey, but at the University, the number of patients who report if you are pressed for time, as most doctors are, the symptoms has defi nitely increased because of this dig- detailed surveys allow you to see other patients while ital world—even when patients are not wearing their you collect critical information. lenses. Digital device use reduces blink rate, which Dr. Jones: Asking about symptomology using a increases evaporation, which in turn is leading to an questionnaire is very helpful for diagnosis. It’s also increase in symptoms. The take-home message here great for management because it gives you a bench- is that you need to routinely ask patients of all ages mark, so when you do begin therapy you can reliably whether they are suffering from symptoms of dry eye. measure any shift that occurs. This includes the whole under-40 crowd, including Dr. Nichols: And these two are selected because kids. they’ve been validated or have shown a shift with Dr. Nichols: It’s also important to look at the young treatments. And so, you’re right. If you don’t see any people in your practice and think about prevention, change at all, maybe you need to approach your man- because if they’re showing signs in their 20s, imagine agement structure a bit differently. what they’re going to be living with when they are 50, Dr. Karpecki: That’s an excellent point. Like OSDI, 60 or 70 years old. We need to try and halt progression the Dry Eye Questionnaire-5 (DEQ-5) and the SPEED and prevent dry eye from emerging in the fi rst place. questionnaire also offer a score, which helps in diag- Dr. Jones: Many kids also are at much greater risk nosis and later in terms of management so you know due to acne medications, such as isotretinoin deriva- whether or not your treatment plan is working.8 tives. This is commonly prescribed and can cause bru- Dr. Karpecki: The list of dry eye symptoms is long. tal dry eyes, dry mouth and dry skin. It includes burning, stinging, transient blur, dryness, Dr. O’Dell: Acne medications aren’t the only cul- photophobia, epiphora, blurred vision, contact lens prits. Some of the acne face washes have been linked intolerance, injection, increased blink rate, foreign to keratitis. There’s still a lot to learn about the chem- body sensation and grittiness. Among these, is there icals in cosmetics including soaps, shampoos, lotions any area that you’re starting to look more closely at and face wash. Our patients are being exposed to in recent years? these products every day without knowing the residual Dr. O’Dell: I’m taking a more serious look at in- effects to the ocular surface. creased blink rate because it leads to a vicious cycle Dr. Karpecki: Why specifi cally are we still seeing a of infl ammation that’s hard to break, even with today’s predilection after age 35 towards women? topical therapies. In some cases, we’ve had to use bot- Dr. O’Dell: I learned so much from the TFOS DEWS ulinum toxin injections to slow the blinking. But even

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0418_Shire_CE.indd 39 4/2/18 10:52 AM this is tricky because if you slow it too much you can defi cient? It’s often mixed, but the new guidelines cause even more dry eye. I often fi rst notice blink rate suggest looking at that scale and determining the issues at the slit lamp when patients appear to be severity of each subtype to fi gure out where the pa- overly photophobic during the exam. tient is on the dry eye spectrum. What is the benefi t Dr. Nichols: I agree. I also elicit information on blink of going through this classifi cation exercise? Does problems by asking patients whether they stop and it offer a better explanation about why signs and close their eyes during a work day or at the end of symptoms don’t always correlate? the day. Many patients—especially contact lens wear- Dr. Nichols: This is where I think we stopped short ers—say their eyes are tired and they need to blink a in previous defi nitions. DEWS II offers a new classi- lot to try and clear the vision. The visual parts of the fi cation scheme that makes it clear that dry eye isn’t symptomatology are central to how I gather meaning- either aqueous defi cient or evaporative. It is often ful information about dry eye. These patients gener- a combination of both, occurring on a sliding scale, ally think there’s something wrong with their prescrip- which makes it necessary to treat both. tion when, in fact, it has more to do with blinking too Dr. Karpecki: What is your testing protocol? much. The body is trying to maintain adequate tear Dr. Nichols: You have to look at the meibomian breakup on an unstable tear fi lm. glands and tear volume. There are many high- and Dr. Karpecki: After screening, the three tests low-tech ways to test for evaporative vs. aqueous identifi ed in the TFOS DEWS II report for measuring defi cient dry eye. Taking a thorough look and taking homeostasis are non-invasive tear breakup time, os- your fi ndings seriously are what matters. For exam- molarity or ocular surface staining testing. Which of ple, if you see only one isolated blocked gland in a these do you perform? contact lens patient, don’t ignore it. Treat it because Dr. Nichols: The guidelines point out that you only this patient is on a road to a place they don’t want to need to perform one of these, but we often do all of go. They already have disease. them. Dr. Jones: It is worthwhile reading the entire TFOS DEWS II report, but if you had to read just one STEP FOUR: SUBTYPE part, it would be the diagnostic report. It dissects ev- CLASSIFICATION ery single dry eye test that could or should be done Dr. Karpecki: After your screening and symptom- in succinct detail. When you see it put together like atology review, the TFOS DEWS II guidelines call for this, you realize that this isn’t rocket science. Every subtype classifi cation testing. In other words, is the single one of us can do this using readily accessible dry eye primarily evaporative or is it mostly aqueous tools.

Classifi cation of Dry Eye Disease* In the fi gure to the left, the upper portion represents a clinical decision algorithm, beginning with the assessment of symptoms and followed by review for signs of ocular surface disease. DED exhibits both symptoms and signs, and can be differentiated from other ocular surface disease with the use of triaging questions and ancillary testing. It is to this DED group that diagnostic subtyping, and conventional dry eye management strategies, apply. The lower portion of the fi gure represents the etiological classifi cation of DED and highlights the two predominant and non-mutually exclusive categories: aqueous defi cient dry eye (ADDE) and evaporative dry eye (EDE).

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0418_Shire_CE.indd 40 4/2/18 10:53 AM STEP FIVE: TREATMENT TFOS DEWS II STAGED MANAGEMENT & Dr. Karpecki: Once you know what you’re trying to TREATMENT RECOMMENDATIONS combat, treatment becomes much more straightfor- Step 1: ward. But have we reached the point where we can • Education regarding the condition, its manage- pick a single treatment based on our diagnostics and ment, treatment and prognosis • Modifi cation of local environment know it’s going to be the silver bullet? • Education regarding potential dietary modifi ca- Dr. Jones: One of the biggest challenges for the tions (including oral essential fatty acid supplemen- Management and Therapy Committee was grouping tation) the incredibly diverse list of therapies and suggesting • Identifi cation and potential modifi cation/elimina- when to use them. To give you an idea of how much tion of offending systemic and topical medications • Ocular lubricants of various types (if MGD is pres- research there is on this topic, the Management and ent, consider lipid-containing supplements) Therapy Committee report has 1,002 references.9 • Lid hygiene and warm compresses of various types What we found was that one treatment alone often Step 2: doesn’t work. Instead, you may need to mix and match If above options are inadequate, consider: a few things. To simplify this process, the committee • Non-preserved ocular lubricants to minimize preservative-induced toxicity developed a four-step process, progressing from the • Tea tree oil for Demodex (if present) simplest therapies to the more complex. (See TFOS • Tear conservation DEWS II Staged Management and Treatment Recom- • Punctal occlusion mendations). • Moisture chamber spectacles/goggles Dr. Nichols: Indeed, the Management and Therapy • Overnight treatments (such as ointment or moisture chamber devices) section is not the cookbook that we may wish it could • In-offi ce, physical heating and expression of the be, but it provides a level of evidence that puts us on meibomian glands (including device-assisted thera- the right path. One outcome that we hope for most as pies, such as LipiFlow [TearScience]) a result of this report is that it will be a call to action, • In-offi ce intense pulsed-light therapy for MGD inspiring more head-to-head studies that will help us • Prescription drugs to manage DED • Topical antibiotic or antibiotic/steroid combination select those silver bullets. applied to the lid margins for anterior blepharitis (if Dr. Karpecki: In the meantime, one thing we do present) know about dry eye is that infl ammation needs to be • Topical corticosteroid (limited duration) addressed at every level. • Topical secretagogues Dr. Jones: That’s very true. By defi nition, dry eye has • Topical non-glucocorticoid immunomodulatory drugs (such as cyclosporine) an infl ammatory component. It’s worthwhile bearing in • Topical LFA-1 antagonist drugs (such as lifi tegrast) mind that many of our mildly symptomatic patients • Oral macrolide or tetracycline antibiotics have low levels of infl ammatory response that now we Step 3: can effectively manage at this earlier stage, getting If above options are inadequate, consider: them out of the vicious cycle of the infl ammatory re- • Oral secretagogues • Autologous/allogeneic serum eye drops sponse that precipitates further damage to the ocular • Therapeutic contact lens options surface, more tear fi lm break-up time and more infl am- • Soft bandage lenses mation. You’ve got to get in there and break that cycle. • Rigid scleral lenses Step 4: ACT SOONER RATHER If above options are inadequate, consider: • Topical corticosteroid for longer duration THAN LATER • Amniotic membrane grafts Dr. Karpecki: A recent study looked at patients • Surgical punctal occlusion preparing for cataract surgery. The patients who had • Other surgical approaches (e.g., tarsorrhaphy, sali- osmolarity scores within normal limits were within vary gland transplantation)

a half diopter of intent, whereas 17% of those with Adapted and reprinted from Ocular Surface (2017) 580–634, Jones L, Downie hyperosmolarity would have missed their IOL calcu- LE, Korb D, et al. TFOS DEWS II management and therapy report, p. 615, © 2017, with permission from Elsevier. lation by more than a diopter.10 What is your protocol for cataract surgery candidates? Dr. Jones: You should always aim to have a primed, cataract surgery. Especially if you have a patient who pristine optical surface before referring a patient for demonstrates an interest in a multifocal or other pre-

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0418_Shire_CE.indd 41 4/2/18 10:53 AM mium IOL, you have to make sure that the ocular surface is ity of life as patients age. ■ healthy. It makes a big difference. 1. Craig JP, Nichols KK, Akpek EK, et al. TFOS DEWS II Defi nition and Classifi cation Dr. O’Dell: If I have a patient that I’m sending out for cat- Report. Ocul Surf. 2017 Jul;15(3):276-83. aract surgery, I always have them come back for a dry eye 2. The defi nition and classifi cation of dry eye disease: Report of the defi nition and classifi cation subcommittee of the international dry eye workshop (2007). Ocul Surf. evaluation with me before they go to the cataract surgeon 2007;5(2):75-92. 3. Wolffsohn JS, Arita R, Chalmers R, et al. TFOS DEWS II Diagnostic Methodology so I can start therapy several weeks before it’s time for sur- report. Ocul Surf. 2017 Jul;15(3):539-74. gery. 4. Jones L, Brennan NA, Gonzalez-Meijome J, et al: The TFOS International Workshop on Contact Lens Discomfort: report of the contact lens materials, design, and care sub- Dr. Karpecki: Dry eye disease is a chronic, progressive committee. Invest Ophthalmol Vis Sci 2013; 54: TFOS37-70. 5. Paulsen AJ, Cruickshanks KJ, Fischer ME, et al. Dry eye in the beaver dam offspring disease that affects millions of people, yet too often it is ap- study: Prevalence, risk factors, and health-related quality of life. Am J Ophthalmol. 2014 Apr;157(4):799-806. proached as a mere nuisance, as evidenced by the fact that 6. Sullivan DA, Rocha EM, Aragona P, et al. TFOS DEWS II Sex, Gender, and Hormones so few people are receiving medical treatment.5,11 It’s en- Report. Ocul Surf. 2017 Jul;15(3):284-333. 7. Schiffman RM, Jacobsen CG, Hirsch J, et al. Relability and validity of ocular surface couraging that there appears to be a growing commitment disease index. Arch Ophthalmol. 2000 May;118(5):615-21. 8. Chalmers RL, Begley CG, Caffery B. Validation of the 5-item dry eye questionnaire to action, at least before surgery. (DEQ-5): Discrimination across self-assessed severity and aqueous tear defi cient dry eye Dr. Nichols: That’s true, but the next step needs to be diagnoses. Cont Lens Anterior Eye. 2010 Apr;33(2):55-60. 9. Jones L, Downie LE, Korb D, et al. TFOS DEWS II Management and Therapy Report. acting sooner rather than later. Our changing environ- Ocul Surf. 2017 Jul;15(3):575-628. 10. Epitropoulos AT, Matossian C, Berdy GJ, et al. Effect of tear osmolarity on repeat- ment and increased dependence on digital technology ability of keratometry for cataract surgery planning. Journal Cataract Refract Surg. 2015 only adds to this growing problem, making intervention Aug;41(8):1672-7. 11. Gayton JL. Etiology, prevalence, and treatment of dry eye disease. Clin Ophthalmol. and prevention that much more critical to sustained qual- 2009;3:405-12.

CE TEST o obtain two hours of continuing education c. 13 about whether a patient might have dry eye disease and credit, complete the exam by recording the best d. 24 the type. Tanswer to each self-assessment question online a. Trick at: https://www.reviewofoptometry.com/ce/frontline- 5. In what demographic population should you routinely b. Triaging ocular-surface-disease-care-march18 ask patients whether they are suffering from symptoms c. Undercover Or, mail the Examination Answer Sheet on the of dry eye? d. Rapid-fire next page to: Jobson Medical Information, Dept.: a. Individuals under 40 years of age Optometric CE, 440 9th Avenue, 14th Floor, New York, b. Women over 40 10. The TFOS DEWS II report recommended which of the NY 10001. A minimum score of 70% is required to c. Men over 40 following diagnostic tests as homeostasis markers? obtain a certification of completion. The fee for this d. All of the above a. Noninvasive tear break-up time course is free. b. Osmolarity 6. What is a true statement when classifying patients into c. Ocular surface staining 1. TFOS DEWS II refers to dry eye as a ______. types of dry eye disease? d. All of the above a. Syndrome a. Patients can’t be diagnosed with both aqueous deficient b. Disease dry eye and evaporative dry eye simultaneously 11. The TFOS DEWS II report suggested that, to classify c. Nuisance b. Many patients have some element of both aqueous subtypes of dry eye disease into evaporative and aqueous d. None of the above deficient dry eye and evaporative dry eye deficiency, it is important to investigate abnormal lipids as c. Patients with aqueous deficient dry eye always exhibit well as possible ______. 2. The TFOS DEWS II revised definition of dry eye dis- more signs and symptoms than those with evaporative a. Ocular hypertension ease includes the following: “Dry eye is a multifactorial dry eye b. Corneal abrasions disease of the ocular surface characterized by a loss of d. Patients with evaporative dry eye exhibit more signs and c. Meibomian gland dysfunction ______of the tear film and accompanied by symptoms than those with aqueous deficient dry eye d. Retinal tears ocular symptoms…” a. Equilibrium 7. What aspect of glaucoma might contribute to increasing 12. Expressing the meibomian glands and assessing tear b. Homeostasis the risk for ocular surface disease? volume can especially help with what aspect of dry eye c. Balance a. Higher intraocular pressure diagnosis? d. Equanimity b. Visual field loss a. Differentiating signs from symptoms c. Topical therapies that use preservatives b. Differentiating symptoms from signs 3. The following is a true statement about the TFOS DEWS d. MIGS procedures c. Differentiating the type of dry eye II definition of dry eye? d. Determining the severity of dry eye a. Symptoms must be specifically defined 8. Though the TFOS DEWS II report left symptoms open, b. Symptoms are unimportant what common symptoms of dry eye do patients often 13. Which of the following triaging questions is recom- c. Symptoms affect comfort and/or vision to varying present with? mended? degrees a. Increased blink rate a. Do you have any mouth dryness or swollen glands? d. None of the above b. Blur b. How long have your symptoms lasted and was there c. Drooping lids any triggering event? 4. The Beaver Dam study found that the incidence of dry d. A and B c. Are the symptoms or any redness much worse in one eye in the patients between age 21 and 34 was about eye than the other? ______. 9. The TFOS DEWS II Diagnostic Committee set forth the d. All of the above a. 4 need to first begin asking patients ______ques- b. 11 tions to help an eye care practitioner make an assessment 14. What commonly prescribed medication puts kids at

REVIEW OF OPTOMETRY 42 DECEMBER 2017

0418_Shire_CE.indd 42 4/2/18 10:53 AM Examination Answer Sheet CE TEST Valid for credit through December 31, 2018 This exam can be taken online at: risk of developing dry eye disease? https://www.reviewofoptometry.com/ce/frontline-ocular-surface-disease-care-march18 a. Amoxicillin Upon passing the exam, you can view your results immediately and download a real-time CE certificate. You b. Azithromycin can also view your test history at any time from the website. c. Isotretinoin derivatives d. Ibuprofen Frontline Ocular Surface Disease Care

15. What was one of the biggest challenges for the TFOS Directions: Select one answer for each question in the exam and completely darken the DEWS II Management and Therapy Committee in preparing appropriate circle. A minimum score of 70% is required to earn credit. recommendations for the report? a. Large number of management and therapy options avail- Mail to: Jobson Medical Information, Dept.: Optometric CE, 440 9th Avenue, 14th Floor, New York, NY 10001. able b. Lack of management and therapy options available COPE approved for 2 hours of CE credit. COPE ID is 56784-AS. c. Unwillingess of doctors to utilize available management and This course is supported by an unrestricted educational grant from Shire. therapy options available d. Lack of patient access to management and therapy options There is an eight- to 10-week processing time for this exam. Rate how well the activity supported your achievement of these learning objectives: available 1. A B C D 1 = Excellent 2 = Very Good 3 = Good 4 = Fair 5 = Poor 2. A B C D 1=Poor, 2=Fair, 3=Neutral, 4=Good, 5=Excellent 16. How many steps did the Management and Therapy Rate the effectiveness of how well the activity: 3. A B C D Committee come up with as eye care practitioners progress 21. Improved my knowledge about the latest research about ocular surface and dry 4. A B C D 21. Met the goal statemenA 1 2 3 4 5 through from the simplest therapies through to the more eye disease in the United States 1 2 3 4 5 5. A B C D 22. Related to your practice needs: 1 2 3 4 5 complex? 22. Learned about some of the risk factors for ocular surface and dry eye disease 6. A B C D 23. Will help you improve patient care: 1 2 3 4 5 a. 3 from the TFOS DEWS II report 1 2 3 4 5 b. 4 7. A B C D 24. Avoided commercial bias/influence: 1 2 3 4 5 23. Became familiar with some of the TFOS DEWS II report’s findings about dry c. 5 8. A B C D 25. How would you rate the overall eye disease, including its new definition and detection of the disease 1 2 3 4 5 d. 6 9. A B C D quality of the material presented? 1 2 3 4 5 24. Better understood the TFOS DEWS II report’s recommendations for diagnosis, 10. A B C D 26. Your knowledge of the subject was increased: 17. What is a true statement about the four therapeutic steps? and treatment and management of dry eye disease 1 2 3 4 5 11. A B C D Greatly Somewhat Little a. The steps are unchangeable 12. A B C D 25. Obtained27. The difficultya basic understanding of the course about was: strategies to classify the type of dry eye b. The steps should not be customized to the patient disease (i.e., aqueous deficient dry eye and evaporative dry eye) 1 2 3 4 5 13. A B C D Complex Appropriate Basic c. They’re not mutually exclusive d. They are mutually exclusive 14. A B C D 26. GainedHow long basic did knowledge it take to about complete the obstacles this course? of differential diagnosis for dry eye disease 15. A B C D 1 2 3 4 5 18. Step 1 includes which of the following recommendations: 16. A B C D RateComments the quality of on the this material course: provided: a. Education on dry eye, and environmental and dietary 17. A B C D 1=Strongly disagree, 2=Somewhat disagree, 3=Neutral, 4=Somewhat agree, 5=Strongly agree modifications 18. A B C D 27. The content was evidence-based. 1 2 3 4 5 b. Identification and potential modification of offending med- 19. A B C D Suggested topics for future CE articles: ications 28. The content was balanced and free of bias. 1 2 3 4 5 20. A B C D c. Various types of ocular lubricants, lid hygiene and warm 29. The information presented was clear and effective. 1 2 3 4 5 compresses 30. Additional comments on this course: d. All the above

19. Step 2 prescribes which possible strategies if Step 1 Please retain a copy for your records. Please print clearly. approaches are inadequate: a. Non-preserved ocular lubricants, tea tree oil for Demodex You must choose and complete one of the following three identifier types: (if present) and tear conservation (punctual occlusion and 1 SS # - - moisture chamber spectacles/goggles) b. Overnight treatments (such as ointment or moisture cham- Last 4 digits of your SS # and date of birth State Code and License #: (Example: NY12345678)

ber devices); in-office physical heating and expression of the 2 - 3 meibomian glands, as well as intense pulsed light therapy for MGD c.Prescription drugs including topical antibiotics/or steroid First Name combinations for lid margins if blepharitis is present; topical Last Name corticosteroids, non-glucocorticoid immunomodulatory drugs and LFA-1 antagonists; and oral macrolide or tetracycline E-Mail antibiotics The following is your: Home Address Business Address d. All the above Business Name 20. What strategies are not mentioned in Step 3 for dry eye that is nonresponsive to therapy? Address a. Amniotic membrane treatment and scleral lenses City State b. Intraocular lenses c. LASIK procedures ZIP d. B and C Telephone # - -

Fax # - -

By submitting this answer sheet, I certify that I have read the lesson in its entirety and completed the self-assessment exam personally based on the material presented. I have not obtained the answers to this exam by any fraudulent or improper means. The opinions expressed in this supplement to Review of Optometry® do not reﬂ ect the views of or imply endorsement by the publisher of the host publication. Copyright 2018 Jobson Medical Information LLC. Signature Date

Lesson #116224 RO-UAB-0318

REVIEW OF OPTOMETRY 43 DECEMBER 2017

0418_Shire_CE.indd 43 4/2/18 10:53 AM Systemic Therapy

Know Your Systemic Meds: The Top 10 to Track Here’s what you need to know about the ocular effects of the heavy-hitters. By Megan Hunter, OD, and Michelle Marciniak, OD

hile systemic medications are often necessary for the patient’s long-term Whealth, ocular side effects, as minor as dry eye and as serious as macular toxicity, can challenge the treatment process, often leading to modification or even discontinuation of the medication. Optometrists must be prepared to manage and comanage patients who present with concurrent medication use and ocular concerns. Here, we discuss some of the commonly prescribed systemic medications with serious ocular side effects, and what to look out for. This SD-OCT of a patient taking 400mg of Plaquenil daily shows no signs of maculopathy, as each eye’s inner/outer segment line is intact. Hydroxychloroquine In the United States, Plaquenil (hydroxychloroquine, the metabolism of retinal cells, including the photore- Sanofi-Aventis) is commonly used to treat rheumatic ceptors.2 Since the toxicity predominately affects the conditions such as rheumatoid arthritis, systemic lupus macula, light absorption, cone metabolism or both may erythematosus and Sjögren’s syndrome. Plaquenil use play a role.3 Hydroxychloroquine binds to melanin, has the potential risk of retinal toxicity.1 Overall, the which concentrates in the retinal pigment epithelium incidence is low; however, risk depends on the length of and prolongs the effects, even after discontinuation of therapy and cumulative dosage. After five years of use, the medication. Tamoxifen use and renal disease can the risk of toxicity is <1%, but increases to 2% after 10 also result in increased risk. years and nearly 20% after 20 years.1 The underlying Optometrists must screen patients taking Plaquenil pathophysiology of the toxicity is not well understood, for early functional and structural changes associated although researchers do know that Plaquenil affects with toxicity, because once a clinically evident bull’s

44 REVIEW OF OPTOMETRY APRIL 15, 2018

044_ro0418_f1.indd 44 3/30/18 5:27 PM eye maculopathy is present, the damage cannot be reversed.3 The current Ameri- can Academy of Ophthalmology (AAO) recommendations advise screening NAION, seen here, has been linked to the with objective use of PDE 5 inhibitors. test for functional retinal damage—such as spectral-domain (SD) optical coherence tomography (OCT), fundus autofluorescence or multifocal electroretinogram (ERG)—in addition to a dilated fundus exam and 10-2 visual fields.1 Clinicians should use wider visual field test patterns (24-2 or 30-2) for patients of Asian descent, as research shows this patient population has early damage in a more peripheral, rather than paracentral, pattern.1 High-resolution OCT can detect localized thinning in the parafoveal region, and loss of the inner/outer segment line, known as the ellipsoid zone, on SD-OCT is considered one of the earliest signs of potential toxicity. Fundus autofluorescence abnormalities have been reported prior to visual field loss and early photorecep- tor damage will show an increase in autofluorescence due to outer segment debris accumulation.2 Multifocal ERG produces local responses across the posterior pole and will show paracentral ERG depression in early Plaquenil toxicity. The medication dosage is also an important factor in monitoring for toxicity. Plaquenil is typically prescribed PASSIONATE ABOUT PATIENT EXPERIENCE? as 200mg or 400mg daily. Clinicians should use real weight rather than ideal weight when calculating dosage because ideal weight can cause an overdose in thin The most advanced individuals.1 The target dosage is usually less than or ® equal to 5mg/kg of real weight. Because the cumulative Phoroptor ever. dose poses the highest risk of retinal toxicity, the AAO’s recommendations call for a baseline examination at the Phoroptor® VRx Digital Refraction System initiation of therapy and then annual screening after five years of treatment for low risk patients.1-3 More fre- A premium refraction experience. Incredibly fast. quent screening is recommended for high-risk patients, Ultra-quiet. Effortless integration. Made in USA. including those on a higher dose and those with renal or liver disease.1 Watch the video at reichert.com/vrx Topiramate This sulfa-derived monosaccharide is an effective anti- seizure medication that enhances the action of gamma- aminobutyric acid, decreases the action of glutamate

Phoroptor is a registered trademark of Reichert, Inc. · www.reichert.com ·

044_ro0418_f1.indd 45 3/30/18 5:27 PM Systemic Therapy

necessary for erection. The most common ocular complaint with PDE 5 inhibitors is a blu- ish tinge or haze to vision along with increased light sensitivity. Other ocular side effects include decreased color vision, blurred or transitory decreased vision with central haze, changes in light perception, transient ERG changes, conjunctival hyperemia, ocular pain, mydriasis (may be an emotional effect) and retinal vascular occlusions and subconjunctival hemorrhages, which may be second- Six weeks after starting isotretinoin for the treatment of acne, this patient with ary to exertion. increased intracranial hypertension presented with bilateral optic disc edema. Ischemic optic neuropathy (ION) is the most concerning potential and blocks sodium channels. It is also a common treat- side effect. Although infrequent (3% of cases) in those ment option for migraine and any number of other taking low doses (25mg to 50mg), incidence can reach conditions such as bipolar, post-traumatic stress and 11% in those taking 100mg and 50% at 200mg.11 obsessive-compulsive disorders.4 Symptoms begin 15 to 30 minutes after taking the ODs must carefully monitor patients taking topi- medication and peak at 60 minutes. Research suggests ramate, as it can cause ciliary body effusion, which ION has a temporal association with PDE 5 inhibitors, relaxes the zonules and allows lens thickening, resulting but this remains controversial.12 For one, many patients in a myopic shift of as much as -9.00D.5,6 It can also taking these medications also have risk factors for ION, cause anterior rotation of the ciliary processes, possibly and the vascular risk factors for nonarteritic anterior inducing appositional acute angle-closure glaucoma.7,8 ION (NAION) often overlap with vascular risk factors Topiramate-induced angle-closure typically occurs for erectile dysfunction. within the first two weeks of starting the medication or within hours of doubling the dose.6 Fingolimod The incidence of myopia and acute angle-closure Gilenya (fingolimod, Novartis), the first oral treatment with topiramate use is a well-recognized adverse reac- for relapsing-remitting multiple sclerosis (MS), is effec- tion, but the true incidence is generally thought to be tive in reducing the number of relapses and improving low. A 2004 study cited only 86 cases of topiramate- overall disability progression over long-term follow associated acute angle closure and 17 cases of acute up.13 Fingolimod is an immunomodulating agent that bilateral myopia in the literature at the time.9 Since binds to sphingosine-1-phosphate (S1P) receptors on 2004, fewer than 50 additional case reports have been the lymphocytes and prevents lymphocyte release from published.10 the lymph nodes, reducing lymphocyte migration into B-scan ultrasound, ultrasound biomicroscopy and the central nervous system.14 This spares the system anterior segment OCT can reveal the anatomic changes from attack by these myelin-reactive lymphocytes. that create this reaction. As sphingolipids are the third most numerous Most ocular issues associated with topiramate lipid in the retina, fingolimod-associated macular resolve after discontinuing the medication. Oral hypo- edema (FAME) is a possible side effect, reported in tensives can help control intraocular pressure, and two pivotal studies that investigated the drug’s safety cycloplegics can help retract the ciliary processes. and efficacy.13,15 S1P receptors in retinal blood vessel endothelial cells are responsible for maintaining cell Phosphodiesterase Inhibitors adhesion complexes, so when fingolimod downregu- The active ingredient in erectile dysfunction drugs, lates the S1P receptors, it also downregulates adhesion phosphodiesterase 5 (PDE 5) inhibitors block the pre- complexes and increases retinal vascular permeability, dominant metabolizer of cyclic guanosine monophos- resulting in macular edema.16 In one study, 0.5% of phate that stimulates the smooth muscle relaxation patients receiving 0.5mg of daily fingolimod and 1.0%

46 REVIEW OF OPTOMETRY APRIL 15, 2018

044_ro0418_f1.indd 46 3/30/18 5:28 PM of those receiving 1.25mg of daily fingolimod developed macular edema.15 Most patients who develop FAME do so within four months of starting treatment, and it resolves after the drug is discontinued.16 Clinicians should screen patients taking fingolimod with a complete eye examination and macular OCT at baseline and again in three to four months. Clinicians should exercise caution when treating diabetic patients due to the preexisting blood- retinal barrier compromise. Isotretinoin An analog of vitamin A, this is used to treat severe, recalcitrant nodular acne, psoriasis and disorders of keratinization. It alters skin lipid composition, reduces sebaceous gland size and decreases sebum production, in addition to having anti-inflammatory properties.17 Isotretinoin-induced meibomian gland dysfunction leads to eye dryness, ocular surface irritation, decreased contact lens tolerance, photophobia, blepharoconjunc- tivitis, decreased vision and even an increase in hordeolum and chalazion frequency.18 Studies link isotretinoin to the development of secondary increased intracranial hypertension due to increased resistance to cerebrospinal fluid outflow. Patients will often present with headaches (typically postural), blurred vision, subjective visual obscurations and tinnitus. Increased intracranial pressure can cause bilateral optic nerve head edema, which can last for weeks after discontinuing the medication and can be vision-threatening if left undetected. While a serious complication, increased intracranial pressure is rare.

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This patient being anti-coagulated with warfarin presented with subconjunctival hemorrhage.

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044_ro0418_f1.indd 47 3/30/18 5:32 PM Systemic Therapy

Ethambutol This medication is most commonly used as part of the lengthy qua- druple antibiotic regimen for the treatment of tubercuolosis (TB) and in the multi-drug therapy for mycobacterium avid complex lung disease.26 It is a metal chelator, which prevents cell wall synthesis in mycobacteria by inhibiting ara- binosyl transferase.27 Ethambutol is known to cause optic neuropathy characterized by bilateral central vision loss, color This patient’s toxic optic neuropathy is due to amiodarone use. vision loss, central or cecocentral visual field scotomas and even- Tamoxifen tual optic atrophy. The exact mechanism is unknown, This oral anti-estrogen medication is used to treat but researchers theorize it is due to either decreased advanced metastatic breast cancer and as an adjunctive mitochondrial copper, which is necessary for oxidative endocrine therapy following resection in early disease. phosphorylation, or the chelation of zinc, which inhib- Endocrine therapy works to combat steroid hormone its lysosomal activation.28,29 assisted tumor growth in hormonally dependent breast Toxicity is dose related with an incidence of 18% cancer cells. Tamoxifen competes with estradiol for with more than 35mg/kg/day, 5% to 6% with doses of receptors in breast, uterine and vaginal tissues as well 25mg/kg/day, 3% with 20mg/kg/day and less than 1% as in tumors containing high concentrations of estrogen at less than or equal to 15 mg/kg/day.30 receptors.19 Between 30% and 64% of patients will show some Ocular toxicity from tamoxifen presents as a crys- visual recovery if the optic neuropathy is detected early talline retinopathy with yellow-white refractile bodies and the medication is discontined.27 Patients should confined to the plexiform and nerve fiber layers, typi- have a baseline exam with vision screening, color cally found in the macular and paramacular areas. vision, Amsler grid and visual field testing, in addition Sometimes, it can be associated with macular edema to a dilated fundus exam and nerve fiber layer OCT. and a whorl-like superficial keratopathy.20 Ocular tox- They should be re-examined monthly while on the eth- icity is typically associated with high doses in excess of ambutol therapy. 120mg daily; it is not common with the standard daily dose of 20mg.21,22 Tamsulosin SD-OCT imaging helps to detect subtle maculopa- Flomax (tamsulosin, Boehringer Ingelheim Pharmaceu- thy associated with tamoxifen use. Low dose usage, ticals) is a selective α1A-adrenergic receptor antagonist for example, can produce pseudo-cystic cavities in the used to treat benign prostate hyperplasia by relaxing macula, which do not leak on fluorescein angiography smooth muscles in the neck of the bladder and in the and do not increase retinal thickness.22 prostatic urethra. These receptors are also found on Research suggests Müller cell dysfunction contributes the iris dilator muscle, leading to ocular effects of the to tamoxifen ocular toxicity because the medication medication. Selective α1A antagonists are known to inhibits the glutamate-aspartate transporter pres- cause intraoperative floppy iris syndrome (IFIS) dur- ent in Müller cells.23 Excess glutamate, in turn, may ing cataract extraction and a likelihood of iris prolapse cause Müller cell dysfunction and neuronal apoptosis, through the surgical wound.31 The exact mechanism of creating cavitary spaces.24 One study found that full- IFIS is unknown, although one study suggests chronic thickness macular holes were five times more likely in blockade of the α1A-adrenergic receptors can decrease patients taking tamoxifen, possibly caused by the foveal smooth muscle tone and cause diffuse atrophy of the cavities.25 All patients on tamoxifen should have a base- iris dilator.32 The researchers found histologic evidence line and yearly dilated eye examination with SD-OCT of decreased iris dilator muscle thickness in cadaver of the macula. eyes with a history of tamsulosin use compared with

48 REVIEW OF OPTOMETRY APRIL 15, 2018

044_ro0418_f1.indd 48 3/30/18 5:32 PM cadaver control eyes.32 Surgeons and comanaging ODs must be aware that IFIS may still occur several years after discontinuing the drug, and stopping tamsulosin preoperatively is of uncertain benefit. Atrial Fibrillation Agents Several vascular medications come with significant ocular effects ODs must be on the lookout for: Amiodarone is an effective anti-arrhythmic medication for ventricular tachycardia and fibrillation and atrial fibrillation. It blocks calcium, potassium and sodium channels in cardiac tissue, which prolongs the cardiac action potential and refractory period. It is also a weak beta blocker and vasodilator. Ocular side effects of amiodarone include corneal ver- ticillata or whorl-like keratopathy, which occur in 70% to 100% of patients. This keratopathy is related to the dose and duration of treatment, generally appears after at least one month of therapy and will resolve upon discontinuation of the medication. Amiodarone can also cause anterior lenticular subcapsular opacities in 50% to 60% of patients. Both the corneal and lenticular deposits are typically asymptomatic.33 Amiodarone has also been linked to optic neuropathy, with a clinical presentation similar to NAION. Amiodarone-induced optic neuropathy should be a diagnosis of exclusion, considering most patients taking amiodarone have vascular risk factors already increasing their NAION risk. One report found an incidence of amiodarone-induced optic neuropathy at roughly 2% compared with a general incidence of 0.3%.34 It has an insidious onset, milder degree of vision loss, longer duration of disc edema and is more commonly bilateral than NAION.35 Amiodarone has a long half-life, aver- PASSIONATE ABOUT PATIENT EXPERIENCE? aging 58 days, but up to 142 days, and accumulates in the lysosomes of multiple tissues, including the optic nerve, so optic disc swelling can persist for months after Elements of pre-test. discontinuing the medication.36,37 Digoxin inhibits the cell membrane Na+/K+-ATPase, OptoChek™ Plus creating an increase in intracellular calcium and sodium Auto Refractor + Keratometer and extracellular potassium. This leads to stronger myo- LensChek™ Plus & Pro Digital Lensometers cardial contraction and excitability and a decrease in the conduction and depolarization velocity in the atrioven- Reichert® combines technology, simplicity, tricular node, which resets the rhythm of the heart rate. and value at the core of your exam. Digoxin is a second-line treatment for atrial fibrillation and in severe symptomatic systolic heart failure.38 Approximately 95% of patients in the toxic range Learn more at reichert.com/exam will report ocular symptoms, the most common being xanthopsia, or yellowing vision.39 Cyanopsia (blue vision) and chloropsia (green vision) have also been reported.40 Other ocular symptoms include flashing,

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044_ro0418_f1.indd 49 3/30/18 5:32 PM Systemic Therapy

scintillating or moving lights phonates are rapidly cleared or spots, blurred, hazy, misty from circulation and are or snowy vision and difficulty absorbed into bone mineral reading. Clinical ocular finding surfaces, where they slow include decreased visual acuity, osteoclasts to allow osteo- central scotoma, color vision blasts to rebuild bone.44 defects and delayed b-wave The most common ocu- time and decreased b-wave lar side effect of bisphos- amplitude on ERG. While still phonates is a self-limiting under debate, most presume conjunctivitis.45 Uveitis and ocular symptoms are related to scleritis, two serious possible Na+/K+ ATPase inhibition.38 ocular side effects, might not Symptomatic patients should resolve unless the medica- be referred back to their cardi- This patient presented two days after bisphosphonate tion is discontinued.45 One ologist for monitoring. infusion with severe ocular inflammation. study found scleritis and Anticoagulants are used to uveitis were rare in bisphos- help prevent clotting in a wide variety of systemic dis- phonate users and that 43% of the patients who orders. The ocular and systemic side effects occur with developed either condition had a systemic condition varying frequencies depending on the specific medica- already associated with uveitis or scleritis.46 Research- tion. Platelet inhibitors such as clopidogrel, dipyridam- ers can only speculate that bisphosphonates use might ole and aspirin are effective but with a lower incidence be a precipitating factor for ocular inflammation in of side effects. patients already prone to these conditions.44 Patients Warfarin is a potent oral anticoagulant that poses who develop serious ocular inflammation need oral and a high risk of bleeding disorders. It inhibits vitamin topical anti-inflammatories and often require discon- K-dependent gamma-carboxylation of coagulation tinuation of biphosphonates for resolution. factors II, VII, IX and X. Warfarin can be affected by other medications, as well as a patient’s dietary intake Ocular side effects from systemic medications can be of vitamin K. Because of its narrow therapeutic win- serious and sight threatening. It is crucial for ODs to dow, warfarin requires frequent monitoring via labora- catalogue each patient’s systemic medications, discuss tory testing.41 the possible side effects and monitor appropriately. Direct-acting oral anticoagulants (DOACs) are Often, additional testing is warranted to screen for used to treat patients with venous thromboembolism effects and detect early toxicity. ■ and nonvalvular atrial fibrillation.42 Research shows Dr. Hunter is an assistant professor of ophthalmol- DOACs are as effective as warfarin in preventing stroke ogy at Loyola University Medical Center in Maywood, due to atrial fibrillation while also having a lower over- IL. She is the current national chair of the American all bleeding risk, especially intracranial bleeding. In Academy of Optometry’s admittance committee. addition, they are less affected by diet and medication Dr. Marciniak works at the Jesse Brown VAMC, interactions.43 teaches at Illinois College of Optometry and works Atrial fibrillation agents all carry the risk of in private practice. She is a member of the Advanced increased bleeding. The most worrisome is the potential Competency in Medical Optometry committee. for intracranial hemorrhage. Ocular side effects of anti- 1. Armor MF, Kellner U, Lai TY, et al. Recommendations on screening for chloroquine and coagulants include subconjunctival hemorrhage, retinal hydroxychloroquine retinopathy (2016 revision). Ophthalmology. 2016;123(6):1386-94. hemorrhage, orbital hemorrhage causing mass effect 2. Marmor MF, Kellner U, Lai TY, et al. Revised recommendations on screening for chloroquine and hydroxychloroquine retinopathy. Ophthalmology. 2011;118(2):415-22. and exacerbation of bleeding from other ocular condi- 3. Marmor MF, Carr RE, Easterbrook M, et al. Recommendations on screening for chloroquine tions such as proliferative diabetic retinopathy and exu- and hydroxychloroquine retinopathy. Ophthalmology. 2002;109(7):1377-82. 4. Silberstein SD, Lipton RB, Dodick DW, et al. Efficacy and safety of topiramate for the treat- dative macular degeneration. ment of chronic migraine: A randomized, double-blind, placebo-controlled trial. Headache. 2007;47(2):170-80. 5. Grinbaum A, Ashkenazi I, Gutman I, Blumenthal M. Suggested mechanism for acute transient Bisphosphonates myopia after sulfonamide treatment. Ann Ophthalmol. 1993;25(6):224-6. These are widely used in the treatment of osteoporo- 6. Mitra A, Ramakrishnan R, Kader MA. Anterior segment optical coherence tomography documentation of a case of topiramate induced acute angle closure. Indian J Ophthalmol. sis, Paget’s disease, metastatic bone disease, multiple 2014;62(5):619-22. myeloma and hypercalcemia of malignancy. Bisphos- 7. Maddalena MA. Transient myopia associated with acute glaucoma and retinal edema. JAMA

50 REVIEW OF OPTOMETRY APRIL 15, 2018

044_ro0418_f1.indd 50 3/30/18 5:35 PM Ophthalmol. 1968;80:186-8. 8. Banta JT, Hoffman K, Budenz DL, et al. Presumed topiramate-induced bilateral acute angle- closure glaucoma. Am J Ophthalmol. 2001;132(1):112-4. 9. Fraunfelder FW, Frauenfelder FT. Adverse ocular drug reactions recently identified by the National Registry of Drug-Induced Ocular Side Effects. Ophthalmology. 2004;111(7):1275-9. 10. Pubmed search. www.pubmed.gov. Accessed March 13, 2018. 11. Armor MF, Kessler R. Sildenafil (Viagra) and ophthalmology. Surv Ophthalmol. 1999;44(2):153- 62. 12. Frauenfelder F. Visual side effects associated with erectile dysfunction agents. Am J Ophthal- mol. 2005;140(4):723-4. 13. Kappas L, Radue EW, O’Connor P, et al. A placebo-controlled trial of oral fingolimod in relapsing multiple sclerosis. N Engl J Med. 2010;362(5):387-401. 14. Groves A, Kahara Y, Chun J. Fingolimod: direct CNS effects on sphingosine 1-phosphate (S1) receptor modulation and implications in multiple sclerosis therapy. J Neurol Sci. 2013;328(1- 2):9-18. 15. Cohen FA, Barkhof F, Comi G, et al. Oral fingolimod or intramuscular interferon for relapsing multiple sclerosis. N Engl J Med. 2010;362(5):402-15. 16. Mandal P, Gupta A, Fusi-Rubiano W, et al. Fingolimod: therapeutic mechanisms and ocular adverse effects. Eye. 2017;31(2):232-40. 17. Tan J, Boyal S, Desai K, Knezevic S. Oral Isotretinoin: New developments relevant to clinical practice. Dermal Clin. 2016;34(2):175-84. 18. Neudofer M, Goldshetin I, Shamai-Lubovitz O, et al. Ocular adverse effects of systemic treatment with isotretinoin. Arch Dermatol. 2012;148(7):803-8. 19. Rolf MM. Clinical implications of tamoxifen ocular toxicity. Clin Eye Vis Care. 1998;10(3):135- 40. 20. McKeown C. Tamoxifen retinopathy. Br J Opthalmol. 1981;65:177-9. 21. Burl DH, Sarraf D, Schwartz SD. Peripheral retinopathy and maculopathy in high-dose tamoxifen therapy. Am J Ophthalmol. 2007;144(1):126-8. 22. Yoshi RR, Fortun JA, Kim BT, et al. Pseudocystic foveal cavitation in tamoxifen retinopathy. Am J Ophthalmol. 2014;157(6):1291-8. 23. Maenpaa H, Mannerstrom M, Toimela T, et al. Glutamate uptake is inhibited by tamoxifen and toremifen in cultured retinal pigment epithelial cells. Pharmacol Toxicol. 2002;91(3):116-22. 24. Brinkmann A, Pannicke T, Grosche J, et al. Muller cells in the healthy and diseased retina. Prog Retin Eye Res. 2006;25(4):397-424. 25. Bernstein PS, DellaCroce JT. Diagnostic and therapeutic challenges. Tamoxifen toxicity. Retina. 2007;27(7):982-8. 26. Griffith DE, Brown-Elliott BS, Shepherd S, et al. Ethambutol ocular toxicity in treatment regimens for Mycobacterium avid complex lung disease. Am J Respir Crit Care Med. 2005;172(2):250-3. 27. Chamberlain PD, Sadak A, Berry S, Lee AG. Ethambutol optic neuropathy. Curr Opin Ophthal- mol. 2017;28(6):545-51. 28. Kodak SF, Underlined CB, Hsu HY, et al. The role of copper on ethambutol’s antimicrobial action and implications for ethambutol-induced optic neuropathy. Diagn Microbiol Infect Dis. 1998;30(2):83-7. 29. Chung H, Yoon YH. Ethambutol-induced toxicity is mediated by zinc and lysosomal membrane permeabilization in cultured retinal cells. Toxicol Appl Pharmacol. 2009;235:163-70. 30. Yang HK, Park MJ, Lee JH, et al. Incidence of toxic optic neuropathy with low-dose ethambutol. Int J Tuberc Lung Dis. 2016;20(2):261-4. 31. Chang DF, Campbell JR. Intraoperative floppy iris syndrome associated with tamsulosin. J Cataract Refract Surg. 2005;31(4):664-73. 32. Santaella RM, Destafeno JJ, Stinnett SS, et al. The effect of α1-adrenergic receptor antagonist tamsulosin (Flomax) on iris dilator smooth muscle anatomy. Ophthalmology. 2010;117(6):1743-9. 33. Mantyjarvi M, Tuppurainen K, Ikaheimo K. Ocular side effects of amiodarone. Surv Ophthalmol. PASSIONATE ABOUT PATIENT CARE? 1998;42(4):360-6. 34. Reiner LA, Young BR, Kazmier FJ, et al. Optic neuropathy and amiodarone therapy. Mayo Clin Proc 1987;62(8):702-17. 35. Macaluso DC, Suhlst Wt, Frauenfelder FT. Features of amiodarone-induced optic neuropathy. His sight depends Am J Ophthalmol. 1999;127(5):610-2. 36. Amiodarone: guidelines for use and Monitoring. Am Fam Physician. 2003;68:2189-97. 37. Manor AM, Puklin JE, O’Grady R. Optic nerve ultrastructure following amiodarone therapy. J Clin Neuro-ophthalmol 1988;8(4):231-7. on your conﬁdence. 38. Renard D, Rubli E, Voide N, et al. Spectrum of digoxin-induced ocular toxicity: a case report and literature review. BMC Res Notes. 2015;8:368. 39. Piltz JR, Wertenbaker C, Lance SE, et al. Digoxin toxicity. J Clin Neuro-Oph. 1993;13(4):275- 80. Ocular Response Analyzer® G3 40. Towbin EJ, Pickens WS, Doherty JE. The effects of digoxin upon color vision and the electroretinogram. Clin R. 1967;15:60. Corneal Hysteresis, 41. Go AS, Hylek EM, Borowsky LH, et al. Warfarin use among ambulatory patients with nonvalvu- a more objective predictor lar atrial fibrillation: the anticoagulation and risk factors in atrial fibrillation IATRIA) study. Ann Intern Med. 1999;131(12):927-34. of glaucoma progression. CPT code 92145. 42. Chadha DS, Bharadwaj BP. Direct acting oral anticoagulant: bench to bedside. Med J Armed Forces India. 2017;73:274-81. 43. Lopez JA, Sterne JA, Thom HHZ, et al. Oral anticoagulants for prevention of stroke in atrial fibrillation: systematic review, network metaanalysis, and cost effectiveness analysis. Br J Ophthal- Watch the videos at reichert.com/glaucomaconﬁdence mol. 2017 Nov 28;359:j5058. 44. Papapetrou PD. Bisphosphonate-associated adverse events. Hormones. 2009;8(20)96-110. 45. Frauenfelder FW, Frauenfelder FT, Jensvold B. Scleritis and other ocular side effects associated with pamidronate disodium. Am J Ophthalmol. 2003;135(2):219-22. 46. French DD, Margo CE. Postmarking surveillance of uveitis and scleritis with bisphosphonates among a national veteran cohort. Retina. 2008;28:889-93.

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044_ro0418_f1.indd 51 3/30/18 5:33 PM Antibiotics

One Size Won’t Fit All: Treating Ocular Infection

Knowing which antibiotic to choose and how to use it are critical when treating and beating ocular infection. By Tracy Offerdahl-McGowan, PharmD, and Greg Caldwell, OD

ue to their complex- ity and temperament, ocular infections can be a pain to treat. Find- Ding the right antibiotic requires a thorough understanding of the most likely causative organisms, resistance patterns, patient-specific data and pharmacologic information that may impact the patient’s response to the drug. And we have to do it all while the clock is tick- ing—the earlier treatment begins, the better the prognosis. However, sometimes, less is more. Exercising discretion in situations where the infection is most likely to be caused by a virus, such as in non-purulent infectious conjunctivitis, has been proven to decrease the spread of resistant organisms.1,2 These images Into this thicket walks the show a patient optometrist, who must navigate with dacryocystitis and preseptal carefully and make many decisions cellulitis before to move forward safely. being treated with antibiotics. Chiefs of Staph. The first key question is whether to use an oral or a topical agent. Oral antibiotics are accepted as the standard of care when treating infections

52 REVIEW OF OPTOMETRY APRIL 15, 2018

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RO0418_Katena.indd 1 3/26/18 10:26 AM Antibiotics

such as hordeolum, pre- traditional therapy that cov- septal cellulitis and dac- ers Staph. aureus, or when ryocystitis.3,4 Compared a patient is colonized with with topical antibiotics, MRSA, it’s a good time to orals produce significant consider a potential MRSA levels in the blood- infection. Susceptibility to stream, which provide MRSA is also heightened superior penetration of in young patients, prisoners the lacrimal apparatus and athletes.29,30,33 and surrounding tissues. These images show the same For this reason, these patient from page 52 a week Beta-Lactams infections are more after initiating antibiotic These antibiotics are widely effectively treated with treatment. used to treat upper respira- an oral agent.3 tory tract infections and ocu- Most corneal and lococcus aureus (MRSA) is a com- lar infections. (Table 3). conjunctival infections are best mon colonizer on skin, clinical Amoxicillin and amox + clavu- managed with a topical fluoroqui- consideration should be given to lanate. These agents are considered nolone, perhaps with an oral agent determine whether a patient needs amino-penicillins or extended spec- added for more coverage if circum- antibiotic coverage for this organ- trum penicillins because the amino stances warrant. ism. This is typically determined by side-chain extends its coverage to Common organisms associated local prevalence and risk factors.5-7 include more gram-negative organ- with hordeolum, dacryocystitis While sulfamethoxazole-trime- isms such as Haemophilus influ- and preseptal cellulitis include the thoprim (SMX-TMP), doxycycline enza and the Enterobacteriaceae gram-positive organisms Staphy- and clindamycin may not be an family, such as Escherichia coli, lococcus aureus, Staphylococcus OD’s typical “go to” drugs when when compared with penicillin VK. epidermidis and Streptococcus treating hordeolum, preseptal cel- Additionally, these agents have pneumonia (Table 1). But they also lulitis and dacryocystitis, they are good coverage against sensitive include gram-negative organisms important to consider, especially Staph. aureus and even Streptococ- such as Haemophilus influenza and when managing community- cus pneumoniae when given in high occasionally Pseudomonas aerugi- acquired (as opposed to hospital- doses. Keep in mind that coagulase- nosa.5-7 acquired) resistant Staph. aureus negative Staph. species (e.g., Staph. When choosing an oral antibiotic MRSA infections (Table 2).33 epidermidis) show a decent amount to treat these relatively common In the past, practitioners relied of resistance to these agents and ocular infections, inquire about on intravenous vancomycin to treat may not be a reasonable choice in a the presence of allergy, pregnancy, MRSA infections, but today we patient infected with this organism. breastfeeding, comorbidities, drug are fortunate to have SMX-TMP, Neither MRSA nor Pseudomonas interactions, prior antibiotic use doxycycline and clindamycin in aeruginosa is susceptible to these and ability to pay out of pocket for our MRSA arsenal. Doxycycline is agents.9,10 the more costly medications. generally considered a “last-line” Mechanistically, these agents in the trio of agents that cover MRSA Matters MRSA, mainly because of toler- Since methicillin-resistant Staphy- ability issues. When a patient fails

Table 1. Likely Organisms Responsible for Lid/Adnexal Infections Hordeolum Staphylococcus aureus Preseptal Cellulitis Staphylococcus aureus, Streptococcus pneumoniae, Haemophilus influenzae The resolution of this patient’s Dacryocystitis Staphylococcus aureus, Staphylococcus dacryocystitis and preseptal cellulitis epidermidis, Pseudomonas aeruginosa was achieved using antibiotics.

54 REVIEW OF OPTOMETRY APRIL 15, 2018

0052_ro0418_f2.indd52_ro0418_f2.indd 5454 33/30/18/30/18 5:015:01 PMPM RO0418_Lacrimedics.indd 1 3/26/18 9:31 AM Antibiotics

Table 2. Dosing Regimens for Community-Acquired MRSA29,30,33 Sulfamethoxazole+Trimethoprim DS 800mg/160mg; take one tab BID x 10 days Clindamycin 300mg to 600mg TID x 10 days Doxycycline 100mg BID x 10 days

erated and include miniscule drug reaction. For example, cephalexin interactions. In general, cephalexin is more likely to cross-react with a This patient presented with a visible has also been considered safe in patient who has penicillin allergy dacryocystitis infection, which required pregnancy.9,10 compared with a drug lacking the antibiotic treatment. Allergy ambiguities. Decades side chain (e.g., cefuroxime axetil). of clinical research have allowed If a patient is listed as having an inhibit bacterial cell wall synthesis us to fine-tune our understand- allergy to a cephalosporin, it’s wise by plugging into penicillin-binding ing of penicillin allergies and the to consider that claim to be true. proteins. This results in bacterial potential cross-reaction between a Also, a cross-reaction from a ceph- cell death. The addition of the beta- penicillin allergy and other beta- alosporin to a penicillin is rare.12-15 lactamase enzyme inhibitor clavula- lactam antibiotics (Table 4). While nate provides increased protection some sources report cross-reactions Meet the Macrolides for amoxicillin against hydrolysis between penicillins and cephalo- The macrolide class of agents when it’s exposed to infections sporins occurring as often as 10% includes erythromycin, clarithro- caused by organisms that produce of the time, other research suggests mycin and azithromycin. Erythro- beta-lactamase, including Hae- that this is an exaggeration. Never- mycin is incredibly well-known to mophilus influenzae and Moraxella theless, the mere “potential” of this cause nausea and vomiting and is catarrhalis. cross-reaction has created a culture typically taken three to four times While traditional penicillin in which physicians tend to avoid per day. For obvious reasons, this has impaired gastrointestinal beta-lactam agents and overuse the agent is rarely used in eye care. absorption when given with food, broader spectrum agents such as Clarithromycin, on the other amoxicillin is relatively stable. macrolides and fluoroquinolones. hand, causes a moderate amount of Additionally, amoxicillin plus When evaluating a patient nausea and vomiting and is dosed clavulanate has improved gastro- who claims to possess a “penicil- BID. As it shows no real benefit intestinal tolerability when given lin allergy,” practitioners should over azithromycin, it is used less. with food and is generally recom- investigate the specific nature of The third agent in this class, mended that patients take it with a the allergic reaction to the drug. azithromycin, proves fairly well- meal. While both amoxicillin and Researchers estimate that 90% of tolerated and is reported as having amoxicillin plus clavulanate are patients who claim to be allergic to the fewest drug interactions. It both fairly well-tolerated, the latter a penicillin are not actually aller- has become the drug of choice for is more likely to cause nausea and gic.9,10,12-14 infections requiring a macrolide vomiting. Drug interactions with Typically, the cephalosporins, treatment. It is taken twice daily these two agents are miniscule, and possessing similar side chains, on the first day and then once the regimen is generally considered increase the likelihood of a cross- for another four days. Due to the safe to take while pregnant.9-11 Cephalexin. A first-generation Table 3. Dosing Regimens for Beta-Lactam Agents cephalosporin, this has gram-pos- Amoxicillin 500mg BID-TID x 10 days itive coverage similar to amoxicil- 875mg BID x 10 days* lin, but is considered more stable against hydrolysis by beta-lacta- Amoxicillin+Clavulanate 500mg/125mg BID-TID x 10 days mase–producing organisms. MRSA 875mg/125mg TID x 10 days* and Pseudomonas aeruginosa are Cephalexin 500mg BID x 10 days not susceptible to this agent. Side * higher dose = increased S. pneumoniae coverage. effects with cephalexin are well-tol-

56 REVIEW OF OPTOMETRY APRIL 15, 2018

0052_ro0418_f2.indd52_ro0418_f2.indd 5656 33/30/18/30/18 5:015:01 PMPM Multi-purpose solutions can Biotruth #47 disinfect as well as peroxides1*†

Biotrue® solution is unsurpassed in disinfection effi cacy1*

The following bio-inspired elements of Biotrue® enhance the dual disinfection system. Matching the pH of healthy tears optimizes the performance of the dual disinfectants, and keeping lysozyme active longer helps maintain tears’ inherent antimicrobial activity.1,2 No wonder it’s the #1 multi-purpose solution used in more households.‡

3 BIO-INSPIRED INNOVATIONS Matches the pH Keeps lenses moist Keeps key beneﬁ cial of healthy tears for up to 20 hours tear proteins such 3 1 # (7.5)1 with hyaluronan (HA) as lysozyme active Provide your patients with unsurpassed disinfection effi cacy.1* Recommend Biotrue®, because their solution matters. For more information, call 1-800-828-9030 or visit bausch.com/biotruesolution

*Based on ISO 14729 testing against the 5 panel organisms. †Among leading peroxides. ‡Highest household penetration among multi-purpose solutions; IRI Data MULO 52 weeks ending 6/11/17. REFERENCES: 1. Data on fi le. Bausch & Lomb Incorporated. Rochester, NY. 2. A lysozyme activity assay was used to determine the ability of Biotrue® to prevent the denaturation of lysozyme, in comparison to multiple marketed multi-purpose solutions and leading hydrogen peroxide solution. This assay is based on the ability of lysozyme to digest the cell wall of micro-organisms in a suspension. The results indicate that Biotrue® has the ability to stabilize lysozyme in its native form under chemical denaturation conditions that typically denature lysozyme. Statistically signifi cant greater stabilization of lysozyme was observed with Biotrue® compared to competitive solutions and a phosphate buffered saline control. 3. In vitro studies evaluated the rate of release of sodium hyaluronate (HA), a conditioning agent in the Biotrue® multi-purpose solution, from both conventional and silicone hydrogel contact lenses over a twenty-hour time period. HA was adsorbed on all traditional and silicone hydrogel contact lenses tested upon soaking in the solution overnight. HA is then released from the lenses throughout at least a twenty hour time period when rinsed with Hank’s balanced salt solution at a rate mimicking tear secretions. The in-vitro performance of Biotrue® multi-purpose solution suggests that it will provide lens conditioning throughout a twenty hour time period. Biotrue is a trademark of Bausch & Lomb Incorporated or its affi liates. ©2017 Bausch & Lomb Incorporated. BIO.0154.USA.17

RO0418_BL Biotrue.indd 1 3/26/18 9:24 AM Antibiotics

post-antibiotic effect, five days of if and when a fluoroquinolone is therapy treat bacteria systemically necessary. If a pseudomonal infec- for approximately 72 hours past tion is suspected or confirmed, con- the last dose.18 sider ciprofloxacin instead. While levofloxacin may have sufficient When Side Effects Set In pseudomonal coverage, it should Pharmacologically, once we move be reserved for gram-positive infec- away from inhibitors of bacterial tions to decrease potential resis- cell wall synthesis (beta-lactams), tance issues.11,19-26 we begin to see more side effects Gemifloxacin and moxifloxa- from antibiotics because they have cin. As members of the “respira- an effect on bacterial cells and tory fluoroquinolone” group, mammalian cells that are rapidly gemifloxacin and moxifloxacin dividing. Examples of these rapidly This 28-year-old patient’s redness is due have bacterial coverage similar to dividing cells include those found to hordeolum and cellulitis. levofloxacin. Occasionally, a Strep. in the skin, gut and bone mar- pneumoniae isolate may be more row.16,17 Table 4. Penicillin Allergy sensitive to one agent than another Mechanistically, the macrolides Quick Facts12-14 in this group; however, they are are protein synthesis inhibitors and • The natural penicillins—penicillin G generally considered fairly equiva- bind to the 50S ribosomal subunits and penicillin VK—are more allergenic lent from an empiric treatment in susceptible organisms. Staph. than other penicillins. perspective. In some situations aureus and Strep. pneumoniae are • A true, life-threatening penicillin levofloxacin and moxifloxacin generally less sensitive to azithro- type-1 hypersensitivity reaction is rare, may have slightly broader cover- mycin as compared with the beta- and is estimated at one to five per 10,000 age against highly resistant Strep. lactam agents. cases of penicillin therapy. species. While less well known, On the contrary, Haemophilus • Parenteral rather than oral adminis- both gemifloxacin and levofloxacin influenzae is generally more sensi- tration is more likely to cause an allergic are generally considered inter- tive to azithromycin than to the reaction. changeable with levofloxacin in beta-lactam agents. While azithro- • Amoxicillin is most likely to cause a the management of gram-positive mycin is generally well tolerated, rash when inappropriately used to treat a infections. Levofloxacin has with occasional mild gastrointes- viral illness. slightly improved gram-negative tinal complaints, it may cause QT activity.20,21,27,28 prolongation (a heart arrhythmia) eration” topical fluoroquinolones These drugs are bacterial DNA in susceptible patients. It has include besifloxacin, moxifloxacin, synthesis inhibitors. It’s generally miniscule drug interactions and is levofloxacin and gatifloxacin.22-26 accepted that fluoroquinolones generally considered safe in preg- Ciprofloxacin. This earlier-gen- have chelation drug interactions, nancy.16-18 eration agent is another frequently which result in a decrease in sys- used oral fluoroquinolone. While temic absorption when the drug is Face the Fluoroquinolones it no longer provides reliable Strep. given with di- and trivalent cations The fluoroquinolone group of pneumoniae coverage, it does have (e.g., multivitamins, calcium, iron). systemic antibiotics includes levo- relatively good efficacy against As such, any dietary supplements floxacin, ciprofloxacin, moxifloxa- Pseudomonas aeruginosa. Both that are cations should be given cin and gemifloxacin, colloquially ciprofloxacin and levofloxacin either two hours prior or four knows as the “respiratory fluo- have decent coverage against Hae- hours after the fluoroquinolone.19-26 roquinolones,” for their excellent mophilus influenzae but no appre- Adverse effects associated with Strep. pneumoniae coverage. The ciable MRSA coverage. fluoroquinolone antibiotics are per- ophthalmic fluoroquinolones are Levofloxacin. Due to the dif- haps their most notable drawback. also divided into two categories. ferences in spectrum of coverage They are generally contraindicated The earlier-generation topical between ciprofloxacin and levo- in pregnancy, breastfeeding and in agents include ciprofloxacin and floxacin, ocular infections are children younger than 18 years old, ofloxacin. The newer “fourth-gen- generally treated with levofloxacin due to the corresponding risk of

58 REVIEW OF OPTOMETRY APRIL 15, 2018

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Administered by OPTOMETRIC CORNEA, CATARACT AND REFRACTIVE SOCIETY ® Review of Optometry *Approval pending **15th Annual Education Symposium Joint Meeting with NT&T in Eye Care Review of Optometry® partners with Salus University for those ODs who are licensed in states that require university credit. See Review website for any meeting schedule changes or updates. Antibiotics

10. Hilal-Dandan R, Brunton LL, eds. Penicillins, Cephalospo- Table 5. Oral Fluoroquinolone Dosing rins, and Other ß-Lactam Antibiotics. In: Goodman and Gilman’s Manual of Pharmacology and Therapeutics, 2e. New York, NY: Levofloxacin 500mg daily x 10 days McGraw-Hill. 11. Frei C, Frei B. Upper respiratory tract infections. In: Pharma- Moxifloxacin 400mg daily x 10 days cotherapy: A pathophysiologic approach, 9 ed. DiPiro J,Talbert R, Yee G, et al., eds. New York, NY: McGraw-Hill, 2014;2014. Gemifloxacin 320mg daily x 5 days* 12. Bhattacharya S. The facts about penicillin allergy: a review. JAPTR. 2010;1(1):11-17. Ciprofloxacin 500mg to 750mg BID x 10 days** 13. Zagursky R, Pichichero M. Cross-reactivity in beta-lactam allergy. J Allergy Clin Immunol. 2018;6(1):72-81. * Coverage for resistant S. pneumoniae may not be sufficient. 20-21,27-28 14. Macy E. Penicillin and beta-lactam allergy: epidemiology ** Choose only if P. aeruginosa is suspected or documented.19-21 and diagnosis. Curr Allergy Asthma Reps. 2014;14(11):476. 15. Prematta T, Shah S, Ishmael F. Physician approaches to beta-lactam use in patients with penicillin hypersensitivity. Allergy Asthma Proc. 2012;33(2):145-51. arthropathy.20,21 Photosensitivity of retinal detachment, newer research 16. Hilal-Dandan R, Brunton L, eds. Protein synthesis inhibi- 36 tors and miscellaneous antibacterial agents. In: Goodman and the skin, resulting from all fluoro- has debunked this. Additional Gilman’s Manual of Pharmacology and Therapeutics, 2e. New quinolones (and QT prolongation research and clinical anecdotes will York, NY: McGraw-Hill;2013. 17. Beauduy C, Winston L. Tetracyclines, macrolides, clindamy- from the respiratory fluoroquino- further determine the severity of cin, chloramphenicol, streptogramins, & oxazolidinones. Basic lones) are listed as potential side this risk.32,33 & Clinical Pharmacology, 14 e. Katzung, ed. New York, NY: 20,21 McGraw-Hill. effects for these agents as well. The expanding role of the 18. Pfizer Labs; Zithromax 250 mg and 500 mg tablets and Additionally, the risk of tendon optometrist requires a multi-dimen- oral suspension (azithromycin) [prescribing information]. New York, NY: December 2015. rupture in the shoulder and Achil- sional perspective on the treatment 19. Beauduy C, Winston L. Sulfonamides, trimethoprim, & qui- les has been well documented; of infections that typically require nolones. Basic & clinical pharmacology,14e Katzung B, ed. New York, NY: McGraw-Hill. it seems more likely to occur in systemic therapy. Additionally, 20. Bayer HealthCare Pharmaceuticals Inc; Cipro (ciprofloxacin) elderly patients and in those tak- staying current on resistance pat- [prescribing information]. Whippany, NJ: July 2017. 31 21. Janssen Pharmaceuticals Inc; Levaquin (levofloxacin) [pre- ing systemic corticosteroids. terns, drug interactions and side scribing information]. Titusville, NJ: February 2017. While practitioners once suspected effects is critical to one’s ability to 22. Alcon; Ciloxan (ciprofloxacin) solution [prescribing information]. Fort Worth, TX: March 2006. a correlation between fluoroqui- choose the appropriate agent as 23. Ocuflox (ofloxacin) [prescribing information]. Irvine, CA: nolone use and the presence of a well as one that will best encourage Allergan; February, 2012. patient compliance. ■ 24. Akorn; Levofloxacin solution [prescribing information]. Lake Forest, IL: December 2010. A Word About Resistance Dr. Offerdahl-McGowan is an 25. Alcon; Moxeza (moxifloxacin) solution [prescribing informa- Antibacterial resistance has been a con- assistant professor of biomedicine at tion]. Fort Worth, TX: May 2013. 26. Allergan Inc; Zymaxid (gatifloxacin) solution [prescribing cern since World War II, when we saw our Salus University. information]. Irvine, CA: January 2014. first global distribution of penicillin. At Dr. Caldwell is an ocular disease 27. Merus Labs; Factive (gemifloxacin) tablet [prescribing information]. Toronto, Ontario, Canada: May 2016. the core of this problem lies the inability consultant in Duncansville and 28. Merck & Co; Avelox (moxifloxacin) [prescribing information]. of practitioners to recognize how their Johnstown, PA, and a past president Whitehouse Station, NJ: September 2016. 29. Hilal-Dandan, Brunton L, eds. Sulfonamides, trimethoprim- individual prescribing practices can and of the Pennsylvania Optometric sulfamethoxazole, quinolones, and agents for urinary tract infec- will directly impact the future success or Association. tions. In: Goodman and Gilman’s Manual of Pharmacology and Therapeutics, 2e. New York, NY: McGraw-Hill. failure of antibiotics. 30. Pfizer Labs; Vibramycin (doxycycline) oral [prescribing infor- Additionally, evolving organisms are 1. Morrow G, Abbott R. Conjunctivitis. Am Fam Physician. mation]. New York, NY: August 2014. 1998;57(4):735-46. 31. van der Linden PD, Sturkenboom MCJM, Herring RMC, growing resistant to antibiotics much 2. Colgan RC, Powers JH. Appropriate antimicrobial prescribing: et al. Increased risk of achilles tendon rupture with quinolone faster than the rate at which we are approaches that limit antibiotic resistance. Am Fam Physician. antibacterial use,especially in elderly patients taking oral corti- 2001;64(6):999-1005. costeroids. Arch Intern Med. 2003;163:1801-7. able to produce new antibiotics to fight 3. Spear C, Obenchain M. When a drop isn’t enough. Rev 32. Etminan M, Forooghian F, Brophy JM, et al. Oral Optom. 2015;152(1):38-44. fluoroquinolone and the risk of retinal detachment. JAMA. them. As physicians, it’s our responsibil- 4. Kabat A, Sowka J. Stye vs. Stye. Rev. Optom. 2012;307(13):1414-9. 2016;153(3):111-3. ity to practice discretion when managing 33. Marcinak JF, Frank AL. Treatment of community-acquired 5. Greenberg R, Dippold A. Current Diagnosis & Treatment: methicillin-resistant staph aureus in children. Curr Opin Infect infectious diseases, in hopes of prevent- Emergency Medicine, 8 Ee. Eye emergencies. In: Stone K, Dis. 2003;16(3):265-9. Humphries R, eds. New York, NY: McGraw-Hill;2017. ing—at all costs—the rise of antibiotic- 34. Quinn R. Rethinking antibiotic research and development: 6. Vagefi MR. Lids and Lacrimal Approachs. Vaughan & Asbury’s resistant organisms. This should be done General Ophthalmology, 19 e. In: Riordan-Eva P, Augsburger J, World War II and the penicillin collaborative. Am J Public Health. by avoiding the use of antibiotics for eds. New York, NY: McGraw-Hill;2017. 2013;103(3):426-34. 7. Carlisle R, Digiovanni J. Differential diagnosis of the swollen 35. Barbosa T, Levy S. The impact of antibiotic use on resis- infections that are likely of viral origin and red eyelid. Am Fam Physician. 2015;92(2):106-12. tance development and persistence. Drug Resistance Updates. by choosing narrow-spectrum antibiotics 8. Borgman CJ. Proteus mirabilis and its role in dacryocystitits. 2000;(3):303-11. Optom Vis Sci. 2014;91(9):230-5. 36. FDA: fluoroquinolones not tied to retinal detachment, at therapeutic doses for appropriate dura- 9. Beauduy E, Winston L. Beta-lactam & other cell wall- & aortic aneurysm. NEJM Journal Watch. www.jwatch.org/ tions of treatment.34,35 membrane-active antibiotics. In: Katzung B, ed. Basic & clinical fw112876/2017/05/12/fda-fluoroquinolones-not-tied-retinal- pharmacology, 14e. New York, NY: McGraw-Hill;2017 detachment-aortic. May 12, 2017. Accessed March 20, 2018.

60 REVIEW OF OPTOMETRY APRIL 15, 2018

0052_ro0418_f2.indd52_ro0418_f2.indd 6060 33/30/18/30/18 5:025:02 PMPM RO0318_Keeler Tono.indd 1 2/22/18 12:46 PM DED Drugs

Sizing Up Anti-Inflammatories in Dry Eye Disease

A practical guide for optometrists applying these medications. By Vin Dang, OD

ry eye disease (DED) is a multifactorial disorder of the ocular surface that severely impacts Dvision and quality of life. Risk factors that contribute to DED include age, gender, hormones, autoimmune disorders, local environment, use of video displays, contact lens wear and exposure to medications/ preservatives, all potentially leading to secretory or evaporative DED, or both.1 Inflammation is another The sodium fluorescein staining used in these patients reveals a compromised corneal key risk factor. The Tear Film and surface due to DED. Ocular Surface Society’s Dry Eye Workshop II definition recognizes diagnosing inflammation in the clini- in the detection of ocular surface the impact of inflammation, saying, cal setting, including options to best damage often seen alongside inflam- “Dry eye is a multifactorial disease treat inflammatory dry eye disease mation. The use of sodium fluores- of the ocular surface characterized with the tools currently available. cein or lissamine green vital dyes are by a loss of homeostasis of the tear particularly helpful in identifying film, and accompanied by ocular Identification and and visualizing the devitalized cells symptoms, in which tear film insta- Classification on the conjunctiva. bility and hyperosmolarity, ocular Inflammation on the ocular surface Tear chemistry can also be asso- surface inflammation and damage, can be overt or covert in its pres- ciated with ocular surface inflam- and neurosensory abnormalities play ence. Conjunctival hyperemia, or mation. Using a system designed etiological roles.” redness, is a hallmark of ocular to measure tear osmolarity (e.g., With this more finely honed inflammation that can be objectively TearLab Osmolarity System, or understanding of DED in mind, evaluated by anterior segment pho- I-Pen [I-Med Pharma]) is one way optometrists must make controlling tography or with the use of grading to quantify inflammation. For inflammation a priority. This article scales, such as the Efron Grading patients without inflammation, their will review the optometrist’s role in Scales.2,3 Vital dyes are also valuable hyperosmolarity will read less than

62 REVIEW OF OPTOMETRY APRIL 15, 2018

062_ro0418_f3.indd 62 4/2/18 10:27 AM 300mOsm/L.1,4 With this presumed to be suppressed quantification, physicians due to ocular inflammation can engage their patients associated with keratocon- by providing pretreat- junctivitis sicca.1 Because of ment and post-treatment the mechanism of action of results. Research shows CsA, the anti-inflammatory matrix metalloproteinases, effects usually won’t take specifically matrix metallo- place until after at least four proteinase-9 (MMP-9), is a to six weeks of starting ther- byproduct of inflammation apy.10,11 This won’t be the and cell insult and, now best medication to use if you that an MMP-9 detection have a patient with acute test (e.g., InflammaDry inflammation. Also because Detector, Quidel) is avail- of the immunomodulator able, we can count that as properties of CsA, it is a yet another biomarker of good option to treat autoim- inflammation.1,5 mune disease associated dry The clinical symptoms eyes, such as Sjögren’s syn- of inflammation include This patient’s injected blood vessels indicate inflammation. In drome. end-of-day burning, sting- this eye, it can be seen without any vital dyes. Lifitegrast is an anti- ing, dry, irritated, scratchy, inflammatory drug that watery and itchy eyes.2 If a patient Thankfully, not all corticosteroids was approved by the FDA in 2016 presents with these clinical signs and are created equal. A “soft” steroid for the treatment of the signs and symptoms, therapeutic intervention such as loteprednol or fluorometho- symptoms of DED. Xiidra (topical is indicated. As soon as patients can lone could be used for four to six lifitegrast 5%, Shire) is the first dry be categorized as mild-to-moder- weeks without having to worry eye medication that targets integrin ate—by either exhibiting corneal about the long-term side effects. signaling as a lymphocyte function- staining signs, decreased tear film Sometimes I will also pulse the soft associated antigen-1 (LFA-1) antago- break-up time or complaining of steroid BID to TID dosage for one nist that blocks coupling of LFA-1 DED symptoms—anti-inflammatory week on and two weeks off, then and ICAM-1.13 LFA-1 is found on medications are justified. repeat as needed with close clinical the surface of the T-cell. By blocking follow ups. the interaction between LFA-1 and The Right Stuff Cyclosporine (CsA) is another ICAM-1, it is thought that one of When deciding which anti-inflam- anti-inflammatory medication used the inflammatory cycle is prevented. matory to use, keep in mind each to combat inflammation associated In the OPUS-1 clinical study, there drug’s mechanisms of action. with DED. In a large multicenter was a significant improvement in Corticosteroids act on various study, 0.05% to 0.1% CsA treat- signs such as inferior corneal stain- inflammatory responses, including ment significantly reduced HLA-DR ing, but not in symptoms.14 The sub- intercellular adhesion molecule-1 expression and to a lesser extent sequent OPUS-2 study established (ICAM-1)-mediated cell adhe- expression of other inflammatory significant improvement in the eye sion, cytokines/chemokines/MMPs and apoptotic markers in patients dryness score, and this was con- expression and induction of lympho- with moderate-to-severe DED.10,11 firmed in OPUS-3.15,16 Symptomatic cyte apoptosis.6-8 Simply put, corti- Topical CsA increase goblet cell relief occurred as early as two weeks costeroids have a broad-spectrum density and conjunctival production after initiating treatment for patients mechanism of action when it comes of immunomodulatory transform- with moderate DED. to controlling inflammation. How- ing growth factor beta-2 (TGF-ß2) After determining the sever- ever, their long-term use in ocular in DED patients.12 In 2003, Restasis ity of the inflammation in a DED conditions is not recommended (topical cyclosporine 0.05%, Aller- patient, whether by having a positive because of steroid-related side- gan) received approval from the response to the InflammaDry test, or effects such as increased intraocular FDA to increase tear production in by simply grading the clinical signs; pressure and cataract formation.9 patients whose tear production is the optometrist can then decide if a

REVIEW OF OPTOMETRY APRIL 15, 2018 63

062_ro0418_f3.indd 63 4/2/18 10:27 AM DED Drugs

The lissamine green staining here highlights the devitalized cells on the conjunctiva, which indicate ocular surface disease.

topical steroid is needed to quickly as Lipiflow (Tearscience), a thermal combination products are useful for decrease the overall inflammation pulsation device that simultaneously decreasing the bacterial load as well along with either Restasis or Xiidra. heats the meibum and pulsates to as managing the inflammation.20 If the inflammation is particularly liberate the melted meibum out of Concerns of antibiotic resistance and severe, you might considering using the glands. long-term exposure to the cortico- a soft steroid with both Restasis and Diet is another aspect in which we steroids comes to mind when using Xiidra together, as their mechanisms can directly affect the level of inflam- these type of medications. After a of action are different. However, if mation in the eye. Oral supplementa- short course of a topical antibiotic- the inflammation isn’t so severe it tion with omega-3 polyunsaturated corticosteroid combo medication, requires a topical steroid, lifitegrast fatty acids, eicosapentaenoic acid or you may want to switch the patient (for faster symptom relief) and CsA docosahexaenoic acid found in fish to a type of hypochlorous acid (if the patient has autoimmune dis- oil all decrease the production of (HOCl) cleanser such as Avenova ease associated DED) without the pro-inflammatory mediators, such as (NovaBay) or Acuicyn (Sonoma steroid is acceptable. prostaglandin E2, and cytokines.18 Pharmaceuticals) to keep the bacte- Gamma-linolenic acid (GLA) is also rial levels at bay.21 HOCl is a natural Complementary Treatments an omega-6 with anti inflammatory product made by neutrophils to kill Controlling inflammation is a properties.19 HydroEye (Science microorganisms.22 Oral doxycycline vital step in reducing DED symp- Based Health) provides the necessary is another tool that can be used to toms, but optometrists can also GLA formulation through black cur- control inflammation via MMP sup- treat mechanical issues that can be rant seed oil. pression.23 A maintenance dose of (but aren’t always) the root cause Another contributor to inflam- 50mg BID can be prescribed for up of dry eye. For instance, patients mation is blepharitis from the lids.20 to three months to try to control the with meibomian gland dysfunction The etiology of the condition is not inflammation systemically. have obstructed glands and may fully understood, but low-grade be able to find relief once they are bacterial infection (primarily Staphy- Topical steroids should not be unclogged. A conservative approach lococcus), Demodex mites, environ- used long-term without frequent involves using heat therapy in the mental factors and certain systemic monitoring because of the potential form of a warm compress that is disease have all been implicated as side effects. They can be used ini- directly applied to the lids to try to potential contributors.20 tially to control the acute stage of reduce the viscosity of the meibum inflammation and then tapered off. within. A more aggressive approach The Combo Approach CsA in the form of Restasis is safe involves in-office treatments, such Topical antibiotic-corticosteroid to use long term but requires contin-

64 REVIEW OF OPTOMETRY APRIL 15, 2018

062_ro0418_f3.indd 64 4/2/18 10:28 AM 25TH ANNUAL OPHTHALMIC ued use to achieve its anti-inflammatory Product Guide properties and also can take up to two months before noticing any improvement in DED symptoms.24 Xiidra is also safe to use long term and can work on the current inflammatory response for Innovative products to faster resolution.15,16 ■ Dr. Dang is an optometrist practicing in a multi- enhance your practice speciality eye clinic in Bakersfield, California. His clinical practice covers a broad spectrum of ocular care with a unique clinical focus on ocular surface disease and dry eye.

1. Baudouin C, Irkeç M, Messmer E, et al. Clinical impact of inflammation in dry eye disease: proceedings of the ODISSEY group meeting. Acta Ophthalmol. 2018 Mar;96(2):111-119. 2. TFOS International Dry Eye WorkShop (DEWS II). Ocular Surf. 2017;15(6):269-650. 3. McMonnies CW & Ho A (1991): Conjunctival hyperaemia in non-contact lens wearers. Acta Ophthalmol (Copenh) 69: 799–801. 4. Sullivan B, Whitmer D, Nichols KK et al. (2010): An objective approach to dry eye disease severity. Invest Ophthalmol Vis Sci. 2010 Dec;51(12):6125-30. The future 5. Luo L, Li DQ, Doshi A, et al. Experimental dry eye stimulates production of inflammatory cytokines and MMP-9 and activates MAPK signaling pathways on the ocular surface. Invest Ophthalmol Vis Sci. 2004 Dec;45(12):4293-301. is in your 6. Pflugfelder S. Antiinflammatory therapy for dry eye. Am J Ophthalmol. 2004;137(2):337– 42. 7. De Paiva C, Corrales R, Villarreal A, et al. Corticosteroid and doxycycline suppress MMP-9 and inflammatory cytokine expression, MAPK activation in the corneal epithelium in experi- hands. One mental dry eye. Exp Eye Res. 2004;83:526–35. 8. Yagci A, Gurdal C. The role and treatment of inflammation in dry eye disease. Int Ophthal- mol. 2014;34:1291–301. tap, many 9. Marsh P, Pflugfelder SC. Topical nonpreserved methylprednisolone therapy for keratoconjunctivitis sicca in Sjogren syndrome. Ophthalmology. 1999;106:811–6. 10. Brignole F, Pisella P, De Saint Jean M, et al. Flow cytometric analysis of inflammatory markers in possibilities. KCS: 6-month treatment with topical cyclosporin A. Invest Ophthalmol Vis Sci. 2001;42: 90–5. 11. Galatoire O, Baudouin C, Pisella P. Flow cytometry in impression cytology during keratoconjunctivitis sicca: effects of topical cyclosporin A on HLA DR expression. J Fr Ophtalmol. 2003;26:337–43. 12. Pflugfelder S, De Paiva C, Villarreal A, Stern M. Effects of sequential artificial tear and Experience the digital edition on cyclosporine emulsion therapy on conjunctival goblet cell density and transforming growth factor-beta2 production. Cornea. 2008;27:64–9. your handheld device. Use your 13. Perez VL, Pflugfelder SC, Zhang S, et al. Lifitegrast, a novel integrin antagonist for treatment of dry eye disease. Ocul Surf. 2016;14(2):207-15. 14. Sheppard J, Torkildsen J, Lonsdale J, et al. Lifitegrast ophthalmic solution 5.0% smart device to scan the code for treatment of dry eye disease: results of the OPUS-1 phase 3 study. Ophthalmology. 2014;121(2):475-83. 15. Tauber J, Karpecki P, Latkany R, et al. Lifitegrast ophthalmic solution 5.0% versus placebo below or visit: for treatment of dry eye disease: results of the randomized phase III OPUS-2 study. Ophthal- mology. 2015;122(12):2423-31. 16. Holland E, Luchs J, Karpecki P, et al. Lifitegrast for the treatment of dry eye disease: results www.reviewofoptometry.com/publications/archive of a phase III, randomized, double-masked, placebo-controlled trial (OPUS-3). Ophthalmology. 2017;124(1):53-60. 17. Nichols K, Foulks G, Bron A, et al. The international workshop on meibomian gland dysfunction: executive summary. Invest Ophthalmol Vis Sci. 2011;52(4):1922-9. Download a QR scanner app. Launch app and hold your 18. Kelley D, Taylor P, Nelson G, et al. Docosahexaenoic acid ingestion inhibits natural mobile device over the code to view killer cell activity and production of inflammatory mediators in young healthy men. Lipids. 1999;34:317–324. https://www.reviewofoptometry.com/publications/archive 19. Sheppard JD, Singh R, McClellan AJ, et al. Long-term Supplementation With n-6 and n-3 PUFAs Improves Moderate-to-Severe Keratoconjunctivitis Sicca: A Randomized Double-Blind Clinical Trial. Cornea. 2013;32(10):1297-304. 20. American Academy of Ophthalmology. Preferred Practice Pattern: Blepharitis. September 2013 revision. www.aao.org/preferred-practice-pattern/blepharitis-ppp--2013. Accessed March 25, 2018. 21. Romanowski E, Stella N, Yates K, et al. In Vitro Evaluation of a Hypochlorous Acid Hygiene Solution on Established Biofilms. Eye Contact Lens. www.ncbi.nlm.nih.gov/ pubmed/29369234. Accessed March 25, 2018. 22. Wang G, Nauseef W. Salt, chloride, bleach, and innate host defense. J. Leukoc Biol. 2015;98:163–72. 23. Geerling G, Tauber J, Baudouin C. The international workshop on meibomian gland dysfunction: report of the subcommittee on management and treatment of meibomian gland dysfunction. Invest Ophthalmol Vis Sci. 2011;52(4):2050–64. 24. Kymionis GD, Bouzoukis DI, Diakonis VF, et al. Treatment of chronic dry eye: focus on cyclosporine. Clin Ophthalmol. 2008 Dec;2(4):829–36.

062_ro0418_f3.indd 65 4/2/18 10:28 AM 2 CE Credits (COPE approved)

PROTOCOLS AND PITFALLS IN TOPICAL STEROID USE It’s always a balancing act between benefit and side effects. Here’s how to keep patients safe while treating with steroids. By Aaron Bronner, OD, and Walter O. Whitley, OD, MBA

opical corticosteroids are Regardless of dosing strategy mechanism of action—is preserved.4 the most frequently pre- (systemic or local), the therapeutic By reducing the production of this scribed class of ophthalmic goal of corticosteroids is to limit the legion of inflammatory mediators, agents by optometrists immune response via the phospho- locally dosed corticosteroids reduce Tacross the United States. In 2013, lipid A2 pathway. Because of their several actions, including: vascular topical corticosteroids (including ste- wide range of target cells, cortico- permeability to immune cells, the roid/antibiotic combination agents) steroids have the broadest, but least recruitment of other immune cells accounted for a little more than specific, effect on inflammation of to that site, tissue breakdown, hista- 50% of ophthalmic prescriptions any immune modulatory agent.4 mine release and subsequent edema, written by ODs.1 Steroids were pre- When dosed orally for systemic angiogenesis and fibroblast activa- scribed three times more frequently therapy, these agents reduce differ- tion (which results in scar tissue), than topical antibiotics, topical entiation and maturation of immune among other consequences.4 antivirals and topical nonsteroidal cells within primary immune tis- With these broad effects and their anti-inflammatory drugs (NSAIDs) sue, as well reduce the expression trickle-down clinical benefits, treat- combined.1 And it’s no wonder we of pro-inflammatory cytokines and ing everything from ocular surface like these drugs, given their mecha- chemokines peripherally.4 When disease to uveitis, it’s easy to see why nism of action. Because essentially all dosed topically, steroids don’t influ- corticosteroids are such a favorite of nucleated cells in the body express ence immune-cell maturation, but the profession. However, although receptors for these molecules, cor- the effect on cytokines, chemo- steroids are quite effective at address- ticosteroids have a sweeping effect kines and other pro-inflammatory ing inflammation, they can cause across many tissues.2,3 molecules—an extremely robust complications. Common side effects

Release Date: March 2, 2018 Credit Statement: This course is COPE approved for 2 hours of CE Expiration Date: March 2, 2021 credit. Course ID is 57000-PH. Check with your local state licensing Goal Statement: Topical corticosteroids can be a useful treatment board to see if this counts toward your CE requirement for relicensure. strategy for everything from ocular surface disease to uveitis—but they Disclosure Statements: can cause complications, and clinicians must account for their side Authors: Dr. Bronner has no relationships to disclose. Dr. Whitley has effects. To better prepare clinicians to prescribe these agents safely, this a relationship with Alcon, Allergan, Bausch + Lomb, BioTissue, Carl Zeiss Meditec, Glaukos, TearScience, TearLab, Johnson & Johnson, article reviews the known side effects of ophthalmic corticosteroids, OcuSoft and Beaver Visitec. appropriate use and dosing-based differences among target tissues. Editorial staff: Jack Persico, Rebecca Hepp, William Kekevian, Faculty/Editorial Board: Aaron Bronner, OD, and Walter Whitley, OD, Francesca Crozier-Fitzgerald and Michael Iannucci all have no MBA relationships to disclose.

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of oral prednisone include increased tion. For example, loteprednol Photo: Jeff Urness, OD intraocular pressure (IOP), cata- 0.5%, rimexolone 1% and ract formation, mood changes and fluorometholone 0.1% are increased blood sugar levels. These associated with a lower risk of are not associated directly with the steroid response, a lower peak desired mechanism of these agents pressure when a response and are truly unintended; with occurs and a slower time to increased IOP possibly leading to peak compared with dexa- irreparable vision loss via glaucoma, methasone phosphate 0.1% or it’s particularly worrisome. prednisolone acetate 1%.8-10 Another negative effect of steroid The mechanism by which use is not an unexpected adverse these steroids achieve their event, but a predicable effect based increased safety differs slightly on the mechanism at play. Because between medications. In fluo- Ths fulminant corneal ulcer was initially treated the primary effect of corticosteroids rometholone 0.1% and rimex- with Tobradex. is limiting the immune response, olone 1%, liphophilicity plays their use may result in worsening of a large part in reducing IOP spikes, associated with posterior subcapsu- any condition where the immune as the medications don’t penetrate lar cataracts.15 Surprisingly, however, response is needed (i.e., an infectious the cornea due to biphasic nature, there is little to no peer-reviewed process). Unfortunately, although thereby lowering the potential for information regarding rates of cata- this effect can potentially lead to spikes.11,12 Phosphate preparations, ract development with ophthalmic catastrophic vision loss, it is often as hydrophilic solutions, penetrate corticosteroids overall, let alone under-recognized by the profession. the epithelium poorly, which may among specific agents. To better prepare clinicians to be ideal for ocular surface condi- Because of loteprednol’s soft drug prescribe these agents safely, this tions.11,12 design, research suggests it has a article reviews the known side effects Hydrophobic alcohol-based and reduced potential to cause cataracts; of ophthalmic corticosteroids, par- acetate suspensions, however, should however, this claim seems to be ticularly within the cornea, their theoretically be more adept at pen- based on one retrospective review of appropriate use and dosing-based etrating all layers of the cornea. 159 patients, none of whom devel- differences among target tissues. Loteprednol achieves its enhanced oped cataracts while using lotepred- safety, in part, from its reduced half- nol 0.2% for more than a year.16 Intraocular Pressure life in the anterior chamber as an Although the differences in the Elevation in IOP is the most fre- ester-steroid, which reduces adverse potential to cause cataracts among quently observed side effect of drug reactions. The newest topical individual agents are still unknown, ophthalmic steroid use, occurring in steroid, difluprednate 0.05%, seems we do know that chronic topical 18% to 36% of patients.5 Regard- to have the highest anti-inflamma- steroid use, at least in cohorts with less of the specific steroid being tory potency.13 This comes at a cost, chronic intraocular inflammation, used, this response is more likely to however, as research shows the medi- is associated with cataract forma- occur with prolonged dosing and has cation can cause the most extreme tion—with greater dose frequency been observed in higher frequency and most rapid IOP responses.14 associated more frequently than in glaucoma suspects and patients.6 lesser dosages.17 Practitioners can Research suggests the mechanism Cataract Development reasonably predict that long-term likely involves the alteration of the The literature shows significant topical steroid use follows the same trabecular meshwork’s (TM) outflow variability in cataract formation trends seen in IOP response among efficacy via increased deposition of in patients on systemic steroids, specific agents: those that don’t pen- extracellular matrix within the TM.7 as between 6.5% and 38.7% of etrate into the anterior chamber well This is usually transient, though patients on them develop cataracts.15 and those that have a short half-life recalcitrant steroid-induced ocular Further research reveals varying (fluorometholone, rimexolone and hypertension is possible. associations with cataract and loteprednol) can be expected to pro- Ophthalmic steroid preparations inhaled steroid compared with peri- duce cataracts at a lower rate than come in varying strengths with nasal dosing.15 Whether topical, oral more potent steroids (prednisolone, equally varying risks of IOP eleva- or inhaled, steroids are commonly dexamethasone and difluprednate).

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Selection and Dosing the anterior chamber. Steroid use for Due to the conjunctiva’s immedi- When dosing corticosteroids for each of these zones carries a risk for ate access to the immune response, inflammation of the ocular surface, the development of cataracts and topical steroid use may reduce the select a poorly penetrating agent (flu- glaucoma, depending on the specific degree of the conjunctival immune orometholone or rimexolone) or soft agent and duration of treatment. The response without eliminating it drug corticosteroid such as lotepred- risks also differ based on the conse- entirely. Steroids can be a useful nol to reduce risk of complications. quences of potentiating infection. adjunct in the therapeutic and pallia- When inflammation is in the Conjunctiva. True conjunctival tive management of both inflamma- anterior chamber or deeper cornea, infections, with the exception of tory and infectious conjunctivitis by the selected agent should balance hyper-acute conjunctivitis, can gen- reducing unnecessary inflammation with the degree of anti-inflammatory erally be treated with corticosteroids that can lead to pain, conjunctival effect necessary. For mild to moder- with near impunity and without fibrosis, destruction of goblet cells ate inflammation, loteprednol is a fearing induction of vision-threat- and symblepharon formation. good option, and more severe cases ening escalation of the disease. The Clinicians must remember that may do well with prednisolone reason for this has to do with the infectious conjunctivitis should be acetate 1%. In particularly severe tissue function, its role in vision and preferentially treated with anti- cases of corneal or anterior chamber the normal immune response. infective medications. Still, it may inflammation, the only topical medi- A mucous membrane, the con- be difficult to differentiate infectious cation we’ve had success with is dif- junctiva is essentially a watershed from non-infectious, and given the luprednate; otherwise, you’re on to between the external and internal access to local immune response, sub-Tenon’s dosing or systemics. environments. As with all mucous treatment of a localized infectious Excess steroid use can be nearly membranes, one of the conjunctiva’s conjunctivitis with steroid will not as harmful as chronic inflammation primary functions is to act as a bar- lead to profound tissue destruction, and is of particular concern with rier. The most effective barrier tissue unlike that which may occur within long-term management of inflamma- of the body is the skin. Non-nucleat- the cornea. Thus, combination drops tion as seen in chronic keratitis (as ed, keratinized tissue, which makes (paired antibiotic/corticosteroid) are seen occasionally with herpes zoster up the most external layer of the safe and effective in most cases. ophthalmicus), prevention of corneal skin, creates a robust physical barrier Likewise, anterior uveitis stem- graft rejection and cases of chronic to microbes and is able to repel most ming from disseminated systemic uveitis. When deep penetration is infections. In fact, it is nearly impos- infections such as tuberculosis, unnecessary but chronic therapy is sible for a virus to infect healthy, syphilis, Lyme disease and leprosy expected, a more superficially act- uncompromised skin.18 may be treated with topical cortico- ing steroid is appropriate, and in all As a mucous membrane without steroids without risk of exacerbat- cases the lowest dose that fully con- the benefit of keratinized tissue, the ing the underlying disease process. trols inflammation should be used. conjunctiva is at a disadvantage Of course, these patients all need With more substantial steroids and relative to the skin at preventing systemic anti-infectives to cure their the increased potential for steroid infection; therefore, infectious con- disease, but topical steroids are safe, complications over an abbreviated junctivitis is more likely than infec- may enhance treatment by reducing time frame, the follow-up interval tious dermatitis. These conjunctival inflammatory sequele and may reveal should be appropriately reduced. infections, however, are almost an infectious etiology if you see an always self-contained and have mini- incomplete clinical response to anti- Immune Response mal long-term consequences because inflammatory treatment. and Tissue Function what the conjunctiva lacks in kera- Although the uveitis generated Beyond the capacity for creating tinized tissue it makes up for with by these etiologies often exhibits IOP spikes and cataracts, steroid immediate access to the immune an incomplete response to topical use comes with tissue-specific pre- response. The conjunctiva is host to corticosteroids, topical steroid use is cautions. Optometrists typically secondary lymphoid tissue (conjunc- always appropriate front-line therapy prescribe corticosteroids for three tiva-associated lymphoid tissue), has for cases of anterior uveitis.20 primary anatomic zones: the ocular a rich vascular supply and, further, The same cannot be said for surface (including lids, conjunctiva, is not directly responsible for visual systemic steroid use for cases of episclera and corneal epithelium), the function—allowing some tissue dam- infectious uveitis, however. Though non-superficial corneal layers and age without impact on function.19 systemic corticosteroid agents may

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0066_ro0418_f4.indd66_ro0418_f4.indd 6868 33/29/18/29/18 2:372:37 PMPM When an ulcer requires steroids, they should be introduced cautiously. This Moraxella catarrhalis ulcer, at left, was treated for one week with medication that it was sensitive to (per culture results) and improved, but only slowly. It wasn’t until a steroid was cautiously introduced that the eye totally quieted, at right. In this case, having a culture result in hand to ensure appropriate antimicrobial treatment made the subsequent addition of a steroid a reasonable step to take.

be indicated on a case-by-case basis associated with steroid use in the often contains the infection at the for infectious disease management cornea revolve around the cornea’s expense of a corneal scar. Because of (shingles treatment is often supple- function and immune response. the inherent antagonism of the cor- mented with oral prednisone, and The cornea has two primary nea’s barrier and optical functions, some severe leprosy-related immune functions: an optical interface that which are precariously balanced in reactions necessitate their use), they transmits and refracts light and a a healthy eye and are thrown out of should not be used for all cases. They barrier to the external environment. balance in an infected cornea, the use have been known to exacerbate the However, maintenance of one sets up of corticosteroid in infected corneas underlying disease and possibly even challenges for the other. The external has significant possible ramifications. lead to death.21 cornea is part of the ocular surface A now somewhat frequently When using topical agents to con- mucous membrane; however, unlike encountered misconception is that trol a severe uveitis, clinicians should most other mucous membrane- the Steroid for Corneal Ulcers Trial not shy away from strong initial derived tissue, the cornea has no (SCUT) shows no benefit or harm in dosing. Anecdotally, treating uncon- local lymphoid tissue, few native the adjunctive use of corticosteroids trolled anterior uveitis with predniso- immune cells and no local vascular for corneal ulcers; therefore, some lone acetate 1% QID often meets supply. Presence of any of these at think we can use steroids for corneal with predictably minimal success. high levels would enhance corneal pathology with impunity.23 This is In cases of moderate to severe acute barrier function through increas- a dangerous clinical mindset and a anterior uveitis, clinicians should pre- ing access to the immune response, misinterpretation of the SCUT study scribe frequent, often hourly, dosing but would result in a loss of corneal and its findings. The study does not of a strong steroid such as diflupred- clarity and reduced optical func- show there was no benefit or harm in nate, which has been shown to be tion. However, the absence of these the use of corticosteroids for corneal non-inferior to prednisolone acetate features from the central cornea ulcers. It shows, instead, no benefit for anterior uveitis when dosed half limits the cornea’s ability to function or harm with light use of cortico- as frequently, and only taper gradu- as a barrier. If the cornea develops steroid (prednisolone phosphate ally once inflammation is totally an infection, the immune system is 1% QID for one week, BID for one controlled.22 initially unable to help, which allows week, then QD for one week) in the Cornea. Corticosteroids are often for early unfettered proliferation of management of bacterial keratitis necessary to facilitate a good, prompt the microbe. when attempts were made to steril- resolution of corneal pathology; Once an immune response is ize the cornea prior to institution of however, when used incorrectly they mounted, corneal optical function steroid.23 All patients in this study may result in catastrophic vision loss. is sacrificed to preserve the barrier were placed on moxifloxacin hourly The specific implications and risks function, as resultant inflammation for two days prior to being grouped

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into steroid plus antibiotic group had been on topical corticosteroids.25 likely you are dealing with an infec- or antibiotic plus placebo groups.23 These outcomes are critical to guard tious process. Therefore, conservative steroid use against; thus, the cavalier use of cor- The possible exception to this rule as an adjunct therapy only follows ticosteroids must be avoided when is a lesion in the far corneal periph- SCUT protocol when attempts to dealing with corneal pathology. ery, as these are typically hypersen- sterilize the cornea are made prior While most eye care providers sitivity/immune-mediated reactions, to initiation of steroid use—a critical know to avoid corticosteroid use which will respond well to combina- distinction.23 with infectious keratitis except in tion drops. In the rare event a far Due to the lack of immune an extremely conservative manner, peripheral ulcer is infectious—which response held by the central cor- the same is not always true with is uncommon near the limbus— nea, further suppression of it with combination therapies, often pre- proximity to the immune response corticosteroids prior to ensuring an scribed for “mystery keratitides.” will generally prevent dramatic esca- effective antimicrobial sterilization These have the most potential to do lation until initiating more appropri- (as assessed with a positive response harm because of the flawed assump- ate therapy. Additionally, scarring in to therapy) may result in spread of tion that the antibiotic agent in the the far periphery is much less likely the ulcer and treatment failure. In combo drop covers against infection to cause reduced vision. addition, while the SCUT study was while the anti-inflammatory covers Though we aren’t promoting inconclusive on conservative use of for inflammation. In the central and cavalier use of steroid on peripheral corticosteroid in bacterial keratitis paracentral cornea, the absent native corneal pathology, the immunology following an attempt at sterilization, immunity may not allow low-dose and function of the peripheral cor- we know from other retrospective antibiotics to cover for the deleteri- nea allows for more forgiveness in reviews that steroid use with cor- ous effects of the steroid when faced outcomes, should your treatment be neal ulcers increases the likelihood with an infectious challenge. Tissue incorrect. As with all corneal pathol- of progression towards outcomes concentrations of the antibiotic in ogy, follow-up should be short when requiring surgical management. these agents may be insufficient to introducing a steroid to identify any More than 50% of patients from slow colonization of the offending worsening. For non-peripheral kera- one series on infectious keratitis that microbe, and the immune suppress- titis, stromal inflammation that is went on to require keratoplasty had ing effect of the steroid may allow small, non-ulcerated and multifocal been on previous steroid (compared further spread by reducing immune (i.e., contact lens-associated red eye, with 18% of the ulcers that did not cell migration and clearance of the Thygeson’s and adenoviral infec- require surgery).24 Likewise, nearly infection. These possibilities are par- tion) generally responds robustly and 25% of patients in another study ticularly concerning given that, in safely to corticosteroid. on eyes requiring enucleation or this setting, any worsening of infec- Though inappropriate use of ste- evisceration for infectious keratitis tion may lead to a permanent wors- roid on bacterial, protozoan or fun- ening in vision. gal keratitis may lead to poor visual It is crucial to outcomes, exacerbation of viral kera- know the corneal titis is probably the most frequently pathology you are described negative corneal sequela dealing with prior of corticosteroid use in optometry. to initiating com- It is certainly true that treating her- bination or steroid pes simplex virus (HSV) infections therapy for any ker- (clinically, this refers to the dendritic atitis. Anecdotally, a spectrum of disease, as well as the good rule of thumb rare HSV-derived necrotizing stromal is to avoid using keratitis) with a steroid will worsen a steroid for any the infectious episode and increase isolated ulcerative superficial scarring. process of the cen- The pathognomonic finding of A rejection of a DSAEK graft manifesting as corneal edema tral and paracentral a dendrite is a telltale sign that a and scattered keratic precipitates. This appearance also cornea. If you have steroid is inappropriate; however, it approximates that seen with viral endotheliitis; in both an infiltrate and an can be more challenging to differenti- cases, topical steroids are indicated. epithelial defect, it’s ate dendritic lesions near the limbus

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066_ro0418_f4.indd 70 3/29/18 2:37 PM from hypersensitivity reactions, often Corneal Transplants leading to the somewhat tongue-in- This management protocol occupies a special place in the hierarchy of corticosteroid use, as cheek “steroid provocative test.” immunologic and rejection concerns necessitate long-term topical corticosteroid use despite For other forms of herpetic kera- the associated risks. While rejection is the first leading cause of vision loss in a penetrating titis, such as stromal keratitis and keratoplasty (PK) setting, glaucoma is the second, illustrating the delicate balance between endotheliitis, topical steroids are treatment benefits and negative consequences.1 an important part of the therapy, Though not all of the blame falls to steroid use (some mechanical strain on the TM occurs though their use should generally be during the surgical procedure itself), steroid-induced glaucoma is responsible for a large per- paired with an antiviral to reduce the centage of cases.1 Likewise, microbial keratitis is up to 55 times more likely in patients with a risk of reactivation. PK compared with normal extended wear soft contact lens users.2,3 These eyes are also much For any significant unilateral more likely to have poor outcomes with medical management. The rate of re-graft as a result of vascularization, especially with a infection is as high as 57%, and only 14% achieve 20/200 or better vision with medical man- nonulcerated stromal keratitis, agement.2,4 Though infection in a PK population cannot solely be pinned on the use of cortico- you are probably dealing with an steroid, given the wide variety of compromises that occur to the ocular surface with PK, steroid immune-mediated process, likely use is certainly among the factors leading to a greater rate of infection and a worse prognosis. HSV immune stromal keratitis, and Fortunately, with lamellar grafting, these risks diminish, either due to reduced necessity of may safely pair a corticosteroid with steroid, as with deep anterior lamellar keratoplasty (DALK), or reduced disruption on immune oral or topical antivirals. The same privilege as with DSAEK and DMEK. treatment holds in cases of unilateral However, a certain patient population continues to need PK, and though risk may be reduced acute corneal edema without stromal with lamellar surgeries relative to PK, these eyes still need steroid use for between one and two infiltration or dramatically elevated years depending on the transplant type. They also need observation to catch any complications IOP, which is generally HSV endo- of the graft or the treatment. theliitis. A sight-threatening infection For average risk of transplants in steroid-responding PK patients, research shows lotepre- of the cornea resulting in this clinical dnol is less likely to result in IOP spiking and does not increase risk of rejection.5 Likewise, in constellation is rare. lamellar surgery, loteprednol seems to effectively prevent rejection while reducing IOP issues.6 Laterality is also helpful in distin- Fluorometholone 0.1%, while also effective at controlling IOP issues compared with predniso- guishing what keratitides are “ste- lone, was associated (somewhat predictably given its poor penetrance into the deep cornea) roid safe.” Though it is possible that with a higher rate of possible rejection episodes.6,7 bilateral corneal inflammation may 1. Ayyala RS. Penetrating keratoplasty and glaucoma. Surv Ophthalmol. 2000;43(2):91-105. be infectious in origin, it’s unlikely— 2. Tseng SH, Ling KC. Late microbial keratitis after corneal transplantation. Cornea. 1995;14(6):591-6. 3. Stapelton F, Keay L, Edwards K, Holden B. The epidemiology of microbial keratitis with silicone hydrogel contact lenses. Eye Contact Lens. approximately 97% of HSV keratitis 2013;39(1):79-85. is unilateral and, barring exceptional 4. Driebe WT, Stern GA. Microbial keratitis following corneal transplantation. Cornea. 1983;2:41-5. 5. Holland EJ, Djalilian AR, Sanderson JP. Attenuation of ocular hypertension with the use of topical loteprednol etabonate 0.5% in steroid risk factors such as bilateral corneal responders after corneal transplantation. Cornea. 2009;28(10):1139-43. 6. Price MO, Feng MT, Scanameo A, Price FW Jr. Loteprednol etabonate 0.5% gel vs. prednisolone acetate 1% solution after Descemet mem- surgery, nearly all cases of microbial brane endothelial keratoplasty: prospective randomized trial. Cornea. 2015;34:853-8. keratitis are unilateral.26 Although 7. Price MO, Price FW Jr, Kruse FE, et al. Randomized comparison of topical prednisolone acetate 1% versus fluorometholone 0.1% in the first year after Descemet membrane endothelial keratoplasty. Cornea. 2014;33(9):880-6. the same rules of avoidance hold— infiltrated ulcerations of the mid- periphery, paracentral or central when adding a steroid to evaluate for ity, however, can breed complacency, cornea should avoid steroid—most a negative response. All patients also which can lead to vision loss. For other bilateral keratitides are safely should be counseled to call the office all ophthalmic steroid use, monitor- treated with a steroid. In our experi- if the condition worsens. ing chronic use for adverse effects, ence, the most common sources of particularly increased IOP, is critical. bilateral corneal inflammation are Without a doubt, corticosteroids And when prescribing them, be sure Staphylococcal hypersensitivities, have earned their place among the to anticipate possible tissue-specific rosacea keratitis, Thygeson’s, contact class of ophthalmic agents most fre- complications and adjust your fol- lens reactions and postviral epidemic quently prescribed by optometrists. low-up schedule appropriately. ■ keratoconjunctivitis, all of which Their ability to aid in the manage- Dr. Bronner is an attending respond well to corticosteroid or ment of almost all forms of ocular optometrist at Pacific Cataract and combination drops. inflammation, even those inflam- Laser Institute in Kennewick, WA. Because inappropriate steroid use mations derived from infectious Dr Whitley is the director of opto- on the cornea can have a devastating processes, means their indications for metric services at Virginia Eye Con- impact, follow up should be reduced use are without peer. This familiar- sultants in Norfolk, VA

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1. Gonzalez A, Lakhani R, Bennett N, De Paz C. A twelve quarter quantita- of fluormetholone 0.1% versus dexamethasone 0.1%. Br J Ophthalmol. 19. Soukiasian SH, Baum J. Bacterial conjunctivitis. In: Krachmer tive analysis of ophthalmic drugs prescription writing by optometrists in 1988;67(10):661-3. JH, Mannis MJ, Holland EJ, eds. Cornea. 4th ed. St. Louis: Elsevier; the United States. Clinical Optometry. 2014;6:5-10. 11. Foster CS, Alter G, DeBarge LR, et al. Efficacy and safety of rimexo- 2017:479-92. 2. Jaanus SD, Cheetham JK, Lesher GA. Antiinflammatory drugs. In: lone 1% ophthalmic suspension vs 1% prednislone acetate in the treat- 20. Emmons W, Preston Church LW. Syphilitic uveitis. West J Medicine. Bartlett JD, Jaanus SD, eds. Clinical Ocular Pharmacology, 4th ed. ment of uveitis. Am J Ophthalmol. 1996;122(2):171-82. 1994;161(2):168-71. Oxford; Butterworth-Heinemann; 2001:265-314. 12. Morrison E, Archer DB. Effects of fluorometholone (FML) on the 21. Khambati FA, Shetty VP, Ghate GD, et al. The effect of corticosteroid 3. Greaves MW. Anti-inflammatory action of corticosteroids. Post Gradu- intraocular pressure of corticosteroid responders. Br J Ophthalmol. usage on the bacterial killing, clearance and nerve damage in leprosy: ate Medical Journal. 1976;52:63. 1984;68(8):581-4. Part 3–Study of two comparable groups of 100 multibacillary patients 4. BenEzra D. Immunosuppression and immunomodulation. In: Ocular 13. Sedrowski DP, et al. Anti-inflammatory drugs. In: Bartlett JD, Jaanus each, treated with MDT + steroids vs MDT alone, assessed at 6 months Inflammation: Basic and Clinical Concepts. BenEzra D, ed. London; SO, eds. Clinical Ocular Pharmacology. 5th ed. St Louis. Butterworth- post – release from 12 months MDT. Lepr Rev. 2010;81(1):41-58. Martin Dunitz: 1999:1-24. Heinemann: 2008. 22. Foster C, Davanzo R, Flynn T, et al. Durezol (Difluprednate ophthal- 5. Tripathi RC, Parapuram SK, Tripathi BJ, et al. Corticosteroids and 14. Cable MM. Intraocular pressure spikes using difluprednate 0.05% mic emulsion 0.05%) compared with Pred Forte 1% ophthalmic suspen- glaucoma risk. Drugs Aging. 1999;15(6):439-50. for post-operative cataract inflammation. ARVO Annual Meeting Abstract. sion in the treatment of endogenous anterior uveitis. J Ocul Pharmacol 6. Jones R, Rhee DJ. Corticosteroid-induced ocular hypertension and 2010; 51(13):1981. Ther. 2010;26(5):475-83. glaucoma: a brief review and update of the literature. Curr Opin Ophthal- 15. Carnahan MC, Goldstein DA. Ocular complications of topi- 23. Srivivasin M, Mascarenhas J, Rajaraman R, et al. Corticosteroids mol. 2006;17(2):163-7. cal, periocular, and systemic corticosteroids. Curr Op Ophthalmol. for bacterial keratitis: the Steroids for Corneal Ulcers Trial (SCUT). Arch 7. Kersey JP, Broadway DC. Corticosteroid-induced glaucoma: a review 2000;11(6):478-83. Ophthalmol. 2012;130(2):143-50. of the literature. Eye. 2005;20(4):407-16. 16. Ilyas H, Slonim CB, Braswell GR, et al. Long-term safety of lotepre- 24. Miedziak A, Miller MR, Rapuano CJ, et al. Risk factors in micro- 8. Leibowitz HM. Bartlett JD, Rich R, et al. Intraocular pressure raising dnol etabonate 0.2% in the treatment of seasonal and perennial allergic bial keratitis leading to penetrating keratoplasty. Ophthalmology. potential of 1.0% rimexelone in patients responding to corticosteroids. conjunctivitis. Eye Contact Lens. 2004;30(1):10-13. 1999;106(6):1166-70. Arch Ophthalmol. 1996;114(8):933-7. 17. Thorne JE, Woreta FA, Dunn JP, et al. Risk of cataract development 25. Contantinou M, Jhanji V, Tao LW, Vajpayee RB. Clinical review of 9. Bartlett JD, Horwitz B, Laibovitz R, Howes JF. Intraocular pressure among children with juvenile idiopathic arthritis- related uveitis treated corneal ulcers resulting in evisceration and enucleation in elderly popu- response to loteprednol etabonate in known steroid responders. J Ocular with topical corticosteroids. Ophthalmology. 2010;117(7):1436-41. lation. Graefes Arch Clin Exp Ophthalmol. 2009;247(10):1389-93. Pharmacol. 1993;9(2):157-65. 18. Sompayrac L. How Pathogenic Viruses Think: making sense of virol- 26. Wilhelmus KR, Falcon MG, Jones BR. Bilateral herpetic keratitis. Br J 10. Akingbehin AO. Comparative study of the intraocular pressure effects ogy. Burlington: Jones and Bartlett Learning; 2002. Ophthalmol. 1981;65:385-7.

OSC QUIZ

ou can obtain transcript-quality d. Reduction of blood sugar levels. d. Cortical cataract. continuing education credit through Ythe Optometric Study Center. Com- 4. Steroids have the broadest and ______10. According to one study, which steroid plete the test form and return it with the $35 specific effect on inflammation of any immune exhibits the highest corneal penetration? fee to: Jobson Medical Information, Dept.: modulatory agent. a. Fluorometholone alcohol suspension. Optometric CE, 440 9th Avenue, 14th Floor, a. Most. b. Rimexolone suspension. New York, NY 10001. To be eligible, please b. Least. c. Prednisolone acetate suspension. return the card within a year of publication. c. No. d. Prednisolone phosphate solution. You can also access the test form and d. Somewhat. submit your answers and payment via credit 11. All of these anatomic zones are commonly card at Review of Optometry online, www. 5. Steroids reduce inflammation by: targeted by optometrists when prescribing reviewofoptometry.com/ce. a. Increasing vascular permeability. topical steroids, except: You must achieve a score of 70 or b. Reducing the recruitment of immune cells. a. Lids. higher to receive credit. Allow four weeks c. Increasing tissue breakdown. b. Cornea. for processing. For each Optomet ric Study d. Activating fibroblast. c. Anterior chamber. Center course you pass, you earn 2 hours of d. Retina. transcript-quality credit from Pennsyl vania 6. With increased IOP, up to what percentage College of Optometry and double credit of patients are steroid responders? 12. Viruses are more likely to invade the toward the AOA Optom et ric Recog nition a. 6%. conjunctiva than the lid due to: Award—Cate gory 1. b. 16%. a. Lack of keratinized tissue. Please check with your state licensing c. 36%. b. Increase in keratinized tissue. board to see if this approval counts toward d. 46%. c. Increased surface area. your CE requirement for relicensure. d. Lack of living cells. 7. Which patient type/condition is most likely 1. What class of topical medications are the to have a steroid response? 13. Topical steroids are beneficial in the most frequently prescribed by optometrists? a. Cataract. treatment of viral conjunctivitis due to: a. Antibiotics. b. Glaucoma. a. Increasing inflammation. b. Antivirals. c. Diabetes. b. Reducing inflammation. c. Antiallergy. d. Allergy. c. Increasing tissue formation after damage. d. Corticosteroids. d. Decreasing goblet cell destruction. 8. “Soft steroids” achieve increased safety 2. Steroids work by inhibiting which pathway? due to the following mechanisms, except: 14. Steroid drops should be used how often in a. Phospholipase A2. a. Decreased penetration. initial treatment of uveitis? b. Cyclooxygenase. b. Reduced half-life. a. QD. c. Lipoxygenase. c. Decreased concentration. b. BID to TID. d. Histamine. d. Increased half-life. c. Q1H to QID. d. They are not indicated for uveitis treatment. 3. Side effects of oral prednisone include all of 9. The most common cataracts caused by the following, except: steroid usage typically are: 15. The SCUT study conclusions show: a. Increased IOP. a. Posterior subcapsular. a. There is no difference in visual acuity b. Cataract. b. Anterior polar. outcomes when adding corticosteroids for c. Mood changes. c. Nuclear cataract. corneal ulcer treatment when their use

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0066_ro0418_f4.indd66_ro0418_f4.indd 7272 33/29/18/29/18 2:382:38 PMPM OSC QUIZ Examination Answer Sheet Protocols and Pitfalls in Topical Steroid Use follows a period of antibiotic only. b. There is no benefit but substantial harm Valid for credit through March 2, 2021 to adding corticosteroids for corneal ulcer Online: This exam can be taken online at www.reviewofoptometry.com/ce. Upon passing the exam, you can treatment following a period of antibiotic view your results immediately and download a real-time CE certificate. You can also view your test history at only. any time from the website. c. There is no benefit or harm to adding Directions: Select one answer for each question in the exam and completely darken the appropriate circle. A corticosteroids for corneal ulcer treatment minimum score of 70% is required to earn credit. prior to initiating antibiotic therapy. Mail to: Jobson Medical Information, Dept.: Optometric CE, 440 9th Avenue, 14th Floor, New York, NY 10001. d. Steroids are contraindicated for use in Payment: Remit $35 with this exam. Make check payable to Jobson Medical Information LLC. corneal ulcers. Credit: This course is COPE approved for 2 hours of CE credit. Course ID is 57000-PH. Sponsorship: This course is joint-sponsored by the Pennsylvania College of Optometry. 16. Peripheral corneal infiltrates are most Processing: There is a four-week processing time for this exam. likely due to ______reactions. a. Hypersensitivity. Answers to CE exam: b. Allergic. Post-activity evaluation questions: 1. A B C D c. Infectious. Rate how well the activity supported your achievement of these learning objectives: d. Viral. 2. A B C D 1=Poor, 2=Fair, 3=Neutral, 4=Good, 5=Excellent 3. A B C D 21. Improve my understanding of the known side effects of topical steroids. 1 2 3 4 5 17. Clinical findings for herpes simplex 4. A B C D 22. Become familiar with the appropriate protocols for immune stromal keratitis include all of the 5. A B C D topical steroid use in optometric practice. 1 2 3 4 5 following except: 6. A B C D 23. Increase my understanding of the dosing-based a. Dendrite. 7. A B C D differences among target tissues. 1 2 3 4 5 b. Stromal edema. A B C D 8. 24. Better understand the effects of topical steroids on the c. Keratic precipitates. 1 2 3 4 5 9. A B C D conjunctiva. d. High IOP. 10. A B C D 25. Increase my knowledge of steroid use for corneal pathology. 1 2 3 4 5 11. A B C D 18. What is the most common cause of 26. Improve my ability to properly prescribe topical steroids 12. A B C D vision loss after penetrating keratoplasty? for ocular conditions. 1 2 3 4 5 13. A B C D a. Graft rejection. Rate the quality of the material provided: 14. A B C D b. Graft failure. 1=Strongly disagree, 2=Somewhat disagree, 3=Neutral, 4=Somewhat agree, 5=Strongly agree c. Glaucoma. 15. A B C D 27. The content was evidence-based. 1 2 3 4 5 d. Uveitis. 16. A B C D 28. The content was balanced and free of bias. 1 2 3 4 5 17. A B C D 29. The presentation was clear and effective. 1 2 3 4 5 19. Microbial keratitis may be more likely 18. A B C D 30. Additional comments on this course: by up to ___ times in patients with a PK 19. A B C D

compared with normal extended wear soft 20. A B C D contact lens users. a. 25. Please retain a copy for your records. Please print clearly. b. 35. c. 45. First Name d. 55. Last Name

20. All of the following are forms of lamellar E-Mail grafting except: The following is your: Home Address Business Address a. Deep anterior lamellar keratoplasty. b. Descemet’s membrane endothelial Business Name keratoplasty. Address c. Descemet’s stripping endothelial keratoplasty. City State d. Penetrating keratoplasty. ZIP

Telephone # - -

Fax # - -

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

TAKE THE TEST ONLINE TODAY! Signature Date www.reviewofoptometry.com/ continuing_education/ Lesson 116173 RO-OSC-0418

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Proceed With Caution: Low Vision and Driving Here’s how you can navigate the complex interplay between DMV standards and the needs of your patients who are visually impaired. By Mark E. Wilkinson, OD, and Khadija S. Shahid, OD, MPH

riving with both visual acu- and counsel patients who are visu- Some states enforce a rejection stan- ity (VA) and visual field (VF) ally impaired and want to drive. dard: an individual will automati- loss has been a hot topic cally be rejected for licensure if they Din the field for decades.1-10 State Standards do not meet the minimum vision Although the literature routinely One 1991 study found uniform standards for VF or VA. Most com- acknowledges that driving is a standards did not exist in the United monly, those standards are VA in privilege, not a right, loss of driving States for VA, VF or the use of one or both eyes of 20/40 or better privileges can have devastating con- bioptic telescopes—which is still and a binocular field of view of 140 sequences such as increased social true today.14 Currently, two vision degrees or more. However, signifi- isolation, decreased quality of life standards exist for driving licensure. cant variances occur; for example, and depression.11-13 Such Wisconsin only requires a high stakes can make the The Aging Driver 40-degree field of view, and a subject of driving tough to Today, more than five million Americans age 65 and older are number of states have no VF bring up during the exami- afflicted with a form of dementia, such as Alzheimer’s disease. specification. nation of individuals with By 2050, this number is expected to grow to 13.8 million as The alternative to the rejec- visual impairments. How- the baby-boom population ages.1 Data indicates that 50% of tion standard is the vision ever, ODs have a duty to persons with Alzheimer’s disease continue to drive up to three screening standard. Rather properly assess and counsel years after they have been diagnosed with the disease, and that than being automatically patients with congenital or these individuals also have worse driving performance and are rejected if they do not meet acquired visual impairments more likely to cause traffic accidents.1-4 Clinicians must be pre- the minimum standards, who would like to acquire pared to care for these patients and properly counsel them— individuals may be granted driving privileges or who will and their loved ones—on safe driving. driving privileges after fur-

become non-drivers because 1. National Center for Chronic Disease Prevention and Health Promotion. 2016 ther evaluation of all factors, of their vision loss. Alzheimer’s disease facts and figures. Alzheimers Dement. 2016;12(4):459-509. including a behind-the-wheel 2. Brown LB, Ott BR. Driving and dementia: A review of the literature. Journal of Geriat- Here, we discuss the com- ric Psychiatry and Neurology. 2004;17(4):232-40. test. Iowa, for example, plexities of the current vision 3. Stout SH, Babulal GM, Ma C, et al. Driving cessation over a 24-year period: allows for individual review, Dementia severity and cerebrospinal fluid biomarkers. Alzheimers Dement. 2018 Jan and licensure standards, 9;5260(17):33854-2. [Epub ahead of print] via a behind-the-wheel test, how they affect patients with 4. American Medical Association. Physician’s guide to assessing and counseling older for individuals with VAs bet- drivers, 2nd ed. www.nhtsa.gov/staticfiles/nti/older_drivers/pdf/811298.pdf. Assessed vision loss and what ODs January 31, 2018. ter than 20/200, a VF greater can do to properly evaluate than 20 degrees or both.

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074_ro0418_f5.indd 74 3/29/18 3:50 PM SLIT LAMPS NEW LED Illumination More than 50,000 hours of clear, cool illumination.

The relative central scotomas in this patient’s eyes, caused by Stargardt disease, did not prevent her from driving safely.

Case 1 A 38-year-old female presented with a history of reduced vision for the past 20 years secondary to Stargardt disease. Her best-corrected visual acuity (BCVA) was 20/160-2 OD, 20/160-1 OS and 20/125-2 OU. She had small bilateral central scotomas consistent with her central acuity. A discretionary review request was made to the Iowa DOT, and she received unrestricted driving privileges following several behind-the-wheel tests that took place during the day and at night. She has maintained full driving privileges, without incident, for the past 17 years.

In addition to vision standards, use this standard for driving.5 two different licensure standards Above and beyond these vision exist for driving, depending on the and licensure standards, states have state. According to some states, different protocols for restricted as long as the individual’s VA and driving privileges, including: day- VFs are adequate enough to allow light-only, no driving when head- them licensure, they can continue lights are required, reduced speed, to drive until that license expires, local area driving or a restricted regardless of how poor their acuity distance from home and no highway or VFs become during the licensing driving. States also vary on whether cycle. Drivers in those states may the use of a bioptic telescope is have a false sense of security, despite allowed for licensure, as well as changes in their vision, when they what VA requirements must be met, have a license that does not expire both with the bioptic telescope and for several years. the carrier lens. Easier observation of In other states, individuals whose All of these variations mean an VA or VFs drop below the state’s individual could be licensed in some minute details. licensure standards are no longer states and not even considered for legal to drive from that time for- driving in others. Color temperature ward, regardless of the licensing Clinicians should be familiar with maintained through the full cycle. This is the same standard used their state’s vision standards for driv- range of illumination for commercial licensure, where the ing to properly educate their patients driver needs to know they meet the who are visually impaired. Unfortu- adjustment. vision standard every time they get nately, it can be difficult to know for behind the wheel of a commercial sure what any given state’s driving vehicle. Currently, only a few states, laws entail, and you must check each such as Illinois and Pennsylvania, DMV/DOT website or call to clarify.

250 Cooper Ave., Suite 100 Tonawanda NY 14150 www.s4optik.com I 888-224-6012 Sensible equipment. Well made, well priced.

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Case 2 valuable information, even in states A 55-year-old male presented for an evaluation stating that he was diagnosed with retinitis that do not specify VF requirements. pigmentosa three months prior. He noted that he has been “losing things” when he puts Alternately, the SSA Kinetic testing them down for the past 15 to 20 years. He stated that based on recent threshold-related strategy on the Humphrey field ana- central VF testing, he was told to stop driving, get a cane or a guide dog and learn Braille. His lyzer (Zeiss) could be used with the BCVA was 20/25 OD/OS. He stated he has driven cautiously for many years without incident. standard testing protocol as well as a Furthermore, he lives in a state that has no VF requirements. When non-threshold related, full- V4e equivalent isopter. field testing was performed, we found he had relatively full fields to the larger isopters tested Contrast sensitivity. This is an (III4e and V4e), with scattered paracentral scotomas. Based on his full-field testing and VA, he important test for assessing an was advised that he did not need to stop driving, nor did he need a guide dog or Braille literacy. individual’s fitness to drive because research shows it is predictive of driving outcomes for individuals older than 65 with normal vision.8 A common cause of contrast sensitivity loss is cataracts, and drivers with cataracts are 2.5 times more likely to have an at-fault accident than those without cataracts.8,20-24 Additionally, individuals with cataracts are four times more likely to report difficulties with driving compared with individuals without Full-field testing shows a restricted cataracts.8,20-23 Some individuals Based on 24-2 threshold related field under lower light conditions and a with binocular cataracts continue to testing, the examiner felt the patient’s significantly fuller field under full light experience driving difficulties, even visual field was severely constricted. conditions. after monocular cataract surgery.23 Research shows improved contrast Roadblocks 35mph with low beams on.17,18 sensitivity after cataract surgery is Given today’s driving environment, • The effective lateral field of view more valuable than improved visual the vision screening standards used when driving with headlights is acuity when assessing driving dif- by state departments of motor vehi- only 35 to 45 degrees.19 ficulties due to vision.10 Finally, one cles/departments of transportation • A driver’s license has no restric- study found that contrast sensitivity (DMV/DOT) may not be satisfac- tions concerning driving during of less than 1.25 log units was the tory in assessing drivers’ functional periods of dense fog, heavy rain only independent predictor of crash vision (Cases 1 and 2).1-10,15 or snow—times when even a involvement for individuals with Although VA has been widely driver with normal VA will have cataracts in the previous five years.23 used in driving regulations for their vision reduced to this pre- Useful field of view (UFOV). decades, it is a poor predictor of per- sumed unacceptable level. Unlike conventional visual field mea- formance for several reasons:8,9 sures, UFOV assesses higher-order • The correlation of VA alone to Vision Testing for Driving visual processing skills such as selec- accidents is less than 1%.10 High-contrast VA testing under tive and divided attention and visual • The minimum standard of photopic conditions continues to be processing speed under increasingly 20/40 is based on an American the standard for licensure. However, complex visual displays. Thus, it Medical Association recommen- additional visual function tests not more closely approximates the com- dation dating back to 1937.16 currently used in the United States plexity of driving as a visual task. Research shows individuals with for driving licensure may be helpful As we age, our ability to process normal sight have a functional when evaluating functional abilities visual information slows. While not VA of less than 20/40 when behind the wheel:8-10 a linear progression, this slowing driving at night at speeds greater Full-field, non-threshold visual makes driving in complex environ- than 55mph with high beams field testing. Testing that includes ments more difficult. UFOV test- on and at speeds greater than at least the I4e and a V4e isopter is ing can be valuable in determining

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which at-risk drivers with Adapted and Semi-Autonomous Cars SEE MORE - normal or near-normal visual In 2016, a total of 37,461 deaths and two million acuity are no longer able to injuries were from automobile accidents, a 5.6% Exceptional process visual information in a increase from 2015.1 With these staggering num- timely manner to allow for safe bers, it’s no wonder so much attention has been Optics driving (Case 3). focused on semi-autonomous safety systems and However, research shows their potential to reduce accident rates. But this S4OPTIK’s visual processing training over technology could also have a significant impact on several hours using UFOV our low vision patients. It may one day allow indi- converging testing with preset criteria for viduals with visual acuity and visual field loss the binoculars success can improve not only ability to continue driving, just as those with physi- DOORZHƪRUWOHVV UFOV test performance, but cal handicaps, including loss of limbs, currently also the driving performance of have the ability to operate an adapted motor vehicle maintenance of persons older than 55. Preset and be licensed to drive. fusion. criteria of 10 training sessions 1. National Highway Traffic Safety Administration. USDOT releases over five weeks resulted in an 2016 fatal traffic crash data. October 6, 2017. www.nhtsa.gov/press- releases/usdot-releases-2016-fatal-traffic-crash-data. Accessed approximately 50% lower January 31, 2018. rate of at-fault motor vehicle European crashes (MVCs) during the subse- when they are only visually craftsmanship and quent six years compared with con- qualified to drive during the trol group.25-28 day. If you don’t ask, you won’t engineering provide know to tell the patient they are reliable optics at Clinical Steps not visually qualified to drive at The American Medical Associa- night according to state law.) DOOPDJQLƬFDWLRQV tion’s (AMA) Physician’s Guide to • Do vision problems cause you IRUFRQƬGHQW Assessing and Counseling of Older to be fearful when driving? examinations. Drivers recommends that clinicians • During the past six months, assess all risk factors when evaluat- have you made any driving ing drivers older than 65, including errors? (e.g., an at-fault motor vision, cognition and motor skills.24 vehicle accident related to the For example, a clock drawing test is patient not seeing someone or an easy test of cognition, and UFOV not judging distance correctly.) is an excellent tool to use to assess • Is your mobility affected by cognition as it relates to fitness to your vision? (If your patient is drive.29 If concerns exist in any of struggling to find their way to H-Series Z-Series these areas, it recommends a referral the exam chair or has difficulty to the state DMV/DOT for a formal getting through the doorway, it driving assessment. is hard to imagine that they can When examining patients of driv- safely operate a motor vehicle.) ing age, clinicians should ask the Patients come to us because of the following questions, regardless of quality of care we provide, which the patient’s current level of visual includes giving honest information functioning. Your patient’s answers about their vision and ocular health. may surprise you: As optometry’s scope of practice • Do you drive an automobile? If continues to expand, we share the so, are you driving at night or burden of not just the accurate and Vertical and compact only during the day? Do you timely diagnosis of ocular disease, FRQƬJXUDWLRQVDYDLODEOH drive only close to home, or are but also the effect that disease may you driving both in town and have on visual function. If your on the highway? (For example, patient develops visual or cognitive they may be driving at night, changes that could affect their ability

250 Cooper Ave., Suite 100 Tonawanda NY 14150 www.s4optik.com I 888-224-6012 Sensible equipment. Well made, well priced.

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to safely operate a motor vehicle, it fellow eye when viewing through Today’s audible GPS devices pro- is your professional responsibility, the telescope for wayfinding such as vide these patients a readily available and legal duty, to share that infor- reading street signs. and significantly cheaper option mation with your patient. While bioptic telescopes are compared with a bioptic telescope. only used for a small percentage A GPS device can allow the driver Assistive Technology of driving time (1% to 10%) for to focus more attention on the road Currently, in 43 states , the acquisi- wayfinding tasks such as spotting and the traffic around them and less tion of a bioptic telescope—a hands- street signs, they reduce the user’s time attempting to read street signs. free, spectacle mounted device—is visual field and can contribute to Based on our clinical experience the only way an individual with inattention blindness. As with cell evaluating hundreds of patients with visual acuity less than 20/70 can phone use while driving, when using vision loss in the 20/71 to 20/199 attempt to qualify for driving privi- a bioptic telescope, the driver must range, many continue to drive safely leges.30 However, research has yet to attend to two tasks at once, which for decades in Iowa, where bioptic provide definitive data on the risks is difficult because of the time lag telescopes are not permitted to gain and benefits associated with this associated with switching from one licensure. Today, all of our patients assistive technology, and the topic activity to another. One study found with impaired vision use a GPS sys- is surrounded by controversy. One as drivers switch repeatedly between tem in lieu of their bioptic telescope. report of 300 bioptic drivers found tasks such as using the radio or Of course, if a person feels a biop- the biggest challenge with reduced information system, the time cost tic helps them drive more safely, they vision (binocular acuity less than or adds up, increasing inattention should be allowed to use it. Clini- equal to 20/200) was reading street blindness.32 Some believe the distrac- cians should carefully discuss the signs—they had no problems seeing tion created by a bioptic telescope pros and cons with patients who are other traffic, people or animals when outweighs the visual benefits, but visually impaired, and counsel them driving.31 In the past, practitioners more research is needed to clarify appropriately on their options when felt that when a bioptic telescope is whether driving with a bioptic tele- it comes to assistive technologies fit on one eye and appropriate train- scope makes individuals who are behind the wheel. ing is performed, the user can main- visually impaired safer drivers than tain peripheral awareness with their those who do not use a device.30 In general, a person’s fitness to drive cannot be determined by their Case 3 age, VA or VF alone. The functional A 56-year-old male presented with a chief complaint of increasing difficulties over the past manifestations of various ocular three months with both clarity and tracking when reading. He noted that he was losing his conditions and an individual’s ability place frequently as he read from line to line and column to column. In addition, his wife said to compensate for any visual impair- she refused to ride with him because his driving was “scary.” His BCVA was 20/20 OD/OS, and ment varies widely. We must use his ocular health evaluation and VFs were unremarkable. He was referred to a neuro-ophthal- our knowledge and tools to assess mologist for a positron emission tomography competency to drive or refer to a scan, which revealed the left occipital and driver rehabilitation specialist for parietal occipital lobes had more atrophy additional assessment. than the right, out of proportion to the We are responsible for helping patient’s age. He was diagnosed with the our patients understand when their visual variant of Alzheimer’s disease (VVAD), vision falls below the state’s stan- and his wife questioned whether he was dards and how that will affect their safe to continue driving. UFOV testing found driving privileges. At the same time, he had nine times slower visual process- we need to serve as advocates for ing speed, five times slower divided visual those with reduced VA or reduced attention skills and severely delayed select- VFs who have the compensatory ed visual attention skills—thus, he was at a skills to continue driving safely, high risk for an automobile accident. The clock drawing test, as seen here, despite those reductions. Finally, Based on these findings, he was advised has an 86% sensitivity and a 96% we need to advocate for standard- to retire from all driving immediately. specificity for assessing dementia.29 ized VA and VF requirements on a national level, so that individuals

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who are visually impaired have the Driving Legalities EFFORTLESS same ability to demonstrate they As clinicians, we have the duty to warn, can safely operate a motor vehicle, which is a legal rationale designed to Digital Imaging regardless of their home state. ■ provide a means of protecting the patient Dr. Wilkinson is a clinical profes- from an unreasonable risk of harm.1 Duty sor in the Department of Ophthal- to warn states that failure to warn a patient mology and Visual Sciences at the of conditions that create a risk of injury will University of Iowa’s Carver College be upheld as a cause of action against eye of Medicine. He is the director of care providers when it can be shown that the institution’s Vision Rehabilita- the failure to warn is the proximate cause tion Service and a faculty member of of an injury. All of this jargon means that if the University of Iowa Institute for an individual with a visual impairment has Vision Research and the National a motor vehicle accident related to their Advanced Driving Simulator. reduced vision, they can hold their eye care Dr. Shahid is a clinical assistant provider responsible for the accident. In professor in the Department of this case, the patient can argue that they Ophthalmology and Visual Sciences had insufficient warning of their impair- at the University of Iowa’s Carver ment, and because of their impairment, College of Medicine, where she their operation of a motor vehicle or other provides vision rehabilitation and machinery resulted in an injury. Thus, you primary eye care. should warn patients whose vision no longer legally qualifies them to operate a NewNew DDigitaligital Vision HR 1. Wilkinson ME. Driving with a visual impairment. INSIGHT. 1998;23(2):48-52. motor vehicle to abstain from driving and aall-in-onell-in-one seamlesslyseamlessly 2. Chapter 8: Sustaining safe mobility in older drivers. In: Iowa note this in the patient’s record. Safety Management System, Iowa State University; Center for cconnectsonnects withwith tthehe Transportation Research and Education. Toolbox of Highway Safety Strategies: Drivers. 1. Classe JG. Clinicolegal aspects of practice. Southern DDigitaligital SSlitlit LamLampsps 3. Wilkinson. ME. Should your low vision patient be driving? Journal of Optometry. January 1986;IV, I. EyeNet. 1998;2(9):21. 4. Wilkinson ME. When is it appropriate to stop driving due to to provide brilliant vision impairment? Aging and Vision. 2003;15(2). 5. Brinig MF, Wilkinson ME, Daly J, et al. Standards for licensing 20. Owsley C, McGwin G Jr, Sloane M, et al. Impact of cataract imaging at the press and driving. Optometry. 2007;78:439-45. surgery on motor vehicle crash involvement by older adults. J Am 6. Wilkinson ME. Driving with a visual impairment: new guidelines Med Assoc. 2002;288(7):841-9. of a button. are needed. Optometry. 2003;74(1):7-10. 21. Owsley C, Stalvey, BT, Wells, J, et al. Visual risk factors for 7. Johnson CA, Wilkinson ME. Vision and driving: The United crash involvement in older drivers with cataract. Arch Ophthalmol. States. Neuro-ophthalmol. 2010;30:170-6. 2001;119(6):881-7. 8. Owsley C, McGwin G Jr. Vision impairment and driving. Surv 22. Owsley C, Stalvey B, Wells J, Sloane ME. Older drivers and Still Images or Video Ophthalmol. 1999;43(6):535-50. cataract: Driving habits and crash risk. J Gerontol A Biol Sci Med 9. Owsley C, McGwin G. Jr. Vision and driving. Vision Res. Sci. 1999;54(4):M203-11. 2010;50(23):2348-61. 23. Fraser ML, Meuleners JB, Lee AH, et al. Which visual mea- Sequences 10. Burg A. Vision and driving: A report on research. Human Fac- sures affect change in driving difficulty after first eye cataract tors. 1971;13(1):79-87. surgery? Accident Analysis & Prevention. 2013 April;58:10-14. 11. Renaud J, Bédard E. Depression in the elderly with visual 24. American Medical Association. Physician’s guide to assessing impairment and its association with quality of life. Clinical Inter- and counseling older drivers, 2nd ed. www.nhtsa.gov/staticfiles/ ventions in Aging. 2013;8:931-943. nti/older_drivers/pdf/811298.pdf. Accessed January 31, 2018. 12. Ragland DR, Satariano WA, MacLeod KE. Driving cessation 25. Edwards JD, Fauston BA, Tetlow AM, et al. Systematic review and increased depressive symptoms. J Gerontol A Biol Sci Med and meta-analyses of useful field of view cognitive training. Neu- Sci. 2005;60(3):399-403. roscience and Biobehavioral Reviews. 2018;84:72-91. 13. Chihuri S, Mielenz TJ, DiMaggio CJ, et al. Driving ces- 26. O’Connor ML, Hudak EM, Edwards JD. Cognitive speed of sation and health outcomes in older adults. Am Geriatr Soc. processing training can promote community mobility among older 2016;64(2):332-41. adults: A brief review. J Aging Res. 2011;2011:430802. 14. Barron C. Bioptic telescopic spectacles for motor vehicle driv- 27. Roenker DL, Cissell GM, Ball KK, et al. Speed-of-processing ing. JAOA. 1991;61:37-41. and driving simulator training result in improved driving perfor- 15. Shipp MD, Penchansky R. Vision testing and the elderly driver: mance. Hum Factors. 2003;45(2):218-33. is there a problem meriting policy change? J Am Optom Assoc. 28. Ball KK, Edwards JD, Ross LA, McGwin G, Jr. Cognitive train- 1995;66(6):343-51. ing decreases motor vehicle collision involvement in older drivers. 16. Black NM, Gradle HS, Snell AC. Visual standards for licensure J Am Geriatr Soc. 2010;58(11):2107-13. to operate motor vehicles, preliminary report of the special com- 29. Brodaty H, Moore CM. The clock drawing test for dementia mittee at Atlantic City Session JAMA. 1937;109(26):61B-4. of the Alzheimer’s type: A comparison of three scoring methods 17. Owens DA, Sivak, M. The role of reduced visibility in nighttime in a memory disorders clinic. Int J Geriatr Psychiatry. 1997 road fatalities (Report #UMTRI-93-33), Ann Arbor: The University Jun;12(6):619-27. of Michigan Transportation Research Institute. 1993. 30. Owsley C. Driving with bioptic telescopes: Organizing a 18. Sturr JF, Kline GE, Taub AJ. Performance of young and old research agenda. Opt and Vis Sciences. 2012;89(9):1249-56. drivers on a static acuity test under photopic and mesopic illumi- 31. Feinbloom W. Driving with bioptic telescopic spectacles (BTS). nance conditions. Human Factors. 1990;32:1-8. Am J Optom Physiol Opt. 1977;Jan;54(1):35-42. 19. Owens DA, Francis EL, Leibowitz, HW. Visibility distance with 32. Strayer DL, Drews FA, Johnston WA. Cell phone-induced headlights: A functional approach, Society Automotive Engineering failures of visual attention during simulated driving. J Exp Psychol: Technical Papers Series #890684. 1989. Applied. 2003;9(1):23-32.

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RO0418_House TAYE.indd 1 3/26/18 2:23 PM Cornea+Contact Lens Q+A

Trouble with Thygeson’s Management for these cases can be quick if done right. However, an exact cause for the disease is still elusive. Edited by Joseph P. Shovlin, OD Photo: Ron Melton, OD, and Randall Thomas, OD I occasionally see patients with bilateral, Dr. Aquavella says, Q classic Thygeson’s superficial because it separates the disease punctate keratopathy. I find these from similar conditions such as cases to be difficult to treat. What are epidemic keratoconjunctivitis today’s best management options for (EKC). “Usually TSPK patients these cases? Also, is there anything still experience vision ranging new regarding the disease’s etiology? from good to normal, while the A “Thygeson’s superficial vision in EKC is usually com- punctate keratitis (TSPK) was promised,” Dr. Aquavella says. first introduced by Phillips Thygeson “Also, unlike TSPK, EKC is not in the mid-twentieth century,” says quickly reversed.” Standard TSPK presentation includes small, James Aquavella, MD, professor central epithelial opacities. of ophthalmology at the University Management of Rochester Flaum Eye Institute. “In TSPK, pain relief is instanta- mechanisms such as herpes simplex “Characteristically, it produces neous with the application of a virus and varicella zoster virus have symptoms of photophobia, tearing bandage contact lens,” says Dr. been suggested in early, limited and foreign body sensation.” Aquavella. Here, it is standard to studies, more recent research has According to Dr. Aquavella, the add a prophylactic antibiotic, he not been able to show viruses as disease’s slit lamp appearance is adds, but antibiotics are not indi- the culprit.1-4 “When TSPK lesions almost pathognomonic, typically cated with other treatments. clear there is no sign of viral with five to 10 intraepithelial Another approach is the involvement,” says Dr. Aquavella. satellite lesions in the central use of a mild steroid such as “Also, post-viral conditions often cornea. “The lesions are discrete, fluorometholone, loteprednol or, on linger for longer periods.” not confluent, limited in number to occasion, 1% methylprednisolone. According to Dr. Aquavella, the central cornea, and the vision is According to Dr. Aquavella, these autoimmune processes have been usually only minimally impaired,” will quickly heal any TSPK lesions. long suspected to play a role in he says. “There is usually bilateral From there, the steroids should TSPK, and research shows that involvement, although the extent be slowly tapered over about a autoimmune diseases such as may vary from left to right.” month or so. “Perhaps start with Sjögren’s syndrome have a positive TSPK usually doesn’t cause tapering the steroid to BID and then, association with the disease.5 Still, a staining, but “on occasion you ultimately, once or twice a week,” definitive underlying cause for TSPK will find an overlying epithelial says Dr. Aquavella. “If there is no remains unknown. ■ disruption,” says Dr. Aquavella. pressure response, some patients will 1. Braley AEK, Alexander RC. Superficial punctate keratitis: isola- “There is also minimal discharge require an occasional extra drop to tion of a virus. Arch Ophthalmol. 1953;50:147. and minimal or absent conjunctival keep the condition in check.” 2. Lemp MA, Chambers RW, Lurdy J. Viral isolation in superficial punctate keratitis. Arch Ophthalmol. 1974;91:8. injection.” Other options that have proven 3. Reinhard T, Roggendorf M, Fengler I, Sundmacher R. PCR for The disease is known for fre- effective are cyclosporine in olive oil varicella zoster virus genome negative in corneal epithelial cells of patients with Thygeson’s superficial punctate keratitis. Eye. quent bouts of recurrence. While and tacrolimus, Dr. Aquavella says. 2004;18(3):304-5. this can make management frus- 4. Connell PP, O’Reilly J, Coughlan S, et al. The role of common viral ocular pathogens in Thygeson’s superficial punctate kerati- trating, it also makes diagnosis Etiology tis. Br J Ophthalmol. 2007;91(8):1038-41. 5. Darrell RW. Thygeson’s superficial punctate keratitis: natural easier when combined with the The jury is still out on an exact history and association with HLA-DR3. Trans Am Ophthalmol fact that TSPK is chronic and often cause for TSPK. Although viral Soc.1981;79:486.

REVIEW OF OPTOMETRY APRIL 15, 2018 83

083_ro0418_CLQA.indd 83 3/29/18 1:52 PM Retina Quiz

Something in the Way What’s behind our patient’s transient episodes of dimming vision? By Mark T. Dunbar, OD

53-year-old Hispanic female presented with intermittent Aocular irritation and itchi- ness in both eyes for the past year. She does not use any drops. In addition, she reported transient episodes of dimming vision, and sometimes her vision even gets dark for several seconds. This started six months ago and happens about once a week. She felt this was occurring in both eyes. Her medical history was sig- Fig. 1. These fundus photographs show our 53-year-old Hispanic patient. Although nificant for well-controlled hyper- her initial complaint was a red eye, can you identify any other pathology here? tension. She was on amlodipine, atenolol, enalapril and lisinopril. a. Usual presbyopia changes. 5. How should this patient be man- She also reported having had brain b. Transient ischemic attacks. aged? surgery in the early 1990s in Nica- c. Amaurosis fugax. a. Observation. ragua for removal of a frontal lobe d. Visual aura. b. Immediate referral for carotid tumor. She felt like she fully recov- evaluation. ered from this operation and did 2. What is the significant finding c. Begin treatment with prostaglan- not have any lasting effects. seen in this patient? din eye drops for IOP control. On examination, her entering a. Advanced optic nerve cupping. d. Visual field and OCT testing. visual acuity with glasses measured b. Nerve fiber layer defects. 20/20 OU at distance and near. c. Thrombin in the retinal vein. For answers, see page 98. Confrontation visual fields were d. Cholesterol plaque in the retinal full-to-careful finger counting in artery. Diagnosis both eyes. Her ocular motility test- Our patient is describing symptoms ing was normal, and the pupils 3. How would you classify these consistent with amaurosis fugax, were equally round and reactive changes? which is a transient loss of vision in without an afferent pupillary defect. a. Calcific. one eye. It is usually fleeting, lasting The anterior segment was unre- b. Thrombin. seconds to minutes and results from markable. Intraocular pressures c. Cholesterol. transient retinal ischemia. It is most measured 19mm Hg OU. d. Fibrin. commonly due to an embolism or Her dilated fundus exam showed plaque from the ipsilateral carotid changes (Figure 1). An OCT and 4. What is the correct diagnosis for artery, but can occur from a num- visual field was also obtained and is this patient? ber of other causes associated with also available for review (Figures 2). a. Whitman plaque. transient ischemic attacks.1 b. Hollenhorst plaque. If the plaque is small enough, it Take the Retina Quiz c. Branch retinal artery occlusion. will continue to pass through the 1. How would you describe the d. Advanced glaucoma with nerve retinal circulation with zero to min- patient’s symptoms? fiber layer defect. imal noticeable effects on vision.

84 REVIEW OF OPTOMETRY APRIL 15, 2018

000_ro0418_RQ.indd 84 3/29/18 2:40 PM Larger plaques can cause a complete blockage of the artery, which in turn can lead to severe ischemia and permanent loss of vision. If this occurs at the level of the optic nerve or more posterior, a complete central retinal artery occlusion can occur. If the blockage occurs along one of the branches of the central retinal artery (CRAO), a branch retinal artery occlusion can occur. Though vision loss may occur with a branch retinal artery occlusion (BRAO), it is much less devastating than a central retinal artery occlusion. So, what is going on with our Fig. 2. How do you explain the visual changes, at right, in the patient’s right eye? patient? On the fundus exam of the Based on the RNFL, could this patient have glaucoma? right eye, an obvious plaque can be seen along the superior temporal elongated. They are also associated Our patient was made aware of artery. The presence of a plaque is a with carotid artery disease. our findings and was referred to her clear “marker” for possible carotid The plaque seen in our patient primary care physician that same artery disease or heart disease. Is did have a refractile, glisteny day. We sent her there with a letter this what is causing our patient to appearance, so it is likely a Hollen- explaining our findings and was have amaurosis fugax? horst plaque; however, it is difficult told that if she was not able to see to determine if our patient’s symp- her primary care physician that day, Discussion toms are a result of the Hollenhorst she should go within the week and Three main types of retinal arterial plaques passing through her retinal that, if she experienced any further emboli exist; Hollenhorst plaques, circulation. What’s more, even symptoms, she should go to the calcific emboli and platelet-fibrin though we only see a single plaque, local emergency room. plaques. she had others. Most patients with She was seen one month later for Hollenhorst plaques, perhaps the Hollenhorst plaques are asymp- follow up of her symptoms as well most common, are highly refractile tomatic; clearly our patient has as for a glaucoma work-up (IOP, and often glisten when the light symptoms and this deserves serious visual fields and OCT). She had not from the indirect lens shines on the attention. experienced any more amaurosis. plaque. Hollenhorst plaques repre- Carotid artery disease is one of She had seen her primary care phy- sent cholesterol emboli that origi- the major causes of stroke. Stroke sician and carotid Doppler studies nate from atheromatous lesions in itself is one of the most common were performed and were normal. the ipsilateral carotid artery or from causes of mortality and severe dis- She scheduled an echocardiogram the aorta. They usually become ability in adults. Patients who have in a few weeks’ time. Her OCT lodged in the bifurcation of one of had a stroke will often have preced- was normal but she did have a cor- the branches of the central retinal ing ischemic events such as tran- responding visual field defect in artery. In most instances, patients sient ischemic attacks, amaurosis the same area of the Hollenhorst are asymptomatic and are discov- fugax, or both.1,2 For that reason, plaque. ered as part of a routine exam. patients with these symptoms need She returned two years later, still Calcific plaques are not refractile a full cardiac work up, as well doing fine and had not had any fur- and have a dull white appearance. as carotid artery studies such as ther symptoms. ■

They tend to be larger and can be carotid duplex Doppler ultrasound. 1. Hayreh SS, Zimmerman MB. Amaurosis fugax in ocular associated with heart valve or aorta Hypercoagulable testing (antiphos- vascular occlusive disorders: prevalence and pathogeneses. Retina. 2014;34(1):115-22. calcification. pholipid antibodies and homocyste- 2. Hayrey SS. Acute retinal arterial occlusive disorders. Prog in Retin Eye Res. 2011;(5): 359-94. Platelet-fibrin emboli also dull- ine levels) and angiography may be 3. Subramanian PS. How urgent is the treatment of transient white in appearance but are more helpful in certain cases.3 vision loss? Br J Ophthalmol. 2014;98(6):719-20.

REVIEW OF OPTOMETRY APRIL 15, 2018 85

000_ro0418_RQ.indd 85 3/29/18 2:41 PM Therapeutic Review

Take Your Lumps The searching for a solution that works for hordeolum, every time, continues. By Joseph W. Sowka, OD, and Alan G. Kabat, OD

t all began with an optometry resident treating a 34-year- old woman for a painful swelling of her eyelid of four days’I duration. The pain had been increasing, forcing her to seek treatment. She had a small, internal focal swelling of her right upper eyelid, which was painful to palpation. The patient reported no trauma, use of new cosmetics or other products and didn’t recall being bitten by any insect. She was not ill and had no fever. After a comprehensive analysis, a resident correctly diagnosed a hordeolum and after educating the patient, had recommended hot, moist compresses and digital massage along with over the This patient’s swollen eyelid conceals a hordeolum, a common condition caused by a counter analgesics. After dismiss- bacterial infection of the sebaceous glands. ing the happy patient, the resident shared the case and asked the opin- conjunctiva with possible mucopu- mian glands, the glands of Zeis are ions of several colleagues. Much to rulent discharge from the glands at associated with the eyelash follicles. her surprise, each person had a dif- the margin of the eyelid. The eyelid These glands produce the superfi- ferent approach to treating patients will be painful to palpation, some- cial lipid layer of tears.1 with hordeola and each assured her times extremely so. There may be A hordeolum represents a bac- that their approach “worked every an associated pustular pimple-like terial infection of these glands of time,” leaving the young doctor lesion at the epidermis or, more the eyelid with subsequent abscess more confused. commonly, at the lid margin. Often, formation. This will be associated Hordeola are commonly encoun- patients will present with a signifi- with a tender, inflamed swelling tered in clinical practice, and cant blepharitis concurrently. Hor- at the lid margin, often pointing many clinicians have their own deolum is one of the most common anteriorly through the skin. If the personal approach to managing acquired lid lesions in children.1 deeper glands are involved, the this rather benign condition. A hordeolum is considered internal patient with a hordeolum will pres- Development and is less well circumscribed in ent with an acutely swollen and The sebaceous glands of the lids, appearance. In these cases, you edematous upper or lower eyelid. the meibomian glands and glands will see more diffuse swelling of Visual function will be normal, of Zeis are the sites of origin of the tarsus. The lesion may enlarge unless the swelling is so profound hordeola. Twenty to 30 meibomian and discharge either through the that it induces a mechanical ptosis glands are located in the upper lid tarsal conjunctiva or through the or astigmatism. There may be an and 10 to 20 in the lower lid and in skin. The literature shows cases of associated inflammation of the the tarsal plate. Unlike the meibo- multiple recurrent hordeola associ-

86 REVIEW OF OPTOMETRY APRIL 15, 2018

086_ro0418_tr.indd 86 3/29/18 4:07 PM ated with selective IgM deficiency.2 biosis offers very little therapeutic Studies also show abnormal triglyc- benefit, since this mode likely eride fatty acid composition with does not offer sufficient intratissue chronic blepharitis associated with concentrations of antibiotics to be hordeola.3 therapeutic. However, topical antibiotics are prudent if there is signifi- Progression cant concomitant blepharitis. We The most commonly encountered believe that oral antibiotic therapy organisms in hordeola are Staphy- is necessary to optimally treat hor- lococcus aureus and Staphylococ- deola. If the hordeolum is external cus epidermis.4 Acute and chronic Treating a hordeolum, such as the one and there is a pimple formed, then inflammation associated with hor- seen in this patient’s lower lid, includes the lesion can be lanced and drained deola may result in a hard retention using hot compresses, digital massage, (anesthetic is usually unnecessary), cyst known as a chalazion, especial- topical antibiotics and ointments. or nearby lashes can be epilated to ly if it is improperly treated. Spread enhance drainage. Digital expres- of infection to neighboring glands was performed only in cases with a sion of purulent material in office or other lid tissue anterior to the flocculated mass, larger lesions or if will expedite healing, but is not tarsal plate may lead to the forma- requested by patients. First choice absolutely necessary. Antibiotic tion of a preseptal cellulitis. While antibiotics were a combination of therapy could include dicloxacil- uncommon, hordeola can produce topical neomycin, polymyxin and lin 250mg PO Q6h; erythromycin ocular surface disruption as a thick- gramicidin eye drop, chlorampheni- 250mg PO QID; or amoxicillin ened lid rubs against the cornea and col eye ointment and oral dicloxa- 500mg PO TID for 10 days. Cepha- conjunctiva during blinking.4 cillin.6 lexin 500mg BID for seven to 10 Clearly, doctors have numerous days is also an excellent, economi- Treatment approaches to handling this com- cal choice. Cold compresses will So, what are the options for treat- mon infection, likely with varying help to suppress inflammation and ing an acute, painful hordeolum? success. When there is debate about pain, while warm compresses will First, remember that the infection best treatment and practices, it is enhance pointing and drainage. is generally self-limiting and will always best to look at evidence- Clearly, optometrists have sev- often resolve within a week or two based medicine. Randomized, eral acceptable methods to man- with spontaneous drainage of the controlled clinical comparative triage patients with hordeola. Each abscess.1 Traditionally, the most als give the best evidence on how probably has varying degrees of common treatment involves the to manage patients when there are success and therapies can be patient use of hot compresses with digital numerous options and speculations. specific. massage along with topical antibi- Unfortunately, hordeolum, though In our resident’s case, she walked otic solutions and ointments. Some common, is considered benign away still confused with yet another advocate for oral antibiotics instead and self-limiting and, as such, has opinion. But we assured her that of topical treatment due to bet- garnered little in the way of clini- our approach “works every time.” ■

ter absorption with subsequently cal research. Reviews of the best 1. Lederman C, Millier M. Hordeola and chalazia. Pediatrics in higher therapeutic concentrations. available literature did not find any review 1999; 20(8):283-4. 2. Kiratli HK, Akar Y. Multiple recurrent hordeola associated with Incision and curettage may also be evidence for or against the effective- selective IgM deficiency. J AAPOS. 2001;5(1):60-1. helpful. ness of nonsurgical interventions 3. Shine WE, McCulley JP. Meibomian gland triglyceride fatty acid differences in chronic blepharitis patients. Cornea. In a survey study involving 501 for the treatment of an internal hor- 1996;15(4):340-6. ophthalmologists, warm compress deolum.7 The few references specific 4. Maldonado MJ, Juberias JR, Moreno-Montanes J. Extensive corneal epithelial defect associated with internal hordeolum after usage was employed by 92% of to treating acute internal hordeola uneventful laser in situ keratomileusis. J Cataract Refract Surg. respondents.6 Additionally, com- were reports of interventional case 2002;28(9):1700-2. 5. Brun SC, Jakobiec FA. Kaposi’s sarcoma of the ocular adnexa. bined topical and oral antibiotics series, case studies or other types Int Ophthalmol Clin. 1997;37(4):25-38. were typically used.6 Only 2.4% of observational study designs and 6. Panicharoen C, Hirunwiwatkul P. Current pattern treatment of hordeolum by ophthalmologists in Thailand. J Med Assoc Thai. of respondents used oral antibiot- were published more than 20 years 2011 Jun;94(6):721-4. 7 7. Lindsley K, Nichols JJ, Dickersin K. Non-surgical interven- ics alone, and 4.2% used no oral ago. tions for acute internal hordeolum. Cochrane Database Syst Rev. antibiotics.6 Incision and curettage It is our feeling that topical anti- 2017 Jan 9;1:CD007742.

REVIEW OF OPTOMETRY APRIL 15, 2018 87

086_ro0418_tr.indd 87 3/29/18 4:07 PM SAVE THE DATE

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RRO0418_HouseO0418_House AAAO.inddAO.indd 1 33/26/18/26/18 10:3010:30 AMAM Glaucoma Grand Rounds

The Devil is in the Details When a glaucoma suspect progresses, it’s time to transition from monitoring to treating. But what happens when devices differ? By James L. Fanelli, OD

n June 2012, a 57-year-old Caucasian female presented to the office with complaints related to headaches and perioc- ularI discomfort that progressed over several months. She was a low hyper- ope wearing a hyperopic presbyopic spectacle prescription that was about five years old at the time. This radial OCT image of the right eye shows a commonly seen steep nasal margin She was taking no medications and and a more sloping inferotemporal margin. reported no allergies to medications. Refractively, she had an expected change in her specta- family history of glaucoma. I explained my findings of cle prescription of increased hyperopia and presbyopia, suspicious discs and, since she was dilated, I took the best corrected to 20/20 OD, OS, OU. opportunity to obtain stereo optic nerve images. She A slit lamp exam of her anterior segments was was scheduled for a full glaucoma work-up in the next unremarkable. Applanation tensions at that visit were few weeks. 15mm Hg OD and OS at 10:39am. Slit lamp estima- tion of her anterior chamber angles demonstrated wide- Evaluation open angles in both eyes. As scheduled, she presented for the glaucoma work-up, Through dilated pupils, her crystalline lenses were which included pachymetry, morning IOP readings, clear bilaterally. Her cup-to-disc ratios were 0.65 x gonioscopy, threshold visual fields and Heidelberg ret- 0.75 OD and 0.65 x 0.65 OS, with discs that were ina tomograph (HRT 3) and optical coherence tomog- average size. There was slight thinning of the temporal raphy (OCT) imaging of the optic nerves. At this visit, rim in both eyes, with a common appearance of sloping pachymetry readings were 478µm OD and 479µm OS. temporal margins of the neuroretinal rim into the optic Applanation tensions at 9:15am were 16mm Hg OD cup. Her macular, vascular and retinal evaluations and 17mm Hg OS. Gonioscopy demonstrated wide- were normal in both eyes. open angles with minimal trabecular pigmentation, a I asked her if anyone had mentioned that she had flat iris-to-angle approach and no angle abnormalities. some characteristics to her optic nerves that put her at Threshold standard automated perimetry (SAP) field risk for glaucoma, and she said no. She also denied a studies were clear and reliable in both eyes. HRT 3

HRT 3 imaging shows a distinct change in the IT neuroretinal rim of our patient’s right eye, first noted in 2015.

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Top row, temporal-superior-nasal-inferior-temporal RNFL circle scans of two different diameters, with the top right image showing the circle scan obtained at a 4.7mm diameter scan. Bottom row left, this macular ganglion cell layer thickness change map of the patients right eye shows stability. Bottom right, this IT BMO OCT scan with minimum rim shows stability over time.

nerve imaging confirmed the clinical appearance of the glaucoma. Her imaging of the left eye remained stable optic nerves with a large cup, a thinned temporal neu- insofar as the HRT 3 images were concerned. And her roretinal rim and Moorfields Regression Classification OCT RNFL circle scans also remained stable. as statistically borderline optic nerves in both eyes. The Accordingly, she was initially managed with 0.5% RNFL circle scan of both eyes was statistically normal. timolol QAM to the right eye, and observation of the Given the findings at that time, I diagnosed her as a left eye. Post treatment IOP readings in the right eye glaucoma suspect only, as there was no frank evidence have averaged 11mm Hg to 12mm Hg, and those of of glaucoma either structurally or functionally. I asked the unmedicated the left eye have remained in the mid- her to follow up in a year. teen range. Over the subsequent years, she presented annually as directed, and essentially all findings remained stable, Discussion though we did substitute threshold flicker-defined form Once the patient converts from a glaucoma suspect visual fields for SAP fields, looking specifically for to a patient needing intervention, I usually see them early field loss. These too remained stable. However, a bit more frequently, and as such, I followed the in the summer of 2015, there appeared to be a change same protocol with this patient. At this point in our in the inferotemporal neuroretinal rim of the OD from management, each visit is tasked with determining baseline, while all other indices remained stable. Given whether the patient remains stable or not, which, for that her imaging to this point was stable and consisted glaucoma, requires an evaluation of both the struc- of high quality images, this change was worthy of fur- tural and functional aspects of the eye. ther investigation. Accordingly, I asked her to return One of the advantages of having adequate instru- in four months for repeat nerve imaging. At that visit mentation to evaluate these patients is that one can in December 2015, the structural defect had wors- see, rather readily, when it occurs, change over time. ened in the right eye, indicating a conversion to early One of the disadvantages to having a variety of ways

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**Additional CE fees if attending both meetings. Agenda subject to change. Review of Optometry® partners with Salus University for those See website for details: www.reviewofoptometry.com/SanDiego2018 ODs who are licensed in states that require university credit Surgical Minute Edited By Derek N. Cunningham, OD, and Walter O. Whitley, OD, MBA The MIGS Just Keep on Coming Two new devices expand the treatment portfolio and target novel pathways. By Christopher Kruthoff, OD Photo: Constance Okeke, MD, MSCE inimally invasive glau- Postoperative Considerations coma surgeries (MIGS) As with standard cataract surgery, Mare quickly earning a place patients will be prescribed a com- in the glaucoma treatment regimen. bination of antibiotics, steroids and Their demonstrated efficacy, along nonsteroidal anti-inflammatory with improved safety and faster drugs after the procedure. Glaucoma recovery compared with traditional drops may be adjusted or discon- surgeries such as trabeculectomy, tinued depending on the resulting have made MIGS a good option postoperative IOP. for patients showing glaucomatous Gonioscopy is critical in the man- damage, progression or even those With the CyPass in place, only the most agement of any MIGS procedure who want to reduce their depen- proximal retention ring and collar are and is especially useful during pres- dence on topical therapy.1 Many visible. sure spikes to monitor for proper MIGS target the traditional outflow stent placement, potential iris pathway, either by bypassing or extraction alone, the group receiv- obstruction or hemorrhage through removing the trabecular meshwork ing CyPass showed a 7.4mm Hg the stent. Patients should also be or by reconstructing Schlemm’s reduction in mean IOP, compared watched closely in the postopera- canal. But two recently approved with 5.4mm Hg with only cataract tive period for hypotony, hyphema, devices have different approaches. extraction at two years.2 iritis and corneal edema. Patients Unlike the CyPass, the Xen 45 gel with the Xen stent should also be Follow a New Path stent (Allergan) mimics the outflow observed for any flattening of the The CyPass Micro-Stent (Alcon), a pattern of traditional glaucoma pro- subconjunctival bleb, as needling of fenestrated stent that connects the cedures by draining aqueous into the the bleb was required in 32.3% of anterior chamber to the supraciliary subconjunctival space, but with the patients.3 space, is used with cataract surgery less invasive ab interno approach. to reduce intraocular pressure (IOP) This stent is indicated as a stand- MIGS are an exciting addition in patients with mild to moder- alone procedure or with cataract to the glaucoma management regi- ate primary open-angle glaucoma. surgery for patients with open-angle, men. These two new procedures in Using the corneal incisions already pseudoexfoliative or pigmentary particular provide many patients yet created for cataract extraction, the glaucoma who failed maximum another avenue for preventing glau- surgeon places the stent posterior to topical therapy or other filtering comatous damage. ■ the scleral spur. The curved design procedures. The Xen, preloaded Dr. Kruthoff practices at Virginia allows natural passage into the in a single-use injector, is inserted Eye Consultants in Norfolk, Va., supraciliary space, while retention through the trabecular meshwork, with a focus on perioperative glau- rings are designed to keep the stent creating a scleral channel through coma care. in place. In the COMPASS trial, which the stent connects the ante- 1. Saheb H, Ahmed II. Micro-invasive glaucoma surgery: cur- which compared cataract extraction rior chamber to the subconjunctival rent perspectives and future directions. Curr Opin Ophthalmol. 2012;23(2):96-104. plus CyPass insertion with cataract space. A clinical trial of 65 patients 2. Vold S, Ahmed II, Craven ER; CyPass Study Group. Two- demonstrated a drop in IOP from a year COMPASS trial results: supraciliary microstenting with phacoemulsification in patients with open-angle glaucoma and To see a video of this mean of 25.1mm Hg preoperatively cataracts. Ophthalmology. 2016;123(10):2103-12. procedure, visit www. 3. Allergan. Directions for use for the XEN glaucoma treatment to 15.1mm Hg postoperatively, with system. https://allergan-web-cdn-prod.azureedge.net/actavis/ reviewofoptometry.com, or a reduction in medications from 3.5 actavis/media/allergan-pdf-documents/labeling/xen/dfu_ scan the QR code. xen_glaucoma_treatment_system_us_feb2017.pdf. Accessed before the procedure to 1.7 after.3 February 26, 2018.

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a) dĞĂĐŚŝŶŐ b) ^ĞƌǀŝĐĞ • WĂƌƟĐŝƉĂƟŶŐ ŽŶ ŽůůĞŐĞ ĂŶĚ hŶŝǀĞƌƐŝƚǇ • ĞǀĞůŽƉŝŶŐ ĂŶĚ ĚĞůŝǀĞƌŝŶŐ ůĞĐƚƵƌĞƐ ĂŶĚͬŽƌ • ,ĞůƉŝŶŐ ƚŽ ŵĂŝŶƚĂŝŶ ĂŶĚ ŐƌŽǁ ƚŚĞ ƐƚĂƚĞ ŽĨ ĐŽŵŵŝƩĞĞƐ͕ĂƐĂƐƐŝŐŶĞĚ͖ ůĂďŽƌĂƚŽƌŝĞƐĨŽƌƌĞůĂƚĞĚĂƌĞĂƐ͕ĂƐĂƐƐŝŐŶĞĚ͖ ƚŚĞ Ăƌƚ ŽƉƚŽŵĞƚƌǇ ƉƌŽŐƌĂŵ ǁŝƚŚ Ă ƐƚƌŽŶŐ • WĂƌƟĐŝƉĂƟŶŐŝŶŽůůĞŐĞĂŶĚhŶŝǀĞƌƐŝƚǇƐĞƌǀŝĐĞ • ŵďƌĂĐŝŶŐĂŶĚĞŶŚĂŶĐŝŶŐƚŚĞĚŝĚĂĐƟĐ ŝŶƚĞƌĚŝƐĐŝƉůŝŶĂƌǇĨŽĐƵƐƚŚĂƚŵĞĞƚƐƚŚĞŶĞĞĚƐ ĂĐƟǀŝƟĞƐ͘ • ƉŚŝůŽƐŽƉŚŝĞƐŝŶƚŚĞK͘͘ƉƌŽŐƌĂŵ͖ ŽĨƉĂƟĞŶƚƐŝŶƚŚĞƐƵƌƌŽƵŶĚŝŶŐĐŽŵŵƵŶŝƚǇ͖ŝƐ • DĂŝŶƚĂŝŶŝŶŐ ĂŶĚ ĞǆƉĂŶĚŝŶŐ ƚŚĞ ŚŝŐŚ ƋƵĂůŝƚǇ ĞĸĐŝĞŶƚ͕ƉĂƟĞŶƚĨƌŝĞŶĚůǇ͕ĂŶĚĐŽƐƚͲĞīĞĐƟǀĞ͖ c) ^ĐŚŽůĂƌůǇĂĐƟǀŝƚǇ ĐůŝŶŝĐĂů ƉƌĂĐƟĐĞ ĞŶǀŝƌŽŶŵĞŶƚ ĨŽƌ ŽƉƚŽŵĞƚƌǇ • tŽƌŬŝŶŐĐůŽƐĞůǇƚŽŐĞƚŚĞƌǁŝƚŚĂůůŽƉƚŽŵĞƚƌǇ ŶŐĂŐŝŶŐŝŶƌĞƐĞĂƌĐŚĂŶĚƐĐŚŽůĂƌůǇĂĐƟǀŝƚǇ͕ŝŶ- ƐƚƵĚĞŶƚƐŽŶƌŽƚĂƟŽŶ͖ ĂŶĚŽƉŚƚŚĂůŵŽůŽŐǇĨĂĐƵůƚǇƚŽƉƌŽǀŝĚĞĂĐŽŵ- ĐůƵĚŝŶŐ ƉƌĞƐĞŶƚĂƟŽŶƐ ĂƚƐĐŝĞŶƟĮĐ ŵĞĞƟŶŐƐ͕ • WƌĞĐĞƉƟŶŐƐƚƵĚĞŶƚƐŽŶĐůŝŶŝĐĂůƌŽƚĂƟŽŶĂƚƚŚĞ ƉůĞƚĞƌĂŶŐĞŽĨĞǇĞĂŶĚǀŝƐŝŽŶĐĂƌĞƐĞƌǀŝĐĞƐ͖ ƌĞƐĞĂƌĐŚ͕ ĂŶĚ ƉƵďůŝĐĂƟŽŶ ŝŶ ƉĞĞƌ ƌĞǀŝĞǁĞĚ DŝĚǁĞƐƚĞƌŶhŶŝǀĞƌƐŝƚǇǇĞ/ŶƐƟƚƵƚĞ͖ • WĂƌƟĐŝƉĂƟŶŐŝŶůĞĂĚĞƌƐŚŝƉƌŽůĞƐŝŶƐƚĂƚĞ͕ƌĞ- ũŽƵƌŶĂůƐ ƐƵĸĐŝĞŶƚ ƚŽ ƋƵĂůŝĨǇ ĨŽƌ ĂĐĂĚĞŵŝĐ ŐŝŽŶĂů͕ĂŶĚŶĂƟŽŶĂůŽƉƚŽŵĞƚƌǇŽƌŐĂŶŝǌĂƟŽŶƐ͖ ĂĚǀĂŶĐĞŵĞŶƚŝŶĂŶŽŶͲƚĞŶƵƌĞƚƌĂĐŬƉŽƐŝƟŽŶ͘

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96 REVIEW OF OPTOMETRY APRIL 15, 2018

ROPT0418.indd 96 3/26/18 8:57 PM Meetings + Conferences

May 2018 email Karen Ruder at [email protected], call (410) 561-3791 or go to www.oep.org. ■ 2-4. CE in Italy/Europe. Hotel Torbräu, Munich, Germany. ■ 7-10. Utah Optometric Association (UOA) Annual Congress. Hosted by: James Fanelli. Key faculty: Joseph Pizzimenti, The Zermatt Resort, Midway, UT. Hosted by: UOA. Key faculty: Lorraine Lombardi, Leonard Messner, James Fanelli. CE hours: 12. For more information, email James Fanelli at jamesfanelli@ Bruce Onofrey. CE hours: 20. For more information, email Alyssa ceinitaly.com, call (910) 452-7225 or go to www.ceinItaly.com. White at [email protected], call (801) 364-9103 or go to ■ 5-7. CE in Italy/Europe. Kongresshaus, Heidelberg, Germany. www.utaheyedoc.org. ■ Hosted by: James Fanelli. Key faculty: Joseph Pizzimenti, 8-10. Everything Therapeutic: Houston. University of Houston Lorraine Lombardi, Leonard Messner, James Fanelli. CE hours: College of Optometry (UHCO), Houston. Hosted by: UHCO. 12. For more information, email James Fanelli at jamesfanelli@ Key faculty: Bruce Onofrey. CE hours: 24. For more information, ceinitaly.com, call (910) 452-7225 or go to www.ceinitaly.com. email [email protected], call (713) 743-1900 or go to ce.opt. ■ 6. 2018 Coding Update. University of Missouri St. Louis JC uh.edu. ■ Penney Conference Center, St. Louis, MO. Hosted by: University 8-10. Northern Educational Escape. Delta Hotels, Quebec of Missouri St. Louis College of Optometry. Key faculty: John City, Canada. Hosted by: Optometric Education Consultants. Key McGreal. CE hours: 4. For more information, email Erin Schaeffer faculty: Greg Caldwell, Joseph Pizzimenti, Barry Frauens, Rim at [email protected], call (314) 516-5615 or go to optometry. Makhlouf. CE hours: 15. For more information, email Vanessa umsl.edu/CE Courses/index.html. McDonald at [email protected], call (954) 262-4224 or go to ■ 17-20. New Technologies and Treatments in Eye Care Orlando www.optometricedu.com. 2018. Disney’s Yacht Club, Orlando, FL. Hosted by: Review of ■ 20-24. AOA/Optometry’s Meeting. Colorado Convention Optometry. Key faculty: Paul Karpecki. CE hours: 18. For more Center, Denver, CO. Hosted by: American Optometric Association information, email [email protected], call (866) 658- and American Optometric Student Association. CE hours: 215 1772 or go to www.reviewofoptometry.com/orlando2018. total, 43 per OD. For more information, email cspampani@aoa. ■ 17-20. Pennsylvania Optometric Association Spring Congress. org, call (314) 983-4124 or go to optometrysmeeting.org. Seven Springs Mountain Resort, Seven Springs, PA. Hosted by: Pennsylvania Optometric Association. CE hours: 22 total, 20 per July 2018 OD. For more information, email Ilene Sauertieg at ilene@ ■ 1-8. Tropical CE Ocean Reef 2018. Ocean Reef Club, Florida poaeyes.org, call (717) 233-6455 or go to www.poaeyes.org. Keys. Hosted by: Tropical CE. Key faculty: Diana Shechtman. CE ■ 30. The Eleventh Central Jersey Optometric Seminar. hours: 20. For more information, email Stuart Autry at isautry@ CentraState Medical Center, Freehold, NJ. Hosted by: Optometry tropicalce.com, call (281) 808-5763 or go to www.tropicalce.com. on West 44th. Key Faculty: Walter Whitley. CE hours: 4. For more ■ 8-18. Therapeutic Pharmaceutical Agents Certification/ information, go to www.optometryonwest44th.com. Board Review Course. Nova Southeastern University College of ■ 31-June 3. Oregon’s Meeting. Mt. Bachelor Village Optometry (NSUCO), Fort Lauderdale, FL. Hosted by: NSUCO. Resort, Bend, OR. Hosted by: Oregon Optometric Physicians Key faculty: Joseph Sowka, Julie Tyler, Chandra Mickles, Diana Association. Key faculty: Tracy Doll, April Jasper, Derek Shechtman, Sherrol Reynolds. CE hours: 100. For more informa- Cunningham, Fraser Horn. CE hours: 15. For more information, tion, email Vanessa McDonald at [email protected], call (954) email Lynn Olson at [email protected], call (800) 922- 262-4224 or go to optometry.nova.edu/ce/index.html. 2045 or go to www.oregonoptometry.org. ■ 12-15. July Advanced Procedures. Oklahoma College of Optometry (OCO) Academic Wing, Tahlequah, OK. Hosted by: June 2018 OCO. Key faculty: Nate Lighthizer, Richard Castillo, Joseph ■ 4-7. Indian Health Service Biennial Eye Care Meeting. Marshall Shetler, Doug Penisten. CE hours: 32. For more information, email B. Ketchum University (MBKU), Fullerton Campus, Fullerton, CA. Callie McAtee at [email protected], call (918) 316-3602 or go Hosted by: MBKU Southern California College of Optometry and to optometry.nsuok.edu/continuingeducation. Indian Health Service. CE hours: 25. For more information, email Antoinette Smith at [email protected], call (714) 872-5684 or To list your meeting, please send the details to: go to www.ketchum.edu/ce. Michael Iannucci ■ 6-10. Art & Science of Optometric Care, A Behavioral Associate Editor Perspective. Nova Southeastern University, Fort Lauderdale, FL. Email: [email protected] Hosted by: The Optometric Extension Program Foundation. Key Phone: (610) 492-1043 faculty: John Abbondanza. CE hours: 35. For more information,

REVIEW OF OPTOMETRY APRIL 15, 2018 97

0097_ro0418_m&c.indd97_ro0418_m&c.indd 9797 33/29/18/29/18 2:032:03 PMPM Diagnostic Quiz

There Will Be Blood By Andrew S. Gurwood, OD

History An 81-year- An 81-year-old Caucasian female old with a reported to the office with a chief history of complaint of a red and painful herpes simplex left eye of two weeks duration. keratopathy The patient had been to multiple presented with eye doctors previously for herpes a bleeding, simplex virus (HSV) keratopathy painful left and was treated for a non-healing eye. What can epithelial defect with active HSV these images keratitis and subsequent elevated and her history pressure in the left eye. Her ocular tell you about history was also remarkable for her likely keratoconjunctivitis sicca in both diagnosis? eyes, for which she had been using artificial tears and erythromycin ointment in both eyes, and half- measured to be 18mm Hg OD and strength dose of fluorometholone 20mm Hg OS. Dilated funduscopy drops in the right eye. The patient was within normal limits, both developed HSV keratitis about 30 eyes, revealing slightly high asym- years ago with multiple episodes of metric cup-to-disc ratios measuring exacerbation and remission. Her 0.5/0.5, 0.55/0.6, OD, OS respec- systemic history was remarkable tively with normal peripheries. for herpes simplex virus treated with oral valacyclovir periodically Your Diagnosis during outbreaks. She denied any Does the case presented require allergies. graphs. Biomicroscopy of the right any additional tests, history or eye showed evidence of anterior information? What steps would Diagnostic Data basement membrane dystrophy you take to manage this patient? Her best-corrected visual acuities with old inactive corneal opaci- Based on the information pro- were 20/50 OD and 20/200 OS. ties. The anterior chamber of the vided, what would be your diag- Her external examination was right eye appeared to be deep and nosis? What is the patient’s most grossly intact. The pertinent ante- quiet with a well-placed posterior likely prognosis? To find out, rior segment findings in the left chamber intraocular lens. Gold- please visit us online at eye are demonstrated in the photo- mann intraocular pressures were www.reviewofoptometry.com. ■

Retina Quiz Answers (from page 84): 1) c; 2) d; 3) c; 4) b; 5) b.

REVIEW OF OPTOMETRY (ISSN 0147-7633) IS PUBLISHED MONTHLY, 12 TIMES A YEAR BY JOBSON MEDICAL INFORMATION LLC, 440 9TH AVENUE, 14TH FLOOR, NEW YORK, NY 10013- 1678. PERIODICALS POSTAGE PAID AT NEW YORK, NY AND ADDITIONAL MAILING OFFICES. POSTMASTER: SEND ADDRESS CHANGES TO REVIEW OF OPTOMETRY, PO BOX 81, CONGERS, NY 10920-0081. SUBSCRIPTION PRICES: US: ONE YEAR $56; TWO YEARS $97, CANADA: ONE YEAR $88, TWO YEARS $160, INT’L: ONE YEAR $209, TWO YEARS $299. FOR SUBSCRIPTION INFORMATION CALL TOLL-FREE (877) 529-1746 (USA); OUTSIDE USA, CALL (845) 267-3065. OR EMAIL US AT [email protected]. PUBLICATIONS MAIL AGREEMENT NO: 40612608. CANADA RETURNS TO BE SENT TO BLEUCHIP INTERNATIONAL, P.O. BOX 25542, LONDON, ON N6C 6B2.

98 REVIEW OF OPTOMETRY APRIL 15, 2018

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*Based on clinical studies with AIR OPTIX® AQUA contact lenses. **Rebate in the form of an Alcon VISA® prepaid card. Must purchase an annual supply (four 6-ct boxes) of AIR OPTIX® brand contact lenses (excluding AIR OPTIX® AQUA [sphere] lenses). Rebate submission must be submitted electronically (or postmarked, if by mail) within sixty (60) days of purchase and no more than ninety (90) days after eye exam/lens ﬁ tting. Valid on purchases made through participating retailers through 4/30/2018. Additional restrictions apply. Visit AIROPTIXCHOICE.com for complete terms and conditions. Questions? Call 1-855-344-6871. References: 1. Eiden SB, Davis R, Bergenske P. Prospective study of lotrafilcon B lenses comparing 2 versus 4 weeks of wear for objective and subjective measures of health, comfort, and vision. Eye Contact Lens. 2013;39(4):290-294. 2. Lemp J, Kern J. A comparison of real time and recall comfort assessments. Optom Vis Sci. 2016;93:E-abstract 165256. 3. Merchea M, Mathew J, Mack C. Assessing Satisfaction with Lotrafilcon B Packaged with an EOBO Wetting Agent Combined with EOBO-Based Lens Care Solutions. Poster presented at the Annual Meeting of the American Academy of Optometry, October 11-14, 2017, Chicago, IL. 4. Nash W, Gabriel M, Mowrey-Mckee M. A comparison of various silicone hydrogel lenses; lipid and protein deposition as Optom Vis Sci Ex vivo a result of daily wear. . 2010;87:E-abstract 105110. 5. Nash WL, Gabriel MM. analysis of cholesterol deposition for ® commercially available silicone hydrogel contact lenses using a fluorometric enzymatic assay. Eye Contact Lens. 2014;40(5):277-282. RReeccoommmmeennd CCLLEAAR CCARE PLUUS 6. In vitro study over 16 hours to measure wetting substantivity, Alcon data on file, 2015. 7. Muya L, Lemp J, Kern JR, Sentell KB, Lane J, Perry ® ® SS, Impact of packaging saline wetting agents on wetting substantivity and lubricity. Ivest Ophthalmol Vis Sci 2016;57:E-abstract 1463. oor OPTTI--FRREE Puurremmoisst Important information for AIR OPTIX® plus HydraGlyde® (lotraﬁ lcon B): For daily wear or extended wear up to 6 nights aass thhee peerffecct combinattion for near/far-sightedness, presbyopia and/or astigmatism. Risk of serious eye problems (i.e. corneal ulcer) is greater for extended wear. In rare cases, loss of vision may result. Side effects like discomfort, mild burning or stinging may occur. wwitth AIRR OPTTIXX® lennses.

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