SOCCEP Questions & Answers Wednesday, March 25

Time Session Details Question Answer

10:00 – 11:00 am Sowmya Srinivas, OD, MS, Which layers of the OCT are we looking The prominent bright/hyperreflective FAAO for when judging the PIL? band anterior to (or above) the RPE is Interpreting OCT Retina the photoreceptor integrity line (PIL).

The bright PIL has the dark inner segments of the photoreceptors above it and the dark outer segments below it

How would you tell that the area in A serous retinal detachment is often photo d was not cystic space or fluid? visualized with an OCT as a smooth diffuse elevation of the neurosensory retina which is wider than it is taller. The RPE will be noted underneath the pocket of optically blank fluid. In contrast, a PED is almost always smaller with similar height and width.

If it is blood from CNVM, it is collected between the RPE detachment and the neurosensory retina

Should we expect VA decrease within Recall that ORT can appear in a few ORTs? different conditions so whether the vision is reduced depends on the diagnosis. Recall that if the PIL is intact, VA will be normal or near normal. Outer retinal tubulation (ORT) is believed to be a rearrangement of photoreceptors secondary to retinal damage. It was first discovered by SD-OCT scans and confirmed on histopathologic sections. The condition has been seen in exudative age-related macular degeneration, nonexuative age-related macular degeneration, and other chorioretinal conditions. ORT can be mistaken as a choroidal neovascular membrane on SD-OCT.

What is the main thing you're looking for Blood is collected between the RPE when trying to find a CNVM? detachment and the neurosensory retina

Are the tubulations clinically significant? ORT can be mistaken as a choroidal Is there anything we do to treat them? neovascular membrane on SD-OCT. Are they benign? Recall that ORT can appear in a few

SOCCEP Questions & Answers Wednesday, March 25

different conditions so whether the vision is reduced depends on the diagnosis. Recall that iIf the PIL is intact, VA will be normal or near normal. Outer retinal tubulation (ORT) is believed to be a rearrangement of photoreceptors secondary to retinal damage. It was first discovered by SD-OCT scans and confirmed on histopathologic sections. The condition has been seen in exudative age-related macular degeneration, nonexudative age-related macular degeneration, and other chorioretinal conditions.

We do not treat ORT but it is important to know not to confuse ORT with CNVM. Know what conditions they can be seen in (please see above).

Can you please go over how to identify If the Nerve fiber layer is thick and which eye again? hyperreflective to the left side of the scan, it is the left eye. If the NFL is thick and hyperreflective on the right side of the scan, it is the right eye.

Could you please repeat the difference The International Vitreomacular between VMA and VMT? Traction Study (IVTS) Group defined abnormalities of the vitreoretinal interface. Vitreomacular adhesion (VMA) was defined as macular attachment of the vitreous cortex within a 3-mm radius of the fovea without change in retinal morphology. VMT was differentiated from VMA by the presence of retinal morphologic changes but without full-thickness defect. Full Thickness Mac Hole was defined as a foveal lesion involving all retinal layers.

Can you repeat how to identify plaquenil There is RPE and photoreceptor loss in toxicity? the parafoveal regions. In other words, outer retinal atrophy in parafoveal regions resulting in a classic “space ship sign” with plaquenil toxicity

Why was answer central serous and not CSCR is characterized by a build up of PED subretinal fluid in the macula caused by

SOCCEP Questions & Answers Wednesday, March 25

abnormalities of the choroidal circulation. Fluid leaks from the choroidal circulation and passes through hyperpermeable areas of the retinal pigment epithelium (RPE), accumulating in the subretinal space.

Optical coherence tomography demonstrates subretinal fluid, often associated with a focal pigment epithelial detachment.

A serous retinal detachment is often visualized with an OCT as a smooth diffuse elevation of the neurosensory retina which is wider than it is taller. The RPE will be noted underneath the pocket of optically blank fluid. In contrast, a PED is almost always smaller with similar height and width.

How do you differentiate PED vs. CSCR? A serous retinal detachment is often visualized with an OCT as a smooth diffuse elevation of the neurosensory retina which is wider than it is taller. The RPE will be noted underneath the pocket of optically blank fluid. In contrast, a PED is almost always smaller with similar height and width.

Sometimes the blister 'CSCR' occurs by itself, but sometimes in the middle of the blister there is also a tiny blister of the pigment epithelial layer underneath, causing a pigment epithelial detachment (PED),

Why was the answer central serious and A serous retinal detachment is often not PED? visualized with an OCT as a smooth diffuse elevation of the neurosensory retina which is wider than it is taller. The RPE will be noted underneath the pocket of optically blank fluid. In contrast, a PED is almost always smaller with similar height and width.

CSCR is characterized by a build up of subretinal fluid in the macula caused by abnormalities of the choroidal circulation.

SOCCEP Questions & Answers Wednesday, March 25

Is there any particular OCT Optocase.com interpretation atlas or book that the speaker recommends? https://optocase.com/octmastery/archi ves

11:00 – 12:00 pm Pierce Kenworthy OD, How do you know the superior is swollen The images I displayed were from the FAAO based of oct? Cirrus OCT specifically, but most devices NAION with Hypertension will have similar displays. In this case, as Major Risk Factor you can specifically view the RNFL thickness map, and it will color code how much thickening (or thinning) there is. It will depend on the OCT, but should be displayed as a color-coded thickness map!

Can we make that diagnosis without Yes, it is possible. Once you take into ordering ECR/CRP? To reduce suspicion account the patient demographics, of A-AION other risk factors and the appearance of the optic nerve, you may be able to make the diagnosis with out ESR and CRP. However, I think in any suspected ischemic optic neuropathy, you are safest to order blood work if it has not already been ordered previously. This will allow you to rule out A-AION. This patient was 49 years old and had none of the other symptoms associated with A-AION, so the findings were most likely leading to a diagnosis of non-arteritic, however even still, blood work would be recommended.

One report says, “NAION is primarily a clinical diagnosis. The most important initial step in management is to exclude giant cell arteritis (ie, A-AION). The presence of pallid edema on exam and symptoms including pain, jaw claudication, scalp tenderness, fever, and malaise should raise suspicion for A-AION.” They add, “Patients presenting with typical features generally do not need neuroimaging or additional laboratory testing other than erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), or platelet count.”

SOCCEP Questions & Answers Wednesday, March 25

https://www.ncbi.nlm.nih.gov/pmc/arti cles/PMC5628702/

Is 5 weeks a typical time period for Yes, definitely by 5 weeks you would be ganglion dropout? able to see ganglion dropout. However, in reality it may have occurred even a little earlier. Some studies have shown ganglion cell loss as early as 2-3 weeks. So likely ganglion cells were dropping out sooner than 5 weeks, but we happened to scan them at 5 weeks!

Why is the Superior temporal portion of Great question! Tough answer! There is the nerve/GCA affected in this case a lot we know about the distribution of versus overall the entire superior the Circle of Zinn Haller, and also a lot portion? we don’t know unfortunately. In this specific case, the superior temporal nerve was affected most dramatically with some sparing of the superior nasal. In reality, the visual field by 5 months showed an almost absolute inferior defect both nasally and temporally, but even at 5 months, the superior nasal nerve and GCA was still surprisingly somewhat normal. So the answer ultimately lies in the distribution of the SPCA vasculature – which unfortunately is very hard to visualize (maybe FA could help in studies!?)

One report highlights the uncertainty of optic nerve head circulation and the challenge we have fully comprehending it! https://www.ncbi.nlm.nih.gov/pmc/arti cles/PMC1857503/

What treatment was being done during The patient was aggressively treated this 5 weeks? with anti-hypertensives, but was not treated with any ocular therapeutics. Unfortunately, there is not a lot that can be done.

One study summarized the management by stating the following: “To date, no definitive high-grade evidence for an effective treatment of NAION exists (Table 2). The highest level of evidence comes from the Ischemic Optic Neuropathy

SOCCEP Questions & Answers Wednesday, March 25

Decompression Trial (IONDT).1,2,10 This was a prospective, randomized trial that assessed optic nerve sheath fenestration as a treatment for NAION. It was the only randomized controlled trial for NAION. It was based upon the theory that an optic nerve sheath fenestration could reduce the compartment syndrome effect.1 However, the study concluded that optic nerve sheath fenestration was not an effective intervention and may actually have a harmful effect.” https://www.ncbi.nlm.nih.gov/pmc/arti cles/PMC5628702/

12:00 – 1:00 pm Denise A. Valenti, OD, What role does dopamine play in the Dopamine is a neuromodulator in the FAAO normal retina? retina and brain that supports motor, Cannabinoids: Dopamine cognitive, and visual function. Retinal Dopamine is involved in circadian response of the retina. Dopamine and visual functions still remain unclear, but appears to be involved in time based response and contrast responses. Role of dopamine in distal retina. Popova E. J Comp Physiol A Neuroethol Sens Neural Behav Physiol. 2014 May;200(5):333-58. doi: 10.1007/s00359-014-0906-2.

Is there a particular area of the retina Cannabinoid receptors are throughout that has these cannabinoid receptors? the entire thickness of the retina and most likely extending to the extreme periphery. And have different functions depending where.

Cannabinoid CB1 receptors and ligands in vertebrate retina: Localization and function of an endogenous signaling system Alex Straiker, Nephi Stella, Daniele Piomelli, Ken Mackie, Harvey J. Karten, and Greg Maguire PNAS December 7, 1999 96 (25) 14565- 14570; https://doi.org/10.1073/pnas.96.25.145 65

SOCCEP Questions & Answers Wednesday, March 25

FOR THOSE AT INDIANA….. That is where Dr. Alex Straiker is. He is very gracious, look him up!!! Another really good paper from his lab, but more on anterior seg and IOP: Miller S, Daily L, Leishman E, Bradshaw H, Straiker A. Δ9-Tetrahydrocannabinol and Cannabidiol Differentially Regulate Intraocular Pressure. Invest Ophthalmol Vis Sci. 2018;59(15):5904–5911. doi:10.1167/iovs.18-24838

Do you perform any tests to determine We did not. Originally, we had planned the strength of the cannabis per on having them bring in a small sample volunteer? How do you know one and having it analyzed in a lab. There volunteer did not have a stronger batch? were no labs in Massachusetts. It would have been illegal to mail and illegal to drive across lines with. There are now labs in Massachusetts.

They were able to choose the product, but were told no dabs (the highly concentrated) and encouraged to keep reasonable. During the first half of the project there were no legal adult sale shops in Massachusetts so we are assuming most obtained a version of home/local grown. However we did see a participant (some we saw three times for three different types of testing) who had local connections for the first two dosings, but went to a legal adult shop for the third. They were over sold, bought a way too strong of product. We did keep them longer than before.

Scripted research As I said at the beginning, this is not the Don’t you need more control of what proper way to do research. It is type of marijuana the participants are necessary to do it this way because of using? laws restricting marijuana. For our purposes, showing concept and not claiming to prove efficacy, it was reasonable. Future work will have to have fully controlled protocols.

Also why not before the age of 16? Marijuana significantly impacts development. A confounder though is that potentially early adopters may have deviations from normal of

SOCCEP Questions & Answers Wednesday, March 25

structure and function at baseline. That may be contributing to why they are early users. That said those using before age thirteen have changes in brain and function. A recent paper was in the media discussing deficits in driving for early users. Recreational cannabis use impairs driving performance in the absence of acute intoxication. Dahlgren MK, Sagar KA, Smith RT, Lambros AM, Kuppe MK, Gruber SA. Drug Alcohol Depend. 2020 Mar 1;208:107771. doi: 10.1016/j.drugalcdep.2019.107771. Epub 2020 Jan 14. PMID: 31952821

Animal models have shown thinning of retina with in vitro cannabis use.

Acuities that decreased? Thats pretty Yes it was. Using a penlight and high significant.. plus lens, corneas without lenses looked reasonable and we know one week earlier things were good. Likely contact lenses themselves or …watery eyes due to marijuana and build up of debris under lens. We did tell the person to get a contact lens update. But, part of the reduced FDT could have been cornea or other. what are some clinical signs that can be Acute use but casual use, not likely any seen in the retina from using marijuana ? structural signs. In this case possible changes in retinal layer thicknesses because suspect chronic long term user. There are no published OCT images. With acute use there are ERG changes and as we saw probable functional visual field changes. Paper on ERG and acute use to left

Can you elaborate on how chronic ERG and chronic abstinent use marijuana use shows in retina?

Here are the Berkeley papers. These were NOT chronic users. Am J Optom Physiol Opt. 1975 Nov;52(11):729-35 Invest Ophthalmol. 1975 Jan;14(1):52-5

SOCCEP Questions & Answers Wednesday, March 25

Am J Optom Physiol Opt. 1976 Dec;53(12):764-7 Am J Ophthalmol. 1977 Mar;83(3):350-4 Psychopharmacology (Berl). 1978 Jan 31;56(1):81-6

1:00 – 2:00 pm Barbara Caffery OD, PhD, How would we get Lissamine Green dyes I believe that you cannot get these FAAO in Canada? items. At the hospital we have LG Is That All It Is? compounded at the pharmacy for Barbara Caffery OD, PhD, clinical use. Liquid dye is probably FAAO better anyway and I do hope that going Is That All It Is? forward there is an effort to reinstate this dye

Can you repeat your description of how It enters into cells that have absent or fluorescein works again? compromised glycocalyx. Also into cells that are stages of apoptosis. Normally the large molecule of fluorescein cannot enter an intact cell membrane. Later the dye can diffuse.

How do you decide which patients you Patients who wear CL into the office are should stain and wait an hour to look at the ones that can fool you. I made her the cornea? What made you suspect the wait because I had already used the LG initial normal cornea? and I saw a great deal of staining. The conjunctiva still stains after CL removal and so it is a better indicator. Even so, the area where the CL sat will not stain the conjunctiva but there is plenty of uncovered area that is diagnostic. Remember, staining a cornea of a patient who has just removed a contact lens can be deceiving.

Could we do phenyl red thread test vs Because Sjogren’s syndrome literature schirmers? is only based on Schirmers, you must use that test. Rheumatology understands it and some of them use it in their own offices.

What other questions can you ask Simply asking if your mouth is dry is instead of "cracker test" to differentiate usually enough. Does food get stuck in true dry mouth secondary to Sjogrens? your throat and do you want sauces on all of your food are other possible questions. Also an increase in caries or gum disease can be asked.

SOCCEP Questions & Answers Wednesday, March 25

For Schirmer test, should we administer No use the Schirmer 1 test as that is anesthetic drops so we don’t trigger what is called for in Sjogren’s diagnosis. reflex tearing due to the discomfort of Sjogren’s patients rarely have reflex the slip? tearing so it is not a problem in that diagnosis.

Can an RA pt with neg ANA testing, but Absolutely. Do all of your normal dry mouth still have possibility of testing. The debate is whether we say Sjogren's? Sjogren’s or do we use primary or secondary Sjogren’s.

Since CLs may mask corneal staining, You will want to assess the CL wear what would your recommendation be? usually. However, if they are coming in Having pts come without CLs in or wait for a dry eye workup insist on glasses. 20 mins before assessing?

2:00 – 3:00 pm Megan Funkhouser, OD At what stage of glaucoma should we 10-2 VF testing is most commonly used A Novel Approach to consider a 10-2 VF in addition to a 24-2 to monitor advanced glaucoma to Visual Field Loss with End or 30-2? better monitor progression, but could also be beneficial for early and Stage Primary Open Angle moderate glaucoma. 10-2 VF testing has Glaucoma been shown to have a greater sensitivity for paracentral scotomas as it tests more than 5 times as many points in the central 10 degrees than 24-2 and 30-2 VF.

Did you do a full filter eval or just show I evaluated one filter for indoors the one filter? (Wellness Protect 15) for this specific patient. However, depending on the patient’s needs and goals I typically evaluate several for both indoors and outdoors.

What kind of pen or stimulous do you I use a black felt tip pen or permanent use for testing Amsler grid functional marker in order to have high contrast visual fields? with the Amsler grid.

How/when do you use OCTa imaging in OCTa has been an active part of the diagnosis/management of POAG? research, but is still new for clinical use and management of POAG. For diagnosis/management of POAG, OCTa measures loss of radial peripapillary capillaries as it measures retinal vessel density. Research shows reduced vessel density is found to occur before subsequent nerve fiber layer thinning, which could potentially be used to

SOCCEP Questions & Answers Wednesday, March 25

monitor progression.

Can you adequately judge pallor in 0.9 The rim tissue is very limited compared C/D nerves? to a healthy optic nerve head so it is more difficult to evaluate, but the rim tissue should still be evaluated for color.

When you start a patient on a new Patient follow up depends on several glaucoma medication (not necessarily in factors including the stage of glaucoma, this scenario due to the limitations of the the rate of progression whether with VF patient not being local), when would you testing or OCT, and the compliance and ideally see the patient for F/U to assess if cooperation of the patient. Follow up the medication is doing its job? time periods can range from 2-3 weeks to 3-6 months. It is ultimately at the discretion of the provider.

3:00 – 4:00 pm Nicole Maierhoffer, OD, I'm wondering how you approach the This is an excellent point. First and FAAO topic of contact lenses with patients with foremost, you always want to make Genetic Clues in the aniridia. Specialty lenses often have sure that your patient’s corneas are Diagnosis of Aniridia longer replacement schedules and pose healthy enough to tolerate contact lens more of a risk. How should we approach wear. You are also correct in that these prescribing these devices for patients specialty lenses are often made from with significantly reduced acuities less oxygen-permitting materials. For a already? What factors do you consider? patient with compromised limbal stem cells, make sure you put your patient on a tighter follow-up schedule to detect signs of over-wear or reduced oxygen as soon as possible (perhaps recommending a 3 or 6 month follow- up instead of a yearly check.) One patient in particular comes to mind who was fit with cosmetic lenses for aniridia and the main purpose was to reduce glare (tinted lenses) vs improvement in acuity (contacts with the patient’s correction.) Interestingly, even with no Rx in the contact lens, simply reducing glare by building an “iris” and tinted pupil improved that patient’s acuity. I would exercise caution before

SOCCEP Questions & Answers Wednesday, March 25

prescribing a contact lens to correct a high myope’s refractive error (due to a thicker periphery in the contact lens.) I really like your thought process on this one – it may seem unconventional to Rx “glare contacts” and then wear glasses to correct the acuity but sometimes thinking outside the box is exactly what is best for the patient!

So is surgery and drugs that reduce Absolutely! This is an excellent point. aqueous production better than drugs Typically, we recommend topical that work by increasing outflow in these medications as first line of treatment patients? due to efficacy of medication and relatively low side effect profile. This would be a good topic to discuss with a glaucoma specialist as well. I would agree that topical medications such as PGA would be a good first option as this works on the uveoscleral pathway (and not on the TM.) Other effective options include medications that reduce aqueous production such as CAI, a- agonists, and b-blockers but don’t forget about the important side effects of these medications. Especially considering that aggressive glaucoma can occur at younger ages than we typically see with POAG. (Be aware of asthma and b-blockers!)

4:00 – 5:00 pm Richard Shuldiner, OD, So do all DMVs consider the Snellen DMV’S do not state which chart is to be FAAO* chart the standard measure of acuity or used. They also do not understand or High Myopia and AMD in does that also vary state to state? know how different testing distances an 80 yer WF work. I test at 5, 10 and 20 feet depending on the circumstances. But i report to DMV with 20/x notation.

5:00 – 6:00 pm Tamara Petrosyan, OD* Do you ever recommend using No - The redness is not due to the blood Subconjunctival vasoconstrictive topical drops for vessels being dilated (such as in a Hemorrhage decrease in redness due to SCH? conjunctivitis) where redness will

resolve with constriction of the vessels and the bleeding has already resolved - you are seeing the aftermath of the

SOCCEP Questions & Answers Wednesday, March 25

bleed with the blood pooling in a constricted area. If it is a very fresh hemorrhage i *may* consider it but generally, no.

Are pts with sickle cell disease more Patients with any bleeding disorder, prone to subconj hemes? including anemia and SC will be more prone to SCH. If the blood in a capillary sickles, pressure can build in that small blood vessel and cause it to burst.

Do you ever recommend using No - The redness is not due to the blood vasoconstrictive topical drops for vessels being dilated (such as in a decrease in redness due to SCH? conjunctivitis) where redness will resolve with constriction of the vessels and the bleeding has already resolved - you are seeing the aftermath of the bleed with the blood pooling in a constricted area. If it is a very fresh hemorrhage i *may* consider it but generally, no.

How do you read a protein C and S Correct. Protein C and protein S help result? From my understanding, if it’s regulate clotting. Decreased levels of low the pt will have more clotting issues protein C or protein S can lead to a but if it’s elevated, it does not confirm a hypercoagulable state and increased pt’s lack of clotting ability risk of thrombus formation. Elevated levels are not indicative that the patient has poor clotting.

The patients entering systolic pressure Yes... this patient in particular had an was very high. Did you have any established PCP and we were confident concerns letting the patient leave the that he understood the situation and office despite scheduling a PCP visit the would visit the PCP the next morning (it following day? was very late at night). We also had all the contact info for the established PCP and were in communication. In a patient where reliability is questionable or if there was no established PCP then we may have referred him to an urgent care / ER. Also, his vessels did not show any signs of hypertensive disease, the decision may have been different if there was any.

SOCCEP Questions & Answers Wednesday, March 25

6:00 – 7:00 pm Andrew Meagher, OD, What is the min amount of change in Great question! This is going to vary FAAO RNFL thickness needed to warrant a based on the OCT you are using. Each Glaucoma Suspects: significant change over time? OCT has a micron resolution that varies Weighing the Risk Factors (ie: Spectral domain>Time Domain)

Once you know this resolution you then have to also consider signal strength (SS), a lower SS is going to yield a lower resolution, from what I’ve read in the literature this doesn’t truly make a difference until your SS goes below 7, with each decrease in SS the OCT loses roughly 2 microns of resolution. So there are a lot of artifacts to consider, the OCT our clinic uses, the Stratus, has 10 microns of resolution, so on a perfect scan the minimal change I’d see to consider progression is just that, 10 microns, but I tend to increase my personal parameters based on how the OCT measured other parameters, so if the disc area was measured vastly different between two scans then you aren’t comparing apples to apples anymore. Given this notion I tend to use 12-15 microns for the Stratus as my personal rule for progression, hope that helps! Below are the two sources I utilized to obtain this information for my presentation. I. https://www.ncbi.nlm.nih.gov/pmc/arti cles/PMC3170667/ II. https://www.reviewofophthalmology.c om/article/managing-glaucoma-with- oct-secrets-to-success

This ganglion cell loss in the left eye has Not every case is going to be textbook an interesting appearance, we see but I felt this was the best suited case I inferior central loss and not that typical could find to represent the inferior squeegee effect of glaucoma we would ganglion cell loss (aka the comma expect inferior temporal. How would you effect). If you look directly at the interpret make sense of the pattern of numbers you can see some values are 14

SOCCEP Questions & Answers Wednesday, March 25 the GCA loss in both eyes? still green but their numbers aren’t too far off from the ones flagged as yellow or red, this is where green disease can have an effect if you don’t look carefully at the micron values. Hope that helps!

What are other possible causes of To my knowledge I’m not entirely aware Ganglion cell loss? of other causes of sole ganglion cell loss, so I did some research so we can both learn something, here’s what I found: - CNS lesions in the visual pathway, https://www.nature.com/articles/s41 433-019-0650-5 - Hemianopia due to stroke- https://www.hindawi.com/journals/jo ph/2016/2394957/ - Ischemic optic neuropathies, optic neuritis, vascular occlusions, https://www.touchophthalmology.co m/retinal-ganglion-cell-life-and-death- mechanisms-and-implications-for- ophthalmology/ Hope that helps!

Why is this not considered NTG if the There is debate within both the max IOP were 18 and 19 mmHg ? optometric and ophthalmologic community on if NTG is even its own entity. In a sense you certainly could deem this NTG but personally I felt her sub 500 micron pachymetry readings accounted for the lower measured IOP, with a normal CCT of say 540 microns that IOP could potentially be in the mid 20s. This is always a gray area and don’t believe you are necessarily wrong to say this could be NTG. Hope that helps!

Could you clarify again why that last Sure thing! For a true glaucomatous visual field wasn’t classified as a nasal defect based off criterion set forth by step? Hodapp, Parrish and Anderson, they state there must be a collection of 3 depressed, non-edge points and goes on to say you should test for repeatability. This case had areas of 2 connected non- edge points but they were in differing

SOCCEP Questions & Answers Wednesday, March 25

areas. Overall I tend to say there is ‘noise’ in this area but by using that criteria it doesn’t meet the exact specifications. Reference - Duker ophthalmology Minimal Abnormality for Glaucomatous Visual Field Defect -Abnormal glaucoma hemifield test -Pattern standard deviation abnormal at P <5% level -Cluster of 3 or more points on pattern deviation plot abnormal at P <5% level, at least 1 at the P <% level in an expected area of the visual field

If any one of the above criteria is met, glaucoma should be suspected provided that the visual field defect is repeatable on a second visual field test in a similar location and is not attributable to other pathologic findings such as nonglaucomatous optic neuropathy or chorioretinal disease.

Hope that helps!

Why didn't you initiate vyzulta earlier? Sorry if the case was misleading in this Why in 2019 when you already saw sense, at our clinic most of the time progressive thinning? routine exams are seen by different doctors, her initial visit in 2014 & 2015 was not seen by me, when I saw her 2 years later in 2017 I had past OCTs and fields to gain the bigger picture that the previous doctors did not have, given those findings treatment was initiated at that visit. I had included the 2018 and 2019 testing for completeness.

Why wasn't a 24-2c run due to ganglion That is a great thought! We just cells loss? recently updated 2 of our Humphrey visual fields to the HFA3s which have that capability, and so in summary it wasn’t available at our clinic initially but can definitely be employed now that we do have the 24-2c software

SOCCEP Questions & Answers Wednesday, March 25

If the RNFL is normal and there is a If I can show progressive ganglion cell beginning of thinning at the GCA and a thinning alone then that is ample small defect at the 10-2 VF, we should information along with patients other then start treating the patient? ( if no VF risk factors to initiate treatment, I feel defect, we only monitor every 3-6 that the 10-2 is only supporting testing months with VF?) that reinforces what is going on but a diagnosis can be made in the absence of this. If you have a case of inferiorly thinning but the other pieces of the puzzles don’t scream glaucoma then I would order a 10-2, if that showed early loss/depressed points then that would be my tipping point to initiate treatment and deem the case glaucomatous.

If the patient came in with IOP of 18/19 This question was already brought up in what makes it POAG instead of normal a previous answer but I’ll share with you tension glaucoma? my response: “There is debate within both the optometric and ophthalmologic community on if NTG is even its own entity. In a sense you certainly could deem this NTG but personally I felt her sub 500 micron pachymetry readings accounted for the lower measured IOP, with a normal CCT of say 540 microns that IOP could potentially be in the mid 20s. This is always a gray area and don’t believe you are necessarily wrong to say this could be NTG.” Hope that helps!

Just to clarify, 2 mmHg IOP asymmetry I’ll help clarify, >4mmHg IOP asymmetry and 0.2 C/D asymmetry are both high and asymmetry in CD ratio of >0.2 is risk for glaucoma, right? considered pathological for glaucoma, additionally the ICD10 deems these to be risk factors from a coding standpoint: I. Family History II. Hispanic or African American Race III. Elevated IOP (>21) IV. Abnormal disc appearance (vertical elongation) V. CCT below 500 microns how does a highly myopic/malinserted In most cases it’s a wash, what I mean

SOCCEP Questions & Answers Wednesday, March 25 disc affect your OCT by that is the OCT becomes of limited to interpretation/judgment? no clinical utility in highly malinserted discs. The OCT is an intelligent piece of equipment but struggles to find the true disc and cup boundaries in a myopic nerve and typically is never the same on OCT year to year. If you take that into account the only true parameter on OCT for myopic nerves that can assist you in diagnosis is the average RNFL measurement. Hope that helps!

Was the antimetropic patient diagnosed I had diagnosed this patient with with unilat glc for the myopic ? Or were moderate glaucoma OD and high risk the OCT and VF defect attributed to suspect OS. The nerve appearance myopia ? matched the OCT thinning which matched the visual field defect, so this was attributed as due to the glaucoma but the greater fragility of this nerve was account for by its myopic appearance. Hope that makes sense and is helpfiul!

Do you think Vyzulta would be an ideal If only I could prescribe the ideal medication choice for those with sleep medication for every patient…but apnea or hypotension due to the nitric insurance/pharmacy coverage doesn’t oxide component? tend to agree. I think this would be an excellent choice for OSA patients as well as any NTG patient. For a secondary drop I’d likely choose brimonidine/alphagan for its presumed neuroprotective properties. I did a lecture before on glaucoma ‘mythbusters’ and one myth I deemed plausible was brimonidine/alphagan being neuroprotective. A study was done that developed criteria to evaluate if brimonidine was neuroprotective, the criterion were I) Are there retina receptors for brimonidine - Yes, II) is there adequate penetrance - Yes (PPVs were done on patients scheduled for a retinal procedure but were given brimonidine to take BID for 2 weeks prior, when the vitreous was examined they found 90x the amount of concentration needed to activate

SOCCEP Questions & Answers Wednesday, March 25

receptors, 2nM needed, 185nM found), III. Are there intracellular changes taking place when brimonidine receptors in the retina are activate - Yes, IV. Can this be translated from animal studies into human studies - No, not to date) Apologies for the long tangent but thought you might find it insightful!

Would you need to rely more heavily This is a really good thought. What I upon macular GC analysis in high tend to find is these patients have thin myopia/malinserted disc vs. ONH OCTs? ganglion cell layers to begin with (goes back to the idea of thinner/more fragile structures in the entire eye itself in high myopes) And so given that the ganglion cell analysis is of fair to limited value unfortunately. Hope that helps!

SOCCEP Q/A Thursday, March 26

Thursday, March 26

Time Session Details Question Answer

10:00 - 10:50 AM Sondra Black, OD, FAAO Can you link the study(ies) for the elderly Masud T. Age Ageing 2001; 30:3-7; Peel Role of the OD in the Era fall data with multifocal lenses in the NM. Can J Aging 2011; 30:7-19 of Refractive Cataract follow up email? Lord SR. J Am Geriatr Soc 2002; Surgery 50:1760-6

Does the stats on presbyopic IOLs only Only multifocals include mulitfocals, or does it also include monovision too?

Can we please see an example of the J&J has those available. They are in educational handout that you give pts? brochure form. The other asset available to patients is the website: Beyondcataracts.com Lots of valuable information for patients there

Is it possible that not as many With the newer lenses, the visual ophthalmologists are implanting quality is much better than the earlier presbyopia correcting IOL due to the generations. Generally the issue in my aberrations that patients seems to observation has been the lack of time complain of afterward? that is spent with the patient to educate them on options. It is too much for the patient to deal with at the consult so they generally revert to the easiest option. It is why pre-education is so important

So you start the patient on a dry eye Yes. Definitely regimen before referring for cat sx?

I love the cataract analogy for the I agree they get confused. One surgeon I patient! How do you explain astigmatism met with uses this analogy and it seems to your patient? I find the soccer to work quite well although not ball/football analogy confusing for the anatomically correct. He says “ you patient. either have a front of your eye that is shaped like an egg or a baseball. Your eye is shaped like an egg. The lenses that are fully covered by your insurance are shaped like a baseball and therefore don’t correct your prescription properly” SOCCEP Q/A Thursday, March 26

what is the cyl cut-off to warrant a toric Generally it is about 1D. Most surgeons IOL? can correct the smaller amounts with either an LRI or AI or by moving their incision

OD Sondra, how you could classify if a You should still be able to measure patient came with hyper mature cataract topography which will give you the and seeing nothing if he is astigmatic or cylinder. The axial length will have to be prespayopic, in the first place measured with an A scan and by looking at that you can guesstimate refraction. The issue is whether the macula is healthy to even warrant a specialty lens so a B scan would be ideal to get an idea as you wont be able to do an OCT

So should ODs being doing topographies If you have a topographer it is ideal but on all patients referred for cataract if you don’t have one, look at the K’s surgery? I was under the impression that with your AR, manual K etc. to at least MDs would do that during the evaluation determine toricity.

How do you comfort and help those First it is a matter of determining what patients who are dissatisfied with their the problem is and seeing if it can be surgical outcomes? resolved. I am going to be doing a postop course next week and will address these issues

11:00 - 11:50 AM Caroline Blackie, OD, PhD, Are you in support of the 2 subtypes for The global scientific and medical FAAO classification of dry eye. Definitle consensus is to continue with the MGD and Dry Eye overlap. Is it that simplistic? evaporative vs. aqueous deficiency model. Personally, I agree that this is a simplistic heuristic however, it is the current global consensus and thus we need to be comfortable with the language. It is helpful from a clinical perspective to focus on the specialized tissues and how to diagnose and address specific problems with the ocular surface system.

12:00 - 12:50 PM Caroline Blackie, OD, PhD, What is the difference between DEQ5, These are all examples of standardized FAAO SPEED or OSDI? Which is better? and well accepted dry eye symptom Identify MGD and Treat It questionnaires. There are other options too. These questionnaires address different aspects of the symptom journey but they are all validated questionnaires. The decision regarding which one to use, has not been standardized. This leaves it somewhat SOCCEP Q/A Thursday, March 26

up to the eye doctor. What can be important is to use the same questionnaire pre and post treatment so that you are comparing apples to apples.

Do you feel that neurolens is beneficial I can’t comment on the product for dry eye treatment? neurolens, specifically. However, I can offer that it is not indicated to treat dry eye disease.

When measuring TBUT with the Schirmer The Schirmer test is not intended to test, do we test both reflexive and basal measure TBUT. When using the tearing simultaneously or only basal? Schirmer test, the decision to measure basal vs. reflex depends on what you are looking to measure. Clinically, the more natural state tends to be for relevant.

During your second session, I missed the What is currently understood is that bit regarding the association between tear film integrity has the potential to tear film integrity and the success of IOL impact the accuracy of IOL planning placement. Would you be so kind as to measurements. This is because many of give me a brief, or guide me toward those measurements are assessed off information. Thank you for the exquisite the tear film (keratometry is a good and informative presentations. example of this). If the tear film is not healthy, the measurements are likely to be unreliable. And, thank you for you kind and generous comments.

How can we obtain a Meibomian Gland Please contact the local J&J Evaluator? representative.

1:00 - 1:50 PM Derek Nankivil, BSAE, No questions MSBME, PhD Introduction to Optics and Contact Lens Optical Design

2:00 - 2:50 PM John Buch, OD, MS, FAAO Are there any data that suggest whether It is well-understood that the Why 20/20 Isn't Visual or not wearing blue blocking lenses violet/blue end of the visible spectrum Comfort outdoors helps with visual discomfort at is much more visually uncomfortable all? than the longer visible wavelengths (Flannagan 1989, Stringham 2003, Leung 2017). Lenses that preferentially SOCCEP Q/A Thursday, March 26

filter these shorter visible wavelengths are certainly more comfortable than clear lenses (Renzi-Hammond 2016), and many skiers and shooters strongly prefer them for their improved contrast outdoors (Wolffsohn 2000).

3:00 - 3:50 PM Tawnya Pastuck, OD, No questions FAAO Health Economics and Market Access: Evidence- based Value for Cataract Treatment

4:00 - 4:50 PM David Lampariello, OD, If a patient does not seem like a good I stress the risks, based on their findings, FAAO candidate, how would you talk them out and let them know that they would be Clinical Pearls for Co- of refractive surgery, especially if they at very high risk of losing vision, not managing Preoperative are insistent? getting a good outcome etc. Be sure to Refractive Surgery document the full conversation. If the Patients patient chooses to go somewhere else for a second opinion they can certainly do that but at least you have your conversation documented should they go somewhere, have the surgery and have a problem.

Why is HZO an absolute contraindication There is a much higher incidence of HZO while HSV is a relative contraindication? reactivation than with HSV

How long do you do preoperative The pre-operative therapy should therapy so to speak to heal dry eye, continue until you have a stable tear blepharitis, and any other ocular surface film, topographies, stable vision and abnormalities? What is your course of clean lids. The course of treatment will treatment and follow up schedule? be different for every patient depending on the severity of the disease. I usually have the patient back every 2-3 weeks to monitor lids. I’ve found if you wait longer they tend to slack off and it takes longer. Plus, patients really want to have the surgery so they are more than happy to come back every couple of weeks. SOCCEP Q/A Thursday, March 26

Why is Plaquenil considered an absolute If a patient is taking Plaquenil it is contraindication? Thank you Dr. because they have RA which is a contra- Lampariello indication.

How would you approach Ortho-K Great question: these patients should patients in terms of refractive surgery, be followed similar to an RGP would they be considered the same as wearer. Once the corneas are back to RGP wearers? Thank you. base line and are stable (stable topo’s and refractions) and look good you can proceed with LVC

What is the best way to determine what The surgeon will determine this based the patient’s optical zone diameter on pupil size, ablation depth, should be before their refractive refraction/astigmatism, angle kappa, surgery? there can be multiple factors. The surgeon however, will have the ultimate say.

SOCCEP Q/A Friday, March 27

Time Session Details Question Answer

10:00 – 11:00 am Kelsey Moody Mileski, I missed what you said about RNFL. In retrobulbar optic neuritis, OD, FAAO* What is the average RNFL and how sometimes the optic nerve OCT will Optic Neuritis: Typical or much would it be increased? show a 5-10µm increase (compared to Atypical? the fellow nerve) even though the Register optic nerve is not swollen

Hi, when do we use MRI without When we are talking about things that contrast? would be ordered for ocular or visual complaints, not often. Typically, you would only not order with contrast only if it’s contraindicated (allergy, reduced kidney function, or pregnancy. If you were looking for thyroid eye disease it wouldn’t necessarily be needed, however, if you were ruling out something in the orbit, then you would want it.

You mentioned that using lower oral It can increase the risk of relapse for doses can increase risk of relapse. Is the current optic neuritis not MS. there a higher risk of relapse in low There is a higher risk of relapse than no dose tx vs. no treatment at all? treatment, yes, although the pathophysiology of why is not well understood.

I missed what you said about ontt The ONTT provided a lot of information about both optic neuritis and MS. It found that most cases of optic neuritis were unilateral and painful, that most patients improved to 20/40 or better with the average BCVA of 20/16 and most importantly that IV steroids improved vision quickly but that at the 1 month mark, it was not significantly better than no treatment at all. Also lower dosages of steroids could cause optic neuritis relapse. Here is a good review of the ONTT and it’s implications to eye care providers and neurologists. https://jamanetwork.com/journals/ja maophthalmology/fullarticle/420680

Who actually treats the patient (orders Great question. I do not know a state and gives the injections)? Would we where we have IV steroid privileges. need to be referring to ophthalmology HOWEVER, if a patient comes to your or sending these patients to their PCP? clinic and you are suspicious for an Just wondering exactly what my role in optic neuritis, you would need imaging, SOCCEP Q/A Friday, March 27

treatment is practically speaking. blood work/LP and treatment, so the best bet is to send them to the hospital ER. I always educate the patient that this is the fastest way to potentially improve their vision. Your hospitalist will not know as much as you do about optic neuritis, so you should call the ER to inform them of the patients arrival and your recommendations. Handing an Rx of instructions to the patient to bring can also be heopful. You should then see them after their hospitalization to make sure that they are improving or if you don’t feel comfortable than I would send them specifically to a neuro-ophthalmologist and/or neurology. I would not recommend sending to a PCP.

Would NMO also have lesions on MRI They definitely can but do not always. like MS? They typically will have lesions around areas that have high AQP4 (aquaphorin so think water!). Typically around the cerebral aquaduct, hypothalamus or brainstem.

For recurrent attacks of optic neuritis, Not necessarily. It can affect either eye. do they typically affect the same eye?

Would you recommend IV I always give the patient the option. I steroids/hospitalization for all first time inform them that going into the cases of optic neuritis, even if visual hospital is the fastest way to get a outcomes are ultimately not improved? diagnosis and potentially treatment to improve their vision. I always call the ER to inform them of the patients arrival, history, examination and recommendations (MRI, etc). Steroids cannot be started until MRI is performed, so it would otherwise take several weeks to get this all done as an outpatient. I

Would you be willing to send out the I would be happy to send it out. Let me typical/atypical table you created along ask the AAO team if that would be a with the answered questions at the end possibility. In general, ATYPICAL optic of the presentation? I found it really neuritis should be suspected if vision is helpful but couldn’t get it copied down worse than 20/400, bilateral, optic in time nerve edema, other evidence of ocular inflammation, long segment of optic nerve enhancement, abnormal blood work (NMO, ANA, MOG, etc) and/or does not improve with IV steroids. SOCCEP Q/A Friday, March 27

Is it common for the atypical optic It is common to have more than one neuritis conditions with ANA+ to autoimmune condition, so they could develop uveitis at some point? potentially have both NMO or MOG and lupus or another autoimmune condition, so it is definitely possible.

Could we have a copy of the previous I would be happy to send it out. Let me optic neuritis diagram? ask the AAO team if that would be a possibility. In general, ATYPICAL optic neuritis should be suspected if vision is worse than 20/400, bilateral, optic nerve edema, other evidence of ocular inflammation, long segment of optic nerve enhancement, abnormal blood work (NMO, ANA, MOG, etc) and/or does not improve with IV steroids.

If our faculty member didn’t mention Contact SOCCEP: this program to us- if we just found out [email protected] via email- how do we find out who our point person is to contact?

Same question as previously asked, You do have the right to send your what exactly is our role here: refer to patient to the ER and recommend ophtalmology ou PCP? I don’t think we work-up based on your examination! have the right to order any of these Most states also do allow you to order tests here… an MRI and blood work as well, however, you and your patient will get quicker results if the patient goes to the ER instead of it being done as an outpatient. This way they can get an MRI, blood work, see neurology and potentially get treatment. I also do recommend you (or a neuro- ophthalmologist if you don’t feel comfortable) see the patient after the hospitalization to make sure their vision gets better. If you see any urgent patient, I can guarantee you will see an optic neuritis patient at some point. It is more common than you think.

How long would you continue the PLEX Typically 5 days. This is always done in treatment? the hospital.

If the OD is referring to Great question. You can, then they will neuroophthalmology, does the OD still have the results prior to seeing the order the blood work? patient which will be helpful for their differential. Also, MOG and AQP4 can take 2 weeks to get back. It can be done at Quest, LabCorp or at a hospital lab. SOCCEP Q/A Friday, March 27

Just double checking, when looking at So if you were looking at an axial or an MRI of the orbit, is the OD on the left coronal image, OD is on the left and OS side and OS on the right side, as if we is on the right. For the coronal it’s like would be looking at their chin and up? you are looking up at their chin yes.

11:00 – 12:00 pm Jennifer Qayum, OD, How long would you do the 6 hour When I increase my patient’s patching FAAO patching to determine whether or not is hours after they have a plateau in Amblyopia in the is helping break through a VA plateau? vision, I have them return to clinic in 4- Presence of Congenital Try it for a month? Two weeks? 6 weeks. This is my typical follow up for Macular Scar any patient I am doing amblyopia Register treatment with.

You mentioned that if they are a severe Full time patching typically means at amblyope already doing 6hours of PTO least 8-10 hours per day. Usually, you would increase to full time parents will put the patch on the child patching, how many hours minimum at breakfast and take it off at bath would that mean? time.

Do we know what caused the macular The macular scar is presumed scar? Did the parents know about the secondary to a congenital infection scar before coming in for the initial such as toxoplasmosis. The parents did visit? not know that she had the scar prior to presenting to clinic. They presented to clinic due to a failed vision screening

What kind of amblyopic patient are you If a patient is wanting to wear contact comfortable fitting in contact lenses? lenses in both eyes, I am comfortable fitting amblyopic patients in contact lenses once their vision has improved to 20/40 or better in their amblyopic eye (this is “driving” vision in most states). This is because contact lenses do increase the risk of corneal infections, and the last thing I want is for one of my patients to get a visually significant corneal ulcer and scar in their non-amblyopic eye, leaving them visually impaired. In addition, patients who have amblyopia worse than 20/40 should be wearing glasses for protection.

If a patient wishes to wear a contact lens in only their amblyopic eye, I do not have a strict visual acuity limitation. However, it is still very important for the patient to wear glasses for protection full time.

Can you please write out your “tapering My typical tapering schedule for a SOCCEP Q/A Friday, March 27

schedule” for 6hr/day patching? Would patient who is patching 6 hours/day is: it be the same for 2hr/day patching? 1. Decrease patching to 2 Thank you - great presentation! hours/day for one month 2. Discontinue patching for one month 3. Return to clinic (one month after discontinuing patching) This captures many patients who have vision regression.

If I have a patient who continually has vision regressions when attempting to stop patching, I typically implement a very slow taper and then continue with maintenance treatment: 1. Taper first to 2 hours/day if not already patching 2 hours/day. 2. 1 hour/day for one month. 3. 1 hour every other day for one month. 1 hour only on weekends (this is our maintenance treatment). if you don't see any improvement on With this patient, because she has a the first visit with 2 hours of patching, pathologic reason for decreased visual what is the next step you take? acuity, I would have stopped patching if there was no improvement in vision with initial patching treatment. However, if a patient is an anisometropic or strabismic amblyope, I will increase patching hours to 6 hours/day or full time.

How did you know this patient had I did not know that she had underlying underlying deprivation ablyopia? Did amblyopia until I tried amblyopia you code her as a suspect at first and treatment and saw improvement in her then after patching switch her vision. So, yes, for her first visit, I coded category? her as an amblyopia suspect

Do you ever implement vision therapy I do not typically include any vision in addition to or instead of patching? therapy exercises with or instead of patching. PEDIG has done a study comparing amblyopia treatment with distance or near activities and found no difference in improvement in visual acuity.

“A Randomized Trial of Near Versus Distance Activities While Patching for Amblyopia in Children Aged 3 to Less Than 7 Years.” Ophthalmology, 2008. SOCCEP Q/A Friday, March 27

Do you use sticky patches? Yes, sticky patches are my first choice for patching treatment. However, if a patient cannot tolerate adhesive, I recommend a PatchPals style cloth patch. Also, if milk of magnesium is applied to the skin prior to an adhesive patch, that can help with irritation secondary to adhesive.

12:00 – 1:00 pm Tiffany H. Phan, OD, Why did you include B scan in your The B-scan was done just to rule out FAAO* follow up? disc drusen (likely wasn’t the case) and A Case of Papilledema also as a learning method to Secondary to Presumed distinguish the difference in its Pseudotumor Cerebri presentation on the scan of Register papilledema vs disc drusen.

How do you know it's an enlarged blind You would see double blind spot on spot on the VF? the VF.

How do you proper document this In order to confirm its papilledema before your tests confirm papilledema? secondary to IIH, an MRI has to be Do you need the vf, mri to diagnose? taken first to confirm that it is normal and unrelated to any other factors, then a spinal tap to confirm that it is optic disc swelling caused by increased ICP. VFs are generally not needed to properly diagnose, but are useful as a diagnostic test to rule out other conditions. I always get an OCT RNFL and HVF 30-2 for my patients with this.

When would you consider a patient for CSF shunts are considered to divert shunts/venous stenting? increased CSF pressure when the patient has vision loss and severe, intractable headaches that are unresponsive to medical treatment/less invasive methods. In both of my patients, they were best corrected to 20/20 and did not experience vision loss.

Why was she not started with Diamox Patient #1 was not started with immediately? Diamox right away as the MRI/spinal tap was not obtained. Again, this patient was seen in a low income community clinic, and her PCP/neurologist was hesitant to start any meds until results come back. It took awhile for the authorization for her MRI to go through and when I had SOCCEP Q/A Friday, March 27

left that rotation, patient was still pending for a spinal tap. Patient #2 was started on Diamox after MRI came back negative and spinal tap confirmed elevated CSF, a neurologist had given her that. I have had cases where a general OMD and optometrist can start patients on Diamox, depends on where you work. At Kaiser I am working at, our protocol is that only general OMDs can order MRI, and neurology can only order spinal tap.

Hi! Was a red cap test performed at any For patient #1: Red cap test was not point during the patient's exams/follow performed at initial. The HRR was used, up? And is it possible for a patient's we had these as students. My color vision test to return normal but classmate actually saw her for the for the patient to still have an initial and did the test on her. When I asymmetrical red cap test? saw her for the follow up, we did a D- 15 color vision test. Her red cap was normal at that time, i did not document that in my case findings, sorry about that.

A patient with an asymmetrical red cap test is due to asymmetric optic nerve function (ie: papilledema worse in one eye than the other eye). A patient’s color vision test can be normal and the patient can still have an asymmetrical red cap test, but very unlikely.

What is the link between IUDs and IIH? Mirena IUDs/Skyla IUDs don’t directly Thank you - great presentation! cause IIH. In literature, researchers have linked levonorgestrel (a progestin hormone that both of these two IUDs release) as a risk factor for increasing chance of getting IIH. There definitely needs to be more studies done, but a few have been published in literature associating the two. Etiology is still poorly understood at this time.

Is IUD a risk factor as much as the At this time there aren’t enough contraceptive pill studies/evidence to conclude which is more of a risk factor. There is a study below that concludes a similar risk factor for the Mirena IUD, an oral contraceptive, EE-norethindrone combination. It is deemed important to educate patients with IUDs on the risk SOCCEP Q/A Friday, March 27

of IIH.

Here is a good study to read up on: https://www.ncbi.nlm.nih.gov/pmc/art icles/PMC4519742/

How long do headaches typically last for Headaches can range from mild to these patients? moderate to severe as well as constant vs. intermittent. The length of the headaches are variable. My first and second patient had constant headaches per their report. I have had a few other patients who get intermittent headaches that did not bother them as much. Headaches tend to improve when my patients start to exercise, lose weight, and when their disc swelling improves.

For my question above, I should have See above! written etiology (of IIH with IUDs) instead of link. Thank you!

I would like to know more about the use Here is an article you can read about: of topiramate in the treatment of PTCS. https://www.ncbi.nlm.nih.gov/pmc/art Thank you! icles/PMC3554852/

Do we always do a VF before referring The Ophthalmologists here at Kaiser to ophtho? Also is papilledema always personally want a VF before referring, an urgent same-day referral? not sure how it is in other practices. When you have any optic disc swelling and cannot manage in your clinic with diagnostic testing, you should definitely refer out STAT to cover yourself. Could be GCA/NAION/tumor...though rare. IIH is a diagnosis of exclusion and you can’t say for sure its papilledema secondary to IIH unless you rule out everything else. For example, if I filled in at a retail practice and I have no OCT/VF, and I saw disc edema, taking a look at case history/age of patient/risk factors and ruling out systemic etiologies would be first (take BP, hx of HTN/diabetes/other systemic history, hx of infectious conditions).

1:00 – 2:00 pm Kelsey Jordan, OD, MS, How do we test corneal sensation? There are both qualitative and FAAO* quantitive methods to check corneal SOCCEP Q/A Friday, March 27

Long term management: sensation. Most commonly, a a case of persistent qualitative measure is used in clinic by neurotrophic keratitis using a wisp of a cotton-tipped Register applicator. The quantitative method is performed with the Cochet-Bonnet esthesiometer, which uses a nylon filament.

Is "SAFE" an acronym for something (for Yes: “Smooth Accurate Full and EOMs)? I've just not seen that before. Extensive.”

How do you grade corneal sensation? Our cornea specialist uses a scale of 0 For corneal sensation, I would just use a to 4. A grading of “0/4” means that the cotton wisp to see if the patient blinks patient did not flinch or blink at all, did and notate it as positive. I am not sense the cotton-wisp at all, no wondering what your notation of 1/4 corneal sensation. A grade of “4/4” means. means normal and intact blink response to a corneal stimulus. The numbers in between represent a gradual increase in corneal sensation from 0 (no corneal sensation) up to 4 (normal corneal sensativity). This method provides a grading scale and will vary from clinic to clinic.

Was the acyclovir (800mg) QD Yes, the 800mg PO QD was prescriped prophylaxis due to his chronic Hx of by his previous eye care provider as HZV? Also what is the condition that the prophylaxis due to his history of HZV FML QD is used for? keratitis. The FML 0.1% QD OS was also prescribed by his previous eye care provider as a treatment for his chronic HZV keratitis.

What do you recommend for a nightly I recommend Refresh PM Ointment ointment? Can patients use the nightly. If a patient is concurrently antibiotic ointment concurrently in the using an antibiotic ointment, I evening or would you want to space out recommend using only the antibiotic application? ointment nightly. Using both is probably overdoing it. The antibiotic ointment alone is sufficient at providing ocular surface protection while the patient is sleeping.

I've heard amniotic membrane use in An amniotic membrane should not be the presence of herpetic infections is used for active dendritic herpetic controversial. What are your thoughts?

Is it possible to make the scleral lens Yes, this would qualify as medically and fitting medically necessary and necessary, but in the left eye only. could it be bilateral or only one eye because the other eye did not meet the requirements? SOCCEP Q/A Friday, March 27

Would a scleral lens be contraindicated Good question, but no. Scleral lenses since the patient has neo? have actually shown to IMPROVE neovascularization and reduce the presence of neovascularization in many cases. The Dk of scleral lenses is very high, increasing oxygen permeability. BostonSight has done several studies demonstrating this.

How do you pick a diagnostic scleral Great question, for diagnostic scleral lens? Do you have to take into account lenses – follow the guidelines the irregular epithelium? Is there no recommended by your fitting set. The concern with putting a contact lens on fitting set I used for this patient irregular epithelium and risk CL related recommends starting with a base cruve infections? Thank you! equal to Flat K. The reason a scleral lens was chosen for this patient was to smooth out the irregular epithelium – in a patient with poor to no corneal sensitivity the cornea becomes very dry leading to the epithelium taking on an irregular appearance. The reason the epithelium is irregular is from corneal desiccation. A scleral lens provides a “liquid bandage.” Scleral lenses lubricate the corneal surface throughout the day, healing and protecting his irregular epithelium. Close follow-up is warranted to check for CL-related infections – but there is very low chance for this with a scleral lens.

Besides scleral lens, have you Good question, yes I did consider both, considered other Tx options listed such however both options are very costly as autologous serum and recombinant (much more costly than a scleral lens). human nerve GF? They are still great options to consider if the scleral lens fails.

During the scleral lens wear, what is he Great question. Since starting to wear using topically if any to get this under his scleral lens, the patient only uses an control? (antibiotic, steroids, etc) artifical tear ointment nightly. He only uses lubricating drops if he is not wearing his scleral lens.

Do amniotic membranes have a role in Yes, cases I have treated with amniotic treatment of these patients? membranes do not have as long lasting of an effect as a scleral lens. In my experience, I have treated patients by placing an amniotic membrane (sometimes requiring 2-3 different amniotic membrane placements) and then the patient will have 1-2 months SOCCEP Q/A Friday, March 27

of relief needing a retreatment.

What drop regimen did you keep this He only uses a lubricating ointment patient on after his scleral fit? Any drop nightly in that left eye. No drop in the in the bowl of the scleral? bowl of the lens.

Would you recommend wearing scleral Great question. This is definitely a lenses full time indefinitely? possibility given the chronic, recurrent nature of this condition. I could consider trialing a month or two out of his scleral lens and monitoring closely for recurrence. However, at this point the patient is doing very well in his scleral lens so we will continue full time wear for now. It is very likely that this will be a full time wear indefinitely situation given the recurrent nature of herpes-related infections.

So would this be a chronic condition? See above J Would you ever consider taking the patient out of the scleral?

2:00 – 3:00 pm Barbara Mihalik, OD, How do we obtain the vertical OCT scan There are various selections for FAAO of the macula? Is there an option on the orientations of scans on the OCT Something a Little More OCT machine or is it by the way the Than Just Cataracts cursor on top of the macula is aligned? Register Did you do fundus photo and OCT in the Yes, they were both done same day. same visit? How does that work with You cannot bill both so generally docs billing and coding? will drop the fundus photo charge and keep the OCT charge. It hurts to be dropping charges, but, if it is in the best interest of your patient to do it then do what is best! I routinely get photos and OCT same day and it has not hurt my bottom line to drop imaging charges

Can you explain where you thought the The exact cause of the clot is unknown, occlusion started originally? which is why the patient was sent to internal med to have their carotids evaluated and lab work done for GCA, hypercoagulable, etc. As far as where the clot had been in the eye, it was a small inf branch of the inf retinal artery which resulted in a sup vf defect

For a BRAO, how urgent is the referral The docs you are referring to will have to retina and internist? their general guidelines as to when SOCCEP Q/A Friday, March 27

they can be seen depending on when the onset of VF loss occurred. I then defer to what they want as follow-up since that is their area of expertise. They will generally get patients in within a week

What do you look for on OCT for Look for inner retinal hyper-reflectivity suspected BRAO but no obvious retinal on OCT if relatively new onset. Further findings on fundoscopy? out from onset you would want to look for inner retinal atrophy/thinning on OCT. Scan the area that corresponds to the VF defect (sup mac VF defect, then inf location of occlusion). You could use an amsler grid to get a better idea of where the VF defect is

3:00 – 4:00 pm Sowmya Srinivas, OD, Do you know of any studies that show Cristescu Teodor R, Mihaltan FD. Eyelid MS, FAAO the association between floppy eyelids laxity and sleep apnea syndrome: a Red Eye and sleep apnea? review. Rom J Ophthalmol. Register 2019;63(1):2–9.

Do you recommend cool compress and I do for comfort measures and provide AT to all SCH patients? reassurance to the patient that SCH is a self resolving condition.

What is the reason for prescribing Topical Antibiotics are considered in topical antibiotics for scleritis? infectious scleritis. Please see the citation for a case report:

Richelle L Guerrero-Wooley, James E Peacock, Jr., Infectious Scleritis: What the ID Clinician Should Know, Open Forum Infectious Diseases, Volume 5, Issue 6, June 2018, ofy140, https://doi.org/10.1093/ofid/ofy140

What is your best advice for triaging red A good case history, medical history, eyes? medications, CL wear, history of trauma is very important for triaging red eyes.

Will this powerpoint be available after? Thank you! The organizers of the this was wonderful program may be able to provide a recording of the lecture. I am happy to share the slides.

4:00 – 5:00 pm Jeffrey Anshel, OD, FAAO When it comes to the 4:1 ratio of No, this ratio is for general nutritional SOCCEP Q/A Friday, March 27

A Nutritional Approach to omega 6 to omega 3, do you personally intake- ESPECIALLY in the diet! You Treating Dry Eyes help construct a diet? Are these just the mis-heard my statement- the SAD ratios needed for supplements? I heard (Standard American Diet) is a 25:1 ratio you mention that the average American of O-6:O3. The corn oils and other O-6 diet is 6:1 so are supplements even intake is so high that it pushes the pro- needed or is this managed well through inflammatory pathway. Reduction in O- diet restrictions? 6 EFAs is essential. I can recommend a diet but prefer to seek out a local nutritionist to work with.

What to you think about NutraVege Algal Oil is pre-formed DHA, which is supplements for vegetarian which are good (it’s how fish make DHA- from algae based? eating algae). That is a good way to go!

What is the best way to obtain a 4:1 Reducing the O-6 intake of ratio of omega-6-fatty acids to omega- corn/safflower/canola oils. They 3-fatty acids within the body? “sound” like they are good to take in (ie, “Vegetable” oil but they are pro- inflammatory. A decent fish oil supplement is good- but look for the EPA-DHA amounts, not the number listed on the front label.

Thank you for that wonderful I have a few different nutrition presentation. I just wanted to know "options" for patients in the office. I how you go about educating your work with a nutritionist PhD in San patients about nutrition? Do you have Diego (he also has an on-line presence) any particular recommendations you who has a nutrition questionnaire that typically use? Do you tend to make deals with specific symptoms. The form more recommendations with regards to takes 10 minutes to fill out. He reviews food intake rather than it and makes recommendations on supplementation? what deficiencies he sees, as well as what supplements he recommends (last part optional). I also do a "supplement evaluation", where patients bring in their supplements and review what they are taking. Often they are duplicating some nutrients and omitting others. I also work with a lab to send them over for a blood workup on a nutrition panel. I've found some supplements that I like and make recommendations based on those (the dry eye ingredients are in Biotears.com). Unfortunately, this has been temporarily discontinued but we are working to get it back to market. i also like "Eye and Body Complete" by Biosyntrx (also out of production), but I give them the list of ingredients and tell them to find one with as much of this as possible. SOCCEP Q/A Friday, March 27

To teach about ocular nutrition, I started the Ocular Wellness and Nutrition Society (www.ocularnutritionsociety.org). Good place to start...... Hope that helps.

5:00 – 6:00 pm Sarah Kochik, OD, PhD, What intervention would you This is a great question and there is not FAAO* recommend for someone of low a great answer. Myopia tends to be a Lily and the Big Blur: socioeconomic status disease that occurs more in patients of Selecting the Best Myopia higher SES. Atropine is the least Control Therapy expensive option if they need to pay for services/materials out-of-pocket (the pharmacy that we typically order from charges $45-55 for a 3-month supply, depending on the strength of the dose we prescribe). If MiSight lenses eventually become covered by insurance though, that may be another good option for patients that have coverage for CLs.

What is the youngest age you would The youngest patient that we have in consider starting each of these our clinic is 4 years old. I am ok therapies? are you okay with dispensing dispensing orthokeratology lenses to lenses to kids if they are dependent on kids if they are dependent on their their parents inserting and removing parents inserting and removing them them? (since they are only worn at home). I am not ok dispensing any daily wear lens to a child that cannot perform I/R on their own.

How is the projected progression The efficacy values that I stated in my deducted? presentation are average reductions from randomized controlled clinical trials.

If you over-minus does it lead to faster Evidence from animal models would progression too? suggest that this is the case, but I don’t know of any human clinical trials where participants were intentionally over-minused.

If fitted in ortho-k lens at what point There’s no hurry to discontinue would they stop wearing orhto k lens? treatment. A recent study reported that 50% of patients continue to experience myopia progression beyond age 20, so I would continue treatment as long as the patient is happy/comfortable with lens wear. The SOCCEP Q/A Friday, March 27

greatest number of dropouts that we see in our clinic is from college-age kids who no longer get the minimum number of hours of sleep required for good vision.

Are there any studies that focus on the It looks like there are! Here’s a link to effect of no correction ( v.s. under- one – there may be others. correction) on myopia progression?

You mention that Jeff is near the age There are actually no age restriction for limit for Ortho-K treatment. What is the ortho-k. He’s near the limit of myopia age range of typical patients treated for that is correctable with ortho-k (- Ortho-K 6.00DS).

Have you tried soft MF toric CL off Yes, we use them in our clinic. We label? Was is as effective as the other haven’t compared the efficacy to other MF soft CL ? Thx !! lenses in our patient population because we don’t have many patients in that design, but I can’t think of a biological reason why that wouldn’t work. It just hasn’t been evaluated yet to my knowledge.

Are there studies that compare the risk Yes, there is a nice review of the safety of CL associated infection like MK with of ortho-k lenses linked here. ortho-k's vs EW lenses?

If a patient started ortho K when young Yes! Even if he reported to me at age ~6YO, but reports at the age of 18 that 7yo that he was uncomfortable with he has always felt uncomfortable with them, I would switch to something them. Would you switch him to regular else. Comfort is never something that I SCL or multifocal SCL? sacrifice in my practice.

For your ortho K patients, how often do We follow them every 3-4 months you follow-up with your patients and since most of our patients are between how often do you replace the lenses? the age of 6-14. We generally recommend annual replacement, but it depends on the condition of their lenses. wouldn't the fact that Jeff is about to It’s possible. In my experience, patients start driving make it difficult for him to respond very differently to different wear mutlifocal lens, wouldn't the designs of multifocal lenses. So, if we multifocal lens cause blur while driving? tried MiSight, for example, and his vision was poor with those, I might try a NaturalVue next to see if he experiences better vision with those, then AV Oasys multifocals or Biofinity.

Is slowing of the rate of progression The risk of developing myopia controlled for genetics? I am curious if definitely increases with the number of SOCCEP Q/A Friday, March 27

these treatments are considered myopic parents. However, it is very equally effective if say both parents are difficult to know how much the rate of high myopes. Thank you. myopia progression is influenced by genetics. However, there are many studies that show that these treatments are effective regardless of parental myopia status.

At what age range do you think about I start myopia control for all myopic starting myopia control? Or do you only patients, unless they have non- consider the rate of myopia progressive myopia (e.g. ROP, stickler’s progression? syndrome, etc.)

How do you monitor myopia We measure axial length and refractive progression after treatment starts & error annually (or sooner if indicated when do you stop treatment? by a change). We discontinue treatment when there is no evidence of additional progression AND the patient is no longer a child (usually early 20’s preferred). However, most of our ortho-k wearers continue to wear their lenses long after we deem it “safe” to discontinue.

Would you consider spectacle lenses Yes! When we have an available option controling myopia like myopilux, or in the US, I would absolutely consider other those, especially for young children who are not ortho-k candidates. However, you always want to consider the added benefit of contact lens wear in general for kids, like the findings of the ACHIEVE study.

Can we get a last view of the table at the end to take notes? pros and cons Yes! All of the slides should be one please! available to you!

Thank you for your wonderful and This is a great question and an area of insightful presentation. I really enjoyed active debate. Right now, we don’t the way you presented the material. have a great method of predicting who will be myopic, although I am hopeful One question I have for you is regarding that we may in the near future. I begin the use of myopia control in a more myopia control for patients with a prophylactic sense. I guess what I’m prescription of -0.50DS (cycloplegic asking is, what’s the earliest age and refraction). amount of prescription that you would consider recommending myopia control?

SOCCEP Q/A Friday, March 27

6:00 – 7:00 pm Tawna Roberts, OD, PhD, What causes epiphora in congenital Corneal changes due to the increased FAAOP* glaucoma? IOP. Hush little baby don't you cry! When diagnosing NLD obstruction, is it Because babies don’t always hold still presumed based on signs and and the anatomical structures are symptoms or is there a way to safely do smaller than in adults, many OMDs D&I in an infant? prefer to the probing the OR. Some will do in office probings but I would not attempt to do this myself. It is not the same as doing on an adult. Also, depending on the state in which you practice, there are likely laws preventing doing a D&I on infants and children.

Hi what causes purulent discharge Associated bacterial infection

Any tips on how to assess a chief Pictures of the baby will help to assess complaint of epiphora if the infant gets corneal diameter. upset and cries during the exam? Hx of redness and discharge Unilateral or bilateral? Most babies don’t cry during examinations – have the parents feed the baby during the exam.

Recurring nasal duct obstruction… Do You see can see a bit of waxing and you see wax and waning nasal duct waning but it’s more of an issue of obstruction? Do you ever see a child get some days are worse than others as better with less epiphora and then get opposed to it going away completely worse? then coming back.

Did you use a Fl strip or fluress to test NaFl strip for NLDO?

What is the treatment for trichiasis for It depends on the severity and the month old babies? cause. If very mild, then ointment and lubrication to protect the cornea and to see if the lashes redirect. If more severe or associated with entropion, then a referral to oculoplastics. It may be as simple as ointment, sometimes a protective contact lens (which also comes with risk), and in more severe cases lid surgery.

Will you re-explain the balloon analogy Massage should be over the lacrimal for massage over the nasolacrimal duct? sac. It creates pressure on each side of Please and thank you! the sac – 1) redirecting tears back to the puncta (regurgitation) and 2) forcing the tears through the duct.

I meant for entropion not trichiasis See above. SOCCEP Q/A Friday, March 27

since they are too young for surgery.

For symptomatic entropions in infants, Absolutely. You want to protect the at what age would you refer out for cornea as much as you can, so you use surgery? Also, might you expect the ointment lubrication and artificial anatomy of the eyelids to change and tears. I like to get oculoplastics possibly “grow out of” the entropion involved early to counsel patients and with time? also to decide when they would want to operate. But as you indicated, the facial anatomy changes and many oculoplastic surgeons like to wait until kids are old to perform surgery. So you have to protect the cornea.

Any thoughts on prepared sprays for Personally, I used them as a resident younger children? occasionally but have never used them since them. There are a couple of studies that have looked at patient satisfaction and young kids (<7 years) seem to prefer the spray. The results are mixed on whether the spray provides adequate cycloplegia. I use drops.

How do you instill drops for patients The same as with other kids but I base with special needs? my strategy on their developmental age rather than the chronological age.

When we diagnose acute dacryosystitis Yes, it’s an urgent referral – they need in children, is it always an urgent have a probing done. Mild cases may referral to OMD or can we Rx a course only require probing and oral antibiotic of oral antibiotics and monitor before and more severe cases include referring? admitting to hospital with IV antibiotics.

Does the spray form of the drops help Good question. I don’t use the spray. to limit systemic absorption?