REVIEW OF OPTOMETRY EARN 2 CE CREDITS: Positive Visual Phenomena—Etiologies Beyond the Eye, PAGE 58 ■ VOL. 155 NO. 1 January 15, 2018 www.reviewofoptometry.comwww.reviewofoptometry.com ■ ANNUAL CORNEA REPORT JANUARY 15, 2018 ■ CXL ■ EPITHELIAL DEFECTS How to Heal Persistent Epithelial Defects PAGE 38 ■ TRANSPLANTS Corneal Transplants: The OD’s Role PAGE 44 ■ INFILTRATES Diagnosing Corneal Infiltrative Disease PAGE 50 ■ POSITIVE VISUAL PHENOMENA CXL: Your Top 12 Questions —Answered! PAGE 30 001_ro0118_fc.indd 1 1/5/18 4:34 PM ĊčĞĉėĆęĊĉĆĒēĎĔęĎĈĒĊĒćėĆēĊċĔėĎēǦĔċċĎĈĊĕėĔĈĊĉĚėĊĘ ĊđĎĊċĎēĘĎČčę ċċĊĈęĎěĊ Ȉ 1 Ȉ 1 ĊđđǦęĔđĊėĆęĊĉ Ȉ Ȉ ĎĒĕđĊĎēǦĔċċĎĈĊĕėĔĈĊĉĚėĊ Ȉ Ȉ ĔēěĊēĎĊēę Ȉ͝ Ȉ Ȉ Ƭ 1 ǡ ǡǡǤ͚͙͘͜Ǥ Ȁ Ǥ ͚͙͘͜ǣ͘͘ǣ͘͘͘Ǧ͘͘͘ ĕĕđĎĈĆęĎĔēĘ Ȉ Ȉ Ȉ Ȉ Ȉ čĊĚėĎĔē̾ėĔĈĊĘĘ Ȉ Ȉ Katena — Your completecomplete resource forfor amniotic membrane pprocedurerocedure pproducts:roducts: Single use speculums Single use spears ͙͘͘ǡ͘͘͘ήĊĞĊĘęėĊĆęĊĉ Forceps ® ,#"EWB3FW XXXLBUFOBDPNr RO0118_Katena.indd 1 1/2/18 10:34 AM News Review VOL. 155 NO. 1 ■ JANUARY 15, 2018 IN THE NEWS Accelerated CXL Shows The FDA recently approved Luxturna (voretigene neparvovec-rzyl, Spark Promise—and Caution Therapeutics), a directly administered gene therapy that targets biallelic This new technology is already advancing, but not without RPE65 mutation-associated retinal dystrophy. The therapy is designed to some bumps in the road. deliver a normal copy of the gene to By Rebecca Hepp, Managing Editor retinal cells to restore vision loss. While the approval provides hope for patients, wo new studies highlight the resulted in infection—while tradi- the $425,000 per eye price tag stands as pros and cons of accelerated tional C-CXL has a reported inci- a signifi cant hurdle. Tcorneal crosslinking (A- dence of 0.0017%.2 The researchers Scutti S. Gene therapy for rare retinal disorder to cost CXL). Researchers in Switzerland examined possible contributory fac- $425,000 per eye. CNN. www.cnn.com/2018/01/03/ health/luxturna-price-blindness-drug-bn/index.html. studied the outcomes of conven- tors in those seven cases and found Accessed January 4, 2018. tional (C-CXL) and accelerated young age, a pre-existing immuno- corneal crosslinking (A-CXL) in compromized state, poor hygiene A study 167 patients with suspected a pediatric population and found at the operation site and in post-op bacterial endophthalmitis after cataract A-CXL was equally effective after environments, long-term steroid surgery found intravitreal dexametha- one year.1 use and poor post-op education sone provided no improved visual “The potential advantages in- and management were all concerns. acuity. Patients were treated twice with clude reduced exposure time, better Although the study was limited to intravitreal injections of 0.2mg vanco- patient compliance and possibly one clinical site, it highlights the mycin and 0.05mg gentamicin, followed lower infection risk (more patient importance of patient education by either 400µg dexamethasone sodium and doctor friendly),” says S. Barry and careful post-op follow up with diphosphate or placebo. The four-week, Eiden, OD, president and medical this new procedure. 10-week, six-month and 12-month fol- director at North Suburban Vision These studies further highlight low ups showed no signifi cant difference Consultants, Ltd., and president not just the evolving nature of treat- in best-corrected visual acuity. and cofounder of the International ment, but “what we at the IKA call Manning S, Ugahary LC, Lindstedt EW, et al. A Keratoconus Academy (IKA). ‘the changing paradigm of kera- prospective multicentre randomized placebo-controlled superiority trial in patients with suspected bacterial en- The study included 78 eyes of toconus management,’” Dr. Eiden dophthalmitis after cataract surgery on the adjuvant use 58 pediatric patients with progres- says. With access to a treatment of intravitreal dexamethasone to intravitreal antibiotics. Acta Ophthalmol. December 7, 2017. [Epub]. sive keratoconus. Half of the eyes that can halt progression and pos- underwent C-CXL and half had A- sibly prevent vision loss, clinicians New research suggests a desktop CXL. One year post-procedure, the have a duty to diagnose patients humidifi er may help patients with researchers noted no difference in as early as possible and identify dry eye symptoms during continuous outcomes between the two groups, those at high risk of progression. computer use. Investigators measured including uncorrected visual acuity, Improved diagnostic technologies noninvasive tear break-up time (NTBUT) best-corrected visual acuity and would be welcome additions to the in patients who did and did not use a kmax values. The treatment failure evolving treatment options, such desktop humidifi er for an hour of com- rate was slightly lower for A-CXL, as A-CXL, for patients at risk for puter use and found improved NTBUT in at 15.4% compared with 23.1% of keratoconus, Dr. Eiden concludes. the humidifi er users compared with those the C-CXL group. 1. Baenninger PB, Bachmann LM, Wienecke L, et al. Pediatric without a humidifi er. However, a second study took corneal cross-linking: comparison of visual and topographic outcomes between conventional and accelerated treatment. Am Wang MT, Chan E, Ea L, et al. Randomized trial of a closer look at other A-CXL J Ophthalmol. 2017 Nov;183:11-16. desktop humidifi er for dry eye relief in computer users. outcomes such as infection rates 2. Maharana PK, Sahay P, Pranita, Sujeeth M, et al. Microbial Optom Vis Sci. 2017;94(11):1052-7. keratitis after accelerated corneal collagen cross-linking in and found 1.3% (seven of 532 eyes) keratoconus. Cornea. November 2, 2017. [Epub ahead of print]. REVIEW OF OPTOMETRY JANUARY 15, 2018 3 0003_ro0118_news(v2).indd03_ro0118_news(v2).indd 3 11/5/18/5/18 22:12:12 PPMM News Review Beware of ISNT Rule Exceptions, Study Says linicians who rely on the Photos: Jarett Mazzarella, OD ISNT rule when assessing Cthe optic nerve—for signs of early glaucoma, for example— should remember it doesn’t neces- sarily apply to all patients. While the rule states optic nerves typically show a larger rim width inferior, superior, nasal and then temporal, a new study highlights just how often patients deviate from this: within Optic nerves come in all shapes and sizes, making the ISNT rule tough to follow. Can this particular study population, you tell which are normal, anomalous but non-glaucomatous and glaucomatous? only 37.0% of rim assessments and 43.8% of retinal nerve fi ber layer most signifi cant causes of devia- for early signs of glaucoma, Dr. (RNFL) measurements follow the tion, with 10.9% of subjects having Mazzarella says the fi ndings serve rule, according to the researchers. a wider nasal rim than inferior, as a stark reminder of the impor- “As we know, there is a wide 29.4% with a wider nasal rim than tance of obtaining baseline readings, variance of normal nerve anatomy, superior, 14.7% with a narrower following for change over time and which makes diagnosing early glau- nasal rim than temporal and 42.9% “not getting stuck in the mindset of coma diffi cult in some patients,” having thinner nasal RNFLs com- always following traditional rules.” says Jarett Mazzarella, OD, who pared with the temporal quadrant. “Early disease is the confounding practices in the VA Health Care Sys- “We know glaucoma patients factor between identifying abnor- tem in Salisbury, NC. “Although a tend to lose neuroretinal rim on the mal structure vs. a normal variant. number of patients in the study did superior and inferior rims, and in For example, we see this often with not conform to the standard rule, this study, excluding the nasal rim our OCT technology when a patient in my opinion it does not invalidate to modify the rule to the IST or IS fl ags as abnormal on OCT RNFL the ISNT rule since the areas of made it apply to roughly 70%,” or ganglion cell compared with the rim we are concerned with in says Justin Cole, OD, of the VA the normative data values,” Dr. early glaucoma are the inferior or Health Care System in Salisbury, Mazzarella says. “Many of these superior rim.” NC. “So the rule still applies, but I patients never change or progress, Researchers looked at 110 nor- also think we have really been using which usually indicates a variant mal subjects and found a larger or it as the ‘IS’ rule all along.” of normal anatomy. It comes down smaller nasal sector was one of the For clinicians assessing patients to establishing a baseline for that individual patient and watching Hot Tea’s Impact on Glaucoma for any indication of structural or Tea drinkers have one more reason to brew another pot this functional progression over time, winter. A new study found drinking hot, caffeinated tea may especially for the normal nerve that be associated with a lower risk of glaucoma. Data from the does not look so ‘typical.’” 2005-2006 National Health and Nutrition Examination Survey “Each clinician must use their indicates hot tea-drinkers were 74% less likely to have own judgment in identifying normal glaucoma. The same was not true for coffee (caffeinated or from abnormal cup-to-disc ratios decaffeinated) decaffeinated tea, iced tea or soft drinks. and appearances, while also having While the survey had a small number of patients diagnosed with glaucoma and didn’t take the wherewithal to know that ana- into account other factors such as cup size, tea type or brewing time, the researchers speculate tomical differences are common,” the tea’s antioxidants and anti-infl ammatory and neuroprotective chemicals may play a role. concludes Dr. Cole. Poon LYC, Valle DSD, Turalba AV, et al. The ISNT rule: how often Wu CM, Wu AM, Tseng VL, et al. Frequency of a diagnosis of glaucoma in individuals who consume coffee, tea and/or soft does it apply to disc photographs and retinal nerve fi ber layer drinks.