CAN TABLETS WORK FOR EMR? P. 12 • CODING TIPS FOR CROSS-LINKING P. 16 A FRESH ANGLE ON RESIDENT TRAINING P. 68 • SIXTH CRANIAL NERVE DYSFUNCTION IN KIDS P. 72 Review of Ophthalmology Vol. XXIV, No. 4 • April 2017 • Fighting for Patient Care • Avoiding Problems Using OCT • Managing Refractive Surprises Problems • Optical Biometry Roundup Care • Avoiding No. 4 • April 2017 • Fighting for Patient Review of Ophthalmology Vol. XXIV, STEM THE TIDE OF EXCESSIVE TEARING P. 76 • POST-INJECTION IOP SPIKES P. 96 April 2017 reviewofophthalmology.com Fixing Patients’ Problems Expert surgeons give you the tools you need to succeed. ALSO INSIDE: Sizing Up Optical Biometers P. 58 001_rp0417_fc-WB.indd 1 3/24/17 12:52 PM VISIT US AT ASCRS BOOTH #1022 It’s all in CHOOSE A SYSTEM THAT EMPOWERS YOUR EVERY MOVE. Technique is more than just the motions. 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WHITESTAR SIGNATURE is a trademark owned by or licensed to Abbott Laboratories, its subsidiaries or affiliates. © 2017 Abbott Medical Optics Inc. | www.Vision.Abbott | PP2017CT0187 RP0417_Abbott.indd 1 3/21/17 10:47 AM REVIEW NEWS Volume XXIV • No. 4 • April 2017 Excess Hydroxychloroquine Dosing All Too Common Hydroxychloroquine, the antimalarial long term impact of the 2016 revision3 of The researchers performed a ret- prescribed by rheumatologists to these guidelines. In 2011, the AAO rospective review of the medical manage autoimmune conditions such recommended that patients receive records of the NorthShore Univer- as lupus and rheumatoid arthritis, no more than 6.5 mg of HCQ per ki- sity Health System. They identifi ed is fi nding newer applications as an logram of ideal body weight daily; in 554 patients who’d been prescribed adjuvant to cancer chemotherapy 2016, that recommendation was re- HCQ at least once between 2009 and in diabetes mellitus and 2016, and who’d also management. Though been seen by a staff oph- its use is increasing, the thalmologist. association between Ninety-two patients long-term HCQ therapy had been started on and retinal toxicity is HCQ before the 2011 well-established. The PhD MD, Browning, J. David dosing guidelines; 462 American Academy started taking it after of Oph thalmology has them. The researchers tried to mitigate retinal found that 54.3 percent toxicity risk to patients, of patients who started many of whom rely HCQ before the 2011 on HCQ therapy to recommendations were prolong their lives and exceeding the 2011 dos- preserve function, by ing threshold of 6.5 mg/ issuing guidance on safe kg/day per ideal body dosing levels. However, weight, compared with a recent study1 suggests 49.4 percent who started that dosing guidance HCQ therapy after the published by the AAO 2011 guidance. When has had little impact on the researchers applied excess HCQ dosing. Paracentral scotomata (top left, red arrow) in a 10-2 visual fi eld test is the 2016 dosing guide- Lead author Re- a sign of toxic hydroxychloroquine dosing, as is an annulus of hyper- lines of up to 5 mg/kg/ bekah A. Braslow, MD, autofl uorescence (top right, green arrow) on blue fundus autofl uorescence day per actual weight imaging. Other signs to look for are paracentral loss of the ellipsoid line and of the Pritzker School using patient weights thinning of the outer nuclear layer (bottom, yellow arrow). of Medicine, Univer- obtained from patient sity of Chicago and records, they found that Division of Ophthalmology, North- vised to 5 mg/kg/day based on actual 56 percent of the 527 patients still Shore University Health System in measured body weight. Dr. Braslow on HCQ therapy were getting excess Illinois, and colleagues undertook and colleagues found, however, that doses. Many of the excess doses were the study to fi nd out what impact the many patients in the health-care sys- within 50 mg of the lower dosing American Academy of Ophthalmol- tem they studied continued to be threshold established in 2016; but 43 ogy’s 2011 HCQ dosing guidance2 prescribed HCQ at levels that may percent of the current HCQ patients has had on prescribing rheumatolo- pose an undue risk to their retinal (224 of 527) were getting doses more gists, and to help predict the long- health. than 50 mg/day above the recom- April 2017 | reviewofophthalmology.com | 3 003_rp0417_news.indd 3 3/23/17 4:53 PM ® E DITORIAL STAFF REVIEW News Editor in Chief mended dose—some up to 450 mg/ chael F. Marmor, MD, professor of Walter C. Bethke day more than the threshold amount. ophthalmology, Byers Eye Institute, (610) 492-1024 The prevalence of retinal toxicity Stanford University, “The biggest [email protected] arising from HCQ is not insubstan- problem is educating rheumatol- tial, with a 2014 study pegging it at ogy. I have published a few alerts in Senior Editor 7.5 percent overall in patients on rheumatology publications, but even Christopher Kent HCQ for a minimum of fi ve years, their subspecialty journals have not (814) 861-5559 spiking to nearly 20 percent after 20 embraced major editorial notice to [email protected] years of daily therapy.4 The retinal the discipline.” Dr. Marmor, who was damage and vision loss that accom- not involved in the current study on Senior Associate Editor panies HCQ toxicity is irreversible HCQ dosing patterns, is the lead au- Kristine Brennan and progresses for a period of time thor of the AAO’s 2011 HCQ dosing (610) 492-1008 after discontinuing the drug. This guidelines and the 2016 revision, and [email protected] complication leaves doctors and their lectures widely on the topic of retinal patients with no recourse other than toxicity. Associate Editor ophthalmologic monitoring of reti- He notes that rheumatology “is Liam Jordan nal toxicity once it develops, and the gradually coming around, teach- (610) 492-1025 dilemma of whether to discontinue ing these new recommendations to [email protected] HCQ to slow and eventually arrest trainees and educating the fi eld.” Dr. retinopathy and vision loss. Prior Marmor also thinks there is room for Chief Medical Editor to modern screening techniques, a improvement on this topic in oph- Mark H. Blecher, MD characteristic bull’s-eye pattern of thalmology, however, adding, “Oph- maculopathy was the fi rst defi nitive thalmologists often fail to follow Art Director sign of retinal toxicity, but it signifi es these guidelines, so our fi eld bears Jared Araujo later-stage damage to the RPE and some responsibility for educating it- (610) 492-1032 photoreceptors. With spectral-do- self.” [email protected] main optical coherence tomography, To step up HCQ dosing sur- multifocal electroretinography and veillance among all health-care Senior Graphic Designer fundus autofl uorescence imaging, providers, the authors recommend Matt Egger more subtle early abnormalities are system-wide education and EMR- (610) 492-1029 detectable. generated prompts and alerts to [email protected] Because the 2016 dosing threshold highlight potentially risky dosing. is based solely on a patient’s weight Dr. Marmor thinks that the idea of International coordinator, Japan instead of an ideal weight calcu- working warnings and dosing tem- Mitz Kaminuma lated using height, the authors note plates into EMR has merit, but it’s [email protected] that the likelihood of a “safe” dose not always feasible. “Alerts only work of HCQ increases correspondingly in systems that accept them. Some Business Offi ces with weight, and that weight-based EMR is too complex, and notices 11 Campus Boulevard, Suite 100 dosing reduces the disproportionate Newtown Square, PA 19073 risk of excess dosing to thin patients. Correction (610) 492-1000 The authors suggest that a “screening Fax: (610) 492-1039 referral” to an ophthalmologist isn’t From Bausch + Lomb: necessary when initiating therapy in In the March 2017 issue of Review of Subscription inquiries: Ophthalmology, a claim was presented patients, and that “the creative use of United States — (877) 529-1746 on the cover tip advertisement for the EMR to guide proper dosing” would Outside U.S. — (845) 267-3065 Trulign toric IOL that stated: “Only one be more helpful to non-ophthalmol- E-mail: lens brings astigmatism AND presby- ogists in determining a safe starting opia into focus.” In light of recent FDA [email protected] dose. approvals, justifi cation for this claim can Website: www.reviewofophthalmology.com The American College of Rheuma- no longer be maintained. Bausch + Lomb tologists released a position paper5 in Incorporated regrets this oversight and 2016 subsuming much of the AAO’s has revised its advertising to refl ect the latest guidance. According to Mi- current marketplace. 4 | Review of Ophthalmology | April 2017 0003_rp0417_news.indd03_rp0417_news.indd 4 33/23/17/23/17 44:59:59 PPMM are hard to get accepted in large aca- demic systems. Also remember that every drug has problems, and if 45 Seibel* Nucleus Choppers drug alerts pop up every time we see Complete Vertical & Horizontal Chopping, a patient, the effect will be to ignore Available In Stainless & Titanium them,” he warns.