ORIGINAL RELEASE: April 1, 2017

COPE COURSE ID:53202-GL

LAST REVIEW: March 17, 2017

COPE COURSE CATEGORY: GLAUCOMA

EXPIRATION: March 16, 2020

in GlaucomaChallenging CasesManaging

THE PRESSURE’S ON!

CE MONOGRAPH

Sponsored by

This continuing medical education activity is supported through

an unrestricted educational grant from Bausch & Lomb Incorporated.

Visit http://tinyurl.com/ThePressuresOnCOPE for online testing and instant CE certificate.

FACULTY

MURRAY FINGERET, OD

BEN GADDIE, OD

Administrator

Distributed with

2

LEARNING METHOD AND MEDIUMThis educational activity consists of a supplement and ten (10) study questions. The participant should, in order, read the learning objectives contained at the beginning of this supplement, read the supplement, answer all questions in the post test, and complete the Activity Evaluation/Credit Request form. To receive credit for this activity, please follow the instructions below in the section titled To Obtain CE Credit. This educational activity should take a maximum of 1 hour to complete.

CONTENT SOURCEThis continuing education (CE) activity captures content from a regional dinner meeting series.

ACTIVITY DESCRIPTIONDespite the variety of treatments available for glaucoma, some patients continue to have vision-threatening intraocular QSFTTVSF�*01�MFWFMT��/FX�ESVHT �OFX�mYFE�DPNCJOBUJPOT�of existing drugs, and new procedures constantly challenge the traditional treatment paradigm and are showing promise in lowering IOP and slowing disease progression by multiple mechanisms of action. The purpose of this activity is to update optometrists on the current state of the art and science for treating patients with glaucoma.

TARGET AUDIENCEThis educational activity is intended for optometrists.

LEARNING OBJECTIVESUpon completion of this activity, participants will be better able to:t�"TTFTT�USBEJUJPOBM�BOE�FNFSHJOH�SJTL�GBDUPST �TVDI�BT�PDVMBS��� QFSGVTJPO�QSFTTVSF�BOE�DFSFCSPTQJOBM�nVJE�QSFTTVSF �JO�UIF�� global risk assessment of glaucomat�%FTDSJCF�UIF�NFDIBOJTN�PG�BDUJPO�PG�DVSSFOU�BOE�FNFSHJOH�� topical glaucoma therapiest�&WBMVBUF�UIF�DMJOJDBM�SFMFWBODF�PG�TBGFUZ�BOE�FGmDBDZ�EBUB�GPS� emerging topical therapies for the treatment of glaucomat�%FWFMPQ�USFBUNFOU�QMBOT�UP�BDIJFWF�FWJEFODF�CBTFE�UBSHFU�� IOP in patients with glaucoma

ACCREDITATION STATEMENTThis course is COPE approved for 1 hour of CE credit for optometrists.

COPE Course ID 53202-GLCOPE Course Category: GlaucomaAdministrator:

DISCLOSURESMurray Fingeret, OD, IBE�B�mOBODJBM�BHSFFNFOU�PS�BGmMJBUJPO�during the past year with the following commercial interests in the form of Consultant/Advisory Board: Allergan; and Bausch & Lomb Incorporated.

Ben Gaddie, OD, IBE�B�mOBODJBM�BHSFFNFOU�PS�BGmMJBUJPO�EVSJOH�the past year with the following commercial interests in the form of Consultant/Advisory Board: Aerie Pharmaceuticals, Inc;

p

Alcon; Allergan; Bausch & Lomb Incorporated; Diopsys, Inc; Marco; Reichert, Inc; TearLab Corporation; TearScience; and Zeiss.

'DYLG�6��*UHHQÀHOG��0'��IBE�B�mOBODJBM�BHSFFNFOU�PS�BGmMJBUJPO�EVSJOH�UIF�QBTU�ZFBS�XJUI�UIF�GPMMPXJOH�DPNNFSDJBM�interests in the form of Consultant/Advisory Board: Aerie Pharmaceuticals, Inc; Alcon; Allergan; Bausch & Lomb Incorporated; and Quark.

EDITORIAL SUPPORT DISCLOSURES7RQ\�5HDOLQL��0'��03+��IBE�B�mOBODJBM�BHSFFNFOU�PS�BGmMJBUJPO�EVSJOH�UIF�QBTU�ZFBS�XJUI�UIF�GPMMPXJOH�DPNNFSDJBM�interests in the form of Consultant/Advisory Board: Alcon; Bausch & Lomb Incorporated; Inotek Pharmaceuticals Corporation; and Smith & Nephew; Contracted Research: Alcon; and F. Hoffmann-La Roche Ltd.

'LDQH�0F$UGOH��3K'��&\QWKLD�7RUQDOO\D\��5'��0%$��&+&3��.LPEHUO\�&RUELQ��&+&3��%DUEDUD�$XEHO��and 0LFKHOOH�2QJ�have no relevant commercial relationships to disclose.

DISCLOSURE ATTESTATIONThe contributing physicians listed above have attested to the following:�� UIBU�UIF�SFMBUJPOTIJQT�BGmMJBUJPOT�OPUFE�XJMM�OPU�CJBT�PS��� � PUIFSXJTF�JOnVFODF�UIFJS�JOWPMWFNFOU�JO�UIJT�BDUJWJUZ�2) that practice recommendations given relevant to the � � DPNQBOJFT�XJUI�XIPN�UIFZ�IBWF�SFMBUJPOTIJQT�BGmMJBUJPOT�� will be supported by the best available evidence or, absent evidence, will be consistent with generally accepted medical practice; and3) that all reasonable clinical alternatives will be discussed when making practice recommendations.

PRODUCT USAGE IN ACCORDANCE WITH LABELING1MFBTF�SFGFS�UP�UIF�PGmDJBM�QSFTDSJCJOH�JOGPSNBUJPO�GPS�FBDI�drug discussed in this activity for approved indications, contraindications, and warnings.

GRANTOR STATEMENTThis continuing education activity is supported through an unrestricted educational grant from Bausch & Lomb Incorporated.

TO OBTAIN CE CREDIT8F�PGGFS�JOTUBOU�DFSUJmDBUF�QSPDFTTJOH�BOE�TVQQPSU�(SFFO�$&��Please take this post test and evaluation online by going to http://tinyurl.com/ThePressuresOnCOPE. Upon passing, you XJMM�SFDFJWF�ZPVS�DFSUJmDBUF�JNNFEJBUFMZ��:PV�NVTU�BOTXFS���out of 10 questions correctly in order to pass, and may take the test up to 2 times. Upon registering and successfully DPNQMFUJOH�UIF�QPTU�UFTU �ZPVS�DFSUJmDBUF�XJMM�CF�NBEF�BWBJMBCMF�POMJOF�BOE�ZPV�DBO�QSJOU�JU�PS�mMF�JU��1MFBTF�NBLF�TVSF�you take the online post test and evaluation on a device that has printing capabilities. There are no fees for participating in and receiving CE credit for this activity. DISCLAIMERThe views and opinions expressed in this educational activity are those of the faculty and do not necessarily represent UIF�WJFXT�PG�5IF�4UBUF�6OJWFSTJUZ�PG�/FX�:PSL�$PMMFHF�PG�Optometry, MedEdicus LLC, Bausch & Lomb Incorporated, or Optometry Times.

5IJT�$&�BDUJWJUZ�JT�DPQZSJHIUFE�UP�.FE&EJDVT�--$�ª������All rights reserved.

3

in GlaucomaChallenging CasesManaging

THE PRESSURE’S ON! FACULTY

MURRAY FINGERET, ODClinical ProfessorState University of New York College of OptometryNew York, New York

BEN GADDIE, ODOwner and DirectorGaddie Eye CentersLouisville, Kentucky

IntroductionThe science of glaucoma evaluation and management is progressing. New drugs with novel mechanisms of action and promising phase 3 clinical data are poised for US Food and Drug Administration review in the near future. New risk factors to guide clinical decision-making are emerging. In this series of clinical cases, key decisions faced daily in the evaluation and management of patients with suspected or established HMBVDPNB�XJMM�CF�JEFOUJmFE�BOE�EJTDVTTFE�

&DVH����$VVHVVLQJ�WKH�1HHG�IRU�7UHDWPHQW�LQ�2FXODU�+\SHUWHQVLRQFrom the Files of Murray Fingeret, OD

A 36-year-old African American male presents for a comprehensive eye examination complaining of blurred vision. His last eye examination was 2 years ago. His medical and family histories are unremarkable.

On examination, his visual acuity is 20/20 OU, with a -1.00 D spherical correction in each eye. Anterior segment examination is unremarkable. Goldmann tonometry at 9 AM

is 28 mm Hg in the right eye and 29 mm Hg in the left eye. 1BDIZNFUSZ�SFWFBMT�DPSOFBM�UIJDLOFTT�PG�����BOE�����çN�in the right and left eye, respectively. The angles are open on gonioscopy. Figure 1 shows his optic nerves, optical DPIFSFODF�UPNPHSBQIZ�0$5�JNBHJOH �BOE�WJTVBM�mFMET�

4��:KDW�LV�JODXFRPD"(MBVDPNB�JT�B�EJGmDVMU�EJTFBTF�UP�EJBHOPTF �JO�QBSU�CFDBVTF�JU�JT�EJGmDVMU�UP�EFmOF��5IF������FEJUJPO�PG�UIF�"NFSJDBO�Academy of Ophthalmology’s (AAO’s) Preferred Practice 1BUUFSO�GPS�1SJNBSZ�0QFO�"OHMF�(MBVDPNB�10"(�EFmOFT�POAG as “a chronic, progressive optic neuropathy in adults in which there is a characteristic acquired atrophy of the optic nerve and loss of retinal ganglion cells and their axons. This condition is associated with an open anterior chamber angle by gonioscopy.”1

5IJT�EFmOJUJPO�JT�OPUFXPSUIZ�JO�TFWFSBM�XBZT��'JSTU �UIF�EJBHOPTJT�PG�HMBVDPNB�JT�CBTFE�TPMFMZ�PO�DMJOJDBM�mOEJOHT��UIFSF�JT�OP�MBCPSBUPSZ�UFTU�UP�HJWF�B�QPTJUJWF�PS�OFHBUJWF�DPOmSNBUJPO��This means that clinicians must have excellent clinical skills to detect glaucoma, and because it is typically asymptomatic until later stages, it must be looked for in every patient.

4��+RZ�GR�ZH�LGHQWLI\�JODXFRPD�LQ�FOLQLFDO�SUDFWLFH"What should be looked for? What clinical skill is the most important to detect glaucoma? The optic nerve head (ONH) FYBNJOBUJPO��5IF�QBUIPHOPNPOJD�DMJOJDBM�mOEJOH�JO�BMM�GPSNT�of glaucoma is glaucomatous optic neuropathy, a nebulous UFSN�UIBU�JT�QPPSMZ�EFmOFE�BOE�FBTJMZ�DPOGVTFE�XJUI�OPSNBM�anatomic variants of optic nerve appearance. The preceding EFmOJUJPO�JT�PG�MJUUMF�IFMQ�UP�DMJOJDJBOT �IFEging on precisely

Figure 1. Clinical data from the patient presented in Case 1. (A) Color optic nerve QIPUPHSBQIT��#�0QUJDBM�DPIFSFODF�UPNPHSBQIZ�SFTVMUT��$�7JTVBM�mFME�SFTVMUT�

Images courtesy of Murray Fingeret, OD

C

A

B

4

what they should be looking for. Describing glaucoma nerve damage as “characteristic acquired atrophy of the optic nerve”1 is only helpful if clinicians already know what they are looking for and assumes that they will know it when they see it.

4��:KDW�GRHV�D�JODXFRPDWRXV�RSWLF�QHUYH�KHDG�ORRN�OLNH"5IF�DMBTTJD�mOEJOH�JO�HMBVDPNBUPVT�PQUJD�OFVSPQBUIZ�JT�cupping of the ONH. Every ONH has 2 main components: the neuroretinal rim, which is made up of axons from retinal ganglion cells coursing through the scleral canal to form the optic nerve, and the physiologic cup, the leftover space not occupied by the neuroretinal rim. In glaucoma, the axons are lost, the rim becomes thinner, and the cup becomes enlarged over time.

On initial examination, however, whether a given cup is healthy and stable or has enlarged over time because of progressive rim loss cannot be known. Larger cups—above 0.5 or so—are more suggestive of glaucoma damage, but healthy eyes can have normal physiologic cups as large as 0.9. So how can a large cup be determined as glaucomatous or healthy?

One clue is disc size. The size of the ONH is determined by the size of the scleral canal (which is quite variable among eyes), whereas the amount of neuroretinal rim is determined by the number of retinal ganglion cells in the eye (which is fairly consistent among eyes). If the same number of axons pass through a large hole and a small hole, there will be more leftover space in the former and less in the latter. Therefore, larger-diameter ONHs tend to have larger physiologic cups, and smaller-diameter ONHs tend to have smaller physiologic cups. A moderate or large cup in a small ONH is potentially worrisome when evaluating for glaucoma. Physiologic cups tend to be round in shape, with an intact neuroretinal rim 360° around the cup. Also, in a healthy physiologic ONH, the ISNT rule often applies: the neuroretinal rim is thickest Inferiorly, UIFO�4VQFSJPSMZ �UIFO�/BTBMMZ �BOE�mOBMMZ�5FNQPSBMMZ��*G�UIJT�ISNT the case, then the ONH likely ISNT healthy.2

*O�BEEJUJPO�UP�DVQQJOH �UIFSF�BSF�PUIFS�0/)�mOEJOHT�UIBU�suggest the diagnosis of glaucoma. One is focal rim notching. Often, in glaucoma, cupping is not concentric. The superior and inferior poles of the ONH have more axons bunched up than the nasal and temporal sectors of the ONH. These crowded regions tend to get preferentially damaged by glaucoma. As a result, the optic cup appears focally thinned in these regions. Damage to the superior or inferior neuroretinal rim typically appears as a focal notch in the rim. If both the superior and inferior rims are thinned, the cup appears vertically elongated.

Focal notching of the neuroretinal rim frequently produces BOPUIFS�DMBTTJD�HMBVDPNB�TJHO��UIF�OFSWF�mCFS�MBZFS�CVOEMF�defect. These wedge-shaped defects can often be seen radiating from the ONH’s notched sector(s). Clinically, they are best observed under red-free illumination. Other ONH mOEJOHT�TVHHFTUJWF�PG�HMBVDPNB�JODMVEF�EJTD�IFNPSSIBHFT�BOE�peripapillary atrophy of the retinal pigment epithelium (Figure 2).

4��:KDW�UROH�GRHV�RSWLF�QHUYH�KHDG�LPDJLQJ�SOD\�LQ�WKH�GLDJQRVLV�RI�JODXFRPD"Two forms of ONH imaging are of value in glaucoma: stereo disc photography and OCT imaging. Disc photographs capture the clinical appearance of the ONH at a moment in time—usually the baseline assessment at the time of diagnosis—to provide a basis for detecting change over time. Photographs may also provide better detection of

disc hemorrhages compared with the clinical examination.3 OCT imaging is best used to assess the status of the retinal OFSWF�mCFS�MBZFS�3/'-��#PUI�EJGGVTF�BOE�GPDBM�3/'-�MPTT�can be detected by OCT. Further, OCT can be helpful in distinguishing between physiologic and glaucomatous ONH cupping; a fully intact RNFL in an eye with a large round cup is suggestive of physiologic cupping. Both photography and OCT can assist in detecting progression over time. Serial ONH photographs must be manually compared, whereas serial OCT images can be automatically compared to detect changes over time.

Neither form of ONH imaging can or should replace a thorough clinical examination of the optic nerve. Universal OCT screening for glaucoma is inappropriate and will result in high rates of false-positive tests (so-called “red disease”), which generate unnecessary anxiety for patients BOE�TJHOJmDBOU�DPTUT�UP�UIF�IFBMUI�DBSF�TZTUFN�GPS�GPMMPX�VQ�DPOmSNBUPSZ�UFTUT�UIBU�XJMM�VMUJNBUFMZ�SVMF�PVU�HMBVDPNB��0$5�imaging should be obtained only if the clinical examination suggests glaucoma.

4��:KDW�UROH�GRHV�SHULPHWU\�SOD\�LQ�WKH�GLDJQRVLV�RI�JODXFRPD"Glaucoma occurs in a continuum that begins with early axon loss that cannot be detected using current examination or testing techniques (Figure 3).4 Early glaucomatous ONH EBNBHF�JT�UZQJDBMMZ�JOTVGmDJFOU�UP�DBVTF�B�NFBTVSBCMF�WJTVBM�mFME�EFGFDU�VTJOH�TUBOEBSE�BDISPNBUJD�BVUPNBUFE�QFSJNFUSZ��"DDPSEJOHMZ �WJTVBM�mFME�MPTT�JT�OPU�OFDFTTBSZ�UP�NBLF�UIF�EJBHOPTJT�PG�HMBVDPNB��5IJT�JT�SFnFDUFE�JO�UIF�QSFDFEJOH�""0�EFmOJUJPO�PG�HMBVDPNB �XIJDI�NBLFT�OP�NFOUJPO�PG�WJTVBM�mFME�MPTT�BT�B�GFBUVSF�PG�UIF�EJTFBTF��1FSJNFUSZ�JT�VTFGVM�JO�EJBHOPTJOH�BOE�TUBHJOH�HMBVDPNB��&BSMZ�WJTVBM�mFME�EFGFDUT�generally appear with moderate ONH damage. The greater

Figure 2. Typical features of glaucomatous optic neuropathy. (A) Concentric enlargement of the cup resulting from diffuse axon loss. Note that this is easily confused with normal physiologic cupping. (B) Focal neuroretinal rim notching. (C) A nerve mCFS�MBZFS�CVOEMF�EFGFDU�BTTPDJBUFE�XJUI�a focal neuroretinal rim notch. (D) A disc hemorrhage. (E) Peripapillary atrophy of the retinal pigment epithelium.

Images courtesy of Murray Fingeret, OD

A B

C D

E

5

4��6KRXOG�WKLV�SDWLHQW�EH�WUHDWHG�RU�QRW"5IFSF�BSF�CFOFmUT�UP�USFBUJOH�UIJT�QBUJFOU��*G�UIF�QBUJFOU�IBT�early POAG, treatment will reduce the risk of progression.� If the patient has ocular hypertension, treatment will reduce the risk of developing POAG.8 There are also detriments to treating this patient. This patient may not have, and may never develop, POAG; thus, treatment may be unnecessary. All interventions to lower IOP, such as medications or laser or incisional surgery, have potential side effects, costs, and a negative effect on quality of life. Subjecting patients to risks XJUIPVU�CFOFmUT�TIPVME�CF�BWPJEFE�XIFOFWFS�QPTTJCMF�

With these considerations in mind, how can patients most MJLFMZ�UP�CFOFmU�GSPN�*01�MPXFSJOH�UIFSBQZ�CF�JEFOUJmFE �#Z�identifying those at highest risk of developing visual disability from glaucoma and treating those patients preferentially. Global risk assessment in glaucoma can help identify high-risk patients. This process involves comprehensive assessment of all known and suspected risk factors for glaucoma, then synthesizing the results into an overall risk impression. Some risk factors are well established, including age, IOP, central corneal thickness, and a family history of glaucoma.1,9,10 Others are less clear, such as myopia,11 diabetes,12 and abnormalities on specialty perimeters like frequency-doubling technology13 or short-wavelength automated perimetry.14 4UJMM�PUIFST�BSF�POMZ�OPX�FNFSHJOH �BOE�UIFSF�BSF�JOTVGmDJFOU�data to fully understand their effect on glaucoma risk. These include corneal hysteresis,15 ocular perfusion pressure (OPP),16 DFSFCSPTQJOBM�nVJE�QSFTTVSF �� and obstructive sleep apnea.18

Several of these risk factors have been incorporated into a validated risk calculator developed from data collected in a pair of major clinical trials: the Ocular Hypertension Treatment Study9 and the European Glaucoma Prevention Study.19 The calculator considers the most well-established risk factors, weighs them accordingly, and generates the probability of QSPHSFTTJOH�UP�10"(�XJUI�SFQSPEVDJCMF�WJTVBM�mFME�MPTT�XJUIJO�5 years.20 This tool is available without charge online at http://ohts.wustl.edu/risk/calculator.html. Expert consensus supports the following treatment guidelines based on risk level: if the risk is below 5%, observation is prudent; for a risk between 5% and 15%, the decision to treat or observe should follow an informed discussion with the patient; and for a risk in excess of 15%, treatment should be encouraged.4

Applying the risk calculator to the patient in Case 1 reveals an 18.5% probability that the patient will develop POAG within the next 5 years �7DEOH���� On this basis, treatment was recommended and the patient agreed.

UIF�mFME�MPTT �UIF�NPSF�BEWBODFE�UIF�HMBVDPNB��1FSJNFUSZ�is also useful in detecting progression of glaucoma over UJNF��4JNQMF�NBOVBM�SFWJFX�PG�TFSJBM�mFMET�PWFS�UJNF�XJMM�PGUFO�demonstrate progression. Modern perimeters also feature advanced progression analysis software that can identify subtle changes over time and assist in differentiating between HMBVDPNBUPVT�QSPHSFTTJPO�BOE�mFME�MPTT�BUUSJCVUBCMF�UP�PUIFS�causes, such as cataract progression.

As with ONH imaging, using perimetry to screen for glaucoma is inappropriate and ineffective. Perimetry is a subjective test and prone to false-positive results based on patient performance FSSPST �FTQFDJBMMZ�PO�mSTU�BUUFNQUT��1FSJNFUSZ�TIPVME�CF�PCUBJOFE�only if the clinical evaluation suggests its value.

4��:KDW�UROH�GRHV�LQWUDRFXODU�SUHVVXUH�SOD\�LQ�WKH�GLDJQRVLV�RI�JODXFRPD"5IF�""0�EFmOJUJPO�PG�HMBVDPNB�OPUFE�QSFWJPVTMZ�NBLFT�no mention of intraocular pressure (IOP) as a feature of the disease. Many patients with POAG do not have elevated IOP,5 and others may have elevated IOP only part of the time. Therefore, a normal IOP in no way rules out the presence of glaucoma. Conversely, the presence of elevated IOP does OPU�NFBO�UIBU�UIF�QBUJFOU�IBT�HMBVDPNB��6Q�UP����PG�IFBMUIZ�adults have IOP greater than 21 mm Hg and no glaucoma.5 However, population studies have demonstrated that the likelihood of glaucoma does increase with increasing IOP.5,6

The relevance of IOP to glaucoma is that IOP reduction is the only established method of reducing the risk of glaucoma progression over time. Regardless of the absolute level of IOP at the time of diagnosis, therapy should be instituted to achieve adequate IOP reduction to slow or halt the rate of progression over time.

4��'RHV�WKLV�SDWLHQW�KDYH�JODXFRPD"The patient described in Case 1 has elevated IOP, healthy-appearing optic nerves, normal OCT imaging of the RNFL, BOE�BO�BCOPSNBM�WJTVBM�mFME�JO�UIF�SJHIU�FZF��)PXFWFS �UIJT�XBT�UIF�QBUJFOU�T�mSTU�WJTVBM�mFME �BOE�UIFSF�JT�B�MFBSOJOH�DVSWF�GPS�DPSSFDUMZ�QFSGPSNJOH�QFSJNFUSZ��8IFO�UIF�WJTVBM�mFME�XBT�repeated, the results were normal in both eyes.

In this case, the differential diagnosis includes both ocular IZQFSUFOTJPO�BOE�FBSMZ�10"( �XJUI�JOTVGmDJFOU�EBNBHF�GPS�detection using standard methods (examination, perimetry, and OCT). At present, there is no easy way to differentiate between these 2 entities other than longitudinal follow-up; POAG will progress over time,� whereas ocular hypertension will not.8

Figure 3. Glaucoma continuum covering the spectrum from early, undetectable disease to advanced disease with visual dysfunction4

"CCSFWJBUJPO��7' �WJTVBM�mFME��

Reprinted from American Journal of Ophthalmology, 138, Weinreb RN, Friedman DS, Fechtner RD, et al, Risk assessment in the management of patients with PDVMBS�IZQFSUFOTJPO �������� �$PQZSJHIU����� �XJUI�QFSNJTTJPO�GSPN�&MTFWJFS�

UN

DET

ECTA

BLE

DISE

ASE

ASYMPTOMATIC DISEASE

FUNCTIONAL IMPA

IRM

EN

T

FACTORS

Age 36RIGHT EYE

MEASUREMENTSLEFT EYE

MEASUREMENTS

1st 2nd 3rd 1st 2nd 3rd

Untreated Intraocular Pressure(mm Hg)

28 27 28 29 30 28

Central Corneal Thickness�ѥP�

520 522 516 510 505 505

Vertical Cup to Disc Ratio by Contour 0.45 0.45

Pattern Standard DeviationHumphrey Octopus loss variance

(dB) (dB)

1.7 1.6 1.4 1.4

This risk assessment tool is available for use free of charge at http://ohts.wustl.edu/risk/calculator.html.

Reprinted with permission.

7KH�SDWLHQW·V�HVWLPDWHG���\HDU�ULVN�����of developing glaucoma in at least 1 eye

�����

7DEOH����Global Risk Assessment of the Patient Presented in Case 1

6

&DVH����,QLWLDO�7KHUDS\�IRU�1HZO\�'LDJQRVHG�3ULPDU\�2SHQ�$QJOH�*ODXFRPDFrom the Files of Murray Fingeret, OD

A 68-year-old Hispanic male with diabetes mellitus presents for an eye examination to screen for diabetic eye disease. He has no personal history of any eye problems. His family history includes a brother with open-angle glaucoma. His medical history is TJHOJmDBOU�GPS�UZQF���EJBCFUFT�NFMMJUVT�EJBHOPTFE����ZFBST�BHP �which is well controlled with oral metformin; his recent HbA1c was 5.8%. He also has hyperlipidemia, which is controlled with simvastatin, and systemic hypertension, which is controlled with atenolol and hydrochlorothiazide.

On examination, his visual acuity is 20/20 in each eye, with a small IZQFSPQJD�DPSSFDUJPO��*OUSBPDVMBS�QSFTTVSF�JT����BOE����NN�)H in the right and left eye, respectively, measured at 9 AM with (PMENBOO�UPOPNFUSZ��$FOUSBM�DPSOFBM�UIJDLOFTT�JT�����BOE�����çN in the right and left eye, respectively. Gonioscopy revealed angles open to the ciliary body band in both eyes. Figure 4 TIPXT�IJT�PQUJD�OFSWFT �3/'- �0$5 �BOE�WJTVBM�mFMET�

4��:KDW�LV�WKH�GLDJQRVLV"Careful inspection of the optic nerve photographs (Figure 4A) reveals thinning of the inferior neuroretinal rim in the right eye, with an associated RNFL bundle defect. A similar inferior RNFL bundle defect can be seen in the left eye. OCT imaging of the 3/'-�DPOmSNT�UIJOOJOH�JOGFSPUFNQPSBMMZ�JO�CPUI�FZFT (Figure 4B). 5IF�WJTVBM�mFME�JO�UIF�SJHIU�FZF�IBT�B�DPSSFTQPOEJOH�TVQFSJPS�BSDVBUF�EFGFDU �XIFSFBT�UIF�MFGU�WJTVBM�mFME�SFNBJOT�FTTFOUJBMMZ�full. Thus, this patient has functional loss in the right eye that correlates with the structural damage evident both clinically and on OCT imaging. In the left eye, however, there is no FWJEFOU�WJTVBM�mFME�MPTT�PO�TUBOEBSE�BVUPNBUFE�QFSJNFUSZ��0O�the basis of these observations, the patient has POAG.

Intraocular pressure values for this patient are within the normal SBOHF��)JTUPSJDBMMZ �UIF�DMBTTJD�mOEJOHT�PG�*01�JO�BO�FZF�XJUI�normal IOP would be considered normal-tension glaucoma (NTG). It is unclear, however, whether NTG is a distinct entity from POAG or simply a subset of POAG. Given that there is no QBUIPHOPNPOJD�mOEJOH�PUIFS�UIBO�*01�UIBU�EJTUJOHVJTIFT�/5(�from POAG, it is likely that they are the same disease and that POAG exists across the full spectrum of IOP.

This patient has been examined only once. Intraocular pressure is a dynamic biologic parameter and exhibits TJHOJmDBOU�WBSJBUJPO�UISPVHIPVU�UIF�EBZ�BOE�GSPN�EBZ�UP�EBZ�JO�both healthy and glaucomatous eyes.21,22 Unless the clinical setting necessitates urgent IOP reduction, there is value in delaying the initiation of therapy to more fully characterize IOP through multiple assessments. After initiating therapy, multiple on-therapy measurements may be necessary to fully characterize the therapeutic response to treatment.23

The patient was asked to return in 2 weeks for a repeat IOP assessment before starting therapy. At that visit, IOP was ���NN�)H�06�BU���PM. The diagnosis of POAG with normal IOP was made. A target IOP of 13 mm Hg (25% reduction) was established.

4��:KDW�LV�WKH�EHVW�ÀUVW�OLQH�WKHUDS\�IRU�WKLV�SDWLHQW"The choice of therapy should consider treatment goals. The AAO Preferred Practice Pattern for POAG recommends an initial 25% IOP reduction for patients with early-to-moderate POAG, citing numerous lines of evidence that this degree of IOP lowering can slow the progression of disease.1 Other considerations when selecting therapy include safety, tolerability, convenience of dosing, and cost.

Prostaglandin analogues optimally provide the desired GFBUVSFT�PG�B�mSTU�MJOF�JOUFSWFOUJPO��5PQJDBM�CFUB�CMPDLFST�represent an alternative medical option. Of note, topical CFUB�CMPDLFST�IBWF�SFEVDFE�FGmDBDZ�JO�TVCKFDUT�PO�TZTUFNJD�beta-blockers (such as this patient), presumably because of a partial therapeutic effect from systemic administration.24 Selective laser trabeculoplasty (SLT) is an effective and safe alternative to daily medical therapy25 that minimizes issues related to side effects, daily dosing, and cost. In a retrospective analysis, SLT was shown to effectively reduce IOP and eliminate medication use in patients with ocular hypertension.26 Surgical interventions are very effective for

Figure 4. Clinical data from the patient presented in Case 2. (A) Right and left PQUJD�OFSWF�QIPUPHSBQIT��HSFFO�BSSPXT�JOEJDBUF�SFUJOBM�OFSWF�mCFS�MBZFS�CVOEMF�EFGFDUT��#�0QUJDBM�DPIFSFODF�UPNPHSBQIZ�JNBHFT�PG�UIF�SFUJOBM�OFSWF�mCFS�MBZFS��$�7JTVBM�mFMET�

Images courtesy of Murray Fingeret, OD

A

B

C

SS 24-2 SS 24-2

7

instillation. Conjunctival or ocular hyperemia rates were similar CFUXFFO�-#/����BOE�MBUBOPQSPTU�������"�QBJS�PG�QIBTF���trials—APOLLO and LUNAR—compared the IOP reduction of LBN, 0.024%, with that of timolol, 0.5%, twice daily. In the APOLLO trial, LBN was superior to timolol, providing a TJHOJmDBOUMZ�MPXFS�*01�BU�BMM���UJNF�QPJOUT���AM, 12 PM, and 4 PM at weeks 2, 6, and 12).33 In the LUNAR trial, LBN was found to CF�OPOJOGFSJPS�UP�UJNPMPM �MPXFSJOH�*01�TJHOJmDBOUMZ�NPSF�UIBO�did timolol at 8 of the 9 time points.34 Across the 2 studies, NFBO�*01�SFEVDUJPO�SBOHFE�GSPN�����UP�����NN�)H with LBN and from 6.6 to 8.0 mm Hg with timolol. In a more recent study in Japanese subjects, LBN was shown to lower IOP by an average of 22% in eyes with low baseline IOP (mean, 19.6 ± 2.9 mm Hg before treatment).35 In an open-label extension study, LBN lowered IOP by 32% to 34%, and the mean diurnal decrease in IOP was 6.3% to 8.3% (Figure 5).36 LBN has also been shown to effectively lower IOP throughout the full 24-hour period, including at night.�� Other NO-donating molecules are in earlier stages of development, including formulations of bimatoprost38 as well as dorzolamide and brinzolamide.39

Another product in late-stage development is netarsudil mesylate, a drug that inhibits both rho-kinase and norepinephrine transporter. Inhibition of the enzyme SIP�LJOBTF�SFTVMUT�JO�CPUI�JODSFBTFE�USBCFDVMBS�PVUnPX�and reduced episcleral venous pressure.40 Inhibition of norepinephrine transporter increases adrenergic activity, which in turn reduces the rate of aqueous production. All 3 of these actions contribute to IOP reduction. Phase 3 studies of netarsudil mesylate have produced mixed results and remain unpublished to date.41 Netarsudil is currently undergoing FWBMVBUJPO�BT�B�mYFE�DPNCJOBUJPO�XJUI�MBUBOPQSPTU�42 In a QIBTF��C�TUVEZ �UIF�DPNCJOBUJPO�TJHOJmDBOUMZ�MPXFSFE�*01�compared with latanoprost or netarsudil alone (P < .0001). Hyperemia, reported as mild in severity, occurred in 40% of patients treated with netarsudil alone or in combination with latanoprost �7DEOH�����

Also in phase 3 evaluation is trabodenoson, an adenosine SFDFQUPS�BHPOJTU�XJUI�IJHI�BGmOJUZ�BOE�TQFDJmDJUZ�GPS�UIF�adenosine A1 receptor. When activated, the A1 receptor lowers IOP in nonhuman primates, in part by regulating the composition of the extracellular matrix of the trabecular meshwork, resulting in increasFE�BRVFPVT�PVUnPX�43,44

achieving low IO1 �CVU�IBWF�B�MFTT�GBWPSBCMF�TBGFUZ�QSPmMF�BOE�BSF�OPU�UZQJDBMMZ�DPOTJEFSFE�GPS�mSTU�MJOF�UIFSBQZ�JO�FBSMZ�PS�moderate glaucoma.

In the current case, generic latanoprost was prescribed for dosing at bedtime OU. One month later, the patient returned with an IOP of 15 mm Hg OU. Intraocular pressure was rechecked 2 weeks later and was 16 mm Hg OU. The patient has suboptimally responded to prostaglandin analogue therapy.

4��:KDW�LV�WKH�QH[W�EHVW�WKHUDSHXWLF�VWHS"Should an additional medication be added to achieve a target IOP of 13 mm Hg? The decision to switch or add should be NBEF�PO�UIF�CBTJT�PG�FGmDBDZ�BOE�TBGFUZ��*G�UIF�UIFSBQZ�XBT�ineffective or poorly tolerated, it should be discontinued and alternative therapy should be implemented. If therapy was well tolerated and provided IOP reduction consistent with its known FGmDBDZ�QSPmMF �JU�TIPVME�CF�DPOUJOVFE�BOE�BEKVODUJWF�UIFSBQZ�should be added.

For patients who cannot tolerate or do not respond to a prostaglandin analogue, alternative therapies must be considered. Prostaglandin analogues have set the bar high BT�UIF�HPME�TUBOEBSE�mSTU�MJOF�UIFSBQZ�GPS�HMBVDPNB �PGGFSJOH�VOSJWBMFE�FGmDBDZ�BOE�TBGFUZ�XJUI�DPOWFOJFOU�PODF�EBJMZ�dosing. Topical beta-blockers can also be dosed once daily and can produce IOP reductions comparable to those of prostaglandin analogues,�� but with more contraindications, including bradycardia, heart block, and pulmonary disease.28

Also, as discussed previously, beta-blockers provide reduced FGmDBDZ�JO�QBUJFOUT�VTJOH�TZTUFNJD�CFUB�CMPDLFST 24 such as this patient. SLT is also a reasonable option. Numerous studies have demonstrated that SLT provides IOP reduction comparable to that seen with prostaglandin analogue therapy.25,29 SLT has the added advantage of eliminating the need for daily adherence with medical therapy and has been shown to be more cost-effective than medications in a model of glaucoma.30

4��:KDW�QRYHO�GUXJV�DUH�LQ�WKH�GHYHORSPHQW�SLSHOLQH"5IJT�DBTF�EFNPOTUSBUFT�B�TJHOJmDBOU�VONFU�OFFE�GPS�NFEJDBM�UIFSBQJFT�UIBU�QSPWJEF�FRVJWBMFOU�PS�TVQFSJPS�FGmDBDZ �TBGFUZ �and dosing convenience compared with prostaglandin analogues for patients who have contraindications to, cannot UPMFSBUF �PS�FYIJCJU�TVCPQUJNBM�FGmDBDZ�XJUI�QSPTUBHMBOEJO�analogues. Several promising drugs are in late-stage development and are expected to garner approval for use in the United States in the near future.

Among these is latanoprostene bunod (LBN), a nitric oxide (NO)-donating form of the latanoprost molecule. Nitric oxide plays key roles in both health and disease throughout the body, including the eye. The molecule relaxes smooth muscle, thus promoting vasodilation. Disease states in which NO is a therapeutic target include angina pectoris, pulmonary hypertension, erectile dysfunction, and, more recently, glaucoma. In the trabecular meshwork, NO activates the cyclic guanosine monophosphate signaling pathway, resulting JO�USBCFDVMBS�SFMBYBUJPO�BOE�JODSFBTFE�USBCFDVMBS�PVUnPX�31 Coupled with latanoprost’s effect on increasing uveoscleral PVUnPX �-#/�XPVME�CF�FYQFDUFE�UP�QSPWJEF�HSFBUFS�*01�SFEVDUJPO�UIBO�MBUBOPQSPTU�BMPOF��*O�UIF�QIBTF���70:"(&3�trial comparing LBN in various doses with latanoprost in 413 subjects, LBN, 0.024%, once daily lowered IOP 1 to 1.5 mm Hg more than did latanoprost, 0.005%, once daily.32 The most common adverse event associated with LBN was pain upon

Figure 5. APOLLO/LUNAR open-label extension study.36 Follow-up times for APOLLO and LUNAR were 9 and 3 months, respectively.

$32//2�/81$5��/RQJ�WHUP�(IÀFDF\�DQG�6DIHW\�2SHQ�ODEHO�([WHQVLRQ�6WXG\

&RPELQHG�QXPEHU�RI�VXEMHFWV�����

&URVVRYHU�IURP�WLPRORO�WR�/%1�DOORZHG

���$GGLWLRQDO�decrease in mean diurnal IOP: 6.3%-8.3%

0HDQ�UHGXFWLRQ�LQ�,23�IRU�DOO�VXEMHFWV����������(P��������IURP�EDVHOLQH�

$GYHUVH�HYHQWV�ZHUH�SULPDULO\�PLOG�WR�PRGHUDWH��!�������

���&RQMXFWLYDO�K\SHUHPLD��������(\H�LUULWDWLRQ���������(\H�SDLQ������

,QWUDRFXODU�3UHVVXUH/DWDQRSURVW 1HWDUVXGLO������� )L[HG�&RPELQDWLRQ

1� �����WRWDO

Baseline, mm Hg 26.0 25.4 25.1

Final, mm Hg 18.4 19.1 16.5

Reduction, mm Hg 7.6 6.3 8.6

* P < .0001 compared with both latanoprost alone or netarsudil alone

7DEOH����1IBTF��C�4UVEZ�PG�'JYFE�$PNCJOBUJPO�/FUBSTVEJM�-BUBOPQSPTU��&GmDBDZ42

8

A topical ophthalmic formulation of trabodenoson is in clinical development for the reduction of elevated IOP in patients with ocular hypertension or POAG. In a dose-ranging phase 1/2 study, IOP reductions with the highest tested dose ranged from -4 to -7 mm Hg.45 In this study, the prevalence of conjunctival hyperemia did not increase from pretreatment baseline in any dose group. Phase 3 clinical development is under way.

Several novel delivery systems for existing glaucoma drugs are also in development. Among these are a punctal plug46 and an intraocular implant47 delivering travoprost, as well as an intraocular implant48 and a conjunctival ring49 delivering bimatoprost. Several of these products are in late-stage development, and the role of these products in current management practice patterns has yet to be established.

Case 3. Glaucoma Progression Despite Low Intraocular Pressure)URP�WKH�)LOHV�RI�'DYLG�6��*UHHQÀHOG��0'

A 70-year-old white female with a 20-year history of POAG presents for a scheduled follow-up visit. She has advanced 10"(�BOE�MPTU�mYBUJPO�JO�IFS�SJHIU�FZF����ZFBST�BHP��)FS�current treatment regimen includes latanoprost OU at bedtime and dorzolamide OU twice daily. She reports excellent adherence to therapy. Her medical history is remarkable for migraine headache, hyperlipidemia controlled with simvastatin, and hypertension controlled with atenolol.

0O�FYBNJOBUJPO �IFS�WJTVBM�BDVJUZ�JT�DPVOUJOH�mOHFST�JO�UIF�right eye and 20/40 in the left eye (due to moderate cataract). Her IOP is 13 mm Hg in the right eye and 14 mm Hg in the left eye. Of note, her pretreatment IOP level was 24 mm Hg in the right eye and 32 mm Hg in the left eye, and her IOP on therapy has never been above 15 mm Hg in the past 10 years. Her central corneal thickness in the right and left FZF�JT�����BOE�����çN �SFTQFDUJWFMZ��)FS�BOHMFT�BSF�PQFO�PO�gonioscopy. Figure 6 shows the left optic nerve photograph, 0$5 �BOE�WJTVBM�mFME�SFTVMUT�UIBU�EFNPOTUSBUF�QSPHSFTTJPO�

Q: Why is this patient progressing with intraocular pressure in the low teens?When confronted with any patient with glaucoma whose EJTFBTF�JT�QSPHSFTTJOH �UIF�mSTU�RVFTUJPO�JT�XIFUIFS�*01�IBT�CFFO�BEFRVBUFMZ�MPXFSFE�GSPN�VOUSFBUFE�CBTFMJOF��*O�UIJT�case, the patient’s left eye IOP has been consistently reduced from 32 to 14 mm Hg, a 56% reduction. This magnitude of IOP reduction would be expected to halt, or at least dramatically slow, glaucoma progression. This is not the case, so alternative explanations must be considered.

An important consideration is whether the patient is adherent to therapy. Some patients use their medications only in the EBZT�QSFDFEJOH�PGmDF�WJTJUT �XIJDI�QSFTFOUT�B�NJTMFBEJOH�BQQFBSBODF�PG�BEFRVBUF�*01�DPOUSPM�UP�UIF�QIZTJDJBO��5IF�reasons for this behavior are poorly understood and likely complex. Such patients are probably unlikely to admit to such behavior, and physicians are generally unable to identify the patients who are most likely to be nonadherent.50 This patient consistently reports excellent adherence to therapy, but such CFIBWJPS�JT�EJGmDVMU�UP�WFSJGZ�PCKFDUJWFMZ�

Central corneal thickness can contribute to artifact in the NFBTVSFNFOU�PG�*01�CZ�BQQMBOBUJPO�UPOPNFUSZ��4QFDJmDBMMZ �UIJO�DPSOFBT�XIJDI�UFOE�UP�CF�nBUUFS�BOE�MFTT�SJHJE�applanate with less force than thicker corneas and can lead to VOEFSFTUJNBUJPO�PG�USVF�*01��5IJT�QBUJFOU�T�DPSOFBT�BSF�RVJUF�

UIJO�MFTT�UIBO�����çN�XIJDI�JT�MJLFMZ�BTTPDJBUFE�XJUI�B�DMJOJDBMMZ�relevant underestimation of IOP. Although the ocular hypotensive SFTQPOTF�UP�UIFSBQZ�BQQFBST�UP�CF�BEFRVBUF �IFS�USVF�BCTPMVUF�

Figure 6. Clinical data from the patient presented in Case 3. (A) Color optic nerve photograph. (B) Optical coherence tomography data showing a decline JO�SFUJOBM�OFSWF�mCFS�MBZFS�UIJDLOFTT�PWFS�UJNF��$�7JTVBM�mFME�EBUB�TIPXJOH�QSPHSFTTJPO�PG�WJTVBM�mFME�MPTT�PWFS�UJNF�

*NBHFT�DPVSUFTZ�PG�%BWJE�4��(SFFOmFME �.%

C

A

B

9

IOP level may be considerably higher than the 14 mm Hg value measured with Goldmann tonometry, and a lower target IOP may be appropriate in light of her recent progression.

This patient’s IOP has consistently been 15 mm Hg or lower XIFO�NFBTVSFE�EVSJOH�SPVUJOF�PGmDF�IPVST �ZFU�*01�UFOET�UP�peak at night when lying down asleep. This is because IOP is higher in the supine position than in the sitting position and also because IOP tends to rise at night as part of its own circadian rhythm.51

4��+RZ�FDQ�LQWUDRFXODU�SUHVVXUH�EH�DVVHVVHG�RXWVLGH�RIÀFH�KRXUV"Routine clinical assessment of 24-hour IOP is impractical because of a lack of safe, affordable, and user-friendly home tonometry devices. Recently, the US Food and Drug "ENJOJTUSBUJPO�BQQSPWFE�UIF�5SJHHFSmTI�DPOUBDU�MFOToCBTFE�24-hour IOP monitor. This device is worn like a regular contact lens and contains a strain gauge that detects changes in corneal curvature that are attributable to changes in IOP. This information is transmitted wirelessly to a receiver worn around the periocular region and is stored on a small data drive connected to the receiver by a wire. The device can record and store up to 24 hours of continuous IOP data. The contact lens has been shown to be well tolerated through 24 hours,52 but data—reported in mV and not mm Hg—are limited to relative changes in IOP curve shape and not to absolute IOP values over time. Optimal use of this device, including both patient selection and data interpretation, has not been described to date.

4��&RXOG�WKH�SDWLHQW·V�V\VWHPLF�K\SHUWHQVLRQ�EH�UHODWHG�WR�KHU�JODXFRPD�SURJUHVVLRQ"Systemic blood pressure tends to dip at night.53 This can be QBSUJDVMBSMZ�TJHOJmDBOU�JO�QBUJFOUT�XIP�UBLF�CMPPE�QSFTTVSF�medications, especially those who dose their antihypertensive therapy in the evening before bed. The nocturnal concurrence of high IOP and low systemic blood pressure may result in a TJHOJmDBOU�SFEVDUJPO�JO�011��011�JT�UIF�EJGGFSFODF�CFUXFFO�systemic blood pressure and IOP and represents the relative pressure of blood perfusing the eye. Numerous epidemiologic studies have demonstrated a higher prevalence of POAG in subjects with low OPP vs normal or high OPP.54-58 A role for OPP in the development of POAG is biologically plausible because low OPP indicates reduced perfusion of ocular tissues, which may contribute to hypoxia/ischemia of optic nerve tissue. Importantly, IOP is typically highest at night when systemic blood pressure is typically lowest, resulting in low OPP.53

4��,V�DQ\�DGGLWLRQDO�ZRUN�XS�DSSURSULDWH�IRU�WKLV�SDWLHQW"This patient is progressing despite a 50% reduction in baseline IOP to the low teens. An additional diagnostic evaluation might be warranted. Ambulatory 24-hour blood pressure monitoring may reveal nocturnal dips. Nocturnal blood pressure dips might be mitigated by reducing the dose of systemic antihypertensive medication, using morning dosing rather than evening dosing, or having the patient ingest salty snacks (such as tomato juice or potato chips) before bed to raise blood pressure. There are no data from epidemiologic studies or trials to support salt loading in this TFUUJOH��-JLFXJTF ����IPVS�*01�NPOJUPSJOH�VTJOH�UIF�5SJHHFSmTI�TZTUFN�NBZ�SFWFBM�TJHOJmDBOU�*01�FMFWBUJPOT�JO�UIF�OJHIUUJNF�hours. Nocturnal IOP peaks may be reduced by sleeping with an extra pillow or 2 to elevate the head.59,60 Coupling 24-hour IOP and blood pressure monitoring can provide insight into circadian OPP and might reveal nocturnal dips in

OP1��011�JT�QPUFOUJBMMZ�NPEJmBCMF �NPTU�FBTJMZ�CZ�BEKVTUJOH�antihypertensive medications to avoid periods of hypotension.

A simpler approach to 24-hour blood pressure assessment JT�UP�PCUBJO�CMPPE�QSFTTVSF�NFBTVSFNFOUT�EVSJOH�PGmDF�based glaucoma visits. Routine daytime blood pressure measurements in all patients is expensive, cumbersome, and may be of limited value. Selecting patients at high risk for progression (eg, patients who report a history of low blood pressure or eyes with optic disc hemorrhage) may provide a snapshot and reveal systemic hypotension, which may CF�NPSF�QSPOPVODFE�BU�OJHIU��5IFTF�QBUJFOUT�NBZ�CFOFmU�most from adjustment of the dose or time of administration of antihypertensive therapy by the primary care physician.

An additional consideration is the possibility that her optic nerve damage is unrelated to her glaucoma. Central nervous system lesions can mimic glaucoma and should be considered when the clinical scenario is atypical for glaucoma progression, such as this case of progression at low IOP. Neuroimaging can help identify potential lesions and should be considered in patients with other signs suggestive of central nervous system involvement, including optic EJTD�QBMMPS�HSFBUFS�UIBO�DVQQJOH��WJTVBM�mFME�EFGFDUT�PVU�PG�proportion to cupping; bitemporal, homonymous, or vertically BMJHOFE�WJTVBM�mFME�EFGFDUT��FBSMZ�MPTT�PG�DFOUSBM�WJTVBM�BDVJUZ �early dyschromatopsia; or an afferent pupillary defect without asymmetric cupping.61

4��:KDW�LV�WKH�QH[W�WKHUDSHXWLF�VWHS�IRU�WKLV�SDWLHQW"This patient is progressing by both structural and functional criteria, despite having an IOP in the low teens on 2 glaucoma medications (prostaglandin analogue and carbonic anhydrase inhibitor). Alternative likely explanations for her progression have been ruled out, and inadequately controlled glaucoma is the likely explanation. Additional IOP lowering is necessary to halt disease progression. A reasonable goal would be an additional 15% to 20% reduction in IOP (approximately 10-11 mm Hg). One therapeutic approach is to add a third topical medication, such as a beta-blocker or adrenergic agonist, to achieve the target IOP and continue close surveillance.

Other options include proceeding directly with laser trabeculoplasty or incisional surgery. Selective laser trabeculoplasty can lower IOP in patients on multidrug regimens.62�)PXFWFS �JO�QBUJFOUT�XJUI�DPOmSNFE�QSPHSFTTJPO�who require a very low target IOP, traditional glaucoma surgery, such as trabeculectomy or tube-shunt implantation, may be the preferred approach.63 Because this patient BMTP�IBT�B�WJTVBMMZ�TJHOJmDBOU�DBUBSBDU�BOE�JT�GVODUJPOBMMZ�monocular, she may be a candidate for a combined cataract and glaucoma procedure. Lastly, a new generation of minimally invasive glaucoma surgery has emerged in recent years, and these procedures may be acceptable in eyes with coexisting cataract and mild-to-moderate open-angle glaucoma. It should be noted that cataract surgery alone often lowers IOP by several points in eyes with elevated IOP.64-66

SummaryGlaucoma evaluation and management are evolving. New risk factors enable better evaluation of the value of treatment in glaucoma suspects and better understanding of the complex pathophysiology of glaucoma. New treatments will soon come to market, offering novel ways to lower IOP. Each of these advances improves clinicians’ ability to ensure that their patients with glaucoma maintain their sight and preserve their quality of life.

10

1. American Academy of Ophthalmology. Preferred Practice Pattern®. Primary Open-Angle Glaucoma. San Francisco, CA: American Academy of Ophthalmology; 2015.2. Harizman N, Oliveira C, Chiang A, et al. The ISNT rule and differentiation of normal from glaucomatous eyes. Arch Ophthalmol.����������������������3. Budenz DL, Anderson DR, Feuer WJ, et al; Ocular Hypertension Treatment Study � (SPVQ��%FUFDUJPO�BOE�QSPHOPTUJD�TJHOJmDBODF�PG�PQUJD�EJTD�IFNPSSIBHFT�EVSJOH�UIF�� Ocular Hypertension Treatment Study. Ophthalmology.����������������������4. Weinreb RN, Friedman DS, Fechtner RD, et al. Risk assessment in the management of patients with ocular hypertension. Am J Ophthalmol.�������������������5. Sommer A, Tielsch JM, Katz J, et al. Relationship between intraocular pressure and primary open angle glaucoma among white and black Americans. The Baltimore Eye Survey. Arch Ophthalmol. 1991;109(8):1090-1095.��� -FTLF�.$ �8V�4: �)FOOJT�" �)POLBOFO�3 �/FNFTVSF�#��#&4T�4UVEZ�(SPVQ��3JTL�� factors for incident open-angle glaucoma: the Barbados Eye Studies. Ophthalmology. 2008;115(1):85-93.��� Heijl A, Leske MC, Bengtsson B, Hyman L, Bengtsson B, Hussein M; Early Manifest Glaucoma Trial Group. Reduction of intraocular pressure and glaucoma progression: results from the Early Manifest Glaucoma Trial. Arch Ophthalmol. ���������������������8. Kass MA, Heuer DK, Higginbotham EJ, et al. The Ocular Hypertension Treatment Study: a randomized trial determines that topical ocular hypotensive medication delays or prevents the onset of primary open-angle glaucoma. Arch Ophthalmol.�������������������9. Gordon MO, Beiser JA, Brandt JD, et al. The Ocular Hypertension Treatment Study: baseline factors that predict the onset of primary open-angle glaucoma. Arch Ophthalmol. ������������������10. Tielsch JM, Katz J, Sommer A, Quigley HA, Javitt JC. Family history and risk of primary open angle glaucoma. The Baltimore Eye Survey. Arch Ophthalmol.�����������������11. Loyo-Berrios NI, Blustein JN. Primary-open glaucoma and myopia: a narrative review. WMJ.���������������� ����12. Costa L, Cunha JP, Amado D, Pinto LA, Ferreira J. Diabetes mellitus as a risk factor in glaucoma’s physiopathology and surgical survival time: a literature review. J Curr Glaucoma Pract. 2015;9(3):81-85.13. Medeiros FA, Sample PA, Weinreb RN. Frequency doubling technology perimetry � BCOPSNBMJUJFT�BT�QSFEJDUPST�PG�HMBVDPNBUPVT�WJTVBM�mFME�MPTT��Am J Ophthalmol. ����������������������4QSZ�1( �+PIOTPO�$" �.BOTCFSHFS�4- �$JPGm�("��1TZDIPQIZTJDBM�JOWFTUJHBUJPO�PG�� ganglion cell loss in early glaucoma. J Glaucoma. 2005;14(1):11-19.15. Mansouri K, Leite MT, Weinreb RN, Tafreshi A, Zangwill LM, Medeiros FA. Association between corneal biomechanical properties and glaucoma severity. Am J Ophthalmol. ������������������F��16. Costa VP, Harris A, Anderson D, et al. Ocular perfusion pressure in glaucoma. Acta Ophthalmol. 2014;92(4):e252-e266.����#FSEBIM�+1 �"MMJOHIBN�33 �+PIOTPO�%)��$FSFCSPTQJOBM�nVJE�QSFTTVSF�JT�EFDSFBTFE�JO�� primary open-angle glaucoma. Ophthalmology.�������������������18. Coleman AL, Kodjebacheva G. Risk factors for glaucoma needing more attention. Open Ophthalmol J. 2009;3:38-42.19. Miglior S, Pfeiffer N, Torri V, Zeyen T, Cunha-Vaz J, Adamsons I; European Glaucoma Prevention Study (EGPS) Group. Predictive factors for open-angle glaucoma among patients with ocular hypertension in the European Glaucoma Prevention Study. Ophthalmology.���������������20. Gordon MO, Torri V, Miglior S, et al; Ocular Hypertension Treatment Study Group; European Glaucoma Prevention Study Group. Validated prediction model for the development of primary open-angle glaucoma in individuals with ocular hypertension. Ophthalmology.�����������������21. Realini T, Weinreb RN, Wisniewski S. Short-term repeatability of diurnal intraocular pressure patterns in glaucomatous individuals. Ophthalmology.�����������������22. Realini T, Weinreb RN, Wisniewski SR. Diurnal intraocular pressure patterns are not repeatable in the short term in healthy individuals. Ophthalmology. ��������������������23. Realini T. Assessing the effectiveness of intraocular pressure-lowering therapy. Ophthalmology.��������������������������4DIVNBO�+4��&GGFDUT�PG�TZTUFNJD�CFUB�CMPDLFS�UIFSBQZ�PO�UIF�FGmDBDZ�BOE�TBGFUZ�� of topical brimonidine and timolol. Brimonidine Study Groups 1 and 2. Ophthalmology. ��������������������25. Katz LJ, Steinmann WC, Kabir A, Molineaux J, Wizov SS, Marcellino G; SLT/Med Study Group. Selective laser trabeculoplasty versus medical therapy as initial treatment of glaucoma: a prospective, randomized trial. J Glaucoma.����������������������(BOEPMm�4" �6OHBSP�/��-PX�QPXFS�TFMFDUJWF�MBTFS�USBCFDVMPQMBTUZ�4-5�SFQFBUFE�ZFBSMZ�� as primary treatment in ocular hypertension: long term comparison with conventional SLT and ALT. Invest Ophthalmol Vis Sci. 2014;55(13):818.����8BUTPO�1 �4UKFSOTDIBOU[�+��"�TJY�NPOUI �SBOEPNJ[FE �EPVCMF�NBTLFE�TUVEZ�DPNQBSJOH�� latanoprost with timolol in open-angle glaucoma and ocular hypertension. The Latanoprost Study Group. Ophthalmology.�������������������28. Lama PJ. Systemic adverse effects of beta-adrenergic blockers: an evidence-based assessment. Am J Ophthalmol. ������������������29. McIlraith I, Strasfeld M, Colev G, Hutnik CM. Selective laser trabeculoplasty as initial and adjunctive treatment for open-angle glaucoma. J Glaucoma. 2006;15(2):124-130.30. Stein JD, Kim DD, Peck WW, Giannetti SM, Hutton DW. Cost-effectiveness of medications compared with laser trabeculoplasty in patients with newly diagnosed open-angle glaucoma. Arch Ophthalmol.�������������������31. Cavet ME, Vollmer TR, Harrington KL, VanDerMeid K, Richardson ME. Regulation of endothelin-1-induced trabecular meshwork cell contractility by latanoprostene bunod. Invest Ophthalmol Vis Sci. 2015;56(6):4108-4116.����8FJOSFC�3/ �0OH�5 �4DBTTFMMBUJ�4GPS[PMJOJ�# �7JUUJUPX�+- �4JOHI�, �,BVGNBO�1-��70:"(&3�� Study Group. A randomised, controlled comparison of latanoprostene bunod and latanoprost 0.005% in the treatment of ocular hypertension and open angle glaucoma: � UIF�70:"(&3�TUVEZ��Br J Ophthalmol.������������������33. Weinreb RN, Scassellati Sforzolini B, Vittitow J, Liebmann J. Latanoprostene bunod 0.024% versus timolol maleate 0.5% in subjects with open-angle glaucoma or ocular hypertension: the APOLLO Study. Ophthalmology. ������������������34. Medeiros FA, Martin KR, Peace J, Scassellati Sforzolini B, Vittitow JL, Weinreb RN. Comparison of latanoprostene bunod 0.024% and timolol maleate 0.5% in open-angle glaucoma or ocular hypertension: the LUNAR Study. Am J Ophthalmol. 2016;168:250-259.35. Kawase K, Vittitow JL, Weinreb RN, Araie M; JUPITER Study Group. Long-term safety � BOE�FGmDBDZ�PG�MBUBOPQSPTUFOF�CVOPE��������JO�+BQBOFTF�TVCKFDUT�XJUI�PQFO�BOHMF�� glaucoma or ocular hypertension: the JUPITER Study. Adv Ther.��������������������

36. Vittitow JL, Liebmann JM, Kaufman PL, Medeiros FA, Martin KR, Weinreb RN. Long-term � FGmDBDZ�BOE�TBGFUZ�PG�MBUBOPQSPTUFOF�CVOPE��������GPS�JOUSBPDVMBS�QSFTTVSF�MPXFSJOH�JO�� patients with open-angle glaucoma or ocular hypertension: APOLLO and LUNAR studies. Invest Ophthalmol Vis Sci.��������������������-JV�+) �4MJHIU�+3 �7JUUJUPX�+- �4DBTTFMMBUJ�4GPS[PMJOJ�# �8FJOSFC�3/��&GmDBDZ�PG�� latanoprostene bunod 0.024% compared with timolol 0.5% in lowering intraocular pressure over 24 hours. Am J Ophthalmol.������������������38. Impagnatiello F, Toris CB, Batugo M, et al. Intraocular pressure-lowering activity of NCX � ��� �B�OPWFM�OJUSJD�PYJEF�EPOBUJOH�CJNBUPQSPTU�JO�QSFDMJOJDBM�NPEFMT��Invest Ophthalmol Vis Sci. 2015;56(11):6558-6564.����)VBOH�2 �3VJ�&: �$PCCT�. �FU�BM��%FTJHO �TZOUIFTJT �BOE�FWBMVBUJPO�PG�/0�EPOPS�� containing carbonic anhydrase inhibitors to lower intraocular pressure. J Med Chem. 2015;58(6):2821-2833.40. Bacharach J, Dubiner HB, Levy B, Kopczynski CC, Novack GD; AR-13324-CS202 Study Group. Double-masked, randomized, dose-response study of AR-13324 versus latanoprost in patients with elevated intraocular pressure. Ophthalmology. 2015;122(2):� ��������41. Katz LJ, Weiss MJ, Heah T, Kopczynski C, Novack GD. Two phase 3 studies of the � FGmDBDZ�BOE�TBGFUZ�PG�"3�������PQIUIBMNJD�TPMVUJPO��������JO�QBUJFOUT�XJUI�PQFO�BOHMF�� glaucoma and ocular hypertension. Invest Ophthalmol Vis Sci.�����������42. Lewis RA, Levy B, Ramirez N, Kopczynski CC, Usner DW, Novack GD; PG324-CS201 Study Group. Fixed-dose combination of AR-13324 and latanoprost: a double-masked, 28-day, randomised, controlled study in patients with open-angle glaucoma or ocular hypertension. Br J Ophthalmol. 2016;100(3):339-344. 43. Shearer TW, Crosson CE. Adenosine A1 receptor modulation of MMP-2 secretion by trabecular meshwork cells. Invest Ophthalmol Vis Sci. 2002;43(9):3016-3020.����;IPOH�: �:BOH�; �)VBOH�8$ �-VP�9��"EFOPTJOF �BEFOPTJOF�SFDFQUPST�BOE�HMBVDPNB�� an updated overview. Biochim Biophys Acta. 2013;1830(4):2882-2890.45. Myers JS, Sall KN, DuBiner H, et al. A dose-escalation study to evaluate the safety, � UPMFSBCJMJUZ �QIBSNBDPLJOFUJDT �BOE�FGmDBDZ�PG���BOE���XFFLT�PG�UXJDF�EBJMZ�PDVMBS�� trabodenoson in adults with ocular hypertension or primary open-angle glaucoma. J Ocul Pharmacol Ther. 2016;32(8):555-562.����0DVMBS�5IFSBQFVUJY �*OD��1IBTF��C�TUVEZ�FWBMVBUJOH�TBGFUZ�BOE�FGmDBDZ�PG�059�51�� compared to timolol drops in the treatment of subjects with open angle glaucoma or ocular hypertension. ClinicalTrials.gov Web site. https://clinicaltrials.gov/ct2/show/ � /$5����������6QEBUFE�%FDFNCFS��� �������"DDFTTFE�.BSDI�� ����������(MBVLPT�$PSQPSBUJPO��4UVEZ�DPNQBSJOH�USBWPQSPTU�JOUSBPDVMBS�JNQMBOUT�UP�UJNPMPM�� ophthalmic solution. ClinicalTrials.gov Web site. https://clinicaltrials.gov/ct2/show/ � /$5����������6QEBUFE�"QSJM��� �������"DDFTTFE�%FDFNCFS�� ����������"MMFSHBO��&GmDBDZ�BOE�TBGFUZ�PG�CJNBUPQSPTU�TVTUBJOFE�SFMFBTF�43�JO�QBUJFOUT�XJUI�PQFO�� angle glaucoma or ocular hypertension. ClinicalTrials.gov Web site. https://clinicaltrials. � HPW�DU��TIPX�/$5����������6QEBUFE�+BOVBSZ��� �������"DDFTTFE�.BSDI�� ������49. Brandt JD, Sall K, DuBiner H, et al. Six-month intraocular pressure reduction with a topical bimatoprost ocular insert: results of a phase II randomized controlled study. Ophthalmology. 2016;123(8):1685-1694.50. Okeke CO, Quigley HA, Jampel HD, et al. Adherence with topical glaucoma medication monitored electronically the Travatan Dosing Aid Study. Ophthalmology. 2009;116(2): 191-199.51. Liu JH, Zhang X, Kripke DF, Weinreb RN. Twenty-four-hour intraocular pressure pattern associated with early glaucomatous changes. Invest Ophthalmol Vis Sci. 2003;44(4): 1586-1590.52. Mansouri K, Medeiros FA, Tafreshi A, Weinreb RN. Continuous 24-hour monitoring of intraocular pressure patterns with a contact lens sensor: safety, tolerability, and reproducibility in patients with glaucoma. Arch Ophthalmol. 2012;130(12):1534-1539.53. Costa VP, Jimenez-Roman J, Carrasco FG, Lupinacci A, Harris A. Twenty-four-hour ocular perfusion pressure in primary open-angle glaucoma. Br J Ophthalmol. 2010;94(10):1291-1294.����.FNBS[BEFI�' �:JOH�-BJ�. �$IVOH�+ �"[FO�41 �7BSNB�3��-PT�"OHFMFT�-BUJOP�&ZF�4UVEZ�� Group. Blood pressure, perfusion pressure, and open-angle glaucoma: the Los Angeles Latino Eye Study. Invest Ophthalmol Vis Sci.������������������������-FTLF�.$ �8V�4: �/FNFTVSF�# �)FOOJT�"��*ODJEFOU�PQFO�BOHMF�HMBVDPNB�BOE�CMPPE�� pressure. Arch Ophthalmol. ������������������56. Bonomi L, Marchini G, Marraffa M, Bernardi P, Morbio R, Varotto A. Vascular risk factors for primary open angle glaucoma: the Egna-Neumarkt Study. Ophthalmology. � ������������������������5JFMTDI�+. �,BU[�+ �4PNNFS�" �2VJHMFZ�)" �+BWJUU�+$��)ZQFSUFOTJPO �QFSGVTJPO�QSFTTVSF �� and primary open-angle glaucoma. A population-based assessment. Arch Ophthalmol. 1995;113(2):216-221.58. Quigley HA, West SK, Rodriguez J, Munoz B, Klein R, Snyder R. The prevalence of glaucoma in a population-based study of Hispanic subjects: Proyecto VER. Arch Ophthalmol. 2001;119(12):1819-1826.����#VZT�:. �"MBTCBMJ�5 �+JO�:1 �FU�BM��&GGFDU�PG�TMFFQJOH�JO�B�IFBE�VQ�QPTJUJPO�PO�JOUSBPDVMBS�� pressure in patients with glaucoma. Ophthalmology.���������������������60. Malihi M, Sit AJ. Effect of head and body position on intraocular pressure. Ophthalmology. ����������������������(SFFOmFME�%4 �4JBULPXTLJ�3. �(MBTFS�+4 �4DIBU[�/+ �1BSSJTI�3,��OE��5IF�DVQQFE�EJTD��� Who needs neuroimaging? Ophthalmology.��������������������������'SBODJT�#" �*BODIVMFW�5 �4DIPmFME�+, �.JODLMFS�%4��4FMFDUJWF�MBTFS�USBCFDVMPQMBTUZ�� as a replacement for medical therapy in open-angle glaucoma. Am J Ophthalmol. 2005;140(3):524-525.63. Gedde SJ, Schiffman JC, Feuer WJ, Herndon LW, Brandt JD, Budenz DL; Tube Versus Trabeculectomy Study Group. Treatment outcomes in the Tube Versus Trabeculectomy � 575�TUVEZ�BGUFS�mWF�ZFBST�PG�GPMMPX�VQ��Am J Ophthalmol.�������������������F��64. Mansberger SL, Gordon MO, Jampel H, et al; Ocular Hypertension Treatment Study Group. Reduction in intraocular pressure after cataract extraction: the Ocular Hypertension Treatment Study. Ophthalmology. 2012;119(9):1826-1831.65. Poley BJ, Lindstrom RL, Samuelson TW, Schulze R Jr. Intraocular pressure reduction� BGUFS�QIBDPFNVMTJmDBUJPO�XJUI�JOUSBPDVMBS�MFOT�JNQMBOUBUJPO�JO�HMBVDPNBUPVT�BOE�� nonglaucomatous eyes: evaluation of a causal relationship between the natural lens and open-angle glaucoma. J Cataract Refract Surg. 2009;35(11):1946-1955.����4IJOHMFUPO�#+ �-BVM�" �/BHBP�, �FU�BM��&GGFDU�PG�QIBDPFNVMTJmDBUJPO�PO�JOUSBPDVMBS�� pressure in eyes with pseudoexfoliation: single-surgeon series. J Cataract Refract Surg. 2008;34(11):1834-1841.

5HIHUHQFHV

11

To obtain COPE CE Credit for this activity, read the material in its entirety and consult referenced sources as necessary. 8F�PGGFS�JOTUBOU�DFSUJmDBUF�QSPDFTTJOH�BOE�TVQQPSU�(SFFO�$&��1MFBTF�UBLF�UIJT�QPTU�UFTU�BOE�FWBMVBUJPO�POMJOF�CZ�HPJOH�UP KWWSV���WLQ\XUO�FRP�7KH3UHVVXUHV2Q&23(��6QPO�QBTTJOH �ZPV�XJMM�SFDFJWF�ZPVS�DFSUJmDBUF�JNNFEJBUFMZ��:PV�NVTU�TDPSF�����PS�IJHIFS�UP�SFDFJWF�DSFEJU�GPS�UIJT�BDUJWJUZ �BOE�NBZ�UBLF�UIF�UFTU�VQ�UP���UJNFT��

CE Post Test Questions

)RU�LQVWDQW�SURFHVVLQJ��FRPSOHWH�WKH�&(�3RVW�7HVW�RQOLQHKWWS���WLQ\XUO�FRP�7KH3UHVVXUHV2Q&23(�

1. Which of the following is necessary to make a diagnosis of POAG? a. Elevated IOP b. Optic nerve damage� D�� 7JTVBM�mFME�MPTT d. All the above

2. When examining a patient’s ONH, which of the following � mOEJOHT�JT�/05�TVHHFTUJWF�PG�HMBVDPNB a. Disc hemorrhage b. Small optic nerve and cup c. Focal notching of the neuroretinal rim d. Vertical elongation of the optic cup

3. With which stage of glaucoma are early visual defects associated? a. Early b. Moderate c. Advanced d. End-stage

4. When evaluating a patient with suspected glaucoma, which component is the least valuable for assessing risk of � GVUVSF�WJTVBM�mFME�MPTT a. IOP b. Central corneal thickness c. Presence of diabetes d. Refractive error

��� :PV�BSF�DPOTJEFSJOH�UIF�VTF�PG�UPQJDBM�UJNPMPM�UP�NBOBHF�B�� patient’s glaucoma. When taking the patient’s medical history, use of which systemic hypertension medication might prompt you to select a different IOP-lowering agent? a. Angiotensin-converting enzyme inhibitor b. Beta-blocker c. Thiazide diuretic d. Angiotensin receptor blocker

6. In glaucoma, NO can lower IOP by:� B�� *ODSFBTJOH�USBCFDVMBS�PVUnPX b. Reducing aqueous production� D�� *ODSFBTJOH�VWFPTDMFSBM�PVUnPX d. Increasing episcleral venous pressure

��� 8IJDI�PG�UIF�GPMMPXJOH�CFTU�EFTDSJCFT�MBUBOPQSPTUFOF�� bunod? a. Latanoprostene bunod lowers IOP better than timolol, but not as well as latanoprost b. Latanoprostene bunod only has a single mechanism of action c. The most common side effect of LBN is conjunctival hyperemia d. Latanoprostene bunod lowers IOP by 32% to 34%

8. When initiating IOP-lowering therapy in a newly diagnosed patient with early POAG and baseline IOP of 20 mm Hg, what is a reasonable target IOP? a. 15% reduction b. < 21 mm Hg c. 25% reduction d. < 18 mm Hg

9. Which is NOT generally an important consideration when selecting initial therapy for early-stage POAG? a. Dosing frequency� C�� *01�MPXFSJOH�FGmDBDZ c. Mechanism of action d. Safety

�����*O�UIF�QIBTF��C�TUVEZ�PG�mYFE�DPNCJOBUJPO�OFUBSTVEJM �� 0.02%, plus latanoprost, the IOP reduction over baseline was: a. 6.0 mm Hg b. 8.6 mm Hg c. 5.8 mm Hg d. 9.1 mm Hg

in GlaucomaChallenging CasesManaging

THE PRESSURE’S ON!

101D

By Carl H. Spear, OD, MBA, FAAO

For optometrists, many of their daily frustra-

tions revolve around vision care plans (VCP).

To name a few gripes, each provider has

its own set of rules, patients don’t know what

plans or benefits they have, staffers spend a lot

of time verifying benefits or explaining ben-

efits to patients, and reimbursements are low.

To gain more insight in preparation for a

lecture on the topic, I crowdsourced on so-

cial media.

I posted on two optometry Facebook groups,

ODs on Facebook and ODs on Practice Man-

agement and Insurance, asking for complaints

about VCPs in preparation for a SECO lecture.

After reviewing the comments, I divided

them into four topic buckets.

Here are the top four complaints ODs have

with VCPs.

By Justin Bazan, OD

With much of the digital revolution occur-

ring after 2008 and most contact lens tech-

nology developing well before it, there is

an inherent design feature mismatch. The

majority of the available contact lenses are

not designed for how patients are using their

eyes. Specifically, older-generation materials

and designs feature technology that isn’t op-

timized for how we stare at multiple digital

devices for nearly all of our waking hours.

Technology revolutionIt wasn’t until just a few short years ago that

we became a digital-device–obsessed nation.

ODs’ top 4 gripes about vision care plans

Upgrade your patients to new technology

See Contact lens technology on page 16

See VCP gripes on page 6

As primary-care optometrists, we are

the gatekeepers for baby boomers in-

quiring about cataract surgery. To-

day’s patients have treatment options

available not only to address their lifestyle

complaints but to provide them with better

vision and possibly reduced dependence on

glasses or contact lenses.

This generation of active seniors are eager

to embrace their intraocular lens (IOL) op-

tions. They include both traditional cata-

ract surgery and femtosecond laser surgery.

Many optometrists assume that

patients already know what cat-

aracts are. I find most patients think cata-

racts are a “film over the eye.” It is impor-

tant for patients to understand cataracts so

they can better realize why their vision is

changing, and the cause of the glare at night

when they drive, read, or watch television.

Together, we pinpoint their lifestyle com-

plaints—once the cataract is removed, we

see if the complaints have been resolved.

The analogy of a camera works very well

to explain to patients the basic optics of

light entering a normal eye as well as dif-

fraction when light passes through a cata-

ract. I explain that the natural lens in our

eye focuses light onto the retina, and over

See Cataract options on page 18

By Barbara J. Fluder, OD

Offer options to your cataract patientsWhat you need to know about standard

vs. femtosecond laser surgery

&Q A | DR. KATHERINE SCHUETZ PEDIATRIC OPTOMETRY, DAILY DISPOSABLES, AND NAPPING SEE PAGE 38

OptometryTimes.com

APRIL 2017VOL . 9 , NO. 04

PRACTICAL CHAIRSIDE ADVICE

FIGURE 1 LenSx imaging. Image courtesy of Alcon

THE FALSE SECURITY OF A FULL SCHEDULE page 12 N E W S E R I E S O N P O C T E S T I N G page 32

1

DAILIESCHOICE.com*Via mail-in or online rebate on an annual supply of DAILIES TOTAL1® or

DAILIES® AquaComfort Plus® contact lenses. Rebate is in the form of an Alcon Visa Prepaid Card. Must be a new patient to DAILIES TOTAL1® or DAILIES® AquaComfort Plus® contact lenses and must purchase an annual supply of the lenses within 90 days of eye exam and/or contact lens fitting. Applies to purchases from participating retailers only. Visit DAILIESCHOICE.COM for full terms and conditions. Offer ends 12-31-17.

See product instructions for complete wear, care and safety information.

© 2016 Novartis 12/16 US-DAL-16-E-4914

ALCON DAILIES®

CH ICEPROGRAM

S T A R T Y O U R P A T I E N T S O N A

HEALTHY ROUTINE TODAY

Now, you can upgrade your weekly and monthly replacement lens wearers with the ALCON DAILIES® CHOICE PROGRAM

Recommend a healthy choice for your patients and practice

Reduce the price barrier with $200 savings* on a year’s supply

A convenient alternative to weekly and monthly replacement lenses

By Carl H. Spear, OD, MBA, FAAO

For optometrists, many of their daily frustra-

tions revolve around vision care plans (VCP).

To name a few gripes, each provider has

its own set of rules, patients don’t know what

plans or benefits they have, staffers spend a lot

of time verifying benefits or explaining ben-

efits to patients, and reimbursements are low.

To gain more insight in preparation for a

lecture on the topic, I crowdsourced on so-

cial media.

I posted on two optometry Facebook groups,

ODs on Facebook and ODs on Practice Man-

agement and Insurance, asking for complaints

about VCPs in preparation for a SECO lecture.

After reviewing the comments, I divided

them into four topic buckets.

Here are the top four complaints ODs have

with VCPs.

By Justin Bazan, OD

With much of the digital revolution occur-

ring after 2008 and most contact lens tech-

nology developing well before it, there is

an inherent design feature mismatch. The

majority of the available contact lenses are

not designed for how patients are using their

eyes. Specifically, older-generation materials

and designs feature technology that isn’t op-

timized for how we stare at multiple digital

devices for nearly all of our waking hours.

Technology revolutionIt wasn’t until just a few short years ago that

we became a digital-device–obsessed nation.

ODs’ top 4 gripes about vision care plans

Upgrade your patients to new technology

See Contact lens technology on page 16

See VCP gripes on page 6

As primary-care optometrists, we are

the gatekeepers for baby boomers in-

quiring about cataract surgery. To-

day’s patients have treatment options

available not only to address their lifestyle

complaints but to provide them with better

vision and possibly reduced dependence on

glasses or contact lenses.

This generation of active seniors are eager

to embrace their intraocular lens (IOL) op-

tions. They include both traditional cata-

ract surgery and femtosecond laser surgery.

Many optometrists assume that

patients already know what cat-

aracts are. I find most patients think cata-

racts are a “film over the eye.” It is impor-

tant for patients to understand cataracts so

they can better realize why their vision is

changing, and the cause of the glare at night

when they drive, read, or watch television.

Together, we pinpoint their lifestyle com-

plaints—once the cataract is removed, we

see if the complaints have been resolved.

The analogy of a camera works very well

to explain to patients the basic optics of

light entering a normal eye as well as dif-

fraction when light passes through a cata-

ract. I explain that the natural lens in our

eye focuses light onto the retina, and over

See Cataract options on page 18

By Barbara J. Fluder, OD

Offer options to your cataract patientsWhat you need to know about standard

vs. femtosecond laser surgery

&Q A | DR. KATHERINE SCHUETZ PEDIATRIC OPTOMETRY, DAILY DISPOSABLES, AND NAPPING SEE PAGE 38

OptometryTimes.com

APRIL 2017VOL . 9 , NO. 04

PRACTICAL CHAIRSIDE ADVICE

FIGURE 1 LenSx imaging. Image courtesy of Alcon

THE FALSE SECURITY OF A FULL SCHEDULE page 12 N E W S E R I E S O N P O C T E S T I N G page 32

1

Prescribe up to the oxygen1

at the price of conventional hydrogel lenses.

clariti®

1 dayAvailable in sphere, toric and multifocal

100% corneal oxygen consumption2

3Chief Optometric EditorFROM THE

| PRACTICAL CHAIRSIDE ADVICE

It’s the time of year when state legisla-

tures convene to do the people’s business.

Which means it is also the time optometry

undertakes legislation to expand scope of

practice to better care for our patients. For

better or worse, we are a legislated profes-

sion. News abounds of the various states

attempting to add this or that to their op-

tometric scope of practice acts.

If you’ve never been involved in this pro-

cess, I highly recommend you participate

in your  state’s efforts. It is an eye-opening

experience. An old saying goes that there

are two things you never want to see: sau-

sage being made and laws being passed.

That figurative pungent aroma emanating

from your state capital is legislation being

crafted. It is not an easy nor gentle process.

I can recall years ago my blood boiling dur-

ing an open floor hearing when the oppo-

sition stated how Georgia residents would

die in the streets if optometrists were given

the right to prescribe topical beta-blockers.

When optometrists go before their state

governing body attempting to enact a piece of

legislation to enhance patient care, it seems

that every special interest group comes out

of the woodwork against us. Ophthalmol-

ogy, the general medical lobby, you name

‘em, they come out to lobby against us.

Meanwhile, on the other side of the aisle,

who aligns with optometry? While we may

garner occasional outside support, often it’s

just us. We’re the ones advocating for our

profession and for our patients’ care. As Dr.

Ben Casella, president of the Georgia Opto-

metric Association, said to me, “If you have

never felt lonely in a crowd, then go to the

Capitol as an optometrist!”

The next time you write a pa-

tient a medical prescription,

take just a moment to think

about that privilege. These

days, we take it for granted.

Yet, that privilege didn’t always

exist and didn’t just magically

happen. It took a lot of our prede-

cessors with the foresight and the willing-

ness to spend their time and their treasure

to win that privilege for our profession so

you can better care for your patients. Those

of us in practice today are standing on the

shoulders of giants past and reaping the

benefits of their efforts.

The process for optometry continues every

year. We need more young giants in our

profession like Dr. Casella and Dr. Johndra

McNeely, South Carolina Optometric Physi-

cian’s Association president-elect, to take

up the mantle.

So, join or become active in your state

association. Associations are our advocates

in the political arena and always work for

our best interests and the interests of the

patients we serve. New and enthusiastic

members are always welcome. Even if you’re

not politically inclined, contribute to

your state association’s political ac-

tion committee (PAC).

It is entirely up to us. The only

people who are going to ensure our

ability to provide absolute state-of-

the-art, cutting-edge patient care

are optometrists. It’s just us.

Optometry stands alone

Our point-of-

care series starts on page

32. Check it out.

Editorial Advisory BoardErnie Bowling, OD, FAAO Chief Optometric Editor

Editorial Advisory Board members are optometric thought leaders. They contribute ideas, offer suggestions, advise the editorial staff, and act as industry ambassadors for the journal.

By Ernie Bowling, OD, FAAOChief Optometric EditorHe is in private practice in Gadsden, AL and is the chair of the Comprehensive Eye Care Section of the American Academy of Optometry.

erniebowling@icloud.com 256-295-2632

Jeffrey Anshel, OD, FAAOOcular Nutrition SocietyENCINITAS, CA

Sherry J. Bass, OD, FAAOSUNY College of OptometryNEW YORK, NY

Justin Bazan, ODPark Slope Eye,BROOKLYN, NY

Marc R. Bloomenstein, OD, FAAOSchwartz Laser Eye CenterSCOTTSDALE, AZ

Crystal Brimer, OD, FAAOCrystal Vision Services,WILMINGTON, NC

Michael Brown, OD, FAAO U.S. Department of Veterans Affairs HUNTSVILLE, AL

Mile Brujic, OD, FAAOPremier Vision GroupBOWLING GREEN, OH

Dori Carlson, OD, FAAOHeartland Eye CarePARK RIVER, ND

Benjamin P. Casella, OD, FAAOCasella Eye CenterAUGUSTA, GA

Michael A. Chaglasian, OD, FAAOIllinois Eye InstituteCHICAGO, IL

A. Paul Chous, OD, MA, FAAOChous Eye Care AssociatesTACOMA, WA

Clark Y. Chang, OD, MSA, MSc, FAAOWills Eye HospitalPHILADELPHIA, PA

Michael S. Cooper, ODWindham Eye GroupWILLIMANTIC, CT

Melanie Denton, OD, MBA, FAAOSalisbury Eyecare and EyewearSALISBURY, NC

Douglas K. Devries, ODEye Care Associates of NevadaSPARKS, NV

Steven Ferucci, OD, FAAOSepulveda VA Ambulatory Care Center & Nursing HomeSEPULVEDA, CA

Barbara Fluder, ODWilliams Eye Institute, MERRILLVILLE, IN

Lisa Frye, ABOC, FNAOEye Care Associates,BIRMINGHAM, AL

Ben Gaddie, OD, FAAOGaddie Eye CentersLOUISVILLE, KY

David I. Geffen, OD, FAAOGordon Weiss Schanzlin Vision InstituteSAN DIEGO, CA

Jeffry D. Gerson, OD, FAAOWestGlen EyecareSHAWNEE, KS

Alan Glazier, OD, FAAO Shady Grove Eye and Vision Care ROCKVILLE, MD

Scott G. Hauswirth, OD, FAAO Minnesota Eye Consultants MINNEAPOLIS, MN

Milton M. Hom, OD, FAAOAZUSA, CA

David L. Kading, OD, FAAOSpecialty Eyecare Group, KIRKLAND, WA

Danica J. Marrelli, OD, FAAOUniversity of Houston College of OptometryHOUSTON, TX

Katherine M. Mastrota, MS, OD, FAAOOmni Eye SurgeryNEW YORK, NY

Ron Melton, OD, FAAOEducators in Primary Eye Care LLCCHARLOTTE, NC

Pamela J. Miller, OD, FAAO, JDHIGHLAND, CA

Brittany Mitchell, ODAlabama Vision Center, BIRMINGHAM, AL

Patricia A. Modica, OD, FAAOSUNY College of OptometryNEW YORK, NY

Leslie O’Dell, OD, FAAODry Eye Treatment Center, HANOVER, PA

Laurie L. Pierce, LDO, ABOMHillsborough Community CollegeTAMPA, FL

Mohammad Rafi eetary, OD, FAAOCharles Retina InstituteMEMPHIS, TN

Stuart Richer, OD, PhD, FAAOJames Lovell Federal Health Care FacilityNORTH CHICAGO, IL

Michael Rothschild, ODWest Georgia Eye CareCARROLLTON, GA

John Rumpakis, OD, MBA, FAAOPractice Resource ManagementLAKE OSWEGO, OR

John L. Schachet, ODEyecare Consultants Vision SourceENGLEWOOD, CO

Scott E. Schachter, ODAdvanced EyecarePISMO BEACH, CA

Leo P. Semes, OD, FAAOUniversity of Alabama at BirminghamSchool of OptometryBIRMINGHAM, AL

Diana L. Shechtman, OD, FAAONova Southeastern UniversityFORT LAUDERDALE, FL

Joseph P. Shovlin, OD, FAAO, DPNAPNortheastern Eye InstituteSCRANTON, PA

Kirk Smick, OD, FAAOClayton Eye CentersMORROW, GA

Joseph Sowka, OD, FAAONova Southeastern University College of OptometryFORT LAUDERDALE, FL

Carl H. Spear, OD, MBA, FAAOPanhandle Vision InstituteNAVARRE, FL

Tracy L. Schroeder Swartz, OD, FAAOMadison Eye CareMADISON, AL

Loretta B. Szczotka-Flynn, OD, MS, FAAOUniversity Hospitals Case Medical CenterCLEVELAND, OH

Marc B. Taub, OD, MS, FAAO, FCOVDSouthern College of OptometryMEMPHIS, TN

William D. Townsend, OD, FAAOAdvanced Eye CareCANYON, TX

William J. Tullo, OD, FAAOTLC Laser Eye Centers/Princeton Optometric PhysiciansPRINCETON, NJ

Walter O. Whitley, OD, MBA, FAAOVirginia Eye ConsultantsNORFOLK, VA

Thomas A. Wong, ODState University of New York College of OptometryNEW YORK, NY

OPTOMETRY TIMES (Print ISSN: 0890-7080, Digital ISSN: 2328-3904) is published monthly (12 issues) by UBM Medica 131 W. First Street, Duluth, MN 55802-2065. Subscription rates: $49 for one year in the United States & Possessions; $59 for one year in Canada and Mexico, and $89 for one year for all other countries. Periodicals Postage paid at Duluth MN 55806 and additional mailing offi ces. POSTMASTER: Please send address changes to OPTOMETRY TIMES, P.O. Box 6089, Duluth, MN 55806-6089. Canadian G.S.T. number: R-124213133RT001, PUBLICATIONS MAIL AGREEMENT NO. 40612608, Return Undeliverable Canadian Addresses to: IMEX Global Solutions, P. O. Box 25542, London, ON N6C 6B2, CANADA. Printed in the U.S.A.©2017 UBM. All rights reserved. No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical including by photocopy, recording, or information storage and retrieval without permission in writing from the publisher. Authorization to photocopy items for internal/educational or personal use, or the internal/educational or personal use of specifi c clients is granted by UBM for libraries and other users registered with the Copyright Clearance Center, 222 Rosewood Dr. Danvers, MA 01923, 978-750-8400 fax 978-646-8700 or visit http://www.copyright.com online. For uses beyond those listed above, please direct your written request to Permission Dept. fax 440-756-5255 or email: maureen.cannon@ubm.com.

ContentCONTENT CHANNEL DIRECTOR Gretchyn M. Bailey, NCLC, FAAOgretchyn.bailey@ubm.com 215/412-0214

ASSOCIATE EDITOR Giovanni Castelligiovanni.castelli@ubm.com 440/891-2602

VP, CONTENT & STRATEGY Sara Michaelsara.michael@ubm.com 203/523-7107

GROUP CONTENT DIRECTOR Mark L. Dlugossmark.dlugoss@ubm.com 440/891-2633

DIRECTOR, DESIGN AND DIGITAL PRODUCTION Nancy Bittekernancy.bitteker@ubm.com 203/523-7074

ART DIRECTOR Lecia A. Landis

Publishing/AdvertisingEXECUTIVE VICE PRESIDENT, MANAGING DIRECTOR Georgiann DeCenzogeorgiann.decenzo@ubm.com 440/891-2778

GROUP PUBLISHER Leonardo Avilaleonardo.avila@ubm.com 302/239-5665

PUBLISHER Erin Schlusselerin.schlussel@ubm.com 215/886-3804

NATIONAL ACCOUNT MANAGER Cherie Pearsoncherie.pearson@ubm.com 609/636-0172

SALES MANAGER CLASSIFIED/DISPLAY ADVERTISING Tod McCloskeytod.mccloskey@ubm.com 440/891-2739

ACCOUNT MANAGER, RECRUITMENT ADVERTISING Joanna Shippolijoanna.shippoli@ubm.com 440/891-2615

VICE PRESIDENT, DIGITAL SOLUTIONS Sarah Cameron Mifsud sarah.mifsud@ubm.com 203/523-7055

SALES DIRECTOR, DIGITAL MEDIA Don Bermandon.berman@ubm.com 203/523-7013

DIGITAL TRAFFIC COORDINATOR Terry Tetzlaffterry.tetzlaff@ubm.com 218/740-6585

SPECIAL PROJECTS DIRECTOR Meg Bensonmeg.benson@ubm.com 732/346-3039

VICE PRESIDENT, MARKETING Amy Erdmanamy.erdman@ubm.com 201/523-7041

DIRECTOR OF MARKETING & RESEARCH SERVICES Gail Kayegail.kaye@ubm.com 732/346-3042

SALES SUPPORT Kathy Dieringerkathy.dieringer@ubm.com 732/346-3055

REPRINTS 877/652-5295 ext. 124, bkolb@wrightsmedia.comOutside US, UK, direct dial: 281/419-5725. Ext. 124

LIST ACCOUNT EXECUTIVE Renée Schusterrenee.schuster@ubm.com 440/891-2613

PERMISSIONS/INTERNATIONAL LICENSING Maureen Cannonmaureen.cannon@ubm.com 440/891-2742

ProductionSENIOR PRODUCTION DIRECTOR Karen Lenzen

CirculationVICE PRESIDENT, MARKETING & AUDIENCE DEVELOPMENT Joy PuzzoDIRECTOR, AUDIENCE DEVELOPMENT Kristina BildeauxAUDIENCE DEVELOPMENT MANAGER Molly TomfohrdeUBM Medica provides certain customer contact data (such as customers’ names, addresses, phone numbers, and e-mail addresses) to third parties who wish to promote relevant products, services, and other opportunities that may be of interest to you. If you do not want UBM Medica to make your contact information available to third parties for marketing purposes, simply call toll-free 866/529-2922 between the hours of 7:30 a.m. and 5 p.m. CST and a customer service representative will assist you in removing your name from UBM Medica’s lists. Outside the U.S., please phone 218/740-6477.

OPTOMETRY TIMES does not verify any claims or other information appearing in any of the advertisements contained in the publication, and cannot take responsibility for any losses or other damages incurred by readers in reliance of such content.

OPTOMETRY TIMES cannot be held responsible for the safekeeping or return of unsolicited articles, manuscripts, photographs, illustrations or other materials.

Library Access Libraries offer online access to current and back issues of Optometry Times through the EBSCO host databases.To subscribe, call toll-free 888-527-7008. Outside the U.S. call 218/740-6477. UBM Medica provides certain customer contact data (such as customers’ names, addresses, phone numbers, and e-mail addresses) to third parties who wish to promote relevant products, services, and other opportunities that may be of interest to you. If you do not want UBM Medica to make your contact information available to third parties for marketing purposes, simply call toll-free 866/529-2922 between the hours of 7:30 a.m. and 5 p.m. CST and a customer service representative will assist you in removing your name from UBM Medica’s lists. Outside the U.S., please phone 218/740-6477.

OPTOMETRY TIMES does not verify any claims or other information appearing in any of the advertisements contained in the publication, and cannot take responsibility for any losses or other damages incurred by readers in reliance of such content.

OPTOMETRY TIMES cannot be held responsible for the safekeeping or return of unsolicited articles, manuscripts, photographs, illustrations or other materials.

Library Access Libraries offer online access to current and back issues of Optometry Times through the EBSCO host databases.

To subscribe, call toll-free 888-527-7008. Outside the U.S. call 218/740-6477.

APRIL 2017 • VOL. 9, NO. 04@Digit l4

Optometry Times is part of the ModernMedicine Network, a Web-based portal for health professionals offering best-in-class content and tools in a rewarding and easy-to-use environment for knowledge-sharing among members of our community.

OptometryTimes.com

By Gretchyn M. Bailey, NCLC, FAAO

Editor in Chief, Content Channel Director

Optometrists in North Carolina hope to ex-

pand patient access to care by adding laser

procedures to their scope of practice, con-

tinuing optometry’s ongoing goal of best pa-

tient care possible.

HB 36, also known as the Enhanced Ac-

cess to Eye Care Act, would allow ODs in

North Carolina to perform:

– YAG capsulotomy (YAG)

– Laser peripheral iridotomy (PI)

– Selective laser trabeculoplasty (SLT)

– Removal and identification of skin le-

sions around the eye

HB 36 passed its first reading and awaits

a hearing in the House Health Committee.

North Carolina Optometric Society (NCOS)

leadership hopes this hearing takes place by

mid-March, although the hearing has not yet

been scheduled.

By A. Paul Chous, MA, OD, FAAO

Patients with diabetes may present a variety of find-

ings best unveiled by use of spectral domain opti-

cal coherence tomography (SD-OCT). OCT is one

of the best way to assess patients for the presence

of diabetic macular edema (DME). It is extremely

useful for monitoring responses to treatments such

as anti-VEGF injections, grid or focal laser, intra-

vitreal steroids, or any combination thereof in pa-

tients with DME.

Let’s consider a few cases showing multiple OCT

presentations that might be encountered in patients

NC ODs say laser

privileges will expand

access to care

USING OCT WITH YOUR

DIABETES PATIENTS

See OCT and diabetes on page 14

See NC lasers on page 6

The time we are spending on digital de-

vices is on the rise, and it’s unlikely to

slow down any time soon. With more

and more apps, games, and social media

options, we have all become more depen-

dent on smartphones, tablets, and other elec-

tronic devices.

This increased time is trickling down to

kids and teens as well. American teens use

nine hours of media per day, in addition to

time spent on homework and schoolwork.2

A 2014 study (n=288) showed that increased

time on smartphones was significant for

dry eye disease; however, interestingly, time

spent watching television and using com-

puters were not factors.1

Meibomian gland dysfunc-

tion (MGD) and dry eye disease (DED) are

thought to primarily affect the older pop-

ulation. However, data shows that digital

device use is an important dry eye disease

risk factor in children.1

Devices and blink rate

Blink quality and quantity suffer when fo-

cused on near tasks. When blink rates de-

cline, problems ensue.

The tear film will likely begin to break

up prior to the blink response. This lack

of protection from the tear film leaves the

surface of the eye vulnerable, resulting in

damage to cells of the cornea and conjunc-

tiva and impaired functional visual acuity

See Digital devices on page 24

By Scott Schachter, OD

MARCH 2017VOL . 9 , NO. 03

How digital device usage

is affecting youthIf you aren’t screening your younger patients,

you should

FIGURE 1a AND b.

These images with different lighting show the same lid in the same patient. A 16-year-old female has

worn soft contact lenses for two years. She regularly wears mascara and uses digital devices. Note

she exhibits almost 40 percent gland loss.

&Q A | DR. SHAUNA THORNHILL Toys for free eye exams, community service, and $2,000 Manolos SEE PAGE 38

PRACTICAL CHAIRSIDE ADVICE

1a

1b

How to survive allergy season as a contact lens wearer page 16 3 STEPS TO SCRIPT FOR SECOND-PAIR SALES page 22

&

Optometry Times offers weekly blogs from some of the leaders in the optometric profession. Haven’t read them yet? Here’s what you’re missing.

MISSION STATEMENT Optometry Times delivers easily digested, practical information by ODs for ODs. This information can be immediately applied to improve the clinical experience of the next patient in your chair as well as your practice performance. In partnering with our readers, Optometry Times provides data, analysis, tools, and resources which are available whenever and wherever our readers want them.Optometry Times blogs

6 steps to survive a ransomware attack Cyberattacks are on the rise as ODs move more daily tasks to a digital platform. Dr. Melanie Denton explains the steps she followed when her practice suffered a ran-somware attack on its files.OptometryTimes.com/Ransomware

6 challenges when changing from a group to private practiceMaking the switch from a group to private practice can be daunting. Dr. Leslie O’Dell ex-plains the difficulties she faced when changing the direction of her practice. OptometryTimes.com/ChangingPractice

12

TOP HEADLINES Check out what your colleagues are reading.

What patients are tweeting about their ODsOptometryTimes.com/ODTweets

5 things you don’t know about punctal plugsOptometryTimes.com/PunctalPlugs

A different approach to treating demodex blepharitisOptometryTimes.com/BlepharitisTreatment3

APP Get access to all the benefits Optometry

Times offers at your finger-tips. The Optometry Times

app for iPad and iPhone is now free in the iTunes store.

© R

awpix

el.co

m/Sh

utter

stock

.com

TOP SOCIAL See what others arereading on Facebook, Twitter, and Instagram.

12

Roth spots show as initial presentation in multiple myelomaOptometryTimes.com/RothSpots

Retinal prosthesis offers hope to blind patientsOptometryTimes.com/RetinalProsthesis

Handling patients who want you to adjust glasses purchased onlineOptometryTimes.com/AdjustOnline3

©Hal Bohlman, OD, FAAO LIKE USfacebook.com/OptometryTimes

TWEET UStwitter.com/OptometryTimes

FOLLOW USinstagram.com/optometrytimes

STAY IN TOUCH

Designed and Manufactured by NIDEK - Represented by Marco800-874-5274 • marco.com

Refractive

TRS Total Refraction Automation

OPD-Scan III Wavefront

ARK Autorefraction Systems

EPIC Refraction Workstation

ion Anterior Segment Imaging

SOLUTIONS Marco Refraction Systems — Advanced automated instrumentation includes the OPD-Scan III Integrated Wavefront Aberrometer, the TRS-3100/TRS-5100 and EPIC Digital Refraction Workstation, Autorefractors/Keratometers (with VA measurement, 6XEMHFWLYH�6SKHUH�5HÀ�QHPHQW��7RQRPHWU\��*ODUH�WHVWLQJ�RQ�FHUWDLQ�PRGHOV��DQG�Lensmeters–all with EMR integration. And introducing ion IMAGINGSM System– D�KLJKO\�VRSKLVWLFDWHG�VOLW�ODPS�LQWHJUDWHG�DQWHULRU�VHJPHQW�LPDJLQJ�V\VWHP�WKDW�HPSKDVL]HV�LPDJH�TXDOLW\��VLPSOLFLW\�DQG�HIÀ�FLHQF\��The Difference is Marco.TRS-5100

Product/Model name:

REFRACTOR RT-5100

In Focus6 APRIL 2017 |

Here are some comments:

– “The fact that you need a PhD

in ‘EOB [explanation of benefits]

Understanding’ to know what you

get paid.”

– “Too time consuming for op-

tical staff to explain to patients.”

– “[VCPs] never mail ID cards,

so patients don’t know what they

have.”

– “Lack of universal reimburse-

ment across all plans within a VCP.”

– “600-page VCP manual.”

2 REIMBURSEMENTSIt’s not surprising that a

major gripe is reimbursements.

What surprised me was that

reimbursements was not the

top complaint.

Comments include:

– “Low exam fees, terrible pay

for frames and lenses.”

– “In many years no increase in

reimbursement (in fact a decrease)

despite the cost of business going

up—making profitability increas-

ingly difficult.”

– “Getting paid less for an exam

than I did in 1984 when I started

practice.”

– “More and more documenta-

tion, less reimbursement.”

– “ H o r r i b l e e x a m

reimbursement.”

3 COMPETING WITH ODS FOR RETAIL

SALES, PATIENTSODs are feeling the pressure as

VCPs move toward a model that

not only cuts reimbursement but

competes with ODs for patients,

goods, and services.

ODs say:

– “Their newest ploy to drive

patients to purchase their glasses

or contact lenses online and use

their benefits from the website

the insurance company owns.”

– “Two [VCPs] that I know of are

actively emailing patients about

using their benefits online as soon

as the exam authorization is pulled.

We’ve resorted to waiting to pull

those until patients are in office.”

– “Promoting their own online

contact lens sales when they are

already giving me extremely low

reimbursements.”

– “Vertical integration means

they push patients to their physical

entities vs. private practice ODs.”

4 MISLEADING AND INCORRECT

INFORMATIONOf all the categories, this one has

the most responses and raw emo-

tion. The general tone of the re-

sponses and conversations with

my colleagues is that VCPs mis-

lead patients about what is covered

and what is not covered.

Most of this discontent centers

around patients with a known med-

ical diagnosis who expect medi-

cal care from the VCP.

Optometrists say:

– “Too many patients come in

with medical complaints and think

they are covered. Many times the

caring doc feels compelled to take

care of people so he takes care of

the patient. Thus, insurance com-

panies get away with not paying

for medical care.”

– “Patients with medical com-

plaints think these plans should

cover the visit. When the patients

1 DOES IT HAVE TO BE THIS DIFFICULT?

Many people commented on how

difficult VCPs have made the vision

coverage process. ODs say their

staff members invest too much

time with VCP coverage before,

during, and after the exam.

I love my bulb projector!

- Said no one ever

Never changing a projector bulb again is just one of the benefits of upgrading to Acuity Pro digital acuity systems! Plus, faster and more accurate refractions. #notabulber

Don’tbe a bulber...

switch to Acuity Pro

Go from this

to THIS!

Call: 580.243.1301

Toll-Free: 1.877.228.4890 AcuityPro.com

and think outside the bulb!

038520 pgs 03 11 2017 03:10 ADVANSTAR PDF/X-1ablackyellowmagentacyan

ODs’ top 4 gripes about vision care plansContinued from page 1

Within the comments and complaints are very real misunderstandings and opportunities for practices to minimalize these challenges

| PRACTICAL CHAIRSIDE ADVICE In Focus 7

S15294 09/16©2016 Shire All Rights Reserved

A Closer Look At Innovation in Eye Care

Interest in wearables is growing, in fact it's estimated that more than 12 million smartglasses will be ordered by 2020.

Source: "The Future of mHealth Wearables May Focus on Smartglasses," mHealth Intelligence. February 2016

12M

SEE MORE ON MANAGED VISION CARE PLANS

10 tips for reducing staff time on managed vision care plansOptometryTimes.com/10tipsMVCP

The shifting sands of vision care plansOptometryTimes.com/shiftingsandsVCP

Vision care plan industry’s vertical monopolyOptometryTimes.com/verticalmonopoly

4 ways to change your thinking—and your reimbursementOptometryTimes.com/4waystochange

call the VCP, customer service always re-

spond that the plan will cover the exam.

These plans have created a huge issue when

we try to explain this. Also, these plans are

simply discount plans!”

– “One of the plans says it covers diabetic

exams and to pay an extra $5 or $10 for the

diabetic exam.”

Moving forwardMany ODs recognize that VCPs bring pa-

tients into the office and help provide ac-

cess to patients.

ODs might accept reduced payments if the

other problems were mitigated:

– Patients knowing their plans

– VCP reimbursement process streamlined

– Representatives available with consis-

tent, accurate information

– Clear distinction made between medical

coverage and VCPs

– Payment systems that are easy to

understand

If these other problems were addressed,

then the trade-off in reimbursement might

be easier to accept.

I know the list is not inclusive, and I expect

a lot of feedback. Within the comments and

complaints are very real misunderstandings

and opportunities for practices to minimize

these challenges.

Our offices accepted every VCP and were

able to build a successful and thriving busi-

ness by understanding the insurances, devel-

oping processes, and providing high-quality

customer service.

Stay tuned for more. I will share ideas on

how ODs can view these problems as oppor-

tunities to grow their practices.

Dr. Carl Spear’s lecture, “What’s My Beef

with Vision Plans?” was heard at SECO 2017

in Atlanta and was a part of SECO’s “What’s

My Beef” series of lectures.

BASEL, SWITZERLAND—Alcon has received ap-

proval from the U.S. Food and Drug Admin-

istration (FDA) for its AcrySof IQ ReStor+2.5

Multifocal Toric intraocular lens (IOL) with

ActiveFocus optical design for patients un-

dergoing cataract surgery who choose to ad-

dress their astigmatism and presbyopia at

the same time.

The optical design of the ActiveFocus toric

lens delivers both crisp, clear distance vi-

sion and a range of vision for patients who

desire less dependence on glasses, accord-

ing to the company.

Previous presbyopia-correcting IOL designs

tend to compromise on distance vision in

order to provide patients with a range of vi-

sion, according to the company—ActiveFo-

cus toric IOL’s central portion is 100 percent

dedicated to distance vision.

“Presbyopic cataract patients with astig-

matism have had limited options in the past,”

says Sergio Duplan, region president, North

America for Alcon.

“Alcon’s ActiveFocus toric IOL is a break-

through for these patients, correcting astig-

matism and allowing them to achieve uncom-

promised distance vision with an increased

range of vision at the same time,” he says.

The ActiveFocus toric IOL is also engi-

neered for stability, according to the com-

pany. Toric IOLs perform optimally if they

stay on axis to correct the astigmatism. In

a retrospective study of IOL orientation data

by Potvin et al in the September 2016 issue

of Clinical Ophthalmology, the AcrySof IQ

toric IOL platform was two and a half times

less likely to rotate than the leading com-

petitor lens.

“The ActiveFocus toric IOL is the mar-

riage of the design features of my two go-to

IOLs for patients wanting outstanding dis-

tance vision and less dependence on glasses

after cataract surgery,” says Bret L. Fisher,

MD, medical director at Eye Center of North

Florida.

“By combining the unique optical proper-

ties of the ActiveFocus design with the un-

paralleled rotational stability of the AcrySof

IQ toric platform, I can now offer a range of

vision to more patients,” he says.

Nearly four million cataract surgeries are

performed each year in the United States, and

more than 50 percent of those patients have

treatable levels of astigmatism that could

be addressed with AcrySof IQ toric IOLs,

including the new ActiveFocus toric IOL,

according to the company.

Alcon plans to commercialize the Active-

Focus toric IOL in the United States begin-

ning in mid-2017.

Alcon gets FDA nod for ActiveFocus Toric IOLIN BRIEF

APRIL 2017 | 8 Focus On DRY EYE

She also is very smart, and sassy,

having earned a PhD in organic

chemistry decades ago. Mom is

a tough old bird whose career

included teaching grade school

science to performing histocom-

patability research at Memorial

Sloan Kettering Cancer Center

in New York. She has a unique

perspectives and interests in top-

ics from community gardening

to urban planning.

Mom has pseudoexfoliation

syndrome (PXF) clinically vis-

ible in both eyes. She experiences pops

of elevated intraocular pressure (IOP) in

one eye and uses glaucoma medications.

We decided that it was in her best in-

terest to proceed with cataract surgery

because she was experiencing difficulty

traveling home at night from local com-

munity board meetings.

Pre-surgery preparations Pre-surgery presented a question-and-an-

swer period that included lecture-qual-

ity review of the ocular manifestations

and potential surgical complications of

cataract surgery—especially in patients

with PXF.

After the pre-surgery preparations,

Mom hesitantly agreed to proceed with

cataract surgery.

Although PXF is considered a systemic

condition,1 its clinical signs are mostly

identified in the eye. Most practitioners

are familiar with the grey-white material

that is deposited on the anterior struc-

tures, notably the anterior lens capsule.

This material, consisting of

nanometer-sized fibrils within a

loose matrix, is generated mul-

tifocally within the eye. The fi-

brils in PXF are thought to be

generated by polymorphisms in

a gene named LOXL-1(lysyl oxi-

dase like 1) that is responsible

for the biogenesis of connec-

tive tissue.2

One must recognize that the

aberrant material deposited in

PXF impacts many structures

of the eye and may compromise

its proper function.

Disorders associated with PXFWith respect to dry eye and the ocu-

lar surface, patients with PXF appear

to have a higher predisposition of tear

function disorders.

One study, using the Schirmer II test

and assessment of lid parallel conjunc-

tival folds in PXF patients, demonstrated

that there was a statistically significant

difference in tear film break-up time com-

pared to controlled patients.3

There is also an up-regulation of the

non-specific inflammatory marker MMP-9

(matrix metalloproteinase-9) in tear film

in PXF-syndrome.4

Studies show tear osmolarity is higher

in both eyes of patients when compared

with normal subjects, and  pseudoexfo-

liation is suggested to alter basic features

of goblet cell morphology—thus affect-

ing tear film stability.5,6

PXF can cause zonular weakness that

can allow for excessive lens movement,

or dislocation, at the time of cataract

surgery. Postoperative inflammation and

corneal edema associated with cataract

surgery may also be increased in eye

with PXF.7

Naturally, I discussed all these things

with my mother prior to her surgery.

Post-surgery outlookFast forward to Mom’s post-operative

statement, “I have no pain.”

My mother had no comment about

her vision, or her lack of possible PXF-

related complications. The comfort of

her eye was the key indicator of success

in her surgery.

It surprised me that in light of my

concerns, it was only lack of discom-

fort that my mother discussed. This ex-

ercise made me re-evaluate my cataract

surgery procedures and how I discuss

surgery with patients.

Would it be better to start by saying,

“We expect minimal postoperative dis-

comfort?”

REFERENCES1. Miglior S, Bertuzzi F. Exfoliative glaucoma: new evidence in the pathogenesis and treatment. Prog

Brain Res. 2015;221:233-41

2. Wiggs JL, Pasquale LR. Expression and regulation of LOXL1 and elastin-related genes in eyes with exfoliation syndrome. J Glaucoma. 2014 Oct-Nov;23(8 Suppl 1):S62-63

3. Škegro I, Suic SP, Kordic R, Jandrokovic S, Petricek I, Kuzman M, Peric S, Masnec S. Ocular surface disease in pseudoexfoliation syndrome. Coll Antropol. 2015 Mar;39(1):43-5.

4. Zimmermann N, Erb C. [Immunoassay for matrix metalloproteinase-9 in the tear film of patients with pseudoexfoliation syndrome - a pilot study]. Klin

Monbl Augenheilkd. 2013 Aug;230(8):804-7.

5. Öncel BA, Pinarci E, Akova YA. Tear osmolarity in unilateral pseudoexfoliation syndrome. Clin Exp

Optom. 2012 Sep;95(5):506-9.

6. Kozobolis VP, Christodoulakis EV, Naoumidi II, Siganos CS, Detorakis ET, Pallikaris LG. Study of conjunctival goblet cell morphology and tear film stability in pseudoexfoliation syndrome. Graefes

Arch Clin Exp Ophthalmol. 2004 Jun;242(6):478-83.

7. Shingleton BJ, Crandall AS, Ahmed II. Pseudoexfoliation and the cataract surgeon: preoperative, intraoperative, and postoperative issues related to intraocular pressure, cataract, and intraocular lenses. J Cataract Refract Surg. 2009 Jun;35(6):1101-20.

Cataract surgery for patients with PXFThese patients are more likely to experience tear function disordersI am fortunate to be able to share stories about my mother.

Many of my article topics have been inspired by experi-

ences and thoughts shared with my mom. For background,

my mother is 79 years old and, except for a bum knee, is

in excellent health.

Patients with PXF appear to have a higher predisposition of tear function disorders

BY KATHERINE M. MASTROTA, MS, OD, FAAO is clinical director of Omni Center for Dry Eye Specialty Care in New York City

Provide a wider range of patients with all-day

comfort and consistently clear vision1

THE BAUSCH + LOMB ULTRA® CONTACT LENS FAMILY IS NOW COMPLETE

FOR MORE INFORMATION, CONTACT YOUR

REPRESENTATIVE OR CALL 1-800-828-9030.

Now for Astigmatism

Helps lenses maintain

95% of their moisture

for a full 16 hours2

Featuring

REFERENCES: 1. Results from a 7-investigator, multi-site 2-week study of Bausch + Lomb ULTRA® for Astigmatism contact lenses on 157 current soft contact lens wearer. 2. Data on file. Bausch & Lomb Incorporated. Rochester, NY; 2013.

®/™ are trademarks of Bausch & Lomb Incorporated or its affiliates. ©2017 Bausch & Lomb Incorporated. UFA.0092.USA.17

APRIL 2017 | 10 Focus On LENS CARE

Many contact lens-wearing patients ask their eyecare pro-

fessional (ECP) about makeup brands, applying makeup,

and how this affects their contact lens wear. What we use

on our faces likely ends up either on the contact lenses

before insertion or in our eyes on the lenses.This includes facial moisturizers,

eye makeup remover, makeup

primers, and most importantly

mascara. A few tips regarding

wearing cosmetics and contact

lens wear can help our patients

wear their lenses with more

comfort.

1Wash hands before applying contact lenses

Always instruct all patients to

wash their hands prior to applying con-

tact lenses. This prevents any type of

contamination or possible infections dur-

ing application.

2Apply contact lenses prior to any facial productSuggest to your patients that they apply

any type of face moisturizers or products

after they handle their contact lenses.

Just like discussing washing hands prior

to applying contact lenses, it is also im-

portant that their hands be free of any

products. Our patients likely assume that

washing hands, then applying facial prod-

ucts means that their hands are clean.

Their hands might not necessarily be

dirty, but that product is now on the con-

tact lenses. Oils and other chemicals pres-

ent in facial cosmetics can affect contact

lens comfort and vision.

3Eye makeup should be hypoallergenic or ECP approved

Most products from major cosmetic compa-

nies have been tested with contact lenses

and are deemed safe. However, many

patients will ask if a brand is safe, es-

pecially if they have had an adverse re-

action in the past.

Always make sure the products they

use are safe to use with contact lenses

and the patient understands the impor-

tance of cleanliness and safety

when using cosmetics around

the eye or when touching the

lids or lashes.

4Makeup removersAll makeup removers are not

made the same and can come

in many forms such as liquids,

foams, oils, pads, cloths, and

creams. Recommend that patients

remove their contact lenses prior

to using an eye makeup remover.

With most of those products, there is a

good deal of scrubbing involved that may

cause some concerns with the contact

lenses. Some brands that work best with

contact lenses are Neutrogena (Johnson

& Johnson) and Clinique (Estée Lauder

Companies), while typical lid scrubs like

OcuSoft (OcuSoft) and Blephadex (Lu-

novus) work well to remove cosmetics

as well. Typically, I recommend the lat-

ter two for your blepharitis patients, but

they also work well for makeup removal

in general.

5Mascara replacementMascara is applied directly to the top

and lower lashes with the same brush

used daily from the same tube. It is rec-

ommended that a single tube of mascara

be replaced every three months. Patients

should replace their mascara immediately

if they contract any type of conjunctivitis.

This three-month rule should also apply

to any cosmetic applicators such as eye

shadow as well. In addition, brushes used

on lids or brows can be cleaned with mild

soap and water.

6Daily replacement contact lenses vs. two-week/monthly

While I think that daily disposable con-

tact lenses are the healthiest choice for

patients, not all patients will be open to

this option. Because of this we must be

prepared to assist even our two-week/

monthly wearers.

For your two-week and monthly re-

placement makeup-wearing contact lens

patients, instruct them to put their con-

tact lenses in their hands and rub for at

least 20 seconds. This will remove any

makeup or debris that has built up. This

even applies to solutions that are “no rub”

because this step may ensure a cleaner

lens, which leads to more comfortable

contact lens wear.

7Case replacementMany makeup-wearing patients store

their contact lens cases in their cos-

metic bags. This causes the cases to be

covered in makeup both on the inside

and the outside of the case.

The cosmetic bag is usually covered in

bacteria from the makeup brushes, con-

tainers, and bottles. Recommend your

patients have a separate bag for their

contact lens products. In general, con-

tact lens cases should be replaced every

three months.

I receive questions almost daily from

patients about cosmetics, face products,

and makeup remover in regard to their

eyes and contact lenses. Making a list of

cosmetic dos and don’ts and printing it

out for your contact lenses patients can

help them better remember and follow

your recommendations and understand

why these steps are important to healthy

lens wear.

Properly discussing these tips can help

our patients wear their contact lenses

safely and avoid any complications.

7 tips for safer lens wear with cosmeticsClean, safe habits when applying makeup can help avoid lens wear complications

Dr. Brittany Mitchell practices in Birmingham, AL, in an OD/MD setting. She is a graduate of the University of Alabama at Birmingham School of Optometry. She is a consultant for Bausch + Lomb and member of B+L’s speaker’s bureau. She also consults for Shire.

Recommend your patients have a separate bag for their contact lens products

BY DR. BRITTANY MITCHELL, ODpractices at Alabama Vision Center

APRIL 2017 | 12 Focus On PRACTICE MANAGEMENT

A filled appointment book is com-

forting; it gives assurances that

the practice will have similar

success in the future as it has

enjoyed in the past. We have

become convinced that filling

our appointment books should

be our primary goal, and ev-

erything else will take care of

itself—and it has worked.

Because filling the appoint-

ment book has been so effec-

tive, we put intense energy into

filling appointment slots. We partnered

with vision insurance companies. We even

took the lead from our dentist mentors

by stressing “recall” and “pre-appoint-

ing”—which also worked.

Many practices that have been estab-

lished and haven’t shown significant

growth find themselves “booked out”—

and that’s a problem.

Full appointment book offers false securityA filled appointment book requires that

your patients are willing to wait until

you are available to see them. This re-

quires your patients to be both patient

and loyal—or they have no other reason-

able choice. If you are in a community

where options are limited, either by lo-

cation or insurance participation, a full

book may serve you well.

Today’s consumers are less willing

to wait for what they want and are less

loyal to your practice than ever before. A

2014 Consumer Health Study found that

61 percent of all American consumers

would change their healthcare

provider for a more convenient

appointment, compared to 47

percent who would change for

a better price.1

These are existing patients

willing to switch providers.

New patients don’t have that

much loyalty and may sched-

ule an appointment with you

but then have an exam at a

competitor later that afternoon.

The cost of no-showsA recent study from the National Insti-

tute of Health estimates that no-shows

cost an average healthcare practice over

$1,000 each and every day.2 And logic

dictates that the further into the future

an appointment is made, the more likely

it is to not be kept.

While simply not showing up for an

appointment is rude, changing the ap-

pointment also costs our practices money.

Staff time taken to communicate with pa-

tients about needs to change an appoint-

ment can add up to significant expenses.

People tend to cancel appointments with

little notice. The longer patients have to

wait to re-schedule, the more likely they

are to cancel.

Pre-appointing vs. recallAlmost everyone in eye care agrees

that annual comprehensive eye exams

are the standard of care maintain visual

wellness. We have implemented a recall

or pre-appointing strategy to help our pa-

tients adhere to this annual exam stan-

dard. These systems have many names

and employ a variety of techniques. For

the sake of this discussion, we will break

the systems into two well-accepted cat-

egories: recall and pre-appointing.

Recall is any action to remind patients

that it is time for them to take action to

schedule their yearly exams. Postcards,

phone calls, email, and text messages are

some examples of tactics used to make

contact. Sometimes the messages con-

veyed are automated to maximize effi-

ciency; others use real people to add the

personal touch. Recalled patients do not

have an existing appointment scheduled

when being “recalled.”

Pre-appointing is the close cousin of re-

call with one difference: Patients already

have an appointment scheduled. A pre-

appointment is different from a standard

appointment because it is scheduled in

the future—typically a year in advance.

As time for the appointment approaches,

many techniques are used to remind the

patient of their appointments, and in-

structions are given to confirm or ad-

just the appointment time. If confirmed,

the pre-appointment is converted to an

appointment. 

I have found in my practice that pre-ap-

pointed patients are more likely to sched-

ule their next annual exams, and some

ODs believe they are more likely to come

to that exam. I have also found that pre-

appointed patients are also more likely

to cancel or no-show for their appoint-

ments than recalled patients.

The answer is the systemProper scheduling techniques depend

heavily on the practice’s situation. The

most important factor is that having an

established system in place and adjusting

it frequently based on your ever-chang-

ing circumstances. New practices with

plenty of openings may be a perfect place

for pre-appointments, but a “booked-out”

The false security of a full scheduleBooking strategies important to keep patients happy, ODs stress levels downIt is not uncommon to hear people talk about the health

of their practices by confidently stating how far they are

“booked out.” How long it takes for a patient to get an ap-

pointment is often a statement of practice wellness.

Many practices that have been established and haven’t shown significant growth find themselves “booked out”—and that’s a problem

BY MICHAEL ROTHSCHILD, OD is the CEO of Leadership OD

what no-shows cost an average healthcare practice per day ac-cording to the National Institute of Health estimates

$1K

| PRACTICAL CHAIRSIDE ADVICE 13PRACTICE MANAGEMENT Focus On

practice trying to attract new patients should consider discontinuing

their pre-appointments practice.

Define the primary scheduling objective of your practice by decid-

ing which is more important:

– Availability for new patients within the next few days

– Comfort of a full appointment book for the next few weeks

Consider this strategyCommit to keeping your schedule 80 percent, instead of 100 percent,

full. Full capacity is measured at 100 percent and anything over that

causes stress and strain. Think about what happens to a balloon when

it exceeds capacity. If you are booked at 100 percent and add an emer-

gency appointment, it is difficult to perform at your best.

Reserve the final 20 percent of your appointments for emergen-

cies, urgencies, and new patients. This allows you to add patients

who call and want to

come in today or to-

morrow without over-

stressing the practice.

The challenge comes

when a loyal, long-time

patient wants one of

those final spots. The team needs to be reminded of the practice’s

policy because loyal patients are more willing to wait.

The strategy listed is not perfect for every practice, but it is a strat-

egy with clear definitions, goals, targets, and room for flexibility.

Every scheduling plan needs clear direction.

REFERENCES1. Collier M, Bashman LM. Patient loyalty: It’s up for grabs. Accenture 2014

Consumer Health Study. 2016. Available at: https://www.accenture.com/t20160322T034105__w__/us-en/_acnmedia/Accenture/Conversion-Assets/DotCom/Documents/Global/PDF/Strategy_7/Accenture-Strategy-Patient-

Dr. Rothschild is also a consultant for Alcon, Optos, and Vision Source; a member of the speakers’ bureau for VSP; and a clinical researcher for CIBA Vision.

Recall is any action to remind patients that it is time for them to take action to schedule their yearly exams

of American consumers would change their healthcare provider for a more convenient appointment61%

Engagement-Consumer-Loyalty.pdf. Accessed 3/15/17.

2. Berg B, Murr M, Chermak D, Woodall J, Pignone M, Sandler RS, Denton B. Estimating the cost of no-shows and evaluating the effects of mitigation strategies. Med Decis Making. 2013 Nov;33(8):976-985.

RALEIGH, NC—The Food and Drug Administration (FDA) has approved Icare

USA’s Icare Home tonometer for patient use at home.

According to the company, the unit’s built-in Icare EyeSmart tech-

nology performs automatic OD/OS recognition. Icare EasyPos uses red

and green light signals to help patients correctly position the tonom-

eter. Icare Home also features Icare AMS, an automated measuring

sequence that can take a single measurement or a series of six mea-

surements with one touch of a button.

Icare Home involves no puff of air and requires no drops. In the

hands of patients, it is quick, effortless and effective, according the

company.

For eyecare professionals, Icare Home may help manage patients

who could benefit from additional intraocular pressure monitoring.

FDA approves Icare HomeIN BRIEF

UniversalSmart PhoneAdaptor forSlit LampImaging

Digital Photography

Solutionsfor Slit Lamp

Imaging

Toll free: 800-322-7373

email: info@ttimedical.com

www.ttimedical.com

TTI MedicalTransamerican Technologies International

Made in USA

e

Sample Images

All-in-One Digital SLR Camera Adaptor

APRIL 2017 | 14 Focus On RETINA

Exam findingsOn examination, her visual acu-

ity was corrected to 20/20 and

20/25 in the right and left eyes.

The anterior segments of each

eye were unremarkable with ap-

planation tonometry pressures

measured at 16 mm Hg.

Dilated fundus evaluation re-

vealed the picture depicted in

Figure 1. The presence of blurred

disc margins was prominent.

With access to B-scan ultraso-

nography, we performed a scan

of each eye at standard as well

as reduced gain. See Figure 2.

Optical coherence tomography (OCT)

was also performed. Figure 3 shows OD

results. The upper left shows a

reflectance image of the optic

nerve head. The lower left is

a representative cross-section

through the disc. Note that the

elevation is confined within the

scleral ring, consistent with optic

nerve head drusen (ONHD).

Topographic representation of

the disc, color image on Figure

3, reflects the elevation seen in

the cross-sectional presentation.

The scale bar indicates that hot-

ter colors are consistent with

greater elevation.

Figure 4 is a composite representing the

fundus photo and OCT data OD. Clockwise

from the center left are the fundus photo,

OCT cross-section, and topographic data;

the lower right image is a presentation of

the data cube emphasizing not only the

elevation, but confirming the elevation

being confined within the scleral ring.

Any encounter of an elevated optic disc

raises the question of whether the pa-

tient is presenting with true or pseudo-

papilledema. The data in this case are

consistent with a diagnosis of optic disc

drusen. These findings spare the patient

a neuro-ophthalmic workup.

Further analysis included a visual field

evaluation. See Figure 5. Both eyes had

good reliability with only a few sporadic

depressions OD but a pattern consistent

with retinal nerve fiber damage second-

ary to the ONHD.

The patient has been asked to return

annually to monitor visul field changes. 

Recent discussionsA recent study examined the use of spectral

domain OCT (SD-OCT) as the gold stan-

dard in distinguishing optic disc drusen

(ODD), ONHD, or optic disc edema (ODE).1

The authors also identified the halo sign

for making the distinction using fundus

photography. In all cases of ODD, the halo

sign was present, indicating the confine-

ment of the elevation within the scleral

The case of blurred disc marginsManaging blurred disc margins can present a challenge for ODsA 16-year-old female was scheduled for her periodic oph-

thalmic evaluation to update her spectacle lens prescrip-

tion. At the visit, she reported a history of migraines, but

the remainder of her personal and family medical history

was non-contributory. She took no medications and had

a history of low hyperopic refractive correction.

Figure 1. Fundus photos of the OD and OS. Note the normal appearance of the maculae but apparent elevation of each optic nerve head.

Figure 3. OD results.

Figure 4. Composite of fundus and OCT.

Figure 2. Ultrasound scans of the OD and OS. Left, OD and OS at standard gain. Right, OD and OS at reduced gain. Note that there is hyperereflectivity localized at the position of the ONH. In addition, the A-scan reflects the same.

BY LEO SEMES, OD, FAAO Professor of optometry at the University of Alabama-Birmingham

1

2

3

4

| PRACTICAL CHAIRSIDE ADVICE 15RETINA Focus On

ring/disc margin. For those without ac-

cess to SD-OCT, identifying the halo sign

at fundus examination and on photogra-

phy may serve as a valuable diagnostic

tool to prevent unnecessary work-ups.2

In cases of mild/early papilledema, oth-

ers have reported that OCT perhaps does

not offer a final adjudication.3 With ad-

vances in OCT technology, the utility as

a differentiator may become more wide-

spread. Alternative imaging may prove

valuable, but not widely available.4 The

utility of OCT for establishing a diagnosis

of optic disc drusen had been suggested

several years ago as a benchmark.5

REFERENCES 1. Lee KM, Woo SJ, Hwang JM. Differentiation between optic disc drusen and optic disc oedema using fundus photography. Acta Ophthalmol. 2017 Jan 13. doi: 10.1111/aos.13338.

2. Costello F. Optical Coherence Tomography in Neuro-ophthalmology. Neurol Clin. 2017 Feb;35(1):153-163.

3. Kulkarni KM, Pasol J, Rosa PR, Lam BL. Differentiating mild papilledema and buried optic nerve head drusen using spectral domain optical coherence tomography. Ophthalmology. 2014 Apr;121(4):959-63.

4. Shah A, et al. Optic disc drusen in a child: diagnosis using noninvasive imaging tools. Optom

Vis Sci. 2013 Oct;90(10):e269-73.

5. Katz BJ, et al. Optic disc edema and optic nerve head drusen. J Neuroophthalmol. 2013 Jun;33(2):204-5. 

Figure 5. Visual fields show a pattern consistent with retinal nerve fiber damage secondary to the ONHD.

Dr. Semes is a founding member of the Optometric Glaucoma Society and a founding fellow of the Optometric Retina Society.

5

APRIL 2017 | Contact lenses16

For example, it seems like smartphones have

been part of our lives forever, but the reality

is that the first iPhone debuted in mid-2007.

The iPad was released in 2010. Factor in so-

cial media not really taking off until 2008,

and you begin to see a picture that

helps explain why so many of our

patients are struggling with contact

lens technology that predates their

mobile technology.

Many of my patients are also on

laptops, desktops, tablets, and TVs—

many of them using multiple devices

at the same time. That is a great deal

of screen time, and it only seems to

be increasing. The jury is still out

on how much these digital devices

are harming our ocular health, but one

thing is for certain: While using these devices,

our blink rates drop dramatically.

This reduction in blinking has led to con-

tact lens-related dryness for patients who have

likely upgraded their smartphones but not

their contact lenses. Optometrists should be

proactive in offering their patients solutions

to digital device-induced dryness.

Missing the opportunityHowever, ODs may be missing the opportunity

to offer their patients the solutions they need.

For example, it’s become a habit for ODs

to simply ask their patients how they are

doing with their contact lenses. If we hear,

“Fine,” we move on. This saves us time, but

is it really in the best interest of the patient? 

Our patients are accepting end-of-day dis-

comfort as the norm because they don’t real-

ize there are better options. It’s also important

to point out that in the past, we often didn’t

have a better option to offer. All we could

often hope to hear was, “Fine,” because we

didn’t have the upgrade available.

Now, however, I encourage all optometrists

to ask questions to find out how their patients

are really doing with their contacts lenses.

Uncover concerns that patients may perceive

as just a normal part of wearing lenses, such

as dryness.

What works well for me is to assume that

those long hours in front of a laptop or device

are leading to comfort problems. A question

that works well for me is, “How dry are your

lenses feeling around 8 o’clock or 9 o’clock

at night?”

That question accomplishes a few

goals. It alerts patients that dryness

is expected and something I want to

hear more about. It also lets them

know that even if they thought their

contact lenses were fine, there is

something that may be better. Once

a challenge is uncovered, it is easy

to get a trial of the upgraded con-

tact lens on patients’ eyes and out

for a test drive.

Upgrade mindsetPatients know that the next generation of

smartphone will be “better”—that is, faster,

more powerful, more storage, better camera,

and so on. They know this because smart-

phone manufacturers market to them in very

effective ways.

Unfortunately, contact lens companies don’t

have the means necessary to replicate that

type of marketing. So, ODs need to step up to

the plate to inform patients about the benefits

of upgraded contact lens technology.

Contact lens manufacturers are bringing

new technology to your practice. Consider

upgrading your patients to some of these new

technology lenses:

– Acuvue Vita (Johnson & Johnson Vision

Care) monthly lenses feature the company’s

HydraMax Technology for a non-coated sili-

cone hydrogel material to maintain lens hy-

dration throughout the day.

– Biofinity Energys (CooperVision) monthly

lenses address device usage with the com-

pany’s aspheric Digital Zone Optics to re-

duce fatigue and Aquaform Technology to

reduce dryness.

– Biotrue ONEday (Bausch + Lomb) daily

disposables incorporate the company’s Surface

Active Technology—hydrophilic polyvinylpyr-

rilidone (PVP), a water loving molecule, and

Poloxamer 407, a surface active macromer—

to form a dehydration barrier that helps the

lens maintain moisture for most of the day.

This lens is available in toric and presbyopic

designs as well.

– Dailies Total 1 (Alcon) daily disposable

water-gradient lenses combine high oxygen

permeability with high water content for a

soft hydrophilic surface gel for improved com-

fort. These lenses are available in a multifo-

cal design as well.

– MyDay (CooperVision) daily disposable

incorporates Smart Silicone, the company’s

material that uses only 4.4 percent silicon,

allowing for the soft feel of a hydrogel lens

with the oxygen transmission of silicone hy-

drogel material.

– Ultra (Bausch + Lomb) monthly lenses

feature the company’s MoistureSeal Technol-

ogy to help maintain 95 percent of the lens

moisture for most of the day plus aspheric op-

tics, high-water content, and low modulus for

better comfort and vision with device usage.

Offer a trialInnovations have united comfort, health, and

vision in ways that will far surpass previous

technology—much like smartphones have vir-

tually eliminated flip phones. That trinity is

the goal for our contact lens wearers.

Once achieved, we find patients loving their

contact lens experiences. They have:

– Lenses that don’t require attention through-

out the day because they are drying out

– Lenses that don’t interrupt their daily flow

– Lenses that don’t disrupt their lives

So many patients who were doing “fine”

are now doing great.

Often optometrists do patients a huge dis-

service by not at least offering a trial of in-

novative technology. Allowing a patient

to experience how much better these new

lenses can be may make a huge difference.

Upgrade patients to new contact lens technologyContinued from page 1

BY JUSTIN BAZAN, OD is owner of Park Slope Eye in Brooklyn, NY

TAKE-HOME MESSAGE More patients are using digital devices for longer periods. This can adversely affect contact lens discomfort. Much like your patients know to upgrade their device technology, offer them upgrades in their contact lens technology. Patients will better value your services when you offer them more value with education and solutions to contact lens discomfort.

ODs need to step up to the plate to inform patients about the benefits of upgraded contact lens technology

| PRACTICAL CHAIRSIDE ADVICE

be may make a huge difference. It certainly pays

off for the patient. How does it pay off for you?

Finally, consider this common story. A patient

contacts the office to say, “I know my prescrip-

tion is expired, but I also know my prescription

hasn’t changed. Can you just send me a new

copy of it, please?”

Let me translate that into what the patient

is really saying.

“I know that when I come in, you are going to

ask me how my contact lenses are. When I say,

‘Fine,’ you are just going to give me the same

brand you have given me for the last 10 years.

I resent having to pay you for that!”

Have you become a burden to your patients?

Are you an unnecessary step standing in the

way of them ordering their cheap contact lenses

online? Yes! Make sure your patients value your

services by providing them with value in turn.

Beyond the education you should be provid-

ing, there is a psychological aspect to our contact

lens exam. If you present innovative technol-

ogy to your patients the same way technology

companies present new features, expect to see

your patients look forward to upgrading their

contact lenses much in the same way they do

their smartphones.

Six Full Months of

Effective Dry Eye Relief

The doctor gave me

six months…

OMG!

…to my next visit!

Beaver-Visitec International, Inc., 411 Waverley Oaks Road, Waltham, MA 02452

BVI, BVI Logo and all other trademarks (unless noted otherwise) are property of

Beaver-Visitec International (“BVI”) © 2017 BVI

The Extend 180® Long-Term Dissolvable Implant

Featuring

*� Simple insertion technique

*� No foreign body sensation

*� Exceptionally reliable retention

Indications

*� Post-ocular surgery or seasonal dry eye

*� Contact lens intolerance

*� Dry eye associated with digital eye strain

For pre-order introductory pricing

*� 866-906-8080

*� customersupport@beaver-visitec.com

Coming Soon!

Extend 180

4 sizes!

Dr. Bazan is a 2004 SUNY grad. Reach him on his Facebook page.

So many patients who were doing “fine” are now doing great

WANT MORE CONTACT LENS CONTENT? WE HAVE IT!

Surviving allergy season as a contact lens wearerOptometryTimes.com/allergyCLwear

7 strategies for fitting keratoconus patientsOptometryTimes.com/7KCstrategies

6 contact lens wear and care habits for patients and ODsOptometryTimes.com/6CLhabits

Why accountable contact lens fitting mattersOptometryTimes.com/accountableCLfitting

Fitting ortho-k contact lensesOptometryTimes.com/fittingorthoklenses

18S P E C I A L S E C T I O N

APRIL 2017 |

Comanagement

time this lens gets cloudy and loses

its ability to change focus. This leads

to presbyopia and eventually cata-

racts. Online resources can demon-

strate this very well.

Explaining proceduresYour patients will have a flood of

questions about cataract surgery. They

will ask if it will be performed at a

hospital or an outpatient facility, how

long the procedure takes, and which

surgeon will perform the procedure.

I recommend contacting your co-

managing surgeons to obtain their

protocols so you can better prepare your pa-

tients’ expectations. Patients will feel much

more comfortable and have a sense of con-

tinuity of care if what you say is reiterated

at the surgeon’s office.

I explain that we operate on only one eye

at a time. If patients require IOLs in both

eyes, the surgeries are scheduled one to two

weeks apart. Cataract surgery is an outpatient

procedure, and the patient will be in the sur-

gery center for approximately two hours, with

the procedure taking only 15 to 20 minutes.

In general, patients experience no

pain, no patching, and no sutures. We

numb the eye with a local anesthetic,

dilate the pupil, and give patients

medication, usually Versed (mid-

azolam, Roche), under the tongue

to relax them.

I use an eye model while explain-

ing the procedure and point out the

structures as I talk. Patients will

typically better understand the pro-

cedure if they see the structures of

the eye. I have found that the big-

gest misconception of cataract sur-

gery is that patients believe they

no longer have to wear eyeglasses or contact

lenses. This is very important to clarify with

your patients.

Patients having cataract surgery need to be

informed that they will be seeing you again

during the postoperative period if you coman-

age cataract surgery or they will be seeing

you after their postoperative care for a new

eyeglass prescription.

Preop clinical concernsDuring your preoperative exam, be sure to

examine the lids and tear film. Starting pa-

tients on warm compresses and lid scrubs

twice a day and artificial tears four times a

day before the surgical consult helps to en-

sure accurate measurements. This is very im-

portant for patients interested in advanced

technology lenses along with femtosecond

laser surgery.

Patients with significant map-dot-finger-

print corneal dystrophy may not be ideal can-

didates for laser surgery. Patients with cor-

neal dystrophy, age-related macular degen-

eration, previous refractive surgery, or other

ocular conditions (such as keratoconus or a

history of retinal detachments) may not be

candidates for multifocal IOLs.

Watch for large or small pupils and iris

atrophy. Patients with large pupils are at a

greater risk for experiencing glare postoper-

atively. Small pupils can cause concerns re-

garding a centered capsulorrhexis. Patients

with iris atrophy are at risk for glare, light

sensitivity, and weak zonules.

After your exam and patient discussion, it

is up to you to offer the cataract surgery op-

tions that best fit your patient and his lifestyle.

Regardless of which surgery the patient

receives, both options begin with IOLMaster

(Zeiss) data. It is the gold standard in opti-

cal biometry. It will show IOL power selec-

Offer options to your cataract patientsContinued from page 1

See Cataract options on page 21

BARBARA J. FLUDER, ODhas been in practice for 22 years and currently practice at Williams Eye Institute in Merrillville, IN

TAKE-HOME MESSAGE Patients requiring cataract surgery usually see ODs first. ODs undertake the bulk of patient education about cataracts, the surgical process, and procedure and IOL options. Coordinate with comanaging or referring surgeons for optimal continuity of care. Understand that femtosecond laser surgery addresses astigmatism while phaco procedures do not. Allow clinical data to help determine if patients are good candidates for premium IOLs.

Figure 2. Verion image showing ocular landscape. Image courtesy of Alcon

Figure 3. Marco OPD Calculations Scan

2

3

I use an eye model while explaining the procedure and point out the structures as I talk

For additional safety information, see accompanying Brief Summaryof Safety Information and Full Prescribing Information on Xiidra-ECP.com.

Marks designated ® and ™�>Ài��Ü�i`�LÞ�-��Ài��À�>��>vw���>Ìi`�V��«>�Þ°�^Óä£Ç�-��Ài�1-���V°��iÝ��}Ì��]��Ƃ�äÓ{Ó£�������-ÓnÇn{ 01/17

Indication Xiidra®�NKƂ�VGITCUV�QRJVJCNOKE�UQNWVKQP�����KU�KPFKECVGF�HQT�VJG�VTGCVOGPV�QH�UKIPU�CPF�U[ORVQOU�QH�FT[�G[G�FKUGCU�G�&'&��

Important Safety Information+P�ENKPKECN�VTKCNU��VJG�OQUV�EQOOQP�CFXGTUG�TGCEVKQPU�TGRQTVGF�KP�������QH�RCVKGPVU�YGTG�KPUVKNNCVKQP�UKVG�KTTKVCVKQP��F[UIGWUKC�CPF�TGFWEGF�XKUWCN�CEWKV[��1VJGT�CFXGTUG�TGCEVKQPU�TGRQTVGF�KP����VQ����QH�VJG�RCVKGPVU�YGTG�DNWTTGF�XKUKQP��EQPLWPEVKXCN�J[RGTGOKC��G[G�KTTKVCVKQP��JGCFCEJG��KPETGCUGF�NCETKOCVKQP��G[G�FKUEJCTIG��G[G�FKUEQOHQTV��G[G�RTWTKVWU�CPF�UKPWUKVKU�

6Q�CXQKF�VJG�RQVGPVKCN�HQT�G[G�KPLWT[�QT�EQPVCOKPCVKQP�QH�VJG�UQNWVKQP��RCVKGPVU�UJQWNF�PQV�VQWEJ�VJG�VKR�QH�VJG�UKPING�WUG�EQPVCKPGT�VQ�VJGKT�G[G�QT�VQ�CP[�UWTHCEG�

%QPVCEV�NGPUGU�UJQWNF�DG�TGOQXGF�RTKQT�VQ�VJG�CFOKPKUVTCVKQP�QH�:KKFTC�CPF�OC[�DG�TGKPUGTVGF����OKPWVGU�HQNNQYKPI�CFOKPKUVTCVKQP�

5CHGV[�CPF�GHƂ�ECE[�KP�RGFKCVTKE�RCVKGPVU�DGNQY�VJG�CIG�QH����[GCTU�JCXG�PQV�DGGP�GUVCDNKUJGF�

Proven to treat the signs of inferior corneal staining in 12 weeks and symptoms of eye dryness in 12, 6, and as little as 2.

:KKFTC�JGNRGF�RTQXKFG�U[ORVQO�TGNKGH�HTQO�G[G�FT[PGUU�KP�UQOG�RCVKGPVU�CV�YGGM��tCPF�C�OGCUWTCDNG�TGFWEVKQP�KP�UKIPU�QH�KPHGTKQT�EQTPGCN�UVCKPKPI�KP�LWUV����YGGMU��%QPUKFGT�:KKFTC�VQ�JGNR�[QWT�&T[�'[G�RCVKGPVU�Ƃ�PF�VJG�TGNKGH�VJG[oXG�DGGP�YCKVKPI�HQT�

Check it out at Xiidra-ECP.com

(QWT�TCPFQOK\GF��FQWDNG�OCUMGF�����YGGM�VTKCNU�GXCNWCVGF�VJG�GHƂ�ECE[�CPF�UCHGV[�QH�:KKFTC�XGTUWU�XGJKENG�CU�CUUGUUGF�D[�KORTQXGOGPV�KP�VJG�UKIPU�OGCUWTGF�D[�+PHGTKQT�%QTPGCN�5VCKPKPI�5EQTG��CPF�U[ORVQOU�OGCUWTGF�D[�'[G�&T[PGUU�5EQTG��QH�&T[�'[G�&KUGCUG�0��������

MAKE XIIDRA YOUR FIIRST CHOICE

7�i��>ÀÌ�w�V�>��Ìi>ÀÃ�>Ài�½Ì�i��Õ}�]�V��Ã�`iÀ�«ÀiÃVÀ�L��}�8��`À>�v�À�ÃÞ�«Ì��>Ì�V��ÀÞ� Þi�«>Ì�i�Ìð�

BRIEF SUMMARY:Consult the Full Prescribing Information for complete product information.

INDICATIONS AND USAGEXiidra®�NKƂVGITCUV�QRJVJCNOKE�UQNWVKQP�����KU�KPFKECVGF�for the treatment of the signs and symptoms of dry eye FKUGCUG�&'&��

DOSAGE AND ADMINISTRATIONInstill one drop of Xiidra twice daily (approximately 12 JQWTU�CRCTV��KPVQ�GCEJ�G[G�WUKPI�C�UKPING�WUG�EQPVCKPGT��Discard the single use container immediately after using in each eye. Contact lenses should be removed prior to VJG�CFOKPKUVTCVKQP�QH�:KKFTC�CPF�OC[�DG�TGKPUGTVGF����minutes following administration.

ADVERSE REACTIONSClinical Trials ExperienceBecause clinical studies are conducted under widely varying conditions, adverse reaction rates observed in clinical studies of a drug cannot be directly compared to rates in the clinical trials of another drug and may PQV�TGƃGEV�VJG�TCVGU�QDUGTXGF�KP�RTCEVKEG��+P�ƂXG�ENKPKECN�UVWFKGU�QH�FT[�G[G�FKUGCUG�EQPFWEVGF�YKVJ�NKƂVGITCUV�ophthalmic solution, 1401 patients received at least ��FQUG�QH�NKƂVGITCUV������QH�YJKEJ�TGEGKXGF�NKƂVGITCUV������6JG�OCLQTKV[�QH�RCVKGPVU������JCF�Ű��OQPVJU�QH�VTGCVOGPV�GZRQUWTG������RCVKGPVU�YGTG�GZRQUGF�VQ�NKƂVGITCUV�HQT�CRRTQZKOCVGN[����OQPVJU��6JG�OCLQTKV[�QH�VJG�VTGCVGF�RCVKGPVU�YGTG�HGOCNG�������6JG�OQUV�EQOOQP�CFXGTUG�TGCEVKQPU�TGRQTVGF�KP��������QH�RCVKGPVU�were instillation site irritation, dysgeusia and reduced XKUWCN�CEWKV[��1VJGT�CFXGTUG�TGCEVKQPU�TGRQTVGF�KP����VQ����QH�VJG�RCVKGPVU�YGTG�DNWTTGF�XKUKQP��EQPLWPEVKXCN�hyperemia, eye irritation, headache, increased lacrimation, eye discharge, eye discomfort, eye pruritus and sinusitis.

USE IN SPECIFIC POPULATIONSPregnancy6JGTG�CTG�PQ�CXCKNCDNG�FCVC�QP�:KKFTC�WUG�KP�RTGIPCPV�women to inform any drug associated risks. Intravenous +8��CFOKPKUVTCVKQP�QH�NKƂVGITCUV�VQ�RTGIPCPV�TCVU��HTQO�RTG�OCVKPI�VJTQWIJ�IGUVCVKQP�FC[�����FKF�PQV�RTQFWEG�teratogenicity at clinically relevant systemic exposures. +PVTCXGPQWU�CFOKPKUVTCVKQP�QH�NKƂVGITCUV�VQ�RTGIPCPV�rabbits during organogenesis produced an increased incidence of omphalocele at the lowest dose tested, ��OI�MI�FC[�����HQNF�VJG�JWOCP�RNCUOC�GZRQUWTG�CV�the recommended human ophthalmic dose [RHOD], DCUGF�QP�VJG�CTGC�WPFGT�VJG�EWTXG�=#7%?�NGXGN���5KPEG�JWOCP�U[UVGOKE�GZRQUWTG�VQ�NKƂVGITCUV�HQNNQYKPI�ocular administration of Xiidra at the RHOD is low, the CRRNKECDKNKV[�QH�CPKOCN�ƂPFKPIU�VQ�VJG�TKUM�QH�:KKFTC�WUG�KP�humans during pregnancy is unclear.

Animal Data .KƂVGITCUV�CFOKPKUVGTGF�FCKN[�D[�KPVTCXGPQWU�+8�� KPLGEVKQP�VQ�TCVU��HTQO�RTG�OCVKPI�VJTQWIJ�IGUVCVKQP�FC[�����ECWUGF�CP�KPETGCUG�KP�OGCP�RTGKORNCPVCVKQP�NQUU�and an increased incidence of several minor skeletal CPQOCNKGU�CV����OI��MI��FC[��TGRTGUGPVKPI�������HQNF the human plasma exposure at the RHOD of Xiidra, based on AUC. No teratogenicity was observed in the rat at ���OI��MI��FC[�����HQNF�VJG�JWOCP�RNCUOC�GZRQUWTG�CV�VJG�4*1&��DCUGF�QP�#7%����+P�VJG�TCDDKV��CP�KPETGCUGF�incidence of omphalocele was observed at the lowest FQUG�VGUVGF����OI��MI��FC[�����HQNF�VJG�JWOCP�RNCUOC�GZRQUWTG�CV�VJG�4*1&��DCUGF�QP�#7%���YJGP�CFOKPKUVGTGF�D[�+8�KPLGEVKQP�FCKN[�HTQO�IGUVCVKQP�FC[U���through 19. A fetal No Observed Adverse Effect Level 01#'.��YCU�PQV�KFGPVKƂGF�KP�VJG�TCDDKV�

Lactation 6JGTG�CTG�PQ�FCVC�QP�VJG�RTGUGPEG�QH�NKƂVGITCUV�KP�JWOCP�milk, the effects on the breastfed infant, or the effects on OKNM�RTQFWEVKQP��*QYGXGT��U[UVGOKE�GZRQUWTG�VQ�NKƂVGITCUV�HTQO�QEWNCT�CFOKPKUVTCVKQP�KU�NQY��6JG�FGXGNQROGPVCN�CPF�JGCNVJ�DGPGƂVU�QH�DTGCUVHGGFKPI�UJQWNF�DG�EQPUKFGTGF��along with the mother’s clinical need for Xiidra and any potential adverse effects on the breastfed child from Xiidra.

Pediatric Use 5CHGV[�CPF�GHƂECE[�KP�RGFKCVTKE�RCVKGPVU�DGNQY�VJG�CIG�QH����[GCTU�JCXG�PQV�DGGP�GUVCDNKUJGF��

Geriatric Use No overall differences in safety or effectiveness have been observed between elderly and younger adult patients.

NONCLINICAL TOXICOLOGYCarcinogenesis, Mutagenesis, Impairment of Fertility Carcinogenesis: Animal studies have not been conducted VQ�FGVGTOKPG�VJG�ECTEKPQIGPKE�RQVGPVKCN�QH�NKƂVGITCUV� Mutagenesis: .KƂVGITCUV�YCU�PQV�OWVCIGPKE�KP�VJG�in vitro #OGU�CUUC[��.KƂVGITCUV�YCU�PQV�ENCUVQIGPKE�KP�VJG�in vivo mouse micronucleus assay. In an in vitro chromosomal aberration assay using mammalian cells (Chinese JCOUVGT�QXCT[�EGNNU���NKƂVGITCUV�YCU�RQUKVKXG�CV�VJG�JKIJGUV�concentration tested, without metabolic activation. Impairment of fertility: .KƂVGITCUV�CFOKPKUVGTGF�CV�KPVTCXGPQWU�+8��FQUGU�QH�WR�VQ����OI�MI�FC[� �����HQNF�VJG�JWOCP�RNCUOC�GZRQUWTG�CV�VJG�TGEQOOGPFGF�JWOCP�QRJVJCNOKE�FQUG�4*1&��QH�NKƂVGITCUV�QRJVJCNOKE�UQNWVKQP������JCF�PQ�GHHGEV�QP�fertility and reproductive performance in male and female treated rats.

/CPWHCEVWTGF�HQT��5JKTG�75�+PE�������5JKTG�9C[��.GZKPIVQP��/#��������

(QT�OQTG�KPHQTOCVKQP��IQ�VQ�YYY�:KKFTC�EQO�QT�ECNN����������������

Marks designated ®�CPF�v�CTG�QYPGF�D[�5JKTG� QT�CP�CHƂNKCVGF�EQORCP[�

������5JKTG�75�+PE� 75�2CVGPVU���������������������������������������������������������������������������������������������������������������������������������CPF�RGPFKPI�RCVGPV�CRRNKECVKQPU�� .CUV�/QFKƂGF�������������5�����

Rx Only

21S P E C I A L S E C T I O N

| PRACTICAL CHAIRSIDE ADVICE

Comanagement

tions, keratometry, anterior chamber depth,

and axial length. Its Haigis-L formula helps

determine surgical parameters for patients

with a history of myopic/hyperopic LASIK. The

newer 700 model incorporates swept-source

OCT technology into biometry, allowing it to

detect tilt or decentration of the crystalline

lens.1 It eliminates the need for A-scans be-

cause it is able to scan through dense cata-

racts. It also performs toric IOL calculations.

Standard phaco surgeryUnless otherwise specified, our goal is to re-

duce the patient’s dependence on her glasses.

We will decrease myopia or hyperopia as much

as we can with standard phaco cataract sur-

gery. Remember, however, that astigmatism

is not being addressed, and residual myopia

or hyperopia may persist. It is important to

explain astigmatism and review the amount

of astigmatism the patient has.

I next explain how femto cataract surgery

addresses astigmatism. The laser will make

incisions in the cornea to relax small amounts

of astigmatism. The laser can usually relax

up to 0.75 D corneal cylinder.

I make sure patients understand that stan-

dard phaco cataract surgery begins with a

small incision in the cornea. With the pupil

dilated, the surgeon will make a capsule open-

ing on the lens and break up the lens with

ultrasound. Next, the surgeon will vacuum

the lens through the corneal incision and in-

sert a lens implant in its place.

I have a sample implant lens so patients

can see for themselves what is being placed

in the eye. Be prepared to answer concerns

regarding implant rejection or “going bad,”

IOL replacement, or dislodged or loosening

IOLs. These may seem like silly questions

to us, but to the patient these are very real

concerns.

Femto laser surgeryIf the patient is interested in femtosecond

laser refractive cataract surgery, we obtain

biometric scans with an IOL Master, Verion

Image Guided System (Alcon), and OPD-Scan

(Marco). We compare the astigmatism data

from all three scans to ensure consistency.

For contact lens-wearing patients, we recom-

mend repeat measurements after discontinu-

ing lens wear for several days.

Verion (Figure 1) offers precision and con-

sistency for refractive cataract surgery when

fitting multifocal and toric IOLs. It captures

the landscape of the patient’s eye by taking

a high-resolution digital image useful for ref-

erencing in the operating room.

This “fingerprint” of the eye allows for

Cataract optionsContinued from page 18

SAN DIEGO—Imprimis Pharmaceuticals, Inc. shares

positive findings from a study published in

2017’s volume four of Current Pharmaceuti-

cal Design.

Dropless Cataract Surgery is a single-use,

injectable combination of antibiotic and ste-

roid formulation administered at the end of

cataract surgery to almost eliminate the need

for post-surgery eye drops.

Findings of the study included:

– Compliance concerns are diminished with

Dropless Therapy compared to standard post-

surgery topical drop regimens.

Lack of patient adherence to topical regi-

mens are due to “drop phobia” and improper

instillation of the drops especially in elderly

patients with tremors, poor near vision and

lack of dexterity. The article refers to a recent

study showing more than 90 percent of pa-

tients incorrectly administered eye drops fol-

lowing cataract surgery. High costs may also

deter some patients from filling all of their

prescribed medications.

– Cost savings to patients can range from

$200 to $600 per cataract procedure.

As health care shifts toward capitated care,

the authors believe it is essential to use safe,

efficacious and cost-effective therapy, such

as Dropless.

– Staff time is significantly reduced without

patient, insurance and pharmacy callbacks

about eye drop substitutions and confusion

over topical regimens.

Jeffrey T. Liegner, MD, one of the authors

of the paper, calculates that callbacks require

an estimated 3,000 staff hours annually, or 1.5

full-time equivalents. Although staff time is

significantly reduced, Dropless requires edu-

cating patients about the procedure, why drops

are not being prescribed, and explaining the

perception of floaters following surgery until

excellent vision is experienced.

– A retrospective review of Dropless Therapy

cases found no postoperative endophthalmitis.

Post- surgery infection and inflammation

rates were similar to reported rates with other

alternative prophylactic therapies, such as top-

ical drops.

– There have been no reported major intra-

operative complications associated with the

transzonular injection technique.

The authors concluded, “We believe that

injection of needed medications at the time of

surgery is an important change in the doctor-

patient relationship. Rather than depending

on the patient to take the necessary steps to

obtain a good result, the surgeon can admin-

ister the drugs directly, gaining greater cer-

tainty that the proper dose will be achieved

and gaining greater confidence in the outcome.

It has been our experience that patients very

much appreciate the opportunity to reduce or

eliminate eye drops after surgery.”

“We continue to capture market share as

more and more physicians understand the ben-

efits of Dropless as a prophylactic alternative

to improve the patient experience, eliminate

their own concerns about compliance and help

lower costs for patients,” says John Saharek,

chief commercial officer at Imprimis.

The paper “Dropless Cataract Surgery: An

Overview” was authored by Richard L. Lind-

strom, MD; M. Stewart Galloway, MD; Andrzej

Grzybowski, MD, PhD, MBA; and Jeffrey T.

Liegner, MD.

The paper is available online at http://www.

eurekaselect.com/147752/article?trendmd-

shared=3#.

Imprimis shares positive Dropless therapy resultsIN BRIEF

After your exam and patient discussion, it is up to you to offer the cataract surgery options that best fit your patient and his lifestyle

See Cataract options on page 22

22S P E C I A L S E C T I O N

APRIL 2017 |

Comanagement

precise positioning of incisions and real-time

accurate alignment. Verion will provide IOL

selection, primary and secondary incision

locations, capsulorhexis location, surgically-

induced astigmatism (SIA), and lens position-

ing. Because Verion knows the exact land-

scape of the patient’s eye, it will automati-

cally track in real time and adjust for any eye

movements, including cyclorotation.2

Marco OPD-Scan III (Figure 2) is a corneal

analyzer that uses wavefront data to perform

autorefraction, keratometer, Placido disc to-

pography, wavefront aberrometry, lenticular

residual astigmatism, angle kappa, pre and

post toric IOL measurements, mesopic and

photopic pupil sizes, Zernike graphs, corneal

refractive power map, and IOL tilt/decentra-

tion.3 I rely on the corneal coma, angle kappa,

and mesopic and photopic measurements for

patients interested in a multifocal IOL.

The femtosecond laser procedure begins

by first making the capsulorhexis (Figure 3).

A femtosecond laser capsulorrhexsis is more

regularly shaped, has better centration, and

shows better intraocular lens/capsule over-

lap than a manual one.4

Next, the laser performs nuclear division.

I inform my patients that there is more pre-

cision and less stress on the eye with the

laser because less ultrasound is being used.

Then stair-step primary and secondary inci-

sions are made.

The patient is then transferred from the

laser room to the operating room where the

rest of the procedure is performed. Patients

with small fissures, deep-set eyes, prominent

brows, or significant blepharospasm may not

be candidates for femtosecond laser if the

surgeon does not feel confident docking on

the globe (Figure 4) Aligning the laser to the

patient takes about five minutes. Local anes-

thesia is used, and the laser procedure itself

takes only 30 seconds.

Premium IOLsAll IOL manufacturers offer plenty of printed

material as well as animated video to show

your patients their options. These resources

can help patients better understand the ben-

efits of premium IOLs.

If a patient is interested in a multifocal IOL,

I adhere to the recommended guidelines for

patient candidacy. Our office works mainly

with Alcon IOLs, so I have more experience

with them. We like the patient to be hyper-

opic; however, these patients tend to have a

larger angle kappa.

Angle kappa is the difference between the

pupillary axis and the visual axis (Figure

5).5 It is defined as the angle between the vi-

sual axis (line connecting the fixation point

with the fovea) and the pupillary axis (line

that perpendicularly passes through the en-

trance pupil and the center of curvature of

the cornea).

It can be identified clinically by the nasal

displacement of the corneal light reflex from

the pupil center, and it represents a misalign-

ment of light passing through the refractive

surface of the cornea and the bundle of light

formed by the pupil.5 Angle kappa is not af-

fected by gender, and it tends to decrease

with age.

A large angle kappa is important clinically

because it may lead to alignment errors and

decentration during laser refractive cataract

surgery. Decentration of the IOL can lead to

photopic phenomena (glare and halos) as well

as decrease in lens effectiveness. An option

to compensate for a large angle kappa is to

Cataract optionsContinued from page 21

Figure 4. LenSx docking device. Image courtesy of Alcon

4

U.S. surgeon adoption of femtosecond laser surgery

Source: Market Scope Cataract & Refractive Surgeon Reports Q1 2015–Q4 2016

50

45

40

35

30

25

20

15

10

5

0

10

9

8

7

6

5

4

3

2

1

0Q1 ‘15

% offer today % femto procedure share

Q2 ‘15 Q3 ‘15 Q4 ‘15 Q1 ‘16 Q2 ‘16 Q3 ‘16 Q4 ‘16

Ado

ptio

n ra

te

Fem

to p

roce

dure

sha

re

IOL manufacturers offer printed material and animated video to explain options

23S P E C I A L S E C T I O N

| PRACTICAL CHAIRSIDE ADVICE

Comanagement

purposely decenter the IOL toward the visual

axis. Centering the IOL on the corneal reflex

will greatly reduce the incidence of photopic

phenomena. A decentered IOL can decrease

multifocal function.

Let the patient know multifocal IOLs are not

for everyone, and clinical measurements will

determine if the patient is a good candidate.

Higher order aberrations consist of spher-

ical aberration, coma, and trefoil. Corneal

coma is an imperfection that results in off-

axis point sources such as stars appearing

to have a tail—or coma. Vertical coma is the

most common higher order aberration in pa-

tients with keratoconus, corneal injuries, or

abrasions.6

One study involving 119 eyes undergoing

uncomplicated cataract surgery with a 2.2-

mm incision showed those patients who re-

ceived a superior incision showed significant

negative changes in vertical coma. Patients

who had a nasal incision showed significant

changes in oblique trefoil, and those that had

a temporal incision had insignificant changes

in higher order aberrations.7

We make sure the corneal coma is less than

0.32 μm for each eye. The angle kappa should

be less than 0.43 mm for ReStor (Alcon) and

0.50 mm for Tecnis (Johnson & Johnson Vi-

sion Care) IOL. Also, the photopic pupil size

should be no smaller than 2.0 mm and the

mesopic pupil size no larger than 6.00 mm.

I find this data on Marco OPD.

Patients who currently wear multifocal con-

tact lenses may also be good candidates. They

tend to have more realistic expectations as

well as those with an easy-going personality.

Tell patients the brain will learn to adapt to

the new vision with an IOL. This is called neu-

roadaptation, and it can take several months

to adapt. Look at the patient as a whole. For

example, a patient who is a +6.00 D hyperope

with a mature cataract will be thrilled with

her new vision. However, a -3.00 D myope

with mild to moderate cataracts may be a bit

more critical of the results.

AcrySof IQ ReStor +2.50 D (Alcon) features

the company’s ActiveFocus optical design with

seven diffractive steps. It has a distance cen-

ter with a large peripheral zone that allows

more light to the distance focal point as the

pupil diameter increases and an apodized

diffractive multifocal zone. This IOL is de-

signed for individuals with an active lifestyle

wanting distance and intermediate vision.2

If the patient has 1.00 D or more of cor-

neal cylinder, we opt for toric IOL instead of

a standard implant.

AcrySof IQ Toric (Alcon) IOL is a biconvex

toric with aspheric design and ranges from

+6.0 to +34.0 with seven cylinder powers.

I use the company’s online calculator (ac-

rysoftoriccalculator.com) to calculate the toric

power and axis placement.

ITCH RELIEF24 HOURS OF OCULAR ALLERGY

IN ONE DROP1

Help your patients SAVE on their co-pay for PAZEO® Solution

Your eligible commercially insured patients may pay as little as $10

with the Co-Pay Savings Card!

Limitations apply.*

Olopatadine is licensed from Kyowa Hakko Kirin Co., Ltd. Japan

Novartis Pharmaceuticals CorporationEast Hanover, New Jersey 07936-1080 ©2017 Novartis 3/17 PAL-1342348

Visit www.pazeohcp.com to learn more about PAZEO® Solution and patient savings.

Alcon Pharmaceuticals

$10*

ELIGIBLE COMMERCIALLY

INSURED PATIENTS MAY PAY AS LITTLE AS

CO-PAY OFFER

PAZEO® Solution: The ONLY FDA-approved therapy with

demonstrated 24-hour ocular allergy itch relief in ONE DROP1

PAZEO® Solution has the highest concentration of

olopatadine available on the market1,2

No generic therapeutic equivalent is available2

PAZEO® (olopatadine hydrochloride

ophthalmic solution) 0.7%:

INDICATION AND DOSING

PAZEO® Solution is indicated for the treatment of ocular itching associated with allergic conjunctivitis. The recommended dosage is to instill one drop in each aff ected eye once a day.

IMPORTANT SAFETY INFORMATION

As with any eye drop, care should be taken not to touch the eyelids or surrounding areas with the dropper tip of the bottle to prevent contaminating the tip and solution. Keep bottle tightly closed when not in use.

Patients should not wear a contact lens if their eye is red. PAZEO® Solution should not be used to treat contact lens-related irritation. The preservative in PAZEO® Solution, benzalkonium chloride, may be absorbed by soft contact lenses. Patients who wear soft contact lenses and whose eyes are not red should be instructed to wait at least fi ve minutes after instilling PAZEO® Solution before they insert their contact lenses.

The most commonly reported adverse reactions in a clinical study occurred in 2%-5% of patients treated with either PAZEO® Solution or vehicle. These events were blurred vision, dry eye, superfi cial punctate keratitis, dysgeusia, and abnormal sensation in eye.

For additional information on PAZEO® Solution, please refer to the brief summary of the full Prescribing Information on the following page.

References: 1. PAZEO® Solution Package Insert. 2. US Department of Health and Human Services. Food and Drug Administration. Approved drug products with therapeutic equivalence evaluations. In: The Orange Book. 36th ed. Rockville, MD: US Department of Health and Human Services; 2016.

* Terms and Conditions: Limitations apply. For commercially insured patients. Up to a $125 cap per bottle. Patient will be responsible for any co-pay once limit per bottle is reached. This off er is not valid under Medicare, Medicaid, or any other federal or state program. Not valid for cash-paying patients. Novartis reserves the right to rescind, revoke, or amend this program without notice. Off er expires 12/31/2017.

Patients with large pupils are at a greater risk for experiencing glare postoperatively

See Cataract options on page 24

24S P E C I A L S E C T I O N

APRIL 2017 |

Comanagement

I also use an online visual simulator which

shows patients simulated visual results with

an IOL for activities including golfing, gar-

dening, shopping, and night driving. Enter

the patient’s astigmatism, level of cataract

development, and IOL option to demonstrate

the visual outcome. Obviously, results may

vary, but it is a great way to demonstrate a

patient’s expected visual results with vari-

ous IOL options.

We also implement the ORA System with

VerifEye+ technology. It offers real-time intra-

operative IOL sphere, cylinder, and alignment

suggestions. This is especially useful in the

operating room for patients with a history of

refractive surgery, including LASIK, PRK, and

RK procedures. It helps to account for both

anterior and posterior corneal astigmatism.

The goal is to reduce the incidence of unin-

tended residual postoperative astigmatism.2

After the surgeryComplications associated with cataract sur-

gery are rare. Cataract surgery is one of the

most successful procedures performed in the

United States.8 However, it can include bleed-

ing, retinal detachment, and infection. I as-

sure patients that they will be using antibi-

otics to prevent infection. Bleeding is usually

limited to the conjunctiva and will resolve in

one to two weeks.

We let our patients know there are no restric-

tions. I tell them they can bend, lift, shower,

BRIEF SUMMARY

PAZEO (olopatadine hydrochloride ophthalmic solution) 0.7%. For topical ophthalmic administration. The following is a brief summary only; see full prescribing information for complete product information.

CONTRAINDICATIONS

None.

WARNINGS AND PRECAUTIONS

Contamination of Tip and Solution

As with any eye drop, care should be taken not to touch the eyelids or surrounding areas with the dropper tip of the bottle to prevent contaminating the tip and solution. Keep bottle tightly closed when not in use.

Contact Lens Use

Patients should not wear a contact lens if their eye is red.

The preservative in PAZEO solution, benzalkonium chloride, may be absorbed by soft contact lenses. Patients who wear soft contact lenses and whose eyes are not red, should be instructed to wait at least five minutes after instilling PAZEO before they insert their contact lenses.

ADVERSE REACTIONS

Clinical Trials Experience Because clinical trials are conducted under widely varying conditions, adverse reaction rates observed in the clinical trials of a drug cannot be directly compared to rates in the clinical trials of another drug and may not reflect the rates observed in the practice.

In a randomized, double-masked, vehicle-controlled trial, patients at risk for developing allergic conjunctivitis received one drop of either PAZEO (N=330) or vehicle (N=169) in both eyes for 6 weeks. The mean age of the population was 32 years (range 2 to 74 years). Thirty-five percent were male. Fifty-three percent had brown iris color and 23% had blue iris color. The most commonly reported adverse reactions occurred in 2-5% of patients treated with either PAZEO or vehicle. These events were blurred vision, dry eye, superficial punctate keratitis, dysgeusia and abnormal sensation in eye.

USE IN SPECIFIC POPULATIONS

Pregnancy Risk Summary There are no adequate or well-controlled studies with PAZEO in pregnant women. Olopatadine caused maternal toxicity and embryofetal toxicity in rats at levels 1,080 to 14,400 times the maximum recommended human ophthalmic dose (MRHOD). There was no toxicity in rat offspring at exposures estimated to be 45 to 150 times that at MRHOD. Olopatadine should be used during pregnancy only if the potential benefit justifies the potential risk to the fetus.

Animal Data In a rabbit embryofetal study, rabbits treated orally at 400 mg/kg/day during organogenesis showed a decrease in live fetuses. This dose is 14,400 times the MRHOD, on a mg/m2 basis.

An oral dose of 600 mg/kg/day olopatadine (10,800 times the MRHOD) was shown to be maternally toxic in rats, producing death and reduced maternal body weight gain. When administered to rats throughout organogenesis, olopatadine produced cleft palate at 60 mg/kg/day (1080 times the MRHOD) and decreased embryofetal viability and reduced fetal weight in rats at 600 mg/kg/day. When administered to rats during late gestation and throughout the lactation period, olopatadine produced decreased neonatal survival at 60 mg/kg/day and reduced body weight gain in offspring at 4 mg/kg/day. A dose of 2 mg/kg/day olopatadine produced no toxicity in rat offspring. An oral dose of 1 mg/kg olopatadine in rats resulted in a range of systemic plasma area under the curve (AUC) levels that were

45 to 150 times higher than the observed human exposure [9.7 ng∙hr/mL] following administration of the recommended human ophthalmic dose.

Nursing Mothers

Olopatadine has been identified in the milk of nursing rats following oral administration. Oral administration of olopatadine doses at or above 4 mg/kg/day throughout the lactation period produced decreased body weight gain in rat offspring; a dose of 2 mg/kg/day olopatadine produced no toxicity. An oral dose of 1 mg/kg olopatadine in rats resulted in a range of systemic plasma area under the curve (AUC) levels that were 45 to 150 times higher than the observed human exposure [9.7 ng∙hr/mL] following administration of the recommended human ophthalmic dose. It is not known whether topical ocular administration could result in sufficient systemic absorption to produce detectable quantities in the human breast milk. Nevertheless, caution should be exercised when PAZEO is administered to a nursing mother.

Pediatric Use

The safety and effectiveness of PAZEO have been established in pediatric patients two years of age and older. Use of PAZEO in these pediatric patients is supported by evidence from adequate and well-controlled studies of PAZEO in adults and an adequate and well controlled study evaluating the safety of PAZEO in pediatric and adult patients.

Geriatric Use No overall differences in safety and effectiveness have been observed between elderly and younger patients.

NONCLINICAL TOXICOLOGY

Carcinogenesis, Mutagenesis, Impairment of Fertility Carcinogenicity Olopatadine administered orally was not carcinogenic in mice and rats in doses up to 500 mg/kg/day and 200 mg/kg/day, respectively. Based on a 35 μL drop size and a 60 kg person, these doses are approximately 4,500 and 3,600 times the MRHOD, on a mg/m2 basis.

Mutagenesis No mutagenic potential was observed when olopatadine was tested in an in vitro bacterial reverse mutation (Ames) test, an in vitro mammalian chromosome aberration assay or an in vivo mouse micronucleus test.

Impairment of fertility Olopatadine administered at an oral dose of 400 mg/kg/day (approximately 7,200 times the MRHOD) produced toxicity in male and female rats, and resulted in a decrease in the fertility index and reduced implantation rate. No effects on reproductive function were observed at 50 mg/kg/day (approximately 900 times the MRHOD).

PATIENT COUNSELING INFORMATIONG�!.80�4+��439&2.3&9.43B��);.8*�5&9.*398�94�349�94:(-�)7455*7 tip to eyelids or surrounding areas, as this may contaminate the dropper tip and ophthalmic solution.

G��43(42.9&39�#8*�4+��439&(9�D*38*8B��);.8*�5&9.*398�349�94 wear contact lenses if their eyes are red. Advise patients that PAZEO should not be used to treat contact lens-related irritation. Advise patients to remove contact lenses prior to instillation of PAZEO.

The preservative in PAZEO solution, benzalkonium chloride, may be absorbed by soft contact lenses. Lenses may be reinserted 5 minutes following administration of PAZEO.

Patents: 8,791,154

ALCON LABORATORIES, INC.

Fort Worth, Texas 76134 USA

© 2015 Novartis.

PAL-1342347

Cataract optionsContinued from page 23

See Cataract options on page 26

Figure 5. Diagram of angle kappa. Image courtesy of Wolters Kluwer5

5

I recommend contacting coman-aging surgeons to obtain their protocols so you can better prepare your patients

© 2016 OCuSOFT, Inc., Rosenberg, TX 77471

Kills Bacteria on Contact -“0” Eye Irritationy

Stable 18 Months Opened or Unopened

Ask Yourself This Question...

“Why Prescribe?”

For more information and to order,

call (800) 233-5469 or visit www.ocusoft.com

www.whyprescribe.com

26S P E C I A L S E C T I O N

APRIL 2017 |

Comanagement

shampoo, and do all their usual activities. We

ask them to avoid swimming or hot tubs for

a week. Patients can usually drive after the

one-day postoperative appointment as long

as pupil dilation is resolving and they feel

comfortable driving. Always check the vi-

sual acuity of both eyes. It is common cour-

tesy to send a short postoperative report to

the surgeon.

REFERENCES1. Carl Zeiss. Zeiss presents the new IOLMaster 700 for better predictability and optimized workflows in cataract surgery. Available at: https://www.zeiss.com/meditec/int/media-news/press-releases/iolmaster-700-with-

sweptsource-biometry.html. Accessed 3/15/17.

2. Alcon. The AcrySof Advantage. Available at: https://www.myalcon.com/products/surgical/acrysof-iq-cataract-iols/index.shtml. Accessed 3/15/17.

3. Marco. OPD-SCAN III Wavefront Aberrometer. Available at: https://marco.com/products/wavefront-aberrometry/opd-scan-iii-wavefront-aberrometer/. Accessed 3/15/17.

4. Nagy ZZ, Kránitz K, Takacs AI, Miháltz K, Kovács I, Knorz MC. Comparison of intraocular lens decentration

parameters after femtosecond and manual capsulotomies J Refract Surg. 2011 Aug;27(8):564-9.

5. Moshirfar M, Hoggan RN, Muthappan V. Angle Kappa and its importance in refractive surgery. Oman J

Ophthalmol. 2013 Sep;6(3):151-8.

6. Gordon-Shaag A, Millodot M, Ifrah R, Shneor E. Aberrations and topography in normal, keratoconus-suspect, and keratoconic eyes. Optom Vis Sci. 2012 Apr;89(4):411-8.

7. Seok Song I, Hoon Park J, Hyoung Park H, Young Moon

S, Yong Kim J, Joon Kim M, Tchah H. Corneal coma and trefoil changes associated with incision location in cataract surgery. J Cataract Refract Surg. 2015 Oct;41(10):2145-2151.

8. Torpy JM, Lynm C, Glass RM. Cataracts. JAMA. 2003; 290(2):286.

Cataract optionsContinued from page 24

6 Figure 6. ORA showing positioning of limbal relaxing incisions. Image courtesy of Alcon

Dr. Fluder is a member of the American Optometric Association and the Indiana Optometric Association. She has no financial interest in any of the devices discussed. eyedive3@gmail.com

BEDFORD, MA—Ocular Therapeutix, Inc. announced

positive results of a patient experience study

of Dextenza (dexamethasone insert) 0.4 mg

for intracanalicular use.

The study, published in Patient Preference

and Adherence, evaluated the overall patient

experience and perceived value of Dextenza

following cataract surgery.

Dextenza is a hydrogel-based drug-eluting

intracanalicular insert that incorporates the

U.S. Food and Drug Administration (FDA)-

approved corticosteroid, dexamethasone, as

the active ingredient.

Inserted non-invasively through the punc-

tum, Dextenza resides within the canalicu-

lus and delivers dexamethasone to the ocular

surface for approximately 30 days. Follow-

ing the completion of treatment, Dextenza

resorbs and exits the nasolacrimal system

without need for removal.

The goal associated with Dextenza is to

reduce noncompliance of patient adminis-

tration of topical eye drops following oph-

thalmic surgery by enabling the physician to

control the entire course of steroid therapy

with a single administration.

In parallel, Dextenza aims to remove the

issues commonly associated with non-com-

pliance of post-operative medications follow-

ing ophthalmic surgery.

A New Drug Application (NDA) for Dex-

tenza is currently under review by the FDA

for the treatment of ocular pain occurring

after ophthalmic surgery. The FDA has set

a PDUFA target action date for July 19, 2017.

According to the company, the patient ex-

perience retrospective study was conducted

with 25 patients who had received active treat-

ment in the company’s Phase 3 clinical trials

of Dextenza for the treatment of post-surgical

ocular pain and inflammation.

– All patients reported that the intracana-

licular insert was comfortable.

– Ninety-six percent felt the insert was ex-

tremely or very convenient compared to topi-

cal eye drops on a tapered schedule.

– Ninety-two percent reported the highest

level of overall product satisfaction, with 88

percent saying they would request the insert if

they were to undergo cataract surgery again.

– Ninety-two percent of patients surveyed

said they would recommend Dextenza to

friends or family members.

“We are encouraged by the experiences

these patients shared, which add another di-

mension to the clinical results achieved in

the Phase 3 clinical trials,” says Jonathan H.

Talamo, MD, chief medical officer of Ocular

Therapeutix.

“If approved, we believe that Dextenza,

which incorporates the Company’s proprietary

hydrogel platform technology, will offer an

attractive alternative to the current post-op-

erative standard of care of steroid eye drops

for those recovering from ophthalmic sur-

gery,” he says.

In the company’s third and most recent

Phase 3 clinical trial, Dextenza successfully

met the two primary efficacy endpoints, ab-

sence of ocular pain on Day Eight and ab-

sence of ocular inflammation on Day 14, when

compared to placebo.

According to the company, Dextenza has

exhibited a favorable safety profile and has

been well tolerated in all clinical trials, re-

gardless of indication.

Subject to the approval of the NDA for post-

surgical ocular pain by the FDA, Ocular Thera-

peutix intends to submit an NDA supplement

for Dextenza to broaden its label to include

a post-surgical inflammation indication.

Study positive Dextenza results prior to FDA review date

IN BRIEF

Biotrue® solution helps their lenses keep up

Lenses alone may not always be able to meet the demands of the digital age.

Biotrue® keeps lenses comfortable all day long, with a unique bio-inspired

formulation that works like your patients’ eyes. No wonder it’s the

multi-purpose solution used by more patients.*

Let patients know their solution matters.

Recommend Biotrue® multi-purpose solution.

For more information, call 1-800-828-9030 or visit Bausch.com/ecp

Patients check their devices

110 times a dayBiotruth #32

#

3 BIO-INSPIRED INNOVATIONS

Matches the pH of healthy tears(7.5)1

Keeps key benefi cial tear proteins such as lysozyme active1

Has hyaluronan (HA), a lubricant found naturally in the eyes, helping to provide up to 20 hours of moisture 2

REFERENCES: 1. Data on fi le. Bausch & Lomb Incorporated. Rochester, NY. 2. In vitro studies evaluated the rate of release of sodium hyaluronate (HA), a conditioning agent in the BPZ02 multi-purpose solution, from both conventional and silicone hydrogel contact lenses over a twenty-hour time period. HA was adsorbed on all traditional and silicone hydrogel contact lenses tested upon soaking in the solution overnight. HA is then released from the lenses throughout at least a twenty hour time period when rinsed with Hank’s balanced salt solution at a rate mimicking tear secretions. The in-vitro performance of BPZ02 multi-purpose solution suggests that it will provide lens conditioning throughout a twenty hour time period.

*Highest household penetration among multi-purpose solutions; IRI Panel 52 weeks ending 12/25/16.

® / ™ are trademarks of Bausch & Lomb Incorporated or its affi liates.© 2017 Bausch & Lomb Incorporated. BIO.0050.USA.17

SPECIAL SECTION28 APRIL 2017 |

When it comes to optometric

care, stroke survivors are

often an under-served pop-

ulation—especially when

most of them have visual or ocular

deficits. Stroke survivors with visual

problems are often dead-ended in

neuro-ophthalmology offices because

the internists and cardiologists who

refer them to neuro-ophthalmology

don’t know that ODs can treat stroke-

related visual/ocular challenges. Plus,

many optometrists are unfamiliar

with how they can help stroke survivors.

Although a background in behavioral op-

tometry, vision therapy, and/or neuro-opto-

metric rehabilitation is helpful, primary-care

ODs can easily learn the basics necessary

to treat the most common visual problems

of those who have had a stroke.

Stroke basicsAlmost 800,000 people suffer a stroke every

year, and it is the most common disability

among American adults.1 A stroke occurs

when there is an interruption of the blood

flow to an area of the brain.

There are two types of strokes: an isch-

emic stroke, occurring when a blood clot

blocks a blood vessel, and a hemorrhagic

stroke, occurring when a blood vessel in the

brain ruptures and causes damage. Some

strokes are preceded by brief episodes of

stroke symptoms known as transient isch-

emic attacks (TIA), which are temporary

interruptions of blood supply to the brain.

Because a TIA can occur hours, days, or

weeks before a full stroke, it behooves us to

be aware of the symptoms and signs—tem-

porary episodes of weakness, numbness, pa-

ralysis of the face, arm or leg (especially on

one side of the body), difficulty speaking or

understanding simple statements, and loss

of balance or coordination.2 These symp-

toms can occur on only one side of the body.

To that list should be added any report of

momentary diplopia, transient loss of visual

field, or a passing episode of blurry vision.

Every primary-care optometrist

can—and should—as a minimum

perform the following work-up on a

patient presenting with any signs:

– History of stroke-related signs

and symptoms

– Best-corrected visual acuity

– Pupil reflexes

– Cover test, phorias, ocular

range of motion

– Threshold visual field testing

– Dilated fundus examination

– Stethoscope auscultation of the

carotid arteries for bruits

Whether a clinical ocular deficit is dis-

covered, any transient visual episode should

trigger a call to the patient’s internist or

cardiologist to urge the physician to sched-

ule the patient for a physical. In addition, I

proactively write the patient an Rx for ca-

rotid Doppler testing and/or a CT scan—

this starts the ball rolling.

When a patient presents with a known,

previously documented stroke, pay attention

to current complaints of persisting hemi-

anopsia, diplopia, or eyelid dysfunction.

These conditions can often be treated by

the primary-care optometrist.

DiplopiaDiplopia from a recent stroke is confusing

to the patient because adaptation by a head

turn or suppression has not yet occurred.

Diplopia also causes symptoms of dizzi-

ness, poor balance, trouble reading, psycho-

logical stress, asthenopia, and headaches.

Patients with double vision may mention

those complaints but not say “double vi-

sion” unless asked.

Most stroke survivors with a known cere-

brovascular accident (CVA)-related diplopia

have been instructed to patch the deviating

eye. This makes the patient happy because

the patch resolves the diplopia. Unfortu-

nately, patching the deviating eye for too

many weeks can embed the binocular dys-

function, reducing the possibility of gain-

ing binocular vision.

Therefore, as a minimum, ensure that the

eye patch is alternated daily from the right

eye to left eye. To keep the schedule simple,

I tell patients to patch the right eye on even-

numbered calendar days and to patch the

left eye on odd-numbered calendar days.

Keep in mind that when patching to com-

pensate for diplopia, the patient may be an-

noyed or uncomfortable because of the re-

duced peripheral vision caused by the patch.

In those cases, selective occlusion can be

used by cutting a piece of Transpore surgical

tape into a small rectangle to block central

vision in front of the pupil of the deviating

eye. The tape blocks double vision and al-

lows the patient to retain an awareness of

periphery in the occluded eye, which feels

more comfortable and is safer than a tra-

ditional eye patch.

Some patients with obvious large angles

of paretic strabismus do not complain of

diplopia. That is because the angle of stra-

bismus is so large that the patient can con-

centrate on the image straight ahead of the

non-strabismic eye while ignoring (but not

necessarily suppressing) the diplopic image

located way off center. Although patients

may not complain of diplopia, they may

still have behavioral symptoms of confu-

sion, poor balance, or poor ambulation due

to visual confusion induced by the ambi-

ent diplopic image. This problem requires

consultation with an OD skilled in treating

binocular vision dysfunction.

Stroke-related binocular dysfunctions with

How to care for stroke patientsODs can help these overlooked patients with visual needs

ERROL RUMMEL, OD, FAAO, FCOVD, FNORA, FIALVSis in private practice in Jackson, NJ

TAKE-HOME MESSAGE Optometrists are able to address the visual needs of stroke survivors, an underserved population. Consider using alternate patching or prism for diplopia. For hemianopsia, prescribe separate pairs of glasses for both distance and near for or consider Side Vision Awareness Glasses designed by the author. Lid massage may help lid paresis.

Comanagement

By Errol Rummel, OD, FAAO, FCOVD, FNORA, FIALVS

29S P E C I A L S E C T I O N

| PRACTICAL CHAIRSIDE ADVICE

mild-to-moderate paretic angles of strabis-

mus often are capable of gaining a wider

range of motion of the effected eye. This can

be achieved by having the patient monocu-

larly track a moving target (pursuits) in the

direction of the restrictions several times

per day for a few weeks.

Using prismMany patients are told by non-optometric

doctors that double vision may resolve on

its own within a vague timeline of months

without mentioning vision therapy or prism.

It is dismaying that people with stroke-re-

lated hemiplegia are recommended to have

physical and occupational therapy, but pa-

tients with diplopia are given only an eye

patch and not afforded a chance for bin-

ocular rehabilitation. I suggest prescribing

prism glasses as a stopgap measure to help

the patient feel more comfortable.

Simple vision therapy procedures using a

Brock string or red-green tranaglyphs may

help until vision therapy is initiated. Never

prescribe a ground prism into glasses until

a two- to three-month trial with a Fresnel

prism has shown the angle of deviation to

be steady and that the double vision has

been resolved.

It is important to prescribe the total amount

of Fresnel prism with the prismatic com-

pensation broken up between the two eyes

to allow the Fresnel-induced reduction in

contrast to be distributed evenly between

both eyes.

For example, if an esotropia-related dip-

lopia is resolved with 20 D base-out prism,

it may seem simple to prescribe a single 20

D base-out Fresnel prism before the deviat-

ing eye. However, the patient will usually

complain of blur in the eye with the Fres-

nel prism. Two 10 D base-out prisms are a

better choice because they equalize the 20

D Fresnel-induced poor contrast, which re-

duces patient complaints.

Furthermore, splitting the prism power

between two eyes allows the freedom to

fine tune the prism power when, or if, the

patient’s angle of deviation changes. Peel

off one of the Fresnel prisms and replace

it with another power as is clinically indi-

cated. Keep in mind that the angle of the

paresis measured when viewing at distance

may be very different than at near, so sepa-

rate prismatic distance glasses and reading

glasses are often required.

When prescribing compensating prism

for vertical diplopias, remember that the

angle of deviation usually varies depend-

ing on head position. Be sure to prescribe

the vertical prism with the patient’s head

in a straight-ahead position and warn the

patient that a chin-up or chin-down head

position will likely cause him to see double

in spite of the prism.

A patient whose diplopia is resolved with

prism may begin to complain again of dip-

lopia in a few months. Never assume that

a renewed complaint of diplopia implies a

worsening of the condition. It may mean

that the strabismic angle is decreasing.

Do not be disheartened if a rare patient

can’t fuse binocularly with any amount of

prism. A prism bar may seem to neutral-

ize the diplopia while the patient is in the

chair, but you may find that when you pre-

scribe Fresnel prisms, the patient still com-

Comanagement

See Stroke patients on page 30

Figures 1 and 2.SVAG (Side Vision Awareness Glasses) clear side vision with a wide viewing area when looking through the prism lens.

1

2

30S P E C I A L S E C T I O N

APRIL 2017 |

plains of double vision. At times despite

re-measuring, fine tuning, and changing

prism power, the patient continues to not

fuse the diplopic images.

Some neuro-related diplopias are difficult

to resolve because of damage in the brain

pathways responsible for the binocular vi-

sion reflex, and horror fusionalis, when it

occurs, is difficult or impossible to resolve—

an alternating eye patch may be the only

treatment available.

HemianopsiaStroke-related hemianopsia is reasonably

common. The field defect is obvious on a

24-2 threshold visual field test.

However, some stroke survivors have

hemi-spatial inattention (also known as

“neglect”), which is an inattention to or

lack of sensory awareness of visual space

to one side. It may or may not be associated

with a hemianopsia.

Patients with hemi-spatial inattention

will usually be unaware of their inability

to perceive space on the affected side, may

not be able to follow a moving target in the

direction of the neglect, and may say that

their physician or occupational therapist

“said” that they have visual concerns to the

side (although the patient is not cognitively

aware of the hemianopic like loss of visual

field). That is a difficult concern to address

and should be referred to an optometrist

skilled in neuro-optometric rehabilitation.

Hemianopsia usually leaves a person dis-

oriented and struggling to make it through

daily living. People with hemianopsia are

often afraid to leave their homes and are

concerned about their safety. They are con-

fused in a busy visual environment—such

as the mall where they may bump into peo-

ple—or have the fear of falling off a curb.

Hemianopsia can cause a sense of loss

of independence due to discontinuing driv-

ing. Others find that ambulatory activities

are more difficult. People with hemianopsia

(but without hemi-spatial inattention) can

often be helped by an optometrist.

As a minimum, recommend two sepa-

rate pairs of glasses: one for distance and

one for near. Separate pairs are needed be-

cause with hemianopsia, bifocals or pro-

gressive lenses limit the width of the see-

ing area through the glasses. In my expe-

rience, hemianopsia patients usually have

fewer field-related complaints with full-field

single-vision glasses.

I have prescribed specially-designed eye-

glasses over the past 20 years to help those

with hemianopsia. The optical care of hemi-

anopsia is based on using prism to expand

side vision awareness. Available hemianop-

sia-related glasses I worked with were dif-

ficult to prescribe, difficult for the patient

to use, or had optical design flaws.

I learned what worked and what didn’t

work. I designed a prism technology called

SVAG (Side Vision Awareness Glasses) that

can be prescribed by any trained optome-

trist (See Figures 1 and 2).

Prior to developing SVAG, hemianopsia-

related eyeglasses afforded only a limited

circular viewing area. This limited the pa-

tients’ appreciation of the expanded field

awareness or required a highly-cognitive

patient who could adjust to simultaneously

viewing straight ahead while noticing out-

of-focus peripheral images caused by Fres-

nel prism.

I developed SVAG with a high Abbe value

because patients with older hemianopsia

glasses complained of distracting color ab-

errations. SVAG also have a higher index of

refraction, making them thinner and more

cosmetically acceptable. There is also no

prism button or Fresnel lens strip on the

front of the lens. SVAG provides clear side

vision with a wide viewing area when look-

ing through the prism lens.

Eyelid paresisSome stroke patients develop blepharopa-

resis, while others develop ptosis.

If there is ptosis, avoid disuse of the ptotic

eye by taping it open about a centimeter

for five minutes a few times per day using

Transpore surgical tape. Be sure to allow

enough slack in the tape for blinking. Pa-

tients should instill an artificial tear every

minute to prevent discomfort and drying

during the interval the eye is taped open.

If there is a blepharoparesis and the eye

won’t close, be sure to use Transpore sur-

gical tape to keep the eye closed to prevent

corneal staining and discomfort.

After years of watching physical therapists

work use massage with stroke patients, I

decided to try a similar massage technique

on the eyelids. I found that some patients

with stroke-related ptosis or blepharopare-

sis responded to an eyelid massage.

The massage is conducted with your fin-

ger, using a brisk moderate stroking of the

affected lid in a lateral and radial fan shape.

An alternating warm or cool pack applied

before lid massages may increase sensory

stimulation to the lids, enhancing the ef-

fect. Massage for a few minutes four times

per day for three weeks. Discontinue if no

change in ptosis or belpharoparesis.

Some ptosis patients have what I call dip-

lopic pseudo-ptosis or DPP. Stroke survivors

with a stroke-related esotropia or exotropia

subconsciously learn to close the offending

eye to avoid diplopia. Although they will

appear to have ptosis, it is not ptosis. Cover

the non-ptotic eye; if the patient is capable

of opening the apparently ptotic eye, you

have discovered a DPP.

For blepharoparesis, I sometimes use

commercially available eyelid weights to

pull the lid down. The lid weights come

in a fitting set of graded weights with an

adhesive backing. These test weights are

used to determine the weight of a gold lid

implant used by oculoplastic surgeons. Op-

tometrists can use the test set weights to

treat blepharoparesis noninvasively until

surgery is indicated.

Specialty optometric consultation is avail-

able through colleagues associated with

Neuro-Optometric Rehabilitation Associa-

tion (NORA) and the College of Optometrists

in Vision Development (COVD).

REFERENCES1. National Stroke Association. What is stroke? Available at http://www.stroke.org/understand-stroke/what-stroke. Accessed 3/22/16.

2. National Stroke Association. Transient Ischemic

Attack. 1999. Print.

Comanagement

Stroke patientContinued from page 29

Dr. Rummel is director of the Neuro-Optometric Rehabilitation and Visual Perception Clinic at the Bacharach Institute for Rehabilitation. He has developed protocols for prescribing reverse telescope glasses and Rummel Reading Guides are used by occupational therapists and neuro-rehab optometrists to help patients with hemianopsia. He has served in the United States Army as a Captain in the Optometry Section of the Medical Service Corps.

Egrumm2020@aol.com

– History of stroke-related signs and symptoms– Best-corrected visual acuity– Pupil reflexes– Cover test, phorias, ocular range of motion– Threshold visual field testing– Dilated fundus examination– Stethoscope auscultation of the carotid

arteries for bruits

What to include in a possible stroke workup

Toll free 888 - 519 - 5375ads@oculususa.com www.oculususa.com

Follow us!

OCULUS Keratograph® 5M

Comprehensive Analysis of the Meibomian Glands

• NEW: The JENVIS Grading Scales for the meibomian glands

• Meibo-Scan: Analysis of the meibomian glands of the upper and lower eyelids

• Comparative display of meibomian glands from up to four examinations

Toll free 888-519-5375ads@oculususa.com www.oculususa.com

Fol

Please note: The availability of the products and features may differ in your country.

Specifications and design are subject to change. Please contact your local distributor for details.

APRIL 2017 | 32 Point-of-care testing

By William Townsend, OD, FAAO

Even in our era of modern health

care, it is often challenging to

identify and manage dry eye

disease (DED)—at least in part be-

cause it is often difficult to diag-

nose.1 This disparity may be due

to the fact that in many instances,

the signs, symptoms, and severity

of the condition correlate poorly or

not at all.2 For the patient, perhaps

the most significant symptom of DED is fluc-

tuating or reduced vision.

Dry eye and osmolarityAccording to the Dry Eye WorkShop (DEWS)

definition, dry eye is “a multifactorial disease

of the tears and ocular surface that results in

symptoms of discomfort, visual disturbance,

and tear film instability with potential dam-

age to the ocular surface. It is accompanied

by increased osmolarity of the tear film and

inflammation of the ocular surface.”3

Stern et al identified the disparate compo-

nents that function together to protect and

nourish the ocular surface:4

– Cornea

– Conjunctiva

– Accessory lacrimal glands

– Meibomian glands

– Main lacrimal gland

– Interconnecting innervation

system

This cumulative system eventu-

ally came to be known as the lac-

rimal functional unit (LFU).4 The

concept of a multi-component unit

that protects the ocular surface is

vital; it reinforces the theory that

failure of one or more segments of the unit

can lead to DED. We must consider dry eye

as a chronic, bilateral, asymmetric, progres-

sive disease.

In 2014, Bron and colleagues sought to

dispel several misconceptions that hamper

clinical diagnosis and management of DED.

They concluded that “osmolarity appears to

be the best marker across all levels of dis-

ease severity as well as in different subtypes

of DED.”5

Tear osmolarityThe concept of an association between in-

creased tear osmolarity (TO) and DED is not

new. In 1981, Farris published the first re-

port showing a positive correlation among

female gender, increasing age, contact lens

wear, and elevated TO. Large-scale studies

have reinforced the value of TO as a consis-

tent marker in DED.6

In 2006, Tomlinson’s meta-analysis of TO

in normal eyes and diverse subtypes of dry

eye showed a predictive accuracy of 89 per-

cent for the diagnosis of DED.7

Early research directed at the relation-

ship between elevated TO and DED used

the freezing point method of osmometry.8

This method has largely been confined to

research facilities because it requires signifi-

TAKE-HOME MESSAGE Tear osmolarity testing in OD offices can help ODs better diag-nose and manage dry eye patients. In-office testing allows ODs to access more information in a timely fashion, retest as needed for better management, better educate patients, and better recognize the severity of a patient’s condition.

How to use tear osmolarity to help treat dry eye diseaseIn-office testing provides more information for better patient management

WILLIAM TOWNSEND, OD, FAAO, practices in Canyon, TX

Figure 1.The device has a small footprint, making it easy to add tear osmolarity testing to your examination flow. Images courtesy William Townsend, OD, FAAO.

1

See Tear osmolarity on page 34

FIRST OF A FOUR-PART SERIES

References 1. Guthrie S, Dumbleton K. Jones L. Financial implications of patient compliance. Contact Lens Spectrum. 2014;29:42-45. 2. Dumbleton K, Richter D, Bergenske P, Jones LW. Compliance with lens replacement and the interval between eye examinations. Optom Vis Sci. 2013;90(4):351-358. 3. Muya L, Lemp J, Kern J, Sentell K, Lane J, Perry S. Impact of packaging saline wetting agents on wetting substantivity and lubricity. Invest Ophthalmol Vis Sci. 2016; 57(12):ARVO E-abstract 1463. 4. Alcon data on file, 2016. 5. Dewetting analysis; Alcon data on file, 2016. 6. Marx S, Sickenberger W. Wettability of different silicone hydrogel lens materials and blister solutions measured using non-invasive keratographic drying up time (NIK-DUT). Optom Vis Sci. 2016;93:E-abstract 165113. 7. Eiden SB, Davis R, Bergenske P. Prospective study of lotrafilcon B lenses comparing 2 versus 4 weeks of wear for objective and subjective measures of health, comfort, and vision. Eye Contact Lens. 2013;39(4):290-294. 8. Lemp J, Kern J. A comparison of real time and recall comfort assessments. Poster presented at: American Academy of Optometry 2016 Annual Meeting; November 9-12, 2016; Anaheim, CA. 9. In a survey of 310 optometrists in the US; Alcon data on file, 2014.

See product instructions for complete wear, care and safety information. © 2017 Novartis 02/17 US-AOH-17-E-0184 Sponsored by

Our passion is to help your patients see, look

and feel their best.

Important information for AIR OPTIX® plus HydraGlyde (lotrafilcon B), AIR OPTIX® AQUA Multifocal (lotrafilcon B) and AIR OPTIX® for Astigmatism (lotrafilcon B) contact lenses: For daily wear or extended wear up to 6 nights for near/far-sightedness, presbyopia and/or astigmatism. Risk of serious eye problems (i.e., corneal ulcer) is greater for extended wear. In rare cases, loss of vision may result. Side effects like discomfort, mild burning or stinging may occur.

Important information for AIR OPTIX® COLORS (lotrafilcon B) contact lenses: For daily wear only for near/far-sightedness. Contact lenses, even if worn for cosmetic reasons, are prescription medical devices that must only be worn under the prescription, direction and supervision of an eye care professional. Serious eye health problems may occur as a result of sharing contact lenses. Although rare, serious eye problems can develop while wearing contact lenses. Side effects like discomfort, mild burning or stinging may occur. To help avoid these problems, patients must follow the wear and replacement schedule and the lens care instructions provided by their eye doctor.

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

*Savings via mail-in (or online) rebate. Rebate is in the form of an Alcon VISA® pre-paid card. Certain criteria must be met to be eligible for the full rebate. Must be a new patient to the AIR OPTIX® Family of contact lenses or an existing patient that is switching lenses within the AIR OPTIX® Family. Must purchase an annual supply (four 6-ct boxes) of AIR OPTIX® brand contact lenses (excluding AIR OPTIX® AQUA lenses) within 90 days of eye exam or contact lens fitting. Partial rebate available for purchasing a 6-month supply (two 6-ct boxes) of AIR OPTIX® brand contact lenses (excluding AIR OPTIX® AQUA lenses) within 90 days of eye exam or contact lens fitting. Rebate submission must be postmarked (or submitted electronically) within 60 days of lens purchase date. Valid on purchases made at participating retailers through 6/30/17. Visit AIROPTIXCHOICE.com for complete terms and conditions.

†Based on a clinical study with AIR OPTIX® AQUA, AIR OPTIX® for Astigmatism, and AIR OPTIX® AQUA Multifocal contact lenses.

At Alcon, we are committed to helping you move ALL of your contact lens patients to a more compliant replacement schedule. Recent studies show that a monthly replacement frequency can have several benefits: 65% of monthly

replacement wearers replaced their lenses on time vs. 30% of 2-week replacement wearers1; and the interval between annual

office visits was shorter with monthly replacement vs. 2-week replacement.2 Because we believe that all patients should have access to contact lenses with a healthy replacement schedule, we are proud to introduce the Alcon AIR OPTIX® Choice Program. Now, patients will benefit when upgrading to many of the products in the AIR OPTIX® contact lens family,* including AIR OPTIX® plus HydraGlyde®, our latest monthly lens innovation combining our 2 breakthrough technologies—SmartShield® surface technology and HydraGlyde® Moisture Matrix—for long-lasting lens surface wettability.3-6

As a practitioner, you expertly consider several factors when choosing which lens brands to recommend to a patient, including lens materials, ocular technologies, and replacement frequencies. The goal of your recommendation is to best meet the needs of your patient as well as the needs of your practice; but, another factor sometimes gets in the way of your top choice: cost. That’s why Alcon continues to

pioneer support programs like the Alcon AIR OPTIX® Choice Program—to allow your patients to save on Alcon’s monthly replacement contact lenses.

The Alcon AIR OPTIX® Choice Program is intended to help your 2-week replacement lens wearers upgrade to a monthly replacement contact lens option within the AIR OPTIX® family of contact lenses—so you can continue to help your patients see, look and feel their best with up to $100 savings on their first annual supply.* Patients can sign up for the Alcon AIR OPTIX® Choice Program and access program benefits at AIROPTIXCHOICE.com. Your Alcon sales representative can also provide you with Point-of-Purchase (POP) materials to help promote the AIR OPTIX® Choice Program to your patients.

The Alcon AIR OPTIX® Choice Program offers savings that significantly reduce the retail price of a 6-month or 1-year supply of AIR OPTIX® contact lenses. Patients new to the AIR OPTIX® family of contact lenses or patients switching within the AIR OPTIX® family (excluding AIR OPTIX® AQUA lenses) can save $100 on an annual purchase or $40 on a semi-annual purchase of eligible AIR OPTIX® contact lenses, via mail-in or online rebate. Current AIR OPTIX® wearers who re-purchase a supply of the same lens may qualify for a $60 savings on an annual supply via mail-in (or online) rebate and a $25 savings on a semi-annual supply purchase via mail-in (or online) rebate through Alcon’s Family Rebate offer. Purchases of AIR OPTIX® AQUA contact lenses do not qualify for the Alcon AIR OPTIX® Choice Program or the Alcon Family Rebate; consider upgrading your AIR OPTIX® AQUA patients to AIR OPTIX® plus HydraGlyde contact lenses where they can save up to $100* and benefit from long-lasting lens surface moisture.3-6

ADVERTORIAL

THE IMPORTANCE OF

SmartShield® Technology delivers consistent comfort from Day 1 to Day 303,4

A consistently comfortable lens with lasting lens surface moisture5-8

The #1 eye doctor recommended contact lens for patients who sleep in their contact lenses9

PRECISION BALANCE 8/4™ lens design that provides outstanding stability for astigmatic patients

A multifocal lens with Precision Profile™ Design that provides seamless vision, near through far

A naturally beautiful lens that enhances eye color with 3-in-1 color technology

ent vs 2-week The Alcon

astigmatic patients

thl l

their contact lenses

t AIR OPTIX®XX Choice Prog

on, near through far

AIR

visio

gram offers savings thatoffice visits was shorter withith

APRIL 2017 | 34 Point-of-care testing

cant expertise, takes considerable time, and

necessitates large volume samples of tears.7

In 2009, OcuSense, Inc. received FDA clear-

ance for the TearLab Osmolarity System, a

tear osmometer that determines osmolarity

values via electrical impedance of tears.9 This

‘‘lab-on-a-chip’’ technology requires a tear

sample of approximately 50 nanoliters (nL)

to measure osmolarity, and I have found the

instrument to be effective and easy use.

To put the required sample size into per-

spective, a nanoliter is one billionth of a liter.

The older freezing point technique required

nearly 500 to 1,000 times the volume used

by the TearLab system.10

Homeostasis and dry eyeHomeostasis is the process by which biologi-

cal systems maintain stability in order to

survive. Diabetes is good systemic example

of failure to maintain homeostasis. When

the endocrine system fails to maintain blood

glucose levels with a normal range of values,

disease and damage result.11

DED can be thought of as a failure of the

LFU to maintain homeostasis.5

Failure to maintain normal TO is a com-

mon and diagnostic feature of evaporative

dry eye disease (EDED), aqueous deficiency

dry eye (ADDE), or most commonly a combi-

nation of the two.3 In dry eye states, regard-

less of the type, TO is frequently elevated or

asymmetric between the eyes, and the dis-

parity increases with severity of the DED.5,12

Incorporating osmolarityBefore I used TearLab in my practice, I was

confident in my ability to diagnose DED. As

I gained experience in DED management, I

realized that in relying on biomicroscopic

evaluation, Schirmer strips (now over 100

years old), vital dye staining, and other tests,

I missed many patients who had DED. Tear-

Lab provided a true biomarker utilizing a lab

test in my own office. It changed the way I

diagnose and manage DED.

Older techniques still have value, but they

are much less consistent and accurate than

obtaining osmolarity values.13 We now real-

ize that corneal and conjunctival staining,

which are often used as markers to initiate

treatment, occur late in the DED process.12

Using staining alone as an indication for ini-

tiating dry eye therapy may result in delayed

treatment for the majority of dry eye patients.

Because TearLab is a lab test, your office

will be considered as such and a Clinical

Laboratory Improvement Act (CLIA)-waived

category license is required. The process is

straightforward. Plus, once you obtain a li-

cense, it is typically good for two years and

allows other CLIA-waived tests to be per-

formed at your point-of-care clinic.

You will be required to perform several

steps to ensure quality control. They are able

to be conducted by office staff, and they are

essential to ensure your that patients are get-

ting precise readings. This is a small price

to pay for having the access to lab tests per-

formed and read in our clinics with quick re-

sults in less than eight seconds per eye and

available while the patient is in the office.

I recommended implementing two steps in

your patient flow protocols to be efficient and

effective in determining which patients re-

ceive the test and how it will be administered.

First, ask your patients to complete a dry

eye-specific questionnaire prior to their exam.

Second, empower technicians to review the

questionnaire based on a protocol that you

establish, then advise patients who fail the

questionnaire that the doctor will want os-

molarity test results available for the exam.

This process allows me to review patients’

TO values and discuss results with them

during my exam. It also promotes office ef-

ficiency and better patient care.

Patients should refrain from using any eye-

drops, including over-the-counter and pre-

scription drops for at least two hours prior

to osmolarity testing. If not, we may obtain

false low readings. The only two exceptions

Tear osmolarityContinued from page 32

If I have a high suspicion of DED, especially with significant intereye difference, retesting TO on subsequent visits may reveal higher values

Figure 2.Using the device is simple to learn and delegate. My techs conduct the test so I have results available to review with the patient during the exam.

2

– Variations in tear stability and osmolarity are at the core of the complex etiologic mechanism of dry eye pathology.

– In non-dry eye individuals, TO ranges 280 to 295 Osml/L (equivalent to normal blood serum osmolarity) and is maintained within a tight range of values in both eyes.

– Intereye difference is a hallmark in DED and is correlated to disease severity.

FDA labeling requires both eyes to be tested; the severity level is based on the higher of the two eyes’ TO value.

Osmolarity testing pearls

See Tear osmolarity on page 36

Find your inspiration

for excellence.

Registration opens April 24, 2017. For more information visit www.aaopt.org

�&72%(5©��g��`©���!© È© �&�250,&.©�/$&(

Find your inspiration for excellence at Academy 2017 Chicago. Join us in Chicago for four days of brilliant speakers, clinically-relevant CE sessions, the latest products and technology in the exhibit hall, captivating papers and posters and cherished social events.

APRIL 2017 | 36 Point-of-care testing

are topical anesthetic drops and/or dilating

drops, which may be used less than two

hours prior to osmolarity testing. Ideally, TO

is the first test administered, even prior to

tonometry or any bright lights, that could

cause significant reflex tearing.

Retest and followPatient education is the foundation of good

care. You may describe dry eye to your pa-

tients as simply having too much salt (sol-

utes) in the tear layer and explain that it

causes some patients to have any number

of symptoms. I explain that our goal is to

reduce that level of abnormal osmolarity.

Remember we are evaluating patients’

risk in the management process. There is

no “magic” number. Patients like to know

their findings and understand their signifi-

cance. A good example is our colleagues in

internal medicine and their long-term model

for cholesterol management. They educate

patients about the risks of hypercholesterol-

emia and benefits of preventive care.

Using the higher of a patient’s two eyes’

values as a starting point allows me to as-

sign a severity range. Typically, mild patients

range 300 to 320; moderate 320 to 340; and

the severe category (only about eight percent

of all dry eye) fall above 340.14

Because the TearLab device ranges from

275 to 400 mOsml/L, I can show each pa-

tient where he falls along a severity scale

and avoid obsessing on an absolute number.

Keep in mind the CV with TearLab is <1.5

percent, which is the equivalent to about

± 4 mOsm/L.

Going back to our cholesterol example, in-

ternists are not concerned about whether a

patient’s total cholesterol is 201 or 198 mg/

dL—rather, they want to know if the patient

is in a mild, moderate, or high risk category

for cardiovascular disease. Once they review

the lab results, they establish a specific goal

of therapy for each patient.

The same holds true for our management

of patients with dry eye disease.

In some cases, patients may present very

early in the process with intereye differences

>8 mOsm/L but still have bilateral TO read-

ings less than 300 mOsml/L; this is the clas-

sic sign of an unstable tear film.

If I have a high suspicion of DED, espe-

cially with significant intereye difference,

retesting TO on subsequent visits may reveal

higher values. Knowing that lab tests are not

about an exact number but rather a range

of values, I do not hesitate to repeat tests.

The caveat is that an intereye difference

>8 mOsm/L is considered to be abnormal.

If patients show normal values on a subse-

quent visit, I follow them over time to ensure

they do not convert to elevated levels of hy-

perosmolarity that are potentially harmful.

Monitoring treatmentOnce you have determined the underlying

etiology of the DED, explained the results to

the patient, and developed a treatment plan,

the next step is monitoring the process. One

additional benefit to tear testing is improved

compliance because patients understand that

you will be repeating this test when they

return. Remind the patient not to use any

drops on the day of the next visit to prevent

unreliable test results.

Avoid the error of bringing the patient

back too soon. A 10 mOsml/L decrease is

considered clinically significant, but some

therapies require at least four to six weeks

before this goal is reached.

In some cases, a patient may return and

despite good compliance have TO values

higher than those obtained on the initial

evaluation. The patient should be advised

this is valuable information because it tells

you her DED is more severe than initially

thought and you will prescribe more aggres-

sive therapy.

In my experience, the patient-doctor edu-

cation made possible by lab tests facilitates

a very high level of patient management.

Dry eye care is one of the most reward-

ing but challenging facets of my practice.

Osmolarity testing has changed my treat-

ment philosophy by providing additional in-

formation to help me diagnose and manage

DED more effectively. In my opinion, many

unsuccessful dry eye treatment plans result

from failing to recognize the true severity of

a patient’s condition and prescribe appropri-

ate therapeutic measures.

REFERENCES1. Bartlett JD, Keith MS, Sudharshan L, Snedecor SJ. Associations between signs and symptoms of dry eye disease: a systematic review. Clin Ophthalmol. 2015 Sep 16;9:1719-1730.

2. Barabino S, et al. Understanding symptoms and quality of life in patients with dry eye syndrome. Ocul

Surf. 2016 Jul;14(3):365-376.

3. The Definition and Classification of Dry Eye Disease: Report of the Definition and Classification Subcommittee of the International Dry Eye WorkShop (2007). Ocul Surf. 2007 Apr;5(2):75-92.

4. Stern ME, et al. The role of the lacrimal functional unit in the pathophysiology of dry eye. Exp Eye Res. 2004 Mar;78(3):409-416.

5. Bron AJ, Tomlinson A, Foulks GN, Pepose JS, Baudouin C, Geerling G, Nichols KK, Lemp MA. Rethinking dry eye disease: a perspective on clinical implications. Ocul Surf. 2014 Apr;12(2 Suppl):S1-31.

6. Farris RL, Stuchell RN, Mandel ID. Basal and reflex human tear analysis. I. Physical measurements: osmolarity, basal volumes, and reflex flow rate. Ophthalmology. 1981 Aug;88(8):852-857.

7. Tomlinson A, McCann LC, Pearce EI. Comparison of human tear film osmolarity measured by electrical impedance and freezing point depression techniques. Cornea. 2010 Sep;29(9):1036-1041.

8. Gilbard JP, Farris RL. Ocular surface drying and tear film osmolarity in thyroid eye disease. Acta

Ophthalmol (Copenh). 1983 Feb;61(1):108-116.

9. Jacobi C, Jacobi A, Kruse FE, Cursiefen C. Tear film osmolarity measurements in dry eye disease using electrical impedance technology. Cornea. 2011 Dec;30(12):1289-1292.

10. Zarbin MA, Montemagno C, Leary JF, Ritch R. Nanotechnology in ophthalmology. Can J Ophthalmol. 2010 Oct;45(5):457-476.

11. Holst JJ, Gribble F, Horowitz M, Rayner CK. Roles of the Gut in Glucose Homeostasis. Diabetes Care. 2016 Jun;39(6):884-892.

12. Lemp MA, Bron AJ, Baudouin C, Benítez Del Castillo JM, Geffen D, Tauber J, Foulks GN, Pepose JS, Sullivan BD. Tear osmolarity in the diagnosis and management of dry eye disease. Am J Ophthalmol. 2011 May;151(5):792-798.e1.

13. Versura P, Profazio V, Campos EC. Performance of tear osmolarity compared to previous diagnostic tests for dry eye diseases. Curr Eye Res. 2010 Jul;35(7):553-564.

14. Potvin R, Makari S, Rapuano CJ. Tear film osmolarity and dry eye disease: a review of the literature. Clin Ophthalmol. 2015 Nov 2;9:2039-3047.

Dr. Townsend is an adjunct professor at the University of Houston College of Optometry and preceptor for senior externs who rotate through his practice. He conducts research in pharmaceutical agents, contact lens materials and solutions, and ocular surface disease and serves on the advisory board and conducts research for TearLab. When not seeing patients, Dr. Townsend enjoys splitting wood at his cabin in New Mexico.

drbilltownsend@gmail.com

Tear osmolarityContinued from page 34

Osmolarity testing has changed my treatment philosophy by providing additional information to help me diagnose and manage DED more effectively

APRIL 2017 / OptometryTimes.com MarketplaceMarketplace 37

CAREERS

CONNECTICUTNATIONAL

ALLDocs (The Association of

LensCrafters Leaseholding Doctors)

has dozens of OD job opportunities.

One of the nation’s leading

optometry organizations, ALLDocs

members hire only the finest ODs,

and provide cutting-edge

technology with tremendous

growth opportunities.

Optometry Jobs Nationwide

Visit

https://www.alldocsod.com/jobs/

for the job listings.

Email rmedwick@medwick.net | Call 860-442-1466 | Visit www.ronaldmedwickod.com

Optometric Associates, P.C. is looking to hire an Optometrist. We are a well-established practice in Waterford, Connecticut. Waterford is a beautiful coastal community, that is located between Boston and New York!

We are very excited to be adding an OD to our team! If you are ready for a change of pace and want to live at the beach, then apply today!

Benefits include

Competitive Salary Health Insurance No Weekends Paid Vacations

We have been providing eye care to the community for over 40 years. The practice has maintained a high level of care by utilizing cutting edge technology, both clinically and in practice management.

This position is open to a well-qualified doctor who is looking for a full time position, with the possibility of practice purchase in the near future!

Acuity Pro Vision Science Software 6

Aerie Pharmaceuticals, Inc. 11

Alcon Laboratories Inc CVTIP, CV4 Tel: 800-862-5266Web: www.alcon.com

American Academy Of Optometry 35

Bausch And Lomb 9, 27

Beaver Visitec International 17

Cooper Vision CV2 Web: www.coopervision.com

Marco Ophthalmic Inc 5

Mibo Medical Group 15Tel: 214-507-8091

Novabay Pharmaceuticals CV3

Novartis Ophthalmics 23, 24

Oculus Inc 31

Ocusoft 25

Shire Ophthalmic 7, 19-20Tel: 415-971-4650

TTI Medical 13Tel: 4800-322-7373Web: www.ttimedical.com

This index is provided as an additional service. The publisher does not assume any liability for errors or omissions.

Advertisers IndexAdvertiser Page

Optometrists and allied

eye care professionals.

Contact me today to

place your ad.

Reach your target audience.

Our

audience.

Tamara PhillipsAccount Manager

440-891-2773

tamara.phillips@ubm.com

Place a recruitment ad in

Optometry Times—

in print or online.

Joanna ShippoliAccount Manager

440-891-2615

joanna.shippoli@ubm.com

Narrow your candidate

search to the best.

APRIL 2017 | 38 A&Q

boards of kids’ frames—we’ve

got five times that. We have

such a great selection that we

can fit most kids. Our techs

are really good. They’re fast

and efficient, and they do a

wonderful job at making the

kids comfortable. In terms

of clinical stuff, one of the

things that makes us stand

out is our passion for myopia

prevention. All these kids are

coming in, and they’re getting

worse every year. If we can

talk to them about strategies

to slow that down, that’s defi-

nitely something that makes

us unique and is lots of fun.

With both monthly and biweekly contact lenses

available, why a daily dispos-ables-only practice? The ben-

efits with daily disposables

are huge, especially with my

pediatric population. Let’s be

honest, kids are dirtier than

we are. There are a multitude

of valid reasons why these

kids should not be reusing

their contact lenses, even

with the best hygiene. It just

makes a lot of sense for them

to be in daily disposables;

they reduce the risks

so, so much. The pa-

tients enjoy the con-

venience. But the

main purpose is

to reduce the

risk of contact

lens-related

complications.

There’s a huge, huge amount of folks in the Asian population who are myopic. Because we see such a large portion of the myopes in central Indiana who are pediatric, you start looking into ways that you can help people. For my whole career, it’s been glasses and contact lenses, which it still is for the most part, but I can look at world-wide trends and ask how I can help my little piece of the world not become so myopic and learn more and do bet-ter for them. We do our part in myopia preven-tion from Indianapolis.

QQHow did you get involved in the global myopia

problem?

 What three things would you advise new ODs who

want to go into pediatric op-tometry? Have the right mo-

tivation. [Laughs] It’s not an

easy task. And know your

own personality, make sure

you can make that work

with kids. I know clinically

I can make kids feel at ease

and do my job quickly and

professionally so that I can

be a good doctor for chil-

dren and make it fun. Num-

ber two: Surround yourself

with staff who can do it. We

went through staff at the be-

ginning who are great tech-

nicians and opticians, but

they’re not meant to work

with kids. The third thing

would be to be brave and

just go for it because it’s not

an easy niche of optometry.

People are looking for it, but

it’s not selling $700 frames.

It’s completely different from

a vision therapy practice or a

primary-care practice.

What do you do for downtime? I really

enjoy my family, of course.

I have two kids, so we enjoy

lots of things with their

sports and activities. I like

to work out, read, and have

a good nap. If I can get those

three things on a regular

basis, I am a happy camper.

What was the biggest challenge starting up

Little Eyes, and how did you meet it? Awareness. People

don’t think about preventa-

tive care for their kids. They

think about, “Oh, my kid

complained that the board is

blurry, so I’m going to bring

him in to the eye doctor.”

Our marketing campaign fo-

cuses on letting people know

that preventative eye care

is just as important as your

yearly checkup at the pedia-

trician or your twice a year

visit to the dentist. The pub-

lic awareness has been huge.

The real boost in awareness

has been schools, pediatri-

cians, and day cares.

What do you consider Lit-tle Eye’s best practices?

An incredible dispensary;

our optician is wonderful.

We have a lot of outside Rxs

come to us because we have

a huge selection of frames.

Most offices have one or two

Pediatric optometry, daily disposables, and nappingKatherine Schuetz, OD Optometrist at Little Eyes, Carmel, IN

Phot

o co

urte

sy K

athe

rine

Schu

etz,

OD

Why did you add ortho-keratology, and how has

it changed your practice? We

added it because we knew

the need was there in terms

of myopia prevention. We

also have a ripe practice pop-

ulation for ortho-k. It’s kids

who are getting worse, we’re

trying to slow that down,

and they’re motivated to try

other things. I had referred a

few patients out over the first

couple of years to a colleague

locally, and I thought, “This

is crazy, I need to learn or-

tho-k, I need to become an

expert and offer it to my pa-

tients.” And that’s what we

did.

—Vernon Trollinger

To hear the full interview with

Katherine Schuetz, listen online:

optometrytimes.com/KatherineSchuetz

AV E N O VA . C O M | � � � � � � � � � � � � | R X O N LY

Daily lid and lash hygiene.

Avenova.The essential part of

any lid hygiene regimen.

Antibiotic and resistance free Avenova

with Neutrox®. The one no-sting solution

that helps manage the itchy, burning,

irritated eyelids often caused by blepharitis,

MGD and dry eye. Used alone or

concomitantly, Avenova is the essential

part of any lid and lash hygiene regimen.

Avenova. Every day.

Avenova contains Neutrox, a proprietary pure hypochlorous acid that mimics the body’s immune response. It works without creating mammalian cell toxicity

or bacterial resistance. It’s well tolerated for daily use.

BRUSH. FLOSS. AVENOVA®.

Visit NovaBay at Vision Source Exchange – Booth #235

-10.00D+6.00DWATER CONTENT (%)

PERFORMANCE DRIVEN BY SCIENCE®

See product instructions for complete wear, care and safety information.

© 2016 Novartis 9/16 US-DTM-16-E-3722

Ask your Alcon representative for details

how these revolutionary lenses may be able

to help your presbyopic patients see clearly.

WATER GRADIENT TECHNOLOGY MEETS

PRECISION PROFILETM DESIGN

DAILIES TOTAL1® Multifocal contact lenses

UNIQUE WATER

GRADIENT

TECHNOLOGY

0.25 steps

LO MED HI

ADDs