Five myths about scleral lenses debunked

Transcription

march 2015
VOL. 7, NO. 3
Practical Chairside Advice
OptometryTimes.com
Five myths about scleral
lenses debunked
Don’t allow misinformation to prevent
you from helping your patients
Figure 1.
A scleral lens
demonstrating clearance
of the ocular
surface that
extends
beyond the
limbus.
THIS IS WHY your patients
Postoperative in-the-bag inferiorly dislocated IOL. Note the
superior view of the capsular bag and peripupillary fibrillar material
Considerations
for pseudoexfoliation
after cataract surgery
Assess patients starting
at 24 hours
By Marta C. Fabrykowski, OD, FAAO
As discussed in the companion article (“Preoperative considerations in patients with cataracts and pseudoexfoliation syndrome,” December 2013), patients with pseudoexfoliation (PXF) have an accelerated incidence
Precision Profile Design
of cataract formation,1,2 and the surgery for
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These patients may require extensive preoperative testing, and they also demand in-
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S
See Pseudoexfoliation on page 1
**
Distance
Intermediate
Near optometrist
Canadian
accuses Yelp of extortion
getting past these myths might help practicleral lenses have gained popularity
tioners begin to embrace sclerals and incorin the last decade. From a lens with
porate them into their practices.
limited viability for over 100 years to
By Colleen E. McCarthy
the fastest growing segment of the gas
Content Specialist
myth Sclerals are hard to fit
permeable lens market, scleral lenses have
come a long way. Yet there is still some hesVancouver, Canada—A Vancouver optometrist has
Many practitioners look at the size of
itance on the part of many practitioners to
accused online review website Yelp of exa scleral lens and assume that it must
Daily Disposable
Lens
™
fit
or
recommend
them,
and
some
miscontortion, according to The Globe and Mail.
be
hard
to
fit.
Practitioners
already
feel
like
PERFORMANCE DRIVEN BY SCIENCE
ceptions about scleral lenses may be holding
Alan Boyco, OD,
says he Replacement
was contacted by
fitting corneal gas permeable lenses is chalMonthly
Lens
back individuals who might otherwise be ofYelp in 2013 to discuss advertising his praclenging enough, and that a lens that is signififering them to the benefit of many patients.
tice, Image Optometry, which has 16 locacantly larger can be only more complicated
®
I
wanted
to
explore
what
I
tions
around
greater
Vancouver,
onand
itsnot
site.
to
fit.
This
is
simply
a
myth.
*AIR OPTIX AQUA Multifocal (lotrafilcon B) contact lenses: Dk/t = 138 @ -3.00D. Other factors may impact eye
health.
**Image
is for illustrative
purposes
an exact
representation.
felt were five myths about
Dr. Boyco agreed to a six-month trial for an
Scleral lenses do require a slightly different
Important information for AIR OPTIX® AQUA Multifocal (Iotrafi lcon B) contact lenses: For daily wear or extended wear up to 6 nights for near/far-sightedness and/or
See Scleral lenses on page 1
See Extortion on page 1
scleral lenses and how
presbyopia. 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
1
stinging may occur.
References: 1. Based on third-party industry report, 12 months ending March 2014, Alcon data on file. 2. 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.
See product
Q A instructions for complete wear, care, and safety information.
See page 34
& | Dr. Jill Autry Tobacco, pharmacy and optometry, and pleading the Fifth
© 2014 Novartis
10/14
MIX14193JAD-A
maRch 2015
VOL. 7, NO. 3
optometrytimes.com
PRACTICAL CHAIRSIDE ADVICE
Five myths about scleral
lenses debunked
Don’t allow misinformation to prevent
you from helping your patients
FIGURe 1.
a scleral lens
demonstrating clearance
of the ocular
surface that
extends
beyond the
limbus.
Postoperative in-the-bag inferiorly dislocated IOL. Note the
superior view of the capsular bag and peripupillary fibrillar material
Considerations
for pseudoexfoliation
after cataract surgery
Assess patients starting
at 24 hours
By Marta c. fabrykowski, OD, fAAO
As discussed in the companion article (“Preoperative considerations in patients with cataracts and pseudoexfoliation syndrome,” December 2013), patients with pseudoexfoliation (PXF) have an accelerated incidence
of cataract formation,1,2 and the surgery for
cataract removal may be more complicated.
These patients may require extensive preoperative testing, and they also demand insee Pseudoexfoliation on page 22
By Jason Jedlicka, OD, fAAO
cleral lenses have gained popularity
in the last decade. From a lens with
limited viability for over 100 years to
the fastest growing segment of the gas
permeable lens market, scleral lenses have
come a long way. Yet there is still some hesitance on the part of many practitioners to
fit or recommend them, and some misconceptions about scleral lenses may be holding
back individuals who might otherwise be offering them to the benefit of many patients.
I wanted to explore what I
felt were five myths about
scleral lenses and how
S
Q&A
magenta
cyan
yellow
black
getting past these myths might help practitioners begin to embrace sclerals and incorporate them into their practices.
myth Sclerals are hard to fit
Many practitioners look at the size of
a scleral lens and assume that it must
be hard to fit. Practitioners already feel like
fitting corneal gas permeable lenses is challenging enough, and that a lens that is significantly larger can be only more complicated
to fit. This is simply a myth.
Scleral lenses do require a slightly dif-
1
see Scleral lenses on page 20
canadian optometrist
accuses Yelp of extortion
By colleen e. Mccarthy
content specialist
Vancouver, Canada—A Vancouver optometrist has
accused online review website Yelp of extortion, according to The Globe and Mail.
Alan Boyco, OD, says he was contacted by
Yelp in 2013 to discuss advertising his practice, Image Optometry, which has 16 locations around greater Vancouver, on its site.
Dr. Boyco agreed to a six-month trial for an
see Extortion on page 5
| DR. JILL AUTRY TOBACCO, PHARMACY AND OPTOMETRY, AND PLEADING THE FIFTH
SEE PAGE 34
ES573263_OP0315_CV1.pgs 02.21.2015 03:44
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ES572780_OP0315_CV2_FP.pgs 02.20.2015 18:10
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| PRACTICAL CHAIRSIDE ADVICE
FROM
THE
3
Chief Optometric Editor
What kind of doctor do you want to be?
By Ernie Bowling, OD, FAAO
Chief Optometric Editor
He is in private practice in Gadsden, AL, and
is the Diplomate Exam Chair of the American
Academy of Optometry’s Primary Care Section
[email protected]
256-295-2632
recently finished reading Doctored:
The Disillusionment of an American Physician by Sandeep Jauhar,
MD. The author is a New York cardiologist, and his memoir is still on
the New York Times Best Sellers list
since its release in August 2014.
The book is a scathing criticism
of our healthcare system, told in
an honest and quite open manner. Reading early on, I found
myself substituting “optometry”
for “medicine” and found there
were a lot of messages ODs could glean. For example: “Eighty percent of medical
diagnoses can probably be made on the basis
of a patient’s history.” So, my old optometry
school professor was right; the case history
never ends. He also subscribes to the Yogi
Berra school of physical diagnosis: “You
I
can learn a lot by looking.”
While the author takes a dim view of
private medical practice—“Those guys are
a bunch of crooks” and “Did I really want
to become another private practice grunt,
overtesting, kissing ass for referrals, fighting insurers to get paid”—he learns from
his successful surgeon brother that practice
success is derived from the
three As: availability, accessibility, and affability.
He also quickly caught on
that, no matter your practice
environ, it was important to
see as many patients as possible. “The culture today is
to grab patients and generate
volume,” the author laments.
Dr. Jauhar is even critical of
medical education. “Medical
school teaches the bad lesson
that in order to succeed, you
have to memorize... they are never taught to
think. ...I have worked in teaching hospitals
(and) I have discerned a gradual decline in
the intellectual climate of these institutions.
Of all the places one might expect doctors
to be curious about medicine, teaching hos-
pitals should be first.” I loved to teach, a
doctor told him, but the residents and fellows just didn’t want to learn.
Dr. Juahar saves his harshest comments
for “the perverse financial incentives of our
current fee-for-service system,” especially
unnecessary medical testing. “No one ever
goes into medicine to do unnecessary testing. However, this sort of behavior is rampant.” According to a colleague, “if a doctor doesn’t do excess testing, forget it, he
isn’t going to be able to live.”
The author, with his worries and misgivings surrounding his profession, is still optimistic. “Every patient teaches a lesson,” he
says. And what, despite all the shortcomings,
redeems the effort? “It’s the tender moments
helping people in need.” Focus on the craft
and your relationship with patients, since
this is something we can control, he says.
That is a take-home lesson for optometry as
well. It is the overarching reason we all do
what we do: to care for our patients. And
he asks the question: “What
kind of doctor do you want
Want
EHR tips?
to be?” A great question
Turn to page 16
for us all, no matter our
for suggestions
health care discipline.
from Dr. Scott
Sikes.
Editorial Advisory Board
Ernie 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.
Jeffrey Anshel, OD, FAAO
Michael P. Cooper, OD
Alan G. Kabat, OD, FAAO
Mohammad Rafieetary, OD, FAAO
Joseph Sowka, OD, FAAO
Ocular Nutrition Society
Encinitas, CA
Chous Eye Care Associates
Tacoma, WA
Southern College of Optometry
Memphis, TN
Charles Retina Institute
Memphis, TN
Sherry J. Bass, OD, FAAO
Douglas K. Devries, OD
David L. Kading, OD, FAAO
Michael Rothschild, OD
Nova Southeastern University College
of Optometry
Fort Lauderdale, FL
SUNY College of Optometry
New York, NY
Eye Care Associates of Nevada
Sparks, NV
Specialty Eyecare Group
Kirkland, WA
West Georgia Eye Care
Carrollton, GA
Justin Bazan, OD
Steven Ferucci, OD, FAAO
Danica J. Marrelli, OD, FAAO
John Rumpakis, OD, MBA
Park Slope Eye
Brooklyn, NY
Sepulveda VA Ambulatory Care
Center and Nursing Home
Sepulveda, CA
University of Houston College
of Optometry
Houston, TX
Practice Resource Management
Lake Oswego, OR
Lisa Frye, ABOC, FNAO
Katherine M. Mastrota, MS, OD, FAAO
Eye Care Associates
Birmingham, AL
Omni Eye Surgery
New York, NY
Eyecare Consultants Vision Source
Englewood, CO
Ben Gaddie, OD, FAAO
John J. McSoley, OD
Gaddie Eye Centers
Louisville, KY
University of Miami Medical Group
Miami, FL
University of Alabama at Birmingham
School of Optometry
Birmingham, AL
David I. Geffen, OD, FAAO
Ron Melton, OD, FAAO
Peter Shaw-McMinn, OD
Gordon Weiss Schanzlin
Vision Institute
San Diego, CA
Educators in Primary Eye Care LLC
Charlotte, NC
Southern California College of Optometry William D. Townsend, OD, FAAO
Sun City Vision Center
Advanced Eye Care
Sun City, CA
Canyon, TX
Jeffry D. Gerson, OD, FAAO
Highland, CA
Diana L. Shechtman, OD, FAAO
William J. Tullo, OD, FAAO
Patricia A. Modica, OD, FAAO
Nova Southeastern University
Fort Lauderdale, FL
TLC Laser Eye Centers/
Princeton Optometric Physicians
Princeton, NJ
Marc R. Bloomenstein, OD, FAAO
Schwartz Laser Eye Center
Scottsdale, AZ
Crystal Brimer, OD
Crystal Vision Services
Wilmington, NC
Mile Brujic, OD
Premier Vision Group
Bowling Green, OH
Benjamin P. Casella, OD
Casella Eye Center
Augusta, GA
Michael A. Chaglasian, OD
Illinois Eye Institute
Chicago, IL
WestGlen Eyecare
Shawnee, KS
Milton M. Hom, OD, FAAO
A. Paul Chous, OD, MA
Azusa, CA
Chous Eye Care Associates
Tacoma, WA
Renee Jacobs, OD, MA
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Practice Management Depot
Vancouver, BC
Pamela J. Miller, OD, FAAO, JD
SUNY College of Optometry
New York, NY
Laurie L. Pierce, LDO, ABOM
Hillsborough Community College
Tampa, FL
John L. Schachet, OD
Leo P. Semes, OD
Joseph P. Shovlin, OD, FAAO, DPNAP
Northeastern Eye Institute
Scranton, PA
Kirk Smick, OD
Clayton Eye Centers
Morrow, GA
Loretta B. Szczotka-Flynn, OD, MS, FAAO
University Hospitals Case Medical Center
Cleveland, OH
Marc B. Taub, OD, MS, FAAO, FCOVD
Southern College of Optometry
Memphis, TN
Tammy Pifer Than, OD, MS, FAAO
University of Alabama at
Birmingham School of Optometry
Birmingham, AL
J. James Thimons, OD, FAAO
Ophthalmic Consultants of Fairfield
Fairfield, CT
Walter O. Whitley, OD, MBA, FAAO
Virginia Eye Consultants
Norfolk, VA
Kathy C. Yang-Williams, OD, FAAO
Roosevelt Vision Source PLLC
Seattle, WA
ES573160_OP0315_003.pgs 02.21.2015 02:10
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ES573444_OP0315_004.pgs 02.21.2015 05:07
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In Focus
| practical chairside advice
continued from page 1
enhanced profile at about $1,500 a month. But after a few
months, he noticed that the ads weren’t driving any new
traffic, so he decided to cancel after the trial was over.
And that’s when he noticed a big change on his practice’s Yelp page.
How to handle a bad online review
While he was advertising with Yelp, Dr. Boyco says all
reviews—good and bad—appeared on his page. After he
cancelled, however, he says many of the positive reviews
suddenly started disappearing into a section at the bottom
of the page labeled “other reviews that are not currently
recommended” (which also features a variety of reviews
from one to five stars).
After contacting Yelp with his concerns, Dr. Boyco was
told by a senior account manager that the reviews are run
through an automated recommendation software with a complex algorithm that weeds out those trying to game system. Dr. Boyco says he was told by a Yelp representative
that a number of factors go into whether a review is recommended—including how many reviews the users has posted
and whether the user is connected to the business or business owner on Facebook.
“But I kept seeing that it would hide the good review
from someone with only one review but show the bad review from someone with only one review,” Dr. Boyco told
Optometry Times. “But I’ve had no choice to go along with
their explanation of things.”
Dr. Boyco says it’s not about the money, but says his
experience made him feel like it was all a scam.
Yelp has denied that advertisers receive special treatment.
cial treatment going on,” he says.
“A business with only great reviews
showing would look illegitimate. It
makes no sense for Yelp to operate
like that.”
“When you get a bad review, people
tend to have very visceral reactions.
They take it personally,” says Dr.
Glazier. “They project what people
said about their business onto themselves. It’s a hard pill to swallow.”
When you get a bad review online,
resist the urge to react right away.
“Take a deep breath. Don’t act on
it. Don’t comment. Don’t get upset,”
he says.
Instead, give it some time and come
back to it later when you have a level
head. Now that you’ve calmed down,
65.7
60.9
extortion
5
turn lemons into lemonade, says Dr.
Glazier. Respond to the review, but
take the high road and offer a resolution to the problem.
“They’re still probably not going
to ever come back, but this isn’t for
them—it’s for the other people who
will read it and see how you responded,” he says. “If you don’t respond, they’re going to assume the
reviewer was correct. The way you
respond can turn a one-star review
into a four-star review.”
Finally, after you receive a bad
online review, take a step back and
look at yourself and your business.
Use the feedback from the review to
improve the services you offer your
patients.
s
e
c
i
t
c
a
r
P
f
o
%
a
i
d
e
M
l
a
i
c
o
S
with
Accounts
magenta
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2013 n=498;
5.5
.7
2
6.0
2.9
17.0
14.9
15.7
14.8
15.1
2014
2013
21.4
Alan Glazier, OD, who lectures on how to utilize sites
like Yelp, says it’s important that business owners understand how the site works in order to best manage their
online reputation.
“The hidden reviews have been a sore spot for a lot of
people, but Yelp is also about as good at it as it can be,”
says Dr. Glazier. “It hides reviews from people who haven’t
done many reviews because some people sign up just to
bash a business.”
Dr. Glazier says the site prefers to highlight reviews from
users who review often and have friends on the site. If a
user reviews more businesses, adds more friends on the
site, and generally becomes a more active, trusted user,
he is more likely to show up in the top reviews.
“You’re going complain when it hides a good review,
but you’re going to be happy when it hides a bad review,”
he says.
Of all the review sites available, Dr. Glazier says he
thinks Yelp does the best job and doesn’t believe the company modifies the reviews based on advertising.
Optometry Times Editorial Advisory Board Member Justin Bazan, OD, agrees, saying that the site wants to show
reviews from the most credible users.
“It would be quite obvious if there was any kind of spe-
16.5
17.4
Understanding Yelp
2014 n=367
ES573375_OP0315_005.pgs 02.21.2015 04:38
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6
In Focus
March 2015
|
New optometry school a possibility
University of Central Arkansas is conducting a feasability study
By Colleen McCarthy
Content Specialist
CONWAY, AR—The University of Central Arkansas (UCA) recently announced it is assessing the possibility of opening a new school
of optometry.
The university hired Tripp Umbach, a
health care consulting group from Pennsylvania, to conduct the feasibility study
to assess the current and projected needs
of optometrists in Arkansas and the surrounding regions. The university says the
consultants will also look at the advantages
and disadvantages of developing a school
of optometry at UCA.
“There is currently no optometry school
in the state of Arkansas,” says Steven Runge,
PhD, executive vice president and provost.
“We are a state institution, and we serve
the citizens of Arkansas. If we can correct
that deficit in a sustained way that will provide educational opportunities for Arkansas students and enhance the medical services for all Arkansans, then that is what
we want to do.”
The feasibility study will also provide a
financial model for construction, start up,
and operation of the potential optometry
school for the first four years. The study
will begin next month and is planned to be
completed by May 31.
Another OD school?
The subject of the number of optometry
schools has been a hot topic in the profession for a number of years. Last summer,
the American Optometric Association (AOA)
and the Association of Schools and Colleges
of Optometry (ASCO) released the results
of the National Eyecare Workforce Study,
which found that there is a sufficient supply of ODs to meet the demand for the next
20 years.
The AOA says it is not in a position to
evaluate any specific proposal to establish a
new optometry school, but says it supports
rigorous accreditation standards.
“The decision to consider starting a new
school is a state and local decision, made by
public and private entities with the proper
authority,” the AOA said in a statement to
Optometry Times. “The option should be
pursued through an open and transparent
review process through which individual
ODs and others can provide input.”
ASCO says it does not comment on potential optometry schools until or if the schools
become a part of its organization.
“The sudden interest in starting new optometry schools is troubling and should be
addressed by the profession at large,” says
Optometry Times Chief Optometric Editor
Ernie Bowling, OD, FAAO. “Optometric manpower numbers have been debated over the
last year. While the established thinking is
that current numbers are ‘adequate’ for projected needs, no one wishes to see a glut of
newly-minted optometrists hit the workforce.
“The business of colleges is education, but
much thought should be given to whether
new optometry schools are in fact necessary to provide for the eyecare needs of the
public we serve,” says Dr. Bowling.
UCA is located in Conway, about 30 miles
north of Little Rock. University President
Tom Courtway says the university is committed to being a state leader in the health
sciences, and he hopes that the study will
help the university come to an informed
decision.
AOA fights back against 1-800
CONTACTS-backed state legislation
By Colleen McCarthy
Content Specialist
WASHINGTON, DC—The American Optometric Association (AOA) recently updated several state
associations on legislation which is backed by
online contact lens retailer 1-800 CONTACTS.
The bills are in process in several states to
block unilateral pricing policies (UPP). AOA
says the bills are an effort to misrepresent
how ODs provide care and prohibits patients
from obtaining contact lenses from community-based independent ODs.
“The AOA believes that the announced goal
of blocking UPP is part of a larger effort to misrepresent how ODs provide care for patients
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and, ultimately, to prohibit patients from obtaining contact lenses from community-based
practices of independent eye doctors,” says
AOA President David Cockrell, OD, FAAO,
speaking exclusively with Optometry Times.
According to the AOA, these bills are in the
works in Arizona, California, Florida, Idaho,
Illinois, Louisiana, Minnesota, Mississippi,
New York, Oregon, Rhode Island, Tennessee,
Utah, and Washington.
“Some individuals connected to 1-800 CONTACTS, Inc. are saying that efforts to undo
UPP do not directly relate to the practice of
optometry or optometry patients,” the AOA
statement reads. “The AOA does not accept
these assurances, is opposed to their legisla-
tion and is mobilized to work with state associations to ensure that any and all attacks on
optometry receive an immediate response.”
The AOA highlights a number of inaccurate claims made by the bills.
According to the AOA, the bills state that
patients do not understand when the exam
ends and the retail portion of their visit begins—which, the bills claim, denies the patient the opportunity to compare prices.
The bills also claim that UPPs were put in
place expressly for the benefit of the private
practice eyecare provider, citing statements
from Johnson & Johnson Vision Care that
claimed UPP will improve the retention of
See 1-800 CONTACTS on page 8
ES573368_OP0315_006.pgs 02.21.2015 04:27
ADV
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ES572771_OP0315_007_FP.pgs 02.20.2015 18:09
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8
In Focus
1-800 CONTACTS
patients in the provider office by removing
price differentials between other retailers and
the private practice doctors.
In addition, the AOA says the bills claim
that UPP damages an already anticompetitive
lens market. According to the statement, the
bills frequently claim that ODs write prescriptions for certain brands without justification,
prohibiting patients from shopping for different brands or generics—calling into question
the OD’s clinical and professional judgment.
“These bills are an unprecedented attack on
the doctor-patient relationship, and the state
associations and the AOA are fighting back
hard against this latest challenge from the online retailers,” says AOA President-elect Steve
Loomis, OD, FAAO, speaking exclusively with
Optometry Times. “ODs in impacted states
should contact their affiliate offices.”
1-800 CONTACTS repsonds
But 1-800 CONTACTS is firm on its stance
on UPP, saying that it is not only harmful
to market competition but also to patients’
eye health.
“1-800 CONTACTS supports legislation to
eliminate UPP practices in the contact lens
industry,” says 1-800 Contacts Chief Marketing Officer Tim Roush, speaking exclusively
with Optometry Times. “UPP, by contact lens
manufacturers, is just price-fixing by another
name. By setting a minimum price at which
their products can be sold, the four contact
lens manufacturers that control more than
98 percent of the market are increasing costs
for consumers in an effort to influence where
contact lenses are purchased. UPP is a relatively new manufacturer initiative, which
has no place in an industry where eyecare
professionals both prescribe and sell contact
lenses, and where the manufacturers brand
is on a prescription.
“1-800 CONTACTS’ research confirms prices
have increased for a majority of contact lens
wearers since UPP was implemented,” Roush
says. “In fact, UPP will have a negative impact
on eye health care in the U.S. When contact
lenses cost more, patients are less likely to
change them as frequently as manufacturers
recommend.”
ODs: AOA’s concerns mirror theirs
“The AOA is spot on in recognizing this as an
attempt to discredit optometry in the broader
effort of the mail order contact lens seller to
portray contact lenses as a commodity and
not a medical device,” says Union of Ameri-
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March 2015
can Eye Care Providers Executive Director
Craig Steinberg, OD, JD. “Unlike optometrists, ophthalmologists, and pharmacists,
all of whom are trained, licensed, and regulated health care professionals, the mailorder sellers of contact lenses are not health
care providers and are concerned with one
thing only, profits.”
“1-800 CONTACTS has a long history of
irresponsibly disregarding patient healthcare
concerns by selling lenses without a current
prescription, selling a different lens than what
was prescribed, and undermining doctor-patient relationships,” says Dr. Steinberg. “Its
legislative efforts should be seen for what
they are, another attempt to put profits ahead
of health care.”
Art Epstein, OD, FAAO, based in Phoenix,
says he doesn’t believe 1-800 CONTACTS understands how online contact lens retail affects patients.
“This latest attack from 1-800 CONTACTS
is yet one more example of why we need to
work cooperatively and cohesively to keep our
patients safe and protect our professional integrity,” he says. “I suspect when 1-800 CONTACTS thinks about contact lenses it think
about a commodity and profit margins. When
we think about them, we think about patients
and their health. The company has never seen
a contact lens abuser with half his cornea
turned to necrotic mush by a large central
ulcer. We have.
“It is up at night trying to time out the passive verification timer by calling when offices
are shut. We’re up at night worrying about
patients,” Dr. Epstein says.
Optometry Times Editorial Advisory Board
member Pam Miller, OD, FAAO, JD, says her
concern with online contact lens retailers is
that the prescription will be outdated, the patient may purchase the wrong type of lens,
and the patient may not be receiving regular
eye care from a professional. She says the
AOA is right to be concerned about the bills.
“The issue really is not one of anti-competitiveness, but more critically, one of patient
safety,” says Dr. Miller. “It is not unusual to
get a fax or phone call after hours requiring
verification of an online prescription. If the
time deadline is not met, the patient receives
the order, regardless of accuracy. Because contact lenses are a medical device requiring a
prescription, there is the potential for inherent damage to the patient, which is not a
concern of any on-line supplier.”
There is a valid reason an OD prescribes a
certain brand of lenses, she says. It should be
the responsibility of the eyecare professional
to determine which lens is best for a patient.
“This is not something that can be left to
|
the patient’s judgment, nor which is based on
what is the cheapest,” says Dr. Miller. “When
companies fill an expired prescription or substitute lenses, they must also take on the responsibility for any harm or permanent damage that occurs to the patient.”
Overall, Dr. Miller says the AOA has optometrists’ and patients’ best interests in mind by
opposing the 1-800 CONTACTS -backed bills.
“The AOA concerns are those of the practitioner,” she says. “We are the ones who are
responsible for the ocular health and wellbeing of our patients. To abrogate that responsibility based on a fallacious argument of
anti-competitiveness is wrong and harmful to
those who depend on our expertise in fitting
and monitoring our contact lens patients.”
Industry weighs in
Alcon says its limited UPP was put into place
to encourage eyecare professionals to invest
time learning about innovative contact lens
technologies and educating patients about
new options.
“Online sellers and mass merchandise stores
do not make this same time investment and
are able to underprice eyecare professionals
on contact lenses,” says Alcon’s Head of U.S.
Communications Donna Lorenson, speaking
exclusively to Optometry Times. “If eyecare
professionals must reduce contact lens prices
to compete against online sellers and other
discounters, they may be less likely to continue to educate patients about new technology contact lenses as a viable option for vision correction.”
Johnson & Johnson Vision Care implemented UPP on its Acuvue Oasys and 1-Day
Acuvue Moist contact lenses last year and
says it opposes state legislation that would
block those policies.
“Our first responsibility is to the patients
we serve,” says Barbara Montresor, vice president of global communications of Johnson &
Johnson Vision Care, speaking exclusively to
Optometry Times. “As a medical device manufacturer, our business decisions will always
reflect that responsibility. We are actively opposing state legislative initiatives attempting
to block unilateral pricing policies on contact
lenses and remain firmly committed to our
pricing policy for Acuvue Brand products that
has already resulted in reduced prices for the
majority of Acuvue wearers.”
“Our pricing policy is intended to lower
prices and make pricing simpler and more
transparent so consumers can make the best
purchasing decisions based on quality, clinical need, and cost,” she says.
Bausch + Lomb and CooperVision were
also asked to comment on this story.
ES573367_OP0315_008.pgs 02.21.2015 04:27
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Opinion
9
Letters to the Editor
AlternAtive Amniotic membrAne
thoughtful editoriAls
I
I
read the amniotic membrane article in the
September issue (“Using amniotic membrane in the primary care office”) by Dr. Gregg
Russell. (Love Optometry Times, by the way!)
The article was good, but it centered around
only Prokera. I’ve switched over to Aril dried
membrane discs by Seed Biotech, distributed by Blythe Medical. They’re easy to insert,
comfortable, and very affordable (price varies
around $250 per disc). There are two sizes, 8
mm and 12 mm. We keep them in place with
an extended wear contact lens for several
days. I haven’t seen any studies, but anecdotally they work as well as the Prokera. David Chandler, OD
Anniston, AL
I did not want the opportunity to pass
without acknowledging your work and
talent.
wanted to thank Chief Optometric Editor Dr.
Ernie Bowling for his insightful and thoughtNick Despotidis, OD, FCOVD, FAAO, FIOA
provoking articles. I often find myself sharDiplomate, American Board of Optometry
ing them with my partners and senior staff
Hamilton, NJ
members. The recent article asking the critical question, “What type of doctor do you want
to be?” (“What Doctored can teach us about
optometry,” page 3) was especially provoking,
have just read your editorial in the January
as was your article, “What’s the value of eyecissue (“What’s the value of eyecare?”).
are?” (January 2015)
This is a very succinct and great arI shared this particular inticle. I agree completely that we first
We
Want to hear
sight with my sons, who ashave to respect ourselves and the
from
you!
pire to become ophthalmolvalue of what we do. Only then
Like something we pubLished?
ogists and optometrists, as
will our patients begin to respect
hate something we pubLished?
well as my resident and my
us and our work.
have a suggestion?
Gary Sneag, OD
send your comments to
colleagues. San Diego
[email protected]
respect ourselves first
I
Letters may be edited
for length or clarity.
my fAvorite App
In BrIef
Weather
Channel
Centre for Contact Lens Research
receives support from JJVC
The Weather Channel app allows
me to get the weather for my
current location and where
I may be traveling. So, this
was helpful when traveling
to the AAO in Denver,
for example, with
the bitter cold
and snow.
—leo semes, od, fAAo
Birmingham, AL
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WAterloo, ontArio—The Centre for Contact Lens
Research at the University of Waterloo recently announced that Johnson & Johnson Vision Care Companies will provide
funding to continue the evolution of its
four-year-old site, ContactLensUpdate.com.
“We believe that it is in everyone’s interest to develop educational materials
with multiple funding sources to ensure
a thorough range of topics are discussed
with a balanced perspective,” says Lyndon
Jones, PhD, FCOptom, DipCLP, DipOrth,
FAAO, FIACLE, director of the Centre for
Contact Lens Research and professor at
the Univeristy of Waterloo. “Johnson &
Johnson Vision Care is known for its longstanding commitment to education around
the world, and this partnership can only
enhance what we provide to eyecare professionals and contact lens wearers.”
ContactLensUpdate.com offers advertising-free access to evidence-based insights,
best practices, and new treatment options
for common eye health concerns, with a
particular emphasis on dry eye and contact lenses. Content is developed by internationally-recognized experts on topic
areas; and the Centre itself has played a
role in the development of new contact
lens materials, designs, and care systems.
“We believe strongly that keeping upto-date on new research is critical to providing effective eye care,” says Ian P. Davies, vice president of Global Professional
Affairs for Johnson & Johnson Vision Care
Companies.
New topic-based features are added to
the site about six times yearly, including
practical insights from leading researchers, one-page research briefs on hot topics, patient handouts, review articles, and
conference highlights. Recently, the site
has explored the growing prevalence of
myopia and eye makeup tips for healthy
contact lens wear.
Johnson & Johnson Vision Care Companies joins The Alcon Foundation in providing funding for the website.
ES573010_OP0315_009.pgs 02.20.2015 23:54
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10
Focus On
Glaucoma
March 2015
|
Field defect, high IOP not what it seems
Small optic nerve heads can make the difference
Glaucoma is a term that describes a family of progressive
optic neuropathies. All of the glaucomas share characteristic and progressive cupping of the optic nerve head, and
this cupping is most easily viewed by means of direct stereoscopic evaluation through a dilated pupil.
Large optic nerve heads may have
Case presentation
physiologically large optic cups,
With this in mind, I was asked
while smaller optic nerve heads
to examine a patient to help contend to have smaller optic cups.
firm or deny glaucoma. The paA large optic nerve head with
tient was a 68-year-old white
a large cup may very well have
female with a medical history
about the same number of ganremarkable for arterial hyperBY BENJAMIN
glion cells traversing through it
tension, hypercholesterolemia,
P. CASELLA, OD,
as a smaller optic nerve head
and hypothyroidism—all reportFAAO Practices
with a smaller cup. Some optic
edly under good control. Medicain Augusta, GA ,
with his father in
nerve heads are so small that
tions included hydrochlorothiahis grandfather’s
they are classified as being conzide (Microzide, Actavis), simvpractice.
genitally hypoplastic (congenital
astatin (Zocor, Merck), and levooptic nerve hypoplasia [CONH]).
thyroxine (Tirosint, Akrimax).
With respect to these optic nerves, it is
The patient had no other complaints or
often difficult to ascertain the presence
apparent ocular concerns. Best-corrected
of an optic cup at all.
visual acuities were 20/25 OU, and slit
Patients with CONH may very well go
lamp examination was remarkable for
on to develop other acquired diseases of
moderate nuclear cataracts in each eye.
their optic nerves unrelated to their CONH.
Pupils were unremarkable in each eye.
Moreover, since visual field defects are
Intraocular pressures (IOP) by means of
not uncommon in patients with CONH,1
Goldmann applanation tonometry were 26
mm Hg OD and 28 mm Hg OS at 1:45 p.m.
it may be difficult to determine if a newly
Photos of the patient’s optic nerve heads
discovered visual field defect is related to
after pupillary dilation are as shown in
the hypoplasticity of the optic disc (relaFigure 1. Peripheral retina evaluation via
tively static) or some other cause such as
indirect ophthalmoscopy was unremarkglaucoma (relatively progressive), espeable, as was the remainder of the exam.
cially if the visual field defect is nasal.
Figure 1. Fundus photos of each eye. Notice the relatively small optic nerve heads and
radial fashion of the vasculature.
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Figure 2. OCT studies of each optic
nerve and ganglion cell complex. Note the
advanced RNFL thinning in each eye.
Right away, the patient’s optic nerve
heads appeared to be very small. In fact,
the right optic nerve head measured just
1.1 mm vertically, while the left measured
1.15 mm (average optic nerve head sizes
vary by study and race, but they are commonly described as being 1.5 to 2 times
greater than those of this patient).2 The
vasculature also emanated from each
optic nerve head in a somewhat radial
fashion, another potential indicator for
some sort of congenital malformation. It
was difficult to determine the presence
of any discernable cup, and there was
also a faint scleral canal visible around
each optic nerve head. As well, the retinal nerve fiber layer (RNFL) in each eye
was noticeably thin virtually 360 degrees
around each optic nerve head. After taking fundus photos of each eye,
I reminded the patient that a glaucoma
work-up was a stepwise process and invited her back the following week (in
ES572192_OP0315_010.pgs 02.19.2015 18:45
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Glaucoma
Focus On
11
RefeRences
1. Kim US, Baek SH, Lee JH. Characteristics of segmental optic
nerve hypoplasia. Eye (Lond). 2012 Dec;26(12):1585-6.
2. Jonas JB, Gusek GC, Naumann GO. Optic disc, cup, and
neuroretinal rim size, configuration and correlation in normal eyes.
Invest Ophthalmol Vis Sci. 1988 Jul;29(27):1151-8.
[email protected]
Figure 3. 24-2 threshold visual field studies for each eye. Note the dense
nasal defects in each visual field.
the morning) for some glaucomaspecific testing. At that visit, visual
acuities were unchanged. IOPs were
27 mm Hg OD and 28 mm Hg OS
at 10:15 a.m. Pachymetry values
were 533 µm OD and 536 µm OS.
Gonioscopy showed that both eyes
had angles open to the ciliary body
with a flat iris approach and trace
trabecular meshwork pigment in all
four quadrants. Optical coherence
tomography (OCT) studies confirmed
the high degree of RNFL thinning
seen upon fundoscopy (see Figure
2). The 24-2 threshold visual field
studies showed significant nasal
visual field defects in each eye (see
Figure 3).
The gorillas in the room
Upon reviewing all of this exam
data, it becomes apparent that the
patient in question exhibits several
diagnostic signs that happen to be
characteristic of glaucoma, including RNFL thinning and nasal visual
field defects. Both of these findings
are commonly seen with CONH, as
well. The 800-pound gorilla in the
room (for me at least) was the presence of ocular hypertension (the
number-one risk factor for the development of glaucoma). The other
gorilla in the room, if you will, was
fact that I could not discern an optic
cup, per se, in either eye. The OCT
studies helped me to visualize a very
small cup displaced temporally in
each eye, but glaucoma involves
cupping of the optic nerve heads.
So, I was uncomfortable with a diagnosis of glaucoma. One thing I
was quite comfortable with, however, was the fact that any degree
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of noticeable cupping with respect
to such small nerves would likely
not be readily visible until a substantial number of ganglion cells
had atrophied. This would present
the scenario of a very small optic
nerve head with a small, yet glaucomatous cup.
I told the patient that I frankly
didn’t know whether or not she
had glaucoma, but that I doubted
it. However, given her visual field
defects, be they glaucomatous or
not, her high eye pressures were
presenting a risk for progression
of these defects, and a modifiable
risk at that. We had a brief discussion regarding the nature of glaucoma, and I decided to label her as
a high-risk glaucoma suspect and
treat her IOPs with a prostaglandin analog. I will recheck her pressures and perform different visual
field studies in a few weeks, and,
although, she is older, I’ve decided
it’s not a bad idea to order an MRI.
(I’m not necessarily looking for tumors or bleeds but rather looking
for other neurological dysplasias
potentially correlated with her optic
nerve hypoplasia).
Lurking variables are frequently
present when working on a glaucoma
diagnosis and have the capacity to
complicate matters. If this patient’s
intraocular pressures were not high,
I would have likely watched her over
a period of months for change by
means of trend and event analysis
using OCT and visual field studies.
However, given her findings, I felt
better about doing at least something to lessen her risk of visual
problems down the road.
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ES572191_OP0315_011.pgs 02.19.2015 18:46
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12
Focus On
CONTACT LENSES
MARCH 2015
|
Gas permeable lenses—special or not?
Not enough practitioners are utilizing this modality to help their patients
To continue on our theme of specialty lenses, I addressed
soft lenses in my past article (“What’s so special about specialty lenses?” January 2014); now, let’s look at gas permeable
(GP) lenses. When we discuss specialty lenses, most doctors
think of multifocal or toric soft lenses. The overwhelming
market share of contact lens fits are in soft lenses.
However, there is a resurgence of
use of gas permeable materials.
This has been led by the introduction of scleral and semi-scleral
gas permeable lenses.
Training with GPs
number of practitioners comfortable in using most GP modalities.
When I ask my audiences how
many are using these lenses, too
few hands are going up. The advent of the wide range of specialty
soft lenses and their excellent optics and comfort has supplanted
GPs in many offices. The use of
hybrids, which many doctors are
more comfortable using, has supplanted traditional GP fits.
BY DAVID I.
Gas permeable lenses seem to be
GEFFEN, OD, FAAO
the forgotten technology in our
Director of
industry. The schools of optomoptometric and
etry have such a heavy patholrefractive services in
ogy-loaded curriculum that they
San Diego, CA.
have cut time away teaching this
important skill. As an adjunct clinical facIntraprofessional referrals
ulty member at one school, I have found
One may ask if this is really so bad? It may
my externs to have very little knowledge in
actually be in our patients’ best interest
using GP lenses. While my students have
if they are going to those doctors using a
received theoretical knowledge on how to
large number of GP lenses with lots of exmodify, neutralize, and fit gas permeable
pertise. Many doctors have developed a
lenses, in reality, when they show up to
subspecialty practice in GPs and are truly
my practice, they have almost no useful
experts. Similar to vision therapy, many
knowledge.
doctors do not offer this service and will
refer to those who are experts. This may
help those patients who would benefit from
the advantages that a GP lens would offer.
It would be nice to see optometry be more
willing to utilize intraprofessional referrals. We are quick to send patients to ophthalmologists but infrequently to our local
optometrists who have equipment and expertise we may not.
Gas permeable
lenses seem to
be the forgotten
technology in our
industry.
I need to teach almost all of my externs
how to use a radiuscope. Our rotation is a
tertiary care site and is not their primary
contact lens site. Many have come from
their contact lens site where they tell me
they never had much opportunity to see
GPs being used. I am saddened by this
lack of experience our future doctors are
receiving. I feel strongly there should be
more time spent in this vital area for the
future of the public.
I find that there is also a relatively small
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Patients who benefit from GPs
Which patients may benefit from use of
GP materials? First, there are still many
patients who are very happy in their current GP lenses. Unless there are comfort or
health concerns, I see no reason to switch
these patients to soft lenses. Gas permeable
patients like the ease of handling and care
of their lenses. When they are comfortable and fit properly, GPs are very healthy
lenses to wear.
Keratoconus is one of the most obvious
needs for GP lenses. According to the Global
Keratoconus Foundation, the incidence of
keratoconus is between one out of every
430-2,000 individuals, depending on the
study conducted.1 With advanced technology to diagnose corneal irregularities, the
incidence increased over estimates from
several years ago. Patients with irregular
corneal disorders such as Salzmann’s, ectasia, and other dystrophies are good candidates. Because of the excellent optics of
GP lenses, patients with high amounts of
astigmatism often do best with rigid designs.
The same is true for multifocal patients. The advantage of GP lenses is the ability
to design a very wide amount of specifications to truly customize the lens-to-cornea
relationship. For highly toric patients, we
can design bitoric lenses with wide varieties of diameters. For our multifocal patients, we can design lenses with a central
aspheric near zone or a central distance
zone. We can design a true bifocal design,
which will translate. Today, we can even
order a scleral multifocal. Scleral and semiscleral designs have changed how we fit
irregular corneas today.
Now, we fit patients with advanced keratoconus who thought they were heading
for corneal transplant into new designs
that offer great comfort and vision. We
have found the initial comfort of the large
diameter lenses to be superior to the traditional GPs. For those who are initially diagnosed with keratoconus, these designs
have made it easier to transition to rigid
lenses without fear and trepidation. The vision has been improved and corneal health
has been excellent.
Gas permeable lenses are truly a specialty
product that will make a life-changing difference for many patients. It is our obligation to become proficient in utilizing these
devices or refer to a colleague who is.
REFERENCE
1. The Global Keratoconus Foundation.
Introduction. Available at http://kcglobal.org/
content/view/14/26. Accessed 02/06/2015. Dr. Geffen sits on the advisory board and speaks for
Alcon, Bausch + Lomb, and Vmax and sits on the advisory
board for TearLab and Accufocus. He speaks for Allergan
and AMO. [email protected]
ES572204_OP0315_012.pgs 02.19.2015 19:02
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SYMPTOMATIC VITREOMACULAR
ADHESION (VMA)
SYMPTOMATIC VMA MAY LEAD TO VISUAL IMPAIRMENT FOR YOUR PATIENTS1-3
IDENTIFY
REFER
Recognize metamorphopsia as a key sign of symptomatic VMA
and utilize OCT scans to confirm vitreomacular traction.
Because symptomatic VMA is a progressive condition that may lead
to a loss of vision, your partnering retina specialist can determine
if treatment is necessary.1-3
THE STEPS YOU TAKE TODAY MAY MAKE A DIFFERENCE
FOR YOUR PATIENTS TOMORROW
© 2014 ThromboGenics, Inc. All rights reserved. ThromboGenics, Inc., 101 Wood Avenue South, Suite 610, Iselin, NJ 08830 – USA. THROMBOGENICS and the THROMBOGENICS logo are trademarks or registered trademarks of
ThromboGenics NV. 9/14 OCRVMA0220
References: 1. Sonmez K, Capone A, Trese M, et al. Vitreomacular traction syndrome: impact of anatomical configuration on anatomical and visual outcomes. Retina. 2008;28:1207-1214. 2. Hikichi T, Yoshida A,
Trempe CL. Course of vitreomacular traction syndrome. Am J Ophthalmol. 1995;119(1):55-56. 3. Stalmans P, Lescrauwaet B, Blot K. A retrospective cohort study in patients with diseases of the vitreomacular interface (ReCoVit).
Poster presented at: The Association for Research in Vision and Ophthalmology (ARVO) 2014 Annual Meeting; May 4-8, 2014; Orlando, Florida.
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14
Focus On
CO-MANAGEMENT
MARCH 2015
|
Why wait to recommend cataract surgery?
Know when a cataract is ready for the blade and suggest its removal
I was asked to stop at the grocery store on my way home
from the office to pick up vegetables for a salad. Now my
first thought was, “How many calories do I have left on
MyFitnessPal that I need to eat a salad?” And the second
thought was, “How do I know what vegetables are ripe?”
digit amounts of astigmatism,
necessary hospital stays, and,
in the end, possibly leaving the
patient with vision on par with
what the cataract was inducing or worse. (For younger ODs:
Google it; all of this it is true!).
BY MARC R.
This is 2015, doctors, and the
BLOOMENSTEIN,
technological advancements that
OD, FAAO Director
have elevated cataract surgery
of optometric
services at Schwartz to one of the safest and efficaLaser Eye Center in
cious surgeries of the eye. This
Scottsdale, AZ.
publication provides you with
up-to-date FDA approvals and
new procedures that make removal of the lens safer than even, well,
the last time I said how safe it is to perWhy wait?
form. The femtosecond revolution that
Years ago, I realized that a cataract is
started with LASIK has transcended the
anomaly of the ocular system that should
cataract ASC into a refractive surgical
be eradicated at its earliest stages. If you
suite. The ability to make custom inciwere in a relationship that was not going
sions, reduce astigmatism, open the capwell and was destined to keep getting
sule, and phaco-chop without ever liftworse, would you stay? If you ate something that started to taste bad, and every
nibble proceeded to get worse, would you
just keep eating? Of course you wouldn’t.
Yet, we, as ODs, look at this formerly
transparent tissue—which induces a refractor error and creates glare, halos, and
degraded vision—as something that needs
to simmer, like a molé. A friend developed a cataract during her pregnancy.
She went to a colleague who told her
that because she was considering getting
ing a blade are what Disney was talkpregnant again, it would not be a good
ing about in Tomorrowland. Measuring
idea to remove the cataract—the 20/400
wavefront aberration and astigmatism
cataract that was making her nauseous. I
in vivo and deciding what lens to use at
am still flummoxed as to why that doctor
the surgical table enhances an already
would suggest waiting until after another
enchanted process.
pregnancy. In fact, I don’t know why we
The natural crystalline lens is not a
would ever wait to remove a cataract.
kind tissue; it induces aberrations and
Don’t get me wrong, I get the notion
forces us to be reliant on cheaters for close
that our forefathers were foreshadowing
vision—nobody looks good in cheaters,
the potential disastrous effects of cataract
sorry, just not sexy. However, your pasurgery—the intracapsular cataract extients do not have to be burdened with
traction, the sutures that induced doubleThis is a big decision, choosing
veggies that are not ready to be
eaten can have a disastrous effect on the palate, which is already stretched from, well, eating
vegetables. As I perused Mother
Nature’s edible delicacies, I realized that I don’t know how to
determine what specific vegetable is ripe. Is it hard? Soft? Yellow? Frankly, as an optometrist,
I should know matters of the optics, el ojo, the visual system—
not ripeness. Yet, how many of
you claim you do what is ripe?
In fact, I don’t
know why we
would ever wait
to remove a
cataract.
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glasses after cataract surgery, or at least
not as much of the time. The biometric analysis and the lens options create
seamless opportunities for the lenticuarly
impaired. The presbyopic- and toric-correcting lenses really work. And you know
what? The lenses don’t have to be ripe.
Creating a differential
diagnosis
When you sit down with a patient who
has noticed any change in his vision, you
should instantly start creating a differential diagnosis. The road map to the refractive error of your patient starts with
the case history. Asking pointed question
like, “Did the change occur rapidly, or
has this been a gradual effect? Is your
vision worse in distance or near? Does
one eye seem worse than the other? Do
you notice any glare or halos at night?”
This query will help point you toward
the correct route. If this patient is close
to 50 years old, then cataracts have to
be on the map.
The ocular surface is the first stop on
your trip before you start assessing the
lens and posterior pole. It is important
at this time to remember that a clinically
significant change from cataracts does
not always manifest in the Snellan acuity chart. Debilitating glare, worse than
20/40, can also be a good reason to remove the lens. During this venture, if you
find that you do not have an adequate
way to measure the glare, pick up your
binocular indirect ophthalmoscope and
use that with the best-corrected visual
acuity to assess the glare. The goal is to
help guide the patient to long-lasting,
sustainable, good vision.
Taking a more active role in the diagnosis and treatment recommendation for
cataract surgery can be a little daunting.
Patients often may be surprised to hear
that at a young age they have the start
of these opacities. However, the sooner
you start alerting them to the advantages
of lens removal and discussing options,
the more they will anticipate the final
product. Remember a lens is not a horrible thing to waste—after a certain time
it is a horrible thing to keep.
[email protected]
ES572190_OP0315_014.pgs 02.19.2015 18:45
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What we do every day matters.
AvenovaTM with NeutroxTM (pure hypochlorous acid)
removes microorganisms and debris from the lids and
lashes. Avenova is an ideal addition to any daily lid and
lash hygiene regimen, including for use by patients with
Blepharitis and Dry Eye. Avenova may also be used
after make-up removal as well as pre and post contact
lens wear.
Daily lid and lash hygiene.
Visit us at Vision Expo East!
March 20-22, 2015
Booth #: MS6944
O PHTHA LMOLOGIST AND OPTOMET RIST TESTED
A V E N O VA . C O M
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|
|
RX ONLY
1-800-890-0329
ES572802_OP0315_015_FP.pgs 02.20.2015 18:31
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Practice Management
16
March 2015
|
Tips & tricks for utilizing EHR
Get to know your system to save time and your sanity
By Scott Sikes, OD
not a desired result, you learn to avoid that
in the future. So, it’s not only about learning what to do, but learning what not to do.
any eyecare providers use some type
In addition to trial and error, you can contact
of electronic health records (EHR)
your EHR software company and ask support
system by now. I also realize that alstaff for tips and tricks. Ideally, they should
most all eyecare providers seem to have comhave conducted training when you
plaints about whatever system they
first set up your EHR, but they often
use and quite a few would prefer to
show you only the basics. However,
go back to paper charts.
they, as the software providers, should
Fortunately, I grew up around opknow all the ins and outs of their
tometry and worked in my father’s
own product. It may take a little
office through high school and into
prodding and potentially some more
college, so I have a working knowlcapital to get more detailed training
edge of paper charts as well as EHR.
SCOTT SIKES, OD
directly from the company, but I’m
I know there are strong arguments
serves as the
sure it is available. on both sides of the topic. However,
Chairman of the
North Carolina State
You can also ask staff, other docsince EHR won’t be going anywhere
Optometric Society
tors in your practice, and even other
in the near future, I would like to
Para-Optometric
offices that use the same EHR softpresent some of its key benefits.
Education
ware. Likely everyone who purchased
I don’t pretend to be a computer
Committee
that EHR software received the same
expert or an EHR aficionado, for
training. However, because everyone has a
that matter. I have never built my own PC
different style of practice, the more people
from scratch, and I don’t attend EHR meetyou ask, the more you can learn. There may
ings on the weekends. However, I am fairly
be an area of your software that you aren’t
proficient with most tech issues and it is my
as familiar with that someone else may have
hope that my experiences will make everyfigured it out. Don’t re-invent the wheel. Learn
one’s EHR use more effortless.
from others and share your experiences, too.
Despite our best efforts, all systems will
Get to know your EHR
inevitably have problems and need to be serOne of my biggest tips is to get to know your
viced. I have found it very useful to be present
EHR. This doesn’t mean to go in and do only
and intently focused on the computer screen
the same simple steps every time. This involves
when anyone is fixing a problem with your
time spent trying new things. Set up a John
software and/or hardware. This is particuDoe patient record and practice under that
larly beneficial if it is a chronic problem that
record. Some of my biggest time-saving steps
is costly to have a professional repair. If you
have come from trial and error. Click on a tab,
can observe the repair process and have the
choose a drop-down menu, try right-clicking
company technician explain the steps he is
in different areas—see what happens. If it is
taking as he goes, then you are much more
likely to be able to troubleshoot that problem in the future without having to call for
reinforcements, saving you time and money.
Now you need to find your own rhythm and
– TAB to move forward to the next box or field without
get it down to a science. The big key here is
having to use the mouse
repetition. The more you perform an action,
– If you TAB too far, then SHIFT + TAB should take you
the more comfortable you will become. Just
backwards
think about the first time you performed a
– ALT + “Underlined letter” lets you access menu oprefraction in an optometry school practical. I
tions via the keyboard
know I was completely and overwhelmingly
– CTRL + C to copy
focused on that one test. However, now that
– CTRL + V to paste
I have done a few thousand, it’s just second
*Note: these shortcuts may not work for all ehr
nature. But you have to be ready for the unsystems, but most will have some shortcuts
expected. Just as in refraction, if something
available.
doesn’t make sense and isn’t working, then
M
Shortcuts for your EHR
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TAKE-HOME MESSAGE Learn your EHR
system. Try new things. Click a new button
or choose a new drop-down menu. Trial and
error is the best way to learn. Take advantage
of your EHR solution provider. In addition to
training, it can offer troubleshooting and ways
to customize your system for your practice.
you have to adjust how you are trying to arrive
at the end result and keep moving forward. Semi-constants—this is a term that I use to
describe what I do 98 percent of the time. For
example, I almost always use the same dilation drops, the same +90.00 D and +20.00 D
lens for posterior segment exams, etc. This is
particularly useful information to gather, especially if you have a technician who scribes
for you during the exam. If you are performing refraction or any task in which there is a
little downtime, your technician can anticipate your next few moves and fill in some
of these semi-constants.
Taking notes
Although I don’t have a scribe, I still take advantage of the downtime when a patient is
applying or removing contact lenses or even
right after instilling dilation drops to fill in
some of these values. I typically will put the
same notes on my refraction Rx depending
on what the patients need. For example, if
the patient’s Rx is over +/- 3.00 D, then I
will write SRC (scratch resistant coating), AR
(anti-reflective), HI-INDEX. Similarly, if the
patient is presbyopic, I will simply add PAL
(progressive addition lens). There are only
a few other variations for me, poly/Trivex if
the patient is under 18 years old and/or Transitions if the patient desires sun protection.
This information prints out on the glasses Rx
and helps my optical department know what
I have discussed with the patient already.
I also end up using the same type of messages for my contact lens-related tab. I don’t
know about everyone else, but it seems like
I have quite a few contact lens patients who
over wear their lenses. Shocking, I know.
Therefore, I have a short sentence that I always use to document that I discussed the
issue with the patient. “Educated pt on proper
ES572252_OP0315_016.pgs 02.19.2015 19:31
ADV
wear and replacement of cls. DWO, replace q
1 mo for [insert lens brand here]” If you really want to get fancy and have
a few extra minutes one night, you can create a word processing document with some
of your most commonly used phrases and
save that to your office exam lane computer
desktop. That way, you don’t even have to
type anything when you need it. The document is opened in the morning before patient
care and stays running in the background
until it’s needed. The nice part about this
strategy is that it’s very easy to update your
master list. Caution should be taken to not
create a book of entries, though. You want
quick and simple.
Practice Management
modified to fit your new findings. However,
if utilized properly, these keyboard shortcuts
can save a lot of time.
Next, let’s talk about the often-overlooked
mouse scroll wheel. It surprises me just how
useful this little piece of hardware can be.
Not only does it let you scroll up and down on
a web page, it will cycle through almost any
17
dropbox that you click on. I use this mainly
for visual acuity (VA) and fields where there
aren’t that many choices. For instance, I use
the scroll wheel on the refraction tab for VAs
both distance and near, as well as the contact lens tab for VAs, eye dominance (OD/
OS), and a few other fields where there aren’t
see EHR tricks on page 18
ADD SIMBRINZA® Suspension to a PGA for Even Lower IOP1*
Shortcuts and time savers
Keyboard shortcuts are a great time saver as
well. The less time you have to take your hands
off the keyboard and mess with the mouse
and then transition back to the keyboard the
better. The TAB key is your friend—at least
in my EHR software it is. This key lets me
move forward to the next box or field without
having to use the mouse to click into the box.
Also, if you TAB too far, then SHIFT + TAB
should take you backwards, somewhat eliminating the need to be dependent on the point
and click method. ALT + underlined letter
Some of my biggest
time-saving steps
have come from
trial and error.
is a widely used keyboard shortcut. The next
time you use your EHR, look at the menus
at the top. More than likely, each different
item will have an underlined letter. This will
let you access the menus at the top without
moving your hands. For example, ALT + S
takes me to the search function in my EHR.
ALT + S P lets me search for a patient by
name, while ALT + S D lets me search for a
patient by date of birth. Each EHR is different, but the concept is the same.
Another fairly universal keyboard shortcut is CTRL + C and CTRL + V CTRL + C
lets you copy highlighted text, while CTRL
+ V lets you paste the last thing you copied. This becomes very beneficial if you have
a master list of commonly used phrases as
well as copying exam findings from OD to
OS or while developing your assessment and
plan. Of course, it goes without saying that
data should never be simply copied and not
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INDICATIONS AND USAGE
SIMBRINZA® (brinzolamide/brimonidine tartrate ophthalmic suspension)
1%/0.2% is a fixed combination indicated in the reduction of elevated
intraocular pressure (IOP) in patients with open-angle glaucoma or
ocular hypertension.
Dosage and Administration
The recommended dose is one drop of SIMBRINZA® Suspension in the
affected eye(s) three times daily. Shake well before use. SIMBRINZA®
Suspension may be used concomitantly with other topical ophthalmic drug
products to lower intraocular pressure. If more than one topical ophthalmic
drug is being used, the drugs should be administered at least five (5)
minutes apart.
IMPORTANT SAFETY INFORMATION
Contraindications
SIMBRINZA® Suspension is contraindicated in patients who are hypersensitive
to any component of this product and neonates and infants under the age of
2 years.
Warnings and Precautions
Sulfonamide Hypersensitivity Reactions—Brinzolamide is a sulfonamide,
and although administered topically, is absorbed systemically. Sulfonamide
attributable adverse reactions may occur. Fatalities have occurred due
to severe reactions to sulfonamides. Sensitization may recur when a
sulfonamide is readministered irrespective of the route of administration.
If signs of serious reactions or hypersensitivity occur, discontinue the use
of this preparation.
Corneal Endothelium—There is an increased potential for developing
corneal edema in patients with low endothelial cell counts.
Severe Hepatic or Renal Impairment (CrCl <30 mL/min)—SIMBRINZA®
Suspension has not been specifically studied in these patients and is
not recommended.
Contact Lens Wear—The preservative in SIMBRINZA® Suspension,
benzalkonium chloride, may be absorbed by soft contact lenses. Contact
lenses should be removed during instillation of SIMBRINZA® Suspension
but may be reinserted 15 minutes after instillation.
Severe Cardiovascular Disease—Brimonidine tartrate, a component of
SIMBRINZA® Suspension, had a less than 5% mean decrease in blood
pressure 2 hours after dosing in clinical studies; caution should be
exercised in treating patients with severe cardiovascular disease.
Adverse Reactions
SIMBRINZA® Suspension
In two clinical trials of 3 months’ duration with SIMBRINZA® Suspension,
the most frequent reactions associated with its use occurring in
approximately 3-5% of patients in descending order of incidence
included: blurred vision, eye irritation, dysgeusia (bad taste), dry mouth,
and eye allergy. Adverse reaction rates with SIMBRINZA® Suspension
were comparable to those of the individual components. Treatment
discontinuation, mainly due to adverse reactions, was reported in 11% of
SIMBRINZA® Suspension patients.
Prescribe SIMBRINZA® Suspension as
adjunctive therapy to a PGA for
appropriate patients
SIMBRINZA® Suspension should be taken at least
five (5) minutes apart from other topical ophthalmic
drugs
Up to
7.1 mm Hg
additional IOP
reduction from
baseline when
added to a PGA1
5.6† mm Hg
additional mean
diurnal IOP
lowering observed
from baseline when
added to a PGA1
Treatment Arm
PGA + SIMBRINZA®
Suspension (N=88)
PGA + Vehicle
(N=94)
Baseline§
Week 6
Baseline§
Week 6
IOP Daily Time Points (mm Hg)‡
8 AM
10 AM
3 PM
24.5
22.9
21.7
19.4
15.8
17.2
24.3
22.6
21.3
21.5
20.3
20.0
5 PM
21.6
15.6
21.2
20.1
Differences (mm Hg) and P-values at Week 6 time points between treatment groups were: -2.14,
P=0.0002; -4.56, P<0.0001; - 2.84, P<0.0001; -4.42, P<0.0001.
§
Baseline (PGA Monotherapy)
‡
Mean Diurnal IOP (mm Hg)||
Treatment Arm
PGA + SIMBRINZA® Suspension (N=88)
PGA + Vehicle (N=94)
Baseline¶
Week 6
Baseline¶
Week 6
22.7
17.1
22.4
20.5
Differences (mm Hg) and P-values at Week 6 between treatment groups were -3.44, P<0.0001.
Baseline (PGA Monotherapy)
||
¶
Study Design: A prospective, randomized, multicenter, double-blind, parallel-group
study of 189 patients with open-angle glaucoma and/or ocular hypertension receiving
treatment with a PGA. PGA treatment consisted of either travoprost, latanoprost,
or bimatoprost. Patients in the study were randomized to adjunctive treatment with
SIMBRINZA® Suspension (N=88) or vehicle (N=94). The primary efficacy endpoint was
mean diurnal IOP (IOP averaged over all daily time points) at Week 6 between treatment
groups. Key secondary endpoints included IOP at Week 6 for each daily time point
(8 AM, 10 AM, 3 PM, and 5 PM) and mean diurnal IOP change from baseline to Week 6
between treatment groups.1
*PGA study-group treatment consisted of either travoprost, latanoprost, or bimatoprost.
†
95% Confidence Interval: -6.23 to -5.06.
Learn more at myalcon.com/simbrinza
For additional information about SIMBRINZA® Suspension, please see
Brief Summary of full Prescribing Information on adjacent page.
Reference: 1. Data on file, 2014
© 2014 Novartis 10/14 SMB14121JAD
ES572250_OP0315_017.pgs 02.19.2015 19:31
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18
Practice Management
EHR tricks
many options. Again, the scroll will not be
particularly useful when the dropbox you
have clicked into has more than 10 entries.
Right-click on the mouse can also save a
lot of time. For my EHR, this offers me op-
BRIEF SUMMARY OF PRESCRIBING INFORMATION
INDICATIONS AND USAGE
SIMBRINZA® (brinzolamide/brimonidine tartrate ophthalmic
suspension) 1%/0.2% is a fixed combination of a carbonic
anhydrase inhibitor and an alpha 2 adrenergic receptor
agonist indicated for the reduction of elevated intraocular
pressure (IOP) in patients with open-angle glaucoma or
ocular hypertension.
DOSAGE AND ADMINISTRATION
The recommended dose is one drop of SIMBRINZA®
Suspension in the affected eye(s) three times daily. Shake
well before use. SIMBRINZA® Suspension may be used
concomitantly with other topical ophthalmic drug products
to lower intraocular pressure.
If more than one topical ophthalmic drug is being used, the
drugs should be administered at least five (5) minutes apart.
DOSAGE FORMS AND STRENGTHS
Suspension containing 10 mg/mL brinzolamide and 2 mg/
mL brimonidine tartrate.
CONTRAINDICATIONS
Hypersensitivity - SIMBRINZA® Suspension is contraindicated in patients who are hypersensitive to any component
of this product.
Neonates and Infants (under the age of 2 years) SIMBRINZA® Suspension is contraindicated in neonates and
infants (under the age of 2 years) see Use in Specific
Populations
WARNINGS AND PRECAUTIONS
Sulfonamide Hypersensitivity Reactions - SIMBRINZA®
Suspension contains brinzolamide, a sulfonamide, and
although administered topically is absorbed systemically.
Therefore, the same types of adverse reactions that
are attributable to sulfonamides may occur with topical
administration of SIMBRINZA® Suspension. Fatalities have
occurred due to severe reactions to sulfonamides including
Stevens-Johnson syndrome, toxic epidermal necrolysis, fulminant hepatic necrosis, agranulocytosis, aplastic anemia,
and other blood dyscrasias. Sensitization may recur when a
sulfonamide is re-administered irrespective of the route of
administration. If signs of serious reactions or hypersensitivity occur, discontinue the use of this preparation [see
Patient Counseling Information]
Corneal Endothelium - Carbonic anhydrase activity has
been observed in both the cytoplasm and around the
plasma membranes of the corneal endothelium. There is
an increased potential for developing corneal edema in
patients with low endothelial cell counts. Caution should
be used when prescribing SIMBRINZA® Suspension to this
group of patients.
Severe Renal Impairment - SIMBRINZA® Suspension
has not
been specifically studied in patients with severe renal
impairment (CrCl < 30 mL/min). Since brinzolamide and
its metabolite are excreted predominantly by the kidney,
SIMBRINZA® Suspension is
not recommended in such patients.
Acute Angle-Closure Glaucoma - The management
of patients with acute angle-closure glaucoma requires
therapeutic interventions in addition to ocular hypotensive
agents. SIMBRINZA® Suspension has not been studied in
patients with acute angle-closure glaucoma.
Contact Lens Wear - The preservative in SIMBRINZA®
Suspension, benzalkonium chloride, may be absorbed by
soft contact lenses. Contact lenses should be removed
during instillation of SIMBRINZA® Suspension but may
be reinserted 15 minutes after instillation [see Patient
Counseling Information].
Severe Cardiovascular Disease - Brimonidine tartrate,
a component of SIMBRINZA® Suspension, has a less than
5% mean decrease in blood pressure 2 hours after dosing
in clinical studies; caution should be exercised in treating
patients with severe cardiovascular disease.
Severe Hepatic Impairment - Because brimonidine
tartrate, a component of SIMBRINZA® Suspension, has not
been studied in patients with hepatic impairment, caution
should be exercised in such patients.
Potentiation of Vascular Insufficiency - Brimonidine
tartrate, a component of SIMBRINZA® Suspension, may potentiate syndromes associated with vascular insufficiency.
SIMBRINZA® Suspension should be used with caution in
patients with depression, cerebral or coronary insufficiency,
Raynaud’s phenomenon, orthostatic hypotension, or
thromboangiitis obliterans.
Contamination of Topical Ophthalmic Products After
Use - There have been reports of bacterial keratitis
associated with the use of multiple-dose containers of
topical ophthalmic products. These containers have been
inadvertently contaminated by patients who, in most
cases, had a concurrent corneal disease or a disruption of
the ocular epithelial surface [see Patient Counseling
Information].
ADVERSE REACTIONS
Clinical Studies Experience - Because clinical studies
are conducted under widely varying conditions, adverse
reaction rates observed in the clinical studies of a drug
cannot be directly compared to the rates in the clinical
studies of another drug and may not reflect the rates
observed in practice.
SIMBRINZA® Suspension - In two clinical trials of 3 months
duration 435 patients were treated with SIMBRINZA®
Suspension, and 915 were treated with the two individual
components. The most frequently reported adverse reactions in patients treated with SIMBRINZA® Suspension occurring in approximately 3 to 5% of patients in descending
order of incidence were blurred vision, eye irritation,
dysgeusia (bad taste), dry mouth, and eye allergy. Rates of
adverse reactions reported with the individual components
were comparable. Treatment discontinuation, mainly due
to adverse reactions, was reported in 11% of SIMBRINZA®
Suspension patients.
Other adverse reactions that have been reported with the
individual components during clinical trials are listed below.
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March 2015
tions to default negative fill and forward info
from the last exam. The default negative option can be particularly useful especially for
new patient exams where the patient is young
and healthy. This prevents you from having
to input “normal” into every box and one or
two mouse clicks does the job for you. I find
the forwarding option to be most useful when
Brinzolamide 1% - In clinical studies of brinzolamide
ophthalmic suspension 1%, the most frequently reported
adverse reactions reported in 5 to 10% of patients were
blurred vision and bitter, sour or unusual taste. Adverse
reactions occurring in 1 to 5% of patients were blepharitis,
dermatitis, dry eye, foreign body sensation, headache,
hyperemia, ocular discharge, ocular discomfort, ocular
keratitis, ocular pain, ocular pruritus and rhinitis.
The following adverse reactions were reported at an
incidence below 1%: allergic reactions, alopecia, chest
pain, conjunctivitis, diarrhea, diplopia, dizziness, dry mouth,
dyspnea, dyspepsia, eye fatigue, hypertonia, keratoconjunctivitis, keratopathy, kidney pain, lid margin crusting or sticky
sensation, nausea, pharyngitis, tearing and urticaria.
Brimonidine Tartrate 0.2% - In clinical studies of
brimonidine tartrate 0.2%, adverse reactions occurring in
approximately 10 to 30% of the subjects, in descending
order of incidence, included oral dryness, ocular hyperemia,
burning and stinging, headache, blurring, foreign body
sensation, fatigue/drowsiness, conjunctival follicles, ocular
allergic reactions, and ocular pruritus.
Reactions occurring in approximately 3 to 9% of the
subjects, in descending order included corneal staining/
erosion, photophobia, eyelid erythema, ocular ache/pain,
ocular dryness, tearing, upper respiratory symptoms, eyelid
edema, conjunctival edema, dizziness, blepharitis, ocular
irritation, gastrointestinal symptoms, asthenia, conjunctival
blanching, abnormal vision and muscular pain.
The following adverse reactions were reported in less than
3% of the patients: lid crusting, conjunctival hemorrhage,
abnormal taste, insomnia, conjunctival discharge, depression, hypertension, anxiety, palpitations/arrhythmias, nasal
dryness and syncope.
Postmarketing Experience - The following reactions have
been identified during postmarketing use of brimonidine
tartrate ophthalmic solutions in clinical practice. Because
they are reported voluntarily from a population of unknown
size, estimates of frequency cannot be made. The reactions,
which have been chosen for inclusion due to either their
seriousness, frequency of reporting, possible causal
connection to brimonidine tartrate ophthalmic solutions,
or a combination of these factors, include: bradycardia,
hypersensitivity, iritis, keratoconjunctivitis sicca, miosis,
nausea, skin reactions (including erythema, eyelid pruritus,
rash, and vasodilation), and tachycardia.
Apnea, bradycardia, coma, hypotension, hypothermia,
hypotonia, lethargy, pallor, respiratory depression, and somnolence have been reported in infants receiving brimonidine
tartrate ophthalmic solutions [see Contraindications].
DRUG INTERACTIONS
Oral Carbonic Anhydrase Inhibitors - There is a potential
for an additive effect on the known systemic effects of
carbonic anhydrase inhibition in patients receiving an oral
carbonic anhydrase inhibitor and brinzolamide ophthalmic
suspension 1%, a component of SIMBRINZA® Suspension.
The concomitant administration of SIMBRINZA® Suspension
and oral carbonic anhydrase inhibitors is not recommended.
High-Dose Salicylate Therapy - Carbonic anhydrase inhibitors may produce acid-base and electrolyte alterations.
These alterations were not reported in the clinical trials
with brinzolamide ophthalmic suspension 1%. However, in
patients treated with oral carbonic anhydrase inhibitors,
rare instances of acid-base alterations have occurred with
high-dose salicylate therapy. Therefore, the potential for
such drug interactions should be considered in patients
receiving SIMBRINZA® Suspension.
CNS Depressants - Although specific drug interaction studies have not been conducted with SIMBRINZA® Suspension,
the possibility of an additive or potentiating effect with CNS
depressants (alcohol, opiates, barbiturates, sedatives, or
anesthetics) should be considered.
Antihypertensives/Cardiac Glycosides - Because brimonidine tartrate, a component of SIMBRINZA® Suspension,
may reduce blood pressure, caution in using drugs such
as antihypertensives and/or cardiac glycosides with
SIMBRINZA® Suspension is advised.
Tricyclic Antidepressants - Tricyclic antidepressants have
been reported to blunt the hypotensive effect of systemic
clonidine. It is not known whether the concurrent use of
these agents with SIMBRINZA® Suspension in humans can
lead to resulting interference with the IOP lowering effect.
Caution is advised in patients taking tricyclic antidepressants which can affect the metabolism and uptake of
circulating amines.
Monoamine Oxidase Inhibitors - Monoamine oxidase
(MAO) inhibitors may theoretically interfere with the
metabolism of brimonidine tartrate and potentially result
in an increased systemic side-effect such as hypotension.
Caution is advised in patients taking MAO inhibitors which
can affect the metabolism and uptake of circulating amines.
USE IN SPECIFIC POPULATIONS
Pregnancy - Pregnancy Category C: Developmental
toxicity studies with brinzolamide in rabbits at oral doses
of 1, 3, and 6 mg/kg/day (20, 60, and 120 times the
recommended human ophthalmic dose) produced maternal
toxicity at 6 mg/kg/day and a significant increase in the
number of fetal variations, such as accessory skull bones,
which was only slightly higher than the historic value at 1
and 6 mg/kg. In rats, statistically decreased body weights
of fetuses from dams receiving oral doses of 18 mg/kg/
day (180 times the recommended human ophthalmic dose)
during gestation were proportional to the reduced maternal
weight gain, with no statistically significant effects on organ
or tissue development. Increases in unossified sternebrae,
reduced ossification of the skull, and unossified hyoid
that occurred at 6 and 18 mg/kg were not statistically
significant. No treatment-related malformations were
seen. Following oral administration of 14C-brinzolamide to
pregnant rats, radioactivity was found to cross the placenta
and was present in the fetal tissues and blood.
Developmental toxicity studies performed in rats with
oral doses of 0.66 mg brimonidine base/kg revealed no
evidence of harm to the fetus. Dosing at this level resulted
in a plasma drug concentration approximately 100 times
higher than that seen in humans at the recommended
human ophthalmic dose. In animal studies, brimonidine
crossed the placenta and entered into the fetal circulation
to a limited extent.
There are no adequate and well-controlled studies in
pregnant women. SIMBRINZA® Suspension should be used
during pregnancy only if the potential benefit justifies the
potential risk to the fetus.
Nursing Mothers - In a study of brinzolamide in lactating
rats, decreases in body weight gain in offspring at an oral
dose of 15 mg/kg/day (150 times the recommended human
ophthalmic dose) were observed during lactation. No other
effects were observed. However, following oral administration of 14C-brinzolamide to lactating rats, radioactivity was
found in milk at concentrations below those in the blood
and plasma. In animal studies, brimonidine was excreted
in breast milk.
It is not known whether brinzolamide and brimonidine
tartrate are excreted in human milk following topical ocular
administration. Because many drugs are excreted in human
milk and because of the potential for serious adverse reactions in nursing infants from SIMBRINZA® (brinzolamide/
brimonidine tartrate ophthalmic suspension) 1%/0.2%, a
decision should be made whether to discontinue nursing or
to discontinue the drug, taking into account the importance
of the drug to the mother.
Pediatric Use - The individual component, brinzolamide,
has been studied in pediatric glaucoma patients 4 weeks
to 5 years of age. The individual component, brimonidine
tartrate, has been studied in pediatric patients 2 to 7 years
old. Somnolence (50-83%) and decreased alertness was
seen in patients 2 to 6 years old. SIMBRINZA® Suspension
is contraindicated in children under the age of 2 years [see
Contraindications].
Geriatric Use - No overall differences in safety or
effectiveness have been observed between elderly and
adult patients.
OVERDOSAGE
Although no human data are available, electrolyte
imbalance, development of an acidotic state, and possible
nervous system effects may occur following an oral overdose of brinzolamide. Serum electrolyte levels (particularly
potassium) and blood pH levels should be monitored.
Very limited information exists on accidental ingestion of
brimonidine in adults; the only adverse event reported to
date has been hypotension. Symptoms of brimonidine overdose have been reported in neonates, infants, and children
receiving brimonidine as part of medical treatment of congenital glaucoma or by accidental oral ingestion. Treatment
of an oral overdose includes supportive and symptomatic
therapy; a patent airway should be maintained.
PATIENT COUNSELING INFORMATION
Sulfonamide Reactions - Advise patients that if serious or
unusual ocular or systemic reactions or signs of hypersensitivity occur, they should discontinue the use of the product
and consult their physician.
Temporary Blurred Vision - Vision may be temporarily
blurred following dosing with SIMBRINZA® Suspension.
Care should be exercised in operating machinery or driving
a motor vehicle.
Effect on Ability to Drive and Use Machinery - As with
other drugs in this class, SIMBRINZA® Suspension may
cause fatigue and/or drowsiness in some patients. Caution
patients who engage in hazardous activities of the potential
for a decrease in mental alertness.
Avoiding Contamination of the Product - Instruct patients
that ocular solutions, if handled improperly or if the tip of
the dispensing container contacts the eye or surrounding
structures, can become contaminated by common bacteria
known to cause ocular infections. Serious damage to the
eye and subsequent loss of vision may result from using
contaminated solutions [see Warnings and Precautions ]. Always replace the cap after using. If solution
changes color or becomes cloudy, do not use. Do not use
the product after the expiration date marked on the bottle.
Intercurrent Ocular Conditions - Advise patients that if
they have ocular surgery or develop an intercurrent ocular
condition (e.g., trauma or infection), they should immediately seek their physician’s advice concerning the continued
use of the present multidose container.
Concomitant Topical Ocular Therapy - If more than one
topical ophthalmic drug is being used, the drugs should be
administered at least five minutes apart.
Contact Lens Wear - The preservative in SIMBRINZA®
Suspension, benzalkonium chloride, may be absorbed by
soft contact lenses. Contact lenses should be removed
during instillation of SIMBRINZA® Suspension, but may be
reinserted 15 minutes after instillation.
©2013 Novartis
U.S. Patent No:
6,316,441
ALCON LABORATORIES, INC.
Fort Worth, Texas 76134 USA
1-800-757-9195
[email protected]
© 2014 Novartis 10/14
SMB14121JAD
|
I’m seeing a patient for a medical follow-up.
This is a quick way to see what was going on
at the last visit and compare it to what you
see today. This option should be used only
if you are dedicated to diligently examining
all forwarded data and changing values appropriately to fit your current exam findings.
Drop-down menus can be useful as long
as your database contains info that you typically diagnose. If you don’t customize your
EHR software to fit your style, then you will
never like it. Work with your EHR software
company to customize drop-down fields to
populate with your most utilized diagnoses.
These diagnoses can also be attached to the
proper ICD-9 or ICD-10 code and auto populate into your assessment and plan, thereby
saving you and your staff more time later. If
the diagnosis that you need is not in the dropdown box, then free typing is OK, but don’t
expect any ICD-9 codes to be auto-populated
The big key is
repetition. The
more you perform
an action, the more
comfortable you
will become.
with free typing. This is why a basic level of
customization is key to success with all EHRs.
If you need a new ICD code, most EHRs
have a search feature. Keep in mind the more
letters you type before you click search, the
more specific results will displayed. Therefore, if you type “D,” you will get every single entry containing the letter D. However,
if you type “diabetic,” your results will be
much more targeted. Not all EHRs are created equally, and it seems like no one has
consistent names for diagnosis. You may have
to search different key words if your initial
search doesn’t produce the desired code.
Make Google your best friend
Google is your best friend. Can’t find an ICD-9
code? Google. Type in your diagnosis and
“ICD-9,” and usually you will get something
close to what you need. This will, at the very
least, allow you to put that code into your
EHR and use the search function to find the
specific code you want.
Dr. Sikes is a past president for the South Eastern District of
the North Carolina State Optometric Society.
[email protected]
ES572251_OP0315_018.pgs 02.19.2015 19:31
ADV
8th Annual
Evidence Based Care In Optometry Conference
Turf Valley Resort & Conference Center · Ellicott City, MD
14 Hours COPE Approved CE Pending
Register Today!
Early Bird Discount
Ends Soon
Presented By:
Wilmer Eye Institute
&
Saturday, May 2, 2015:
Morning Session
Sunday, May 3, 2015:
Morning Session
8:15a.m. - 8:55a.m. Registration | Continental Breakfast | Exhibitors
8:55a.m. - 11:40a.m.
8:15a.m. - 9:00a.m. Registration | Continental Breakfast | Exhibitors
9:00a.m. - 11:45a.m.
· Welcome and Conference Goals
Andrew Morgenstern, O.D., MOA President-Elect
· Show Me the Evidence Before I Buy It
Elliott Myrowitz, O.D., M.P.H.
· What Wavefront Technology Can and Cannot Do in the Office
Christina Prescott, M.D., Ph.D.
· Recurrent Cornea Erosion: How to Treat
Karen Dunlap, O.D.
· Corneal Cross-Linking: Not Just for Ectasia
Ashley Behrens, M.D.
· Panel Discussion
· Nutrition and AMD: Impact of AREDS 2 and
What Role Does Genetics Play
Catherine Meyerle, M.D.
· Recognizing Ocular Tumors
Mary Beth Aronow, M.D.
· Suture of the Future
Ashley Behrens, M.D.
· Panel Discussion
· Keratoconus Contact Lens Treatment
Anisa Gire, O.D. & Amanda Marks, O.D., M.S.
· Surgery and Keratoconus: Cataracts and Transplants
Divya Srikumaran, M.D.
· Keratoconus Genetics and Pathophysiology
Albert Jun, M.D., Ph.D.
Roxana
· Panel Discussion with Challenging Cases
Rivera,
M.D.
· Viral Ophthalmic Disease From Adeno
to Zoster
Irene Kuo, M.D. & Elliott Myrowitz, O.D., M.P.H.
· Blepharoptosis: Surgical and Non-surgical Considerations
Timothy McCulley, M.D.
· Panel Discussion with Challenging Cases
Afternoon Session
1:00p.m. - 4:40p.m.
· OCT, With Case Presentations
Mahsa Salehi, O.D. & Anupam Laul, O.D.
· Topography, With Case Presentations
Elliott Myrowitz, O.D., M.P.H.
· Scleral Lens: Where to Star t and How to Become Advanced
Susan J. Gromacki, O.D., M.S., Amanda Marks, O.D., M.S.,
& Anisa Gire, O.D.
· American Board Certification:
Clinical Pearls in Preparing for the Exam
Alan Wilder, O.D. & Wilmer Optometry Group Panel
· 2015 Therapeutic Medications Update
Francisco Burgos, O.D., Gayle LePosa, O.D. & Robert Stutman, O,D., M.B.A.
· 2015 Retina: What You Most Need to Know
Mahsa Salehi, O.D. & Alexander Leder, M.D.
Afternoon Session
12:45p.m. - 4:20p.m.
· Glaucoma Cases
Anupam Laul, O.D. & Baltimore Optometry Residents
· New Glaucoma Treatments and Surgeries
Adam LePosa, O.D.
· Oculoplastic Considerations in Glaucoma Patients
Nicholas Mahoney, M.D.
· Pseudoexfoliation Syndrome
Mar ta Fabr ykowski, O.D. & Anupam Laul, O.D.
· High IOP in Children: What You Need to Know
Anya Trumler, M.D.
· Pediatric Practice Building Based on Current Evidence
Josephine Owoeye, O.D., M.P.H.
· Plaquenil Retinal Toxicity: Review and Update
Jack Prince, O.D.
· Retina Case Presentations, Diagnosis, and Management
Mahsa Salehi, O.D. & Alexander Leder, M.D.
· Panel Discussion
Information & Online Registration:
Maryland Optometric Association
[email protected]
marylandoptometry.org
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410.870.9662
Turf Valley Resort & Conference Center
2700 Turf Valley Road · Ellicott City, MD 21042
410.465.1500
www.marylandoptometry.org/?page=EBCConference
Special MOA Room & Golf Rates: www.turfvalley.com/MOA
ES572770_OP0315_019_FP.pgs 02.20.2015 18:09
ADV
Special Secti o n
Contact Lenses
20
March 2015
Scleral lenses
ness, redness, and discomfort. You
can tell if there is limbal clearance
by looking for the fluorescein under
the lens to extend beyond the limbal
ferent way of thinking than other
area (Figure 1). If you do not have
lenses. Instead of thinking in terms
limbal clearance, it is as simple as
of curves, it is helpful to think in
asking your lab consultant to make
terms of depth or clearance. Once
JaSon JeDlicKa, oD the lens with more clearance.
we clear that hurdle, fitting scleris an associate
Step three. Make sure the lens
als can seems quite simple.
professor at the
bears
evenly on the sclera. Lenses
Fitting scleral lenses is a threeindiana University
that are too flat on the edge will have
step process, and following this proSchool of optometry
and immediate
edge standoff. Lenses that are too
cess each and every time will lead
past president of
steep on the edge will compress the
to success in a majority of patients.
the Scleral lens
blood vessels of the conjunctiva and
Step one. Choose a lens with
education Society.
create blanching. Lenses that are too
enough depth to clear the cornea
flat or steep in one meridian only
entirely. Scleral lenses by definition
will require a toric landing zone. Modifying
do not touch the cornea. If you put a lens
the landing zone is usually as easy as asking
on that touches the cornea, it is simply not
for steeper, flatter, or toric landing curves.
deep enough. Moving to a lens with greater
Fitting a scleral lens is actually quite straightdepth will eventually lead to a lens that clears
forward because the sclera is more forgiving
the cornea entirely. Once you have achieved
than the cornea. If the idea that fitting scleral
lenses is difficult is what is holding you back,
you are falling prey to Myth 1.
Three-step fitting process
for scleral lenses
1. choose a lens with enough depth to
clear the cornea entirely
2. ensure the lens clears the limbus
3. Make sure the lens bears evenly on
the sclera
that clearance, you can get more specific and
work on getting the exact amount of clearance you desire. This amount of clearance
will be part of the fitting guide for the lens
design you use, it but should be somewhere
in the neighborhood of 150-450 µm.
Step two. Ensure the lens clears the limbus. A scleral lens that bears on the limbus
will eventually lead to problems with dry-
myth Sclerals are expensive
2
Relative to corneal GP lenses, scleral
lens are expensive. But, relative to a
year’s supply of hybrid or soft lenses,
there is much less difference. When considering that for many patients the scleral lens
provides better comfort and wear than a corneal GP and better vision than a soft, the cost
should not often be a concern.
I have fitted hundreds of individuals in
scleral lenses, and the cost aspect has been a
sticking point for only a small percentage of
them. Once they have had the opportunity to
try on a lens, feel the comfort, and see the vision, the price of the lens becomes secondary.
In many instances in which corneal irregu-
Figure 2.
Multifocal scleral lens
on eye with normal
cornea and compound
myopic astigmatism with
presbyopia resulting in
20/20 distance and 20/25
near acuity.
magenta
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|
TAKE-HOME MESSAGE Scleral gas
permeable contact lenses have seen an increase
in popularity in recent years. however, some
practitioners are still reluctant to fit them. Five
myths about scleral lenses are debunked, including difficult fitting, cost, potential long-term
adverse effects, lens of last resort, and only
a few patients need such lenses. expand your
repertoire and give more patients the benefit of
better vision and comfort with scleral lenses.
larity or ocular surface disease exist, scleral
lenses can be covered by insurance. In cases
where the lenses are used for refractive error
only, charge the cash pay patient a reasonable
amount to make the lenses and the fitting process worthwhile financially for the office, but
still keep the cost to the patient affordable.
myth Sclerals are a lens of last resort
3
This has been the reality for most
of the history of scleral lenses, but
it is changing as more practitioners
realize they are easy to fit, provide good vision, good comfort, and can be affordable.
There was a time as recently as 1991 when
a survey reported that GP lenses comprised
nearly 40 percent of the contact lens fits in
the UK.1 Certainly there was a time when we
as a profession were very comfortable fitting
GP lenses on a substantial percentage of our
patients who wanted correction with contact
lenses. If scleral lenses are more comfortable
than corneal GPs and correct the vision as
well, could we return to a time when we
were increasingly comfortable using scleral
lenses for correcting simple refractive error?
Scleral lenses can be used to correct any
type of refractive error, as well as presbyopia
(Figure 2). Athletes who require excellent
acuity and a stable lens fit while they are
physically active could benefit from scleral
lenses. Individuals with nystagmus would
benefit from the stable optics as well as the
quality of vision provided by a scleral lens for
the high prescriptions that often accompany
it. Mild to moderate dry eye sufferers who
desire contact lens correction may do better
in sclerals than other contact lens options.
In addition, the use of scleral lenses for
managing ocular surface disease could certainly be greater because there are no doubt
thousands of individuals who would benefit
from scleral lenses if only they were made
aware of the power of the lenses to help manage their conditions. There is a substantial
percentage of the eyecare community who
do not fully understand the applications of
ES573267_OP0315_020.pgs 02.21.2015 03:44
ADV
Special Secti o n
scleral lenses for managing ocular surface
disease until every other option has failed.
If scleral lenses were implemented at an earlier stage of the management of these ocular
surface disease patients, such patients might
find relief more quickly. This comes down
to education of the eyecare community—including optometrists, ophthalmologists, and
the medical community that works with individuals with systemic diseases that lead to
ophthalmic effects—and the willingness to
refer for or implement scleral lenses much earlier in the process of managing eye disease.
Contact Lenses
RefeRence
1. Pearson RM. Contact Lens Trends in the
United Kingdom in 1991. Cont Lens Anterior Eye.
1992:15(1);17-23.
impacted by wearing scleral contact lenses.
Fitting individuals in scleral contact lenses
can be a rewarding professional experience.
This experience can be yours as well if you
look past the myths and start to embrace
this new trend in GP lenses that looks like
it will become a permanent and continually
growing segment of the contact lens market.
Dr. Jedlicka is a frequent author and lecturer on contact lens
and anterior segment related topics, and has helped develop
unique scleral and orthokeratology lens designs.
[email protected]
OCULUS Easyfield® C
myth Sclerals are a niche lens for a small
4
21
population of patients
Speed and Accuracy
This myth goes back to the previous
point. Right now, scleral lenses are a
niche lens for a small population of patients,
but that is up to us to make them more of a
mainstream option. As mentioned previously,
GPs made up a substantial percentage of contact lens wearers as recently as 25 years ago.
The reason for the shift was most assuredly
comfort for the vast majority of those who
converted from GP to soft lenses or those who
chose soft lenses over GPs from the outset.
Now that the comfort gap has been bridged
by sclerals, the percentage of individuals in
contact lenses who are candidates for reintroduction to GP lenses is significantly more
than it was in the recent past.
The idea that sclerals are a niche lens is
only a matter of what we as fitters make it.
We have the option to make sclerals more
mainstream if we choose.
Celebrating 15 years
of Innovative Perimetry and
Customer Satisfaction!
myth We don’t know scleral lenses’
The final myth of scleral lenses is
that we do not know the long-term
effects on the eye, and this is true to a degree—it depends on what you consider longterm. Scleral lenses have been utilized in
their current form for more than a decade,
and for years before then on a limited scale
by Boston Foundation for Sight and in other
countries. To date, there has been little published that would indicate any long-term side
effects to scleral lens wear.
Possible concerns have been for endothelial
cell loss, increased intraocular pressure, or
limbal stem cell or goblet cell damage from
lens compression. However, review of the scientific literature produces no studies that indicate any of these effects are observed across
the board. Further studies will be conducted
in these areas of potential concern, but after
more than a decade of use and thousands
and thousands of wearers, there is nothing
that indicates long-term health is negatively
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* This offer cannot be combined with any other discounts or special offers. Only for a new Easyfield®.
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ES573265_OP0315_021.pgs 02.21.2015 03:44
ADV
Co-Management
22
March 2015
endothelial cells found in PXF eyes, often
there is more intense and prolonged postopcontinued from page 1
erative anterior segment inflammation.4,5 This
potentially includes higher levels
of aqueous flare with accompanied
creased postoperative vigilance,
fibrinoid reaction, even leading to
even after an uneventful phacoposterior synechiaes. Such an inemulsification with endocapsular
crease in inflammation may necesintraocular lens (IOL) placement.
sitate a more frequent topical steroid
Postoperative patients with PXF
dosing schedule, a stronger topical
pose both short- and long-term consteroid, or, in rare cases, adjunctive
cerns due to the underlying pathMARTA C.
cycloplegia. Of course, this follows
ological changes that occur from
FABRYKOWSKI,
with increased surveillance of the
the fibrillar deposition with some
OD, FAAO
IOP and may require more visits.
complications arising years after
received her Doctor
of optometry
Some cases of significant postoperathe surgery. This review provides
in 2011 from
tive corneal edema may benefit from
a time-oriented approach to comthe ohio State
adjunctive topical sodium chloride
prehensively assess patients with
University college
solution or ointment in addition to
PXF who have undergone cataract
of optometry.
increased steroid use (see Figure
surgery, beginning with immedi1). Thankfully, corneal decompenately 24-hours after surgery.
sation requiring surgical intervention after
routine phacoemulsifiShort-term complication watch
cation in eyes with PXF
It has been reported that intraocular pressure
is exceedingly rare.3
(IOP) spikes, within 24 hours, can reach over
3
30 mm Hg in 7 percent of patients. PostopAnterior capsular
erative IOP spikes are more common and
phimosis is another
may be higher than non-PXF eyes. Acutely
potential early postophigh IOPs may necessitate topical hypotenerative phenomenon,
sive therapy, or oral diuretics such as acetslightly more common
azolamide or methazolamide may need to
in eyes with PXF.6 It is
be used. In rare cases, when IOP becomes
characterized by condangerously high, some practitioners advotraction of the anterior
cate for release of aqueous from the paracapsule and potential
centesis.3 Any of the above cases require
decentration or tilt of the IOL in the X, Y,
or Z plane. It may be beneficial to perform
diligent in-office follow up.
Nd:YAG laser relaxing incisions to the phiDue to the decrease in integrity of corneal
pseudoexfoliation
|
TAKE-HOME MESSAGE patients with
pseudoexfoliation undergoing cataract surgery
may experience complications. Such patients
should be carefully monitored starting immediately after surgery to detect problems such
as iop spikes, prolonged anterior segment
inflammation, anterior capsular phimosis, and
posterior capsular opacification. Surveillance should be ongoing for several years to
catch decentered iols, lengthy inflammatory
response, macular integrity and iris trauma.
motic area of the capsule at the earliest sign.3
Posterior capsular opacification (PCO) has
also been reported in higher frequency in
eyes with PXF (Shingleton & Crandall).6 One
study found that after two years, 45 percent
of PXF eyes had posterior capsular opacifi-
The long-term
complications or effects after
phacoemulsification in eyes
with PXF are fewer but may
be more serious than in the
short term.
cation vs. 24 percent of non-PXF.7 If visually
significant, this may require prompt Nd:YAG
laser to the posterior capsule.
Long-term adverse events
Figure 1. Corneal edema 24 hours status post phacoemulsification. Note haze view and endothelial folds.
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The long-term complications or effects after
phacoemulsification in eyes with PXF are
fewer but may be more serious than in the
short term.
Even with uneventful surgery, decentration of the IOL may still occur many years
postoperatively due to progressive zonular
disintegration and capsular contraction.5
The actual incidence of postoperative subluxation/dislocation of an IOL in eyes with
PXF is higher than eyes without PXF, and
the mean is 8.5 years after the initial surgery.6 If the IOL is significantly displaced
and affecting vision or causing friction, it
may be managed by either repositioning the
existing IOL in the capsular bag by suturing to sclera, iris fixation, or exchanging
the IOL altogether (see Figure 2).3
As eyes with PXF have an alternation in
the tissues of the anterior segment, the initial inflammatory response can sometimes
linger for some time.2 Cells and flare may
ES573268_OP0315_022.pgs 02.21.2015 03:44
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Co-Management
23
toids macular edema (CME). Interestingly, iris trauma incurred during phacoemulsification, which is more likely to
occur with patients who dilate poorly, like those with PXF,
has been found to be a risk factor for CME.6 Postoperative
use of topical NSAIDs may be beneficial in PXF eyes with
glaucoma and have had iris trauma.
Pseudoexfoliation presents challenges after cataract surgery
see Pseudoexfoliation on page 24
Digital Photography
Solutions
Figure 2. Postoperative in-the-bag inferiorly dislocated IOL. Note the superior view of the
capsular bag and peripupillary fibrillar material.
for Slit Lamp
Imaging
Digital
SLR Camera
Figure 3. Retroilluminated view of inferiorly dislocated IOL. Again note the superior band
of capsule, demonstrating that the IOL is still in the capsular bag.
persist with or without an increase
in IOP. This may require the use
of increased topical steroids, with
added use of topical hypotensives
should IOP increase with the frequency of anti-inflammatories. Conversely, there may also be longtime
reduction in IOP after the bulky
natural lens has been removed. IOP
reduction after phacoemulsification has been noted in both PXF
and non-PXF eyes, though some
reports have noted that reduction
is greater in eyes with PXF.2
In this similar vein, it is important to note that glaucoma concerns
should be discussed in full prior
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to cataract surgery. This includes
the previously mentioned possibility that IOP may be initially high,
requiring adjunctive topical hypotensives, and then may lessen to
a number lower than that prior to
surgery. There is also a possibility that IOP may remain the same
or become higher postoperatively,
which may require further surgical intervention.
Posteriorly in the eye, macular
integrity in eyes with PXF should
be monitored closely. It has been
found that eyes with not just PXF
but those with PXF glaucoma are
indeed at increased risk for cys-
Universal
Smart Phone
Adaptor for
Slit Lamp
Imaging
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Transamerican Technologies International
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email: [email protected]
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ES573269_OP0315_023.pgs 02.21.2015 03:44
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Co-Management
24
pseudoexfoliation
that must be closely monitored. Approaching
the eye comprehensively—including monitoring and addressing IOP, inflammation,
capsular contraction, and IOL decentration
concerns—is necessary. Postoperative care
may include adjunctive topical therapy, and
sometimes surgical/laser intervention. Vigilant visits may lead to earlier intervention
and better overall outcomes.
Special thanks to Jules Winokur, MD, for
his insights and edits.
RefeRences
1. Fingeret M. Exfoliation Glaucoma. Optometric
Glaucoma Society Residency Education Meeting. Fort
DR
AC
OL
OG
Y
ST
PH
AR
M
RY
Y
TR
ME
TO
OP
Worth. August 5, 2013.
2. Calafati J, Tam D, Ahmed II. Pseudoexfoliation
syndrome in cataract surgery. EyeNet. 2009 April: 37-39.
3. Shingleton BJ. How to manage pseudoexfoliation
syndrome in cataract surgery. Glaucoma Today. 2013
March/April:44-46
4. Crista AR. Pseudoexfoliation syndrome and cataract
surgery in pseudoexfoliation syndrome. Timisoara
Medical Journal. 2009;59(3-4): 378-80. 5. Drolsum L, Ringvold A, Nicolaissen B. Cataract and
glaucoma surgery in pseudoexfoliation syndrome: a
review. Acta Ophthalmol Scand. 2007 Dec;85(8):810-21.
7. Küchle M, Amberg A, Martus P, Nguyen NX, Naumann
GO. Pseudoexfoliation syndrome and secondary
cataract. Br J Ophthalmol. 1997 Oct;81(10):862-6.
Dr. Fabrykowski completed a residency in ocular disease
in 2012 at omni eye Services of nJ. currently, she is on
staff at the manhattan eye ear and throat hospital Faculty
ophthalmology practice, under lenox hill hospital.
[email protected]
-
RO
U
NE
ST
|
6. 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):110120.
FUNCTIONAL VISION AVE
AV
OM
ET
March 2015
CONTACT
O
C LE
IN BRIeF
FDA approves Lucentis
for diabetic retinopathy
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Optometry’s Meeting® June 24–28, where new education sessions and formats
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industry could look like in 10-15 years
· Jimmy Bartlett, OD speaks to 21st century therapeutics
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To register for Optometry’s most enlightening
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SEATTLE, WA
JUNE 24-2 8, 2 015
The U.S. Food and Drug Administration recently expanded the approved use for Lucentis (ranibizumab injection, Genentech)
0.3 mg to treat diabetic retinopathy (DR) in
patients with diabetic macular edema (DME).
The drug’s safety and efficacy to treat DR
with DME were established in two clinical studies involving 759 participants who
were treated and followed for three years. In
the two studies, participants being treated
with Lucentis showed significant improvement in the severity of their DR at two years
compared to patients who did not receive
an injection.
The most common side effects include
bleeding of the conjunctiva; eye pain; floaters; and increased intraocular pressure. Serious side effects include infection within
the eyeball (endophthalmitis) and retinal
detachments.
The FDA granted Lucentis for DR with
DME breakthrough therapy designation.
The FDA previously had approved Lucentis
to treat DME and macular edema secondary
to retinal vein occlusions. Lucentis also is
approved to treat wet age-related macular
degeneration.
ES573266_OP0315_024.pgs 02.21.2015 03:44
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SPECIal SECTIOn
| PracTIcaL chaIrSIDE aDVIcE
Frames & Lenses
25
Modernized lifestyle
dispensing
How to meet your patient’s lifestyle vision needs
n
sive eye care.
ever before have we had such
The most important part of lifea plethora of choices at our
style dispensing comes down to
disposal when it comes to
good old-fashioned communication
offering solutions to visual
and listening skills. We, as eyecare
needs. It seems as though what used
professionals, must be skilled in
to require occasional education on
discovering needs and knowledgenew products and their benefits has
able in finding an eyewear solunow become an ongoing necessity
LISA FrYe, ABOC
is a veteran optician
tion to solve that need. No matter
as advances in technology grow by
with more than 30
how we choose to gather informaleaps and bounds.
years of experience
tion about the patient’s lifestyle, we
Lifestyle dispensing is taking the
in managing optical
need to assist our patients in funcfocus from selling eyewear to idenpractices.
tioning visually in whatever task,
tifying specific needs and finding
activity, or sport in which they participate.
real benefits and solutions to those needs.
This is rewarding because it feels good to
help someone function visually, and the secCommunicate to find opportunities
ondary benefit is to the growth and profitCommunication skills among patients, staff,
ability of a practice or business.
and doctors open the door to opportunities.
Although taking time to practice lifestyle
Some of the most successful practices have
dispensing has always been important to
reached that success because, as a group,
they are truly looking out for
the best interest of the patient.
At every stage of the patient
care—from check-in with the
front office staff, to pretesting with the technicians, to
comprehensive examination,
to special testing or contact
lens fitting, from the doctor
to the hand-off to the optical
dispensing staff—we work as
the success of a practice or business, now
a team to discover more about the patient’s
it is a must. With multimedia exposure full
lifestyle. We can take this knowledge to
of information to make shoppers more tech
our next step in specific solution and bensavvy and more online sites offering eyeefit offerings.
wear options, it behooves us to be up to date
At the doctor hand-off, the staffer or opand skilled at lifestyle dispensing.
tician in the dispensary can recap some of
We can introduce lifestyle solutions to our
the needs discussed with the patient earlier.
patients in ways that are relevant. In our
This is where communication and listening
office, we have large-screen TV monitors to
skills become most vital—along with proddisplay informative on solutions to specific
uct knowledge and understanding how to
needs. Some offices have set up interacmatch products to a specific need. This is
tive software that walks a patient through
also where we can help a patient find eyethe usual questions that would have previwear that truly fits, functions as expected,
ously been collected in written form. All of
and is fashionable. When we do this well,
these are wonderful tools at our disposal
our patients become our best advocates in
in modern times in providing comprehenmarketing our practices. The most important part of
lifestyle dispensing comes
down to good old-fashioned
communication and
listening skills.
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TaKE-HOME MESSaGE We now have
more vision solutions options to offer our
patients than ever before. it is up to everyone
in a practice—from the front desk to the techs
to the doctors—to work together as a team to
find out which solutions will work best for the
patient’s lifestyle. ask open-ended questions to
discover the patient’s priorities and then find
the lens, lens treatments, and frames that will
offer the patient an optimal vision experience.
Finding the patient’s priorities
Exploring the options can be endless. We
should ask open-ended questions that require specific answers. Examples of openended questions include, “What activities
do you participate in? How do your current
glasses function when you go about your
day?” The questions you ask should allow
you to gather data about specific needs and
should not be answerable with just a yes or
a no response. You want to get to know each
patient personally in order to personalize
what you offer. A thorough discussion not
only identifies needs but can also lend information about preferences in frame styles
and the patient’s priorities.
As a patient describes a day in the life of
her visual experience, a prepared eyecare
professional can already be formulating in
his mind what solutions and benefits to recommend to meet each need. This process is
successful only if you are natural with your
terminology and have working knowledge
of what products to offer to match specific
situations. You must be the expert and assure the patient that you have just the answer to her visual application..
Remember to mention what the patient
said is her first priority in vision correction,
and demonstrate how your recommendation solves that need.
See Dispensing on page 26
ES573014_OP0315_025.pgs 02.20.2015 23:56
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Special Secti o n
Frames & Lences
26
Dispensing
If fashion is the first priority to a patient,
then finding the perfect frames would take
precedence. If you discovered that finding a
way to afford both prescription eyewear and
prescription sun wear was important, then
achieving both within the established budget
range would be priority. Never be afraid to
offer benefit solutions that are above a stated
True lifestyle
dispensing is taking
the focus from
selling eyewear to
identifying specific
needs and finding
real benefits and
solutions to those
needs.
budget when you believe that they are required to solve a need. More often than not
if you strongly believe in the benefit to the
patient, she will see that the benefit is important and will find a way to afford eyewear
that will meet her needs. There is a wide variety of product categories, which allow us to
offer good, better, and best scenarios while
still achieving the desired benefit.
March 2015
General needs for every patient
There are some general needs that should
be addressed for every single patient we
see. Every patient should have frames that
fit properly regardless of budget. With so
many available options in where to purchase eyewear, this important starting point
is the foundation of function and comfort
for your patient. Pay particular attention to
the details. Does the frame fit the patient’s
bridge? Will it accommodate the required
lenses? Are the temples the correct length?
And will it hold up to the task for which it
will be utilized? If we are into solving lifestyle needs, then no small detail can be
considered unimportant.
An expert eyecare provider needs to explain how different frame and lens options
can give patients the best visual experience
to meet their needs and expectations. All
patients can benefit from:
UV protection
Anti-reflective coating
Polarized lenses for sun wear
Lenses that offer the best distance solution for their lifestyle
I am really listening when the patient describes how his glasses will be used. As a
patient explains his lifestyle, I repeat back
what he told me, inserting my recommendations and how he can benefit from each offer.
Most of us use some type of electronic
device and are finding that our eyes are
getting a real workout as we enjoy modern
technology. More patients than ever before
can benefit from anti-fatigue lenses, multifocal correction, or lenses designed for
|
Never be afraid
to offer benefit
solutions that are
above a stated
budget when you
believe that they are
required to solve a
need.
computer or office setting tasks. One pair
of eyeglasses cannot meet every need. If
a patient cannot function without correction, then it is imperative that we recommend and offer a backup pair of glasses in
the event that the primary pair needs repair or service. The amount of effort you put into lifestyle
dispensing will determine your success. Successful lifestyle dispensing includes:
The right staff in place
Working in tandem with the goal of
meeting needs and retaining patients
for life
Offering top-notch patient care
A variety of product offerings in a variety of price ranges
Educating the staff on products and
their benefits
Lisa Frye is certified by the american Board of opticians and is
a Fellow of the national academy of opticians.
[email protected]
In BrIeF
Transitions launches new media, advertising campaigns
OrlandO, Fl—This year, Transitions Optical, Inc.
announced it will reach consumers through
an integrated mix of media partnerships and
television, digital, and social media advertising. To bring new groups of consumers to
the photochromic category, the company is
making Transitions XTRActive lenses and
its benefits a focus of this year’s campaign.
According to the company, the TV ad will
continue to communicate the performance
of Transitions Signature lenses with Chromea7 technology through its “Modes” campaign—but this year, a new TV tag will call
out Transitions XTRActive lenses beginning
in April. Transitions says the “Modes” ad
will be on air every quarter and will be seen
over one billion times on premium cable
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networks, like CNN, ESPN 2, Nat Geo Wild,
the Travel Channel, and Spanish-language
TV networks, such as Discovery en Español and Telemundo.
“We are continuing the ‘Modes’ campaign
because we have proof that it is working
and helping to grow consumer interest in
the brand,” says Patience Cook, associate
director, North America marketing, Transitions Optical. “Nine out of ten consumers
aware of Transitions Signature lenses feel
that our technology has improved. We are
building on the success of the campaign,
but modifying it slightly to maximize choice
with Transitions XTRActive lenses.”
The company will also have online advertising shown before and during streaming
videos through services like Hulu.
In addition to the online outreach, placements in high-profile print and tablet editions
of national magazines, including Cooking
Light, Southern Living, and WIRED magazine. Print ads will help illustrate the extra
protection Transitions XTRActive lenses provide wearers in bright sunlight, harsh indoor light and even in the car.
Transitions also has new partnerships
with media like National Geographic and
Rolling Stone.
“Rolling Stone is an exciting and unique
partnership for us,” saysCook. “It will enable us to reach a segment of consumers
who are more fashion conscious and tend
to skew younger.”
ES573015_OP0315_026.pgs 02.20.2015 23:56
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VISIONARIES
IN EDUCATION, FASHION AND TECHNOLOGY
International Vision Expo is always
enhancing its educational offerings
and adding new tracks that address
trending industry topics. New tracks
in 2015 include Retail, in collaboration
with the Accessories Council, Wearable
Technology and the Ocular Wellness
Program, and features spotlight
sessions with topics delivered by the
Ritz Carlton and other noted service
experts.
International Vision Expo integrates
new technology throughout the
show. Courses demonstrate how to
maximize technology for better patient
outcomes, and the exhibit hall offers
hands-on demonstrations of the latest
innovations.
Get exclusive access to next-generation
technologies at the Technology Theater,
Medical and Scientific Theater, and the
Vision Monday Eye 2 Zone.
From early morning until late at night,
thousands of like-minded professionals
from more than 50 unique groups
gather for co-located meetings,
participate in education and host
events. These alliances, state and
national associations, and buying
groups choose International Vision
Expo as the global hub for the eyecare
industry.
INTERNATIONAL VISION EXPO 2015
EDUCATION: THURSDAY, MARCH 19–SUNDAY, MARCH 22 EXHIBITION: FRIDAY, MARCH 20–SUNDAY, MARCH 22
JAVITS CENTER | NEW YORK, NY | VisionExpoEast.com | #VisionExpo
REGISTER TODAY AT VisionExpoEast.com/OptTimes
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PROUD SUPPORTER OF:
ES572778_OP0315_027_FP.pgs 02.20.2015 18:10
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28
InDispensable
March 2015
|
Karen Walker Eyewear launches
summer 2015 collection
Karen Walker Eyewear recently launched
its summer 2015 collection, which quickly
went viral thanks to the campaign’s latest
model—Toast, an Instagram-famous King
charles cavalier Spaniel (follow her at @
toastmeetsworld).
“We were after a model for this campaign
who could fit with our caramel-ly color palette
and also someone whose hair would work
with our three wind machines hitting her from
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every angle to create a slightly ‘70s vibe,”
says Karen Walker. “Toast ticked every one of
those boxes.”
The new collection introduces five new
styles with elevated detailing, and each fea-
turing a variety of strong but dusty colors.
Many of the styles feature two-tone patch
working with gold trim.
all of the styles are double-polished and
cured to ensure durability and strength.
ES573022_OP0315_028.pgs 02.21.2015 00:01
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InDispensable
| PracTIcaL chaIrSIDE aDVIcE
29
HOT HOUSE
KHAKI/
GOLD
STARBURST
NAVY /GOLD
CROP
CREEPER
CRAZY TORT/
CLEAR/GOLD
MAZE
BLACK/
GOLD
MAZE DUSTY
PINK/GOLD
HOT HOUSE
BLACK/
GOLD
FLOWER
PATCH
TAN/ DUSTY
PINK/GOLD
DEEP
ORCHARD
CRAZY TORT/
CLEAR/GOLD
ONE MEADOW
KHAKI/GOLD
ClearVision launches Aspire Eyewear
HAUPPAUGE, NY—clearVision recently launched its
latest brand, aspire Eyewear.
according to the company, the aspire
collection was designed using 3D technology prior to prototype creation, significantly
reducing sample development from several
weeks to 20 minutes. created with a thin
and lightweight proprietary “memory plastic”
material, aspire frames offer a “barely there”
feel and fit.
aspire will launch with 12 optical styles
available in three colors each, including
six styles for women and six styles for men
that offer some crossover, and feature five
architecturally inspired temple designs in
both stainless steel and TR-90. Three sun
styles in traditional shapes including cat eye,
aviator, and navigator, are also available in
the launch collection. Models are named according to aspirational adjectives including
Special, Stylish, and Independent.
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Aspire Eyewear features:
almost 50 percent lighter than a regular
plastic frame (weight = 14 g)
22 percent lighter than a typical titanium
frame
adjustable nose pad system
almost 50 percent thinner than typical
acetate frames (front = 2.25 mm thick)
Three colors for each model, including
translucents and fades
Screwless hinges
ES573024_OP0315_029.pgs 02.21.2015 00:01
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30
InDispensable
March 2015
|
Rudy Project introduces next
generation of unbreakable lenses
DENVER—rudy Project recently launched the
latest advancement in technical lenses, ImpactX-2. The ImpactX lens has been updated
with photochromic particles which provide
faster color transition and enhanced contrast
via a newly designed hDr filter, all within an
absolutely unbreakable lens that can transition from clear to multiple colors.
ImpactX-2 lenses feature the ability to
automatically lighten and darken from a semitransparent tone to a specific color according
to light conditions. Unlike traditional photochromic lenses which can change only from
clear to black, ImpactX-2 will be launched
in five variations that transition from
either clear to black, clear to laser
black, clear to red, clear to laser red or clear
to laser brown.
according to the company, these lenses
are also 20 percent more temperature stable
over the previous generation, offering a wider
photochromic range of up to 65 percent light
transmission difference. Furthermore, this
photochromic activation occurs in all natural
light within seconds, including behind surfaces which screen UV rays such as windows
or car windshields.
Not only does ImpactX-2 activate 25 percent faster than the previous ImpactX lens
generation, but the photochromic pigments
incorporate an advanced high Dynamic
range (hDr) filter which eliminates a portion
of light not seen by our eyes.
These sleek lenses are offered in five photochromic colors, inspired by the legendary
first ImpactX generation. The all-around
lenses (clear to black and clear to laser black)
are engineered for variable weather and will
perform in any terrain and climate condition.
The racing red series (clear to red and clear
to laser red) are designed for fast action and
maximum stimulating color contrast. The laser
brown lenses (clear to laser brown)
lower overall optical stress and maximize comfort for all-day activities.
For those who wear prescription
lenses, ImpactX-2 can be crafted with
their specific parameters by utilizing
rudy Project’s FreeForm TEK digital
backside surfacing.
LASER GREEN
LASER BLACK
LASER RED
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ES573023_OP0315_030.pgs 02.21.2015 00:01
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March 2015 / OptometryTimes.com
Go to:
31
products.modernmedicine.com
Products & Services
ShowcaSe
PRODUCTS
Search for the company name you see in each of the ads in this section for FREE INFORMATION!
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ES573150_OP0315_031_CL.pgs 02.21.2015 02:06
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32
Marketplace
March 2015 / Optometry Times
Products & services
disPensary
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ES573148_OP0315_032_CL.pgs 02.21.2015 02:06
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Marketplace
March 2015 / OptometryTimes.com
33
Products & services
conferences & events
Practice management
American Academy of Optometry
New Jersey Chapter
13t h Annual Educational Conference
April 22-26, 2015
Myrtle Beach, South Carolina
Hilton Embassy Suites at Kingston Plantation
Dr. Mark Friedberg, M.D.
Founding Editor of the
Wills Eye Manual
16 HOURS
COPE CE
Dr. Alan Kabat, OD., F.A.A.O.
Registration: $475.00
One, Two or Three Bedroom Suites
Accommodations Include a Daily Breakfast Buffet
and Evening Cocktail Reception
PACK YOUR CLUBS!
Golf details to follow.
Call Karen Gerome
QuikEyes
Web-Based Optometry EHR
• $198 per month after low cost set-up fee
• Quick Set-Up and Easy to Use
• No Server Needed
• Corporate and Private OD practices
• 14 Day Free Demo Trial
• Email/Text Communications
to place your
Products & Services ad at
800-225-4569, ext. 2670
[email protected]
www.quikeyes.com
For Accommodation and Additional Information, contact:
Dennis H. Lyons, OD, F.A.A.O.
Phone: (732) 920-0110
E-Mail: [email protected]
Advertisers Index
ClaSSified workS!
Advertiser
Alcon Laboratories Inc
Tel: 800-862-5266
Web: www.alcon.com
careers
illinois
Looking for a place to start your “Medical Model” Optometric practice?
I am a 64 year old OD with a beautiful 4400 sq ft office fully remodeled with
all of the latest technology. I am located across the street from a major hospital in
a professional building with other physicians. You can view my office website:
www.hardestyeyecare.com. We have 5 exam rooms, a full Optical, a well trained
staff, with 2 Pre-test rooms.
I am offering my space to help the right person start their practice. I am here for
advice and help to get you on a private practice road. There is also the option of
taking over my practice in the next 3 years as you grow your own. I have been
successful at the “Medical Model” and am willing to help the right candidate get
started.
You can reach me or my office manager at
630 517 2000 or email [email protected]
Recruitment Advertising
Joanna Shippoli: (800) 225-4569 x2615;
[email protected]
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Page
CVTIP, CV2
17, 18, CV4
AcuityPro Vision Science Software
Tel: 877-228-4890
Web: www.acuitypro.com
11
American Optometric Association
Web: www.optometrysmeeting.org
24
Bausch + Lomb
Tel: 800-227-1427
Customer Service: 800-323-0000
Web: www.bausch.com
7
Cooper vision
Web: www.coopervision.com
CV3
Nova Bay Pharmaceuticals
Web: [email protected]
15
Oculus Inc
Tel: 425-670-9977
Fax: 425-670-0742
Web: www.oculususa.com
21
Thrombogenics
Tel: 732-590-2900
Web: www.thrombogenics.com
13
TTI Medical
Tel: 800-322-7373
Web: www.ttimedical.com
23
Vision Expo
Web: www.visionexpoeast.com
27
Wilmer
Tel: 410-502-9635
Web: www.hopkinscme.edu
19
This index is provided as an additional service.
The publisher does not assume any liability for errors
or omissions.
ES573149_OP0315_033_CL.pgs 02.21.2015 02:06
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34
Q&A
MARCH 2015
Jill Autry, OD, RPh
|
Bellaire, TX
Tobacco, pharmacy and optometry, pleading the Fifth
Where did you grow
up? Nowhere, North
Carolina, an hour south of
Raleigh in the middle of tobacco country, and I grew
up barning tobacco. Started
when I was four or five years
old. Until I was 18, in summers we would put in a few
barns in the morning and
then I would wait tables at
night. I spent a lot of time
trying to make money when
I was a kid; I was quite the
entrepreneur.
What led you from
pharmacy into optom-
etry? That’s the million-dollar question. I wish I had a
quarter for every time I’m
asked. [Laughs] I went to
the University of North Carolina; I thought I would go
into some type of medical
field. Then I met a guy—you
know how that can change
your life’s course—he was
going to pharmacy school.
So I started looking around
to see what that entailed.
After I started working, I realized pretty quickly that I
didn’t have a lot of control
over what happened with the
patient. I could make recommendations, but I didn’t
have any final say. So after a
year, I wanted to further my
education. At the same time,
pharmacy schools were requiring all programs to go
to a doctorate program. That
meant people like me who
had just graduated would be
competing with a six-year
doctorate. If you were already out, you would have to
go back for two more years to
get the doctorate. I thought,
if I’m going to go back for
two years and basically have
the same degree, I might as
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Q
How do you
find the two
disciplines
complementing
one another?
North Carolina has always been a very progressive state as far
as optometry is concerned, so I assumed
that all the states
were like North Carolina. Once I found that
was not the case, especially in Texas, it
started to open my
eyes at how much
there was a lack of
orals and understanding and education that
goes along the pharmaceutical route of ocular diseases. It was
nice to put those two
together. I’ve been
able to be that liaison
in education, lecturing,
and write about what
medications can be
used and ease optometrists into the realm
of pharmaceuticals,
especially oral pharmaceuticals in ocular
disease.
well plunge into something
else. That’s how I ended up
in optometry school.
What common drug interactions should ODs
be more aware of? For a long
That’s a myth. People are
concerned about using topical sulfa-meds, such as glaucoma medication that have
a sulfide chain, in patients
who are sulfa-allergic. We
have to remember that sulfaallergic patients are generally
allergic to sulfa-antibiotics.
In optometry, you’re not usually going to have patients on
long-term therapy. Most of
the drugs that we start, especially orally, you’re talking about seven to ten days.
In pain medications, probably two or three. So, in general most of the things we’re
doing are short term.
What medications
should ODs be more cautious with? States have been
reluctant to allow oral steroid
use in optometry, and I can’t
blame them until we’re much
more educated. Steroids are
one of our biggest concerns
for how they can change
people’s basal metabolic rate,
there are diabetic concerns,
and they have to be tapered
appropriately. They are going
to be the biggest hurdle we
face in making sure
we are properly educated and understand the decisions
and contraindications that go with
them.
What do you do for down
time? I’m not a good
down-timer. We have two
boys, 8 and 9, so they keep
us busy. I’m not a very good
idler, I don’t watch television.
Because I’m the farm girl,
I still get up very early. It’s
hard to sleep in.
If you could do it all over
again, what would you
change? I don’t know that I’d
change anything. Some say I
should have become an ophthalmologist. If I had gone
to med school, I would have
ended up in internal medicine or maybe neuro. I think
I ended up in the right place.
What’s the craziest
thing you’ve ever done?
Things that shouldn’t be discussed that would not make
me look as good as I think I
should. I’ll plead the Fifth.
—Vernon Trollinger
Photo courtesy Jill Autry, OD, RPh
To hear the full
interview with Jill
Autry, listen online:
optometrytimes.com/
JillAutry
time, people were thinking
about antibiotics and interference with birth control.
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SUPPLEMENT TO
1
AND
EXAmininG PEDiAtRiC EyES
CLINICAL PEARLS FOR HELPING YOUR SMALLEST PATIENTS
1
2
Figures 1 and 2. The author using his hands to physically simulate the directions of
eso-deviations and exo-deviations to help parents better understand.
By Alex Christoff, BS, Co, Cot
t
he common eye problems
found in adults, developing
over decades of life as acquired
disease, are diferent in
children. There is an old pediatrics adage
that “children are not little adults.” This is
certainly true when it comes to the pediatric eye exam that many allied health care
personnel fnd themselves facing, often
with dread, on a weekly or daily basis.
Obtaining pertinent history—often
from a source other than the patient—and
relevant clinical information to help the
physician arrive at the proper diagnosis
and provide the appropriate treatment,
requires a diferent and creative approach,
patience, and talent. Technical staf who
themselves are parents have a distinct
advantage: they are familiar with the
nuances of behavior in young children.
They know the various developmental
milestones, when children start to sit up,
stand, learn to walk, and start talking.
These milestones are an important part
of the pediatric history and often play an
equally important role in illuminating and
the underlying cause of clinical signs and
symptoms.
The pediatric eye exam can be broken
down into fve basic components:
■ History and chief complaint
■ Sensorimotor evaluation
■ Visual acuity testing
■ External exam and pupillary evaluation
Instillation of dilating eye drops.
We will conclude with a brief review of
the more common causes of decreased
vision in infancy.
■
Preliminaries of an exam
The pediatric eye screening begins by
observing the child at ease, frst in the
waiting area as you walk out to call and
greet him, then as he walks in to the exam
room with you. Introduce yourself. Ofer a
handshake to adults and older children. Be
cognizant of the fact that some cultures
and religions do not shake hands. You
should become familiar with your patient
demographic and apply these concepts
accordingly. Comment to a child about
See Pediatrics on Page 3
volume 04 | issue 1 | spring 2015
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I n f o . I n s p I r at I o n . C o m m u n i t y.
Pediatrics
Continued from page 1
clothes, toys, what they’re eating,
siblings, etc.
As you enter the exam room,
have the children and their
families take seats away from the
exam chair if possible, guarding
exam-chair time as a precious
commodity. Once the child is
seated in the exam chair, her
attention timer is ticking. If you
approach the interview and this
initial part of the exam with dread,
children will sense your tension
and become uncomfortable. It is
incumbent on you as the examiner
to gain the child’s confdence and
trust, and you will want to do so
in a relaxed, open, honest, and
playfully engaging way.
Once the child is seated in the
exam chair, you should establish
and maintain eye contact. Sit at the
child’s eye level by lowering your
chair/exam stool and/or raising
the child’s exam chair. Maintaining
eye contact may or may not be
possible with autistic children
who often avoid eye contact
with others. You will want to
initiate verbal rapport with simple
questions comments, such as,
“How old are you?” Over-estimate
age and grade level. Ask about
siblings who came with her to the
appointment today. These quick
simple pearls warm the experience
for the child and her family, and for
you as the examiner.
It is important to remember
that as you work with children
you have to focus your exam.
Check what you need early on
while you have cooperation, and
save the more difcult tasks for
last. You will have to develop a
diferent vocabulary. For example,
say “magic sunglasses” when
introducing the anaglyphic glasses
of the Worth 4-Dot test and the
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Components of a pediatric eye exam
■
History and chief complaint
■
Sensorimotor evaluation
■
Visual acuity testing
■
External exam and pupillary evaluation
■
Instillation of dilating eye drops.
polarized glasses of the various
stereo acuity tests. Use “special
fashlight” to describe your
retinoscope, and “funny hat” or
“coal miner’s hat” when describing
what the physician will do with
the indirect ophthalmoscope.
“Magnifying glass” is an apt
description of the magnifying
lens used with the indirect
ophthalmoscope, and suggest
“let’s ride the motorcycle/bicycle”
when it is necessary to do a slit
lamp exam.
Taking a history
“When all else fails, take a history.”
These words were the sage advice
of J. Lawton Smith, MD. Former
ophthalmology resident at the
Wilmer Eye Institute in the 1950s,
Dr. Smith went on to become an
internationally recognized neuroophthalmologist at the Bascom
Palmer Eye Institute in Miami.
All medical histories should
begin by identifying the patient’s
chief complaint, preferably in as
close to their own words as the
electronic medical records of the
present day may allow. Examples
of a chief complaint include,
“decreased vision,” “headaches,”
“blurred vision,” or “double vision.”
The clinician will next want to
evaluate the history of present
illness, or HPI. For the parents, ask
who referred the child in to your
ofce and why. Sometimes the
simple question, “What can we
do for you today?” works best. Try
to establish when the problem
started (onset), how often the
problem is noticeable (frequency/
severity) and when the symptoms
manifest do themselves, how long
do they last (duration).
Who notices? Relatives,
teachers, the pediatrician?
Sometimes you can ask the child
simple question like, “Which eye
hurts?” or “Which is the bad eye?”
But avoid complex topics like
questions about double vision in
younger children because this is a
difcult concept at best for most
preschoolers.
Expand your history with
questions about treatment and
what has been done to address
the problem. Was a more extensive
workup required that might have
included blood work or imaging
studies? And how has the problem
developed or changed in the
interim between the last ofce visit
and the most recent visit? Do the
parents know anything about the
problem? This is the Internet age,
and most parents have explored
their child’s eye problem online
before having sought treatment.
With the HPI, you are trying to
develop a diferential diagnosis—
basically, a short list of possible
causes by defning the problem
and making sense of the history. Of
course you will want to explore the
symptoms and signs observed by
the parents. Are they constant, or
Check what
you need
early on while
you have
cooperation,
and save the
more difficult
tasks for last.
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intermittent? When do they occur?
What time of day? Are they worse
at the end of day, or with fatigue?
Failed vision screening
history. Children often present to
the pediatric eyecare practitioner
because they failed a vision
screening at school or at their
pediatrician’s ofce. It is very
important for the technician to ask
when the child was tested. There
are obvious clinical implications
and expectations if the failed
screening was six months ago vs. a
few weeks ago.
What was wrong? What part
of the screening test did they fail?
Was it because of an observed
misalignment? Did she do poorly
on the visual acuity test? How was
vision measured? Was it an ageappropriate test? Did the screener
use letters, numbers, pictures, and
isolated, linear, or single-surround
optotypes? As you will learn in
the pages that follow, all of these
elements factor in to how young
children perform on visual acuity
tests. In other words, a failed vision
screening may or may not really be
indicative of a real problem.
Strabismus history. When
it comes to strabismus, parents
will often use the term “lazy
eye” to mean strabismus and/
or amblyopia, the decreased
best-corrected visual acuity
often associated with strabismus.
Similarly, many parents use the
word “crossing” to refer to any
type of strabismus; esotropia,
exotropia, even in describing
vertical deviations. All of which
means the technician will have to
verify the direction of the observed
misalignment graphically with the
parents in order to make sense of
the history.
I use my hands to physically
simulate esotropia, or in-crossing
of the eyes by pointing to my
nose with both hands. Similarly
with a suspected exo-deviation,
I use both hands to point out
away from my ears to simulate
an outward drifting of the eyes
(Figures 1 and 2). Explore possible
strabismus more in your history
by asking which eye is seen to be
misaligned. Do the parents notice
any squinting? Bilateral squinting
is typically a sign of uncorrected
refractive error or ocular allergy,
while unilateral squinting is often
associated with strabismus. Ask
about eye rubbing. Does the
Children often
present to the
pediatric eyecare
practitioner because
they failed a vision
screening at school or
at their pediatrician’s
office.
child always rub the same eye?
Who notices? Is it the parents, the
pediatrician, the child’s teachers,
other family members? Is eye
misalignment visible in family
photos? Is it constant, intermittent?
Is it happening at distance fxation,
with daydreaming, or at near
fxation, when the child attempts
to focus?
Diplopia history. Double
vision occurs when one fovea is
not directed at the same object
of regard as the other. While this
is quite common in older patients
with an acquired strabismus, it is
uncommon in young children with
an early-onset misalignment who
develop suppression, or the ability
to “turn of” the image from the
deviating eye. This phenomenon
occurs at the level of the brain’s
cerebral cortex. So double vision
in a pediatric patient, if it is real,
implies an acquired etiology and
may require special laboratory
tests or neuro-imaging studies
like MRI or a CT scan to explore a
possible neurological cause.
When interviewing patients
of any age with a complaint of
double vision, one of the frst
questions the clinician should ask:
“Does the double vision go away
if you cover either eye?” Binocular
diplopia resolves with unilateral
occlusion, while monocular
diplopia, diplopia still present after
covering one eye and most often
due to refractive error, resolves in
almost all cases with a pinhole. You
should also ask the patient if the
double vision is worse in certain
positions of gaze, at a certain time
of day, or at rest.
Pregnancy and birth
history. Children who were
born prematurely have been
shown to have a substantially
higher incidence of strabismus,
amblyopia, and high refractive
errors compared to full term
controls.1 So for these reasons,
you will want to ask questions
about the pregnancy, birth, and
developmental history of all
pediatric patients.
For the pregnancy, you should
ask the mother or parents about
illicit drug use, consumption of
alcoholic beverages, whether
there was a problem with preterm
labor, maternal age, paternal age,
prematurity (a full-term delivery is
40 weeks), low birth weight, use
of supplemental oxygen, presence
of retinopathy of prematurity and
whether it regressed/resolved on
its own or if it required laser photoablation, whether it was a normal
spontaneous vaginal delivery
(NSVD) or caesarean section, and
whether this was planned or
unplanned, and whether there
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5
were any labor complication.
Continue with questions about
birth complications, whether
there was an anoxic event/loss of
oxygen/delayed breathing, or any
breathing problems. You should
inquire as to whether there was
any trauma/instruments used
during the delivery (forceps,
suction), or any history of intracranial hemorrhage, convulsions,
seizures, or known syndromes.
defects and syndromes, and other
health problems become more
common in these situations. If
you are employed in one of these
facilities, you need to come to
terms with the various ophthalmic
sequelae and the medications
associated with them so you know
what to ask if and when these
children present to your clinic.
Because these kids tend to have
a team of healthcare providers,
The sensorimotor examination is
the key element. The problems that bring
children in can impact ocular alignment,
depth perception, and sensory fusion.
Developmental history.
Technicians who are parents
have a decided advantage here
because they are familiar with the
developmental milestones of their
own children. But there are a few
developmental milestones that
all technicians can easily learn to
help shed light on the observed
ophthalmic eye fndings as they
may contribute to a fnal diagnosis.
You should ask if the child has
met all of his or her milestones
to date. Familiarize yourself with
some of the basic components
of pediatric developmental
milestones, available online at the
website of the American Academy
of Pediatrics.2
Past medical history. Most
children are very healthy and take
few, if any, medications. However,
this may not be the case for
children seen in a tertiary care
facility or a hospital that is part of
a large inner city medical training
center. Conditions associated
with prematurity like retinopathy
of prematurity, hydrocephalus,
seizure disorders, anomalous birth
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the past medical histories and
medications are often, but not
always, well documented in the
medical record.
Family history. Asking about
the family history for pediatric
patients is not only good
medicine, it is now mandated
by the federal government
as part of its Meaningful Use
criteria for afective utilization
of the information obtained by
ophthalmologists in the electronic
medical record, or EMR. Questions
about other individuals with
strabismus, nystagmus, amblyopia,
or history of early-childhood
patching or glasses should be
routine. Additionally, individuals
with childhood blindness,
glaucoma, cataract, or heritable
diseases should be documented in
the EMR.
Social history. Lastly, it is
also important to know the living
conditions at home because social
stressors like divorce, abuse, foster
parents, and institutionalization
due to developmental delay may
have implications for compliance
with prescribed glasses, patching,
use of eye drops, and attendance
at follow-up examinations. Ask
about who lives with the child,
especially if he is accompanied
by only one parent, grandparent,
older sibling, aunt, or uncle. Is
there smoking in the house? Are
the parents married, separated,
or divorced? Are there pets in or
around the house?
Pediatric sensory motor
examination
The sensorimotor examination is
the key element in the pediatric
eye screening. The problems
that bring children in to see the
pediatric eyecare professional
include a number of diferent
types of strabismus, vergence
abnormalities, amblyopia, and
refractive dilemmas, all of which
can impact ocular alignment,
depth perception, and sensory
fusion. The examination typically
starts by assessing (sensory) fusion
frst and then measuring (motor)
alignment by prism and alternate
cover testing, both typically
performed by a trained specialist.
Sensory testing. Assessing
sensory fusion begins by
measuring gross binocular fusion
potential with the Worth 4-Dot
Test, which uses red/green
anaglyph glasses and a special
fashlight that displays four
lights—two green, one red, one
white. Convention dictates that
the patients wear the glasses with
the red lens over the right eye, if
there is a choice. The fashlight is
then shown to the patient at both
distance and near fxation, and she
is asked to report how many lights
are seen with both eyes open.
The response for binocular fusion
is four lights seen, in any color
arrangement. The response for
suppression is only one color seen,
either only two lights (red) for
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6
suppression of the left eye or only
three lights (green) for suppression
of the right eye. A response of
fve lights seen is consistent with
diplopia or manifest strabismus.
Interpreting the results of the
Worth 4-Dot test should be done
with caution because the test
is dissociating, meaning it may
cause an otherwise controlled
or intermittent strabismus or
phoria to manifest itself as a tropic
deviation behind the darkened
anaglyph glasses. Children from
age 3 to less than 5 years of age
can be asked to just count the
lights on the fashlight by touching
them one at a time, usually just at
near fxation (Figure 3).
3
correspond to increasingly fne
stereo images—the more circles
that are seen, the fner the stereo
acuity, and the better the visual
acuity in each eye. We use the
animal fgures only for preschool
children. Many of these tests come
in pediatric versions as well, which
can enhance cooperation.
Measuring strabismus. In
assessing strabismus, there are
basically two ways to quantify
ocular misalignment. The prism
and alternate cover test utilizes
either bar and/or loose prisms and
some type of opaque occluder.
Often a child will not allow you to
approach him with an occluder,
so your hand, palm, or thumb,
Figure 3.
Ask younger
children to count
lights on the
fashlight when
using the Worth
4-Dot Test.
Near stereo acuity testing
assess fne sensory fusion ability,
requiring clear and equal acuity
in both eyes and fner motor
alignment than what is required
by the Worth 4-Dot test. There
are a number of near stereo tests
available, though the industry
standards are typically the Titmus
or Randot stereo tests from Stereo
Optical. In each test, the wings
of the fy are the most disparate
and easily perceived, even by
children as young as 2.5 or 3
years of age. The circles of the test
though not preferable, will have
to do (Figure 4). Corneal light
refex estimating techniques are
based on the observed position
of a corneal light refex in relation
to the patient’s pupil in the
misaligned eye. These will be
discussed below. But let’s frst talk
about the basic type of strabismus
seen in the pediatric clinic.
When strabismus does present
itself, there are four types of
deviations with which the clinician
needs to become familiar. An
esotropia is an eye that deviates
in toward the nose, with a corneal
light refex temporal to the center
of the pupil. An exotropia is an
eye that deviates out away from
the nose, with a corneal light
refex nasal to the center of the
pupil. A hypertropia is an eye that
deviates up with a corneal light
refex inferior to the center of the
pupil. And a hypotropia is an eye
that deviates down with a corneal
light refex superior to the center
of the pupil. The term orthophoria
or orthotropia means that the eyes
appear straight with corneal light
refexes centered in both pupils
or by alternate prism and cover
testing.
Clinicians who routinely
perform sensorimotor evaluations
on younger children have to
fnd creative ways to maintain
the child’s interest. For distance
measurements, animated toys
and projected movies work well.
A parent or coworker can also
assist by standing at the end of
the exam lane, holding a fashing
toy, and calling the child’s name.
For near measurements, young
children are asked to sit on a family
member’s lap. The child usually
feels more secure there, and the
family member can then be asked
to hold a fxation stick or toy on
the examiner’s nose, leaving both
hands free to hold an occluder or
prism bar. Unfortunately, it is not
the scope of this article to discuss
the specifc details of how to
perform the prism and cover test.
The take-home message is that
children tend to respond favorably
to animal puppets and toys, and of
interest, there seems to be some
science to support why.3
Despite our best eforts to
engage the patient, there will
times when a frightened or
uncooperative child will not
permit sensory testing or a prism
and alternate cover test. Other
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7
times, a patient may have such
poor vision in one eye, that she
is unable to fxate well enough
to be measured with prism and
alternate cover testing. In these
circumstances, the clinician can use
a number of corneal light refex
tests to estimate and quantify the
observed strabismus.
To perform the Hirschberg
test, simply shine a bright penlight
or fxation light at the patient
from a distance of about arm’s
length. Observe the position of
the corneal light refexes from
the fashlight in each eye of the
patient. They should be centered
in each pupil if the eyes are
straight. However, if the light
refex is displaced near the pupil
margin in one eye, this represents
an approximate deviation of 15
degrees or 30.00 prism diopters
(PD). If the light refex in one
eye is displaced mid-iris, this
represents 30 degrees or 60.00 PD
of misalignment. And if the corneal
light refex in one eye is displaced
at the limbus, this represents
approximately 45 degrees or 90.00
PD of misalignment. It is up to the
examiner to identify the proper
type of strabismus or direction
of misalignment, but temporally
displaced corneal light refexes
correspond to eso-deviations,
medially displaced light refexes to
exo-deviations, inferiorly displaced
light refexes to hyper-deviations,
and superiorly displaced refexes
to hypo-deviations.
To estimate strabismus by
the modifed Krimsky test, the
examiner uses loose or bar prism
to eventually center the displaced
corneal light refex in the deviating
by trial and error, placing the
appropriate prism over the nondeviating eye.
Abnormal head postures.
Children sometimes develop an
abnormal head posture called
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torticollis (Figure 5), and their
families are asked by the child’s
pediatrician to have the patient
evaluated by a pediatric eye-care
specialist to determine if the
head position is being driven
by strabismus or some other
abnormality of binocular vision.
The strabismus measurements
required to diagnosis an ocular
abnormality in this situation are
not always possible in younger
children. But one of the quickest
and easiest ways to rule out an
abnormality of binocular vision is
to do a patch test. Simply place a
patch over one of the child’s eyes
and observe for 60 to 90 seconds,
asking the parents to restrain the
child’s arms if necessary to prevent
her from removing the patch. If
the head posture improves, this is
suggestive of an underlying ocular
abnormality of binocular vision
and requires further assessment
and more detailed measurements.
If the torticollis does not improve,
this is suggestive of a nonocular, perhaps musculoskeletal
abnormality, most often of the
sternocleidomastoid muscle on
the side of the neck toward the
head tilt.
Assessing visual acuity
in children
Birth to 2 to 3 months. If
the clinician is going to try
to measure vision in young
children, it’s important to frst
have an understanding of what
is considered normal, or age
appropriate visual acuity in the
pediatric population. Is a baby
born with 20/20 acuity? Not at all.
Birch and coworkers estimated,
through preferential looking
techniques, that vision at birth
is somewhere around 20/600,
developing rapidly in the frst
year of life and improving to
approximately 20/60 by 12 months
of age, and reaching an adult
normal of 20/20 by 60 months or 5
years of age.4
Newborn children are by
defnition visually inattentive and
immature. They will, however,
blink to a bright light shown close
to their eyes. Their eyes will also
pop open suddenly when the
room lights are fashed on and of,
a refex some clinicians call eye
popping, which tends to disappear
by around 6 months of age. Some
children will also respond with
saccadic eye movements to the
rotating stripes of the optokinetic
drum. This is just about all you can
expect from a neonate in his frst
several weeks of life.
Intermittent strabismus may
also be observed, but it should
not be present by 2 to 3 months
of age, correcting for prematurity.
Pupils become active, and
accommodation begins by 2
to 3 months of gestational age,
which you can demonstrate by
showing the child a target that
stimulates accommodation, the
multi-colored lights of the Worth
4-Dot fashlight, for example, and
observing the constriction of the
child’s pupils. Mid-dilated pupils
sluggishly responsive to light by
this age predicts reduced visual
acuity for age. Nystagmus in this
age group suggests abnormality
of the anterior visual pathway,
while the absence of nystagmus
in an otherwise visually inattentive
neonate is suggestive of cortical
visual impairment, or impairment
at the level of the brain.
3 to 6 months. As children
approach 6 months of age,
they become extremely visually
attentive in the near range,
preferring faces over objects and
toys. They will sit on their parents’
laps and stare at you with an
astounding aplomb. Acuity can be
assessed for this age group in a
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8
4
5
Figure 5.
Abnormal
head posture
called torticollis
may indicate
strabismus or
some other
abnormality of
binocular vision
or a non-ocular
cause.
Figure 4. Often a child will not allow you to
approach him with an occluder, so your hand,
palm, or thumb, though not preferable, will
have to do.
6
7
Figure 7.
Demonstration of
the “blink them
in” technique for
administering
dilating eye drops
in children.
Figure 6. Occluding can sometimes be a
challenge. The author recommends special
occlusive glasses designed for visual acuity
testing in children.
number of ways, including forced
recognition grated acuity tests
like Teller Acuity Cards (Stereo
Optical) and by observing how
they fxate on and follow silent
fashing targets, like a fashing toy
star, through a smooth pursuit
with each eye. This is typically an
abduction movement out toward
the ear followed by adduction
back again toward the nose,
without losing fxation. Repeat if
necessary. Last, but certainly not
least, if all else fails, they can fxate
on and follow the examiner’s face
through the same smooth pursuit
movements!
One can also take advantage
of the vestibular ocular refex to
assess the visual pathways by
taking the child (make sure you ask
for permission from the parents!)
and holding her up in front of
you at eye level, face toward you,
spinning around gently in one
direction on a rotating stool. This
motion stimulates optokinetic
nystagmus (OKN) through the
inner ear. What you will see is the
child doing a smooth pursuit in
the opposite direction of the spin
as she watches the environment
rotating by behind you, then a fast
saccade back in the direction of
the spin, repeated over and over
again until you stop spinning. At
this point, a child with intact visual
acuity may exhibit a beat or two
of residual OKN, dampening in less
than 5 seconds. But in a child with
decreased or absent visual acuity,
the OKN will not dampen and
persist for more than 5 seconds.
6 to 36 months. Preverbal
children from 6 to 24 months of
age can be presented with a base
down prism in front of one eye,
typically 16.00 or 18.00 PD. With
both eyes open, this creates a
vertically diplopic second image
of a target at distance or near
fxation. This is called the induced
tropia test.5 If vision is intact,
and the child is not suppressing
visual input from the eye behind
the prism, you will see a vertical,
hypertropic shift in both eyes as
the child attempts to fxate on
the second image that appears
above the original fxation object
of interest. Absence of induced
vertical shift is suggestive of
amblyopia in the eye behind the
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9
prism. This can be documented
in the chart as C for central (the
eye is straight), S for steady (no
nystagmus), and M for maintained
(fxation through the prism), or
CSM. If fxation is not maintained
for more than one to two seconds,
you would document this as
CSUM, for Central, Steady, UnMaintained.
After age 3: Recognition
visual acuity. Testing recognizable
optotypes, whether Allen or Lea
symbols, HOTV or Snellen letters,
can begin from 30 to 36 months,
depending on the cognitive ability
and cooperation of each child. The
author’s personal bias, based on
15 years of clinical experience, is
not to attempt recognition acuity
before 36 months due to variability
of maturity. Of course there are
always exceptions to every rule.
This age group will also peak
during the test, so occlusion of
the untested eye needs to be with
a tape patch or special occlusive
glasses designed for visual acuity
testing in children (Figure 6), or
adhesive tape directly over the
child’s eye, or on the lens of his
glasses. Single surround bars, also
called crowding bars, expedite
testing in the younger children and
have been shown to accurately
replicate the resolution challenge
of linear optotypes in amblyopic
patients while minimizing test time
in our most inattentive patients.6
You can help the child stay
engaged by turning the matching
card to the blank side and
advancing to the next letter. Point
at the screen and ask the child to
look at the screen, then fip the
card over to show the choices and
ask the child to match the shape
she sees.
From age 4, HOTV crowded
optotypes can be used with good
reliability, though every child is
developmentally diferent, and
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sometimes the examiner has to
resort back to a matching version
of the test. Most children will
progress to full Snellen recognition
optotypes by age 5, though I tend
to minimize the attention required
with linear Snellen acuity testing
by using the single surround,
crowded optotypes until age 10,
again, depending on the child,
maturity, and intellectual abilities.
Checking pupils
An important part of any complete
eye exam, this component of the
encounter, while straightforward
in adults, can be challenging
in inattentive children. A direct
ophthalmoscope is often helpful if
you have a less than cooperative
child because you can illuminate
the pupils from a more remote
distance and see a red refex in
addition to the corneal refexes
of the Hirschberg test. This is
also very useful in patients with
dark irides, as it makes the iridopupillary border a lot easier to see,
especially for those of us who are
presbyopic!
Giving eye drops
The last step in the pediatric eye
exam is arguably one of the most
stressful. here are a few techniques
that will foster cooperation, help
minimize stress, and overall make
the process of instilling eye drops
less tumultuous for the patient, his
family, and you as the examiner.
My favorite technique is the
“blink them in” technique. I explain
to the child that we need to put
eye drops in her eyes. I then direct
her attention to a playful sticker
attached to the ceiling above her
head. I ask her to tilt her head
back, then close her eyes, which
is exactly opposite of what she is
expecting you to say. “Close your
eyes tight, and I’m going to put the
cold water on your eye lashes,” I
tell her. This seems to be accepted
by most children. “And when I
count to three, we’re going to do
a big blink, really fast.” I give her
a tissue and tell her that she can
wipe after she blinks. I also gently
hold the child’s chin up until she
blinks to avoid the drops streaming
of her face and into her lap (Figure
7). I explain to the parents that
while this is a messy technique
(drops run all over the place,
usually on the child’s clothes), it
really works. Give it a try.
Another technique is the
“kangaroo pouch” technique in
which you cajole the child into
looking up in a similar manner
and at a similar target as described
above, then place the drops in
cul-de-sac of his lower lids. The
lower lid cul-de-sac is much less
sensitive, and a great place to
instill an eye drop. I don’t have as
much use with this technique in
the younger children, but it does
work well with older children and
teenagers.
Despite these techniques
some children, especially infants
and toddlers younger than 36
months of age, will not cooperate
with instillation of drops. In these
cases, it is necessary to restrain
the child in order to properly instill
the drops. In doing so, you will
frst want to explain to the child’s
parents why you have to restrain
the child. Once parents agree,
small babies and very young
children can be placed on their
backs on the right arm of one
parent seated in the exam chair,
the child’s head toward the crook
of the parent’s elbow, feet across
the parent’s lap. Have the parent
hold the arms while you take care
of the head, lids, and instilling
drops. In older children, or bigger,
stronger kids who require restraint,
there is a real risk of injury to the
parent, the child, or even you as
itech
ADV
10
Alex Christof is
assistant professor
of ophthalmology
at The Wilmer Eye
Institute at Johns
Hopkins Hospital
in Baltimore.
E-mail him at
[email protected]
the examiner. A diferent technique
is recommended for these kids.
Have the child straddle the
parent’s lap facing toward the
parent, with one leg on either side
of the parent’s hips. Seat yourself
directly in front of the parent’s
knees, ask the parent to lean the
child backward onto your lap so
that he is prone on his back on
your legs and his head is in your
lap, facing the ceiling. You can
now ask the parent to restrain the
child’s arms and hands with their
hands, the legs are immobilized
around the parent’s hips, and you
have both hands free to restrain
the head, manipulate the lids, and
instill the drops.
Lastly, it is extremely important
for the technician to control the
dosing of dilating drops instilled
in the eyes of young children
because these medications can be
toxic,7 trigger seizures,8 and even
lead to cardiac arrest9 in neonates
and small children.
For newborn babies and
children younger than 6 months
of age, one drop of cyclomydril
(Alcon), which consists of
cyclopentolate hydrochloride 0.2%
and phenylephrine hydrochloride
1%, is my drop of choice. In
children with darkly pigmented
irides, I add an additional drop
of tropicamide 1% because it is a
better midriatic drop, though on
its own, a poor cycloplegic agent.
Starting at age 6 months
and progressing to age 16, instill
cyclopentolate 1% drops in
lighter-pigmented eyes, adding
tropicamide 1% or phenylephrine
2.5% drops for more darkly
pigmented eyes. Some children
who have had laser photo-ablative
surgery for threshold retinopathy
of prematurity may require all
three drops to dilate adequately
enough for the physician to see
into the eye.
Causes of decreased vision in
infancy
The causes of decreased vision in
children, in addition to amblyopia
and refractive error, include
developmental malformations and
acquired lesions of eyes and visual
pathways. Clinical markers and
signs include the oculo-digital sign,
a habitual pressing on one or both
eyes by the child with their fnger
or fst. This behavior is specifc to
bilateral congenital or early-onset
blindness due to retinal diseases
and heritable retinal dystrophies,
predicting best-corrected visual
acuity usually 20/200 or less in the
afected eye. Index of suspicion
should be high in children greater
than 6 months who do not readily
make eye contact with you.
Congenital nystagmus is
commonly seen in disorders
of the anterior pathways, such
as ocular cutaneous albinism,
which involves the optic nerves.
Look for a compensatory head
posture, implying optimal acuity,
binocularity, and functional vision.
Nystagmus is typically absent in
cortical visual impairment (CVI).
Large, slow, roving nystagmus
or eye movements are often
associated with poor vision and/
or visual loss before the age of
6 months. These types of eye
movements are not seen in CVI.10
End on a happy note
There are many challenges
associated with examining children
in the eye clinic. Indeed, it is one
part science, two parts art, and
mastering the required skills takes
skill, patience, practice, having the
right tools, and perhaps above
all, having the right attitude. After
a challenging session with any
child, end on a high note and
reward her for a job well done,
after making sure that is fne with
her parents, with a lollipop, or a
playful sticker she can wear out of
the ofce when she leaves. Treat
your pediatric patients the way
you would want someone to treat
your child, or you, for that matter.
Use dignity, empathy, and respect,
and they and their families will
remember you for it.◗
References
1. Kushner, BJ. (1982). Strabismus and
amblyopia associated with regressed retinopathy of prematurity. Arch Ophthalmol. 1982
Feb;100(2):256-61. 2. Hagan JF, Shaw JS, Duncan P, et al. 2008.
Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents, Third
Edition. Pocket Guide. Elk Grove Village, IL:
American Academy of Pediatrics. Available
at http://brightfutures.aap.org/pdfs/bf3%20
pocket%20guide_fnal.pdf. Accessed 2/18/15.
3. Mormann FA, Dubois J, Kornblith S, et al. A
category-specifc response to animals in the
right human amygdala. Nat Neurosci. 2011
Aug 28;14(10);1247-9. 4. Birch EE. Visual acuity testing in infants
and young children. Ophthalmol Clin North
Am. 1989;2:369-89.
5. Frank JW. The clinical usefulness of the
induced tropia test for amblyopia. Am Orthopt
J. 33(1983):60-9.
6. Peskin MA. Threshold visual acuity testing
of preschool children using the crowded
HOTV and Lea Symbols acuity tests. J AAPOS. 2003;7(6):396–9.
7. Adcock EW 3rd. Cyclopentolate (Cyclogyl)
toxicity in pediatric patients. J Pediatr. 1971
Jul;79(1):127-9.
8. Demayo AP, Reidenberg MM. Reidenberg
Grand Mal Seizure in a Child 30 Minutes
After Cyclogyl (Cyclopentolate and 10% NeoSynephrine (Phenylephrine Hydrochloride)
Eye Drops Were Instilled. Pediatrics. 2004
May;113(5):499-500.
9. Lee JM, Kodsi SR, Gafar MA, et al.
Cardiopulmonary arrest following administration of Cyclomydril eyedrops for outpatient
retinopathy of prematurity screening. J AAPOS,
2014 Apr;18(2):183-4.
10. Brodsky MC, Baker RS, Hamed LM. Pediatric Neuro-Ophthalmology. New York: Springer
Press, 1996.
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