Dry Eye - Modern medicine

Transcription

SEPTEMBER 2015
VOL. 7, NO. 9
OptometryTimes.com
PRACTICAL CHAIRSIDE ADVICE
Warm compresses to treat
meibomian gland disease
Eyecare community
raises red flags
over Opternative
A compress bundle warms the eyelid above
aPatients
therapeutic
temperature
for better results
sleeping
in their
By Colleen E. McCarthy
Content Specialist
contact
lenses don’t have
1
to keep you up at night
Figure 1.
Warm compress
bundle prior to
soaking.
Did you know 1 in 3 patients sleep overnight in their
contact lenses1? AIR OPTIX® NIGHT & DAY AQUA is the
#1 eye care professional-recommended contact lens2
for patients who sleep in their lenses for these reasons:
HIGHEST
OXYGEN PhD;UNIQUE
TO 30
NIGHTS
By Jeffrey
R. Schubert,
David PLASMA
K. Murakami,UPOD,
MPH,
FAAO; Caroline A. Blackie,
TRANSMISSIBILITY *
SURFACE TECHNOLOGY
CONTINUOUS WEAR**
OD, PhD,Our
FAAO;
and
Donald
R.
Korb,
OD,
FAAO
Our unique surface
contact lens
Approved for daily wear
Chicago— Online refraction is officially here with
the recent launch of Opternative, a company
offering its online vision test to the public
for the first time.
How it works
CEO Aaron Dallek says he and Steven Lee,
OD, founded Opternative to provide an option for otherwise healthy patients who may
not require a yearly exam but may still need
a new prescription.
The company offers an online vision test
through its website, Opternative.com. The
test takes about 25 minutes, and the patient
can take the test via a computer or smartphone. An ophthalmologist verifies the prescription, and it is provided digitally to the
patient within 24 hours. The patient can receive a prescription for glasses or contact
lenses for $40 or for both for $60.
Dallek says patient satisfaction is guaranSee Opternative on page 5
3
provides the highest
and up to 30 nights of
technology smooths and
level of oxygen of any
continuous wear.**
helps protect the lens
material
obstructing the glands. The goal is
eibomian
gland
disease
(MGD)
is
4,5
available soft contact lens.
from deposits so lenses
a chronic, progressivestay
disease
andevery to stabilize the tear film and provide the occomfortable
day.
1
M
New eye drop
could cure cataracts
ular surface with adequate defense against
the leading cause of dry eye (up
Ask
your
salesof
representative
about evaporative stress.8-13 In terms of supportto 86
percent
all dry eye sufferAIR OPTIX®
& DAY
MYALCON.COM
2
ers have MGD).
gland function, it has been established
The NIGHT
prevalence
ofAQUA
MGD or
in visiting
that warmer is better when it comes to WCs.
several large general Asian population-based
Content Specialist
This is especially true for more advanced
studies has been found to be as high as 69
disease. However, warmer is not better for
percent.3-5 Recent data from a general Cauthe ocular surface. The challenge with any
casian clinical population, using appropriSan Diego—Researchers from the University of
form of front surface lid heating is to transate metrics for diagnosis, indicates similarly
California, San Diego, have developed an
fer therapeutic levels of heat to the meihigh prevalence ~70 percent.6
eye drop solution that may dissolve catabomian glands™(>40°C/104°F),14 while not
racts, according to a study recently pubWarm compresses (WCs) are commonly
PERFORMANCE DRIVEN BY SCI ENCE
lished in Nature.
recommended as supplementary therapy for
risking thermal injury to the ocular surface
Molecular biologist Ling Zhao and her
MGD as well as a number of other condior the skin.
team developed the eye drop after finding
tions of the eyelid.7 While the core therapy
*Dk/t
175 @ -3.00D.
wear for up
to 30 nights continuous
wear, as prescribed
by an eye
care professional.
that children with a genetically inherited
for= MGD
is **Extended
to remove
obstruction,
which
The
use
of warm compresses
Important information for AIR OPTIX NIGHT & DAY AQUA (lotrafi lcon A) contact lenses: Indicated for vision correction for daily wear (worn only while awake) or extended wear (worn while awake and asleep) for up to 30 nights. Relevant Warnings: A
corneal
ulcer
may
develop
rapidly
and
cause
eye
pain,
redness
or
blurry
vision
as
it
progresses.
If
left
untreated, a scar, and
in rare cases
loss
of vision,designs,
may result. The risk of seriousform
problemsof
is greater
for extended
wear vs. daily
wear and smoking
increases
cataracts
shared
genetic
aberrations
requires
an
in-office
procedure,
the
theraWarm
compresses
come
in
many
this risk. A one-year post-market study found 0.18% (18 out of 10,000) of wearers developed a severe corneal infection, with 0.04% (4 out of 10,000) of wearers experiencing a permanent reduction in vision by two or more rows of letters on an eye chart.
Relevant
Precautions:
Not
everyone
can
wear
for
30
nights.
Approximately
80%
of
wearers
can
wear
the
lenses
for
extended
wear.
About
two-thirds
of
wearers
achieve
the
full
30
nights
continuous
wear.
Side
Effects:
In
clinical
trials,
approximately
3-5% of
in an enzyme called lanosterol synthase.
peutic goal of adjunctive WC use is to heat
ranging from various homemade versions
wearers experience at least one episode of infiltrative keratitis, a localized inflammation of the cornea which may be accompanied by mild to severe pain and may require the use of antibiotic eye drops for up to one week. Other less serious side effects were
conjunctivitis, lid irritation or lens discomfort including dryness, mild burning or stinging. Contraindications: Contact lenses should not be worn if you have: eye infection or inflammation (redness and/or swelling); eye disease, injury or dryness that interferes
This genetic mutation shut down the prothe eyelids to help soften and
heated in a microwave to self-heating, comwith contact lens wear; systemic disease that may be affected by or impact lens wear; certain allergic conditions or using certain medications (ex. some eye medications). Additional Information: Lenses should be replaced every month. If removed before
then, lenses should be cleaned and disinfected before wearing again. Always follow the eye care professional’s recommended lens wear, care and replacement schedule. Consult package insert for complete information, available without charge by calling
See Cataract drop on page 6
partially melt any remaining
See Compress bundle on page 38
(800) 241-5999 or go to myalcon.com.
®
®
Reference: 1. In a survey of 2,115 daily and extended wear contact lens patients. Alcon data on file, 2012. 2. In a survey of 302 optometrists in the U.S.; Alcon data on file, 2012. 3. Based on the ratio of lens oxygen transmissibilities; Alcon data on
file, 2009, 2010. 4. Nash W, Gabriel M, Mowrey-Mckee M. A comparison of various silicone hydrogel lenses; lipid and protein deposition as a result of daily wear. Optom Vis Sci. 2010;87: E-abstract 105110. 5. Nash W, Gabriel M. Ex vivo analysis
of cholesterol deposition for commercially available silicone hydrogel contact lenses using a fluorometric enzymatic assay. Eye Contact Lens. 2014;40(5):277-282.
See product instructions for complete wear, care, and safety information.
Q&A
| DR. BARBARA HORN OPTOMETRIC LEADERSHIP, ROLLERBLADING, AND MARRYING AN OD SEE PAGE 58
© 2015 Novartis
2/15
AND15003JAD
SEPTEMBER 2015
VOL. 7, NO. 9
OptometryTimes.com
PRACTICAL CHAIRSIDE ADVICE
Warm compresses to treat
meibomian gland disease
Eyecare community
raises red flags
over Opternative
A compress bundle warms the eyelid above
a therapeutic temperature for better results
Content Specialist
Figure 1.
Warm compress
bundle prior to
soaking.
1
Chicago— Online refraction is officially here with
the recent launch of Opternative, a company
offering its online vision test to the public
for the first time.
How it works
CEO Aaron Dallek says he and Steven Lee,
OD, founded Opternative to provide an option for otherwise healthy patients who may
not require a yearly exam but may still need
a new prescription.
The company offers an online vision test
through its website, Opternative.com. The
test takes about 25 minutes, and the patient
can take the test via a computer or smartphone. An ophthalmologist verifies the prescription, and it is provided digitally to the
patient within 24 hours. The patient can receive a prescription for glasses or contact
lenses for $40 or for both for $60.
Dallek says patient satisfaction is guaran-
By Jeffrey R. Schubert, PhD; David K. Murakami, OD, MPH, FAAO; Caroline A. Blackie,
OD, PhD, FAAO; and Donald R. Korb, OD, FAAO
eibomian gland disease (MGD) is
a chronic, progressive disease and
the leading cause of dry eye1 (up
to 86 percent of all dry eye sufferers have MGD).2 The prevalence of MGD in
several large general Asian population-based
studies has been found to be as high as 69
percent.3-5 Recent data from a general Caucasian clinical population, using appropriate metrics for diagnosis, indicates similarly
high prevalence ~70 percent.6
Warm compresses (WCs) are commonly
recommended as supplementary therapy for
MGD as well as a number of other conditions of the eyelid.7 While the core therapy
for MGD is to remove obstruction, which
requires an in-office procedure, the therapeutic goal of adjunctive WC use is to heat
the eyelids to help soften and
partially melt any remaining
M
Q&A
material obstructing the glands. The goal is
to stabilize the tear film and provide the ocular surface with adequate defense against
evaporative stress.8-13 In terms of supporting gland function, it has been established
that warmer is better when it comes to WCs.
This is especially true for more advanced
disease. However, warmer is not better for
the ocular surface. The challenge with any
form of front surface lid heating is to transfer therapeutic levels of heat to the meibomian glands (>40°C/104°F),14 while not
risking thermal injury to the ocular surface
or the skin.
See Opternative on page 5
New eye drop
could cure cataracts
Content Specialist
Warm compresses come in many designs,
ranging from various homemade versions
heated in a microwave to self-heating, com-
San Diego—Researchers from the University of
California, San Diego, have developed an
eye drop solution that may dissolve cataracts, according to a study recently published in Nature.
Molecular biologist Ling Zhao and her
team developed the eye drop after finding
that children with a genetically inherited
form of cataracts shared genetic aberrations
in an enzyme called lanosterol synthase.
This genetic mutation shut down the pro-
See Cataract drop on page 6
The use of warm compresses
| DR. BARBARA HORN OPTOMETRIC LEADERSHIP, ROLLERBLADING, AND MARRYING AN OD SEE PAGE 58
For the 75% of dry eye patients worldwide with evaporative dry eye (MGD) symptoms 1...
DRY EYE CAN BE RELENTLESS
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layer for long-lasting relief from
the symptoms associated with
evaporative dry eye (MGD).
This unique formulation is
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increasing LLT. This helps create
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LIPID LAYER
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M UC
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US LAYE
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of burning and irritation due to dryness of the eye.
References: 1. Akpek EK, Smith RA. Overview of age-related ocular conditions. Am J Manag Care. 2013;19
(5 suppl):S67-S75. 2. Korb DR, Blackie CA, Meadows DL, Christensen M, Tudor M. Evaluation of extended tear stability
by two emulsion based artificial tears. Poster presented at: 6th International Conference on the Tear Film and Ocular
Surface: Basic Science and Clinical Relevance; September 22-25, 2010; Florence, Italy.
© 2014 Novartis
05/14
SYS14005JAD-B
Relief that lasts
| PRACTICAL CHAIRSIDE ADVICE
FROM
THE
Chief Optometric Editor
The power of ‘And’
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
here are times when I think television
commercials are more entertaining than
the shows themselves. One excellent example is an old Coke Zero commercial. You
probably know the one I’m talking about. It
starts with a young lad getting an ice cream
cone when he asks the seller, “And?” He’s
rewarded with sprinkles. Later in life upon
entering the workforce when he gets the job
he again asks, “And?” He’s rewarded with
stock options. This young man was always
trying to get just a bit more, and all the effort
it took on his part was to utter that tiny word.
His “And?” got him more than the usual
and customary. Which got me thinking about
using “and” in my office. Perhaps we should
be saying “and” to our patients. Raising the
bar above the usual and customary. I can
T
Perhaps we should
be saying ‘and’
to our patients.
Raising the bar
above the usual
and customary, I
can think of any
number of instances
in the office.
think of any number of instances in the office.
“Mrs. Smith, you need a spectacle prescription change and I recommend you consider
prescription sunglasses and have you ever
considered contact lenses?”
“Mr. Jones, let’s renew your current contact lens prescription and let’s consider daily
disposables during this allergy season.”
“Mrs. Reed, your exam is normal and I’m
going to communicate the results to your family physician and here’s my business card
with my cell number if you ever need me.”
“Mr. Thomas, we’re going to make a referI mean, why do things have to be just one
ral to the surgeon for your cataract evaluaway? I doubt any one of us would use a single
tion and based on my findings, I think you
word to describe ourselves to others. I am an
should consider a specialty intraocular lens
optometrist, sure, but I’m also a father, and
for your condition.”
a son, and a husband. “And” represents the
Many of our patients have become accusunion of two items becoming one. Like milk
tomed to the usual and customary. Most paand cookies, steak and potatoes.
tients know what to expect when they arrive
Just like the character in the commerfor their annual eye exam. It’s time we
cial, by saying “and,” you’re leaving
think about upping our game with
Read
all options open. So the question bethe use of “and.” As an optometrist
about lipid
comes, are you just accepting way
and business owner, it is imporeye drops.
things are, or are you open to the
tant to continually raise the bar
Turn to page 26
possibility of more? And what are
and search for ways to differentifor this great
you willing to do to achieve that?
ate myself from my competition.
story.
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
3
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
Digit@l
4
SEPTEMBER 2015
t VOL. 7, NO. 9
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AUGUST 2015
NO. 8
VOL. 7,
CHAIRSIDE
ADVICE
Pediatrics
your
Using OCT fortients
younger pa ications
SPECIAL SECTION
future appl
Current and
Figure 1.
OCT of optic
disc drusen.
1
ls
Urine in pooeyes
causes red
McCarthy
By Colleen
Content Specialist
PreControl and
for Disease
Women’s Health
recently told
vention (CDC)
some swimmers
the reason
isn’t the
magazine that
in the pool
after a dip
get red eyes
the water.
the urine in
director
chlorine—it’s
PhD, associate
Michael J. Beach, Water Program, tells the
Healthy
with sweat and
of the CDC’s
chlorine binds forms chemimagazine that
and
by swimmers
for
urine produced
is also to blame
inThat irritant
get from an
cal irritants.
swimmers
the cough many chemicals enters the lungs.
the
think before
door pool after
will make you
“This report
says Chief Opin a public pool,”
OD, FAAO.
ever getting
Ernie Bowling, there for
tometric Editor
you’re
even though
fluids
“Remember,
sharing body
no
potentially
recommend
fun, you are
populace. I
r, and I
with the entire
their eyes underwateof course
And
one ever open
goggles.
swimming
swimming.”
recommend
lenses before
and
remove contact pool? Take a shower
the
pee in
Heading to
Don’t ever
break first.
what you’re
a bathroom
no—we know
lake
the water (and, not safe to do it in a
you’re
recommends
thinking—
The CDC also
or ocean, either). from swimming if they’re
refrain
that people
any open wounds.
have
or
sick
Atlanta—The Centers
OD, MS, FAAO
and Erin Jenewein,
OD, MS, FAAO,
to make miA. Coulter,
t with the ability
evithe optometris abnormalities clearly
in
relatively uncommon
croscopic retinal
replicate measures
ye disease is
however,
quantify and
better able
it is present,
dent and to
Patients are
children. When find the tasks of seother diagnosmay
of tissue structure.
and
testing than
optometrists
not
obtaining findings,Chilto tolerate OCT not invasive and does
lecting tests,
is
more difficult.
of an immertic tests—OCT
results to be
contact or use
They quickly
interpreting
not require
require a probe1
moving targets.
The opOCT also does be a pardren are often
sion medium.
or resist testing.
2
which may
exposure,
begin to fatigue more dependent on objecpopulation.
radiation
be
a
in the pediatric
in obtaining
tometrist may
cross-sect ion
ticular concern
to limitations
high-qual ity
Young pediattive tests, due
interferOCT creates
detailed history. describe their
structure using its time
tissue
complete or
of
images
developed in
frequently cannot accompanies
1
n
ric patients
who
ometry. It originally
time compariso
and the parent
that uses a
n may or may
symptoms,
domain form
arm to determine
eye examinatio
their
reference
to
unfolded.
was
them
3
with a moving
Stratus OCT
as the symptoms
tomogreretinal tissue.
not be present
OCT. More
the depth of
of optical coherence
and mana time domain
The potential
page 26
designed as
See OCT on
to support diagnosis
paris
(OCT)
disease
raphy
pediatric ocular OCT provides
agement of
ticularly intriguing.
By Rachel
E
MISSION STATEMENT
Q&A
try
talks optome
HANSE N
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Dr. Prouty has
But that doesn’t
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Opternative
Continued from page 1
teed. If a patient is not happy with the way she sees with the
glasses or contact lenses she received using the Opternative
prescription, the company will recheck the prescription. If
the company cannot correct the problem, Opternative will
Opternative is aware of
the controversy within the
eyecare community
offer a full refund.
“There is no risk in trying the Opternative exam,” he says.
The test is currently available in 27 states, but the company has plans to expand to more states soon.
In Focus
Dallek says Opternative is aware of
the controversy surrounding the company within the eyecare community.
“We are familiar with ODs’ concerns, and we take them seriously,”
the CEO says. “We make it clear to
patients that the Opternative eye exam
is a refractive exam meant to provide a prescription for glasses and
contact lenses.”
Dallek says Opternative recommends patients visit an eyecare professional in person for a full ocular
health exam once every two years.
The company restricts patients from
using the service more than four times
within in a five-year period without
getting an eye health exam, in accordance with the American Academy of
Ophthalmology’s recommendations.
Eventually, Dallek says Opternative
would like to bring its technology
from online to the eyecare practice.
“We think we can help optometrists improve their patient efficiency
so they can focus on eye health concerns,” he says.
Opternative’s approach
is ‘infuriating, deeply
troublesome’
Optometry Times Editorial Advisory
Board member Justin Bazan, OD, says
he found Opternative's promotional
video to be “infuriating and deeply
troublesome.” The video’s inspiration is taken from the usual line of
See Opternative on page 6
Development to launch
Eyecare community raises concerns
But not everybody is feeling the love for Opternative. Several
ODs expressed concerns that patients will choose the online Opternative vision test and neglect getting a full exam.
“The rollout of this online vision test is a troubling development in the eyecare industry,” says Optometry Times
Chief Optometric Editor Ernie Bowling, OD, FAAO. “There
is a real possibility consumers will perceive this online refraction test as a true ocular exam and subsequently ocular
pathology may never be diagnosed.
“Technology is a wonderful adjunct in the right hands,
but it should never be substituted or mistaken for a comprehensive ocular health evaluation,” says Dr. Bowling. “The
American Optometric Association (AOA) House of Delegates
resolved at the 2015 meeting that safeguards need to be in
place to insure patient’s eye health and safety aren’t compromised by remote technology.”
AOA President Steven Loomis, OD, spoke out recently to
raise awareness among consumers about the potential dangers.
“We are concerned consumers will mistakenly believe
that a refractive eye test is a comprehensive eye health examination, which can uncover diseases such as diabetes,” he
says. “Consumers can be lulled into a false sense of security.”
LENS MODALITY
MIGRATION
50
45%
42%
40
Percentage of Patient Fits
Optometry Times spoke with Dallek in early 2014 when the
company was still in its early stages of developing its technology. The company has spent the last year and a half testing its technology on 1,500 patients to prove it works and it
is safe, Dallek says.
“We’ve been focusing on perfecting our technology as
we concluded a clinical trial that showed the Opternative
refractive vision exam is statistically equivalent to an inoffice refractive exam. We finished the clinical trial earlier
this year,” he says.
Although the company officially launched just a few days
ago, Dallek says the reaction from the public has been positive.
“Consumers recognize we offer a service that saves them
time and money," he says. "They also appreciate the freedom
to shop anywhere they want for glasses or contact lenses.
Consumers understand the value of what we offer.”
38%
30%
30
23%
20
13%
10
4%
0
0%
1-day
1/2-wk
Source: Contact Lens Spectrum Annual Report—Contact Lenses 2010, 2014
5
1-mo
3-mo
2010
3% 2%
1-year
2014
6
In Focus
Opternative
questioning during a refraction.
“You’ve run out of contacts, and your
glasses are ancient. It’s time to get an eye
exam. Which is better: one or two? One,
putting that silly appointment card to use
or two, enjoying your morning coffee?” the
video’s narrator asks.
“I applaud Opternative for bringing patient-driven subjective refractions online.
I’m excited about the possibilities it brings,”
says Dr. Bazan. “I do feel that Opternative
has very promising technology that I’m sure
Cataract drop
duction of lanosterol—an oily compound
found in the skin. Researchers suspected
that lanosterol prevented the clumping of
proteins in the eye.
Testing lanosterol drops
The UC San Diego team tested a lanosterol
solution in three experiments. First, the solution was tested on human lens cells to see
how effectively the lanosterol shrank lab
models of cataracts. The researchers observed a significant decrease, leading them
Is this the end of
cataract surgery?
to believe the lanosterol breaks apart the
crystalline clumps like detergent splits dirt.
Second, researchers tested the solution
on rabbits with cataracts. At the end of six
days, the cataracts in 11 of the 13 rabbits
had gone from severe or significant to mild
or no cataracts at all.
For the final test, researchers moved onto
dogs, testing the solution on a group of seven
black Labs, Queensland Heelers, and Miniature Pinschers, all with naturally occurring cataracts. Researchers administered
the solution both in the form of an injection and eye drops. Over the course of six
weeks, the dogs’ lenses showed the same
dissolving pattern shown in the human and
rabbit lens cells.
The researchers say that the next step
is attempting to translate this success into
human lenses.
SEPTEMBER 2015
|
will lead to the development of other technology that will have a positive benefit to
both patients and doctors.
“However, I feel the company leaders are
taking some very misguided steps—one of
them being to encourage the public to enjoy
their morning coffee and ignore that silly
appointment card from their eye doctor,” he
says. “They have chosen to throw shade at
eyecare providers by downplaying the importance of scheduled comprehensive eye
care with the patient’s eye doctor. As evident by this video from their homepage, they
are purposefully misleading the public. The
powerful and purposeful messaging it con-
tains certainly overshadows any info about
the limitations of their testing and the need
for scheduled eye care.”
ODs on Facebook founder Alan Glazier,
OD, agrees, saying that spinning the technology as “disruptive” doesn’t hide the fact
that it can’t diagnose eye disease.
“Their use of the phrase ‘eye exam’ to
sell their service screams that the founders
of the company don’t care about the overall
wellness and safety of netizens,” Dr. Glazier
says. But he’s not worried. “For more than
a co-pay people can spend a half hour on
an incomplete eye exam that might miss eye
disease—good luck with that!”
The end of cataract surgery?
kind of a ‘backbone’ of other steroids and
cholesterol—is in very early stages of research. The research in peer-reviewed literature has been mostly animal studies,
and needs to be verified and repeated by
a number of different sources and make it
through an FDA trial for both efficacy and
safety before it will be available for the public to take,” says Dr. Hauswirth. “We’ve got
a long way to go before we get there. So,
the sensationalism is exciting, and it’s always great to have some promise of a new
compound which can help a great number
of people, but let’s see how the next round
of testing goes before we get carried away.”
Could these drops be the beginning of the
end of cataract surgery?
“We show that lanosterol plays a key role
in inhibiting lens protein aggregation and
reducing cataract formation, suggesting a
novel strategy for the prevention and treatment of cataracts,” the study’s authors write.
“In addition, our results may have broader
implications for the treatment of protein-aggregation diseases, including neurodegenerative diseases and diabetes, which collectively are a significant cause of morbidity
and mortality in the elderly population, by
encouraging the investigation of small-molecule approaches, such as the ones demonstrated here,” they write.
If the lanosterol solution proves to be as
successful in human trials, it could not only
have a significant impact for patients, but also
for optometrists. ODs could see big changes
in the cataract comanagement landscape.
“These drops would certainly be a huge
addition to the optometric treatment arsenal, and cataract surgery could theoretically become completely refractive,” says
Tracey Schroeder-Swartz, OD, MS, education chair for the Optometric Council for
Refractive Technology.
Scott Hauswirth, OD, FAAO, says he’d like
to see further research because this isn’t
the first study to claim to combat cataracts.
“Several products in the past decade have
touted the ability to do this from either a
preventative or reversal standpoint,” he
says. “Some have even begun FDA trials,
but none have completed it—for example,
a company called Chakshu had a Phase II
trial a few years ago.
“At this juncture, lanosterol—which is
Science looking for
chemotherapeutic therapies
“Science has been looking for chemotherapeutic therapies for many conditions that
in the past and present have had only mechanical/surgical remedies,” says Optometry Times Editorial Advisory Board member
Mohammad Rafieetary, OD, FAAO. “Scientific explorations in this line has resulted in
many triumphs as well as failed attempts.”
Dr. Rafieetary says that most degenerative conditions in nature happen as a result of altered chemicals in our body, so it
is not hard to believe that science should
be able to find antidotes to either stopping
or reversing tissue alteration.
“Beyond the efficacy of such antidotes,
we have to be more concerned with safety
and potential side effects,” he says. “I am
excited to hear about a topical treatment for
cataracts but have to wait for further studies
to show that ‘a solution tested in dogs that
may be able to dissolve the cataract out of
the lens’ is safe and effective in humans.”
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Cosopt PF is a registered trademark of Merck Sharp & Dohme Corp and is used under license. ZIOPTAN is a registered trademark of Merck Sharp & Dohme Corp and is used under license.
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©2015 Akorn, Inc. All rights reserved. P455
Rev 06/15
8
In Focus
SEPTEMBER 2015
|
New federal bill targets
vision, dental care plans
WASHINGTON, DC—Congressman Earl “Buddy”
Carter (R-GA) recently introduced a new
bill titled “Dental and Optometric Care Access Act (DOC Access Act)” that would address conflicts between dentists and eyecare
providers and insurance providers.
There are a number of similar bills at the
state level that address doctor grievances,
such as the limiting of laboratory choice,
These are unfair
provisions that the
insurance industry
has put in.
in a medical plan. If the bill were passed,
the DOC Access Act would remedy some of
these conflicts.
“This bill is a counterattack to policies
that have been threatening optometric practices across the country as well as the patients they serve,” says William T. Reynolds, OD, American Optometric Association
(AOA) trustee.
“These are all unfair provisions that the
insurance industry has put in. They’ve already been attacked on the state level, and
now the AOA is attacking them on a federal
level," he says.
Details of the bill
forcing discounts on noncovered services,
and forcing doctors to participate in a vision plan as a condition for participating
HR 3323 aims to improve coverage under
dental and vision plans by outlining the
following provisions:
In general: “The plan or coverage shall
provide, with respect to a doctor of optom-
etry, doctor of dental surgery, or doctor of
dental medicine that has an agreement to
participate in the plan or coverage and that
furnishes items or services that are not covered by the plan or coverage to a person
enrolled under such plan or coverage, that
the doctor may charge the enrollee for such
items or services any amount determined
by the doctor that is equal to, or less than,
the usual and customary amount that the
doctor charges individuals who are not so
enrolled for such items or services.”
Regarding covered items and services: “An item or service shall be considered, with respect to a plan or coverage, to
be covered by the plan or coverage only if
the negotiated rate agreed to by such plan
or coverage and the doctor for such item or
service, without regard to any cost sharing obligation of the enrollee, is an amount
See Vision, dental bill on page 10
IN BRIEF
SECO and Energeyes partner, host Energeyes
East Coast meeting at SECO 2015
ATLANTA—SECO International has partnered
with Energeyes to host the Energeyes
East Coast Regional Meeting at SECO
2016. SECO 2016 will take place in Atlanta February 24 through February
28, 2016. This is the first time SECO
International has partnered with Energeyes to co-host an Energeyes meeting.
“Forming partnerships like this is
one of our strategic goals to not only
strengthen participation at our Congress, but to benefit both organizations
by providing greater value to optometrists everywhere,” said Stan Dickerson,
OD, president of SECO International.
Energeyes recently has reached
the 500 members mark and is now
looking for ways to serve its growing membership. Energeyes plans on
moving its 2016 National Meeting to
September 23-25 so members can attend both events.
“We have already annunced the SECO
partnership to our membership and
have received very positive feedback,”
says Michael Porat, executive director of the Energeyes Association. “We
are holding our February board meeting during SECO and will shortly announce a full day of education and
training, which is sure to attract many
members.”
SECO International and Energeyes
have agreed to both promote the East
Coast Meeting and SECO 2016 Congress
to their respective members. Energeyes
members will receive a $50 discount
to attend the congress.
Energeyes is not the only outside
group to host meetings with SECO.
The Armed Forces Optometric Society (AFOS) and the College of Optometrists in Vision Development (COVD)
also host their meetings with SECO.
Rx safety glasses with
Vizux Smart Glasses
ROCHESTER, NY—Vizux M100 Smart Glasses are now
available in prescription-capable safety glass
format. Safety glasses for M100 Smart Glasses
produced by Rochester Optical meet American
National Standards Institute (ANSI) standards.
These Vizux M100 Smart Glasses have met ANSI/
ISEA Z87.1-2010 standards.
Rochester Optical is currently the only optical manufacturer to offer prescription safety
glasses for Vizux M100.
Because employees who use smart glasses
often view displays for long periods, Rochester
Optical designed its “Smart Gold” Lenses to be
worn comfortably for long durations. According to the company, “Smart Gold” Lenses eliminate prismatic effects and off-axis aberrations
in order to “minimize eyestrain and eye fatigue.
“Our objective is to help remove any barriers to smart glasses adoption by leading the
way with robust safety standards and excellent quality,” says Patrick Ho, CEO of Rochester Optical.
Looking deeper
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10
In Focus
Vision, dental bill
that is reasonable and is not nominal or de
minimis.”
Regarding changes to the plan: “The
terms of an agreement between such a plan
or coverage and such a doctor (including, in
the case of a plan or coverage that provides
for a provider network, the negotiated rate
for providers that participate in the network
of such plan or coverage), may be changed
only pursuant to a subsequent agreement
signed by the doctor that documents the acknowledgment and acceptance of the doctor
(as applicable) to such changes.”
Regarding the duration of limitedscope plans: “In the case of an agreement
SEPTEMBER 2015
pliers of services or materials provided by
the doctor to an individual who is enrolled
under the plan or coverage.”
AOA and the DOC Access Act
The AOA says the DOC Access Act would level
the playing field for patients and doctors by
targeting anti-patient and anti-competitive
health insurance and vision plan abuses.
According to the AOA, the bill came as
a result of a strong relationship the Georgia Optometric Association built with Congressman Carter.
“Congressman Carter has been a great
friend of optometry since his days in the
Georgia State House and Senate,” says John
Whitlow, OD, GOA Legislative Committee
chair. “It’s exciting to see how our friend-
Allowing us to use our own labs, or labs of
our choice, will lower costs and improve
both quality and service.
between such a doctor and such a plan or
coverage that offers limited scope dental or
vision benefits, the agreement may not be
for a period that is greater than two years.”
Regarding ancillary services and procedures: “Such plan or coverage may not
deny such a doctor participation in the plan
or coverage or remove such a doctor from
participation in the plan or coverage for
the sole reason of the failure of the doctor
to accept the terms and conditions under
such agreement for any ancillary service
or procedure.”
Regarding the conditions to join a
provider network: “The plan or coverage
may not require that such a doctor must
participate with, or be credentialed by, any
specific plan or coverage offering limited
scope dental or vision benefits as a condition to participate in the provider network
of such plan or coverage.”
Regarding interference with existing relationships and requirements: “Unless otherwise required by law or regulation, such plan or coverage may not directly
communicate with an individual enrolled
in such plan or coverage in a manner that
interferes with or contravenes any State or
Federal requirement, or doctor-patient relationship in existence at the time of such
communication.”
Regarding laboratory choice: “The
plan or coverage may not, directly or indirectly, restrict or limit, such a doctor’s choice
of laboratories or choice of source and sup-
ships on the local level can flourish and
have an impact nationally.”
Dr. Reynolds says size matters when it
comes to supporting this bill in Washington.
“The biggest thing that optometrists can
do to help support this bill is to join the
AOA,” he says. “And we need members to
be active in relation to the PAC and at a
grassroots level. We’re going against a formidable opponent—the insurance industry.”
Optometry needs to rally behind the AOA
and this bill, says Craig Steinberg, OD, JD,
in a post on online forum ODWire and reprinted here with his permission.
“This is a very pro-consumer/pro-patient
bill. Allowing us to use our own labs, or
labs of our choice, will lower costs and improve both quality and service (time),” says
Dr. Steinberg.
“It is a consumer bill to eliminate unfair
business practices that increased vision care
plan profits and hurt our patients. We need
to get consumer groups to support it," he
says. “It is what the American Association
of Doctors of Optometry (AADO) and Union
of American Eye Care Providers (UAECP)
have been fighting for.”
Dr. Steinberg is founder and executive
director of AADO and UAECP.
According to Tommy Lucas, OD, president of the Texas Optometric Association,
the AOA has worked to bring this bill to
Congress after seeing the results of similar
language passed at the state level.
“The AOA collaborated with American
|
Dental Association (ADA) to have the language applicable to vision plans and dental
plans,” he says in a post on ODWire and included with permission. “The bill language
closely resembles the ‘model’ language created by the AOA State Government Relations
Center a few years ago when working with
state affiliates to pass state legislation.
"The dentists passed a non-covered service law in a majority of states, but the ODs
on the state level have expanded that base
concept to create a more robust law designed
to promote fairness by vision plans toward
doctors and patients," says Dr. Lucas.
Dentists react to the new bill
The AOA partnered with the ADA in working toward the DOC Access Bill.
Dr. Reynolds says this partnership made
sense because both professions are facing
very similar challenges with insurance companies. Putting their combined memberships behind the bill will make it easier
for the AOA and ADA to find support in
Washington.
ADA President Maxine Feinberg, DDS,
says she’s thrilled with the bill.
“I speak on behalf of the ADA’s 158,000
members in thanking Rep. Carter for introducing this legislation, which would prohibit dental insurance companies from interfering in the doctor-patient relationship
by dictating prices for services they don’t
even cover,” says Dr. Feinberg.
“State after state have passed similar laws,
but federal action is necessary in order to
apply the prohibition to all health care coverage products," she says.
Sheri B. Doniger, DDS, Editorial Advisory
Board member of Optometry Times' sister
publication Dental Products Report, says the
bill is a good option for dentists who are
enrolled in dental plans.
“Previously, those dentists have not received any payment for any items that were
not covered under the old agreement that’s
currently in place with the place with the
patient and the benefit company,” she says,
speaking exclusively with Optometry Times.
“But if this bill goes through, this is allowing the dentist to charge her normal fee
to the patient for a procedure that is not
listed under the bevy of procedures that
are available to the patient through his existing plan," says Dr. Doniger.
"I think it’s a good thing. I am not involved
in any restrictive plans, but I don’t get paid
if I do things out of the scope," she says.
Tribute
12
SEPTEMBER 2015
|
Remembering Brien Holden
Researcher, humanitarian, philanthropist, friend leaves legacy
By Gretchyn M. Bailey, NCLC, FAAO
Editor in Chief, Content Channel Director
everal weeks ago the optometric profession heard the shocking news that
Professor Brien Holden, PhD, DSc,
OAM, had passed away suddenly.
Brien was larger than life, and I’m sure I
wasn’t alone in thinking that such an event
wouldn’t be happening any time soon. Sadly,
we were wrong.
I had spoken with Brien only weeks earlier
in Liverpool at the British Contact Lens Association (BCLA) meeting. He chaired a session on myopia management and delivered
a typical Brien Holden lecture—informative,
research-filled, funny, and inspiring—on
managing myopia with contact lenses. Our
story highlighting that lecture was the topread piece in our BCLA coverage.
Brien was the first person to be showcased
in our Q&A column when it launched in
January 2014. I was honored that he agreed
to kick off this new feature in Optometry
Times. If you missed it, I hope
you’ll check it out: http://
Read
ow.ly/QCIhi.
Professor
He was always happy to
Holden’s
speak
to anyone interested
Q&A
http://ow.ly/
in learning more about his
QCIhi
work. Collaborating with
others and facilitating new
research and insights was his specialty. Over my 26-year career in optometry, I’ve looked forward to the times when
S
Brien A. Holden, PhD, DSc, OAM
January 6, 1942—July 27, 2015
BELOVED HUSBAND, DAD,
GRANDFATHER, BROTHER, FRIEND,
MENTOR, AND COLLEAGUE
Desmond Fonn, MOptom, FAAO
Distinguished Professor Emeritus, School of Optometry and Vision Science,
University of Waterloo
B
rien Holden passed away at the age of
73, pretty young according to today’s
standards. His departure was sudden, and
fortunately he didn’t suffer. I think he died
as he would have liked—holding a beer in a
pub while talking to close friend Dr. Serge
Resnikoff while waiting for his wife and
daughter-in-law to join them for dinner.
Brien was my best friend, and his sudden departure should not have happened
because it has shocked the world. At least
Brien was my best friend, and his sudden
departure should not have happened
because it has shocked the world.
our paths would cross—from discussing the
launch of a revolutionary silicone hydrogel
contact lens to working with Optometry Giving Sight to learning about innovations to
help curb preventable blindness worldwide.
Brien was gracious to work with, inspiring
to say the least, and entertaining always. I
will miss him.
Those who were closer to him are far better than I to comment on Brien’s life and his
work. See what they had to say.
we should have had time to say goodbye.
His family and friends needed more time
with him, his profession needed more of his
time, so did all the organizations which he
was part of, his hundreds of colleagues and
collaborators and certainly the contact lens
fraternity. He more than any other individual shaped the contact lens industry and
how we practice contact lenses.
Brien was a generous, principled, sensitive,
brutally honest, caring, lovely, humanitar-
ian with unparalleled integrity whose ultimate goal was to commercialize the research
efforts of the Brien Holden Vision Institute
(BHVI) and pour those profits into vision
care for the millions of underprivileged people. BHVI at the University of New South
Wales (UNSW) in Sydney was established
in 2010 in recognition of his outstanding
contribution to eye care research.
He was the most optimistic and charismatic person I have ever known. He lived
life to the fullest, no half measures in work
or play. He was often the last man dancing at the Australia parties and up the next
day after a few hours sleep, seemingly fully
charged and ready to tackle the next project. His aim was to continue working until
2020, but we knew he would never stop because there was always something new to be
accomplished, something that only he saw
as achievable whereas most others would
have thought it impossible. If you were in
his company or part of a meeting with him,
you could feel the magnificence of his presence and command. He demanded evidence
and scientific detail to support whatever
endeavor he was charged up about, but he
was always a “big picture” person.
Dr. Earl Smith, dean of the University of
Houston College of Optometry, described
Brien as the most influential optometrist
of our generation when Brien was awarded
the Prentice Medal last year, the American
Academy of Optometry’s highest honor. Brien
was never in it for personal gain but was
driven by the money that could be made to
enable BHVI to provide vision for everyone.
He leaves a legacy of striving to improve
contact lens wear and the encouragement
to achieve the humanitarian goals he set.
Rest in peace, my dear friend.
KINDNESS, LOYALTY, AND FRIENDSHIP
Rick Franz, OD, FAAO
Laguna Beach, CA
W
e recently lost the guiding light of
ophthalmic research, contact lenses,
and public health. Much has been and will
be written about Brien Holden’s legacy, his
contributions to optometry and mankind,
but I would like to write about Brien Holden
as my friend. Many colleagues will be able
See Brien Holden on page 14
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14
Tribute
SEPTEMBER 2015
|
Brien Holden
to do much better justice to describing his professional accomplishments, but I think I can better explain who he was as a
friend and person.
Behind all the bravado and hutzpah was the largest and kindest heart I have ever known. The depth of his friendship found no
bottom, and the magnitude of his kindness was without bounds.
Finding those attributes in a person is extremely rare today.
We first met in 1981 at the B+L European Symposium, which
we comoderated. It was a rather rocky start because I just wasn’t
accustomed to a personality like Brien’s. But by the end of the
meeting, we had started an incredibly close friendship which
has lasted for 35 years. There are too many stories to share here
about his fun-loving character, but needless to say, if you ever
met Brien, you know what I mean.
Brien was an incredibly loyal friend. For the last 30+ years,
he has made time in his busy schedule to come to my cabin in
Ohio to be with friends at the so-called “Ohio Research Symposium.” As a founding member of the Australian Scottish League
of International Corneal Assessors (ASLICAS) golf tournament,
his friendship and golf skills, or lack thereof, extended around
the world. Brien flew from Russia to be at my parents’ 50th wedding anniversary. And he was present during difficult times—
he showed up at my parents’ and in-laws’ funerals. Whenever
there was an important event or a time when I needed love and
Brien Holden was the founder of the Brien Holden Vision Institute (BHVI), formerly the Cornea
and Contact Lens Research Unit (CCLRU) at the University of New South Wales in Sydney.
(Photos courtesy of Brien Holden Vision Institute)
support, Brien would find a way to get there.
He was an advisor, a counselor, a colleague, but mostly a true
friend. Just a few weeks ago he spent a few days in our home, and
we joked about getting old and what we still wanted to accomplish.
My heart is sad, and I have a huge empty space in my life now that
Brien is not here. It is hard to believe that he will not come through
the door with a huge smile and a big hug.
Brien will be missed by everyone he has touched, his contributions
to our profession will stop, but his legacy will live forever. The dedicated colleagues at Brien Holden Vision Institute will continue his
good work and provide insight and knowledge to our profession, but
it just won’t be quite the same without the “big guy” being around.
Rest in peace, Brien. You can now get some of that much-needed
rest we talked about. We love you.
ACRYSOF® IQ TORIC INTRAOCULAR LENSES IMPORTANT PRODUCT INFORMATION
LARGER THAN LIFE
CAUTION: Federal (USA) law restricts this device to the sale by or on the order of a physician.
Clive Miller
INDICATIONS: The AcrySof IQ Toric posterior chamber intraocular lenses are intended for primary implantation in the capsular bag of the eye for visual correction of aphakia and pre-existing corneal astigmatism secondary to
removal of a cataractous lens in adult patients with or without presbyopia, who desire improved uncorrected
distance vision, reduction of residual refractive cylinder and increased spectacle independence for distance vision.
®
WARNINGS/PRECAUTIONS: Careful preoperative evaluation and sound clinical judgment should be
XVHGE\WKHVXUJHRQWRGHFLGHWKHULVNEHQHWUDWLREHIRUHLPSODQWLQJDOHQVLQDSDWLHQWZLWKDQ\RIWKH
conditions described in the Directions for Use labeling. Toric IOLs should not be implanted if the posterior capsule is
ruptured, if the zonules are damaged, or if a primary posterior capsulotomy is planned. Rotation can
reduce astigmatic correction; if necessary lens repositioning should occur as early as possible prior to lens
encapsulation. All viscoelastics should be removed from both the anterior and posterior sides of the lens;
residual viscoelastics may allow the lens to rotate. Optical theory suggests that high astigmatic patients (i.e.,
> 2.5 D) may experience spatial distortions. Possible toric IOL related factors may include residual cylindrical
error or axis misalignments. Prior to surgery, physicians should provide prospective patients with a copy of the
3DWLHQWΖQIRUPDWLRQ%URFKXUHDYDLODEOHIURP$OFRQIRUWKLVSURGXFWLQIRUPLQJWKHPRISRVVLEOHULVNVDQGEHQHWV
associated with the AcrySof® IQ Toric Cylinder Power IOLs. Studies have shown that color vision discrimination is
QRWDGYHUVHO\DHFWHGLQLQGLYLGXDOVZLWKWKH$FU\6RI ®1DWXUDOΖ2/DQGQRUPDOFRORUYLVLRQ7KHHHFWRQYLVLRQ of the AcrySof® Natural IOL in subjects with hereditary color vision defects and acquired color vision defects
secondary to ocular disease (e.g., glaucoma, diabetic retinopathy, chronic uveitis, and other retinal or optic nerve
diseases) has not been studied. Do not resterilize; do not store over 45° C; use only sterile irrigating solutions
such as BSS® or BSS PLUS® Sterile Intraocular Irrigating Solutions.
ATTENTION: Reference the Directions for Use labeling for a complete listing of indications, warnings and
precautions.
CEO, Optometry Giving Sight
L
ike many people, I had heard of the legendary Brien Holden long
before I actually met him. He had the reputation of being a great
scientist, humanitarian, optometrist, and as we say in Australia, a
bit of a larrikin.
The man I finally met was all those things, but he was also charming, charismatic, inspiring, frustrating, and as I was to find, unbelievably thoughtful and generous.
I still remember the day he came to my father’s funeral. Not because he ever met my Dad. He didn’t even know me that well. But
he came because he wanted to support me in a time of great emotional turmoil. It was an act of incredible kindness and one that I
still appreciate.
He liked to say when he first assumed responsibility for Optometry
Giving Sight he had created a fundraising organization but that no
one really knew enough about professional fundraising. That was
not true. Brien was the most amazing fundraiser—he had the ability to inspire people everywhere to share and support his vision of
a world in which everyone has access to the vision care they need.
Brien always gathered wonderful people around him. He inspired
them to think big and really own this audacious dream that by
© 2015 Novartis
3/15 IOL15005JAD
Tribute
16
SEPTEMBER 2015
|
Brien Holden collaborated with students and colleagues around the world to further his research and humanitarian work.
Brien Holden
working together, changing the game, and
mobilizing serious resources we could forever transform the lives of the millions of
people in need of affordable and accessible
eye and vision care.
Brien’s passing is an incredible shock.
He was one of those people who seemed
like they would always just be there: full
of seemingly impossible ideas, forever challenging those around him to keep up, be
ready for the next opportunity, and still have
enough energy and humor to get together at
the end of the day to share a drink or dinner, stories of the day, and of course, plan
new ones for tomorrow.
Larger than life barely begins to describe
Brien, but he left us a huge legacy and will
continue to inspire us all for years to come.
A TEAR IN OUR EYE
Joseph T. Barr, OD, MS, FAAO
Emeritus professor at The Ohio State University College of Optometry
L
ike many in optometry, I first knew
Brien as he lectured on his team’s latest research at an Academy meeting. I was
a graduate student, and within a year had
a lifetime experience of getting to know
Brien better when he did his sabbatical at
Ohio State in the late 1970s.
He was a role model as a clinical researcher
and demonstrating never to be afraid of
challenging the status quo in cornea research—turning the heads of leading cornea
researchers of the time. Endothelial blebbing caused by a contact lens? The stroma
thins in long-term soft contact lens wear?
Brien was always fun to be with while we
all learned. One day in a lab at Ohio State,
he and Steve Zantos had a rabbit wearing a
contact lens with nitrogen blowing across
its cornea. The tape recorder was on, and
Steve and I watched Brien observe the rabbit’s corneal endothelium.
“We have a rabbit, and his name is Briar,
Briar Rabbit,” said Brian in his exaggerated Aussie.
“And Briar has no !@#$ing blebs,” Brian
announced loudly.
Steve and I howled in laughter. That lab
was a room about 10 feet x 10 feet and was
full of gas cylinders, slit lamps, and other
research instruments, a few stools, halfempty coffee cups, donut parts, and a few
other objects from past meals. It was in
Richard Hill’s pristine, nearly sterile, white
lab area. Brian apologized to Dick Hill for
keeping the room so messy. Dick, always
one to understate while being appreciative
of Brien’s work, said, “That’s OK, Brien.
We’ll just close the door.”
Later, when Karla Zadnik persuaded me
to nominate Brien for an honorary degree
at Ohio State, he could not have been more
gracious in thanking Dick for his hospitality and support when he was visiting there.
He is the most well-known, bright, motivational leader and philanthropist in optometry and loved by so many. We all have a
tear in our eye when we talk about Brien—
a good laugh as well. We feel privileged to
have known him and the work of his teams.
A WILD, MAGICAL OPTOMETRY
JOURNEY
Glenda Secor, OD, FAAO
Huntington Beach, CA
L
ike our entire eyeball family, I am shocked
and saddened to hear that we have lost a
giant. Brien Holden educated, enlightened,
and entertained us with his wit, wisdom,
and passion. We recognized his brilliance
and his hope that the world’s vision could
be improved by optometry’s intelligence,
research, and generosity.
As a past education chair for the California Optometric Association (COA), American Optometric Association’s Annual Meeting, and the American Academy of Optometry’s Ellerbrock Committee, I was always
able to count on Brien’s research presentations being clinically relevant. Practitioners
like me were able to use his research and
those he inspired to enhance our patient
care and expand our clinical tool box in
contact lenses. Before PowerPoint, I remember him putting together a lecture, the hour
before he was scheduled to speak, by leafing through pages of slides that covered his
18
Focus On
CONTACT LENSES
SEPTEMBER 2015
|
Offer innovation to contact lens patients
We all must begin to go beyond the ‘if it ain’t broke’ school of thought
Innovation as defined by Wikipedia is a new idea, more
effective device or process.1 Innovation can be viewed as
the application of better solutions that meet new requirements, inarticulated needs, or existing market needs.2 This
is accomplished through more effective products, processes, services, technologies, or ideas that are readily
available to markets, governments and society. The term
“innovation” can be defined as something original and
more effective and, as a consequence, new, that “breaks
into” the market or society.3
introducing innovation to our
practice. We commonly have
patients come into our office
year after year and ask them the
same type of questions, such as,
“How are your lenses?” What
is the answer? “Fine.” So we
BY DAVID I.
end up often just keeping the
GEFFEN, OD, FAAO
patient in the same lens year
Director of
after year.4 We abide by the rule
optometric and
refractive services in of law that has taught us “if it
San Diego, CA.
ain’t broke, don’t fix it.”
Well, where has that path led
us as a profession? The dropout
Innovation is the future
rate is still 15 to 20 percent, which is
of optometry
the same as 10 years ago.5 Patients are
So where does that put us in optometric
practice? Are we innovating new ideas,
purchasing their contact lenses from alWhile a novel device is often
described as an innovation, in
economics, management science, and other fields of practice and analysis, innovation
is generally considered to be
a process that brings together
various novel ideas in a way
that they have an impact on
society. Wikipedia goes on to
say that innovation in business
is the catalyst to growth. If we do not keep moving forward with
new products, technology, and ideas,
we become obsolete.
products, and systems? If not, what does
that hold for the future of our profession? This may not be something that
you think much about, but it is the thing
which I believe holds the future of optometry in its hands. If we do not keep
moving forward with new products,
technology, and ideas, we become obsolete. If that happens, then we will go
the way our brethren in pharmacy have
gone and will be technicians working
for corporations. Contact lens practice is one of the best
examples of changing our habits and
ternative sources which were not available 10 years ago. Many in our profession feel that contact lenses are a loss
leader and not worth the time.
Innovation is vital to the
optometric practice
Contact lenses are still a very vibrant part
of an optometric practice. Contact lens
patients are some of our most loyal and
highest referring patients. The key is to
make sure we are perceived as vital in
the contact lens process. We must learn
to break the habits we have tumbled into
after years of practice. Just because the
patient says her lenses feel “fine,” do not
take that to mean everything is great.
We need to go more into depth about
the nature of the patient’s wearing day.
Ask more open-ended questions, such as,
“How do your lenses feel at the end of
the day?” Make sure the patient is experiencing minor irritations she may think
are normal. These are the little things
which lead to dropout of patients and
loss of revenue to your office. If we just
fit the same thing year after year, the
patient may come to the conclusion after
two or three years that if everything is
the same, why shouldn’t she purchase
her lenses online and save herself the
examination fees?
Habit change is crucial to implement
new technology to our practices. We need
to repeat a process many times to make
it a habit and must make an effort to repeat a new procedure to change the habits which are not good for our practice.
We are in a great time for innovation in
the contact lens industry. We have had
the most new technologically advanced
lens materials we have seen in over 10
years. Now is the time to upgrade our
patients into these great new products
and achieve a higher level of comfort
for our patients.
REFERENCES
1. Wikipedia. Available at: https://en.wikipedia.org/
wiki/Innovation#cite_note-1. Accessed 7/6/15.
2. Merriam-Webster. Available at: http://www.
merriam-webster.com/dictionary/innovation.
Accessed 7/6/15.
3. Maranville, S (1992), Entrepreneurship in the
Business Curriculum, Journal of Education for
Business, Vol. 68 No. 1, pp.27-31.
4. Richdale K, Sinnott LT, Skadahl E, et al.
Frequency of and factors associated with contact
lens dissatisfaction and discontinuation. Cornea.
2007 Feb;26(2):168-174.
5. Rumpakis J. New data on contact lens dropouts:
An international perspective. Rev Optometry.
Available at: http://www.revoptom.com/content/d/
contact_lenses_and_solutions/c/18929/.
Accessed 7/6/15.
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]
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 West!
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20
Focus On
CO-MANAGEMENT
SEPTEMBER 2015
|
New correction option for presbyopes
Removable corneal inlay now a choice for emmetropes requiring refractive help
For the longest time, I felt that to be a true ophthalmic
pioneer, it would take finding a cure for the single most
heinous of nature’s evolutionary designs—presbyopia! Such
a cure would make even the most skeptical of investors
on Shark Tank envious.
At present eyecare practitioners
are limited with our ability to
treat presbyopic patients. Sure,
we have progressive spectacle
lenses and multifocal contact
lenses; however, from a surgical standpoint, monovision corneal refractive surgery is limited, and clear lens extraction is
often extreme for emmetropes.
There is now another option
which can provide a large percentage of these patients with
good distance and near vision
with the use of Kamra corneal
inlay from AcuFocus.
BY MARC R.
BLOOMENSTEIN,
OD, FAAO Director
of optometric
services at Schwartz
Laser Eye Center in
Scottsdale, AZ.
Inlay for the non-dominant eye
Kamra is the only FDA-approved refractive inlay designed to be implanted in the
non-dominant eye and is removable. This
microperforated, opaque inlay increases
depth of focus by creating a shield to
unfocused light. At 5.0 μm thick, with a
central aperture of 1.6 mm and an overall diameter of 3.8 mm, this small inlay
casts a large presbyopic shadow. The
inlay has over 8,000 randomized spots
that provide for this novel form of presbyopic correction.
As in any early surgical procedure, it is
important to understand limitations and
who will have the best chances at success.
I recall with not such great fondness the
excitement that the refractive community
had when new lenses or surgical options
were first approved. This translated into
wanting to provide options for anyone,
only to be let down when patients didn’t
experience the same success as in clinical trials.
At the 2014 Optometric Council on
Refractive Technology (OCRT) meeting
in Denver, Sondra Black, OD, described
the important pre- and postoperative
regimens needed for Kamra’s success.
In her estimation, when best practices
are followed, patients typically
achieve J1 to J2 near and 20/20
to 20/25 intermediate in the inlay
eye. Our clinic successfully implanted the Kamra inlay in 11
patients, closely mirroring the
results that Dr. Black described.
Visual acuities at distance and
near were markedly improved
in these neophyte cases.
Good candidates for
corneal inlay
Because this is a surgical option
and medicine is not an exact science, the decision to implant the inlay
first starts with proper patient profiles.
The sweet spot is a patient who is aged 4555, emmetropic to low hyperopia, <0.75
D astigmatism, a stable refraction for a
year, pachymetry >500 microns and a
mesopic pupil <6.0 mm in size. Subjectively, the patient should have a de-
1
Figure 1. Kamra Inlay in the right eye.
sire to be spectacle free and understand
the process to achieve full results. Patients who have ocular or systemic disease, such as amblyopia, keratoconus,
severe dry eye, or corneal dystrophy or
degeneration, would not render a great
outcome. AcuFocus researchers realized
that light scatter from early to late cataracts has a detrimental effect. An objective scatter index (OSI) is achieved by
the use of AcuTargetHD, which detects
and quantifies all lens changes, which
is then correlated with the Lens Opacities Classification System III (LOCS III).
AcuTargetHD also captures a tear film
assessment, which will reinforce the need
to improve the ocular surface.
Because the inlay is placed in a pocket
created by the femtosecond laser, you
can combine the insertion with a PRK/
LASIK procedure for those who are outside emmetropia. A potential deterrent
to the success of these patients is the
ocular surface. Although this rings true
with all refractive surgical options, it appears that Kamra is even more sensitive
to ocular surface abnormalities. Preoperative care should always include a thorough ocular surface diagnosis and treatment. Clinicians advocate the instillaSee Presbyopia on page 22
22
Focus On
22
Focus On
Presbyopia
tion of cyclosporine pre- and postoperatively, as well as
the use of punctal plugs. Patients should be aware that
reduction on the dependency of reading glasses doesn’t
mean that correction may not be needed at some point.
These patients should realize, like new presbyopes, that
there are strategies to obtain better near vision, such as
increasing light.
2
Figure 2. Kamra Inlay in the left eye.
Managing inlay patients
The experience gained by optometrists such as Dr. Black
and AcuFocus over the evolution of this lens have created
a unique postoperative management of Kamra. Any inlay
induces more healing to reach the refractive goal. Although
most patients will see refractive stability within four to six
weeks, some outliers may take three to six months. As optometrists comanage corneal inlay patients, it is important
to encourage the patient to neural adapt to the new lens
and use binocularity without the crutch of a spectacle.
Because these patients are expected to be on a steroid for
3
Figure 3. One week postoperative Kamra Inlay.
CO-MANAGEMENT
4
Focus On
23
In my limited experience, Kamra inlay has demonstrated
good distance and near acuity in a binocular environment. Patients have the peace of mind knowing the inlay
is removable with very few side effects. Presbyopes may
finally be ready to be the stars of the refractive world and
soon we will hear “Lights, Kamra, Action!”
[email protected]
Figure 4. One day postoperative Kamra Inlay.
three months, it is important to monitor the intraocular pressure (IOP)
at each visit. Patients should continue be monitored for any combination refractive result they may also have had performed. Continued use
of cyclosporine and aggressive use of artificial tears is also necessary.
When examining the patient, it is important to realize the need for
light and that the inlay’s increased depth of focus will make your refractive endpoint somewhat skewed. The inlay will appear to be off center
when viewed at the slit lamp, and there may be inflammation in and
around the lens. However, following the postoperative protocol should
eliminate residual inflammation. Future examinations on these patients
will be seamless because all aspects of the comprehensive eye exam can
be performed with the lens in place. Patients who develop cataracts in
their inlay eye may opt to have a standard lens placed in the bag with
the inlay still in the visual axis.
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IN BRIEF
Shire acquires Foresight Biotherapeutics,
rights to late-stage drug FST-100
LEXINGTON, MA—Shire plc has acquired New York-based Foresight Biotherapeutics, Inc. for $300 million. The acquisition gives Shire the rights for
FST-100, a therapy for late-stage development for infectious conjunctivitis. FST-100 also compliments lifitegrast, Shire’s dry eye treatment.
This acquisition fits with Shire’s strategy of continuing to strengthen
its late-stage pipeline.
“Ophthalmics is a highly attractive growth area for Shire, and this
acquisition allows us to strengthen our presence in this therapeutic
area,” said Flemming Ornskov, MD, Shire CEO. “FST-100 and lifitegrast would address two of the leading reasons people seek eyecare
treatment.”
Currently, there is no therapy for resolving clinical signs and symptoms of adenovirus, the most common cause of viral conjunctivitis. If
approved, FST-100 could be the first agent to treat viral and bacterial
conjunctivitis. FST-100 could reduce inflammation and kill viruses
and bacteria, all without using antibiotics.
Shire has also gained the global rights to FST-100. It will soon evaluate a filing strategy for markets outside the United States.
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24
Focus On
GLAUCOMA
SEPTEMBER 2015
|
Not knowing IOPs can make a better clinician
Evaluate your patients’ optic nerves without preconceived ideas from the chart
A couple of years ago at a continuing education conference, I was sitting in a practice management lecture when
the lecturer asked for a show of hands for all those who
had purchased electronic health record (EHR) software
as of yet. Nearly all those in attendance raised a hand.
Then, he asked for a show of hands for all those who were
happy with their EHR. The show of hands was essentially
the polar opposite.
seeing the patient (including
With that in mind, there are sevIOPs at the bottom of the front
eral aspects of my own EHR that
page). Now, I am able to look
I really appreciate over paper
at a new patient’s chief comcharts. Beside that I can actually
plaint and medical history beread what I wrote (or typed), one
fore a comprehensive examinathing that I enjoy is the fact that
tion without having IOPs staring
I am able to consistently look
BY BENJAMIN
me in the face. Rather, I would
at a new patient’s optic nerves
P. CASELLA, OD,
have to actively tab over in my
without knowing his or her intraFAAO Practices
EHR software to see IOPs. This
ocular pressure (IOP) values bein Augusta, GA ,
makes it a lot easier for me not
forehand. I’ve been aware of this
with his father in
his grandfather’s
to “cheat” before seeing a new
concept since optometry school
practice.
patient, especially one who has
and residency, but I was unable
been referred in for a glaucoma
to consistently practice it until
consultation.
my father and I decided to make
the transition to EHR several years back.
With paper records, my assistant would
Why not knowing works
simply hand me a new patient’s chart,
Take this first scenario into consideration:
and I would briefly look it over before
a young myopic patient who presents with
low IOPs but suspicious optic nerves. It
may be easy for a clinician to convince
WANT MORE ON
himself that the optic nerves of a young
GLAUCOMA? WE GOT THAT
patient whose IOPs are 14mm Hg are fine.
Is glaucoma a neurological disease?
Of course, the potential lurking variables
optometrytimes.com/glaucoma
are almost too many to count. At what
neurological
time of day was the IOP measured? What
Your pet may increase your glaucoma risk
do the angles look like via gonioscopy?
optometrytimes.com/petsandglaucoma
Is the patient spiking at other times during the day or night? Is the patient takMarijuana and optometry: Practicing
ing something systemically, such as an
post-legalization
oral beta blocker, which could potentially
optometrytimes.com/MJandODs
mask ocular hypertension? What are the
High IOP, corneal edema with unknown
sizes of the optic discs? Was the patient
etiology
on a steroid for a long period of time beoptometrytimes.com/unknownetiology
fore discontinuing? These questions all
seem readily apparent in the moment.
Field defect, high IOP might not signal
However, on the run and in the trenches
glaucoma
optometrytimes.com/maybenot
of clinical life, it may become far too
glaucoma
easy to just write something off as normal and move on.
The importance of pachymetry and CCT
Now, let’s consider scenario number
optometrytimes.com/pachymetryandcct
two: a middle-aged patient who presents
with IOPs in the upper 20s and small optic
cups. The patient’s optic nerves may be
completely non-glaucomatous. Yet, a clinician may be lulled into a false positive
diagnosis, especially on a busy day. The
same questions (and more) exist as in scenario number one, and this particular scenario is a big reason why I do not like to
be overbooked around a patient who has
glaucoma or is a glaucoma suspect (or at
all, for that matter). One IOP measurement
does not a diagnosis make. Further, IOPs
would have to be pretty high (higher than
the upper twenties) for me to recommend
pulling the trigger and treating without
any frank signs of glaucoma. That is why
we have separate diagnosis codes for “glaucoma suspect” and “ocular hypertension.
Now, I’m not saying that the practice of
looking at optic nerves without knowing
IOPs beforehand should serve as an absolute rule in the lexicon of glaucoma. However, it has served a good and meaningful
One IOP
measurement
does not a
diagnosis make.
purpose for me by allowing me to evaluate
optic nerves with little or no pre-conceived
notions. I appreciate this because dealing
with glaucoma patients is how I spend the
majority of my clinical day.
In the age of spectral domain optical
coherence tomography (SD-OCT), we are
able to quantify ganglion cell dropout and
its corresponding retinal nerve fiber layer
thinning down to just a few microns. This
high degree of measurement is the most
significant mainstream advancement in
the field of glaucoma since I have been
in practice. However, I fear that actually examining the optic nerve and its
surrounding structures stereoscopically
may be in danger of becoming a lost art.
Further, it should be mentioned that the
complex algorithms and progression software that exist with newer SD-OCT technology were written by humans actually
looking at optic nerves.
[email protected]
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SPECIAL SECTION
26
SEPTEMBER 2015
|
Dry Eye
Treating dry eye with
lipid-based eye drops
Imaging shows positive changes to lipid layer of the tear film
the most common cause of
reating dry eye has become
symptoms associated with
a significant part of practicdry eye disease.3
ing optometry, and many of
us are seeing a growth in
this part of our practices. Patient
Importance of the lipid
complaints of eyes that are dry,
layer
irritated, and uncomfortable will
The function of the lipid layer
JENNIFER FOGT,
increase as the Baby Boomer pophas been studied extensively
OD, FAAO
ulation grows older and digital dein recent years. While some
Dr. Fogt is chief of
vice use increases with associated
believe that is merely a propediatric contact
reduced blink rate. It is estimated
tective layer to prevent the
lens clinic at
that 40 million people in the United
aqueous tears from evapoThe Ohio State
University College of
States suffer from dry eye.1 The
rating, the lipid layer is even
Optometry.
more complicated; keeping
prevalence of dry eye varies based
the tear film intact, allowon parameters used to gather data
ing it to spread across the
and ranges from 14 percent for paocular surface instead of coltients over age 48 in the U.S., to 25
lapsing. This also keeps the
percent in Canada, and 33 percent
tears flowing across the eye
in Taiwan and Japan.2
and into the puncta. WithMany aspects of dry eye are still
out this layer, the tear film
not well understood, and its manJOSEPH T. BARR,
cannot spread properly and
agement can be challenging. Most,
OD, MS, FAAO
worse yet, is then prone to
or perhaps nearly all, symptomatic
Dr. Barr is professor
evaporation.4
forms of dry eye have an evaporative
emeritus at
The Ohio State
component,3 which likely contribTreatment of meibomian
University College of
utes to aqueous tear loss through a
gland dysfunction has tradiOptometry.
defective lipid layer. This, in turn,
tionally been with the use of
can lead to increased osmolarity,
warm compresses, lid scrubs,
ocular surface inflammation, and damage.
and artificial tears. Adding a liquid to
The meibomian glands in the eyelids secrete
tears almost always provides initial remeibum, a lipid complex that forms the prolief of dry eye discomfort, but patients
often complain that the relief is short
lived. There are a number of lipid-containing eye drops on the market that
are underutilized.
Using a lipid-containing artificial tear
to help reform the protective layer of
the tear film could give patients more
relief from the collapse of the overall
tear film and the evaporation of aqueous tears. One study shows that lipidbased tears are as safe, effective, and
acceptable as aqueous-based artificial
tears.5 As we gain a greater understandtective lipid layer of the tear film. The lipid
layer prevents evaporation of aqueous tears
ing of the layers of the tears, it makes
and prevents drying. Lipid deficiency due
sense that adding lipid eye drops to
to meibomian gland dysfunction (MGD) is
See Lipid drops on page 28
T
It is easy to see the
positive changes
to the lipid layer of
the tear film when
lipid-containing
drops are used.
1
Figure 1. Baseline image of the lipid layer of the tears of a
62-year-old male patient before instilling any eye drops.
2
Figure 2. Image of the lipid layer 15 minutes after using a
lipid-based eye drop.
3
Figure 3. Image of the lipid layer 15 minutes after using a
lipid-based eye drop.
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SPECIAL SECTI O N
28
SEPTEMBER 2015
Dry Eye
Lipid drops
|
TABLE 1 Available over-the-counter lipid drops
tears helps to recreate the protective and
spreading function of the tears that the lipid
layer provides. This may be more helpful
than simply increasing the aqueous layer
with artificial tears. Lipid-based Eye Drop
Manufacturer
Active Ingredients
Soothe XP
Bausch + Lomb
Light mineral oil (1.0%)
Mineral oil (4.5%)
Systane Balance
Alcon
Propylene glycol (0.6%)
Retaine
OCuSOFT
Light mineral oil (0.5%)
Imaging the lipid layer
Recently, we have been measuring lipid layer
thickness and observing the lipid layer with
interference techniques. Using a stroboscopic
microscope developed by Ewen King-Smith,
PhD,6 we are able to not only measure the
thickness of the lipid layer but also to view
videos and visualize the thickness using a
color scale. Figures 1-5 are images we have taken of
the lipid layer of a 62-year-old male patient
with MGD. This patient had moderate MGD
with visual fluctuations and has had comprehensive treatment in the past, including
lid margin debridement and LipiFlow (TearScience) treatment several months ago. He
now uses Restasis (cyclosporine, Allergan)
and a lipid-based eye drop once a day or
less. We used our instrumentation to show
the effects of these eye drops on his lipid
layer. The initial image shows his lipid layer
Mineral oil (0.5%)
Refresh Optive Advanced
Allergan
Glycerin (1%)
Polysorbate 80 (0.5%)
before any drops were instilled.
We used lipid-based artificial tears from
four different manufacturers and measured
the lipid thickness after the drops had been
in the eyes for 15 minutes. Even after that
period of time, the lipid layer was significantly thicker than before the eye drops
were used. Mathematical analysis and photography both show great results in lipid
layer enhancement.
As the lipid layer becomes thicker, the
amount of colors present in the interferometry photos increases. Referencing the color
scale on the right side of each picture, you
IN BRIEF
BHVI partners with Bono, Revo eyewear
NEW YORK—The Brien Holden Vision Institute
(BHVI), eyewear brand Revo, and U2 singer
Bono have partnered together to help fight
vision impairment. The initiative, “Buy Vision, Give Sight,” hopes to help more than 5
million people worldwide by 2020 by spending $10 million to improve eye health in under-resourced countries. The program plans
to improve access to eye screening, glasses
prescription, and general eye care.
The general public can help by buying
Revo-branded sunglasses; $10 from each
sale of new Revo sunglasses will go toward
the eyecare initiative.
Funds from the purchase of Revo sunglasses will go to BHVI. The majority of
the funds will support the “Our Children’s
Vision” campaign to help prevent impaired
vision problems in more than 50 million
children. All “Buy Vision, Give Sight” contributions will help pay for eyecare services.
To promote this initiative, Bono will wear
Carboxymethylcellulose sodium (0.5%)
only Revo sunglasses during U2’s Innocence
+ Experience World Tour. He has also designed five styles of Revo sunglasses, which
will be available for purchase in late 2015.
Bono will appear in Revo advertisements
and campaign materials for “Buy Vision,
Give Sight.”
Bono has a long record of international
charity, but “Buy Vision, Give Sight” hits
home for him—20 years ago, he was diagnosed with glaucoma. He hopes to give
back after he received exceptional treatment.
“Sight is a human right, and the ‘Buy Vision, Give Sight’ initiative will help ensure
millions of people have access to the eye
exams and glasses they need to see,” says
Bono in a statement.
An estimated 625 million people worldwide have vision-impairment or are unnecessarily blind. According to BHVI, 75 percent of those cases could have been cured
with preventative eye care or treatment.
Adding lipid eye
drops to tears
helps to recreate
the protective and
spreading function
of the tears that the
lipid layer provides
can see that tears with more colors have a
thicker lipid layer. Notice that the grey color
indicated a lipid layer up to 80 nm. This is
most evident in the image taken before a
lipid-based eye drop was used. Brown corresponds to thicknesses around 130 nm,
while blue becomes apparent when the lipid
layer reaches a thickness around 230 nm.
Striking improvements to the thickness
of the lipid layer are evident. In these photos, it is easy to see the positive changes to
the lipid layer of the tear film when lipidcontaining drops are used. Table 1 lists currently available over-the-counter (OTC) lipidcontaining eye drops and their active ingredients. Why aren’t we recommending
these lipid-based tears?
Of course, there are many other aspects
to consider when treating our MGD patients
and those with other types of dry eye. These
patients may benefit from increased hydration—drinking more non-dehydrating liquids,
avoiding low humidity, blinking more fully
and consistently (yes, it can be taught), and
eating a diet rich in omega-3 fatty acids. If
these measures don’t produce the desired
results, prescribe anti-inflammatory eye
drops such as steroid or antibiotic-steroid
combinations to treat blepharitis-related inflammation or cyclosporine and oral antibiotics such as low-dose doxycycline as
well as continued use of hot compresses.
SPECIAL SECTI O N
Dry Eye
29
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PDQDJLQJPHLERPLDQ
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4
Figure 4. Image of the lipid layer 15 minutes after using a lipid-based eye drop.
5
7KHQH[WVWHSLV
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Figure 5. Image of the lipid layer 15 minutes after using a lipid-based eye drop
A complete treatment plan and adherence to the plan is required.
Our thanks to Matt Kowalski for assisting with image capture
and analysis.
REFERENCES
1. Ding J, Sullivan DA. Aging and dry eye disease. Exp Gerontol. 2012;47(7):483–90.
2. Gayton JL. Etiology, prevalence, and treatment of dry eye disease. Clin Ophthalmol. 2009;
3: 405–412.
3. Nichols KK, Foulks GN, Bron AJ, et al. The international workshop on meibomian gland
dysfunction: executive summary. Invest Ophthalmol Vis Sci. 2011 Mar 30;52(4):1922-9.
4. Millar TJ, Schuett BS. The real reason for having a meibomian lipid layer covering the outer
surface of the tear film.- A review. Exp Eye Res. 2015 Aug;137:125-38.
5. Simmons PA, Carlisle-Wilcox C, Vehige JG. Comparison of novel lipid-based eye drops with
aqueous eye drops for dry eye: a multicenter, randomized controlled trial. Clin Ophthalmol.
2015 Apr 15;9:657-6.
6. King-Smith, PE, Reuter KS, Begley CG, Braun RJ. Tear Film and Lipid Layer
Structure in Relation to Four Phases of the Blink Cycle. Poster presented at: The
Association for Research in Vision and Ophthalmology; 2014 May 4-8; Orlando, FL.
Dr. Fogt is active in dry eye, contact lens, and pediatric research.
[email protected]
Dr. Barr is working on innovation in eye care at OSU and was previously VP of clinical and medical
[email protected]
affairs at Bausch+Lomb Global Vision Care.
0HHWXVDW$2$LQ6HDWWOH
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See Keyword on page 29
XXXNJCPNFEJDBMHSPVQDPN
SPECIAL SECTI O N
30
SEPTEMBER 2015
Dry Eye
|
5 things you don’t know
about punctal plugs
Why plugs can be the right treatment for the right patient
life. However, a complete history of a dry
ow often are you using punctal plugs
eye disease patient must go beyond how
in your practice? If your answer is
the patient feels. A full medical history is
similar to mine, it’s “not as often as I
required to establish the root of
used to.” Classically, punctal
the patient’s complaint and may
plugs were a go-to treatment for dry
point toward a specific tear film
eye patients. If artificial tears failed
deficiency. Medications, systemic
to yield relief, plugs were a logical
disease, and surgical history are
next choice. When research began to
key to providing the whole picture. support a significantly higher prevPunctal plugs can provide sigalence of evaporative dry eye disnificant
relief to the patient with
ease compared to aqueous deficiency,
WHITNEY
HAUSER, OD, is
decreased lacrimation. Diagnostic
punctal plugs fell by the wayside in
Clinical Development testing is essential to differentiate
many practices. However, plugs conConsultant at
aqueous deficient dry eye disease
tinue to be a reliable treatment for
Tearwell Advanced
(ADDE) from evaporative dry eye
the right patient at the right time.
Dry Eye Center at
disease (EDE). Schirmer’s strip testSCO
ing is the most common method of
STEP Choose wisely:
evaluating
aqueous production. However, the
Accurate diagnosis
more
than
100-year-old test is not without
Accurately diagnosing dry eye disproblems. It offers low specificity, sensitivity,
ease begins with a thorough case
and reproducibility. Additionally, patients who
history. Typically, doctors and patients alike
often present with pain as a complaint find
focus on the frequency and onset of sympthat Schirmer’s strips add insult to injury.
toms. Blur, foreign body sensation, and phoPhenol red thread (PRT) testing is emergtosensitivity affect the patient’s ability to
ing as an alternative to conventional Schirmwork comfortably, drive safely, and enjoy
H
1
TAKE-HOME MESSAGE Punctal plugs
aren’t getting as much use as they used to.
However, they remain a reliable treatment
for the right patient at the right time. Plugs
can provide relief to patients with decreased
lacrimation, and risks of adverse events are
low. Occlude inferior puncta first, then occlude
superior if necessary. Use a gauge to measure
puncta to guide size choice for best fit. Medicare and most insurance carriers will cover
punctal plugs if medically necessary.
er’s strips. PRT uses a thread inserted at the
temporal conjunctival sac of an anaesthetized eye. The pH of the tears changes the
thread from yellow to red and indicates tear
volume. While reported to be more sensitive and comfortable for patients, the jury
is still out on exactly what PRT measures.1
While Schirmer’s testing and PRT validate the ADDE diagnosis, it is equally informative to rule out an EDE component.
A
B
Figure 1. Reversible occlusion with punctal plug inserted in the inferior punctum.
Figure 2. Sufficient depth of placement is required to secure punctal plug and insure
patient comfort.
SPECIAL SECTI O N
Dry Eye
31
Performing meibography and lipid layer thickness analysis help
determine if there is a mixed mechanism to the patient’s dry eye
disease. Once a diagnosis of ADDE has been made, proceeding
with punctal plugs is a reasonable course if the patient failed to
resolve with less invasive treatments.
STEP Take the risk out of Risky Business
The risks associated with punctal plugs are generally very
low and easily managed. Foreign body sensation (FBS) or
irritation after insertion is the most common complaint
(60 percent of all reported).2 If the patient has a feeling of awareness vs. FBS, consider encouraging a re-assessment after 24 hours.
If awareness persists or the complaint mirrors pain, repositioning
or removal eliminates the problem. Inserting a “low profile” style
plug may allow for more comfortable wear.
Epiphora can result if EDE is treated with a punctal occlusion. In
fact, some physicians use epiphora after plug insertion as a diagnostic indicator of evaporative dryness. Fortunately, conventional
diagnostic testing and a trial with a temporary collagen plug often
decrease the occurrence. Again, extracting the plug will resolve
the complaint.
Infections such as dacryocystitis pose a greater risk. Removal of
the plug and initiation
of an antibiotic such
as a fourth-generation
fluoroquinolone is recommended. On occasion, surgical intervention is required such as
dacryocystorhinostomy.
Punctal canalicular erosion can occur
beneath the plug due to
chronic irritation. After removing the plug, an antibiotic and steroid will treat acute complaints. Rarely, suturing is necessary to reconstruct the puncta. Dry eye patients who concurrently suffer from
ocular allergy may appreciate an increase in symptoms. When an
increased tear volume is maintained, the eye is bathed in inflammatory mediators. These mediators can increase itching and redness.2
2
Before selecting a plug or utilizing a gauge to measure,
stop and look at the puncta behind the slit lamp. Getting
the lay of the land often saves time for the doctor and
frustration for the patient. Using a gauge—often provided by the
manufacturer—measure the puncta for the appropriate plug size.
Ideally, the punctal opening will stretch slightly when the plug is
properly inserted. Slight blanching may be noted. If no resistance
is felt, the next size up should be attempted. Likewise, if significant resistance is appreciated, a step down is size is warranted.
Measuring puncta of the fellow eyelids are recommended due to
potential anatomical variations in size and orientation. When in
doubt, do not force a plug into place. Keep in mind that extrusion rates with plugs are relatively high. Warn your patient that
a reinsertion may be required even with careful measurement.
3
STEP Location, location, location
4
The inferior canaliculus contributes approximately 60 percent of the maximum outflow of the lacrimal drainage.3
See Punctal plugs on page 32
COM
RE
1
#
BR
ENDED
M
STEP Measure twice, plug once
Top hat and cane
pricing not required.
HypoChlor™ is just as
effective and saves your
patients money.
CTOR
DO
Phenol red thread
testing is emerging
as an alternative
to conventional
Schirmer’s strips
AND
SPECIAL SECTI O N
32
SEPTEMBER 2015
Dry Eye
Punctal plugs
Most physicians start with occluding the
inferior puncta, then determine if measurable improvement occurs. If improvement
is reported, but symptoms fail to resolve to
either doctor or patient satisfaction, insertion of superior plugs may be necessary.
Consider, however, that superior plugs are
often the last to be inserted and the first removed. Physicians may shy away because
they can be tricky to insert from behind the
microscope. Patients may not prefer superior plugs because the plugs increase the
occurrence of FBS. If symptoms are severe
enough to demand superior plugs, thermal
cautery is often a better permanent solution.
WANT MORE ON DRY EYE?
Diagnosing and treating dry eye
with technology
optometrytimes.com/dryeyetech
Why dry eye means poor vision
optometrytimes.com/dryeyeandvision
A new tool for managing ocular
surface disease
optometrytimes.com/OSDdevice
STEP Show me the billing
Pitfalls may present from a billing
and coding perspective as well as
clinically. When medically necessary, Medicare and most major insurance
providers will cover punctal occlusion (68761,
5
When medically
necessary, Medicare
and most major
providers will cover
punctal occlusion
Closure of lacrimal punctum; by plug, each).
As a surgical procedure, supportive documentation in the patient’s medical record is
required. Risks, benefits, alternatives, and
the procedure itself should be outlined for
the patient. Documented informed consent
is a necessity. Details of the procedure such
as location, brand, size, material, and lot
number are logged in the medical record.
In terms of medical necessity, punctal occlusion is not an acceptable primary treatment for dry eye disease. Documentation
of insufficient or failed therapies is needed
before proceeding.
|
A 10-day global fee applies to plug insertion, and the examination is a piece of the
global surgical package unless there is a documented and identifiable separate diagnosis.4
REFERENCES
1. Savini G, Prabhawasat P, Kojima T, et al. The
challenge of dry eye diagnosis. Clin Ophthalmol. 2008
Mar;2(1):31-55.
2. Kronemyer B. Minimize punctum plug complications by
proper patient, design choice. Primary Care Optometry
News. 2007 November. Available at: http://www.healio.
com/optometry/cornea-external-disease/news/print/
primary-care-optometry-news/%7B70201df3-b84f4126-9bc1-6f15cf58599c%7D/minimize-punctumplug-complications-by-proper-patient-design-choice.
Accessed: 08/07/2015.
3. Murgatroyd H, Craig JP, Sloan B. Determination
of relative contribution of the superior and inferior
canaliculi to the lacrimal drainage system in health
using the drop test. Clin Experiment Ophthalmol. 200
Aug;32(4):404-10.
4. Corcoran Consulting Group. Medicare reimbursement
for punctal occlusion with plug (FCI Ophthalmics).
Available at: http://www.corcoranccg.com/products/
faqs/punctal-occlusion-fci/. Accessed: 08/07/2015.
Dr. Hauser received her Doctor of Optometry degree in 2001
from Southern College of Optometry, where she completed a
postgraduate residency in primary care optometry. She is a
member of the American Optometric Association, Tennessee
Association of Optometric Physicians, the West Tennessee
Optometric Physicians Society, and the Association for Research
in Vision and Ophthalmology. [email protected]
IN BRIEF
Allergan recalls Refresh eye drops
DUBLIN—Allergan recently announced that it
is conducting a voluntary recall down to
consumer level of specific lots of its Refresh Lacri-Lube 3.5g and 7g for dry eye,
Refresh P.M. 3.5g for dry eye, FML (fluorometholone ophthalmic ointment) 0.1%
(sterile ophthalmic ointment topical antiinflammatory agent for ophthalmic use,
3.5g), and Blephamide (sulfacetamide sodium and prednisolone acetate ophthalmic
ointment, USP) 10%/0.2% sterile topical
ophthalmic ointment combining an antibacterial and a corticosteroid, 3.5g.
The company chose to initiate this recall
based on a small number of customer complaints which reported a small black particle at the time of use. According to the
company, the black particle is part of the
cap and can be created by the action of unscrewing the cap from the aluminum tube
and potentially introduced into the product.
If the particle gets into the eye, potential adverse events may include eye pain,
eye swelling, ocular discomfort or eye irritation. Specific lots are being voluntarily
recalled in the interest of patient safety; a
complete list is available at Allergan.com.
The lot number and expiration date may
be found on the bottom flap of the carton
with the safety seal and on the crimp seal
of the product tube.
This recall does not affect any other Refresh or Allergan product.
Consumers who currently have product
from any of the affected lots should using
the product and return it to Allergan.
For any questions regarding product returns, contact GENCO at 877-674-2087 from
7 a.m. to 5 p.m. CST. For questions regarding credit or reimbursements, contact Allergan at 1-800-811-4148 from 7 a.m. to 5
p.m. PST.
Essilor launches Essilor
Colors sun lenses
PARIS—Essilor of America announced the launch
of Essilor Colors, a new line of sun lenses available in a range of colors and gradients.
Patients will be able to select from six tints, six
gradients, and three mirrors for up to 48 custom
color combinations. Lens color choices feature
gray mist, sienna brown, forest gray, emerald
blue, grape, and plum. These colors can be combined with gold, blue, and silver mirror effects.
All colors are available in 1.5 standard plastic or
polycarbonate prescription lenses and in single
vision and full back side progressive designs.
Essilor Colors will utilize a specialized lab
process and machinery to provide wearers with
benefits such as longer lasting and consistent
color and will be available as Xperio UV polarized sun lenses, Crizal Sunshield UV tinted
lenses, standard polarized, and standard tinted
lenses.
Refractive
“The Xfraction Process
helps me rapidly discern
between patients that can
be corrected to 20/20 with
simple refinements or full
refractions...and who
I can’t correct to 20/20,
and exactly why not.”
April Jasper, OD
West Palm Beach, FL
“Efficiency is paramount
today; anytime I can save
time and be more accurate
– it’s the perfect solution.”
Ian Benjamin Gaddie
OD, FAAO
Louisville, KY
SOLUTION
“With Xfraction, everything
is smoothly connected,
and with a single button
push, all test results from
all devices are immediately
uploaded to my cloudbased EHR system.”
Dori M. Carlson, OD
Park River, ND
“The Xfraction WOW
factor with my patients is
huge! They really notice
and appreciate the new
high-tech and integrated
experience...making them
more likely to come back
in the future.”
Nathan Bonilla-Warford
OD, FAAO
Tampa, FL
Marco Refraction Systems — Advanced automated instrumentation includes the
OPD-Scan III Wavefront Aberrometer, the TRS-3100/TRS-5100 and EPIC Digital
Refraction Workstation, Autorefractors/Keratometers (with VA measurement,
SubMective SShere ReÀnement, Tonometr\, *lare testing on certain models and
Lensmeters–all with EMR Integration.
Designed and Manufactured by NIDEK - Represented by Marco
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SPECIAL SECTI O N
34
SEPTEMBER 2015
Dry Eye
|
A stepwise approach
to diagnosing MGD
Protocol betters documentation and foundation for treatment
Understanding the definition of
ocusing on dry eye manMGD is the foundation. Through
agement is a great practice
the work of TFOS, MGD was forbuilder, but is not without
mally defined as a “chronic, difchallenges. These challenges
fuse abnormality of the meibomian
lie in making the proper diagnogland, commonly characterized by
sis, implementing new technology,
terminal duct obstruction and/or
properly training staff, developing
LESLIE E O’DELL,
qualitative/quantitative changes in
an effective treatment plan and
OD, FAAO
the glandular secretion. It may rethe time it takes to properly eduis the director of the
sult in alteration of the tear film,
cate patients.
Dry Eye Center of
symptoms of eye irritation, cliniWhen facing any challenge,
PA, Wheatlyn Eye
Care in York, PA.
cally apparent inflammation, and
establishing and following a set
ocular surface disease.”1
protocol helps. The Tear Film and
Ocular Surface Society (TFOS) Workshop
on meibomian gland dysfunction (MGD)
STEP History
helped to organize the evaluation of a paQuestionnaires can expedite your
tient when MGD is suspected, listing the
history intake. These can be valiappropriate tests needed for proper diagdated surveys, such as the Ocular
nosis.1 (Table 1) Let’s go through each one
Surface Disease Index (OSDI) and Standard
Patient Evaluation of Eye Dryness (SPEED)
and create a step-by-step approach to a
questionnaires, as well as customized quesvast and complicated disease, MGD. For
tionnaires. Here are a few important quesall testing, be sure to develop a standard
tions to ask for all patients—symptomatic
of care that is universal for every patient
or not. encounter to track improvement during
subsequent exams.
How do your eyes feel in the morning
F
1
TAKE-HOME MESSAGE A step-by-step
protocol to diagnosing meibomian gland
dysfunction provides a universal standard of
care for all of your patients. Standardizing
your diagnosis process provides easy and clear
documentation for all patients, plus you are
able to better track improvement or worsening
of clinical signs. A proper diagnosis process
lays the foundation for better treatment.
when you are waking? For some patients,
morning complaints clue us into other potential problems with demodex blepharitis, nocturnal lagophthalmos, and recurrent corneal erosion high on the list of
differentials.
How long can you read or use a computer before your vision blurs or you become aware of your eyes? Because a lot of patients coming in for
an exam are already using an over-thecounter drop or have tried one, also ask if
1.
2.
Figure 1. Korb-Blackie method of transillumination of the lid for inadequate lid seal.
The transilluminator is held at the upper lid crease on a gently closed eye and the lash
margin is evaluated closely for any light to spill out indicating an inadequate lid seal.
(Image courtesy Caroline Blackie, OD, FAAO)
Figure 2. Conjunctival folds. (Image courtesy of Caroline Blackie OD, FAAO)
SPECIAL SECTI O N
the drop she is currently using provides
some relief to her symptoms. For a contact lens patient, the questions
can seem endless:
What brand of lens is he wearing?
What’s the replacement schedule for
the lenses?
How compliant is he to replacement
and cleaning?
What does he use for disinfecting his
lenses?
1. Patient questionnaire
2. Measure the blink rate
3. Measure tear meniscus
4. Measure tear osmolarity
5. Fluorescein for TBUT
6. Corneal and conjunctival staining
7. Schirmer test
8. MGD evaluation: lid features, expression,
meibography
Adapted from TFOS workshop on Meibomian Gland Dysfunction
How often does he sleep in lenses?
Is he aware of the lens during the day?
Is his vision stable even with blinking?
When reviewing medications and other
systemic conditions that contribute to MGD,
ask if the patient is also experiencing dry
mouth symptoms. For many dry eye sufferers, taking the time to talk about their
symptoms is like opening Pandora’s box.
Once you have a chance to take back over
control of the conversation, you can start
your examination. STEP
Take a step back
Before a slit lamp evaluation, take
a step back from the patient to
evaluate her external appearance.
Look for signs of rosacea, abnormalities
to the lid-globe congruity, blink rate, and
overall appearance of the eye.
Next, pick up your transilluminator and
evaluate the patient for inadequate lid seal.
Ask the patient to close her eyes as if she
were resting—no forced closure—and rest
the transilluminator on the top eyelid (Figure 1). Evaluate the lid for inadequate lid
seal centrally, nasally, and temporally. Then
start your slit lamp evaluation.
2
STEP
3
The bread and butter of
MGD: slit lamp examination
Through research studies, I have
developed superior techniques for
using vital dyes to best determine corneal
and conjunctival staining as well as lid
wiper epitheliopathy.
A formal dry eye strip can be used to
measure tear break-up time (TBUT) and
35
is applied to the superior conjunctiva with
the patient looking down. This applies a
very thin amount of fluorescein. Average
TBUT for three blink cycles per eye and
record. If you don’t have time for this or
access to dry eye strips, use a fluorescein
strip applied superiorly and record it in a
way that is the same for every patient enSee Diagnosing MGD on page 36
OCULUS Keratograph® 5M
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TABLE 1 Sequence of testing in
MGD-related dry eye in a private
practice setting
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SPECIAL SECTI O N
36
SEPTEMBER 2015
Dry Eye
Diagnosing MGD
counter; simply stating “decreased TBUT”
or “instant TBUT.” The next step is to instill fluorescein dye
using a strip. This is best applied inferiorally and temporally while the patient is
looking up. It’s important to wait 60 to 90
seconds after instillation before evaluating the cornea for staining. During that
time, bring the patient to the slit lamp and
start evaluating his lid and lash margin for
blepharitis or demodex. Instruct the patient
to open his eyes and observe the bottom
lid margin looking for obvious changes to
3
Figure 3. This
schematic illustrates
how to section both the
cornea and conjunctiva
when grading both
fluorescein and lissamine
green staining. (Image
courtesy of Association
for Research in Vision
and Ophthalmology and
Tear Film and Ocular
Surface Society)
4
Figure 4. Grading
meibomian gland atrophy
is an important part of
a dry eye evaluation. Dr.
Heiko Pult has developed
this grading scale
ranging from degree 0,
normal glands to degree
4, > 75 percent loss of
glands. (Image courtesy
of Tear Science)
5
Figure 5. TFOS and
the Meibomian Gland
Workshop helped to
classify MGD into
low delivery and high
delivery. (Image courtesy
of Association for
Research in Vision and
Ophthalmology and Tear
Film and Ocular Surface
Society)
|
the meibomian glands. You are looking for
cicatricial changes of the glands, telangetatic vessels, meibomian gland cyst and/
or a frothy tear film.
Next, observe the conjunctival tissue adjacent to the cornea both nasally and temporally looking for conjunctivochalsis, a
bagginess to the episclera that can interfere
with tear distribution as well as a continuous feeling of “my eyes are tearing” (Figure 2). Also, take this time to evaluate the
tear meniscus height when enhanced with
fluorescein dye. Once the wait time is up,
the cornea can be evaluated for keratitis.
Using a standardized grading system
will help when you follow the patient. I
recommend looking at the cornea broken
into five segments: central, superior, temporal, inferior, and nasal. Then grade superficial punctate keratitis (SPK) in each
segment using a grading scale of Grade 0
to 3 where zero is no staining.2 (Figure 3).
The location of keratitis helps to guide the
diagnosis as well as best treatment plan. Now add lissamine green stain using the
same method as fluorescein, adding dye
inferiorly and waiting 60 to 90 seconds before evaluating the conjunctiva for staining.
During this time, start to evaluate meibomian gland secretions. This is best done
using the Korb Meibomian Gland Evaluator
developed by Dr. Donald Korb. This gland
evaluator provides a standardized pressure
comparable to the pressure exerted with
blinking to determine how many glands are
secreting.3 With the patient looking upward,
gently push on the bottom lid and section
the glands in groups of five, grading the
expressibility of the glands first on a scale
of 0 for no secretion to 3 for easy secretion and thin healthy oil. When the time
has lapsed for the lissamine dye, evaluate
the conjunctival tissue looking for staining
again on a scale of Grade 0-3 in the nasal
and temporally quadrants. Again, using a
standardized scale allows for easy documentation as well as uniformity in your
charts to know when patients are getting
better from your treatment or worse.
STEP
MGD must-haves
There are a few essentials to an
MGD evaluation that if you aren’t
doing presently, you should add
to your exam today. All are easy and don’t
cost you a dime to add. First, transillumination of the MG using
a penlight at the slit lamp. This is a quick
and easy method to evaluate for MG atrophy. Again, a grading scale should be used;
4
SPECIAL SECTI O N
a preferred grading scale was developed by
Dr. Heiko Pult and is a great education tool
for the patient as well4 (Figure 4).
A tool to express the glands in another
must-have in a MGD evaluation. Being able
to express the glands allows for grading
of inspissation and obstruction. There are
a few commercially available, some with
flat metal plates, some with barrels that
roll over the glands to aid in expression.
The evaluation of a dry eye patient now
has diagnostic testing available to enhance
our clinical skills and improve our ability to diagnose a patient. These include
Dry Eye
dysfunction: executive summary. Invest Ophthalmol Vis
Sci. 2011 Mar 30;52(4):1922-9.
2. Barr JT, Schechtman KB, Fink BA, et al. Corneal scarring
in the Collaborative Longitudinal Evaluation of Keratoconus
(CLEK) Study: baseline prevalence and repeatability of
detection. Cornea. 1999 Jan;18(1): 34-46.
3. Korb DR, Blackie CA. Cornea. Meibomian gland
diagnostic expressibility: correlation with dry eye
symptoms and gland location. Cornea. 2008 Dec;
27(10): 1142-7.
4. Pult H, Riede-Pult BH, Comparison of subjective
grading and objective assessment in meibography.
Cont Lens Anterior Eye. 2013 Feb;36(1):22-7.
5. Nelson JD, Shimazaki J Benitez-del-Castillo JM,
et al. The international workshop on meibomian gland
dysfunction: report of the definition and classification
subcommittee. Invest Ophthalmol Vis Sci. 2011 Mar
30;52(4):1930-7.
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Using a standardized
grading system
will help when you
follow the patient.
tear osmolarity (TearLab), InflammaDry
(RPS), meibography (Oculus), interferometry (TearLab) and external photography
and videos. These tests enhance patient
education—seeing is believing for our patients. Think of our glaucoma patients. If
we practiced in the days prior to optic nerve
analysis, we could still diagnose a patient
with glaucoma based on observations to
their nerve fiber layer. The new diagnostics available with OCT and HRT improve
our ability for early detection, but an optic
nerve evaluation is still needed to correlate all the tests. The same is true with
advancement in diagnostics for dry eye.
A strong dry eye clinician can use these
data points to develop a patient-centered
treatment plan.
STEP
Diagnosis
The next challenge is changing
the way we document this disease.
Consistent nomenclature is imperative, and we as a profession need to use
the recommendations laid out by the MGD
workshop.5 Meibomian gland dysfunction
can be classified as either low delivery (hyopsecretory/obstructive) or high delivery
(hypersecretory) (Figure 5).
Making the right first diagnosis based on
a complete history and examination with
the proper testing using technology available within your practice sets the foundation for treatment.
5
REFERENCES
1. Nichols KK, Foulks GN, Bron AJ, et al. The
international workshop on meibomian gland
37
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SPECIAL SECTI O N
38
SEPTEMBER 2015
Dry Eye
Compress bundle
cornea is more susceptible to corneal warpage when it is heated,
patients should be advised not to
massage their lids during or immediately after warm compress
application.18
A recent study compared the
efficacy of heat transfer to the
outer and inner eyelid surfaces
of eight different warm compress
methods. The methods tested included several commercially available beaded masks, a chemically
activated heating compress, a rice
bag, an electronic mask, and two
methods of applying moist heat.
The only compress which was
shown to elevate inner eyelid surfaces (where the MGs are located)
above a therapeutic temperature of
40°C after the 10-minute heating
period was the heated moist towels that were wrapped in a bundle.
This method has been named the
Bundle method. Because the performance of the Bundle method
elevated all measured eyelid temperatures above a therapeutic 40°C,
its design and preparation will be
further described for practical use.19
mercially available masks and goggles. Some unique methods have
been described to heat eyelids, including hard-boiled eggs, heating
lamps, and even baked potatoes.15,16
JEFFREY R.
SCHUBERT, PHD
Unfortunately, most patients perDr. Schubert is a
forming WCs find themselves unpatient of Korb &
enthusiastic about the procedure
Associates, and
due in part to the lack of personal
sufferer of chronic
results, the laborious nature of the
dry eye due to
meibomian gland
application, and/or the lack of indysfunction.
structions about how to optimize
their efficacy.
A 2008 study determined the
following key features to increase
the effectiveness of a WC.17 WCs
applied to the outer lid surface
must maintain a consistent 45°C
(113°F) in order for the therapeutic heat to reach the MGs, ideally
DAVID K.
>40°C (104°F). Forty-five degrees
MURAKAMI, OD,
Celsius, when the heat source is
MPH, FAAO
Dr. Murakami is a
steadily cooling from the time of
clinical researcher,
application, can be applied safely
trainer and
against the external eyelid skin
consultant for
without risking thermal injury
TearScience.
for the duration of a treatment,
but heat needs to be applied for a
minimum of four to six minutes in order for
Bundle method preparation and use
the heat to pass through anatomical barThe Bundle method involves heating several
riers that naturally shield the glands, e.g.,
moistened cloth towels, wrapped together,
skin, fat, the tarsal plate, and vasculature
into a circular bundle as shown in Figure
of the eyelids. The compress needs to be
1. The concentric geometry of the bundle
replaced with a freshly heated compress
facilitates heat retention of the inner towevery two minutes. In addition, because the
els while the outer towels are being used.
TABLE 1 Instructions for Bundle Method preparation and use
Materials
5-6 microfiber towels
Glass or ceramic bowl with lid
Microwave
Instructions
Dampen towels in water; squeeze out excess water
Fold towels into long rectangles
Wrap first towel into tight cylinder; continue wrapping remaining towels around
first towel until you have a large bundle
Place towels in a container, cover with lid; microwave 1 minute, 50 seconds as
a starting point (adjust based on microwave power settings)
Allow towels to cool at least 1-2 minutes before using (cover with lid)
The goal is to heat the towels to a warm but comfortable and tolerable
temperature when applied to the lids
Apply first outermost towel (keep remaining towels in covered dish)
Replace towel roughly every 2 minutes; peel towels from outside and work
toward center towel to be used last
|
TAKE-HOME MESSAGE A recent study
compared the efficacy of heat transfer to the
outer and inner eyelid surfaces of eight different warm compress methods. The only compress which was shown to elevate inner eyelid
surfaces (where the meibomian glands are
located) above a therapeutic temperature of
40°C after the 10-minute heating period was
the heated moist towels that were wrapped
in a bundle. This method has been named the
Bundle method.
Making the bundle large enough to supply
a 10-minute treatment eliminates the time
and inconvenience of needing to reheat a
warm compress during the treatment. This
also frees the patient to conduct treatment
at any comfortable location rather than having to remain near the microwave.
The following section details the necessary items to perform this method, along
with how to prepare and heat the towels
for use. A convenient reference is outlined
in Table 1.
STEP Folding, wrapping, and wetting
the towels in a bundle. Prior to
wetting the towels, each cloth is
folded, as shown in Figure 2. The
first cloth is then rolled into a cylinder. The
next cloth is wrapped around the first, and
so on, until all of the cloths have been added
to the bundle. The entire bundle is then
rinsed in warm tap water until it is soaked,
and then squeezed (using both hands to
compress the circumference of the bundle)
to remove excess water.
STEP Heating the bundle. The wet bundle is placed in a microwave-safe
container as shown in Figure 3 and
heated for about 1 minute and 50
seconds. It is beneficial to use a container
with a lid for more rapid heating in the microwave and better heat retention after the
bundle is removed from the microwave.
Allow the bundle to cool for about one to
two minutes.
STEP Applying the WCs from the bundle. The first WC is peeled from
the bundle to begin the treatment
when it can be safely applied to the
outer eyelid without the patient feeling discomfort from the heat. This temperature will
be ~45°C. If the outer towel is still too hot
after up to two minutes of cooling, the patient should wait another 10 seconds and try
again.
1
2
3
SPECIAL SECTI O N
STEP
Replacing the WC at regular intervals. Each WC lasts for approximately two minutes, during which time the temperature
will have cooled such that the temperature is no longer in the
therapeutic range. An egg timer or smartphone timer can be set
to alert every two minutes when it is time to change from one WC to the
4
Dry Eye
39
next. The cooled towel is replaced with the next outermost
towel from the bundle. The final towel at the center of the
bundle is the most tightly rolled and thus tends to be much
hotter at one end. Advise your patient to apply the heat from
part of the towel that feels most consistent with previous
towels.
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Figure 2 (A, B ,C) Preparation of each individual compress prior to bundling.
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SPECIAL SECTI O N
40
Dry Eye
Compress bundle
cotton and microfiber towels were tested
with very consistent and similar results.
The temperature was measured on the inner
and outer surface of each cloth immediately after its removal from the bundle. The
WC temperatures with the Bundle
outer temperature of the outermost
method
WC was also measured upon reWhen the Bundle method was inimoval from the microwave, one
tially developed, a series of test
minute prior to commencement
bundles were prepared, and an
of the treatment. Figure 6 shows
infrared thermometer was used
the temperature of each cloth at
to quantify the varying temperathe moment when it is ready to
tures among the towels in varibe applied. The outer surface of
ous situations: pre-heated baseline
CAROLINE A.
each of the five WCs was between
temperatures, temperature differBLACKIE, OD,
46°C and 49°C (115°F and 120°F,)
ences among the towels immediPHD, FAAO
just a few degrees above the ideal
ately after being heated, and the
Dr. Blackie is the
target of 45°C (113°F.) Each WC
temperature of towels as they were
head of professional
would require several seconds of
pulled apart at regular intervals.
and scientific
communication for
air-cooling before it could be comThe approximate location within
TearScience.
fortably applied.
the bundle of the points measured
is shown in Figure 4. The corresponding temperatures after being
Variations on the
heated and one minute prior to
procedure and other tips
treatment are plotted in Figure 5.
Other key points to keep in mind
Prior to heating, the temperature of
include:
the exterior of the moistened bunt Wait slightly longer if bundle
dle was found to be between 34°C
remains too hot after removal from
DONALD R. KORB,
and 42°C (94°F and 107°F.) Immemicrowave. (A compress should
OD, FAAO
diately after heating, the exterior
never be applied too hot)
Dr. Korb is the
cloth measured approximately 49t The inner surface of each WC
cofounder of
TearScience.
54°C (120-130°F), while the core
is considerably warmer than the
of the bundle was between 66°C
outer surface
and 77°C (150°F and 170°F.)
t The bundle retains heat better
The temperature of each WC was meaand cools slower than an individual WC;
sured when it was removed at regular interreplacing a towel is quick when wrapped
vals, mimicking an actual treatment. Both
in a bundle and heated together
3
Figure 3. Warm compress bundle after soaking
SEPTEMBER 2015
|
t Tailor the number of towels required
to fit the needs of the patient—using more
towels is useful for patients with more advanced stages of MGD who require longer
periods of heat
t Lint-free microfiber cloths can be alternated for cotton washcloths. (Lightweight
and inexpensive)
Warmer is not
better for the ocular
surface
t Towels can be also be soaked individually before wrapping into a bundle
t Water temperature for initial wetting
can vary—heat for a few additional seconds
if cooler water is used
t Stress the importance of keeping towels clean by washing regularly
Patient experience
The first author, a PhD in physics and a
patient with MGD from a clinic in Boston,
developed the bundle method. This method
45ºC
The temperature needed for
a home-heated compress,
used for at least 8 minutes
has been subsequently taught to and used
by several additional patients at the same
clinic, all of whom reported positive feedback
and excellent compliance. For the following
two cases, patient symptoms were gathered
with the SPEED Questionnaire (scored from
0 – 28)20 and MG function (the ability of a
meibomian gland to release liquid oil during a deliberate blink) was assessed with
a standardized meibomian gland evaluator (MGE).21
Case 1. A 46-year-old Caucasian female
diagnosed with MGD was switched to the
Bundle method when she reported that her
compliance with a single-towel WC had been
waning over the year prior. Her symptoms
of eye dryness steadily increased from 5 to
8 over the previous year. Using the MGE,
only one functional gland was observed in
each eye. After nine months of daily Bundle
method WC application, the patient returned
for a follow-up evaluation and reported that
she had been “doing better” and was very
enthusiastic with the Bundle method. Her
symptom score was down to 4, which was
half the value from her previous exam, nine
months prior. MG function also showed im-
SPECIAL SECTI O N
4
Dry Eye
41
patient is aware of the dangers of massaging the lids and
globe during or immediately after heating.
When recommending a WC, clinicians should educate their
patients that a consistent temperature of ~45°C is needed
for a home-heated compress and that the WC should be used
for a minimum of eight to 10 minutes. We have found that
compliance is greatly improved when patients are educated
about the role of the supplemental therapy for MGD when
Rely on something that
Figure 4. Approximate locations of temperature measurement points within the bundle. Each
WC temperature is measured near its own center, except for the final WC, which is measured at
two points each roughly one third of the way from the ends.
STAYS PUT
provement in both eyes, with four to six functioning glands of each eyelid. It was also noted that all functional glands were also expressing significantly greater volume.
Case 2. A 43-year-old Caucasian female, using a daily single-towel WC
since 2011, admitted that her compliance was poor. Her symptom score
had increased from 6 to 8. There were two to three functional glands in
each lower eyelid. The Bundle method was recommended in November
2013. After 16 months of using the Bundle method WC, the patient reported her compliance was up to five to six days per week. The number
of functional glands on each lower lid had doubled. Interestingly, her
symptoms showed no quantitative improvement despite her perception
Because the cornea is more
susceptible to corneal warpage
when it is heated, patients should
be advised not to massage their
lids during or immediately after
warm compress application
that she had improved. Given the chronicity of her condition and the
progressive nature of MGD, it was clinically significant that her symptoms were not worsening.1
Prescribing the Bundle method
Once MGD has been identified and the in-office treatment plan executed
(removal of obstruction via manual expression of glands or via LipiFlow
[TearScience] therapeutic procedure), the supplementary at-home therapy plan should be prescribed. This plan frequently includes the use
of self-administered front surface lid heating in the form of a WC. WCs
prepared by the Bundle method have been shown to increase inner eyelid surface temperatures above a therapeutic level (>40°C or >104°F),
if performed correctly.19 The general form of supplemental front surface
lid heating is not as important as ensuring that the heat reaching the
MGs falls within the therapeutic range (>40°C or >104°F) and that the
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SPECIAL SECTI O N
SEPTEMBER 2015
Dry Eye
Compress bundle
they receive specific instructions how to prepare and use the WC (analogous to brushing and flossing our teeth, we understand
that just rinsing will not be effective because we understand the individual roles
of brushing and flossing). The conventional
approach to offer nonspecific instructions
such as “use warm compresses daily” or
“just heat a washcloth and hold it over your
eyes for a few minutes” is ineffective. This
vague approach minimizes the importance
of the supplemental therapy and sets patients up for failure.
MGD is a prevalent, obstructive, and
progressive disease. Our modern lifestyle,
whereby we subject ourselves to chronic
evaporative stress,22 places us all at risk for
MGD; hence, the high reported prevalence
of 60 to 70 percent. There are many areas
in which we can raise the level of awareness of MGD as well as greatly improve
the standard of care we offer our patients
by performing the necessary baseline MG
evaluations on all patients. However, in the
interim, we can at least provide specific instructions for a self-administered efficacious
WC such as is described with the Bundle
method presented here.
REFERENCES
1. Nichols KK, Foulks GN, Bron AJ, et al. The International
Workshop on Meibomian Gland Dysfunction:
Executive Summary. Invest Ophthalmol Vis Sci. 2011
Mar;52(4):1922-9.
treatment of meibomian gland dysfunction. Ophthalmol
and Vis Sci. 2011 Mar 30;52(4):2050-64.
10. Geerling G, Tauber J, Baudouin C, et al. The
International Workshop on Meibomian gland dysfunction:
Report of the subcommittee on management and
11. Goto E, Endo K, Suzuki A, et al. Improvement of tear
stability following warm compression in patients with
meibomian gland dysfunction. Adv Exper Med Biol.
5
Approximate temperature gradient within the bundle,
one minute prior to treatment
170
160
5. Jie Y, Xu L, Wu YY, et al. Prevalence of dry eye among
adult Chinese in the Beijing Eye Study. Eye (Lond). 2009
Mar;23:688-693.
6. Murakami DK, Blackie CA, Korb DR. The Prevalence
of Meibomian Gland Dysfunction in a Caucasian Clinical
Population. Poster presented at: The Association for
Research in Vision and Ophthalmology; 2015 May 4-8;
Denver, CO.
7. Olson MC, Korb DR, Greiner JV. Increase in tear
film lipid layer thickness following treatment with
warm compresses in patients with meibomian gland
dysfunction. Eye Contact Lens. 2003 Apr;29:96-99
8. Gifford SR. Meibomian glands in chronic
blepharoconjunctivitis. Am J Ophthalmol. 1921;4:489–
94.
9. Korb DR, Henriquez AS. Meibomian gland dysfunction
140
130
120
110
a
b
c
d
e
f
g
Location within bundle
Figure 5. Approximate temperature gradient within the bundle, one minute prior to treatment.
6
Temperature of each successive WC after being removed
from the bundle
140
135
Temperature (degrees F )
4. Uchino M, Dogru M, Yagi Y et al. The features of dry
eye disease in a Japanese elderly population. Optom Vis
Sci. 2006 Nov;83:797-802.
150
100
2. Lemp MA, Crews LA, Bron AJ, et al. Distribution of
aqueous-deficient and evaporative dry eye in a clinicbased patient cohort: a retrospective study. Cornea.
2012 May;31(5):472-8.
3. Lin PY, Tsai SY, Cheng CY, et al. Prevalence of
dry eye among an elderly Chinese Population in
Taiwan: the Shihpai Eye Study. Ophthalmology. 2003
Jun;110(6):1096-101.
|
and contact lens intolerance. J Am Optom Assoc. 1980
Mar;51(3):243–51.
Temperature (degrees F )
42
130
125
120
115
110
inside
outside
105
100
95
-2
90
0
2
4
6
8
10
Time from start of treatment (minutes)
Figure 6. Temperature of each successive WC after being removed from the bundle.
12
14
SPECIAL SECTI O N
Dry Eye
2002;506(Pt B):1149–52.
Vis Sci. 2015 Jul 8.
12. Korb DR, Baron DF, Herman JP, et al. Tear film lipid layer thickness as a function of blinking.
Cornea. 1994 Jul;13(4):354-9.
20. Ngo W, Situ P, Keir N, et al. Psychometric properties and validation of the
standard patient evaluation of eye dryness questionnaire. Cornea. 2013.
Sep;32(9):1204-10.
13. Arita R, Morishige N, Shirakawa R, Sato Y. Comparison of effect of five warming devices onto
tear functions, meibomian glands and ocular surface. Poster presented at: The Association for
Research in Vision and Ophthalmology; 2014 May 4-8; Orlando, FL.
14. Bron AJ, Tiffany JM, Gouveia SM, et al. Functional aspects of the tear film lipid layer. Exp Eye
Res. 2004 Mar;78(3):347-60.
43
21. Korb DR, Blackie CA. Meibomian Gland Diagnostic Expressibility: Correlation
with dry eye symptoms and gland location. Cornea. 2008 Dec;27(10):1142-7.
22. Suhalim JL et al. Effect of desiccating stress on mouse meibomian gland
function. Ocul Surf. 2014 Jan;12(1):59-68.
15. Lam A, Lam C. Effect of warm compress therapy from hard-boiled eggs on corneal shape.
Cornea. 2007;26(2):162-67.
16. Nichols KK. Let’s ask Siri a dry eye question. Optom Management. 2012. Mar;47, 66-69.
17. Blackie CA, Solomon JD, Greiner JV, et al. Inner Eyelid Surface Temperatures as a function of
warm compress methadology. Opt Vis Sci. 2008 Aug;85(8):675-83.
18. McMonnies C, Korb D, Blackie C. The Role of heat in rubbing and massage-related corneal
deformation. Contact Lens Anterior Eye. 2012;35:148-154
19. Murakami DK, Blackie CA, Korb DR. All warm compresses are not equally efficacious. Optom
Dr. Schubert received a doctorate in physics from Michigan State University and is a senior staff scientist
at American Science and Engineering, Inc., working on the design of X-ray imaging systems for inspection
of vehicles and baggage. Dr. Murakami received a Masters in public health from Boston University and
attended the University of California, Berkeley School of Optometry. He completed a residency in cornea and
contact lenses through the New England College of Optometry. He specializes in educating and lecturing on
meibomian gland dysfunction and evaporative dry eyes. Dr. Blackie’s passion is to improve diagnosis and
treatment options for patients who suffer from meibomian gland disease and dry eye, with an ultimate goal
of generating a culture of prevention. Dr. Korb has divided his time between the practice of optometry and
research, authoring over 100 refereed articles and 50 US patents. He has named and described 10 entities;
3 of contemporary significance are meibomian gland dysfunction (MGD), GPC and lid wiper epitheliopathy
(LWE). He is a co-inventor of Systane Balance, a lipid dry eye product marketed by Alcon.
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ATLANTA—The Centers for Disease Control and Prevention (CDC) recently
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approximately 99 percent of contact lens wearers reported at least one
hygiene risk behavior.
According to the CDC, nearly one third of contact lens wearers reported
having experienced a previous contact lens-related red or painful eye
requiring a doctor’s visit.
Half of wearers reported ever sleeping overnight in contact lenses (50.2
percent). More than 87 percent reported ever napping in contact lenses,
while 55 percent admitted they've topped off disinfecting solution; 49.9
percent admitted to extending the recommended replacement frequency
of lenses, while 82.3 percent did the same with their cases.
Another 84.9 percent said they've showered in contact lenses, while 61
percent said they've gone swimming in contact lenses.
Approximately one third (35.5 percent) of contact lens wearers reported
ever rinsing their lenses in tap water and 16.8 percent reported ever storing their lenses in tap water. Almost all rigid wearers (91.3 percent) reported ever rinsing their lenses in water, and 33.3 percent reported ever
storing their lenses in tap water.
Nearly one third of all wearers reported ever having experienced a contact lens-related red or painful eye that required a doctor’s visit.
According to the CDC, the survey findings have informed the creation
of targeted prevention messages aimed at contact lens wearers such as
keeping all water away from contact lenses, discarding used disinfecting solution from the case and cleaning with fresh solution each day,
and replacing their contact lens case every three months.
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SPECIAL SECTI O N
44
SEPTEMBER 2015
Dry Eye
|
The nutritional influences
on today’s dry eye disease
Research hints at potential for expanded nutritional options
ability to fight off cellular injury,
ry eye disease today goes
including ocular injuries. Reactive
beyond thinking about inmolecules—including oxygen ions,
creased tear evaporation vs.
peroxides, and ionizing radiation—
decreased aqueous produccan increase dramatically during
tion. As evidenced, it is now known
the aging process and in times of
the disease is multifactorial, inflamphysical, psychological, and envimatory-mediated, and may include
AUDREY TALLEY
ronmental stress.3,4
a combination of aqueous and evapROSTOV, MD,
orative factors (AAO PPP–Dry Eye
Healthy tears provide key antiis a cornea and
Syndrome, 2013).
oxidant
molecules for preventing
refractive surgeon
Further, newer diagnostic testoxidative
stress to the cornea and
with Northwest Eye
ing (AcuTarget HD, AcuFocus) and
ocular
surface.
Evidence continSurgeons, Seattle,
where she is a
imaging can help the clinician in
ues to grow that suggests oxidapartner.
the dry eye diagnosis and provide
tive stress is a contributing cause
objective means for patient educaof dry eye disease.
tion. Ocular surface imaging may
Oxidative stress affects blink reprovide diagnostic clues to refracsponse5 and three-layer tear film
tive instability.
production, including lacrimal and
Treatment options for dry eye
meibomian gland output,6 as well
disease have included artificial tear
as tear film base layer goblet cells
supplementation, topical cyclospoand appropriate production of tear
ELLEN TROYER,
rine, topical steroids, and punctal
film mucins.7
MT MA,
occlusion. Now, nutritional suppleAll biomolecules can be attacked
is chief executive
mentation (BioTears, Biosyntrx) is
by reactive oxygen species, and celofficer and chief
research officer at
an area receiving more interest in
lular membrane lipids are the most
Biosyntrx.
the management of dry eye disease.
likely to undergo destructive oxidaNutritional deficiencies play a
tion. Cellular membranes are fatty
major role in a number of diseases, includacid-dependent and extremely susceptible
ing dry eye.1 Oxidative stress and inflammato oxidative damage.
Therefore, supplementing with fatty acids
tion linked to nutritional deficiencies have
and additional nutrient co-factors may stimbeen proven to affect the aging process, tear
D
The human body has nutrient-dependent,
antioxidant defense systems to help control
the destructive effects of continuous
reactive oxygen species production.
film biochemistry, and ocular surface health
by inducing cornea and conjunctiva tissue
damage, leading to visual impairment, and
impaired quality of life.2
Oxidative stress is the biochemical endpoint of the imbalance between chemically
reactive oxygen molecules and antioxidants.
This imbalance interferes with the body’s
ulate fatty-acid metabolism and may help
prevent intracellular and extracellular oxidative destruction that can potentially damage ocular cells.8
The human body has nutrient-dependent,
antioxidant defense systems to help control
the destructive effects of continuous reactive oxygen species production. They are
TAKE-HOME MESSAGE Nutritional deficiencies play a major role in many diseases,
including dry eye. Healthy tears provide key
anti-oxidant molecules for preventing oxidative
stress to the cornea and the ocular surface.
Oxidative stress may be a contributing factor
to dry eye disease. Certain nutrients can slow
the reactions of oxidation. Nutritional supplementation can offer benefits to these patients
suffering from dry eye.
located in cytoplasm, cellular membranes,
and extracellular spaces. Defenses include
enzymatic intracellular mechanisms, such
as superoxide dismutase (SOD) and metalloproteinase, that accelerate the dismution
of superoxide to hydrogen peroxide, which
is catalyzed into water or molecules of oxygen in the cytoplasm by copper and zinc
(CuZnSOD) and catalyzed inside the mitochondrial by manganese (MnSOD).2,9
Free-radical scavengers
Scavenging nutrients slow the reactions of
oxidation by transforming molecules into
less-aggressive compounds. These nutrients
are water-soluble vitamins, such as vitamin
C and the B vitamins, or fat-soluble vitamins located in cellular membranes, such
as vitamins A, E, and D, and specific carotenoids, including lutein and zeaxanthin.2
Green tea is also found in a few dry eye
formulations. It is both water- and fat-soluble with potentially anti-inflammatory, antioxidative, and hyperosmolarity effects on
the ocular surface.10
The essential fatty acid omega-6 linoleic acid
(LA) is enzymatically metabolized down the
delta six desaturase to gamma linoleic acid
(GLA), which instantly converts to the mucosal-tissue-specific, anti-inflammatory prostaglandin series E1 if the nutrient co-factors
are readily available, including vitamins C,
E, and B6, and the minerals magnesium or
zinc. This metabolic process can be affected
by aging, alcohol, and prescription drugs (see
SPECIAL SECTI O N
Figure 1 on page 46).
Of all the omega-6 seed oils, only three include GLA: black currant
seed oil, evening primrose seed oil, and borage oil. Black current seed
oil may be considered the most stable because it includes a biochemically balanced amount of omega-6, omega-3, and omega-9 fatty acids.11
Curcumin, another nutrient with anti-inflammatory and hyperosmolarity activity, is also included in some dry eye nutritional formulations.12
Flaxseed oil may also be an effective anti-inflammatory for some pa-
Dry Eye
45
Omega-3 fatty acids EPA and DHA
Fish oil is one of the most commonly used nutritional supplements for dry eye. Fish oil alone does not address the role
of oxidative stress in tear film dysfunction, and some additional nutritional formulations have been designed that incorporate both fish oil and nutritional co-factors.14-16
The base layer of the tear film, including goblet cells and
mucin production, is vitamin A-dependent. Cod liver oil
See Nutrition on page 45
Fish oil is one of the most
commonly used nutritional
supplements for dry eye. Fish oil
alone does not address the role
of oxidative stress in tear film
dysfunction.
tients. This alpha linolenic acid (ALA) omega-3 fatty acid quickly metabolizes to another fatty acid—steridonic acid (SDA) with anti-inflammatory properties.13
A small amount of flaxseed oil will metabolize further downstream to
omega-3 eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA),
which may potentially provide additional omega-3 DHA and address
some meibomian gland cellular membrane lipid activity, thereby improving the tear film.
The VeraPlug
challenge
results are in.
™
Additional Resources
Barabino S, Rolando M, Camicione P, Ravera G, Zanardi S, et al.
Systemic linoleic and gamma-linolenic acid therapy in dry eye syndrome with an inflammatory component. Cornea. 2003;22:97–101.
The guide is available online. Visit www.websiteurl.com
in Public Health button.
Arragona P, Bucolo C, Spinella R, Gluffrida S, Ferreri G. Systemic
omega-6 essential fatty acid treatment and pge1 tear content
in Sjogren’s syundrome patients. Invest Ophthalmol Vis Sci.
2005;46:4474–4479.
The guide is available online.
Visit www.websiteurl.com in Public Health button.
Sheppard JD Jr. Singh R, McClellan AJ, Weikert MP, Scoper SV,
Joly TJ, Whitley WO, Kakkar E, Pfugfelder SC. Long-term supplementation with n-6 and n-3 PUFAs improves moderate to-severe
Keratoconjunctivitis Sicca. A randomized double-blind clinical
trial. Cornea. 2013 Jul 23. [Epub ahead of print]
The guide is available online. Visit www.websiteurl.com in Public
Health button.
Kawashima M, Kawakita T, Inaba T, et al. Dietary lactoferrin alleviates age-related lacrimal gland dysfunction in mice. PloS One.
2012;7:e33148. Published online 2012 Mar 27.
The guide is available online. Visit www.websiteurl.com in Public
Health button.
“After over 300 plugs inserted, the
VeraPlug™ has me convinced it is
the winner. I’ve observed the best
retention, ease of insertion and
hands down the best
patient comfort ever.”
Joe B. Collins, O.D., FAAO, FIOA
Jacksonville, Arkansas
Try the VeraPlug.™ What will you say?
A FRESH PERSPECTIVE™
lacrivera.com
(855) 857-0518
2500 Sandersville Rd
■
See Keyword on page 45
Lexington KY 40511 USA
© 2015 Lacrivera, a division of Stephens Instruments. All rights reserved.
SPECIAL SECTI O N
46
|
SEPTEMBER 2015
Dry Eye
METABOLIC PATHWAYS OF OMEGA-6 AND OMEGA-3 FATTY ACIDS
1
Omega-6
Omega-3
Linoleic Acid (LA)
Polyunsaturated oils: corn and safflower
Alpha-Linolenic Acid (ALA)
Flax seed oil, fish oil
Δ6 desaturase is impaired by aging, alcohol, drugs, nutrient
deficiencies, including vitamins C, E, B5, and Mg or Zn
Δ6 desaturate
Gamma-Linolenic Acid (GLA)
Δ6 desaturate
Steridonic Acid (SDA)
Black Currant, EPO, Borage (18% to 24% GLA)
PGE1
Series-1 prostaglandin
anti-inflammatory
Eicosatetiaenoic Acid (ETA)
Dihomo-γ-Linolenic Acid (DGLA)
Δ5 desaturate
Δ5 desaturate
EPA competitively inhibits the conversion of
Omega-6 fatty acids to pro-inflammatories
Arachidonic Acid (AA)
EPA/DHA
Fish oil and cod liver oil
e
as
yg
en
ox
e
as
yg
en
ox
Lip
Lip
)
)
x2
CO
x2
CO
e(
e(
as
n
ge
as
n
ge
xy
xy
loo
loo
Cy
Cy
LBT-4
PGE-2
LBT-5
PGE-3
Pro-inflammatory
Pro-inflammatory
Anti-inflammatory
Anti-inflammatory
Figure 1. Metabolic pathways of omega-6 and omega-3 fatty acids. (Figure courtesy of Audrey Talley Rostov, MD, and Ellen Troyer, MT MA)
Nutrition
should be considered for dry eye, since it
includes omega-3 EPA and DHA, as well
as sufficient amounts of natural vitamin A
retinol and vitamin D, which fish oil and
flaxseed oil alone do not include.
In summary, nutritional supplementation can offer benefits to patients with dry
eye and can provide clinicians with a safe
treatment option.
As research continues in the field of tear
science, the hope is that expanded nutritional and other treatment options will become available.
This story originally appeared in Ophthalmology Times.
REFERENCES
1. Jalbert I. Diet, nutraceuticals and the tear film. Exp
Eye Res. 2013 Dec;117:138-46.
2. Pinazo-Durán MD, Gallego-Pinazo R, GarcíaMedina JJ, Zanón-Moreno V, Nucci C, Dolz-Marco R,
Martínez-Castillo S, Galbis-Estrada C, Marco-Ramírez
C1, López-Gálvez MI, Galarreta DJ, Díaz-Llópis M.
Oxidative stress and its downstream signaling in aging
eyes. Clin Interv Aging. 2014 Apr 11;9:637-52.
3. Van der Vaart R, Weaver MA, Lefebvre C, David RM.
The association between dry eye disease, depression
and anxiety in a large population-based study. Am J
Ophthalmol. 2015 Mar;159(3):470-4.
4. Ames BN, Shigenaga MK. Oxidants are a major
contributor to aging. Ann N Y Acad Sci. 1992 Nov
21;663:85-96.
5. Nakamura S, Shibuya M, Nakashima H, Hisamura
R, Masuda N, Imagawa T, Uehara M, Tsubota K.
Involvement of oxidative stress on corneal epithelial
alterations in a blink-suppressed dry eye. Invest
Ophthalmol Vis Sci. 2007 Apr;48(4):1552-8.
6. Uchino Y, Kawakita T, Ishi T, Ishi N, Tsubota K. A
new mouse model of dry eye disease: oxidative stress
affects functional decline in the lacrimal gland. Cornea.
2012 Nov;31 Suppl 1:S63-7.
7. Tei M, Spurr-Michaud SJ, Tisdale AS, Gipson IK.
Vitamin A deficiency alters the expression of mucin
genes by the rat ocular surface epithelium. Invest
Ophthamol Vis Sci. 2000;41:82-88.
8. Warnakulasuriya SN, Ziaullah, Rupasinghe HP. Long
chain fatty acid acylated derivatives of quercetin-3o-glucoside as antioxidants to prevent lipid oxidation.
Biomolecules. 2014 Nov 6;4(4):980-93.
9. Kojima T, Wakamatsu TH, Dogru M, Ogawa Y,
Igarashi A, Ibrahim OM, Inaba T, Shimizu T, Noda S,
Obata H, Nakamura S, Wakamatsu A, Shirasawa
T, Shimazaki J, Negishi K, Tsubota K. Age-related
dysfunction of the lacrimal gland and oxidative
stress: evidence from the Cu, Zn-superoxide
dismutase-1 (Sod1) knockout mice. Am J Pathol. 2012
May;180(5):1879-96.
10. Cavet ME, Harrington KL, Vollmer TR, Ward KW,
Zhang JZ. Anti-inflammatory and anti-oxidative effects
of the green tea polyphenol epigallocatechin gallate
in human corneal epithelial cells. Mol Vis. 2011 Feb
18;17:533-42.
11. Tahvonen RL, Schwab US, Linderborg KM,
Mykkänen HM, Kallio HP. Black currant seed oil and
fish oil supplements differ in their effects on fatty acid
profiles of plasma lipids, and concentrations of serum
total and lipoprotein lipids, plasma glucose and insulin.
J Nutr Biochem. 2005 Jun;16(6):353-9.
12. Chen M1, Hu DN, Pan Z, Lu CW, Xue CY, Aass I.
Curcumin protects against hyperosmoticity-induced
IL-1beta elevation in human corneal epithelial cell via
MAPK pathways. Exp Eye Res. 2010 Mar;90(3):437-43.
13. Zhu W, Wu Y, Li G, Wang J, Li X. Efficacy of
polyunsaturated fatty acids for dry eye syndrome: a
meta-analysis of randomized controlled trials. Nutr Rev.
2014 Oct;72(10):662-71.
14. Harauma A. Salto J, Watanabe Y, Moriguchi T.
Potential for daily supplementation of n-3 fatty acids
to reverse symptoms of dry eye in mice. Prostaglandins
Leukot Essent Fatty Acids. 2014 Jun;90(6):207-13.
15. Kangari H, Eftekhari MH, Sardari S, et al. Shortterm consumption of oral omega-3 and dry eye
syndrome. Ophthalmology. 2013 Nov;120(11):2191-6.
16. Surette ME. Dietary omega-3 PUFA and health:
stearidonic acid-containing seed oils as effective and
sustainable alternatives to traditional marine oils. Mol
Nutr Food Res. 2013 May;57(5):748-59.
Audrey Talley Rostov, MD, has no financial interest in
Biosyntrx.
[email protected]
Ellen Troyer, MT MA, has more than 30 years of experience
in medical science and professional education services and has
led Biosyntrx product research and development, education,
and marketing activities for the past 10 years.
[email protected]
Brien Holden
assigned topic. While at times his
lectures were controversial, they
always inspired questions and provided a platform for change.
Like many of Brien’s friends, the
stories will always make me smile.
I have personal memories of whale
watching in Maui harbor during a
COA education meeting in 1989.
We didn’t see many whales but had
great onboard adult beverages to
make the experience memorable.
Another memory was Brien sitting
next to my husband and me at an
American Optometric Foundation
luncheon, sharing rugby stories.
My husband happened to be wearing an “All Blacks” sweater from
the New Zealand rugby team—the
vile opponent of Australia’s Wallabys. After the Academy dumped
its lackluster annual Hofbrau dinners at the Annual Meeting, Brien
began the legendary Australia party
after his personal suite became too
small. Nothing is better than joining a group of respected researchers, youthful students, stiff academics, and boring clinicians rocking
to slide shows of Australia while
eating pizza and drinking Foster’s
beer. I hope the Academy will not
break this tradition in his memory.
While contact lenses were his
gift, global eye care was his passion.
He dreamed of a world in which
the need for vision correction due
to uncorrected refractive error and
the plight of progressive myopia
has vanished. Brien’s humanitarian vision created optometry’s philanthropy Optometry Giving Sight.
He felt poor vision was a worldwide
disability which impacts every aspect of a person’s life. Regardless of
Brien’s physical presence, optometry must continue to lead and contribute to improving the quality of
people’s lives by simple refractive
correction. We must also continue
to reach for his goal of preventing
and treating myopia and the visual
conditions linked to its pathology.
Brien’s contribution was recognized often, and he was recipient
of the Academy’s highest honor,
the 2014 Charles F. Prentice Medal.
He spoke about his 50-year career
and the major events in his life. His
recurring message was the impact
of the people in his life who were
generous and collaborative “giants.”
His sentiment about his family, collaborators, and the untold millions
of people impacted by his life makes
us all grateful.
While I was incoming chair of
the AOA’s Contact Lens and Cornea Section, Brien made an extra
effort to attend Optometry’s Meeting to receive the Legend’s Award
from the Section. Like Babe Ruth’s
famous quote, “Heroes get remembered, but legends never die,” Brien
let us come along on his wild, magical optometry journey. His gift to
us is the generosity of his spirit to
inspire change. The world is truly
a better place because the Legendary Dr. Holden chose optometry.
Tribute
Lens Research, founder of the Optometric Vision Research
Foundation, and founding director of the Institute of Eye
Research. In addition, he was an extremely active member of the
Association for Research in Vision and Ophthalmology, the American Academy of Optometry, the World Health Organization’s
Refractive Error Working Group, and countless other professional
organizations. Regardless of his role or position, he always
SO MUCH MORE....
Rick Weisbarth, OD, FAAO
Vice president of professional affairs, Alcon
I
t is with a heavy heart that I write
about Brien Holden. The entire
eyecare community was saddened
upon hearing the news of his passing. During his career, Professor
Holden served as an inspirational
leader and role model for so many
in the profession.
In addition to being a colleague
and friend, he was so much more...
He was internationally renowned
in eye care and vision research, an
awarded scientist, visionary, educator, scholar, author, lecturer, presenter, collaborator, inventor, debater, humanitarian, entrepreneur,
and mastermind behind the Annual
Australian Room at the AAO meeting. Without a doubt, he was one
the most interesting and intriguing
individuals that many of us have
ever known. Brien lived life to the
fullest—each and every day.
His contributions to the eye and
vision care field were extraordinary.
With tremendous insight, Brien was
a leader and actively involved in
the formation of many organizations. For example, he was a cofounder of the International Association of Contact Lens Educators,
the founding president-elect of the
International Society for Contact
47
BEFORE
AFTER
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BlephEx®
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48
Tribute
SEPTEMBER 2015
|
Higher quality of life and educational performance of Pakistani schoolchildren through improved vision was brought about by the Brien Holden Vision Institute.
Brien Holden
was willing to roll up his sleeves and contribute. His contributions to all that he touched
were remarkable.
As I reflect, a number of great memories of Brien come to mind. It seems like
just yesterday when we first met. The setting was the Dick Hill’s laboratory at The
Ohio State University College of Optometry.
I was a student with a keen interest in contact lenses, and he was on sabbatical working with Steve Zantos. During that time, I
learned so much from him, including: all
I ever wanted to know about transient endothelial changes (aka blebs), smuggling
refreshments for the research subjects into
the lab (aka Fosters beer), and most importantly, controlling perceptions (aka keeping
the door shut so that people think that you
are always working and to cover up your
messy office).
I also remember the time that we took
Brien to a pub on campus. It was a fun evening, but it resulted in being barred from
that establishment for the rest of my years
at OSU. There was also the time that he
wanted to play basketball. It was challenging
trying to teach him the meaning of “foul”
and how the game differed significantly
from rugby and Australian rules football.
When I started my career in industry, we
began to interact on a very regular basis.
His involvement in clinical studies, research
projects, brain-storming meetings, IACLE
activities, and on the lecture circuit allowed
our friendship to grow and develop. There
were definitely some interesting experiences
in those early years. And most amazing was
that we made it through that period without a criminal record.
Like many others, I have been so fortunate to learn from him at Academy meetings. Brien was a Diplomate in the Section
on Cornea, Contact Lenses and Refractive
Technologies. In addition, he was an avid
supporter of the American Optometric Foundation. Among the several Academy awards
received, Brien was honored with the Academy’s Charles F. Prentice Medal and Lecture (the AAO’s highest honor) at Academy
2014 Denver.
Finally, I had the opportunity to witness
Brien work on his ultimate passion—Optometry Giving Sight. What a wonderful
experience seeing him pay it forward and
live out his dream of “Vision for Everyone,
Everywhere.”
Brien—thank you so much for all your
many contributions. You will always be with
us in the memories we have shared, your
fun spirit, warmth, wisdom and the special ways that you cared. May all the good
times together help console us in a gentle
and lasting way, and fill our hearts with
peace and comfort with each passing day.
SIX-PACKS OF FOSTER’S
AND CONTACT LENSES
Jan Jurkus, OD, MBA, FAAO
Professor, director of residency programs, Illinois College of Optometry
B
rien Holden lived large. In the past few
days, much has been written about his
professional accomplishments, including the
development of Cornea and Contact Lens
Research Unit (CCLRU), IACLE, and more
recently his humanitarian efforts with Optometry Giving Sight. Truly amazing.
I remember some of his other contributions to optometry. Years ago, the Academy
had a Houfbrou dinner each year. Well, the
young Aussie thought something else could
be more fun. A group of the “young members” gathered in Brien’s hotel room, filled
the bathtub with Foster’s and ice, moved the
furniture into the hall, and partied! After a
few years, the hotels were not happy, and the
party grew to become the Australia Party
we have today. Brien danced at each event!
I also remember sitting with George Mertz,
Sheldon Weschler, and Brien Holden as they
shared a six-pack of beer and explained to
me that one day, contact lens manufacturing would get to the point of excellence
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Tribute
50
SEPTEMBER 2015
|
Brien Holden
that soft lenses would be sold in six-packs
rather than a single vial. What visionaries.
Brien also honored those who he admired.
The educational event in Prague to celebrate
Otto Wichterle’s 80th birthday brought people
from all over the world to share knowledge.
Brien Holden was truly an impressive man.
He will be missed, but his legacy goes on.
WHERE’D YOU GET
THE F*#@ING BEER?
Kevin Roe, OD, FAAO
Director, optometry and professional organizations, Alcon
I
first met Brien Holden at the 2003 Academy
meeting in Dallas when Rick Weisbarth,
my new boss, stopped him in the exhibit
hall and stated, “Brien, I’d like to introduce
you to someone.” Whatever anxiety I may
have had in meeting such an icon immediately increased as I took in the sheer size
and presence of the man. However, my intimidation was short-lived as Brien replied,
“Sure thing, but hold on a moment…”, and
then shouted out in a booming voice to someone across the hall, “Hey mate, where’d you
get the f*#@ing beer?” Seconds later he was
chatting with us about his latest research
with silicone hydrogel lenses and ideas for
humanitarian efforts.
To me, that single encounter sums up
Brien Holden beautifully. He loved life (and
The Pakistan Optometric Association was one of the many groups and organizations that partnered with the Brien Holden
Vision Institute in its attempt to eradicate preventable blindness around the world.
to find resolutions, and his overriding desire to improve the visual well-being of humanity, particularly the underprivileged,
combine to make him a unique member of
not only the optometric profession but all
healthcare professions.
Brien’s career and my own had many parallels—our sharing the commonality of the
effect of contact lenses on ocular physiology
Brien shouted out in a booming voice to
someone across the exhibit hall, ‘Hey mate,
where’d you get the f*#@ing beer?’
beer), and lived it to the fullest. But at the
same time he was a warm, brilliant, and
incredibly caring individual who had time
for everyone and devoted his life and his
genius to making the world a better place.
There is an old Greek proverb that states,
“A society grows great when old men plant
trees whose shade they know they shall
never sit in.” Thank you, Brien, for the shade
that future generations will be sitting in because of the many trees you have planted.
SOCIETY THANKS
PROFESSOR BRIEN A. HOLDEN
Donald R. Korb, OD, FAAO
Chief technical officer and cofounder, TearScience
B
rien Holden’s passion for recognizing
problem areas in eyecare, his ability to
create teams of researchers and clinicians
provided me with the opportunity to follow his steady rise in clinical research and
education. We became and remained close
friends for 40 years. Within a short period
of time, he would highlight and dominate
any educational program, not only with his
“science-based” practical information, but
by mannerisms and vocabulary unique to
Brien and initially rather startling to Americans. He was a much sought-after lecturer.
His PhD thesis on the development and
control of myopia and the effects of contact lenses on corneal topography established the course of his career, the early
years devoted to contact lenses and corneal
physiology, and the later years expanding
to myopia and uncorrected refractive error.
It was remarkable to observe Brien evolve
from a single and lead investigator to his
recruiting and collaborating with over 80
colleagues to extend his scientific research
from contact lenses to many areas of ocular
research and more recently to public health.
He obtained over $100M to support these
endeavors, ultimately carried out through
his Brien Holden Vision Institute. This seemingly impossible financial support allowed
him to pursue many areas simultaneously
and to implement programs to translate the
scientific concepts into clinical reality.
As a long-term member and chair of the
Awards Committee of the American Academy
of Optometry, I had the privilege of gaining
further insight into the depth of his commitment and contributions. He was recognized
by the Academy, as well as by many other
organizations, in a manner that no other
optometrist has achieved. He received six
major awards from the Academy, exemplifying the extent and far-reaching effects of
his work. He was the first recipient of the
Essilor Award for Outstanding International
Contributions to Optometry and a recipient
of the Carel C. Koch Memorial Medal Award
for interprofessional relationships. His contact lens contributions were recognized by
the Contact Lens Section’s Schapero Lecture
and Founders Award. He was awarded the
Fry and Prentice Awards, the two highest
academic awards of the Academy.
These six awards encompassing the ultimate of accomplishments in contact lenses,
academia, scientific research, philanthropy,
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52
Tribute
Brien Holden
and international contribution have been accomplished only by Brien, and I predict will
never be duplicated. However, Brien may
be best known within the Academy for the
annual Australia Party, in true Australian
style, with Fosters, music, dancing, and a
good time for all! This party is a tribute to
Brien’s culture and generosity.
I had the privilege of writing the seconding letter for the Prentice Award, which he
received in November 2014. Before doing so,
SEPTEMBER 2015
areas simultaneously was remarkable, as
was his ability to obtain funding.
In addition to his remarkable scientific
activities, almost 500 peer-reviewed publications, mentoring over 100 graduate students, his founding of organizations and his
philanthropic interests, Dr. Holden was the
most vivid example of an individual dedicated to a career-long goal of advancement
in all areas of vision and visual science and
a desire to bring vision to all, particularly
to those of limited resources. He was intimately involved with helping the underprivileged. He was a founder of Optometry
Giving Sight, an international organization
Thank you, Brien, for all you accomplished
for so many, and thank you for simply
being Brien Holden.
I questioned Brien about what he considered
his three most important accomplishments
as a scientist. His reply was the following:
tUnderstanding the ocular effects of contact lenses and surgery on corneal structure
and function in order to develop ways of reducing and avoiding structural and physiological compromise. Following 15 years of
research, the levels of oxygen required to
maintain optimal physiology were established. The results of this work led to the
understanding that high Dk lenses are desirable if not mandatory and the subsequent
development of high Dk lenses.
tRecognizing the need for studying the
effects of uncorrected refractive error. Seminal research was conducted to document
the prevalence, societal outcomes, and economic consequences of uncorrected refractive error, blindness, and visual impairment
in children, adults, and presbyopes. This
was recognized by the Australian government, which contributed $80M for this work
in the Western Pacific.
tStudying myopia, its consequences, and
control. Recognizing the great increase in
the incidence and degree of myopia worldwide, an extensive program over many years
evaluated all areas of myopia with the intent
of developing methods of control.
His work was and continues to be the
work of hundreds, those within his organizations as well as collaborators around
the world. He demonstrated a passion for
training others. He had the ability to pragmatically focus his drive on achieving his
goals. He was never deterred. His ability to
directly provide the ideas, leadership and
management of major projects in different
dedicated to reducing the prevalence of vision impairment due to uncorrected refractive errors. It is the only global fundraising
organization with the mission of alleviating this problem, which affects 600 million worldwide. He envisioned optometry
as the optimal method to deliver vision care
to all, while working closely with ophthalmologists and ophthalmological institutions
throughout the world.
I can emphatically state that if there were
an award for the OD who has accomplished
the most in the modern era worldwide, Brien
Holden would have no competition.
He will be missed not only by the professions but by the millions who have benefited
and will continue to benefit from his work.
Thank you, Brien, for all you accomplished
for so many, and thank you for simply being
Brien Holden.
THE GREATEST VISIONARY AND
HUMANITARIAN IN THE PROFESSION
Ed Bennett, OD, MSEd, FAAO
Professor, assistant dean for student services and alumni relations,
University of Missouri-St. Louis College of Optometry
I
first met Professor Brien Holden in 1979
at the Bausch + Lomb National Research
Symposium, and he was then—as he was to
the day he died—larger than life. It was evident then that he was a brilliant researcher
who had his finger on the pulse of the contact lens industry and was on his way to
becoming the individual who exhibited the
greatest impact on both cornea and contact
lens research globally and, ultimately, on
worldwide vision care.
My memories of him are all quite wonderful. I presented a controversial paper at
|
the American Academy of Optometry meeting in 1988, and someone in the audience
attacked me verbally; I was not allowed to
respond. Brien did, and he defended me. He
was always extremely complimentary of the
GP Lens Institute. He never said no whenever I would ask if my student or resident
could have their photo taken with him—of
course, always accompanied by that definitive charismatic smile.
I’ve always enjoyed giving award presentations as much or more than receiving awards,
but I’ll always remember when we were on
the podium together for the 2009 Bronstein
Award ceremony in Arizona, and fearing
that Brien would not receive the tribute he
so rightly deserved, I devoted much of my
speech reminding the audience that they
were in the presence of the greatest visionary and humanitarian in their profession.
That remains my favorite memory of him.
Of course, he is renowned for initiating
the Center for Contact Lens and Cornea Research Unit (CCLRU) in Sydney (now the Brien
Holden Vision Institute [BHVI]). Among his
many innovations included co-developing
the silicone-hydrogel lens material, standards for oxygen transmission, extended
wear materials and safety and, most recently,
novel spectacles and soft lenses to slow the
progression of myopia in young children.
Only Brien Holden could have the leadership and vision to initiate organizations such
as the International Association of Contact
Lens Educators, which developed resources
targeted at educating hundreds of contact
lens educators throughout the world and,
ultimately, Optometry Giving Sight, a global
fundraising organization aimed at was what
always so near and dear to Brien’s heart:
reducing the prevalence of vision impairment due to uncorrected refractive errors.
Now that the sun has sat on the life of
a legend—and the memories of our experiences with him always in our heart—it
would be most appropriate that the next time
you are in a pub, raise your glass in the air
in tribute to Brien Holden. Somehow that
seems like the fitting testimonial to someone whose impact on our profession and,
most importantly, vision care worldwide is
legendary and will never be equaled.
LOOKING UP TO AN OPTOMETRIC IDOL
Loretta Szczotka-Flynn, OD, MS, FAAO
Director, contact lens service, University Hospitals Case Medical Center;
professor, ophthalmology, Case Western Reserve University School of
Medicine
B
rien Holden was a true optometry hero.
My interactions with him began as an
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Brien Holden
optometry student attending the North American Contact Lens Research Symposia in the
early 1990s where Brien was always a key
presenter who stole the show and mesmerized the audience with his cutting-edge research and presentation style.
He was the leading authority on everything
related to contact lenses and the Cornea &
Contact Lens Research Unit (CCLRU) which
he founded was the leading institution on
contact lens research worldwide. It was a
young research optometrist’s dream to interact with Brien scientifically, personally,
and socially. Brien continued to impress the
profession with his research institutes (Institute for Eye Research and later the Brien
Holden Vision Institute) through the silicone
hydrogel era where he co-developed such
lenses with CIBA Vision, and later revolutionizing the industry in myopia stabilization research.
What is most memorable about Brien (other
than his fun-loving personality, lively debates, and Australia Parties at the Academy) is his commitment to global health
and worldwide blindness. He just about
single-handedly led worldwide efforts to
“cure” the number one cause of preventable blindness worldwide: uncorrected refractive error. Through his efforts, glasses
are prescribed to once-blind individuals in
third-world populations at little cost.
My memories of Brien will always be
happy ones. I feel privileged to have graduated from the lowly graduate student looking up to such an optometric idol to being
his peer sharing research interests. His legacy must continue. Anyone who crossed
his path should cherish and permanently
file away those moments, and those who
watched from afar, never forget the impact
he made on our profession. There will never
be anyone as powerful as Brien Holden in
this profession in our generation.
WHAT DOES IT ALL MEAN?
Tom Quinn, OD, MS, FAAO
Athens, OH
T
he year 1978 was a big one for me. I
was a third-year optometry student at
The Ohio State University. I met the woman
who was to later become my wife. And I
learned to speak Australian—and contact
lenses—from a bloke named Brien Holden.
Brien was doing his sabbatical at OSU
and invited some students to help with the
grunt work. Seven or eight of us volunteered,
Tribute
having very little notion of what we were
in for. Brien was working with Steve Zantos on trying to understand changes in the
corneal endothelium, the “endothelial bleb
response,” when a contact lens was applied
to the ocular surface. He would often have
two or three projects going simultaneously.
While a master multitasker, even Brien would
be occasionally be overcome with all the
chaos, which would prompt him to recite
his call to calm with this mock plaintive
cry: “Why are we here? What is life? What’s
it all mean?”
There were numerous additional escapades that went on during those months of
the Great Blizzard of ’78. Blizzard is both
a reference to the brutal winter weather to
which we treated our Australian visitor but
also to the intense impact Brien had on all
those he touched, particularly the students
he embraced so completely. My experience
with Brien played a large role in developing my lifetime interest in contact lenses.
Thank you, Brien, for the many lives
you’ve touched worldwide. That’s “what it
all means.” But a special thanks for being
part of mine.
FORCE OF NATURE
Dave Hansen, OD, FAAO
Laguna Hills, CA
I
have been asked to share my thoughts
about our beloved friend, Professor Brien
Holden. It is an honor, but with deep sorrow,
and a difficult assignment to characterize
his life and not leave out many of his vast
accomplishments. He was a professional colleague, world-class innovative researcher,
international spokesperson for the eyecare
industry, vibrant lecturer, trusted consultant, global humanitarian, dedicated educator, progressive entrepreneur, boss, husband, father, grandfather, and most of all
a committed friend. His friendship was appreciated by millions throughout the world
within the ophthalmic profession and by
many who benefited from his expansive
research and philanthropy. In a sense, he
was a force of nature.
I had the pleasure to know Brien, to engage and collaborate with him on professional optometric and ophthalmic industry projects, and yes, enjoy fun with Brien
since 1978. Anyone who has been closely
associated with him or knew him only remotely will probably have a lifelong image
of him and admire his tremendous accomplishments. As educational program chair
for the Heart of America Contact Lens Society (HOACLS) in 1978, I decided to take
a chance to invite a little-known Austra-
57
lian to be one of the lecturers at the first
HOACLS International Program in Kansas
City. Brien proceeded to capture the audiences with stimulating, revolutionary, and
scientific data for improving clinical skills.
He then continued throughout the world!
Only a few people in history have been
fortunate enough to influence others with
the magnitude that Brien possessed using his
perpetual charisma and vision. We have all
been blessed to know, interact, and watch his
gifted persona guide our eyecare profession.
We will miss him, especially when the
eyecare community needs a scientific pragmatist willing to travel around the world
to successfully address difficult healthcare
situations. I will miss him personally for his
astute wisdom, wry humor, and friendship.
OSU DURING FULBRIGHT YEAR
Richard Hill, OD, PhD
Dean emeritus of The Ohio State University College of Optometry
W
ith the passing of Professor Brien
Holden, the ophthalmic community
has lost an extraordinary scientist, entrepreneur, and international diplomat for vision science. We were fortunate to have
him with us at The Ohio State University
College of Optometry for most of his Fulbright year (1978-79). He engendered in all
an enthusiasm for what could be done for
the visually impaired.
He later went on to assemble an internationally recognized cornea and contact
lens institute at the University of New South
Wales, leaving a remarkable legacy of PhD
scientists and landmark studies. He will be
remembered as well as the inspiring spirit
behind the International Society for Contact Lens Research (ISCLR), a unique forum
for open discussion and debate among the
ophthalmic sciences. The Ohio State University was pleased to recognize Professor
Holden’s exceptional accomplishments by
awarding him the honorary degree Doctor
of Science.
OUR COVERAGE OF BRIEN
HOLDEN’S WORK
Brien Holden on contact lens myopia
management
optometrytimes.com/CLmyopiamangement
Brien Holden Q&A
optometrytimes.com/HoldenQA
New technologies to improve global health
optometrytimes.com/globaleyehealth
Fast forward 10 years:
How will we treat myopia?
optometrytimes.com/myopiain10years
58
Q&A
SEPTEMBER 2015
Barbara Horn, OD
|
Owner of ExpertEyes, Washington, MI, Trustee for the American Optometric Association Board
Leadership, rollerblading, and marrying an OD
Why did you get started
in leadership?
When I was in my first week
of optometry school, the
teacher in a practice management course asked us to pick
a topic. I picked my own because I was confused by the
alphabet soup of optometry—
AOA, AAO, etc. [laughs], so
I looked them all up. The
teacher wanted us be more
comfortable speaking in
front of people, and I learned
that all of these alphabet
soup organizations are important to our profession, but
there’s only one that really
fights for advocacy, for parity, and safeguards our profession: the AOA. So I knew
from the first week in optometry school that I wouldn’t
just be an optometrist, I
would be someone who volunteered any way I could to
help continue to fight for the
advocacy of our profession. Why is it important to
encourage leadership
and participation in women?
Optometry used to be a profession of men who just felt
an obligation to join their
professional organization.
The AOA and our state affiliates are the only ones that
fight for our scope that allows us to do what we do.
More women are now graduating than men, so we need
to make sure that women are
supported in the profession—
part-time, full-time, doesn’t
matter. We need women to
have that same feeling of obligation to support their own
livelihood by supporting
the organization. I think we
need women in leadership to
be mentors for other women.
Women or men should all
Q
When and why
did you start
rollerblading?
[Laughs] I was rollerblading in high school,
just to get some exercise, and it’s something that’s out in the
sun. We have a park
just a few miles from
home that’s six-mile
loop. I would put some
weights on my wrist,
and I would go around.
And I found it’s really good exercise, it’s
not hard on my knees.
Running and biking
for some reason hurts
my knees, so I started
doing that, it’s a great
way to clear my head,
and you can go faster
than running. [Laughs]
I really enjoy it. If I really need to get out
some stress, I just go.
try to be leaders or volunteer any way that they can, I
think it’s really important.
What advice can you
give to women ODs trying to find a work/life balance?
Optometry is a really good
career to pick. You can do
part-time, full-time, you can
raise kids. I have a lot of
support around me, so just
make sure that you’re married to the right person, that
he is there to help you out
if you need it. You need to
definitely need to take the
time with your kids because
they’re only young once. I
was doing a lot as an AOA
trustee and on the board of
my township. I served my
term and then they asked
me serve another term—I
saw that when I was traveling so much that when I
come home I need to be with
my kids, not necessarily at
yet another meeting for the
township. So, it was very important to me but there are
certain things that you might
have to give up that you
don’t want to. I didn’t want
to give that up, but my children came first. There are
some tough decisions that
you’ll make.
What’s one thing you
would change about optometry as it stands now?
I think that we’ve got a lot
of battles going on which we
didn’t always have to fight. I
wish we could always keep
moving forward. There are a
lot of changes going on, and
we’re trying to make sure
that we’re advancing the profession and sometimes we’re
attacked. That’s one thing I’d
like to change would be just
let us be.
—Vernon Trollinger
What are the pros and
cons of being married to
another OD?
I don’t have any cons, to be
honest. I think it’s a really
great thing because we
can talk about it and
not have to do 20
minutes of background as to
what I’m
about to tell
you. We
just talk
about it and
be done
with it in a couple minutes as a
quick story. We understand the stresses,
too. So, I think it’s a really good thing. I don’t have
any negatives being married
to an optometrist. I think it’s
wonderful.
To hear the full
interview with Dr.
Horn, listen online:
optometrytimes.com/
BarbaraHorn
Photo courtesy Barbara Horn, OD
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SUPPLEMENT TO
AND
TREATING THE AGING EYE
CERTAIN CONDITIONS AFFECT YOUR OLDER PATIENTS MORE
By Phyllis L. Rakow, COMT, NCLM, FCLSA(H)
2
Advances in medicine have extended the average life span of American men to 76.4 years and
American women to 82.1 years,1 but greater
life spans have brought one or more chronic
illnesses to 80 percent of those over the age of
60.2 Along with their general medical problems,
older patients must deal with declining vision
and its physiological and psychological effects.
Loss of vision can restrict
one’s ability to carry out
1
daily activities and lead to
depression, social isolation,
falls, fractures, and the inability to live independently.
In the aging eye, accommodation decreases;
the crystalline lens yellows,
hardens, and eventuFigure 1. Amsler grid for patient use at
ally opacifies; and systemic
home to determine visual changes from
age-related macular degeneration.
diseases such as arthritis,
thyroid disease, cancer, diabetes, atherosclerosis, and
high blood pressure take their toll on the eye.
In addition, cognitive and functional limitations
affect the aged. They may not have support
from their families or be unaware of available
community services. Often changes in vision are
undiagnosed and untreated. Patients may be
Figure 2. Cataract This is a common cause of vision loss in the elderly. (Images
living with unoperated cataracts, undiagnosed
courtesy Tracy Swartz, OD, FAAO)
See Aging eye on Page 3
volume 04 | issue 03 | Fall 2015
1
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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.
Aging eye
3
Figure 3.
Glaucoma
This is the second
most common
cause of visual loss
among seniors.
Early diagnosis and
treatment can
prevent vision loss.
primary open-angle glaucoma,
age-related macular degeneration, or diabetic retinopathy.
Keep in mind that one-third
of new cases of blindness could
have been prevented by early
intervention.
Let’s look at some of the common visual conditions that affect
our senior population.
Macular degeneration
Age-related macular degeneration (ARMD) is a significant cause
of vision loss in the elderly.3 Risk
factors include increasing age,
family history, fair complexion
and light irises, smoking, sleep
apnea, metabolic syndrome
(the most serious heart attack
risk factors, including diabetes,
prediabetes, abdominal obesity,
high cholesterol, and high blood
pressure), and high myopia.3
Initially, vision may be normal
in spite of subtle degenerative
changes, such as yellow, subretinal
deposits known as drusen. In this
“dry” form of ARMD, vision loss
may be gradual. Straight lines may
appear broken, wavy, or crooked,
and patients may have difficulty
reading or seeing road signs. Macular degeneration can be
demonstrated with the Amsler Grid
(see Figure 1). Patients should wear
their near correction when being
tested. One eye is covered, and the
chart positioned is 14 inches from
the eye being tested. The patient
is then asked to stare at the white
dot in the center and notice if any
of the lines on the grid appear to
be wavy, broken, or missing. “Wet” ARMD usually starts out
as the dry form and results in a
sudden, significant loss of vision
caused by leakage of blood or
Fall 2015
iTech
4
Figure 4.
Temporal arteritis
This condition is an
inflammation of the
lining of the arteries
that supply blood to
the brain.
fluid from new, abnormally-formed
vessels under the retina (subretinal
neovascularization). Although it
affects only about 20 percent of
those who have macular degeneration, it accounts for two-thirds
of the people with profound
vision loss.4 ARMD affects only
central vision. Patients develop a
large central scotoma (blind spot),
although they still maintain the
ability to walk around without
the assistance of a cane or seeing
eye dog. Injections such as Eylea
(aflibercept, Regeneron), Lucentis
(ranibizumab, Genentech), and
Avastin (bevacizumab, Genentech)
may slow or stabilize vision loss
by preventing the growth of leaky
new blood vessels.5
Can we prevent the development of macular degeneration?
Positive steps to take include
stopping smoking, controlling
cardiovascular disease, taking
antioxidant dietary supplements,
and following a diet high in fruits
and vegetables, especially dark
green, leafy vegetables like spinach
and kale.
Cataracts
Cataracts represent another
common cause of visual loss in
the elderly. Although we all will
develop cataracts if we live long
enough, the decrease in vision
from cataracts is gradual, and
not everyone who lives a normal
life span will require surgery (see
Figure 2). In addition to age, causes
of cataract include ultraviolet radiation from sunlight or other sources,
corticosteroids, diabetes, family
history, smoking, and previous eye
injuries, inflammation, or surgery.6
As cataracts develop, the
crystalline lens becomes yellow or
cloudy. Initially, vision may be imSee Aging eye on Page 4
3
4
Aging eye
proved with a simple prescription
change in eyeglasses. As cataracts
progress, they cause reduced
visual acuity, increased glare,
starbursts around headlights and
streetlights at night, reduced color
vision, and the need for more light
when reading. These changes in
vision are related to the size and
location of the cataract and are
generally slow and painless.
Surgery becomes necessary
to blindness if left untreated (see
when cataracts interfere with norFigure 3). Risk factors include fammal daily activities, such as driving,
ily history of glaucoma, high blood
watching television, or reading the
pressure, diabetes, myopia, African
newspaper. Cataract surgery is the
racial heritage, and elevated IOP.9
most frequently performed surgiEarly diagnosis and treatment can
cal procedure in the United States
prevent optic nerve damage, visual
and has an excellent prognosis,
field loss, and subsequent vision
with 90 percent of patients achievloss. Because pain is not associing vision of 20/40 or better.7 The
surgery, a procedure called phacoated with open-angle glaucoma,
emulsification, is done under local
the disease may be well advanced,
or topical anesthesia with IV sedawith significant visual field loss, betion. A tiny incision is made, and
fore patients become aware of it.
the contents of the crystalline lens
Many categories of medicaare emulsified, suctioned out, and
tions are available to decrease IOP.
replaced with an intraocular lens
Because seniors tend to be more
(IOL). The IOL power is determined
sensitive to some glaucoma mediby presurgications than
cal measureyounger
of new cases of
ments. We
patients and
blindness could have
been prevented by early may also
are now able
intervention
to correct
be taking
astigmatism
systemic
with toric IOL designs and presbymedications that can interact with
opia with bifocal and multifocal
their eye drops, the likelihood of
IOL implants.
side effects is greater in the elderly
population. Side effects can be
Glaucoma
limited and systemic absorption
Primary open-angle glaucoma,
reduced by covering the punctum
an optic neuropathy (optic nerve
(the tiny hole in the inner corner
disease), is the second most comof the lower eyelid) and compressmon cause of visual loss among
ing the nasolacrimal duct when
seniors.8 It causes changes in
instilling eye drops. If IOP is not
the optic nerve head, visual field
adequately controlled with eye
loss, and in most cases, increased
drops, surgical intervention may
intraocular pressure (IOP), leading
be necessary.
1/3
Figure 5.
5
Dry eye
This is a
significant
problem
among
seniors.
Extreme
dryness
can lead
to corneal
damage and
affect both
vision and
comfort.
Diabetic retinopathy
Diabetic retinopathy is the fourth
most common cause of vision loss
among the elderly in America.8
Over time, diabetes, especially
poorly controlled diabetes, affects
the circulatory system of the retina.
Microaneurysms (tiny bulges that
form and protrude from the walls
of retinal blood vessels) can rupture and leak blood and fluids.
Symptoms are mild or
nonexistent in the early stage,
which is known as background
or non-proliferative diabetic retinopathy, although leakage from
the microaneurysms may cause
macular edema (swelling and fluid
retention). As the disease progresses, new, fragile blood vessels form
in the retina and vitreous (the gel
that fills the back of the eye) and
leak blood into the vitreous. This is
known as proliferative diabetic retinopathy, which can cause severe
vision loss and even blindness if
left untreated. Laser treatment
stops the leakage of blood and
fluid and seal the abnormal, leaky
blood vessels.
Retinal occlusions
Total, sudden loss of vision may
be caused by an embolus (blood
clot or plaque) that lodges in and
occludes the central retinal artery
iTech
Fall 2015
5
(central retinal artery occlusion).
The loss of vision may be transient
or permanent and requires immediate referral to an ophthalmologist. The entire retina, except for
the fovea (center of the macula),
becomes edematous. Loss of a
portion of the visual field can be
caused by a branch retinal artery
occlusion. In either case, treatment involves trying to move the
embolus further downstream to
minimize retinal damage, but loss
of vision is often permanent.
Central or branch retinal vein
occlusions can also occur and are
caused by a thrombus (blood clot)
blocking the vein that drains the
blood from the eye. They are often
seen in patients with high blood
pressure, diabetes, glaucoma,
and atherosclerosis, and require
comanagement with the patient’s
primary care physician.10
Temporal arteritis
Temporal arteritis, also known as
giant-cell arteritis is an inflammation of the lining of the arteries
that supply blood to the brain (see
Figure 4). Symptoms include head
pain and tenderness, especially
around the temples; scalp pain;
jaw pain (claudication); sudden,
permanent loss of vision in one
eye; night sweats; and unexplained
weight loss. Immediate referral
to an ophthalmologist is critical
to prevent loss of vision in the
contralateral (opposite) eye. The
condition is treated with steroids.
Dry eye syndrome
Dry eye syndrome, although a
more benign condition, is still a
significant problem among the
senior population. Good tear
quality and quantity is essential
to maintain corneal integrity: to
remove debris, to lubricate the
eye, and to protect against disease.
Fall 2015
iTech
Keratitis sicca is the term used for
markedly dry eyes. Patient symptoms include burning, grittiness,
excessive tearing, and injection
(redness). Patients with rheumatoid arthritis and other collagen
diseases may have been diagnosed
with Sjögren’s syndrome, and live
with dryness of the mouth and
other mucus membranes in addition to dry eyes. Extreme dryness
can lead to corneal damage and
affect vision as well as comfort (see
Figure 5).
In mild cases, artificial tears,
used as needed, may provide
sufficient relief. Restasis (cyclosporine A, Allergan) is a prescription
eye drop that may increase tear
production in patients whose tear
deficiency is due to ocular inflammation associated with keratoconjunctivitis sicca (severe, chronic dry
eye).11 Other dry eye treatments
include punctal occlusion (silicone
plugs placed in the tear drainage
ducts to keep more tears in the
eye), intense pulsed light therapy
(IPL) that directs bursts of light
at the lower eyelids and lower
cheek areas to heat blocked eyelid
glands; sleep masks that hydrate
the eyes during the night; dry eye
vitamins; and nutritional supplements such as flaxseed oil and
fish oil.
Conclusion
Although the aging eye is affected by multiple conditions and
diseases, technology and modern
medicine enable eyecare practitioners and primary care physicians
to work together and treat and
manage many of them. By making senior citizens aware of the
importance of regular eye care, we
can help them to benefit from new
treatments and therapies, maintain
their mobility and independence,
and prevent the depression and
social isolation that often occur
when elderly patients are confronted with severe vision loss.◗
References
1. Copeland L. Life expectancy in the USA hits
a record high. USA Today. 2014 Oct 9. Available: http://www.usatoday.com/story/news/
nation/2014/10/08/us-life-expectancy-hitsrecord-high/16874039/. Accessed 07/27/2015.
2. Council on Social Work Education. Chronic
illness and aging. Available at: http://www.
cswe.org/File.aspx?id=25462. Accessed
7/27/15.
3. National Eye Institute. Facts about agerelated macular degeneration. Available at:
https://nei.nih.gov/health/maculardegen/
armd_facts. Accessed 07/27/2015.
4. American Society of Retina Specialists.
Age-related macular degeneration. Available
at: http://www.asrs.org/patients/retinaldiseases/2/agerelated-macular-degeneration.
Accessed 7/27/15.
5. EyeSmart. Avastin, Eylea and Lucentis—
What’s the difference? Available at: http://
www.geteyesmart.org/eyesmart/living/
avastin-eylea-lucentis-whats-the-difference.
cfm. Accessed 07/27/2015.
6. Bailey G. Cataracts. AllAboutVision.com.
Available at: http://www.allaboutvision.
com/conditions/cataracts.htm. Accessed
07/27/2015.
7. Farzad F, Sarraf D, Coleman AL. Visual impairment in the elderly. Office Care Geriatrics.
Ed. Rosental TC, Williams ME, Naughton BJ.
Philadelphia: Lippincott Williams & Wilkins,
2006. 123. Print.
8. Quillen D. Common causes of vision loss in
elderly patients. Am Fam Physician. 1999 Jul
1;60(1):99-108.
9. Mayo Clinic. Glaucoma: Risk factors. Available at: http://www.mayoclinic.org/diseasesconditions/glaucoma/basics/risk-factors/
con-20024042. Accessed 07/27/2015.
10. Prevent Blindness. Central retinal vein
occlusion. Available at: http://www.preventblindness.org/central-retinal-vein-occlusion.
Accessed 7/27/15.
11. Allergan. Restasis prescribing information.
Available here: http://www.allergan.com/assets/pdf/restasis_pi.pdf. Accessed 07/27/2015.
Dummy text only
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Phyllis Rakow,
COMT, NCLM,
FCLSA(H) is a
JCAHPO-certified
ophthalmic
medical technologist, at a large
three-location
group practice in
central NJ. She has
almost 40 years of
experience in the
contact lens field
and has written
numerous journal
articles, authored
a textbook on
contact lenses
Author
name aufor
technicians,
thorlectures
bio author
and
on
bio
contact
lenses
throughout the
United States.
6
It’s all fun and games
with pediatric patients
Start simple with your younger patients
and increase complexity as they age
By Jessica Barr, COMT, ROUB
The pediatric eye exam differs greatly from the adult eye
exam—children are more than
just tiny adults. To further that
point, the whole dynamic of the
examination is different because
you are really interviewing and
interacting with the family and
not just the patient. In the pediatric arena, the family becomes
your patient.
The first step to eliciting a
good examination is to build
rapport with your young patient
and his family. Small children
are often timid, hiding behind
Mom or Dad’s leg, and shying
from the big scary exam chair.
Let them shy away for now; you
don’t need smaller patients in
the exam chair in order to get
your history and have a chat with
Mom or Dad.
Setting a relaxed tone for
your initial interaction is reassuring to younger patients. Aside
from having to read an eye chart
at a fixed distance, most other aspects of the examination can be
conducted with the child sitting
in a different seat, or even sitting
on the floor. With a small child,
history starts with the parents
(this helps make the child com-
1
Author name author bio author
bio
Figure 1. Reclining a child in a chair or on a parent’s lap aids with history and when instilling medications.
iTech
Fall 2015
fortable and builds trust).
2
In an older child, history
starts with the patient
and is then verified or
added to by the parent.
See Figure 1.
Moving forward,
children’s participation in
their medical care should
increase commensurate
with their age. Autonomy
is one of the pillars of
medical ethics, and that
extends to minor-aged
patient.
Next, we move on to the
physical examination. Have you
ever written “unable” for the
exam of the child who has come
to your office? Unless you work
for a pediatric ophthalmologist,
it may be standard operating
3A
Figure 2.
A child’s gaze is
reflexively drawn
to the grating
lines on the Teller
Acuity card, which
is why it is called
a preferential
looking test.
procedure to write “unable” (or
something similar) for the young
child who has come in to your
adult or general ophthalmology
practice.
Here is the most important
tip in this article: Something
written in the exam record is
better than nothing. In our
youngest and least cooperative
patients, we start with the most
basic techniques and eventually
graduate to the more sophisticated techniques used for
examining adults.
See Pediatric patients on Page 8
3B
Figures 3A and 3B. Children are taught from a very young age to make associations through matching games.
Instead of making them read the eye chart, create a fun and exciting matching game that uses letters or symbols to
have the child engage with increasingly smaller optotypes on the eye chart.
Fall 2015
iTech
7
8
Pediatric patients
Let’s review these techniques
for a pediatric eye examination.
Visual acuity
Perhaps a 1-year-old cannot read
the eye chart, but can he fix and
follow? At the very least,
is the child light averse
4
or light perceptive? As
children get older, the
method of visual assessment becomes increasingly more sophisticated.
The visual assessment
technique evolves from
light averse, to fix and
follow, the preferential
looking test, matching
pictures, then finally
graduating to the standard Snellen acuity chart
that we use on adults.
First, assess if your young
patient is reactive to light. Next,
see if she can fixate on the light
and follow the stimulus. This is
the fix and follow (F+F) technique. After that, the technique
gets slightly more sophisticated.
Is her gaze central, steady, and
maintained (CSM) on the stimulus? Remember, these two techniques require only a target to
fixate—no other special
equipment.
5
In the pediatric
ophthalmology practice, technicians also
utilize a type of visual
assessment called the
preferential looking test
(see Figure 2). For this
test, the patient is shown
large, rectangular cards.
Stripes or pictures are
docked to either the left
or the right side of the
card. The Teller Acuity Cards use
stripes, and Cardiff Cards use pictures. As you progress through
the cards during the test, the
stripes or pictures grow fainter
and fainter, requiring higher and
higher levels of visual acuity to
see.
The cards are held face down
to the stripes or pictures on the
card. This level of interaction
offers a greater level of accuracy
in the results.
Once the children begin interacting with you, you can start
trying to check visual acuity on
the eye chart. Pre-verbal children
can hold a card with the symbols
Figure 4.
Retinoscopy is
an effective and
accurate method
for objectively
measuring the
refractive error
of a child when
subjective
refraction is not
possible.
so the examiner is blind to
what is on the other side. The
examiner holds up the card to
the patient and judges the side
of the card where the patient
preferred to look. Hence, this is
named the “preferential looking
test.” The fainter the stripes or
pictures the patient responds to,
the higher the level of visual acuity. If cooperation permits, you
can also ask the child to point
on it and point to each symbol
to match to the optotypes on
the acuity chart. We begin by
using pictures, instead of letters,
for pre-literate children. A similar,
yet slightly more sophisticated
method, is HOTV matching.
The child holds a card with the
letters H-O-T-V. The eye chart is
matched to use only these letters. See Figures 3A and 3B.
Finally, we graduate them to
Figure 5.
The Krimsky
technique takes
the Hirschberg
one step further
by utilizing a prism
to recenter the
abnormal corneal
light reflex.
iTech
Fall 2015
the Snellen chart. The examiner must be forgiving and
acknowledge that children may
know most letters, but not all.
If children are afraid to say the
wrong letter, encourage them
to trace the letter in the air. At
times, children may lack the confidence to get started reading
the letters, and you need to help
them. Young children need help
getting started with many tasks,
so give them the first letter on a
Snellen line. This can help give
them momentum to get started.
Use lots of encouraging words.
Offer lots of smiles and high
fives. Give your younger patients
praise when they are doing
well to encourage them to keep
participating.
Retinoscopy is an effective
and accurate method for objectively measuring the refractive
error of a child when subjective
refraction is not possible (see
Figure 4).
Pupils
With adults, we instruct them to
fixate in the distance while we
employ the swinging flashlight
test to assess direct and consensual reaction to light. We are
documenting PERRL or PERRLA
(pupils equal round reactive to
light and accommodation). Maybe you cannot
6
complete a full swinging
flashlight test to assess
pupils, but are the pupils
equal and round? Reactive? No obvious pupil
defect? This is an area of
the examination in which
it is critical to document
something.
for adults and most sophisticated
methods to evaluate ocular
alignment are the covers tests
and Maddox rod. We use videos,
flashing lights, or any type of
visually stimulating target, to
promote fixation in children
sitting for the cover tests. If they
cannot fixate and cooperate for
cover tests, learn the Hirshberg
technique, which requires only
that you shine a light at them.
If cooperation permits, incorporate prisms and use the Krimsky
technique.
If pediatric
patients cannot fixate
and cooperate for
cover tests, learn the
Hirshberg technique,
which requires only
that you shine a light
at them
To utilize the Hirshberg technique, the only tool you need is
a strong and direct light source
like the transilluminator we use
to check pupils. The light is
shined at both eyes while seated
in front of the patient. You want
to be reasonably close to see the
reflection of light on the cornea
(corneal light reflex, or CLR),
but as far away as possible to
minimize accommodation and
convergence.
The technician assesses how
central the CLR is in each eye
and the symmetry of the light
reflex on the eyes. A reflection
that is slightly decentered nasally
in both eyes, but symmetric, is a
normal and common finding. If
the CLR is decentered nasally in
only one eye, this can indicate
the presence of exotropia. For
each 1 mm of decentration, we
estimate approximately 15.00 D
of prism deviation. Conversely, if
the light reflex is decentered in
one eye in the temporal direction, this indicates the presence
of esotropia, and the same 1 mm
to 15.00 D of prism deviation applies. When the light reflex is decentered superiorly or inferiorly,
this indicates the presence of a
vertical, or hyper, deviation.
Moving forward, we integrate
of the use of prisms to recenter
the CLR and take our measurement of the deviation from the
amount of prisms required to
center the reflex. This is the
Krimsky technique (see Figure 5).
Figure 6. This
method of holding the
child is very effective
when administering
medications. The
parent tucks the child’s
legs under her arms,
then crosses the child’s
arms across the chest,
and leans the child
back. The technician
stabilizes the head
and administers the
medications efficiently.
Motility
The standard technique
See Pediatric patients on Page 10
Fall 2015
iTech
9
10
Pediatric patients
Both of these techniques are significantly less sophisticated than
the cover tests with prisms and
provide only an estimation of the
deviation. If you cannot recall
all of the details of utilizing and
documenting the Hirshberg or
Krimsky techniques, at the very
least, document the presence of
CLR asymmetry for the patient
record and the physician.
Confrontation visual fields
Children are not unlike many
of our adult patients: they have
Young children
need help getting
started with many
tasks, so give them the
first letter on a Snellen
line.
the firmness of the globe underneath. Once an eye becomes
firm from elevated intraocular
pressure, the pressure is usually
very high, so this is not a very
sensitive test.
If you know you have
always had normal intraocular
The pediatric exam
When adminstering the following tests, start with the most basic method of
assessment, then eventually graduate to the more sophisticated.
Jessica Barr is the
clinical supervisor
for the Division of
Ophthalmology
at The Children’s
Hospital of Philadelphia. She is the
current president
for the Philadelphia Regional
Ophthalmic
Society and a program co-coordinator and adjunct
professor for
the Ophthalmic
Medical Technician program at
Camden County
College.
■
Visual acuity
■
Confrontation visual fields
■
Pupils
■
Tonometry
■
Motility
■
Instilling eye drops
difficulty fixating on a nonmoving target for long periods of
time. Turn a confrontation visual
field test in to a staring contest
to encourage fixation. Consider
using toys instead of having
them count fingers. Be patient.
Give the pediatric patient multiple opportunities to accurately
participate in the confrontation
visual field.
Tonometry
If you are unable to applanate
or use a Tonopen, palpate the
eye and document a soft globe.
A common description for this
technique is “soft to palpation”
or “STP.” This technique requires
only that you gently press on
closed eyelids and comment on
pressure (IOP), consider touching
your own eyes for a point of
comparison to the patient
(and always sanitize between
touching your hands and the
eyes of the patient!).
Instilling eye drops
You may use tropicamide and
phenylephrine to dilate, but
we use “giggle drops,” “Batman
drops,” and “Princess drops.”
Try relating the experience of
getting drops to something that
does not scare them. For example, “Do you like swimming?
Getting eye drops is a lot like
getting pool water in your eye. It
feels funny, or maybe burns, but
it goes away really fast.”
Try putting a drop on the
child’s hand to demonstrate the
drops will not hurt. If children
still refuse, make sure you obtain
the consent and assistance of the
parents if more force or restraint
is required. Let children sit in
their parent’s lap, or hold the
parent’s hand (see Figure 6). You
need to work quickly if you are
instilling more than one drop.
Make sure to get multiple drops
ready on the counter and take
all the lids off the bottles before
you start administering.
Summary
Start with broad details and, as
the pediatric patient gets older,
you can drill down further and
obtain the perfect adult type of
eye exam. Use the less sophisticated methods, and gradually
increase the complexity of methods as the child gets older. You
have to accept that you will not
get a perfect exam on a child,
but that does not mean you
should not try to get something
on every pediatric patient.
If you have never used some
of these techniques, give them
a try with your next pediatric
examination. The more you
perform these techniques, the
more confident you will become
interpreting and documenting
the results.
Keep in mind that even a
well-equipped pediatric ophthalmology practice must employ
less sophisticated methods of
evaluation to begin yielding
exam results on young children.
Make it fun, use games, and start
documenting your findings and
observations on your pediatric
patients. By doing this, you will
get more of an examination and
have a more productive and fulfilling experience with your pediatric patients and their families.◗
iTech
Fall 2015
Providing Assistance
in Support of Patients
Helps eligible patients* with
commercial insurance cover certain
out-of-pocket co-pay costs
The Newly Improved EYLEA® (aflibercept) Injection
Co-Pay Card Program Now:
Provides up to $10,000 of co-pay assistance per year±
Covers up to $600 per EYLEA treatment, per eye+
Has no eligibility income requirement
* Patients must have commercial or private insurance (not funded through a government healthcare program) that covers EYLEA
for an approved indication, along with a co-pay that exceeds $5 per purchase/treatment. They must also be residents of the
United States or its territories/possessions.
± $5,000 per eye, per year.
+
Patients are responsible for the first $5. The EYLEA Co-Pay Card Program will cover the co-pay balance up to $600 per EYLEA
treatment per eye. Any additional co-pay costs that exceed the co-pay reimbursement are the patient’s responsibility.
The program does not cover or provide support for supplies, procedures, or any physician-related service associated with EYLEA.
General, non-product-specific insurance deductibles above the co-pay amount are also not covered.
Important Information:
Not open to uninsured patients or patients covered by a government-funded insurance program
(Medicare, Medicaid, etc.) or where prohibited by law. Restrictions and limitations apply.
Offer subject to change or discontinuation without notice. No cash value.
For More Information about EYLEA4U, visit www.EYLEA.com
EYLEA and EYLEA4U are registered trademarks of Regeneron Pharmaceuticals, Inc.
©2014, Regeneron Pharmaceuticals, Inc.
777 Old Saw Mill River Road, Tarrytown, NY 10591
All rights reserved
05/2014
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Optom Vis Sci. 2014; 91: E-abstract 145192. © 2015 Novartis 5/15 CCS15069AD-B
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Dry Eye - Modern medicine

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