Optometry Times

Advertiser Index
Welcome to the March 2011 issue of Optometry Times magazine
This digital edition is brought to you by Advanstar Communications, Inc.
Below you’ll find an alphabetical index of the advertisers in this issue. If you’d like more information about the
advertiser, you can click on the name or the page number to see their ad.
Advertiser
Page(s)
Alcon Laboratories Inc
CV2, CV4, 27-28
Allergan Inc
5-6, 7-8, 19-20
American Optometric Association
37
Bausch & Lomb
10 a-b
Heidelberg Engineering
17
Oculus Inc
31
Odyssey Medical
33
Transition Optical
13
Vision Expo East
CV3
Vistakon
CV TIP, 22-23
WHEN IT COMES TO REUSABLE LENSES…
TAKE A FRESH VIEW
ON COMPLIANCE.
Study shows modality doesn’t drive compliance, the patient does.
Chances are, it’s what you’ve been suspecting all along—that when it comes
to replacement compliance, there is no reusable modality to which patients
better adhere: there was no significant difference regarding compliance with
replacement frequency for patients wearing 2-week or 1-month lenses.1
NEW
Annual Supply/24-Pack
TM
FIT A FRESHER LENS.
SEE WHAT COULD BE™
See
Se
e st
stud
udy
y results on
n bac
a k >>
DIFFERENT REUSABLES, NO SIGNIFICANT
DIFFERENCE IN RATE OF COMPLIANCE.
Perfect Compliance:
No Difference (P=NS)
44
%
2-week
lenses
51
Moderate Overwear:
No Difference (P=NS)
%
Monthly
lenses
WORN FOR UP TO:
2 WEEKS vs 4 WEEKS
46
%
2-week
lenses
42
Considerable Overwear:
No Difference (P=NS)
%
Monthly
lenses
WORN FOR UP TO TWICE AS LONG:
4 WEEKS vs 8 WEEKS
11
%
2-week
lenses
8
%
Monthly
lenses
WORN FOR MORE THAN:
4 WEEKS vs 8 WEEKS
An ongoing online survey (updated quarterly) of 659 frequent replacement contact lens wearers who answered questions relating to
lens replacement frequency. The respondents represented wearers of hydrogel and silicone hydrogel lenses prescribed for two-week or
monthly replacement. The results show the 3rd consecutive quarter in which there were no significant differences in rate of wear, based
on rolling four-quarter data.
The next time you see patients who have “compliance challenges,”
go with what you know: select the freshest lens you have, and make
sure they know the importance and value of proper compliance with
the recommended wear schedule.
Reference: 1. Data on file, Johnson & Johnson Vision Care, Inc. 2010.
ACUVUE® Brand Contact Lenses are indicated for vision correction. As with any contact lens, eye problems, including corneal ulcers, can develop. Some wearers may experience mild irritation, itching
or discomfort. Lenses should not be prescribed if patients have any eye infection, or experience eye discomfort, excessive tearing, vision changes, redness or other eye problems. Consult the package
insert for complete information. Complete information is also available from VISTAKON®, Division of Johnson & Johnson Vision Care, Inc., by calling 1-800-843-2020 or by visiting jnjvisioncare.com.
ACUVUE®, ACUVUE® ASSURED™, ACUVUE® OASYS®, ACUVUE® ADVANCE®, HYDRACLEAR®, SEE WHAT COULD BE™, and VISTAKON® are trademarks of Johnson & Johnson Vision Care, Inc.
© Johnson & Johnson Vision Care, Inc. 2011. February 2011
March 2011
VOL. 3, NO. 3
Bringing Eye Health into Focus
OptometryTimes.com
Piggybacks offer comfort, quality of vision
Keratoconus Tx seen as valuable option
By Ron Rajecki
Reviewed by Chuck Faron, OD, and Marsha M. Malooley, OD, FAAO
San Francisco—Piggyback contact lenses (CLs) are an effective and underutilized modality that has gotten an undeserved “bad rap” as an
option for keratoconus patients, according to Chuck Faron, OD, and
Marsha M. Malooley, OD, FAAO, Chicago Cornea Consultants, Chicago. Drs. Faron and Malooley were speaking here at the American
Academy of Optometry’s annual meeting.
Although rigid gas permeable (RGP) lenses remain the gold standard for patients who have keratoconus or pellucid marginal degeneration, some patients are intolerant
of RGPs. For many keratoconus
patients, piggyback lenses are a
great option to improve their comfort while maintaining the quality of their vision, Drs. Faron and
Malooley said. Piggyback lenses
Dr. Faron
Dr. Malooley
protect the epithelium and help
See Piggyback lenses on page 21
6
Optometry News
Vision Expo East marks its 25th anniversary by
offering exclusive programs, expanded CE, tech
updates, and more—all under one roof.
29
Glaucoma
Instrument adds assessment power.
Normative database, asymmetry analysis
extend OCT device’s reach into glaucoma.
34
Practice Management
Just say ‘no’ to mixing EMRs with laptops.
Practice caution with office files. Use security
measures to help ensure patients’ privacy.
Marsha M. Malooley, OD, FAAO.)
LASIK outcomes are enhanced
Surgical and technology advances, customized procedures help raise the bar
By Cheryl Guttman Krader
Reviewed by Jim Owen, MD, MBA
but the incidences of these events are
quite low and patient satisfaction after
LASIK is very high,” said Dr. Owen, in
Encinitas, CA—Outcomes of LASIK have
private practice, Encinitas, CA.
continued to improve thanks to adResults from a number of studies
vances in technology and medical
demonstrate that the WFG technique
management, Jim Owen, MD, MBA,
improves LASIK refractive predictabilDr. Owen
said recently.
ity and provides patients with better
“Results in the current era of LASIK using quality of vision compared with a conventional
a customized wavefront-guided (WFG) abla- ablation. Steven Schallhorn, MD, and David
tion with a femtosecond laser for flap creation Tanzer, MD, have been leaders in research
have made the refractive procedure better than performed at the U.S. Naval Medical Center,
ever with efficacy, predictability, and quality
See WFG LASIK on page 30
of vision outcomes that can truly be described
as phenomenal. Complications still can occur,
Starts on page 14
Getty Images: Nick Rowe (Contact Lens)
Inside
Figure 1 Piggyback lens with corneal sodium fluorescein staining. (Image provided by
TearGlyde® Reconditioning System keeps lenses moist
for up to 14 hours and provides enhanced comfort.1, 2, 3
References: 1. Data on file. Alcon Laboratories, Inc.; Fort Worth, TX. 2. Schachet J, Zigler L, Wakabayashi D, Cohen S. Clinical
assessment of a new multi-purpose disinfecting solution in asymptomatic and symptomatic patients. Poster presented at: AAO;
December 2006; Denver, CO. 3. Meadows D, Ketelson H, Napier L, Christensen M, Mathis J. Clinical ex vivo wettability of
traditional and silicone hydrogel soft contact lenses. Poster presented at: BCLA; May 2006; Birmingham, UK.
©2010 Alcon, Inc.
2/11
ORP11070JAD
www.opti-free.com/ecp
MARCH 2011 / OptometryTimes.com
CATARACT / REFRACTIVE
SECTION EDITOR
Editorial Advisory Board
Jennifer L. Smythe, OD, MS, FAAO
Portland, OR
Marc R. Bloomenstein, OD, FAAO
Schwartz Laser Eye Center
Scottsdale, AZ
Laurie L. Sorrenson, OD
Lakeline Vision Source
Austin, TX
Louis J. Catania, OD, FAAO
Nicolitz Eye Consultants
Jacksonville, FL
CORNEA / EXTERNAL DISEASE
David Geffen, OD
Gordon Binder & Weiss Vision Institute
San Diego, CA
Jimmy Jackson, OD, MS, FAAO
Insight Lasik LTD
Parker, CO
Daryl F. Mann, OD
Southeast Eye Specialists
Chattanooga, TN
Elliott H. Myrowitz, OD, MPH
Wilmer Eye Institute
Johns Hopkins University
Baltimore, MD
Christopher J. Quinn, OD, FAAO
Omni Eye Services
Iselin, NJ
Tracy Schroeder Swartz, OD, MS, FAAO
VisionAmerica
Huntsville, AL
William J. Tullo, OD, FAAO
TLC Laser Eye Centers/
Princeton Optometric Physicians
Princeton, NJ
SECTION EDITOR
Paul Karpecki, OD, FAAO
Koffler Vision Group
Lexington, KY
Milton M. Hom, OD, FAAO
Azusa, CA
Katherine M. Mastrota, OD, MS
Omni Eye Surgery
New York, NY
Ron Melton, OD, FAAO
Educators in Primary Eye Care LLC
Charlotte, NC
Jeff D. Miller, OD
Cockrell Eyecare Center
The Laser Eyecare Center of Stillwater
Stillwater, OK
Jim Owen, OD, FAAO
Encinitas Optometry
Encinitas, CA
Louise A. Sclafani, OD, FAAO
University of Chicago Hospital
Chicago, IL
William D. Townsend, OD, FAAO
Advanced Eye Care
Canyon, TX
COMPLEMENTARY MEDICINE /
NUTRITION
DISPENSING
Jeffrey Anshel, OD, FAAO
Ocular Nutrition Society
Encinitas, CA
Sol Regwan, OD
F Y Eye Optometry Center
Encino, CA
Stuart Richer, OD, PhD, FAAO
Dept of Veterans Affairs Medical Center
North Chicago, IL
GLAUCOMA
CONTACT LENSES
SECTION EDITOR
Loretta B. Szczotka-Flynn, OD, MS, FAAO
University Hospitals Case Medical Center
Cleveland, OH
John L. Schachet, OD
Eyecare Consultants Vision Source
Englewood, CO
Jack L. Schaeffer, OD
Schaeffer Eye Center
Birmingham, AL
Christine Sindt, OD, FAAO
Iowa City, IA
SECTION EDITOR
Murray Fingeret, OD
VA New York Harbor Health Care System
Brooklyn, NY
Michael A. Chaglasian, OD
Illinois Eye Institute
Chicago, IL
John G. Flanagan, PhD, MCOptom, FAAO
University of Waterloo School of Optometry
Waterloo, ON, Canada
Thomas F. Freddo, OD, PhD
University of Waterloo School of Optometry
Waterloo, ON, Canada
Danica J. Marrelli, OD, FAAO
University of Houston College of Optometry
Houston, TX
John J. McSoley, OD
University of Miami Medical Group
Miami, FL
Michael Bacigalupi, OD, MS, FAAO
Nova Southeastern University
Fort Lauderdale, FL
Eric E. Schmidt, OD
Omni Eye Specialists
Wilmington, NC
Kim Castleberry, OD
Plano Eye Associates
Plano, TX
Joseph Sowka, OD, FAAO
Nova Southeastern University College of
Optometry
Fort Lauderdale, FL
Walter L. Choate, OD
Goodlettsville, TN
Michael Sullivan-Mee, OD, FAAO
Veterans Affairs Medical Center
Albuquerque, NM
Kathy C. Yang-Williams, OD, FAAO
Roosevelt Vision Source PLLC
Seattle, WA
NEURO-OPTOMETRY
Patricia A. Modica, OD, FAAO
SUNY College of Optometry
New York, NY
PEDIATRIC OPTOMETRY
SECTION EDITOR
Valerie M. Kattouf, OD, FAAO, FCOVD
Illinois College of Optometry
Chicago, IL
Don W. Lyon, OD
Indiana University School of Optometry
Indianapolis, IN
Leonard J. Press, OD, FCOVD, FAAO
Family Eyecare Associates PC
Fair Lawn, NJ
Douglas K. Devries, OD
Eye Care Associates of Nevada
Sparks, NV
Scot Morris, OD
Eye Consultants of Colorado LLC
Conifer, CO
Kirk Smick, OD
Clayton Eye Centers
Morrow, GA
PRIMARY CARE OPTOMETRY
Mile Brujic, OD
Bowling Green, OH
Linda Casser, OD, FAAO
Pennsylvania College of Optometry at Salus
University
Elkins Park, PA
A. Paul Chous, OD, MA
Chous Eye Care Associates
Tacoma, WA
Kenneth R. Mueller, OD
International Eyecare and Laser Centers
Hannibal, MO
RETINA
Marc B. Taub, OD
Southern College of Optometry
Memphis, TN
Steven C. Ferrucci, OD, FAAO
Sepulveda VA Ambulatory Care Center
Sepulveda, CA
PHARMACOLOGY
Jeffry D. Gerson, OD, FAAO
WestGlen Eyecare
Shawnee, KS
SECTION EDITOR
Jimmy D. Bartlett, OD, ScD
University of Alabama at Birmingham
School of Optometry
Birmingham, AL
Tammy Pifer Than, OD, MS, FAAO
University of Alabama at Birmingham
School of Optometry
Birmingham, AL
Randall Thomas, OD, MPH, FAAO
Educators in Primary Eye Care LLC
Concord, NC
3
William L. Jones, OD, FAAO
Albuquerque, NM
Diana L. Shechtman, OD, FAAO
Nova Southeastern University
Fort Lauderdale, FL
Leo P. Semes, OD
University of Alabama at Birmingham
School of Optometry
Birmingham, AL
PRACTICE MANAGEMENT
SECTION EDITOR
Ben Gaddie, OD, FAAO
Gaddie Eye Centers
Louisville, KY
How to Contact Optometry Times
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Optometry Times Masthead
Official publication sponsor of
Optometry Times Mission Statement
March 2011
Optometry Times is an optometry-driven publication that disseminates news and information of a clinical,
socioeconomic, and political nature in a timely and accurate manner for members of the optometric community.
In partnership with our readers, we will achieve mutual success by:
●
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Being a forum for optometrists to communicate their
clinical knowledge, insights, and discoveries.
● Providing management information that allows
optometrists to enhance and expand their practices.
Addressing political and socioeconomic issues
that may either assist or hinder the optometric
community, and reporting those issues and
their potential outcomes to our readers.
●
Vol. 3, No. 3
Editorial
Director of Editorial Dan Schwartz
Editor-in-Chief Mark L. Dlugoss
[email protected] 440/891-2703
Senior Editor Paul Matheis
[email protected] 440/891-2606
Editorial Assistant Theresa Gromek
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[email protected] 218/740-7136
Contributing Editors
Kimberly Bonvissuto, Lynda Charters, Nancy Groves,
Cheryl Guttman Krader, Lisette Hilton, Jill Luebbert, CPOT, ABOC,
Lynn R. Novelli, Carol Patton, Ron Rajecki, Stephanie Skernivitz,
Helen Thams, Jennifer A. Webb
Column Editors
Managing Practice Management Ben Gaddie, OD, FAAO
Glaucoma Angle Murray Fingeret, OD
Publishing/Advertising
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• Practice Management
Bringing Eye Health
into Focus
• Primary Care Optometry
• Cornea / External Disease
• Student Center
• Cataract, Refractive, Retina
• Low-Vision Solutions
• And Much More!
Philadelphia—Researchers
have concluded that
the most effective form
of treatment for convergence insufficiency (CI)
in children is officebased vision therapy with
a trained therapist
resources, and the economy.
It is clear that this
previously underappreciated
condition now
should be regarded as
a serious public health
problem that is worthy
of diagnosis and efcle, dry eye disease is
a major and increasin
g
health-ca re problem due
to its prevalence and
effects on patients’ quality
of life, health-ca re
based vision therapy with
a trained therapist Newer
knowledge
resources, and the economy.
It is clear that this
previously underappreciated
condition now
the most effective form
of treatment for convercombined with home
reinforcem
The Convergence Insufficie ent.
ncy Treatment
Trial (CITT) demonstr
ated that office-based
vergence/accommodative
therapy (OBVAT) with
home reinforcement was
more effective than
By Debra A. Schaumb
See Convergence on page
erg, ScD, OD, MPH,
42
and Gerd Geerling , MD,
PhD
Dry eye a serious
public health problem
Inside
6
Editorial
Welcome to the premiere
issue
of Optometry Times—or
is it déjà vu?
By Mark L. Dlugoss, Group
36
Editor
Glaucoma
When is a case truly glaucoma?
If a definitive diagnosis seems
elusive,
gather corroborating evidence.
By Murray Fingeret, OD
40
Special Section: VEE
Get into a ‘New York state
of mind.’ Preview
all that’s new at this year’s
Vision Expo East.
By
Christina Phillis
C
onsiderable progress has
been made
in the past 15 years regarding
knowledge on the epidemiology
of dry eye
disease. As we describe
in this article, dry eye disease is
a major and increasin
g
health-ca re problem due
to its prevalence and
effects on patients’ quality
of life, health-ca re
the most effective form
of treatment for convergence insufficiency (CI)
in children is officebased vision therapy with
a trained therapist
resources, and the economy.
It is clear that this
previously underappreciated
condition now
should be regarded as
a serious public health
problem that is worthy
of diagnosis and efcle, dry eye disease is
a major and increasin
g
health-ca re problem due
to its prevalence and
effects on patients’ quality
of life, health-ca re
resources, and the economy.
It
previously underappreciated is clear that this
condition now
should be regarded as
a serious public health
problem that is worthy
of diagnosis and effective treatment.
See Tear Film on page 16
starts on page 10
• Glaucoma
CI manifests
with symptoms
that include
diplopia, eyestrain,
headaches,
blurred vision,
and difficulty
concentrating.
J. Brittan
By Nancy Groves
Reviewed by Eric Borsting,
OD, MS, FAAO, FCOVD,
Marjean Kulp, OD, MS, and
Mitchell S. Scheiman,
OD, FAAO
Getty Images/Digital Vision/Philip
Office-based therapy, home
reinforcement best therapeutic
effect for convergence insuffic
iency
• Contact Lenses
Production
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Circulation Manager Ryanne Battaglia
[email protected] 218/740-6466
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W
‘Double teaming’ shown eff
for childhood vision disorderective
• Industry News and FastTrack
• CE Center
www.optometry times.co
m
March 2009 Vol. 1, No.
1
Combined effort
Vice President/General Manager Jim Vitkus
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®
Only RESTASIS is approved to help your patients make more of their own real tears
Indications and Usage: RESTASIS®
Ophthalmic Emulsion is indicated to increase
tear production in patients whose tear
production is presumed to be suppressed
due to ocular inflammation associated with
keratoconjunctivitis sicca. Increased tear
production was not seen in patients currently
taking topical anti-inflammatory drugs or
using punctal plugs.
Important Safety Information
Contraindications: RESTASIS® is
contraindicated in patients with active
ocular infections and in patients with known
or suspected hypersensitivity to any of the
ingredients in the formulation.
©2011 Allergan, Inc., Irvine, CA 92612
®
marks owned by Allergan, Inc. APC67DY11
Warning: RESTASIS® has not been studied
in patients with a history of herpes keratitis.
Precautions: The emulsion from one
individual single-use vial is to be used
immediately after opening for administration
to one or both eyes, and the remaining
contents should be discarded immediately
after administration. Do not allow the tip
of the vial to touch the eye or any surface,
as this may contaminate the emulsion.
RESTASIS® should not be administered while
wearing contact lenses. If contact lenses are
worn, they should be removed prior to the
administration of the emulsion.
Adverse Reactions: The most common
adverse event was ocular burning (upon
instillation)—17%. Other events reported in
1% to 5% of patients included conjunctival
hyperemia, discharge, epiphora, eye pain,
foreign body sensation, pruritus, stinging, and
visual disturbance (most often blurring).
Please see brief Prescribing Information
on adjacent page.
To find local average co-pays
Scan your way to
RESTASIScopay.com
with the ScanLife app
Text “SCAN” to 43588 to download free scanner
6
RESTASIS®
(cyclosporine ophthalmic emulsion) 0.05%
Sterile, Preservative-Free
INDICATIONS AND USAGE
RESTASIS® ophthalmic emulsion is indicated to increase tear production in patients whose
tear production is presumed to be suppressed due to ocular inflammation associated with
keratoconjunctivitis sicca. Increased tear production was not seen in patients currently taking
topical anti-inflammatory drugs or using punctal plugs.
CONTRAINDICATIONS
RESTASIS® is contraindicated in patients with active ocular infections and in patients with
known or suspected hypersensitivity to any of the ingredients in the formulation.
WARNING
RESTASIS® ophthalmic emulsion has not been studied in patients with a history of
herpes keratitis.
PRECAUTIONS
General: For ophthalmic use only.
Information for Patients
The emulsion from one individual single-use vial is to be used immediately after opening
for administration to one or both eyes, and the remaining contents should be discarded
immediately after administration.
Do not allow the tip of the vial to touch the eye or any surface, as this may contaminate
the emulsion.
RESTASIS® should not be administered while wearing contact lenses. Patients with decreased
tear production typically should not wear contact lenses. If contact lenses are worn, they
should be removed prior to the administration of the emulsion. Lenses may be reinserted
15 minutes following administration of RESTASIS® ophthalmic emulsion.
Carcinogenesis, Mutagenesis, and Impairment of Fertility
Systemic carcinogenicity studies were carried out in male and female mice and rats. In the
78-week oral (diet) mouse study, at doses of 1, 4, and 16 mg/kg/day, evidence of a statistically
significant trend was found for lymphocytic lymphomas in females, and the incidence of
hepatocellular carcinomas in mid-dose males significantly exceeded the control value.
In the 24-month oral (diet) rat study, conducted at 0.5, 2, and 8 mg/kg/day, pancreatic islet
cell adenomas significantly exceeded the control rate in the low dose level. The hepatocellular
carcinomas and pancreatic islet cell adenomas were not dose related. The low doses in
mice and rats are approximately 1000 and 500 times greater, respectively, than the daily
human dose of one drop (28 μL) of 0.05% RESTASIS® BID into each eye of a 60 kg person
(0.001 mg/kg/day), assuming that the entire dose is absorbed.
Cyclosporine has not been found mutagenic/genotoxic in the Ames Test, the V79-HGPRT Test,
the micronucleus test in mice and Chinese hamsters, the chromosome-aberration tests in
Chinese hamster bone-marrow, the mouse dominant lethal assay, and the DNA-repair test
in sperm from treated mice. A study analyzing sister chromatid exchange (SCE) induction
by cyclosporine using human lymphocytes in vitro gave indication of a positive effect (i.e.,
induction of SCE).
No impairment in fertility was demonstrated in studies in male and female rats receiving oral
doses of cyclosporine up to 15 mg/kg/day (approximately 15,000 times the human daily dose
of 0.001 mg/kg/day) for 9 weeks (male) and 2 weeks (female) prior to mating.
Pregnancy-Teratogenic Effects
Pregnancy category C.
Teratogenic Effects: No evidence of teratogenicity was observed in rats or rabbits
receiving oral doses of cyclosporine up to 300 mg/kg/day during organogenesis. These
doses in rats and rabbits are approximately 300,000 times greater than the daily human
dose of one drop (28 μL) 0.05% RESTASIS® BID into each eye of a 60 kg person
(0.001 mg/kg/day), assuming that the entire dose is absorbed.
Non-Teratogenic Effects: Adverse effects were seen in reproduction studies in rats and
rabbits only at dose levels toxic to dams. At toxic doses (rats at 30 mg/kg/day and rabbits at
100 mg/kg/day), cyclosporine oral solution, USP, was embryo- and fetotoxic as indicated by
increased pre- and postnatal mortality and reduced fetal weight together with related skeletal
retardations. These doses are 30,000 and 100,000 times greater, respectively than the daily
human dose of one-drop (28 μL) of 0.05% RESTASIS® BID into each eye of a 60 kg person
(0.001 mg/kg/day), assuming that the entire dose is absorbed. No evidence of embryofetal
toxicity was observed in rats or rabbits receiving cyclosporine at oral doses up to 17 mg/kg/
day or 30 mg/kg/day, respectively, during organogenesis. These doses in rats and rabbits are
approximately 17,000 and 30,000 times greater, respectively, than the daily human dose.
Offspring of rats receiving a 45 mg/kg/day oral dose of cyclosporine from Day 15 of pregnancy
until Day 21 post partum, a maternally toxic level, exhibited an increase in postnatal mortality;
this dose is 45,000 times greater than the daily human topical dose, 0.001 mg/kg/day,
assuming that the entire dose is absorbed. No adverse events were observed at oral doses up
to 15 mg/kg/day (15,000 times greater than the daily human dose).
There are no adequate and well-controlled studies of RESTASIS® in pregnant women.
RESTASIS® should be administered to a pregnant woman only if clearly needed.
Nursing Mothers
Cyclosporine is known to be excreted in human milk following systemic administration
but excretion in human milk after topical treatment has not been investigated. Although
blood concentrations are undetectable after topical administration of RESTASIS®
ophthalmic emulsion, caution should be exercised when RESTASIS® is administered to a
nursing woman.
Pediatric Use
The safety and efficacy of RESTASIS® ophthalmic emulsion have not been established in
pediatric patients below the age of 16.
Geriatric Use
No overall difference in safety or effectiveness has been observed between elderly and
younger patients.
ADVERSE REACTIONS
The most common adverse event following the use of RESTASIS® was ocular burning (17%).
Other events reported in 1% to 5% of patients included conjunctival hyperemia, discharge,
epiphora, eye pain, foreign body sensation, pruritus, stinging, and visual disturbance (most
often blurring).
Rx Only
Based on package insert 71876US14B Revised February 2010
©2010 Allergan, Inc.
Irvine, CA 92612, U.S.A.
®
marks owned by Allergan, Inc. APC67DY11
U.S. Patent 5,474,979
Made in the U.S.A.
Optometry News
New focus on eye care
Inspire cuts more than onequarter of its workforce
Raleigh, NC—Inspire Pharmaceuticals has
announced a corporate restructuring that
will include a workforce reduction of about
65 positions, or 27% of total headcount.
According to the company, in light of the
failure of its cystic fibrosis drug denufosol
tetrasodium to pass clinical trials, Inspire
will refocus on its eye-care business.
Most of the eliminated positions will be
in research and development, manufacturing and technical operations, and general
and administrative. Inspire expects to take
a restructuring charge of $10 million to $13
million in Q1 2011, including the termination of all denufosol tetrasodium contracts.
“We conducted a strategic evaluation
of our operations following the recent announcement of the disappointing results
with our cystic fibrosis program and believe the prudent strategy for Inspire is to
leverage our eye-care business and discontinue our pulmonary therapeutic focus,”
said Adrian Adams, president and chief executive officer, Inspire. “Therefore, we are
implementing a substantial corporate restructuring that we anticipate will enable
us to drive toward profitability and positive cash flow by significantly reducing
our cost base and cash burn.”
Inspire’s eye-care business continues to
generate a revenue stream for the company
through growth in the anchor product
azithromycin ophthalmic solution (AzaSite) 1% for the treatment of bacterial conjunctivitis, according to Adams.
The restructuring will affect 45% of the
non-sales force. With minimal changes to
the commercial infrastructure, there will
be no reductions to the company’s specialty eye-care sales force.
Upside, downside
QLT—disappointing clinical
trials, success in treating
hereditary blindness
Vancouver, British Columbia—Interim results
from a phase II proof-of-concept clinical
trial for QLT Inc.’s olopatadine punctual
plug delivery system (O-PPDS) show it is
generally safe and well tolerated in patients
with allergic conjunctivitis, but showed no
significant differences against a placebo.
The punctual plug delivery system is
a minimally invasive drug delivery sys-
tem that houses a drug-eluting device in
the puncta. The goal is to enable delivery
of a variety of drugs to the eye over time
through sustained release to the tear film.
It is being investigated as a treatment for allergic conjunctivitis. More than 50 million
people in the United States suffer from allergic diseases and between 40% and 60% of
those individuals suffer ocular symptoms.
The study assessed itching and other signs
of allergic conjunctivitis in subjects exposed
to ragweed allergen after having the PPDS
placed in their lower puncta bilaterally for
four days. The data demonstrated no significant differences between the O-PPDS and
placebo-PPDS subjects in reduction of the
signs and symptoms of allergic conjunctivitis.
“These equivocal results from the first
trial examining the potential utility of sustained low dose olopatadine delivery in the
eye support the notion that the EEC model,
as utilized in the conduct of this trial, was
not sufficiently sensitive to adequately
demonstrate the potential benefit of the
O-PPDS in patients suffering from allergic conjunctivitis,” said Dipak Panigrahi,
MD, QLT senior vice president of research
and development and chief medical officer,
adding that the study has been stopped.
“We are disappointed that the O-PPDS
study model could not generate definitive
clinical results, however we plan to continue to evaluate alternative study designs
for the O-PPDS,” said Bob Butchofsky, QLT
president and chief executive officer. “We
do not plan to begin further clinical trials of
the O-PPDS pending the outcome of our ongoing Latanoprost-PPDS trial in glaucoma.”
On a more positive note for the company,
QLT’s QLT091001, an oral synthetic retinoid, received positive opinions from two
Orphan Drug Designations by the European Medicines Agency (EMA) Committee
for Orphan Medicinal Products (COMP) to
treat the inherited retinal degenerative diseases Leber Congenital Amaurosis (LCA)
and retinitis pigmentosa (RP).
Positive opinions by the COMP precede official designations of QLT091001
as an orphan drug by the EMA. The drug,
an oral synthetic retinoid replacement for
11-cis-retinal, already received orphan
drug designations from the FDA for the
treatment of LRAT and RPE65 genetic mutations in both LCA and RP.
The EMA’s Orphan Drug Designation
program provides incentives to promote
the development of drugs and biologics
for patients suffering from rare and lifethreatening diseases that affect no more
than five in 10,000 people in the European
See In Brief on page 8
For patients with itching
due to allergic conjunctivitis…
TAKE A LOOK
AT LASTACAFT™
• FDA approved to prevent ocular itching all day1
• Proven to work fast: Efficacy shown at 3 minutes2-4
• Proven to last all day: Prevents ocular itching
through 16 hours2-4
INDICATIONS AND USAGE
LASTACAFT™ is an H1 histamine receptor antagonist indicated for the prevention of itching associated with allergic conjunctivitis.
Important Safety Information
WARNINGS AND PRECAUTIONS
To minimize contaminating the dropper tip and solution, care should be taken not to touch the eyelids or surrounding areas with
the dropper tip of the bottle. Keep bottle tightly closed when not in use.
Patients should be advised not to wear a contact lens if their eye is red.
LASTACAFT™ should not be used to treat contact lens-related irritation.
Remove contact lenses prior to instillation of LASTACAFT™. The preservative in LASTACAFT™, benzalkonium chloride, may be
absorbed by soft contact lenses. Lenses may be reinserted after 10 minutes following administration of LASTACAFT™.
LASTACAFT™ is for topical ophthalmic use only.
ADVERSE REACTIONS
The most frequent ocular adverse reactions, occurring in < 4% of LASTACAFT™ treated eyes, were eye irritation, burning and/
or stinging upon instillation, eye redness, and eye pruritus.
The most frequent non-ocular adverse reactions, occurring in < 3% of subjects with LASTACAFT™ treated eyes, were
nasopharyngitis, headache, and influenza. Some of these events were similar to the underlying disease being studied.
Please see adjacent page for brief prescribing information.
1. LASTACAFT™ Prescribing Information. 2. Torkildsen G, Shedden A. The safety and efficacy of
alcaftadine 0.25% ophthalmic solution for the prevention of itching associated with allergic conjunctivitis.
Curr Med Res Opin. 2011;27(3):623-631. 3. Data on file, Allergan, Inc., 2005; Clinical Study Report
05-003-11. 4. Data on file, Allergan, Inc., 2005; Clinical Study Report 05-003-13.
©2011 Allergan, Inc., Irvine, CA 92612
™
mark owned by Allergan, Inc.
www.Lastacaft.com APC52OM11 107532
8
Optometry News
In Brief
Continued from page 6
Union. Incentives include a 10-year market
exclusivity, regulatory guidance and direct
access to centralized marketing authorization, fee reductions and tax credits.
“We are pleased that the EMA has recognized QLT091001 as a potential treatment for the thousands of patients who
suffer from inherited blindness by granting positive opinions for these orphan
drug designations for the treatment of
LCA and RP,” said Bob Butchofsky.
Relationship building
Allergan launches doctorand patient-oriented site
Irvine, CA—In an effort to strengthen the
relationship between Allergan Inc. and
practitioners in the trenches, the company
recently launched www.allerganoptometry.
com. The Web site offers single-site access
to information about Allergan therapeutics
and to information about patient cost-saving programs through rebates.
Blending information aimed at doctors
with information geared toward patients,
the Web site also offers downloadable documents for practice management tools and
unbranded patient educational materials.
The practice management information includes questionnaires and tracking sheets
to document the start of a patient’s treatment and follow that treatment throughout the process. The patient-oriented information features literature on glaucoma
and dry eye.
Brands featured in the patient cost-saving material include Alphagan, Combigan,
Latisse, Lumigan 0.01%, and Restasis.
Failing system
USPSTF children’s vision
screening problematic
Washington, DC—The American Optometric
Association (AOA) warned that if a set of
U.S. Preventive Services Task Force (USPSTF) recommendations were adopted as
policy, significant harm would be caused
to the ongoing efforts of optometrists nationwide to reverse the high rates of preventable vision loss in young children
across the nation.
The recommendations, recently updated
and released by the federally-funded committee, did not take into account opinions
of optometrists and disregard the vision
and eye-health needs of America’s children under the age of 3 based on a “child’s
inability to cooperate,” according to the
AOA.
“This nation’s doctors of optometry are
extremely concerned that the USPSTF Children’s Vision Screening Recommendations
will hamper ongoing efforts to combat unacceptably high rates of preventable vision
loss in children—especially among vulnerable and at-risk children in communities across America,” said Joe E. Ellis, OD,
AOA president. “With nearly one in four
school-aged children now suffering from
preventable vision loss, which directly impacts their ability to learn, grow, and function normally, ensuring that our children
receive early and periodic comprehensive
vision and eye-health examinations will
prove both cost-effective for our country
and the key to fully confronting and potentially solving this continuing crisis.”
The AOA contends the USPSTF’s recommendations rely on a failed vision screening methodology and a broken screening
system as a means of identifying visual
impairment in preschool-age children.
“These ill-advised USPSTF recommendations seem to ignore mountains of scientific data showing that the vast majority
of vision screenings for children demonstrate an unacceptably high rate of error,”
said Dori Carlson, OD, AOA presidentelect. “To make matters worse, for those
children lucky enough to have been told
they have failed a screening, numerous
studies have also clearly shown that the
overwhelming majority of those kids do
not receive proper diagnosis and follow-up
care. High error rates found in most children’s vision screening programs coupled
with little or no assurances of proper diagnosis or follow-up care are the very reasons we find ourselves facing this crisis
today. We simply can’t expect to repeat
the mistakes of the past and somehow
produce any level of improved results for
our children’s future.”
Some doctors of optometry reportedly
are urging the task force to join the AOA
in calling for the flawed screening recommendations to be immediately withdrawn.
These optometrists have been reportedly calling for an emergency dialogue to
strengthen, rather than undermine, the
most effective risk reduction and health
promotion policies and recommendations
on eye disease and vision.
AOA members may access the letter at
www.aoa.org.OP
MARCH 2011 / OptometryTimes.com
Vision Voice
9
Solid business models
Vision Expo—the ‘official’
eye-care commerce meeting
Expos East and West continue to beef up practice-building education, offer ‘MBA’ program
By Kirk L. Smick, OD, FAAO
M
ost meetings have a footprint, something that they can be identified
with. Optometric meetings are no
exception. Affairs of state are best
observed in the House of Delegates at Optometry’s Meeting, while new scientific developments are best seen at the annual meeting of
the American Academy of Optometry. SECO
has always been identified as the best place
to go for clinical updates and best practices
procedures.
Vision Voice
B r o u g h t to yo u by
Vision Expo means business
When it comes to running a business, Vision
Expo takes the cake hands down. Several years
ago, being successful was easy in spite of ourselves. Today, with managed care involvement
growing and reimbursements shrinking, our
practices need to become good business models. Business education is sorely missing in
our formal training programs and traditionally there have been few courses we can attend
that are practical for our practices.
Recognizing this lack of information and the
need for it, Vision Expo has tailored its educational presentations with best business practices in mind. Of course, the clinical courses
remain strong because the need for updated
clinical information continues to grow, but the
business component of education programs
has increased dramatically.
NEW
YORK
By Author Name XXxxxxxxxxxx
NEWS FLASH—THIS JUST IN . . . Essilor
and CIBA Vision announced that the muchtalked about MBA program will be presented
live at Vision Expo East in New York City,
March 16 to 20. Traditional presenters of the
Author Info
Kirk L. Smick, OD, FAAO, is chief
of optometry services at Clayton Eye
Center, Morrow, GA, and an owner of
the facility. Dr. Smick also serves as a
technical advisor to many companies
in the ophthalmic industry and has
helped pioneer several visual advances,
including bifocal contact lenses.
Practice Management
Images: Getty Images (dollar sign) Digital Vision/ Chad Baker, (clocks) Photodisc/ Don Bishop
Architects of business training
There are many individuals whom we associate with historic business training, including
Gerber, Wright, Shaw-McMinn, Hays, West,
Burns, and Gailmard, to name a few. And these
speakers all have one thing in common—they
all are regulars on the podium at Vision Expo
East and West meetings. Many of us remember the practice management programs supported by B + L and Allergan back in the
1980s, but recently those programs have been
sorely missing.
The most relevant optometric business event
taking place today is the Management and Business Academy (MBA) program supported by
Essilor and CIBA Vision. Unfortunately, this
program is open by invitation only and an invitation is difficult to get.
MBA program will assemble there and bring
their information to registered attendees.
“This is an excellent opportunity for the practicing optometrist to receive relevant business
and management education” said Charlie Ficco,
OD, of Atlanta. Monty Smick, OD, Spokane,
WA, said “To have the ability to keep up with
my clinical education and get the best business
education at the same meeting makes sense
from a time-out-of-the-practice perspective.”
The MBA program can only accommodate
a finite number of attendees, so those interested practitioners should register early to be
certain of reserving a place in the program.
Other business courses will continue to be a
part of the overall program during the week.OP
Boom times.
Tough times.
Optometry Times.
No matter what the economic climate, you’ll see how to
optimize patient care and maximize profit potential.
Timely, relevant, practical advice from real
optometrists practicing in the real world.
Every month in Optometry Times.
www.OptometryTimes.com
10
MARCH 2011 / Optometry Times
Optometry News
Professional development
Vision Expo East marks 25 years
Silver anniversary event offers exclusive programs, expanded CE, tech updates—all under one roof
By Heather Onorati
T
he International Vision Expo and Conference East (VEE) will celebrate its
25th year March 16-20 at the Jacob K.
Javits Convention Center, New York
City. To mark the silver anniversary, conference organizers have planned several special
programs. In addition, the meeting will feature a host of new improvements and courses
to better benefit this year’s attendees.
Twenty-five years ago, VEE commenced
to bring together the worlds of International
optical fashion, medical equipment, and lens
technologies. Through quality continuing education (CE) sessions and hands-on product
comparisons and evaluations, VEE has helped
optometrists enhance their clinical and professional skills as well as their business acumen. Today, VEE has become the pre-eminent
fashion and medical eye-care event.
Celebrating educational excellence
To celebrate, conference goers are encouraged to visit the 25th anniversary booth (#MS
1076), located in the Medical and Scientific
Pavilion, where they can join VEE’s social
media community and enter to win one of
25 iPads that will be raffled off during all 3
days of the show.
In addition, attendees are invited to celebrate VEE’s 25th anniversary on Saturday,
March 19 from 5 p.m. to 6 p.m. in the new
North Hall walkway.
Finally, attendees are encouraged to send
in pictures of themselves and colleagues at a
VEE event. Photos can be sent to Leigh Roell
at [email protected] and will be posted to
the Vision Expo Web site commemorating
the successful 25-year run.
Every year, VEE adds new content and features to provide a dynamic educational experience for attendees. This year, more than 60
new courses have been added to help fill a
schedule covering more than 220 unique concepts including clinical care, new technologies, patient care, and practice management.
‘The addition of the MBA
program will provide a
strong opportunity for
attendees to advance their
knowledge and skill set.’
Kirk Smick, OD, FAAO
One highly anticipated addition to the CE
program is the reputable Management and
Business Academy (MBA), created by CIBA
Vision and Essilor and endorsed by American Optometric Association. The day-and-ahalf program, which kicks off the conference,
comprises 10 hours of classroom instruction
that will provide proven techniques from effectively managing staff and finances to developing patient loyalty and boosting referrals.
“The addition of the MBA program will
provide a strong opportunity for attendees
to advance their knowledge and skill set,”
said Kirk Smick, OD, FAAO, chairman of the
International Vision Expo Conference advi-
sory board. “Offering independent optometrists and their staff the chance to participate
in the premier business education program
for optometry is one of the exciting developments making this year’s show even more
beneficial for attendees.”
In addition to the MBA courses, VEE will
be offering CE courses in conjunction with
a number of other highly regarded organizations, including the Ocular Surface Society
of Optometrists, the Optometric Council on
Refractive Technology, the Optometric Nutrition Society, the Optometric Retina Society,
and others. And, for those preparing for the
board certification exam, VEE 2011 will introduce 21 hours of review courses specifically designed to provide optometrists with
comprehensive preparation.
Attendees also can look forward to a new
breakout of course content. This year, the CE
program will be divided into interest areas
making it easier for attendees to select courses
focused on a particular topic or to create an
educational strategy that combines sessions
from multiple areas.
MBA program highlights
Wednesday, March 16
•Managing finances to increase practice
equity
• Leading staff to excellence
• Breakout workshop
Thursday, March 17
• Exceeding patient expectations and driving practice profitability
• Creating the high-performance practice
• Providing memorable patient experiences
• Delivering persuasive patient presentations
CE program highlights
Expand business solutions, such as managing people, processes, and expenses through
MBA, Visionomics, boot camps, and e-technology courses. Some topics will include:
• Five ways to increase profits
• Essential systems for helping patients
accept your treatment plan
• Increase profits from services and products through internal marketing
• How to get started in Internet eyewear sales
• Must-have features and functionality for
your practice Web site
Through the medical/clinical course offerings, optometrists can advance their clinical
knowledge with hands-on technical practice,
case history reports, and the latest advances
in treatment strategies. Topics will include:
• Ocular adverse drug reactions to systemic medications
• Contemporary management of ocular inflammation and allergy
• Sports vision testing and enhancement
• Co-management of cataract surgery
• Current treatment strategies in refractive surgery
Keep up with the latest in optical technology. Find overviews of new technologies that
are available or will soon be available. Learn
about new exam instrumentation and treatment strategies, how the technologies work,
optimal patient selection, what to present to
patients, and how to best implement these
new technologies within your practice. Topics include:
Optometry News
• What’s new in eye care?
• Innovation in sight: Electronic lens
technology
• Using wavefront technology to improve
your patients’ vision
• Applying innovative technologies in clinical practice
• Technology within in a technology oriented office
Contact lenses—Improve compliance and
learn best practices. Topics include:
• The business of contact lenses and ocular surface disease
• Essentials in contact lens care
• How to present and sell free-form lenses
• Lens material selection guide
• Keratometry and basic corneal topography
Navigating the show
Due to a large renovation project currently
taking place at the Javits Convention Center, conference organizers have not only increased floor signage, but also have seized
technology to help attendees better navigate
the show floor.
The new online My Show Planner helps
attendees prepare for the show by allowing
them to search exhibitors and products and
create agendas. It also syncs with the new
Vision Mobile Smartphone app, which also
provides the ability to explore exhibitor show
specials and navigate the show with an interactive interface.
For those attendees who may still be turned
around, Mobile Geniuses will be roaming
11
the floor with iPads to point the direction
to booths and classrooms.
Discounts and deals
To help attendees and exhibitors get the most
from this year’s meeting, convention organizers have negotiated discounts on travel, hotel,
transportation, shopping and entertainment.
“We want those traveling to New York for
International Vision Expo to get the most out
of their investment in money and time away
from the practice,” said Tom Loughran, vice
president for Reed Exhibitions.
Attendees can find travel, hotel, dining,
and entertainment information at www.visionexpoeast.com. Specials include:
• Special hotel pricing
• Discounted airfare with American Airlines and Delta Airlines
• Amtrak discounts
• Rental car specials through Avis and
Enterprise
• Exclusive shopping offers, such as a Macy’s Savings Pass, good for 10% off thousands
of purchases at Macy’s on Broadway
• Dining features and discounts
• Discounted Broadway show tickets
• Discounted tour programs
• Complimentary shuttle service from the
Jacob K. Javits Convention Center to all three
major airports serving New York City.OP
Photos provided by International Vision Expo
MARCH 2011 / OptometryTimes.com
SEASONAL ALLERGIC CONJUNCTIVITIS | 1
HI:G>A:DE=I=6AB>8HJHE:CH>DC
Considerations in the Treatment of
Seasonal Allergic Conjunctivitis
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d[i]^hegZeVgVi^dcVcYiddi]ZgXdgi^XdhiZgd^Yh#
Marc R. Bloomenstein, OD, FAAO
ABSTRACT Seasonal allergic conjunctivitis is a common
cause of discomfort. Although many patients self-medicate
with over-the-counter oral antihistamines, the ocular
component of seasonal allergy is, I believe, best treated
with topical agents. Te allergic reaction has two phases,
an acute, or early, phase in which conjunctival mast cells
release preformed mediators, including histamine, which
can bring on symptoms in minutes. In the late phase, we
see a more typical patern of ocular surface inflammation.
Management of seasonal ocular allergy may include topical
drugs from two classes: a dual-action antihistamine/mast
cell stabilizer, used primarily to treat the acute phase, and
a corticosteroid, used primarily to treat the late phase.
My corticosteroid of choice for these patients is ALREX®
(loteprendol etabonate ophthalmic suspension 0.2%; Bausch
+ Lomb), which combines proven efficacy with a safety
profile that makes me comfortable using it to treat seasonal
allergic conjunctivitis.
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Seasonal allergy affects a large fraction of the population,
and the great majority of those with seasonal allergy have
ocular signs and symptoms. Despite the prevalence of ocular
symptomatology, few patients consult an eye doctor first when
they have allergy-related problems. Most seek the counsel of
a primary care physician or allergist. Others medicate themselves with over-the-counter (OTC) products, sometimes with
the aid of their pharmacist. As an eye doctor, I believe it is
imperative that we manage these patients and that the treatment of seasonal ocular allergy, like the treatment of other
ocular surface conditions, is a vital part of optometric practice.
Ocular allergy and its hallmark symptom, itching, can
make our patients quite uncomfortable. It affects the quality of their work; and it can destroy their ability to enjoy
the outdoors. For patients who wear contact lenses, allergy
season can be extremely uncomfortable, ofen forcing them
to suspend contact lens wear. Fortunately, we have effective pharmacologic tools that enable us to help patients
manage their allergic symptoms.
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Treat on the Surface
Te primary care physicians who patients see for their
allergies typically make little use of topical ocular therapies. Instead, they tend to treat the primary symptom, rhinorrhea, with oral medications, thus ignoring the ocular
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.%%*,%(
PH3631, Rev. 1/11
symptoms. Many of these oral antihistamines cause ocular
dryness as a side effect, with the result that all too ofen one
problem is solved and another created.1 My preference is to
treat allergic conjunctivitis at its source, the ocular surface.
As I conceptualize it, ocular surface disease is a spectrum
of conditions that includes allergy, dry eye, and blepharitis.
Tese conditions can occur alone or in combination as comorbidities that can complicate diagnosis. Te significant
commonality is inflammation, which appears to drive symptom formation in all three. Tus, when seasonal allergy occurs in an eye with preexisting ocular inflammatory conditions, for example, the conditions can exacerbate each other.
LOTEPREDNOL ETABONATE FOR THE TREATMENT OF
SEASONAL ALLERGIC CONJUNCTIVITIS
Two pivotal phase III trials of loteprednol etabonate ophthalmic suspension 0.2% enrolled 133 and 135 patients, respectively.1,2
Designed to evaluate the efficacy and safety of loteprednol etabonate 0.2% in reducing the signs and symptoms of seasonal allergic conjunctivitis, both investigations were randomized, doublemasked, placebo-controlled, parallel group, multicenter studies in
which patients were given loteprednol etabonate or placebo four
times a day in both eyes for 42 days.
RESULTS Tere were no statistically significant differences between treatment groups with regard to age, sex, race, iris color, or
baseline pollen counts in either trial. With regard to safety, loteprednol etabonate and placebo were well tolerated in both trials.
In one of the phase III trials, mean intraocular pressure (IOP)
at study entry was 14.6 and 14.4 mm Hg for the loteprednol etabonate and placebo treatment groups, respectively. No patient
in either treatment group had an IOP increase of 10 mm Hg or
greater during the 6 weeks of treatment.1
In the other trial, mean IOP at study entry was 14.9 and 15.7 mm
Hg for the loteprednol etabonate and placebo treatment groups,
respectively. One patient (of 67) in the loteprednol etabonate
group and 1 of 68 in the placebo group had an IOP elevation of
10 mm Hg or greater during the 6 weeks of treatment. Cessation of
investigational therapy was sufficient to allow the IOP to decrease.2
CONCLUSION In these two phase III trials, the rate of significant IOP elevation for loteprednol etabonate ophthalmic suspension 0.2% was comparable to that of placebo.
SOURCES
1. Dell SJ, Lowry GM, Northcut JA, et al. A randomized, doublemasked, placebo-controlled parallel study of loteprednol etabonate 0.2% in patients with seasonal allergic conjunctivitis. J
Allergy Clin Immunol. 1998;102:251-5.
2. Shulman DG, Lothringer LL, Rubin JM, et al. A randomized, double-masked, placebo-controlled parallel study of loteprednol
etabonate 0.2% in patients with seasonal allergic conjunctivitis.
Ophthalmology. 1999;Feb;106(2):362-9.
Sponsored by Bausch + Lomb
2 | SEASONAL ALLERGIC CONJUNCTIVITIS
Diagnosis
It is important to be sure that the conjunctivitis is allergic in origin. Antihistamine/mast cell stabilizer combination agents are central to the treatment of ocular allergy,
but they are not known to be eTective for the treatment of
other ocular surface infiammatory conditions. ffie first step
in diagnosis is simply to ask patients: Do you have allergies?
Most who do will answer yes and describe what they take for
it—usually some oral agent. A careful history and slit lamp
examination should confirm the diagnosis.
Symptoms of allergy include itching and redness; signs
include chemosis, lid swelling, and/or tearing. It is important to rule out infection, particularly viral infection, as viral conjunctivitis and allergic conjunctivitis can sometimes
be confused. ffie patient history can be very helpful here,
as can the presence of follicles and papules, which are not
typically seen in seasonal allergy.
DOUBLE-MASKED, PLACEBO-CONTROLLED STUDY
OF LOTEPREDNOL ETABONATE FOR
SEASONAL ALLERGIC CONJUNCTIVITIS
ffiis randomized, double-masked, placebo-controlled, parallelgroup study compared loteprednol etabonate 0.2% with placebo
(vehicle) to determine the drug’s safety and efficacy for reducing
the signs and symptoms of seasonal allergic conjunctivitis. One
hundred thirty-tve patients with signs and symptoms of seasonal
allergic conjunctivitis participated in the study for a total of 6
weeks. Patients received loteprednol etabonate 0.2% or vehicle
four times a day in both eyes for 42 days. ffie primary outcome
measures were bulbar conjunctival injection and itching over the
trst 2 weeks of treatment.
RESULTS ffie data showed no statistically signitcant diTerences between treatment groups with regard to age, sex, race, iris
color, or baseline pollen counts.
Both treatment groups showed improvement in bulbar conjunctival injection. On a three-point scale used to evaluate severity
(with 0 = none and 3 = severe), the mean score for both groups
at enrollment was 2.2. At the 2-week evaluation, the loteprednol
etabonate-treated group showed a reduction in severity of 1.5
units versus 1.0 units for the placebo-treated group.
Both groups also showed improvement in itching. A four-point
scale was used to evaluate severity (with 0 = none and 4 = severe);
all patients had a +4 score at enrollment. At the 2-week evaluation,
the loteprednol etabonate-treated group showed a reduction in
itching of 3.4 units versus 3.0 units for the placebo-treated group.
In addition, the loteprednol etabonate-treated group showed
statistically signitcant improvement when compared to placebo
with regard to palpebral conjunctival injection, discomfort, erythema, and epiphora at the 2-week evaluation. No serious or unexpected adverse events were reported in either treatment group.
CONCLUSION Loteprednol etabonate 0.2% was found to
provide clinically and statistically signitcant improvement in signs
and symptoms of seasonal allergic conjunctivitis. Its safety protle
was comparable to that of placebo.
SOURCE Shulman DG, Lothringer LL, Rubin JM, et al.
Randomized, double-masked, placebo-controlled parallel study
of loteprednol etabonate 0.2% in patients with seasonal allergic
conjunctivitis. Ophthalmology. 1999;Feb;106(2):362-9.
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3 | SEASONAL ALLERGIC CONJUNCTIVITIS
Treating Seasonal Ocular Allergy
Seasonal ocular allergy symptoms begin when an antigen from the environment initiates a series of events that
eventually causes mast cells on the ocular surface to degranulate and release histamine, which triggers the itching,
redness, lid swelling, chemosis, and tearing characteristic
of ocular allergy. In conjunctival antigen challenge testing,
itching begins within 3 to 5 minutes, and the other signs
and symptoms develop afler 20 to 30 minutes.2 ffiis is the
acute, or early, phase of the allergic reaction.
Since this reaction is mast-cell mediated, the prescription of a dual-action antihistamine/mast cell stabilizer will
both block the eTects of histamine and limit its future release from mast cells. ffiese dual-acting agents are safe and
eTective, but their action is limited to the first phase of the
allergic reaction.3,4 In addition to releasing histamine, mast
cell degranulation sets oT a complex cascade of events that
mobilizes calcium stores, a key element for the activation
of phospholipase A2 and the cleaving of arachidonic acid
from cell membrane phospholipids.2
So begins a second, infiammatory, phase of the reaction. Keeping this under control requires something more
than the antihistamine/mast cell stabilizers that are effective for the early phase. I find that corticosteroids are
the most eTective agents for bringing both the early- and
late-phase allergic reactions under control. Steroids block
the infiammatory cascade at the point where it is initiated,
inhibiting phospholipase A2, thereby stymieing the creation
of arachidonic acid and preventing the formation of proinfiammatory arachidonic acid metabolites.5
While at least one nonsteroidal antiinfiammatory drug
(NSAID) is approved for use in allergic conjunctivitis,
NSAIDs don’t block the entire cascade the way corticosteroids do.5 ffius, I oflen use a topical steroid in my treatment
of seasonal ocular allergy.
My Regimen
My initial regimen for treating seasonal allergic conjunctivitis begins with an antihistamine/mast cell stabilizer.
However, since patients don’t oflen rush in at the first sign
of ocular allergy, many times I do not see a patient before
the late-phase infiammatory reaction has begun. If there
are signs of infiammation, eg, chemosis or injection, I start
the patient on a steroid.
I continue the steroid until I am confident that the infiammation has been brought under control. I find that I
use the steroid principally during the height of the patient’s
allergy season, with appropriate follow-up and safeguards
(which I will describe below).
Important Risk Information for ALREX®
Loteprendol etabonate ophthalmic suspension 0.2%
(ALREX®; Bausch + Lomb) is contraindicated in most
viral diseases of the cornea and conjunctiva including
epithelial herpes simplex keratitis (dendritic keratitis),
vaccinia, and varicella, and also in mycobacterial
infection of the eye and fungal diseases of the ocular
structures. ALREX® is also contraindicated in individuals with known or suspected hypersensitivity
to any of the ingredients of this preparation and to
other corticosteroids.
Prolonged use of ALREX® is associated with several warnings and precautions, including glaucoma
with optic nerve damage, defects in visual acuity,
cataract formation, secondary ocular infections, exacerbation or prolongation of viral ocular infections
(including herpes simplex), delay in wound healing
and increase in bleb formation.
If this product is used for 10 days or longer, intraocular pressure should be monitored. ffie initial
prescription and renewal of the medication order
beyond 14 days should be made by a physician only
afler examination of the patient with the aid of magnification. Fungal infections of the cornea may develop with prolonged use of corticosteroids.
Ocular adverse reactions occurring in 5–15% of
patients treated with loteprednol etabonate ophthalmic suspension (0.2%–0.5%) in clinical studies included abnormal vision/blurring, burning on instillation, chemosis, discharge, dry eyes, epiphora, foreign
body sensation, itching, injection, and photophobia.
Please see the brief summary regarding contraindications, warnings, precautions, and adverse
reactions on the last page..
Steroid Safety
Steroid side eTects are well known, and these drugs
must be used carefully. For treating patients with ocular
allergy, I select a steroid with an appropriate safety profile, and I follow the patients carefully. I never prescribe a
treatment regimen without having the patient return in a
short period of time for follow-up; moreover, if I am using
a steroid, I tend to follow my patients even more closely. In
addition, I usually don’t prescribe refills, thereby ensuring
the patient comes in to be checked.
ALREX® is my steroid of choice for treating seasonal
allergic conjunctivitis. ALREX® has been shown to be effective with an established safety profile for the treatment
of seasonal allergic conjunctivitis.7,8 Because loteprednol
etabonate is an ester steroid, there is a low risk of significant intraocular pressure elevation.9 In addition to the
safety profile associated with the loteprednol etabonate
molecule, the concentration of active drug in ALREX®
is relatively low. I find, however, that this concentration
is quite eTective for treating infiammation on the ocular surface.
Steroids usually make patients’ eyes feel better, and
thus patients like taking them. It’s simply human nature
that some patients will come to think that if four drops
are good, six drops will be better—despite my strong
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SEASONAL ALLERGIC CONJUNCTIVITIS | 4
MEDICAL MANAGEMENT OF ALLERGY
I think optometrists as eye physicians need to utilize all of
the agents at their disposal to help patients. When it comes to
the treatment of seasonal ocular allergy, we are fortunate to
have some excellent topical medications in both the steroid and
antihistamine/mast cell stabilizer classes.
The use of a dual-acting anti-histamine/mast cell stabilizer is
important in quelling the early phase allergic response, but we
mustn’t lose sight of the infiammatory processes that are part
of the late phase. ALREX® (loteprednol etabonate ophthalmic
suspension 0.2%) can help to reduce the level of infiammation
and provide our patients with very useful symptom reduction.
There was a time when we would not have considered using a
steroid to treat seasonal allergic conjunctivitis. With our growing
understanding of the role of infiammation in symptom formation
and the advent of ALREX®, which is approved for the treatment
of seasonal allergic conjunctivitis, thinking about steroids and
ocular allergy has undergone a sea change. We now realize that
a steroid—especially one with the safety profile of ALREX®—is
a highly appropriate option along with other medications routinely used to treat seasonal allergic conjunctivitis.
Is medicine the only way to deal with allergy? No. To some
degree, seasonal allergy symptoms can also be reduced by allergen avoidance, and I counsel patients about how to do this.
Yet at the end of the day our treatment has to fit with the reality
of our patients lives. Patients with seasonal ocular allergy simply
want to go outside and enjoy themselves. Most of them will do
this whether we prescribe something for them or not. The difference is that, if we prescribe a drop that is eTective with an
established safety profile, we render them an important and
useful service.
Marc R. Bloomenstein, OD, FAAO, is director of optometric services
at the Schwartz Laser Eye Center in Scottsdale, AZ, and adjunct assistant
professor at the Southern California College of Optometry.
References
1. Ousler GW, Wilcox KA, Gupta G, et al. An evaluation of the
ocular drying eTects of 2 systemic antihistamines: loratadine
and cetirizine hydrochloride. Ann Allergy Asthma Immunol
2004;93(5):460-4.
2. Abelson MB, Smith L, Chapin M. Ocular allergic disease: mechanisms, disease sub-types, treatment. Ocul Surf 2003;1(3):127-49.
3. Abelson MB, Gomes PJ, Pasquine T, et al. Eccacy of olopatadine
ophthalmic solution 0.2% in reducing signs and symptoms of allergic conjunctivitis. Allergy Asthma Proc 2007 Jul-Aug;28(4):427-33.
4. Whitcup SM, Bradford R, Lue J, et al. Eccacy and tolerability
of ophthalmic epinastine: a randomized, double-masked, parallel-group, active- and vehicle-controlled environmental trial
in patients with seasonal allergic conjunctivitis. Clin Ther 2004
Jan;26(1):29-34.
5. Senderowski DP, Jaanus SD. Anti-infiammatory Drugs, in Bartlett JD,
Jaanus SD. Clinical Ocular Pharmacology Fiflh edition. 2008. 221-245.
6. Acular® Package Insert. Accessed at: http://www.drugs.com/mmx/
acular.html.
7. Shulman DG, Lothringer LL, Rubin JM, et al. A randomized,
double-masked, placebo-controlled parallel study of loteprednol
etabonate 0.2% in patients with seasonal allergic conjunctivitis.
Ophthalmology 1999;106:362-9.
8. Dell SJ, Lowry GM, Northcutt JA, et al. A randomized, doublemasked, placebo-controlled parallel study of loteprednol etabonate
0.2% in patients with seasonal allergic conjunctivitis. J Allergy Clin
Immunol 1998;102:251-5.
9. Bodor N. Sofl drugs: principles and methods for the design of safe
drugs. Med Res Rev 1984 Oct-Dec;4(4):449-69.
ALREX is a registered trademark of Bausch + Lomb Incorporated.
©2011 Bausch + Lomb Incorporated.
injunction to use the medication exactly as prescribed.
Although I make a point of teaching my patients that
corticosteroids’ eccacy comes with some potential risks,
there is always the possibility of a patient who doesn’t
comply with recommended dosing. ffie steps I take
to ensure safety, and the safety profile associated with
loteprednol etabonate 0.2%, reassure me of the benefits
of using ALREX® in these patients.
To summarize, I work to ensure my patients’ safety
in several ways: I choose ALREX® because of its proven
safety profile; I instruct patients very carefully in the use
of the medication; I see my patients frequently (every 2
to 3 weeks at minimum); and I don’t prescribe refills, so
patients have no choice but to come in and be monitored.
Importance of Steroid
In the infiammatory process, mediators recruit infiammatory cells, which can release additional mediators in a
cycle that must be broken. My goal is to break the cycle,
quell the infiammation, and reduce symptoms. I choose
ALREX® (loteprendol etabonate ophthalmic suspension
0.2%) since it has a rapid and targeted action. Both its efficacy and its safety profile are well demonstrated, and its
high lipophilicity allows this topical agent to penetrate into
the ocular surface.
Sfffnsfpon sr Bedsby + Lfas
12
MARCH 2011 / Optometry Times
Pediatric Optometry
Pediatric amblyopia
Further study needed for refractive
correction and patching therapy
While shorter patching times prove effective, more research needed to develop proper therapy
By Liz Meszaros
Reviewed by Josephine O. Owoeye, OD, MPH
Baltimore—Visual acuity and amblyopia can be
improved by refractive correction and patching in children with unilateral amblyopia, said
Josephine O. Owoeye, OD,
MPH, here at the third annual Evidence Based Care
in Myopia Control, Retina
and Vision Enhancement
meeting of The Wilmer Eye
Institute, held in conjuncDr. Owoeye
tion with the Maryland Optometric Association.
The proper treatment for amblyopia and
anisometropic amblyopia in children is as yet
unknown, but researchers of several trials
have tried to determine the role of refractive
correction, patching, and atropine, said Dr.
Owoeye, who is clinical associate and pediatric optometrist, The Wilmer Eye Institute,
Johns Hopkins School of Medicine, Baltimore.
Take-Home Message
In children with unilateral amblyopia, effective
treatment has yet to be defined. Data from two
amblyopia treatment studies (ATS 3 and ATS 5) show
that both patching and refractive correction are helpful
in these patients.
“Amblyopia can be treated in children
ages 7 to 12. Patching can be an appropriate treatment for amblyopia in children 13
to 17, especially if the amblyopia has never
been treated,” said Dr. Owoeye. “In addition,
visual acuity can improve with spectacles
alone, and you may not need to patch at all
in some cases. If visual acuity improves with
spectacles first, amblyopia treatment may be
tolerated better, if needed.”
ATS 2a trial
The Amblyopia Treatment Study (ATS) 2a
trial was a randomized, controlled trial comparing full-time patching during all hours or
all but 1 hour per day to 6 hours of patching
per day for children younger than 7 years
(n=175) with severe amblyopia (20/100 to
20/400). In addition to patching, all children
had at least 1 hour of near-visual activities
while patched.
In both groups, visual acuity in the amblyopic eye improved similarly. Average line
improvement in this eye, from baseline, was
4.7 lines in the full-time patching group, and
4.8 lines in the 6-hour patching group.
“Six hours of daily patching and full-time
patching produce similar improvements in
visual acuity in treating severe amblyopia
in children 3 to less than 7 years of age,”
Dr. Owoeye said. “Children may have better
compliance to treatment with shorter patching times,” she added.
Improvements in visual acuity
Two hours of daily patching and 6 hours of
daily patching produce a similar magnitude
of visual acuity improvement, when combined with 1 hour of near-visual activities
in treating moderate amblyopia in children 3
to 7 years old, continued Dr. Owoeye. These
results were based on the ATS 2b trial, in
which researchers compared 2 hours of daily
patching with 6 hours of daily patching in
children younger than 7 years with moderate amblyopia (20/40 to 20/80).
The primary outcome in this trial, which
lasted for 4 months, was visual acuity in the
amblyopic eye.
In both groups again, visual acuity in the
amblyopic eye improved similarly, with an
average improvement from baseline of 2.40
lines. At 4 months, ≥20/32 or a ≥3-line improvement were seen in 62% of each group.
ATS 3
Researchers of the Amblyopia Treatment Study
(ATS) 3 trial assessed the efficacy of amblyopia
treatment (20/40 to 20/400) in children aged
7 to 17 years (n=507). Treatment consisted
of optimal optical correction for all children.
A control group received optical correction
only, while a treatment group received optical correction, patching with near activities,
and atropine for children less than 13 years
old. Responders were considered those children in whom visual acuity improved by 10
or more letters (≥2 lines) by 24 weeks.
In children aged 7 to 12 years (n=404),
53% of children treated with optical correction, patching, and atropine were responders,
compared with 25% of those who received
optical correction only. In children aged 13
to 17 years (n=103), the corresponding responder rates were 25% and 23%, respectively.
Among patients who had not had previous treatment with either patching or atropine, however, 47% of the treatment group
and 20% in the optical correction group were
responders.
Treatment outcomes
Researchers of this trial concluded:
• Amblyopia improves with optical correction alone in about 25% of patients aged 7 to
17 years. Most will require additional treatment, however, because of residual deficits
in visual acuity.
• In patients aged 7 to 12 years, 2 to 6
hours per day of patching, combined with
near-visual activities and atropine can improve visual acuity, even if the child’s amblyopia has been previously treated.
• In patients aged 13 to 17 years, 2 to 6 hours
of patching per day with near-visual activities may improve visual acuity if amblyopia
has not been previously treated. Treatment
may be of little benefit if amblyopia was previously treated with patching.
• It is unclear if this improvement in visual acuity will be sustained once treatment
is discontinued.
• Follow-up is needed.
The primary outcome in this trial was maximum improvement in visual acuity in the amblyopic eye and proportion of children whose
amblyopia resolved (inter-ocular difference
of ≤1 line) with refractive correction alone.
Amblyopia improved with corrected by
≥2 lines in 77% of patients, and resolved in
27%. Improvement took about 30 weeks for
stabilization criteria to be met.OP
FYI
Josephine O. Owoeye, OD, MPH
Phone: 410/955-5650
E-mail: [email protected]
Dr. Owoeye did not indicate a financial interest in the
subject.
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MARCH 2011 / Optometry Times
14
Investigators apply CL technologies
to tackle myopia progression
Manipulation of diverse optical approaches is the path researchers hope will lead to control
By Cheryl Guttman Krader
Reviewed by Pete Kollbaum, OD, PhD
San Francisco—Recent commercial advances
in contact lens (CL) optics have centered primarily on presbyopia correction, but the control of myopia progression with novel CL designs potentially represents an even bigger
consumer market, said Pete Kollbaum, OD,
PhD, at the annual meeting
of the American Academy
of Optometry.
“Research investigating
different methodologies to
control myopia progression
by manipulating optics has
Dr. Kollbaum
been ongoing for 2 decades
or longer. However, there
has been a recent resurgence of interest in
this area as a result of the primate work by
Smith and colleagues (2005, 2007),” said Dr.
Kollbaum, assistant professor, Indiana University School of Optometry, Bloomington.
Dr. Kollbaum told Optometry Times, “The
outcome of these studies is that the peripheral
retina may be more responsible for the regulation of eye growth than previously thought.
This finding has lead to several studies evaluating potential CL technologies and even the
manufacture of a commercially available soft
CL in Asia (CooperVision MiSight) designed
to slow myopic progression.”
Anecdotal evidence
There have been several anecdotal reports
of some success with multi-zone or bifocal
CLs in controlling myopic progression. In one
such report, Aller and Wildsoet reported on
a pair of identical twins with near esophoria in which use of bifocal CLs in one twin
reduced myopia progression by roughly 1 D
in 1 year.1
This approach is based on the theory that
reduction of near esophoria increases accommodative accuracy, leading to decreased lag
of accommodation, decreased hyperopic defocus, and ultimately a reduced stimulus for
ocular growth, he explained.
In a larger unpublished, prospective, 12month, double-masked, randomized, controlled
study with 78 subjects aged 8 to 18 years,
Aller et al. (2006) achieved similarly promising results with bifocal soft CLs. Compared
Take-Home Message
Various approaches to contact lens designs, based
on optical and mechanical mechanisms, are being
investigated as a means to control myopia progression.
with the control subjects wearing single vision
soft CLs, the subjects fitted with bifocal soft
CLs had roughly 0.5 D less increase in refractive error and almost 0.2 mm less increase in
axial length. Data from a subset of 47 of these
patients wearing the bifocal soft CLs followed
for an additional 2 years showed only minimal change in refraction (<0.25 D) and axial
length (<0.1 mm) over the longer follow-up.
Playing with design
Other optical approaches aimed at reducing
myopia progression are designed to optimally
correct vision within the central pupil while
also moving the peripheral image from behind the retina onto or in front of it.
One series of such designs from Holden,
Ho, Sankaridurg, Aller, and Smith (US
2007/0296916) provides optical correction
for distance within a central zone that is
approximately the size of the pupil and has
a higher-power peripheral zone that curves
or shifts the focus of the oblique rays forward
onto or in front of the peripheral retina. This
technology has been licensed to CIBA Vision
for use in CLs and to Zeiss for use in spectacle lenses (MyoVision).
“Zeiss reports that a study of the spectacle
lenses at Sun Yet-Sen University, in China,
found this design reduced myopia progression by 30% in a series of young children,”
Dr. Kollbaum said.
Dual focus, alternating zones
John Phillips, MCOptom, PhD, at the University
of Auckland in New Zealand, created a similar optical design (WO 2008/11856) that has
been licensed to CooperVision and is currently
commercially available in a soft CL product
sold in Hong Kong (MiSight, CooperVision).
This dual-focus lens contains several alternating zones providing central distance and
near correction, and zones at the pupil margin
designed to induce myopic retinal defocus.
Preliminary data from a study investigating this lens design was presented at the 2010
meeting of the Association for Research in Vision and Ophthalmology (Phillips and Anstice,
2010).2 The trial enrolled 40 children aged 11
to 14 years who wore a single vision lens in
one eye and the dual-focus lens in the other
eye for 10 months before crossover to the alternate lens. After the first 10 months, the
eye with the dual-focus lens had roughly 0.25
D less change in refraction and 0.1 mm less
increase in axial length compared with the
single vision eye. At the end of the crossover
period, the eye previously corrected with the
dual-focus lens caught up with the fellow eye.
‘The peripheral retina
may be more responsible
for the regulation of eye
growth than previously
thought. This finding has
lead to several studies
evaluating potential CL
technologies.’
Pete Kollbaum, OD, PhD
In an earlier study, Dr. Phillips investigated
the idea that monovision may slow progression of juvenile myopia by decreasing the
amount of required accommodation.3 The trial
enrolled 18 children aged 11 years old with
-1.0 D to -3.0 D of myopia. The participants
had normal ocular health and binocularity,
wore distance correction on the dominant
eye, and had their non-dominant eye uncorrected or corrected to maintain a maximum
2 D imbalance between eyes.
Monovision-type defocus
Although these researchers did not find that
monovision correction effectively controlled
the progression of myopia in both eyes, the
results supported the efficacy of monovisiontype defocus for slowing myopic progression
MARCH 2011 / OptometryTimes.com
unilaterally in near-corrected eyes, because
there was a 0.36 D per year inter-eye difference in refractive change and 0.13 mm per
year inter-eye difference in vitreous chamber depth favoring the near corrected eye.
However, researchers investigating bilateral
undercorrection in myopic children failed
to observe any benefit, Dr. Kollbaum said.
Undercorrection, corneal reshaping
“The fact that unilateral undercorrection and
bilateral undercorrection yield different results
could be a result of the fact that bilateral undercorrection causes myopic defocus at distance in both eyes, but clear retinal images at
near, whereas in monovision with unilateral
undercorrection, the non-dominant eye may
receive constant undercorrection at distance
and near,” said Dr. Kollbaum.
A group from Queensland University of Technology has designed a unique CL for controlling myopia progression (US 2000/6045578).
This design aims to exert a force on the cornea via the eyelids pressing on elevated areas
of the lens when the eye focuses at near, Dr.
Kollbaum said.
For reasons similar to those described for
some of the soft CLs discussed above, during
15
the past decade there also has been interest
in using corneal reshaping CLs to control
myopia progression. In a prospective Corneal Reshaping And Yearly Observation of
Nearsightedness (CRAYON) study, Walline et
al demonstrated this approach to hold some
promise.4
In the CRAYON study, 28 children ages 8
to 11 years old who were existing CL wearers wore corneal reshaping CLs for 2 years.
Compared with an age-matched control group
wearing soft CLs for spherical error correction only, the children wearing the corneal
reshaping lenses had an increase in axial
length of about 0.22 mm less than the children
wearing the soft CLs. These results are quite
similar to those reported in another largescale study on corneal reshaping in controlling the progression of myopia.5
In conclusion, Dr. Kollbaum said “The studies discussed here are a sampling of the research that is progressing in this area. Much
work is still needed to rigorously evaluate the
long-term effectiveness of many of these approaches. However, there appears to be hope
that some retardation of the progression of
myopia may be possible with some type of
CL correction.”OP
References
1. Aller TA, Wildsoet C. Bifocal soft contact
lenses as a possible myopia control
treatment: a case report involving identical
twins. Clin Exp Optom. 2008 Jul;91(4):394-9.
2. Phillips JR, Anstice NS. Myopic Retinal
Defocus With a Simultaneous Clear Retinal
Image Slows Childhood Myopia Progression.
Poster presentation: 2010 annual meeting
of the Association for Research in Vision and
Ophthalmology. May 3, 2010.
3. Phillips JR. Monovision slows juvenile myopia
progression unilaterally. Br J Ophthalmol.
2005 Sept;89(9):1196-200.
4. Walline JJ, Jones LA, Sinnott LT. Corneal
reshaping and myopia progression. Br J
Ophthalmol. 2009 Sep;93(9):1181-5.
5. Cho P, Cheung SW, Edwards M. The
longitudinal orthokeratology research in
children (LORIC) in Hong Kong: a pilot study
on refractive changes and myopic control.
Curr Eye Res. 2005 Jan;30(1):71-80.
FYI
Pete Kollbaum, OD, PhD
E-mail: [email protected]
Dr. Kollbaum has received recent research funding from
Alcon, Ciba Vision, CooperVision, and Vistakon.
Getty Images/Somos/Veer
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MARCH 2011 / Optometry Times
16
Study documents comfort, safety of
SiH DD compared with spectacle wear
New silicone hydrogel daily disposable lens provides comfort, even in CL-naïve users
By Cheryl Guttman Krader
Reviewed by Jeffrey J. Walline, OD, PhD
San Francisco—Results from a prospective, randomized study seem to dispel the myth that
comfort and physiology may affect patients
who are initiating contact lens (CL) wear, said
Jeffrey J. Walline, OD, PhD, here at the American Academy of Optometry’s
annual meeting.
Dr. Walline and fellow
researchers randomized 98
eligible patients aged 15 to
39 years to continue wearing their spectacles or begin
wearing the first marketed
Dr. Walline
silicone hydrogel daily disposable (SiH DD) lens in the United States
(narafilcon B, 1-DAY ACUVUE TruEye, Johnson & Johnson Vision Care Inc.). All patients
self-rated comfort after 1 week and 1 month.
Take-Home Message
A total of 94 patients with no history of contact lens
(CL) wear were randomized to continue wearing their
spectacles or initiate wear of the new daily disposable
silicone hydrogel CL (narafilcon B; 1-DAY ACUVUE
TruEye, Vistakon). Comfort and ocular physiology were
similar between CL and spectacle wearers.
able late in the day. However, after 1 month
of wear, comfort was comparable between the
two groups, which suggests that there may
be a slight adaptation when adjusting to CL
wear, said Dr. Walline, assistant professor,
Ohio State University College of Optometry,
Columbus.
Analysis of the collected physiology data
noted statistical equivalence at a 99% confidence level for corneal vascularization, conjunctival hyperemia, limbal hyperemia and
corneal staining at the 6-month visit. Conjunctival staining and papillary conjunctiEarly findings
vitis were greater in the CL wearers at the
In addition, ocular findings on slit-lamp exami- 6-month interval.
nation—corneal vascularization, conjunctival
For CL wearers, the mean conjunctival stainhyperemia, limbal hyperemia, corneal stain- ing grade was 1.2 (trace) out of 4.0 and the
ing, papillary conjunctivitis—were graded in mean papillary score was 0.7 (trace) out of
0.1 increments using the Efron grading scale 4.0. These levels are considered clinically in(0 = none, 4 = severe) after 2 weeks and 1, significant and no subjects discontinued due
3, and 6 months by investigators masked to to the findings (see Figure 1).
study assignment.
“Most studies investigating new CLs will
After 1 week of CL wear, results showed include patients wearing another CL as the
that spectacles were slightly more comfort- comparator group. Our study design using
spectacle wearers as the con4.0
trol is unique and allows us
to address the assumptions
3.5
Contact Lens
that CLs are not as comfort3.0
Spectacle
able as spectacle wear and
2.5
may compromise the ocular
surface,” said Dr. Walline.
2.0
“The findings from our
1.5
study show that even in patients with no history of [CL]
1.0
wear, this new [SiH DD CL],
0.5
which combines oxygen trans0.0
missibility with the convePapillae
Conjunctival Limbal redness Conjunctival
nience of single use, is assoredness
staining
ciated with similar comfort
and ocular physiology comFigure 1 Average score for ocular physiology at the 6-month visit, based
pared with spectacle wear.”
on a 0 to 4 scale. Corneal vascularization is not included due to extremely
Dr. Walline noted that while
low average scores. Papillae and conjunctival staining were statistically
the results of this study cangreater for CL wearers, but the average score was not clinically
meaningful. (Graph provided by Jeffrey J. Walline, OD, PhD.)
not be directly generalized to
other CL products, the performance of other
SiH DD CLs may be similar.
“Such studies have yet to be conducted,”
he said.
Study methods
Patients were eligible for participation in the
randomized study if they had -0.50 to -6.00
D distance correction and no more than 0.75
D of astigmatism on non-cycloplegic manifest refraction. Of the 94 subjects enrolled, 46
were randomized to CLs and 48 to continue
with their own spectacles. The 1-month visit
was completed by 43 CL wearers (3 patients
could not insert the lens) and 48 patients in
the spectacle group, and 34 CL wearers and 40
spectacle wearers were evaluated at 6 months.
“The statistical analysis was designed to establish equivalence between groups, defined
as a difference in scores of 0.5 units or less,
and according to sample size calculations, 66
subjects were needed to have 80% power for
establishing equivalence for comfort and the
physiology parameters. Therefore, the lack of
differences between groups in the various endpoints is not due to insufficient study power,”
Dr. Walline said.
Ratings of comfort were obtained by text
messaging with patients asked to submit the
data every 3 hours from 9:00 a.m. to 9:00 p.m.
over a period of several days at around 1 week
and 1 month after randomization.
“Our use of text messaging to obtain patient’s subjective reports of comfort is another
novel aspect of this study. In contrast to diaries or interviews that ask patients to recall
prior experience, text messaging provides realtime data,” he noted.
“There were also no statistically significant differences in visual acuity between CL
wearers and spectacle wearers at any visit,”
said Dr. Walline.OP
FYI
Jeffrey J. Walline, OD, PhD
E-mail: [email protected]
Dr. Walline is a paid consultant for Johnson & Johnson
Vision Care Inc. The study was supported by Vistakon, a
division of Johnson & Johnson Vision Care.
MARCH 2011 / Optometry Times
18
Best of both worlds
MPS delivers potency of hydrogen
peroxide in safe, efficacious product
Study shows new product reduces adverse events, effectively cleans multiple lens types
By Ron Rajecki
Reviewed by Nick Tarantino, OD
Santa Ana, CA—A multi-purpose solution (MPS)
for disinfecting contact lenses, based on a
propriety combination of alexidine dihydrochloride and polyquaternium-1 (Complete RevitaLens OcuTec Multi-Purpose Disinfecting Solution,
Abbott Medical Optics Inc.),
provided robust disinfection with a variety of soft
contact lenses, not unlike
the disinfection provided
Dr. Tarantino
by a solution comprised of
polyquaternium-1 and myristamidopropyl dimethylamine (Opti-Free
Replenish Multi-Purpose Disinfecting Solution, Alcon Laboratories), but with fewer adverse events.
Those were the findings of a 6-month,
double-masked, parallel group study of 270
patients that built upon 3-month results reported in a poster at the British Contact Lens
Association.1, 2
Take-Home Message
In a recent trial, a multi-purpose contact lens
disinfecting solution based on a proprietary
combination of alexidine dihydrochloride and
polyquaternium-1 (RevitaLens OcuTec Multi-Purpose
Disinfecting Solution, Abbott Medical Optics Inc.) was
found to safely and effectively clean five different
types of soft contact lenses.
FDA Group IV materials. The patients were
instructed to use the solutions on their habitual lenses according to the recommended
label directions. The test solution is a ruband-rinse solution, while the control solution is a no-rub solution. Patients were followed for 180 days, with follow-up visits at
days 7, 30, 90, and 180.
The lenses were assessed for cleanliness
by computer-measured light reflectance from
the lens surface with dark field microscopy.
The patients also were examined for corneal
staining and asked to subjectively rate overall lens comfort.
Impact of adverse events
‘It’s quite satisfying to
see a lens product work
as well as this one on so
many different types of
lenses.’
Nick Tarantino, OD
Patients were randomly assigned to receive
one of the two solutions according to a predetermined schedule. Two patients were assigned to receive the alexidine dihydrochloride and polyquaternium-1 solution (the test
solution) for every patient that was assigned
to receive the polyquaternium-1 and myristamidopropyl dimethylamine solution (control).
The patients all wore soft contact lenses
made of one of these materials: galyfilcon A,
balafilcon A, lotrafilcon B, comfilcon A, or any
The researchers found no statistically significant differences between any of the five
types of lenses cleaned with either of the
two solutions. The only exception was a
lower light reflectivity—indicating a cleaner
lens—with the control solution on balafilcon A lenses, which was a statistically but
not clinically significant difference. There
was no difference between the two solutions in corneal staining change from baseline (p=0.320) and subjective overall lens
comfort change from baseline (p=0.509).
Adverse events were more common in the
control group than in the test group. At the
3-month visit, adverse events were reported
in 11.8% of the patients using the control
solution and 2.8% of the patients using the
test solution. At the 6-month visit, adverse
events were reported in 12.9% of the patients using the control solution and 3.4%
of the patients using the test solution. These
differences were statistically significant at
both the 3-month (p=0.005) and 6-month
(p=0.004) visits.
The adverse events were reported and clas-
sified by the principal investigators. There
were a total of 6 events in the test group
and 19 in the control group. These events
included suspected viral conjunctivitis, corneal infiltrates, peripheral ulcers, giant papillary conjunctivitis, and corneal erosions.
All the events were classified by etiology:
related to the solution, of uncertain etiology, or not related to the solution. Many of
the adverse events were reported to be of
uncertain etiology.
‘Our goal was to provide
in a [MPS] all of the best
qualities of hydrogen
peroxide . . . with
convenience for all kinds
of soft contact lenses.’
Nick Tarantino, OD
“[The alexidine dihydrochloride and polyquaternium-1 test solution] is a highly effective dual-disinfectant soft lens care solution, with a kill rate exceeding the standard
requirements with both panel organisms as
well as clinical isolates,” the researchers
wrote. “It is therefore remarkable that this
potent multi-purpose disinfecting solution
has also been found to be gentle to ocular
tissue and acceptably comfortable for patient use on a daily basis with all lenses,
including silicone hydrogels.”
Creating a universal product
Nick Tarantino, OD, global head of clinical
research and development, Abbott Medical
Optics (AMO), told Optometry Times that
the company’s goal was to create a solution
that virtually any soft lens wearer can use.
“The goal in formulating this product was
really to save the clinician from having to
See MPS trial on page 20
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1
Indication: LUMIGAN® 0.01% and 0.03% (bimatoprost ophthalmic solution)
is indicated for the reduction of elevated intraocular pressure in
patients with open-angle glaucoma or ocular hypertension.
Important Safety Information
Warnings and Precautions: Pigmentation: Bimatoprost ophthalmic
solution has been reported to cause changes to pigmented
tissues: most frequently, increased pigmentation of the
iris, eyelid, and eyelashes. Increases are expected as long as
bimatoprost is administered. Iris color change may not be
noticeable for several months to years. After discontinuation of
bimatoprost, iris pigmentation is likely to be permanent, while
eyelid and eyelash changes have been reported to be reversible
in some patients. Patients should be informed of the possibility
of increased pigmentation. The long-term effects of increased
pigmentation are not known.
Intraocular Inflammation: LUMIGAN® 0.01% and 0.03%
should be used with caution in patients with active intraocular
inflammation (eg, uveitis) because the inflammation may be
exacerbated.
Macular Edema: Macular edema, including cystoid macular
edema, has been reported during treatment with bimatoprost
ophthalmic solution. LUMIGAN® 0.01% and 0.03% should be used
with caution in aphakic patients, in pseudophakic patients with a
torn posterior lens capsule, or in patients with known risk factors for
macular edema.
Adverse Reactions: In clinical studies with bimatoprost ophthalmic
solutions (0.01% or 0.03%), the most common adverse event was
conjunctival hyperemia (range 25%-45%). Approximately 0.5% to 3% of
patients discontinued therapy due to conjunctival hyperemia with 0.01%
or 0.03% bimatoprost
ophthalmic solutions.
Other common events
(> 10%) included growth of
eyelashes and ocular pruritus.
Please see brief prescribing
information on adjacent page.
1. LUMIGAN 0.01% and 0.03% Prescribing Information.
®
Visit us at www.lumigan.com
©2011 Allergan, Inc., Irvine, CA 92612
®
marks owned by Allergan, Inc. APC50EX11 107999
LUMIGAN 0.01% AND 0.03%
(bimatoprost ophthalmic solution)
MARCH 2011 / Optometry Times
®
INDICATIONS AND USAGE
LUMIGAN® 0.01% and 0.03% (bimatoprost ophthalmic solution) is indicated for the reduction of elevated intraocular pressure in patients with open
angle glaucoma or ocular hypertension.
CONTRAINDICATIONS
None
WARNINGS AND PRECAUTIONS
Pigmentation: Bimatoprost ophthalmic solution has been reported to cause changes to pigmented tissues. The most frequently reported changes
have been increased pigmentation of the iris, periorbital tissue (eyelid), and eyelashes. Pigmentation is expected to increase as long as bimatoprost
is administered. The pigmentation change is due to increased melanin content in the melanocytes rather than to an increase in the number of
melanocytes. After discontinuation of bimatoprost, pigmentation of the iris is likely to be permanent, while pigmentation of the periorbital tissue
and eyelash changes have been reported to be reversible in some patients. Patients who receive treatment should be informed of the possibility
of increased pigmentation. The long-term effects of increased pigmentation are not known.
Iris color change may not be noticeable for several months to years. Typically, the brown pigmentation around the pupil spreads concentrically
towards the periphery of the iris and the entire iris or parts of the iris become more brownish. Neither nevi nor freckles of the iris appear to be
affected by treatment. While treatment with LUMIGAN® 0.01% and 0.03% (bimatoprost ophthalmic solution) can be continued in patients who
develop noticeably increased iris pigmentation, these patients should be examined regularly.
Eyelash Changes: LUMIGAN® 0.01% and 0.03% may gradually change eyelashes and vellus hair in the treated eye. These changes include
increased length, thickness, and number of lashes. Eyelash changes are usually reversible upon discontinuation of treatment.
Intraocular Inflammation: LUMIGAN® 0.01% and 0.03% should be used with caution in patients with active intraocular inflammation (eg, uveitis)
because the inflammation may be exacerbated.
Macular Edema: Macular edema, including cystoid macular edema, has been reported during treatment with bimatoprost ophthalmic solution.
LUMIGAN® 0.01% and 0.03% should be used with caution in aphakic patients, in pseudophakic patients with a torn posterior lens capsule, or in
patients with known risk factors for macular edema.
Angle-closure, Inflammatory, or Neovascular Glaucoma: LUMIGAN® 0.01% and 0.03% has not been evaluated for the treatment of angleclosure, inflammatory, or neovascular glaucoma.
Bacterial Keratitis: There have been reports of bacterial keratitis associated with the use of multiple-dose containers of topical ophthalmic
products. These containers had been inadvertently contaminated by patients who, in most cases, had a concurrent corneal disease or a disruption
of the ocular epithelial surface.
Use With Contact Lenses: Contact lenses should be removed prior to instillation of LUMIGAN® 0.01% and 0.03% and may be reinserted 15
minutes following its administration.
ADVERSE REACTIONS
Clinical Studies Experience: Because clinical studies are conducted under widely varying conditions, adverse reaction rates observed in the
clinical studies of a drug cannot be directly compared to rates in the clinical studies of another drug and may not reflect the rates observed
in practice.
In clinical studies with bimatoprost ophthalmic solutions (0.01% or 0.03%), the most common adverse event was conjunctival hyperemia (range
25%-45%). Approximately 0.5% to 3% of patients discontinued therapy due to conjunctival hyperemia with 0.01% or 0.03% bimatoprost ophthalmic
solutions. Other common events (> 10%) included growth of eyelashes and ocular pruritus.
Additional ocular adverse events (reported in 1% to 10% of patients) with bimatoprost ophthalmic solutions included ocular dryness, visual
disturbance, ocular burning, foreign body sensation, eye pain, pigmentation of the periocular skin, blepharitis, cataract, superficial punctate
keratitis, eyelid erythema, ocular irritation, eyelash darkening, eye discharge, tearing, photophobia, allergic conjunctivitis, asthenopia, increases
in iris pigmentation, conjunctival edema, conjunctival hemorrhage, and abnormal hair growth. Intraocular inflammation, reported as iritis, was
reported in less than 1% of patients.
Systemic adverse events reported in approximately 10% of patients with bimatoprost ophthalmic solutions were infections (primarily colds and
upper respiratory tract infections). Other systemic adverse events (reported in 1% to 5% of patients) included headaches, abnormal liver function
tests, and asthenia.
USE IN SPECIFIC POPULATIONS
Pregnancy: Pregnancy Category C.
Teratogenic effects: In embryo/fetal developmental studies in pregnant mice and rats, abortion was observed at oral doses of bimatoprost that
achieved at least 33 or 97 times, respectively, the maximum intended human exposure based on blood AUC levels.
At doses at least 41 times the maximum intended human exposure based on blood AUC levels, the gestation length was reduced in the dams, the
incidence of dead fetuses, late resorptions, peri- and postnatal pup mortality was increased, and pup body weights were reduced.
There are no adequate and well-controlled studies of LUMIGAN® 0.01% and 0.03% (bimatoprost ophthalmic solution) administration in pregnant
women. Because animal reproductive studies are not always predictive of human response, LUMIGAN® should be administered during pregnancy
only if the potential benefit justifies the potential risk to the fetus.
Nursing Mothers: It is not known whether LUMIGAN® 0.01% and 0.03% is excreted in human milk, although in animal studies, bimatoprost
has been shown to be excreted in breast milk. Because many drugs are excreted in human milk, caution should be exercised when LUMIGAN®
is administered to a nursing woman.
Pediatric Use: Use in pediatric patients below the age of 16 years is not recommended because of potential safety concerns related to increased
pigmentation following long-term chronic use.
Geriatric Use: No overall clinical differences in safety or effectiveness have been observed between elderly and other adult patients.
Hepatic Impairment: In patients with a history of liver disease or abnormal ALT, AST, and/or bilirubin at baseline, bimatoprost 0.03% had no
adverse effect on liver function over 48 months.
OVERDOSAGE
No information is available on overdosage in humans. If overdose with LUMIGAN® 0.01% and 0.03% (bimatoprost ophthalmic solution) occurs,
treatment should be symptomatic.
In oral (by gavage) mouse and rat studies, doses up to 100 mg/kg/day did not produce any toxicity. This dose expressed as mg/m2 is at least 70
times higher than the accidental dose of one bottle of LUMIGAN® 0.03% for a 10-kg child.
NONCLINICAL TOXICOLOGY
Carcinogenesis, Mutagenesis, Impairment of Fertility: Bimatoprost was not carcinogenic in either mice or rats when administered by oral
gavage at doses of up to 2 mg/kg/day and 1 mg/kg/day respectively (at least 192 and 291 times the recommended human exposure based on
blood AUC levels respectively) for 104 weeks.
Bimatoprost was not mutagenic or clastogenic in the Ames test, in the mouse lymphoma test, or in the in vivo mouse micronucleus tests.
Bimatoprost did not impair fertility in male or female rats up to doses of 0.6 mg/kg/day (at least 103 times the recommended human exposure
based on blood AUC levels).
PATIENT COUNSELING INFORMATION
Potential for Pigmentation: Patients should be advised about the potential for increased brown pigmentation of the iris, which may be
permanent. Patients should also be informed about the possibility of eyelid skin darkening, which may be reversible after discontinuation of
LUMIGAN® 0.01% and 0.03% (bimatoprost ophthalmic solution).
Potential for Eyelash Changes: Patients should also be informed of the possibility of eyelash and vellus hair changes in the treated eye during
treatment with LUMIGAN® 0.01% and 0.03%. These changes may result in a disparity between eyes in length, thickness, pigmentation, number of
eyelashes or vellus hairs, and/or direction of eyelash growth. Eyelash changes are usually reversible upon discontinuation of treatment.
Handling the Container: Patients should be instructed to avoid allowing the tip of the dispensing container to contact the eye, surrounding
structures, fingers, or any other surface in order to avoid contamination of the solution by common bacteria known to cause ocular infections.
Serious damage to the eye and subsequent loss of vision may result from using contaminated solutions.
When to Seek Physician Advice: Patients should also be advised that if they develop an intercurrent ocular condition (e.g., trauma or infection),
have ocular surgery, or develop any ocular reactions, particularly conjunctivitis and eyelid reactions, they should immediately seek their physician’s
advice concerning the continued use of LUMIGAN® 0.01% and 0.03%.
Use with Contact Lenses: Patients should be advised that LUMIGAN® 0.01% and 0.03% contains benzalkonium chloride, which may be
absorbed by soft contact lenses. Contact lenses should be removed prior to instillation of LUMIGAN® and may be reinserted 15 minutes following
its administration.
Use with Other Ophthalmic Drugs: If more than one topical ophthalmic drug is being used, the drugs should be administered at least five (5)
minutes between applications.
Rx only
© 2010 Allergan, Inc., Irvine, CA 92612
marks owned by Allergan, Inc. APC26XC10 based on 71807US11X.
®
MPS trial
Continued from page 18
choose between hydrogen peroxide and a
[MPS],” Dr. Tarantino said. “In the past, when
a patient developed a hypersensitivity to a
[MPS], the clinician would usually switch
him or her to hydrogen peroxide. Our goal
was to not force them to make that choice.
Our goal was to provide in a [MPS] all of the
best qualities of hydrogen peroxide, including high kill rates, low adverse events, good
comfort, and good cleaning with convenience
for all kinds of soft contact lenses.”
Although rigid gas permeable lenses were
not included in this study, Dr. Tarantino said
there’s no reason to believe that the alexidine dihydrochloride and polyquaternium-1
solution would not be suitable for cleaning
those lenses.
The solution was formulated to pass all
no-rub use criteria, he added, but AMO is
labeling their product with rub-and-rinse
instructions, based on guidance from clinicians, regulatory agencies, and professional
societies that assert rub-and-rinse as the safest and most efficacious means of cleaning
contact lenses.
Dr. Tarantino said there is a certain pride
that comes from crafting an effective and
safe lens cleaning solution—a task that he
feels is occasionally taken for granted by the
industry.
“It’s a huge challenge,” he said. “It’s a product that must kill all microbiological organisms while maintaining the well-being of the
corneal epithelium and the ocular tissues, be
formulated at a pH that will maintain stability over long periods of time, and work for all
types of lenses. It’s quite satisfying to see a
lens product work as well as this one on so
many different types of lenses.”OP
References
1. Tarantino N, Kao E, Huang LC, Ziegler DA. A
clinical safety and acceptability evaluation of
a novel multi-purpose disinfecting solution.
Poster presentation: 34th British Contact Lens
Association Annual Clinical Conference and
Exhibition; May 27-30, 2010; Birmingham, UK.
2. Tarantino N, Kao E. A six-month clinical
evaluation of the safety and acceptability of
a novel multi-purpose disinfecting solution.
Poster presentation: 88th Annual American
Academy of Optometry Meeting; November
17-29, 2010; San Francisco, CA.
FYI
Nick Tarantino, OD
Phone: 714/247-8613
E-mail: [email protected]
Dr. Tarantino is an employee of Abbott Medical Optics.
MARCH 2011 / OptometryTimes.com
21
Piggyback lenses
‘A good option is to
Continued from page 1
simply slide a soft lens
prevent recurrent apical erosions, which may
lead to scarring.
“A piggyback system is easy to try in your
office,” Dr. Malooley said. “Patients can give
you immediate feedback, and they’re usually
very impressed by the comfort and quality
of vision piggybacks provide. Plus, they typically are able to continue using their current RGP lens.”
Modern improvements
Silicone hydrogel and daily disposable soft contact lenses make piggybacks a much healthier
option today than they may have been in the
past. “With the new soft lenses, the chance of
an infection or a hypoxic issue is very much
minimized,” Dr. Faron said.
Fitting patients with piggyback lenses isn’t
difficult, he added. “You just use the basic
principles of reading fluorescein patterns,
as we do with normal RGPs, and extrapolate
those to the lenses used.”
Dr. Malooley noted that optometry schools
have traditionally taught students not to use
fluorescein staining with soft lenses, but disposable lenses have diminished that concern.
“Back when patients kept their soft lenses
for a year, you didn’t want to put fluorescein on
them, but that’s not much of an issue today,”
she said. “However, if you’re still concerned
about using fluorescein with soft lenses, you
can always read the fluorescein pattern of
the gas permeable lens on the cornea and
‘Patients can give you
immediate feedback,
and they’re usually very
impressed by the comfort
and quality of vision
piggybacks provide. Plus,
they typically are able
to continue using their
current RGP lens.’
Marsha M. Malooley, OD, FAAO
underneath a well-fit
RGP and then follow [the
patient] carefully to see
Take-Home Message
Piggybacking lenses—adding a soft contact lens
underneath a rigid gas permeable lens (RGP) in
keratoconus patients who are experiencing discomfort
with their RGP lenses—is an underused and effective
modality. Piggyback lenses protect the epithelium and
help prevent recurrent apical erosions and scaring,
dramatically increase patient comfort, and provide the
vision quality the patient has come to expect from his
or her RGP lens.
how they do.’
Chuck Faron, OD
then add the soft lens and look for different
characteristics to see if it’s a good fit as well.”
Fitting techniques
Dr. Malooley added that when fitting piggyback lenses, it’s best to ensure that the edge
of the gas permeable lens is slightly flatter
than it is in a non-piggyback application.
“Err on the side of having a little bit flatter
peripheral curve,” she said. “If it’s too tight
it can bind down on the soft lens.”
The two lenses should be stable but should
be able to move independently of each other.
Dr. Faron advised to always use lenses
with high Dk values when piggybacking.
The higher the value the better it will transmit oxygen to the eye. “You really need the
higher Dk because you have two lenses. If a
patient is in a low-Dk RGP, it behooves the
practitioner to upgrade him or her to a lens
with a higher level of oxygen transferability
when piggybacking.”
Proper lens solutions
Drs. Faron and Malooley both noted that patients who are fitted for piggyback lenses
must be educated about the importance of
using the correct lens solution.
“You can use soft lens solutions on a gas
permeable lens, but you can’t use gas permeable solutions on a soft lens,” Dr. Malooley said. “For our piggyback patients, we
either have them use a soft lens solution for
both lenses, or we have them use the hard
solution for the hard lens, the soft solution
for the soft lens, and then rinse both with
the soft lens solution. Another option is to
have patients use a hydrogen peroxide solution on both lenses, and then rinse them
well with saline.”
Don’t be afraid to try piggybacking lenses,
Dr. Faron said. “Get your feet wet and try it,”
he continued. “What we see on many keratoconus patients is that the apex of the cornea
is much steeper than the RGP lens, and that
‘Practitioners need to be
encouraged to persevere
and not be afraid to try
things that might be a little
outside of their comfort
zone.’
Marsha M. Malooley, OD, FAAO
leads to apical scarring and abrasions. These
patients can really benefit from piggybacking because you want to get them back into
a lens as quickly as possible, and you may
not have time to fit them into a hybrid lens.
So a good option is to simply slide a soft lens
underneath a well-fit RGP and then follow
them carefully to see how they do.”
Although patients at first may be puzzled
or even intimidated by the idea of adding
a second lens, the immediate comfort they
experience often sells them on piggybacks,
Dr. Faron added.
“We see many patients who tell us, ‘I was
never told this existed,’ or, ‘No one ever tried
this on me,’ and we’re not really doing anything unusual,” Dr. Malooley said. “This is
something that every optometrist can offer,
if they so desire. Practitioners need to be
encouraged to persevere and not be afraid
to try things that might be a little outside of
their comfort zone.”OP
FYI
Chuck Faron, OD
E-mail: [email protected]
Marsha M. Malooley, OD, FAAO
Phone: 847/432-6010
E-mail: [email protected]
Drs. Faron and Malooley have no relevant disclosures.
WHEN IT COMES TO REUSABLE LENSES…
TAKE A
FRESH
VIEW
ON COMPLIANCE
TM
SEE WHAT COULD BE™
Study shows modality doesn’t drive compliance,
the patient does.
Chances are, it’s what you’ve been suspecting all along—that when it
comes to replacement compliance, there is no reusable modality to which
patients better adhere: there was no significant difference regarding
compliance with replacement frequency for patients wearing 2-week
or 1-month lenses.1
Different reusables, no significant difference in rate of compliance.
Perfect Compliance:
No Difference (P=NS)
44
%
2-week
lenses
51
Moderate Overwear:
No Difference (P=NS)
%
Monthly
lenses
WORN FOR UP TO:
2 WEEKS vs 4 WEEKS
46
%
2-week
lenses
42
Considerable Overwear:
No Difference (P=NS)
%
Monthly
lenses
WORN FOR UP TO TWICE AS LONG:
4 WEEKS vs 8 WEEKS
11
%
2-week
lenses
8
%
Monthly
lenses
WORN FOR MORE THAN:
4 WEEKS vs 8 WEEKS
An ongoing online survey (updated quarterly) of 659 frequent replacement contact lens wearers who answered questions relating to lens replacement
frequency. The respondents represented wearers of hydrogel and silicone hydrogel lenses prescribed for two-week or monthly replacement. The results show
the 3rd consecutive quarter in which there were no significant differences in rate of wear, based on rolling four-quarter data.
The ACUMINDER™ Tool assures even better compliance.
Since replacement frequency is driven by patients, ACUMINDER™ gives
them important reminders about changing lenses, buying new ones, and
scheduling their next eye exam—to keep patients on track and in your
practice. Best of all, ACUMINDER™ is proven to help patients stay compliant.2
Patients join free at acuminder.com.
References: 1. Data on file, Johnson & Johnson Vision Care, Inc.
c. 2010. 2. Data on file, Johnson & Johnson Vision Care, Inc. 2010.
ACUVUE® Brand Contact Lenses are indicated for vision correction. As with any contact lens, eye problems, including corneal ulcers, can develop. Some
wearers may experience mild irritation, itching or discomfort. Lenses should not be prescribed if patients have any eye infection, or experience eye
discomfort, excessive tearing, vision changes, redness or other eye problems. Consult the package insert for complete information. Complete information
is also available from VISTAKON®, Division of Johnson & Johnson Vision Care, Inc., by calling 1-800-843-2020 or by visiting jnjvisioncare.com.
ACUVUE®, ACUVUE® ASSURED™, SEE WHAT COULD BE™, ACUMINDER™, and VISTAKON® are trademarks of Johnson & Johnson Vision Care, Inc.
© Johnson & Johnson Vision Care, Inc. 2011. February 2011
MARCH 2011 / Optometry Times
24
Inflammation 101
Treat CL-related microbial keratitis
as bacteria until proven otherwise
By Ron Rajecki
Reviewed by Art Epstein, OD, FAAO
Las Vegas—Microbial keratitis (MK) that arises
from contact lens (CL) wear can be a delicate
subject. CLs are by any measure extremely
safe devices, and cases of MK are relatively
rare. Only about 30,000 cases are reported annually in the United States, and less than onehalf of those are related to CL wear. Contrast
that to 30,000,000 wearers,
most of whom experience
no major issues. Still, two
recent outbreaks that were
traced to CL solutions hold
useful lessons on how to
manage patients who present
Dr. Epstein
with signs and symptoms of
MK, said Art Epstein, OD,
FAAO, here at International Vision Expo West.
“The incidences of [MK] are so small, and
the occurrences so rare, that we really don’t
get a sense of patterns,” said Dr. Epstein, of
North Shore Contact Lens and Vision Consultants, New York. “And patterns and pattern recognition are important ways that we
refine our clinical skills. Ironically, these two
outbreaks that caused so much misery were
helpful in that they allowed us to observe patterns that we’d otherwise not see.”
From differential to management
Consider MK in your differential diagnosis
when a patient presents with a corneal lesion,
said Dr. Epstein, which is accompanied by:
• Acute onset
• Worsening pain and photophobia
• Lid swelling
• Ciliary flush with conjunctival injection
• Mucopurulent discharge
• Tear film debris and thick tear film with
cells
• Anterior chamber reaction
“The first step when dealing with a keratitis is to determine if it’s sterile or infectious,”
he said. “The next step is to determine the
causative pathogen: bacteria, virus, fungus,
or Acanthamoeba.”
To help you determine the cause of the keratitis, Dr. Epstein advised starting with a thorough history, including CL wear and solutions
used, contributory medical problems, current
ocular medications, recent trauma to the eye,
and recent travel.
Take-Home Message
Contact lens-related cases of microbial keratitis
(MK) are rare and can have a number of causative
pathogens, which can make differential diagnosis
difficult. Treat MK of unknown etiology as if it’s
bacterial, absent other indications. Never add a steroid
to the treatment regimen until you’re sure of what
you’re treating.
“The role of staining caused by [CL] care
products is somewhat controversial,” he said.
“Every textbook likens staining—or almost
anything that disturbs external corneal barriers—as a pre-disposing factor to infection. The
question then becomes if staining caused by
[CL] wear or products is a factor in increased
risk of infection. I don’t know that staining is
a ‘smoking gun,’ but I do think as clinicians
we have to consider it suggestive.”
When performing slit lamp examination on
these patients, do not let their photosensitivity cause you to reduce the slit lamp intensity,
Dr. Epstein advised.
“Yes, these patients are in pain, but they
are counting on you to help them,” he said.
“That means getting to best view you can
so you can make the correct diagnosis and
initiate the correct treatment as soon as possible. Almost every patient is empowered by
the feeling that they are teaching you something that may help them or someone else.
They are willing to put up with significant
discomfort for that.”
Smears and cultures are indicated prior to
initiating treatment in sight-threatening and
severe keratitis, and when the patient has deep
and large stromal infiltrates involving the visual axis.
Treat as bacterial until disproven
Dr. Epstein said that the standard of care is
generally to presumptively consider any possible CL-related MK as bacterial in the absence
of evidence to the contrary, and to treat it accordingly. That’s good news for optometrists,
because “we have many excellent options when
it comes to treating bacterial infections of the
eye,” he said. “We have very effective antibacterials—specifically, the fourth generation fluoroquinolones—that can provide tremendous anti-infective levels into the cornea,
which can shut down infection very quickly.”
Not too long ago, he added, patients who
had CL-related infections almost universally
had to be sent to corneal specialists for treatment with fortified antibiotics that had been
made specifically to treat them.
Dr. Epstein offered some treatment caveats,
however: if a patient presents with a large central ulcer that you’re not comfortable treating,
it’s advisable to refer the patient immediately
to a fellowship-trained cornea specialist in
your community if one is available. There is
no medicolegal support for any OD or general
ophthalmologist treating a risky patient where
specialty care is readily available.
Candidates for referral
Patients who have fungal or Acanthamoeba
infections—which may not be identified until
after they have proven non-responsive to bacterial therapy—may also be candidates for referral depending on your locale and comfort
managing complex cases.
“Acanthamoeba often presents appearing
very much like herpes, including decreased
corneal sensitivity, unilateral presentation,
and it sometimes presents with a dendritic
ulcer,” Dr. Epstein said. “So, it looks like herpes, so you treat it like herpes. When it fails
to respond, some clinicians wrongly conclude
that inflammation is the cause and initiate
treatment with topical steroids and the patient
ends up in very serious trouble. Usually it’s
therapeutic failure that produces the forced
differential diagnosis.
“Never use a steroid in patients who present with a MK unless you’re sure what you’re
treating and the benefit outweighs the risk,”
he added. “You have to be open-minded and
fast on your feet when it comes to treating
[MK]. Although [CL]-related infections are very
rare, the consequences of a missed diagnosis
or mismanagement can be devastating.”OP
FYI
Art Epstein, OD, FAAO
Phone: 602/549-2020
E-mail: [email protected]
Dr. Epstein has received honoraria or serves on the
speaker’s bureau of Advanced Vision Research, Alcon
Labs, Allergan Inc., CIBA Vision, CooperVision, Inspire
Pharmaceuticals, TearScience Inc., Vistakon, and VSP.
He serves as a consultant for Alcon Labs, Inspire
Pharmaceuticals, TearScience Inc., and Vistakon Inc.
MARCH 2011 / OptometryTimes.com
25
CL-induced corneal swelling
Previous estimates of minimum Dk/t
may be seriously underestimated
Meta-analysis shows criterion for extended CL wear to avoid corneal edema could have been inaccurate
By Cheryl Guttman Krader
Reviewed by Craig Woods, PhD, FAAO
San Francisco—Findings from a meta-analysis indicate that values from previous research on the minimum oxygen transmission (Dk/t) needed to avoid overnight lensinduced corneal swelling are gross underestimations. The new data,
however, also support the
need for further research
to fully understand factors
responsible for the development of corneal edema with
extended lens wear, said
Dr. Woods
Craig Woods, PhD, FAAO.
The research, which was
presented at the annual meeting of the American Academy of Optometry, pooled data
from a number of studies conducted at the
Centre for Contact Lens Research (CCLR),
School of Optometry, University of Waterloo, Ontario, Canada.
‘Silicone hydrogel lenses
have not completely
mitigated problems of
lens-induced physiological
changes.’
Craig Woods, PhD, FAAO
Each investigation enrolled patients with
no history of contact lens (CL) use, who were
assigned to wear different hydrogel and silicone hydrogel lenses overnight on one eye.
Corneal thickness was measured with a
digital optical pachymeter just prior to lens
insertion and immediately after the lens was
removed on waking in the morning. Measurements were also obtained in the fellow eye
as a no-lens control. Each study evaluated
more than one CL, and the order of lens wear
was randomized. Data from 26 lens groups
were analyzed, representing lenses with Dk/t
values ranging from 16 to 215 Barrer/cm.
Take-Home Message
Findings from a meta-analysis suggest that a Dk/t
value of 340 Barrer/cm would be needed to avoid lensinduced corneal swelling. Researchers of this analysis
pooled results from previous studies measuring
changes in central corneal thickness with overnight
contact lens wear Further research is needed to test
this theoretical value, but the physiological effect
of lens wear-associated factors other than oxygen
transmissibility should also be considered.
ing other explanations for existing problems
associated with soft CL wear,” Dr. Woods
commented.
‘Research now needs to
focus on identifying other
explanations for existing
problems associated with
Exceeding Holden-Mertz
A best-fit function for the plot of increase
in central corneal swelling with the various lenses versus the respective central lens
Dk/t value intercepted the line representing
the amount of corneal swelling of the control eye (3.5%) at a Dk/t value of about 340
Barrer/cm.
This value far exceeds the Holden-Mertz
criterion for critical oxygen transmission of
an extended wear lens, 87 Barrer/cm, which
was established more than 25 years ago, as
well as more recent proposals that the appropriate value is around 125 Barrer/cm, said
Dr. Woods, principal scientist, CCLR, and
adjunct associate professor, School of Optometry, University of Waterloo.
Dr. Woods told Optometry Times, “The idea
that corneal hypoxia was the culprit in the
adverse events associated with extended CL
wear has fueled research to determine what
is the minimum oxygen transmissibility requirement for a CL to avoid corneal edema.
It is the basis for the development of silicone
hydrogel lenses.
soft CL wear.’
Craig Woods, PhD, FAAO
Recognizing that theoretical models cannot account for all possible confounders associated with in vivo CL wear, testing is
needed to confirm the prediction that a CL
with a Dk/t value of 340 Barrer/cm would
limit overnight lens-induced corneal swelling
to the level seen without lens wear. That, in
turn, awaits the availability of such a lens.
Meanwhile, Dr. Woods and his colleagues
at the CCLR have been conducting research
to understand other variables influencing
corneal swelling, and plan to present some
interesting findings later in 2011.OP
The definitive answer
“Debate on this topic continues, however,
and there is still firm indication that despite their having high oxygen transmissibility exceeding the thresholds established by
previous research, silicone hydrogel lenses
have not completely mitigated problems of
lens-induced physiological changes,” he said.
“However, apart from a rare patient whose
cornea has a very high oxygen demand, the
current silicone hydrogel lenses are delivering as much oxygen as the cornea needs.
Research now needs to focus on identify-
FYI
Craig Woods, PhD, FAAO
E-mail: [email protected]
The studies were supported by Ciba Vision and
CooperVision. Over the past 3 years, the members of the
CCLR have received research funds or honoraria from
Alcon, Allergan, AMO, Bausch + Lomb, Cetero, Ciba Vision,
CooperVision, Essilor, Inspire Pharmaceuticals, Johnson &
Johnson, OcuSense, Menicon, and Visioneering.
MARCH 2011 / Optometry Times
26
The right stuff
In-vitro evaluations question epithelial
barrier function with MPS use
By Nancy Groves
Reviewed by Mohinder M. Merchea, OD, PhD, MBA
San Francisco—Biotrue (Bausch + Lomb) and
two other solutions with similar polyhexamethylene biguanide (PHMB) formulations
did not alter corneal barrier function as compared with balanced salt
solution (HBSS) and phosphate buffered saline (PBS)
controls, according to findings from in-vitro evaluation of a series of multipurpose contact lens solutions
Dr. Merchea
(MPSs), said Karen L. Harrington, BS, and Mohinder
M. Merchea, OD, PhD, MBA,
here at the annual meeting
of the American Academy
of Optometry.
However, the resistance
of human corneal epithelial cells exposed even to
Harrington
only 50% concentrations of
two additional polyquaternium-1 (PQ-1)/ myristamidopropyl dimethylamine (MAPDA) MPSs differed significantly
from that of the controls and the three other
solutions.
“Since MPSs are routinely inserted into
the eye, it is important that they are fully
biocompatible with the ocular surface. The
corneal epithelium is the first layer of contact on the ocular surface. By performing
in-vitro assays on these monolayers, assessments can be performed on whether MPSs
are having an effect on the epithelium,” said
Harrington, of Bausch + Lomb.
In-vitro assays of five solutions
To study the effects of the five commercially
available MPSs, investigators analyzed epithelial barrier function by using two in-vitro assays. Monolayer integrity (scanning
electron microscopy) was used to monitor
ultrastructural alterations, and monolayer
resistance (electric cell-substrate impedance
sensing [ECSIS]) was used to perform a realtime, noninvasive, highly sensitive assay.
Electric cell-substrate impedance testing
revealed that the epithelial cells exposed to
only 50% levels of Opti-Free Express and
Opti-Free Replenish (Alcon) were different
Take-Home Message
To study the effects of the five commercially available
MPS products, investigators analyzed epithelial
barrier function with two in-vitro assays. Epithelial
cells exposed to only 50% levels of two of the
commercially-available solutions were different from
media and phosphate buffered saline control after
20 minutes, while cells exposed to the other three
solutions were not significantly different at any time.
from all groups after 20 minutes, while cells
exposed to the other three solutions, Biotrue,
AQuify (CIBA Vision), and Complete Multipurpose Solution Easy Rub (AMO), were
not significantly different from media and
PBS control at any time.
“It is likely that a combination of excipients in the lens care solutions—antimicrobial agents, buffering agents, surfactants and
chelating agents—are the causative factors
in the adverse effects seen with using OptiFree Express and Opti-Free Replenish on the
corneal epithelial cells,” said Dr. Merchea,
who is director, medical affairs, Bausch +
Lomb. “These in-vitro assays may be a valuable indicator of the eventual clinical observations or trends in determining MPS and
contact lens biocompatibility.”
Breaking it down
Biotrue, AQuify, and Complete MPS Easy
Rub contain PHMB. Biotrue also contains
a low concentration of PQ-1, while the two
solutions with more negative effects on the
cell cultures (Opti-Free Express and OptiFree Replenish) are preserved with high concentrations of PQ-1 and MAPDA.
Harrington also noted that studies in the
peer-reviewed literature indicate that in general, PQ-1 is not a major factor causing reduction in cell viability. Biotrue contains
PQ-1 at a much lower concentration than
Opti-Free Express or Opti-Free Replenish,
and its lack of an effect on barrier function
may suggest that this is a contributing factor, in addition to other potential excipients.
Dr. Merchea added that there have been
a growing number of reports of clinically
adverse events such as infiltrative keratitis
associated with certain MPS solutions, especially those containing PQ-1 and MAPDA,
and certain silicone hydrogel lenses.
Results of the scanning electron microscopy analysis showed that the monolayers of
human epithelial cells exposed to HBSS control remained intact, while cells exposed to
100% Opti-Free Express demonstrated breakdown of the tight junctions as well as cell
membrane damage. The novel MPS Biotrue
and solutions AQuify, Complete MPS Easy
Rub, and Opti-Free Replenish appeared similar to the control.
In-vitro, in-vivo data
Further investigation is necessary to determine whether the findings have any direct
clinical significance, but it is possible that the
cumulative in-vitro data correlate with some
in-vivo clinical findings, Dr. Merchea said.
“Opti-Free Replenish has been shown to
be associated with an increase in corneal
infiltrates in an in-vivo study (Carnt et al.,
Arch Ophthalmol, 2009), and also has been
shown to cause adverse effects during the
in-vitro ECSIS assay on the corneal epithelial
monolayers,” Dr. Merchea said. “Although
a direct link between in-vitro and in-vivo
data has yet to be established, the infiltrative
keratitis outcomes observed with Opti-Free
Replenish suggest that these established cellular assays provide insight into the eventual
compatibility of MPS products and the eye.”
The assays used in the study are well-established methodology in cellular research,
but Dr. Merchea added that these in-vitro
methods are still only part of the assessment
of the biocompatibility of MPSs.
“The true measure of biocompatibility
is a proven safety profile through clinical
usage,” he said.OP
FYI
Mohinder M. Merchea, OD, PhD, MBA
Phone: 585/338-8043
Karen L. Harrington, BS
Phone: 585/338-6714
Dr. Merchea and Ms. Harrington are both employees of
Bausch + Lomb.
Close to allergens.
Far from allergies.
PATADAY™ Solution—trust the #1 prescription
allergy eye drop for all-day relief
1,2
• Relief in 3 minutes3
• Just one drop lasts all day2
• More than 90% of insured patients covered; excellent tier 2 coverage4
INDICATIONS AND USAGE: PATADAY™ Solution is indicated for the treatment of ocular itching associated with
allergic conjunctivitis.
DOSING AND ADMINISTRATION: The recommended dose is one drop in each affected eye once daily.
IMPORTANT SAFETY INFORMATION: PATADAY™ (olopatadine hydrochloride ophthalmic solution) 0.2% should not
be used to treat contact lens related irritation. The preservative in PATADAY™ Solution, benzalkonium chloride, may
be absorbed by soft contact lenses. Patients who wear soft contact lenses and whose eyes are not red should be
instructed to wait at least ten minutes after instilling PATADAY™ Solution before they insert their contact lenses. Safety
and effectiveness in pediatric patients below the age of 3 have not been established.
Contraindications: PATADAY™ Solution is contraindicated in patients with a hypersensitivity to
any components of this product.
Adverse Events: The most common adverse reactions to PATADAY™ Solution
were cold syndrome and pharyngitis reported at an incidence of
approximately 10%. Other adverse events included eye pain, blurred
vision, sinusitis and headache occurring in 5% or less of the patients.
Please see Prescribing Information on following page.
©2010 Alcon, Inc.
11/10
PAT11500JAD
MARCH 2011 / Optometry Times
28
Practice pearls
10 tips for fitting presbyopic CLs
By Ron Rajecki
Reviewed by Michael S. Gzik, FCLSA, NCLE, COT
Las Vegas—Have you ever asked a colleague
for a contact lens (CL) fitting tip? How about
60 colleagues? Michael S. Gzik, FCLSA, NCLE,
COT, conducted an informal survey of eyecare practitioners to garner a “top 10” list of
INDICATIONS AND USAGE
PATADAY™ solution is indicated for the treatment of ocular itching associated with allergic conjunctivitis.
CONTRAINDICATIONS
Hypersensitivity to any components of this product.
WARNINGS
For topical ocular use only. Not for injection or oral use.
PRECAUTIONS
Information for Patients
As with any eye drop, to prevent contaminating the dropper tip and solution, care should be taken not to touch the eyelids or surrounding areas with the dropper tip
of the bottle. Keep bottle tightly closed when not in use. Patients should be advised not to wear a contact lens if their eye is red.
PATADAY™ (olopatadine hydrochloride ophthalmic solution) 0.2% should not be used to treat contact lens related irritation. The preservative in PATADAY™ solution,
benzalkonium chloride, may be absorbed by soft contact lenses. Patients who wear soft contact lenses and whose eyes are not red, should be instructed to wait at
least ten minutes after instilling PATADAY™ (olopatadine hydrochloride ophthalmic solution) 0.2% before they insert their contact lenses.
Carcinogenesis, Mutagenesis, Impairment of Fertility
Olopatadine administered orally was not carcinogenic in mice and rats in doses up to 500 mg/kg/day and 200 mg/kg/day, respectively. Based on a 40 L drop
size and a 50 kg person, these doses were approximately 150,000 and 50,000 times higher than the maximum recommended ocular human dose (MROHD). No
mutagenic potential was observed when olopatadine was tested in an in vitro bacterial reverse mutation (Ames) test, an in vitro mammalian chromosome aberration
assay or an in vivo mouse micronucleus test. Olopatadine administered to male and female rats at oral doses of approximately 100,000 times MROHD level resulted
in a slight decrease in the fertility index and reduced implantation rate; no effects on reproductive function were observed at doses of approximately 15,000 times
the MROHD level.
Pregnancy:
Teratogenic effects: Pregnancy Category C
Olopatadine was found not to be teratogenic in rats and rabbits. However, rats treated at 600 mg/kg/day, or 150,000 times the MROHD and rabbits treated at 400
mg/kg/day, or approximately 100,000 times the MROHD, during organogenesis showed a decrease in live fetuses. In addition, rats treated with 600 mg/kg/day of
olopatadine during organogenesis showed a decrease in fetal weight. Further, rats treated with 600 mg/kg/day of olopatadine during late gestation through the
lactation period showed a decrease in neonatal survival and body weight.
There are, however, no adequate and well-controlled studies in pregnant women. Because animal studies are not always predictive of human responses, this drug
should be used in pregnant women only if the potential benefit to the mother justifies the potential risk to the embryo or fetus.
Nursing Mothers:
Olopatadine has been identified in the milk of nursing rats following oral administration. It is not known whether topical ocular administration could result in
sufficient systemic absorption to produce detectable quantities in the human breast milk. Nevertheless, caution should be exercised when PATADAY™ (olopatadine
hydrochloride ophthalmic solution) 0.2% is administered to a nursing mother.
Pediatric Use:
Safety and effectiveness in pediatric patients below the age of 3 years have not been established.
Geriatric Use:
No overall differences in safety and effectiveness have been observed between elderly and younger patients.
ADVERSE REACTIONS
Symptoms similar to cold syndrome and pharyngitis were reported at an incidence of approximately 10%.
The following adverse experiences have been reported in 5% or less of patients:
Ocular: blurred vision, burning or stinging, conjunctivitis, dry eye, foreign body sensation, hyperemia, hypersensitivity, keratitis, lid edema, pain and ocular pruritus.
Non-ocular: asthenia, back pain, flu syndrome, headache, increased cough, infection, nausea, rhinitis, sinusitis and taste perversion.
Some of these events were similar to the underlying disease being studied.
DOSAGE AND ADMINISTRATION
The recommended dose is one drop in each affected eye once a day.
HOW SUPPLIED
PATADAY™ (olopatadine hydrochloride ophthalmic solution) 0.2% is supplied in a white, oval, low density polyethylene DROP-TAINER® dispenser with a natural
low density polyethylene dispensing plug and a white polypropylene cap. Tamper evidence is provided with a shrink band around the closure and neck area of the
package.
NDC 0065-0272-25
2.5 mL fill in 4 mL oval bottle
Storage:
Store at 2°C to 25°C (36°F to 77°F)
U.S. Patents Nos. 5,116,863; 5,641,805; 6,995,186; 7,402,609
Rx Only
References:
1. Wolters Kluwer Pharma Solutions, Source® Pharmaceutical Audit Suite, August 2010-September 2010, among all specialties.
2. Abelson MB, Gomes PJ, Pasquine T, Edwards MR, Gross RD, Robertson SM. Efficacy of olopatadine ophthalmic solution 0.2% in reducing signs and symptoms
of allergic conjunctivitis. Allergy Asthma Proc. 2007;28:427-433.
3. Granet DB, Amin D, Tort MJ. Evaluation of olopatadine 0.2% for the elimination of ocular itching in the conjunctival allergen challenge (CAC) model. Poster
presented at: Western Society of Allergy, Asthma and Immunology; January 24-28, 2010; Maui, HI.
4. www.FingertipFormulary.com. Accessed June 17, 2010.
©2010 Alcon, Inc. 11/10 PAT11500JAD
fitting tips for soft, multifocal CLs. Gzik, of
New York Optometric, Syracuse, NY, shared
the tips at International Vision Expo West.
1. Always perform a pre-fitting visual acuity test for near and distance.
2. Always favor the dominant eye for the
best-corrected distance vision.
3. Measure pupil size in normal light. For
example, outside of the exam room and not
under fluorescent lights. Be aware that pupil
sizes of 4.0 mm or less seem to do best with
both designs, and pupil sizes larger than 5.0
mm don’t do well with either.
4. Be aware that most successful patients are
those with a distance prescription of +0.75
to +6.00 and –0.75 to –7.00, with add ranges
of +1.00 to +2.00. These patients are accustomed to distance visual acuity compromises
without their correction and typically have
higher motivation preferring contact lenses
over glasses.
5. Use the flattest fitting lens available.
Often, excessively steep lenses cause fluctuating visual acuity.
6. Make sure the lens centers. This is very
important, as lenses that aren’t centered are
often a cause of bifocal soft CL failure for
patients.
7. Conduct a careful slit lens examination.
This will play the most important part in
your success. Corneal desiccation in the inferior quadrant will indicate your patient is
an incomplete blinker, may have meibomian
gland disorder, or may be getting external
oil into the eye—such as eye cream or baby
oil from make-up removal—and will require
“blink therapy,” lid scrubs, or supplemental lubrication. Advise your patients prior
to fitting that not only their comfort, but
also their visual success, depends on their
compliance to your advice.
8. Use a topography map over soft CLs to
determine alignment of the optics with the
visual center based on the patient’s pupil size.
9. Run as fast as you can in the other direction when a patient presents asking to be
fit in soft lens multifocals! (Just kidding.)
10. Avoid the three Rs of fitting presbyopes:
refit, refit, refund.OP
MARCH 2011 / OptometryTimes.com
Glaucoma
29
RNFL thickness
Instrument adds assessment power
Normative database, asymmetry analysis extend OCT device’s reach into glaucoma
By Ron Rajecki
Reviewed by Sanjay Asrani, MD
Durham, NC—An age-adjusted retinal nerve
fiber layer (RNFL) thickness normative database for a proprietary ocular coherence tomography (OCT) device (Spectralis, Heidelberg
Engineering GmbH) gives clinicians a tool
for assessing glaucoma risk
from a patient’s first visit,
according to Sanjay Asrani,
MD, associate professor of
ophthalmology and head of
the Glaucoma OCT Reading Center, Duke University
Dr. Asrani
Eye Center, Durham, NC.
FDA clearance of the normative database was announced at Vision
Expo West in Las Vegas.
The normative database, combined with the
OCT instrument’s new posterior pole asymmetry analysis and existing fovea-to-disc (FoDi)
alignment software and active eye-tracking
capability (via proprietary TruTrack technology), is designed to add to the power and usefulness of the instrument for glaucoma risk
assessment and progression management.
Assessment technology
“This technology is an important addition
to our glaucoma assessment toolbox,” Dr.
Asrani said. “The combination of [the OCT
device’s] precision with the new normative
database and the asymmetry analysis adds
to our ability to detect glaucomatous changes
as well as changes over time.”
The normative database and asymmetry
analysis are part of the instrument’s Version
5.3 software. The proprietary OCT’s platform
features fovea-to-disc alignment technology
(FoDi) that is designed to improve the accuracy
and reproducibility of RNFL measurements
by automatically tracking and anatomically
aligning circle scans. The alignment technology helps overcome measurement errors
due to patients’ changing their head or eye
position during scanning.
The alignment technology improves the
data integrity of the normative database, according to Heidelberg Engineering. Using the
instrument’s proprietary eye-tracking technology, all scans in the database are aligned
along the fovea-to-disc axis, ensuring pointto-point thickness comparisons.
“It’s quite a robust normative database,”
Dr. Asrani said. “In my experience, if there
Take-Home Message
An age-adjusted retinal nerve fiber layer thickness
normative database for a proprietary ocular coherence
tomography (OCT) device (Spectralis, Heidelberg
Engineering GmbH) has received clearance from the
FDA. The normative database, combined with the
OCT instrument’s new posterior pole asymmetry
analysis and existing alignment software and eyetracking capability, is designed to add to the power
and usefulness of the instrument for glaucoma risk
assessment and progression management.
to pick out a small amount of changes. The
[proprietary OCT device] has a compressed
color scale, with many additional colors incorporated into the 0 to 300-μm range to
enable us to discern very small changes in
thickness.”
‘We [are] measuring the
macula in glaucoma . . .
because that’s where the
is an abnormality in a patient’s eye indicative
of possible early glaucomatous changes, the
database frequently identifies it.”
Along with the normative database, the
device’s Version 5.3 software release also includes a posterior pole asymmetry analysis
capability.
Posterior pole asymmetry analysis
The posterior pole asymmetry analysis maps
retinal thickness across the posterior pole
and graphs asymmetry both between hemispheres and between eyes. RNFL measurements combined with retinal thickness measurements may help paint a clearer picture
of glaucoma.
“Posterior pole asymmetry analysis can
help identify early structural damage. Asymmetry is a hallmark of glaucoma, [because]
glaucomatous damage is often marked by
retinal thinning in the zone surrounding
the fovea and extending toward the optic
nerve head,” Dr. Asrani said. “In glaucoma,
the ganglion cells are dying in the macula,
and this is a concept that is lost in many
people. People start wondering why are we
measuring the macula in glaucoma. That’s
because that’s where the action is taking
place. It’s just that we haven’t been able to
measure it accurately and in a wide area
up until now.”
Dr. Asrani said the proprietary OCT unit
measures the macular thickness in an 8 × 8
mm area centered on the fovea, with a high
density of measurements that are displayed
on a macular thickness map in a compressed
color scheme.
“The traditional macular thickness maps
have three colors: blue, green, and yellow,”
Dr. Asrani said. “That means you must have
a change of 100 μm to be able to see a
change in color. It’s very difficult to be able
action is taking place.’
Sanjay Asrani, MD
According to Dr. Asrani, many ophthalmologists already use the proprietary OCT unit
for RNFL measurement, but the instrument’s
Version 5.3 software will allow them to identify and track changes over time, which he
called the “holy grail” in glaucoma.
“In the early stages of glaucoma, it’s very
likely that the changes identifiable with the
posterior pole asymmetry analysis and normative database would be not yet be seen on
the visual field,” he said. “If we can structurally track changes over time, our dependence on visual fields is reduced.
“However, we must have reliable measurements to be sure that what we are measuring is indeed change, and [not] an error
caused by the instrument or user,” Dr. Asrani said. “There were already two features
in the [OCT device] that helped us with that:
its eye-tracking feature, and its alignment
software. Now, with the normative database
for RNFL measurements and the macular
thickness posterior pole map, we are adding
two more pieces to help us solve the jigsaw
puzzle of glaucoma.”OP
FYI
Sanjay Asrani, MD
Phone: 919/684-8656
E-mail: [email protected]
Dr. Asrani receives lecture honoraria
from Heidelberg Engineering.
30
MARCH 2011 / Optometry Times
Refractive
WFG LASIK
‘Results in the current era of LASIK using a customized
Continued from page 1
San Diego, evaluating the potential benefits
of WFG LASIK.
Dr. Owen highlighted the results from a
matched analysis comparing 500 eyes operated on with conventional LASIK and 170
eyes that underwent a WFG procedure to
highlight the superiority of the customized
procedure.
At 3 months, mean MSE was close to
emmetropia in both the conventional and
WFG LASIK groups, +0.01 and –0.16 D, respectively. The proportion of eyes achieving 20/20 or better UCVA was high in both
groups, 91% and 93%, respectively. The
WFG procedure did have a slight advantage for predictability, with 90% of WFG
eyes achieving MSE within 0.5 D of target
compared with 84% of eyes in the conventional LASIK group.
WFG benefits reported
Analyses of changes from baseline BCVA
and low-contrast acuity showed statistically
significant differences favoring the WFG
group—a higher proportion of eyes gained
lines. Additionally, the proportion of patients with reduced complaints about halos
at night after surgery was higher among
those who had the WFG procedure.
Take-Home Message
LASIK outcomes continue to improve, thanks to a
number of advances in techniques, technology, and
medical management. Results of clinical studies
support the advantages of the various innovations,
such as wavefront-guided ablation, latest generation
femtosecond lasers, and treating postoperative dry eye.
Evaluation of night driving performance
using a simulator showed improvement in
both the ability to detect and identify hazards after surgery in patients who underwent WFG surgery.
“Low contrast acuity was found to be a
good predictor of skills necessary for naval
aviators, and it is an indicator of the quality of vision for patients in the everyday
world,” he said.
All-laser LASIK
All LASIK procedures begin with flap creation, and the femtosecond laser has become
the most commonly used technology for
making the lamellar cut. First introduced
less than a decade ago, the innovator in
femtosecond lasers for ophthalmology, the
IntraLase (Abbott Medical Optics), is cur-
[WFG] ablation with a femtosecond laser . . . have made
the refractive procedure better than ever with efficacy,
predictability, and quality of vision outcomes that can truly
be described as phenomenal.’
Jim Owen, MD, MBA
rently in its 5th generation (iFS Advanced
Femtosecond Laser) and offers multiple benefits compared with previously available
versions, Dr. Owen said.
“Its features include a 150 kHz repetition rate for faster flap creation time, use
of tighter spot separation that reduces energy per pulse, and greater versatility in
flap geometry and side cut options. Use of
this femtosecond laser results in a smoother
bed, a lower incidence of opaque bubble
layer formation, and a flap that is more
stable after surgery,” he said.
Tackling postoperative dry eye
Again, citing research conducted by Drs.
Schallhorn and Tanzer, Dr. Owen reported
that use of the femtosecond laser for flap creation has reduced the risk of intraoperative
complications compared with a mechanical
microkeratome, minimized the occurrence
of epithelial ingrowth, hastened visual recovery, and resulted in better low contrast
visual acuity and lower enhancement rates.
In addition, there are some data to suggest
the femtosecond laser flap creation procedure
results in less induced higher order aberrations and less postoperative dry eye.
Dry eye remains a common problem after
LASIK and is the result of cutting corneal
nerves during flap creation. However, results
from several studies indicate that treatment
with topical cyclosporine emulsion 0.05%
(Restasis, Allergan) can help to mitigate dry
eye and its sequelae, Dr. Owen said.
Benefits of topical cyclosporine
Results of a study by Paymen showed that
corneal sensitivity measured by an esthesiometer was significantly better in eyes treated
with topical cyclosporine compared with untreated control fellow eyes.
“The mechanism for this benefit is not
known for sure, but it may be that cyclosporine enhances corneal nerve regeneration,” he noted.
Other studies, including a retrospective
study by Ursea et al. and research conducted
by Dr. Owen and colleagues, indicated a
benefit of topical cyclosporine for improving visual acuity after LASIK. In the latter
study, the functional benefit appeared to
translate into a reduced enhancement rate
after myopic LASIK.
Study: cyclosporine versus control
Dr. Ursea analyzed data from 109 eyes treated
with topical cyclosporine and 112 control eyes.
The two study groups were similar preoperatively with respect to demographics, refractive characteristics, and mean pachymetry. At 3 months post LASIK, eyes treated
with cyclosporine had a significantly better
mean sphere outcome compared with the
controls and a significantly better mean logMAR UCVA outcome.
Dr. Owen and colleagues conducted a retrospective analysis of 221 myopic eyes that
had LASIK performed by a single surgeon
for refractive error up to –6.5 D with up
to 2.5 D of cylinder. Topical cyclosporine
was used in 109 eyes, and this subgroup
was significantly less likely to require enhancement than eyes not treated with cyclosporine (2.8% versus 9.8%; p = 0.031).
At 3 months, eyes treated with cyclosporine
also had significantly better mean UCVA
than eyes not treated with cyclosporine (p
= 0.033).
“We know that LASIK affects the ocular
surface and that the tear layer may remain
unstable for months. The tear layer is the
first refractive surface of the eye, and an
unstable tear layer can affect vision,” Dr.
Owen concluded.OP
FYI
Jim Owen, MD, MBA
E-mail: [email protected]
Dr. Owen is on the speakers bureau for Abbott Medical
Optics, Allergan, and Bausch + Lomb.
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32
MARCH 2011 / Optometry Times
Retina
Achieving best visual enhancement
Prescribing for patients with AMD
When evaluating patients receiving anti-angiogenic therapy, explore several considerations
By Liz Meszaros
Reviewed by Judith E. Goldstein, OD, FAAO
Baltimore—Knowing when and how to prescribe vision enhancement in patients with
neovascular or wet age-related macular degeneration (AMD) is the key to
achieving the greatest possible visual improvements
in the impaired population,
said Judith E. Goldstein,
OD, FAAO.
A MD is the pr ima r y
Dr. Goldstein
cause of the majority of
cases of legal blindness in
the United States, said Dr. Goldstein, who
is with The Wilmer Eye Institute and assistant professor of ophthalmology and rehabilitative medicine, at Johns Hopkins Hospital, Baltimore. Ten to 15% of patients with
AMD have the neovascular form of macular degeneration, which is characterized by
the abnormal growth of new blood vessels
under the retina, Dr. Goldstein explained.
“It can lead to exudation, disruption of
photoreceptors, and ultimately retinal scarring,” she said. “Neovascular age-related macular degeneration (NV AMD) affects both
eyes in 50% of the population, so you can
expect that at least half of individuals with
the neovascular form will experience visionrelated problems with daily activities over
their lifetime.”
Treating NV AMD
Historically, treatment for NV AMD has had
less than satisfactory outcomes until the advent of anti-angiogenic therapy, which has
revolutionized the field over the past 5 years,
Dr. Goldstein said.
“The timing of these treatments has changed
the way we think of neovascular AMD,” she
said. “Originally with subfoveal choroidal neovascularization, focal photocoagulation was
often performed once or twice (depending on
recurrences of new blood vessel growth), a
macular scar was created and patients were
left with vision in the 20/100 to 20/200 range.
“Macular translocation surgery consisted
of one surgical event, and again, patients
were left with severe visual impairment,”
Dr. Goldstein continued. “The development
of photodynamic therapy (PDT) incurred an
increase in the number of treatments and
better visual results than prior therapies,
however patients were still receiving, on av-
Take-Home Message
Before prescribing any type of visual enhancement for
patients with neovascular or wet age-related macular
degeneration, there are several considerations to
explore, including the duration of anti-angiogenic
treatment and how long to wait after this therapy
before glasses and other forms of vision enhancement
are prescribed.
erage, only three treatments over a period
of 12 months.
“But with use of anti-angiogenic therapy,
which includes agents such as bevacizumab
(Avastin, Genentech) and ranibizumab (Lucentis, Genentech), treatment for neovascular AMD has completely changed the management of the disease,” she said. “Stabilization of visual acuity is common and even
improvement in some cases occurs.
“The treatment regimen, however, typically
requires monthly injections for an unknown,
indefinite period of time, and can be thought
of as chronic therapy,” Dr. Goldstein said.
Prescribing for patients
Before prescribing any type of visual enhancement for these patients, there are several considerations to explore, including how
long after therapy to wait before prescribing
glasses or other forms of vision enhancement. To better answer these questions, Dr.
Goldstein reviewed results from two recent
studies that shed light on the timeframe of
visual improvement and stabilization in patients receiving anti-angiogenic treatment.
The first of these is the Anti-VEGF Antibody for the Treatment of Predominantly
Classic Choroidal Neovascularization in AMD
(ANCHOR) study. Researchers evaluated 423
patients with classic choroidal neovascular
disease.1 The primary endpoint was a loss
of <15 letters. In the verteporfin (Visudyne,
Novartis) or PDT group, 64% of patients were
able to maintain a <15-letter loss, as compared with 96% of patients in the ranibizumab 0.5% group.
“What was exciting about this study was
that 40% of patients in the ranibizumab group
gained ≥ 15 or more letters—equivalent to a
three line acuity improvement—while only
5% of the patients in the PDT group reached
this threshold,” Dr. Goldstein said.
“With ranibizumab, longitudinally, 7 days
after injection, patients gained on average
5 letters on the EDTRS chart. Between 2 to
6 months, visual acuity levels off, and patients gain on average 10 letters,” she said.
“There is frequent objective and subjective
fluctuation in vision and when these patients
come to you, they’ll tell you that their vision
changes day to day.
“Some of this may be secondary to the
underlying disease process and part of this
may be due to the drug therapy,” she added.
“But what the data tells us is that between
2 and 6 months, they will achieve the maximum levels of visual acuity that they will
ever have, under most circumstances.”
MARINA study
A second study, the Minimally Classic/Occult Trial of the Anti-VEGF Antibody Ranibizumab in the Treatment of Neovascular AMD
(MARINA) study, included patients with the
occult form of neovascular disease.2 For this
prospective randomized controlled trial, 716
patients received 0.3 or 0.5 mg ranibizumab
or sham treatment.
‘We’re seeing that after
vision enhancement is
received, patients see the
greatest improvements in
reading ability, which is
their primary complaint.’
Judith E. Goldstein, OD, FAAO
Results here were similar to those from
the ANCHOR study, Dr. Goldstein said. In
the sham group, 53% of patients had a loss
of <15 letters, compared with 90% in the
ranibizumab group. Improvement of ≥ 15
letters occurred in almost 4% of the sham
group, compared with 33% of the patients
in the ranibizumab group.
“Again, longitudinally, about 7 days after
injection, patients gained 2.5 letters on average on the EDTRS chart. But between 3 and
6 months, these patients show some stabilization gaining 6 to 7 letters on average,”
she said. “They may fluctuate after that, but
MARCH 2011 / OptometryTimes.com
generally speaking, they are at their maximum visual acuity gain, and we cannot expect much improvement beyond 6 months
of therapy.
“A common perception is that these patients
are maintaining good vision, and they do not
require vision enhancement,” Dr. Goldstein
said. “They may not be referred to or seek
out their optometrist or general ophthalmologist for additional improvement that may be
provided through refraction or use of magnification,” Dr. Goldstein added.
Misperceptions
“The excitement over maintenance of 20/50
visual acuity has commonly translated into
thinking that patients are doing great and
have no difficulty with their visual function,” “But this is not the reality,” she said.
The mean baseline visual acuity in patients in the MARINA study was 20/80. “This
means that patients may be improving to
20/40 or 20/50, but even at that level, they’re
still going to have difficulty reading small
print, seeing road signs, and recognizing facial features of others to assist with social
interaction,” she added.
“The other perception is that patients should
wait until their injections have stopped before considering a change in their glasses
or other forms of visual enhancement,” Dr.
Goldstein continued. “Maybe not. If patients
are getting maximum visual acuity within
3 to 6 months, maybe we should begin prescribing earlier, move away from the traditional model of completing treatment, and
then referring for vision enhancement.”
What are these patients complaining about?
“They can’t read the newspaper, they can’t
read road signs, they can’t see the expressions on people’s faces. They have difficulty
managing daily activities, and they consistently report fluctuating vision,” she said.
LVROS study
In the Low Vision Rehabilitation Outcomes
Study (LVROS), an ongoing study conducted
by the Low Vision Research Network (LOVRNET) with the coordinating center at Johns
Hopkins, 27 centers across the United States
are collecting baseline and follow-up data
on new patients seeking low vision services.
“In more than 200 patients with follow up
data we’re seeing that after vision enhancement is received, patients see the greatest
improvements in reading ability, which is
the most common presenting complaint,”
Dr. Goldstein said.
“The take-home here is that these patients
who are getting these injections are probably the best candidates for improvement in
reading function,” she noted.
When reading outcomes were analyzed
Retina
by visual acuity subgroups, we found that
patients with 20/60 or better visual acuity
have the greatest improvement in overall
near visual tasks including reading ability
after rehabilitation.
Vision enhancement therapy
33
FYI
Judith E. Goldstein, OD, FAAO
Phone: 410/955-0580
How should you evaluate patients receivE-mail: [email protected]
ing anti-angiogenic therapy? Do everything
Dr. Goldstein did not indicate a financial interest in the
you would ordinarily do, Dr. Goldstein said.
subject.
Check acuity, distance and near, contrast
sensitivity if you are able
to, assess the presence of
scotomas, perform a careful refraction, and evaluate
the impact of magnification
and lighting on near tasks
such as reading.
“Prescribe everything
you normally do as it relates to spectacles. You need
to be sensitive to fact that
you will have to use more
plus at near,” she said. “If
necessary, consider prescribing the higher add in
a near vision only lens as
opposed to a bifocal, as you
don’t want to adversely affect mobility function and
increase risk of falls.
“If you put patients in a
progressive, consider the
impact of blur zones, especially if they have scotomas
and you are recommendSELLING PUNCTAL OCCLUDER†
ing the practice of eccenIN THE DRY EYE MARKET
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“Lighting, microscopic
spectacles, hand-held magHIGHEST RETENTION RATE‡
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nification, video magnification, Kindles, and iPads
are all part of the vision
enhancement rehabilitation
process and should not be
overlooked during any stage
of anti-angiogenic therapy,”
Dr. Goldstein concluded.OP
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1.Brown DM, Kaiser,
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Oct5;355(14);1432-1444.
2.Rosenfeld PJ, Brown
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34
Practice Management
MARCH 2011 / Optometry Times
SMART management
Drive practice growth—set staff goals,
monitor progress toward objectives
Each employee objective should be SMART: Specific, Measurable, Aligned, Realistic, Time-framed
By Carol Patton
Reviewed by Stacey Bearden
D
o your employees know what you
expect of them? Do they understand
how their jobs relate to the well being
of your practice? These are important questions that every optometrist in private practice must ask.
If your practice is to succeed, you must set
goals for employees, help them achieve those
goals throughout the year and link the goals
to the practice’s overall business strategy.
“The purpose of setting goals is to drive
results across your [practice],” said Stacey
Bearden, a senior associate who specializes
in performance management at Mercer LLC,
a global human resources consulting firm.
A SMART approach
The first step: Determine how each job contributes to the overall success of the practice,
Bearden said. Then, identify what results and
behaviors you need from employees so that
they can contribute effectively.
Suppose, for example, you want to grow
your patient base by 20% this year. One goal
for the receptionist may be to offer excellent
customer service by answering the phone
within three rings or by welcoming each patient to the office. Likewise, a goal for the
dispensary staff may be to personalize customer service by asking each patient at least
three questions.
Each employee goal should be SMART:
Specific, Measurable, Aligned, Realistic, and
Time-framed. For example, an employee goal
may be to dispense more frames in 2010 than
last year. A SMART goal: Dispense 20% more
frames each month in 2010 compared with
the same month last year.
Another employee goal might be to promote
the practice’s new senior services by targeting new markets. A SMART goal: Market the
new senior services by visiting at least three
different health-care facilities each month.
Each goal should be challenging but attainable. If you set goals too high, Bearden
said, employees will expect to fail. If you set
them too low, employees won’t be motivated
to perform, enhance their skills or change
problem behaviors.
Take-Home Message
If you want your practice to succeed, you must set goals
for your employees. These goals should be SMART:
Specific, Measurable, Aligned, Realistic, and Timeframed. Avoid setting too many or too few goals, and
offer employees ongoing feedback.
The biggest mistakes you can make are to
not set any employee goals or to create too
many. Either way, she said, employees won’t
know how to prioritize. For example, a job
may require that an employee complete paperwork and help patients. If the employee
doesn’t have any goals, she may not know
that customer service is a priority and spend
most of her time on the paperwork.
Focus for success
If an employee has too many goals, the question becomes which is the most important:
Servicing customers? Performing inventory?
Ordering supplies? Meeting with vendors? If
you do not clearly spell out goals, the employee must make uninformed decisions that
may not align with your overall business
strategy. Bearden suggested setting no more
than 10 goals so that employees know what
they need to accomplish and in what order.
One more suggestion: Encourage employees
to participate in creating their performance
goals. Discuss your expectations and how
the employee’s job fits into the business plan.
Also ask employees about their aspirations
or career goals. If employees are involved in
setting their own goals, they’ll be more motivated to perform, Bearden said.
An ongoing process
Once they set goals, some optometrists let
employees fend for themselves, offering no
feedback about their performance until their
annual reviews.
“Don’t wait until the end of the year to say
anything,” Bearden said. “Coach employees
throughout the year. It’s their supervisor’s
responsibility to provide feedback on an ongoing basis.”
Bearden’s advice:
• Conduct quarterly reviews, and correct
employee behavior as it occurs. If customer
service was poor, explain why. Then, offer
suggestions on how the employee could have
handled the situation differently so that she
doesn’t repeat the same mistakes and alienate patients. Also, reinforce what each employee does well so that other employees can
emulate the same behavior.
• Look at performance throughout the year,
not just during the past few weeks or months.
When conducting annual reviews, focus on
the employee’s performance throughout the
year, not just in recent weeks, Bearden said.
For example, an employee may have surpassed her goals for most of the year, but
due to current personal problems, may be
tardy with assignments.
• Balance behavior with results. For example, an employee may have exceeded her
sales goals but created unhappy patients who
felt pushed into buying something they didn’t
want. “Look at what was done and how it
was done,” Bearden said.
‘Coach employees
throughout the year.
It’s their supervisor’s
responsibility to provide
feedback on an ongoing
basis.’
Stacey Bearden
Senior associate, Mercer LLC
• Don’t rely on personal feelings. “This is
hard to do in a small business because you
get close to employees,” she said.
Bearden’s mantra is simple: “Focus on behavior and performance.”OP
FYI
Stacey Bearden
Phone: 415/743-8874
E-mail: [email protected]
Bearden is a senior associate with Mercer LLC.
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MARCH 2011 / Optometry Times
Practice Management
Just say ‘no’ to mixing EMRs, laptops
Practice caution with office files, employ security measures to help ensure patients’ privacy
By Ron Rajecki
Reviewed by Anastas Pass, OD, MS, JD, FAAO
O
il and water. The Hatfields and
the McCoys. Now, there is another pair of items to add to the
list of bad matches: laptop computers and patients’ medical information.
According to Anastas Pass, OD, MS, JD,
FAAO, optometrists and
other health-care practitioners should “just say
no” to the idea of putting
patient information on a
laptop computer, no matter
how well-intentioned their
Dr. Pass
reason. Dr. Pass is associate professor, director of
emergency eye-care service, chief privacy/
security officer, and director of HIPAA/HITECH compliance, University of Houston,
College of Optometry, University Eye Institute.
HITECH regulations
“Laptops are sometimes more mobile than
we want them to be, and therein lies a problem,” Dr. Pass said. “It’s very important that
optometrists and other health-care providers understand their obligations under the
HITECH regulations.”
The Health Information Technology for
Economic and Clinical Health (HITECH) Act,
about eyewear,
contact lenses,
in-house finishing
equipment, and
other dispensingrelated topics.
Health care providers have always faced the
responsibility of protecting patient information;
however, in an electronic age, caution and security
must be the bywords more than ever before.
was among the provisions of the American
Recovery and Reinvestment Act of 2009.
It includes financial incentives for certain
health-care providers who adopt electronic
records systems (electronic medical records,
or EMRs) and imposes various obligations
related to the privacy and security of electronic health records.
According to the HITECH Act, one obligation
providers face is to “utilize technologies
and methodologies to protect the electronic
transmission of health information from
incursion from unintended sources.” The
information contained in EMRs must be made
unusable, unreadable, or indecipherable to
the unauthorized. It may be relatively easy
to meet these obligations using passwordprotected computers that contain encrypted
data and never leave the office.
or other sensitive patient information onto
a laptop or other mobile storage device to
work on at home. While you can’t condemn
the employee for being hard-working, the
risks of allowing employees to do this simply aren’t worth it.
“I strongly advise practitioners not to
allow any patient information to leave the
office,” Dr. Pass said. “This means on laptops that can be stolen, or ‘jump’ or ‘flash’
drives that can be lost.”
Dr. Pass suggested that a better option
is setting up a password-protected virtual
access network, whereby employees can remotely access information in the office’s
computer system.
‘I strongly advise
practitioners not to allow
any patient information to
leave the office.’
Anastas Pass, OD, MS, JD, FAAO
Remote homework
Laptop computers present a different scenario. In many cases, an employee who simply wants to do a good job will load EMRs
Getty Images/Stockbyte/Claran Griffin
Look for the
latest news
Take-Home Message
“The information never leaves the office’s
system. It’s not downloaded onto the remote
computer. It’s not foolproof, but it is safer
if employees really must work remotely at
times,” he said.
Security breech laws
The information on most stolen laptops is
usually never accessed, Dr. Pass added. Most
computer thieves are simply looking to sell
the computer for cash, and will often wipe
the computer’s memory clean before they
sell it. That does not, however, prevent the
provider who reports a stolen laptop from
being subjected to tedious security breech
notification regulations.
Having to notify patients that their personal information may have been stolen is
not only harmful to a practice’s image and
worrisome to patients, it can also be expensive. (HITECH breach notification guidelines
and procedures can be found at the HHS
Web site, www.hhs.gov/ocr/privacy/hipaa/
administrative/breachnotificationrule).
Security breech laws vary from state to
state. Under the “Red Flag” rule, which applies to financial institutions and other businesses, such laws can entail providing credit
MARCH 2011 / OptometryTimes.com
www.optometrytimes.com
monitoring services or other safeguards for
all individuals whose information may have
been breeched.
“There has been a great deal of lobbying
to try to eliminate health-care practitioners
from having to be compliant with the Red
Flag rule,” he said. “Much of what that rule
covers is already covered by the HITECH
Act and the Health Insurance Portability
and Accountability Act (HIPAA). But the
bottom line is that health-care providers
need to be very aware of their responsibility to protect patient information.”
Practice Management
fied ophthalmic EMR in the marketplace,
so it’s a “buyer beware” situation.
“I understand CCHIT is in the process of
beginning to look at ophthalmic systems,
and hopefully very soon there will be some
certification for these ophthalmic EMRs. I
would advise eye-care practitioners to be
watching for certification for the system they
may be looking to purchase,” Dr. Pass said.
“But, conversely, if today you’re told by
37
a rep that it’s certified, I would take that
with a grain of salt.”OP
FYI
Anastas Pass, OD, MS, JD, FAAO
Phone: 713/202-2861
E-mail: [email protected]
Dr. Pass has no financial interest in the subject.
Selecting EMR programs
Dr. Pass also advised practitioners to be cautious and selective when it comes to choosing the program they will use to generate
their EMRs. Many programs will generate
records that are pre-populated with normative statements that can lead to payment
challenges from Medicare and Medicaid,
or even liability issues.
“If a patient doesn’t have, for example,
a normal optic nerve because of glaucoma,
you must go into the EMR and remove any
normative statements to the contrary that
automatically exist in the template,” he said.
“If you don’t and there is ever a court
case involving that patient, it’s not going
to bode well for you because there’s conflicting information in the medical record.”
‘Cloned’ letters
Normative statements also cause problems
when a practitioner asks the EMR system to
generate a letter to Medicare or Medicaid.
“Many EMR systems generate ‘cloned’
letters, and Medicare or Medicaid do not
like cloned letters. It’s an alert for them to
say, ‘Maybe we should audit this person,’”
Dr. Pass said.
“The Recovery Audit Contractor program
within the Medicare system incentivizes
their workforce to actively go out and look
for problems. They’re basically bounty hunters looking for improper billing, and cloned
letters are just one of the things that draws
their attention,” he added.
Dr. Pass advised practitioners to be aware
of what EMR programs they purchase, examine what kinds of pre-populated normative statements might exist within them,
ensure that such statements can be modified, and double-check the information in
each EMR before closing the record.
Although some specialties such as internal
medicine, surgery, and radiology have EMR
systems that have been certified for proper
performance through the Certification Commission for Health Information Technology
(CCHIT), there’s currently no CCHIT certi-
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38
MARCH 2011 / Optometry Times
After 5
Heeding the call
Optometrist finds God, now sees clearly
OD helps enhance other people’s views of both the physical and spiritual worlds
F
or most of his adult life, Maurice Geldert,
OD, was not a religious man. In fact, Dr.
Geldert says he was an atheist and an
alcoholic. But, all that changed one day
when he was backpacking in the mountains of
the Weminuche Wilderness in southern Colorado, an area he had hiked in for many years.
“I was working my way out of the mountain
when I stopped to take a drink of water and
looked around,” said Dr. Geldert, who practices
at Roswell Vision Source in Roswell, NM. “It
was a bad time in my life. All of a sudden, the
thought hit me—‘God, if you’re there, I need
you. I can’t do this by myself anymore.’ ”
Take-Home Message
Maurice Geldert, OD, was an atheist and an alcoholic
when he answered God’s call and became an Episcopal
priest. Today, Dr. Geldert not only takes care of people’s
eyes, but also their souls.
The presence he suddenly felt was so overwhelming that the hair stood up on the back
of his neck, Dr. Geldert recalled.
He says that mountain top experience in 1988
probably saved his life and forever changed
the way he thought, behaved, and believed.
Since that day, Dr. Geldert has not touched another drink. His vision also drove him straight
to the local priest to ask, “Where do I start?”
More than 20 years later, he still practices
optometry, but also can add Episcopal priest
to his resume. Not only is he taking care of
people’s eyes, but he also cares for their souls.
A rural calling
For the past several years, Dr. Geldert has
served as the vicar of the rector at an Episcopal church in Artesia, NM, a small town 45
miles south of Roswell. He conducts Sunday
morning and Wednesday evening services for
the 40 people in his parish. When needed,
he also visits hospitalized patients and conducts religious ceremonies—everything from
baptisms and weddings to funerals.
Yet, he never receives any payment for
his services.
“There’s an enormous shortage of clergy in
all major denominations,” Dr. Geldert said,
explaining that since church membership has
steadily declined, many parishes cannot afford to pay for clergy so they must support
themselves in other ways. “Most people come
into the clergy as a second vocation or are
bi-vocational people.”
Roughly 1 year after his mountain vision,
Dr. Geldert became a lay minister. He dreamed
about becoming a priest, but believed it was too
late because of his age—he was in his mid 50s.
Then, one afternoon, he was assisting the local
bishop to perform a confirmation and baptism.
During the service, the bishop turned to him
and asked, “Maurice, when are you going to
come talk to me about your call to Holy Orders?”
“He just knocked me off my feet,” Dr. Geldert
said. “That’s when I realized God was telling
me I needed to do something else.”
The next big step
So he came home and told his wife that he
wanted to become a priest. Dr. Geldert said
that he will never forget her reaction. She
asked, “We’re not going to have to become
missionaries, are we?”
For the next 3 years, he studied at the Trinity Episcopal School for Ministry in Ambridge,
PA, which offered classes within his local
diocese. He completed a variety of courses,
such as systematic theology, Old and New
Testament, and Christian morals and ethics.
Every quarter, he traveled to the seminary
for 4 or 5 days, taking exams and engaging
in class discussions with other clergy.
He first was ordained as a deacon in 2006,
then as a priest the following year.
Ministry and medicine
“When I went though seminary, I was told
by one of our diocese people that I would
find a great deal of my ministry would be in
my practice,” Dr. Geldert said. “That’s been
very true.”
Still, he never mixes medicine with religion. Dr. Geldert doesn’t display religious
icons on his office walls or invade a patient’s
religious beliefs. Instead, he talks to patients
as one human being to another.
Since many of his patients are seniors with
serious health problems, they often need a
compassionate ear.
“Some just unburden themselves about all
the things that are going wrong with them,”
Dr. Geldert said. “Every now and then, if I
think it’s appropriate, I’ll ask if they would
like me to pray for them. If somebody says
‘yes,’ I will anoint them and pray for them.”
Dr. Geldert has no doubt in his mind that
becoming a priest has affected his percep-
tions of people and enhanced his level of
empathy and compassion. He said his life is
very full, very rich, and credits God for the
transformation.
‘We all need to take a
deep breath and put
things into perspective. . . .
Life isn’t all about being a
doctor.’
Maurice Geldert, OD
“It’s so easy for any health-care professional, particularly with the strain and stress
we’re under these days, to let their spiritual
life go,” Dr. Geldert said. “We all need to
take a deep breath and put things into perspective, which affects our family and our
personal and professional lives. Life isn’t all
about being a doctor.”OP
FYI
Maurice Geldert, OD
Phone: 575/317-4664
E-mail: [email protected]
Dr. Geldert has no financial interest in the subject.
Getty Images/Digital Vision/Adam Jones
By Carol Patton
Reviewed by Maurice Geldert, OD
Meeting Planner
MARCH 2011 / OptometryTimes.com
April 2011
April 6-9, 2011
CLSA Annual Education Meeting
Hyatt Regency Jacksonville Riverfront
Austin, TX
May 2-8, 2011
Continuing Education in Ireland
Conference
Cork City, Killarney, and Dublin, Ireland
Sponsored by Contact Lens Society of America
April 7-10, 2011
OptoWest
Indian Wells, CA
Tel: 800/877-5738
E-mail: [email protected]
www.optowest.com
Tel: 800/284-3937
E-mail: [email protected]
www.CEinItaly.com
www.jcahpo.org
Sponsored by CE in Italy
Sponsored by Joint Commission on Allied Health
Personnel in Ophthalmology
May 10, 2011
JCAHPO Web seminar: Advanced OCT
visualization
Tel: 800/284-3937
E-mail: [email protected]
www.jcahpo.org
Sponsored by Joint Commission on Allied Health
Personnel in Ophthalmology
Sponsored by California Optometric Association
April 7-8, 2011 [Clinical skills courses]
April 9-10, 2011 [General conference]
NORA Annual Multi-Disciplinary Conference
Atlanta, GA
Contact: Robert Williams
Tel: 866/222-3887
E-mail: [email protected]
May 13, 2011
JCAHPO CE Program
Houston, TX
Tel: 800/284-3937
E-mail: [email protected]
www.jcahpo.org
Sponsored by Joint Commission on Allied Health
Personnel in Ophthalmology
Sponsored by Neuro-Optometric Rehabilitation
Association International Inc.
May 13-15, 2011
Annual Clinical Eye-Care Conference
Davie, FL
April 12, 2011
JCAHPO Web seminar: DSEK: Clinical
implications and outcomes
Tel: 954/262-4224
E-mail: [email protected]
Tel: 800/284-3937
E-mail: [email protected]
Sponsored by Nova Southeastern University College of Optometry
Sponsored by Joint Commission on Allied Health
Personnel in Ophthalmology
April 15-16, 2011
Educational Meeting
Mission Inn, Howey-in-the-Hills, FL
Contact: Arthur T. Young
Tel: 239/542-4627
E-mail: [email protected]
Sponsored by Florida Chapter of the American Academy of Optometry
http://optometry.nova.edu/ce
June 2011
June 3-4, 2010
JCAHPO CE Program
Kiawah Island, SC
Tel: 800/284-3937
E-mail: [email protected]
www.jcahpo.org
Sponsored by Joint Commission on Allied Health
Personnel in Ophthalmology
Apr. 27- May 1, 2011
Annual Educational Conference
Myrtle Beach, SC
June 14, 2011
JCAHPO Web seminar: Five triage
decisions that can save a life
Contact: Dennis H. Lyons, OD, FAAO
Tel: 732/920-0110
E-mail: [email protected]
Sponsored by American Academy of Optometry, New Jersey Chapter
Tel: 800/284-3937
E-mail: [email protected]
May 2011
May 1-5, 2011
ARVO Annual Meeting
Fort Lauderdale, FL
www.arvo.org
Sponsored by Association for Research in Vision and Ophthalmology
June 29-July 2, 2011
World Glaucoma Congress
Paris, France
www.oic.it/wgc2011
Sponsored by World Glaucoma Association
July 2011
July 7-16, 2011
Therapeutic Pharmaceutical Agents
Certification Course
Ft. Lauderdale, FL
Tel: 954/262-4224
E-mail: [email protected]
http://optometry.nova.edu/ce
Sponsored by Nova Southeastern University
www.nora.cc
www.jcahpo.org
June 24-26, 2011
JCAHPO CE Program
Palm Beach, FL
E-mail: [email protected]
www.clsa.info/educational-meeting
39
July 22-23
ALOA Summer Conference
Perdido, AL
http://alabama.aoa.org
Sponsored by Alabama Optometric Association
August 2011
Aug. 12-14, 2011
SWFOA Educational Retreat
South Seas Island Resort, Sanibel, FL
Contact: Brad Middaugh, OD
Tel: 239/481-7799
Fax: [email protected]
Sponsored by Southwest Florida Optometric Association Inc.
Aug. 13-15, 2011
Primary Care Update
St. Simons Island, GA
Tel: 954/262-4224
E-mail: [email protected]
http://optometry.nova.edu/ce
Sponsored by Nova Southeastern University
www.jcahpo.org
Sponsored by Joint Commission on Allied Health
Personnel in Ophthalmology
August 20-21, 2011
JCAHPO CE Program
Boston, MA
June 15-19, 2011
AOA Annual Congress, “Optometry’s
Meeting”
Salt Lake City, UT
Tel: 800/284-3937
E-mail: [email protected]
www.aoa.org
www.jcahpo.org
Sponsored by Joint Commission on Allied Health
Personnel in Ophthalmology
Sponsored by American Optometric Association
See Meetings on page 42
40
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MARCH 2011 / OptometryTimes.com
PRODUCTS & SERVICES
CONFERENCES/EVENTS
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April 27 - May 1, 2011
Myrtle Beach, South Carolina
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41
42
Meeting Planner
MARCH 2011 / Optometry Times
Continued from page 39
Oct. 8, 2011
Reducing the Risk of Age-Related Vision Loss
Hot Springs, AR
Contact: Chris Halsten
Tel: 515/222-5679
E-mail: [email protected]
September 2011
Contact: Melissa Flower
Tel: 314/983-4136
E-mail: [email protected]
www.iowaoptometry.org
www.aoa.org
Oct. 17, 2011
Reducing the Risk of Age-Related Vision Loss
Groton, CT
Meetings
Sponsored by Iowa Optometric Association
Sept. 16-17, 2011
JCAHPO CE Program
Asheville, NC
Sponsored by American Optometric Association Vision
Rehabilitation Section
Tel: 800/284-3937
E-mail: [email protected]
Oct. 8-9, 2011
New Hampshire Optometric Association
Portsmouth, NH
www.jcahpo.org
Contact: Melissa Flower
Tel: 314/983-4136
E-mail: [email protected]
www.aoa.org
Sponsored by Joint Commission on Allied Health Personnel in Ophthalmology
Tel: 603/964-2885
E-mail: [email protected]
Sponsored by the American Optometric Association
Sept. 20-22, 2011
Continuing Education in Italy Conference
Florence, Italy
www.nhoptometry.org/
Oct. 20-23, 2011
EastWest Eye Conference
Cleveland, OH
E-mail: [email protected]
Oct. 11, 2011
ONS Fall Educational Symposium
Boston, MA
www.CEinItaly.com
Sponsored by CE in Italy
Sponsored by New Hampshire Optometric Association
E-mail: [email protected]
www.eastwesteye.org
Sponsored by Ohio Optometric Association
www.ocularnutritionsociety.org
Sept. 21-24, 2011 (Conference)
Sept. 22-24, 2011 (Exhibition)
International Vision Expo West
Sands Expo Center, Las Vegas, NV
Oct. 21-25, 2011
OPS Orlando Educational Program
Orlando, FL
Sponsored by Ocular Nutrition Society
www.visionexpowest.com
Oct. 12–15, 2011
AAO Annual Academy
Boston, MA
Sponsored by Reed Exhibitions and The Vision Council
www.aaopt.org/meetings
www.opsweb.org/Educat/Annual
Sponsored by Ophthalmic Photographers’ Society
Sponsored by American Academy of Optometry
October 2011
Oct. 12–15, 2011
OCRT Annual Refractive Symposium
Boston, MA
Oct. 6–9, 2011
GWCO Annual Congress
Portland, OR
E-mail: [email protected]
Oct. 25-29, 2011
COVD Annual Meeting
Las Vegas, NV
www.covd.org
Sponsored by the College of Optometrists in Vision
Development
www.ocrt.org
Contact: Tracy Oman
Tel: 503/654-1062
E-mail: [email protected]
Oct. 29-Nov. 2, 2011
APHA Annual Meeting and Exposition
Washington, DC
Optometric Council on Refractive Technology
Oct. 13-14, 2011
Iowa Optometric Association
Cedar Rapids, IA
www.gwco.org
Sponsored by Great Western Council of Optometry
www.apha.org/meetings
Sponsored by American Public Health Association
Advertisers Index
Advertiser
Page
Alcon Laboratories Inc.
Tel: 817/293-0450
Customer Service: 800/862-5266
Internet: www.alcon.com
CV2, CV4, 27-28
Allergan Inc.
Tel: 714/246-4500
Fax: 714/246-4971
Customer Service: 800/433-8871
Internet: www.allergan.com
5-6, 7-8, 19-20
American Optometric Association
Tel: 800/365-2219
Internet: www.aoa.org
Bausch & Lomb
57
10 a-b
Advertiser
Page
Tel: 585/338-6000
Fax: 585/338-6007
Internet: www.bausch.com
Advertiser
Page
Fax: 901/382-2712
Internet: www.odysseymed.com
Heidelberg Engineering
Tel: 800/931-2230
Fax: 760/598-3060
Internet: www.heidelbergengineering.com
17
Oculus Inc.
Tel: 888/284-8004
Fax: 425/670-0742
E-mail: [email protected]
Internet: www.oculususa.com
31
Odyssey Medical
Tel: 888/905-7770
33
Transitions Optical
Tel: 800/533-2081
Internet: www.transitions.com
13
Vision Expo East
Internet: www.visionexpoeast.com
Vistakon
Tel: 800/843-2020
Internet: www.acuvue.com
CV3
CV TIP, 22-23
This index is provided as an additional service.
The publisher does not assume any liability
for errors or omissions.
YOUR
FIELD
OF
VISION
SAVE THE DATE
Conference: September 21-24, 2011
Exhibition: September 22-24, 2011
Las Vegas, LV
Sands Expo & Convention Center
www.visionexpowest.com
Conference: March 22 – 25, 2012
Exhibition: March 23 – 25, 2012
New York, NY
Jacob K. Javits Convention Center
www.visionexpoeast.com
STAY CONNECTED TO THE GLOBAL VISION COMMUNITY
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