Optometric Office April 2017

OPTOMETRIC OFFICE PRODUCTS AND TECHNOLOGY FOR YOUR PRACTICE

DIGITAL REFRACTION TECHNOLOGY TO IMPROVE PATIENT EXPERIENCE

MANAGING GLAUCOMA— FROM TREATMENT TO ENCOURAGING COMPLIANCE

APRIL 2017

ALTERNATE REVENUE STREAMS YOUR PATIENTS WILL APPRECIATE

SCLERALS IN THE SPOTLIGHT:

HOW TO ADD THEM TO YOUR PRACTICE SUPPLEMENT TO VCPN APRIL 2017

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Prescribe up to

the oxygen1

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TABLE OF CONTENTS 10

ON THE COVER | Atlantis Scleral from X-Cel Specialty Contacts

DEPARTMENTS 4 | Views 8 | One-to-One: James Kirchner, OD, president and CEO of SynergEyes, Inc. 10 | Buzz

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26 | The Optometric Technician 28 | Lid Hygiene Products At-A-Glance 30 | New Product Gallery

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32 | Docs Speak Out

FEATURES 12 | New Business Models for a Better Practice 14 | Going Digital 16 | A Foolproof Way to Free Up Time 18 | Set Your Sights on Sclerals 20 | Rx for Alternate Revenue Streams 22 | The Challenge of Glaucoma

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24 | Doctor’s Orders 25 | La Dolce Vita

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OPTOMETRIC OFFICE EDITORIAL STAFF VP, Editorial John Sailer | JS@VisionCareProducts.com Professional Editor Richard Clompus, OD | RC@OptometricOffice.com Editor-in-Chief Joanne Van Zuidam | JVZ@VisionCareProducts.com Assistant Editor Cara Aidone Huzinec | CH@VisionCareProducts.com Vice President, Design Jane Kaplan | JK@VisionCareProducts.com Assistant Art Director Bruce Kenselaar | BK@VisionCareProducts.com Production and Web Manager Anthony Floreno | AF@VisionCareProducts.com Contributing Writers Roberta A. Beers, CPOT • Glenn Corbin, OD • Ann Hoscheit, OD, FAAO, FAARM • Shane R. Kannarr, OD • Beth T. Kinoshita, OD • Katherine Shen, OD • Jennifer L. Stewart, OD • Gina M. Wesley, OD, MS, FAAO

BUSINESS STAFF Executive Vice President/Publisher Shawn Mery | SM@VisionCareProducts.com President/Associate Publisher Frank Giammanco | FG@VisionCareProducts.com Director of Sales Janet Cunningham | JC@VisionCareProducts.com Vice President, Marketing Debby Corriveau | DC@VisionCareProducts.com Vice President, Operations Sharon O’Hanlon | SO@VisionCareProducts.com

EDITORIAL ADVISORY BOARD

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Jeffrey Anshel, OD • Sherry Bass, OD • Murray Fingeret, OD • Ed De Gennaro, MEd, ABOM Deepak Gupta, OD • Alan Homestead, OD • Nikki Iravani, OD • Bill Jones, OD Alan G. Kabat, OD • Kenneth A. Lebow, OD, FAAO • Jerome A. Legerton, OD, MBA Scot Morris, OD • John Schachet, OD • Eric Schmidt, OD • Leo Semes, OD Peter Shaw-McMinn, OD • Joseph Sowka, OD, FAAO Jennifer Stewart, OD • J. James Thimons, OD

INDUSTRY ADVISORY BOARD Dwight Akerman, OD, Alcon Laboratories, Inc., a Novartis Company Steve Baker, EyeFinity • Joseph Boorady,OD, TearScience, Inc. Sally M. Dillehay, OD, Visioneering Technologies, Inc. Dave Hansen, OD, Ophthalmic Consultant • Carla Mack, OD, Alcon Laboratories, Inc. Dave Sattler, Dave Sattler Consulting Michele Andrews, OD, CooperVision, Inc. • Ellen Troyer, Biosyntrx, Inc. Millicent Knight, OD, Johnson & Johnson Vision Care, Inc. Throughout this magazine, trademark names are used. Instead of placing a trademark or registration symbol at every occurrence, we are using the names editorially only with no intention of infringement of the trademark.

Correction: In the March 2017 issue, we inadvertently referred to a rebate program offered by Vistakon for the purchase of ACUVUE OASYS Brand Contact Lenses two-week disposables. The rebate was for the ACUVUE brand two week disposables.

© 2017 AMETEK, Inc. & Reichert, Inc. (2-2017) · Made in USA Phoroptor is a registered trademark of Reichert, Inc. · www.reichert.com

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ScleralFil preservative free saline solution ™

NEW

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Offer your scleral lens patients a new option with ScleralFil™ preservative free saline solution.

From Bausch + Lomb Specialty Vision Products, ScleralFil™ is indicated as a scleral insertion solution — a new alternative for rinsing and inserting scleral lenses. It is a sterile, buffered isotonic saline solution that can be used to rinse soft and gas permeable lenses.

• Buffered to maintain pH • Travel-friendly, single-use, 10 mL vials stand upright • Each carton contains a 30-day supply • Indicated for soft and gas permeable lenses

Only available online at bauschSVPstore.com 800.253.3669 | info@bauschSVP.com

ScleralFil is a trademark of Bausch & Lomb Incorporated or its affiliates. © 2017 Bausch & Lomb Incorporated. SCFL.0017.USA.16

All-new!

VIEWS IS THERE A DOCTOR ON BOARD?

We’ve all seen movies where a traveler on a plane has a health crisis and the flight attendants make the hurried announcement, “Is there is a doctor on board?”

In February, while on a coast-to-coast flight, a passenger fell unconscious while waiting to use the bathroom. The announcement went out quickly asking for assistance. I immediately stood up and made my way up the aisle. The person was lying on his back unresponsive.

There are many things that go through your mind at a time like this. While it was difficult to tell if he had a radial pulse, he certainly had a strong carotid pulse. He was pale but breathing on his own. In less than a minute, he was responsive but still very dizzy. The crew provided a blood pressure cuff and

There are many things that go through your mind at a time like this.

Pixel-perfect acuity testing.

ClearChart® 4 · 4X · 4P Digital Acuity Systems Simple-to-use interface. 24-inch, LED backlit display.

Custom developed for acuity testing. Made in USA. Vision Expo East #MS4811 · reichert.com/clearchart

© 2017 AMETEK, Inc. & Reichert, Inc. (2-2017) · Made in USA ClearChart is a registered trademark of Reichert, Inc. · www.reichert.com

Richard Views.indd 4

stethoscope so I could check his blood pressure. It turns out the man was making his way to the bathroom due to nausea from food poisoning. The medical team on the ground recommended 30 minutes of oxygen, which was administered.

A passenger in business class gave up her seat so we could get the sick traveler in a seat that reclined. For the remainder of the six-hour flight, I stood in the aisle next to him, providing ice chips or a large plastic bag to collect the contents when he threw up. He continued to improve but was still taken off the plane by EMTs and admitted to a local hospital. He made a complete recovery from his illness.

A few years ago, I read an editorial by Walt West (from Vision Source) who described an incident where he provided care for a patient on a Southwest flight. At the time, I thought this to be a rare occurrence and how fortunate the traveler was to have Walt on board. As an OD, I am proud to use my training and expertise in caring for others in need.

Richard Clompus, OD, FAAO | Professional Editor | RC@OptometricOffice.com

3/13/17 10:43 AM

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All-new!

VIEWS FAST TRACK YOUR PRACTICE

While at SECO I had the chance to attend the CooperVisionsponsored presentation, “A Different POV: New Perspectives on Optometry’s Future” with Troy Hazard, author of the book, Future-Proofing Your Business. Hazard spoke about three elements that will power change for your business: vision, influence and execution—essentially providing a roadmap for these uncertain times.

His guiding philosophy is, “Business happens in cycles.

Your ability to manage these cycles successfully lies in how you interpret information from the past and deal with it in the present, to be more resilient through cycles of the future.”

Based on this, he suggests making time to reflect on your day and determine what can be approached in another way. Find

Stop looking at what’s here, and start looking over there.

Elements of pre-test.

OptoChek™ Plus Auto Refractor + Keratometer LensChek™ Plus & Pro Digital Lensometers Reichert® combines technology, simplicity, and value at the core of your exam.

Vision Expo East #MS4811 · reichert.com/exam

© 2017 AMETEK, Inc. & Reichert, Inc. (2-2017) · www.reichert.com

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30 minutes daily to think about your business and what can be done differently. Write down things you can influence, things you have influenced and need to set aside, and things you can no longer influence nor allow to take up space in your mind.

Another piece of advice he shared with the attendees is to focus on the next thing. “Stop looking at what’s here, and start looking over there,” he said to the room. It’s this type of forward thinking that will propel your vision. He shared an anecdote from his favorite hobby, racing cars. While navigating a course, he lost control of his car at the very first turn.

His instructor’s constructive criticism lends credence to the business world as well: While he knew how to take the first curve, he was overthinking it and lost control. Instead, he should have been thinking about his strategy for the curve that’s two turns ahead. That’s what helps win the race.

Good advice to help steer your practice in these uncertain times.

Joanne Van Zuidam | Editor-In-Chief | JVZ@VisionCareProducts.com

3/13/17 10:43 AM

Refractive

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SOLUTIONS Marco Refraction Systems — Advanced automated instrumentation includes the OPD-Scan III Integrated Wavefront Aberrometer, the TRS-3100/TRS-5100 and EPIC Digital Refraction Workstation, Autorefractors/Keratometers (with VA measurement, Subjective Sphere Refinement, Tonometry, Glare testing on certain models) and Lensmeters–all with EMR Integration.

The Difference is Marco.

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ONE-TO-ONE James Kirchner, OD, president and CEO of SynergEyes Inc., joined the company in 2012 as VP of professional relations. He was the founder of EyeCare Specialties, a multi-doctor, multioffice optometric practice in Lincoln and Beatrice, NE. He is a past president of the Nebraska Optometric Association and the

Corneal Hysteresis: His sight depends on your confidence.

Ocular Response Analyzer® G3 Add clarity to your glaucoma decision making.

Corneal Hysteresis: CPT code 92145 Vision Expo East #MS4811 · reichert.com/glaucomaconfidence

North Central States Optometric Council. Kirchner also served as chair of the American Optometric Association’s Communications Group Executive Committee.

Richard Clompus, OD, FAAO: How did you transition from being a clinician in practice to becoming the CEO of an innovative contact lens company?

James Kirchner, OD: My career path took a dramatic shift in 2010, when after 33 years in private practice, I sold my interests in the practice and began a path on the industry side. I had a strong history in electronic medical records (EMR) and practice management systems.

Our practice converted into a paperless entity in 1999, a pretty aggressive move in that era. I started my post-practice life at VSP in the Eyefinity/OfficeMate division as chief professional officer, a role that was charged with the responsibility to provide practitioner guidance to the software development as well as being the professional link to

© 2017 AMETEK, Inc. & Reichert, Inc. (2-2017) · Made in USA Ocular Response Analyzer is a registered trademark of Reichert, Inc. · www.reichert.com

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the optometric community. In late 2012, there was an opportunity to move back into the contact lens world, so I joined SynergEyes as VP of professional relations. About a year later, I was offered the position of president and CEO of SynergEyes, which I accepted.

RC: SynergEyes has a history of producing hybrid lens designs that combine rigid and flexible materials that are unique in the industry. What are the indications for prescribing Duette and UltraHealth lenses?

JK: Duette lenses are a family of products in both single vision and multifocal that are designed for the correction of astigmatism (especially corneal) and for astigmatic presbyopes. The UltraHealth family of lenses were created with a design that incorporates reverse geometry in the back surface of the RGP center, allowing the lenses to vault over many corneal irregularities, especially those that are not in the far periphery. Keratoconus and post-surgical patients are prime candidates for this lens design. The post-surgical patients that have oblateshaped corneas are especially well treated with the UltraHealth FC (flat curve) that engages a very flat base curve, but yet with a vault, to provide exceptional vision and comfort to those patients.

RC: How does SynergEyes provide support to optometrists and their technicians with complex fitting issues?

JK: We’ve initiated a program of having all of our technical support and sales team members NCLE certified. As of December, 2016, all of our team members have achieved that goal. Because SynergEyes is a leading specialty contact lens company, I knew as a contact lens clinician that the company needed to have an extremely trained and capable team to provide the technical guidance required. I’m quite proud that we have accomplished this strategy.

RC: Where do you see SynergEyes five years from now?

JK: Our mission is to continue to innovate new designs, platforms and materials for our lens product offerings. We are the first to have achieved FDA approval of Tangible Hydra-PEG, a super lubricious coating (covalent bond) developed by Tangible Science, Inc., and we are now offering it on our Duette lenses. Plans are to extend Tangible Hydra-PEG over our other products in the next few months.

We are also working on a next-generation hybrid that will bring extreme innovation to the contact lens market. Additionally, we are in the process of developing hybrid products for the myopia management needs of our customers. Finally, we are widening our portfolio of products to enable us to offer best-in-class lenses that will meet the specific needs of the patient. OO

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PRODUCT | BUZZ LAUNCHES, PROMOTIONS, MERCHANDISING, EVENTS AND OTHER THINGS TO KEEP YOU IN THE KNOW.

COOPERVISION ANNOUNCES 2017 BEST PRACTICES HONOREES The 2017 class of Best Practices was chosen after a nationwide search for eyecare practices that advance the profession through innovation, industry leadership and patient experience. This year’s honorees are: Amarillo Vision Specialists, Amarillo, TX; Blount County Eye Center, Maryville, TN; Caruso Eye Care, Lake Worth, FL; Castle Pines Eye Care, Castle Pines, CO; Complete Eye Care of Medina, Medina, MN; Havasu Eye Center, Lake Havasu, AZ; Lawrenceville Family Eyecare, Lawrenceville, GA; Little Eyes, Carmel, IN; Premier Eyecare, Knoxville, TN; and Specialty Eyecare Group, Kirkland, WA. “We are so proud to introduce and congratulate our new Best Practices honorees,” said Michele Andrews, OD, senior director of professional and academic affairs, North America, CooperVision. “Through this program, we have had the privilege of getting to know some of the nation’s most wonderful eye doctors, who have all found success in various ways.

We look forward to partnering with them to share their experiences throughout the industry.” CooperVision Inc., Eyecare-BestPractices.com.

PARAGON VISION SCIENCES OPENS THE ACADEMY Paragon Vision Sciences has announced the launch of the Paragon Education and Training Academy, a state-of-the-art comprehensive learning and training center, located at the company’s new headquarters in Gilbert, AZ. The high-tech facility includes a fully equipped media suite capable of offering live-streaming content worldwide. The Academy will host a series of live monthly webinars from leading industry experts to help practitioners keep

up to date on techniques and developments in myopia management, specialty contact lenses and other subjects. Additionally, Paragon Vision Sciences will work with its strategic laboratory partners and leading experts from around the world to produce high-quality original digital video content in any language. ParagonVisionSciences.com

BAUSCH + LOMB HOSTS B+LIEVE SYMPOSIUM More than 200 eyecare professionals were introduced to Bausch + Lomb’s newest daily disposable contact lens, Biotrue ONEday for Astigmatism, at an event held in San Francisco, CA. Attendees at this year’s first B+Lieve symposium learned about the design of the lens, received training on fitting techniques, and had the opportunity to fit themselves and colleagues with the complete family of Biotrue ONEday contact lenses. “At Bausch + Lomb we are dedicated to providing eyecare professionals education and training on our new contact lens innovations and how to best present these technologies to their staff and patients,” said Jill Saxon, OD, director, professional strategy, U.S. Vision Care, Bausch + Lomb. “The feedback and insights we receive from eyecare professionals during these events is invaluable. It helps to inform our progress and also advances our ability to offer the latest in lens technology to eyecare professionals and their patients.” Bausch + Lomb, Bausch.com.

ALCON ADDS AIR OPTIX CHOICE TO REBATE PROGRAMS Created for new contact lens wearers, AIR OPTIX Choice helps eyecare professionals provide patients who prefer a monthly modality access to significant savings. The program offers a rebate of up to $100 off a patient’s first annual supply purchase.

The program is for patients new to the AIR OPTIX family and those who want to switch from their current AIR OPTIX lens to another lens within the AIR OPTIX family (excluding AIR OPTIX AQUA). Alcon, AlconChoice.com

News

Imprimis Pharmaceuticals has begun dispensing from FDAregistered 503B outsourcing facility.

Valeant Pharmaceuticals and EyeGate entered into a licensing agreement for manufacturing rights for EyeGate II Delivery System and EGP-437 combination product candidate for the treatment of postoperative pain and inflammation.

Bausch + Lomb and Nicox announced the resubmission of a new drug application (NDA) to the FDA seeking approval for latanoprostene bunod ophthalmic solution, 0.024%.

The Sjögren’s Syndrome Foundation named Steven Cohen, OD, chairman of the board.

Johnson & Johnson completed acquisition of Abbott Medical Optics and changed Johnson & Johnson Vision Care’s name to Johnson & Johnson Vision.

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Buzz April.indd 10

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

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

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THINK ABOUT YOUR EYES

New Business Models for a Better Practice Optometrists wear many hats. First and foremost, we monitor and protect our patients’ vision and overall health. This is what we train for and where our passion lies. However, many optometrists are also small business owners and must face the challenges that come with that responsibility. One such challenge is finding new revenue streams for a practice.

Each year, reimbursements decrease and expenses increase. Practice owners must identify and implement opportunities to increase incremental revenue or their margins will get slimmer and slimmer.

Less revenue means less money for new technology, office updates, additional staff, and ultimately the patients’ care can suffer.

There are a multitude of options when it comes to developing new revenue streams, but it is important to figure out which one(s) are right for your practice. In my opinion, the most efficient improvement in revenue comes from increasing direct payment from patients (cash). How might this work? Our office completes a “payer matrix” each year to measure reimbursement from vision plans and medical insurance providers and then contacts the lowest payers to make an attempt to improve their reimbursements. This process doesn’t always yield positive outcomes.

We started a long-term plan to discontinue vision plans.

As a result, we started a long-term plan to discontinue vision plans. Each year, we dropped a few of the lower reimbursing vision plans and began offering our patients an alternative. For a nominal enrollment fee, patients can receive their care and materials for special savings. This allows us to reduce expenses (for example, calling to verify benefits, file claims, work denials, balance bill patients, etc.) which translates into savings for patients. (A word of caution, programs such as this must comply with managed care rules and guidelines.)

Another new revenue stream option to consider relates to my current project, developing a business model for a concierge practice.

This will feature two options—membership model and fee-forservice model. Patients may self-refer or be referred primarily for

Ann Hoscheit, OD, FAAO, FAARM, the founding consultant for EyeBridge Consulting Associates ODPA in Cramerton, NC, provides patient care in Cherryville, NC, and is among the 19,000 doctors listed on the Think About Your Eyes online locator. Think About Your Eyes is a nationwide public awareness initiative promoting the importance of an annual eye exam and overall vision health. First Vision Media Group (publisher of Optometric Office) supports Think About Your Eyes as a media partner and provides space for this monthly Guest Editorial.

ocular surface/dry eye management. This practice will not accept insurance, but I believe it will be successful, particularly with ODs who have a very loyal following and excellent community reputation.

Ultimately, revenue opportunities exist throughout our practices, but the first step begins with an annual eye exam. While many practices’ schedules are full, there is always room for improvement, and it starts with getting the message out to patients that an eye exam needs to be a yearly event. There is profound value in Think About Your Eyes and its message of the importance of annual eye exams for the profession as a whole. Supporting this campaign as an optometrist is an important step in continued success for practices. OO

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TAYE April.indd 8

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COMMUNICATING

WITH YOUR DRY EYE PATIENTS Communication is a key component in the delivery of high quality, patient-centered medical care. Both, what you communicate and how you deliver the information, help foster a fruitful doctor-patient relationship, maximize adherence to treatment, and improve overall patient satisfaction. Here’s how you can facilitate a productive dialogue with your Dry Eye Disease (DED) patients:

Step 1 |

Validate Your Patients’ Condition

Step 3 |

Prescribe a Treatment Plan

Empathetic listening and responsiveness on your part will help both you and your patient handle their condition positively.

The key to treating DED is identifying the cause and severity of the condition, so you can develop an appropriate treatment plan which includes medication, lifestyle modifications, as well as day-to-day self care guidelines. To improve compliance, ensure that your patients understand what their medication does and how the prescribed dosage and regimen can help manage their symptoms, and in turn, improve their quality of life. You also have to assume that your patients may need some form of “hand-holding” during the initial phase of their treatment plan.

Step 2 |

Step 4 |

Help your patients understand how… n

the symptoms they’re experiencing,

n

their lifestyle factors, and

n

the clinical signs you’ve observed

…may be related to Dry Eye Disease (DED)

Discuss Your Evaluation

Schedule Follow-Up Visits Inform your patients that DED takes time to treat, and schedule a follow-up visit to examine how well they are responding to their treatment plan. Depending upon the severity of their condition at this first post-treatment follow-up, further appointments may be scheduled.

Once you have completed a thorough medical examination and can confirm your Dry Eye diagnosis, speak to your patients about what their vital dye tests and eyelid examination revealed. Where possible, show them images so they can see the test results for themselves.

In summary, ODs play a critical role in helping patients understand DED and the care needed to treat it. In addition, having an ongoing conversation with patients is vital to improving adherence to treatment, for the best possible outcomes.

The Dry Eye Real World Management educational tools were made possible through unrestricted educational grants from Alcon, Santen, and Shire. The tools have been created for informational purposes only and do not constitute medical service. The opinions expressed in these tools do not necessarily reflect the views, or imply endorsement, of the editor, publisher, or program supporters. To learn more about the sponsors and their products, please visit their respective websites.

www.alcon.com

www.santeninc.com

www.shire.com © 2016 BioScience Communications

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INSTRUMENTATION

Going Digital

By Jennifer L. Stewart, OD Upgrading refraction technology offers a one-two punch for your practice: making an impact on productivity and making an impression on patients.

Two of the main criteria most optometrists have when adding a piece of equipment is that it must measurably improve patient care and provide a healthy return on investment for the practice. While manual refraction has been the mainstay of our profession for many years, the conversion to digital refraction systems is proving to help offices provide a better patient experience and also generate significantly more revenue. Other digital technologies, such as autorefraction systems and wavefront analyzers, provide doctors with more information, allowing for customized prescriptions and sharper, crisper vision.

By speeding up the process, digital refraction systems can shave minutes off each patient. While this doesn’t seem impressive, this adds up over the course of the day, week, month and year. This frees up a practitioner to spend more time on patient education while in the room, see more patients per day, spend more time developing the business portion of the practice or spend more time out of the office. The programmable nature of these systems also makes delegation an easy step, allowing the doctor to spend more time on other parts of the exam or to see more patients overall.

How can digital technology improve the patient experience? Technologies from companies such as ZEISS, Reichert Technologies, Marco and OCULUS go beyond the standard measurements to collect

valuable data such as higher order aberrations, pupil size and topography, as well as autorefractive and keratometry data. This is integrated into the automated refraction systems and allows the doctor to fully customize a precise prescription (in less time). Patients are able to compare their new prescription with their current one with a single press of a button, leading to both the wow factor for the patient and an increase in revenue for the practice. The high-tech experience versus a traditional refraction will set your practice apart and drive in new patients through referrals.

The leaders in ophthalmic technology have amassed a wide array of instruments that will fit in every size and mode of practice.

ZEISS ZEISS offers an integrated and modern solution for your refraction workflow.

Starting with a straightforward autorefractor/keratometer, ZEISS features the VISUREF 100. This basic diagnostic instrument has four measurement modes: refraction and keratometry combined, refraction, keratometry and contact lens base curve, and pupil and iris diameter evaluations.

As a more advanced device for objective refraction measurement, ZEISS promotes the i.Profilerplus, a compact four-in-one system that includes an ocular wavefront aberrometer, autorefractometer, ATLAS corneal topographer and keratometer. In

The new OptoChek Plus Autorefractor + Keratometer from Reichert measures spherical and cylindrical refractive errors and keratometry.

60 seconds, this instrument analyzes the refractive power of both eyes across their entire pupil apertures. The device gives doctors a way to visualize how different aberrations impact a patient’s vision, for example at night, and gives them an “individual fingerprint” of each patient’s eye.

Moreover, i.Profilerplus opens the gate to ZEISS lenses with i.Scription technology. i.Scription involves an innovative patented algorithm that combines the subjective refraction values with the i.Profilerplus ocular wavefront aberrometry data to calculate an individualized prescription to 1/100th of a diopter—especially for lower light situations.

Once a prescription is generated from the VISUREF 100 or the i.Profilerplus, it can be seamlessly transmitted to the VISUPHOR 500 digital phoropter from ZEISS. It wirelessly connects to the VISUSCREEN 100/500 visual acuity chart system, which is customizable for different chart sequences based on the preference of the examiner. This acuity chart system comes with a variety of vision tests for both monocular and binocular

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testing, polarization tests and the ability to demonstrate the effect of the different lenses. Both chart and phoropter can be simultaneously controlled as one subjective refraction unit via an easy-to-use touch-screen interface that makes switching between charts easy and efficient. The browser-based controls can be operated with an iPad or with a medical grade PC to provide a modern refraction experience.

For a complete integration, the measurement data can be submitted from the VISULENS 500 digital lensmeter, the VISUREF 100 autorefractor/keratometer or the i.Profilerplus four-in-one device right to the subjective refraction unit, for seamless, efficient refracting.

REICHERT TECHNOLOGIES Made in the USA with premium components, the Phoroptor VRx Digital Refraction system’s thin, compact design allows it to seamlessly fit in to even the smallest office space. This unit features fast, smooth lens exchanges, motorized prisms, split cylinder lenses and a quiet operation. It connects to electronic medical record (EMR) systems, as well as pretest and acuity devices from Reichert and other manufacturers for a complete, efficient system. It features a refraction time, which helps track efficiency and productivity. The touch screen and keypad devices are user friendly and ergonomic, featuring pre-programmed and programmable tests for practitioner use or delegation.

Also from Reichert, the new OptoChek Plus Autorefractor + Keratometer measures spherical and cylindrical refractive errors and keratometry. As part of the VisionChek Digital Exam Suite, it also features a Scotopic Pupil Size and Photopic Pupil Size mode

that adjusts illumination to accommodate different conditions of lighting.

MARCO The TRS- 5100 digital refraction system allows practitioners to obtain fast, accurate refractive results using a control pad. The large range of lenses available (-29.00D to 26.75D, and cyl 0.00D to 8.75D) makes this system extremely versatile. Once complete all data is then sent to the EMR for accurate recording of data.

The OPD-Scan III Wavefront Aberrometer combines an autorefractor, keratometer, pupillometer, corneal topographer and integrated wavefront aberrometer into one compact, state-of-the-art device. This instrument completes 20 diagnostic metrics in less than 20 seconds per eye and features auto X, Y, Z eye tracking. Mesopic refraction calculations can be determined, as well as angle kappa and angle alpha, average pupil power, higher order aberrations and point spread function. The OPD-Scan III determines the best starting point based on each patient’s optical system. Knowing if a patient is correctable to 20/20 before you begin refracting is just one of the advantages of integrating the OPD-Scan III with the TRS. The EPIC Workstation is the ultimate combination of technology in an extremely small footprint (4-ft. x 5-ft.). This includes the TRS-5100 digital refractor, autolensometer, ARK/OPD-Scan III and an electronic chart—all in one location. This extremely efficient system combines the best of Marco’s technologies to give faster, more accurate results, allowing the practitioner to spend more time on patient education.

This system decreases work-up times to less than 10 minutes, and refractions can be performed in three to five minutes.

The PARK1 from OCULUS combines a non-contact pachymeter, autorefractor and keratometer in an ergonomic, patient-friendly, award-winning design.

OCULUS The PARK1 combines a non-contact pachymeter, autorefractor and keratometer in an ergonomic, patient-friendly design. This unit gives objective refraction values, keratometery values, pachymetry, Horizontal Visible Iris Diameter, pupil diameter and far PD. The space-saving, sleek design won the PARK1 the RED DOT Award for product design.

With so many choices, it is easier than ever to incorporate the newest in refraction technologies into any practice. OO Jennifer L. Stewart, OD, is a partner at Norwalk Eye Care, in Norwalk, CT. She is also the co-founder and chief optometric officer at Performance 20/20, a sports and performance vision clinic in Stamford, CT. WHERE TO FIND IT: Carl Zeiss Meditec, Inc. 800.342.9821 | Zeiss.com/Meditec/US/ Carl Zeiss Vision, Inc. 800.358.8258 | Zeiss.com/Lenses Customer.Service@Zeiss.com Marco 800.874.5274 | Marco.com Oculus, Inc. 888.284.8004 | OculusUSA.com Sales@OculusUSA.com Reichert Technologies 716.686.4500 | Reichert.com

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INSTRUMENTATION

A Foolproof Way to Free Up Time

By Gina M. Wesley OD, MS, FAAO Today’s refracting processes liberate ODs to see more patients every day.

To be efficient we need to constantly manage how we spend our own time with our patients. Fortunately, there are advanced technologies available that allow us to expand our ability to gather data, interpret it and make recommendations. Refraction is one area of tremendous opportunity, and as much as we have our own “art” of doing this on our own, this can be delegated with the appropriate instrumentation.

STREAMLINED PROCESS Take, for instance, the following scenario: A patient is new to the office, arriving for a comprehensive exam. After initial history inquiries, a technician sits this patient down in one chair, where the patient’s visual acuity is determined, autorefraction

performed and manifest refraction completed….all while sitting in one seat, in front of one instrument. The doctor then serves to confirm the refractive outcome in the exam lane and makes the appropriate prescription recommendations and eyewear enhancements. Then the external/internal ocular exam can proceed Or, perhaps, you prefer to have the patient’s topography, point spread function and day/night autorefraction measured on advanced technology, which is then loaded into digital refracting equipment in the exam lane. The doctor preprograms the refracting instrumentation to move through a logical and preferred sequence of steps, so a technician is able to refract a patient in the same style and manner as the doctor would. The technician can even compare the patient’s current spectacle prescription to that day’s manifest refraction with a touch of a button. This process allows for consistency, but also efficiency, so once again the doctor can see more patients per day without sacrificing quality time with the patient.

ACCURATE REFRACTIONS

Marco’s OPD-Scan III with its TRS-5100 digital refraction system allows for seamless integration of data input from the pre-test room.

The amazing truth is that both of these scenarios are completely possible with today’s technology. Many doctors utilize variations of these techniques with fantastic success and refractive outcomes

The Phoroptor VRx Digital Refraction System from Reichert features pre-programmed tests, including astigmatism, phoria, binocular balance and near vision.

that are as statistically successful as their own refractions. The beauty is that the doctor still has the final say in the prescription but does not have to go through all the steps to get there. What’s more, these techniques also allow the doctor to see one to three more patients per day, all while maintaining the same excellent quality of care patients are accustomed to.

Conveniently, advanced refractive technology can be purchased piece by piece or all at once for ease of transition. Additionally, it’s often beneficial for doctors to utilize the instrumentation themselves for a period of time before delegating to ensure that they understand the ideal flow of the process. However utilized, delegating refractive processes is a way to compete in a prominent facet of your practice, and today’s technologies make this opportunity attainable. OO Gina M. Wesley OD, MS, FAAO, is in private practice in Medina, MN. WHERE TO FIND IT: Marco 800.874.5274 | Marco.com Reichert Technologies 716.686.4500 | Reichert.com

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CONTACT LENSES

Set Your Sights on Sclerals

By Beth T. Kinoshita, OD Advances in materials and the ability to manufacture large diameter scleral GP lenses for patients makes it easy to add these specialty lenses to your practice.

The use of scleral contact lenses has increased dramatically over the past 10 years. The advantages of a scleral lens to vault an irregular cornea or to provide a moisture chamber to a dry eye has led many practitioners to embrace this contact lens type where other modalities may have failed. The ability to offer this lens option has helped to widen the services provided to the patient.

ANATOMY OF A SCLERAL The anatomy of a scleral lens consists of a central base curve, peripheral zone, limbal zone and scleral landing zone. Each zone of the lens can be altered to change the fitting relationship of the lens on the eye. The fit of a scleral lens is specified in terms of sagittal depth or how close or far the posterior portion of the contact lens sits from the cornea. The ideal sagittal depth apically will allow for approximately 200 microns of tear lens between the back surface of the contact lens and the front surface of the cornea. Oftentimes the diagnosis can be used as a guide to select the initial depth of the diagnostic lens.

Interaction between the contact lens and the limbus is discouraged. Using sodium fluorescein in the bowl of the lens is imperative when fitting to ensure that there is a layer of tears between the contact lens and the limbus. Since the weight of the lens is primarily distributed on the sclera, it is important to view the blood

A

B

C

Elevation map (A) of a patient with keratoconus with a corneal elevation difference of 655 microns. The corneal gas permeable lens fit with a large apical bubble (B) and a scleral lens (C) fit on the same eye.

vessels at the edge of the lens to rule out impingement of blood flow or excessive lift off of the lens edge.

Not all corneas will require a scleral lens. In a recent study, an elevation display topographical map was used to determine the elevation change along the meridian of greatest elevation difference.

The results indicated that a difference of greater than 350 microns may necessitate a scleral contact lens.

TIPS FOR PRACTITIONERS With new technology come changes in cost. These lenses are much larger than the typical corneal gas permeable lens, thus material cost of the scleral lens is greater.

Professional fees may also increase as sclerals are specialty lenses and sometimes require more follow-up than the typical gas permeable or soft contact lens.

If you are ready to give scleral lenses a go, begin by developing a relationship with a specialty lens lab (see Where to Find It) and requesting a fitting set. Many companies offer consultation services and are happy to help you with your first few

patients or with troubleshooting.

If you are already fitting scleral lenses, seek out specialty contact lens conferences to gain more experience in fitting complex cases, such as the Global Specialty Lens Symposium, or visit the Scleral Lens Education Society website. There is a wealth of information out there to assist in your venture of this exciting lens modality! OO Beth T. Kinoshita, OD, is an assistant professor at Pacific University College of Optometry.

WHERE TO FIND IT: ABB Optical Group 800.852.8089 | ABBOptical.com Art Optical Contact Lens Inc. 800.253.9364 | ArtOptical.com Bausch + Lomb Specialty Vision Products Bausch.com | Info@BauschSVP.com Blanchard Contact Lens, Inc. 800.367.4009 | BlanchardLab.com Valley Contax 800.547.8815 | ValleyContax.com Contax@ValleyContax.com

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

References: 1. Nash W, Gabriel M, Mowrey-Mckee M. A comparison of various silicone hydrogel lenses; lipid and protein deposition as a result of daily wear. Optom Vis Sci. 2010;87:E-abstract 105110.

2. Nash WL, Gabriel MM. Ex vivo analysis of cholesterol deposition for commercially available silicone hydrogel contact lenses using a fluorometric enzymatic assay. Eye Contact Lens. 2014;40(5):277-282.

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See product instructions for complete wear, care and safety information. © 2017 Novartis 1/17 US-AOH-16-E-4693a

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PATIENT CARE

Rx for Alternate Revenue Streams

By Joanne Van Zuidam Supplements, skin care and soothing home treatments can improve patient care and increase practice profits.

You think of yourself as an optometrist first, business owner second. But with shrinking reimbursements and increasing competition, it’s time to shift your thinking a bit. The good news: Opportunities abound to sell different products or services to your patients. While they won’t make you rich, they will make your practice a one-stop shop for eye health and bolster patient loyalty and retention.

SUPPLEMENTS One of the biggest reasons to sell nutraceuticals in your office—and why your patients will appreciate it—is sheer volume.

It’s overwhelming for the average person

to face shelf after shelf of supplements and figure out which one to take (or remember which one was recommended at their exam). Companies, such as Nordic Naturals offer omega-3 formulas for general ocular health, and others focus on specific conditions.

MacuHealth LMZ3 is indicated for those at risk of age-related macular degeneration (AMD). It contains three macular pigments in the vitamin A family, lutein, zeaxanthin and meso-zeaxanthin, to help maintain healthy cells by reducing oxidative stress on the eye.

Another option for AMD is LumegaZ from Guardion Health Science, which is composed of more than 35 micronutrients with potent antioxidant ability and the three critical carotenoids (lutein, zeaxanthin and meso-zeaxanthin), which make up the macular pigment.

Lumega-Z is a medical food and must be recommended and administered under the supervision of a physician.

SKIN CARE The popularity of subscription-based beauty companies Birchbox and Ipsy have The Tranquileyes XL Chronic Dry Eye Advanced kit from Eye Eco includes goggles, gel packs, beads and more to relive dry eye symptoms.

MacuHealth LMZ3 is indicated for those at risk of age-related macular degeneration.

boosted product sales in retail spaces. If you focus on skin care for the eyes, including lids and lashes, you can include the optometric office in that space. Here are a few that were, interestingly, created by female eyecare professionals.

OcuDerma Eye Gel from MediNiche, Inc. was formulated to reduce the visible signs of aging and keep the skin around the eyes healthy. An updated formula reduces puffiness and minimizes fine lines and wrinkles without clouding lenses or causing irritation. It won’t clog pores and is free of parabens, artificial dyes and perfumes, making it ideal for patients with sensitive skin.

The Zoria Boost line from OCuSOFT includes a mascara and a lashintensifying serum. The mascara can be applied throughout the day, and the serum is applied at night to strengthen and condition lashes. The line is available through OCuSOFT, which boasts its own line of lid wipes and hygiene products.

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The We Love Eyes product line includes an eye makeup remover oil, cleansing oil and an all-natural foaming cleanser with tea tree oil to clean lashes (and even eyelash extensions). The product’s tea tree oil controls dermodex and reduces inflammation caused by bacteria, dirt and allergens. It is recommended for everyone but especially for patients with blepharitis, meibomian gland dysfunction (MGD) and dry eye syndrome.

SOOTHING EYE TREATMENT You probably have a steady stream of patients presenting with blepharitis and MGD. In addition, recent consumer campaigns have helped with dry eye awareness so patients are now more likely to discuss any symptoms with you and inquire about treatment. There are many adjunct services and products for in-office and at-home care to help alleviate and manage these chronic conditions.

The We Love Eyes product line includes tea tree oil, which controls dermodex and reduces inflammation caused by bacteria, dirt and allergens.

OcuDerma Eye Gel reduces puffiness and minimizes fine lines and wrinkles without clouding lenses or causing irritation.

For treating MGD in the office, there are currently a few options to choose from. MiBo ThermoFlo from MiBo Medical Group is a procedure that is not unlike a heated massage for the eyelids with the goal of prompting the glands to produce more oil. BlephEx cleans biofilm from the lid margin, and LipoFlow from TearScience utilizes therapeutic heat to restore gland function. The treatment schedule for these therapies depends on the severity of the condition and can be used as often as weekly and taper down to maintenance every few months. The relief MGD patients will feel from the gland expression procedures will keep them returning to your office.

For milder cases of MGD and for patients with dry eye, there are myriad at-home products that you can offer in your office for patients to take home. The Bruder Eye Hydrating Mask utilizes moist heat to stimulate meibomian oil gland production. Another option for chronic MGD and blepharitis is the Tranquileyes XL Chronic Dry Eye Advanced kit from Eye Eco. Its reusable gel pack technology creates a natural, controlled moist-heat or cold compress for up to 20 to 25 minutes.

The kit includes googles, gel packs, beads

and more. Eye Eco also sells Eyeseals 4.0, a sleep mask with an adjustable microfiber head wrap, which gently shelters eyes from drafts, dust and low humidity environments. This retains moisture over the eyes, hydrating the sensitive eyelid area and preserving tears to help soothe dry, tired eyes. Made in the USA, it’s recommended for use to relieve dry eye, lagophthalmos, aqueous deficient dry eye, floppy eye syndrome and recurrent corneal erosions. It can also be used with C-PAP and during air travel. OO Joanne Van Zuidam is editor-inchief of Optometric Office.

WHERE TO FIND IT: BlephEx 800.257.9787 | BlephEx.com Bruder Healthcare Company 888.827.8337, ext. 203 | BruderOphthalmic.com Eye Eco 888-730-7999 | EyeEco.com Info@EyeEco.com Guardion Health Sciences 800.873.5141 | GuardionHealth.com/Lumega- Z MacuHealth 866.530.3222 | MacuHealth.com MediNiche, Inc. 888.325.2395 | MediNiche.com MiBo Medical Group 855.642.6356 | MiboMedicalGroup.com Nordic Naturals 800.662.2544 | NordicNaturals.com Info@NordicNaturals.com OCuSOFT, Inc. 800.233.5469 | Ocusoft.com Ocusoft@Ocusoft.com TearScience, Inc. 919.459.4880 | TearScience.com We Love Eyes 855.687.3279 | ODs.WeLoveEyesXO.com

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PHARMACEUTICAL

The Challenge of Glaucoma

By Katherine Shen, OD What you need to know to manage a newly diagnosed glaucoma patient.

Glaucoma is a complicated group of diseases that without intervention can progressively cause damage to the optic nerve head tissue, resulting in loss of peripheral vision and eventually blindness.

Currently, it is estimated that three million Americans have glaucoma with only half of them formally diagnosed.

Glaucoma is a non-curable disease that, luckily, for most patients under proper care can be slow progressing. As ocular health providers, our main management goal is to lower the intraocular pressure (IOP). Current treatment options for lowering IOP include myriad topical ophthalmic drops, laser procedures and surgical intervention. The least invasive of these treatments and the recommended first line of therapy are topical ophthalmic drops. With so many drugs now available, the question is: Where do you begin with a newly diagnosed glaucoma patient?

MAKING THE DIAGNOSIS When a patient is diagnosed with glaucoma at our office, there are several measurements needed before making the official diagnosis. It is important to get a full picture of the patient’s ocular health, linking all the various tests that support the diagnosis. These measurements include: patient’s IOP, optical coherence tomography (OCT) of the optic nerve head, a Humphrey automated perimeter 24-2 visual field test (HVF) and Diopsys

electroretinography (ERG).

The patient’s corneal thickness and gonioscopy findings should also be considered when making the diagnosis. If the HVF shows a glaucomatous defect, a repeat test is run and analyzed for a consistent defect. When analyzing the OCT, we look for glaucomatous thinning of the retinal nerve fiber layer (RNFL). Our office has both the ZEISS Cirrus-HD 5000 series OCT and Optovue iWellness OCT; both are beneficial in the diagnosis.

Once the patient is diagnosed with glaucoma such as Primary Open Angle, Normal Tension or any other form, the main treatment goal is to halt disease pro-

reduction in IOP by increasing the uveoscleral outflow. One-drop a day dosing also helps improve compliance. Prostaglandins, as a class, are an ideal drug when treating glaucoma. Our office typically tries to avoid generic drugs, due to decreased efficacy and increased side effects from preservatives.

Our first option is to prescribe bimatoprost (Lumigan 0.01% from Allergan). Depending on the patient’s insurance, travaprost (Travatan Z from Alcon Laboratories) is another good option. After using this drop every night in the glaucomatous eyes for four to six weeks, patients return for a follow up of their IOP. If the IOP is at goal, then we monitor again in three to four months.

IT IS ESTIMATED THAT THREE MILLION AMERICANS HAVE GLAUCOMA WITH ONLY HALF OF THEM FORMALLY DIAGNOSED. gression. When choosing the ideal drug for treatment the following should be considered: a) decreasing IOP, b) few adverse effects or systemic exacerbation of disease, and c) affordability with once-aday dosing. Most commonly, the first line of treatment should be the least invasive, which are the topical ophthalmic drops.

PROSTAGLANDIN In our office, the class of drugs that is our first line of therapy is the prostaglandin analog (PGA). This class of drugs has very few side effects with a 25% to 30% expected

ALPHA 2-ADRENERGIC AGONIST If the PGA does not reduce the patients’ IOP enough, they will be re-evaluated with a follow up IOP, OCT and ERG in six to eight weeks. If follow-up testing continues to show abnormalities, we consider adding our second drug of choice, brimonidine 0.1% (Alphagan P 0.1% from Allergan). Brimonidine is within the selective alpha 2-adrenergic agonist drug class with roughly a 20% to 30% expected reduction in IOP. Brimonidine may also be used if there are too many adverse effects to PGA. Brimonidine works by decreas-

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ing aqueous humor secretion as well as increasing uveoscleral outflow. Brimonidine is dosed at two to three times a day with the greatest side effect being a follicular conjunctivitis.

Apraclonidine (Iopidine from Alcon Laboratories) is the other alpha 2-adrenergic agonist that could be prescribed, but it has a greater risk for adverse side effects. After using this drop for another four to six weeks, the patient’s IOP will be re-checked. On both drops, the patient’s IOP typically decreases significantly enough to appropriately manage the glaucoma.

BETA-BLOCKERS Another drug class to consider as a second line treatment are beta-blockers, which work by decreasing the amount of aqueous humor production. Timolol maleate (Timoptic and Timoptic XE from Valeant Pharmaceutical; Istalol from Bausch + Lomb) is a popular non-selective beta-blocker that is dosed with either one drop every morning or one drop twice a day. Non-selective beta-blockers, like alpha 2-adrenergic agonists, have roughly a 20% to 25% expected reduction. The side effects of beta-blockers are perhaps the most numerous and by far the most serious. Among these serious side effects are bronchospasm, brady-

cardia and masking hypoglycemia symptoms in diabetic patients. Apart from these severe systemic side effects, betablockers tend to cause dry eye.

COMBINATION DROPS So, if the first two lines of treatment (PGAs and alpha 2-adrenergic agonists) are not adequate, our third line of treatment is typically a combination drop.

Brinzolamide/brimonidine tartrate (Simbrinza from Alcon Laboratories) is the most frequently prescribed combination drop in our office. Simbrinza is a good option when looking for a combination drop to manage glaucoma. Brinzolamide is one of the components of Simbrinza, and it is a carbonic anhydrase inhibitor. Carbonic anhydrase inhibitors are dosed twice a day and typically have a 14% to 17% reduction in IOP. Side effects of the topical ophthalmic drops in this category include a bitter taste and punctate keratopathy.

The other topical drug in this category is dorzolamide (Trusopt from Merck & Co., Inc.). Carbonic anhydrase inhibitors also create corneal tissue symptoms, albeit to a lesser degree compared to beta blockers.

This is why we prefer not to use it as a first or second line of treatment. When brinzolamide is in combination with brimonidine, the percent reduction in IOP makes Simbrinza a good third line treatment. Fi-

nally, the other combination drop that our office uses is brimonidine tartrate/timolol maleate (Combigan from Allergan). This combination has comparable efficacy, but the systemic side effects of timolol once again need to be considered.

Patient follow up should be based on how advanced the glaucoma is. After first initiating treatment, a patient should be seen in about four to six weeks to determine how the topical treatment is working. Adjusting treatment at each of these visits is dependent on the patient’s target IOP. Once the target IOP is met and scans show no further progression, the follow up visits do not need to be as frequent.

Patients with mild stage glaucoma can be seen every six months. Moderate stage glaucoma should be evaluated every four months and severe stage glaucoma every three months or sooner.

Glaucoma is a complex disease and its management varies with each patient.

This is what makes glaucoma not only challenging in diagnosis but urges a practitioner to consider all possibilities when deciding on management. OO Katherine Shen, OD, is an associate at Specialty Eyecare Group in Seattle and Kirkland, WA. WHERE TO FIND IT: Alcon Laboratories 800.451.3937 | Alcon.com Allergan 800.347.4500 | Allergan.com Bausch + Lomb 800.553.5340 | www.Bausch.com/ECP Merck & Co., Inc. 908.740.4000 | Merck.com Valeant Pharmaceuticals International, Inc. 866.246.8245 | Valeant.com

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PHARMACEUTICAL

Doctor’s Orders

By Glenn Corbin, OD How to encourage your patients with glaucoma to be adherent and compliant.

Lack of adherence and compliance with medications in general is an issue—and caring for glaucoma is no exception. Although often used interchangeably, adherence implies filling a new or refilling an existing prescription, while compliance means taking the medication as prescribed. Often, non-compliance stems from poor patient education/doctor communication. Although we can blame many factors, including the cost of medication, the complexity of multiple meds or dosing schedules, adverse events, physical and lifestyle barriers, and memory issues, among others, our responsibility is to assure that our patients can access their prescriptions and successfully maintain compliance for the best medical outcomes.

GLAUCOMA EDUCATION Compliance starts with educating our patients on what glaucoma is and the potential for blindness as a result of non-compliance. Emphasizing blindness is accurate and sends a clear message about the importance of following your directives. When dealing with an asymptomatic disease, it is often difficult for patients to appreciate the consequences of non-compliance. The more educated patients are about their disease and the potential risks of noncompliance, the better chance you have of their adhering to a specific treatment regimen. I spend a significant amount of time educating my glaucoma patients prior to initiating treatment. I discuss the best-case

scenario of one medication to the worstcase scenario of invasive surgery.

MAKE COMPLIANCE EASIER Patients tend to view topical drugs as less important than oral drugs. Review drop instillation to assure that patients can actually put their drops in properly. Try to limit the number of bottles they have to use by prescribing combination drugs when indicated vs. multiple individual drugs. (For instance, prescribe Combigan from Allergan instead of Alphagan P from Allergan and Timolol Maleate Ophthalmic Solution from Akorn Ophthalmics.) If that’s not an option, I have my patients number (for example, 1, 2 and 3) the bottom of each bottle so they don’t confuse which drop they instill first and so on. Most people don’t forget to brush their teeth, so I suggest placing their drops next to their toothbrush, especially since most glaucoma drops are dosed once or twice daily.

Based on a patient’s insurance coverage and financial situation, I often need to prescribe generic drugs. Remember, the best glaucoma drug is the one they can afford. Researchers at the University of Michigan studied medication adherence rates 18 months before and after the first generic PGA (latanoprost) became available in March 2011. Their results demonstrated improved compliance when co-pays were lower, compared to a 39% decline in adherence for those who remained on a brand-named drug.

Combigan 0.2%/0.5% from Allergan is available in a 15ml bottle, providing patients with a 90-day supply and fewer trips to the pharmacy.

MONITOR COMPLIANCE I am blunt when questioning a patient’s compliance on follow-up visits, so I don’t change my course of therapy based on false information. You can review the number of refills used vs. the time frame since their last visit. Or consider alternative, nonmedical treatment options such as selective laser trabeculoplasty or microinvasive glaucoma surgery to reduce or eliminate the need for topical drops. This can often be very effective and limit the patient’s monthly pharmacy expense.

Our burden is great in assuring that our patients understand that although glaucoma starts out as a painless, asymptomatic disease, the risk of vision loss is significant and irreversible. I explain that my role is to be sure that they never lose their ability to drive or read due to glaucomatous visual field loss—a statement that resonates with most. OO Glenn S. Corbin, OD, is partner/ president of Wyomissing Optometric Center in Reading, PA. WHERE TO FIND IT: Akorn Pharmaceuticals 800.932.5676 | Akorn.com Allergan 800.416.8780 | Combigan.com

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CLOSE UP

La Dolce Vita

By Shane R. Kannarr, OD Your contact lens patients will be living the good, comfortable life all month long with the latest contact lens from Johnson & Johnson Vision.

A recent study has shown that one-half of monthly wearers are not satisfied with the final week of their contact lens wear.

A leading cause for this comfort decline may be a change in lens hydration. This leads patients to rely on rewetting drops, or they even drop out of lens wear for a day or two. Over two-thirds of patients are experiencing comfort-related issues and 84% of them are annoyed as a result of having to resort to these compensating behaviors. And, 73% of these patients do not plan on telling their doctors their concerns. Johnson & Johnson Vision created the ACUVUE VITA with these patients in mind.

HYDRATION ACUVUE VITA was created with the goal of providing an excellent contact lens experience from beginning to end for patients. The secret: HydraMax, which was engineered to both maximize and maintain hydration over a four-week contact lens wearing cycle. The new, uncoated silicone hydrogel formulation, Senofilcon C, integrates significant amounts of wetting agent to help maximize hydration. It also integrates an optimal density and distribution of the eye’s lipids while limiting lipid deposits. These lipids can then perform their natural, beneficial function of preventing tear film evaporation, helping the contact lens maintain hydration over

Created for monthly lens wearers, ACUVUE VITA by Johnson & Johnson Vision incorporates its HydraMax technology to provide comfort.

the course of an entire month, addressing the complaints reported by many monthly contact lens wearers.

LENS DESIGN For additional comfort, HydraMax Technology was combined with Johnson & Johnson Vision’s INFINITY EDGE Design. A patient’s contact lens awareness is often based on lid interaction with the lens. ACUVUE’s INFINITY EDGE Design provides a smooth, tapered lens edge for optimal comfort. It minimizes lid interaction and contact lens awareness, providing great initial and all-day wear. ACUVUE VITA also provides Class 1 UV blocking, a long-term health benefit for patients.

PATIENT SATISFACTION ACUVUE VITA allows our practice to provide a monthly lens that exceeds patient expectations at the end of the lens wear cycle. According to Johnson & Johnson Vision, patient ratings for “Overall Comfort” are superior for ACUVUE VITA vs. leading monthly lenses at weeks 1, 2, 3 and 4. In fact, the week 1 comfort ratings for these leading monthly lenses do not surpass ACUVUE VITA at week 4. OO Shane R. Kannarr, OD, is in private practice at Kannarr Eye Care in Pittsburgh, PA, and Girard, KS. WHERE TO FIND IT: Johnson & Johnson Vision 800.843.2020 | ACUVUEProfessional.com

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THE | OPTOMETRIC TECHNICIAN

BY ROBERTA BEERS, CPOT 8 COMMON EYELID DISORDERS AND HOW TO TREAT THEM. As optometric technicians we need to understand the various diseases and treatments of the eyelid so we can gather the necessary information for the doctor to properly diagnose the patient’s condition.

THE CONDITION: STY What causes it: Also known as a hordeolum, a sty is an infection of the sebaceous gland of Zeis. It is usually caused by staphylococcus aureus bacteria and is characterized by an acute onset of swelling. It looks like a painful lump, boil or pimple near the edge of the eyelid. While they usually form on the outer lid, they can also form on the inner lid (common in patients with staph blepharitis).

How to treat it: Warm compresses to the eyelid for 10 minutes, three to four times a day may promote faster healing.

A sty is normally harmless, does not cause long-lasting damage and usually disappears within a week without treatment.

THE CONDITION: BLEPHARITIS What causes it: Blepharitis is an inflammation/irritation of the eyelid margins, typically around the eyelashes, often with scales and crust. It can be caused by a bacterial infection or an over-production of oil by the meibomian glands.

How to treat it: Usually a chronic condition, blepharitis can begin in early childhood and last throughout life. Symptoms include itching, a feeling that something is in the eye, inflammation, scales, mattering or hard crust just above the eyelashes. Limiting or stopping the use of eye makeup is often recommended, as its use will make lid hygiene more difficult. Warm compresses can be applied to loosen the crusts, followed by gentle scrubbing of the eyes with a mixture of water and baby shampoo or an over-thecounter lid-cleansing product (see At-aGlance on page 28). In cases involving bacterial infection, an antibiotic may also be prescribed. If the glands in the eyelids are blocked, the eyelids may need to be massaged to clean out oil accumulated in the eyelid glands. Artificial tear solutions or lubricating ointments may be prescribed in some cases, while others may require more complex treatment plans.

is unable to flow out of the gland. The oil builds up inside the gland and forms a lump in the eyelid. Initially, a chalazion may appear as a red, tender, swollen area of the eyelid. Eventually, the gland may break open and release the oil into the surrounding tissue causing an inflammation of the eyelid. It often starts out very small and barely visible, but it could grow to the size of a pea. They may be confused with sties, which are also areas of swelling in the eyelid.

How to treat it: Apply warm compresses to the eyelid for 10 to 15 minutes, four to six times a day for up to seven to 10 days. The warm compresses may help soften the hardened oil that is blocking the ducts and allow drainage and healing.

Also, gently massage the external eyelids several minutes each day to help promote drainage. Once the chalazion drains, keep the area clean, and keep hands away from eyes. A chalazion will heal within a few months if treated. They will usually resorb within two years.

THE CONDITION: BLEPHAROSPASM What causes it: Commonly known as eyelid twitching, blepharospasm is an involuntary spasm of the eyelid muscle.

The most common causes are fatigue, stress or caffeine.

How to treat it: Eyelid twitching is not considered harmful, so there is no treatment available. However, the doctor may advise the patient to get more sleep and consume less caffeine.

THE CONDITION: CHALAZION Lubricant eye drops, such as Soothe XP from Bausch + Lomb, are used to treat symptoms of eyelid disorders, including blepharitis, ectropion and entropion.

What causes it: A chalazion can develop when the oil produced by the meibomian glands becomes thickened and

THE CONDITION: EYELID EDEMA What causes it: This is most often caused by allergic reactions to eye

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Over-the-counter lid hygiene products, such as those from OCuSOFT, help control chronic blepharitis.

makeup, eye drops, drugs or allergens (dust, pollen, etc.). If the patient is experiencing eyelid swelling on a regular basis it could be due to an allergic reaction to fragrances, make-up or laundry detergent. If there are no known allergies, there could be a more serious problem.

How to treat it: A cold, damp cloth on swollen eyelid(s) twice a day or splashing cool water on the face helps to reduce facial swelling. The doctor may prescribe a prescription-strength antihistamine, eye drops or an ointment to treat the swelling. The doctor will also be able to determine whether there is an infection or not.

THE CONDITION: ENTROPION What causes it: This abnormal turning in of the eyelid, which causes the lashes to rub on the ocular surface, is usually due to aging. Other causes may include a congenital defect, a spastic eyelid muscle or a scar on the inside of the lid from surgery, injury or disease. It is an asymptomatic condition that can rarely

lead to trichiasis, which requires surgery.

It mostly affects the lower lid.

How to treat it: Ocular lubrication and tear preparations are helpful for protecting the ocular surface and also may break the cycle in patients with spastic entropion due to dry eye syndrome. Small amounts (approximately 5U) of botulinum toxin (Botox)—are quite effective for the treatment of spastic entropion by weakening the pretarsal orbicularis oculi muscle.

THE CONDITION: ECTROPION What causes it: This condition is where one or both eyelid margins turn outward. Ectropion typically affects the lower lid, which exposes the inner conjunctival side of the eyelid, and like entropion, it is usually due to aging (though it may be the result of allergies). Its main symptoms are pain, excessive tearing and hardening of the eyelid conjunctiva.

How to treat it: Artificial tears may ease dryness and keep the cornea moist. Using artificial tears or lubricating ointments

may prevent injury to the cornea. Surgery to tighten the muscles that hold the eyelids in place is very often effective.

THE CONDITION: PTOSIS What it is: Drooping eyelids may occur due to trauma, age or various medical disorders. This condition can affect one or both eyes; it may come and go or might be permanent. Children who have ptosis may also develop amblyopia, commonly known as lazy eye. This disorder can also delay or limit their vision. Depending on the severity of the condition, drooping eyelids can block or greatly reduce vision depending on how much it obstructs the pupil.

How to treat it: Eyelid drooping isn’t usually harmful to a patient’s health, but when it blocks the vision the doctor may recommend surgery. During surgery, the levator muscle is tightened. For children who have ptosis, doctors may recommend surgery to prevent the onset of amblyopia or lazy eye. OO Roberta Beers, CPOT, is an optometric assistant in Erie, PA.

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AT-A- GLANCE LID HYGIENE PRODUCTS PRODUCT

TYPE

FEATURED INGREDIENTS

BENEFITS

Cliradex | 844.425.4723 | Cliradex.com | Info@Cliradex.com Cliradex

pre-moistened wipes

4-Terpineol, a component of tea tree oil

• preservative-free formula • s ymptom relief from moderate to severe ocular irritation due to blepharitis, demodex and more

Johnson & Johnson Vision | 800.843.2020 | JustBlink.com Blink Lid Wipes

pre-moistened wipes

chamomile

• suitable for contact lens wearers •e ffective removal of debris and other secretions on the eyelids • cleans, moisturizes and soothes eyelids

Lunovus | 800.980.6551 | Lunovus.com Blephadex

foaming cleanser and pre-moistened wipes

patented combination of tea tree oil and coconut oil

•p reservative-free, all-natural formula cleans, soothes and moisturizes the lids • tea tree oil has antibacterial properties •c oconut oil has anti-inflammatory properties

Blephadex Warming Eyelid Wipes

pre-moistened wipes

patented combination of tea tree oil and coconut oil

•p reservative-free, all-natural formula cleans, soothes and moisturizes the lids •w armth stimulated by an innovative water-activated heat technology • r ecommended for people who wake up with irritated eyes

Novabay Pharmaceuticals, Inc. | 800.890.0329 | Avenova.com | Sales@Novabay.com Avenova

cleanser

0.01% hypochlorous acid

• f or daily cleansing of eyelid surfaces on pre/peri-operative patients • f or symptoms often caused by blepharitis, MGD, dry eye and rosacea •e ffective against a broad range of microorganisms, including common skin bacteria, yeast and fungi

OCuSOFT | 800.233.5469 | OCuSOFT.com | OCuSOFT@OCuSOFT.com HypoChlor

spray

0.02% hypochlorous acid solution

• for moderate to severe blepharitis •e xtra-strength, leave-on formula has antibacterial properties and removes oil, debris and pollen from the lids

Paragon BioTeck | 888.424 1192 | ParagonBioTeck.com ilast Clean

cleansing gel

0.2% hyaluronic acid

• preservative and fragrance free •c ontains polysorbate 20, formulated to remove oil, debris and flaky skin that can cause eye irritation •h ydrates and soothes the dry/irritated skin around the eye

We Love Eyes | 855.687.3279 | ODs.WeLoveEyesXO.com We Love Eyes

foaming cleanser

tea tree oil

• reduces bacteria, dirt and allergens that can cause inflammation • safe to use with eyelash extensions • all-natural, paraben-free formula

FOR AN EXPANDED LIST OF LID HYGIENE PRODUCTS, GO TO OPTOMETRICOFFICE.COM 28 A pr il 2 0 1 7 | O p to m e tri c O f f i c e .c o m

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NEW PRODUCT | GALLERY A SOLUTION FOR SCLERALS FROM BAUSCH + LOMB SPECIALTY VISION PRODUCTS Offering patients an easy way to insert scleral lenses, ScleraFil from Bausch + Lomb Specialty Vision Products is a sterile buffered solution that maintains pH and contains no preservatives or mercury. ScleraFil can also be used to rinse both soft and rigid gas permeable lenses to remove debris and traces of daily cleaner. ScleraFil is available to order from the Specialty Vision Products web store and select Authorized Boston Manufacturers. For more information, contact Bausch + Lomb Specialty Vision Products at 800.704.6954 or BauschSVPstore.com.

ACUVUE OASYS 1-DAY FAMILY ADDS CONTACT LENSES FOR ASTIGMATISM Johnson & Johnson Vision introduced ACUVUE OASYS 1-Day Brand Contact Lenses for ASTIGMATISM, a daily lens that incorporates Blink-Stabilized Lens Design and HydraLux Technology for clear vision and comfort. ACUVUE OASYS 1-Day for ASTIGMATISM provides Class I UV protection to block more than 90% of UVA and 99% of UVB rays and is available in the “widest range of parameters among daily disposable contact lenses for astigmatism,” according to the company. For more information, contact Johnson & Johnson Vision at 800.843.2020 or ACUVUEProfessional.com.

NEW ATLANTIS SCLERAL LENS DESIGNS FROM X-CEL SPECIALTY CONTACTS X-Cel Specialty Contacts has added two new lens options to its Atlantis Scleral product line: Atlantis Scleral Multifocal and Atlantis Scleral 3-D Vault with Limbal Control Technology. The bi-aspheric multifocal design of Atlantis Scleral Multifocal allows a controllable center distance zone for clear distance, near and intermediate vision. The Atlantis Scleral 3-D Vault with Limbal Control Technology allows a limbal sag apex to be adjusted in and out or up and down to optimize peripheral clearance. Both scleral lenses utilize the standard Atlantis fit set. For more information, contact X-Cel Specialty Contacts at 800.241.9312 or XCelSpecialtyContacts.com.

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BAUSCH + LOMB LAUNCHES BIOTRUE ONEDAY FOR ASTIGMATISM Biotrue ONEday for Astigmatism from Bausch + Lomb offers patients a convenient, daily disposable contact lens that incorporates an evolved peri-ballast design that utilizes spherical aberration control in both axes to reduce halos and glare. Surface Active Technology helps lenses maintain 98% of moisture for up to 16 hours, according to the company. For more information, contact Bausch + Lomb at 800.828.9030 or Bausch.com.

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COOPERVISION CLARITI 1 DAY TORIC LENSES NOW IN 90-PACK Giving patients with astigmatism the availability of a daily contact lens, clariti 1 day toric lenses contain silicone hydrogel for all-day comfort. WetLoc technology ensures the entire lens surface is continuously moist by mimicking moisture dispersion of healthy eyes. The toric lenses are available in power ranges including plano to -9.00D. For more information, contact CooperVision at 800.341.2020 or CooperVision.com.

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DOCS | SPEAK OUT TREATING GLAUCOMA PATIENTS Treating glaucoma has become a growing opportunity for optometrists. According to a study in the journal, Ophthalmology, the global prevalence of open-angle glaucoma is expected to rise to 76 million people by 2020. The majority of optometrists in our survey (82%) said the number of patients with glaucoma in their practice has increased in the past three years. If you practice in a state that allows ODs to treat the condition, you know that earlier diagnoses enabled by improved imaging and visual field algorithms together with improved medications support optometric care of this disease. In this issue’s “Docs Speak Out,” we explore how you manage patients with glaucoma—and how they have affected your practice.

Do you initiate treatment for glaucoma patients in your practice?

NO 4%

YES 96%

Has this number grown in the past three years?

NO 18%

YES 82%

What are your main reasons for referring patients to a glaucoma sub-specialist for co-management?

(Select all that apply.)

80 70 60 50 40 30 20 10 0

77% 52%

16%

24%

24%

t P is al nce lian gic d IO nos lera sur onsult iag pinion -comp atient trolle o / d t r l n e p c ia o non ni con las init econd rly atio s dic poo e m

HOW TREATING GLAUCOMA HAS CHANGED YOUR PRACTICE: “ Glaucoma is growing as our population ages. I owe it to my patients to give them this care. It continues to create loyal patients who need this care for the rest of their lives.” “ It gives patients more avenues of treatment opportunities. New technologies are helpful in getting a better overall picture of the disease.” “ Helps grow a loyal core group of patients who are seen several times a year.“ “ It’s been pretty steady over the past five to ten years.”

“ We have become more aggressive in our treatment with our access to technology like the OCT and the Diopsys.”

“ It helps with income, which is a good thing with the declining revenue from optical.”

“ I feel that I am working up to my potential. I am providing the service that patients come to me for and they see me as their ‘Doctor’ not a provider of glasses. I also teach optometry students about glaucoma management. It has raised our status as ODs in general.”

“ It has helped change the focus of the practice from mostly refractive services to medical care.”

“ It significantly increased number of medically related exams, OCT and visual fields. Also, patient sees us in a more medical light.”

“ Treating glaucoma made us purchase technology we probably would not have and has made clinical diagnosis more reliable.”

“ It has changed for the better.

Patients appreciate not having to go to a separate doctor for treatment.”

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CONVERSATIONS SR Conversations is a game-changer in the way healthcare providers communicate with their patients. You can categorize incoming texts to make it easy to Annual Check-up

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