Optometric Office January 2017

OPTOMETRIC OFFICE PRODUCTS AND TECHNOLOGY FOR YOUR PRACTICE

TREATING DIABETIC RETINOPATHY

NUTRACEUTICALS FOR CHRONIC DRY EYE

JANUARY 2017

DIAGNOSTIC DROPS FOR THE EXAM LANE

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TABLE OF CONTENTS 8

ON THE COVER | DEPARTMENTS 4 | Views 8 | Buzz 9 | One-to-One: Masoud Nafey, OD, vice president of professional relations at Eyefinity

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26 | The Optometric Technician 28 | Apps for Patients At-A-Glance 30 | New Product Gallery 32 | Docs Speak Out

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FEATURES 10 | Advances in Diagnostic Technology 12 | Detecting Changes in Diabetic Retinopathy 13 | Diabetic Retinopathy: The Silent Stealer of Sight 14 | Give Athletes the MVP Treatment 16 | Top Drops for Docs 18 | To Dye For 20 | Delivering Relief from Dry Eye

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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 Beers, CPOT • Robert A. Davis, OD • Joshua S. Gordon, OD • Douglas B. Haigh, OD Mark MacMillan, OD • Amanda Nanasy, OD • Charlie Ronan Randall Sakamoto, OD, PhD, FAAO • Katherine Shen, OD • Jennifer L. Stewart, OD J. James Thimons, O.D., FAAO, ABO • 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

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EDITORIAL ADVISORY BOARD 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 • Jerome A. Legerton, OD, MBA • Scot Morris, OD John Schachet, OD • Eric Schmidt, OD • Leo Semes, OD • Peter Shaw-McMinn, OD • Joseph Sowka, OD • 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.

© 2016 AMETEK, Inc. & Reichert, Inc. (12-2016) · Made in USA Phoroptor is a registered trademark of Reichert, Inc. · www.reichert.com

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VIEWS 2017 AND BEYOND

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Richard Views.indd 4

In 2016, you probably noticed newer, bolder graphics and a modern, fresh layout in Optometric Office. We even changed the magazine’s tagline: Products and Technology for Your Practice. In many ways, the technology we use for patient care determines, to a large extent, the quality of care that we deliver. No one would question the advances OCT has made to all eyecare professionals. But it has been especially beneficial to optometrists. The rapid advancement in technology levels the diagnostic abilities of optometrists and ophthalmologists. It allows optometrists to diagnose and manage patients with more sophisticated disease as well as make better referrals when needed.

This may come as a surprise to some practitioners, but there has never been a better time to be in practice. Naysayers may proclaim that practicing today is not nearly as satisfying as it was 20 to 30 years ago when managed care didn’t dictate reimbursement for services or products. Managed care has changed all health care delivery—not just our profession. The upside is the rapid evolution of optometry as a true primary health care provider.

Optometric Office is also on a continuous path of evolution. In 2017, we will be developing and expanding pharmaceutical coverage, including articles from colleagues who will share insights prescribing meds to improve the quality of our patients’ lives. Prescribing the optimal drug and helping patients maintain compliance will improve the outcome of your treatment plans. But we will still deliver the same great content, such as diagnostic instruments, contact lenses, and other technologies that continue to improve this profession.

Finally, I’d like to especially thank our readers. Great publications evolve to better serve the interests of their readers, and I’m always open and thankful for feedback that improves Optometric Office. Here’s to an interesting year with lots of learning and perhaps some pleasant surprises.

Richard Clompus, OD, FAAO | Professional Editor | rc@optometricoffice.com

12/21/16 1:32 PM

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VIEWS DIABETIC RETINOPATHY AWARENESS

The elements of refraction.

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Joanne Views.indd 6

Untreated diabetic retinopathy can cause blindness. You know that, but do your patients? Research suggests that less than half of Americans living with diabetes are aware of this sight-stealing risk.

An estimated one in three people with diabetes have diabetic retinopathy. Non-proliferative diabetic retinopathy, the early stage of the disease, is identified by deposits forming in the retina. There are no physical symptoms. By the time a patient experiences changes in vision they may have proliferative diabetic retinopathy. An annual, dilated eye exam can detect vision problems before your patient notices anything is wrong.

In fact, the American Optometric Association recommends that everyone with diabetes have a comprehensive dilated eye exam once a year. This issue’s Docs Speak Out survey on page 32 discusses how optometrists handle patients who refuse dilation. The good news is that many respondents said that patients agreed to dilation (or rescheduled for a better day) after learning of its importance in detecting disease.

Something else to emphasize: early detection and treatment of the disease can reduce risk of blindness by 95%, according to the National Institutes of Health. Stereoscopic fundus photography and/or dilated biomicrosopy with OCT combined with treatments such as Anti-VEGF drugs, steroids and laser surgery will go a long way to save someone’s sight.

Also, if you practice in remote areas or on mission trips, a cross-sectional study recently published in JAMA Ophthalmology found the sectors approach showed accuracy in the detection of clinically significant macular edema. Researchers say this approach may be considered when the use of OCT is not feasible.

Early detection and treatment can limit the potential for significant vision loss from diabetic retinopathy—you have an arsenal of tools at your disposal. Again, you know that. Make sure your patients do too!

Joanne Van Zuidam | Editor-In-Chief | jvz@visioncareproducts.com

12/21/16 1:18 PM

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

COOPERVISION PROVIDES FREE EYE EXAMS AND EYEWEAR TO CHILDREN LensFerry S, a subsidiary of CooperVision, recently embarked on a mission trip to Mexico with Optometry Giving Sight to provide free eye exams and glasses to those who otherwise do not have access to vision care. The team visited two schools near Oaxaca, Mexico, and provided 1,000 eye exams to elementary school students.

About 80 of those children received glasses.

CooperVision Inc., CooperVision.com.

PRACTICE EXCELLENCE SCHOLARSHIP RECIPIENTS RECOGNIZED AT AAO The VSP Global and the American Optometric Foundation (AOF) Practice Excellence Scholarship reception took place on November 10th at the American Academy of Optometry. Nearly $200,000 was distributed among top-performing fourthyear optometry students in the U.S., Puerto Rico and Canada. Two students from each school or college of optometry were selected to receive the scholarship by nomination of their individual institutions. The awards were funded through VSP Global’s Eyes of Hope Global Charitable Fund in collaboration with FYi Doc-

tors in Canada (for Canadian recipients) and were administered through the AOF. Some key criteria for selecting scholarship recipients included the student’s commitment to enter the independent practice of optometry and clinical and academic performance. VSPGlobal.com

“EYES ON MILLENNIALS” WHITE PAPER NOW AVAILABLE The National Optometric Association (NOA) and Transitions Optical Inc. have released an educational paper titled “Eyes on Millennials: The Most Culturally Diverse Generation,” which summarizes highlights from a “Multicultural Millennial Matters” panel that took place during the NOA’s 2016 Annual Convention in Chicago. Download the digital white paper to learn about cultural considerations to improve care, who multicultural Millennials are and what they value along with best practices and strategies. Moderated by NOA vice president, Sherrol Reynolds, OD, FAAO, the panel included a mix of experienced and Millennial eye doctors, each having strong familiarity with both multicultural and Millennial patients. MyMultiCulturalToolkit.com.

BAUSCH + LOMB LAUNCHES ONE BY ONE RECYCLING PROGRAM

About 80 children received glasses thanks to LensFerry S and Optometry Giving Sight

Blister packs, top foil and contact lenses have not been widely recycled…until now.

Bausch + Lomb has partnered with TerraCycle for the ONE by ONE Recycling Program so that you and your patients can recycle contact lenses properly. Bausch + Lomb celebrated the launch of the partnership on America Recycles Day in November with a consumer event hosted by Biotrue ONEday at Marshall B. Ketchum University’s Southern California College

of Optometry in Anaheim, CA. The recycling program allows contact lenses and packaging to be repurposed, with the goal of reducing landfill waste associated with contact lenses. BauschRecycles.com

UNIVERSITY OF HOUSTON WINS FIRST EVER CUSTOM STABLE CUP Congratulations to the University of Houston College of Optometry for winning the inaugural Custom Stable Cup at the AAO meeting. The event, co-sponsored by Optovue, Valley Contax and Contamac, drew 172 students and alumni from across the country. Competitors visited the Valley Contax booth, put on a Custom Stable Elite scleral contact lens and had OCT images taken at the Optovue booth. The school was awarded two $500 travel grants to AAO 2017 as well as the Custom Stable Cup trophy. Runner-up Illinois College of Optometry was awarded one $500 travel grant to AAO 2017. ValleyContax.com

News

Allergan received FDA clearance for the XEN Gel Stent, a surgical procedure for refractory glaucoma.

SunPharma released BromSite to prevent pain and treat inflammation after cataract surgery.

Novartis has agreed to acquire Encore Vision, which is developing a drop to correct presbyopia.

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As a result of the new robust patient portal and voice and text recall system, office staff is spending less time on the phone. Patients have access to their exam results, pharmaceutical prescriptions and consent forms in the patient portal. The voice and text recall system reminds existing patients to return for their annual exams. To save time in the office, new patients can also fill out their medical and personal history questions in the portal before their appointment, and it will be imported into the patients’ exam notes. To save time in the exam lane, the free e-Fax and auto-letter features allow doctors to send a referral letter to a corresponding physician using just a tap on the screen of an iPad. Finally, to streamline the pharmaceutical prescription process for practices, Eyefinity EHR’s free e-Rx feature allows doctors to import their patients’ medication list directly from the pharmacy as well as prescribe their medications and directly send prescriptions to the patient’s pharmacy of choice.

RC: How can the cloud help optometrists and their staff provide better patient care?

ONE-TO-ONE

Masoud Nafey As vice president of professional relations at Eyefinity, Masoud Nafey, OD, enhances product development through peer-topeer interactions and communications. He also serves as the national director of professional services for VSP Onsite Clinics and maintains clinic hours two days a week. Nafey earned his undergraduate degree at the University of California, Davis, and his Doctor of Optometry from The Ohio State University College of Optometry.

Richard Clompus, OD, FAAO: Eyefinity was one of the first software packages written specifically to support optometry. How does it assist with EHR efficiency?

Masoud Nafey, OD: Our new cloud-based software, Eyefinity EHR, and its corresponding practice management system, Eyefinity Practice Management, work together to increase EHR efficiency so doctors can see more patients and spend more time with them.

MN: Cloud storage is now the easiest, safest and most popular form of data banking. It is crucial that optometrists stay at the cutting edge of consumer needs and expectations. The features I mentioned previously are all possible because Eyefinity EHR is cloud-based software. We have to move forward with technology because soon enough our patients and even government regulations will most likely expect it of us. Also, the iPads our doctors are using in their exam lane have allowed them to perform an entire comprehensive eye exam without ever having to put their back to the patient to type something into a desktop computer. The result is more face-to-face time, increased patient engagement and more opportunities to better develop the doctor and patient relationship.

RC: Does Eyefinity provide any checks and balances to support accurate billing and coding?

MN: We have spent thousands of hours to ensure our software is always up-to-date with the new ICD-10 codes and auto-coding for our doctors. One of the best compliments we hear as an organization is when doctors tell us how much of a non-issue the ICD-10 changes were for their practices. Eyefinity EHR has a built-in “ICD-10 Expert” that allows doctors to select the correct details that correspond to their diagnosis so it is auto-coded correctly for them. In addition, our software auto-codes procedural CPT codes for our doctors based on the level of detail they placed in their visit note. We have simplified this structure so our doctors can focus on their quality of care for their patients, not coding and billing. OO

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INSTRUMENTATION

Advances in Diagnostic Technology

By J. James Thimons, OD, FAAO, ABO The latest developments to treat and manage patients with diabetic retinopathy.

The 21st Century has ushered in a remarkable array of diagnostic systems to aid the primary eyecare professional (ECP) in assessing and managing the diabetic patient.

From advances in fundus camera technology to the latest in OCTs the role of the ECP has evolved exponentially.

Retinal Cameras From a practical perspective, there is no better investment a clinician can make than a high quality fundus camera system.

The versatility and ease of use allow for rapid integration into clinical care protocols, while at the same time providing image quality that is unparalleled with results that can challenge viewing the retina with a biomicroscope and 78D condensing lens. The elevation of the technology is related to both the quality of the camera systems as well as new applications that are available for reviewing and managing diabetic retinopathy. Software that allows for progression analysis of retinopathy is available as is the capacity for excellent stereo photography that provides enhanced assessment of macular edema, cotton wool spots and other pathologies.

Optical Coherence Tomography What was once a luxury has now become a remarkable new tool for the assessment

and long-term management of patients with diabetes. Optical Coherence Tomography (OCT) has catapulted itself into the mainstream of clinical practice, making it difficult to imagine how we, as clinicians, have dealt with the disease state prior to its development.

The essential application is the imaging of the macular region to determine the presence or absence of diabetic macular edema, one of the primary causes of vision loss in patients with diabetes. The technology can be applied as a screening tool, or as a definitive diagnostic assessment in patients who have reductions in visual acuity. In one of its more elegant applications, OCT can be utilized in conjunction with the co-managing retinal specialist to monitor the success of interventional therapy, such as anti-VEGF, steroids and more as patients are treated through the course of their diabetic disease state. Traditional OCT has to a large degree replaced the use of fluorescein angiography in assessment of macular edema, especially once therapy has been initiated. An advancement that has recently been introduced is the ZEISS AngioPlex OCT Angiography (available on the CIRRUS 5000 HD-OCT platform).

This is a new technology that produces FFA level examination of the underlying

The Nonmyd 8 retinal camera from Kowa features 24 megapixel color and FAF (Fundus Autofluorescence) images.

vascular architecture without the need to inject venous dye. One of its best software programs is the ability to analyze change between visits in relation to macular edema and assess the success or failure of therapy.

Another important aspect of OCT is the ability to document the ONH, RNFL and ganglion cell complex. This is crucial in the body of patients with diabetes who are either ocular hypertensives and/ or glaucoma suspects and at greater risk for progression. Recent advances such as Glaucoma Progression Analysis (GPA) and Ganglion Cell Analysis (GCA) give the clinician the ability to identify the transition to glaucoma at the earliest possible moment and also aid in the long term management of the disease.

One of the complex issues in managing the diabetic patient is interpreting data following either panretinal laser photocoagulation or focal laser photocoagulation as it relates to glaucoma. Visual fields can be complex to analyze and unreliable, but the OCT can provide accurate and repeatable information.

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Electrophysiology Another modality that has concurrently developed along with OCT is the use of electrophysiology to identify early diabetic changes at the physiologic level.

While other devices are typically directed toward anatomic analysis, such as OCTs and fundus photography, the use of officebased electroretinography (ERG), such as Diopsys Nova or Diopsys Argo systems, is a relatively newer tool to identify early physiologic changes at the cellular level that can identify the impact of diabetes in the macula at a much earlier stage than the visualization of retinopathy. The current use of electrophysiology has been notably enhanced by the reduction of the complexity of the device, the remarkable decrease in cost and the minimal footprint of the instrumentation. Another major advance in the technology is the software programs that provide change analysis.

Ocular Surface Disease Testing Another technology in the ophthalmic diabetic space is the use of ocular surface diagnostic systems to identify abnormalities of tear film production and the presence of inflammatory-induced ocular surface disease. In the diabetic population, as with so many ophthalmic issues, the rate and in-

ZEISS AngioPlex OCT allows practices to easily integrate advanced vascular imaging into their routine OCT diagnostic exams.

tensity of ocular surface disease state is notably greater than in a healthy population of the same age. As a result, the measurement of tear osmolarity and matrix metalloproteinase-9 (MMP-9) inflammatory assessments have become an integrated component of our day-to-day management. Tear osmolarity (as measured by TearLab technology) is a critical biomarker of the performance of the ocular surface and has a significant role in understanding both the patients’ symptoms and the clinical signs associated with ocular surface disease. This gives the clinician a valuable tool to not only identify ocular surface disease but to quantify its management.

InflammaDry by RPS Diagnostics detects elevated levels of MMP-9 to assess the ocular surface. It is invaluable in its ability to allow clinicians to understand the role of inflammation and construct appropriate clinical intervention as a result of identification of this biomarker.

Office Laboratory Testing A final thought on new technologies is the integration of laboratory testing within the modern optometric practice. An additional technology that can be integrated into a primary care optometric practice is the ability to assist the patients in understanding their disease state by assessing fasting blood glucose in the office. This allows for rapid information acquisition and the ability to better integrate with primary care physicians and endocrinologists who are the global managers of the patients’ diabetic disease state.

The technologies that have arisen in the past decade have markedly altered the playing field with respect to the role of the ECP in the diagnosis and management of the diabetic patient. It is clear that new

The Diopsys NOVA ERG and VEP Vision Testing System can detect early physiologic changes at the cellular level in the macula at a much earlier stage than visualization of retinopathy.

diagnostic technologies will continue to produce greater and more improved systems permitting us to provide higher levels of care to our diabetic patients of the future. OO J. James Thimons, OD, FAAO, ABO, is founding partner/ophthalmic medical director of Ophthalmic Consultants of Connecticut.

WHERE TO FIND IT: Carl Zeiss Meditec, Inc. 800.341.6968 | Meditec.Zeiss.com/USA Diopsys, Inc. 973-244-0622 | Diopsys.com Kowa American Corporation 800-966-5692 | Kowa-USA.com RPS Diagnostics 877.921.0080 | RPSDetectors.com Info@InflammaDry.com TearLab 855.TEARLAB | TearLab.com Marketing@TearLab.com

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INSTRUMENTATION

Detecting Changes in Diabetic Retinopathy

By Katherine Shen, OD, and Charlie Ronan Retinal imaging tools assist with detection, patient education and disease management.

A large majority of the diabetic population is unaware of the risk factors associated with the disease and the major implications they may cause to ocular health. It is our job to make these facts known to our patients and to outline a detailed plan with the use of new technology to manage and detect changes in our patients with diabetes.

PATIENT HISTORY A key aspect of managing these patients is to know their medical history, risk factors for progression of diabetic retinopathy and the status of their glucose control.

The HbA1c provides us with a threemonth average of blood sugar control as a better prognosticator for blood sugar control than any daily personal monitoring of blood sugar. The test results can be ordered with a blood panel and are often already done a few times a year for established patients with diabetes.

In a patient with poor glucose control, small caliber blood vessels can be damaged, specifically the pericytes lining the endothelium of a blood vessel wall, which cause the blood vessels to lose their integrity and leak at the blood-retinal barrier.

Fortunately, there are several lifestyle modifications that can help prevent diabetic retinopathy from progressing into a proliferative stage.

RETINAL IMAGING In our office, we utilize retinal OCT scans and fundus photography to view structural integrity of the retina at annual visits, or sooner depending on severity. For retinal imaging, we use medical screening Optos images to photo-document and quantify any presence of retinopathy and to use as a baseline when judging progression. The images link directly to a computer monitor in each exam lane for review and patient education.

It is also imperative to monitor the macular area for any presence of edema secondary to leakage of blood vessels, so we perform a Macular Thickness scan with a Cirrus HD-OCT 5000 series to detect any clinically significant macular edema. If there is any further suspicion of macular edema from those scans, or from the best correctable visual acuity, we can further test for presence of diabetic macular edema by performing a 5 line HD Raster OCT scan of the macula to evaluate the presence of any cystic spaces from blood vessel leakage. As the standard of care, any presence of retinopathy in either eye indicates a dilated fundus exam.

The California from Optos provides more than 80% or 200° of the retina in a single capture.

merit of our profession, is by co-managing patients with diabetes by communicationg the results of each diabetic evaluation to their medical care providers. This creates relationships between medical professions and leads to better management and care of our patients.

Technology has simplified monitoring the ocular health of people with diabetes by having the ability to reference stored data from each previous visit at the click of a mouse. As the incidence of the disease continues to grow and evolve, we must continue to push the limits of what we are able to do in the management and care of our patients.

Katherine Shen, OD, is an associate at Specialty Eyecare Group in Seattle and Kirkland, WA. Charlie Ronan is a fourth-year student at Indiana University interning at Specialty Eyecare Group.

WHERE TO FIND IT:

CO-MANAGING THE DISEASE

Carl Zeiss Meditec, Inc. 800.342.9821 | Meditec.Zeiss.com/USA

A great way to continue to expand the scope of optometry, and increase the

Optos 866.OPTOMAP | Optos.com

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THINK ABOUT YOUR EYES

Diabetic Retinopathy: The Silent Stealer of Sight Every day, 3,835 Americans are diagnosed with diabetes. Over time, many of those patients will develop diabetic retinopathy, at least at the non-proliferative stage. Without treatment, many of those progress to the more serious level of proliferative retinopathy, with possible retinal detachment or vitreous hemorrhaging.

Diabetic retinopathy currently affects over 8 million Americans—yet 50% don’t know they have it! As an optometrist this is both frightening and frustrating, because with early detection and treatment, we can reduce the risk of blindness by 95%.

The problem is one of circumstances—we all lead busy lives, with many things competing for our time. Diabetic retinopathy can sneak up on someone, in most cases exhibiting no symptoms at all until well advanced. If a person is not experiencing any major problems with their vision, and have no idea they may have a hidden but escalating condition like diabetic retinopathy, the tendency is to go on about their lives. A simple comprehensive eye exam could detect the presence of retinopathy and highlight the need for treatment.

Again, as individual doctors, how do we communicate this message to the general population and get people in for a regular exam?

Diabetic retinopathy currently affects over 8 million Americans—yet 50% don’t know they have it!

In our office, we talk to patients of all ages and say, “To keep your eyes healthy, keep your body healthy with good diet, nutrition and exercise.” We also stress the need for annual exams. Beyond that, we support the Think About Your Eyes campaign and the initiative’s national TV and radio advertising that simply tells the public to make an appointment for their annual exam.

Here in Wyoming our state association pays for a basic listing on the ThinkAboutYourEyes.com website practice locator for every member of the Wyoming Optometric Association. Our office pays a small amount per year for an upgraded listing so we can add more information about our practice and our services, and we get higher visibility with patients in our locale who are searching for a doctor.

Sue E. Lowe

Sue E. Lowe OD, FCOVD, FAAO, is a member and past president of the Wyoming Optometric Association and among the

John Torrey 18,000 doctors listed on the Think About Your Eyes online loca-

tor. 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.

Since Think About Your Eyes launched nationally, over three million people have visited the website.

Between what we do to educate our patients and what Think About Your Eyes is doing with its prime-time TV and radio advertising, we can educate Americans on the need for better eye health and vision care and find the patients who, while they think they can see just fine, have asymptomatic conditions such as diabetic retinopathy.

With earlier diagnosis and treatment, we can prevent many of these patients from progressing to proliferative retinopathy, and we can help maintain their healthy vision and quality of life. OO

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CONTACT LENSES

Give Athletes the MVP Treatment

By Robert A. Davis, OD, and Amanda Nanasy, OD Yes, your active patients can wear contact lenses. Here’s what you both need to know.

Fitting contact lenses is a routine part of any optometrist’s daily patient care. We are lucky to have the opportunity to work with a wide variety of athletes in our practice.

For these patients, there are several factors that come into play, which can make the difference between giving our athletic patients contact lenses that “do the job” vs. contact lenses that give them peak visual performance to enhance their game.

Contact lens companies are concerned with more than good vision, comfort and health. They design lenses that meet athletes’ unique demands. Our colleagues can use our experience fitting various athletes as a model to easily find contact lenses that may take their athletic patients to the next level.

PREFERRED MODALITY The gold standard for sports vision is that whenever possible a daily disposable lens is always best. For ocular health reasons, our athletes are taught that if a lens feels uncomfortable or is unclear during play,

throw the lens away, put in a drop of artificial tears (see page 20 for some recommendations), and start with a fresh lens.

This is the quickest route back to clear, comfortable vision and can prevent further irritation or infections.

Silicone hydrogel daily disposables such as ACUVUE OASYS 1 Day Brand Contact Lenses from Johnson & Johnson Vision Care or DAILIES TOTAL1 from Alcon are great lenses for athletes who require simple spherical correction. Si-Hy lenses provide patients with the least chance of losing clarity in situations that cause dryness, such as windy environments, running back and forth or prolonged concentration (less blinking). Football, track, skiing and basketball are all sports for which we very often fit our athletic patients in these daily disposable lenses.

ATHLETES WITH ASTIGMATISM How and when should you pull the trigger on cylinder correction? There is no easy answer because every athlete will have a

SynergEyes Duette lenses offer the athlete stability and ease of use.

unique Rx and situation. Here are some basic rules to consider: 1. In small (less than 1.25D) amounts of astigmatism, can you improve acuity without compromising stability of vision? Athletes who may have a tilted head posture (such as a baseball player at bat, a shooter or a tennis player) are among those who require the most discrete acuity. But you must test vision with the head positioned as it would be during play. CooperVision’s clariti 1 day toric is one such daily Si-Hy toric currently available.

2. If rotation is an issue or the vision is not stable, it may be necessary to try hybrid lenses. We prefer to use SynergEyes Duette lenses due to their stability and ease of use.

3. Don’t shy away from correcting the cylinder if it provides clear and stable vision. However, consider testing dynamic or contrast acuity in addition to just static Snellen acuity to demonstrate the impact it has made on vision.

IN THE POOL Alcon’s DAILIES TOTAL1 are great lenses for athletes that require simple spherical correction.

Swimmers are contact lens patients who technically shouldn’t be wearing contact lenses. These athletes should always be

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informed about the option of goggles that correct refractive error. In the event that they insist on contact lenses, educate them on proper care: 1. If water gets in their eyes, swimmers must use artificial tears to stabilize pH as much as possible.

2. Instill artificial tears post-swim, then wait five minutes to remove lenses to prevent damage from a “stuck-on” lens.

3. Throw lenses away. These athletes will be in a daily disposable modality. Due to the risk of not properly lubricating the lens prior to removal, avoid prescribing a lens with a high water content. 1-DAY ACUVUE TruEye from Johnson & Johnson and MyDay contact lenses from CooperVision are easily removed in this environment.

On the rare chance you get to work with a synchronized swimmer, consider the fact that they are not permitted to wear goggles during performances. We recently educated a junior Olympic level swimmer and her coaching facility that flushing the eye with milk is not the best way to get rid of redness and there are no such things as “swimming lenses.” Make sure to ask your athletes about their normal eyecare routines. Sometimes their answers will surprise you.

ON THE GREEN X-Chrom lenses from Art Optical can be used for more than color deficiencies.

The lens is used monocularly on the non-

CooperVision’s clariti 1 day toric can improve acuity without compromising stability of vision.

dominant eye in order to intensify the color of red and green objects. Although golf comes to mind, other sports to consider are ones that require an athlete to discriminate between two different color jerseys quickly, such as football.

Fun fact: one color-deficient quarterback, Vinny Testaverde, challenged this argument. He pointed out that he did just fine winning his Heisman Trophy prior to being introduced to the X-Chrom lens.

(But, we wonder if that had anything to do with the Bucs wearing white instead of orange for home games.)

ON THE FIELD Are there any specific recommendations for lenses to use or avoid in contact sports? Not exactly. SynergEyes points out that its lenses are less likely to pop out of the eye compared to RGP lenses due to the soft skirt of hybrid lens design. This is a great point and one of the reasons we have used them for some of our football players. The reality is that in almost any sport, eye injuries can occur. Prioritize education about when to remove lenses if an injury occurs and how to prevent inju-

ries with protective gear when available.

Did you know that male lacrosse players wear helmets and women often don’t? My female lacrosse patient knows to see me if she gets cross-checked in the face.

No matter which contact lens you choose for your athletes, connect the dots for them. Explain why you are choosing a specific lens option for them and how it directly relates to their game. Think of a golfer reading the greens or a baseball player looking for seams on a ball. Consider even doing a local depth-perception test before and after your correction.

Make sure they know you are giving them the MVP treatment, and they may turn out to be your best source of referrals. OO Robert A. Davis, OD, and Amanda Nanasy, OD, are team doctors for the Miami Dolphins and in private practice at The Eye Center in Pembroke Pines, FL. WHERE TO FIND IT: Alcon Laboratories 800.451.3937 | Alcon.com Art Optical Contact Lens, Inc. 800.253.9364 | ArtOptical.com CooperVision, Inc. 800.341.2020 | CooperVision.com

1-DAY ACUVUE TruEye from Johnson & Johnson Vision Care provide high Dk along with excellent fit and comfort.

Johnson and Johnson Vision Care, Inc. 800.843.2020 | ACUVUEProfessional.com Order@Acuvue.com SynergEyes, Inc. 877.733.2012 | SynergEyes.com

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PATIENT CARE

Top Drops for Docs

By Joshua S. Gordon, OD While technology continues to evolve, the diagnostic eye drops used to aid in thorough eye examinations and diagnosis have remained a constant. The following outlines those agents, their mechanism of action and how they are applied specifically to practice.

disclosing corneal injury. They can also be used in evaluating rigid gas permeable contact lenses as well as measuring tear breakup time in cases of dry eye. While these strips are technically not an ophthalmic drop, they are essential in every day examination of the cornea and its components.

DIAGNOSTIC AGENTS

4

1

Proparacaine 0.5% ophthalmic solution (Alcaine, Opthaine, Ophthetic) is a rapid acting, topical anesthetic that induces anesthesia lasting approximately 10 to 20 minutes. It can be used during procedures such as gonioscopy, applanation tonometry and the removal of corneal and conjunctival foreign bodies.

2

Fluorescein sodium/benoxinate hydrochloride ophthalmic solution (Altafluor, Flurox) and fluorescein sodium/proparacaine hydrochloride ophthalmic solution (Fluorocaine, Flucaine) are indicated for procedures that require a staining agent with a rapid acting, short term anesthetic. These procedures include but are not limited to applanation tonometry, removal of corneal foreign bodies and short term relief of ocular pain while trying to evaluate the cornea in cases of ulcers and abrasions. These products are a convenient way of administering a dye and anesthetic in one drop.

3

Fluorescein sodium strips (BioGlo, Ful-Glo) are ophthalmic strips used for staining of the anterior segment when

Phenylephrine ophthalmic solution 2.5% and 10% (Phenylephrine-Akorn, Phenylephrine Hydrochloride-Paragon BioTeck) is an Alpha-1 adrenergic receptor agonist indicated for the dilation of the pupil in adult and pediatric patients. It is the only topical sympathomimetic mydriatic agent on the market. After topical application, phenylephrine ophthalmic solution acts directly on the Alpha-1 adrenergic receptors in the eye by producing contraction of the dilator muscle of the pupil and contraction of the arterioles in the conjunctiva. It takes approximately 15 to 60 minutes to achieve maximum mydriasis and roughly three to five hours to recover. It can be used in combination with anticholinergic agents to further enhance pupil dilation.

5

Phenylephrine ophthalmic solution is also an excellent diagnostic drop that can be used to help differentiate conjunctival inflammation from deeper, episcleral inflammation. Superficial vessels will blanch or constrict more.

6

Phenylephrine 10% ophthalmic solution is relatively contraindicated

in patients with any preexisting cardiovascular disease or hyperthyroidism. It is also relatively contraindicated in children under five years of age and children with low body weight.

7

Tropicamide ophthalmic solution 0.5% and 1.0% (Mydriacyl, Tropicacyl, Opticyl, Mydral, Ocu-Tropic) is an anticholinergic agent that blocks the responses of the sphincter muscle of the iris and ciliary muscle to cholinergic stimulation, thus causing pupillary dilation (mydriasis). The 1% solution also paralyzes accommodation (cycloplegia) while the 0.5% might cause slight cycloplegia. Mydriasis begins in 15 to 30 minutes and can last roughly three to five hours. The 1.0% solution is better indicated in patients with darker irides; while the 0.5% solution is quite efficient in achieving full mydriasis in those with lighter irides.

8

Cylclopentolate ophthalmic solution 0.5%, 1.0% and 2.0% (AKPentolate, Cyclogyl, Ocu-Pentolate) is an anticholinergic agent that has the same mechanism of action as tropicamide 1.0%, causing mydriasis and cycloplegia. The difference is in the time it takes to cause maximum cycloplegia (25 to 75 minutes) after installation and the time it takes to recover (six to 24 hours). In some patients, full recovery can take up to a week. Heavily pigmented irides may require more doses than lighter irides. Cyclopentolate ophthalmic solution is indi-

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cated for refractions in children to control accommodation as well as pre-refractive surgery evaluations. It is also an excellent adjunctive drop for anterior uveitis. The cyclopentolate helps dilate the pupil to prevent the pain caused by spasm of the ciliary muscle.

9

Tropicamide 1.0% ophthalmic solution in combination with phenylephrine 2.5% ophthalmic solution is excellent when trying to achieve a wide dilation as well as in breaking synechiae in cases of anterior uveitis.

10

Sterile saline eye wash is not necessarily a diagnostic agent, however, I find that it is a very useful tool to have handy when using fluorescein sodium strips. I simply use a few drops to moisten the tip of the strip before applying the strip to the eye.

MAINTENANCE AND ADMINISTRATION All of these diagnostic agents can be purchased from most of the major ophthalmic pharmaceutical distributors (see Where to Find It, at right). These companies will often run specials that make it more cost efficient to purchase larger quantities. The diagnostic agents can be stored in an eyedrop tray in the exam room, which can be purchased from the same distributors.

I administer these drops almost always unless we are prepping a patient for a procedure that requires corneal anesthesia or dilation before it is begun, in which my

technicians will administer the drops. On some occasions when a patient presents with a bad corneal ulcer or abrasion, I will have my technicians administer fluorescein sodium with anesthetic to provide the patient with comfort until I can examine them.

For most of my dilated fundus examinations, I use tropicamide 0.5%. I have found that it gives me an excellent dilated pupil while not paralyzing the patient’s accommodation beyond normal function. The recovery time is also shorter. Many of my patients have to return to work, while others prefer the milder dilation when they are driving.

POST DILATION Every patient who is dilated is walked out to the optical if they are purchasing glasses or escorted to the waiting room to relax while the dilation takes effect. This not only maximizes the patient’s time by allowing them to look at glasses, it gives my technicians an open exam room to bring back another patient.

Not all patients can be dilated, so I make a note that the patient deferred the dilation, educate them on the importance of a thorough fundus examination, and then I reschedule them to return within four weeks. I perform an undilated fundus examination at that visit.

Lastly, before a patient leaves my office they are given a pair of post-mydriatic spectacles to wear—the type that wrap around and can be worn over the patient’s

spectacles or by themselves. Even if patients bring their own sunglasses, I will often insist they take the post-mydriatic spectacles because they offer coverage of the periphery.

Just about every optometrist and ophthalmologist uses these diagnostic agents in some capacity. Some of these pharmaceuticals are available as generic drops and may be more economical than the brand name drops. Doctors may favor a particular brand or percentage over another, but the drops are being used for the same purpose. These essential diagnostic agents will allow you to provide a complete and thorough eye examination to every patient who walks in your door as well as assist you in diagnosing a large majority of ocular diseases and conditions. OO Joshua S. Gordon, OD, is in private practice at Barenburg Eye Associates in Baltimore, MD. WHERE TO FIND IT: Akorn Pharmaceuticals 800. 932.5676 | Akorn.com Eye Supply 813.975.2020 | EyeSupplyUSA.com Sales@EyeSupplyUSA.com Henry Schein 800.472.4346 |HenrySchein.com Sigma Pharmaceuticals 800.779.3784 | SigmaPharmaceuticals.com Sales@SigmaPharmaceuticals.com Wilson Ophthalmic 800.222.2020 | WilsonOphthalmic.com

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PATIENT CARE

To Dye For

By Mark MacMillan, OD Three must-have specialty diagnostic drops every primary care practice should have.

Visualization of clear structures is of the utmost importance in eyecare. Viewing structures a different way helps more efficiently diagnose lid disease and corneal and conjunctival disorders. It even helps when viewing contact lenses. Vital dyes such as sodium fluorescein (NaFL), lissamine green and rose bengal make this task significantly simpler. Here’s more on why you should have this trio in your tray.

area of pooling allows measurement of the defect. Staining over an area where there is an infiltrate is more likely an infective process. All of the above appear as positive staining. Negative staining or

NaFL

areas where NaFL is decreased after application can indicate an uneven cornea.

This would include map-dot-fingerprint/ epithelial basement membrane dystrophy or Salzmann’s nodules.

Used post surgically, NaFL can be used to paint the wound site to determine the presence of wound leakage. In addition to disease processes, fluorescein sodium is beneficial when viewing rigid contact lenses. It allows the viewing of the tear film underneath the lens to evaluate lens fit.

The versatility of NaFL is apparent in its extensive applications. NaFL works preferentially on tissues where there is damage, which allows this dye to enter the cell. The dye is most useful aiding in the diagnosis and grading of dry eye disease since tear break-up time can be measured with NaFL. A tear break-up time less than 10 seconds is indicative of dry eye disease.

NaFL’s ability to stain breaks in the corneal epithelium allows us to not only visualize but grade the level of dry eye disease. For instance, according to the Report of the Definition and Classification Subcommittee of the International Dry Eye Workshop, corneal staining more than a mild amount classifies as moderate dry eye.

Corneal staining is also of use when determining corneal abrasions versus an infective etiology. Punctate staining or pooling on the cornea can indicate an abrasion. When the abrasion is larger the

If you are practicing primary eyecare, these dyes are a must.

ROSE BENGAL AND LISSAMINE GREEN Rose bengal and lissamine green are dyes that work very similarly. Both stain dead and devitalized cells on the conjunctiva and the cornea, and neither can penetrate a healthy mucous layer.

I find rose bengal is easier to visualize on the eye but is more irritating to the patient. This irritation can last up to a day in severe dry eye cases. Rinsing with

saline after use can improve this.

Diagnosing herpetic corneal infections is the greatest impact of these two dyes.

While NaFL can help in the diagnosis of herpetic infections by staining eroded areas of the dendrites, rose bengal will stain the characteristic epithelial dendrites of herpetic corneal disease. Both dyes will stain the conjunctiva in dry eye disease. The thickened lid margin at the line of Marx will also be stained by these dyes. This can be debrided to help improve evaporative dry eye.

There are certainly other dyes that are more specialized but not used on an almost daily basis. If you are practicing primary eyecare, these dyes are a must.

These are the primary specialty dyes that I find myself utilizing most frequently in my practice. OO Mark MacMillan, OD, is in private practice in Virginia Beach, VA. WHERE TO FIND IT: Amcon Labs 800.255.6161 | AmconLabs.com Sales@AmconLabs.com Eye Supply 813.975.2020 | EyeSupplyUSA.com Sales@EyeSupplyUSA.com Sigma Pharmaceuticals 800-779-3784 | SigmaPharmaceuticals.com Sales@SigmaPharmaceuticals.com Wilson Ophthalmic 800.222.2020 | WilsonOphthalmic.com

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PHARMACEUTICAL

Delivering Relief from Dry Eye

By Jennifer L. Stewart, OD Six Rx and OTC options for patients with ocular surface disease.

The hottest topic in optometry right now is....dry eye? While studies estimate more than 30 million people suffer from dry eye disease, it has not been in the spotlight.

That’s because many patients suffer in silence, believing dry eyes to be a normal part of aging or contact lens wear, or they have a lack of improvement in symptoms and fail to continue treatment.

However, with the first new prescription drug in 13 years hitting the market in 2016, along with a full national campaign with star presence, patients will be more likely than ever to speak to their eyecare professionals (ECPs) about their symptoms.

As practitioners, we are at the forefront of treatment for these patients, and we have an arsenal full of both over-the-counter and Rx treatments at our disposal.

PRESCRIPTION TREATMENTS Restasis Allergan’s Restasis (cyclosporine 0.05%), the first treatment approved by the FDA for treatment of dry eye in 2002, is an ophthalmic emulsion that increases tear production suppressed by ocular inflammation associated with keratoconjunctivitis sicca. While the exact mechanism of action is unknown, Restasis is believed to be an anti-inflammatory agent, preventing T-cells from releasing cytokines, which leaves the tissue of the lacrimal

glands and ocular surface intact. This may prevent damage to the tissues, which could affect the quality and quantity of tears, and actually can promote normal tear production. Restasis is sterile, preservative free, dosed BID and can be used along with artificial tears or topical steroids. It is now available in a multi-dose bottle (see page 30). The most common adverse reaction when using Restasis is burning on installation.

Xiidra In mid-July, Xiidra (lifitegrast 5% ophthalmic solution) from Shire, was approved by the FDA to treat both the signs and symptoms of dry eye, and it is the first in a class of drugs known as lymphocyte function-associated antigen-1 (LFA-1) antagonists. Lifitegrast binds to the integrin lymphocyte function-associated antigen-1 (LFA-1), a cell surface protein found on leukocytes, and blocks the interaction of LFA-1 with its cognate ligand intercellular adhesion molecule-1 (ICAM1). ICAM-1 may be overexpressed in corneal and conjunctival tissues in dry eye disease. LFA-1/ICAM-1 interaction can contribute to the formation of an immunological synapse, resulting in T-cell activation and migration to target tissues. In vitro studies demonstrated that lifitegrast may inhibit T-cell adhesion to ICAM-1 in

Xiidra from Shire is the first in a class of drugs known as lymphocyte function-associated antigen-1 (LFA-1) antagonists.

a human T-cell line and may inhibit secretion of inflammatory cytokines in human peripheral blood mononuclear cells. The exact mechanism of action of lifitegrast in dry eye disease is not known.

Early clinical usage is promising, with some dry eye patients experiencing a reduction in their symptoms in as early as two weeks; patients in clinical studies had a large reduction in their Eye Dryness Score (EDS) at six and 12 weeks. The most common side effects (incidence 5-25%) of Xiidra include instillation site irritation, an unusual taste sensation (dysgeusia) and blurred vision (decreased visual acuity). Xiidra is a preservative-free solution that comes in individual vials and has BID dosing.

OVER-THE-COUNTER TREATMENTS Refresh The Refresh brand of artificial tears

by Allergan promises patients myriad choices for relief. Refresh Optive Advanced stabilizes the tear film layer by layer, reduces tear evaporation, hydrates the aqueous layer, and lubricates and protects the mucin layer. Refresh Optive and Refresh Plus are preservative free and protect the surface of the eye, while

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The Refresh brand of artificial tears from Allergan offers myriad choices for dry eye relief.

adding moisture for the tear film. These are both recommended for dryness in post-LASIK patients. Refresh Optive Gel Drops are a more viscous tear that delivers a shear-thinning effect, providing patients with a significant reduction in dry eye symptoms. Refresh Celluvisc, a preservative-free gel, provides long-lasting relief for dry eyes during either day or night. For nighttime protection, Refresh PM (mineral oil 42.5%, white petrolatum 57.3%) and Refresh Lacri-lube (mineral oil 42.5%, white petrolatum 56.8%) help protect from dryness and exposure.

Retaine OCuSOFT’s line of lubricant eye drops and artificial tears, Retaine has many solutions for dry eye and meibomian gland dysfunction. Retaine MGD Emulsion (preservative-free, single-dose vials) works by using electrostatic attraction to stabilize the tear film. Retaine HPMC Lubricant Eye Drops consists of a preservative-free, hypromellose ophthalmic solution (0.3%) The Retaine line from OCuSOFT has many solutions for patients with dry eye or meibomian gland dysfunction.

that delivers multiple sterile doses to the eye with no preservatives and guaranteed sterility after opening. Retaine PM is an oil-based, preservative-free formula for overnight protection. For patients suffering from dry eye caused by environmental factors or prolonged computer use, singledose vials of Retaine CMC Lubricant Eye Drops with carboxymethylcellulose sodium 0.5% will provide immediate relief.

Soothe XP Dry eye can happen when the eye’s outer protective lipid layer breaks down. Soothe XP emollient (lubricant) eye drops contain Restoryl mineral oils. Soothe XP helps restore this layer, seal in moisture and protect against further irritation.

Systane Alcon’s Systane offers multiple ways to help relieve dry eye symptoms. SYSTANE BALANCE helps support the three layers of the tear film, especially the delicate lipid layer. SYSTANE Gel Drops create a

barrier of protection using the coverage of a gel combined with the convenience of a drop. SYSTANE ULTRA provides high performance, long-lasting relief for patients with dry eye symptoms and is also available in preservative-free, singleuse vials. For patients needing nighttime protection, SYSTANE Lubricant Eye Gel offers the thickest formulation for lasting relief.

Dry eye is one of the most common conditions that brings patients into our offices for treatment. An aging population, increased use of computers and screens, a large number of patients on systemic medications and a national advertising campaign will continue to drive these patients to ECPs for treatment. We are now armed with more options than before to help these patients gain better comfort and relief. 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: Alcon Laboratories 800.451.3937 | Alcon.com Allergan 800.347.4500 | Allergan.com RefreshBrand.com Restasis.com Bausch + Lomb 800.553.5340 | www.Bausch.com/ecp OCuSOFT, Inc. 800.233.5469 | Ocusoft.com Ocusoft@Ocusoft.com Shire 617.349.0200 | Shire.com

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PHARMACEUTICAL

Go Fish!

By Randall Sakamoto, OD, PhD, FAAO A healthy serving of omega-3 fatty acids may help patients manage dry eye disease. Here’s what to know and what to tell (and sell) your patients.

Prescribing nutraceuticals for eyecare in general is a must for all primary care optometric practices. Optometry has historically been a leader in the prescription of nutraceuticals for macular degeneration.

This naturally extended to diabetic retinopathy and now, dry eye treatment.

The keystone nutraceutical for treating dry eye is omega-3 fatty acids, or fish oil.

Many different formulations have been introduced. Rather than recommend that patients shop on their own to find fish oil, it is more beneficial to the patient if the eyecare practitioner selects and prescribes a particular brand of omega-3 fish oil.

TRIGLYCERIDE OR ETHYL ESTER? While triglyceride forms of fish oils are more expensive to manufacture, research has shown they allow up to 70% more absorption compared to the less expensive “ethyl ester” form. The process also includes a rigorous distillation process to

FOUR Fish Oil Supplements Not sure what brand to prescribe or sell directly to patients? Here are a few brands to consider: • Dry Eye Omega from PRN (Physicians Recommended Nutriceuticals) • HydroEye from Science Based Health • P roOmega and ProOmega 2000 from Nordic Naturals • T heraTears Eye Nutrition from Akorn Consumer Health

purify the oil and expunge pollutants such as dioxins, mercury, lead and others.

The “Styrofoam Cup Test” is a great way to discuss the difference with patients. You can easily demonstrate in the office. Cut an ethyl ester fish oil gel cap in half and express it into a Styrofoam cup.

The ethyl ester oil will proceed to melt the Styrofoam itself. This is a strong demonstration to convince patients that just going to a big box store for their fish oil may not be such a good idea.

HOW OMEGA-3 HELPS Two components in omega-3 fatty acids help dry eye. EPA (eicosapentoenoic acid) promotes cell nucleosis, membrane fluidity, and fluidity of secretions, while DHA (docosahexaenoic acid) enhances the structural integrity of cells. Omega-3 fatty acids generate anti-inflammatory prostaglandins E3 and luekotrine B5. EPA directly blocks the pro-inflammatory cytokines, tumor necrosis factor-alpha, interleukin-1-alpha, and interleukin-1-beta.

Many studies have shown that omega-3 treatment can reduce ocular inflammation associated with chronic dry eye and increase tear break up time, tear production and meibomian gland function.

PRESCRIBING FOR DRY EYE Prescribing dry eye nutraceuticals in a primary eyecare practice is essential to make sure that patients are obtaining the

TheraTears Eye Nutrition from Akorn Consumer Health is available at major retailers and direct to physicians that have an Akorn account.

correct formulation of omega-3 fatty acids and to allow us to be more involved in the ongoing preventative care of other conditions for which omega-3’s are beneficial, such as macular degeneration and diabetic retinopathy.

In our practice, we routinely prescribe omega-3 fatty acids as an integral part of our dry eye treatments. We begin with meibomian gland imaging, tear and meibomian oil layer analysis, lid hygiene with modern blepharitis pharmaceuticals, warm compresses, prescription of omega-3 fatty acids (1,000mg to 2,000mg per day) and meibomian gland expression procedures as needed. OO

By Randall Sakamoto, OD, PhD, FAAO, is in private practice in Honolulu, HI WHERE TO FIND IT: Akorn Consumer Health 800.932.5676 | TheraTears.com Consumer.Service@Akorn.com Nordic Naturals 800.662.2544 | NordicNaturals.com Info@NordicNaturals.com PRN Physician Recommended Nutriceuticals 800.900.2303 | PRNOmegaHealth.com Info@PRNOmegaHealth.com Science Based Health 888.433.4726 | ScienceBasedHealth.com

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THE DRY EYE WORK-UP Dry Eye Disease (DED) is a common chronic condition with a multifactorial etiology that can make it a challenge to treat. Successful management of the condition begins with careful screening of patient-reported symptoms for undiagnosed DED during their initial visit, followed by a comprehensive work-up at a follow-up visit for a complete diagnosis. The vital dye tests and eyelid examination conducted as part of this work-up will not only pinpoint the cause of DED but can also shed light on the severity of the condition, thus allowing for an appropriate treatment course to be planned.

Jason R. Miller, OD

EyeCare Professionals of Powell Powell, Ohio

VITAL DYE TESTS Corneal epithelial staining with Fluorescein dye helps to detect superficial punctate keratitis, which is characterized by the presence Figure 1 Stained Ocular Surface of damaged or irritated cells on the ocular surface.

It also helps determine the patient’s tear film break-up time (the degree of staining correlates with the amount of exposed cornea due to tear film evaporation).

Conjunctival surface staining using Lissamine Green dye reveals dead and degenerate conjunctival cells, while lid staining with the dye can uncover any signs of lid wiper epitheliopathy. This dye also stains other damaged or irritated areas of the ocular surface not stained

by Fluorescein.

Both vital stains can be used to detect early DED even in asymptomatic patients, while the patterns of staining can help determine the etiology of the condition and the appropriate treatment. Depending on the severity of DED

ODs can recommend from a variety of treatment options, from artificial tears, corticosteroids, cyclosporine, and lifitegrast, to punctal plugs, autologous serum, bandage contact lenses, and biological corneal membranes.

EYELID EXAMINATION Eyelids contain meibomian glands, which help produce the outer layer of the tear film. In meibomian gland dysfunction, wherein the glands are blocked or unable to secrete enough meibum or oil into the tears, the tears “break-up” and leave dry patches on the ocular surface. The rapid break up and evaporation of tears is a very common cause of DED. Meibomian gland obstructions can be cleared in the office by expressing the glands using the Mastrota paddle after warming the glands with a Bruder mask. I find that the center and nasal glands Figure 2 Blocked Meibomian Gland are the easiest to express. Depending on the severity of gland inflammation, anti-infective, anti-inflammatory eye drops and oral antibiotics (like doxycycline) may also be prescribed. In addition, I also recommend that my patients use a Bruder mask as a nightly procedure, apply lid scrubs like Ocusoft, and continue to follow day-to-day self-care tips to help prevent complications.

To encourage your patients to adhere to their treatment, educate them about DED, and also show them their test results. For example, after conjunctival staining, I show them a photo of their stained eyelid taken on their own smartphone. It helps them better understand their condition, when they actually see the test results for themselves. After all, seeing is believing!

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

Acknowledgement Rendia is patient education software that blends stunning clinical artwork with interactive technology to help medical professionals and patients understand each other better. Rendia empowers patients to make informed health decisions and experience better outcomes. For more information on Rendia’s interactive patient education solution, please visit www.rendia.com © 2016 BioScience Communications

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CLOSE UP

Prescription for Comfort

By Gina M. Wesley, OD, MS, FAAO Bausch + Lomb’s latest multifocal monthly lens provides presbyopes with an ultra-comfortable vision experience—up close, far away and in between.

As eyecare practitioners today, we have the tremendous opportunity to allow our patients relief from presbyopic struggles.

Never before have we had the privilege to fit our presbyopic patients with advanced technology in contact lens design, material and performance. Bausch + Lomb ULTRA for Presbyopia has allowed me to grow in my success with presbyopic patients, and most importantly, offer a novel vision solution for my patients.

fitting guide.

When patients can instantly experience the clarity the lenses provide, the success with fit becomes easy. When educating your patients on how multifocal contact lenses perform, seeing is believing, literally.

REVOLUTIONARY MATERIAL 3-ZONE PROGRESSIVE The demands that today’s presbyopic patients with active lifestyles face create challenges when attempting to correct for those visual stresses. Not only are they struggling with various focal points, but they also must deal with the dynamic nature in which they must shift between them all. Bausch + Lomb ULTRA for Presbyopia’s 3-Zone Progressive design provides patients with the clarity of vision they need, at the distances they need it.

My patients wearing this lens report high satisfaction when using mobile devices, while working at the computer and when driving.

SUCCESSFUL FITS According to Bausch + Lomb, 96% of patients are fit successfully within the first two visits, which I’ve found to be true in my practice when following the concise, easy-

The high Dk, low modulus properties of the Bausch + Lomb ULTRA platform allow for easy handling. MoistureSeal

Comments From the Docs “Bausch + Lomb ULTRA for Presbyopia elevates the level of visual solutions I can provide my patients.

It’s incredibly easy to fit, retains excellent moisture throughout the day, and patients love their vision.”

–Ben Gaddie, OD, Louisville, KY “Bausch + Lomb ULTRA for Presbyopia has become my go-to multifocals for patients. The comfort and hydration of the lens material allows my patients to wear them throughout the day, and the 3-zone progressive design helps my patients achieve functional distance, intermediate and near vision.”

–Stephanie Woo, OD, Lake Havasu City, AZ

Bausch + Lomb ULTRA for Presbyopia’s 3-Zone Progressive design helps eyecare professionals achieve an easy, predictable fit.

technology helps the lens maintain 95% of its own moisture in a day’s wear. Truly, the comfort of the lens allows my patients an ease of wear that frees them to perform the activities they need and want to do daily.

When, as a doctor, you are able to deliver on the innovation of a lens that proves itself in how well it works for your patients, and it’s easy to fit, the success with multifocal wearers follows naturally. Educating your patients on the opportunity they have in contact lens correction is a first step, but you need to have a lens that can perform.

Having confidence in a product such as Bausch + Lomb ULTRA for Presbyopia is a win for both practice and patient, and I’m excited to have its technology at my disposal. OO Gina M. Wesley, OD, MS, FAAO, is in private practice in Medina, MN. WHERE TO FIND IT: Bausch + Lomb 800.321.4576 | Bausch.com/ecp

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THE | OPTOMETRIC TECHNICIAN

BY ROBERTA BEERS, COPT HOW TO MANAGE PATIENTS WITH DIABETIC RETINOPATHY, FROM ASKING THE RIGHT QUESTIONS TO ADMINISTERING THE DIAGNOSTIC TESTS AND MORE. As an optometric technician, we play an important role in the success of the optometric practice. We need to know the ramification of different diseases in the eye. One disease that might present in the office is diabetic retinopathy. It is imperative to know the symptoms and when a diabetic would be at risk.

WHAT IS DIABETES? To understand diabetic retinopathy you need to first understand diabetes. Diabetes is the condition in which the body does not properly process food for use as energy. Most of the food a person consumes is turned into glucose, or sugar, for the body to use as a form of energy. The pancreas, an organ that lies near the stomach, produces the hormone insulin to help glucose get into the cells of bodies. When someone has diabetes, their body either doesn’t make enough insulin or can’t use its own insulin as well as it should. This

causes sugars to build up in blood. Diabetes can cause serious health complications including heart disease, kidney failure, lower-extremity amputations and blindness. High blood sugar level (diabetes) can cause the following symptoms: • frequent urination, especially at night • blurred vision • fatigue or low energy • increased thirst • increased hunger • dry skin • slow healing wounds

WHAT ARE THE CAUSES OF DIABETIC RETINOPATHY? Beyond the presence of diabetes, how well a patient’s blood sugar is controlled is a major factor in determining how likely they are to develop diabetic retinopathy with accompanying vision loss.

Diabetic retinopathy is caused by changes in the blood vessels of the retina,

Taking OCT and OCTA images, such as with the AngioVue from Optovue, Inc., can provide detailed views of the retina so the optometrist can determine ocular health.

which is the thin, light-sensitive inner lining in the back of the eye. Diabetic retinopathy happens when high blood sugar damages the tiny blood vessels of the retina. When the nerve cells are damaged, vision is impaired. These changes can result in blurred vision, hemorrhage in the eye, or, if untreated, retinal detachment. The longer a person has diabetes, the higher the risk of developing diabetic retinopathy.

THE STAGES OF RETINOPATHY Diabetic retinopathy is broadly classified as non-proliferative diabetic retinopathy and proliferative retinopathy.

Non-proliferative diabetic retinopathy is generally not sight-threatening itself unless macular edema is present. Proliferative retinopathy is a more dangerous state of diabetic eye disease. This could block the passage of light to the retina causing loss of vision and even blindness to occur. Another risk is that the fragile blood vessels hemorrhage, which causes scar tissue, and may pull on the retina and cause a retinal detachment.

THE RIGHT QUESTIONS As an optometric technician, we are the first to have interaction with the patient.

It is important to ask the right questions so we can provide the doctor with information in understanding the patient’s current condition. To do so, we need to: • identify any recent episodes involving vision or overall health • understand and properly administer appropriate tests • identify patient’s signs and symptoms of diabetic retinopathy • educate the patient about the importance of annual eye exams

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For patients with diabetes, always ask: • case history questions • do they know their last A1c?

• do they know if their cholesterol is within normal levels?

• when was the last time their blood sugar was tested?

• how are they managing their diabetes (pills, insulin, etc.)?

• is their glucose under control?

• has their vision been stable since their last visit?

• how are they feeling today?

• are they eating right and exercising?

• are they taking their medications?

• are they new or established with your practice?

Always be sure to check blood pressure and document, document, document.

DIAGNOSTIC TESTS Many times diabetic retinopathy is detected during a comprehensive dilated eye exam that includes: 1. Visual acuity testing: This eye chart test measures a person’s ability to see at various distances.

2. T onometry: This test measures pressure inside the eye.

3. Pupil dilation: Drops placed on the eye’s surface dilate (widen) the pupil, allowing an optometrist to examine the retina and optic nerve.

4. O ptical coherence tomography (OCT): This is similar to ultrasound but uses light waves instead of sound waves to capture images of tissues inside the body. The OCT provides detailed images of tissues that can be penetrated by light, such as the eye.

This test is usually performed by a tech-

nician, while the optometrist interprets the information and determines the diagnosis.

During the examination the optometrist will be looking for changes of the blood vessels that might be leaking or swelling in the macula (DME). If DME or severe diabetic retinopathy is suspected, the optometrist would refer the patient to a specialist to perform a fluorescein angiogram. This is used to look for damaged or leaky blood vessels. In this test, a fluorescent dye is injected into the bloodstream, often into an arm vein. Pictures of the retinal blood vessels are taken as the dye reaches the eye.

TREATMENT Treatment of diabetic macular edema has evolved a great deal in the last five to ten years and is based on the severity of the edema. At present, there are three options: laser treatment, injection or steroids.

Laser Treatment A retinal surgeon uses a beam of highintensity light, which is directed into the eye to seal off leaking blood vessels and prevent additional blood and fluid from leaking into the vitreous.

Injections The most effective treatments to date for blood vessel damage are the anti-angiogenic drugs Avastin, Lucentis and Eylea.

They are administered by injection directly into the eye. The abnormal vessels will disappear within 24 to 48 hours; however, the effects of the drug will wear off. Treating edema requires frequent injections.

Steroids Intravitreal steroids are used to treat swelling caused by diabetic macular edema. While steroids can reduce retinal edema dramatically, they have side effects, including the development of glaucoma and cataracts in some patients. The steroid medications currently available are Kenalog, Ozurdex and Iluvien.

In addition, many diabetics develop a tractional retinal detachment. This occurs when fibrous tissue pulls the retina away from the underlying tissue layers.

The technique to repair is called vitrectomy, which is the removal of the vitreous from the eye, and replacing it with a clear salt solution. This allows the physician to have clear media to look through in order to perform the laser treatment. OO Roberta Beers, CPOT, is an optometric assistant in Erie, PA.

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AT-A- GLANCE APPS FOR PATIENTS APP

OPERATING SYSTEM

PRIMARY USE

BENEFITS

Screen warmth/light adapter

•C hanges temperature/display of phone as day progresses •H elps circadian rhythms •R educes blue light exposure

Relieves eyestrain while reading on-screen

•M akes reading on-screen easier and faster using patented visual technology • I mproves visual tracking ability •E specially helpful for readers with vision difficulties, dyslexia and ADD • I mproves reading fluency and comprehension for students

Color blindness test

•2 0-plate color vision test •E ducational website for color blind patients

Self-guided vision screening

•S creening for visual acuity, color vision, AMD, dry eye and more •H elps patient locate providers and request appointments

Drug price checker

•C ompare drug prices •F ind generics and coupons •U seful tool to learn about usage of particular drugs

Apple | Apple.com Night Shift

iOS 9.3

BeeLine Reader | BeeLineReader.com BeeLine Reader

iOS 9 or later, Chrome, Firefox, PDF and Android

EnChroma | EnChroma.com Color Blindness Test

Online, iOS and Android 2.1 and up

EyeXam | EyeXam.com EyeXam

iOS 6.0 or later and Android 3.2 and up

GoodRx | GoodRx.com GoodRx

Online, iOS 8.0 or later and Android 4.0 and up

Konan Medical USA Inc. | KonanMedical.com Amsler Grid Eye Test

iOS 7.0 or later (compatible with iPad)

Amsler Grid

•W orking Amsler Grid •P atient can track changes by drawing on grid •F ollow changes and analysis over time

FLEX Visual Acuity

iOS 7.0 or later (compatible with iPad)

Visual acuity assessment

• I nstant, flexible test distances from 14in to 20ft •E nhanced logic for resolution dependence of smallest optotypes at closest test distances •C omprehensive Sloan specification optotypes library

UV measurements

•D elivers UV index levels based on geo location •F eatures a store locator for the nearest store that offers Polaroid sunglasses •O ffers user recommendations for UV protection

Eyestrain test

• Free • Measures digital eyestrain •T ests vision by looking far-to-near and vice versa

Safilo USA, Polaroid.com Polaroid UVTest

iOS 8.3 and later

Safilo USA, Polaroid.com Digital Eye Strain Test

iOS 5.0 or later and Android 4.0 and up

28 J a n ua r y 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 ALCON ADDS AIR OPTIX PLUS HYDRAGLYDE AIR OPTIX plus HydraGlyde, the latest monthly replacement contact lens from Alcon, combines SmartShield Technology, an ultra-thin protective shield that resists lipid deposits, with HydraGlyde Moisture Matrix to provide longer-lasting lens moisture. Lenses come in a power range of +8.00D to -12.00D including expanded plus and minus powers. Availability is scheduled for February 2017. For more information, contact Alcon Laboratories, Inc. at 800.451.3937 or Alcon.com.

ALLERGAN ANNOUNCES RESTASIS MULTIDOSE Allergan received FDA approval for Restasis Multidose, a new preservative-free, multi-dose bottle of the company’s drops for chronic dry eye. Its new bottle design incorporates a unidirectional valve with air filter technology to eliminate the need for preservatives, offering a convenient option at no additional cost compared to single-use vials. For more information, contact Allergan at 800.347.4500 or Allergan.com.

OPTOHOOD AIMS TO IMPROVE IMAGE QUALITY This patent-pending apparatus for a non-mydriatic retinal camera, OCT, ocular wavefront aberrometer and glaucoma diagnostic equipment integrates with most ophthalmic instruments. By reducing ambient light to facilitate mydriasis, OptoHood minimizes small pupil artifact. Its built-in ocular shutters force the pupil to dilate to its maximum, allowing more light into the eye and improving both diagnosis and image quality with a shorter dilation time, according to the company. For more information, contact OptoHood at 858-863OPTO or OptoHood.com or Sales@OptoHood.com.

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FDA CLEARS ZEISS PLEX ELITE 9000 SWEPTSOURCE OCT AND OCTA ZEISS received FDA clearance for Swept-Source OCT imaging technology for posterior ocular structures with its PLEX Elite. Widefield and high-resolution visualization provided by Swept-Source OCT and OCT Angiography of the PLEX Elite 9000 “expands clinicians’ ability to examine the critical microstructures and microvasculature of the posterior segment at any depth of interest from vitreous to sclera,” according to the company. ZEISS PLEX Elite 9000 Swept-Source OCT and OCT Angiography platform has a limited release as a research tool for clinicians conducting retina research. For more information, contact ZEISS at 800.341.6968 or ZEISS.com/med.

OCUDERMA EYE GEL RELEASES NEW FORMULA MediNiche, Inc. revamped the formula and packaging of OcuDerma Eye Gel. The new bottle features an “Accu-Dose” pump dispenser that allots an accurate amount of gel, eliminating the need to dip fingers into a jar and risking contamination. The new formula reduces puffiness and minimizes fine lines and wrinkles without clouding lenses or causing irritation. Ideal for sensitive skin, OcuDerma won’t clog pores and is free of parabens, artificial dyes or fragrances. For more information, contact MediNiche, Inc. at 888.3252395 or MediNiche.com.

NEW SCLERAL LENS FOR REGULAR CORNEAS FROM ALDEN OPTICAL Zen RC scleral lenses from Alden Optical/Bausch + Lomb Specialty Vision Products are made for the normal cornea where excessive diameter and vault aren’t necessary. They provide a smaller diameter for easier insertion and removal and a reduced nominal center thickness. SmartCurve technology simplifies fittings by modifying only the parameter you want. Available options include toric peripheral curves, custom center thickness, front toric prescriptions, MicroVault and flexure-controlling profiles. Lenses have a Sagittal Depth Range of 3500 to 5000 (in 10 micron steps), diameters of 14.8mm and 15.4mm, a power range of +20.00D to -20.00D and an Advanced Peripheral System of Steep-10 through Steep-1, standard and Flat-1 through Flat-10 (in 30 micron increments).

For more information, contact Alden Optical/Bausch + Lomb Specialty Vision Products at 800.253.3669 or Bausch.com/ZenLens or Info@Bauschsvp.com

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DOCS | SPEAK OUT DILATING DURING EXAMS Dilating pupils has been the standard of care for comprehensive eye exams for decades. Though “nothing can replace a dilated fundus exam by a highly educated optometrist,” many doctors in our survey cited Optos, Optovue and Eiden systems as alternatives. In cases where patients opted not to be dilated, some doctors felt confident in the use of these instruments. Although such improvements in imaging technology may be changing attitudes of clinicians, 50% of optometrists in our survey dilate patients in comprehensive eye exams. “While technology can allow for a tremendous view of the fundus, I don’t feel confident that technology can fully replace a dilated view of the fundus,” said one OD. So what do you do when your patient refuses dilation? See below.

What percentage of your patients do you dilate during comprehensive eye exams?

Do you offer widefield fundus imaging as an alternative to dilation during comprehensive eye exams?

After installing dilating drops, where do you have patients wait the 20-30 minutes for the pupils to fully dilate?

(Select all that apply.)

60 50 40 30

50%

20%

23%

7%

20

NO

60 50

YES

40

32%

30

68%

10 0

00%

o1 %t

76

5%

51

o7 %t

26

47%

41%

13%

10 0

l in nt era oom ain me art ewear Rem room Gen area ly-lit r ilated s p e n m l d ey io Dim for d atient exa ica at ept d p the opt o look rec rve e e h s t T re

5%

0%

o5 %t

52%

20

o2 %t

1

WHAT TO DO WHEN A PATIENT DOESN’T WANT TO BE DILATED. “Refusal form needs to be signed, and we document refusal in chart. Strongly advise dilation for higher risk patients, such as those with diabetes, previous retina history, over 65, etc.”

“Fundus examination performed behind the slit lamp with off-axis 90D or digital widefield lens. Document that dilation was recommended and deferred by the patient.”

“We offer digital widefield imaging if they absolutely refuse to dilate. If there is something suspicious on the image, we will have them schedule for a full dilation.”

“Sign a form stating that I may not be able to detect retinal eye disease and cannot be held responsible.”

“They don’t get dilated and it is noted in their chart. Seldom happens.”

“I only see children. If they are new or hyperopic or high myopes I insist on the child coming back for dilation before committing to a prescription.

If they are established and low myopes, I will perhaps skip a year of dilation.”

“Tell them that I wouldn’t skip it for myself or my family.”

“I give the analogy of taking a car to a mechanic for a thorough check-up and then telling him not to raise the hood. Works virtually every time.”

“If they were dilated the year before, I allow them to wait till the next year for their dilation. I dismiss patients who refuse dilation after hearing my explanation of why it is so important.“ “We tell them, ‘nobody likes to be dilated, but it is the only way I am able to view the inner structures of the eye properly to ensure everything is healthy. Now quit yapping and tilt your head back.’”

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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. 3. In vitro study over 16 hours to measure wetting substantivity; Alcon data on file, 2015. 4. In vitro wetting analysis: out-of-pack and wetting substantivity; Alcon data on file, 2014.

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