Optometric Office July 2017 by First Vision Media Group

OPTOMETRIC OFFICE PRODUCTS AND TECHNOLOGY FOR YOUR PRACTICE

JULY 2017

HOW TO RELIEVE CONTACT LENS DRYNESS ACCESS PATIENT DATA FROM THE CLOUD NEW SOLUTIONS FOR EYE HYGIENE

PEDIATRIC EYECARE

EXAMINING CHILDREN AND ADDRESSING THE GROWING MYOPIA EPIDEMIC SUPPLEMENT TO VCPN JULY 2017

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TABLE OF CONTENTS 10

12 | One-to-One: Holly Swain, OD, iCare USA 32 | The Optometric Technician 34 | New Product Gallery

36 | Docs Speak Out

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30 | Reducing Digital Eyestrain

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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 Jeffrey Eisenberg | JE@VisionCareProducts.com Assistant Editor Cara Aidone Huzinec | CH@VisionCareProducts.com Assistant Editor Alex Evans AE@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 Christine Allison, OD, FAAO, COVD • Kenneth Daniels, OD, FAAO Mary Lou French, OD, MEd, FAAO • Steven Lutz, OD • Robert A. Ryan, OD Charles Shidlofsky, OD, FCOVD • 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

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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, 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.

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All-new!

VIEWS

Richard Clompus SUNGLASSES & KIDS

A trip to Disneyland in California last month revealed something quite commonplace: Many adults wore sunglasses, but very few kids did so. I’ve heard many excuses from parents who have tried to get their children to wear sunglasses. I experienced the same issues with my own kids. Their children, they complain, usually refuse to wear sunglasses because they are uncomfortable, fit poorly and aren’t cool. Parents often purchase plano sunwear for their children while traveling on vacation or at drug stores. Cost doesn’t seem to be near the top of the list for many parents who willingly make sacrifices to protect their children’s well being. Rather, they aren’t aware of the importance of starting early in childhood to protect the eyes and skin from UV exposure, the effects of which accumulate over a lifetime.

Perhaps it’s time for each practice to offer comfortable, safe and quality plano sunwear for children.

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The Vision Council made June 27 a commemorative date to celebrate National Sunglasses Day. In 2016, National Sunglasses Day resulted in more than 500 million media impressions, becoming an official trending topic on social media. That viral success increased to more than 644 million broadcast, online and social media impressions in 2017. The council’s message stresses the importance of wearing sunwear to protect the eyes from the sun’s harsh UV rays. This is a good start. Industry statistics show that optometric practices account for a minority of plano sunwear sales in the U.S. Perhaps it’s time for each practice to offer comfortable, safe and quality plano sunwear for children. Out of 500 frames in an optical dispensary, it shouldn’t be that difficult to include 10 to 15 pairs of sunglasses for children. After all, if they don’t get this message from their eyecare provider, who will they learn it from? Richard Clompus, OD, FAAO | Professional Editor | RC@OptometricOffice.com

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All-new!

VIEWS

Jeffrey Eisenberg

TRADING IN THE ROSE-COLORED GLASSES?

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Maybe I’ve traded in my rose-colored glasses for much darker ones, because I find myself feeling quite disheartened. I’m disheartened that there’s even a debate about whether healthcare is a basic right of every individual or a privilege reserved only for those who can afford to buy coverage if not offered by their employers. And, I’m disheartened that the coverage of more than 20 million individuals is at risk. I’m also disheartened any time I hear more emphasis on making sure consumers can shop around for contact lenses and not enough emphasis on making sure they only get lenses with a valid—and current—prescription and receive appropriate follow-up care. I consider this a matter of public health. But, even through the dark lenses, the view is becoming rosier, especially when I think about more than 2,300 students and recent graduates—the future of optometry—making their voices heard at a rally on Capitol Hill during Optometry’s Meeting in Washington, DC, last month. I also take heart when I think of students and member doctors who attended more than 250 meetings and events with Senators, House members and staff to urge them to support legislation that would protect optometrists from anticompetitive practices and discrimination from health insurers, and to urge the Federal Trade Commission to impose new paperwork burdens on ODs, all in the name of proving that they allow their patients to shop for contact lenses where they wish. As you can read about in “Buzz” (page 10) the AOA has launched its Health Policy Institute, a public policy think tank, while Johnson & Johnson Vision has launched its Advocacy Academy virtual learning tool. As I hear of more ODs—individually and collectively—making their voices heard to protect their patients and practices, those glasses will continue to grow brighter. Jeffrey Eisenberg | Editor-In-Chief | JE@VisionCareProducts.com

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Every child should have an eye exam Photo courtesy Ver Bien para Aprender Mejor

GLANCE KEEPING YOU INFORMED AND UP TO DATE. ONE OF THE MOST PRODUCTIVE FIVE MINUTES OF YOUR DAY. READY?

Jackie Garlich

For parents who ask if their child is more likely than an adult to get an infiltrate from contact lens wear ... The short answer: No. A review published in Optometry and Vision Science examined data from a wide range of studies on contact lens wear in the pediatric population. They found “the overall picture is that the incidence of corneal infiltrative events in children is no higher than in adults.” For your AMD patients who have trouble swallowing pills … Alcon introduced a chewable supplement: SYSTANE ICAPS Chewable AREDS2 Eye Vitamin.

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Let’s make sure that every child can see the future clearly! Visit givingsight.org or call 888-OGS-GIVE to access office materials and social media tools to share with your patients

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For your dry eye patients ... Allergan received approval from the U.S. Food and Drug Administration to market TrueTear, its new dry eye treatment device. Thehandheld intranasal neurostimulator provides a temporary increase in tear production that can last up to four hours. For your allergy patients … A generic version of Alcon Laboratories’ Pataday (olopatadine hydrocholride) is now available from Teva Pharmaceutical Industries Ltd. Also, the FDA has approved a new drug application for Zerviate from Nicox S.A. The second-generation antihistamine (H1 receptor antagonist) contains cetirizine, the active ingredient in Zyrtec. Dosing is twice daily. For your patient who asks you about online eye exams … Warby Parker launched its online refraction app, Prescription Check. After a 20-minute eye test for eligible patients, a doctor reviews the Rx and responds within 24 hours with either an OK to renew or a referral recommendation for a full eye exam. However, the state of Connecticut isn’t having it. A bill (HB 6012) that limits the use of online eye tests just passed in the Senate. Great work! Now that you’ve read this, you even have a few minutes to play with the new Snapchat filters. Jackie Garlich, OD, FAAO | 20/20 Glance | 2020glance.com

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THINK ABOUT YOUR EYES

Success in the Classroom Starts with the Eyes Even though it’s summer, parents are already making back-to-school checklists of things to buy and appointments to make. Unfortunately, they may ignore an important appointment that can be the key to success for their children: an annual eye exam. The American Optometric Association estimates that one in four elementary school-aged children has vision problems that can impact every aspect of the classroom—from learning to behavioral problems.

BEYOND 20/20 When most people think about vision, they think only about visual acuity. But many children have vision problems other than not being able to see 20/20. These include vision processing, vision perception, oculomotor skills and visual spatial skills. In addition, the vision system rarely acts alone; it integrates with the vestibular, auditory, tactile and kinesthetic system to interpret what we look at. Knowing the symptoms of poor vision and how they manifest in the classroom is important. They include: poor motor control (hand/eye coordination, inconsistent handwriting, clumsiness), visualization difficulties (poor memorization, daydreaming), and organizational challenges (difficulty interpreting body language, reading words one-by-one). Educators often mistake these for behavioral and performance issues. They may discipline children or give them remedial work instead of identifying the root cause of the issue. TWO THERAPIES Children often visit my office with 20/20 distance vision but have significant problems in these other areas, making learning particularly difficult. We can help these children with two types of therapies: passive or active. Passive therapies include lenses, prisms, tints or occlusions. Active therapies include vision therapy or vision rehabilitation. The goal of vision therapy is to help patients develop or improve fundamental visual skills and abilities. It also helps improve visual comfort, ease and efficiency, and changes how the patient processes or interprets visual information.

Charles Shidlofsky Charles Shidlofsky, OD, FCOVD, is vice president of the Inter-

national Sports Vision Association, a member of the Texas Optometric Association and among the 18,000 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 supports Think About Your Eyes as a media partner.

FAR REACHING The far-reaching effects of vision issues may be associated with other common disorders: ADD/ADHD, sensory processing disorders, pervasive developmental disorders, autism spectrum disorders, developmental delays, strabismus and/or amblyopia, and dyslexia. The first step treating these should be a comprehensive eye exam. Think About Your Eyes recognizes the importance of children getting an annual eye exam, especially before starting a new school year. Each year at this time, the campaign encourages parents to schedule an eye exam for the whole family. Make sure you and your employees discuss children’s eye exams and the impact of vision on learning with parents when they have their own evaluations. Children should be given every advantage in the classroom, starting with their vision. OO

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

ABB OPTICAL GROUP ANNOUNCES FOURTH ANNUAL ABB CARES PROGRAM ABB OPTICAL GROUP will begin accepting applications for its fourth annual ABB Cares Program on Monday, Aug 1, 2017. Grants totaling $38,000 will be given to 24 different organizations, one grant of $5,000, two grants of $2,500 and four grants of $1,000 to non-profits nominated by eyecare professionals for improving the quality of life in their respective communities. Organizations aren’t required to specialize in eye health in order to qualify. ABBOptical.com/ABBCares

ZERVIATE RECEIVES FDA APPROVAL The FDA has approved Nicox’s New Drug Application (NDA) for ZERVIATE, a topical ocular formulation of cetirizine that is used to treat the itching associated with allergic conjunctivitis. During clinical trials, the drug showed statistically and clinically significantly less ocular itching compared to the placebo at 15 minutes and eight hours post-treatment. Partnering discussions are already underway for commercialization rights in the U.S. Nicox.com

VITA RISK TEST RECEIVES U.S. MEDICARE APPROVAL Vita Risk, a pharmacogenetic test launched by ArcticDx in 2013, has been approved for reimbursement by the U.S. Centers for Medicare and Medicaid Services Palmetto Molecular Diagnostic Services Program. Based on an individual’s personal genetics, Vita Risk determines which eye vitamin formulation that person should take to maximize benefit and avoid progression to blindness. VitaRisk.com

BAUSCH + LOMB UNVEILS AMD VR During the annual meeting of the American

Optometric Association, held June 21-25 in Washington, DC, Bausch + Lomb announced the launch of its Age-Related Macular Degeneration (AMD) Virtual Experience. To help optometrists better understand the struggles their patients go through, the AMD Virtual Experience allows eyecare professionals to experience the challenges AMD brings to the estimated 13 million people affected by its mild to more advanced stages. Bausch.com

JOHNSON & JOHNSON VISION CHAMPIONS EYE HEALTH THROUGH ADVOCACY The latest addition to Johnson & Johnson Vision’s Vision to Action advocacy efforts, Advocacy Academy is an on-demand virtual learning tool that uses self-paced modules to educate, empower and mobilize a new community of eye health advocates to engage with lawmakers, agencies and patient associations on key eye health issues. The program is designed with generational learning styles in mind, and the modules provide guidance to eye health professionals who are interested in sharing their expertise and insights with lawmakers, agencies and associations to effectively advocate for policies that put patients first. JNJVisionCareInfo.com

AOA LAUNCHES HEALTH POLICY INSTITUTE TO ADVANCE PROFESSION The American Optometric Association (AOA) unveiled the AOA Health Policy Institute (HPI), a think tank that will develop evidence-based research, analysis and solutions in healthcare policy. HPI plans to use experts from inside and outside the profession to analyze information and evidence, and it will use that material to guide

policy development. Under the direction of AOA past president Steven A. Loomis, OD, and AOA staff member, Rodney Peele, JD, HPI will look to carry on work started by the National Commission on Vision and Health, a national non-partisan group of public health leaders that works to include access to vision care as part of public health programs. AOA.org/PolicyInstitute

News

For private practice ODs looking to remodel or build a new facility, the first annual National Eyecare Facilities Conference from business consultancy Cleinman Performance Partners will take place October 13-15 at the Crowne Plaza Chicago O’Hare. (BMoore@Cleinman.com) SynergEyes has named Louise Sclafani, OD, VP of professional affairs. Jonathan Talamo, MD, joined Johnson & Johnson Vision as chief medical officer and worldwide vice president of medical affairs and clinical affairs. CLX System is fully integrated to OOGP.

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A FLEXIBLE LENS-WEARING EXPERIENCE TO HELP PATIENTS SEE, LOOK, AND FEEL THEIR BEST…

DAY OR NIGHT Scot Morris, OD, FAAO Optometrist Eye Consultants of Colorado Conifer, Colorado

In my 20 years of practicing optometry, I have come across various types of patients with a multitude of visual and lifestyle needs - busy professionals, frequent travelers, new mothers, doctors and nurses with unpredictable work schedules, and even those who live in low-humidity environments like right here in Conifer, Colorado (elev. 8,200 feet). It is only by listening to our patients and understanding their needs that we can recommend the contact lens option that will give them the best contact lens experience.

These patients share one common need—a flexible lens-wearing experience which will allow them to wake up with comfortable, clear, immediate vision to perform their best. The one contact lens that immediately springs to my mind for these patients is AIR OPTIX NIGHT & DAY AQUA contact lenses from Alcon. ®

In addition to the proprietary SmartShield Surface Technology, which is featured in the entire AIR OPTIX family, I like that AIR OPTIX NIGHT & DAY AQUA contact lenses are made of a material (lotrafilcon A) which has the highest oxygen transmissibility in the market, * and an established safety profile. ®

Unpredictable Work Schedules Need immediate vision waking up for shift

Busy Professionals

Frequent Travelers

Eyes feel strained looking at my mobile devices

Travel too often to hassle with my lenses

Moms with Young Kids Can’t see clearly getting up throughout the night

AIR OPTIX NIGHT & DAY AQUA contact lenses are the first to be introduced with these features and the only contact lenses designed to provide comfort for up to 30 nights of continuous wear. They are the #1 practitioner-recommended contact lens for people who sleep in their lenses, and ideal for people who lead busy lives. I also prescribe these to my patients who not only sleep in their lenses but also face lens dehydration and discomfort from living in our low-humidity environment, knowing that lenses from the AIR OPTIX family maintain lens surface wettability and provide comfort throughout the wearing period. ®

I am confident in recommending AIR OPTIX NIGHT & DAY AQUA contact lenses for extended periods and encourage you to give them a try. The benefits are quick and easy to communicate, and you can rest assured that they will give your patients the flexible lens-wearing experience they need to see, look, and feel their best. ®

When patients express dissatisfaction with their contact lens-wearing experience, it may stem from their sleeping habits. Around 30% of contact lens-wearing patients admit that they sleep in their lenses, with a whopping 64% of these patients doing so for at least a week at a time in lenses not approved for this use. In addition, many patients may not have been offered contact lenses approved to meet their needs. 1

2,3

Our passion is to help your patients see, look, and feel their best. *Dk/t = 175 @ -3.00D. Other factors may impact eye health. Important information for AIR OPTIX NIGHT & DAY AQUA (lotrafilcon A) contact lenses: Indicated for vision correction for daily wear (worn only while awake) or extended wear (worn while awake and asleep) for up to 30 nights. Relevant Warnings: A corneal ulcer may develop rapidly and cause eye pain, redness or blurry vision as it progresses. If left untreated, a scar, and in rare cases loss of vision, may result. The risk of serious problems is greater for extended wear vs. daily wear and smoking increases this risk. A one-year post-market study found 0.18% (18 out of 10,000) of wearers developed a severe corneal infection, with 0.04% (4 out of 10,000) of wearers experiencing a permanent reduction in vision by two or more rows of letters on an eye chart. Relevant Precautions: Not everyone can wear for 30 nights. Approximately 80% of wearers can wear the lenses for extended wear. About two-thirds of wearers achieve the full 30 nights continuous wear. Side Effects: In clinical trials, approximately 3-5% of wearers experience at least one episode of infiltrative keratitis, a localized inflammation of the cornea which may be accompanied by mild to severe pain and may require the use of antibiotic eye drops for up to one week. Other less serious side effects were conjunctivitis, lid irritation or lens discomfort including dryness, mild burning or stinging. Contraindications: Contact lenses should not be worn if you have: eye infection or inflammation (redness and/ or swelling); eye disease, injury or dryness that interferes with contact lens wear; systemic disease that may be affected by or impact lens wear; certain allergic conditions or using certain medications (ex. some eye medications). Additional Information: Lenses should be replaced every month. If removed before then, lenses should be cleaned and disinfected before wearing again. Always follow the eye care professional’s recommended lens wear, care and replacement schedule. Consult package insert for complete information, available without charge by calling (800) 241-5999 or go to myalcon.com. ®

References 1. In a survey of 2,115 daily and extended wear contact lens patients. Alcon data on file, 2012. 2. In a survey of 284 daily and extended wear contact lens patients. Alcon data on file, 2012. 3. Alcon data on file, 2012. 4. Eiden SB, et al. Prospective study of lotrafilcon B lenses comparing 2 versus 4 weeks of wear for objective and subjective measures of health, comfort, and vision. Eye & Contact Lens. 2013; 39:290-294. 5. Based on published manufacturer-provided Dk and thickness values in: Tyler’s Quarterly Soft Contact Lens Parameter Guide, June 2016. 6. Schein O, McNally J, Katz J, Chalmers R, et al. The incidence of microbial keratitis among wearers of a 30-day silicone hydrogel extended-wear contact lens. Ophthalmology. 2005;112:2172-2179. 7. In a survey of 301 optometrists in the US; Alcon data on file, 2016. See product instructions for complete wear, care, and safety information.

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RC: How has the Icare ic100 handheld tonometer changed how ODs measure IOP? HS: We live in a fast-paced world and are always looking for ways to be more efficient. With the Icare ic100 tonometer, no anesthetic drops or specialized skills are needed to run the device. It is quick, easy to use, accurate and repeatable. Goldmann tonometry remains the gold standard in IOP measurement. Nevertheless, there are some patients whose IOP we cannot measure using this method. RC: The Icare HOME self tonometer received clearance from the U.S. Food and Drug Administration on March 21, 2017. Can you describe its use and benefits for treating glaucoma?

ONE-TO-ONE

Holly Swain

Holly Swain, OD, received her doctor of optometry degree from Illinois College of Optometry and a BS in applied biol-

ogy from Ferris State University. She previously worked for a cataract specialist before switching to capital equipment sales. She joined Icare USA, Inc., in 2015 as product manager and soon after earned a marketing strategy certificate from Cornell University.

Richard Clompus, OD, FAAO: Following graduation, did you know you wanted to work in the ophthalmic device industry? Holly Swain, OD: Ever since my first encounter in this industry, I knew I wanted to be involved in optometry. My first encounter was with the family optometrist. When I was in second grade, I failed the school vision screening. I was amazed how the doctor put this machine in front of my face, moved some dials and I could see clearly for the first time. I wanted to know how he could make my world crisp and clear by moving these dials. Today, I am excited to work for a company that is invested in helping doctors and patients—not just locally but globally—learn more about their intraocular pressure.

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HS: The HOME tonometer is designed for patients to measure their own pressures outside the doctor’s office. We know IOP fluctuates throughout the day, but we don’t know how much, how often or when. The HOME tonometer could help identify these IOP variations and/or spikes and give us more information regarding that patient’s pressures. Several uses come to mind: in patients who show glaucoma progression on optical coherence tomography even though their IOP appears to be controlled during clinic visits, before and/or after administering a new drop or laser procedure, as well as in glaucoma suspects. The HOME tonometer will provide a better range of that patient’s IOP throughout the day and help us better understand IOP in some of these situations. Self-tonometry is a valuable adjunct to clinic. However, diagnosis and management decisions will continue to be based on established methods of evaluating IOP, optic nerve and visual fields. RC: How will advances in diagnostic instruments and wireless connectivity impact the delivery of eyecare in the next five years? HS: As more diagnostic instruments go wireless, I suspect there will be a lot more remote testing in the future. I envision patients having a variety of tests done at one location and going home. The doctor will interpret the results and devise a plan from a distance. There are pros and cons to this situation. For patients who don’t have the means to see an eye doctor, this could be an alternate way to have their eyes evaluated. However, the patient is not present when the doctor needs to run another test, has questions about the patient’s history or, more importantly, educate that patient. In my opinion, not having the direct interaction between doctors and patients could minimize the importance of patient education and their conditions. OO

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His sight depends on your confidence. Make a more confident glaucoma risk assessment with Corneal Hysteresis. Only Ocular Response Analyzer® G3 from Reichert Technologies® measures Corneal Hysteresis, which is more associated with visual field progression than CCT or IOP. 1-3 Visit reichert.com/glaucomaconfidence

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References: 1. Medeiros FA, Meira-Freitas D, Lisboa R, Kuang TM, Zangwill LM, Weinreb RN. Corneal hysteresis as a risk factor for glaucoma progression: a prospective longitudinal study. Ophthalmology. 2013 Aug;120(8):1533-40. 2. De Moraes CV, Hill V, Tello C, Liebmann JM, Ritch R. Lower corneal hysteresis is associated with more rapid glaucomatous visual fi eld progression. J Glaucoma. 2012 Apr-May;21(4):209-13. 3. Aashish Anand, MD, Carlos Gustavo De Moraes, MD, Christopher C Teng, MD, Celso Tello, MD, Jeffrey M Liebmann, MD Robert Ritch, MD. Lower Corneal Hysteresis Predicts Laterality in Asymmetric Open Angle Glaucoma, IOVS Papers in Press. Published on June 23, 2010 as Manuscript iovs.10-5580. CPT is registered trademark of the American Medical Association.

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Predicting Glaucoma Progression with Greater Certainty CORNEAL HYSTERESIS AND ITS ROLE IN GLAUCOMA RISK ASSESSMENT Glaucoma is the second leading cause of irreversible blindness in the world. Although there is no cure for glaucoma, you can slow its progress through treatment. However, predicting the progression of glaucoma can be challenging because there are many risk factors, as identified by the Ocular Hypertension Treatment Study (OHTS). Among them: age, race, cupto-disc ratio, visual field pattern standard deviation, intraocular pressure (IOP), central corneal thickness (CCT) and family history. 1

PREDICTING GLAUCOMA RISK Glaucoma is a progressive disease, and the rate of progression varies. For example, two glaucoma patients might have very similar risk factors, such as IOP, CCT, and age. The disease may progress rapidly in one patient and slowly in the other. This is a major concern for patients and eyecare practitioners alike. The ability to

A single touch of a button initiates a fully automated alignment and measurement. The screen simultaneously displays IOPcc, corneal hysteresis, Goldmann-correlated IOP, and waveform score. The waveform score indicates the reliability of each measurement, with a numerical scale of 0-10. If you already have a non-contact tonometer, you can simply replace that device. If you

“By collecting measurements of corneal hysteresis, clinicians will be able to determine which patients are at higher risk for glaucoma progression.” –Felipe A. Medeiros, MD, PhD, San Diego, CA

WHAT IS CORNEAL HYSTERESIS? More recently, corneal hysteresis has become of great interest in glaucoma risk assessment. Corneal hysteresis is the cornea’s ability to absorb and dissipate energy. The Ocular Response Analyzer G3 from Reichert, measures corneal hysteresis by calculating the difference between the inward and outward pressure values obtained during the patented dynamic bidirectional applanation process. It is representative of biomechanical properties of the cornea, differing from thickness or topography, which are geometrical attributes. Research has found that eyes with lower corneal hysteresis measurements have faster rates of visual field loss than those with higher measurements—even with low IOP. 2, 3

predict future glaucoma progression is essential for diagnosing the disease and establishing an appropriate treatment strategy.

WHAT IS IOPcc? Beyond corneal hysteresis, the Ocular Response Analyzer G3 simultaneously measures IOP. In fact, the instrument’s patented corneal-compensated intraocular pressure (IOPcc) has been shown to be a better indicator of true IOP because it is less influenced by corneal properties. 4

UTILIZING ORA TECHNOLOGY Using the Ocular Response Analyzer G3 in your practice is easy. Its design has no chin rest, so you can quickly position the patient. Plus, Reichert’s patented air pulse ensures maximum patient comfort.

are considering adding the Ocular Response Analyzer G3 to your practice, you can simply put it next to your autorefractor, as it is similar in size and speed and is typically performed before the patient enters the exam lane.

CORNEAL HYSTERESIS AND CPT CPT code 92145 became available in 2015 for the corneal hysteresis measurement provided by the Ocular Response Analyzer. Medicare reimburses at approximately $15.00 bilateral in patients who qualify for the test. Reimbursement may not be available in all states, as Medicare payers operate independent from one another. Private payers set their own rates and payment policies, which may differ significantly from the Medicare published fee schedule.

LEARN MORE ABOUT CORNEAL HYSTERESIS AND OCULAR RESPONSE ANALYZER G3 AT WWW.REICHERT.COM/ORA. 1. Gordon MO, Beiser JA, Brandt JD, et al. The Ocular Hypertension Treatment Study: baseline factors that predict the onset of primary open-angle glaucoma. Arch Ophthalmol 2002 Jun;120(6):714-20; discussion 829-30. 2. Medeiros FA, Meira-Freitas D, Lisboa R, et al. Corneal hysteresis as a risk factor for glaucoma progression: a prospective longitudinal study. Ophthalmology. 2013 Aug;120(8):1533-40. 3. De Moraes CV, Hill V, Tello C, et al. Lower corneal hysteresis is associated with more rapid glaucomatous visual field progression. J Glaucoma. 2012 Apr-May;21(4):209-13. 4. Medeiros FA, Weinreb RN. Evaluation of the influence of corneal biomechanical properties on intraocular pressure measurements using the ocular response analyzer. J Glaucoma. 2006 Oct;15(5):364-70.

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PATIENT CARE

Examining Children: Challenges and Rewards Mary Lou French, OD, MEd, FAAO Here’s a look at the equipment you’ll need when you see pediatric patients. I’ll never forget the young boy who made my staff cry—for a good reason, that is. The patient was about 4 years old at the time, and his exam revealed significant hyperopia. He was shy and quiet and had difficulty interacting with others, which I suspect was related to his vision problems. He would not look people in the eye and always looked down. When he put on his first pair of glasses, he looked at his mother and told her how beautiful she was. My entire staff was in tears with that comment—along with the mom. Experiences such as this are among the reasons I love examining children. Of course, examining children also can be challenging when you consider such issues as evaluating visual acuity, especially very young children, and dealing with their increased activity levels, decreased attention span and smaller physical size. Setting up your practice for children begins in the reception space. There should be a small, dedicated area for children, with small chairs and tables, toys and some form of video entertainment. After that, you’ll need to determine what equipment you’ll need. Then you can address the challenges and rewards of examining children in these four age groups: infants (ages 6 to 12 months), toddlers (ages 1 to 4 years), preschool to

primary school (ages 5 to 8), and elementary and high school (ages 9 to teens).

A handheld tonometer, such as the ic100 from iCare USA, can be helpful when examining children.

INFANTS You don’t need much extra equipment or modifications to an exam room. You’ll already have the basic diagnostic equipment: retinoscope, trial lenses, transilluminator or penlight, and a binocular indirect or direct ophthalmoscope. You’ll also need one or two small toys to get the infant’s attention, or you can use a toy that the parents bring. One additional note: Don’t forget to register as an InfantSEE provider. InfantSEE, the public health program managed by Optometry’s Charity—The AOA Foundation, provides a one-time, comprehensive eye assessment to infants at no cost to families. The challenges: You have to be quick. Because this is essentially a screening examination, retinoscopy is critical for detecting significant amounts of anisometropia, hyperopia, astigmatism and myopia. Central steady, and fix and follow findings in each eye will be adequate for measuring visual acuity. Pay close attention to determine unequal responses between the eyes. Dilating drops will sting upon instillation, and 20 to 30 minutes are needed for

the patient to dilate. Then, you must be quick (and occasionally a little forceful) so that the infant will keep his or her eyes open long enough to get an adequate view of the fundus. The rewards: The biggest reward is being able to tell most parents that their child is fine and that you recommend another examination when he or she is 3 years old. Should you find a significant visual issue, the reward is that you found it at a young age, when it is potentially treatable.

TODDLERS Toddlers are the most challenging age group of all. Besides your standard equipment, you’ll need toys, age-appropriate eye charts such as HOTV, which are available from several distributors, and videos. Some older toddlers can do well with an autorefractor as well as iCare USA’s ic100 tonometer when in the hands of an experienced technician. Handheld slit lamps are useful. Or, you could go with a less expensive option, such as the old standby, namely the Burton slit lamp.

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The challenges: Once again, “quick” is the operative word. Infants do not move; toddlers do. Some need to sit on a parent’s lap, while others can sit on their own. In my office, an EPIC-5100 refraction workstation from Marco has proven useful with any child physically mature enough to sit in the patient chair. I have found that many 3-year-olds can be examined at this workstation. The ease of raising and lowering the table and phoropter to adjust for the height of the patient minimizes the risk of the child falling from a chair that is raised too high. The rewards: As with infants, the reward here is being able to reassure parents that their child is fine and should return at age 5. If you find a significant visual issue, the reward is doing so while it can be treated and managed.

PRESCHOOL THROUGH PRIMARY SCHOOL For the preschool through primary school age group, your standard acuity charts should be sufficient. Toys and videos are great, too. You can use your autorefractor on most children this age. If you suspect that the refraction is questionable, you can perform a repeat autorefraction after dilation to double check your findings. The challenges: There are fewer technical challenges with older children. However, there can be more diagnostic issues involving children wanting glasses, not wanting glasses and/or problems in school. Depending on your inclination, you can conduct more binocular vision and visual efficiency testing. If you look for these issues but are not sufficiently prepared to treat them, try to develop a good working relationship with a colleague who does.

The rewards: Detecting problems when a child is young can spare them so many problems related to vision disorders later, giving them the confidence to go forth and succeed.

ELEMENTARY AND HIGH SCHOOL For the older child and teen, nothing extra in the way of equipment is needed. I would recommend tolerance and patience. These patients can be lots of fun once you to get to know them. The challenges: Sometimes the challenge here is the parent, not the child. Try to remember that the child is your patient, not the parent. This is the age at which patients become interested in contact lenses. The challenge here is determining who is a good candidate for contact lenses. The rewards: These patients can be fun and lively. And, this age group is the most rewarding when being fit with contact lenses.

ment needed to examine children. If you wish to examine children without specializing in pediatrics, you’ll need only a few extra tools, such as appropriate visual acuity targets, some small toys and videos to keep their attention, a handheld tonometer, a Burton lamp or portable slit lamp, and a lot of patience. If you see any handicapped patients, some of the handheld and/or portable instruments will work well also. If you keep these items together in a drawer or cabinet then they will be available as needed. OO Mary Lou French, OD, MEd, FAAO, is in private practice and is the owner of Children’s Eyecare, P.C. in Orland Park, IL. WHERE TO FIND IT: Icare USA 888.422.7313 | Icare-USA.com

FEW MODIFICATIONS

InfantSEE 888.396.3937 | InfantSEE.org InfantSEE@AOA.org

For most eyecare practitioners, there are surprisingly few modifications in equip-

Marco 800.874.5274 | Marco.com

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INSTRUMENTATION

A Hand in Examining Children By Christine Allison, OD, FAAO, COVD Examining children, particularly young children, demands a different approach to collecting data than you would take with an adult. You need to do as much objective testing as possible when it comes to children.

VISUAL ACUITY Although we typically test visual acuity using the Snellen chart, if a child is too young to know letters, it’s time to try something different. For a child ages 3 and up, you may have better luck using charts with LEA symbols from Good-Lite Company. LEA symbols, the standard of care for this age group, are available in several formats. These include distance LEA charts that you can hang on the wall or have an assistant hold. There are pocket near cards and near charts that are larger and have a working distance measuring cord attached. The LEA sets come with matching cards that children can point to so that they do not have to verbalize anything if they choose not to. Another useful test is the Broken Wheel Test from Bernell. On this forced choice test, Landolt “C”s represent the tires of a car. You hold the cards at 10 feet from the patient, who must choose which car has the “broken wheel.” Because there are only two choices, the child can choose rapidly, and you can quickly go to cards that represent lower acuity values. This test can be useful even for children as young as age 2.

For younger children, you may use the more portable version of the research standard of Teller Acuity cards, with options such as Patti Stripes Square Wave Grating Paddles from Precision Vision or LEA Grating Paddles. The premise of these tests is that children will choose to look at a striped pattern if they can see it rather than a gray background. Most options for testing stereo acuity in children are portable. These include the Stereo Acuity Fly or Stereo Acuity Butterfly, Stereo Smile Cards or Stereo Optical’s Randot Preschool Stereotest. For children who do not want to put the stereo glasses on, the Lang-Stereotest is a favorite.

RETINOSCOPY No test is more important for a pediatric exam than retinoscopy. Loose trial lenses can be used, or Sciascopy Bars Lens Racks are a great way to unobtrusively perform retinoscopy quickly and accurately. I would stay away from handheld autorefractors for this age group, but if you are considering using one, the Retinomax handheld autorefractor seems to work well at least for collecting the correct axis for astigmatism.

OCULAR HEALTH There are two good options for checking

intraocular pressure in children. You may use the Tonopen, which requires the use of anesthetic, or the ICare Tonometer, which does not. For assessing the anterior segment, you probably want to use a handheld slit lamp. You also can get great magnification and a cobalt filter with the much less expensive option of using a Burton Woods Lamp. Traditional binocular indirect ophthalmoscopy with a 20.00D lens is always portable, but if you need magnification, your portable ophthalmoscope will give you all you need. OO Christine Allison, OD, FAAO, FCOVD, Diplomate American Academy of Optometry, FNAP, is a professor and coordinator of the Pediatric Residency Program at Illinois College of Optometry. WHERE TO FIND IT: Bernell 800.348.2225 | Bernell.com Good-Lite Company 800.362.3860 | Good-Lite.com ICare USA 888.422.7313 | Icare-USA.com Precision Vision 815.975.3999 | Precision-Vision.com Stereo Optical 800.344.9500 | StereoOptical.com

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CONTACT LENSES

Bringing Myopia Control Into Sight By Kenneth Daniels, OD, FAAO As myopia among children is being described as ‘epidemic,’ a variety of techniques for treating them are coming to the forefront. A 6-year-old Asian female who presented for an exam already had –1.00D of myopia, and both her parents were significantly myopic. As studies have shown, early manifestations of myopic refractive error and the number of myopic parents are significant predictors of the child’s risk of myopia progression. Her young age and the onset of myopic shift related to refractive error and axial length before the onset of juvenile myopia. The clinical question we have with this patient: What options do we have for slowing this patient’s myopic progression? We could obviously prescribe glasses to correct the presenting ametropia and re-evaluate in six months, or flat-top bifocals or progressive addition lenses could be used to relax accommodative stress. However, these options will not have a lasting effect on myopic progression, delaying it by only 0.25D to 0.50D. We could also consider using atropine in conjunction with corrective spectacle lenses. Studies suggest that might be appropriate, particularly if the child is not ready to be fit with contact lenses. There are also behavioral modifications, such as an extra 40 minutes of time outdoors, which research shows can reduce the progression of myopia, and fol-

CooperVision’s Biofinity Multifocal can slow myopia progression without compromising visual function.

lowing the 20-20-20 rule (a 20-second break to view something 20 feet away every 20 minutes) to reduce eyestrain from increased use of digital devices. The other option: using contact lenses to halt the progression of myopia.

IMAGE SHELL The simple essence of myopia control is to focus all incoming images into the fovea centralis and bring parafoveal defocused images (the image shell) into focus to prevent accommodative stress. The goal of a proper contact lens design is to control the stress of accommodation in which the eye tries to refocus the image shell. The result of this stress is increased axial length of the eye, which causes myopia to progress. Standard gas permeable contact lenses cannot control this stress successfully, because the basic lens design only provides refractive correction. To control accommodative stress, a gas permeable design requires central corneal epithelial compression, with the spread of the tissue to

the periphery. This allows the paracentral region to refocus the image shell onto the peripheral parafoveal retina.

ORTHO-K Standard gas permeable designs do not provide significant control of axial length and myopic progression. Myopia control with orthokeratology, however, is highly achievable. Orthokeratology dates back more than 70 years. Eyecare practitioners used a progression of polymethyl methacrylate (PMMA) lenses in a sequentially flatter base curve to compress the central cornea. As we approached the mid-1990s, manufacturers began using more advanced lathe and computer designs, which enabled them to take the original reverse peripheral curve lenses developed in the 1980s and advanced the study of orthokeratology. This led us to the “modernday” reverse geometry accelerated corneal reshaping with overnight ortho-k lenses. There are a variety of orthokeratology lenses for controlling myopia. Each has a

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unique design but follows similar concepts of method. Ortho-k can reduce the amount of myopic refractive error and affect the progression of myopia as a child ages.

SOFT CONTACT LENS But, can a child at a younger age, such as my 6-year-old patient, perform the task of contact lens insertion, removal and care? This patient and even an older child may initially do better with a soft contact lens. However, there is a problem. Standard soft lenses only prolong the issue of myopia progression rather than cause a clinically relevant decrease. A distance-center multifocal soft contact lens may be the best place to start because it can result in 50% reduction in the progression of myopia and a 29% reduction in axial elongation, suggesting the potential for soft multifocal contact lens myopia control. Two designs from CooperVision, the Proclear and Biofinity Multifocal, allow for a distance zone of 75% of the child’s average pupil. The peripheral region of the lenses, which progress to intermediate and near plus power, refocus the image shell for the paravisual axis rays. This allows for sustained myopic defocus (refocusing of the image shell) and can

slow myopia progression without compromising visual function—even when presented to the retina simultaneously with a clear image. When fitting this design, I tend to use a multifocal add power of no less than +1.50D to +2.00D (“D” design), with the appropriate distance power centrally. CooperVision also has entered the arena of myopic control with the MiSight daily disposable myopia control contact lens, which has alternating visual correction and treatment zones. A study comparing this lens to a single-vision daily disposable contact lens in 144 myopic children demonstrated that the dual-focus lens effectively slowed myopic progression by 59%, as measured by cycloplegic refraction, and 52%, as measured by mean axial elongation of the eye. Another new entry to the market is the NaturalVue Multifocal 1 Day Contact Lenses with Neurofocus Optics from Visioneering Technologies, Inc. The lens is designed to provide spectacle-level stereo acuity and vision at near, intermediate and at a distance. A study from University of Waterloo found the lens designs of –10.00D led to nearly complete inhibition of defocus-induced myopia in chickens compared to control lenses (also –10.00D).

NaturalVue Multifocal 1 Day is designed to provide spectacle-level stereo acuity and vision at near, intermediate and at a distance.

The lack of significant axial length increase seen with the NaturalVue test groups indicates that these lens designs reduced the progression of defocusedinduced myopia by inhibiting axial elongation. The optical design suggests a reduction in accommodative lag, another risk factor for myopia progression, while having minimal effect on visual acuity, PREP score quality of life and MNREAD scores in children of the age that myopia progresses quickly. They found in additional studies that the corrected peripheral hyperopia so that each meridian was focused within the retina, an improved amplitude test accommodation by 1.00D improved lag of accommodation by 0.50D. Visual quality was rated as the same or better visual quality as compared with a single vision soft lens.

COMPLEX DECISION Myopia control is a complex management decision based on many factors. The primary factors are the awareness and concern of the parents, while other concerns are the capabilities and understanding of the child. Each approach must be planned from a long term perspective using a building block approach. OO Kenneth Daniels, OD, FAAO, is an adjunct assistant clinical professor and National Eye Institute clinical investigator at the Pennsylvania College of Optometry, and he is in private practice in Hopewell and Lambertville, NJ. WHERE TO FIND IT: CooperVision, Inc. 800.341.2020 | CooperVision.com

A longer version of this article with sources fully referenced can be found online at OptometricOffice.com.

Visioneering Technologies, Inc. 844.884.5367 | VTIVision.com

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PATIENT CARE

One for the Record Jennifer L. Stewart, OD Electronic health records have made inputting and accessing patient data much easier. Eyecare practitioners today gather more data than we have in years past. Advances in glaucoma testing, retinal photography, visual field testing, tear chemistry and corneal health have allowed us to diagnose diseases earlier and better manage ocular disorders. Acquiring this data has gotten easier, but some questions arise: How do you store this information? How can you access it quickly? If youâ&#x20AC;&#x2122;re not in the office, are you still able to see this information? With the advent of electronic medical records (EMRs) and electronic health records (EHRs), inputting and accessing this data has become much easier. One limitation of paper charts has been the inability to access patient information from outside the office. With EHR, and information being stored in the cloud, you can now access patient records, medical history and other information from anywhere. Communication with other healthcare practitioners has also become much more streamlined and efficient. Most EHRs have referral and co-management templates that you can customize and send electronically. Many of the top EHRs in optometry also include e-prescription software, patient management tools, the ability to monitor and track IOP values over time, and integration and storage of images and data from other equipment, such as

Patient documentation is easily accessed through the RevolutionEHR patient dashboard.

digital cameras and visual field analyzers. Integration with other diagnostic equipment is extremely important for streamlining exams and data entry so that you can import and store it directly in the EHR instead of manually entering information.

EYEFINITY EHR Eyefinity EHR is a cloud-based system with adaptive technology that learns which tests and procedures each doctor does for different diagnoses. This makes data entry extremely simple and efficient for the OD or scribe, saving time in the exam room. You can also create exam protocols, which allow you to quickly document common procedures. Eyefinity EHR users can access information from any computer or with the Eyefinity EHR app on an iPad, iPhone, or Apple Watch.

OFFICEMATE/EXAMWRITER ExamWRITER is one of the first EHRs and still one of the most widely used in the optometric industry. Users can automatically generate co-management reports, chart and access IOPs and confirm

proper billing levels. OfficeMate can also integrate with a number of diagnostic equipment interfaces, including Heidelberg Spectralis OCT, Humphrey, Konan Specular Microscopes, Marco, Nidek, Oculus, Optos, Optovue, Reichert, Topcon and Zeiss, with more integrations in development.

REVOLUTIONEHR RevolutionEHR simplifies documentation with flexible data entry, customizable exam templates, document and image management, automated referral letters, patient education tools, access to historical exam data, e-prescribing, and patient engagement and recall.

CRYSTAL PM Crystal Practice Management Softwareâ&#x20AC;&#x2122;s EHR, Crystal PM, features customizable records, auto history (allowing the ECP to see all previous patient data in a given field), and free e-prescribing. Crystal PM also integrates with numerous pieces of equipment, making data acquisition, analysis and storage efficient. Currently, this software integrates with equipment from

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Canon USA, Essilor of America, Eyelogic Systems, Carl Zeiss Meditec, Huvitz Co., Reichert Instruments, Tomey USA, Topcon Medical Systems, as well as others.

MAXIMEYES MaximEyes EHR from First Insight Corp. lets you completely customize and modify exam fields. It also has more than 30 exam templates. Problem-oriented assessment/plans and disease-specific templates can be developed for patients with glaucoma, cataracts, macular degeneration and other retinal and corneal diseases. This saves time and improves flow and information storage. Customized letters and reports are available for co-management, as well as treatment summary forms for patient education. There are touch-screen capabilities for mouse-free data entry with compatible monitor use. MaximEyes integrates with a number of devices from both Zeiss and Canon, including instruments from Humphrey, Cirrus, and different autorefractors and keratometers.

EYECLINIC IMAGING EyeClinic Imaging, also from First Insight, is a cloud-based image-management system that consolidates diagnostic data, images and reports from fundus cameras, visual field analyzers and optical coherence tomographers. It integrates with any EHR system, or it can be used as a standalone system. The information is easily accessible 24/7 from any computer or mobile device.

PATIENT CARE As we continue to capture and integrate more data, the question becomes how do

Multiple images can be viewed simultaneously with cloudbased Eye Clinic Imaging.

we access and manage this information, and how does that translate to patient care. Many efficient offices use scribes, who gather patient information and input that information into the EHR that is being used. The ECP can then review the chart in the room in real time, or access the patient chart at another station before seeing the patient. The scribe becomes extremely efficient at data entry, leaving the ECP more time for patient education and communication. And, by reviewing the chart before entering the exam room, the ECP can begin to formulate a plan. In other offices, the doctor inputs all the information and usually determines and enters the treatment plan while with the patient. This system, similar to paper charts, can be less efficient but involves less staff. In our office, our technician does pretesting and collects all of the pertinent data. He or she takes a basic history on the patient, including the chief complaint, medications, allergies, and any glasses or contact lenses the patient is wearing. The tech also acts as a scribe, entering all data during the exam. By having a scribe in the room, I never look at the EHR or type. Instead, I focus all my attention on the patient. I review the records after the exam, making sure all findings are documented correctly, and then send the charges and codes to my billing team, optical information to my

opticians and any necessary prescriptions to pharmacies. I also take care of any referrals after the exam, using referral and co-management templates. We have found this system to be extremely efficient, and having two scribes has allowed us to improve patient care. Electronic health records can make an ECPâ&#x20AC;&#x2122;s office more efficient by streamlining care and data entry. They also allow ECPs to view patient records remotely, whether it is at another workstation in the office or even at home. 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: Crystal Practice Management Software 800.308.7169 | CrystalPM.com Info@CrystalPM.com Eyefinity/OfficeMate 877.448.0707 | Eyefinity.com CustomerCare@Eyefinity.com First Insight 800.920.1940 | First-Insight.com Sales@First-Insight.com RevolutionEHR 877.738.3471 x1 | www.RevolutionEHR.com Sales@RevolutionEHR.com

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PHARMACEUTICAL

The Solutions for Cleanliness By Gina M. Wesley OD, MS, FAAO New multipurpose solutions aim to make contact lens care more comfortable without sacrificing lens hygiene. In the early 2000s, you may remember, a sudden flurry and panic surrounded the contact lens solution industry. Sightthreatening microbial infections were occurring in relation to specific soft contact lens solutions, particular lenses and the manner in which patients were using (or not using) the solutions as directed. This was a huge moment for many in the profession. We expect the solutions we recommend to deliver effective cleaning, disinfection and overall safety for our patients—no matter how they use that solution. But, when the effectiveness of those solutions and lens compatibility came into question, we realized that we needed to examine those expectations more closely. Proper education of patients, pairing specific contact lenses with cleaning/disinfection systems, and ensuring that the solutions we were prescribing met the standards we desired became even more important. Thankfully, the solution industry responded, leaving those fears of microbial keratitis in the past. Even though my practice primarily dispenses daily disposable contact lenses, I still study the technology available to our patients as far as contact lens solutions. Every multipurpose solution must pass rigorous standards of disinfection

to receive approval from the U.S. Food and Drug Administration. The days of “no rub” solutions are long past. Indeed, if you look at contact lens solutions (under “Medical Devices”) on the FDA’s website, the instructions, in bold, tell patients to “rub and rinse” contact lenses, to not top off solutions in the case and to be sure to replace the lens case at least every three months. Here are some of the solutions available today and how they work.

BIOTRUE Biotrue Multipurpose Solution from Bausch + Lomb is “formulated to work like the eyes,” according to the company. The solution contains hyaluronan, a lubricant found naturally in the body and in the eye to help lenses stay moist and comfortable throughout the day. Bausch + Lomb formulated this solution to match the pH of healthy tears to enhance the performance of the dual disinfectants. Biotrue is designed to keep tear proteins, which have natural antimicrobial actions, active while breaking up denatured proteins that build deposits on lenses. Also, Biotrue only requires a four-hour soak in the lens case to deliver the FDA-required disinfection standards.

CLEAR CARE’s special case contains a platinum disk to activate cleaning bubbles and neutralize the peroxide after six hours.

Bausch + Lomb also recently launched renu Advanced Formula multi-purpose solution for soft contact lenses, including silicone hydrogel lenses. This new formula, which contains three disinfectants and two surfactants replaces the company’s renu sensitive and renu fresh solutions.

OPTI-FREE Alcon Laboratories, a division of Novartis, has several multipurpose solution options on the market under its OPTI-FREE brand. Its newest formulation, OPTIFREE Puremoist Contact Lens Solution, contains a HydraGlide Moisture Matrix. This wetting agent embeds itself on the surface of and within the lenses to create a lubricating “cushion” of moisturre around the lens to reduce lipid deposition and provide lasting lens surface moisture. The solution is preserved with Polyquad

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and Aldox to disinfect soft lenses following the rub and rinse instructions and sixhour soak.

CLEAR CARE Clear Care Cleaning and Disinfecting Solution, also from Alcon, is a 3% hydrogen peroxide, preservative-free, based cleaning and disinfecting solution that is indicated for use with soft and gas permeable contact lenses. The hydrogen peroxide cleans and disinfects lenses with a special case that contains a platinum disk to activate cleaning bubbles and neutralize the peroxide to a gentle saline after six hours of soaking. For sensitive patients, this preservativefree neutralized solution is gentler to the eye creating an overall improved lenswearing experience. Instruct patients to be careful not to use the solution imBlink Revitalens Multi-Purpose Disinfecting Solution uses Alexidine and Polyquad as its preservatives/disinfectants.

properly as 3% hydrogen peroxide solution directly from the bottle or that hasn’t yet been fully neutralized/converted into a gentle saline can irritate the ocular surface and cause temporary but severe burning and stinging. More recently, Alcon introduced CLEAR CARE PLUS, with HydraGlyde Moisture Matrix technology added to the formulation. As mentioned above, this wetting agent surrounds soft lenses in long lasting moisture for extra hydration.

BLINK REVITALENS Blink Revitalens Multi-Purpose Disinfecting Solution from Johnson & Johnson Vision is intended for soft contact lenses, including silicone hydrogel lenses. This solution uses Alexidine and Polyquad as its preservatives/disinfectants. There is no noted wetting agent, however, it conditions and removes proteins, providing more than 16 hours of comfortable wear. In studies, it demonstrated broad-spectrum disinfecting similar to hydrogen peroxide systems and a 100% kill rate of Acanthamoeba.

GENERICS Generic multipurpose solutions are available, but studies have shown that these “store brand” solutions are not equivalent to, or as effective as, branded solution systems. This can be confusing to our patients, especially since the same manufacturers of branded solutions are the ones who supply generic brands. However, generic brands are often older formulations with key differences in preservatives— which, if anything, are what our patients are most likely to be sensitive to. Also, store brands may keep the same name and packaging, but they may also

The new renu Advanced Formula multi-purpose solution contains three disinfectants and two surfactants.

change producers, affecting the chemistry of the solution itself. To remain protected and consistent, prescribing a branded solution is the safest for our patients. Fortunately for us and for our patients, there exist many options for contact lens care in regards to solutions, several of which have been highlighted here. It’s important that we keep ourselves and our patients informed about the what, how and why of the solutions we provide to preserve patient safety. OO Gina M. Wesley OD, MS, FAAO, is in private practice in Medina, MN. WHERE TO FIND IT: Alcon Laboratories 800.451.3937 | Alcon.com Bausch + Lomb 800.828.9030 | Bausch.com Johnson & Johnson Vision 800.843.2020 | JustBlink.com

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PHARMACEUTICAL

Drop the Problem of Contact Lens Dryness Restasis, now in a multidose bottle, is an option for patients with inadequate tear volume.

By Robert A. Ryan, OD By addressing the etiology of the patient’s condition, you’ll increase the likelihood of successful lens wear. When a patient complains of contact-lensrelated dryness, you’ll first want to determine its degree and etiology to determine which of these options to recommend.

LUBRICATION Preservative-free lubricating drops can be used in conjunction with contact lens wear without concern for preservative hypersensitivity or toxicity to the ocular surface. Available brands of preservative-free drops include Alcon’s Systane, Allergan’s Refresh Optive and Oasis from Oasis Medical, Inc., among others. Punctal occlusion also enhances the lens wearing experience by increasing the patient’s natural tear volume via reduced outflow, and increasing the efficacy of lubricating agents by prolonging their residence time on the eye. In cases of inadequate tear volume, patients may also benefit from a prescription agent such as Restasis (cyclosporine) from Allergan or Xiidria (lifitegrast) from Shire.

ADDRESS LID DISEASE If the patient has lid disease or meibomian gland disease, you’ll likely want to select a lipid-based drop such as Systane Balance, Refresh Optive MEGA-3 or Retaine MGD from OCuSOFT. Also instruct the patient to use warm

compresses, such as the Bruder moist heat compress, and practice good lid hygiene. Consider an in-office treatment such as the Lipiflow Tear Activator from TearScience. One agent I’ve found helpful for addressing lid disease and thereby enhancing contact lens wearability and comfort is Avenova with Neutrox from NovaBay. With 0.01% hypochlorous acid, this agent limits the microbial colonies on the lids and lashes. OCuSOFT also offers a lid scrub with 0.02% hypochlorous acid, namely OCuSOFT HypoChlor (hypochlorous acid 0.02%) Gel & Spray.

antihistamines and mast cell stabilizers available. One convenient option is Pazeo (olopatadine), a mast cell stabilizer from Alcon that requires once-daily dosing.

THE WHOLE SITUATION Any time a patient complains of dryness related to contact lens wear, look at the overall situation in the eye rather than assume that the contact lens is to blame. OO Robert A. Ryan, OD, practices in a multispecialty practice at Flaum Eye Institute, University of Rochester Medical Center.

ALLERGY Patients who suffer from ocular allergy often find contact lens wear to be more problematic. Dryness and allergy often are interrelated, as a compromised precorneal tear film renders the patient more susceptible to allergic insult. Topical antihistamines and mast cell stabilizers can help control the allergic response, thereby minimizing the negative impact of a contact lens in that environment. The prudent course is to minimize exposure to allergens; dilute allergens with a daily lavage of saline, and add an overthe-counter option such as Alaway (ketotifen) from Bausch + Lomb. For patients whose condition is recalcitrant to that treatment, there are a plethora of prescription

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PRODUCT DETAILER

OCuSOFT Lid Scrub Eyelid Cleansers

The root cause of anterior blepharitis is the overproduction of oils, and eyelid hygiene is one of the mainstays in the management of blepharitis, meibomian gland dysfunction, demodex infestation and other lid margin related diseases. Mild surfactants in OCuSOFT® Lid Scrub® Eyelid Cleansers act to dissolve and remove oil, debris and desquamated skin. OCuSOFT Lid Scrub Original Formula is a mild surfactant formulation and is intended for continuous daily eyelid hygiene and make-up removal. OCuSOFT Lid Scrub PLUS and OCuSOFT Lid Scrub PLUS PLATINUM Eyelid Cleansers contain surfactants plus a moisturizer and preservative blend that effectively removes seven different strains of bacteria commonly found on the eyelids. Both offer unique leave-on formulas, so there is no need for rinsing. OCuSOFT Lid Scrub PLUS PLATINUM also contains PSG-2™ that mimics the natural lipid layer of the outer epidermis for increased moisturizing throughout the day. PSG-2 has also been reported to have anti-bacterial and anti-inflammatory properties.

Hypochlorous Acid for Severe Eyelid Treatment The role of hypochlorous acid in eyecare is not for continuous everyday eyelid cleansing, but instead it is used as an adjunct to OCuSOFT Lid Scrub cleansers in severe cases only. Only in such severe cases might hypochlorous acid (OCuSOFT® HypoChlor™) be beneficial. In such cases, a Combination Therapy including both a surfactant cleanser and hypochlorous acid is recommended to achieve optimum results. OCuSOFT® HypoChlor™ Gel is ideal in these cases since it can be applied and left on overnight in order to expedite healing. In addition, OCuSOFT HypoChlor is non-irritating to the eye and was tested for use directly in the eye (although all hypochlorous acid products are intended for use on the eyelid rather than in the actual eye itself) and received a “O” perfect non-irritating score. Debridement claims made by hypochlorous acid products are due to their spray projectile packaging rather than strength of the concentration. No hypochlorous acid formulations on the mar-

ket contain any surfactants to remove oil from the eyelids. Most expert ophthalmologists and optometrists agree that the surfactant components of existing eyelid cleansers are necessary to remove excessive oil, debris and desquamated skin from the eyelids. Since OCuSOFT Lid Scrub PLUS contains anti-bacterial properties, in cases of bacterial blepharitis, it will effectively treat most patients.

Hypochlorous Acid OTC vs. Rx Claims Hypochlorous acid can be marketed as either a prescription (Rx) or an over-thecounter (OTC) product, and the Rx vs. OTC argument relies on the claims that can be made of the product as contrasted with ingredient concentration. More specific claims can be made if the product is marketed as an Rx and more general claims for products marketed as OTC. OCuSOFT HypoChlor Solution and Gel are both marketed as OTC and contain 0.02% hypochlorous acid. Other company brands are available at lower strengths than HypoChlor, yet one may be Rx and another may be OTC.

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CLOSE UP

Reducing Digital Eyestrain By Steven Lutz, OD CooperVision’s latest monthly contact lens provides relief for users of digital devices. My eyecare practice is located in Ann Arbor, MI. I drive through the campus of the University of Michigan to get to work each day. The vast majority of students I see are staring at their cell phones as they walk to and from class. Of course, students aren’t the only ones who spend many hours a day viewing digital devices. Many people spend eight or more hours a day viewing these screens, which causes increased accommodative burden and tired eyes. CooperVision’s new Biofinity Energys contact lens provides optics in the center of the lens that allows the wearer to change focus from on screen to off screen and back with less accommodative effort. The Biofinity Energys lens has

very successfully reduced digital eyestrain for patients in my practice. Biofinity Energys is made with the polymer comfilcon A. This material is naturally wettable, has a low modulus, offers a higher DK (128), and is approved

power across the entire zone. This allows the wearer to change focus from the digital screen and back with less accommodative effort. The Biofinity Energys lens fits like a single vision lens. No special power ad-

CooperVision’s new Biofinity Energys contact lens provides optics in the center of the lens that allow the wearer to change focus from on screen to off screen and back with less accommodative effort. for extended wear for up to six nights and seven days. This is the tried-and-true Biofinity material with Aquaform technology that doesn’t require a wetting agent or surface treatment to wet properly. This is critically important considering that digital device users often blink up to 50% less than non-users. This lens does not feel dry and is very deposit resistant. Biofinity Energys lenses have Digital Zone Optics design, which reduces eye fatigue caused by viewing digital screens. Multiple front surface aspheric curves are used in the optical zone. These curves distribute a small amount of positive

justments are needed to provide crisp distance vision for patients. This lens succeeds at doing what it was designed to do! Research by CooperVision shows that eight out of 10 digital device users agreed that Biofinity Energys made their eyes feel less tired at the end of the day. Biofinity Energys has received rave reviews from my patients, including the aforementioned college students, who are heavy digital device users. They say their eyes feel less strained and tired at the end of a long day. I encourage you to try Biofinity Energys in your practice. I think you will be very pleased with the results. OO Steven Lutz, OD, a graduate of Michigan College of Optometry at Ferris State University, is in private practice in Ann Arbor, MI.

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THE | OPTOMETRIC TECHNICIAN BY ROBERTA BEERS, COPT EARLY DIAGNOSIS AND TREATMENT OF GLAUCOMA CAN STOP IT FROM ROBBING INDIVIDUALS OF THEIR SIGHT. Glaucoma is often called the “sneak thief of sight” because glaucoma can strike without pain or other symptoms. Glaucoma is one of the leading causes of blindness in the U.S. According to National Glaucoma Research, approximately 2.2 million Americans age 40 and older have glaucoma, and as many as 120,000 people per year go blind because of this disease. Although glaucoma is not curable, it is treatable. Most patients whose condition is caught early do not lose their eyesight.

PROGRESSIVE LOSS Glaucoma is a condition in which the optic nerve experiences a specific pattern of damage, resulting in a progressive loss of the visual function. It is characterized by increased pressure in the eyeball, caused by the abnormally high production of aqueous humor or decreased drainage

of the aqueous. Left untreated, it can lead to permanent damage to the retina and the optic nerve, resulting in reduced vision or possible blindness. The ciliary body constantly produces aqueous humor, which drains from the anterior chamber through Schlemm’s canal. If this fluid is prevented from draining out of the chamber, an increase in pressure within the eye will result. Intraocular pressure, or IOP, is the fluid pressure within the eye that keeps the cornea and sclera in a state of tension. IOP normally ranges from 8mm Hg to 22mm Hg. Glaucoma can develop in one or both eyes. Generally, it occurs in both eyes, with one worse than the other. While anyone can develop glaucoma, some individuals are at higher risk. These include African-Americans, Hispanics, anyone age 60 and older, and individuals with a family history of glaucoma.

While the patient is seated at the slit lamp, you can use tonometry to measure intraocular pressure.

THE TESTS Glaucoma does not happen overnight. It is usually a slow process. There are no visual symptoms or pain, though individuals with advanced glaucoma may notice a gradual decline in peripheral vision. In other words, objects in front may still be seen clearly, but objects to the side may be missed. The patient may develop “tunnel vision” and can see only straight ahead. Over time, straight ahead vision may decrease until no vision remains. A comprehensive series of tests help monitor over time if a change in the optic nerve or nerve function has occurred and, if so, determine the level of damage that exists. These tests include: Tonometry, a simple and painless measurement of IOP. The gold standard is the Goldman applanation tonometer, which is usually attached to a slit lamp and measures IOP by flattening the cornea a small fixed amount. When performing this test, instill one drop of a fluorescein/ anesthetic combination solution in each eye. Then, using the slit lamp, bring the head of the tonometer to the center of the cornea. On contact, the limbus will shine a bluish light. Another applanation tonometer, the non-contact tonometer, uses a puff of air to flatten a circular area of the cornea. The non-contact tonometer measures IOP accurately without anesthesia and without physical contact. A visual field test. This measures the visual sensitivity of the peripheral, or side, vision. It checks the development of the abnormal blind spot and any visual field defect to detect glaucomatous damage. Corneal pachymetry. This measures the thickness of the cornea. This is impor-

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Primary open angle glaucoma: This most common form of glaucoma develops slowly as the drainage canal of the eye gradually becomes obstructed. There are no early warning signs, so individuals are not aware that they are losing their vision until the advanced stage when tunnel vision occurs. Acute closure glaucoma: Unlike primary open-angle glaucoma, this type does have symptoms, including severe eye pain that is often associated with nausea and vomiting, blurred vision, halos around lights and/ or reddening of the eye or eyes. Congenital glaucoma: This rare form occurs in infants and young children and can be inherited. It’s usually the result of incorrect or incomplete development of the eye drainage canals during pregnancy. Low- or normal-tension glaucoma: Intraocular pressure stays within the normal range, but damage still occurs to the optic nerve and visual fields. A comprehensive medical history is important to identify potential risk factors, such as low blood pressure, that contribute to low-tension glaucoma. The treatment options for low-tension glaucoma are the same as open-angle glaucoma. Secondary open-angle glaucoma: This form of glaucoma occurs as the result of an eye injury, inflammation or tumor.

Individuals with glaucoma may notice a gradual decline in peripheral vision.

tant because individuals who have thicker or thinner corneas may get artificially high or low IOP readings, respectively. Individuals with thinner corneas also have a higher risk of developing glaucoma. An examination of the optic nerve. Using a high-powered binocular microscope and lenses, the OD looks for subtle signs of optic nerve damage. Areas of thinning may indicate glaucoma. This test helps ensure the accuracy of the intraocular pressure readings. Also, digital optic nerve photography allows the doctor to monitor the optic nerve head changes. Imaging, such as optical coherence tomography. OCT determines whether there is a change in the nerve fiber layer of the optic nerve. This should be done once a year. Gonioscopy. A magnifying device (a goniolens) used in combination with a strong illumination, lets the doctor examine the angle of the anterior chamber of the eye. This device allows a direct view of the eye’s “drainage” system.

GLAUCOMA TREATMENTS Glaucoma treatments include the following to lower IOP: Topical medications. Most patients respond to topical medications, though

Courtesy: National Eye Institute, National Institutes of Health

TYPES OF GLAUCOMA

they may need multiple drops or, in some instances, oral medication. Laser trabeculoplasty. This procedure, done one eye at a time, helps increase fluid drainage from the eye and may be warranted if drops alone do not control IOP. In many cases, the patient needs to continue using glaucoma medications, and additional laser treatment might be necessary. Surgery. Conventional surgery to make a new opening for the fluid to leave the eye may become necessary if medication and laser trabeculoplasty fail to control IOP. As with laser procedures, conventional surgery is performed on one eye at a time. Surgery is about 60% to 80% effective at lowering IOP. If the new drainage opening narrows, a second operation may be needed. While these treatments may save remaining vision, they do not improve sight already lost from glaucoma. That is why early detection and continuous monitoring are very important. The ultimate goal when treating glaucoma, regardless of severity, is to stop further progression of optic nerve damage, visual field loss and loss of visual function. OO Roberta Beers, CPOT, is an optometric assistant in Erie, PA.

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NEW PRODUCT | GALLERY REFRESH OPTIVE MEGA-3 ENHANCED WITH FLAXSEED OIL JOINS REFRESH PORTFOLIO Allergan has introduced REFRESH OPTIVE MEGA-3, over-the-counter artificial tears that help meibomian gland dysfunction patients with dry eye. MEGA-3 is made with flaxseed and castor oil, two natural plant-based oils that protect tears from evaporating while hydrating all three layers of the tear film. Along with the usual solutes used in all OPTIVE products, REFRESH OPTIVE MEGA-3 contains a fourth osmoprotectant: trehalose. MEGA-3 is available in 30-count single-use vials. For information, contact Allergan at 862.261.7000 or REFRESHBrand.com.

MENICON AMERICA ADDS BASE CURVE TO MIRU 1DAY FLAT PACKS Menicon America has introduced a second base curve in addition to the existing 8.6 base curve for its Miru 1day Menicon Flat Pack daily disposable contact lenses. Miru 1day Flat Pack’s new 8.4-base lenses are available in trial six-packs, 30-packs and 90-packs. For information, contact Menicon at 800.636.4266, MeniconAmerica.com or Information@Menicon.com.

RIGHTEYE DEBUTS MAZE MASTER EYETRACKING GAME The RightEye Maze Master computer game helps users gain better control of their eye movements. Maze Master, in conjunction with the existing RightEye Reading Test, helps users improve the oculomotor skills deficits that impair their reading abilities. Keeping their gaze within maze-like lines, users have to move one or both of their eyes through a maze, “popping” numbers encountered within the mazes, which narrow as the game progresses, upon seeing them with their eyes. The movements they create with their eyes build more stable and accurate motions, including those that mimic the movements necessary for reading. For information, contact RightEye LLC at 301.979.7970 or RightEye.com.

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MENTHOLATUM CO. INTRODUCES DRY-AID LUBRICANT DROPS The Mentholatum Company announced the launch of ROHTO DRY-AID, a new over-the-counter lubricant eye drop for the relief of dry eye symptoms. The non-blurring drop uses Liquidshield technology to provide moisture to the entire tear film and reduce key symptoms of dry eye disease such as dryness, irritation, grittiness, burning and stinging due to overuse of digital devices, extended use of contact lenses, laser eye surgery, hormonal changes and dry indoor or outdoor environments. ROHTO DRY-AID comes in a single 10ml multidose bottle. For information, contact The Mentholatum Company at 716.677.2500 or ROHTOEyeDrops.com/professionals.

EYECARE PRIME PRESENTS PRIME NEXUS PATIENT RELATIONSHIP MANAGEMENT SYSTEM EyeCare Prime has unveiled Prime Nexus, a cloud-based patient relationship management system. Prime Nexus uses a simple interface that includes features such as the synchronization of appointment confirmations into compatible electronic health record systems, mobile-friendly post-appointment survey requests, streamlined online review posting to a dedicated web page, personalized email campaigns and improved reporting and alerts. For information, contact EyeCare Prime at 866.575.3937 or EyeCarePrime.com.

BEAVER-VISITEC LAUNCHES EXTEND 180 LONG-TERM DISSOLVABLE IMPLANTS Beaver-Visitec International has announced the U.S. launch of Extend 180 Absorbable Synthetic Implants, a new long-term punctal implant for patients experiencing dry eye symptoms. Extend 180 implants are made of dissolvable polydioxanone material, and they are available in 0.3mm, 0.4mm and 0.5mm sizes. The implants provide six months of dry eye relief for patients who have seasonal dry eye, contact lens intolerance and dry eye associated with digital eyestrain or following ocular surgery. For information, contact Beaver-Visitec at 866.906.8080 or Beaver-Vistec.com.

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DOCS | SPEAK OUT IS YOUR PRACTICE KID FRIENDLY? Providing comprehensive eyecare for children is certainly different than caring for adults. Children are usually very curious and sometimes apprehensive when they enter your practice. When new patients are children, the rest of the family often follows. This issue’s Docs Speak Out survey explores optometrist attitudes about caring for children.

What have you done to modify your practice to facilitate care for children? (Check all that apply.)

Do you actively promote your practice as being kid friendly?

100

YES 83%

Do you participate in the AOA-sponsored InfantSEE program by providing a comprehensive infant eye assessment between 6 and 12 months of age at no cost?

NO 17%

60 40

66% 23%

32% 93% 56%

20 0

g ed ial ed eld tor itin wa ren andh efrac uteriz ener re-bas s ferent tests d d t re ng e e h tor l p t r u s i t c a e h m p wi ic c au pic ion t co ion s dedea for vie vis vis ar

YES 65%

NO 35%

HOW DOES YOUR OPTICAL DISPENSARY CATER TO CHILDREN WHO REQUIRE GLASSES? “Dedicated area for kids to sit, with mirrors set so they can see themselves. We allow kids to pick the colors they like in cases and straps if required.” “We lowered our frame boards to kids’ heights, offer lots of kid frames, have a little play area and TV with DVD.”

“We keep a wide selection of children’s frames and supply specialty frames for special-needs children that are stylish and durable.”

CR-39. AR is offered at 50% off for 12 and under. Glasses are automatically warranted for two years against breakage and scratches.”

“Our children’s section has 75 frames for infants to junior high age. Lens prices are packaged to include polycarbonate lenses at the same price as

“We like to answer parent concerns for strength and durability before they arise. We also offer plano Digital Warrior packages with blue-blocking protection.”

WHAT HAVE BEEN YOUR MOST CHALLENGING OBSTACLES TO OVERCOME WHEN EXAMINING CHILDREN? “Overprotective parents who try to help the kids during the exam. In the presence of the child, they sometimes denigrate the use of glasses or press for contacts.”

children is paramount for helping transform life through vision!”

“We see 60% children, so making sure every team member has the education, passion and tools to work with

“We only hire staff that are comfortable with children; it is one of our interview questions. If families bring

“Children with severe autism tend not to look at fixation targets.”

multiple children in, we occasionally have pulled a staff member into the exam room to play with the other children.” “Educating parents about the importance of children’s eye exams. They think that the pediatrician screenings are eye exams.”

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DAILIESCHOICE.com *Via mail-in or online rebate on an annual supply of DAILIES TOTAL1® or DAILIES ® AquaComfort Plus ® contact lenses. Rebate is in the form of an Alcon Visa Prepaid Card. Must be a new patient to DAILIES TOTAL1® or DAILIES ® AquaComfort Plus ® contact lenses and must purchase an annual supply of the lenses within 90 days of eye exam and/or contact lens fitting. Applies to purchases from participating retailers only. Visit DAILIESCHOICE.COM for full terms and conditions. Offer ends 12-31-17. See product instructions for complete wear, care and safety information. © 2016 Novartis

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