Optometric Office March 2017 by First Vision Media Group

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TABLE OF CONTENTS 8

ON THE COVER | CIRRUS HD-OCT from ZEISS DEPARTMENTS 4 | Views 8 | Buzz 10 | One-to-One: G. Timothy Petito, OD, FAAO, DNAP, director of professional relations, Marco Ophthalmics

26 | The Optometric Technician 28 | Nutraceuticals for Dry Eyes At-A-Glance 30 | New Product Gallery

32 | Docs Speak Out

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24 | Prevent Springtime Dropouts

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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 Christopher J. Babin, OD • Lindsay Baker-Howse, OD • Steven Berger, OD Lassa J. Frank, OD • David Kading, OD, FAAO, FCLSA • Shira Kresch, OD, MS Kenneth A. Lebow, OD, FAAO • Christine Ma • Kim Pickett, COMT Joseph Sowka, OD, FAAO • Charlene Walton, OD

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

HAND SANITIZERS AND HEALTHCARE PRACTICES

Having the opportunity to visit many healthcare practices and hospitals, it’s hard to miss the countless numbers of hand sanitizer dispensers along hallway walls, exam room doors, entrances and exits. A shift has occurred in physician hygiene from the days of washing hands at the sink before greeting patients. I was a patient at the Mayo Clinic in Jacksonville, FL, for routine care while director of The Vision Care Institute at Johnson & Johnson Vision Care. It was difficult to miss the hundreds of alcohol-based hand sanitizer dispensers being installed in every exam room, alongside elevators, hallways and waiting areas. When physicians, nurses or technicians entered a Mayo exam room, they were either rubbing their hands to

Perhaps it’s time for optometrists to install some hands-free sanitizer stations.

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assist with the cleaning and evaporation of the alcohol-based hand sanitizer or looking for a dispenser in the room while starting a conversation. I received a quality assurance survey to understand if this behavior was noticed and if the healthcare practitioners were compliant. Eventually these behavior changes became habits. These days, even grocery stores are getting involved with hand sanitizer stations and disinfectant wipe dispensers at entrances and exits. Perhaps it’s time for optometrists to take a look at their offices that are full of healthy and sick patients and install some hands-free sanitizer stations for patients, technicians, opticians and doctors to use. Although alcohol-based hand sanitizers are quick and easy to implement, let’s not forget that hand washing with soap and water remains a viable method for healthcare providers to decrease the chance of passing along pathogens to patients. You just have to use warm water and wash long enough to sing the happy birthday song twice. Richard Clompus, OD, FAAO | Professional Editor | RC@OptometricOffice.com

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VIEWS THE GREAT OUTDOORS

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Spring is in the air despite what the groundhog predicted in early February. It’s only a matter of time before eyecare practices become inundated with patients suffering from allergy symptoms. Once prepared for the onslaught of pollen, your patients will confidently tend to their flower beds, plant window boxes and resume outdoor activities—without the annoyance of itchy red eyes and swollen eyelids. But there’s more to just being able to be outside symptomfree on a spring day. A recent study has further linked natural light with the reduced incidence of myopia. The results suggest that increased ultraviolet B (UVB) exposure is associated with reduced myopia—particularly if exposure was in adolescence and young adulthood. (A good reason to get your teens involved in yard work.) For the study, published in the January issue of JAMA Ophthalmology, over 4,000 participants from the European Eye Study were given an eye exam, a blood test to determine Vitamin D levels and a questionnaire about their previous sun exposure. Myopia was defined as a mean spherical equivalent of −0.75 diopters or less. Participants were excluded if they had aphakia, pseudophakia, late age-related macular degeneration and vision impairment due to cataract, resulting in 371 participants with myopia and 2,797 without. An increase in UVB exposure at age 14 to 19 and 20 to 39 years was associated with a reduced adjusted odds ratio (OR) of myopia. While there was no convincing evidence for a direct role of vitamin D in myopia risk, the highest quintile of plasma lutein concentrations was associated with a reduced OR of myopia. This requires replication in future studies. The reason sunlight may help reduce incidence of myopia is still unknown (Is it the sunlight? Is it focusing the eyes on something in the distance?) But the association may be enough to prescribe sunlight to patients, along with sunglasses, sunscreen and allergy meds, of course.

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

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Right

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360

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FOV:

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33 28 <0 29 35 31 33 30 12 29

-27 -27 -27 -4

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30°

-4 -2 -4

-1

0 -25 0

2 -24 6 4

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Deviation from agerelated norm values

6 6

30°

6 4

Corrected deviation

MS:

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NEW LENS TECHNOLOGY FROM ART OPTICAL

A VISIBLE IMPACT: BY THE NUMBERS The Vision Council’s 2016 annual report, A Visible Impact, is now available. The following highlights show some of the organization’s accomplishments last year: Market Research: 120,000 consumers interviewed, 200+ in-depth reports issued, 67% growth in ad-hoc custom data reports created for companies from Wall Street to Silicon Valley. Consumer Campaigns: 1.5 billion impressions generated 828,463 incremental exams driven by the Think About Your Eyes campaign; 7,000 television ads; 670,000 radio ads; and 36 million online radio ads. Vision Expo: 35,000+ eyecare providers in attendance and over 300 education hours. The report is available to download online. TheVisionCouncil.org.

Tangible Hydra-PEG, the FDA-approved polymer coating from Tangible Science, LLC, is now available from Art Optical exclusively on Optimum GP materials. Designed to provide a comfortable wearing experience, Tangible Hydra-PEG increases wettability, surface water retention, tear break-up time and increased lubricity while decreasing lens deposition for enhanced wearing time. Hydra-PEG will be available on Art Optical’s complete suite of specialty lens designs, including the Ampleye Scleral and Renovation Multifocal product lines. 800.253.9364; ArtOptical.com.

STUDENT CHALLENGE WINNERS ANNOUNCED ABB Optical Group, in partnership with Paragon Vision Sciences, announced the winners of the Optometry Student Challenge. The lead authors of the top three posters were Sara Siebert, Indiana University School of Optometry; KimberlyAnne Llamzon, New England College of

News Envision named Mark Eaton chief financial officer. Sushanta Mallick joined Shire as vice president & global development lead for clinical development, ophthalmics. SynergEyes partnered with Menicon to expand its specialty contact lens portfolio. Professional Eyecare Resource Cooperative (PERC) partnered with Vision Associates. FDA granted orphan status to Impavido (miltefosine) from Knight Therapeutics Inc. for the treatment of Acanthamoeba keratitis. The World Council of Optometry named Susan J. Chiles managing director. Stealth BioTherapeutics initiated a Phase 1 Study of Elamipretide in dry age-related macular degeneration.

CARECREDIT CELEBRATES 30 YEARS Thirty years ago, CareCredit was founded on a simple idea: Everyone deserves a smile. Over the years the CareCredit flexible payment option has grown beyond dental to other health-based services, including vision. To celebrate, the brand is inviting cardholders to tell their stories to commemorate the company that

Optometry; and Michael Kreuzer, University of Waterloo. They were awarded travel grants of $1,500 each to attend and present their posters at the recent 2017 Global Specialty Lens Symposium (GSLS). Ryan Chia, a student at Salus University, and Olivia Cheng, a student at UC Berkeley, received honorable mentions and $250 each. ABBOptical.com/ OptometryStudentChallenge.

Investors Management Corporation acquired Independent Doctors of Optometric Care (IDOC). Genentech ‘s Lucentis 0.5mg prefilled syringe is now available in the U.S. (L-R) Aaron See, ABB Optical Group VP of Marketing; Kimberly-Anne Llamzon; Michael Kreuzer; Sara Siebert; Richard Jeffries, President of Paragon Vision Sciences

Taron Sutcliffe has been named CFO of Eschenbach Optik of America.

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ONE-TO-ONE G. Timothy Petito, OD, FAAO, DNAP, is director of professional relations for Marco Ophthalmics. He obtained his BS degree from Michigan State University and his Doctorate of Optometry from Ferris State University. In addition to 20-plus years in private practice, his extensive experience includes a residency in pediatric vision and vision training, academic positions at the State University of New York and a research scientist role at Columbia University. He is also an internationally known author and lecturer.

Richard Clompus, OD, FAAO: In 2017, Marco will be celebrating 50 years of innovation that began with Seymour Marco, an optometrist who had previously founded Frontier Contact Lenses prior to founding Marco. How did you become the first OD in the “executive ranks” since Dr. Marco retired? G. Timothy Petito, OD, FAAO, DNAP: Four years ago, I began using the OPD Scan from Marco, which completely changed the way I practice. It greatly improved my diagnostic efficiency, and it allowed me to diagnose optical conditions that previously eluded (or just plain baffled) me and cost me a lot of time and money over the years.

Then, about two years ago, I got a call from a former colleague who was working for Marco at the time. Marco was considering adding a professional relations position to its administrative team, and he asked if I would be interested. I thought about how the technology had changed my practice, improved the outcomes for my patients and rejuvenated my excitement for the cases I used to dread. I thought I should do my part to help my colleagues learn about these great benefits, especially since at that time HIPAA, Meaningful Use, ICD-10 and PQRS were forming to be the perfect storm to sink a lot of practices. (Not to mention the uncertain effects of telemedicine, online retailers and the ACA with its alternative payment models that were not specifically defined then.) It was clear to me those who were not efficient or could not take care of complex cases—which may be one of the few profitable niches left—would have hard times ahead. I thought the position would give me a great platform to spread the message that we all need to improve our diagnostic and operational efficiency if we were going to survive the sweeping changes coming our way.

RC: How does the Xfraction Process improve efficiency and accuracy with eye exams? GTP: Xfraction, the examination process that combines the use of the OPD-Scan III for optical path diagnostics, and the RT-5100 digital refractor for wavefront-guided refraction allow one to rapidly diagnose the condition of the patient’s optics, understand their likely endpoint acuity and adjust the examination routine as needed for maximum efficiency and best outcomes. These instruments and the automated lensometer share their data digitally and transfer it all to the EMR, tremendously increasing documentation speed and accuracy. This system can be implemented in a standard office design, with the OPD-Scan III in a “pre-test” room and the RT-5100 on a traditional stand next to a chair in an examination room elsewhere in the office. Or, the system can be configured on the EPIC workstation, which allows the OPD-Scan III, RT-5100, automated lensometer and a specialized acuity chart to fit in a 6 ft. x 6 ft. area. RC: Marco is taking advantage of gains in smartphone technology with its new ION imaging device for biomicroscopes. How does the device work? GTP: The ION Imaging system has three components. The first is a device that fits into the optical pathway of a biomicroscope between the oculars and the turret that contains the objective optics (the same location where the beam splitter for other imaging systems or observation tubes have traditionally been placed). The beam splitter and optical system divert light from the left ocular

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and transmit it to the camera of the iPhone 6 Plus (the second component of the system), which the ION body holds in the specific location and orientation needed to capture the image. The third component is the ION app for the iPhone. The app stores and transmits the images with appropriate HIPAA-compliant safeguards in place.

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RC: As devices become more connected with the internet of things (IoT), how do you see instruments of the future used by optometrists for patient care? GTP: This is a very interesting question because it touches on the topic of telemedicine and all the potential good and bad that it conjures. Certainly, we can gather data in various settings, remotely from the physician who is analyzing the collected data and formulating the treatment plans for a patient. There are situations and data types for which this arrangement is perfectly acceptable and will not impact the quality of care at all. In those applications, the improved access and patient convenience argue for broad acceptance of telemedicine as part of the delivery system. But, there are also scenarios where quality is very likely to be sacrificed with potentially disastrous consequences by the use of telemedicine to replace face-to-face care, and the dilemma right now is to decide which scenarios fall into which category. Right now, we (society) get great benefits from the comprehensive nature of primary eyecare as it is provided by optometrists. In my opinion, we need to carefully consider the effects of segmentation of that care as currently described by the proponents of telemedicine in eyecare. Separating refractions from the history and physical examination of the eye and adnexa, or replacing actual examination of the eye with images of parts of it, will likely have costs in terms of quality. On the diagnostic side, every day in my practice I discover a serious health problem in a patient who presents with something unrelated to the condition I discover. It is very likely that without the comprehensive face-to-face examination currently utilized most of those people would not be diagnosed until much later in their disease course. On the therapeutic side, we know that long-term compliance with treatment for chronic conditions, whether it is dry eye, glaucoma or diabetic care, is not great. The longer between clinical visits, the worse the compliance becomes. It is yet to be seen whether telemedicine can improve that compliance or not. I suspect it will be better than nothing, but not as good as a face-to-face visit in this regard. In short, the instruments of the future depend on how we and our patients accept the trade-offs and benefits of remote data capture. OO

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INSTRUMENTATION

Guidance for Glaucoma Patients By Shira Kresch, OD, MS How to support a glaucoma practice—from patient education materials to imaging techniques. Glaucoma, known as a silent blinding disease, is a test of communication between doctors and their patients. Its asymptomatic nature leaves it to the discretion of doctors to explain its slowly progressive tendency toward blindness. Thus, glaucoma is a disease that relies on the ability of a practitioner to impart the seriousness of the condition and the subsequent importance of strict compliance with medications and follow-up schedules. Luckily for us, technology has advanced in ways that can make this daunting task more manageable. Utilizing patient education materials both in and out-of-office as well as the implementation of a communication system can help convey the disease process to our patients, which in turn can improve compliance and loyalty to a practice.

CONTINUE DURING THE EXAM Imaging techniques used in the management of glaucoma may be intimidating, confusing and not enjoyable for the patient. At diagnosis, it is helpful to explain that there is a battery of tests needed to be performed regularly for properly monitoring the progression of the disease. At each follow-up appointment it is important to go over the results from whatever imaging was performed. Unfortunately, this is not always accomplished, and patients may leave confused. There is no shortage of instruments used in the management of glaucoma patients, but imaging techniques commonly used are optical coherence tomography (OCT), visual field and retinal photography. Here’s how to best utilize these tools to help patients understand their disease.

START IN THE WAITING ROOM It has never been easier to implement effective education materials in the office. The waiting room, both before and after seeing the doctor, sets the stage for the overall patient experience. The use of educational videos, interactive tablets, diagrams and pamphlets placed around the office not only show your patients that you care about their understanding of their disease but encourages them to take their condition more seriously.

OPTICAL COHERENCE TOMOGRAPHY When shown to a patient, OCT results indicated by the red, yellow and green colors can alert patients to the seriousness of their disease. However, OCT images can further inform patients and offer more detailed explanations of such results to them. Heidelberg Engineering’s SPECTRALIS OCT Glaucoma Module Premium Edition (GMPE) offers a 3D analysis through the optic nerve head with a dramatic display

The CIRRUS HD-OCT from ZEISS is unique in that it contains several options for displaying progression, including the Guided Progression Analysis for assessing RNFL and optic disc change.

of the optic nerve head morphology. This is even more impressive when these images are compared to the patient’s previous scans, showing changes that illustrate potentially progressive damage. Furthermore, the GMPE enables clinicians and patients to visualize such progression using a built-in progression map. The sequence of these scans can show patients the importance of visiting their eyecare specialist on a consistent basis in order to have OCT scans of their eyes acquired for close monitoring of such small but irreversibly damaging changes. The CIRRUS HD-OCT from ZEISS is unique in that it contains several options for displaying progression. Slowing progression is the primary goal of therapy and highly dependent on patient compliance. Guided Progression Analysis (GPA) assesses retinal nerve fiber layer (RNFL) and optic disc change. Focal Progression Analysis has up to six progression maps compared to two baselines, and the Trend Analysis with Rate of Change plots RNFL thickness values over time. With colorcoded areas marking possible to definite progression, CIRRUS HD-OCT offers a

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range of tools that can help patients understand that their glaucoma may be worsening, despite its asymptomatic nature.

VISUAL FIELD The visual field is the only test we have that can show a patient functional vision loss. Simply showing the Guided Progression Analysis of the Humphrey Visual Field (which identifies statistically significant changes in visual field threshold sensitivity) or an up-to-date sequence of tests over a few years help patients appreciate that they are losing vision. Although not much has changed with the standard visual field printout, the advent of the Compass Fundus Automated Perimeter allows for a qualitative structure-function type assessment. The Compass accomplishes this with displaying the results of the visual field overlying a photograph of the patient’s posterior pole. To mimic this printout, a practitioner can show patients the results of their visual field side-by-side with their retinal photograph and explain the correlation when appropriate.

RETINAL PHOTOGRAPHY A high resolution optic nerve head (ONH) photograph in the exam room can go a long way to educate patients on their condition. The structure of the glaucomatous ONH, when compared side-byHeidelberg Engineering’s SPECTRALIS OCT Glaucoma Module side to that of a normal Premium Edition enables clinicians and patients to visualize glaucoma progression using a built-in progression map. nerve head, can be displayed and discussed in simple terms in order to help patients ‘vicific websites prevents your patients from sualize’ glaucoma. Taking this experience finding inaccurate or difficult-to-underto the next level by including “Automatic stand information. Implementation of a 3D Stereo Imaging,” a standard feature in reminder system with a portal for patients the AFC-330 from Marco, gives patients the to be able to ask questions is an invaluable opportunity to view their retinal anatomy in addition to an office setting as well. 3D as well. Having an “automated” stereo These steps are easy to implement even fundus camera provides the clinician with in very busy glaucoma practices and make repeatable diagnostic information in order all the difference for more effective manto accurately compare the ONH over time. agement and establishing loyal patientAnother function of a colored retinal doctor relationships. OO photograph is the visualization of “wedge defects” in the areas of RNFL loss. The Shira Kresch, OD, MS, is an instructor Centervue Eidon camera, with its true of Optometric Sciences at Columbia color confocal scanner, allows clear idenUniversity Medical Center and an tification of wedge defects. The SPECTRAoptometrist at New York PresbyteLIS MultiColor Scanning Laser Imaging rian Hospital. She is also the founder offers a modality for clear visualization of of EyeInquire.com, a patient-facing RNFL wedge defects. The blue and green website for eyecare information. reflectance images from the MultiColor modality accentuate the boundaries of WHERE TO FIND IT: such defects, enabling clinicians and paCarl Zeiss Meditec, Inc. tients to appreciate their extent. 800.342.9821 | Meditec.Zeiss.com/USA

CONTINUING EDUCATION

Automatic 3D Stereo Imaging, a standard feature in the AFC-330 from Marco, gives patients the opportunity to view their retinal anatomy in 3D.

Choose your favorite resources and encourage your patients to stay educated about their glaucoma. The internet is the most common source for people to look for information, so giving suggestions of spe-

Centervue, Inc. 408.988.8404 | CenterVue.com InfoUS@CenterVue.com Heidelberg Engineering, Inc. 800-931-2230 | HeidelbergEngineering.com Marco 800.874.5274 | Marco.com

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THINK ABOUT YOUR EYES

Better Outcomes for Glaucoma Patients Begin with You Glaucoma currently affects three million Americans, but fewer than half know they have it. As it commonly affects patients over the age of 60, that number will only increase as Baby Boomers continue to age. Are we, as optometrists, doing enough to educate our patients about this disease? The key to being advocates for our patients’ eye health is communication. Patients are trusting us with their most precious sense— their window to the world. Glaucoma is a threat to that window because even though it starts gradually, if left untreated progressive damage to the optic nerve will occur and rob our patients of their vision. It’s our duty to ensure we’re having the right conversations so that patients are educated about their risks. Try to develop an accurate perspective of a patient’s entire health picture. Review the patient’s medical history and identify risk factors, which include family history of glaucoma, thin corneas, heritage (African-American and Latino patients are at a higher risk), history of eye injury and increased intraocular pressure. Ask about systemic issues that are potential contributors, including diabetes, high blood pressure and migraines, and ensure that the patient is also aware that they need to update you on any changes to their systemic health.

Many patients who have glaucoma can think that blindness is inevitable, but this isn’t true. The most common and dangerous misconception about vision health among the public is that if there’s no pain, their eyes must be healthy. While the patient may not physically feel the symptoms of glaucoma, remind them that you are monitoring their optic nerves and intraocular pressures as part of their annual eye exam, highlighting the importance of being checked at least annually. Many patients who have glaucoma can think that blindness is inevitable, but this isn’t true. Between medications and surgery, we have a number of options that can slow or stop the progression of the disease in order to prevent blindness. What else is true: Glaucoma can be a frightening diagnosis. It’s the responsibility of optometrists to build a trusting and open relationship with patients so a strong line of communication exists. The best

Charlene Walton Christopher J. Babin, OD, and Charlene Walton, OD, are members of Optometric Physicians of Washington 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 (publisher of Optometric Office) supports Think About Your Eyes as a media partner and provides space for this monthly Guest Editorial.

way to do this is to encourage patients to schedule eye exams annually. Encouraging patients to receive an annual eye exam is the main message of Think About Your Eyes, the public awareness campaign for the vision industry. OO

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CONTACT LENSES

Single (Use)…and Loving It! By David Kading, OD, FAAO, FCLSA and Christine Ma How the daily disposable modality is making patients’ eyes happier and healthier. Contact lenses have come a long way since their inception. If we think back to our original materials and designs, we quickly realize that both health and vision have benefited from the progression. But time marches on and there will always be something new and something better. Take, for example, daily disposables. There are a lot to choose from, including DAILIES Total1 and DAILIES AquaComfort Plus from Alcon, ACUVUE OASYS 1-DAY brand contact lenses from Johnson and Johnson Vision Care, Inc., clariti 1 day from CooperVision and Biotrue ONEday from Bausch + Lomb— just to name a few! In our practice, we follow the philosophy that we always do what is in the best interest of our patients’ health first, their vision second and their pocketbook third. We certainly work with our patients to maximize their vision and their pocketbook, but we always start with health. With this philosophy in place, we have reached a point where we are 93% successful in moving our patients to daily disposable lenses. Following are five reasons why patients leave the office happier with this lens choice.

1. Simplified Lens Care The convenience of daily disposables is a major advantage. Patients do not have to worry about cleaning and storing their lenses at the end of the day. 2. Better Compliance Sometimes no solution is the best solution. We found that we get better compliance when patients are fitted into daily disposables. With other modalities, they often do not clean their lenses with enough solution or for the recommended amount of time. In addition, they may not replace their lenses when they should. 3. Freedom for Active Lifestyles From athletes to weekend warriors, daily disposables are convenient for patients who live active and busy lives. For instance, since daily lenses do not require solution, they can quickly be inserted while in the gym locker room or anywhere on-the-go. 4. Flexible Wear They are a great option for patients who only wear contact lenses on occasion. With

Some daily disposables come in different base curves, including ACUVUE OASYS 1-Day Brand Contact Lenses, both from Johnson & Johnson Vision Care, Inc.

Bausch + Lomb Biotrue ONEday maintains over 98% of its moisture for up to 16 hours.

monthly and two-week lenses, patients need to replace them regardless of the number of times they have worn them. For this reason, many patients feel like they are wasting their lens wear if they choose to wear glasses and become contact lens dropouts. With daily lenses, patients can choose to wear their contact lenses only when they want to without feeling like they are wasting a lens wear. 5. Similar Cost to other Modalities Although it may appear that two-week or monthly replacement lenses cost less than daily disposables, we cannot forget to factor in solution costs. To effectively clean contact lenses, it is estimated that one ounce of solution is needed. If a patient is effectively cleaning their lenses every night and each bottle of solution has 10 ounces, they are estimated to use 30 ounces (three bottles) in one month. Let’s say each bottle is approximately $8, a patient on a monthly-replacement lens would be spending about $250 to $300 extra on solution. That is an amount that patients and practitioners forget to fac-

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tor into the total cost when purchasing contact lenses. In reality, we know that patients are just not likely to clean their lenses properly. As such, we feel that it is best to place them in a lens that will fit their needs to help keep them healthy.

FITTING AN AGING POPULATION Presbyopes Over the last 10 years, we have improved on the availability of multifocal contact lenses for our older population. We now have DAILIES AquaComfort Plus Multifocal and DAILIES Total1 Multifocal from Alcon, Proclear 1 day Multifocal and clariti 1 day multifocal from CooperVision, Biotrue ONEday for Presbyopia from Bausch + Lomb and many more. Astigmats With daily disposable toric lenses, we are able to provide our patients with lenses that have astigmatic powers that go up to -1.75D and -2.25D and an axis at every 10 degrees all around the clock dial. Presbyopic Astigmats Multifocal contact lenses are not limited to presbyopes. The parameters available for patients are certainly there. The patients who do not fit into these parameters are very few such as the toric multifocal patients or high toric patients. Daily disposables are better able to accommodate patients with high spherical

The clariti 1 day lens from CooperVision is available in sphere, toric and multifocal designs.

power now than they were in the past. Some patients may need a specialized base curve or diameter that is available through a one-month replacement lens. However, there are daily disposables that come in different base curves such as ACUVUE OASYS 1-Day and 1-day ACUVUE MOIST Brand Contact Lenses, both from Johnson & Johnson Vision Care, Inc. In the past, oxygen transmissibility was an argument for one-month replacement lenses. However, this is not the case anymore. Many contact lens companies have created silicone hydrogel daily disposables that transmit more oxygen to the cornea.

SPEAKING OF MONTHLY MODALITIES There are patients who work extended hours or have a lifestyle that requires continuous wear such as on-call doctors. These patients would benefit most from a monthly disposable lens such as AIR OPTIX NIGHT & DAY from Alcon, Bausch + Lomb ULTRA and ACUVUE VITA from Johnson & Johnson Vision Care, Inc. With all the advances in soft contact lenses, we are able to fit the majority of our patients in some type of daily dis-

posable. Again, health is the number one driving factor when we are recommending daily disposables to our patients. For our patients, concerns such as protein deposits, dryness, improper cleaning and storage are reasons why contact lenses feel uncomfortable. Nothing feels better than putting on a fresh pair of lenses every day. Corneal neovascularization, superficial punctate keratitis, corneal ulcers or giant papillary conjunctivitis should be red flags for practitioners and are all reasons to move patients into a daily disposable modality. With so many contact lens options on the market, it is our job as eyecare professionals to educate our patients regarding the health of their eyes. That is why we recommend daily disposables to every patient in our practice. OO David Kading, OD, FAAO, FCLSA, is in private practice at Specialty Dry Eye and Contact Lens Center in Seattle, WA. Christine Ma is a fourth year optometry student at Pacific University. WHERE TO FIND IT: Alcon Laboratories 800.451.3937 | Alcon.com Bausch + Lomb 800.828.9030 | Bausch.com/ECP

DAILIES Total1 Multifocal from Alcon is available in extended powers ranging from +6.00D to -10.00D, in three add powers, totaling 195 parameters.

CooperVision, Inc. 800.341.2020 | CooperVision.com Johnson and Johnson Vision Care, Inc. 800.843.2020 | ACUVUEProfessional.com Order@Acuvue.com

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CONTACT LENSES

A Rewarding Practice By Steven Berger, OD Patients want to save money, you want to make some. Rebates for annual supplies of contact lenses accomplish both goals. It was probably close to 20 years ago that Vistakon instituted a program called 20/20 that offered a rebate tied to the purchase of eight six-packs of ACUVUE OASYS Brand Contact Lenses twoweek disposables. That was the start of patients benefiting financially from an annual supply. Soon after, other manufacturers offered similar rebates tied to an annual supply purchase. That was when we introduced a new office policy. We emphasized to staff the only way to quote contact lens prices to patients would be to provide the annual supply price along with the current rebate connected to them.

COMPETING WITH E-TAILERS Today, it’s easy for patients to compare contact lens prices. Our office tries to stay competitive by buying the products at the best prices that we can to maintain an appropriate profit on the contact lenses we dispense. Rebates, in many cases, have become larger and have offered money back to patients for both materials and contact lens exam fees. In some cases, the rebate is only offered on products purchased from the same office that performed the contact lens examination. Patients also benefit from the nocharge shipping offered by most lens companies. In our practice, this conve-

nience—along with pricing and rebates— keeps us competitive with internet suppliers. The judicious use of diagnostic lenses to demonstrate the benefits of disposable contact lenses is a distinct advantage to our patients. Patients often prefer purchasing their contacts from an office they trust and are comfortable with. They understand we have their best interests in mind.

Rebate Programs Most contact lens manufacturers offer rebates for your patients, and there are programs that help keep the sale within your practice. Here is a brief look at some of the offers currently available.

• The Alcon Dailies Choice Program

•

COMMUNICATING WITH PATIENTS I have found that in this age of managed care, our contact lens patients are more profitable in combination with the contact lens exam fees and an annual supply of lenses. With accelerated growth of vision plans over the past 10 years any practice can benefit from retaining revenue from contact lens purchases while providing a service to patients. The key: communication. There is no doubt that success is heavily tied to office staff and doctor enthusiasm in presenting the annual supply to patients. It’s amazing how little resistance you come up against after explaining the convenience (no-cost shipping), total cost (including rebate), and benefits of compliance (what annual supplies deliver in terms of health) to patients. OO Steven Berger, OD, is owner of Eye to Eye Contact in Haverton, PA.

•

offers a $200 fit rebate with annual supply purchase of DAILIES Total1 or DAILIES AquaComfort Plus contact lenses. DailiesChoice.com. Bausch + Lomb’s rebate program offers patients up to $120 on their annual supply purchases. The Bausch + Lomb PLUS program allows patients to enjoy an additional $20 savings if they purchase an annual supply of Bausch + Lomb ULTRA or Biotrue ONEday contact lenses. BauschRebates.com Johnson & Johnson Vision Care, Inc. offers patients up to $160 on ACUVUE OASYS Brand Contact Lenses. There are other available rewards across the ACUVUE brands. MyACUVUERewards.com LensFerry S from CooperVision keeps contact lens sales within a practice and encourages annual supply sales. Patients subscribe for an annual supply (all modalities, multiple manufacturers) with the cost divided into 12, automatic monthly payments. The patient receives automatic quarterly lens deliveries. LensFerry.com

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MPS, multipurpose solution. *Compared to MPS in symptomatic users. References: 1. Gabriel M, Bartell, J, Walters R, et al. Biocidal efficacy of a new hydrogen peroxide contact lens care system against bacteria, fungi, and Acanthamoeba species. Optom Vis Sci. 2014;91:E-abstract 145192. 2. Alcon data on file, 2014. 3. Alcon data on file, 2015. © 2016 Novartis 04/16 US-CCS-16-E-1913

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PATIENT CARE

3 Keys of Office Efficiency By Lassa J. Frank, OD Technology, technicians and time-saving communication will boost your practiceâ&#x20AC;&#x2122;s productivity without sacrificing care. When I first started in the industry, I had the pleasure of working in an office that had been in existence for over 50 years. It was always fun to pull out a record where the entirety of the notes, sometimes for several years of visits, were written on a single index card. With the myriad changes we have all experienced in the medical and insurance world, we have all had to become more efficient, not only when collecting personal and medical data but also how itâ&#x20AC;&#x2122;s organized and stored.

TECHNOLOGY We as medical professionals are bombarded on a daily basis with information about how different instrumentation or

software will save us time so that we can see more patients and hopefully become more financially successful. One of the latest technologies that our office is currently exploring is the PatientReach Tablet by Solutionreach. This easyto-use software allows our staff to collect personal history along with contact and insurance information from iPads that patients use in the waiting room. It also allows us to collect signatures on all of those informational forms we are required to show our patients. The software is flexible enough so that you can not only ask the required questions for a Review of Systems, but you also can add other questions. For example, we added the questions from

A new check-in app from First Insight Corp. for the iPad integrates with MaximEyes software.

the Dry Eye Speed Questionnaire to our review. (WebSystem3 from CooperVision, Demandforce and 4PatientCare also offer customizable surveys.) In the few weeks in which we have been utilizing this new technology it has created a lot of buzz and questions about dry eye, which can only lead to better patient care and practice profitability. The best part is that all of the information is saved by Solutionreach, and at the next visit it will re-populate everything and alert the staff to any changes that have been made. First Insight Corp. also helps maximize office efficiency with online welcome and medical history forms, scheduling and faxing built into its MaximEyes software, which also integrates a new check-in app for the iPad.

TECHNICIANS For those of you who have been lucky enough to find a great optometric technician or staff person, you know that they are worth their weight in gold. They are the ones who can utilize and keep working all of that wonderful technology that frees us up as doctors from collecting and organizing all of that personal and medical information. Like technology upgrades, good staff requires a time commitment for both development and training. Extra staff and new technology also come at a financial cost, and although good arguments can be made for the investment

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and the risk, it does mean that we have to generate quite a bit of revenue before we can make a profit.

TIME-SAVING COMMUNICATION Another thing to consider when trying to improve office efficiency is asking yourself and your staff, “What are we saying and how are we saying it?” I would encourage you to determine how much time is wasted in your practice because of the all-too-common variations on the following scenarios:

• Patients who don’t complete the Review of Systems so you or your staff have to go through it question by question with them. • Patients who are looking around during the visual fields test so you have to wait while your staff repeats it or you have to order a more extensive test. • Patients who return for an Rx problem visit because it’s their first time wearing progressive lenses and they weren’t told to expect a re-calibration period because of a 2.00D Rx change. These are just a few of many scenarios. What do they have in common? All could have been avoided by a simple explanation or one that was worded in a slightly different way. In our office we try to make a game of it. Not only am I always looking at how I say things and observe the results I get, but I encourage my staff to do the same. For example, for the first scenario above we utilize a tablet-based Review of Symptoms questionnaire as mentioned earlier. On it, the patient is asked 31 questions about their personal and family health history. I noticed that I was starting to get results in

The PatientReach Tablet by Solutionreach allows patients to sign required forms, take customized surveys and request additional materials—all from your waiting room.

which the patient was only answering part of the questionnaire. After a little research and eavesdropping, I found that the staff was handing the tablet to the patient and directing them to “answer all of the questions.” After a quick meeting, we decided to tell the patient to “answer all 31 questions” instead. That little tweak in direction to the patient solved the problem of incomplete patient history. Another technique I am constantly encouraging the doctors and staff to use is the power of prediction. By correctly predicting the outcome, we not only reinforce our credibility, but we also avoid a lot of wasted time and effort later. The third scenario above is a classic example of this. I can always tell when my opticians are not predicting because I either get called out to reinforce the explanation they gave the patient when the glasses were tried on, or the patient refuses to take the glasses and demands a Rx problem visit. This not only takes up both staff and doctor time but sometimes results in unnecessary redo’s because the patient is convinced that there is something wrong with the glasses.

This could have been avoided by the doctor and the staff spending 20 seconds to predict that the glasses will be clear but that they will feel different or strange during the re-calibration phase—and sharing that with the patient. This approach requires ongoing observation and effort by you and your staff. By encouraging your staff to play the game and have some fun with it, you can get some amazing savings in time and effort while providing better patient care—all with a much smaller financial investment. OO Lassa J. Frank, OD, is in private practice in San Anselmo, CA. WHERE TO FIND IT: 4PatientCare 877.777.9078 | 4PatientCare.com Demandforce 800.210.0355 | Optometry.Demandforce.com Solutionreach 866.605.6867 | Solutionreach.com WebSystem3 866.575.3937 | www.WebSystem3.com

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PHARMACEUTICAL

A Symptom-Free Season By Lindsay Baker-Howse, OD, and Joseph Sowka, OD, FAAO There is hope for your patients with serious ocular allergies, and itâ&#x20AC;&#x2122;s found in the following medications. As an eyecare practitioner, you probably deal with patient complaints of itchy, watery and red eyes on a routine basis. Allergic conjunctivitis (AC) is a common allergic disorder that affects 6% to 30% of the general population conservatively. The prevalence of ocular allergies is dramatically increasing due to changing environmental factors, such as pollution and climate changes, and growing numbers of immunological sensitive individuals in the general population. A majority of AC patients have mild recurrent episodes that flare up seasonally, called perennial conjunctivitis, but approximately 30% of ocular allergy patients suffer with intense and persistent symptoms that occur on a regular basis throughout the year.

OCULAR ALLERGY SYMPTOMS Signs and symptoms of AC include tearing, itching, chemosis, conjunctival injection, papillary conjunctivitis and photophobia if the cornea is involved. When an individual becomes sensitized to a particular allergen, a cascade reaction triggers proallergic and proinflammatory mediators to stimulate itching and vasodilation in the eyes. Specifically, the cross bridging of IgE molecules initiates mast cell degranulation resulting in the release of histamine. Histamine binds with nociceptors, leading to the subjective complaint of itching.

Treatment of ocular allergy completely varies with severity. AC can be managed successfully with a stepwise approach by assessing the severity of the signs and symptoms. In many cases, it is necessary to target multiple pathways to achieve both acute and long term relief. You may also find yourself treating the condition under the confines of a patientâ&#x20AC;&#x2122;s insurance (see Docs Speak Out on page 32).

AVOIDANCE AND OTC MANAGEMENT If an offending antigen can be identified (such as animal dander), potentially the best management is simple avoidance. This is often not possible and other modalities need to be employed. Patients that present with mild signs and symptoms will find relief from palliative treatment including cool compresses for five to 10 minutes BID and artificial tears as needed. The artificial tears will dilute the allergen and provide soothing relief, while cool compresses will trigger vasoconstriction in the affected area and diminish the blood-borne allergic response. Many patients with acute symptoms self-medicate with overthe-counter (OTC) oral antihistamines, however, this can lead to dryness and paradoxical worsening symptoms. Best results are achieved by using OTC topical ketotifen fumarate ophthalmic solution, such as Zaditor from Alcon Laboratories or Alaway from Bausch +

For mild symptoms, suggest combining an OTC topical ketotifen fumarate 0.035% ophthalmic solution, such as Alaway from Bausch + Lomb, in addition to an OTC oral antihistamine.

Lomb, in addition to the oral antihistamine.

ANTIHISTAMINE/MAST CELL STABILIZERS A topical prescription combination antihistamine/mast cell stabilizer (see box below) is the best option for treating seasonal AC cases because of its dual action blocking the effects of histamine and prohibiting mast cells from releasing the chemicals responsible for allergy symptoms. Olopatadine is a favorite choice among practitioners because of its diverse mechanism of action (MOA) and effectiveness. In a recent study, 0.77% olopatadine hydrochloride ophthalmic solution (Pazeo from Alcon) was found to be superior to milder concentra-

Antihistamine/mast cell stabilizers Alcaftadine: Lastacaft from Allergan Azelastine: Optivar Ophthalmic from Meda Pharmaceuticals Bepostastine: Bepreve from Bausch + Lomb Epinastine: Elestat from Allergan Ketotifen: Zaditor from Alcon; Alaway from Bausch + Lomb Olopatadine: Patanol, Pataday and Pazeo, all from Alcon

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tions (Patanol and Pataday, both from Alcon) on rapid relief of ocular itching and conjunctival redness with no safety concerns. It is debatable whether prescription allergy drops are more effective than OTC agents. Similar efficacy was found between olopatadine and ketotifen in a 30-day trial comparing redness, chemosis and eyelid swelling, and both were effective in diminishing the expression of inflammatory mediators. Mast cell stabilizers, such as nedocromil sodium ophthalmic solution (Alocril from Allergan) or Cromolyn Sodium Ophthalmic Solution from Bausch + Lomb, are acceptable for long term AC management, but they do not provide acute relief. Because it takes approximately four weeks of BID dosing before mast cell stabilizers become effective, it is best to supplement initially with a combination of palliative treatment, topical antihistamine or topical steroids/NSAIDs.

TOPICAL STEROIDS For moderate to severe AC, adding a topical steroid can enhance the effect of the antihistamine/mast cell stabilizer and relieve patient’s symptoms temporarily during an acute flare up. Steroids, such as loteprednol etabonate ophthalmic suspension (0.2% Alrex, 0.5% Lotemax or Lotemax Gel—all from Bausch + Lomb) or fluorometholone (FML from Allergan), are best to start with because of their safety profile and low intraocular absorption. Pulse therapy is appropriate for more severe cases, however, it is recommended to monitor IOP closely if using a steroid for longer than two weeks. Alrex is the only topical steroid approved for allergy treatment and has demonstrated long term safety.

TOPICAL NSAIDS If steroids are contraindicated for a particular patient, topical NSAIDs such as ketorolac tromethamine (Acular LS and Acuvail—both from Allergan) or bromfenac (Bausch + Lomb’s PROLENSA) are another option for temporary relief for one week while ramping up chronic AC management. Topical NSAIDs relieve itching by inhibiting cyclooxygenase, which is part of the inflammatory cascade, however, they do not block histamine. Therefore, topical NSAIDs should serve only as temporary relief for AC.

IMMUNOMODULATORS More severe forms of allergic conjunctivitis, including atopic keratoconjunctivitis (AKC) and vernal keratoconjunctivitis (VKC), have more of an inflammatory response and require aggressive treatment. These patients often are treated initially with an extended pulse steroid therapy in conjunction with a mast cell stabilizer for long term management. Several studies have investigated the efficacy of topical immunomodulators such as cyclosporine A ophthalmic emulsion 0.5% (Allergan’s Restasis) and tacrolimus (Prograf from Astellas Pharma US, Inc.) for managing chronic AC. VKC and AKC have been found to respond to treatment within one month of initiating therapy of either cyclosporine A or tacrolimus and show significant improvement after six months of therapy. Tacrolimus therapy alone can significantly reduce corneal epithelial involvement in VKC patients. Both immunomodulators have a good safety profile and have minimal side effects. Although mast cell stabilizers have been the mainstay treatment for

A topical prescription combination antihistamine/ mast cell stabilizer, such as Pazeo from Alcon, relieves itching and reduces redness.

AKC and VKC, growing evidence indicates practitioners should consider an immunomodulator for severe AC cases. The prevalence of ocular allergies is increasing in the general population, and eyecare providers need to be ready to handle not only the mild cases but also have a game plan for the more severe ocular allergy cases. Using a stepwise approach in managing ocular allergies will help you manage any severity of ocular allergies. OO Lindsay Baker-Howse, OD, is a primary care/ocular disease resident and Joseph Sowka, OD, FAAO, is a professor at Nova Southeastern University in Fort Lauderdale, FL. WHERE TO FIND IT: Alcon Laboratories, Inc. 800.451.3937 | Alcon.com Allergan 800.347.4500 | Allergan.com Astellas Pharma US, Inc. 800.888.7704 | Astellas.us Bausch + Lomb 800-828-9030 | Bausch.com/ECP Meda Pharmaceuticals 732.564.2200 | MedaPharma.us

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PHARMACEUTICAL

Prevent Springtime Dropouts By Kenneth A. Lebow, OD, FAAO How to treat seasonal allergy symptoms in the contact lens wearer. Contact lens designs and materials continue to evolve and improve, resulting in increasing numbers of people wearing contact lenses. However, some people have to forego their preferred form of vision correction when seasonal allergies spring up. Some form of allergy affects approximately 15% to 30% of the world population, and ocular symptoms are present in 40% to 80% of those patients. Seasonal allergic conjunctivitis (SAC) and perennial allergic conjunctivitis (PAC) by far represent the most frequently encountered allergic conjuctivitis and are typically treated with a combination of palliative, systemic and topical pharmacological treatments.

TREATING CL WEARERS The same classes of medication are used to treat those with allergies regardless of whether the person wears contact lenses or not. Olopatadine (Patanol, Pataday and Pazeo—all from Alcon Labs) is generally considered the gold standard treatment for itching associated with allergic conjunctivitis. The big difference in treating contact lens wearers is the frequency of dosing. Most contact lens wearers prefer BID dosing so that they do not need to remove their lenses during the course of the day. Even though the recommended treatment may be QID dosing, I will often prescribe from QID to BID to TID dosing depending on the wearing time. For example, if patients wear their lenses from 8am until 6pm, I can treat them TID with-

out having them remove their lenses during the day. If, however, they wear their lenses from 8am until 11pm and refuse to remove their lenses during the day, BID dosing is all we do. Of course, if they are being treated for a severe allergic response, they will either have to stop wearing contact lenses and wear glasses so that they can achieve the appropriate dosage or remove their lenses twice during the day so that the drops can be applied without the lenses on the eye.

ADVICE FOR THE ALLERGIC Avoidance of allergens (tree and weed pollens, grasses and outdoor molds) for sensitized individuals is the simplest approach to preventing allergic conjunctivitis. But that’s easier said than done. The use of daily disposable contact lenses (see “Single (Use) and Loving It” on page 16) as a barrier to allergens during exacerbations is also an effective treatment for the contact lens wearer. This, along with cold compresses to reduce itching and artificial tears to dilute and wash away allergens, are effective measures to manage mild early stage allergic conjunctivitis. While this approach may also improve symptoms associated with PAC since degranulation of mast cells in PAC recruits eosinophils, a more aggressive therapeutic approach may be required. The two most effective pharmaceutical agents to treat allergic conjunctivitis are dual-acting antihistamine/mast cell

Bepreve from Bausch + Lomb is prescribed for itching associated with allergic conjunctivis.

stabilizers and steroids. Newer dualacting agents, such as Pazeo from Alcon or Bepreve from Bausch + Lomb, are extremely effective in controlling itching in both early and late stage responses. They combine histamine receptor antagonists and mast cell stabilizers. Steroids, such as Lotemax from Bausch + Lomb and Durezol from Alcon, are used to suppress late-phase production of inflammatory mediators such as basophils, eosinophils, T-cells and neutrophils that are responsible for more severe ocular reactions and corneal damage associated with more serious allergic conditions, such as vernal keratoconjunctivitis and atopic keratoconjunctivitis, and therefore are generally not used for early stage reactions. As eyecare practitioners we now have significant tools to treat allergic conjunctivitis and provide improved quality of life to our patients. OO Kenneth A. Lebow, OD, FAAO, is in private practice in Virginia Beach, VA, and is on the Optometric Office editorial advisory board. WHERE TO FIND IT: Alcon Laboratories, Inc. 800-451-3937 • Alcon.com Bausch + Lomb 800-828-9030 • Bausch.com/ECP

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YOUR QUICK GUIDE TO DRY EYE MANAGEMENT SCREEN FOR UNDIAGNOSED DRY EYE DISEASE (DED) Identify DED-related symptoms, risk factors, and clinical signs n

Clinical history - health and ocular Speed symptom questionnaire

If you suspect your patient may have DED, schedule a follow-up visit for a thorough medical evaluation of their ocular surface

Autorefraction, Keratometry, Visual fields, Visual acuities, Routine vitals, and Slit lamp examination

CONDUCT A THOROUGH MEDICAL EVALUATION Confirm the presence of DED and its underlying cause

Classify its severity

Fluorescein Dye Test

Superficial Punctate Keratitis

Tear Film Instability

Mild

+/- Symptoms + Mild Clinical Signs

Lissamine Green Dye Test

Dead and Degenerate Conjunctival Cells

Lid Wiper Epitheliopathy

Moderate

+ Symptoms + Moderate Clinical Signs

Eyelid Evaluation

Meibomian Gland Dysfunction

Severe

+ Symptoms + Severe Clinical Signs

PRESCRIBE A TREATMENT REGIMEN Medication*

Lifestyle Modification / Self-Care

COMMUNICATE WITH YOUR PATIENT n n

3 Eye Drops

Omega-3 and vitamin A

Eyelid Hygiene

Eye protection

Gels / Ointments

Hydration

Autologous Serum

Air conditioning

Digital device use

Validate your patients’ condition Discuss your evaluation Prescribe a treatment regimen

Schedule follow-up visits to monitor how well your patient is responding to treatment

GET REIMBURSED Maintain an accurate record of all findings from the very first visit onwards, to be properly compensated for your services n

n n

Collect your patients’ insurance information Don’t mix vision and medical care Select the right codes (visit and diagnosis) and pair them

Submit the codes to the correct payer Get paid

*Other treatment options not listed may also apply

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

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THE | OPTOMETRIC TECHNICIAN BY KIM PICKETT, COMT HERE’S WHAT YOU NEED TO KNOW ABOUT INTRAOCULAR PRESSURE AND THE INSTRUMENTS THAT ARE USED TO MEASURE IT. To better understand intraocular pressure (IOP), picture the eye as a fluid-filled balloon or firm grape that is inflated by pressure. Pressure that is too high and left untreated can damage the delicate optic nerve, permanently affecting vision. Aqueous humor is a fluid that is secreted by the ciliary body. It is in continuous circulation until it drains out of the trabecular meshwork. High eye pressure can be caused when too much fluid is produced by the ciliary body or if the aqueous drains too slowly from the trabecular meshwork. Eye trauma, certain medications and other eye conditions can also cause high eye pressure and glaucoma. Fortunately, there are accurate methods to assess eye pressure by measuring

The PASCAL DCT from the Ziemer Group is ideally suited for measurements on eyes with scars or those that underwent surgical interventions, such as LASIK and PRK.

the flexibility of the eye. In a sense, we measure how hard it is to poke the grape or balloon. With lower pressure, it is easier to poke, and with a high amount of pressure, it will be more difficult to poke. The “poking” is done with a variety of delicate contact and non-contact eye instruments.

CONTACT TONOMETERS Applanation tonometry is the process of flattening the cornea, and the Goldmann tonometer has long been considered the gold standard of tonometry. With this method, a topical anesthetic and fluorescein dye are instilled in the eye and a disinfected prism tip is gently placed against the cornea while the patient is seated at the slit lamp. The amount of force applied to the prism is measured when a tension spring within the device is adjusted. The Tono-Pen AVIA and Tono-Pen XL from Reichert Technologies are used to measure IOP. These handheld devices are tapped gently on the anesthetized cornea, and the IOP value is displayed on the screen. A disposable tip cover, Ocu-Film, is used for each patient to reduce the risk of contamination and eliminate the need for instrument sterilization. Tono-Pen can be used in any position and is especially useful with children and patients who have difficulty getting in front of the slit lamp. The Model 30 Pneumotonometer, also from Reichert, provides fast and accurate tonometry and optional tonography functions. The anesthetized cornea is gently touched by a probe tip that floats on an air bearing while a regulated flow of air applies force to the tip. Increasing pressure is continually applied to the cornea

The ic100 from Icare USA utilizes rebound technology, in which a probe momentarily touches the central cornea and then rebounds at a certain rate to determine IOP.

until the force being applied is equal to the pressure in the front of the eye. When these forces are in balance, a pneumatic sensor records the IOP. Dynamic Contour Tonometry (DCT) measures true direct IOP highly independent of corneal properties. The PASCAL DCT from the Ziemer Group is mounted on a slit lamp. The sensor tip covered by a sterile single-use sensor cap contains a miniature pressure sensor and is placed on the central cornea. The concave sensor tip removes surface tension from the cornea and eliminates corneal influences on IOP measurement. PASCAL is ideally suited for measurements on eyes with scars or those that underwent surgical interventions, such as LASIK and PRK. Due to the high sampling rate, PASCAL measures precisely the ocular pulse amplitude (OPA).

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The latest addition to the tonometry family is rebound tonometry. With rebound technology, a probe momentarily touches the central cornea and then rebounds at a certain rate. Icare USA has two handheld devices for eyecare professionals, the ic100 and the TA01l. There are two coils within the device, one for moving the probe toward the eye and one for measuring the probe speed. IOP is based on an algorithm at the point of contact and other motion parameters of the probe. A new probe is used for each patient, and no anesthetic drops are needed.

NON-CONTACT TONOMETERS Non-contact tonometry (or air-puff tonometry) uses a pulse of air to applanate (flatten) the cornea while at the same time an infrared light beam is reflected by the flattened surface. The reflected light is compared to the amount of time it takes for the air puff to flatten the cornea and provide the IOP measurement. Non-contact tonometry is not the most accurate method of measuring IOP but has the ad-

The Diaton Tonometer from BiCOM, Inc. is helpful for patients with corneal abnormalities that would be difficult to measure with contact tonometry.

The non-contact Ocular Response Analyzer G3 from Reichert Technologies minimizes cross-contamination and does not require topical anesthesia or sterilization between patients.

vantage of very low risk of infection transmission since there is no contact with the patient. The Ocular Response Analyzer G3 from Reichert uses dynamic bi-directional applanation to simultaneously measure the IOP and corneal biomechanical properties. This unique and patented method provides the unique corneal hysteresis measurement, which is a tissue property that is independently associated with glaucoma risk. In addition, this information is used to provide an IOP measurement that is compensated for corneal biomechanical properties (IOPcc), which has been shown to be more accurate than other methods of tonometry. The noncontact Ocular Response Analyzer G3 minimizes cross-contamination and does not require topical anesthesia or sterilization between patients. Transpalpebral tonometry measures IOP through the eyelid. The Diaton Tonometer from BiCOM is a handheld device that uses a free-falling rod that rebounds against the outside of the upper eyelid at the tarsus and over the sclera.

Corneal thickness does not influence the reading because it is measured against the sclera and not the cornea. It is effective for patients with corneal abnormalities that would be difficult to measure with contact tonometry. There are some instances where we should not check an IOP measurement. If the patient has a red eye, foreign body or eye trauma, consult with the provider before any tonometry. OO Kim Pickett, COMT, is a certified ophthalmic medical technologist and ophthalmic writer in Minneapolis, MN. WHERE TO FIND IT: BiCOM, Inc. 877.342.8667 | TonometerDiaton.com Contact@TonometerDiaton.com Icare USA 888.422.7313 | Icare-USA.com Reichert Technologies 716.686.4500 | Reichert.com Ziemer USA 866.708.4490 | ZiemerGroup.com USA@ZiemerGroup.com

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AT-A- GLANCE NUTRACEUTICALS FOR DRY EYES SUPPLEMENT

SUGGESTED DAILY INTAKE

FEATURED INGREDIENTS

BENEFITS

Akorn Consumer Health | 800.579.8327 | TheraTears.com TheraTears Eye Nutrition

3 softgels in the morning

PA: 450mg / DHA: 300mg E omega-3s from flaxseed oil: 450mg Vitamin E: 183 IU

• supports eye comfort and healthy tears •a vailable in 90-count, easy-to-swallow softgels

Alcon | 800.757.9780 | ICapsVitamins.com ICaps Eye Vitamin 1 softgel per day Vision Health For- with a meal mula

omega-3s: 280mg FloraGLO lutein: 10mg zeaxanthin: 2mg

• no beta-carotene • contains highly refined fish oil

Bausch + Lomb | 800.553.5340 | Bausch.com Ocuvite Adult 50+

omega-3s: 250mg 1 softgel with morning meal and a lutein: 5mg zeaxanthin: 1mg full glass of water

• replenishes nutrients as you age • also contains vitamins C, E and zinc • supports proper retinal function

EyePromise | 866.833.2800 | EyePromise.com EyePromise EZ Tears

2 softgels

fish oil (TG): 1,480mg total omega-3s: 1,100mg proprietary blend: evening primrose oil, turmeric root extract, green tea leaf extract, N-Acetyl-L-Cysteine, mixed tocotrienol/tocopherol oil

•h elps produce more natural tears with a greater level of lubrication to relieve the associated discomfort and irritation of occasional dry eye • r apid relief as early as one week after initiating supplementation

Fortifeye Vitamins| 866.503.9746 | Fortifeye.com Super Omega-3 Fish Oil

2 softgels daily

Lunovus | 800.980.6551 | Lunovus.us Tear Support PLUS

4 softgels per day

omega-3s: 1,600mg EPA: 860mg / DHA: 580mg

• t riple molecularly distilled triglyceride form of fish oil •c hewable with natural orange/lemon flavor; no odor

omega-3s: 2,668mg EPA: 1,680mg DHA: 560mg

•m olecularly distilled to offer the purest form of omegas • t he process removes mercury and polychlorinated biphenyls out of the oils

Nordic Naturals | 800.662.2544 | NordicNaturals.com Omega Vision

2 softgels daily with food

FloraGLO lutein: 20mg zeaxanthin: 4mg total omega-3s: 1,460mg

•u nique blend promotes eye moisture and tear production • protects from harmful blue light

omega-3 fish oil: 500mg flaxseed oil: 500mg plus lactoferrin, borage seed oil and vitamins E and B6

•c ontains lactoferrin, shown to be half the normal amount in those with dry eyes •o mega-3s suppress inflammation of the tear gland •b orage seed oil activates PGE1 and cAMP which stimulates aqueous tear production

Viteyes | 800.890.3937 | Viteyes.com Dry Eye Formula

1 softgel daily with meal

These statements have not been evaluated by the Food and Drug Administration. These products are not intended to diagnose, treat, cure or prevent any disease.

FOR AN EXPANDED LIST OF NUTRACEUTICALS, GO TO OPTOMETRICOFFICE.COM 28 M a r ch 2 0 1 7 | O p to m e tri c O f f i c e .c o m

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“ T H E N E X T G E N E R AT I O N O F O PTO M E T R I ST S H AV E N O CHOICE BUT TO BE PROACTIVE AND NOT REACTIVE. THEY H AV E T H E POW E R , T H E Y HOLD THE ABILITY TO MAKE THE PROFESSION GO IN A POWERFUL AND POSITIVE P L AC E , B U T I T ’ S U P TO T H E M .” MATT GELLER, OD, Co-founder & CEO, CovalentCareers.com & NewGradOptometry.com, Member, International Vision Expo Young Professionals Advisory Group

MEET THE VISIONARIES in Education + Fashion + Technology VisionExpo.com/Visionaries

NEW YORK THURSDAY, MARCH 30 – SUNDAY, APRIL 2, 2017 BROUGHT TO YOU BY:

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NEW PRODUCT | GALLERY NEW PACKAGING FOR ALCON DAILIES AQUACOMFORT PLUS Beginning the second quarter of 2017, wearers of Alconâ&#x20AC;&#x2122;s DAILIES AquaComfort Plus contact lenses will notice a new package with a fresh design. Inside, theyâ&#x20AC;&#x2122;ll find illustrated instructions for lens preparation, insertion and removal, as well as a patient helpline and email address. A U.S. flag symbol on the new package signifies the product is meant for sale in the U.S. For more information, contact Alcon Laboratories at 800.451.3937 or Alcon.com.

ABYDE SOFTWARE SOLUTION FOR HIPAA MANAGEMENT Continual Compliance Solutions recently launched Abyde software for small and mid-sized healthcare practices to manage HIPAA compliance. Users can obtain information on risk assessment, ongoing compliance, policies and HIPAA training. Abyde software also addresses Meaningful Use, MACRA and MIPS protecting electronic health information core measure. For more information, contact Continual Compliance Solutions at 800.594.0883 or ContinualCompliance.com.

NEW EARTH-FRIENDLY, PERSONALIZED RETAIL BAGS FROM THE AOA MARKETPLACE The American Optometric Association (AOA) is now offering 9-in. x 12-in. biodegradable plastic retail bags that are personalized with your practice information and the AOA member logo imprinted in black lettering. Made in the U.S., bags have fold-over, reinforced die-cut carrying handles and will biodegrade after 18 months (even if not used). The bags are available to members only and come in packs of 250 or discounted packs of 500. For more information, contact the American Optometric Association Marketplace at 800.262.2210, Store.AOA.org or Orders@AOA.org.

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28-LENS ZENLENS DIAGNOSTIC SET FROM BAUSCH + LOMB SPECIALTY VISION PRODUCTS Adding to its 24-lens Dx format that contains two diameters (16mm and 17mm) and two designs (prolate and oblate), this new 28-lens set for Zenlens adds four diagnostic lenses with toric peripheral curves. This helps specialty lens fitters quickly and accurately assess scleral toricity to better determine proper peripheral lens toricity with the Zenlens toric peripheral system. For more information, contact Alden Optical/Bausch + Lomb Specialty Vision Products at 800.253.3669, Bausch.com/ZenLens or AldenOptical.com/ZenLens

ART OPTICAL LAUNCHES AMPLEYE MULTIFOCAL SCLERAL LENS This latest Ampleye design features a center-near multifocal add option to provide scleral lens comfort and gas permeable lens clarity for those with presbyopia. Designed to fully vault the cornea and limbus and land on the sclera with 360° of alignment, Ampleye doesn’t require corneal involvement, simplifying cornea fitting. The standard center-near multifocal zone of 2.00mm is adjustable from 1.00mm to 4.00mm in 0.50mm steps; and add powers can be specified from +1.00D to +3.50D in 0.25D steps. Ampleye’s inherent toric haptic accurately matches the sclera’s true shape for more predictable diagnostic fitting. For more information, contact Art Optical Contact Lens, Inc. at 800.253.9364 or ArtOptical.com.

ROSE K2 SOFT LENSES BY MENICON AMERICA The Rose K2 Soft from Menicon America is indicated for those with intolerance to gas permeable (GP) lenses, new contact lens wearers with irregular corneas or early to moderate irregular corneas, or conditions where the environment may be unsuitable for GP wear or where a GP lens may be unstable, such as sport. The daily wear silicon hydrogel lens is available as a three-month replacement lens. The design features an aspheric back optic zone, front surface toricity and front surface aberration control. Rose K2 Soft uses the same five-step fitting method as all Rose K designs and is available from ABB Optical and from Art Optical Contact Lens, Inc., in addition to other authorized distributors. For more information, contact Menicon America at 800.636.4266 or MeniconAmerica.com.

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DOCS | SPEAK OUT SEASONAL ALLERGIES Every spring, our offices provide treatment and relief for patients with seasonal allergies. The upshot? “Patients realize that we do more than sell glasses and contact lenses,” said one optometrist in this issue’s Docs Speak Out survey. Another OD uses the allergy visit as a way to educate patients regarding “single-use contact lenses for seasonal wear, spectacle updates for seasonal wear and dry eye disease and how it can impact seasonal allergies and contact lens wear.” While some ODs said the season “brings in more patients” and an “enhanced bottom line,” others said their practice hasn’t changed much. But, an overwhelming 80% of optometrists in our survey were in agreement that they felt they did not receive sufficient drug samples from major pharmaceutical companies to initiate a treatment plan. That causes a problem when a patient can’t afford the medication. See below for what respondents suggested to bring relief to those patients.

Are you caring for more seasonal allergy patients now compared to three to five years ago?

When diagnosing seasonal allergic conjunctivitis, which other concomitant conditions are present that complicate the diagnosis? (Select all that apply.) 100

YES 69%

NO 31%

What is your current drug of choice for treating recurrent seasonal allergies? artificial topical decongestant: tears: 6%

topical 3% ester steroid:

12%

combination topical: 79%

60 40

52%

90%

48%

63%

20 0

riti

pha

ble

dry

eye

t ry illa lian ear pap tivitis comp ens w t n l gia njunc non ntact co co

WHAT TO DO WHEN A PATIENT CAN’T AFFORD ALLERGY MEDICATIONS: “Pharmaceutical companies supply discount cards for patients. If not available, attempt to get similar results from generic or OTC products.” “I prescribe a different, less-expensive drop or suggest an over-thecounter drop.” “Occasionally a patient is willing to buy a drug out of pocket if they are uncomfortable. In general, however, we must start with an OTC first or it will cost the patient a significant amount of money.”

“There are older but adequate less expensive alternatives, which usually work but take longer.” “I first will make sure that the condition is properly managed with the prescribed medication using samples. Once improvement is proven, my staff will contact the pharmaceutical company itself, and generally the patient is provided the medication at a significantly reduced fee.” “Go to OTC drops! Zaditor or Alaway.”

“Not an issue. Generics are now very affordable.” “Try a combination of OTC antihistamines, cold compresses and artificial tears.” “Suggest a nutritional or homeopathic drop that addresses allergy reaction.” “Check GoodRx.com for coupons, change the medication prescribed if unsuccessful at overcoming the Prior Authorization requirement.”

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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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