Optometric Office May 2017

OPTOMETRIC OFFICE PRODUCTS AND TECHNOLOGY FOR YOUR PRACTICE

MAY 2017

CONTACT LENSES FOR DIGITAL EYESTRAIN AND DRY EYE

KEEPING AN EYE ON AMD PROGRESSION

INTEGRATE GLAUCOMA CARE INTO YOUR PRACTICE

A NEW DIGITAL EXAM SUITE

THAT DELIVERS TECHNOLOGY AND VALUE SUPPLEMENT TO VCPN MAY 2017

May_Cover_2017.indd 1

4/26/17 1:11 PM

The first contact lens specifically designed

for your patients’ digital life and everyday living_ 9 out of 10

digital device users* agreed that Biofinity Energys™ contact lenses made their eyes feel good1.

8 out of 10

digital device users* agreed that Biofinity Energys™ contact lenses made their eyes feel less tired1.

Biofinity Energys™ contact lenses help with eye tiredness and dryness commonly associated with digital device use. Considering 90 percent of U.S. adults use digital devices more than two hours per day2, the opportunity to upgrade your patients is significant. Biofinity Energys™ contact lenses feature a revolutionary Digital Zone Optics™ lens design and Aquaform® Technology.

Energize your practice—prescribe the patent-pending contact lens innovation made for today's digital lifestyle.

Visit coopervision.com, or talk to your CooperVision® representative for details.

Welcome to the new comfort zone_ * Among patients who use digital devices at least 4 hours per day at least 5 days per week and self-report symptoms of eye fatigue at least once per week.

1 After 1 week of wear; data on file.

2 The Vision Council. Eyes overexposed: the digital device dilemma: 2016 digital eye strain report. ©2016 CooperVision 4107 12/16

Untitled-3 1

4/21/17 4:02 PM

TABLE OF CONTENTS 10

ON THE COVER | VisionChek Digital Exam Suite from Reichert Technologies

DEPARTMENTS 4 | Views 10 | Buzz

18

12 | One-to-One: Anne-Marie Lahr, OD, director of education for Hoya Vision Care 26 | The Optometric Technician 28 | Lubricant Drops At-A-Glance

24

30 | New Product Gallery 32 | Docs Speak Out

FEATURES 8 | Dry Eye—When it’s More than Seasonal Allergies 14 | Advances in Imaging Technology for AMD 16 | Managing AMD with Microperimetry 18 | Stopping Dropouts 20 | 7 Tools to Build the Glaucoma Practice 22 | Care for a Sample?

30

OO_May17.indd 1

24 | Co-Managing Anti-VEGF Therapy

4/26/17 11:30 AM

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 • Randolph Brooks,OD, FAAO • Mile Brujic, OD, FAAO Kenneth Daniels, OD, FAAO • Alan G. Kabat, OD, FAAO Brooke S. Kaplan, OD • Kim Pickett, COMT Leticia Rousso, OD • 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

The most advanced Phoroptor ® ever built.

Phoroptor® VRx Digital Refraction System Incredibly fast. Ultra-quiet. Effortless integration.

Made in the USA with premium components.

Watch the video at reichert.com/vrx

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.

© 2017 AMETEK, Inc. & Reichert, Inc. (4-2017) · Made in USA Phoroptor is a registered trademark of Reichert, Inc. · www.reichert.com

OO_May17.indd 2

4/26/17 11:31 AM

ScleralFil preservative free saline solution ™

NEW

Introducing a solution indicated for scleral lens insertion.

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

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

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

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

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

All-new!

VIEWS CAN YOU HEAR ME NOW?

Pixel-perfect acuity testing.

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

Custom developed for acuity testing. Made in USA. See the full line at reichert.com/clearchart

© 2017 AMETEK, Inc. & Reichert, Inc. (4-2017) · Made in USA ClearChart is a registered trademark of Reichert, Inc. · www.reichert.com

OO_May17.indd 4

It starts almost imperceptibly. As an optometrist, it reminds me a lot of presbyopia. Small changes occur in near vision followed by small modifications of behavior until you realize you need technology to restore function. Progressive spectacle lenses or multifocal contact lenses can be prescribed for most patients with presbyopia today with a successful outcome. But what happens when the condition is presbycusis (age-related hearing loss)?

Dealing with the rigors of air travel, attending industry meetings or spending an afternoon managing international conference calls requires adequate hearing. I was not exposed to high decibel rock concerts in my youth, and as a long-time motorcyclist I always suit up and wear hearing protection. Even so, genetics and the natural act of aging have a way of catching up with you. Both of my parents have hearing loss at ages 93 and 94.

An easy visit to an ENT doc and a hearing test in a sound booth pointed out the obvious—I would benefit with a boost in some frequencies. Just like our industry that went from molded flat tops to digitally surfaced progressive lenses, digital hearing aids have come a long way. The newest technology makes them almost invisible, and in addition to amplifying just the sound frequencies needed they’re also Bluetooth enabled. My iPhone controls the sound programming that can also be set to change automatically by GPS location.

I can now hear the slight movement of keys in my pocket and the quiet turn signals in my car. Music sounds a whole lot better, and I’ve made my wife very happy. My advice to colleagues: if you think you may have some hearing loss, don’t wait until you have to ask your patients repeatedly to repeat themselves. The technology is worth the investment.

Now if you see me in a business meeting and I’m leaning into the conversation, it’s because I’m really interested in hearing what’s been said.

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

4/26/17 11:37 AM

Ask Yourself This Question...

“Why Prescribe?”

OTC Savings Compared to Rx Costs Kills Bacteria on Contact -“0” Eye Irritation Stable 18 Months Opened or Unopened

www.whyprescribe.com © 2016 OCuSOFT, Inc., Rosenberg, TX 77471

Untitled-1 1

For more information and to order, call (800) 233-5469 or visit www.ocusoft.com

12/20/16 12:55 PM

VIEWS GLARING MAD

Corneal Hysteresis: His sight depends on your confidence.

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

Corneal Hysteresis: CPT code 92145 Watch the videos at reichert.com/glaucomaconfidence

© 2017 AMETEK, Inc. & Reichert, Inc. (4-2017) · Made in USA Ocular Response Analyzer is a registered trademark of Reichert, Inc. · www.reichert.com

OO_May17.indd 6

In a rant usually reserved for an outlet like Facebook, I am going to vent about sun glare. While driving the busy, congested roads of the New York City metro area, I am always amazed to see so many people drive without wearing sunglasses. I drive east during my morning commute and head west on my way home. That means a menacing sun on the horizon in both directions that can literally bring traffic to a standstill. And still, a lot of my fellow road warriors are not wearing sunglasses.

Older drivers are more likely to get involved in crashes if glare obstructs their vision, according to a study by the National Center for Statistics and Analysis at the National Highway Traffic Safety Administration. The research found 38.5% of drivers involved in crashes resulting from glare exposure were 45 years of age or older. That’s not to say younger drivers are immune—blindness from the sun results in just that, temporary blindness, and puts all drivers at risk for an accident.

Sun glare is more problematic during the fall and spring— around the time of the equinox—because that’s when the sunrise and sunset are due east and west, respectively.

These periods of extreme sun glare pose a danger to motorists, but the hazard is really visible year-round. For instance, in the winter sunlight reflects off the snow, and the summer sun can reflect off a light-colored dashboard.

I know you are already asking your patients about their lifestyle habits. (Do they spend a lot of time in front of a computer screen or on a mobile device? Do they spend a lot of time outdoors?) Maybe it’s time to ask about their driving habits. Do they wear polarized sunglasses when they get behind the wheel? Who knows? Maybe you’ll be able to upsell them a pair of polarized ophthalmic sunnies for their daily commute—a benefit for both of you.

Rant over.

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

4/26/17 12:53 PM

Refractive

OPD-Scan III Wavefront

TRS Total Refraction Automation

EPIC Refraction Workstation

ARK Autorefraction Systems

ion Anterior Segment Imaging

SOLUTIONS

TRS-5100 Product/Model name: REFRACTOR RT-5100

Marco Refraction Systems – Advanced automated instrumentation includes the OPD-Scan III Integrated Wavefront Aberrometer, the TRS-3100/TRS-5100 and EPIC Digital Refraction Workstation, Autorefractors/Keratometers (with VA measurement, Subjective Sphere Refinement, Tonometry, Glare testing on certain models) and Lensmeters–all with EMR integration. And introducing ion IMAGINGSM System– a highly sophisticated slit lamp integrated anterior segment imaging system that emphasizes image quality, simplicity and efficiency.

Marc OPDDigita Subje Lens a hig emph

The D

The Difference is Marco.

Designed and Manufactured by NIDEK - Represented by Marco 800-874-5274 • marco.com

Untitled-3 1 598 RefSol-ion-OO.indd 1

4/21/17 4:03 PM 4/11/17 10:47 AM

*

THINK ABOUT YOUR EYES

Dry Eye—When it’s More than Seasonal Allergies Dry Eye is a multifactorial disease of the tears and ocular surface resulting in tear film instability that causes symptoms of discomfort, burning, stinging, grittiness, foreign body sensation, tearing, ocular fatigue and dryness. Dry eyes occur as a result of inadequate amount of tears, poor tear quality or a combination of both.

Prevalence rates of dry eyes can be as high as 33%. Risk factors include advanced age, gender (females have a greater risk of dry eyes), smoking, extreme climates, low relative humidity, medications, medical conditions, contact lens wear and computer use.

Optometrists can help diagnose and treat the condition effectively through comprehensive eye examinations. This starts with a thorough case history that lets us identify the symptoms along with the risk factors present. External examination of the eyes and lids then allows us to determine presence of structural problems, quantity and quality of the tear film and the blink dynamics.

Chronic dry eyes can be treated with a variety of different methods. Artificial tears and punctal plugs can help supplement natural tears and help in the retention of tears already produced, but they only treat the symptoms of dry eyes. Immune modulat-

Prevalence rates of dry eyes can be as high as 33%. ing medications such as Restasis and Xiidra can help decrease the inflammatory nature of the disease and increase the eyes’ natural tear production. We must also manage eyelid problems that contribute to dry eyes through the use of lid hygiene techniques and/or medications. Addressing environmental factors such as placement of air vents and humidity is beneficial.

Education regarding the impact of diet and smoking habits is an important component to this discussion. Finally, addressing systemic etiologies (with primary care providers) allows us to be more complete in dry eye management.

The first step in treating dry eye is encouraging patients to schedule annual eye exams. The more we know about our patients’ eye health over time, the better we can narrow down the

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.

causes and potential treatments for dry eye. Think About Your Eyes is a great resource capable of reinforcing the importance of annual comprehensive eye examinations after we have educated our patients about this fact.

Combining our efforts of educating patients along with the advertising the Think About Your Eyes campaign provides means we can improve the quality of life of our patients by addressing the etiology of dry eyes and offering treatment recommendations. OO

8 M a y 2 01 7 | O p to m e tri c O f f i c e .c o m

OO_May17.indd 8

4/26/17 11:37 AM

BILLING AND CODING FOR DRY EYE SERVICES Step 1 |

Obtain your patients’ insurance information

Obtain your patients’ medical insurance in addition to their vision plan coverage. This can be done at the front desk, as a routine part of their check-in process when they arrive.

Step 2 |

Schedule vision and medical exams on separate days

Conduct all vision-related tests during your patients’ first visit, when screening for undiagnosed Dry Eye disease (DED). At screening, if you suspect your patient has DED, schedule a follow-up visit to conduct the medical eye exams.

Step 3 |

Next, code each diagnosis/procedure you conduct. Remember, you can also bill for advanced procedures like punctual plugs, bandage contact lenses and biological corneal membranes.

General Opthalmological services:

92xxx series

Evaluation and Management Services:

99xxx series

Common ICD-10 codes for DED: ry Eye Syndrome of Bilateral Lacrimal D Glands: Keratoconjunctivitis Sicca, not specified as Sjögren’s, bilateral:

H04.123

Sicca Syndrome, Sjögren’s: Neurotrophic Keratoconjunctivitis:

M35.0 H16.233

H16.223

VISION INSURANCE

HOW YOU SEE Contact Lenses

Eyeglasses

Submit the codes to the right payer

Pair each visit code with the codes for diagnoses/procedures conducted at that visit, and submit them to the appropriate vision or medical - insurance company.

Step 5 |

Eye care visits may be reported with either of two sets of codes:

Select the right codes

Code your office visit! The most common DED-related visit codes (depending on the contents of your medical record) are 99213, 99214, 92012 and 92014.

Step 4 |

COMMON CODES

MEDICAL INSURANCE TREATMENT AND MANAGEMENT OF

OCULAR DISEASE

Get paid

Getting remunerated for the treatment and management of your DED patients is crucial. Adding this therapeutic opportunity to your primary practice not only gets your patients the care they need, but also expands your medical management population within your practice.

Tests

Diagnosis

Treatment

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

www.alcon.com

www.santeninc.com

www.shire.com © 2016 BioScience Communications

Untitled-1 1

4/17/17 3:44 PM

Alcon Dry Eye Article 05 Billing 8_5x10_875 OO.indd 1

1/4/17 10:46 AM

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

ESSILOR AND OPTOMETRY GIVING SIGHT AWARD STUDENT LOANS IN MALAWI Essilor of America and Optometry Giving Sight have announced the recipients of study loans for students of optometry at Mzuzu University in Malawi, Africa.

The loans will cover full tuition and living costs for the five years of the Bachelor of Vision Science, commencing in this academic year. “These loans will ensure that economically disadvantaged students are able to complete their studies and then provide urgently needed vision care services to women, men and children in their local communities,” said Howard Purcell, OD, senior vice president, Customer Development Group, Essilor of America, in a press statement. Purcell visited the program in November 2015 and was highly impressed with the School of Optometry, which was established in 2009 and has so far produced 35 graduates. There are currently 71 students enrolled in the program. GivingSight.org.

FDA APPROVES ALCON’S IOL LENS Alcon has received approval from the FDA for its AcrySof IQ ReSTOR +2.5 Multifocal Toric intraocular lens (IOL) with ACTIVEFOCUS optical design for patients undergoing cataract surgery who choose to address their astigmatism and presbyopia at the same time. The unique optical design of the ACTIVEFOCUS toric lens delivers both crisp, clear distance vision and a range of vision for patients who desire less dependence on glasses. Presbyopic cataract patients with astigmatism have had limited options in the past. With ACTIVEFOCUS toric IOL, in which the central portion is 100% dedicated to distance vision, Alcon extends its platform to a broader population. Alcon.com

DROPLESS CATARACT SURGERY STUDY PUBLISHED Dropless Cataract Surgery is a singleuse, injectable combination of antibiotic and steroid formulation administered at the end of cataract surgery to essentially eliminate the need for postsurgery eye drops.

A paper published The recipients of the student loans are (L-R): Adson Mitochi, Mariam Aliya, in the journal CurGibson Nkhwekwe, Kettie Lozario, Tambuzai Liyo and Thandiwe Nyirenda. rent Pharmaceutical the Eastern Virginia Medical School; and Design provides a retrospective review Patrick McDermott, president and chief of data and efficacy of Dropless Cataract innovation officer, Transitions Optical.

Surgery. The findings of the study inPreventBlindness.org. clude: compliance issues are diminished with Dropless compared to standard LENSFERRY S OFFERS POST-EXAM ONLINE post-surgical topical drop therapy; cost ORDERING FOR PATIENTS savings to patients can range from $200 EyeCare Prime has added an option to $600 per cataract procedure; staff for online patient enrollment on its time is significantly reduced without LensFerry S subscription service. This callbacks from patients, insurance and enhanced functionality joins the existpharmacies; and no postoperative ening in-practice enrollment option. Staff dophthalmitis has been reported with can now enter patients into the system Dropless therapy. ImprimisRx.com or following an on-site exam or appointGoDropless.com ment, or–with the new feature–enter a patient’s information later then trigger PREVENT BLINDNESS ELECTS FIVE an email to the patient with contact lens NEW MEMBERS TO NATIONAL BOARD product and pricing details. From there, OF DIRECTORS patients can easily confirm their interPrevent Blindness announced the election est and enroll in a matter of seconds. of five new members to its board of direcAccording to the company, this contors: Andy Davis, COO of Bouchard Invenient, post-exam digital touchpoint surance; Charles Garcia, EVP, director of helps eyecare professionals capture treasury management, Associated Bank, even more subscriptions, keeping conN.A.; Dr. Theodore Gillette, president & tact lens sales and revenue within their CEO, I2, LLC.; Dr. Stephanie Marioneaux, practice. LensFerry.com. assistant professor of ophthalmology at

10 M a y 2 01 7 | O p to m e tri c O f f i c e .c o m

OO_May17.indd 10

4/26/17 11:32 AM

Mounir Ebdellaoi of San Francisco received what was previously out of reach for him—an eye exam and eyeglasses—thanks to an initiative by VSP Global and the U.S. Conference of Mayors.

VSP’S MOBILE EYECARE CLINICS ROLLING OUT FOR SECOND YEAR A pilot partnership between the U.S. Conference of Mayors and VSP Global is being continued for the second year in a row.

The two organizations are teaming up to identify five cities which VSP’s mobile eyecare clinics will visit in outreach events where qualifying adults and children will receive no-cost comprehensive eye exams from a local VSP member optometrist and prescription eyewear if needed.

More than 45 million households in the U.S. don’t have access to vision insurance. Without glasses, adults might have a harder time filling out job applications, performing in the workplace, and other everyday tasks. Healthy vision is essential to children’s ability to learn and achieve their academic potential as well as to play sports and other activities. “We witnessed the impact we were able to have in partnership with VSP and local VSP member optometrists in communities in need and are excited to be able to continue to fulfill that civic duty while making a difference

in people’s lives,” said Tom Cochran, CEO and executive director, U. S. Conference of Mayors. VSPGlobal.com

TANGIBLE SCIENCE ANNOUNCES FIRST LICENSING PARTNERS AND LABORATORIES The Tangible Hydra-PEG coating is designed to reduce discomfort and has been shown to improve wettability, increase surface water retention and lubricity and minimize deposits on lenses. Authorized U.S. lab partners include AccuLens, Advanced Vision Technology, Art Optical, Boston Foundation for Sight, GP Specialists, Metro-Optics, TruForm Optics and X-Cel Specialty Contacts. Contamac is a global licensing partner and offers Tangible Hydra-PEG on its optimum gas permeable lenses. SynergEyes is also a global licensing partner and offers the coating on its Duette hybrid lens materials. TangibleScience.com

ALLERGAN PARTNERS WITH PREVENT BLINDNESS As part of its recently launched “See America” initiative, Allergan is working

with Prevent Blindness to sponsor vision screening events across the country to help provide adults with access to quality vision care. As well as learning about the leading causes of preventable blindness and vision loss, attendees will receive a free Prevent Blindness certified vision screening, referral to professional eyecare and financial assistance as needed.

SeeAmerica.Vision.

News

CooperVision has become the first major contact lens manufacturer to join The Vision Council.

The Envision Broadcast Network merged with Rocking M Media, LLC. The merger will grow and expand employment opportunities in the radio industry for people who are blind or visually impaired.

The FDA has exempted optical lenses from its Unique Device Identifier regulations.

Imprimis Pharmaceuticals acquired license to Klarity, a patented ophthalmic topical solution for patients with dry eye.

FDA approved Lucentis from Genentech for monthly treatment of all forms of diabetic retinopathy.

O p tometr ic O ffic e. c om | March 2017 11

OO_May17.indd 11

4/26/17 11:32 AM

processing. What I learned is that Hoya has the best technology—and when Hoya asked me to be the director of education, I was excited to share the message—and I still am!

RC: Digital surfacing has revolutionized the fabrication of ophthalmic lenses. Where do you see this technology taking us in the next five years?

ONE-TO-ONE Anne-Marie Lahr, OD, earned her doctor of optometry degree at The Ohio State University College of Optometry in 1991. She completed a primary care residency at The Eye Institute at the Pennsylvania College of Optometry, Philadelphia, as well as an international teaching fellowship at the Hogeschool van Utrecht, Utrecht, The Netherlands. Since that time, Lahr dedicated her career to teaching, twice earning the Clinical Science Teacher of the Year Award and, most recently, the Educator of the Year Award for Excellence in Teaching at the Pennsylvania College of Optometry at Salus University. Lahr has lectured extensively within the U.S. and abroad. She is currently the director of education for Hoya Vision Care.

Richard Clompus, OD, FAAO: Optometrists have many choices in their career paths. What attracted you to product development and technical education at Hoya Vision Care?

Anne-Marie Lahr, OD: When I started out in optometry, I had no idea that I’d do anything other than patient care. I then stumbled into teaching optics, and I had to educate myself about lens designs and

AL: I think of digital surfacing like Legos—everyone has the basic technology, but it’s what you do with those blocks that matters. Are you building a basic square or recreating the Statue of Liberty? Every lens manufacturer can say that they “digitally surface” or “free-form” a lens. But what does that mean? Lens manufacturers often take old, outdated lens designs and “digitally surface” them. At Hoya, we freeform a lens on both sides of the lens and split the vertical and horizontal components of the add onto two surfaces. In our premium lens designs, we’re not even dealing with a progressive surface, we’re combining two aspheric surfaces to create a progressive lens. In the future, personalization is where it’s at—considering position of wear, patient lifestyle needs, prior experience with a previously prescribed lens design—all these factors equate to better vision and quality of life for our patients.

RC: Providing high energy blue light protection combined with AR coatings is quickly growing in popularity. Can you share Hoya’s advancements in this area?

AL: Hoya was the first to successfully implement a blue light solution.

Hoya’s advancements regarding blue light protection are multi-fold and ongoing. Hoya is always advancing our technologies to help protect patients from harmful HEV light and to ease the stress of chromatic aberration that is the result of viewing backlit HEV-emitting screens.

RC: Sharing insights about new lens technology is very important to keep our colleagues up to date. In this age of being busy and having short attention spans, what have you found to be the most successful way to communicate technology updates with practitioners?

AL: Ultimately, the bottom line is the benefit to the patient. To communicate the latest technology to opticians, technicians and staff, we offer free ABO courses on our online education portal, EmpowerU. For the OD, we find it valuable to have succinct marketing pieces as well as more in-depth literature, such as white papers. Of course, another tried and true method is to take the docs to dinner and give them a brief presentation while getting to know about them and the current and future needs of the profession while enjoying good food and wine. OO

12 M a y 2 01 7 | O p to m e tri c O f f i c e .c o m

OO_May17.indd 12

4/26/17 12:54 PM

OCULUS Keratograph® 5M Please note: The availability of the products and features may differ in your country.

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

Comprehensive Analysis of the Meibomian Glands

•

NEW: The JENVIS Grading Scales for the meibomian glands

•

Meibo-Scan: Analysis of the meibomian glands of the upper and lower eyelids

•

Comparative display of meibomian glands from up to four examinations

Toll free 888 - 519 - 5375 Follow us! ads@oculususa.com www.oculususa.com

Untitled-3 Office 1 Optometric USA K5M Meibom 215.9x276.23 e 4c 04.17 v2.indd 1

4/21/1712:57:43 4:04 PM 11.04.2017

*

INSTRUMENTATION

Advances in Imaging Technology for AMD Leticia Rousso, OD OCT, FAF, MPOD and more for monitoring patients with macular degeneration.

These advanced non-invasive imaging tools are a safe, efficient and cost-effective way to gain additional information not otherwise seen during clinical examination.

SD-OCT/OCTA Offering an in-depth analysis of retinal tissue, SD-OCT/OCTA has long been used in the management of patients with AMD. The high resolution and fast image acquisition coupled with the ability to dynamically view cross-sectional scans of the retina aids in the diagnosis and management of AMD. OCTA is a newer, non-invasive imaging technique that acquires angiographic information without the use of dye. This system gives information about structural and functional blood flow movement within the retina and choroid by using a unique motion detection technique.

The AngioVue software of the Avanti Widefield OCT from Optovue uses a split-spectrum amplitude deccorelation algorithm and scans at 70,000 A-scans per second in 3.0 seconds.

Optovue AngioVue and ZEISS Angioplex are two commercially available OCTA systems. The AngioVue software of the Avanti Widefield OCT uses a split-spectrum amplitude deccorelation algorithm and scans at 70,000 A-scans per second in 3.0 seconds. AngioVue automatically segments vasculature into superficial and deep inner retinal plexuses, outer retina and choriocapillaris. This segmentation system is useful for detecting, localizing and classifying choroidal neovascular membranes (CNVM) found in wet AMD cases. OCTA allows for early detection of CNVM by examining the outer retinal area between the outer plexiform layer (OPL) and Bruch’s membrane.

FAF Fundus autofluorescence (FAF) is a valuable, non-invasive tool that details the health of the retinal pigment epithelium (RPE). FAF instruments, such as the Canon CR-2 PLUS AF Digital Non-Mydriatic Retinal camera, use a specific wavelength of light absorbed by lipofuscin within the RPE cells, creating a “fluorescence” appearance of the retina. In early and intermediate AMD, FAF can be used to detect sub-clinical alterations in the RPE, allowing for earlier diagnosis and treatment of the disease.

It is important for clinicians to be able to identify and interpret fluorescence pat-

Marco’s AFC-330 features three-dimensional (x-y-z) automatic alignment, to capture clear images in very little time.

terns to determine the status and prognosis of the disease. A normal, healthy fundus exhibits a diffuse homogenous autofluorescence with a decrease in autofluorescence when approaching the fovea. In early AMD, large soft drusen typically appear as defined areas of hyperfluorescence. Small and medium drusen are harder to detect and can present as a normal fluorescence pattern.

Reticular photodrusen are important entities to identify as they are highly associated with disease progression. Photodrusen typically appear as multiple, small, oval areas of hypo-autofluorescence surrounded by normal autofluorescence. FAF is also used in identifying and detecting progression of geographic atrophy, which appears as an area of hypo-autofluorescence on FA. Although all three types of CNVM can have a variable appearance on FAF, many studies have reported common FAF characteristics for each type. A classic (type I) CNVM is often characterized by an area of hypo-autofluorescence with a thin halo of hyper-autofluorescence. An occult (type II) CNVM often shows irregular intensity with multiple areas of hypo-autofluorescence.

Retinal angiomatous proliferation (type III) CNVM typically shows discrete, uniform hypo-autofluorescence.

14 M a y 2 017 | O p to m e tri c O f f i c e .c o m

OO_May17.indd 14

4/26/17 11:32 AM

PERIMETRY Standard automated perimetry (SAP) instruments, such as the Humphrey Field Analyzer from Carl Zeiss Meditec, Inc. or the Octopus 900 from Haag-Streit, have frequently been used to monitor central vision in AMD patients. The Octopus offers a central 10° static Macula field test and has the ability to analyze progression using the EyeSuite Progression Analysis.

Unlike Humphrey and Octopus, Goldman perimetry uses kinetic testing and is performed by an experienced perimetrist.

When compared to standard automated perimetry, short wavelength automated perimetry (SWAP) has been shown to have increased sensitivity in detecting early AMD changes with a decrease in sensitivity as AMD advances.

MPOD QuantifEye MPS II from EyePromise is a computerized device that measures macular pigment optical density (MPOD).

There is a strong association with decreased MPOD and the development and progression of AMD. MPOD testing allows proper recommendation for ocular vitamin supplementation in the early stages of AMD. A recent meta-analysis study revealed that lutein, zeaxanthin and meso-zeaxanthin supplementation improved MPOD both in patients with AMD and healthy subjects.

RETINAL PHOTOGRAPHY Scanning Laser Ophthalmoscopy (SLO) is a relatively new imaging technique producing high image resolution, improved contrast and enhanced penetration through ocular media, particularly cataract formation.

The Canon CR-2 PLUS AF Digital Non-Mydriatic Retinal camera can be used to detect sub-clinical alterations in the RPE allowing for earlier diagnosis and treatment of the disease.

CenterVue has two products that adopt the confocal technology of SLO systems but use a white LED to guarantee true color images. This new technology has the benefit of combining SLO and Fundus camera capabilities. The Compass from CenterVue is a commercially available SLO device also offering both anatomy and function analysis by including an automated perimeter using a real-time retinal tracker.

The Eidon, another commercially available device from CenterVue, offers a true color widefield confocal view of the retina with excellent image quality and resolution.

This instrument has the capability of combining autofluorescence with the Eidon AF. SLO infrared imaging is a useful feature in detecting sub-clinical structural changes in the macula seen in the early stages of AMD. Other retinal cameras to consider: Marco’s AFC-330 features three-dimensional (x-y-z) automatic alignment, to capture clear images in very little time. The camera also includes automatic 3D stereo imaging, auto-panoramic imaging and external photography.

Daytona and California from Optos offer optomap the only clinically validated, ultra-widefield, retinal image. Only optomap captures up to 200° or 82% of the

retina in a single image, according to the company. Using a green laser, optomap af captures images that allow for visualization of the metabolic changes in the retinal pigment epithelium to identify areas that may be at high risk for AMD and other ocular disease. OO Leticia Rousso, OD, is an instructor at Nova Southeastern University in Fort Lauderdale, FL. WHERE TO FIND IT: Canon 800-970-7227 |USA.Canon.com Carl Zeiss Meditec, Inc. 800.342.9821 | Meditec.Zeiss.com/USA CenterVue, Inc. 408.988.8404 | CenterVue.com InfoUS@CenterVue.com Haag-Streit USA 800.787.5426 | Haag-Streit-USA.com GDellacqua@Reliance-Medical.com Marco 800.874.5274 | Marco.com Optos 800.854.3039 | Optos.com Optovue Inc. 866-344-8948 | Optovue.com Info@Optovue.com

O p tometr ic O ffic e.com | May 2017 15

OO_May17.indd 15

4/26/17 12:56 PM

*

INSTRUMENTATION

Managing AMD with Microperimetry

By Alan G. Kabat, OD, FAAO How fundus perimetry detects changes in progression that may go unnoticed.

Age-related macular degeneration (AMD) is a leading cause of visual impairment. As many as 11 million Americans have some form of AMD, and that number is expected to double by 2050. Fortunately, we now have therapies that can help stabilize or even reverse vision loss in “wet” AMD, including EYLEA (aflibercept), Lucentis (ranibizumab), Avastin (bevacizumab) and Macugen (pegaptanib), as well as laser photocoagulation. Unfortunately, the wet form accounts for only 10% of AMD cases. Dry AMD is typically managed with high-dose antioxidant vitamins and zinc in an effort to delay or prevent the condition—and vision—from worsening. These measures are no guarantee against progression, however, and therefore careful monitoring is critical.

Enter, microperimetry (fundus perimetry). This technology permits the simultaneous correlation of function with structural changes at the level of the macula. While standard perimetry detects the ability to perceive light in different aspects of one’s visual field, microperimetry utilizes projected light directly onto focal areas of the retina and combines those sensitivity measurements with a corresponding retinal image, thereby precisely associating functional data with anatomical information. Through the use of an automated eye-tracking system, micro-

perimeters ensure repeatability and even account for eccentric fixation. In AMD, microperimetry can detect small, localized functional changes due to atrophy or neovascularization that might otherwise go undetected. It also has the ability to track progression over time by determining which changes are statistically significant and which represent an inherent disease variation. Here are two microperimeters available in the U.S.: MP-3 Microperimeter from NIDEK employs a digital fundus camera and computerized perimeter that uses stimulus projection within the region of interest.

An infrared light source allows testing to be done under non-mydriatic conditions.

Automatic image registration ensures accurate test-to-test repeatability. As a means of reliability, an analysis of fixation stability (stable or unstable) and location (central or eccentric) is generated for each exam. Results of these analyses can be viewed as either a numerical representation (in dB) for each stimulus point or as an interpolated color map. The MP-3 has a 10.4-inch color touch screen testing display and requires a dedicated computer and monitor.

MAIA Macular Integrity Assessment from CenterVue, Inc. utilizes a confocal scanning laser ophthalmoscope (SLO) rather than a digital camera to obtain its retinal image. The SLO is better

MAIA from CenterVue utilizes a confocal scanning laser ophthalmoscope rather than a digital camera to obtain its retinal image.

able to penetrate cloudy ocular media with less degradation than traditional photography. MAIA also uses infrared lighting and is therefore non-mydriatic and boasts many of the same features as the MP-3, such as precision eye tracking, numerical and colorimetric sensitivity representation, and fixation stability assessment. It compares results to a normative database, rating assessments as “normal,” “suspect” or “abnormal.” It also has the ability to compare prior and subsequent examinations. In terms of size, MAIA is roughly equivalent to the MP-3, but because it is self-contained (with a touch screen interface) and requires no external computer or monitor, it maintains a smaller office “footprint.” MAIA is also available with scotopic test capability and offers a FDA-approved biofeedback module to help train patient fixation stability and eccentric vision. OO Alan G. Kabat, OD, FAAO, is professor, Southern College of Optometry in Memphis, TN. WHERE TO FIND IT: CenterVue, Inc. 408.988.8404 | CenterVue.com InfoUS@CenterVue.com Nidek, Inc. 800.223.9044 | USA.Nidek.com

16 M a y 2 01 7 | O p to m e tri c O f f i c e .c o m

OO_May17.indd 16

4/26/17 11:33 AM

YO U R PAT I E N T S ’ E Y E S TA K E I N A L O T. Sometimes it’s not all good. SYSTANE ® BALANCE Lubricant Eye Drops are scientifically formulated to work on all 3 layers of the tear film, protecting the ocular surface with ingredients that increase lipid layer thickness by 40%.*,1 Recommend SYSTANE ® BALANCE to your patients for the temporary relief of dry eye symptoms, and see how science leads to real relief. *Prospective, randomized, double-masked, single-dose, contralateral eye study, N=40.

Lipid layer thickness was measured in nanometers, and baseline measurement was 63.38.

1. Korb D, et al. Evaluation of extended tear stability by two emulsion based artifi cial tears.

Poster presented at: 6th International Conference on the Tear Film and Ocular Surface: Basic Science and Clinical Relevance; September 22-25, 2010; Florence, Italy.

Untitled-3 1 97177_US-SYS-16-E-5049.indd 1

The Relief is Real © 2016 Novartis 12/16 US-SYS-16-E-5049

4/21/17 4:05 AM PM 4/4/17 9:02

*

CONTACT LENSES

Stopping Dropouts

By Brooke S. Kaplan, OD New advances are keeping patients with dry eye or those who use digital devices in contact lenses longer.

In my practice, patients present on a daily basis complaining of new discomfort in contact lenses that they’ve worn for years.

In the past two years, contact lens manufacturers have addressed the complaint and have made major improvements to their lens arsenal to combat two major causes of lens dropout: digital eyestrain and dry eye.

TREATING THE OCULAR SURFACE First and foremost, treatment of the ocular surface is paramount to successful contact lens wear. We have every patient over the age of 18 complete a dry eye questionnaire before they are even brought back for the work-up. It’s amazing how many patients are off the chart on the symptomology score, but as soon as I mention treating their dry eye, they retort, “Oh, that only happens when I wear my contacts.” If I see signs behind the slit lamp that directly contradict that statement, like meibomian gland dysfunction for example, I educate patients that no contact lens I put on their eye will feel good. I start them on a dry eye regimen and bring them back for the contact lens evaluation. The plan depends on the eye.

I always recommend HydroEye, a dry eye supplement from ScienceBased Health, as the first defense along with warm compresses using a Bruder mask and drops (Restasis, Xiidra and Freshkote lubricant eye drops are at the top of the list).

AIR OPTIX plus HydraGlyde from Alcon helps prevent end-of-day discomfort.

DAILY DISPOSABLES Once the ocular surface is clear, the goal is to prevent these symptoms from returning. My number one recommendation to every patient with any contact-lens-related dryness are daily disposable lenses.

With patients wanting to wear contacts for longer hours and later into their lives, I usually start with a daily that has a full family of products (sphere, toric and multifocal) such as clariti 1 day lenses from CooperVision and Biotrue ONEday contact lenses from Bausch + Lomb. The Biotrue lens is specifically designed for digital device use due to its non-blink-activated rewetting system. Patients appreciate hearing this, and I have had multiple patients describe both of these lenses as a “breath of fresh air” for their eyes.

MONTHLY MODALITIES If a patient is not interested in a daily disposable lens because of cost, several

monthly options are available. Bausch + Lomb’s ULTRA has the same hydration system as the Biotrue ONEday lenses.

CooperVision recently launched Energys, a digital device lens in the Biofinity family. The aspheric optics help with end-of-day awareness and strain that patients tend to experience when looking at computers for eight hours a day. In addition, Alcon just released AIR OPTIX plus HydraGlyde (which will replace the AIR OPTIX Aqua) that helps prevent end-ofday discomfort as well.

MULTIFOCALS Don’t forget that a part of lens discomfort could be from straining to see. How many early presbyopes walk in the office refusing to admit that they cannot read up close anymore? Now couple that with long hours of near demand and it is a recipe for disaster. A vast majority of patients need to see clearly at multiple distances.

18 M a y 2 01 7 | O p to m e tri c O f f i c e .c o m

OO_May17.indd 18

4/26/17 11:33 AM

This can only be achieved in multifocals.

Will it take more chair time? Yes. Will it take more follow-ups to get it right? Yes. Come up with an “all inclusive” plan or set your fees appropriately for follow up visits, but I assure you, it will be worth it because these patients will be yours for life. Plus, they will recommend you to family and friends. Again, I always talk multifocal first. I mentioned the Biotrue ONEday for Presbyopia and clariti 1 day multifocal lenses before. I also like Alcon’s family of DAILIES because they are available in a medium add. With the DAILIES TOTAL1 Multifocal, comfort and vision are excellent.

As for monthly lenses, ULTRA, Biofinity and Alcon’s AIR OPTIX plus HydraGlyde are all excellent options for ideal vision and comfort. The key to success with multifocals from any manufacturer is setting the patient up for realistic expectations. Vision is almost always going to be sharper in their glasses, but the contact lenses can give them functional vision at all ranges.

Biotrue ONEday contact lenses from Bausch + Lomb offers a full family of products for the patient continuum.

LENS SOLUTION Another tip for successful contact lens wear in patients with dry eye is solution compatibility. It is up to us to educate the patient about the difference between generic and name brand solutions. If they are already using a good solution, like Blink RevitaLens from Johnson & Johnson Vision, adding a peroxide-based solution, such as CLEAR CARE PLUS from Alcon, can be just the boost the lens needs to extend wearing time to the end of the day.

For those dealing with severe dry eye patients and who enjoy prescribing specialty lenses, the use of scleral lenses can be considered for the treatment of the ocular surface disease. Giving the patient

The aspheric optics in Energys from CooperVision minimizes the eyestrain that patients tend to experience when looking at computers for eight hours a day.

a well of hydration throughout the day can make or break the patient’s ability to function with contact lenses.

Patients with dryness, either contactlens-induced or otherwise, can now wear contacts with lens formulary improving by leaps-and-bounds every year. You can make a major impact in your patients’ lives with just a little more chair time that equates to a vast improvement in quality of life. Your patients will be extremely grateful to have an eye doctor who took the time to listen and work with to find the right lens for them. OO Brooke S. Kaplan, OD, is in private practice in Mountain Brook, AL. WHERE TO FIND IT: Alcon Laboratories 800.451.3937 | Alcon.com Allergan 800.347.4500 | Allergan.com Bausch + Lomb 800.828.9030 | www.Bausch.com/ECP Bruder Healthcare Company 888.827.8337, ext.203 | BruderOphthalmic.com CooperVision, Inc. 800.341.2020 | CooperVision.com Johnson & Johnson Vision 800-843-2020 | ACUVUEProfessional.com ScienceBased Health 888.433.4726 | ScienceBasedHealth.com Shire 617.349.0200 | Shire.com

O p tometr ic O ffic e.com | May 2017 19

OO_May17.indd 19

4/26/17 12:58 PM

*

PATIENT CARE

7 Tools to Build the Glaucoma Practice

By Mile Brujic, OD, FAAO Incorporating technologies to care for both glaucoma suspects and patients is critical.

Optometry’s role in medical eyecare continues to expand. As such, many in the profession are contributing in the care of chronic ocular conditions. Take glaucoma, for example. The long-term visually debilitating effects of this disease make it critical for us to identify individuals with this disease early and to provide appropriate medical therapy and referrals for surgical consultations when indicated.

The Ocular Response Analyzer G3 from Reichert measures corneal hysteresis, a marker associated with optic nerve and visual field damage in glaucoma.

Here are the tools to embrace glaucoma care as an important part of the care you deliver to patients.

1 GONIOSCOPY This is fundamental and should be done once a year on glaucoma patients and glaucoma suspects. This gives us an indication of whether additional concerns exist with the patient, including any areas of angle recession, excessive pigment in the anterior chamber angle, the presence of narrow angles along with any other abnormalities of the iris or the angle that may influence the way aqueous leaves the eye through the trabecular meshwork.

2 THRESHOLD VISUAL FIELD TESTING Measuring threshold visual fields and being able to monitor them over time is critical to appropriately care for both glaucoma suspects and glaucoma patients.

Although this is often a difficult test for patients, it is critical to perform repeatedly to assess visual function. Standard threshold visual field testing typically involves testing 30° from the point of fixation in the nasal region and anywhere from 24° to 30° in all other areas of the field. Remember to periodically assess the central 10° of the visual field in those individuals who appear to have decreased sensitivity in this region

The Diopsys NOVA ERG and VEP Vision Testing System is useful in detecting functional changes prior to structural changes.

with other testing strategies. Also keep in mind that this technology has many other clinical uses including the investigation of neurological conditions and monitoring visual function in patients taking plaquenil.

3 FUNDUS PHOTOGRAPHY This is considered a standard of care in the management of patients who are either glaucoma suspect or diagnosed with glaucoma. It is critical in detecting subtle changes in the optic nerve head architecture that over time would be difficult to detect utilizing subjective assessments describing the cup-to-disc ratio and the rim tissue characteristics. It is often difficult to identify subtle changes in the nerve fiber layer with the physical examination and is much more easily viewed in a static image that can be viewed with a variety of filters. Interestingly, in an ocular hypertensive treatment trial, a majority of the optic nerve head hemorrhages were

20 M a y 2 01 7 | O p to m e tri c O f f i c e .c o m

OO_May17.indd 20

4/26/17 11:33 AM

discovered upon optic nerve head photography inspection. This very point and its association with increased risk of developing glaucoma and also progressing glaucoma warrants regular fundus photography of the optic nerve.

4 OPTICAL COHERENCE TOMOGRAPHY This single technology has changed the way we assess the macula, optic nerve and the anterior segment. Nerve fiber layer thickness has been a longstanding anatomical structure that we have tracked in glaucoma. With advances in optical coherence tomography (OCT) technology, our ability to measure the nerve fiber layer around the optic nerve has increased in its level of accuracy and repeatability.

The ganglion cell complex is now a common measurement that is evaluated and analyzed. This typically measures the thickness of the nerve fiber layer and the ganglion cell layer up to the inner plexiform layer in the macular region. This provides the clinician with an additional diagnostic tool to study an anatomical structure over time that may indicate treatment is warranted for a patient.

Icare HOME measures IOP outside of the office to more accurately gauge fluctuations.

The Avanti Widefield OCT from Optovue provides eyecare professionals in-depth analysis of ocular structures.

Additionally, the OCT provides the clinician the opportunity to accurately measure the central corneal thickness.

It also offers the clinician views of the angle between the iris and the cornea. It is important to note that this is complementary to gonioscopy and does not take the place of performing gonioscopy on both glaucoma suspects and those being treated for this disease.

5 CORNEAL HYSTERESIS Corneal hysteresis reflects the ability of corneal tissue to absorb and dissipate energy during a bidirectional applanation process. The Ocular Response Analyzer G3 from Reichert measures this. Clinically, low corneal hysteresis is associated with optic nerve and visual field damage in glaucoma and the risk of structural and functional glaucoma progression.

6 ELECTRORETINOGRAM Pattern electoretinograms (pERG) measure the retinal ganglion cells response to contrast reversing visual stimuli. This test has the extraordinary ability to detect functional changes in an objective manner prior to structural changes. This is becoming increasingly integrated into eyecare practices as a strategy to detect glaucoma at an earlier phase.

7 HOME-BASED TONOMETRY The FDA recently approved the Icare HOME, allowing patients to have the ability to measure intraocular pressure (IOP) at home. This will provide us the ability to determine whether out-of-office IOP fluctuations are greater than what would be indicated by in-office measurements.

With more IOP readings, we will be better able to cater appropriate therapy to those patients who may need it most.

Through proper testing, we have access to information that will help us both educate and manage our patients. Consider incorporating these technologies to improve outcomes and provide contemporary care for your glaucoma patients. OO Mile Brujic, OD, FAAO, is owner of Premier Vision Group in Bowling Green, OH. WHERE TO FIND IT: Diopsys, Inc. 973-244-0622 | Diopsys.com Icare USA 888.422.7313 | Icare-USA.com Optovue Inc. Â 866-344-8948 | Optovue.com Info@Optovue.com Reichert Technologies 716.686.4500 | Reichert.com

O p tometr ic O ffic e.com | May 2017 21

OO_May17.indd 21

4/26/17 11:34 AM

*

PATIENT CARE SAMPLE CHECKLIST

Care for a Sample?

To avoid risk with samples, the physician should have a SOP (standard operating procedure) in place to monitor the inventory and reduce risks. Here are a few items to include: Avoid giving medication samples for long-term use unless they are part of a program that includes pharmacy review and dispensing.

Always check the expiration date and the sample package integrity.

Ask patients to bring their medications to the visit and review. Examine the bottles for samples versus prescribed and expiration dates.

Store medication samples in accordance with manufacturers’ labeling and in locked cabinets away from patient and staff traffic.

Maintain a log of samples to avoid theft and discard old samples.

•

By Kenneth Daniels, OD, FAAO What to consider when stocking a drug sample—from its true cost to when to use one.

As I walk the square in Cape May, NJ, all of the fudge shops are handing out free samples. Of course, I partake then succumb to the need to buy one or two pounds of the treat. How is this different than your patients who need a medication but have gotten used to you handing them free samples? Drug samples come with a cost.

Take contact lenses, for example. Patients assume that the trial lens is “free” – but in actuality there is a cost. The practitioner must purchase revenue boxes to be able to obtain additional diagnostic lenses.

Pharmaceutical companies offer limited free sampling to enhance the recognition of the product by the practitioner and to encourage writing of the prescription for the patient. And then there is the potential outcomes of clinical decisions.

DOCS AND PHARMA It is usually the contact with the pharmaceutical sales representative that will influence the utilization of the drug more so than peer-reviewed data, (which can be influenced by the selection of study investigators). This suggests that the adoption of a new drug is more likely related to commercial influences rather than to a doctor’s professional insight and knowledge of research on treatment outcomes. The strategy is if one can see it on the shelf or on the counter, they will more likely prescribe it.

The utilization of certain medications based on company-prepared, marketing-

based information can be very informative—but also very biased. As such, the physicians’ utilization of drug samples may place a higher level of risk against clinically guided decision making. Company representatives with similar products will typically present information and statistics about the prowess of their drug and demean the other pharmaceuticals. To guard against treatment risks, physicians should not depend on the provided information and consider declining drug samples if they are unsure of the clinical outcomes or the risks to the patient.

WHEN SAMPLES MATTER Topical drops are the mainstay in which samples are particularly useful in an emergency situation or after-hours prescribing. I will often receive a call from a patient after hours about “red eye” and email the prescription only to have the pharmacy already closed. In this situation, the antibiotic or steroid sample is sorely needed to start therapy and avoid potentially catastrophic delay of care.

In dry eye therapy, a sample will never get you to the therapeutic threshold to understand the clinical outcomes. It requires multiple weeks to determine a subjective and objective effect. In this case, we use the sample to simply explain how to administer the drop and what the packaging looks like to avoid errors at the pharmacy. Glaucoma falls into the same category. A 1 ml sample

• • • •

will last one or two days, but you can’t realistically determine the clinical success of therapy in that time. The only time a sample anti-glaucoma agent is useful, for example, is a post-operative cataract IOP spike or the use of a sample bottle for postrefractive infection and/or inflammation.

Lastly, if affordability is an issue, there are many sources from the pharmaceutical companies to assist based on financial need. Direct your patients to utilize rebates and pharmaceutical coupons to assist in cost reduction. We offer a page on our website for such programs and refer patients to the URL. Samples are not bad, but like too many pieces of fudge, they just need to be utilized in moderation. OO Kenneth Daniels, OD, FAAO, is in private practice at SeeLife Hopewell and Lambertville Eye Associates in NJ.

22 M a y 2 01 7 | O p to m e tri c O f f i c e .c o m

OO_May17.indd 22

4/26/17 11:34 AM

Untitled-2 1

4/17/17 4:18 PM

*

PHARMACEUTICAL

Co-Managing Anti-VEGF Therapy

By Randolph Brooks, OD, FAAO Overcome the challenges of coordinating care for patients with AMD. Optometrists represent the patient’s primary entry into eye health and vision care and often provide secondary care in the treatment and management of many ocular diseases. We also refer for consultation and treatment when appropriate and will co-manage patients with macular degeneration with a retinal specialist once the referral decision has been made. Oftentimes, patients present with comorbidities including ocular hypertension and primary open angle glaucoma.

Coordination of care with retinal specialists presents a number of challenges to practitioners. Clinical outcomes can be enhanced by preparing for and anticipating potential issues.

PATIENT COUNSELING Counseling is a critical component of patient care and may involve recommendations to change a patient’s lifestyle, such as advising better nutrition including AREDS 2 formulation, stopping smoking, avoidance of beta carotene in smokers and UV protection in spectacle correction. Although retinal specialists may convey some or all of this information to patients, counseling by an optometrist, including written material as well as staff reinforcement, will lead to better clinical outcomes.

FOLLOW UP Some patients fail to understand the need for follow-up treatment with the consulting

retinal specialist and fail to keep followup appointments unless they have vision symptoms. However, a fairly large percentage of patients who have discernible vision loss will keep their appointments for retina follow-ups but fail to follow up with their primary care optometrist.

It is essential that patients in the latter group receive the proper messaging from the retinal specialist: retinal examinations and treatment, including intra-

appointment scheduled in our office. If no follow-up appointment has been made or a previously scheduled one needs to be changed, we make a phone call to the patient to schedule that appointment.

In the event that a patient has failed to return to us in an appropriate time interval and has not responded to either recall letters or phone calls, the doctor will call the retinal specialist and discuss the patients’ failure to return to us for needed

Anti-VEGF treatment by the retinal specialist does not replace the need for optometrist follow-up in patients who have co-morbidities such as glaucoma. vitreal injections, do not replace the need for comprehensive eye exams by their optometrist Conversely, it is critical that the treating optometrist and staff impress upon the patient the sub-specialty nature of their retinal visits and the need for followup with their optometric physician at appropriate intervals.

INTERPROFESSIONAL COMMUNICATIONS In our office, receipt of co-management reports from the retinal specialist represents another opportunity for a touch point. All reports received are reviewed and initialed by the optometrist providing care in our office. We also make appropriate notes that are added as an addendum in their electronic record, and we ask our staff to be certain the patient has an appropriate

care. In those cases, the retinal specialist makes the appropriate notes in the patient chart to have a discussion at the next visit regarding appointments with their referring optometrist.

TWO-WAY STREET Conveying patient information is a two-way street and is not limited to us receiving reports from the treating retinal specialist. It is equally important for retinal specialists to receive reports from us including our OCT images as well as refractive information and IOPs. Remember that visual acuities are usually performed by one of their staff members and may or may not be the patient’s appropriate distance vision correction.

Moreover, other than a possible pinhole test, there is usually no attempt to refract

24 M a y 2 01 7 | O p to m e tri c O f f i c e .c o m

OO_May17.indd 24

4/26/17 11:34 AM

for best corrected visual acuity. Patients treated with anti-VEGF agents may have variability and/or changes in refraction and may be unaware that their vision may be corrected more fully. Patients rely on us to provide them with best corrected visual acuity, and retinal specialists rely on us to provide their offices with that important information.

GLAUCOMA Anti-VEGF treatment by the retinal specialist does not replace the need for optometrist follow-up in patients who have co-morbidities such as glaucoma. Their tonometry readings are often performed by technicians who may be using a handheld electronic tonometer rather than a Goldman applanation tonometer. Additionally, retinal specialists rarely perform threshold visual fields on patients, nor will they typically perform OCTs of the optic nerve head or other diagnostic testing appropriate for glaucoma patients. Patients need to understand the importance of follow-up with their treating optometrist. It is also incumbent upon the treating optometrist to stress to

the retinal specialist that they need to advise their patient to follow-up with their optometrist at appropriate intervals.

NEW RISKS It has been well documented that antiVEGF treatment may result in both short-term IOP spikes as well as longterm IOP increases. A recently published study has reported that patients receiving seven or more bevacizumab injections are associated with a statistically significant risk for the need for glaucoma surgery. This further reinforces the need for all of our patients to be scheduled for and receive appropriate care in our offices. It is even more critical that our ocular hypertensives and glaucoma patients fully understand this risk and be scheduled for follow-up diagnostic testing and treatment by the referring physician. It is especially challenging from a patient adherence perspective given that the very patients at the most risk, those receiving seven or more bevacizumab injections, will likely be the most resistant to multiple office visits from both their retinal specialist and their optometrist.

INSURANCE ISSUES As we have all seen firsthand, patients rarely understand the difference between their medical coverage and any routine vision plan. Our patients need us to fully explain that their follow-up care in our office is medical in nature and not subject to the limitations of a vision plan covering an annual eye exam. Conversely, it is incumbent on our staff to understand the role of patient deductibles and copays to support patient adherence to our treatment plan.

Treatment and follow-up should always be at your comfort level and with mutually agreed upon clinical protocols based on patient retinal diagnosis and comorbidities. Make sure there is threeway communication between the patient, the consulting retinal specialist and the referring optometrist. Keeping the patient centered at the forefront of the treatment plan will help ensure the best possible clinical outcomes. OO Randolph Brooks, OD, FAAO, is in private practice at Advanced Eyecare Associates in Ledgewood, NJ

O p tometr ic O ffic e. com | May 2017 25

OO_May17.indd 25

4/26/17 11:34 AM

THE | OPTOMETRIC TECHNICIAN

BY KIM PICKETT, COMT TAKE YOUR TECHNICIAN SKILLS TO THE NEXT LEVEL WITH THESE TIPS FOR STAFF TRAINING. As an optometric technician, you need to keep current through continuing education. Even though a lot of what you learn is on the job, that doesn’t mean you can’t get a little help now and then.

CONTACT LENSES If your office fits contacts, you may not need to search any further than the lens manufacturers. Bausch + Lomb’s website offers a wealth of information for eyecare

INSTRUMENTS Whether your office is considering a new piece of equipment or you simply want to learn more about your existing equipment, again, look to a manufacturer’s website.

For instance, Reichert Technologies has PDFs, videos and diagrams describing the Ocular Response Analyzer G3 and the principle of corneal hysteresis. Marco offers videos and animated brochures for some products on its website as well.

Being creative with staff education is a great way to continuously learn at your own pace and tailor it to your needs. professionals. This includes lens and lens care videos, patient information booklets and a gallery of clinical slit lamp eye photos from corneal diseases to contact lens fittings. Parameters and key features for all the Bausch + Lomb lenses can easily be found on the website as well.

Alcon created the Academy for Eye Care Excellence to provide ECPs with updated training and information. While most of the content is geared toward optometrists and optometry students, there is some information for the optometric technician.

For instance, A Guide to Clinical Contact Lens Management is a reference for all contact lens practitioners regardless of experience.

The Vision Care Institute offers in-person, hands-on training to optometrists, but Johnson & Johnson Vision’s website houses a video and webinar library for all ECPs. You can learn about their different products and access fitting guides. Patient education and practice resources are available online as well.

Optovue has a more structured online training module, which includes OCT training videos, with Optovue Academy.

The technician training track consists of

five lessons starting with an overview of the iVue OCT system up to the acquisition of optic nerve and retinal scans. The dashboard shows a clear summary of your lesson progress and makes it easy to come right back to where you left off.

PATIENT CARE Buying groups and alliances are other resources for staff training. IDOC, an alliance for independent optometrists, offers staff training sessions (some with ABO credits) at its national and regional meetings as well as a closed Facebook group for members. PEN (Primary Eyecare Network), a division of ABB Optical Group, offers quality education programs to independent optometric practices. The classes include both webinars and in-person programs covering myriad topics from lensometry to billing.

Marco offers an animated video of the AFC-330 to explain the camera’s technology and features.

26 M a y 2 01 7 | O p to m e tri c O f f i c e .c o m

OO_May17.indd 26

4/26/17 11:34 AM

CONTINUING ED Are you in need of CE credits? The American Optometric Association (AOA) has a wide range of courses and study guides available in CD-ROM and book formats in the Paraoptometric and Education Training Product Catalog. AOA Associate members also have access to articles in PDF format. Members may download an archived article, complete the exam, and mail the answer sheet with a small fee.

The member will receive one hour of CE for successfully passing the exam at the end of each article.

Quantum Optical presents web-based classes for paraoptometric, ABO and NCLE credits. This organization will grade the accompanying test immediately and send the credit directly to your email account. Topics include dry eye, diabetes, contact lenses and pediatric dispensing to name a few. Standard, gold and platinum memberships are available with varying costs and benefits.

EyeCareCE by JCAHPO (Joint Commission on Allied Health in Ophthalmology) has an enormous library of online CE courses for the entire eyecare team. There are classes offered for JCAHPO, ABO and NCLE credit. Another section is devoted to courses for practice managers, scribes and front office personnel. One option is the annual Clinic CE Subscription plan that provides unlimited access to over 150 JCAHPO courses for all clinic staff for one fee.

First Vision Media Group (publisher of Optometric Office) also offers courses for credit on the TotallyOptical.com website.

The online education page features CE classes on eyewear, lenses, digital eyestrain and more.

Being creative with staff education is a great way to continuously learn at your own pace and tailor it to your needs. OO Kim Pickett, COMT, is a certified ophthalmic medical technologist and ophthalmic writer in Minneapolis, MN.

Optovue Academy offers a technician training track.

WHERE TO FIND IT: Alcon 800.241.5999 | MyAlcon.com Bausch + Lomb 800.553.5340 | www.Bausch.com/ECP EyeCareCE 800.284.3937| EyeCareCE.JCAHPO.org IDOC 203.853.3333 | IDOC.net.

Johnson & Johnson Vision 800.843.2020 | ACUVUEProfessional.com Marco 800.874.5274 | Marco.com Optovue Academy OptovueAcademy.com | Academy@Optovue.com PEN, a division of ABB OPTICAL GROUP PrimaryEye.net | Info@PrimaryEye.net Quantum Optical QuantumOptical.com Reichert Technologies, Inc. 716.686.4500 | Reichert.com

O p tometr ic O ffic e. com | May 2017 27

OO_May17.indd 27

4/26/17 11:35 AM

AT-A- GLANCE LUBRICATING DROPS FOR DRY EYES COMPANY

DIRECTIONS

KEY INGREDIENT(S)

BENEFITS

Akorn Consumer Health | 800.579.8327 | TheraTears.com TheraTears Dry Eye Therapy

1-2 drops as needed

sodium carboxymethylcellulose 0.25%

•h ypotonic and electrolyte balanced formula replicates healthy tears •a vailable in nighttime and preservative-free formulas

Alcon Laboratories | 800.451.3937 | Systane.com Systane Balance

1-2 drops as needed

propylene glycol 0.6%

•h elps restore lipid layer by replenishing moisture •w orks on all three layers of tear film • r elieves moderate to severe dry eye symptoms • t hicker gel formulation also available

Allergan | 800.347.4500 | RefreshBrand.com Refresh Plus

1-2 drops as needed

carboxymethylcellulose sodium 0.5%

• preservative-free •p rovides long-lasting moisture and gentle enough for sensitive eyes • recommended for post-LASIK dryness • available in gel formula

Bausch + Lomb | 800.828.9030 | www.Bausch.com/ECP Soothe XP

remove contact lenses; 1-2 drops in affected eye(s) as needed

light mineral oil: 1.0% mineral oil: 4.5%

•c ontains Restoryl mineral oils to restore outer lipid layer • s eals in moisture and helps to prevent further irritation •a vailable in nighttime, long-lasting hydration and preservative-free formulas

Johnson & Johnson Vision | 800.843.2020 | JustBlink.com Blink Tears

1-2 drops as needed

polyethylene glycol 400 0.25%

•h yposmolar, viscoelastic formula mimics tears to restore tear film • r elieves mild to moderate dry eye symptoms •a vailable in gel and preservative-free formulas

Natural Ophthalmics | 877.220.9710 | NatOph.com Tear Stimulation Forté

1-3 drops as needed

Alumina HPUS 10x •p reservative-free and can be used with Arscuicam album HPUS 12x contact lenses NUX moschata HPUS 6x •h omeopathic formula stimulates Zincum met HPUS 10x production of all three tear film layers Euphrasia (Eyebright) HPUS 5x • special women’s formula available

OCuSOFT, Inc. | 800.346.2922 | RetaineBrand.com Retaine MGD Ophthalmic Solution

1-2 drops in affected eyes as needed

light mineral oil: 0.5% mineral oil: 0.5%

•u ses electrostatic attraction to stabilize tear film • r eplenishes lipid layer and reduces tear evaporation • preservative free

Prestige Brands | 877.274.1787 | ClearEyes.com Clear Eyes Pure Relief

1-2 drops

glycerin: 0.25%

•c ontains a built-in purifying filter to prevent bacteria • preservative free • one-drop control, soft-squeeze bottle

2 8 M a y 2 01 7 | O p to m e tri c O f f i c e .c o m

OO_May17.indd 28

4/26/17 11:35 AM

Think About Your Eyes Advertising Has Driven

1,153,512

Incremental Eye Exams! and

$494.5 Million Total Additional Industry Revenue!

57-0536-TAYE-OO-April-Ad.indd Untitled-1 1 1

3/13/17 3/13/17 10:18 8:59 AM

NEW PRODUCT | GALLERY SOLUTIONREACH INTRODUCES SR CONVERSATIONS SR Conversations, a new chat feature from Solutionreach, allows ECPs to categorize incoming texts to determine priority—without extra equipment or an additional phone number. ECPs are also able to view the full thread of messaging between practice and patient, and messages are synced to a patient database so the practice can identify who is texting. Patients can also initiate texts, reducing the number of phone calls to the practice. For more information, contact Solutionreach at 866.605.6867 or Solutionreach.com.

ICARE HOME NOW AVAILABLE IN U.S.

Icare USA’s at-home tonometer uses the same patented rebound technology as the company’s other Icare tonometers, allowing ECPs to observe patients’ IOP fluctuations throughout the day. Icare Home is easy to use and requires no special skills. Its built-in EyeSmart technology performs automatic OD/OS recognition, and EasyPos allows for easy positioning. Icare Home also features Icare AMS, which takes either a single measurement or a series of six with one touch of a button. For more information, contact Icare USA at 888.422.7313 or Icare-USA.com.

NEW LIGHT FOAM LID CLEANSER FROM CLIRADEX

Ideal for preventative care, mild to moderate lid irritation and everyday ocular hygiene, Cliradex Light Foam Cleanser helps to relieve irritation naturally and prevent dry eye disease and blepharitis. The natural, preservative-free lid and lash cleanser contains 4-Terpineol (T40), a component of tea tree oil, and can be used two to three times daily for maximum benefits.

For more information, contact Cliradex at 844.425.4723, or Cliradex.com.

30 M a y 2 01 7 | O p to m e tri c O f f i c e .c o m

OO_May17.indd 30

4/26/17 11:35 AM

TECHNOLOGY, VALUE AND THE ELEMENTS OF REFRACTION FROM REICHERT The latest offering from Reichert Technologies is a cost-effective solution to compete against the digital exam lane of the large chains. The VisionChek Digital Exam Suite includes: SightChek Digital Phoroptor, AcuityChek Digital Acuity Chart (with an option to upgrade to ClearChart 4X Enhanced Digital Acuity System or ClearChart 4P Polarized Digital Acuity System), OptoChek Plus Auto Refractor + Keratometer and choice of LensChek Plus Digital Lensometer or LensChek Pro Digital Lensometer with PD + UV. Reichert’s flagship digital Phoroptor VRx, “made of premium components and build quality,” according to the company, can be bundled with the same pre-test and acuity devices. For more information, contact Reichert Technologies at 716.686.4500 or Reichert.com/ VisionChek.

BAUSCH + LOMB ADDS ULTRA FOR ASTIGMATISM These new monthly toric contact lenses from Bausch + Lomb provide clear vision and all-day comfort for patients with astigmatism. ULTRA for Astigmatism silicone hydrogel lenses combine the company’s MoistureSeal technology, which maintains 95% of lens moisture for 16 hours, with its OpticAlign design for stability. The addition of the toric lens expands the ULTRA product portfolio to offer a full family of monthly replacement lenses. For more information, contact Bausch + Lomb at 800.828.9030 or www.

Bausch.com/ECP.

EYEFINITY LAUNCHES REVENUE CYCLE MANAGEMENT Revenue Cycle Management (RCM) from Eyefinity supports ECPs with a team of over 500 associates, including 100 CPC/AHIMA certified and AAPC certified professional coders, to help with medical coding, A/R management, patient billing, denial management and appeals. RCM also provides benefits verification for payers, compliance issues, payment options for patients and more at a flat monthly rate. For more information, contact Eyefinity at 877.448.0707 or Eyefinity.com.

O p tometr ic O ffic e.com | May 2017 31

OO_May17.indd 31

4/26/17 11:35 AM

DOCS | SPEAK OUT GROWING YOUR PRACTICE Managing a modern optometric practice requires the integration of new technology—and staff. It’s always a good idea to upgrade technology that improves patient care. But the success of most practices is also dependent upon the delegation of duties to trained and dedicated staff. While some optometrists said that staff turnover was not a problem, what do you do when there’s room to grow and you have to hire? That’s the question we asked in this issue’s Docs Speak Out survey. Here’s where optometrists start when seeking to hire new staff.

To grow your practice, which do you explore first? delegating more duties to current staff

31%

YES 13% 69%

adding new staff

Has the number of staff directly involved with patient care changed in the past three years? increased by two people

NO 31% acquiring new instruments with better technology

14%

stayed the same

25%

56%

80

60

40

increased by three people

25%

sales rep provides hands-on training

70

50

25%

increased by one person

How do you train your staff to operate new instruments in your practice?

(Select all that apply.)

30

staff reads manuals

9% 22% 36% 77% 60%

20 10 0

decreased by two people 3%

decreased by one person 8%

independent consultant/ trainer is hired to train staff

staff views internet-based video training provided by the manufacturer

optometrist trains staff

RESOURCES YOU USE WHEN LOOKING TO HIRE STAFF: “Vision Source website, professional community, reps, online and local agencies.”

“My office manager handles this, allowing me more time for patients.”

“Word-of-mouth referrals and medical staffing agencies.”

“The local technical college.”

“Facebook, interviews with team leaders, rest of staff and doctors. We also run ads, observe potential employee hires in the community in other work environments.”

“Online advertising and knowledge by the current staff of those who apply.”

“Local Eye Site.”

“Social media.”

“I haven’t had a new hire in ten years!”

“We have an ideal staff member profile against which we compare the applicants.”

“Friends of current staff, internet (Indeed and Craigslist), and even recommendations from patients.”

“Word of mouth from sales reps.”

“State association newsletter.”

“Zip Recruiter, Indeed and word of mouth.”

“We use a temp agency to trial new staff.”

3 2 M a y 2 01 7 | O p to m e tri c O f f i c e .c o m

OO_May17.indd 32

4/26/17 11:35 AM

Untitled-3 1

4/21/17 4:06 PM

For work play and a

special day Patients want multiple pairs of eyewear to enhance the way they live. Help make them easier to purchase from your practice with promotional financing options* available through the CareCredit credit card.

Call for more information and enroll at no cost today^.

866.853.8432

www.carecredit.com

visioninfo@carecredit.com

* Subject to credit approval. Minimum monthly payments required. See carecredit.com for details. ^ Subject to change.

Untitled-3 1

OO0517OA

4/21/17 4:02 PM