Optometric Office May 2018 by First Vision Media Group

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OPTOMETRIC OFFICE PRODUCTS AND TECHNOLOGY FOR YOUR PRACTICE

MAY 2018

DAILIES TOTAL1® MULTIFOC AL CO NTAC T LENSES

THIS IS WHY correcting

presbyopia will never be the same

>80%

DISTANCE

>80% 33%

INTERMEDIATE

WATER CONTENT (%)

NEAR

UNIQUE WATER GRADIENT TECHNOLOGY

The world’s first and only Water Gradient lens designed for presbyopic patients. Seamless Vision Correction

Exceptional Comfort 3

Industry-leading Precision Profile™ Design is built to deliver clear, uninterrupted vision.1,2

Water Gradient technology creates a cushion of moisture on the eye.4

PERFORMANCE DRIVEN BY SCIENCE ®

References: 1. Alcon data on file, 2017. 2. Alcon data on file, 2008. 3. Alcon data on file, 2011. 4. Angelini TE, Nixon RM, Dunn AC, et al. Viscoelasticity and mesh-size at the surface of hydrogels characterized with microrheology. Invest Ophthalmol Vis Sci. 2013;54:E-abstract 500. See product instructions for complete wear, care and safety information. © 2016 Novartis 4/17 US-DTM-17-E-1026

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OPTOMETRIC OFFICE PRODUCTS AND TECHNOLOGY FOR YOUR PRACTICE

ONE-TO-ONE: THOMAS ALLER, OD ON MYOPIA CONTOL

SOLVE DRYNESS IN CONTACT LENS PATIENTS

MAY 2018

INJECTABLE AGENTS TO PREVENT VISION LOSS

AMD DIAGNOSIS GOES DARK IMPAIRED DARK ADAPTATION IS AN EARLY WARNING SUPPLEMENT TO VCPN MAY 2018

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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

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OPTOMETRIC OFFICE EDITORIAL STAFF

Table of Contents

VP, Editorial John Sailer | JSailer@ FVMG.com Editor-in-Chief Jeffrey Eisenberg | JEisenberg@FVMG.com Editor Cara Aidone Huzinec | CHuzinec@FVMG.com Creative Director Megan LaSalla | MLaSalla@FVMG.com Production and Web Manager Anthony Floreno | AFloreno@FVMG.com Contributing Writers Robert A. Ryan, OD, FAAO Leo P. Semes, OD, FAAO • Bridgitte Shen Lee, OD

DEPARTMENTS

BUSINESS STAFF President/Publisher Terry Tanker | TTanker@FVMG.com Executive Vice President Shawn Mery | SMery@FVMG.com Vice President, Marketing Debby Corriveau | DCorriveau@FVMG.com

2 | Views 4 | Think About Your Eyes

5 | Product Buzz 6 | One-to-One

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

13 | At a Glance 14 | New Product Gallery 16 | Docs Speak Out

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.

FEATURES

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.

10 | CONTACT LENSES: SOLVE THE DRYNESS PROBLEM

8 | INSTRUMENTS: AMD DIAGNOSIS GOES DARK

12 | PHARMACEUTICALS: INJECTABLES FOR NEOVASCULARIZATION Cover art courtesy of Maculogix, Inc.

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VIEWS

Jeffrey Eisenberg

FUNNY STORIES AND YUMMY KNISHES DESPITE SEVERE VISION LOSS My grandmother had a dear friend of many years whom I always knew as “Aunt” Reba. She was quite the remarkable woman during her approximately 104 years. She worked in a sweater factory starting at age 14 to help support her family; raised thousands of dollars for a charity that helped women, children and families; and helped play matchmaker to a number of couples, including my grandparents. Even well into her 90s, she could entertain the family with her stories, make known her strong political opinions, and bake incredible knishes. While she could make knishes based on years of doing so, she had trouble with such visual tasks as signing her name to a check or identifying people in a photo. I had edited enough articles about age-related macular degeneration and seen pictures simulating how the world appears to an individual with AMD. Still, I had a whole new perspective as I watched her struggle, even with the help of a magnifier, to make sure she signed on the line, to pick out people from a group photo and even to see letters on the Snellen chart when she visited her eyecare practitioner. Whatever complaints she expressed about other maladies of old age or loneliness from having outlived friends and family, I don’t recall her complaining about her vision loss. Still, I can only begin to imagine how it felt. Numerous studies have shown that vision loss due to AMD is associated with increased risk of depression and anxiety. To show how important vision is to individuals, in one study,

an average person with 20/40 vision was willing to trade two of every 10 remaining years of life in return for perfect vision, while the average person with counting fingers vision in the better eye was willing to trade about five of every 10 remaining years. The good news is that AMD does not need to be an automatic sentence to blindness. In this month’s issue, Leo P. Semes, OD, FAAO, discusses technology to measure dark adaptation that may enable you to detect AMD almost three years before other signs such as drusen can be observed on clinical exam (page 8). This gives you time to monitor the patient and suggest strategies, such as quitting smoking, making dietary changes and taking supplements, to prevent, or at least delay, vision loss. For patients whose conditions progress, injectable medications can treat neovascularization, offering hope not only to patients with AMD but those with diabetic retinopathy and diabetic macular edema. We offer a review of two such agents (page 12). Though not AMD related, Robert A. Ryan brought greatly improved visual acuity and increased comfort to an individual who experienced 20/100 vision, lagophthalmos, exposure keratopathy and dry eye following tumor resection. Read more about this case, his outside-the-box approach, and some tips for keeping patients in contact lenses despite dry eye (page 10). Semes points out how having advanced technology will help differentiate your practice. What also helps differentiate your practice is the patient who, for many years, is still able to read a novel, sign a check, follow a recipe, or enjoy viewing family pictures.

*** Jeffrey Eisenberg | Editor-In-Chief | JEisenberg@FVMG.com

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101733

DAILIES TOTAL1® MULTIFO C AL CO NTAC T LENSES

THIS IS WHY correcting

presbyopia will never be the same

>80%

DISTANCE

>80% 33%

INTERMEDIATE

WATER CONTENT (%)

NEAR

The world’s first and only Water Gradient lens designed for presbyopic patients.

UNIQUE WATER GRADIENT TECHNOLOGY

Seamless Vision Correction

Exceptional Comfort 3

Industry-leading Precision Profile™ Design is built to deliver clear, uninterrupted vision.1,2

Water Gradient technology creates a cushion of moisture on the eye.4

PERFORMANCE DRIVEN BY SCIENCE ®

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THINK ABOUT YOUR EYES

COMMON ISSUE, MANY CAUSES Patients often think that dry eye is a normal condition to experience. Numerous over-the-counter eye drops promise to relieve dry eye, leading patients to think it’s not a matter for their eye doctors. In fact, 60% to 70% of the patients in my practice have dry eye symptoms, yet many have not thought to seek professional treatment. CONNECT THE DOTS

Increased amounts of screen time play a big part in dry eye, meibomian gland dysfunction (MGD), and other symptoms of digital eye strain. We ask our patients about screen habits in order to “connect the dots”—that is, to help them understand there are solutions to prevent and relieve both dry eye and symptoms of digital eye strain. In addition to increased digital screen time, other common causes of dry eye symptoms in healthy patients include ingredients in eye makeup ingredients, application of eyeliner across the lid margin, eyelash extensions, frequent air travel, contact lens wear, LASIK and dehydration. MGD, the leading cause of dry eye symptoms, occurs due to blockage or atrophy of the sebaceous glands at the edge of the upper and lower eyelids. These glands secrete the meibum (oil or lipid) that protects the natural tear from evaporating and stabilizes the tear film. Top MGD symptoms are burning, watery eyes and foreign-body sensation. Other dry eye symptoms include eyes that are red and feel itchy, gritty and tired. Patients also experience blurry or fluctuating vision. Patients often think their symptoms are the result of allergies and treat these actual or alleged allergies with over-the-counter drops. Patients often complain about blurry vision without mentioning dry eye, assuming the two are unrelated.

HOMEWORK

During a patient’s routine eye exam, we discuss and review digital eye strain, dry eye, and MGD symptoms and prescribe vision correction solutions. We also perform meibomian gland imaging (via LipiView) on every patient aged 18 and older to identify MGD and to guide our treatment options.

Bridgitte Shen Lee, OD Bridgitte Shen Lee, OD, the founder and CEO of Vision Optique in Houston and iTravelCE, writes and lectures on digital eye health, dry eye disease, anti-aging eyecare, healthcare social media, and aesthetic optometry. Shen Lee is one of the TFOS (Tear Film & Ocular Surface Society) global ambassadors representing the U.S. She is one of 19,000 doctors listed on the Think About Your Eyes doctor locator. First Vision Media Group is a media partner of Think About Your Eyes. We schedule patients we identify as having dry eye or MGD for a separate medical eye exam. We educate our patients on why we give them glasses with anti-fatigue and blue light/UV protections and prescribe the latest one-day modality contact lenses. We also give patients “homework.” Their assignment: Learn about the multifactorial and chronic nature of dry eye disease and treatment options. Vision Optique has a designated website section, YouTube playlist, and Facebook albums that use patient-friendly language and visual examples.

QUALITY OF LIFE

Dry eye disease affects patients’ vision and quality of life. Early detection and education should be a part of every patient’s annual eye exam. Think About Your Eyes, the vision industry’s public awareness campaign, encourages patients to schedule an annual eye exam with their optometrists and promotes the importance of both vision and eye health. These annual exams give you the opportunity to diagnose symptoms of dry eye disease and educate your patients. O|O

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PRODUCT | BUZZ LAUNCHES, PROMOTIONS, MERCHANDISING, EVENTS AND OTHER THINGS TO KEEP YOU IN THE KNOW. DIRECT-TO-PATIENT SHIPPING IMPROVES ODS’ CONTACT LENS SALES For SCL, practices with high DTP share outpace market growth

10 8

4 2 0

8.2%

8.3%

8.4%

8.5%

8.6%

6.3%

Total Dollar Growth

7.8%

7.2%

Nation

<= 10%

> 10%

> 15%

> 20%

> 35%

> 40%

> 45%

DTP dollar share

Eyecare practices that ship more than 10% of soft contact lens sales directly to patients outpace the national average for dollar growth, while those with little to no direct-to-patient shipping activity under perform the national average, according to ABB OPTICAL GROUP’S analysis of 2017 sales data from about 11,000 eyecare offices. The national average for direct-to-patient dollar share was 25%, and the national average for dollar growth in 2017 was 7.2%. Practices with more than 45% direct-to-patient dollar share grew 8.6% year-over-year, while practices with less than 10% direct-to-patient dollar share only grew at 6.3%. The data also show that patients are seven times less likely to return contact lenses that are shipped directly to their homes or workplaces. Go to ABBOptical.com.

NEW AI SCREENING TOOL FOR DIABETIC RETINOPATHY

The U.S. Food and Drug Administration has granted IDx its De Novo request to market IDx-DR, a software program that uses an artificial intelligence algorithm to analyze images of the eye taken with a Topcon NW400 retinal camera. You upload the digital images of the patient’s retinas to a cloud server on which

IDx-DR software is installed, and the software provides one of two results: “more than mild diabetic retinopathy detected; refer to an eyecare professional” or “negative for more than mild diabetic retinopathy; rescreen in 12 months.” IDx-DR is available for immediate installation. Call 319.248.5620, or go to EyeDiagnosis.net/diabetes.

E-VISION DEMONSTRATES ELECTRONIC CONTACT LENSES

News The California Optometric Association honored Anthem Blue Cross of California with a Health Care LeaderVisionary Award for partnering with ODs and health clinics to deliver comprehensive diabetes screenings, including eye exams. EyeCarePro offers free campaign materials about allergy, including a poster, Facebook cover and posts, a website interstitial page, eblast and point-of-care materials, at hubspot. EyeCarePro.net/allergies-giveaway?utm_campaign. Two abstracts supporting EyePoint Pharmaceuticals’ YUTIQ (fluocinolone acetonide 0.18mg) intravitreal implant, a three-year micro-insert for noninfectious posterior segment uveitis, were accepted for presentation at the Association for Research in Vision and Ophthalmology 2018 Annual Meeting.

E-Vision Smart Optics has completed a platform device to demonstrate its electronic contact lenses, which are currently in development. The base optical power for the contact lenses is molded into a polymer, and liquid crystal molecules are sandwiched between thin layers of the polymer. When a small voltage is applied, these molecules change their optical properties from no optical power to 1.00D, 2.00D or 3.00D. Higher and more distinct optical powers may also be designed into the lens. Features of the electronic contact lenses will include an onboard power/control, remote setting and activation, dimensions that fit within current contact lens size requirements, and up to 4.00D of control that can be switched in 50 milliseconds. Go to EVisionOptics.com.

RETINAL IMAGING COLLABORATION ENHANCES ZEISS OCT DEVICES

The Advanced Retinal Imaging Network, a global consortium of doctors, clinicians, and scientists, has collaborated with ZEISS to integrate new advanced technologies into the PLEX Elite 9000 Swept-Source OCT/OCTA platform. Advances include visualization tools enabling wider and deeper imaging of the eye for improved visualization of agerelated macular degeneration and diabetic retinopathy. These new visualization technologies developed for PLEX Elite have been integrated into the CIRRUS OCT and OCT angiography platforms for use in daily clinical practice. Go to ZEISS.com/ ARINetwork.

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would start at age 8 or 9 and stop at age 16 or 17. In my area in the Silicon Valley and the Bay Area, everybody’s on computers. It didn’t seem like people were stopping at age 16 or 17. That’s when I had to decide: Either I’d been a lousy optometrist or my professors must’ve been wrong. That’s what led me on a quest to see which of those was actually the case, and it’s been quite a journey since then.

ONE-TO-ONE

Thomas Aller

Thomas Aller, OD, FBCLA, launched an educational and informational website, ManageMyopia.org, last month. Aller, who has been conducting myopia control research for more than 25 years, is the clinical content editor and curator for the website, which will summarize the latest data on myopia. He is a visiting scholar at UC Berkeley School of Optometry and an adjunct professor at University of Houston College of Optometry and serves on several boards. Aller also developed Myappia, an app for Android devices that lets ODs predict the progression of a child’s myopia in 10 years.

Jeffrey Eisenberg: You’re considered an authority on myopia. Will you tell us more about your experience?

Thomas Aller, OD: I’ve been actively treating myopia with various methods for over 25 years. I first started getting interested in optometry as an ortho-K patient myself. Just the ability to make significant changes in people’s vision was somewhat enticing and probably led me on some level to think about optometry. There wasn’t really any research to back up being able to control myopia [progression] when I was a student. We were taught that myopia was largely genetic and that it

JE: Why did you start this particular website? TA: I had some websites for my business. They mostly feature my work in myopia and my practice but nothing intended for the larger profession. About two years ago, I started working with a new contact lens from Visioneering Technologies, Inc. called the NaturalVue Multifocal 1 Day. We started working together and doing a pilot study in my practice. I did a little speaking for them. They had an interest in developing a website that would be directed toward practitioners interested in myopia control, and they asked me to be the editor for it. So, they did the groundwork to set it up, and they’ve given me resources to update it and maintain it. They’ve allowed me to have a board of advisors that I’ve selected from the field to give me the benefit of perspectives from other areas of expertise. It officially launched in conjunction with the Vision By Design Conference. What we intend it to be is an up-to-date, useful resource for practicing optometrists or ophthalmologists interested in either starting or improving a myopia control practice. I think it’ll be a good opportunity to try to move the profession into the area of myopia management. JE: Isn’t myopia management something ODs already do as part of their overall services? TA: Myopia has been considered simply to be a refractive error that you correct with lenses to put the focus back on the retina. There has been increasing interest in incorporating methods for actually controlling myopia progression into hopefully everyone’s practice. We know that there are a number of ways that myopia progression can be controlled. Just increasing the number of hours spent outdoors, primarily before a child becomes nearsighted, has been shown to delay the beginning of myopia. That’s valuable and free, and every kid can do it. There are some eyeglass strategies that are helpful for certain categories of patients. Some innovations are coming in spectacle designs that may make these types of lenses

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more effective than they have been in the past. Then, the three big ones that generate a lot of interest and a lot of research would be low-dose atropine, orthokeratology, and bifocal and multifocal contact lenses. A consensus has been developing that these are all effective treatments that are reasonable for any optometrist or ophthalmologist to provide for their patients. At some point, I hope that these types of treatments will be their standard of care and that every progressing young myope will be offered one of these types of methods for slowing down their myopia progression. JE: What do you expect to be some of the future areas of myopia research? TA: Right now, one of the big challenges for the contact lens industry is that contact lens manufacturers are aware that they could create contact lenses that would control myopia if they’re not already doing so and that practitioners are already using their lenses. But, none of the lenses in the U.S. have an indication from the FDA for the treatment of myopia progression. So, pretty much everything in the U.S. is off-label. In Europe, for instance, there are contact lenses that have achieved a CE mark for myopia control. In those markets the manufacturers are a little bit more free to make claims about what their lenses can do. The FDA had a meeting in 2016 to try to develop new standards for evaluating and granting approval to a contact lens for the control of myopia. They’re likely to require studies that might be three to four years in length that would have to perhaps show a 50% control of myopia progression as compared to a control group. The control group might be spectacles or standard contact lenses. You’re going to want research to prove that when children wear contact lenses they have no higher rates of infection than adults. There have been some interesting eyeglass innovations, and then there are some atropine studies. There’s a multi-site study in the U.S. on low-dose atropine 0.01% through the Pediatric Eye Disease Investigator Group. There are some pharmaceuticals. JE: On your website you talked about the long-term impact of myopia. It sounds as though this research is really necessary to delay some of these other problems that can result. TA: Projections have been done by the Brien Holden Vision Institute. They looked at current rates and projected in all the countries for which they had data what the likely number of myopes would be by the year 2050. What they came up with

was an estimate of five billion people with myopia by the year 2050. Of that number, one billion are projected to have high myopia. It’s in the high levels of myopia in which we expect there to be significant impact on the health of the eye. There’s a range between four and 15 times increase in retinal detachment with higher levels of myopia. Even cataracts show a two to five times increase with myopia. Glaucoma is running about a two to three times increase with myopia. And then there’s a newly recognized disease: myopic maculopathy. It’s not quite the same as macular degeneration from age-related reasons, but it targets the macula and causes scarring. There’s a 60 times increase in that condition in people with high myopia. Myopia is now the number one leading cause of new blindness in some areas in Asia. All of these conditions, including myopia itself, are irreversible for the most part. In terms of their linkage to myopia, you can think of them as preventable. At least you can lower the risks. A paradox has been pointed out by Irish ophthalmologist Ian Flitcroft: There’s a higher risk of all these pathologies with any level of myopia. Even a low myope has an increased risk, so he would urge his colleagues and has urged everyone to treat myopia a little bit more seriously, even the low levels. The other point he likes to make is that there are quite a few more people in the world with -1.00D to -5.00D of myopia, levels that are considered low to moderate. But, because there are so many more of those people, you’re actually going to find more pathology in low to moderate myopes. There are so many more of them than patients with -7.00D to -8.00D, so he doesn’t think that we should think of myopia in terms of these two different levels as though they’re different conditions. JE: What do you plan to add to ManageMyopia.org in the future? TA: We’re expanding the content from what’s on there now to be more inclusive of each of the various treatments that are available. We’re going to have content available only to registered doctors that will include practice-management tips from clinicians who have a lot of experience in practicing myopia control. We’re going to have a lot of information on consumer marketing, social media strategies, how to get referrals and how to build a referral network. We’ll have some sources that give us some guidance on how parents view myopia, what concerns them, and what might drive them to consider specialty care in this area. I hope to deliver a lot of very useful information for the practicing doctors.

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INSTRUMENTATION

AMD | DIAGNOSIS GOES DARK Impaired dark adaptation in AMD patients appears even before there are clinically visible signs.

PROGRESSION PROGRESSION

NoAMD AMD No

Nodrusen drusen ••No NoAMD AMDpigmentary pigmentaryabnormalities abnormalities ••No Normaldark darkadaption adaption ••Normal

SubclinicalAMD AMD Subclinical

Nodrusen drusenororsmall smalldrusen drusen ••No NoAMD AMDpigmentary pigmentaryabnormalities abnormalities ••No Impaireddark darkadaption adaption ••Impaired

EarlyAMD AMD Early

+/-Small Smallorormedium mediumdrusen drusen ••+/+/-AMDpigmentary pigmentaryabnormalities abnormalities ••+/-AMD Impaireddark darkadaption adaption ••Impaired

IntermediateAMD AMD Intermediate

largedruse druse>>125µm 125µm ••11large AnyAMD AMDpigmentary pigmentaryabnormalities abnormalities ••Any

AdvancedAMD AMD––22forms forms Advanced Geography Geography Atrophy Atrophy

Choroidal Choroidal Neovascularization Neovascularization

By L eo P. S emes, OD , FAAO An estimated 1.8 million Americans aged 40 and older already have agerelated macular degeneration (AMD), according to the Centers for Disease Control and Prevention. An additional 7.3 million with large drusen are at substantial risk for vision loss. Even so, the prevalence of AMD remains under diagnosed. One crosssectional study, for example, found that primary eyecare providers, both optometrists and ophthalmologists, missed one in four cases of AMD.1 That finding isn’t entirely surprising given that individuals often experience night vision problems early in the disease process, a finding that doesn’t show up when measuring

high-contrast Snellen acuity or structural imaging technology. However, we now can objectively measure dark adaptation, the time it takes for the eye to adjust from bright light to darkness, known as dark adaptation, to diagnose individuals with AMD as many as three years before any visible clinical findings.

NONINVASIVE TEST

The AdaptDx from Maculogix, Inc. is a non-invasive tabletop instrument that can measure dark adaptation rapidly. Gregory Jackson, PhD, cofounder and chief technology officer of Maculogix, was the principal inventor. While I was still teaching at University of Alabama at

Birmingham, my colleagues at the optometry clinic and I became among the first doctors to use the device. In a darkened room, patients rest their chin and forehead on supports similar to those of other ophthalmic instruments. The AdaptDx presents a brief camera-like flash to bring the patient to a light-adapted state. It then presents a bleaching stimulus just above the macula, then the detection stimuli become progressively dimmer. The patient presses a handheld response button when a stimulus light appears. At the end of the test, the AdaptDx uses a plot to calculate rod intercept time (RIT), which is the number of

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minutes at which the visual sensitivity recovery crosses three log units of recovery. At this point, recovery of visual sensitivity is completely rod-mediated, hence the term “rod intercept.” The rod intercept characterizes dark adaptation speed. To date, patients tested with AdaptDx in clinical studies are past age 50, the same threshold as the Age-Related Eye Disease Study, or AREDS. In the future, we might consider testing patients aged 40 and above with risk factors for AMD, including family history and lifestyle.

SIX-MINUTE ANSWER

The original testing protocol was about 20 minutes, but we now know that a rod intercept time of less than 6.5 minutes is normal, while a rod intercept time greater than 6.5 minutes is an early indicator of retinal disease. In the earlier stages of AMD, a patient can takes three times longer to adapt than a patient without AMD. Patients in the later stages of AMD can take 10 times longer. To be sure, impaired dark adaptation is the first detectable consequence of emerging AMD. Impaired dark adaptation is not a risk factor for AMD; instead it is the earliest manifestation of AMD. The Alabama Study on Early Age-Related Macular Degeneration, or ALSTAR Study, a prospective study of subclinical AMD, looked at 325 adults without clinically detectable AMD.2 At baseline, 24% of the subjects exhibited impaired dark adaptation. Results showed that impaired dark adaptation identifies subclinical AMD at least three years before it can be seen with standard clinical methods. That means the patient may have clinical AMD even in the absence of telltale drusen or changes in the retinal pigment epithelium. Furthermore, ALSTAR shows,

individuals with impaired dark adaptation were twice as likely to develop clinically evident AMD and eight times as likely to advance beyond the earliest stage of AMD. More recently, evidence has been reported that subclinical drusenoid deposits (SDDs) are consistent with prolonged dark adaptation but not by other sophistocated measures except dark adaptation.3 Eyes with clinically normal ocular health and early AMD who have been identified with SDDs warrant careful scrutiny because of their increased risk for incident early AMD and its progression.

START THE CONVERSATION

At this point, further testing is warranted. Once you’ve identified a patient with impaired dark adaptation, use those results to start a conversation with the patient. Ask patients about such questions as lifestyle, smoking, exposure to sunlight and family history of AMD. While you can’t change certain risk factors, you can modify others. For example, you can encourage the patient to quit smoking. You might also recommend dietary changes and use of a supplement containing the AREDS or AREDS2 formula. If your practice offers genetic testing, you might want to recommend that to the patient as well. Consider this example: A patient presents complaining about poor night vision, and the rod intercept is 8.2 minutes. You instruct the patient to return in two weeks for further testing, including optical coherence tomography, at which time there are no visible drusen. You diagnose the patient with subclinical AMD and recommend lifestyle changes, dispense nutraceuticals and provide eyewear to protect against ultraviolet radiation and blue light. The patient returns for follow-up every six months and, as dark adaptation worsens and drusen become more prominent, every three

months. Four years later, you identify early choroidal neovascularization and refer the patient to a retinal specialist. Your timely referral has saved this patient’s vision. In addition, you’ve seen the patient more often to provide medically necessary testing, dispense items that can help prevent vision loss and, in the process, distinguished your practice.

DELAY VISION LOSS

As life expectancy continues to increase, we can expect many more individuals to suffer vision loss due to age-related macular degeneration. Obviously no patient wants to lose vision, especially if we can work with the majority of AMD patients who have the dry, or nonexudative form, and delay their vision loss as much as possible. Besides the benefits to your patients, you also have a way of making your practice stand out. O|O Leo P. Semes, OD, FAAO, a former Professor of Optometry at UAB, has authored more than 250 articles, book chapters and posters and is principal author of the AOA’s Clinical Practice Guideline, Care of the Patient with Ocular Surface Disorders. He is a founding member of the Optometric Glaucoma Society and a founding fellow of the Optometric Retina Society. Semes is a speaker for Maculogix. 1. Neely DC, Bray KJ, Huisingh CE, et al. Prevalence of Undiagnosed Age-Related Macular Degeneration in Primary Eye Care. JAMA Ophthalmol 2017 Jun 1;135(6):570-5. 2. Owsley C, McGwin G Jr, Clark ME, et al. Delayed Rod-Mediated Dark Adaptation Is a Functional Biomarker for Incident Early Age-Related Macular Degeneration. Ophthalmology 2016 Feb;123(2):344-51. 3. Neely D, Zarubina AV, Clark ME, et al. Association Between Visual Function and Subretinal Drusenoid Deposits in Normal and Early Age-Related Macular Degeneration Eyes. Retina. 2017 Jul;37(7):1329-36.

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CONTACT LENSES

CASE FILES:

SOLVE THE DRYNESS PROBLEM Following tumor resection, this patient required contact lenses for symptom relief and improved acuity. By Ro b ert A . Ryan, OD , FAAO A 55-year-old female presented with a history of acoustic neuroma on her left side for which she underwent resection. Following the procedure, she experienced lagophthalmos in her left eye, for which she had a gold weight implanted in her left upper eye lid. She also had exposure keratopathy and dry eye in her left eye. The patient previously had no refractive error and required no vision correction. At this visit, visual acuity was 20/25 in her right eye and 20/100 in her left, limited by the compromised ocular surface. The left eye showed no improvement with refraction. The slit lamp examination revealed a clear cornea in her right eye and grade 3 diffuse punctate keratitis in the left. How would you treat this patient? Read on for more details.

BANDAGE LENS

I fit this patient with a soft bandage lens using an 8.6mm base curve, 13.8mm diameter and plano prescription. I also placed a punctal plug in her left lower lid.

The patient returned three days later complaining of blurred vision and discomfort in the left eye. The punctate keratitis persisted. We placed an alternate bandage lens using an, 8.6mm base curve, 14mm diameter and +0.50D prescription, but this, too, provided little improvement. Searching to deliver additional hydration and improve protection of the ocular surface, I fit her with a semi-scleral gas permeable contact lens using a 7.7mm base curve, 15.0mm diameter and -2.87D prescription. This brought her visual acuity to 20/30 and relieved her symptoms during the daytime hours. However, she remained uncomfortable following removal of the lens at bedtime and throughout the night.

TWO-LENS APPROACH

Eventually, I recommended that she wear TruForm’s DigiForm N1 semi-scleral gas permeable lens during waking hours and switch to CooperVision’s Biofinity lens at bedtime. That way, her cornea would always be protected.

The patient still struggled with poor wettability of the anterior surface of the gas permeable lens. I added a plug to her upper lid as well. This provided a solution to the wettability issue for the next two years. As contact lens technology continued to evolve, I refit her into a Zenlens Prolate from Alden Optical using a 7.8mm base curve, 17mm diameter and +1.50D sphere, which brought her visual acuity to 20/25. I also switched her nighttime lens to Alcon’s DAILIES TOTAL 1 Water Gradient Contact lens, 8.5mm base curve, 14.1mm diameter and -0.50D sphere. This combination resolved her keratopathy and resulted in improved comfort, wettability and visual acuity. The patient eventually developed a dense posterior subcapsular cataract in the left eye. She underwent cataract extraction with an intraocular lens implant, which brought her visual acuity to 20/30.

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TWOFOLD ISSUE

This case demonstrates the need to think outside the proverbial box. The combination of a semi-scleral gas permeable lens during waking hours and a soft contact lens overnight provided adequate relief and surface integrity. She continues to experience relief today with improved visual function and no evidence of hypoxia. Consider how patients might benefit from the particular surface characteristics of different polymers and perhaps employ them in offlabel applications where indicated. For example, the DAILIES Total 1 lens is not approved or designed for overnight wear or as bandage lens therapy. But its surface characteristics satisfied the challenges presented in this case. Without this solution, the patient would likely be debilitated and perhaps a candidate for tarsorrhaphy.

PREVENTING DROPOUTS

Though you may not see cases as severe as this patient’s was, you will likely encounter patients who experience contact lens-related dryness—one of the principle reasons patients discontinue contact lens wear. Treatment may determine whether these patients continue wearing their lenses. When you encounter a contact lens patient with dry eye, your first priority is to evaluate the etiology which, in turn, will determine how you manage the patient. Some considerations: • Is the patient’s condition limited to contact lens wear, or do symptoms occur even when the patient is not wearing lenses? • Does the patient have blepharitis or meibomian gland dysfunction? • Is this simply a case of tear volume deficiency? • Does the patient have an anatomical issue such as ectropion or one of the issues presented by the patient discussed above?

Management will depend on the pathology. For lid disease, start with conventional means, including warm compresses; digital expression; hypochlorous acid lid cleanser; and oral antibiotic, topical steroid or combination drops. You might also consider omega-3 and fish oil supplements.

MATERIAL CHANGE

You can take additional measures if contact lens wear remains limited. One benefit of daily disposables: There’s no need to use disinfecting agents, which may further compromise the dry eye environment. Simply refitting to new technology, daily disposables, often ameliorates the symptoms, affording greater comfort and tolerance, expanding wear schedules and increasing satisfaction. In recent years, we have seen numerous advances in contact lens materials and designs. For example, CooperVision’s Biofinity Energys combines Aquaform technology—which features high oxygen permeability, low modulus and uniform wettability—with Digital Zone Optics, which helps alleviate symptoms of asthenopia that can often mimic dry eye. (The lens is especially designed for users of digital devices.) In addition, Bausch + Lomb’s Ultra monthly disposable features MoistureSeal technology which helps maintain moisture for up to 16 hours and allows for a highly wettable surface, as well as a proprietary aspheric design to reduce spherical aberrations. Additional examples include Alcon’s DAILIES TOTAL 1 Water Gradient Contact Lenses, B+L’s Biotrue ONEday, and CooperVision’s MyDay lenses and Johnson & Johnson Vision’s 1-DAY ACUVUE MOIST.

NEXT STEPS

When changes in lens materials fall short of resolving dryness-related issues, consider adjunct agents. My preference is to offer more convenient options. Topical lubricants may address the patient’s needs, but

the effect is likely to be limited in duration, requiring frequent application and increased frustration for the patient. Gel drops, such as Alcon’s SYSTANE Gel Drops and Allergan’s REFRESH LIQUIGEL Lubricant Eye Gel, have proven more efficacious due to their increased residence time on the ocular surface. These are not labeled for use with contact lenses, but I’ve found that they tend to perform well without compromising the contact lens or ocular surface. My next step: Punctal occlusion. I prefer surface plugs due to their ease of self-monitoring and removal. If contact lens success remains limited, a consideration would be employing Allergan’s Restasis (cyclosporine 0.05%) or Shire’s Xiidra (lifitegrast 0.5%). With either agent, instruct the patient to use 10 minutes before inserting a contact lens in the morning and after lens removal at the end of the day. O|O Robert A. Ryan, OD, FAAO, is an associate professor in ophthalmology at Flaum Eye Institute at the University of Rochester Medical Center. He is actively engaged in contact lens specialty practice and clinical research.

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PHARMACEUTICALS

INJECTABLES OFFER HOPE TO PATIENTS | WITH RETINAL NEOVASCULARIZATION Patients with diseases such as wet AMD and diabetic retinopathy face the risk of severe vision loss, but research with injectable medications continues to offer these patients new hope. Here are some of the latest developments with two such medications.

LUCENTIS (RANIBIZUMAB) MANUFACTUERER: Genentech, a member of the Roche Group.

The news: Genentech, a member of the Roche Group, announced FDA approval of Lucentis (ranibizumab injection) 0.3 mg prefilled syringe for treating all forms of diabetic retinopathy in individuals with or without diabetic macular edema.

EYLEA (AFLIBERCEPT) INJECTION MANUFACTURER: Regeneron Pharmaceuticals, Inc.

The news: Earlier this year, Regeneron Pharmaceuticals, Inc. announced that the Phase 3 PANORAMA trial evaluating EYLEA (aflibercept) Injection in moderately severe to severe nonproliferative diabetic retinopathy (NPDR) met its 24-week primary endpoint. In the trial, 58% percent of EYLEA-treated patients experienced a two-step or greater improvement from baseline on the Diabetic Retinopathy Severity Scale (DRSS) at week 24, compared to 6% of patients receiving sham injection. What it is: EYLEA is part of the antiVEGF class of drugs, which bind to the vascular endothelial growth factor protein to help keep blood vessels in

the eye from leaking fluid. It is FDAapproved to treat wet age-related macular degeneration (AMD), diabetic macular edema, diabetic retinopathy in patients with diabetic macular edema, and macular edema following retinal vein occlusion. Possible side effects: The most common side effects reported in patients receiving EYLEA are increased redness in the eye, eye pain, cataract, moving spots in the field of vision, increased pressure in the eye and vitreous detachment. There is a potential risk of serious and sometimes fatal side effects related to blood clots, leading to heart attack or stroke in patients receiving EYLEA. Serious side effects related to the injection procedure with EYLEA are rare but can occur including infection inside the eye and retinal detachment.

What it is: Also a VEGF inhibitor, Lucentis is FDA-approved for the treatment of patients with wet AMD, macular edema following retinal vein occlusion (RVO), diabetic macular edema (DME), diabetic retinopathy (DR) and myopic choroidal neovascularization (mCNV). Possible side effects: Some Lucentis patients have had detached retinas and serious eye infections. Some patients have had increased eye pressure before and within one hour of an injection. Uncommonly, Lucentis patients have had serious, sometimes fatal, problems related to blood clots, such as heart attacks or strokes. Some Lucentis patients have serious side effects related to the injection, including serious infections inside the eye, detached retinas, and cataracts. The most common eye-related side effects are increased redness in the white of the eye, eye pain, small specks in vision, and increased eye pressure. The most common nonâ&#x20AC;&#x201C;eye-related side effects are nose and throat infections, anemia, nausea and cough.

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AT-A- GLANCE LUBRICANT DROPS COMPANY

DIRECTIONS

KEY INGREDIENT(S)

BENEFITS

Akorn Pharmaceuticals | 800.579.8327 | TheraTears.com TheraTears Dry Eye Therapy Lubricant Eye Drops

1-2 drops as needed

sodium carboxymethylcellulose 0.25%

• hypotonic and electrolyte-balanced formula replicates healthy tears • available in nighttime and preservative-free formulas

propylene glycol 0.6%

• fast-acting hydration and lasting relief • tear evaporation protection • nano-droplets for better coverage

carboxymethylcellulose sodium 0.5%

• preservative free • provides long-lasting moisture and is gentle enough for sensitive eyes • recommended for post-LASIK dryness • available in gel formula as Refresh Celluvisc

light mineral oil: 1.0% mineral oil: 4.5%

• contains Restoryl mineral oils to restore outer lipid layer • seals in moisture and helps to prevent further irritation • also available in preservative free, nighttime, and long lasting hydration formulas

Alcon Laboratories | 800.451.3937 | Systane.com SYSTANE Complete

1-2 drops as needed

Allergan | 800.347.4500 | RefreshBrand.com Refresh Plus

1-2 drops as needed

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

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

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

1-2 drops as needed

polyethylene glycol 400 0.25%

• hypoosmolar, viscoelastic formula mimics tears to restore tear film • relieves mild to moderate dry eye symptoms • available in gel and preservative-free formulas

Natural Ophthalmics | 866.505.7501 | NaturallyHealthyConcepts.com Tear Stimulation Forte Eye Drops

1-3 drops as needed

OCuSOFT, Inc. | 800.233.5469 | OCuSOFT.com Retaine MGD 1-2 drops in affected eye(s) as needed

Prestige Brands | 877.274.1787 | ClearEyes.com Clear Eyes Pure Relief 1-2 drops in affected eye(s) as needed

sulphur 6x nux v. 12x euphrasia (Eyebright) 5X alumina 10x arsenicum album 12x nux mosch. 6x zincum m. 10x

• preservative free • homeopathic formula designed to produce a healthy tear film and maintain corneal health • special women’s formula available

light mineral oil mineral oil

• uses electrostatic attraction to stabilize tear film • replenishes lipid layer and reduces tear evaporation • preservative free

glycerin 0.25%

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

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NEW PRODUCT | GALLERY SYSTANE COMPLETE FEATURES NANO-DROPLET TECHNOLOGY

Alcon has expanded its SYSTANE family of dry eye drops with the introduction of SYSTANE Complete, a new formula designed to relieve evaporative, aqueous teardeficient or mixed dry eye. SYSTANE Complete uses intelligent moisture and lipid delivery to enhance delivery of the active ingredient, propylene glycol, across the surface of the eye and stabilize the tear film. Nano-droplet technology allows for fastacting hydration and protection from tear evaporation. SYSTANE Complete will be available in eyecare practitionersâ&#x20AC;&#x2122; offices this month and nationwide for over-the-counter purchase next month. Call 800.451.3937, or go to SYSTANE.com

COBURN TECHNOLOGIES OFFERS FIELD ANALYZER, RETINAL CAMERA

Coburn Technologies has introduced two FDA-approved devices: the SK-850A Visual Field Analyzer and the non-mydriatic SK-650A Retinal Camera. The SK-850A, an automatic pure optical projection perimeter, fully complies with the Goldmann Standard and comes in Standard and Expert models. It features 3D fixation monitoring with infrared light tracking of the pupil, an easy-to-read printed report, and automatic calibration and brightness measurement. The SK-650A is compatible with DICOM (Digital Imaging and Communications in Medicine). It transitions from ocular surface to fundus examination. It features a nine-point fixation system for auto mosaic photography over a large retinal area, red-free visual testing for comparing nerve fiber layers to help diagnose glaucoma, and full 45Â° image capture to avoid losing fundus information. Call 800.COBURN.1 (800.262.8761), or go to CoburnTechnologies.com.

JOHNSON & JOHNSON DEVELOPS PHOTOCHROMIC CONTACT LENS

Johnson & Johnson Vision, in a strategic partnership with Transitions Optical, has developed ACUVUE OASYS with Transitions Light Intelligent Technology to continuously balance the amount of light entering the eye. These contact lenses quickly adjust from clear to dark in response to changing light conditions; reducing exposure to bright light indoors and outdoors, filtering blue light and blocking ultraviolet rays. ACUVUE OASYS with Transitions has received 510(k) clearance from the U.S. Food and Drug Administration and is indicated for the attenuation of bright light. The two-week reusable, spherical contact lens will be marketed by Johnson & Johnson Vision Care, Inc. and will be commercially available in the first half of 2019. Call 800.843.2020, or go to ACUVUE.com 14 M a y 2 01 8 | O p to m e tri c O f f i c e .c o m

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AIR OPTIX CONTACT LENSES NOW IN GEMSTONE COLORS

Alcon has introduced its new AIR OPTIX COLORS Gemstone Collection contact lenses in colors amethyst, true sapphire and turquoise, bringing the total number of colors in the AIR OPTIX COLORS contact lens line to 12. Eyecare practitioners can find social and online media materials for the Gemstone Collection on the Alcon Vision Care Marketing Portal (MyAlcon.Intuition.com/ECPMarketingPortal/). Patients can virtually try on the colors before their appointments through the AIR OPTIX COLORS Color Studio (AIROPTIX.com/colors/color-studio.shtml). Alcon also is launching a two-count pack for all AIR OPTIX COLORS lenses. Call 800.451.3937, or go to Alcon.com.

FDA APPROVES B+L’S SCLERAL LENS CASE

The Specialty Vision Products business of Bausch + Lomb has received 510(K) clearance from the U.S. Food and Drug Administration for the Boston scleral lens case. The case can hold lenses up to 23.5mm in diameter and 10.0mm in sagittal depth. The Boston scleral lens case is indicated for use with Boston original conditioning solution, Boston Advance formula conditioning solution and Boston Simplus multiaction solution. Patients can purchase the lens case from the Specialty Vision Products Web Store. Call 800.828.9030, or go to BauschSVPstore.com.

NEUROSTIMULATION DEVICE TEMPORARILY INCREASES TEARS

Allergan plc has launched TrueTear, a handheld neurostimulation device with disposable tips, to use in adults who have inadequate tear production. When inserted into the patient’s nasal cavity, TrueTear provides tiny pulses of energy to create tears. In two clinical trials, TrueTear was shown to be safe and effective for temporarily increasing tear production in adult patients. Call 800.347.4500, or go to Allergan.com.

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DOCS | SPEAK OUT Age-related macular degeneration affects 1.8 million Americans aged 50 years and older, and another 7.3 million are at substantial risk of vision loss from AMD, according to the Centers for Disease Control and Prevention. Optometrists can educate patients about ways to reduce their risk for developing AMD, help diagnose patients before they experience severe vision loss, and refer patients for treatment or prescribe low vision aids. In this month’s “Docs Speak Out,” we ask about your recommendations and methods for managing patients at risk for or who have AMD.

To whom do you recommend and/or dispense nutritional supplements?

Which of the following do you use to diagnose AMD? (Check all that apply.)

YES 12%

100

NO 88%

30 20

22%

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What recommendations do you offer patients to reduce their risk of developing AMD or for managing existing AMD? “Quit smoking, eat dark green leafy vegetables, wear sun protection, maintain blood pressure, take MacuHealth supplement.” “I like to put it into the simplest terms possible by saying something similar to ‘Anything good for your circulation is good for your AMD’ (i.e., diet, exercise, nutrition, etc.).” “Dietary counseling, quit smoking and protection from UV. The hidden issue is the proper control of any essential hypertension and/or diabetes, which can complicate and mimic AMD.”

Do you do genetic testing for AMD in your practice?

“Omega-3s, do not smoke, lifestyle changes (exercise/diet), supplements, blue light protection, Amsler grid home testing, schedule follow-up.” MacuHealth, omega-3 fatty acids, UVand blue light-blocking lenses, hat or visor, dark green leafy veggies. Control body mass index, blood pressure and cholesterol. Eat a heart-healthy diet, oily fish twice a week. Exercise daily.” “A good diet, exercise, lutein, zeaxanthin, omega-3 fatty acids, sunglasses, no smoking or alcohol, and blue blocker.” “Low vision devices.” “I discuss the importance of regular exercise, aiming for normal BMI, eating a wide variety of fruits and vegetables (with emphasis on spinach and kale).

40 20

83% 41%

72% 38%

ng hy ing phy agi est rap gra iog id t e im mo r g c o g n t n r ce ce in a sle res ren sce Am fluo ohe ore o c u t l l F au ica dus Opt Fun

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I also make sure they understand the risks of smoking.” ”MacuHealth or AREDS, depending on genetic testing results. Blue-filtering lenses such as BluTech lenses. Foods high in lutein and zeaxanthin, such as dark green leafy vegetables, egg yolk, dark red and blue berries and orange peppers. I also recommend monitoring periodically depending on how advanced the AMD is. I also run a visual field 10-2 to evaluate central 10° of vision correlating to the macular region of the retina.” “Eye Omega Advantage (physicianrecommended neutraceuticals), Macular Vitamin Benefits (PRN also), UV protection, good diet, no smoking, Rx sunglasses.”

T a

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Please note: The availability of the products and features may differ in your country. Specifications and design are subject to change. Please contact your local distributor for details.

AMD

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Optome

OCULUS Keratograph® 5M

NEW!

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.

Crystal TEAR Report

Let’s Focus on Dry Eye! The Keratograph® 5M assists you in finding the cause of dry eye quickly and reliably. Summarize all data from your dry eye workup in the Crystal TEAR Report. •

Save time: The complete examination process can be delegated.

•

Excel with your dry eye diagnosis: The complete course of treatment is recorded.

•

Combine screening and patient education: Your patient receives an easy-to-grasp printout.

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