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OPTOMETRIC OFFICE PRODUCTS AND TECHNOLOGY FOR YOUR PRACTICE
APRIL 2018
Don’t let Irritating Lens Face ruin your patients’ important moments. Recommend OPTI-FREE® Puremoist® with HydraGlyde® Moisture Matrix to help your patients stay comfortable in their contact lenses from morning ‘til night.1
3X
fewer patients report end-of-day dryness
2*
*Compared to habitual lens care solutions (at baseline); Based on patient responses to a survey after trying OPTI-FREE® Puremoist® solution for 2 weeks; n=10,602
1. Lally J, Ketelson H, Borazjani R, Senchyna M, Napier L. A new lens care solution provides moisture and comfort with today’s contact lenses. Optician. 2011;241(6296):42-46. 2. Lemp J, Kern JR. Results from a global survey of contact lenswearer satisfaction with OPTI-FREE® PureMoist® Multi-Purpose Disinfecting Solution. Clinical Optometry. 2013;5:39-46.
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SEE COMFORTABLY.TM
© 2018 Novartis
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OPTOMETRIC OFFICE PRODUCTS AND TECHNOLOGY FOR YOUR PRACTICE
DOES YOUR ACUITY CHART | NEED AN UPGRADE?
CASE FILES: HOW I FIT THESE IRREGULAR CORNEAS
APRIL 2018
MORE SCREEN TIME EQUALS | MORE EYE STRAIN
YOUR ROLE IN RELIEVING DIGITAL EYE STRAIN SUPPLEMENT TO VCPN APRIL 2018
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Optometric Office USA Pentacam CSP Report 215.9x276.23 e 4c 03.18.indd 1 Untitled-1 1
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OPTOMETRIC OFFICE EDITORIAL STAFF
Table of Contents
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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
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Contributing Writers Lindsay Berry, OD • Lassa J. Frank, OD • David Kirschen, OD, PhD • Robert A. Ryan, OD, FAAO
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
DEPARTMENTS 2 | Views 4 | One-to-One 6 | Product Buzz
EDITORIAL ADVISORY BOARD Jeffrey Anshel, OD • Sherry Bass, OD • Murray Fingeret, OD • Ed De Gennaro, MEd, ABOM • Deepak Gupta, OD • Alan Homestead, OD • Nikki Iravani, OD • Bill Jones, OD Alan G. Kabat, OD • Kenneth A. Lebow, OD, FAAO • Jerome A. Legerton, OD, MBA Scot Morris, OD • John Schachet, OD • Eric Schmidt, OD • Leo Semes, OD Peter Shaw-McMinn, OD • Joseph Sowka, OD, FAAO Jennifer Stewart, OD • J. James Thimons, OD
INDUSTRY ADVISORY BOARD Dwight Akerman, OD, Alcon Laboratories, Inc., a Novartis Company Steve Baker, EyeFinity • Joseph Boorady,OD, TearScience, Inc. Sally M. Dillehay, OD, Visioneering Technologies, Inc. Dave Hansen, OD, Ophthalmic Consultant • Carla Mack, OD, Alcon Laboratories, Inc. Dave Sattler, Dave Sattler Consulting Michele Andrews, OD, CooperVision, Inc. • Ellen Troyer, Biosyntrx, Inc. Millicent Knight, OD, Johnson & Johnson Vision Care, Inc.
Throughout this magazine, trademark names are used. Instead of placing a trademark or registration symbol at every occurrence, we are using the names editorially only with no intention of infringement of the trademark.
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15 | Think About Your Eyes 16 | New Product Gallery
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FEATURES 8 | Does Your Acuity Chart Need an Upgrade? 10 | Case Files: How I Fit These Irregular Corneas 12 | Your Role In Relieving Digital Eye Strain 14 | PHARMACEUTICALS New Glaucoma Drugs Added To Treatment Arsenal
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VIEWS
Jeffrey Eisenberg
WHAT’S IN A NAME?
I recently asked myself this question, though I wasn’t considering whether a rose by any other name would smell as sweet. Instead, I was questioning the difference between the words “patient” and “consumer” as I listened to parts of the Federal Trade Commission’s workshop, “The Contact Lens Rule and the Evolving Contact Lens Marketplace,” and heard the terms used interchangeably. Merriam-Webster defines “patient” as “an individual awaiting or under medical care and treatment.” A “consumer,” the dictionary tells us, is “one that utilizes economic goods.” The FTC held this public workshop as it considers whether to revise its Contact Lens Rule, which requires eyecare practitioners to automatically provide contact lens patients with a complete copy of the prescription and verify or provide the prescription to authorized third parties. The rule also requires that contact lens sellers dispense contact lenses only with a valid prescription or once the prescriber has verified it.
have to happen,” says Shaun Schooley, vice president of global marketing technology at CooperVision, who participated in the workshop. “In our market it’s a little different. Prescribers seem to be bearing a lot of responsibility. They want to comply, but it’s hard for them to do that. They’re not getting fed the information in a way that allows them to more easily or precisely react.” Although contact lenses have become commodities and the FTC wants to make sure that “consumers” have freedom of choice as to where they obtain their lenses, contact lenses are still medical devices. They require an accurate, up-to-date prescription and regular follow-ups between “patients” and ECPs. Don’t get me wrong. While I’m not a contact lens wearer myself, I comparison shop for plenty of other things. As I’ve said in these pages before, I’m not against freedom of choice. I’m for making responsible choices—in this case choices that won’t cause “patients” to have less-than-optimal vision or threaten their eye health.
However, some of the eyecare practitioners at the workshop described receiving robo calls that were often incomprehensible, for inaccurate prescriptions or for patients they hadn’t seen in some time. That makes it somewhat difficult to verify that a prescription is accurate.
Perhaps Peter Menziuso, Johnson & Johnson Vision’s president, North America, puts it best. “Three things are critical to ensuring a healthy eye health community—both now and in the future,” he says. “First, is continuing to promote the importance of the doctor-patient relationship and regular, comprehensive eye exams. Next, is making sure patients receive the exact contact lenses as prescribed, regardless of where they choose to purchase. And lastly, we believe that contact lens wearers deserve care consistent with the high standard of care they receive in their eye doctor’s office, regardless of where or how they receive it.”
“If you’re in a marketplace environment, generally the seller is responsible for most of the additional steps that
*** Jeffrey Eisenberg | Editor-In-Chief | JEisenberg@FVMG.com
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M aking your p atie nt s’ c o nt a c t le nse s f e e l like new is e asy.1 Just a d d
BUBBLES.
Recommend the bubbling power of CLEAR CARE PLUS to your patients. It features an easy-to-use, preservative-free formula that provides symptomatic lens wearers almost three more hours of comfortable wear time.2* ®
Learn more at ClearCareProfessional.com. *CLEAR CARE® PLUS patients experienced an average of 11.96 hours of comfortable wear time (per day), compared to 9.16 hours of comfortable wear time with their habitual multi-purpose solutions. Reference: 1. Alcon data on file, 2016. 2. Alcon data on file, 2015. © 2018 Novartis
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We’re doing that through a number of different initiatives. One, is we have a program in which we bring practitioners to the Alcon Experience Center in Fort Worth, and we share with them the tips and techniques that we’ve learned to enhance fit success. We also have a program where we take the training to practitioners and do the training in their offices. We refer to that as the Multifocal Fit Training Road Shows. And, we provide hands-on experience showing the practitioners how easy it is to fit multifocal contact lenses.
ONE-TO-ONE
Rick Weisbarth
Rick Weisbarth, OD, FAAO, Alcon’s vice president, professional affairs, has been with the company for more than 36 years—starting at CIBA Vision, which became the eyecare unit of Novartis in 1996. Novartis then acquired Alcon in 2011. In this interview, he discusses several of the company’s recent initiatives. Jeffrey Eisenberg: Alcon announced several initiatives recently, such as the Patient and Practice Experience Team. How will the team work for doctors? Rick Weisbarth, OD, FAAO: The eyecare landscape is increasingly complex and difficult to navigate, with forces external to the practice and demands inside the practice. We believe we can partner to help improve patient experiences, patient outcomes and practice outcomes. This new team will serve in a consultative role to help practitioners and their employees understand how they can improve patient and practice outcomes and stay competitive in an everchanging marketplace. So, they’ll have a role apart from what traditional salespeople do within a practice. JE: Alcon also plans to significantly increase its investment in hands-on multifocal contact lens training. RW: By the year 2020, there will be 1,800 presbyopes for each practitioner. That’s a huge number, yet today, the majority of multifocal contact lenses are being fit by only 13% of the practitioners. In our mind, that spells opportunity to help drive patient satisfaction. We are more than doubling our efforts to train practitioners on how to improve patient outcomes and their success rate with multifocal contact lenses.
JE: There is now so much competition for doctors from alternative sources, which also raises safety concerns. RW: One point we always make is we would love to see the contact lens market grow. We want to see it grow responsibly, lawfully and with the eye practitioners in the loop. We want responsible growth — not growth for growth’s sake. JE: Alcon launched U.S.-specific packaging for AIR OPTIX plus HydraGlyde. How does this tie into patient safety? RW: This is the second such initiative that we have launched. Last year, we announced new packaging for DAILIES AquaComfort Plus. The new packaging features more specific instructions to improve patient outcomes. Specifically, on the AIR OPTIX plus HydraGlyde packaging as well as the DAILIES AquaComfort Plus packaging, we have illustrated instructions for wear and care. We have a 1-800 helpline and an email address that patients can contact. We also have the U.S. flag and the wording “For sale in the U.S.A. only” on the packaging. There are a number of reasons for that. Specifically, we believe that it’s important that patients who do purchase our products get them through a reliable source. Patients are best served when our products are transported, stored and distributed through clear and reliable channels, which can only be achieved when our products are sold through authorized customers and distribution channels.
JE: What else will help grow the contact lens marketplace? RW: We believe that there’s no better way to wear contact lenses than a daily disposable. When you look at the growth of daily disposables, it is the fastest growing category in the U.S., but the U.S. still is way down the line in terms of the percentage of daily disposables that are sold, compared to other countries. So, last year, we launched the DAILIES and AIR OPTIX Choice Programs to increase patient awareness and education of one-day and one-month replacement contact lenses and to help reduce financial barriers. Additionally, we believe patients should receive an annual comprehensive exam, so we want to drive patients into practices so more can experience the benefits of these lenses. We have all these initiatives and want to help practitioners to harness them. While they are separate initiatives, it’s all tied to improving patient outcomes, and practice performance. For the full interview, go to OptometricOffice.com.
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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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PRODUCT | BUZZ LAUNCHES, PROMOTIONS, MERCHANDISING, EVENTS AND OTHER THINGS TO KEEP YOU IN THE KNOW.
• Make patients, legislators, and regulators aware of the importance of the doctor-patient relationship and existing and potential threats to patients’ eye health and safety.
J&J VISION LAUNCHES NEW DIGITAL PLATFORM
Johnson & Johnson Vision announced the U.S. launch of JNJVisionPro.com, a digital platform that delivers online learning, patient education materials, practice resources and connected commerce. JNJVisionPro.com is a single destination offering in-office support for eyecare professionals in managing the diverse needs of their practices, including a connected commerce site to order ACUVUE Brand Contact Lenses and request direct shipping to patients, online education for ECPs and paraprofessionals; instructional videos and other downloadable education materials, and downloadable images and marketing materials for the practice. For more information and to register for access, visit JNJVisionPro.com.
NEW ALLIANCE PROMOTES PATIENT SAFETY, TRANSPARENCY
The newly launched Health Care Alliance for Patient Safety, a collaboration between eye health advocates, innovators, and members of the eye health community, will: • Work with patients, policymakers, and regulators to deliver transparent and factual information regarding eye health products, procedures, technology, and safety. • Support laws, regulations, increased enforcement, and other public policy solutions designed to safeguard public health.
The American Optometric Association and Johnson & Johnson Vision joined the Alliance as Leadership and Charter members. CooperVision, Inc. joined as an Associate and Charter member. Visit PatientSafetyToday.com.
NEW WEB APP LETS STAFF TRANSFER PATIENT FORMS
Vision Wholesale Club, LLC released Vision e-Forms (VeF) the app, a web application that allows ECPs’ staff and patients to easily access and transfer specific patient forms. Offices that use VeF will be able to ascertain medical and optical insurance information, lifestyle activities, contact lens wearing patterns such as daily or overnight wear, and optical preferences such as photochromic lenses. VeF provides each office and each doctor with his or her own VeF Dashboard. Utilizing the dashboard, the office sends patients a text directly to their smartphones. Patients then click onto the VeF link and can immediately start filling out the data that is being requested. For instructional videos and to register, go to VisioneForms.com.
APP SENDS PERSONALIZED CONTENT TO PATIENTS’ SMARTPHONES
Compulink Business Systems, Inc. has enhanced Eyecare Advantage with a mobile Patient Engagement app that lets you send personalized content to patients’ phones via text message. Content can be targeted based on a patient’s appointment type and diagnosis, and you can use the
app to market products and services and deliver patient education. You can also send surveys to a patient’s phone, and the feedback collected is automatically brought back into Advantage for analysis. For more information, visit CompulinkAdvantage.com.
CLEINMAN PERFORMANCE PARTNERS TO HOST NATIONAL CONFERENCES
Cleinman Performance Partners will host three Business of Eyecare Forum National Conferences in 2018: • The National Eyecare Facilities Conference, May 16 and 17, St. Louis. This conference is intended for ECPs who plan to invest in a new facility. Topics include site selection, project planning, financing, marketing, contractor relations and design. • The National Practice Transitions Conference, October 11, Chicago. The workshop will take participants from start to finish on how to transition ownership, from both a seller and buyer perspective. Topics include preparing your practice for transition, valuation, transaction, design, financing, tax implications, documentation, negotiations and communications. • The Exiting Vision Plans Conference, November 1, Chicago. The conference will explore the means and methodology of eliminating reliance upon Vision Plans. Topics include brandbuilding, economics, negotiations, maximizing vision plan profit contribution and how to exit. For information, call 607.431.1001, email: Info@Cleinman.com, or go to Cleinman.com.
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SEEN AT VISION EXPO EAST NEW SYSTEM LETS YOU PERFORM EXAMS REMOTELY
DigitalOptometrics LLC introduced Tele-Optometry, its remote comprehensive eye health exam system. The system lets you perform comprehensive eye examinations at all your locations from remote sites by combining proprietary software from DigitalOptometrics, remotely operated equipment, high-definition video conferencing and Internet accessibility. Tele-Optometry includes a complete vision analysis, gathering of ocular and physical health histories, subjective visual findings to determine an accurate prescription for vision correction and an evaluation of current eye health, including a glaucoma screening test. Call 877.506.0002, email Info@DigitalOptometrics.com, or go to DigitalOptometrics.com.
EYEFINITY KIOSK STREAMLINES INFORMATION GATHERING
Eyefinity launched its Eyefinity Kiosk application, which lets new patients enter their information via an iPad in the waiting room. Patients access the “electronic clipboard” by entering their last name and date of birth and then securely and efficiently enter their personal information and health history, sign consent forms, and select their pharmacy via Google Maps. This data automatically populates in the electronic health record. Call 800.269.3666, email CustomerCare@Eyefinity.com or go to Eyefinity.com.
DRY EYE REPORT DOUBLES AS PATIENT EDUCATION TOOL
Using the new Crystal TEAR Report, the OCULUS Keratograph 5M corneal topographer walks you through a comprehensive dry eye analysis, lets you manually enter your dosage recommendations for individual treatments and summarizes all results in a printout that can also be used for patient education. The printout includes your personal logo, an easy-to-understand color-coded pie chart, explanations of abbreviations and technical terms, comprehensible presentation of individual measurements and their results, explanation of the treatment goal along with the necessary therapeutic steps and space for the doctor’s personal recommendation. Call 888.284.8004, email Sales@OculusUSA.com or go to OculusUSA.com.
COOPERVISION EXPANDS PARAMETERS OF MYDAY TORIC LENS CooperVision, Inc. announced the addition of plus powers to its MyDay Toric contact lens. The expanded parameters, which include +0.50DS to +6.00DS in 0.50D steps, will be available this month. Call 800.341.2020, or visit PrescribeMyDay.com/Toric.
News Emilio H. Balius, OD, who was born in Cuba and has been in private practice in Florida for the past 25 years, became the first Hispanic president to lead SECO International at the organization’s meeting in Atlanta last month. EyeGate Pharmaceuticals, Inc. has submitted an amended Investigational Device Exemption (IDE) application to the U.S. Food and Drug Administration (FDA) for a pilot study of its EyeGate Ocular Bandage Gel (EyeGate OBG) for accelerating re-epithelialization of large corneal epithelial defects in patients who have undergone photorefractive keratectomy. U.S. Vision and its affiliate, Nationwide Vision, selected MaximEyes EHR by First Insight Corporation as its new electronic health record partner for 600-plus locations. pSivida Corp. announced that its New Drug Application for its Durasert three-year treatment for posterior segment uveitis has been accepted by the FDA for filing. Vitamin Science launched a new dry eye nutritional formula, Dr. Krawitz Dry Eye Support, which contains 1,000mg triglyceride omega-3 fish oil from Alaskan pollack to promote healthy tear production; phytosterols, the lipid-soluble molecules formed by the meibomian glands, to support the outer oily layer of tears; and curcuminoids from natural turmeric root, flaxseed oil and gamma linolenic acid from black currant seed oil to provide long-lasting, soothing relief. O p tometr ic O ffic e. c om | Apri l 2018 7
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INSTRUMENTATION
DOES YOUR ACUITY CHART |
NEED AN UPGRADE? Precise measurements, randomization and ease of use with children are among the advantages to digital systems. By Davi d Kirschen, OD , P hD About 15 years ago, I noticed that the acuity charts in the two exam rooms at my practice looked different, namely the contrast. Specifically, one appeared more yellow and darker. Given that I was doing sports vision, in which contrast sensitivity is extremely important, this was less than ideal. If I want to test the patient at 20% contrast, I don’t want 20% contrast +/-5%. I realized it was time to upgrade my exam rooms with a digital visual acuity chart, and I’ve never regretted it.
WHY UPGRADE?
If you still rely on a standard projector, there are several reasons to consider an upgrade. Perhaps the biggest one is the precision of the visual acuity measurements, particularly contrast. Consider: With a traditional system,
the slide ages, and the bulb begins to yellow or decrease in intensity. The contrast of the target, in turn, also decreases in intensity, so you’re no longer assessing visual acuity in the classical sense. Some additional advantages: • You can randomize the letters and images. That way, patients don’t memorize letters as they read from one eye to the other. • Digital visual acuity systems often have several different kinds of charts. These include Snellen letters, Sloane letters, pictures and numbers, so you can use whichever you prefer. There are specialty charts built into most of them, such as in the ETDRS chart, which is particularly important if you’re collecting data as part of a clinical study.
• They’re ideal for pediatric patients. Besides a Snellen chart, systems also have built-in HOTV testing and numbers. You can also insert an arrow and toggle it to the specific symbol or letter you want the child to identify. For preverbal children, you can ask them to select a handheld card that matches the image on the screen. In addition, some digital acuity systems allow you to project cartoons to the other end of the room to keep the fixation of pediatric patients as you perform retinoscopy and ophthalmoscopy.
EASY EXPERIENCE
There are some additional steps you can take to ensure a positive experience. Some specific things to ask:
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• What is the company’s customer service like, and what warranties does it offer? Does the company provide support in setting up the system in your office and training you to use the equipment? Does the company offer technical support, and will it replace any parts of the system that break? • Can your employees use it? Given that your staff probably does pretesting, they should know how to use it as well. • Are software updates included and, if so, for how long? For example, if the company updates the software to improve image quality, is this included in your purchase price? Ask to compare two systems. If one system offers you unlimited updates for one year while another offers you unlimited updates for five years, which are you more likely to choose? • Does the system qualify for the Americans with Disabilities Act tax credit?
Examples of Digital Acuity Systems System
ACUITY PRO | 877.228.4890 | AcuityPro.com Acuity Pro Digital Acuity System
David Kirschen, OD, PhD, has been team optometrist for several professional sports teams, in MLB, NBA, NHL and with the U. S. Olympic Team. He is director, Binocular Vision and Orthoptic Services, at Jules Stein Eye Institute, University of California-Los Angeles; vice president and cofounder, EYEcheck Systems; and owner, Customized Vision Care.
• • • • • •
Software only or all-in-one systems Free tech support – telephone and email support options 56-key custom remote Smart randomization, multiline display choices, three letter sets for each line Customizable image and video playlists Charts: Snellen, Sloane, number, six standard ETDRS charts and illiterate charts, including pediatric symbols, HOTV, tumbling C and tumbling E • English, metric, decimal, or LogMar display • Smaller increments of larger optotypes for low vision • Includes patient education slides and cartoons as fixation target for children
M&S TECHNOLOGIES, INC. | 877.225.6101 | MSTech.eyes.com Smart System 2 20/20 USA
• All-in-one visual acuity and contrast sensitivity testing system that installs easily in mirrored and direct exam rooms • CPU with 22-inch screen and Customizable Software • Ability to integrate with autorefraction systems • Includes patient education videos Smart System Tablet Technology, Glare Testing System (GTS), CustomLink, Electronic Low Vision Testing (eLVT), ATS and eETDRS, contrast testing that is validated to the Pelli-Robson charts, sine wave grating contrast, Landolt Ring and ETDRS Contrast Testing and Protocol One • Same features as Smart System Standard but faster processor • Increased RAM and larger capacity for patient education and fixation videos • 20% lighter in weight
MARCO | 800.874.5274 | Marco.com PROVUE LCD Acuity System
• What financing options are available, and how can you pay it off? The experience in adding digital acuity charts to my practice was easy, and the learning curve was rapid. Most work by remote control, with the images projected directly ahead. Or, you can use the systems in a mirrored room, which allows you to put the eye chart behind the patient, an advantage in narrow exam rooms, and most companies will help you set up the system. O|O
Features
• Charts: Snellen, English, numeral, children, mask (horizontal, vertical, single optotype), specialty testing charts (separate red/green), Amsler grid, red/green 3D, ETDRS, test for phorias, charts for astigmatic testing • Comfortable, user-friendly remote control • Multiple levels of contrast sensitivity testing • Animation video for pediatric fixation • Patient education images • Randomization function helps prevent letter/character memorization
REICHERT TECHNOLOGIES | 716.686.4500 | Reichert.com ClearChart 4 Digital Acuity System
• All-in-one system • Optotypes include 17-letter set, eight-letter set, Sloan, HOTV, Landolt C, Landolt C and O, Tumbling E, and children’s optotypes • Special test charts: astigmatic testing, fusion, phoria, and binocular balance • Optotypes can be isolated, increased or decreased in size, and displayed in LogMar, Snellen, or linear progression • 24-inch, high-resolution, LED backlit displays • Intuitive user interface that can be controlled by the Phoroptor VRx Digital Refraction System or SightChek digital phoroptor, or by an infrared remote
ClearChart 4X Enhanced Digital Acuity System
• Same features as ClearChart 4, plus ETDRS, contrast sensitivity, and patient education slides • Lets users import images and videos from USB drive
ClearChart 4P Polarized Digital Acuity System
• Same features as ClearChart 4X, plus a linear polarized screen that has polarization angles of 45° and 135° and uses articulating mount to provide proper viewing for stereo testing • Additional polarized charts are available
VEATCH OPHTHALMIC INSTRUMENTS | 800.447.7511 | VeatchInstruments.com Potec PLC-8000 Visual Acuity System
• All-inclusive unit with blue tooth capabilities • Standard optotypes and updated pediatric optotypes • Slide images available
Insight System
• • • •
Guided by Android device, so no software to be replaced Lets you add images and videos using SD Card Simplified remote for easier navigation Built-in contrast sensitivity
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CONTACT LENSES
CASE FILES: HOW I FIT
THESE IRREGULAR CORNEAS
Today’s contact lens technology lets us address more challenges than in the past. CASE 1: KERATOCONUS PATIENT
Semi-scleral gas permeable contact lens demonstrates minimal vaulting from limbus to limbus.
CASE 2: POST-RK PATIENT
CASE 3: SOFT KERATOCONIC DESIGN
This patient underwenet radial keratotomy in the mid-1990s. Note the long incisions approximating limbus and small, slightly decentered optical zone.
Here is a well-fit KeraSoft IC toric silicone hydrogel toric contact lens. Note the toric indicator at 6 o’clock.
lenges that patients present with and, in some instances, delay the need for corneal transplant.
foreign-body sensation, poor lens stability, fluctuating vision, and, in some instances, limited tolerance and wear schedules.
By Ro b ert A . Ryan, OD , FAAO A 68-year-old white male with a history of keratoconus and dry eye presented complaining of frequent foreign-body sensation and limited tolerance of his gas permeable contact lenses, particularly on windy and pollen-filled days. Refraction: OD -1.25 -1.00 x 40 20/30- and OS -2.50 -1.50 x 105 20/30-. A +2.50 add brought visual acuity to 20/25- in each eye. Examination revealed apical thinning of the cornea without fibrosis, consistent with ectasia. There was diffuse mild epithelial basement membrane dystrophy and grade 1 apical staining. The contact lenses were fit well and showed good centration and movement. A divided support fluorescein pattern showed adequate axial edge lift. While this patient appears to be doing well with a corneal contact lens, he could be doing better. Today, we have a wide array of contact lens designs to address chal-
CASE 1: KERATOCONUS PATIENT
We told the patient continue wearing these lenses until he was due for a replacement, at which time we would increase the sagittal depth to minimize any ocular surface compromise.
By refitting this patient into a semiscleral gas permeable design, we were able to address the limitations and improve his quality of life. All semi-scleral designs offer flexibility of altering sagittal depth and peripheral curve design to address comfort, hydration and ease of removal. Many even offer toric designs, as in this instance, to correct residual astigmatism and toric peripheral curves to facilitate comfort and orientation and even quadrant-specific alterations. The importance of the toric periphery relates to common variations in scleral curvature between the horizontal and vertical meridians.
Discussion. This patient had a relatively modest presentation of keratoconus that appeared to be well managed with corneal contact lens designs. However, patients such as this typically have reported
When following these patients, be sure to watch for conjunctival impingement and blanching of conjunctival vessels under the periphery of the lens. This may be a sign of a tight peripheral curve system.
I refit the patient described above with the Zenlens toric, a gas permeable semi-scleral lens from Alden Optical, choosing the prolate design. At his follow-up visit, each lens was well centered with minimal movement and 75µm of clearance, and the lens rotation was 10 degrees counterclockwise. The slit lamp exam revealed grade 1 diffuse punctate epithelial keratitis in each eye.
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Some patients may find handling these newer lens designs to be cumbersome, yet they often are more comfortable, with greater lens stability, less dryness and increased wearing time. And, because centration is rarely an issue, visual quality is generally better with fewer haloes in low-light conditions. One additional note: Contact lens care may have significant impact on patient acceptance and success. We generally recommend Boston ADVANCE cleaning and conditioning solutions from Bausch + Lomb and a nonpreserved saline solution such as ScleralFil, also from B+L.
CASE 2: THE POST-RK PATIENT
A 57-year-old white female who underwent radial keratotomy (RK) in both eyes in the mid-1990s presented complaining of blurred vision. She wore a gas permeable reverse-geometry lens design and used readers, but she believed that she needed new lenses. Her entering acuity was 20/40 in the right eye and 20/25 in the left. A +1.00D overrefraction in the right eye brought her to 20/25 in that eye as well. Her current lenses were wellcentered with minimal movement. Examination revealed 12-incision RK with T cuts in the right eye and eight-incision RK in the left eye. Both eyes had grade 2 punctate epithelial keratitis, mild neovascularization along the radial incisions, and hemosiderin stellate deposits centrally. Intraocular pressure was 20mm Hg in each eye. Naked-eye refraction was +9.50 -6.00 x 115 for 20/60 in the right eye and +1.50 -1.50 x 50 for 20/30 in the left. A +2.25D brought her near acuity to 20/25+ in the right and 20/20- in the left. We refit her with the Naturalens Scleral from Advanced Vision Technologies. Her acuity was 20/20 at distance in the right eye and J2 at
near in the left. By fitting her with monovision, she would be much less dependent on her readers. The lenses showed 150µm clearance and minimal movement. There was no conjunctival impingement, and the patient reported excellent comfort. Discussion. This patient had a history of myopic astigmatism before undergoing RK. Years later, she presents with hyperopic astigmatism. This is due to progressive central corneal flattening, which itself is due to the permanent compromise in corneal structural integrity that often occurs with aggressive RK. This patient most likely was highly myopic, which required deep incisions and a small optical zone to achieve the desired effect, but it also left her prone to consecutive hyperopia. Compromised corneal integrity also can result in fluctuations in refractive error throughout the day. Because the corneal structure has been weakened, its topography can be affected by variations in diurnal IOP. Without gas permeable contact lenses, this patient might require multiple spectacle prescriptions throughout the day. Due to the oblate surface of the cornea, however, corneal lenses often present centration problems and excessive edge lift. Reverse geometry and/or scleral contact lenses are the ideal and often only solution for these challenging cases. Long corneal incisions that approximated the limbus can invite neovascularization, particularly in the presence of contact lens-induced hypoxia. The newer design semiscleral contact lenses such as the Naturalens are designed to incorporate a generous pool of saline residing between the lens and the cornea to facilitate oxygen supply.
CASE 3: SOFT KERATOCONIC DESIGN
A 55-year-old white female with advanced keratoconus presented complaining of discomfort in her
current corneal gas permeable contact lenses. Entering acuity was 20/20 at distance and J3 at near in the right eye and 20/25-2 at distance and J5 at near in the left. Refraction was -7.50 -2.00 x 80 for 20/30 in the right eye and -10.50 -2.25 x 40 for 20/60- in the left. The slit lamp exam showed apical thinning without fibrosis, Vogt’s striae and Fleisher’s ring in both eyes and basement membrane dystrophy involving the visual axis in the left. We refit the patient into the toric version of KeraSoft IC, a custom soft silicone hydrogel lens that was created in the U.K. and licensed to Bausch + Lomb. We fit her with a steep peripheral curve in the left eye and a standard peripheral curve in the right. Both lenses were well centered with appropriate movement and 0° of rotation, and the patient reported that the lenses were well tolerated. Discussion. For years, we believed that soft contact lenses could not satisfy this population. By adhering to the fitting guide with KeraSoft IC, it’s possible to increase the success rate with this design. These lenses tend to move more generously than typical soft lenses and have a greater center thickness to help mask irregular astigmatism. The optic zone is larger, which helps avoid symptoms of flare. 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.
WHERE TO FIND IT Alden Optical, Inc. 800.253.3669 | AldenOptical.com Advanced Vision Technologies 888.393.5374 | AVTlens.com Bausch + Lomb 800.828.9030 | Bausch.com
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PATIENT CARE
YOUR ROLE IN RELIEVING DIGITAL EYE STRAIN More than 83% of Americans use digital devices more than two hours daily, so this should be part of our patient care.
By Lassa Frank , OD One of the biggest changes we as a society have seen in the last decade is the unbelievable increase in the use of digital devices by people of all ages. More than 83% of Americans use digital devices for more than two hours daily, and 53.1% use two digital devices simultaneously, according to statistics from The Vision Council. Further, 60.5% experience symptoms of digital eye strain, including eye discomfort, dry eyes, headaches, blurred vision, and neck and shoulder pain, as a result of prolonged use of computers, tablets and cell phones. However, we may be missing an opportunity to help our patients and grow our practices. In its latest
Digital Device Usage and Your Eyes report, CooperVision found that contact lens wearers and non-wearers worry about how much they use digital devices. Globally, 19% of people who use vision correction and 18% of people who do not wear correction express concern about the amount of time spent looking at screens. This number rises to 26% globally for contact lens wearers, according to the CooperVision report. However, only 14% of contact lens wearers reported that they had spoken with an ECP regarding digital device use, even though 78% would be very or somewhat interested in exploring ways to reduce eye tiredness with
their eyecare practitioners. As ECPs, we should be looking for digital eye strain, or digital vision syndrome, as part of our patient care.
THE SEARCH
The search for this condition starts in the history. When taking a history, ask simple questions, such as how much time patients spend on digital devices each day and whether their eyes feel dry or sting when doing extended work on a digital device. Also ask how often patients get headaches and whether they get them more often when working on digital devices.
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The answers to these questions can help guide your exam and further treatment. For example, convergence insufficiency and accommodative insufficiency may be at work, and the correction may be as simple as prescribing more prism. You may also need to treat the patient’s dry eye, the symptoms of which may become worse with digital eye strain. Your patients no doubt do a lot of research online and are probably familiar with digital eye strain, so it is imperative that you talk to your patients about this subject.
EDUCATION A MUST
Patient education is a must as well. For example, the American Optometric Association recommends the following to patients: • Follow the 20-20-20 rule, namely take a 20-second break every 20 minutes and view something 20 feet away. • Maintain a comfortable working distance from the device by using the zoom feature to see small print and details, rather than bringing the device closer to your eyes. • Reduce glare by adjusting device settings or using a glare filter to decrease the amount of blue light reflected from the screen. • Turn digital devices off at least one hour before bed. • Consider buying protective eyewear, such as blue light filter glasses to limit the blue light beaming from screen.
DIGITAL LENSES
Many lens makers now offer lenses made for distances inside of 20 ft., what you might call an “office environment.” These lenses work well for computer and digital devices such as smartphones and tablets and as an occupational lens in the office environment.
PROGRESSIVE PRISM TECHNOLOGY
Other options have become available as well. One example is neurolens, which eyeBrain Medical launched last month at Vision Expo East. Specifically, neurolens is designed to relieve digital eye strain by reducing or eliminating eye misalignment and correcting the eyes from overcompensating during digital device use. It does so by incorporating progressive prism technology that enables practitioners to relieve binocular misalignment detected at distance, intermediate and near in a single lens. You start with the SightSync visual testing system, which lets you determine the prism needs of the patient at all distances. SightSync creates a dynamic customized measurement of misalignment at 6 meters and 50cm, analyzing all elements of ocular fusion, including heterophoria, vergence conditioning, binocular peripheral fusion, fixation disparity, accommodative convergence response and alternating monocular central fixation. SightSync (shown right) uses sophisticated eye-tracking technology to be 100% objective without patient or operator interaction. Measurements are calculated to 100th of a prism diopter, and testing is performed in less than three minutes by a technician. The measurements are then used to manufacture this prism lens design in either single vision or progressive addition lenses.
on-screen to off-screen and back with less effort. Biofinity Energys also features Aquaform Technology, which attracts and binds water throughout the lens material to retain moisture even during times of reduced blinking, which is common with device use. (For more on this lens, see “Reducing Digital Eyestrain,” July 2017.)
GREATER COMPETITION
We all face greater competition, and our patients are presented with more and more options. Differentiating ourselves is the key and the detection, understanding of, and the reduction of the symptoms of digital vision syndrome is a great way to do it. O|O Lassa Frank, OD, owns Mt. Tam Optometric Center in San Anselmo, CA, and has traveled extensively around the world, giving more than 25,000 free eyecare exams to the poor.
WHERE TO FIND IT CooperVision, Inc. 800.341.2020 | CooperVision.com
eyeBrain Medical 949.339.5157 | neurolenses.com
CONTACT LENS OPTION
For those interested in contact lenses, CooperVision introduced its Biofinity Energys contact lens design specifically for digital device users. The lens features Digital Zone Optics, which integrates multiple front-surface aspheric curves across the entire optical zone. This simulates what’s known as positive power in the center of the lens, helping reduce strain on the eyes’ ciliary muscles as individuals move their gaze O p tometr ic O ffic e. c om | Apri l 2018 13
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PHARMACEUTICALS
NEW GLAUCOMA DRUGS ADDED TO TREATMENT ARSENAL Last year saw the introduction of two glaucoma drugs. Both work to lower intraocular pressure in patients with open-angle glaucoma or ocular hypertension. Here are some facts you need before you prescribe them.
VYZULTA | Bausch + Lomb, 800.828.9030, Bausch.com Generic: latanoprostene bunod ophthalmic solution 0.024%, Dosage: One drop in the affected eye(s) once daily in the evening.
Possible side effects:
• Brown color, or increased brown color, of the iris that may be permanent. • Darkening of the eyelid skin, which is usually reversible after treatment is discontinued. • Gradual changes to eyelashes, including increased length, thickness, color, number of eyelashes and/or direction of eyelash growth. These changes are usually reversible after treatment is discontinued. • Most common ocular adverse effects: conjunctival hyperemia, eye irritation, eye pain, and pain at the instillation site.
What B+L wants you to know:
• VYZULTA provides consistent and sustained IOP lowering. • VYZULTA works by metabolizing into two moieties: latanoprost acid and butanediol mononitrate. Latanoprost acid, an F2α prostaglandin analog, primarily works within the uveoscleral pathway to increase aqueous humor outflow. Butanediol mononitrate releases nitric oxide to increase outflow through the trabecular meshwork and Schlemm’s canal. • The safety and efficacy of VYZULTA is supported by published clinical studies.
RHOPRESSA | Aerie Pharmaceuticals, Inc., 919.237.5300, Rhopressa.com Generic: netarsudil ophthalmic solution 0.02% Dosage: One drop in the affected eye(s) once daily in the evening.
Possible side effects:
• The most common ocular adverse effect was conjunctival hyperemia. • Other common effects: corneal verticillata, instillation site pain, and conjunctival hemorrhage. The majority of these ocular adverse effects were mild.
What Aerie Pharmaceuticals wants you to know:
• Rhopressa is the first FDA-approved Rho kinase (ROCK) inhibitor. It represents the first new class of IOP-lowering medications in 20 years. • Rhopressa targets a main cause of elevated IOP. It is believed to work at the cellular level within the trabecular meshwork to improve outflow of aqueous humor. • Rhopressa produces consistent IOP reductions across a range of baseline pressures. • Once-daily dosing with Rhopressa simplifies the treatment regimen. • Rhopressa has minimal systemic adverse events and no contraindications. • Rhopressa will be available in spring 2018.
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THINK ABOUT YOUR EYES
MORE SCREEN TIME EQUALS MORE EYE STRAIN Smartphones are practically tethered to our arms. We sit in front of screens at home and work. Our kids watch movies and play games on tablets while on a long flight and elsewhere. Technology has changed our habits—and could be changing our vision. We don’t yet know the long-term effects of digital eye strain on patients. Baby boomers, who started using computers in middle-age, when their eyes were developed and even becoming presbyopic, will have different vision issues than today’s youth who started Skyping with their grandparents and watching Doc McStuffins on a tablet at age 2. Because of this, digital eye strain is a must-discuss topic for optometrists and their patients, regardless of age.
IMPORTANT FIRST STEP
Lindsay Berry
Lindsay Berry, OD, practices in Plano, TX. She specializes in neuro-optometry, helping children and adults with problems that can affect vision development and visual performance. Berry is one of the more than 19,000 doctors listed on the Think About Your Eyes online locator. First Vision Media Group is a media partner of Think About Your Eyes.
Understanding your patients’ professions is the first step. Do they work at a computer most of the day or sporadically? Are patients reliant on their smartphones or tablets? Do they spend time gaming on these devices?
which include eye strain, eye fatigue and blurred vision when working on devices—occur because blue light scatters within the eye, making it harder to focus clearly.
Pediatric patients are of special importance, given the exposure to screens they’ll have over their lives. Computers are increasingly incorporated into a variety of subjects at school, and students often complete their homework on the computer. This brings their total screen time to several hours a day, and that’s not counting time spent playing games, texting and doing other activities on smartphones and tablets.
TOP PRIORITY
In my practice, many parents have expressed concerned about their children’s exposure to blue light. Specifically, they want to know more about its effects on vision.
SCATTERING LIGHT
Blue light is light on the visible spectrum that has a short wavelength and a high amount of energy. Blue light is not harmful to the eye in small amounts, but long periods of time using digital devices increases the risk of developing symptoms from blue light exposure. These symptoms—
The good news is that many lenses have been developed that help block blue light that is emitted by devices. This allows for improved visual efficiency and fewer symptoms. Helping our patients understand that their daily habits affect their vision is a top priority. We often only see patients once a year at their annual comprehensive eye exam, and we have a limited amount of time to show how their lifestyle affects vision health. Think About Your Eyes, the vision industry’s awareness campaign, reminds patients year-round that their vision is important. It does so via TV ads, radio commercials, online video and banner ads, and social media. Encouraging patients to schedule an annual eye exam is the most important message we can convey, and it is the first step in monitoring any issues increased screen time may present. O|O
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NEW PRODUCT | GALLERY X-CEL INTRODUCES OPAQUE DISPOSABLE TORIC LENS
X-Cel Specialty Contacts, in partnership with PolyDev LTD, introduces TORIColors Comfort Cosmetic Lens, an opaque disposable toric contact lens. TORIColors is a monthly disposable lens made with a patented glycerol methacrylate (GMA)/hydroxethyl methacrylate (HEMA) copolymer that enables the lens to retain 97% of its moisture and powered by Extreme H2O Toric LC (low cylinder) and Extreme H2O Toric MC (mid-cylinder) lenses. TORIColors is available in seabreeze blue, emerald green, golden amber, and horizon grey. The lens is available in powers of plano to -2.50D (0.25D steps) and -2.50D to -4.00 (0.50D steps); LC axes of 15°-90°-180° and MC axis of 10°90°-180°. Call 877.336.2482, or go to XCelSpecialtyContacts.com.
PORTABLE MAGNIFIER FEATURES 12-INCH INTERACTIVE SCREEN
Eschenbach Optik of America, Inc. introduces the Visolux Digital XL FHD portable video magnifier for your low vision patients. Features include: • A 12-inch interactive touch screen with speech output that lets users zoom in and out, navigate the image on the screen and select menu items with a simple touch. • Dynamic Line Scrolling, or DLS, which lets the user scroll horizontally and vertically when on the higher magnification levels without having to move the device. • An FHD camera that provides 1,920x1,080 image resolution and 14 color-contrast modes. • HDMI input and output functionality, which lets patients view distance objects on the magnifier by connecting an external video camera to the device. • Bright LED illumination and a high magnification range from 2x to 22x. Users can capture and store images on a removable 8GB SD card and view the images on the magnifier or on a computer via the USB connector. Call 800.487.5389, email Info@Eschenbach.com or visit Eschenbach.com.
BRUDER HEALTHCARE OFFERS NEW OPTION IN LID HYGIENE
Bruder Healthcare’s new micro-fine Hygienic Eyelid Sheets, designed for use with the Bruder Moist Heat Eye Compress, helps patients who have blepharitis or who wear heavy make-up cleanse oil, bacteria, debris and makeup from eyelids and lashes. The microwave-activated Bruder Moist Heat Eye Compress helps keep meibomian oils flowing to soothe dry eyes and helps liquefy and release clogged meibum from the glands. The heated Eye Compress also naturally moistens the Hygienic Eyelid Sheet. There are 35 individually wrapped sheets in each box, with 12 boxes in a case. Call 888.827.8337, email Pro.Order@Bruder.com, or go to Bruder.com.
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YOUR INDUSTRY YOUR CAMPAIGN
OWN IT.
Think About Your Eyes (TAYE) not only promotes vision health among Americans, it also
supports the health of the vision industry. In 2018, TAYE messaging will reach 95% of Americans aged 25-49 with its new campaign encouraging consumers to schedule an annual eye exam.
An investment in TAYE is an investment in industry success. Join the effort now. Contact Ron Sallerson at 703-740-1093 or rsallerson@thinkaboutyoureyes.com to join our 21 industry partners and 43 state optometric associations in supporting TAYE.
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For dad For mom For the whole family From premium lenses and designer frames to prescription sunwear or an annual supply of contact lenses — families need eyewear that fit a wide range of activities in their lifestyle. You can help make it easier for them to purchase all the products they want right from your practice with promotional financing options* available through the CareCredit credit card.
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* Subject to credit approval. Minimum monthly payments required. See carecredit.com for details. ^ Subject to change. OO0418OA
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