Optometric Office September 2019 by First Vision Media Group

CULTIVATING INNOVATION AND LEADERSHIP IN EYE CARE

Celebrating 5 Years

AN INITIATIVE OF

OPTOMETRIC OFFICE PRODUCTS AND TECHNOLOGY FOR YOUR PRACTICE

SEPTEMBER 2019

CONTACT LENSES:

INSTRUMENTS:

PHARMACEUTICALS:

FITTING COSMETIC AND PROSTHETIC LENSES p 8

6 DEVICES FOR DIAGNOSING CORNEAL DISEASE p 9

THREE TOPICAL THERAPIES FOR DRY EYE p 12

PREVENTING DRY EYE | SUPPLEMENTS THAT SUPPORT AND RESTORE TEAR FUNCTION

p 10

SUPPLEMENT TO VCPN SEPTEMBER 2019

OPTOMETRIC OFFICE EDITORIAL STAFF VP, Editorial John Sailer | JSailer@ FVMG.com Editor Joanne Marchitelli | JMarchitelli@FVMG.com

Table of Contents

Creative Director Production and Web Manager Megan LaSalla | MLaSalla@FVMG.com Contributing Writers Jeffrey Anshel, OD, FAAO Andrew S. Gurwood, OD Ann M. Hoscheit, OD, FAAO Alan G. Kabat, OD, FAAO Nicholas Karbach, OD

BUSINESS STAFF President/Publisher Terry Tanker | TTanker@FVMG.com Regional Sales Manager Eric Hagerman | EHagerman@FVMG.com

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.

FEATURES

8 | CONTACT LENSES: Docs Speak Out About Cosmetic and Prosthetic Contact Lenses 9 | INSTRUMENTS: Topography Technology for Irregular Corneas 10 | PATIENT CARE: A Proactive Approach to Dry Eye Disease 12 | PHARMACEUTICALS: Prescribing the Right Remedy for Dry Eye www.Facebook.com/OptometricOffice www.Twitter.com/OO_Magazine www.Linkedin.com/showcase/Optometric-Office-Magazine

VIEWS Joanne Marchitelli Vision and hearing loss, long considered a normal part of aging, may actually impact not only how we age but how long we live. That’s according to a six-year study on vision and hearing impairments and life expectancy that found those impairments were associated with poor health outcomes. The study, conducted by researchers at Duke-NUS Medical School (DukeNUS) in Singapore, was recently published in the Journal of the American Geriatrics Society. For the study, researchers asked 3,452 Singaporean adults to rate their own vision and hearing abilities. In addition, they were asked about physical limitations, such as difficulty walking for 200 to 300 meters, climbing 10 steps without resting and raising their hands above their heads. Problems completing activities of daily living (ADLs), including bathing, dressing, managing prescriptions and doing housework, were also taken into account. Researchers found that older adults with both hearing and vision impairments had the greatest reduction in overall life expectancy and health expectancy (the amount of life expected to be lived without health problems). The study found life expectancy for a 60-year-old with vision and hearing loss was four years shorter than a 60-year-old without similar impairments but also included about three more years of life with limited physical function. According to researchers, older adults with both impairments could expect to spend 62% of their remaining life with

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A LOOK AT VISION LOSS AND LIFE SPAN limitation to physical function, while the estimated figure for those with neither impairment was 38%. In addition, older adults with both impairments could expect to spend nearly one-third of their remaining life with limitation in completing ADLs, while those with neither impairment could expect only 16%. Previous research has linked declining vision and hearing to increased mortality, but this study was able to track impairment status over time. “What’s unique about our study is that we allowed vision and hearing impairment status to vary over time in the analysis. This is reflective of real-life cases, where some people would progress in their impairment over time, while others would remain stable or improve upon treatment of the underlying cause. We also accounted for the respondents’ existing chronic diseases,” said Dr. Chan Wei-Ming Angelique, executive director, Centre for Ageing Research and Education, Duke-NUS, and coauthor of the study. “Early detection and timely management of vision and hearing impairments by older adults, their families and health systems are key to increasing the quality of life for older adults,” stressed Professor Patrick Casey, senior vice dean for research at Duke-NUS. On the bright side, this research (and others like it) may inspire healthcare providers, policy makers and even patients themselves to take these health concerns more seriously. Managing vision and hearing impairments now will help increase quality of life later. *** Joanne Marchitelli | Editor | JMarchitelli@FVMG.com

JM: What is your involvement with Best Practices? JP: In the spring, we hosted our fourth annual Best Practices Summit, and again my role was tied to communications. I worked with the honorees on storytelling, which was the theme of this year’s summit. Our keynote speaker, Kindra Hall, talked to them about crafting their own stories— both within their communities and within their profession. Beyond the Summit, I help honorees throughout the year to increase their exposure, including conducting interviews and summarizing them for ECP Viewpoints. JM: Where are you in the cycle of the Best Practices process? What are doing to prepare for 2020?

ONE-TO-ONE Jennifer A. Palombi, OD, FAAO

Senior Manager, Professional and Scientific Communication, CooperVision Jennifer A. Palombi, OD, FAAO, is senior manager, professional scientific communication at CooperVision. As a member of the North America professional affairs team, she provides clinical insights to ensure accuracy and relevance of the company’s communication to doctors. Prior to her role at CooperVision, she spent 20 years in clinical practice and lectured extensively on both ocular disease and contact lens topics. Joanne Marchitelli: You joined CooperVision two years ago. In that time, what initiatives have you started? Jennifer Palombi: My first big undertaking at CooperVision was ECP Viewpoints which is a blog on the CooperVision Practitioner webpage that covers a variety of topics that resonate with doctors, such as legislative advocacy, CooperVision’s Best Practices program, practice management, tips and tricks from the lane, clinical pearls, and updates for students and educators. I have also been tasked with training our speakers bureau doctors so that they are able to maximize the limited time they have at CooperVision’s events for eyecare professionals. I spend a lot of time developing communication around our products, as well as how to succeed in today’s marketplace.

JP: We recently filmed video segments of honorees sharing practice insights, which we will promote throughout the industry. Applications for our 2020 honorees open in September and will run through the deadline in November. It is kind of serendipitous timing that the fifth anniversary of the program will hit in the year 2020, which is an exciting year for eyecare.

JM: You specialized in specialty contact lenses and neuroophthalmic disease while you were in private practice. How did that come about? JP: I was in a large OD/MD practice. There were 12 of us: nine MDs and three ODs. When our contact lens specialist retired, the partners asked me to take over the contact lens side of the practice too, and that is how I found myself doing both. I had so many years of neuro and many patients in poor health—it made me very mindful of preventative care. It was the genesis of a personal mission to make sure that I had my contact lens patients in the healthiest possible materials and modalities. CooperVision has such a broad silicone hydrogel portfolio and so many options, which enabled me to keep my patients in lenses and modalities that I was comfortable with— especially when the clariti 1 day family was introduced. That was a game-changer in our practice. We were able to combine the benefits of SiHy and daily disposables at a decent price point. That brought me close to CooperVision to begin with, and when I was looking for the career change, CooperVision was the first place I looked. JM: Which CooperVision lens technology are you most excited about? JP: Personally, I accomplished so much with the SiHy one-day portfolio, that it is probably the area that I am most excited about. The thing that made clariti 1 day such a success in my practice was the fact that I had it available in sphere, toric and multifocal options from the day it arrived, which does not often happen. When a new one-day comes to market, a lot of times you get the sphere and maybe a year or two later a toric option, and then maybe somewhere down the road, a multifocal. But when clariti 1 day arrived with all options available up front, I was able to get everybody into a family of lenses that performed well and provided a healthier lens-wearing experience. Overall, I love everything that CooperVision is doing. ***

To read the full interview, go to OptometricOffice.com. O|O

O p tometr ic O ffic e. c om | Sep tembe r 2019

THINK ABOUT YOUR EYES

A CLOSER LOOK AT

THE SUNSHINE

VITAMIN

The “sunshine vitamin” has received quite a bit of attention in the last decade or so, especially its role in osteoporosis, autoimmune disorders, cardiovascular and infectious disease and common cancers. For eyecare providers, it is important to note that vitamin D deficiency also plays a role in common ocular conditions, including dry eye, glaucoma, macular degeneration and myopia, to name a few. As an eyecare provider, we diagnose and manage a variety of conditions associated with vitamin D deficiency, and it is reasonable for our patient care to include not only understanding the association but also diagnosing and managing the deficiency.

VITAMIN D AND OCULAR HEALTH

Ann M. Hoscheit, OD, FAAO Ann M. Hoscheit, OD, FAAO, is president of EyeBridge Consulting Associates, board certified in integrative medicine, an associate of Cherryville Eye Care, and one of the 22,000 doctors on the Think About Your Eyes doctor locator. First Vision Media Group supports Think About Your Eyes as a media partner.

When it comes to dry eye patients, we commonly think of omega 3 deficiency, but it’s also important for optometric physicians to consider the role of vitamin D in dry eye disease as well. In fact, a recent study reported the following:

lar degeneration odds were highest in those with deficient vitamin D status and two risk alleles for the CFH and CFI genotypes, suggesting a synergistic effect between vitamin D status and complement cascade protein function.

• 74% of the vitamin D deficient women had dry eye symptoms, including pain, fatigue and functional impairment of their vision

Several studies have looked at the correlation of vitamin D deficiency and presence of myopia, particularly progressive myopia in youth. In a study of 946 participants, myopic subjects had a lower serum 25(OH)D concentration compared to non-myopic participants; and in univariable analysis, the lower levels were also associated with high risk of having progressive myopia. The association persisted after adjustment for potential confounders (e.g. age, ethnicity, parental myopia, education status and sun-exposure biomarker score).

• 52% of the vitamin D deficient women had dry eyes compared to only 4% of the controls Vitamin D deficiency plays a role in glaucoma as well. Research found that individuals with primary open-angle glaucoma (POAG) had 15% lower average vitamin D levels compared with those without the disease. For each 4ng/ dl increase in the mean 25(OH)D levels there was an association of 11% decreased risk for POAG, which remained consistent after controlling for potential confounding variables. Numerous studies point to the neuro-protective role of vitamin D in conditions such as multiple sclerosis, so this association should not surprise us. Enzymes involved in the metabolism of vitamin D have been found in the retina of the eye, so it is not unusual to see research correlating this deficiency and macular degeneration. In 2015, Amy E. Millen, PhD, reported in a study comprising post-menopausal women that age-related macu-

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NOW WHAT? Eyecare providers can order testing of vitamin levels for patients. Working in tandem with a patient’s primary care physician can isolate these deficiencies earlier, and a patient can avoid complications. Positioning eye exams as vital health check-ups can help patients realize how their daily habits and lifestyle can impact their vision. Think About Your Eyes (TAYE) is striving to do just that—change consumer behavior and thinking. By supporting TAYE and its marketing efforts, we can encourage patients to think of eye exams as a part of their holistic health plan. O|O

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O p tometr ic O ffic e. c om | Sep tembe r 2019

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

ESSILOR VISION FOUNDATION CELEBRATES ONE MILLION MAGIC MOMENTS Meet Khloe, she’s Essilor Vision Foundation’s recipient of the onemillionth pair of glasses provided by the foundation since 2017. She represents the estimated 10 million children in the U.S. who can’t see clearly and need vision care. Khloe loves unicorns, dancing and shopping with her mom, and reading and using her tablet. But she was having vision problems and began struggling in school. “Before I got glasses it was hard to see the board,” she said. Khloe is thrilled with her new pink and black eyeglasses. “When I got glasses it was easy to see. Now I

can see my mom, the board and my brother.” Khloe’s mom Santana had also noticed a difference since Khloe got her glasses. “With the glasses, she pays more attention,” she said. “Before, she didn’t want to read and she wouldn’t do her homework.” Khloe is one in a million, and the foundation is celebrating this milestone with the yearlong “One Million Magic Moments” campaign. Glasses provide magic moments through a child’s life, from seeing the board in school and catching a ball to seeing a loved one’s smile—moments many people take for granted every day.

them to help children with vision impairments. “Many people can’t imagine living in a world where everything is blurred and may be surprised to learn that one in four children in the U.S. has a vision problem that’s significant enough to affect their ability to learn,” said Becky Palm, president and executive director of Essilor Vision Foundation. “Vision issues not only impact the success of children in school, they also affect their ability to function in life. The good news is 80% of all vision impairment can be prevented or cured, often with a pair of eyeglasses.” Essilor Vision Foundation encourages eyecare professionals, teachers, parents and their communities to become advocates for vision care to help millions more. Every $50 donated as part of the “One Million Magic Moments” campaign provides a vision exam and pair of glasses to a child in need at no cost to their family. Go to EVFUSA.org/OneMillion

CONTACT LENS MUSEUM OPENS IN OREGON

The campaign informs parents and advocates about the importance of children’s eye health and encourages

Patrick J. Caroline, FAAO, Jiah Pack and Craig Norman, FCLSA, longtime collectors of contact lens artifacts, instruments and publications, hosted the grand opening of The Contact Lens Museum, located in Forest Grove, OR, on July 30. With

Ella Gudwin has been promoted from

Advancing Eyecare has acquired

to be worn with the company’s augmented

president to CEO of VisionSpring.

Ophthalmic Instruments and Consult-

and virtual reality eyewear.

Novartis has acquired Xiidra from Takeda.

ing Company.

CooperVision has promoted Joel Kamp

Wendy Hauteman has been named chief

to U.S. commercial director at Paragon

marketing officer at VSP Global.

Vision Sciences.

Inc., has acquired the worldwide rights

Innovega has received approval from the

Notal Vision, Inc., celebrated the completion

to the Zian antimicrobial molecule for

Institutional Review Board for on-eye testing

of six million patient tests performed

ophthalmic and otic uses.

of iOptik, the company’s contact lens created

with ForeseeHome, the first FDA-cleared

Harrow

Health’s

newly

formed

subsidiary, Stowe Pharmaceuticals,

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COOPERVISION TO DONATE UP TO $500K TO OUR CHILDREN’S VISION

Ribbon cutting for grand opening of The Contact Lens Museum. Left to right: Craig W. Norman, FCLSA; Patrick J. Caroline, FAAO; Jiah Pack; Dr. Donald Ezekiel; and Roy Wesley, OD, PhD.

the purpose to preserve, protect and educate eyecare practitioners, researchers, historians and the public about these optical devices and objects, the museum has more than 2,000 historical items documenting the history of this field over the past 100+ years. Exhibits include a chronological selection of the evolution of contact lenses from early glass and plastic scleral lenses, the discovery of corneal designs, original soft lenses from Czechoslovakia, and gas permeable designs through the recent rebirth of scleral lenses. “We’re really excited to share these treasures with all who have an interest,” said Caroline. “We were fortunate to have the dream of the museum kick started by the donation of items from the personal collection of Dr. Don Ezekiel from Perth, Australia, and the Dr. Newton K. Wesley Foundation which we feature at the facility.” In 2020, the museum will travel to at least four major contact lens meetings and education institutions. Go to TheContactLensMuseum.org

home-monitoring device for patients with intermediate dry AMD who are at risk for developing wet AMD. National Vision has awarded $7,000 in grants to three student members of the National Optometric Student Association. Alimera Sciences has appointed John Snisarenko to its board of directors. Vision Source won a $2 million contract

WILLS EYE VOTED A TOP CENTER FOR EXCELLENCE IN PATIENT CARE In the 2019-2020 U.S. News & World Report Best Hospitals Rankings, boardcertified physicians throughout the U.S. voted Wills Eye Hospital a top center of excellence where they would refer their most complex patients. “The news of this peer recognition is tremendously gratifying and humbling,” said Julia A. Haller, MD, ophthalmologistin-chief of Wills Eye and chair of the Department of Ophthalmology of the Sidney Kimmel Medical College at Thomas Jefferson University. “Our world-renowned Wills Eye medical staff is deeply committed to the pillars of our mission: clinical care, education and research,” said Joseph P. Bilson, chief executive officer, Wills Eye Hospital. “It is because of this dedication and great mentoring relationship among our faculty, residents and fellows that we continue to be recognized and are grateful for this honor.”

CooperVision has supported the Our Children’s Vision campaign for the last two years by donating a percentage of its CooperVision MiSight 1 day contact lens sales to the organization. Through its continued support, the company expects to contribute up to $500,000 from its global MiSight sales to Our Children’s Vision by the end of 2020. Our Children’s Vision is a large global network of partners dedicated to children’s eye health. Its goal is to bring together individuals, governments, development agencies and the public and private sectors to reach 50 million children worldwide by 2020. “Vision impairment is a disability overlooked on lists of public health priorities, but clear vision is necessary for children to thrive at school, play safely and connect with family and friends,” said Juan Carlos Aragón, OD, president of CooperVision’s Specialty EyeCare Division. “Myopia progression and its increasing prevalence is an epidemic that will threaten economic productivity and have social implications. That is why we are working diligently on the best ways to help manage the progression of the condition in children to help them see clearly and minimize the risk of potential ocular disease related to high levels of myopia and live brightly.” Go to CooperVision.com

Go to WillsEye.org

for achievements in value-based care from Southern New England Practice Transformation Network. The money will be awarded to over 1,100 Vision Source member practices in payments of up to $2,500 per practice. Trefoil Therapeutics raised $28 million Series A to advance engineered FGF-1 for the treatment of corneal diseases.

Foundation Fighting Blindness has named Judy Taylor as vice president, development. Clerio Vision has acquired Hydrogel Vision Corporation, the manufacturer of Extreme H2O contact lenses, from X-Cel Specialty Contacts. The divestment will allow X-Cel to focus on specialty lens designs. ABB Optical Group added John Weber to its board of directors.

O p tometr ic O ffic e. c om | Sep tember 2019

CONTACT LENSES

DOCS | SPEAK OUT Co sm e t i c Co n t a c t L e ns es

Prosthetic lenses help hide disfigurement from trauma to the eye or disease, such as albinism, amblyopia, aniridia, cornea damage and retinal detachment. But cosmetic lenses go beyond, well, being cosmetic. Prosthetic lenses, as well as prescription or plano color contact lenses, may help improve a patient’s self-esteem. The Docs Speak Out survey this month asked about your experience in fitting these custom contacts. Whether these lenses are prescribed for fun or functionality, respondents agreed that these lenses have the power to change patients’ lives.

As a contact lens fitter, do you ask your contact lens patients if they are interested in wearing color contact lenses?

What is the primary way you promote cosmetic and/or prosthetic lenses in your practice? 5%

emails, newsletters, and/or other marketing collateral

58%

discuss during an eye exam or contact lens fitting

48%

3% social media

YES

3% website 0

Can you share a story of how fitting a patient with a prosthetic lens improved their quality of life? “It’s incredibly empowering for a patient when they have albinism to be able to help them with the amount of light that reaches the retina. They can function better, and then they in turn also have more confidence in all areas of their lives.”

visible in-office signage and/or handouts

25%

47%

63%

YES

“Patient had a botched cataract surgery that left only 20% of the iris intact. I fit her with a prosthetic colored lens with a blacked out backing that created a 4mm pupil for her.”

“We fit a patient with no pigment in one eye with an opaque lens that matched her other eye very closely. People no longer stared at her because her eyes were two different colors.”

“I had a patient that was fitted with a prosthetic lens to help hide an iris coloboma. This patient no longer felt self-conscious about his eyes.”

“My patient was extremely light sensitive as well as embarrassed about her eye color. A green opaque contact lens made a huge difference in her self-esteem.”

“Teenager who had corneal scarring was quiet, shy and withdrawn. Boy, did she come to life with that prosthetic lens and very quickly!”

“I have patients that have corneal deformities that discolor their corneas. Specialty prosthetic lenses make them less self-conscious.”

“A preteen boy had a congenital condition that caused his cornea to become cloudy white in great contrast to his normal dark brown eye. A dark brown prosthetic lens was used to ‘match’ his eye color. This young man no longer was bullied in school for having a funny looking eye.”

“I’ve seen personalities change from victim to self-confident almost immediately with a prosthetic lens.”

“Not only was glare and blurred vision decreased, the patient also felt more confident now that others were not staring at his distorted pupil.”

Have you treated any patients who have had problems from wearing color contact lenses?

“I had a patient who had retinal detachment surgery with structural damage to the iris leaving it disfigured and very large. Patient was photophobic and very self-conscience of the cosmetic appearance of her eye. She was fitted with a prosthetic opaque tinted contact lens with a matching pupil size to the fellow eye.”

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“A patient was blind in her left eye but had enough vision to distract from the good eye. By getting a block-out contact we were able to eliminate the glare and allow her to have more comfortable vision.” “Patient was able to obtain good employment from prosthetic lens results.” “For aniridia, these lenses provide a more normal looking eye—especially on light eye individuals.” “These patients just feel better that people are not staring at them. They live a better life without being self-conscious.”

INSTRUMENTS

TOPOGRAPHY TECHNOLOGY FOR IRREGULAR CORNEAS Six devices for managing patients with corneal disease and keratoconus. B y J o anne Marchitelli Topography is key for managing keratoconus and irregular corneas. The three types of technologies available are Placido-based topography, anterior segment tomography and corneo-scleral profile measurements. All can help assess the curvature of the cornea to map and manage patients with corneal disease as well as patients with keratoconus who want to wear contact lenses. 1. The Oculus Keratograph 5M has a built-in keratometer and a highresolution color camera optimized for external imaging. Placido-based topography gives a detailed measurement of the anterior surface of the cornea. Additional features include dry eye tests such as assessing tear film, evaluating lipid layer and measuring tear film breakup time and tear meniscus height. 2. OPD-Scan III Wavefront Aberrometer from Marco Ophthalmic also uses Placido-based topography technology. The instrument’s blue light, 33-ring, Placido disc topography is gathered in one second. Mapping methods include OPD, visual acuity corneal topography/topographer and more. Besides being a corneal topographer, the OPD-Scan III features an autorefractor, keratometer, pupillometer and integrated wavefront aberrometer. 3. The Oculus Pentacam utilizes the Belin/Ambrosio Enhanced Ectasia Display to measure topography and elevation of the anterior and posterior corneal surface and corneal thickness. The Belin ABCD

Progression Display can show keratoconus progression for up to eight exams per eye and provide direct comparisons of right and left eye. Its software package also features a fast screening report, contact lens fitting, overall pachymetry and Scheimpflug image overview. The software can be easily upgraded to refractive and/or cataract packages and other modules. 4. Optovue’s Cornea Advance Anterior Segment OCT module features Optovue’s epithelial thickness mapping to evaluate early ocular surface changes that may indicate corneal disease. The two-second scan identifies thickening or thinning related to dry eye disease, keratoconus or previous refractive surgery. Change Analysis allows for tracking changes over time; Cornea B-Scan visualizes and measures corneal cross sections; the Angle Scan visualizes and measures angle parameters; and Total Cornea Power calculates both the front and back surfaces of the cornea to better calculate post-refractive IOL. 5. VX130 Corneal Segment Analyzer from Visionix combines Scheimpflug tomography, ShackHartmann wavefront aberrometry and Placido ring corneal topography. The Scheimpflug corneal tomography measures the posterior surface of the cornea for screening and managing keratoconus; the Placido ring technology provides data for contact lens fitting; and the wavefront technology measures high and low order aberrations. When used with the patient acuity simulation, you can show

The VX130 shows Scheimpflug pachymetry, wavefront refraction, and topography summary data in the same screen.

patients how much of their vision will be correctable with glasses and contact lenses. 6. The sMap3D from Visionary Optics features 360° coverage and 10-micron precision to capture one million measurement points to create detailed maps of the cornea and sclera. The data from this technology is used to design contact lenses customized to your patients’ eyes. Visionary Optics provides the following scleral lens designs: Latitude, Europa Scleral, Elara Sceral and Jupiter Scleral. O|O

O p tometr ic O ffic e. c om | Sep tember 2019

PATIENT CARE

A PROACTIVE APPROACH TO

DRY EYE DISEASE

The latest, research-backed nutrients for supporting and restoring tear function. B y J ef f rey Anshel, OD , FAAO Dry eye disease (DED) is a “big deal” these days—and getting bigger. Estimates are that over 30 million Americans have the disease and this is likely to continue to increase with the aging of the population.

Other stress-producing factors may be corneal and cataract surgery and contact lens wear.

ESSENTIAL FATTY ACIDS

CAUSES OF DRY EYE DISEASE

TREATING DED WITH NUTRACEUTICALS

Oral nutritional formulations of essential fatty acids (EFAs) are being used to treat DED—some with more success than others. EFAs as an effective treatment for DED is dependent on the proper balance of both Omega 6 and Omega 3 EFAs from chemically stable plant oil to consistently produce series 1 tear-specific anti-inflammatory prostaglandin (PGE1). EFA formulations will also block arachidonic acid (AA) fatty acid cleavage to the series 2 cyclooxygenase enzyme (COX-2), which can convert to a pro-inflammatory series 2 prostaglandin (PGE2) without the nutrient co-factors that inhibit the formation of COX-2 (see chart opposite).

As science has revealed more about the genesis of degenerative diseases, we have realized that the ocular and periorbital glands respond to stress and degenerative change just as joint cartilage in arthritis and vessel walls in hypertension and arteriosclerosis. Age, stress and degeneration appear to be related to a build-up of free radicals in tissue at the cellular level. This results in loss of function and premature aging of tissues. Chronic DED may be the result of such changes.

Recent studies indicate that one of the major contributors to the accumulation of free radicals in the lacrimal, mucous and meibomian glands of the eye and orbit may be nutritional deficiency. Scientific research over the past decade has shown that specifically targeted nutritional supplements can restore function to the glands providing lubrication. It is this research that has led to the identification of specific nutrients that can restore and support improved tear function.

EFA treatment of DED is dependent on specific nutrient co-factors that aid the downstream metabolic conversion to anti-inflammatory prostaglandins. These nutrient co-factors also stimulate the production of healthy goblet cells as well as enhance production of clearer and thinner meibomian gland oil production. Properly designed formulations will also stimulate lacrimal gland secretion as well as stimulate the production of tear lactoferrin,

There are no shortages of opportunities to learn about treating dry eyes, with a plethora of “boot camp,” specialty and university courses available. However, the one area of study that always seems to garner the least attention is that of the nutritional approach to treating the disease. Here we actually have the opportunity to prevent DED in our patients by just educating them about the likely cause of the condition.

In addition, the eyes produce about 40% less moisture with advancing age. Thus, the normal aging process, with a concomitant decrease in hormone production could be the source behind this disorder. Moreover, certain medications (the average senior takes seven) may also interfere with tear production. Also, drooping lower eyelids and excessive computer use (accompanied by less blinking) may expose the surface of the eyes to the air, increasing evaporation and dryeye symptoms.

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LACTOFERRIN

the anti-viral, anti-bacterial ironbinding protein that is particularly vital to LASIK and other post-operative patients. Dry eye nutritional formulations that are based on the most recent science now include ironfree lactoferrin in the product. Serum lactoferrin is released from the eyelid in a manner similar to serum IgG and possibly from tear neutrophils during infection and inflammation. By binding iron, lactoferrin prevents the pathogen from obtaining sufficient iron for growth.

OMEGA 6 The nutritional formulations that are designed around chemically stable Omega 6 plant oils all contain linoleic acid (LA) and significant amounts of gamma linolenic acid (GLA) plus the nutrient co-factors necessary to ensure the delta-6 desaturase (D6D) enzymatic metabolic conversion to the tear-specific anti-inflammatory PGE1. They also contain varying amounts of omega-3 alpha linolenic acid (ALA), which converts to EPA and DHA. To support this plantbased ALA/EPA/DHA conversion, products include small amounts of mercury-free fish oil, which contains DHA and EPA necessary to block the delta-5-desaturase (D5D) enzymatic AA conversion of the omega 6 downstream DGLA metabolite by the COX-2 enzyme. This enzyme, if not blocked, can convert omega 6 DGLA to the pro-inflammatory series 2 prostaglandins (PGE2).

OMEGA 3 Some manufacturers are designing formulations that are focused on the metabolic action of the omega 3 EFA, primarily found in flax and fish oils. The omega 3 EFA also requires nutrient co-factors to consistently convert downstream to EPA and DHA, which subsequently convert to the antiinflammatory series 3 prostaglandins (PGE3). PGE3 is an important site-specific anti-inflammatory, particularly for the rheumatoid arthritis patient but not as specific to tears as

Scientific research over the past decade has shown that specifically targeted nutritional supplements can restore function to the glands providing lubrication. Metabolic Pathways of Omega-3 and Omega-6 Fatty Acids

Omega-6

Omega-3

Linoleic Acid (LA)

Alpha-Linoleic Acid (ALA)

Polyunsaturated oils, including flax, corn and safflower

Black Currant (15%) Flax (85%)

Delta-6-desaturase

Delta 6 enzymes impaired by aging, alcohol and nutrient deficiencies, trans fatty acids and elevated cholesterol.

Gamma-Linolenic Acid (GLA)

Steridonic Acid (SDA)

Black Currant, EPO, Borage (18-24% GLA) Eicosatetiaenoic Acid (ETA) Dihomo-Gamma-Linolenic Acid (DGLA) Delta-5-desaturase Delta-5-desaturase

PGE1

Series One Prostaglandin Anti-inflammatory

EPA/DHA Arachidonic Acid (AA)

Lipoxgenase

LBT— 4 Pro-inflammatory

Cylooxygenase (COX2)

PGE— 2 Pro-inflammatory

Fish Oil & Cod Liver Oil

EPA appropriately blocks Omega 6 delta-5-desaturase downstream conversion

the series 1 prostaglandins from the omega 6 fatty acid metabolites. Some practitioners are still using flax oil as a stand-alone treatment for DED because it contains a large amount of omega 3 and a small amount of omega 6. Unfortunately, flax oil is highly unstable and contains none of the nutrient co-factors necessary to ensure the consistent enzymatic conversion to either the series 1 or the series 3 anti-inflammatory prostaglandin, nor does it enhance the production of tear lactoferrin. Lactoferrin is the main glycoprotein component of tears that has multiple functions, including anti-inflammatory effects and the promotion of cell growth. It has antimicrobial activity and is part of the innate defense, mainly at mucosal tissue. A decrease of lactoferrin in tears can be an indicator of aqueous deficient dry eye. Traditional thinking about dry eye treatment requires medication in the form of artificial tears or pharmaceutical solutions used to restore tear production and comfort. Anything other than this is contrary to belief and intuition. Yet, scientific research over the past decade has shown that specifically targeted nutritional supplements can restore function to the

Cylooxygenase

PGE— 3 Pro-inflammatory

Lipoxgenase

LBT— 5 Pro-inflammatory

glands providing lubrication to the eye. It is this research that has led to the identification of specific nutrient antioxidants that can restore and support improved tear function. The challenge for patients is finding one with the right nutrients. I’ve found that BioTears (Biosyntryx) has the right balance of nutrients. Others that come close include EyePromise EZ Tears (ZeaVision) and HydroEye (ScienceBased Health). With judicious use of oral nutritional supplements many patients can regain the comfort they had lost to dry eye. In the October issue, I will discuss the latest technology and tests for earlier diagnosis for dry eye disease. O|O

Jeffrey Anshel, OD, FAAO, is founding president of the Ocular Nutrition Society and is in private practice in Encinitas, CA.

WHERE TO FIND IT Biosyntrx 800.688.6815 | Biosyntrx.com ScienceBased Health 888.433.4726 | ScienceBasedHealth.com ZeaVision 866.401.1838 | EyePromise.com

O p tometr ic O ffic e. c om | Sep temb er 2019

PHARMACEUTICALS

PRESCRIBING THE RIGHT REMEDY FOR DRY EYE Exploring three topical therapies that target the causes of this common ocular surface disorder. B y Al an G. Kabat , OD , FAAO, N ic holas Ka r b a c h , OD , a n d An d rew S. G u r wo o d , OD Dry eye is a multifactorial disorder of the ocular surface characterized by one or more of three issues: 1) Tear deficiency (tear volume and tear quality), 2) Excessive tear evaporation (poor glandular function), or 3) Poor oculo-tear adherence (insufficient tear wetting, insufficient tear chemistry, poor or insufficient mucus production, poor eyelid functionmisdirected lid/globe congruity, poor eyelid posture, conjunctival scarring or poor blink rate).1-8 The inability to adequately moisturize the palpebral and bulbar conjunctival surfaces along with the cornea creates damage to those tissues inciting variable loss of function (loss of visual acuity) and symptoms such as itching, burning, foreign body sensation and general-

ized discomfort. The ocular surface and dry eye disease (DED) are also influenced by contact lens wear and refractive surgery.1 DED now affects more than 16 million adults in the U.S.1 Ocular therapy (topical and/or oral) should be customized based on the etiology and examination findings. If there is a lid position anomaly it can be repaired. Gold weights can be added in cases that demonstrate lagophthalmos.8 Partial or complete tarsorraphy can be considered in cases that threaten corneal clarity.9 Since systemic medications and systemic diseases are known to play a role in provoking, initiating or worsening DED, ocular therapy cannot be

12 Se p t e mb e r 2 0 1 9 | O p to m e tri c O f f i c e .c o m

prescribed without an understanding of these factors. This may include correspondence with the general medical team to test for an undiagnosed systemic disease or modifying a current systemic disease therapy in favor of an alternative with fewer side effects on the ocular surface. DED management should preserve ocular tissue integrity while reducing symptoms.1-9 But not all therapies work for all patients. Here are three different approaches depending on disease cause and symptoms.

LUBRICATING DROPS Ocular lubrication, tear supplementation or tear replacement therapy are the mainstays of topical intervention. Topical tear preparations (artificial

A “one-preparation-fits-all” approach frequently fails and can cloud the picture by eliminating signs that enable proper diagnosis.

tears) come in many different viscosities with many different bases. Selections with a thin base soothe and assist in discomfort as necessary. The advantage is they do not blur vision; the disadvantage is they must be used more frequently. Selections with a thick viscosity assist the patient by providing increased contact time and resurfacing of the tissues. The advantage is increased comfort over time; the disadvantage is they can affect acuity and feel “sticky.” These preparations should be tried by the prescribing practitioner so they develop a “feel” for how they work and what they can offer. Ointments offer the most extreme advantages and disadvantages of the viscous preparations. They are used daily in only the worst circumstances and typically are prescribed to administer at bedtime. Nightly topical antibiotic ointment (bacitracin, polysporin) can be substituted for topical artificial tear ointment in cases when prophylactic antimicrobial coverage is desired. Topical hypertonic ointment can be used to reduce corneal edema when injurious inflammation is present.

lacrimal gland to make more tears. The preparation also improves goblet cell stability increasing tear wettability.10-12 The principle disadvantage is that the medication works by limiting the immune system of the host; if it is not used consistently over a three-month period results may not be optimal.10

While punctal plugs (collagen and permanent) can be installed in cases of tear-deficient dry eye, new thinking regarding tear composition and inflammatory biomarkers within the tears of patients with chronically dry eye have classified their use as a remedy for cases that do not resolve with topical solutions.13,14

Topical steroids can be used to treat DED. These preparations minimize ocular inflammation and are well documented for use in DED that is refractory to topical tear and topical cyclosporine solutions. They can be used with these agents or in place of them. They are not an ideal choice as they have a litany of recognized adverse effects, the most common being the elevation of intraocular pressure. In most cases the practitioner will start these topical agents along with the topical cyclosporine drop to assist the short-term relief of symptoms. Once symptoms are improved they can be tapered or removed altogether.

CYCLOSPORINE Topical cyclosporine ophthalmic emulsion 0.05% (Restasis, Allergan), is indicated for cases of aqueous deficient dry eye.10.11 This can be determined by Schirmer tear testing or observation of a diminished lacrimal lake.10,11 These medications decrease inflammation within the lacrimal gland, permitting it to function better and allowing the patient’s

In August 2018, the U.S. Food and Drug Administration approved OTX-101 0.09% (CEQUA, Sun Pharmaceuticals, Ltd.) to increase tear production in patients with keratoconjunctivitis sicca.15 OTX-101 is a novel, aqueous, nanomicellar ophthalmic solution of cyclosporine in a preservative-free, aqueous solution.16 Two randomized controlled trials demonstrated increased tear production compared with vehicle-only drops at 12 weeks (max P <0.01), with improvements in ocular staining assessments beginning at four weeks after treatment initiation.17 Pain upon instillation and conjunctival hyperemia were the most common adverse events.15-18

STEROIDS

Lifitegrast ophthalmic solution (Xiidra, Novartis) is a lymphocyte

function-associated antigen-1 (LFA1) antagonist.19 In clinical trials, lifitegrast improved the feeling of eye dryness versus placebo.20 The downsides? In one study up to 15% of patients receiving the medication had the adverse event of eye lid irritation, 13.2% experienced an eye lid reaction after instillation, 11.4% noted decreased visual acuity and 16.4% of patients complained of dysgeusia.21 Finally, scleral contact lenses have been used to provide increased comfort for patients with dry eye. They can create a tear reservoir, which increases comfort and vision by providing a new, improved corneal surface. They can be used with any of the above treatments.22 A “one-preparation-fits-all” approach frequently fails and can cloud the picture by eliminating signs that enable proper diagnosis. Exploring the above therapies for your patients will help them find the relief they were looking for. O|O Article containing references available on OptometricOffice.com.

Alan G. Kabat, OD, FAAO, is a professor at Salus University, Pennsylvania College of Optometry. Nicholas Karbach, OD, is a clinical instructor at The Eye Institute, Pennsylvania College of Optometry at Salus University. Andrew S. Gurwood, OD, is a professor at Salus University, an attending optometric physician at The Eye Institute of the Pennsylvania College of Optometry at Salus University, and an attending physician at Albert Einstein Medical Center, department of ophthalmology.

WHERE TO FIND IT Allergan 800.347.4500 | Allergan.com Sun Pharmaceuticals SunPharma.com Novartis 862.778.2100 | Novartis.com

O p tometr ic O ffic e. c om | Sep temb er 2019

NEW PRODUCT | GALLERY ZEISS DEBUTS THE CLARUS 700 ZEISS has received 510(k) clearance from the FDA for the CLARUS 700, High-Definition, Ultra-Widefield Imaging system. The imaging system with True Color has a complete range of fundus imaging modalities, including fluorescein angiography (FA). Ultra-widefield FA helps eyecare professionals identify earlier more severe forms of diabetic retinopathy like neovascularization and retinal diseases such as uveitis, choroidal masses, retinal tears, detachments, and peripheral ischemia. The high-resolution and high-contrast images of the FA from the CLARUS 700 allows clinicians to capture the smallest details from the macula in early phase to the periphery in late phase of FA. The CLARUS 700 allows retina specialists to manage all needed capture modalities including True color with RGB separation, autofluorescence-green, autofluorescence-blue, stereo image pairs, external eye and fluorescein angiography in one session from one device, all without having to reposition the patient, thus providing patients a comfortable exam experience. Zeiss.com/Meditec

X-CEL SPECIALTY INTRODUCES NEW LENS MATERIAL X-Cel Specialty Contacts is now manufacturing sclerals and corneal GPs in the new Optimum Infinite hyper Dk GP lens material. This breakthrough material from Contamac is stable, wettable, scratch-resistant and easy to handle by both practitioners and patients. Optimum Infinite’s unique properties make it ideally suited for scleral lenses, while its versatility ideally matches the requirements of corneal lens designs. Optimum Infinite has received 510(k) clearance from the U.S. Food and Drug Administration (FDA) for a full range of indications, including myopia, hyperopia, astigmatism and aphakia. Optimum Infinite includes a UV blocker, is compatible with Tangible Hydra-PEG, and is available in customizable larger diameter sizes. Go to XCelSpecialtyContacts.com

ALCON LAUNCHES AIR OPTIX FOR ASTIGMATISM AIR OPTIX plus HydraGlyde for Astigmatism contact lenses is the newest addition to Alcon’s contact lens portfolio. The lenses offer a unique combination of technologies that support long-lasting lens surface moisture and outstanding comfort to provide astigmatic patients a consistently stable lens-wearing experience. AIR OPTIX plus HydraGlyde for Astigmatism contact lenses include a blend of unique technologies: Proprietary HydraGlyde Moisture Matrix for long-lasting lens surface moisture; Unique Precision Balance 8|4 lens design to hold the lens in place with every blink; and SmartShield Technology that helps guard against irritating deposit build-up. Go to Alcon.com

BAUSCH + LOMB PRESENTS OCUVITE EYE PERFORMANCE Bausch + Lomb’s latest eye supplement, Ocuvite Eye Performance, is formulated with seven vital nutrients that help strengthen the macula, protecting the eye from the stress of sun light and blue light emitted from digital devices. Based on insights from consumers and eyecare professionals, Bausch + Lomb created the supplement to meet the changing needs of consumers in a tech-driven world while further expanding the company’s eye vitamin portfolio. The Ocuvite Eye Performance nutrient formula contains high levels of seven vital nutrients including lutein and zeaxanthin, omega-3’s, zinc and vitamins C, D and E. Ocuvite Eye Performance eye vitamins are available at major retailers nationwide. Go to Ocuvite.com 14 Se p t e mb e r 2 0 1 9 | O p to m e tri c O f f i c e .c o m

THEMA UNVEILS VIRTUAL EYEWEAR ASSISTANT Thema Optical, an Italian manufacturer of bespoke eyewear, announced the U.S. debut of new biometric technology, known as the “Virtual Eyewear Assistant” (VEA). The technology lets consumers custom-design eyewear that is manufactured to their unique facial measurements. The VEA’s 3D camera scans and measures over 500,000 biometric points on a customer’s face—in less than 20 seconds—and creates a unique 3D facial rendering that the customer can use to virtually try on more than one million style and color combinations in Thema’s iGreen Hi-Tech collection of eyewear. The frames are manufactured in the company’s state-of-the-art facility in Miami to the exact specifications of the customer’s facial measurements in their preferred style, color and overall design, with a turnaround time of three to five business days. Benefits of biometrically designed eyewear include a more comfortable fit on the nose and less tension headaches caused by poor-fitting frames that irritate pressure points behind the ears. The VEA is currently available at Edward Beiner Optical in Miami, with plans to roll it out to additional Edward Beiner locations in Florida later this year. VEA is opening additional locations in Chicago, Boston and Washington, DC, this fall with an eventual national roll out to more than 1,000 eyewear retailers across the country that carry Thema’s iGreen line. Go to VirtualEyewearAssistant.com

EYEPROMISE ADDS SCREEN SHIELD PRO TO VITAMIN LINE Screen Shield Pro from EyePromise is designed to protect and relieve the associated symptoms of digital eye strain of adults (ages 18 and up) who spend eight-plus hours staring at digital screens while working, gaming, or just binge watching their favorite shows. The formulation contains all-natural zeaxanthin, lutein, omega-3s and other nutrients that have been proven to positively impact the symptoms associated with increased screen time. “EyePromise Screen Shield Pro is formulated for health-conscious consumers to help relieve digital eye strain and improve visual performance. It helps build a strong macular pigment layer which shields your eyes from blue light,” noted Dennis Gierhart, PhD, cofounder of ZeaVision, the parent company of EyePromise. The company recently introduced Screen Shield Teen, an ocular nutrition supplement specially formulated to preserve and support visual comfort and wellness for children ages 4 to 17. Both are designed to complement a daily multivitamin and are not intended to treat, cure, or prevent any disease. EyePromise advises that patients talk to their primary care physician before beginning any supplement regimen. Go to Explore.EyePromise.com/ScreenShieldPro

NEW FACEBOOK VIRTUAL TRY-ON TOOL FROM TRANSITIONS Transitions Optical has partnered with Facebook to create an augmented reality tryon experience using the Facebook camera. The social media experience allows users to see themselves in all 13 Transitions lens colors, including Transitions Signature lenses style colors and Transitions XTRActive style mirrors. Users can tap through the different Transitions lens colors and switch between indoor and outdoor settings. The try-on is accessible by clicking on a link that’s on the Transitions Facebook Page or by scanning the QR code with their Facebook app (to find the QR code scanner, simply type “QR code” in the top of the Facebook search bar). The user can take a photo or video selfie to share on Facebook, and the media can be saved to the camera roll and shared via text, email, or other social networks. Go to TransitionsPRO.com/FacebookTryOn

O p tometr ic O ffic e. c om | Sep temb er 2019

AT-A- GLANCE TONOMETERS TONOMETER

TYPE

MEASUREMENT RANGE

BiCOM Inc. | 877.342.8667 | TonometerDiaton.com Diaton Handheld, scleral/ 5-60 mmHg transpalpebral

METHOD

BENEFITS

Non-contact (No corneal contact)

• no corneal contact; IOP measured through the eyelid and sclera, so reading is CCT independent • can take reading with patient in seated or supine positions • no sterilization or replacement covers required

• • • • •

Icare | 888.422.7313 | Icare-USA.com

EyeSmart automatic OD/OS recognition technology EasyPos intelligent positioning assistant AMS automatic measuring sequence series and single mode with one button AMS automatic measuring sequence; series and single mode with one button • EasyNav advanced navigation interface • EasyPos intelligent positioning assistant

Icare HOME

Handheld

5-50 mmHg

Patented rebound technology

Icare ic100

Handheld

7-50 mmHg

Patented rebound technology

5-50 mmHg

Air puff

• • • • • •

Applanation tonometer

• check weight and check weight holder • two measuring prisms standard • smoother rotation and operation for accurate positioning

Air Puff Non-contact Tonometry and Pachymetry

• video of air puff with visualization • provides 4300 frames/second with high speed camera • takes optical pachymetry measurements

Keeler | 800.523.5620 | KeelerUSA.com

TonoCare

Handheld

advanced optical and sensor technology puff automatically adjusts for the next measurement takes fast measurements with patient in any position advanced optical and sensor technology puff automatically adjusts for the next measurement takes fast measurements with patient in any position

Marco | 800.874.5274 | Marco.com

AT-9

Slit lamp mounted 0-80 mmHg

OCULUS, Inc. | 888.284.8004| OculusUSA.com

Corvis STL

Tabletop

6-60 mmHg

Reichert | 888.849.8955 | Reichert.com Ocular Response Analyzer G3

Tabletop

7-60 mmHg

Air Puff

• measures corneal hysteresis • provides IOPcc: IOP compensated for corneal biomechanics

Tono-Pen AVIA

Handheld

5-55 mmHg

Contact tip

• portable • uses average of 10 different readings • IOP measurements that are less sensitive

16 Se pt e mb e r 2 01 9 | O p to m e tri c O f f i c e .c o m

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