Optometric Office September 2018 by First Vision Media Group

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OPTOMETRIC OFFICE PRODUCTS AND TECHNOLOGY FOR YOUR PRACTICE

SEPTEMBER 2018

A S T I G M A T I C

SUCCESS from chair

TO WEAR NOW AVAILABLE: -2.75D Cylinder for Bausch + Lomb ULTRA® for Astigmatism. The only monthly toric lens with a -2.75D Cylinder in your fit set.

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OPTOMETRIC OFFICE PRODUCTS AND TECHNOLOGY FOR YOUR PRACTICE

ONE-TO-ONE: AOA PRESIDENT SAMUEL D. PIERCE, OD

SEPTEMBER 2018

CASE FILES: COLOR AND OCCLUSION FROM CONTACT LENSES

PATIENT CARE: NUTRITION, GENETICS AND AMD PROGRESSION

A NUTRITIONAL APPROACH: TO TREATING DRY EYE

HOW SUPPLEMENTS QUELL INFLAMATION SUPPLEMENT TO VCPN SEPTEMBER 2018

Healthy Eyes Start with Healthy Eyelids The root cause of anterior blepharitis is the overproduction of oils. Surfactants in OCuSOFT® Lid Scrub® Eyelid Cleanser dissolve and remove oil, debris and desquamated skin. When the most severe conditions occur, the combination of OCuSOFT® Lid Scrub® and OCuSOFT® HypoChlor® (0.02% Hypochlorous acid) is ideal. To achieve optimum results, CLEAN all oil, debris and other contaminants associated with eyelid irritations using OCuSOFT® Lid Scrub® Eyelid Cleanser and then SPRAY OCuSOFT® HypoChlor® for fast action against microorganisms.

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OPTOMETRIC OFFICE EDITORIAL STAFF VP, Editorial John Sailer | JSailer@ FVMG.com Editor-in-Chief Jeffrey Eisenberg | JEisenberg@FVMG.com

Table of Contents 8 10

Editor Cara Aidone Huzinec | CHuzinec@FVMG.com Creative Director Megan LaSalla | MLaSalla@FVMG.com Production and Web Manager Anthony Floreno | AFloreno@FVMG.com Contributing Writers Jeffrey Anshel, OD, FAAO Sherry J. Bass, OD, FAAO, FCOVD Brooke Messer, OD, FAAO Jennifer Zolman, OD, FCOVD

BUSINESS STAFF President/Publisher Terry Tanker | TTanker@FVMG.com Executive Vice President Shawn Mery | SMery@FVMG.com

DEPARTMENTS 2 | Views

4 | One-to-One: Samuel D. Pierce, OD 5 | Think About Your Eyes 6 | Product Buzz

Vice President, Marketing Debby Corriveau | DCorriveau@FVMG.com

14 | New Product Gallery

Regional Sales Manager Eric Hagerman | EHagerman@FVMG.com

16 | At-A-Glance: Tonometers

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: Color and Occlusion 10 | PATIENT CARE: Is AMD Progression in the Genes? 12 | PHARMACUETICALS: A Nutritional Approach To Treating Dry Eye

www.Facebook.com/OptometricOffice www.Twitter.com/OO_Magazine www.Linkedin.com/showcase/Optometric-Office-Magazine

VIEWS

Jeffrey Eisenberg

A COURSE CATALOG

FOR YOUR PRACTICE As September gets underway, many of you no doubt are thinking about education, whether it’s buying an endless supply of pencils and notebooks, braving the gridlock of a college campus on move-in day, or getting ready to attend Vision Expo West to further your own education. No matter what age your patients are, it’s never too late for them to learn either. Think of them as lifelong learners, students who will look to you as teacher for their continuing education. Here are some classes you might want to include in your course catalog: Children’s Vision 101. Now that school is back in session, it’s an ideal time to educate parents that a vision screening in the school nurse’s office doesn’t replace the need for regular comprehensive eye exams. It’s also an opportunity to educate them about the connection between binocular vision disorders and poor school performance, and to remind them to bring any child who has experienced a concussion for a comprehensive eye exam. Contact Lenses 101. Most contact lens wearers admit to at least one bad hygiene habit that puts them at risk for eye infections, according to research from the Centers for Disease Control and Prevention. For example, one in three contact lens wearers sleep or nap in their lenses even though this carries a six- to eightfold greater risk for a serious eye infection. These patients need you to educate them about proper lens wear and care. While you’re at it, you might want to remind patients not to flush their used contact lenses down the toilet or sink or

place them in the recycling bin. Researchers from Arizona State University found that these end up affecting the environment and ocean life or adding to waste at landfills. Diabetes 101. More than 30 million Americans have diabetes, and another 84 million have prediabetes and are at risk for developing type 2 diabetes, according to the CDC. Although diabetes is the leading cause of new cases of blindness among adults, an American Eye-Q Survey from the AOA found that 79% of Americans don’t know diabetic eye diseases have no visible symptoms, and more than half do not know comprehensive eye examinations can detect diabetes. Your patients with diabetes will need you to educate them about the importance of regular eye exams as well as keeping their diabetes under control. Digital Eye Strain 101. Americans spend nearly half of their waking hours looking at a screen, whether it’s phones, laptops, TVs or tablets, according to a new study conducted by OnePoll on behalf of CooperVision. They’ll need you to educate them about the signs and symptoms of digital eye strain, healthier habits for screen time, and contact lenses or ophthalmic lenses that can relieve their symptoms. The syllabus should also include a reminder that overexposure to blue light increases the risk of developing age-related macular degeneration. Nutrition 101. Your older patients no doubt see advertisements and talk with their friends about supplements that might protect them against AMD. But, they and your patients with dry eye need you to educate them about which supplements are most appropriate. This is also a good time to educate patients about the importance of a diet rich in carotenoids and omega-3s as well as lifestyle changes that can reduce their risk of AMD. Your students’ passing grade: improved ocular and visual health. They may also recommend that other prospective students take your class.

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

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THE INTELLIGENT

TONOMETER THE PATIENT CHOICE

THE PROFESSIONAL CHOICE

VISIT VEW 2018 BOOTH #MS7045 FOR SHOW SPECIAL! Learn more: info@icare-usa.com or www.icare-usa.com

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JE: The AOA has been active on several fronts: combating illegal contact lens sales and online eye exams, legislation concerning contact lenses and access to optometric services, state scope-of-practice laws, the opioid epidemic … the list goes on. What are your top priorities for the coming year?

ONE-TO-ONE Samuel D. Pierce, OD Samuel D. Pierce, OD, was sworn in as 2018-2019 president of the American Optometric Association at Optometry’s Meeting in June. Pierce was first elected to the AOA’s board of trustees in June 2009 and has volunteered his time to the AOA’s Communications Advisory Group and several AOA committees. He has been in private practice in Trussville, AL, for more than 29 years and is past president of the Alabama Optometric Association. Jeffrey Eisenberg: Congratulations on being installed as the 2018-2019 president of the American Optometric Association. What experiences from your 29 years in practice will guide you in your position? Samuel D. Pierce, OD: My years of experience as a doctor as well as my long-time and active involvement in the Alabama Optometric Association and American Optometric Association have truly set my vision for this dynamic profession. It is because of my hands-on experience in changing the profession that I am focused on it continuing to evolve to better serve patients. Serving as a volunteer and on the AOA’s board of trustees for nearly a decade has prepared me well for this role. I’ve had the privilege of being on the board with 10 different presidents, which means 10 different styles of leadership. In that time, I have learned many valuable lessons from each one. 4 Se pt e mb e r 20 1 8 | O p to m e tri c O f f i c e .c o m

SP: The AOA’s number one priority has been and will continue to be advocating for optometry and what is right for patients. To do this, we must take assertive steps to expand the scope of optometric practice across states. The AOA is deploying an advocacy team comprised of several AOA leaders and staff who will work with individual state optometric associations to assess their current scope of practice and the steps they need to take to expand it. This group will evaluate the state associations’ grassroots structure, PAC donations and relationships with key decision-makers, such as governors, lieutenant governors and key legislative committee members, to provide them with the tools and support to take on scope-of-practice expansion. JE: With proposed changes to the Fairness to Contact Lens Consumers Act, optometrists would have greater recordkeeping requirements. What specific changes, if any, would you like to see to the Contact Lens Act? SP: As far as the Federal Trade Commission’s proposed rule goes, this proposal will only serve to divert from patient care and put a wedge in the doctor-patient relationship. In fact, according to an AOA survey of contact lens wearers, more than eight in 10 oppose additional government regulation of the doctor-patient relationship. We will continue to urge officials to oppose the harmful FTC proposal that would undermine the doctor-patient relationship and impose needless, burdensome requirements on physicians, who are already struggling to keep pace with ever-changing regulatory requirements. It currently costs optometrists approximately $47 million annually to comply with the Contact Lens Rule, and the new requirement would cause an additional cost burden. Doctors are following the law and want government agencies to take action against the real problem at hand: those online retailers who have been found to be lowering quality care standards for medical devices, using deceptive sales tactics and placing patient safety at risk. JE: Are there any additional areas you would like the AOA to address during your term? SP: We will see a great deal of activity across the country as a large number of states take a hard look at their current optometry acts and evaluate what needs to be done to raise the bar for optometry. I believe that we will see more and more health plans integrating comprehensive eye exams into their medical plans. We will continue to push state and federal agencies to enforce patient protection laws. To read the full interview with Samuel D. Pierce, OD, go to OptometricOffice.com.

THINK ABOUT YOUR EYES

KEEPING AN EYE ON

PATIENTS’ DIETS Scientists have understood for years that proper nutrition is critical to eye health. Intensive research conducted in this area has identified essential nutrients that promote healthy vision and may reduce the risk of eye disease. Consider: The Age-Related Eye Disease Study, or AREDS, found that individuals who had a high-risk of developing advanced age-related macular degeneration but took a supplement containing high doses of vitamins and antioxidants reduced their risk of progression by 25%. They also reduced their risk of visual acuity loss due to advanced AMD by 19%. Research also has suggested that an individual’s genetic make-up may help determine the role of nutrition in preventing AMD progression. (See “Is AMD Progression in the Genes?” page 10.) We also know that a diet rich in nutrients with antioxidant properties, such as vitamins C and E, lutein, and zeaxanthin, may help slow the progression of cataracts. There’s now evidence that several nutrients play a role in the treatment of dry eye disease as well. (See “A Nutritional Approach to Treating Dry Eye,” page 12.) By contrast, chronic inflammation can cause long-term damage to our eyes as well as our bodies. Our digestive systems are not able to absorb the “good” nutrients effectively when in an inflamed state. Even so, the common Western diet, which is saturated with corn and grains that contain gluten, sugar, high-fructose corn syrup, caffeine and alcohol, vegetable oils, and red meat, is associated with an increased AMD risk.

START THE CONVERSATION

The important concern for us is to start a conversation about diet and nutrition with our patients. Now that ODs are in the primary care arena, this needs to be one of the conversations in the exam room. This ties in with the message that Think About Your Eyes promotes, namely the importance of an annual eye exam.

Jennifer Zolman, OD

Jennifer Zolman, OD, FCOVD, is the immediate past president of The South Carolina Optometric Physicians Association and is among the 18,000 doctors listed on the Think About Your Eyes online locator. Think About Your Eyes is a nationwide public awareness initiative promoting the importance of an annual eye exam and overall vision health. First Vision Media Group supports Think About Your Eyes as a media partner. To educate our patients, we need to educate ourselves as well with basic knowledge about nutrition and its effects on the eyes and body. For example, not all supplements are created equal. Many have low bioavailability, which can hinder absorption of the nutrients. Each of us should do some research and be able to recommend the most appropriate supplements available for our patients. They should get their information from us rather than purchase whatever supplement for which they have a coupon. It is always best to get our nutrition from foods, but when we can’t, a supplement can fill the void.

BIG IMPACT

Changes in diet can have a big impact on eye health and improve the quality of life. Eyecare professionals know that good eye health is proactive. Our bodies do not create all the nutrients we need, so it’s essential to get them through our diet and/or nutritional supplements such as ocular vitamins. O|O

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PRODUCT | BUZZ LAUNCHES, PROMOTIONS, MERCHANDISING, EVENTS AND OTHER THINGS TO KEEP YOU IN THE KNOW. VISION EXPO EXPANDS EDUCATION OFFERINGS

Vision Expo West, taking place Sept. 26 to 29 in Las Vegas, will introduce an expansive scope of education, products, trends and solutions to keep attendees updated on best practices in patient care, practice management, retail strategies and more. New educational sessions at Vision Expo West 2018 include “Attract and Retain Customers,” “Ocular Aesthetics,” “Supporting the Practice Experience,” “Clinical Concepts for Opticians and Technicians” and “Private Equity and Eye Care: Should I Stay or Should I Go?” In other news, Vision Expo has announced a new category as part of its Best Booth Awards, namely Best In-Booth Brand Activation. Attendees can vote for their favorite booths using the Vision Expo mobile app. One voter each day will be selected to win a $500 AmEx Gift Card. Voting for the Best Booth Awards will open Thursday, Sept. 27, at 9:30am, and the winners in each category will be announced Saturday, Sept. 29, at 4pm. Go to VisionExpoLV.com.

SECO MEETING GOES TO THE BIG EASY

SECO will take place Feb. 20 to 24, 2019, at the Ernest N. Memorial Convention Center in

New Orleans—the first time SECO will be held outside of Atlanta since 1957. Attendees can earn more than 50 hours of continuing education and can take advantage of new Saturday and Sunday sessions. This year’s conference also offers flexible registration pricing, with packages for optometrists, allied health professionals, faculty, students and even group discounts. Registration opens Oct. 1. Go to AttendSECO.com.

WEB VISION, NIDEK DEVELOPING TESTING DEVICES FOR NASA

Web Vision Technologies, with two grants from Translational Research Institute, is developing vision testing devices to allow NASA scientists to detect, monitor progression, and guide medical interventions for vision issues astronauts experience on long-duration, deep-space missions. Spaceflight-Associated Neuro-ocular Syndrome, or SANS, is known to cause significant vision issues in astronauts and to cause physical changes in the interior of their eyes. The first device, in its second phase of development, is a compact, selfimaging retinal camera that will allow astronauts to take images of their retinas that doctors on the ground can use to look for signs of SANS and monitor its progression. The second device is a specially designed goggle-based headset that will allow astronauts to test the functionality of their visual fields and perform other vision tests. Web Vision is partnering with NIDEK TECHNOLOGIES to help with the development, design and prototyping of the two devices. Go to WebVisionTechnologies.net.

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News

Sun Pharmaceutical Industries Ltd. has received FDA approval for approval for CEQUA (cyclosporine 0.09%) to increase tear production in patients with keratoconjunctivitis sicca. Joseph Gordon has been named U.S. president for Bausch + Lomb and will oversee its Vision Care, Consumer Health, Surgical and Pharmaceuticals business units. Bausch + Lomb also announced that VYZULTA (latanoprostene bunod 0.024%), its nitric oxidereleasing prostaglandin analog, is now available in a 2.5ml bottle as well as its 5 ml bottle. Bob Ferrigno, who has led sales and marketing efforts at SynergEyes, Inc., is now CEO, succeeding James Kirchner, OD, who is now president emeritus. Amanda K. Lee, Lee, formerly vice president, COO and co-owner of Vision Source at Seaside Eye Associates in Myrtle Beach, SC, has joined MacuLogix as director of professional relations. EyePromise has appointed Andreas Wolf, former vice president and general manager at Young Dental, as president and Peggy Stohr, who has a financial and administrative background with medical device organizations, as chief financial officer. The International Sports Vision Association has named Gary Esterow as executive director, a position he plans to assume while still serving as executive director of The Neuro-Optometric Rehabilitation Association, International, and operating Esterow Communications, LLC.

A S T I G M A T I C

SUCCESS from chair

TO WEAR NOW AVAILABLE: -2.75D Cylinder for Bausch + Lomb ULTRA® for Astigmatism. The only monthly toric lens with a -2.75D Cylinder in your fit set.

Contact your representative to request lenses for your office

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CONTACT LENSES

CONTACT LENS CASE FILES: | COLOR AND OCCLUSION

Hand-painted lenses allowed us to match the patient’s injured eye to her healthy one.

For patients with disfigured eyes, cosmetic/prosthetic lenses can alleviate visual symptoms and improve self-esteem. By Bro o ke M esser, OD , FAAO

CASE 1: ANIRIDIA

A 63-year-old white female presented with a history of a penetrating injury to her left eye, resulting in a traumatic aniridia. This patient needed a prosthetic lens to relieve her extreme light sensitivity and improve the appearance of her left eye. Her natural iris is a hazel-blue color with several pigment spots—an appearance that can be challenging to duplicate. We opted for a custom, hand-painted lens for this patient for several reasons. First, she desired her contact lens to match her natural iris as closely as possible. Second, we needed good light control, and a hand-painted lens can have a very dark base color to allow light only through the open pupil. To begin a hand-painted prosthetic lens fitting, take several photos of the patient’s natural eye color with a good quality camera in several lighting conditions, like natural light, bright and average room lighting. These images will be sent to the lab,

where the photos will be analyzed and the lens will be designed. This lens was ordered from Adventures in Color, and the patient was satisfied with the overall result after a small pupil size adjustment. Discussion. Patient education is essential to ensure realistic expectations on how their eyes will appear in most settings. During this discussion, discover what is the most important aspect of your patient’s lens wearing experience. Is it function, appearance, out-of-pocket costs, or turnaround time from the lab? This patient was highly motivated for best cosmesis, and she was willing to pay extra, and wait longer, for this custom product. Additional tips: When creating an artificial iris for patients such as this one, the main focus often falls on lens appearance and if it’s blocking enough light. Be sure to encourage your patient to wear the lens in different lighting conditions, including dim situations, to ensure that the lens does not block too much light.

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CASE 2: PUPIL OCCLUSION

A 22-year-old white male presented to our office with a chief complaint of diplopia. His medical history included a recently diagnosed brain tumor, leaving him with extraocular muscle restrictions of the left eye in several gazes. In order to alleviate his diplopia, the goal was to occlude his left eye. A first-line approach to this case would be to utilize a lens that covers his pupil only. It would simply include selecting a pupil diameter to match most lighting situations and would not require matching the contact lens coloring to his natural iris. His pupil size was measured at 4mm in average room lighting, so a prosthetic tinted contact lens with a lens with a clear iris and 4.5mm pupil was ordered to ensure the vision in his left eye was fully occluded. After a couple lens adjustments, it was found that the occluding pupil needed to be 7mm in diameter to fully occlude his left eye. Given his blue eye color, the

large and dark pupil of the prosthetic lens was cosmetically unacceptable. We transitioned the patient into a prosthetic tinted lens from Orion Vision Group’s BioColors fitting set. This set contains varying shades of brown, green and blue iris colors, as well as limbal and pupil enhancement rings. The set comes with a stand that allows you to layer the iris colors and enhancement rings to build a custom look. For corneas that are scarred and white in appearance, there are dark underprints for a base color, and the iris tints can be layered on top. For this patient, I used a dark underprint with a black pupil to make sure his vision was fully occluded, and then layers blue colors over top. This resulted in a beautiful match to his natural iris and provided the full occlusion we desired. Discussion. Pupil size is an important consideration in a case like this. Obviously, there will be times when the pupil size of the contact lens does not match the pupil size of the natural iris. Accurately determining the pupil size is an important task, so it’s critical to ask about where the patient spends most of their time and when it’s most important for good cosmesis. Additional tips: Because these lenses are custom made, there can be a varying range of lens diameters and base curves. In addition to pupil size, keratometry and horizontal visible iris diameter measurements are important. A desired lens fit would

be one that moves enough to allow some tear exchange but snug enough that it doesn’t move significantly as the patient moves the eye or during blinks.

CASE 3: CATARACT COVER-UP

A 27-year-old white male presented with an ocular history of retinopathy of prematurity that resulted in a total retinal detachment of the left eye and no light perception. Subsequently, a cataract developed, giving his pupil a white appearance—a stark contrast to his dark eyes and hair. Given this was a non-seeing eye with the dark iris, we were successful in the simple occlusion approach for this eye. He was fit in a pupiloccluding lens with a clear iris from Alden Optical. His natural pupil was about 3.5mm, so a clear lens with a 4mm dark pupil was ordered. Ultimately, the final pupil size ended up at 4.5mm to fully occlude the white pupil. Thankfully, this patient has a dark brown iris, so the 1mm difference between the natural and prosthetic pupil is barely noticeable when conversing with the patient outside the exam room. Discussion. This case was one of my first prosthetic lens fits, and while it was less challenging than the previous two cases, it was extremely rewarding. Being able to offer a tool to improve self-confidence is an amazing experience. Additional tips: The final lens parameter had a slightly larger pupil size and more snug fit than the first

Before and after: A cataract gave this patient’s pupil a white appearance, but a clear lens with a 4mm dark pupil resulted in a much more natural appearance.

lens ordered to limit movement with blinks. Since his cornea was normal, we were able to obtain reliable keratometric data via topography measurements of the left eye. We did this by providing an alternative fixation target for his right eye during testing. O|O Brooke Messer, OD, FAAO, graduated from Southern California College of Optometry, where she also completed her cornea and contact lens residency. She works in private practice, focusing on specialty contact lenses, and lectures on cornea and contact lens topics.

WHERE TO FIND IT Adventure in Colors 800.537.2485 | TechColors.com Alden Optical, Inc. 800.253.3669 | AldenOptical.com Orion Vision Group 866.289.773 | OrionVisionGroup.com Before and after: Another patient, a truck driver with an injury to his eye, complained of glare. This lens gave him a controlled pupil.

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PATIENT CARE

IS AMD PROGRESSION | IN THE GENES?

Research suggests that the AREDS formula can help many patients, but depending on genetics, it may not be appropriate for everyone. By Sherr y B ass, OD , FAAO, FCOV D In 2001, we had great news for our patients with age-related macular degeneration when results of the Age-Related Eye Disease Study, or AREDS, were announced. The study, launched nine years earlier, provided evidence that individuals who had a high risk of vision loss from agerelated macular degeneration could reduce the risk that their AMD would progress to the advanced stages by 25% and reduce their risk of vision loss by 19% by taking a supplement. The supplement consisted of 500mg of vitamin C, 400 international units of vitamin E, 15mg of beta-carotene, 80mg of zinc and 2mg of copper. Five years later, researchers launched AREDS 2, which showed a moderate effect from adding to the AREDS formula lutein and zeaxanthin, the carotenoids that make up the macular pigment, while removing beta-carotene. The AREDS 2 formula also proved effective in slowing the progression to advanced AMD. It also

demonstrated that 25mg of zinc was as effective as 80mg of zinc. Since then, it has made sense to offer patients, especially those individuals at risk, a supplement made up of the AREDS formula. Or has it? Can the supplements, especially the zinc, possibly worsen the patient’s condition? The answer depends not on an individual’s stage of AMD. Rather, researchers later learned, it lies in an individual’s genetic make-up.

GETTING WORSE

In 2013, Carl C. Awh, MD, and colleagues reported on a subgroup of the AREDS population and found that AMD worsened in about 13% of individuals, even though they were taking the AREDS formula. After genotyping patients, they found that individuals who had one or two highrisk alleles on the CFH gene but not the ARMS2 gene worsened when taking the supplement. By contrast, individuals who had the two alleles

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on the ARMS2 gene did benefit from the supplement. The most likely explanation was that the alleles on the ARMS2 gene were needed to metabolize the zinc. Awh’s findings were somewhat controversial, and reaction was swift. For example, Emily Chew, MD, and colleagues from the AREDS Research Group examined a larger cohort of 1,237 AREDS participants who were genotyped and considered to be at high risk of AMD progression. Among the 385 individuals (31.1%) who progressed to late AMD, Chew found, CFH and ARMS2 genotypes were associated with the progression. However, she and her colleagues still found that the risk of progression to late AMD was reduced across all genotype groups when using the AREDS formula. In 2015, Awh and colleagues published another paper showing that patients with two CFH risk alleles

and no ARMS2 risk alleles still had a much higher risk of progression when taking a zinc-containing treatment. In 2017, however, Demetrios G. Vavvas, MD, PhD, Awh and colleagues used a random sampling technique called bootstrapping, which effectively looked at every possible combination. This study, indeed, showed that there is an association between your genetic makeup for these alleles and what nutraceutical you should use. Specifically, the researchers said, these variations at the CFH and ARMS2 genes also determine the effectiveness of prophylaxis using the AREDS formula, with some individuals getting greater-than-average benefit and some individuals worsening with treatment.

CHEEK SWAB

Given these findings, I recommend genotyping to all my patients who have intermediate AMD and, occasionally, patients with early AMD. The Vita Risk test from ArcticDx helps determine whether AREDS/ AREDS2 vitamin supplements will help the vision of individuals with dry AMD or individuals who have unilateral advanced AMD or whether it could potentially cause progression to advanced AMD (choroidal neovascularization), which could result in loss of vision. The Macula Risk test determines a dry AMD patient’s prognosis to develop advanced AMD in addition to the Vita Risk results. Insurance carriers typically cover the test as long as the patient has physical signs of AMD (drusen). Carriers’ pol-

icies may differ, so you might need to check with your patient’s carrier.

to 100% for progressing to advanced AMD during the next 10 years.

The test itself is easy to perform. After the patient signs a consent form, instruct the patient to roll one of the enclosed brushes inside the left cheek along the jaw line for 30 seconds, and then repeat with the other brush along the right cheek. Allow the brushes to air dry for 30 seconds, and then return them to the original sleeve. Put the sleeve in the mailer that comes with the test and enclose a copy of the patient’s insurance information. Also complete and enclose the form that comes with the test which contains information about the stage of the patient’s AMD along with the patient’s height, weight, gender and smoking status.

A GUIDE

ArcticDx sends back its report, which describes the patient’s genetic specific single nucleotide polymorphisms, or SNPs. Given these features and other factors, such as smoking status, gender and weight, the report states the patient’s two-year, five-year and 10-year risk of progressing to choroidal neovascularization or geographic atrophy. And based on the status of the CHF and ARMS2 alleles, the report provides a vitamin recommendation. The report also assigns the patient a 10-year Macula Risk score ranging from one to five. A score of one or two indicates that the patient has no greater risk than the general population of progressing to advanced AMD, while a score of three to five means the patient is at higher risk than the general population for progressing. Individuals who have a score of five have a risk that ranges from 60%

The report can guide us in managing these patients with AMD. For patients who have a macular risk score of one or two, for example, follow-up every six to 12 months may be sufficient. However, individuals with a score of three, four or five may require follow-up every four to six months, depending on the phenotypic presentation of the drusen. The report also helps clinicians to determine what supplement is most appropriate for the patient. Depending on the patient’s CFH and ARMS2 genotyping, we might recommend that the patient remain on the AREDS formulation or take the AREDS formulation but without the zinc. Or, their genotype may indicate that a supplement won’t increase or decrease their risk of progression. Still, it is recommended to keep these patients on an AREDS supplement. Patients who should not be on zinc can be on a formulation containing lutein and zeaxanthin. What’s important is if the results come back and suggest that patients should not be taking a supplement containing high zinc. Given that patients talk with friends, read articles or see television commercials about supplements, it’s important that they get this information from their eyecare provider. For a fully referenced version of this article, visit OptometricOffice.com. O|O

Sherry Bass, OD, FAAO, FCOVD, is a distinguished clinical professor at the State University of New York State College of Optometry in Manhattan. She is a stockholder of ArcticDx.

WHERE TO FIND IT ArcticDx Inc. 866.964.5182 | MaculaRisk.com tom ic O ffic e. c om | Sept e mber 2018 11 O p tometr

PHARMACEUTICALS

A NUTRITIONAL APPROACH

| TO TREATING DRY EYE

Metabolism of fatty acids and vitamins can help quell the inflammation behind ocular surface disease. J ef f rey Anshel, OD , FAAO We know now that there are myriad causes of dry eye disease, all with a common denominator of underlying inflammation. However, we now have more diagnostic tests and more treatment tools at our disposal, including nutritional input. A look at the science behind this approach to treating dry eye can offer us a complete picture of dry eye from an alternative perspective.

TWO ESSENTIAL ACIDS

Numerous studies have shown that omega-3 fatty acids (fish oil) are effective at treating dry eye disease. However, they are not the only nutrient that addresses dry eye disease. There are two essential (needed in our diet) fatty acids: alpha-linolenic acid (ALA), an omega-3, and linoleic acid (LA), an omega-6. Internal enzymes inside our bodies act upon these acids, producing functional molecules, including molecules that have pro- or anti-inflammatory reactions. Once metabolized, ALA and LA become prostaglandins E3 and E2 respectively. However, the pro-

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gressive enzyme action is affected by many factors. For example, the delta-6 desaturase enzyme action on both omega molecules is reduced by aging, alcohol, nutrient deficiencies, trans fat, and elevated cholesterol. Thus, the metabolism of these molecules may not be as efficient as it appears.

THE RIGHT BALANCE

One of the most important aspects of this metabolism is the balance between the two omegas. Because omega-3 progresses to an antiinflammatory prostaglandin, we might think our bodies need more of that one. However, we also need

the pro-inflammatory prostaglandins to fight off infections, diseases and a whole host of conditions. The ideal ratio of omega-6 to omega-3 should be about four to one (yes, more omega-6). However, the standard American diet maintains a ratio closer to 25 to one, which means that the proinflammatory pathway is pushed to the chronic inflammatory state. However, if the omega-3 balance is maintained, the omega-3 molecules of docosahexaenoic acid (DHA) and eicosapentaenoic acid (EPA) will block off the conversion to arachidonic acid (AA). This will allow the omega-6 molecules gamma-linolenic acid (GLA) and dihomo-gamma-linolenic acid (DGLA) to convert to a mucus-specific antiinflammatory prostaglandin E1. This reduces inflammation in all mucous membranes in the body, including those in the tear film. So, should individuals increase the amount of omega-3 EFAs in the diet to balance out the ratio of omega-6 to omega-3 fatty acids? Not necessarily. Given the amount of omega-6 we currently consume, the additional amount of omega-3 required could lead to notso-beneficial effects. For example, fish oil is a blood thinner, so ingesting excessive amounts could lead to easy bruising and other blood-thinning effects. A better approach is to reduce the amount of omega-6 fatty acids in our diet while moderately increasing the omega-3 fats in our diet. DHA and EPA are formed when fish eat algae and are found in the triglyceride form. A triglyceride consists of a three-carbon glycerol “backbone” with each carbon linked to a fatty acid molecule. Thus, each triglyceride molecule contains three fatty acids. In normally produced fish oil, about 20% to 30% of the fatty acids are EPA and DHA, while highly concentrated oils can contain 60% to 85% EPA and DHA. This is why it is important to check the label for the actual EPA/DHA concentrations in any particular formula.

ADDITIONAL NUTRIENTS

Besides omega-3s and omega-6s, other nutrients also support the anterior segment of the eye, namely: • vitamin A, which is vital for the health of the corneal and conjunctival epithelial cells of the cornea and conjunctiva, as well as the function of the immune system. It is also necessary for goblet cell and lacrimal gland production of the large variety of mucins now associated with the base layer of the tear film. • vitamin B6, which is one of the nutrient co-factors required to push the metabolic pathway conversion of GLA to DGLA. It is also required for the neuronal blink response. • vitamin C, which as ascorbyl palmitate (fat-soluble form) modulates PGE1 synthesis. This vitamin C form also enhances the production of immunoglobulin E concentrates in tears, the first line of basophil and mast cell defense against invading pathogens and allergens that frequently cause dry eye symptoms. • vitamin E, which should be included in all fatty acid-based formulations to help prevent or slow lipid oxidation. This particularly includes any formulation that includes flaxseed oil or any type of fish oil. • vitamin D, which improves tear hyperosmolarity and should be included in all formulations that include vitamin A due to an increased risk of fractures in older patients taking large amounts of supplemental vitamin A. Black currant seed oil is an excellent source of GLA due to its fourto-one balance of omegas and should be included in a full-spectrum dry eye formula. Lactoferrin is one of the proteins that transfer iron to the cells and control the level of free iron in the blood. Adequate levels of tear lactoferrin, naturally produced by the lacrimal gland and neutrophils, are particularly important for eye surgery and contact lens

patients, who are disposed to a risk of infection. Quality dry eye products also contain minerals, mucin enhancers, antioxidants and natural anti-inflammatory ingredients. Making recommendations based on solid science will assure that your patients receive products that can make a significant as well as rapid resolution to their dry eye concerns. For a fully referenced version of this article, go to OptometricOffice.com. O|O

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

Available Dry Eye Supplements Biosyntrx | 800.688.6815 | Biosyntrx.com BioTears Oral Gel Caps MedOp Health, Inc. | 888.577.4165 | MaxiTears.com MaxiTears Dry Eye Formula Nordic Naturals, Inc. | 800.662.2544 | NordicNaturals.com Nordic Naturals ProOmega OCuSOFT, Inc. | 800.233.5469 | OCuSOFT.com Retaine Flax Omega 3, 6 Supplement Retaine OM3 Nutritional Supplement Retaine Vision Gelcap Supplements PRN Physician Recommended Nutriceuticals | 844.776.4968 | PRNOmegaHealth.com Dry Eye Omega Benefits Dry Eye Omega Benefits Liquid TheraTears | 800.579.8327 | TheraTears.com TheraTears Eye Nutrition Viteyes | 800.890.3937 | Viteyes.com/ Viteyes Dry Eye ZeaVision LLC | 866.401.1838 | EyePromise.com EyePromise EZ Tears

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NEW PRODUCT | GALLERY NEW ARTIFICIAL TEAR CONTAINS OSMOPROTECTANTS

REFRESH REPAIR Lubricant Eye Drops, an over-the-counter artificial tear formulation from Allergan plc and the latest addition to its REFRESH portfolio, is designed to repair and protect the eyes from the harmful effects of dry eye and improve clarity of vision, REFRESH REPAIR contains carboxymethylcellulose, hyaluronic acid and osmoprotectants. These restorative osmoprotectants displace salt in the tear film to safeguard epithelial cells against hyperosmotic stress, thus helping to maintain the health of the ocular surface. REFRESH REPAIR is safe to use with contact lenses. Go to RefreshBrand.com.

OCUTECH INTRODUCES AUTOFOCUSING BIOPTIC

Ocutech has introduced its new VES Falcon Autofocus Bioptic Telescope. The Falcon’s advanced technology provides low vision patients with natural, hands-free magnified vision, and the device weighs just 3.2 ounces. The bright, high-contrast widefield 4x Keplerian optics provide a 12.5° field of view and a focusing range as close as 13 inches. The Falcon operates for eight hours on a single charge. The Falcon is in initial limited release with select low-vision specialists in the U.S. and will be available to all low-vision prescribers in the fall. Go to Ocutech.com.

REV360 LAUNCHES IMAGE MANAGEMENT SOLUTION

RevImaging, an image-management solution from Rev360, is built for and enabled directly within RevolutionEHR. Centralized image management and the ability to simultaneously view images from different devices, regardless of which device captured the image, allow you to monitor disease progression and make treatment decisions. The completely integrated, cloud-based, image-management solution offers enhanced viewing of patient images through thumbnails, side-by-side comparisons and image overlays, all from within RevolutionEHR. Go to Rev-360.com/RevImaging/.

WAM700+ OFFERS SEVEN MEASUREMENTS

Essilor Instruments’ WAM700+ wavefront aberrometer, based on Shack-Hartmann wavefront technology, allows you to analyze the anterior chamber and assess patients’ visual needs. WAM700+, a fullyautomatic wavefront aberrometer, features a large touch screen and provides seven detailed measurements of both eyes in 90 seconds. This includes screening patients for conditions such as cataract, glaucoma and keratoconus. Go to EssilorInstrumentsUSA.com. 14 Se pt e mb e r 2 0 1 8 | O p to m e tri c O f f i c e .c o m

OCULUS Keratograph® 5M

NEW!

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

Crystal TEAR Report

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

Save time: The complete examination process can be delegated.

•

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

•

Combine screening and patient education: Your patient receives an easy-to-grasp printout. See it for yourself and give the newly released software a try at the OCULUS booth #MS8053 during Vision Expo West.

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

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AT-A- GLANCE TONOMETERS TONOMETER

TYPE

MEASUREMENT RANGE

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

Patented rebound technology

• AMS automatic measuring sequence; series and single mode with one button • EasyNav advanced navigation interface • EasyPos intelligent positioning assistant

Contact tip

• Gravity Offset Technology provides precise measurements with less calibration • Sighting lines for easy visualization of the cornea • Contoured molding with a large, visible LCD, enabling ambidextrous use • Takes fast measurements with patient in any position

Applanation tonometer

• Check weight and check weight holder • Two measuring prisms standard • Smoother rotation and operation for accurate positioning and approach at the patient cornea

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

Air puff

• Measures corneal hysteresis • Provides IOPcc: IOP compensated for corneal biomechanics

Non-contact

• Touch screen alignment • Auto alignment and auto shot • Corneal thickness related IOP

BiCOM Inc. | 877.342.8667 | TonometerDiaton.com Diaton

Handheld, scleral/ transpalpebral

5-60 mmHg

Icare | 888.422.7313 | Icare-USA.com Icare ic100

Handheld

7-50 mmHg

Keeler | 800.523.5620 | KeelerUSA.com AccuPen

Handheld

5-60 mmHg

Marco | 800.874.5274 | Marco.com

AT-9

Slit lamp mounted 0-80 mm Hg

OCULUS, Inc. | 425.670.9977 | OCULUSUSA.com

Corvis STL

Tabletop

6-60 mmHg

Reichert | 888.849.8955 | Reichert.com

Ocular Response Analyzer G3

Tabletop

1-60 mmHg

Tomey | 888.449.4045 | TomeyUSA.com

FT-1000

Tabletop

0-60 mmHg

For a longer listing of tonometers, go to OptometricOffice.com. O|O 16 Se pt e mb e r 20 1 8 | O p to m e tri c O f f i c e .c o m

WORLD S I

G LEN E AL

T DAY CH H G

A child should never be limited by poor vision Help a child to see.

Take the Challenge DONATE today Every $100 can provide eye care for up to 20 children! To learn more or to donate today visit givingsight.org or call 303-526-0430

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For work play and a

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

Visit booth #13058 at Vision Expo West. Or call for more information and enroll at no cost today^.

866.853.8432

www.carecredit.com

visioninfo@carecredit.com

*Subject to credit approval. Minimum monthly payments required. See carecredit.com for details. ^Subject to change. OO0918OA

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