Optometric Office April 2019 by First Vision Media Group

OPTOMETRIC OFFICE PRODUCTS AND TECHNOLOGY FOR YOUR PRACTICE

APRIL 2019

PHARMACEUTICALS:

PATIENT CARE:

AT-A-GLANCE:

MANAGING THE PROGRESSION OF GLAUCOMA p 8

DOCS SPEAK OUT ABOUT AMNIOTIC MEMBRANES p 10

PRODUCTS FOR LID & LASH HYGIENE p 16

CONTACTS FOR KERATOCONUS | OPTIMIZE A PATIENTâ&#x20AC;&#x2122;S WEARING EXPERIENCE p 6 SUPPLEMENT TO VCPN APRIL 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 Mile Brujic, OD, FAAO | Deepak Gupta, OD Christopher J. Babin, OD

BUSINESS STAFF President/Publisher Terry Tanker | TTanker@FVMG.com Vice President, Marketing Debby Corriveau | DCorriveau@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 6 | CONTACT LENSES: Contacts for Keratoconus 8 | PHARMACEUTICALS: Managing the Progression of Glaucoma 10 | PATIENT CARE: DOCS SPEAK OUT Amniotic Membranes

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VIEWS

THE MYOPIA TASKFORCE

Joanne Marchitelli Myopia is common. About 42% of Americans ages 12-54 are nearsighted. Though it is common, its prevalence is increasing—up from 25% of adults in the 1970s. The refractive disorder is linked to serious eye-related diseases that can occur later in life. Patients, especially those with high myopia, are at a greater risk of conditions such as retinal detachment, glaucoma and macular degeneration. That’s why the focus now is on slowing the progression of myopia in children. Many children with myopia tend to progress from mild to moderate to high myopes. Essilor created a Myopia Taskforce—a panel of 14 eyecare professionals, each with a diverse background and area of interest in the space—to develop a protocol for myopia management. Millicent Knight, OD, FAAO, FAARM, senior vice president of customer development at Essilor of America, is heading up the initiative. Her first order of business: Getting all of the taskforce members in one room, which took place in February. “The backgrounds that I was looking for in particular were people who were academically steeped in myopia as well as those who are clinically involved in myopia so when we came out of this with protocols they would be relevant to everyone no matter what type of practice modality they are in so they can find a way to incorporate it in their business.” Knight said the panel has a variety of practitioners with different mindsets, strengths, and length of time in this area. Members include some who are involved in animal research (the genesis of a lot of outcomes we have now); faculty members who are leading initiatives in their schools around

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myopia management; and those in clinical practices who have the conversations with parents and children who they want to engage in more innovative, non-transactional treatments of myopia. For many years we’ve been correcting the vision, not the condition. “We’ve been treating myopia the same way since the 1920s,” Knight told us at Vision Expo East. “We just give the patient a pair of glasses and not really follow the patient on a regular basis, tracking for myopia progression.” That’s too bad, because while corrective lenses improve vision for patients with myopia, they don’t prevent myopia from progressing. Currently, there are a few ways of slowing its progression: • certain types of soft contact lens (multifocals) • Ortho-K therapy (wearing rigid lenses while sleeping) • defocus spectacle lenses • low-dose atropine therapy (daily eye drops) Another problem is communication with the patient. “What I find challenging is that if you don’t bring everyone along on the journey—with a parallel path for the staff to be trained as well—its hard to keep reinforcing it and keep the momentum going in the practice,” Knight said. “You’ll hit a roadblock because you don’t know how to introduce the treatment to a parent and explain the commitment time, how to notice changes, the importance of being compliant, and the costs. Those conversations are important to the success of the treatment.” That’s one way Essilor plans to offer support to independent doctors. Knight explained that as part of the upcoming protocol they plan to provide best practices and new information that comes out, and share cases and other initiatives to make people feel more comfortable and grow in the space of myopia management. *** Joanne Marchitelli | Editor | JMarchitelli@FVMG.com

building up in the retina and blocking transport of vitamin A across Bruch’s Membrane. This causes a localized vitamin A deficiency resulting in impaired dark adaptation function— which can happen at least three years before AMD is clinically evident with imaging. Knowing this, we started performing an AdaptDx Rapid Test on any patient who said they’re having trouble seeing at night. To be honest, we were floored by how many people failed that test, which has an astounding 90% sensitivity to the presence of AMD and 90% specificity to the absence of the disease. When a patient fails the Rapid Test, it prompts us to further investigate with imaging and the AdaptDx Extended Test to determine the severity of disease and follow up treatment plan. Before AdaptDx, we were missing early functional signs of AMD and sending patients home without taking action. But now, with the AdaptDx, we are able to manage and treat disease well before any permanent damage occurs.

ONE-TO-ONE Amanda K. Lee, OD

Senior Director of Professional Relations, MacuLogix In her role as senior director of professional relations at MacuLogix, Amanda K. Lee, OD, focuses on elevating the standard of care for age-related macular degeneration (AMD) to improve patient outcomes. Prior to joining MacuLogix, Lee was in private practice in Myrtle Beach, SC. In addition to practicing optometry for 20 years, Lee has been a professional speaker and consultant for Alcon, Bausch + Lomb and MacuLogix. Joanne Marchitelli: Tell us about your initial experience with the AdaptDx while still in private practice. Amanda K. Lee, OD: Once I understood the science behind dark adaptation and the ability of the AdaptDx to dramatically improve our diagnostic ability, I knew we needed to bring it into clinic. However, just like any new piece of technology, it took a moment to figure out how it would fit into our workflow. Once we did, it quickly became our standard of care for anyone with a night vision complaint. In a nutshell, the AdaptDx is an automated dark adaptometer that simply measures a patient’s ability to adjust from bright light to darkness. This is important because before drusen are visible, there is an invisible layer of cholesterol

JM: How did patients respond to the outcome of the test? AL: That was the shocking part because as ODs we feel like, ‘I’ve got to tell this person they have a blinding eye disease and I don’t want to deliver bad news.’ Nobody wants to have that conversation. But the fact of the matter is our patients know much more about this disease than we give them credit for because they know someone who’s lost their vision—an aunt, uncle, grandmother, pastor—somebody they know is either blind or is getting retinal injections to treat AMD. Our patients are so grateful that we have the technology to identify AMD at such an early stage. Plus, most patients are relieved to better understand why their night vision has been failing them. Honestly, I’ve never seen a patient population more engaged in supporting their own treatment regimen, which includes nutritional supplements, lifestyle modifications, like quitting smoking, and optical products like UV and blue light filters. JM: MacuLogix held its first AMD speaker alliance in January. What is the goal of the alliance? AL: We’ve recruited this wonderful group of 30 optometrists from around the nation who share our passion for eliminating unnecessary blindness caused by AMD. Our goal is to get the message out that AMD is the number one cause of adult blindness in the industrialized world—but it shouldn’t be! As primary eyecare practitioners, optometrists have the unique ability to change the outcome of this disease, simply with an OCT and the AdaptDx dark adaptometer. Patients with AMD shouldn’t be going blind, but we are missing the diagnosis and the opportunity to manage and treat the disease before vision loss occurs. Sadly, a majority of patients with CNV are showing up for their first anti-VEGF treatment having already lost vision in one eye. Saving the second eye isn’t good enough anymore because we have the technology and knowledge to save vision in both eyes. Our goal for the AMD Speakers Alliance is to amplify our message by having ODs hear directly from their peers. These early adopters of AdaptDx have seen its impact on patient care, as well as practice revenue, and they are as excited as I am to get the message out to everyone. *** O p tometr ic O ffic e. c om | A pri l 2019

THINK ABOUT YOUR EYES

GLAUCOMA: THE SILENT VISION THIEF

It is estimated that three million Americans have glaucoma and approximately half of them are unaware they have the disease. As our population ages the incidence is likely to increase. This creates an opportunity for us, as optometrists, to play a key role in diagnosing and treating the condition as well as educating the public about the disease. WHO’S AT RISK? Glaucoma has several risk factors, which we can identify and use to educate and diagnose our patients. Among these include family history of glaucoma (which increases risk four to nine times); age (likelihood increases five times in adults over the age of 60); heritage (glaucoma is six to eight times more common in African Americans than in Caucasians; people of Asian descent are at increased risk of angle-closure glaucoma; those of Japanese descent are at greater risk for normal-tension glaucoma); and history of eye injury, steroid use, high myopia and thin corneas (less than 500 µm). Systemic diseases such as hypertension and diabetes are also risk factors. For instance, patients with diabetes have a twofold increased risk of developing the disease. Other lifestyle factors and activities may increase intraocular pressure, such as excess coffee consumption, playing wind instruments, wearing neckties, practicing certain yoga poses (inversions where the heart is above the eyes) and weightlifting. Conversely, regular exercise may help to reduce the risk of glaucoma by lowering intraocular pressure.

PREVENTING VISION LOSS The key to reducing vision loss from glaucoma lies in early diagnosis and treatment. Diagnosis is based on intraocular pressure, evaluation of the optic nerve and retina through a dilated fundus exam, ocular coherence tomography of the disc and macula, perimetry, gonioscopy and pachymetry.

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Christopher J. Babin, OD Christopher J. Babin, OD, is a member of Optometric Physicians of Washington and among the 22,000 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. Visual evoked potential may quickly become a standard diagnostic tool for glaucoma as more is learned of its capabilities. Once we diagnose glaucoma there are several modalities in which we can help reduce the risk of progression. These include several different classes of glaucoma medications with some of the newer treatments being Rhopressa and Vyzulta along with numerous surgical procedures designed to lower intraocular pressure. Given that glaucoma silently causes vision loss we have an opportunity to educate our patients about the importance of annual eye exams to evaluate their risk of glaucoma and to take steps to reduce these risks. Think About Your Eyes is playing an important role in this effort—by encouraging all patients to get an annual eye exam to ensure their overall health. When we diagnose patients with glaucoma we can then take necessary steps to reduce the risk of progression and subsequent vision loss. O|O

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

ZEISS received 510(k) clearance from the FDA for the CIRRUS HD-OCT platform, expanding the capabilities of its Anterior

COOPERVISION ANNOUNCES 2019 BEST PRACTICES HONOREES

TWO VSP INITIATIVES HELPED MORE THAN 100,000 PEOPLE IN NEED VSP has announced the completion of two large multi-year initiatives: WE SEE: A Child Eye Health Project and a partnership with the U.S. Conference of Mayors. Partnering with Nike and Brien Holden Vision Institute, WE SEE helped to implement vision screenings and eye health management for local schools in Soweto, South Africa. “At the end of the project, the eyecare clinic was donated to the local community and, through a local hospital, continues to provide critical access to eyecare for adults,” said Matthew Alpert, OD, VSP Global board member and network doctor, who led the project exploration and launch. “WE SEE has led to a sustainable solution for a community that was very much in need, and we are proud to have been a part of that journey.” VSP’s partnership with the U.S. Conference of Mayors set out to accomplish similar goals in the US. After more than two years of traveling across the country and partnering with local mayors, more than 12,000 people in need across 15 communities gained access to no-cost eyecare and eyewear from a VSP network eye doctor. VSPGlobal.com

CooperVision has named ten exceptional eyecare practices Best Practices. The program, in its fourth year, recognizes practices that provided extraordinary care to their patients. This year’s honorees are: Azman Eye Care Specialists / Global Complex Eye Care, Timonium, MD; Briggs Vision Group, Dunwoody, GA; Drs. Quinn, Foster & Associates, Athens, OH; Lakeline Vision Source, Cedar Park, TX; Northeast Ohio Eye Surgeons, Kent, Stow, and Akron, OH; Shoreline Optometry, Mountain View, CA; Spring Hill Eyecare, Spring Hill, TN; Vancouver Vision Clinic, Vancouver, WA; Vision Source of Farr West, Farr West, UT; and West Shore Eye Care, Ludington, MI. “It is our hope that their varied experiences can help inspire other eyecare professionals to perhaps try a new approach, implement meaningful changes, and find even greater success in their own practices,” said Michele Andrews, OD, senior director of professional and academic affairs, North America, CooperVision. “Congratulations to our 2019 Best Practices honorees.” CooperVision.com

Segment Premier Module to include epithelial thickness mapping. Alcon has acquired PowerVision, Inc., a privately held, U.S.-based medical device development company focused on creating fluid-based intraocular lens implants. The SynergEyes VS scleral lens is now available with Tangible Hydra-PEG on Contamac material. Total Eye Care Partners has named Ben Gaddie, OD, as president. Howard J. Braverman, OD, has been appointed to the MediXall advisory board, signaling the company’s expansion into the eyecare arena. MacuLogix has relocated its headquarters to a larger campus in Harrisburg, PA. ABB OPTICAL GROUP welcomed Donna “Dede” Reyes to its team of specialty contact lens consultants. Scott Filion is named chief executive officer at Rev360 Professional Eye Care Associates of America. Avedro, Inc. announced Patrick B. Jacques as vice president of sales.

HEALTHY EYES HEALTHY CHILDREN COMMUNITY GRANTS PROGRAM Healthy Eyes Healthy Children (HEHC), a community grants program administered by Optometry Cares – The AOA Foundation, will award grants up to $5,000 each for projects that align with HEHC’s goal: to spread awareness and increase vision care to underserved children across the country. The grants will fund collaborations between optometrists and community resources to projects that focus on comprehensive pediatric eyecare. Applications must be submitted by July 2 in order to be considered. Applicants must also obtain letters of support from both their state affiliate and project collaborator(s). Grantees will be notified in August. AOAFoundation.org/HEHC

O p tometr ic O ffic e. c om | A p ri l 2019

CONTACT LENSES

CONTACTS FOR KERATOCONUS

From standard soft torics to more advanced designs, we have plenty of options to optimize a patient’s contact lens wearing experience. B y Mi l e Br uj i c, OD , FAAO Keratoconus is a challenging, yet rewarding, condition to treat. Patients find themselves up against an inability to optimize vision through spectacle lenses because of the irregular nature of the cornea. The irregular optics of the cornea creates a difficult optical system to focus light through. Practitioners who work with keratoconus patients are often these patients’ only opportunity for clear vision. More clinicians are embracing corneal topographers during their contact lens fittings and as such are identifying patients with keratoconus who may not have been identified in the past. Additionally, new technologies such as anterior segment optical coherence tomography (OCT) allow us to identify these patients at a much earlier phase. In Figure 1, we can see the characteristic thinning that occurs in the cornea and epithelium in keratoconus. There are currently algorithms that are available to help the clinician calculate a patient’s risk of having keratoconus based on their corneal thickness measurements (Figure 2). Anterior segment OCT also 6 A pr il 2 01 9 | Op to m e tri c O f f i c e .c o m

helps the clinician monitor the condition over time as well.

to helping patients understand their condition and treating them for any additional or underlying conditions, such as ocular allergy symptoms, that may cause eye rubbing, further propagating their condition. Early education on corneal cross linking to stabilize the cornea is also essential.

TORIC CONTACT LENSES Figure 1. Total pachymetry map is seen on the lower left. Epithelial thickness map is seen on the lower right. The thinning in both maps in this patient is located at the apex of the cone.

CONTACT LENS OPTIONS Early in keratoconus, patients may only have just slight corneal thinning and minor corneal steepening. Oftentimes these individuals will manifest low-to-moderate amounts of against-the-rules stigmatism. With the technologies discussed previously these individuals are being identified earlier. As such, it gives us the opportunity to help prevent further progression through appropriate management of these patients. This often requires a very strategic approach

If treated early, we can usually correct the visual acuity with standard soft toric contact lenses. Steep keratometry findings along with the corneal sagittal depth is mild enough to simply correct with a standard contact lens. The stabilizing mechanisms of today’s soft contact lenses are typically adequate to maintain lens stability, even on these early keratoconus patients. As the condition progresses, we need to consider other contact lens options for managing the patient’s visual needs.

SPECIALTY LENSES As keratoconus advances and the cornea becomes steeper, it can be difficult to continue with a standard soft

toric contact lens. In those instances, there are specialty soft contact lenses specifically designed for an ectatic cornea. Kerasoft Thin is a silicone hydrogel specialty lens that provides a patient with more advanced thinning an opportunity to continue to wear a soft lens. NovaKone (Baush + Lomb Specialty Vision Products) is another soft contact lens option. It provides a steeper central base curve for fitting over the cone and independent manipulation of the peripheral portions of the lens.

Figure 2. Keratoconus risk score table. In this individual, after the first two metrics are placed in the table, they are already at a high risk of having keratoconus.

GAS PERMEABLE LENSES

HYBRID LENSES

As the condition continues to progress, it may become more difficult to correct for the higher order aberrations with soft contact lens options. In those cases weâ&#x20AC;&#x2122;re fortunate that we have small diameter gas permeable (GP) contact lenses. Small diameter GP lenses provide a rigid surface in order to correct some of the higher order aberrations created by the irregular keratoconic cornea. These GP lens designs are specifically made to be steeper centrally where they come in close contact with the apex of the cone and then flatten towards the periphery, allowing a better fit characteristic with portions of the cornea progressively further away from the apex of the cone. A number of patients function remarkably well with small diameter GP lenses, and this is the mainstay for their vision correction. However, there are times when small diameter GP lenses are difficult for patients to wear because of poor adaptation to the lens and need an alternative.

One of those options is a hybrid lens design, specifically the UltraHealth lens from SynergEyes. This lens design provides the advancing keratoconic patient the optical benefits of a GP lens with a soft silicone hydrogel skirt. It has a reverse geometry vaulted design that produces a lacrimal lens between the lens and cornea, reducing aberrations. The lens may be ordered with Tangible Hydra-PEG for a more comfortable wearing experience.

Figure 3. An optic section view of a scleral lens at the slit lamp after fluorescein was placed in the bowl of the lens and the lens was placed on the eye.

Keratoconus Risk Score Table

SCLERAL LENSES Scleral lenses have fundamentally changed the way we think about fitting patients with keratoconus and provide opportunities to further enhance the visual experience for them. Scleral lenses are large diameter GP lenses that rest solely on the conjunctiva and underlying sclera surrounding the cornea (Figure 3). Scleral lenses are fit with three basic principles in mind: 1) Central corneal clearance should be between 100 Âľm to 300 Âľm over the central portion of the cornea or the portion of the cornea where the apex approaches the lens at the closest point; 2) there needs to be appropriate limbal clearance in order to mitigate any type of excessive pressure on the limbal region of the cornea; and 3) there needs to be adequate landing zone fitting characteristics that allow for no excess of pressure in any regions of the conjunctiva where the landing zone rests.

Unlike the other GP lens designs, when fit appropriately, the lens never rests directly on the cornea. There are currently several specialty lens labs that produce scleral lenses. Each lab has unique designs that make their lenses optimized for the irregular cornea. With the number of contact lens options available for patients with keratoconus, these individuals can be proactively and successfully managed by the eyecare practitioner. A combination of early identification with the advent of these lens technologies can help promote the best visual outcome for these individuals and ultimately provide them an optimal contact lens wearing experience as well. O|O

Mile Brujic, OD, FAAO, is a partner of Premier Vision Group, a three-location practice in northwest Ohio. He has authored more than 250 articles for publication and given more than 1,300 lectures.

WHERE TO FIND IT Bausch + Lomb Specialty Vision Products 800.253.3669 | BauschSVP.com SynergEyes 877.733.2012 | SynergEyes.com Tangible Science 650.241.1045 | TangibleScience.com

O p tometr ic O ffic e. c om | A pri l 2019

PHARMACEUTICALS

MANAGING THE PROGRESSION OF GLAUCOMA

Until there’s a cure for glaucoma, doctors can only slow its progression with IOP-reducing drugs. Here, a primer on managing glaucoma patients, from wellestablished therapies to the two latest advancements in treatment. B y Deep ak G upta, OD In an ideal world, our goal in glaucoma would be to cure patients of this potentially blinding disease. Of course, that is not possible. In a more practical world, our goal would be to stop the progression of this condition. Unfortunately, that only happens for a small fraction of our patients. As primary eyecare providers, our true clinical goal in glaucoma is to slow the progression of the disease so the patient does not lose their sight in their lifetime. Of all of the significant risk factors for progression, the only one we can modify is intraocular pressure (IOP) so that is what we work with. All of the treatment options we have, 8 A pr il 2 01 9 | Op to m e tri c O f f i c e .c o m

medical and surgical, focus on lowering IOP as a means of decreasing the risk of glaucomatous progression.

INITIATING TREATMENT Although there is a great deal of variability when one actually initiates therapy, there are some common scenarios in which most clinicians would initiate treatment. These include the following: • a repeatable visual field defect in a pattern consistent with glaucoma • a repeatable and/or progressive defect of the nerve fiber layer • progressive enlargement of the cup-to-disc ratio

• a high IOP level warranting treatment in the absence of the above findings (I treat any patient with an IOP of 28mm Hg or higher in the absence of thick corneas.) When we start treating glaucoma patients, one of the first things we do is to establish a target IOP (this is a range of IOP values at which the patient will not demonstrate any glaucomatous progression). It is based on many factors such as age, highest IOP prior to treatment, disease severity, family history and thickness of the cornea. Despite this, please keep in mind that a target IOP is no more than an educated guess. It needs to

All of the treatment options we have, medical and surgical, focus on lowering IOP as a means of decreasing the risk of glaucomatous progression.

be constantly reassessed at every visit. Also keep in mind that, in recent years, the overall trend has been to aim for lower target IOPs.

IOP-LOWERING THERAPIES The vast majority of patients are started on a prostaglandin such as latanoprost (Xalatan, Pfizer), bimatoprost (Lumigan, Allergan) or travaprost (Travatan Z, Novartis). Over the past several decades these agents have demonstrated excellent efficacy and tolerability with great safety profiles. However, this past year we saw two new options in the management of glaucoma: Rhopressa and Vyzulta. Rhopressa (netarsudil ophthalmic solution, Aerie Pharmaceuticals, Inc.) is a rho kinase inhibitor, which is believed to reduce IOP by increasing the outflow of aqueous humor through the trabecular meshwork route. The exact mechanism is unknown. Vyzulta (Bausch + Lomb) is one molecule with a dual mechanism of action. The latanoprost acid, a prostaglandin analog, works primarily within the uveoscleral pathway. The second component, butanediol mononitrate releases nitric oxide, which inhibits rho kinase and calcium signaling relaxing the trabecular meshwork. This is what is so exciting about this drug—it works directly on decreasing the resistance

in the trabecular meshwork to lower IOP. Until now, enhancing outflow through the trabecular pathway was limited to the use of laser trabeculoplasty and poorly tolerated miotics. I hope most of you have had a chance to try this wonderful treatment option. In my practice, I have achieved incredible patient results. Here is the way I utilize it in my practice: All newly diagnosed patients are started on Vyzulta. It offers convenient oncea-day dosing, provides significant IOP lowering and has an acceptable safety profile. In previous years, I would have added a second medication for any patient taking a prostaglandin and needing additional IOP-lowering therapy or referred the patient to an ophthalmologist for an SLT. However, now I switch that patient to Vyzulta instead and have achieved excellent clinical success. Also, most patients currently on prostaglandin therapy will be switched to Vyzulta even if they are doing well. Why? Because we know that the lower the IOP, the better the long-term outcome. The truth is that most patients with glaucoma will eventually progress so why not treat them more aggressively now to delay the onset of that progression?

The one downside: The cost, of course. As with any new name-brand medication, the price is high when it is first launched. However, over time, that cost comes down and we are starting to see that with Vyzulta now. One way to reduce the cost, particularly for your non-Medicare patients, is to take advantage of the “Pay No More than $35 or $45” discount cards. These can be found on Vyzulta.com. As an added bonus, Vyzulta is available in a 5mL bottle, which should last the patient two months.

MONITORING DISEASE PROGRESSION Once patients are diagnosed with glaucoma, they should be seen every three to four months to check for progressive changes. They should have yearly dilated exams with optic nerve head evaluation using fundus photography, yearly nerve fiber layer analysis, and yearly visual field testing. They should be educated at every visit that glaucoma is a lifetime diagnosis and requires constant monitoring and reevaluation. O|O

Deepak Gupta, OD, handles a high volume of glaucoma patients in Rochester, NY. He has no financial conflicts to disclose. He can be reached at deegup4919@ hotmail.com.

O p tometr ic O ffic e. c om | A p ri l 2019

PATIENT CARE

DOCS | SPEAK OUT A m n i o t ic M e m b r a n e s

The use of amniotic membranes in optometric practices is becoming more common with the ease of a less invasive, suturefree application and as more products are introduced. The treatment is used to promote healing, reduce scarring, and minimize pain of ocular surface disease. In this month’s “Docs Speak Out” survey, we asked about your experience with amniotic membranes and what you want your patients to know. Here’s what you told us.

What conditions do you use amniotic membranes for?

Do you use amniotic membranes in your practice?

73% 61%

64%

20 10

keratitis

YES

dry eye

corneal ulcers

61%

dehydrated

33% other

neurotrophic keratopathy

(check all that apply)

If used in your practice, what type of amniotic membrane do you use? cryopreserved

% 39% 26

35% BOTH

What do you wish more patients knew about amniotic membranes? “I would like patients to know that it is an effective way to fight corneal issues, ranging from dry eye all the way to infectious processes.” “The price and their insurance coverage.” “They’re not going to cure disease, but merely help treat symptoms/sequelae for a short time.” “The expense is well worth the healing benefits.” “We use it in our ophthalmology office to treat mostly ulcers, keratitis, RCE, and occasionally dry eye. We have not used it to improve the ocular surface precataract surgery, though some places do. Better understanding for the general population would improve understanding and applicability.” “That I have them in stock and they work well for many conditions!” 10 A pr il 2 01 9 | O p to m e tri c O f f i c e .c o m

Can you share your experience in using amniotic membranes as a treatment? “The process of inserting a cryopreserved lens takes about five seconds to insert and about 15 minutes of counseling on expectations to prevent telephone calls later.” “It is a great service to provide, and I’ve had results in the dry eye arena that have lasted from only three weeks to over a year when nothing else prior had brought the patient relief.” “I found Prokera to be more effective that BiODisc, even though BioODisc is more comfortable for the patient than Prokera. I wish Prokera would change the hard ring for something softer.” “My bullous keratopathy patient was in so much pain that she had to wear a bandage contact lens 24/7. After treatment with the amniotic membrane, she has been pain free and contact lens free for one year.”

“I believe they work well in the healing of corneas in most conditions. I wish there was a better delivery system (for comfort). Patients have avoided it sometimes because of this and also the decrease in VA.” “Bilateral acid burn patient, 95% epithelium burned down into stromal layer on 75% both corneas. Treated with Prokera and healed with 20/20 OU in five days.” “Two individuals had central corneal ulcers greatly reduced and much more quickly healed with the use of membranes. The acuity improvement was striking, and the patients did not think that their vision could be improved that much so quickly with them.” “Cryopreserved ones give more consistent results compared to dehydrated ones.” “Best application: neurotrophic ulcers.” “Patients appreciate the increased speed of healing. I have had patients with recurrent keratitis return asking for the treatment.”

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DRY EYE DIAGNOSIS How one doctor quickly added dry eye diagnosis to his busy practice

B y J o anne Marchitelli

Tony Giannotti, OD, of Giannotti Vision Care in Scotts Valley, CA, has been using the OCULUS Keratograph® 5M in his general practice for the last eight months. He has a mature practice and finds his ultra-widefield retinal camera and OCT invaluable for an older population of patients. Now, he is finding his OCULUS Keratograph® 5M indispensable for dry eye disease. At first, he thought, what am I doing? What am I buying another big piece of equipment for? But, once he started using it, he says it was more like, what are the capabilities of it, and what can we do? While there was a learning curve to the equipment, he says his young, enthusiastic staff just took to it. “They’re all computer savvy, know how to operate a joystick, and they know the things that I’m looking for. They don’t just run through tests to do tests, they make sure that the data I get is good data, whatever it might be.”

A PERFECT FIT FOR PRE-TEST PROTOCOL “My pretest actually takes a long time— probably a half-hour,” he explains. “In addition to other tests, including an optomap and iVue iWellness scan, we’ll do a screening test with the Keratograph. We measure the volume of tears, the quality of the tears, tear film break-up time, and then also take an image to look at the amount of redness that’s there.”

NOTE: OCULUS is not responsible for the accuracy of the reimbursement information mentioned in this document. Keratograph® 5M users should consult with their code and billing experts and proceed according to the latest laws and regulations.

All imaging is reviewed in the exam room. “We review the screening OCT, we grade the dry eye, and about two and a half minutes later, I’ve got just a tremendous amount of data in my hand to show patients that everything is great, or here’s what we need to address.” He says the test opens up dialog with patients about what dry eye is, whether or not they have any symptoms. “If we see things along the way that merit further evaluation on there, then we’ll schedule a medical visit specifically looking at dry eye, which happens with about 10% of patients.”

ENGAGING PATIENTS IN THE PROCESS Giannotti finds the OCULUS Keratograph® 5M helps in backing up the results of the SPEED questionnaire that his patients fill out. “Objectively, they can look and say, “Wow, I don’t have very many tears,” or, “Wow, my eyes are really, really red and scary looking.” Or, they look at the noninvasive tear film break-up time, and a discussion ensues about the quality of the tears and the quantity of the tears that they have—and a return medical visit is scheduled to evaluate more completely the cause(s) of the dry eye and formulate a plan.

PINPOINTING THE PROBLEM

SEEING AN IMPRESSIVE ROI

The instrument’s functions include assessment of tear film, tear film breakup time, meniscus tear height, tear film quality, lipid layer, and tear film particle flow. It is also capable of meibography (Meibo-Scan) to review glandular tissue in the top and bottom lids.

Medically, Giannotti explains that you can charge for anterior segment photography, you can charge for a medical office visit, but you can’t charge for the screenings and the specific test that the instrument does. “What we do is typically a level three exam along with anterior segment photography. And the reimbursement for the two of those combined usually ends up being about $90 a patient.”

“The Keratograph makes it easy to say, for instance, ‘you’re not producing enough tears, the tears that you have are of poor quality,” says Giannotti. “From there, we can take a picture to show what the lid margins look like. You can show your patient the greasy, scaly, cruddy stuff that points to blepharitis and explain how an antibiotic will help.” When a patient can see these things, it helps with compliance. “They’re not just listening to me, they’re looking, too,” he says. The technology also helps determine the most effective way to approach the condition and guide the patient in their treatment. The instrument’s Crystal TEAR Report presents the assessment and the treatment goals with a patient printout explaining what tests were done, what it found, and the treatment recommendations.

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Essentially, he says the 5M screening has evolved into the gateway for the medical reimbursement for dry eye treatment in his office. In the meantime, the unit is generating three times his monthly finance cost—more than paying for itself. As much as he’s using it, he’s finding that he’s just scratching the surface as far as the things that this instrument is capable of doing. “As time goes on I look forward to expanding our uses but for now, it is certainly nice to show a patient what I’m looking at and to let them see their progress.”

NEW PRODUCT | GALLERY J&J VISION CARE ANNOUNCE ACUVUE OASYS WITH TRANSITIONS The world’s first photochromic contact lens, ACUVUE OASYS with Transitions, was developed and introduced through a partnership between Johnson & Johnson Vision Care, Inc. and Transitions Optical. It uses Transitions Light Intelligent Technology to help reduce exposure to bright light, including filtering blue light and blocking UV rays. The two-week reusable contact lenses adapt from clear to dark and back again—similar to eyeglass lenses with Transitions technology. The contacts begin to darken as soon as they’re exposed to UV or HEV light and return to clear lenses within 90 seconds when going from outdoors to an indoor environment. TIME magazine selected them as one of the “Best Inventions of 2018.” Go to JJVision.com

TANGIBLE SCIENCE LAUNCHES CONTACT LENS CLEANING SOLUTION Tangible Science has launched Tangible Clean, a multi-purpose cleaning solution for Tangible Hydra-PEG coated lenses. The solution can be used for cleaning, conditioning, disinfecting, protein removal, rinsing and storing gas permeable (GP) lenses. Tangible Hydra-PEG, a surface coating for GP lenses, requires a cleaning solution that will not damage the coating, such as those that contain alcohol or enzymes. The Tangible Hydra-PEG coating helps the lens resist protein and lipid deposits so a strong solution is not required and may in fact wear away the lens coating. Tangible Clean is thinner than other GP lens care solutions and can be rinsed off easily to help with sensitivity and fogging from cleaner residue on lenses. Tangible Clean has been cleared by the FDA for daily cleaning and disinfection for any gas permeable contact lens, in addition to coated lenses, and it is conveniently available to patients online via a subscription program. Go to TangibleScience.com

ESSILOR INSTRUMENTS DEBUTS THE VISION-R 800 Essilor of America announced AVA (Advanced Vision Accuracy) along with a new phoropter, the Vision-R 800, at Vision Expo East. The AVA Integrated Solution combines the company’s latest refraction technology with its digital lens designs. The Vision-R 800’s patented optical module allows for instant focus and exact refraction. It offers a refractive power of 0.01D steps and instantaneous changes of sphere, cylinder and axis simultaneously for accuracy and a shorter procedure. The prescription is then delivered through Varilux and Eyezen+ lenses. In addition, the Rx can be demonstrated to patients in simulated real-life conditions. Go to EssilorInstrumentsUSA.com

BAUSCH + LOMB RECEIVES FDA APPROVAL FOR LOTEMAX SM LOTEMAX SM (loteprednol etabonate ophthalmic gel) 0.38% was recently approved by the U.S. Food and Drug Administration. The new gel formulation from Bausch + Lomb is a corticosteroid indicated for the treatment of postoperative inflammation and pain following all ocular surgeries, including cataract surgery. LOTEMAX SM uses SubMicron (SM) Technology to adhere to the ocular surface and penetrate key ocular tissues to control pain and reduce inflammation after ocular surgeries. Compared to LOTEMAX GEL (loteprednol etabonate ophthalmic gel) 0.5%, LOTEMAX SM delivers a submicron particle size for faster drug dissolution in tears and provides two times greater penetration to the aqueous humor. Go to Bausch.com

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MYCO INDUSTRIES RELEASES THE AB MAX FOR ANTERIOR BLEPHARITIS The AB Max is an adapter for an Algerbrush that converts it into a multipurpose device that treats the same conditions as a standard Algerbrush PLUS as well as anterior blepharitis. The AB Max utilizes two on-board computers and proprietary tips specifically designed to treat anterior blepharitis. It provides forward and reverse functionality and has a patent pending Pulse mode specifically engineered to remove even the most tenacious scurf and debris while gently massaging the anterior eyelid margins for better patient outcomes. Go to AB-Max.com

RIGHTEYE INTRODUCES FUNCTIONAL VISION EYEQ RightEye LLC has launched Functional Vision EyeQ, a first-of-its kind automated test that allows optometrists to quickly and objectively identify functional vision issues in patients. Once a problem is identified, Functional Vision EyeQ automatically recommends computer-based exercises for patients to do at home, under the supervision of their optometrist. The quick, game-like tests help identify issues with dynamic vision skills, including eye alignment, eye teaming, depth perception, object tracking, gross visual motor, and visual perception and integration. Once completed, the test generates quantifiable reports that foster doctor-patient communication and understanding of identified conditions. Functional Vision EyeQ tests are conducted using the RightEye eye-tracking system, an all-in-one-solution for vision-derived health testing, tracking eye movements and correlating them to health issues. Go to RightEye.com/Functional-Vision

BRUDER PRESENTS HYGIENIC EYELID SOLUTION Bruder Healthcare announces Bruder Hygienic Eyelid Solution, a 0.2% pure hypochlorous acid solution thatâ&#x20AC;&#x2122;s safe for daily, long-term use. The all-natural isotonic saline wash contains no alcohol, oil, sulfates, parabens or added fragrance, making it an ideal foundation for good eyelid health and a beneficial addition to a daily eyecare regimen for patients with mild or moderate conditions. The spray application is easy, patients just spray onto closed eyelids and let dry. The eyelid and lash solution works to support rapid and effective relief from dry eyes, sties, and red, itchy eyelids associated with conditions such as blepharitis and meibomian gland dysfunction. It can also assist in the removal of foreign material and debris on and around the eyelid margins. Bruder Hygienic Eyelid Solution is available in two sizes, 1 fl oz. (30mL) and 2 fl oz. (60mL). Go to Bruder.com

EYEPOINT LAUNCHES DEXYCU The biopharmaceutical company, Eyepoint, announced that it has commercially launched DEXYCU (dexamethasone intraocular suspension) 9% in the U.S. DEXYCU is an intraocular steroid indicated for the treatment of postoperative inflammation and is administered as a single dose at the end of cataract surgery. It is administered using the companyâ&#x20AC;&#x2122;s Verisome sustained-release drug delivery technology to deliver a biodegradable extended-release formulation of the steroid dexamethasone into the posterior chamber of the eye via a single injection at the end of surgery. It is intended to replace the use of steroid eyedrops which have a dosing regimen that, depending on the brand, can require self-administration for up to four times a day and titrating down over four weeks. This complicated dosing regimen can often lead to poor patient compliance. DEXYCU is the first long-acting intraocular steroid approved by the FDA for postoperative inflammation. Go to EyePointPharma.com O p tometr ic O ffic e. c om | A p r i l 2019

AT-A- GLANCE LID AND LASH HYGIENE PRODUCTS COMPANY

TYPE

Alcon | 800.757.9780 | Systane.com SYSTANE Lid Wipes individual, pre-moistened wipes

FEATURED INGREDIENTS

BENEFITS

cocoamido propyl amine oxide

• hypoallergenic formula removes debris, makeup and irritants that cause eye irritation • comforts and soothe eyelids • gentle enough to use every day

Bruder Healthcare | 800.827.8337 | Bruder.com Bruder Hygienic Eyelid Solution

spray

0.02% pure hypochlorous acid • contains no alcohol, oil, sulfates, parabens or added fragrance

• safe for daily, long-term use

Johnson & Johnson Vision | 800.347.5005 | JustBlink.com

Blink Lid Wipes

pre-moistened wipes

chamomile

• suitable for contact lens wearers • ideal for removing debris and crusting from eyelids and lashes • cleans, moisturizes and soothes eyelids

Lunovus | 800.980.6551 | Lunovus.com

Blephadex

foaming cleanser or pre-moistened wipes

patented combination of tea tree oil and coconut oil

• preservative-free, all-natural formula cleans, soothes and moisturizes the lids • tea tree oil has antibacterial properties • coconut oil has anti-inflammatory properties

Blephadex Warming Eyelid Wipes

pre-moistened wipes

patented combination of tea tree oil and coconut oil

• preservative-free, all-natural formula cleans, soothes and moisturizes the lids • warmth stimulated by an innovative water-activated heat technology • recommended for people who wake up with irritated eyes

Oasis Medical | 844.820.8940 | OasisMedical.com

Oasis Lid & Lash

cleansing pads

tea tree oil

• removes eye debris and dust particles • hydrates skin around the eyes • gentle for daily use

OCuSOFT | 800.233.5469 | OCuSOFT.com OCuSOFT Lid Scrub Original

available as a cocamidopropyl foaming cleanser and hydroxysultaine pre-moistened wipes

• for daily hygiene and mild to moderate blepharitis • removes oil, debris and pollen from the lids

OCuSOFT Lid Scrub PLUS Platinum

foaming cleanser

phytosphingosine

• for moderate to severe blepharitis • extra-strength, leave-on formula has antibacterial properties and removes oil, debris and pollen from the lids

HypoChlor

spray

0.02% hypochlorous acid solution

• cleans and removes debris from lids, including microorganisms • for severe lid conditions

For a longer listing of lid and lash hygiene products, go to OptometricOffice.com. O|O

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