Optometric Office July 2019

OPTOMETRIC OFFICE PRODUCTS AND TECHNOLOGY FOR YOUR PRACTICE

JULY 2019

CONTACT LENSES:

PHARMACEUTICALS:

DOCS SPEAK OUT:

A LOOK AT LENSES FOR MYOPIA p 10

TREATING ANTERIOR UVEITIS p 12

DETECTING DISEASE EARLIER p 14

DIAGNOSING BINOCULAR VISION DISORDERS TOOLS FOR PATIENTS WITH AMBLYOPIA, DIPLOPIA, STRABISMUS & MORE

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SUPPLEMENT TO VCPN JULY 2019

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

Table of Contents

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Creative Director Production and Web Manager Megan LaSalla | MLaSalla@FVMG.com Contributing Writers Laurel O’Connor Jennifer Lee, OD Andrew S. Gurwood, OD

DEPARTMENTS

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2 | Views

Nicholas Karbach, 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.

3 | One-to-One: Heather E. Whitson, MD, MHS, Center for Vision and Population Health at Prevent Blindness

4 | Think About Your Eyes: Help Patients Think Beyond What They See 5 | Product Buzz

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15 | New Product Gallery 16 | At-A-Glance: Ophthalmoscopes

FEATURES 8 | INSTRUMENTS: Diagnosing Binocular Vision Disorders 10 | CONTACT LENSES: Slowing the Progression of Myopia 12 | PHARMACEUTICALS: Diagnosis: Uveitis 14 | PATIENT CARE: DOCS SPEAK OUT Detecting Disease Earlier Cover photo courtesy of Diopsys, Inc.

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VIEWS Joanne Marchitelli There’s a reason we cover myopia in this magazine multiple times a year. The condition is approaching epidemic proportions. Myopia has increased nearly 70% in the U.S. in the last century and nearly 90% in East Asia countries.

Those of us who work in the vision care field—in any capacity—know that. But, parents of the many children who are increasingly being diagnosed as being nearsighted (at earlier ages than ever before) aren’t necessarily aware of the condition and how it can affect vision later in life.

A new book explores the causes and consequences of myopia and how to slow its progression. A Parent’s Guide to Raising Children with Healthy Vision by pediatric optometrists, Noah Tannen, OD, and Nicholas Despotidis, OD, FAAO, not only addresses this issue but aims to educate parents on the science of myopia. For instance, explaining how the condition is not only genetic, but environmental, too.

The book explains myopia development and that it’s not only genetic but also environmental—the result of such factors as the lack of exposure to sunlight and the impact technology plays on a child’s vision. Its goal is to provide “a tool to allow parents to make the best decision for their own children when it comes to vision.”

We know children in today’s world spend a lot of time in front of a screen. The authors believe that electronics have an addictive effect on children that is not found with other near work, such as reading or sewing (two activities that have been blamed for myopia in the past).

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EDUCATING PARENTS ON MYOPIA They recommend parents follow the American Academy of Pediatrics’ (AAP) recommendations that children under 18 months get zero time with a screen, and that those ages two to five be limited to 30 minutes a day. Plus, since electronic devices (tablets and laptops) are being used in school, they suggest that all elementary school children avoid electronics while at home during the school week In addition, they recommend parents prioritize ways for children to spend more time playing outdoors. The AAP and the Centers for Disease Control recommend an hour of free play daily. Recent studies published in Optometry and Vision Science have found that children who spent more time outside during the day tended to have better distance vision than children who spent more time indoors. The researchers believe the exposure to sunlight plays a role in addition to the eyes having the opportunity to focus on things in the distance.

Also helpful, according to Tannen and Despotidis: when children do use computers and smartphones, instruct them to blink often. Studies show that people blink as much as 80% less while using electronic devices. Lack of blinking leads to lack of tear film renewal and causes dry eyes (and possibly cornea damage).

That covers prevention, but what about intervention? The three most used therapies for myopia include atropine eye drops, orthokeratology lenses worn at night or multifocal contact lenses worn during the day.

It’s important for parents to understand that myopia, left untreated, can cause serious vision problems later in life, including retinal detachment, cataracts, glaucoma and macular degeneration.

To reverse this trend, we have to keep educating patients as to the increased risk of myopia for their children, and once diagnosed, how, and why, to effectively treat it. As eyecare professionals, we have to keep educating ourselves to stem the tide on this epidemic. *** Joanne Marchitelli | Editor | JMarchitelli@FVMG.com

about making eye health a vision health priority was that there really are so many different stakeholders involved that an organization such as this was needed to pull them all together. That way, they can create an inventory of what they all would need to be able to elevate the priority of vision health within health in general and then start to prioritize those and figure out how to make them happen.

JM: How will the organization work?

HW: We’ve defined ourselves, this center, as a backbone organization to create a structure to enable the different activities and actions that need to happen in order to change knowledge and behaviors about vision health.

ONE-TO-ONE Heather E. Whitson, MD, MHS

Heather E. Whitson, MD, MHS, is associate professor of medicine (geriatrics) and ophthalmology, and deputy director of the Center for the Study of Aging and Human Development at Duke University. She is committee chair of the newly formed advisory committee for the Center for Vision and Population Health at Prevent Blindness (CVPH).

The organization was recently established as a national coordinating body for effective practices, state-level technical assistance and programmatic interventions.

Joanne Marchitelli: What is the goal of the Center for Vision and Population Health (CVPH)?

Heather Whitson: We’re looking to impact policies, problematic practices, and things like the quality of surveillance at population level for eyecare, and then also ways that we can change behaviors and beliefs in the population. We’re trying to identify what drives the actions and behaviors that then affect the vision health of the population.

JM: What was the catalyst for the CVHP? HW: It was created to try to carry out some of the recommendations or take steps toward carrying out some of the recommendations of a 2016 National Academies of Sciences, Engineering and Medicine (NASEM) report, Making Eye Health a Population Health Imperative: Vision for Tomorrow. One of the findings that came out of the report

Let’s say one need that’s identified is a toolkit or a list. A city planner in some city is going to build a new public space and wants to make it vision-friendly, where could they find a checklist of what they should do? What should they think about to be able to do that? If that’s something that doesn’t exist, we wouldn’t necessarily be the center to make the checklist and make sure it’s in the hands of all those people, but we should be the center that identifies that need.

JM: How were the advisory members selected?

HW: We tried to populate it with people who represented various stakeholder groups or at least had some knowledge of the various stakeholder groups. And we recognized that we probably, once we got started with our work, would identify some gaps that would need to be filled by future members.

I’m not an eyecare professional. I’m an internist and geriatrician, so I obviously have a different perspective than the ophthalmologist and optometrists who specialize in eyecare. There are members who are population health researchers who think a lot about the epidemiology of eye disease. There are several people who are, themselves, visually impaired, so are stakeholders in that sense. There are patient advocates, including people who run programs for people, such as programs for blind companion dogs. And then public health is the other large contingent there.

JM: Has the board discussed any initiatives or timelines?

HW: At our first meeting one of the charges was to create smaller groups that can start sketching out initiatives— some that could potentially happen within a year’s timeframe; others will be ongoing efforts.

We formed six working groups that brainstormed about what would be the sorts of things to focus on. One group wanted to use some recent surveillance data that’s been collected to write a report on the status of vision impairment and vision health, and that’s an example of something that could be achieved within the year. Another one of the breakout groups was charged with conducting an assessment of existing multi-stakeholder groups and missions that would align with the center’s mission and then try to establish a communication sharing plan. The idea is if we’re forming this new backbone organization that hasn’t existed before, one thing that we’re going to need is a communication platform to be able to share information with each other.

O|O

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THINK ABOUT YOUR EYES

HELP PATIENTS THINK BEYOND

WHAT THEY SEE Recently, Think About Your Eyes (TAYE) polled optometry office staff and asked what the most common vision-related issue patients ask about. The answer? Glasses. Whether it’s a new prescription, repairs, or needing a second pair—glasses are the most common topic for patients.

LOOKING AT VISION CARE DIFFERENTLY The challenge for the industry is to expand patients’ thinking beyond just vision correction products when they visit an eye doctor—and instead get them to think of each visit as a vital health check-up. Eye health is indicative of overall health, not just being able to see clearly. By positioning annual eye exams as a necessary health check-up, same as dental visits and a visit to a primary care physician, it will become something most patients would never dream of skipping.

DETECTING DISEASE EARLIER Through TAYE, I have heard numerous eye disease stories, with major issues caught by chance at a routine eye exam.

However, so many patients, and honestly even peers of mine, don’t realize that an eye exam can alleviate many health issues they’re blaming on other things. For example, dry eye can mean more than an inconvenience of moving to an arid climate or sitting beneath a vent at work. A visit to an eye doctor can determine if a patient is suffering from dry eye disease and can be managed before vision suffers. Headaches and dizziness are symptoms of digital eye strain, yet many patients’ minds go to the extreme as to what could be wrong with them—when frequent breaks from screens and computer glasses can be all that’s needed to alleviate these symptoms.

Also, as patients age, the need for annual eye exams gets more and more important. Cataracts, glaucoma and macular degeneration are just a few of the eye health issues that can afflict patients, and early detection is key to treatment and preservation of vision and eye health. If patients wait until they notice a problem with their vision, and aren’t keeping up with annual eye exams, the time for early treatment may have passed.

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Laurel O’Connor

Laurel O’Connor is the senior communications manager for Think About Your Eyes, the vision industry’s public awareness movement around the importance of annual eye exams. First Vision Media Group supports Think About Your Eyes as a media partner.

PARTNERING WITH PATIENTS AND TAYE At Think About Your Eyes, we’re attempting to get patients to think just beyond what they see—too often patients think they’re the best judge of their vision and eye health because of course they would know if they have a problem. By highlighting the things that healthy vision and eyes allow us to experience, we’re emphasizing the importance of caring for this important sense. We’re only able to do this through the support of 19 industry companies and 46 AOA affiliates who recognize the importance of this message and reaching patients. Consider supporting Think About Your Eyes and help us reach even more patients in 2020. O|O

PRODUCT | BUZZ LAUNCHES, PROMOTIONS, MERCHANDISING, EVENTS AND OTHER THINGS TO KEEP YOU IN THE KNOW. “KEEP SIGHT” FOCUSES ON GLAUCOMA PREVENTION Allergan, Sightsavers and the International Agency for the Prevention of Blindness (IAPB) have created a unique joint initiative to prevent glaucoma-related vision loss. The Keep Sight initiative will build healthcare capacity in lowand middle-income countries with the highest unmet need. It plans to provide training for healthcare professionals to screen at-risk populations, ensure early and accurate diagnosis and provide appropriate treatment and long-term care in an effort to make a positive impact on people with glaucoma. “Allergan is honored to partner with Sightsavers and IAPB on Keep Sight. Their wealth of knowledge and expertise, combined with our passion for science and solutions will have a real impact on our shared goal of reducing the high burden of irreversible blindness,” said Marc Princen, executive vice president and president, international commercial at Allergan.

“Keep Sight is an initiative that will make a real difference to people with glaucoma in these underserved populations.”

THE VESTIBULARVISION CONNECTION

MaximEyes practice management software now integrates with EyeCare Prime Nexus.

Vision plays a significant role in our ability to balance, orient ourselves in space, and process movement of things in our environment. The vestibular (inner-ear balance) system and the visual system coordinate with each other through brain pathways in order to control the eyes’ ability to maintain a visual gaze on a single location. This connection, known as the vestibulo-ocular reflex, has a critical role in keeping the eyes still during head motion and helping us maintain our balance.

Common Visual Dysfunctions Nystagmus - A reflexive motion, where the eyes appear to jerk one direction (fast) and then slowly reset in the opposite direction, leading to vertigo, the perception of movement/spinning, either of the self or of the environment.

Oscillopsia - During head movement, persons may experience problems focusing on an object or perceive that objects are moving from side to side or revolving around them.

Binocular Vision Dysfunction - When the eyes don’t work as a team, resulting in misalignment between the line of sight of one eye and the other and causing problems with focusing and double and/or blurred vision.

Vertical Heterophoria - When one eye aims higher than the other, causing the person to tilt their head to help align the eyes. This causes dizziness, imbalance, neck pain, headaches, anxiety, nausea, motion sickness and reading/learning disabilities.

Aniseikonia - A condition where there is a significant difference in the perceived size of images. This can cause disorientation, eyestrain, headache, dizziness and imbalance.

Evaluation

Treatment

A regular eye exam may not reveal the extent that the visual process is affected. Specialists who may be involved in the evaluation of visual deficits related to a vestibular disorder include: • Neuro-Optometric Rehabilitation Optometrist: An eye care professional who specializes in the diagnosis and treatment of neurological conditions adversely affecting the visual system.

• Neurologist: A medical doctor who may be able to identify central nervous system causes of visual/vestibular deficits.

Treatment for balance problems related to vision is first aimed at correcting (if possible) the underlying cause of the disorder. A combination of neuro-optometric rehabilitative therapy and balance or vestibular therapy can be effective for reducing or resolving these symptoms.

Optometric therapies may include: • Corrective lenses including prisms and spectacles • Phototherapy (light therapy) • Therapy to enhance vision and functional visual skills such as fixation, eye movement, focusing, and eye teaming ability

The Neuro-Optometric Rehabilitation Association and Vestibular Disorders Association have partnered to create a new educational resource. The Vestibular-Vision Connection assists individuals who may be experiencing visual dysfunctions—such as nys-

Optelec awarded the Optelec Excellence in Low Vision Award to Christopher Theodore Pereira, a 4th year graduating student at SUNY Optometry.

Carl Zeiss Meditec has invested in MicroOptx Inc., a privately held company focused on innovative minimally invasive glaucoma surgery (MIGS) devices for surgical treatment of glaucoma.

GET HELP Vestibular Disorders Association: (800) 837-8428, info@vestibular.org Neuro-Optometric Rehabilitation AssociationTM: (949) 250-0176, info@noravisionrehab.org This information is not intended to be a substitute for professional medical advice, diagnosis, or treatment.

NEURO-OPTOMETRIC REHABILITATION ASSOCIATIONTM (NORA)

VESTIBULAR DISORDERS ASSOCIATION (VeDA)

NORAVISIONREHAB.ORG

EYOTO named Kurt Gardner vice president and general manager, North America.

VESTIBULAR.ORG

tagmus, oscillopsia, binocular vision dysfunction, vertical heterophoria and aniseikonia, which may contribute to dizziness and balance problems. The vision and vestibular (inner-ear balance) system work together to focus our gaze on a single location. Called the vestibulo-ocular reflex, it plays a critical role in producing eye movements and stabilizing the image during head motion and helping us to maintain our balance. The patient education resource can be viewed and downloaded on NORA’s website.

NORAVisionRehab.org

Go to IABP.org

NORA AND VDA RELEASE THE VESTIBULAR-VISION CONNECTION

The International Sports Vision Association (ISVA) has appointed Donald Teig, OD, FAAO, and Greg Appelbaum, PhD., to its board of directors.

SIXTH ANNUAL ABB CARES PROGRAM ABB OPTICAL will be accepting applications for the Sixth Annual ABB Cares program beginning Thursday, August 1.

“Through ABB Cares, we have been introduced to some truly remarkable charities that are supporting children

Visioneering appointed Mat Hamilton executive territory manager, Boston.

LumiThera and Product Creation Studio received a silver award in the 2019 Medical Design Excellence Awards competition for Valeda Light Delivery System.

EyePoint Pharmaceuticals has named Scott Jones chief commercial officer and Said Saim, PhD, chief technology officer.

Surgical Specialties Corporation (SSC) launched Caliber Ophthalmics, a new business division, combining SSC’s Sharpoint brand with its two recent ophthalmic acquisitions, Unique Technologies, Inc. and VPM Surgical, Inc. NovaBay Pharmaceuticals named Justin Hall president and chief executive officer and Jason Raleigh as chief financial officer.

Glauconix Biosciences Inc. appointed W. Daniel Stamer, PhD, FARVO, president of the Association for Research Vision and Ophthalmology and distinguished professor of ophthalmology at Duke University to its scientific advisory board.

Alimera Sciences launched a consumer marketing campaign to raise awareness and educate consumers on diabetic macular edema and ILUVIEN, a sustainedrelease intravitreal implant.

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PRODUCT | BUZZ in need, feeding the hungry, providing healthcare and vision care to vulnerable populations, creating opportunities for people with disabilities and more,” said Tom Burke, ABB OPTICAL GROUP’s chief executive officer. “Thanks to eyecare professionals around the country, we can spotlight these organizations and the tremendous impact they have on their communities. Every year we look forward to learning more about what they do and helping them in achieving their mission through ABB Cares.”

This year, ABB OPTICAL GROUP will award one ABB Cares Platinum Grant of $5,000, two Gold Grants of $2,500 each, and four Silver Grants of $1,000 to charities nominated by professionals in the eyecare industry, including optometrists, opticians and office staff. Organizations do not need to focus on eye health to qualify for a grant. The community grants program has awarded non-profit organizations across the country with more than $65,000 in grants in the past five years.

Go to ABBOptical.com/ABBCares

FIRST ACQUISITION FOR VSP VENTURES In a partnership with Rosin Eyecare, VSP Ventures acquired two practices in Tennessee. Shanks Family Eye Care and Coley and Coley Family Eye Care, both based in Nashville, will continue to operate under their respective brands.

“We’re pleased to partner with an organization of the caliber of Rosin Eyecare, leveraging their expertise to ensure seam-

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less transitions for practices,” said Steve Baker, president of VSP Ventures. “Our first two acquisitions enable the founding doctors to continue their passion for delivering exceptional patient care.”

“Our core beliefs and values are shared by the VSP Ventures team, and we are excited for this opportunity to partner,” said Jonathan Rosin, MD, and copresident of Rosin Eyecare. “Together, we are committed to preserving the legacy of the practices we acquire and reinforcing the value of the comprehensive care delivered to their patients now and into the future.”

Fred Shanks, OD, founded Shanks Family Eye Care in 1998. Greg Coley, OD, and Ginger Coley, OD, opened Coley and Coley Family Eye Care in 1989 and were among the first group of optometrists in Tennessee certified to prescribe therapeutic pharmaceutical agents to treat eye diseases.

Go to VSPVentures.com

TAYE TAKES IT ON THE ROAD Life is an adventure. TAYE has partnered with Airstream to send The Daily Bumps, an influencer family with four million YouTube subscribers, on a summer road trip. From sun glare to sun protection and outdoor play and myopia prevention, the campaign will show how important healthy vision is to a life well lived. Once summer fun begins to fade, the focus will shift to back-to-school eye health, including a family trip to the eye doctor for annual exams.

The Daily Bumps—Mom Missy, Dad Brian, and kids Oliver and Finn—will begin their journey around the Western U.S. in August. They plan to enjoy sights of both nature and the big city, and visit family and friends. The Daily Bumps will share at least 20 pieces of content for the campaign, emphasizing healthy vision. In addition, TAYE will conduct a survey around summer travel and backto-school plans and make the results available to industry, along with graphics to promote results.

ThinkAboutYourEyes.com

PEDIATRIC AND BINOCULAR VISION CENTER OPENS The Illinois Eye Institute (IEI), the clinical arm of the Illinois College of Optometry, recently opened a revitalized service area for pediatric and binocular vision patients to the public. The Dr. Robert and Lena Lewenson Pediatric and Binocular Vision Center was dedicated on May 18, 2019. The center had been welcoming patients since a soft open earlier this year.

The Lewenson Center provides binocular vision services for patients of all ages; comprehensive eye exams for infants and children; cutting-edge vision therapy and specialized sports vision care, including issues resulting from traumatic brain injury. Valerie Kattouf, OD, FAAO, is the chief of pediatrics and binocular vision service at the IEI. She admires the center’s “willingness to take on any case” as no one is turned away from the center.

Go to ICO.edu

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DIAGNOSING BINOCULAR VISION DISORDERS Photo courtesy of Diopsys, Inc.

INSTRUMENTS

Low- and high-tech tools for patients with amblyopia, diplopia and more.

B y J o anne Marchitelli For binocular vision disorders, such as strabismus, diplopia and amblyopia, the goal of treatment is to get the two eyes working together, which usually includes corrective lenses, contact lenses, prisms, occluders and vision therapy. The conditions are usually diagnosed after a comprehensive exam—the earlier the better for more positive treatment outcomes.

THE EXAM First things first. “The most important part is a comprehensive examination to rule out what the pathology is,” said Curtis R. Baxstrom, OD, FAAO, immediate past president for Neuro-Optometric Rehabilitation Association and an adjunct faculty at Pacific University.

After you rule out other medical conditions and conduct a patient history, you start with entrance skills such as visual acuities and if needed, non-verbal preferential looking tests, such as Cardiff cards. “The Cardiff is a great set of cards for doing visual 8 J uly 2 01 9 | Op to m e tri c O f f i c e .c o m

“That’s why I recommend using a retinoscope, so you can observe changes over time, and you know what the patient’s pattern is.” — Curtis R. Baxstrom, OD, FAAO, immediate past president for Neuro-Optometric Rehabilitation Association.

acuities on young infants, toddlers and even brain injury patients who cannot speak,” he said.

That’s followed by a retinoscopy. For young children, a handheld retinoscope is easy to use. “You could also use an autorefractor to get an estimate of the prescription. But to be honest, it takes a measurement which needs to be repeated because the infant may be overfocusing or underfocusing,” Baxstrom explained. “That’s why I recommend using a retinoscope, so you can observe changes over time, and you know what the patient’s pattern is.”

His practice may do other testing, such as neutralizing prisms, while optometrists who do more vision therapy or specialize in head trauma may also include fixation disparity tests.

“We used to just go and estimate angles by a scale of 0 to 4, but now we have what’s called a Vision Disk (Bernell),” said Baxstrom. “The head-mounted piece of hardware has degrees on it, so you can actually measure the degrees, which is by far much more accurate than a scale of 0 to 4.” The instrument measures the degrees of movement of the eye laterally, both monocularly and binocularly. For example, in diplopia, he would check to determine the monocular range of motion and the angle where the double vision begins.

If you want to evaluate tracking, he recommends the Developmental Eye Movement (DEM) test or the King-Devick Test. “If I want to use something a little more technical I could do a Visagraph (Reading Plus),” he said. “The Visagraph is a

head-mounted device you put on the patient that is is used for both schoolaged children or head injury.” Patients read text, usually 100-word passages, that help ODs check eye movements and the patient’s ability to read. This includes comprehension of the text, the number of fixations, the number of regressions and the amount of time that the patient is looking at a word before they recognize it, thus measuring the duration of fixation.

A full examination for binocular vision disorders should rule out any other conditions so should include visual field testing, he stresses. “We should also include a confrontation fields with these patients, but then also some type of threshold testing, like a Goldmann perimeter or a Humphrey visual fields machine.”

“The last instrument that we use for a lot of our pediatric amblyopia patients or for our head injury patients is from Diopsys, which is a visually evoked potential (VEP) test.” The test creates a computer-generated stimulus, which is a black and white checkerboard where the black and white squares alternate back and forth starting with large squares, and you work toward smaller ones, as well as high contrast black and white checkerboards versus shades of gray.

“Gray is more of a contrast sensitivity test, which is generally going to be more of an issue with the head injury patients,” he explained.

In this test, Baxstrom looks at two different findings from these patients.

Number one, the amplitude of the signal, and that means the strength of the signal coming in. If the patient has damage somewhere along the pathway, the signal is going to be weak.

He also looks at the latency, which is how long between the flashes does it take before it gets registered in the visual cortex. O|O

ON THE RIGHT TRACK

For some of the more observational tests, your patient has to take your word on your findings. “One of the hardest things is to be able to say you found something, but you can’t show them what you see,” said Kristopher A. May, OD, FAAO, Coldwater, MS. “That makes it hard to get buy-in from the patient or caretaker.”

In some cases, parents of pediatric patients tell him that their child has behavioral issues. Parents say things like “he’s just messing around.” Or “my kid doesn’t pay attention to anything.” The fact is that some of these kids have functional vision issues that are affecting their concentration and behavior.

Fortunately, there are now tools that quantify and measure functional vision. More importantly, these tools allow doctors to clearly illustrate these findings for their patients.

May uses the RightEye eye-tracking system to help identify functional vision problems in young patients. “The single most amazing thing that RightEye does is record the patient’s eye movements,” said May. “We used RightEye to test one of our initial patients for several issues, including binocularity, vergence and ocular motility. As he went through the test, it was clear that he was having difficulty reading.”

May described how the RightEye gaze replay feature showed the patient’s tendency to re-read certain words, pause, and move backward and forward a few times—all before proceeding through a single paragraph. “His mother thought he was having trouble with specific words. I explained that he knows these words but his eyes are not able to track them properly.”

The problem was what the oculomotor system was doing during the reading of the words. “With RightEye I was able to show her exactly what was happening with her son’s eyes,” added May. “I also emailed her a link to the recording, which she was able to show dad at home. The mother found it so helpful, she also shared the recording with her son’s teacher, telling her, ‘that’s what his eyes do.’”

Now, the parents and teacher realize that this isn’t a behavioral issue but a significant vision issue that can be fixed. That’s what changes things.

The educational aspect of the instrument is as equally important as its assessment aspect,” said May. May believes that tools such as RightEye help doctors provide better care.

“Especially in an area of our practice where we feel less confident, and where we have a need for better tools,” he said. “That’s where it’s fantastic.”

WHERE TO FIND IT

Diopsys 973.244.0622 | Diopsys.com

Bernell 800.348.2225 | Bernell.com

Reading Plus 800.732.3758 | ReadingPlus.com

King-Devick Technologies 844.606.7513 | KingDevickTest.com

RightEye 301.979.7970 | RightEye.com

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CONTACT LENSES

SLOWING THE PROGRESSION OF MYOPIA A look at three interventions—atropine, peripheral hyperopic defocus and orthokeratology—in a pediatric patient.

B y J enni fer L e e, OD As the discussion of myopia continues, practitioners must continue to educate the population of the importance to slow its progression. By the year 2050, half the global population is predicted to become myopic.1 At Treehouse Eyes, our mission is to focus exclusively on children with myopia and educate parents of myopic children as well as the community whether it be fellow optometrists, pediatricians, or ophthalmologists.

Many of the patients seen are those of myopic parents and wish there was some sort of intervention available when they were children like that of a little boy we saw almost a year ago. CB at the time of his myopia management consultation was 7 years old. His primary care optometrist referred him to us after finding he developed myopia since his previous examination. Both parents are myopic; mother is approximately -8.00D that started at age 8; father is unsure of the degree of myopia which had started around age 6. CB reduced his digital device use to one to two hours on weekends only since being diagnosed with progressing myopia.

He likes to read and play the piano but rarely spends time outdoors. His initial consultation revealed the following information: Refractive error: OD: -1.50-0.50x140 10 J uly 2 01 9 | O p to m e tri c O f f i c e .c o m

OS: -1.50-0.50x020 Axial length: OD: 23.53mm OS: 23:83mm Topography readings (Figure 1): OD: 44.17@008/ 45.55@098 OS: 44.18@174/ 45.75@084

Figure 1: Initial topography (OD left, OS right); small amount of apical astigmatism OU.

After the initial consultation and gathering reliable data, we asked ourselves, which treatment plan works best for CB? He could either be prescribed atropine, soft multifocal contact lenses, or customized overnight lenses. With each treatment plan there are advantages and disadvantages given the age, degree of myopia, patient lifestyle and family history.

ATROPINE The ATOM-1 study2,5,10 demonstrated that atropine at 1% dosing every night for two years was effective in slowing the progression of myopia and axial elongation, however, it caused a decrease in accommodation and pupil dilation. ATOM-23,5,10 tested the efficacy and visual side effects of

low doses (0.05%, 0.1% and 0.01%) and found that 0.01% results compared to the placebo group were not statistically significant. Most recently, the LAMP study,4,5,10 like ATOM 2, also looked at lower dosages and demonstrated that lower dosages of atropine were effective in myopia progression and slowing axial elongation. However, the LAMP study states that of the three dosages tested, 0.05% was the most effective. Most common side effects noted with higher doses of atropine are pupil dilation and blur at near.24,5,10 Although effective in stabilizing myopia and axial length growth, the patient must continue to wear corrective lenses whether it be contacts or glasses. Clinically, 0.01% atropine may not slow the myopia progression and/or growth of the eye enough so 0.02% atropine in both eyes at bedtime five nights a week is our current clinical advisor-recommended protocol at Treehouse Eyes.5 However, every patient progresses differently; changes in dose are dependent on age, family history and rate at which the myopia is progressing, which is carefully monitored frequently via axial length measurements with optical biometry.

SOFT MULTIFOCAL CONTACTS An important concept one must grasp in myopia management is the the-

ory of peripheral hyperopic defocus.

Studies performed by world renowned researcher and Treehouse Eyes clinical advisor, Dr. Earl Smith et. al. describe that the peripheral retina may be responsible for growth of the eye due to hyperopic defocus.6-7,10 When corrected with conventional contacts or glasses the central retina is in focus, but peripherally, light is focused behind the retina resulting in peripheral growth.

Multifocal contact lenses change where those peripheral light rays focus, i.e., myopic defocus, focusing light in front of the retina.8-10 By doing so, the eye does not have a stimulus for growth, but the central retina remains corrected fully for optimal visual acuity. The difference between multifocals for adults and children is that we customize lenses to have high plus adds without affecting the child’s vision. A disadvantage is that older children tend to be able to discern the distance and add powers leading to noticeable glare at night and haloes. The multifocals we routinely use are NaturalVue daily multifocals (Visioneering Technologies, Inc.) or SpecialEyes custom multifocals.

NaturalVue uses extended depth of focus type design11 and we are unable to alter add powers or treatment zone sizes. SpecialEyes are customizable whether it’s changing the treatment zone diameter to reduce haloing in the older children or using a +4.00 add on a young child who is progressing rapidly or creating a multifocal toric.

PEDIATRIC ORTHOKERATOLOGY LENSES Our overnight/pediatric orthokeratology lenses use our KIDS (keratometric induced dioptric steepening) design.

Different than conventional orthokeratology lenses that can be fit onto adults, KIDS lenses are designed by our experts and manufactured by Euclid to push a lot of plus power within the pupil while reshaping the cornea.

Depending on pupil size of the patient, these lenses can easily be redesigned to fit each patient’s anatomy. With overnight lenses, the next morning when a patient removes the lenses their vision

is clear, reducing the need for glasses or contacts during the daytime. This is beneficial especially for those participating in sports where glasses can easily break or contacts can become lost.

Regardless of the recommended treatment plan, patients and parents are always reminded to have an updated backup pair of glasses in case they are unable to wear the contacts.

Back to 8-year old, CB. Figure 1 shows his relatively uniform, average corneal topographies with apical astigmatism.

He’s an early myope who has never worn glasses or contact lenses. After reviewing our protocol and a lengthy discussion with CB and his parents, we decided together on our proprietary design KIDS lenses. After his first night, we observed an early central flattening and mid-peripheral steepening close to the edge of the pupil. Due to his pupil size we opted for a smaller treatment zone to get as much plus power into the eye without disrupting his distance acuity or introducing haloes or peripheral distortion (Figure 2). On day one his vision was OD: 20/20, OS: 20/20.

Figure 2. Day one topographies taken in bright light.

His one-week topographies (Figure 3) showed more prominent mid-peripheral corneal steepening within the pupil.

Figure 4. Month one topographies.

At six months into treatment, everything remained stable. CB continues to wear the lenses nightly with very good compliance. Axial lengths were measured with Pentacam AXL, OD: 24.33mm, OS: 24.31mm

Figure 5. Month nine topographies.

By month nine (Figure 5) CB reports no issues of glare or long-term discomfort. In July he will return for his annual progress evaluation at which point a cycloplegic refraction will be repeated and axial lengths will be re-measured with our Pentacam AXL. Being able to safely and precisely reshape the corneal epithelium with our KIDS lens design to create a natural myopic defocus ring and correcting the patient’s refractive error makes them an effective treatment and highly liked by active children. O|O Jennifer Lee, OD, is a 2015 graduate of the Pennsylvania College of Optometry at Salus University. She currently works at Treehouse Eyes in Bethesda, MD, helping slow myopia progression one child at a time.

References: Please see OptometricOffice.com for full references.

WHERE TO FIND IT Euclid 800.477.9396 | EuclidSYS.com Figure 3. Week one topographies.

At one month, his acuities remained stable and topographies (Figure 4) were optimal for myopia management.

SpecialEyes 866.404.1060 | SpecialEyesQC.com Visioneering Technologies, Inc. 844.VTILENS | VTIVision.com

O p tometr ic O ffic e. c om | J u ly 2019

11

PHARMACEUTICALS

DIAGNOSIS: UVEITIS Treating the cause and complications of the inflammatory disease.

B y Ni cho l as Karbac h, OD , and Andrew S . G u r wo o d , OD Uveitis is a common inflammatory condition that involves the uveal tunic of the eye. The uvea is a highly vascular layer of the globe comprised of the iris, ciliary body and choroid.

Uveitis is caused by the upregulation of inflammatory factors in the eye by a primary or secondary cause such as trauma, systemic inflammation, toxic exposure, contact lens issue or infection. The condition is often painful and can cause photophobia, pain and blurry vision. Left unmanaged, significant long-term complications including macular edema, cataracts and glaucoma can develop.

Uveitis is named by the primary site of inflammation: anterior, intermediate, posterior or panuveitis. Anterior uveitis (inflammation of the iris and ciliary body) is the most common presentation of uveitis and is usually treatable with topical ophthalmic corticosteroids and cycloplegics.

Intermediate and posterior uveitis are less effectively treated by topical pharmaceuticals because they must penetrate ocular tissues to reach the site requiring therapy, making the addition of periocular injected steroids or oral corticosteroids necessary.

12 J uly 2 01 9 | O p to m e tri c O f f i c e .c o m

Oral and topical corticosteroids are effective and quick acting antiinflammatory agents that work by interrupting the body’s inflammatory pathway through inhibition of phospholipase A2 in the arachidonic acid pathway. Secondary effects of the drug class include downregulation of vascular endothelial growth factor (VEGF) and stabilization of cell membranes and mast cell granules (inhibiting degranulation).

Topical corticosteroids are generally delivered as a suspension or an emulsion (as opposed to a solution) to maximize the drug’s bioavailability and penetrance. A suspension is a mixture of a non-dissolved solvent with an aqueous solution. An emulsion is a mixture of both lipophilic and hydrophilic solutions. Both require shaking before instillation to prevent settling and separation of the different components. The penetrance of a corticosteroid medication influences not only its treatment potency but also its predilection for causing the well-known side-effects of steroid use: increased intraocular pressure (IOP) and cataract formation. In cases of chronic use these complica-

tions can cause serious vision loss but can be easily mitigated by judicious prescribing methods.

• Treatment should be dosed based on the severity of the issue (usually every six hours, or QID dosing is sufficient for most cases of anterior uveitis).

• Tapering the dosage frequency is recommended when treatment extends beyond two weeks.

Otherwise rebound inflammation may occur.

• Intraocular pressure must be monitored if treatment extends beyond 10 days, although the steroid difluprednate has been reported in the literature to have the capability of elevating IOP within a shorter period of time.

• Any rise in IOP should be managed by adding an IOP-lowering medication rather than prematurely decreasing the corticosteroid dosage. Since the topical steroid was deemed necessary for the treatment, its premature withdrawal will increase the risk of ocular complications and symptoms. IOP control prevents optic nerve compromise and allows maintenance of the necessary therapy for the inflammation.

Other considerations for steroid treatment include the risks associated with long-term treatment (treatment extending beyond three months). These include posterior subcapsular cataract formation and opportunistic fungal or bacterial infection. Contraindications for topical corticosteroid use include active herpetic viral infection and acute corneal abrasion from trauma.

TOPICAL OPHTHALMIC CORTICOSTEROIDS • Prednisolone acetate ophthalmic suspension 1% (Pred Forte, Allergan; Omnipred, Novartis). These are extremely reliable medications for the treatment for anterior uveitis. It is also available in a 0.125% concentration for milder inflammation (Pred Mild, Allergan).

• Difluprednate ophthalmic emulsion 0.05% (Durezol, Alcon). This corticosteroid was initially FDA approved in 2008 as a post-cataract surgery medication but has become widely used for severe cases of uveitis due to its efficacy. Studies of equivalency have determined that difluprednate 0.05% can be dosed half as often as prednisolone acetate 1% with non-inferior efficacy. Its potency is due to increased penetrance which has the drawback of increasing the risk for IOP elevation.

• Loteprednol etabonate ophthalmic suspension 0.5% (Lotemax, Bausch). This medication is unique among commercially available corticosteroids as having an ester base rather than a ketone base. The ester base brings a much lower risk of IOP elevation and reduced risk of cataract formation when used over a longer period of time compared to ketone-based steroids. Equivalency studies have found it non-inferior to prednisolone acetate 1% in the treatment of anterior uveitis. It is available as an ointment or a gel as well as a lower concentration, loteprednol 0.2% (Alrex, Bausch).

• Dexamethasone ophthalmic suspension 0.1% (Maxidex, Alcon). This drug has a similar side-effect profile as prednisolone acetate 1%.

• Fluorometholone acetate ophthalmic suspension 0.1% (Flarex, Eyevance). This drug is an effective ketone-based steroid with a designed poor intraocular penetrance. This has the benefit of lowering incidence of IOP elevation and cataract formation. It is useful for ocular surface inflammation, such as allergic conjunctivitis but is not recommended for uveitis. It is available as an ointment or suspension.

CYCLOPLEGIC AGENTS Concurrent pain management is also recommended. This is best accomplished through the use of topical cycloplegics. Atropine sulfate ophthalmic solution 1% is the most potent drug in this class (parasympatholytic).

The reported duration of action is two to three weeks, however, this is far lower in eyes with active uveitis due to higher blood flow from inflammation. Consequently, the recommended dosage is QD-BID. Other drugs in this class produce the same effect with shorter duration of action. Homatropine 5%, scopolamine 0.25% and cyclopentolate 1% or 2% are all acceptable alternatives with QD-TID dosing when atropine is unavailable or impracticable. Tropicamide is not recommended due to its relative weak cycloplegic effect. There is significant regional variation in the availability of these cycloplegic agents, making knowledge of different substitutes necessary. O|O

ORAL STEROIDS When topical steroids are ineffective in managing uveitis, a short-term course of oral corticosteroids may be helpful.

Methylprednisolone is often used and at a dose of 0.5 to 1mg/kg/day. Caution with oral steroids is needed when the underlying cause of the uveitis is unknown. Systemic inflammatory conditions can be masked by oral steroid therapy making diagnosis difficult.

Infectious etiologies can be exacerbated by temporary steroid-induced immunosuppression.

INJECTIONS Another option is a periocular steroid injection. Options include posterior subtenon’s injection or intravitreal injection. Available agents include triamcinolone 1mg/0.1mL or a sustained release delivery dexamethasone capsule (Ozurdex, Allergan) which can last three to six months. Other intravitreal options include fluocinolone acetate (Retisert, Bausch; Iluvien, Alimeria Sciences).

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

WHERE TO FIND IT Alcon Laboratories 800.451.3937 | Alcon.com Alimera Sciences 844.445.8843 | AlimeraSciences.com Allergan 800.347.4500 | Allergan.com Bausch + Lomb 800.828.9030 | Bausch.com/ECP Eyevance Pharmaceuticals 817.677.6120 | Eyevance.com Novartis 862.778.2100 | Novartis.com

O p tometr ic O ffic e. c om | J u ly 2019

13

PATIENT CARE

DOCS | SPEAK OUT E a r l y D is e a s e De t e ction

A comprehensive eye exam checks more than just a patient’s vision. It can uncover early indicators of eye disease, such as diabetic retinopathy and those that signal other serious health problems, such as brain tumors, cancer, autoimmune diseases including multiple sclerosis and rheumatoid arthritis and even intestinal bowel diseases (IBDs).

In fact, a recent brief from the AOA Health Policy Institute noted that 72% of patients with IBDs, including Crohn’s disease and ulcerative colitis, had clinical manifestations of the disease in their eyes. Those manifestations include inflammatory changes in the blood vessels of the conjunctiva and sclera and ciliary body.

In our Docs Speak Out survey this month we asked what you are doing to detect disease earlier—from using trusted instruments to patient education—and your experience discovering disease at an earlier stage.

How do you educate patients on disease prevention and awareness?

17

%

0

% 34% 38

72

%

100

%

Currently have

Have you ever detected health conditions in patients other than eye disease?

NO 3

Wish

%

corneal hysteresis

8%

92%

dark adaptation

verbally during an exam

20

(select all that apply)

printed materials (brochures, hand-outs, etc.):

40

social media

60

community outreach

80

digital materials (eblasts, newsletters, website, etc.)

(select all that apply)

100

Which of the following instruments do you have (or wish you had) that aid in detecting early diseases of the eye?

8%

92%

23%

77%

ocular surface analyzer, osmolarity system, corneal topographer

50%

50%

0

“OCT indicated ganglion cell layer thinning indicating early pre-perimetric normal tension glaucoma.”

“Dilated fundus exam found previously undetected ocular melanoma and diabetes.”

“Poor fundus view with ophthalmoscope led to diagnosis of cataracts.”

YES

OCT and OCT-A

70%

How did an instrument help diagnose a patient’s early eye disease in your practice?

97%

electroretinography (ERG) and visual evoked potential (VEP)

20

40

30% 60

80

“Automated Humphrey visual fields help me detect brain tumors during routine exams about once every few years and my auto fluoresce function on my Optos has helped me diagnose a melanoma and early retinitis pigmentosa this year.”

“Glaucoma—in my wife!”

Have you diagnosed a disease other than eye disease in a patient during an eye exam?

“Seizure disorder with electro diagnostics.”

100

melanoma. She was referred and treated in a timely manner.”

“A 20-year-old who presented with poor accommodation was diagnosed with myasthenia gravis.”

“I told a patient of retinal pigment and they had their colon cancer caught early.

Hypercholesteremia is also a common find due to corneal arcus.”

“Patient said things were blurry lately.

OCT showed diabetic macular edema.

The patient—my sister—had no idea!”

“Refractive changes due to high blood sugar; and a visual field defect due to aneurysm.”

“Threshold perimetry has detected many intracranial lesions later confirmed by brain imaging.”

“OCT detected early AMD/glaucoma.”

“High cholesterol via slit lamp.

“It was not necessarily an instrument but a massive shift in prescription that led to a diabetes diagnosis.”

“Keratoconus determined with corneal topographer.”

“Patient came in with vague symptoms.

A retinal exam revealed malignant

“Dry eye had led to the diagnosis of Sjogrens after running bloodwork on a patient.”

14 J uly 2 01 9 | Op to m e tri c O f f i c e .c o m

NEW PRODUCT | GALLERY B+L LAUNCHES ULTRA MULTIFOCAL FOR ASTIGMATISM Bausch + Lomb released its latest lens at Optometry’s Meeting in St. Louis. The ULTRA Multifocal for Astigmatism contact lens is the first and only multifocal toric lens available as a standard offering in the eyecare professional’s fit set. The new monthly silicone hydrogel lens combines the company’s unique 3-Zone Progressive multifocal design with the stability of its OpticAlign toric design to provide eyecare professionals and their patients an advanced contact lens technology and the convenience of same-day fitting during the initial lens exam. The lens is aimed at the population of would-be contact lens wearers with both astigmatism and presbyopia. The lens is available in a broad range of parameters from +4.00D to -6.00D with two add powers and three cylinder of around the clock astigmatism correction.

Go to StillComfortable.com/UFA

OCUSOFT ADDS NEW ALLERGY LID SCRUBS OCuSOFT has added Lid Scrub Allergy Eyelid Cleanser to its lineup of eye hygiene products. The convenient pre-moistened pads help remove allergens from the eyelids to provide relief and reduce the risk of transfer into the tear film. OCuSOFT Lid Scrub Allergy removes oil, debris, pollen and other contaminants from the eyelids while utilizing green tea extract, tea tree oil and PSG-2 (Phytosphingosine) to reduce redness, inflammation and itching of allergy-affected eyelids. These properties combine with the proven effectiveness of mild OCuSOFT Lid Scrub eyelid cleansers to soothe, calm and moisturize inflamed, irritated eyelids. Discounted pricing is available for doctors’ offices.

Go to OCuSOFT.com

COLORBLIND DIAGNOSTIC AND CORRECTION SYSTEM NOW AVAILABLE IN U.S. The Colorlite Colorblind Diagnostic and Correction System is now available in the U.S. The system has been in use in Europe for more than 20 years with over 95% of patients passing the Ishihara color blindness test. After performing a Colorlite diagnostic exam to determine the patient’s color deficiency you will be able to write a prescription for color vision correction lenses. The lenses can come with or without a vision correction prescription and can be cut to fit most frames. This not only helps the colorblind patient see in color, but eyecare professionals can expand their businesses to benefit an entirely new segment of the market.

Go to ColorliteLens.com

TRANSITIONS OPTICAL DEBUTS REVAMPED EYEGLASS GUIDE The Eyeglass Guide helps patients select frame styles and lenses that best fit their needs and preferences. It includes eight questions that determine how often a patient is bothered by light and glare, what activities they do indoors and out, and their eyeglass persona. When the patient has finished, the builder provides an image of the eyeglasses the patient designed, as well as their personalized recommendation of lens options that they can print or email directly to the practice. Patients can also share the eyeglasses they designed on social media. Eyecare practices can sign up online to personalize their own URL with their logo, practice name and contact information.

Go to EyeglassGuide.com/Create

O p tometr ic O ffic e. c om | J u ly 2019

15

AT-A- GLANCE OPHTHALMOSCOPES COMPANY

TYPE

WIRELESS

BENEFITS

Heine | 800.367.4872 | Heine.com/en_US BETA 200 S LED

direct

Yes

• range: -36.00D to +38.00D • ideal for small pupils • eliminates corneal reflex

BETA 200 LED

direct

Yes

• range: -35.00D to +40.00D • ideal for small pupils • dustproof

OMEGA 500

indirect

Yes

• for pupils > 1mm • LED or XHL (xenon-halogen lamp) illumination • dustproof

iC2 Funduscope

digital

Yes

• adjustable from +1500D to -15.00D • field of view up to 34° • for iPhone 5, SE, 6, 6s, 7, and 8

Keeler Ophthalmic Instruments | 800.523.5620 | KeelerUSA.com AII PUPIL II

indirect

Both

• PD range: 47 to 75mm • IR & UV filters • five apertures & filters

Vantage Plus Slimline

direct

Yes

• Intelligent Optical System for 3D views of the retina through all pupil sizes • available in wireless and wired units

Spectra Iris

indirect

• compact, lightweight and portable • adjustable aperture for all pupil sizes

Welch Allyn | 800.535.6663 | WelchAllyn.com

PanOptic

direct

Yes

• range: -25.00D to +40.00D • 5X larger view of the fundus vs. standard ophthalmoscope in an undilated eye • digitally capture, store and share images with iExaminer technology • iExaminer works with iPhone 4, 4S, 6, 6S and 6 Plus

PocketScope

direct

Yes

• 12 aperture/filter combinations for greater versatility • halogen HPX lamp illumination for true tissue color • 48 focusing lenses for better resolution

16 J uly 2 01 9 | O p to m e tri c O f f i c e .c o m

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