Optometric Office September 2017 by First Vision Media Group

OPTOMETRIC OFFICE PRODUCTS AND TECHNOLOGY FOR YOUR PRACTICE

SEPTEMBER 2017

Bausch + Lomb ULTRA® for Astigmatism

PROVIDES ALL-DAY COMFORT, STABILITY, AND CONSISTENTLY CLEAR VISION1

Helps maintain 95% of lens moisture for a full 16 hours2

OPTICALIGN™ DESIGN For stability to promote a successful first fit1

• ECPs reported rotation at dispensing of 5 degrees or less for 94% of patients1 • Spherical aberration control optimized in both axes helps reduce halos and glare1,2

PRESCRIBE BAUSCH + LOMB ULTRA® FOR ASTIGMATISM REFERENCES: 1. Results from a 7-investigator, multi-site 2-week study of Bausch + Lomb ULTRA® for Astigmatism contact lenses on 157 current soft contact lens wearers. 2. Data on file. Bausch & Lomb Incorporated. Rochester, NY. ®/™ are trademarks of Bausch & Lomb Incorporated or its affiliates. ©2017 Bausch & Lomb Incorporated. UFA.0134.USA.17

Sept 2017 OO CoverTip.indd 1

8/25/17 2:53 PM

OPTOMETRIC OFFICE PRODUCTS AND TECHNOLOGY FOR YOUR PRACTICE

MAPPING THE IRREGULAR CORNEA

FITTING COLOR CONTACT LENSES FOR PRACTICE GROWTH

SEPTEMBER 2017

A PRESCRIPTION FOR MANAGING DRY EYE DISEASE

SUPPLEMENTAL PLAN NUTRITION TO PREVENT AMD PROGRESSION

SUPPLEMENT TO VCPN SEPTEMBER 2017

OOSeptembe2017 Cover.indd 1

8/25/17 2:49 PM

WHEN YOU THINK ABOUT IT, EVERY EYE NEEDS A SPECIAL LENS.

Innovative. Advanced. Trusted. Only Biofinity® offers the widest range of monthly silicone hydrogel contact lenses on the market—all made from advanced lens material featuring Aquaform® Technology. With its vast and ever-growing family of contact lenses, Biofinity® is committed to helping you meet the vision needs of virtually every patient in your practice. That’s why we’ve added Biofinity Energys™, featuring Digital Zone Optics™ lens design to the family. The world’s first contact lens designed for digital life and everyday living supports wearers’ eyes on-screen and off. Because today’s digital device use takes a toll on your patients’ eyes. Find out more about what the unparalleled advantages of Biofinity Energys™ and the rest of the Biofinity® family can mean to your practice. Visit OnlyBiofinity.com/Energys.

SPHERE

TORIC

M U LT I F O C A L © CooperVision 2017 4319 BC 717

Untitled-5 1

8/23/17 4:27 PM

TABLE OF CONTENTS 12

14 | One-to-One: Kalpana Singh, Reichert Technologies 26 | The Optometric Technician 28 | Tonometers At-A-Glance

30 | New Product Gallery 32 | Docs Speak Out

OO September2017.indd 1

8/25/17 2:41 PM

OPTOMETRIC OFFICE EDITORIAL STAFF VP, Editorial John Sailer | JS@VisionCareProducts.com Professional Editor Richard Clompus, OD | RC@OptometricOffice.com Editor-in-Chief Jeffrey Eisenberg | JE@VisionCareProducts.com Assistant Editor Cara Aidone Huzinec | CH@VisionCareProducts.com Assistant Editor Alex Evans AE@VisionCareProducts.com Vice President, Design Jane Kaplan | JK@VisionCareProducts.com Assistant Art Director Bruce Kenselaar | BK@VisionCareProducts.com Production and Web Manager Anthony Floreno | AF@VisionCareProducts.com Contributing Writers Jeffrey Anshel, OD • Roberta Beers, CPOT • S. Barry Eiden, OD, FAAO Jackie Garlich, OD, FAAO • Christopher Lehman, OD • Carl H. Spear, OD, MBA, FAAO Jennifer L. Stewart, OD • Jennifer Smith Zolman, OD, FCOVD

BUSINESS STAFF Executive Vice President/Publisher Shawn Mery | SM@VisionCareProducts.com President/Associate Publisher Frank Giammanco | FG@VisionCareProducts.com Director of Sales Janet Cunningham | JC@VisionCareProducts.com Vice President, Marketing Debby Corriveau | DC@VisionCareProducts.com

The most advanced Phoroptor ® ever built. Phoroptor® VRx Digital Refraction System Incredibly fast. Ultra-quiet. Endless connectivity. Made in the USA with premium components. Vision Expo West #MS 9043 · reichert.com/vrx

Vice President, Operations Sharon O’Hanlon | SO@VisionCareProducts.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.

Phoroptor is a registered trademark of Reichert, Inc. · www.reichert.com

OO September2017.indd 2

8/25/17 2:42 PM

The most comprehensive GP lens care system available.

Menicon LacriPure Rinsing and insertion saline solution.

Indicated for use with soft, hybrid and rigid gas permeable lenses, LacriPure is a sterile, non-preserved saline which provides an alternative to tap water rinsing. Packaged in a 5ml unit-dose vial, LacriPure has been cleared as a scleral lens insertion solution and provides the patient with exceptional sterility.

Menicon LacriPure joins Menicon Unique pHÂŽ multi-purpose solution and Menicon PROGENT protein remover to complete the industryâ&#x20AC;&#x2122;s most comprehensive GP lens care system.

800-636-4266 | meniconamerica.com | information@menicon.com

Untitled-2 1

8/24/17 1:45 PM

All-new!

VIEWS

Richard Clompus EXPANDING YOUR PRACTICE

Pixel-perfect acuity testing. ClearChart® 4 · 4X · 4P Digital Acuity Systems Simple-to-use interface. 24-inch, LED backlit display. Custom developed for acuity testing. Made in USA. Vision Expo West #MS 9043 · reichert.com/clearchart

When you hear the phrase “expanding your practice,” you may think of adding a room or moving to a larger physical space. In some cases, this is exactly what you need to grow your practice. However, a more immediate opportunity exists that doesn’t require changing the physical structure of your office. One change you can make immediately: Provide care to the fullest extent of your education and state optometric laws. By diagnosing and managing chronic diseases, such as glaucoma and ocular surface disease, you can provide care and relief to more patients while expanding your practice. Years ago, Cristina Schnider, OD, of Johnson & Johnson Vision, and Dave Sattler, formerly of Alcon Laboratories, Inc., introduced a special awareness program called “The Power of the Pen.” The concept was simple: Writing prescriptions for patient care is a powerful tool for optometrists. A prescription carries authority from the prescriber and provides treatment options not available with overthe-counter remedies. Each small step to expand the scope of your practice can lead to big changes in practice growth. Over time, patients will associate medical eyecare with your primary eyecare. Upgrades to your office may include staff training, new insurance billing and reporting, e-prescribing and new diagnostic instruments. The scope of optometric care has grown tremendously thanks to the dedication of others. I’d like to recognize the tireless efforts of: Thomas Lewis, OD, PhD, who as a professor and past president of the Pennsylvania College of Optometry (now part of Salus University) offered one of the first 100-hour therapeutic courses; Lou Catania, OD, who taught many therapeutic courses and was an evangelist, of sorts, for optometric therapeutics; and Michael Cohen, OD, for introducing the first-generation Visual Field Analyzer from Humphrey Instruments to optometrists. The future for prescribing by optometry is very bright indeed. Richard Clompus, OD, FAAO | Professional Editor | RC@OptometricOffice.com

OO September2017.indd 4

8/25/17 2:43 PM

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

Belin/Ambrósio Enhanced Ectasia Display

OCULUS Pentacam®

Standard package now includes Belin/Ambrósio software!

Now you can easily screen for early ectatic corneal diseases to be more confident in selecting the candidates for refractive surgery. New affordable price, including the computer and motorized table, starts at $36,995! Visit the OCULUS booth #MS8053 at VEW in Las Vegas

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

Untitled-5 Office 1 Optometric USA Pentacam Basic BAD III 215.9x276.23 e 4c 02.17.indd 1

8/23/1715:48:52 4:32 PM 27.02.2017

VIEWS

Jeffrey Eisenberg

BACK-TO-SCHOOL EDUCATION

His sight depends on your confidence. Ocular Response Analyzer® G3 Corneal Hysteresis, a more objective predictor of glaucoma progression. CPT code 92145. Vision Expo West #MS 9043 · reichert.com/glaucomaconfidence

As I sat editing articles on pediatric eyecare for our July issue, I realized my 11-year-old son was overdue for an eye exam. Even so, less than three weeks before school started, I hadn’t scheduled one. As it turns out, I’m not the only parent not to do so (though as editor-inchief of an optometric magazine I should know better). In July, the American Optometric Association released new clinical guidelines for pediatric eyecare. Among them: Children ages 6 to 18 should receive a comprehensive eye exam before beginning first grade and then annually. But, a new survey by VSP Vision Care and YouGov showed that half the parents in the U.S. do not take their children for back-to-school eye exams. It’s not that we don’t take our children’s eyesight seriously; three out of four individuals who responded to VSP’s survey said they consider sight the most valuable of all the senses. In my case, I simply forgot. Parents responding to VSP’s survey also skipped taking their children for eye exams because they assumed that the school vision screening is the same as a comprehensive exam, they don’t have vision insurance, or they wait until something is wrong. Often, they simply aren’t aware of when their children should receive an exam. Consider: Fewer than one in 10 parents responding to the VSP survey knew that children should have an eye exam at age 6 months. Also, one in five did not take their children for their first eye exam until they were of school age, and one in 10 have never taken their children. Ironically, the public school code in my state (Pennsylvania) lists requirements for medical and dental examinations, yet nowhere could I find any requirements for an eye examination. This is despite the AOA’s estimates that one in four children have vision problems that can negatively impact their classroom performance. Although the profession has taken steps to increase public awareness—the Think About Your Eyes campaign is one example—further education is needed. What can you do in your practices? Jeffrey Eisenberg | Editor-In-Chief | JE@VisionCareProducts.com

OO September2017.indd 6

8/25/17 2:43 PM

SPEED & ACCURACY The TRS-5100 automated refraction system represents a powerful technology upgrade from your standard old manual refractor. The sleek, modernized digital system is controlled with a programmable keypad; allowing the doctor to remain comfortably seated throughout the entire exam eliminates repetitive stress injuries. The TRS offers a split prism Jackson Cross cylinder with simultaneous target comparisons, for faster, more accurate and more positive exam experiences. Maximize exam efﬁciency, patient ﬂow, and overall practice revenue. TRS 5100 Product/Model name: REFRACTOR RT-5100

• Digital accuracy without error • Instant comparison of old/new Rx • Portable control pad • Multiple automated programs • Reduces repetitive stress injury

• Large LCD touch screen • Reverse-tilt screen for patients • Enhanced patient understanding • Fully integrated and EMR ready • Rapid ROI generation

The Difference is Marco.

VISIT MARCO

September 14-16

VEW • MS8031

Untitled-5 1 590 TRSAutoSpeed-OO.indd 1

Designed and Manufactured by NIDEK - Represented by Marco 800-874-5274 • marco.com

8/23/17 4:29 PM 8/16/17 12:56 PM

BOOTH

LP 6075 | VEW 2017

GLANCE GIVING YOU A QUICK RUNDOWN ON THE TOP NEWS AND RESEARCH FROM THE PAST MONTH. CONSIDER THIS THE MOST PRODUCTIVE FIVE MINUTES OF YOUR DAY. READY?

Jackie Garlich

If you co-manage dropless cataract surgery ... The FDA issued a safety alert after 43 patients in Dallas had “serious adverse events” after receiving intravitreal injections of Tri-Moxi (compounded triamcinolone and moxifloxacin) at the end of cataract surgery. If you prescribe name-brand drops ... A study in Ophthalmology found that eyecare providers prescribe more brand-name drugs than other healthcare specialists. The study examined data from Medicare Part D claims in 2013 and found that 71% of OMD claims and 67% of OD claims were for name-brand medications. The biggest culprit? Glaucoma meds.

INTRODUCING NEW PRODUCTS WITH

NEW CAPABILITIES INCREASED ACCURACY & AFFORDABLE PRICES AUTO REFRACTOR / KERATOMETER HRK--

AUTO LENSMETER HLM--

If you wonder if a healthy diet really matters ... A study published in JAMA Ophthalmology found an association between a diet high in vitamin K and reduced cataract formation. A separate study presented at the Association for Research in Vision and Ophthalmology meeting found differences between the gut bacteria of people who ate a healthy diet and those who didn’t and suggested a protective link between a healthy diet and agerelated cataracts. If you see patients who have diabetes ... The CDC released new statistics that say 1 in 10 people in the U.S. have diabetes and that a shocking 34% of adults in the U.S. had prediabetes in 2015. Another study published in the American Journal of Respiratory and Critical Care Medicine found that individuals who have type 2 diabetes and obstructive sleep apnea (OSA) had a greater risk of developing advanced diabetic retinopathy than individuals with diabetes who do not have OSA. CONSIDER YOURSELF INFORMED. SEE YOU NEXT MONTH!

Jackie Garlich, OD, FAAO | 20/20 Glance | 2020glance.com

8 Se pt e mb e r 2 0 1 7 | O p to m e tri c O f f i c e .c o m

OO September2017.indd 8

8/25/17 2:44 PM

Think About Your Eyes

Because Life is Worth Seeing! Your sight is a gift. That’s the message of new Think About Your Eyes advertising. Millions of

Americans will be seeing our powerful new commercials and will be actively searching for an eye doctor to schedule an exam. So there’s never been a better time for you to join Think About Your Eyes and help support this important initiative. And if you’re already a member, consider upgrading to Premium to get your practice to the top of search results. Remember: supporting Think About Your Eyes is good for your patients, your practice, and our industry. JOIN OR UPGRADE TODAY! For more information call 855-449-TAYE (8293) or info@thinkaboutyoureyes.com

57-0544 2017 August Trade Ad-8.5x10.75.indd 1 Untitled-5 1

8/9/17 11:20 AM 8/23/17 4:35 PM

THINK ABOUT YOUR EYES

Make Diet a Conversation Topic with Your Patients The subject of diet isn’t always a natural conversation topic with patients. We’re much more likely to focus on other lifestyle questions—smoking, occupation and even time spent in the sun. However, diet plays an important role in vision health—and one rich in the correct nutrients and vitamins can help promote a lifetime of healthy vision.

DIABETES RISK Diet often comes up when discussing diabetes risk and its impact on vision. Uncontrolled diabetes can damage the retina of the eye, possibly leading to permanent vision loss. Patients with diabetes need to think about diet as one of the most important preventive measures in their lives, not only for their eyes but their overall health. They should be educated to maintain a plant-based diet that is low in sugars and limited in refined carbohydrates.

Beyond being part of an overall healthy diet, certain foods may contribute to eye health.

Jennifer Smith Zolman

Jennifer Smith Zolman, OD, FCOVD, is an optometrist in

Charleston, SC, and one of the 20,000 optometrists supporting Think About Your Eyes. Think About Your Eyes is a nationwide

I tell my patients that they should always shop around the perimeter of a grocery store. That’s where the fresh fruits, vegetables and proteins are. When they go into the center of the store they are exposed to all the processed foods that should not be a part of their diets.

public awareness initiative promoting the importance of an annual

EYE HEALTH Beyond being part of an overall healthy diet, certain foods may contribute to eye health. These foods are rich in such nutrients as vitamins C and E, lutein and zeaxanthin—all of which have been shown to prevent or slow the progression of some eye diseases. While carrots are hyped as beneficial for eyes and beta carotene does aid in night vision, dark, leafy greens, such as kale, collards and spinach are rich in lutein and zeaxanthin, making them the best foods for vision health. Additionally, citrus fruits such as oranges, grapefruit and papaya are high in vitamin C.

BEYOND 20/20 Ocular health goes beyond being able to see 20/20. We can play an important role in educating our patients about ways to protect their vision, which can mean addressing overall lifestyle choices. An annual eye exam is the best opportunity to have this ongoing conversation with patients. I’m proud to support Think About Your Eyes and its mission to promote annual eye exams to the greater public. Our vision is a gift, and we should do everything we can to protect it. OO

eye exam and overall vision health. First Vision Media Group is a Think About Your Eyes media partner.

10 Se pt e mb e r 2 0 1 7 | O p to m e tri c O f f i c e .c o m

OO September2017.indd 10

8/25/17 2:44 PM

Biotrue ® ONEday for Astigmatism daily disposable contact lenses with Surface Active Technology ™ maintain 98% of their moisture for up to 16 hours and provide comfortable vision for your astigmatic patients.1,2

Advanced technology for today’s patients Provide your patients with consistently clear vision and comfort throughout the day.2

3 2

1. Evolved peri-ballast lens design for comfort and stability 2. Spherical aberration control helps to reduce halos and glare 3. Thin, tapered edge design for limited lid interaction 4. Orientation mark for measuring rotational stability and helping patients during insertion

REFERENCES: 1. Data on file. Bausch & Lomb Incorporated. Rochester, NY; 2012. 2. Results from a 7-investigator, multi-site, randomized, crossover study of Biotrue® ONEday for Astigmatism and control contact lenses on 123 current non-daily disposable toric soft contact lens wearers. Each lens brand was worn on a daily wear basis for 1 week. ®

/™ are trademarks of Bausch & Lomb Incorporated or its affiliates.

Untitled-5 1

8/23/17 4:25 PM

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

JOHNSON & JOHNSON VISION TO ACQUIRE TEARSCIENCE Johnson & Johnson Vision announced a definitive agreement to acquire TearScience, Inc., which manufactures medical devices, including LipiFlow and LipiFlow Activator II (pictured), for evaluating meibomian gland health and treating meibomian gland dysfunction. Johnson & Johnson Vision will acquire TearScience through its surgical vision operating company, Abbott Medical Optics Inc. The transaction is expected to close by the end of the year. For more information, visit JNJVC.com and TearScience.com.

EYES OF AMERICA SEMINAR OFFERS EIGHT HOURS OF CE Primary Eyecare Network (PEN), a division of ABB OPTICAL GROUP, will present its annual Eyes of America Fall Seminar on Sunday, Sept. 24, 8am to 5pm in Columbus, OH. Participants can earn up to eight hours of optometric continuing education credits while learning about topics such as glaucoma surgery, glaucoma pharmaceuticals, ocular triage and pediatric eyecare. The cost is $170 for the morning session, $145 for the afternoon session or $250 for the full day. For more information or to register, visit EyesOfAmerica.org or call 800.444.9230.

News

MacuLogix, Inc., has formed a new Optometric Advisory Board led by MacuLogix co-founder and chief technology officer Greg Jackson, PhD, and has named these seven optometrists as clinical advisors: Glenn S. Corbin, Steven G. Ferrucci, Jeffry D. Gerson, Paul M. Karpecki, Gary S. Kirman, Pamela Lowe and Laurie Sorrenson. Shire plc has submitted a Marketing Authorization Application for lifitegrast, its lymphocyte function-associated antigen-1 (LFA-1) antagonist used to treat dry eye signs and symptoms, in Europe. HOYA Corp. has completed the acquisition of Performance Optics, LLC, including its subsidiaries, VISION EASE and Daemyung Optical.

12 Se p t e mb e r 20 1 7 | O p to m e tri c O f f i c e .c o m

OO September2017.indd 12

8/25/17 2:44 PM

ADV ERTORIAL

DRY EYE RELIEF INCLUDES DAILY EYELID HYGIENE compliance is minimal at best. The reason most cited by patients: It is just too time consuming and inconvenient.

IMPROVE PATIENT COMPLIANCE

Dry eye disease affects millions of people in the U.S.1 Many of them will come into your practices looking for relief. Itâ&#x20AC;&#x2122;s up to you not only to treat their symptoms but to identify the underlying causes. One place that deserves careful attention: the eyelids, which are crucial to the health of the underlying eye. In its recently released report, the Tear Film & Ocular Surface Societyâ&#x20AC;&#x2122;s Dry Eye Workshop II (DEWS II) reinforced lid hygiene as one of the mainstays in the management of conditions that can result in dry eye.2 These include blepharitis, meibomian gland dysfunction, demodex infestation and other lid margin diseases. It is now well accepted that the daily use of a heat compress followed by gentle lid cleansing helps maintain healthy eyelids and relieves dry eyes. Despite the benefits of prescribing lid hygiene and daily compress use patient

Now these treatments can be offered to your patients without the inconvenience. With the introduction of their new Hygienic Eyelid Sheets, Bruder Healthcare is offering a system that brings both these treatments together. The Bruder Moist Heat Eye Compress (Mask), with patented MediBeads, delivers therapeutic moist heat to the meibomian glands. The beads absorb water molecules from the air (no need to add water) and the mask is ready to use after being microwaved for 20 to 25 seconds. The addition of the new Bruder Hygienic Eyelid Sheets, designed specifically to work with the Mask, offers a convenient way to add lid hygiene to the treatment. The microfine sheets, which are individually

packaged, are designed to enhance the moist heat penetration of the mask and to clean oil, debris and/or makeup from 02017-06_Bruder Half Page_Vertical.pdf 1 5/12/2017 the eyelids and lashes.

GREATER CONVENIENCE Your patients can achieve the benefits of a moist heat treatment and practice good lid hygiene by using the Mask and Hygiene Eyelid sheets together. An added benefit of using the Eyelid sheets is keeping the compress cleaner for a longer time resulting in fewer washes needed. We recommend that you have the patient visit for in-office treatments followed by use of the Bruder Moist Heat Eye Compress and Bruder Hygienic Eyelid Sheets at home. While patients might enjoy using either treatment alone, remind them they really work better together.

Successful treatment of lid conditions leads to better overall eye health and improved patient satisfaction.

1. Dry eye redefined: TFOS DEWS II report is now available. Available at: TearFilm.org (Accessed August 23, 2017). 2. Jones L, Downie LE, Korb D, et al. TFOS DEWS II Management and Therapy Report. Ocul Surf. 2017 Jul;15(3):575-628.

OO September2017.indd 13

8/25/17 3:49 PM

JE: And corneal hysteresis is important in that it takes into account biomechanical properties of the cornea? KS: Exactly. It provides an assessment of the risk of progressing into glaucoma. So it’s really how able is the cornea to withstand the pressures that are there. The ORA G3 is an additional tool. It does the IOP and it does corneal-compensated IOP (IOPcc) as well, but this additional corneal hysteresis measurement gives more breadth to the assessment. JE: Over Reichert’s 175 years, there have been a lot of changes, including digital. Is that something that optometrists have been able to adopt?

ONE-TO-ONE

Kalpana Singh

Kalpana Singh has a love of problem-solving—so much so that it led her to become a chemical engineer, a profession about solving problems. Five years later, she pursued an MBA in marketing and

KS: I would have expected the adoption to be much faster than it is. Having such a rich heritage with the manual phoroptor, we still see that that’s very prominent in the market, and we’re still producing many of those. We also have the automated version of it, and it provides a lot of different tools to clinicians that they can take advantage of. For example, it improves efficiency in the practice. It’s also helpful from an ergonomic standpoint, as clinicians don’t have to raise their hands so many times to adjust lenses; they can do it at their fingertips. So, your pretest information automatically gets input into the Phoroptor VRx, and that gives you a very good starting point automatically. Once you’re done, instead of having to manually write down the numbers, it automatically goes into your electronic medical record. JE: Are there any other directions that you see the profession heading in over the next several years?

strategy to further use those skills in deciding what products to bring to market. She has been in the medical devices field for more than 15 years and now serves as divisional vice president and business unit manager at Reichert Technologies. Optometric Office caught up with her at Optometry’s Meeting in Washington, DC, in June.

Jeffrey Eisenberg: Reichert brought optometrists the phoroptor, the lensometer and other instruments. The company has a long history. Kalpana Singh: We have a pretty rich heritage, dating back almost 175 years now. We started as American Optical Company and throughout the years have transitioned into what we have now as Reichert. Throughout that process, there have been many first innovations to the industry, including the lensometer and then phoroptors and non-contact tonometers (NCTs). Now we have our automated phoroptor, called the Phoroptor VRx, as well as the Ocular Response Analyzer G3 (ORA G3), which is an NCT that also measures corneal hysteresis.

KS: Having access to care but also having access to data and information and making that mobile, I think, is an interesting trend that will happen. So making sure that there’s care that’s accessible to everyone and then, once that care is given, making sure that information that’s generated is accessible to everyone. So the concept of telemedicine, I think, is very interesting, and remote care is also very interesting for those areas that don’t have ready access to care. JE: What’s on the horizon for Reichert? KS: At Reichert, we’re very focused on our core competencies, our technologies that are key for us, which are mainly refraction and tonometry. So phoroptors and how refractions are done are very interesting to us. And we’ll continue to innovate and make sure that we understand the pain points of the clinicians as well as patients and adapt our technology to meet those needs. OO

14 Se p t e mb e r 2 0 1 7 | O p to m e tri c O f f i c e .c o m

OO September2017.indd 14

8/25/17 2:45 PM

SmartReviewsOnePager-September.pdf

8/18/17

4:06 PM

Use your strongest patient relationships to start building new ones.

80% About 80 percent of your prospective patients are using online reviews to ﬁnd new providers.

That’s why Solutionreach created SR Smart

Reviews, a platform that empowers all of

your practice staﬀ to encourage patients

to leave helpful reviews for your practice.

CMY

What makes SR Smart Reviews so smart? It uses a feature we like to call ‘intelligent guidance,’ which is a fancy way of saying that Solutionreach has analyzed billions of patient-provider interactions to develop an algorithm to help you ﬁnd the patients most likely to leave a positive review about your practice.

To schedule a demo, contact your sales representative today. Untitled-5 1

www.solutionreach.com | 888-979-7161

8/23/17 4:33 PM

INSTRUMENTATION

Mapping the Irregular Cornea and Anterior Segment By S. Barry Eiden, OD, FAAO Evolving systems let us do a better job managing patients with corneal disease and difficult-to-fit contact lens patients. Each day we see patients who have irregular corneas, but thanks to evolving topography systems, we can improve diagnosing and managing corneal disease and fitting otherwise difficult-to-fit contact lens patients. There are three types of technologies for assessing the shape of the cornea and general anterior segment, especially when prescribing contact lenses for patients with corneal irregularity: Placidobased topography, anterior segment tomography and corneo-scleral profile measurements.

PLACIDO-BASED TOPOGRAPHY The traditional system most of us are familiar with is Placido-based topography, in which the system shines rings on the cornea and measures the distance between the rings to determine curvature. As the curvature steepens, the rings get closer together. As it flattens, they get further apart. This technology has been available for decades, and the systems are somewhat affordable. Also, there are Placido-based topography systems that integrate other functions, such as aberrometry and dry eye diagnostic software. For example, the Oculus Keratograph 5M features a built-in color camera

for external imaging. For dry eye patients, you can use the Keratograph 5M to assess the tear film, scan the meibomian glands and view morphological changes, evaluate the lipid layer and measure tear film break-up time and tear meniscus height. The Oculus Pentacam offers corneal thickness measurements and elevation Another system, data for evaluating patients, such as this one, who have keratoconus. the OPD-Scan III Wavefront Aberrometer from Marco not two categories: Scheimpflug imaging sysonly features corneal topography, but it tems and anterior segment optical coheralso includes an autorefractor, keratomence tomography (ASOCT). eter, pupillometer and an integrated waveExamples of the Scheimpflug tomogfront aberrometer. raphy systems are the Oculus Pentacam Keep in mind, that Placido-based toand the GALILEI G4 from Ziemer Ophpography systems measure a limited area thalmology, Scheimpflug imaging systems of the cornea, and not all provide elevation can measure across the entire cornea and data, so their usefulness is sometimes limonto the scleral surface as well as from the ited when fitting scleral and hybrid lenses. corneal surface to the crystalline lens of Also, they donâ&#x20AC;&#x2122;t provide information about the eye. These systems offer true elevation corneal thickness, which we need for diagdata and allow us to obtain global corneal nosing corneal ectasia. thickness measurements. This is especially

SCHEIMPFLUG TOMOGRAPHY Anterior segment tomography falls into

helpful for evaluating patients with corneal disease as well as for obtaining information about the anterior chamber angle and the

16 Se p t e mb e r 20 1 7 | O p to m e tri c O f f i c e .c o m

OO September2017.indd 16

8/25/17 2:45 PM

configuration of the iris and pupil. Using this system, we can also evaluate the crystalline lens as cataracts develop. So, these systems are useful not only for evaluating patients with irregular corneas but also for evaluating glaucoma patients and performing calculations for cataract surgery. The main disadvantage is cost because these systems tend to cost significantly more than Placido-based systems.

ANTERIOR SEGMENT OCT Anterior segment OCT is becoming much more common in optometric practice. These multifunctional systems have very high corneal and anterior chamber resolution. They can give you the global thickness of the cornea, and they are able to analyze sclera. They’re especially useful because they allow us to see how scleral and hybrid contact lenses vault over the cornea and land on the sclera. We can assess and modify fits based upon the very high-resolution images. So that’s a great advantage for the assessment when fitting vaulting, scleral and hybrid contact lenses. Additionally, the high-resolution anterior segment OCT images allow the cli-

Placido-based topography helped identify irregular astigmatism in this patient.

nician to document a variety of anterior segment anomalies, and newly introduced software in some systems (such as Optovue OCT) allow for measurement of corneal epithelial thickness, which is thought to show abnormalities, in keratoconus and dry eye at very early stages of the diseases.

CORNEO-SCLERAL PROFILE MEASUREMENTS

New technology is available to measure the shape of the anterior segment across the cornea and onto sclera. Examples of these corneo-scleral profiling devices include the sMap3D from Visionary Optics and the Eye Surface Profiler from Eaglet Eye. These systems measure four quadrants and offer us the ability to simulate the design of a scleral lens Anterior segment OCT allows us to assess the fit of this scleral lens in a that fits the contour patient with keratoconus. of the eye, determine how much will vault over the cornea and how it will land on the sclera. So it creates a customized fit that is obviously advantageous since we’ve learned over the years that the scleral surface is asymmetrically astigmatic or toric.

This represents a change from the past, when we could only put a diagnostic lens on the eye and evaluate it with fluorescein staining at the slit lamp, making these systems helpful for the patient as well as the practice. OO S. Barry Eiden, OD, FAAO, is the president and medical director of North Suburban Vision Consultant, Ltd., in Deerfield and Park Ridge, IL, and Keratoconus Specialists of Illinois. He is an adjunct faculty member at the University of Illinois, Chicago, Department of Ophthalmology, Cornea and Contact Lens Service, and at the Indiana, Illinois, SUNY, UMSL and Salus Colleges of Optometry

O p tometr ic O ffic e. c om | S e pt ember 2017 17

OO September2017.indd 17

8/25/17 2:45 PM

CLOSE UP

Fitting Ortho-K with Corneal Topography Christopher Lehman, OD Hereâ&#x20AC;&#x2122;s how these maps can be used in myopia control. Myopia control remains a hot topic among optometrists and patients, especially as the prevalence of myopia continues to increase. Consider: There are 34.1 million Americans who are myopic today, according to the National Eye Institute, and the number is expected to reach 39 million by 2030. That means we can expect more patients to ask us about how to limit its progression. Multiple studies have been conducted to determine what steps may be taken to do so. Unfortunately, some of these studies show limited potential or conflicting results. One of the more promising treatments for myopia control is the use of orthokeratology (ortho-k) lenses.

A CRUCIAL STEP Corneal topography becomes a crucial step in determining the correct lens parameters for our patients. Corneal mapping allows us to evaluate important corneal characteristics necessary for an optimal contact lens fit. We can actually evaluate thousands of corneal data points on a single map. Important factors when determining the ideal candidate for ortho-k lenses are corneal steepness and eccentricity. Patients with steeper corneas and high eccentricity tend to make the best candidates.

Using corneal mapping to look at the distribution of power becomes important when fitting patients for myopia control. The hypothesis is that ortho-k lenses reduce myopia progression This subtractive map shows a â&#x20AC;&#x153;smiley faceâ&#x20AC;? pattern. This is caused by by increasing myoa lens that is riding too high, causing superior corneal flattening. pic defocus of the pre- and post-treatment eyes using subperipheral retina. Peripheral myopic defotractive maps. These maps allow the user cusing is essentially creating an add power to monitor change in dioptric power, for the patient. This peripheral defocusing treatment zone position, treatment zone is thought to play a role in slowed progressize and lens position. sion of axial length. In addition to being used for fitting contact lenses, the E300 can also be used AN EXAMPLE to evaluate dry eye by measuring tear In our practice, we use the E300 Corneal break-up time with 94% specificity and Topographer from Medmont (and distrib82% sensitivity. The E300 by Medmont uted in the United States by Nidek, Inc). does have the ability to be integrated into The E300 analyzes 102,000 corneal points current practice management systems utiwith a standard deviation of error of less lizing Medmont Studio. OO than 2 microns and is capable of measuring the cornea from limbus to limbus. On the current model, data can be extrapolated out to 17mm. This provides excellent mapping for optometrists fitting specialty contact lenses. Map analysis and display can be customized by the user with up to four images shown per screen. The E300 allows the user to compare

Christopher Lehman, OD, practices with Clompus, Reto & Halscheid Vision Associates P.C. in West Chester, PA. WHERE TO FIND IT: Medmont 800.663.4248 | Medmont.com

18 Se pt e mb e r 20 1 7 | O p to m e tri c O f f i c e .c o m

OO September2017.indd 18

8/25/17 2:45 PM

Ask Yourself This Question...

“Why Prescribe?”

OTC Savings Compared to Rx Costs Kills Bacteria on Contact -“0” Eye Irritation Stable 18 Months Opened or Unopened

Untitled-1 1

For more information and to order, call (800) 233-5469 or visit www.ocusoft.com

6/28/17 11:34 AM

CONTACT LENSES

Color Their World By Jennifer L. Stewart, OD Color contact lenses take less chair time than you might think and can help grow your practice. Ask any eyecare practitioner if he or she fits many color contact lenses, and you may get responses such as “very few of my patients are interested” and “fitting them takes too much chair time.” Not necessarily. Indeed, a tremendous opportunity exists to make color contact lenses a bigger part of optometric practice. Consider: Research from Alcon Laboratories, Inc. found that color contact lenses were responsible for 13.2% of the dollar share of the contact lens market in 1999 but fell to 3.3% in 2013. Even so, Alcon found, more than 40 million people are interested in color contact lens wear. This includes 16 million clear contact lens wearers, 13.7 million spectacle wearers, 10.3 million individuals who require no correction, 0.8 million individuals who currently wear prescription color contact lenses and 0.5 million individuals who wear plano color contact

lenses. Alcon also reports that 70% of patients who try color contact lenses purchase them. ECPs might not fully recognize the upside opportunity with color contact lenses for their practices due to perceptions that color contact lenses require more chair time and patient education. However, there are now many resources to help reduce fitting time and educate patients. For example, patients who currently wear AIR OPTIX AQUA or AIR OPTIX plus HydraGlyde contact lenses require no refit when changing to AIR OPTIX COLORS contact lenses. And, I’ve found my contact lens technicians to be extremely valuable for helping patients select the best color(s), taking no time away from my patient care.

AIR OPTIX COLORS feature SmartShield and 3-in-1 color technology.

Alcon’s 3-in-1 color technology features an outer ring to define the iris, the primary color to change the eye color, and an inner ring to brighten and add depth.

SIMPLE STEPS There are other simple steps ECPs can do to grow the color contact lens portion of their practices. When patients enter the office, we ask if they are interested in wearing contact lenses and/or color contact lenses. Patients who may not have thought of themselves as contact lens wearers ask if they are candidates, and our current contact lens wearers will often ask about colors. Having proper signage in your office showcasing the different lenses available is another way to start a discussion. If your technicians or opticians are contact lenses wearers, having them wear color lenses is a great way for patients to see how the lenses look. Some offices even offer a discount to patients who purchase both clear and color lenses. Contact lens manufacturers also provide resources to help. For example, Alcon’s AIR OPTIX COLORS Education Salon features an interactive training platform and resource portal for techni-

20 Se p t e mb e r 20 1 7 | O p to m e tri c O f f i c e .c o m

OO September2017.indd 20

8/25/17 2:45 PM

cians. They can also find e-newsletters and information about social media, websites, point-of-purchase materials, articles and promotional media there. Johnson & Johnson Vision also offers several resources on its ACUVUE Professional website. These include practicebuilding resources to teach doctors and staff how to properly select the correct lens color effect, what questions to ask patients to gauge their interest and tools to be used in the office. ACUVUE helps doctors generate referrals by using the hashtag #BeautyDEFINED. With so many new color lenses available today, we no longer have to sacrifice comfort of breathability. Staying current on the features, colors and uses of the lenses available is key to incorporating color lenses into your practice.

ALCON AIR OPTIX COLORS contact lenses, made of a lotrafilcon A silicone hydrogel material, feature a smooth, permanent plasma surface technology for comfort. These lenses are made with the unique SmartShield Technology, which delivers a protective layer of moisture that resists irritating deposits, so lenses stay comfortable all month long. AIR OPTIX COLORS contact lenses also have high oxygen transmissibility, with a Dk/t of 138 at -3.00D, and a monthly replacement schedule, which allows for better patient compliance. The power range available is +6.00D to -8.00D, including plano. The patented 3-in-1 color technology blends with a patient’s eye color to achieve a completely natural look. The technology features an outer ring (limbal ring) that defines and emphasizes the

1-DAY ACUVUE DEFINE adds definition to the individual’s natural eye color.

iris, the primary color to transform the eye color, and an inner ring to brighten and add depth. Available colors include pure hazel, blue, green, gray, brown, honey, brilliant blue, gemstone green and sterling gray.

JOHNSON & JOHNSON VISION 1-DAY ACUVUE DEFINE Brand Contact Lenses from Johnson & Johnson Vision, are made of etafilcon A and feature LACREON Technology, which permanently embeds a moisture-rich wetting agent directly into the lens matrix for reduced friction and end-of-day comfort. Available powers are +1.00D to -9.00D, including plano. Studies have shown the size of our limbal ring decreases with age. 1-DAY ACUVUE DEFINE lenses are designed to enhance a patient’s limbal ring for a more youthful appearance and to make eyes look whiter and brighter. This lens has a subtle effect; instead of changing the color of the eyes, it adds definition to the natural eye color. The five effects available are natural sparkle, natural shimmer, natural shine, accent style, and vivid style. The lens is a daily disposable, so patients can decide whether they want to enhance their eyes on a full- or parttime basis.

COOPERVISION Expressions Colors contact lenses from CooperVision, Inc. feature a three-layer tinting process, giving a more natural color change. This monthly planned replacement, methafilcon A lens is available in eight colors: blue, aqua, blue topaz, gray, green, jade green, hazel and brown. It is available in +4.00D to -6.00D, including plano. Many optometrists want to grow the contact lens portion of their practices. By offering all your current contact lens and spectacle lens patients, as well as patients who need no correction, the chance to enhance or change their eye color, you can increase revenue, garner patient referrals and improve patient satisfaction. OO Jennifer L. Stewart, OD, is a partner at Norwalk Eye Care, in Norwalk, CT. She is also the co-founder and chief optometric officer at Performance 20/20, a sports and performance vision clinic, in Stamford, CT. WHERE TO FIND IT: Alcon, a Novartis division 800.241.5999 | MyAlcon.com CooperVision, Inc. 800.341.2020 | CooperVision.com Johnson & Johnson Vision 800.843.2020 | ACUVUEProfessional.com

O p tometr ic O ffic e. c om | Se pt ember 2017 21

OO September2017.indd 21

8/25/17 2:46 PM

PATIENT CARE

A Supplemental Plan Against AMD By Jeffrey Anshel, OD Nutritional influences might help prevent individuals from progressing to advanced AMD. Although many studies show that nutritional intervention can slow the progression of age-related macular degeneration, there is still no way to forestall its development or reverse its course. There aren’t studies showing that nutrition (or anything else) might forestall AMD. However, if we look carefully at the molecular changes that happen, we can extrapolate how supporting the eye with nutrients might help prevent AMD from starting.

A BETTER ZINC? The largest studies of nutritional treatment for AMD are the Age-Related Eye Disease Study (AREDS) and Age-Related Eye Disease Study 2 (AREDS 2). The original AREDS formula, consisting of beta carotene (15mg), vitamin C (500mg). vitamin E (400 IU), zinc oxide (80 mg) and copper oxide (2 mg), slowed the progression of AMD from stage III to stage IV (the most advanced stages). Quality supplement formulations include a more bioavailable form of zinc than the formulation used in AREDS and AREDS 2, which was poorly absorbed zinc oxide. Zinc monomethionine is balanced with the scientific standard ratios of both copper and manganese to stimulate manganese superoxide dismutase, which is

required to neutralize both singlet oxygen and super-oxide free radicals. The 80mg of zinc used in the AREDs formulation was based on a single nutrient study published more than 35 years ago. The Health and Medicine Division of the National Academies of Sciences, Engineering, and Medicine recommends an upper limit of 40mg per day for daily zinc supplementation. Some formulas use 50mg as the maximum amount of zinc safe for daily consumption. Zinc has also been studied in relation to its influence on the progression of AMD, especially in individuals genetically predisoposed to advanced AMD. A pharmacogenetic analysis of the original AREDS data set showed that components of the AREDS formulation may be beneficial or harmful depending on a patient’s genotype in the complement factor H age-related maculoptathy susceptibility 2 genes. The Vita Risk pharmacogenetic analysis from Arctic Dx, helps determine whether AREDS/AREDS2 vitamin supplements will help or harm the vision of individuals with dry AMD or individuals who have lost sight to advanced AMD (i.e., wet AMD or geographic atrophy in one eye). Depending on an individual’s genetics, some patients derive no benefit and may

even be harmed by this treatment, while others benefit greatly. This test may be done alone or with the Macula Risk test, which determines an individual’s genetic predisposition to developing advanced AMD.

CAROTENOIDS AREDS 2 showed a moderate effect from adding two carotenoids—lutein and zeaxanthin, which make up the macular pigment—to the AREDS formula while removing beta-carotene. The AREDS 2 formula also proved effective in slowing the progression to advanced AMD. Lutein helps protect the macula against damage from blue light and other parts of the body, such as the lens and the brain, from damage by free radicals. Established science strongly suggests a central macula

22 Se pt e mb e r 20 1 7 | O p to m e tri c O f f i c e .c o m

OO September2017.indd 22

8/25/17 2:46 PM

ANTIOXIDANTS Anthocyanins are a class of pigments that occur naturally in plants. These antioxidants increase intracellular vitamin C levels, improve ocular microcirculation and protect the vascular endothelium. They also inhibit collagen destruction and decrease the fragility of capillaries. Another group of antioxidants, the bioflavonoids further prevent the oxidation of low-density lipoprotein, which plays a key role in vascular damage. Bioflavonoids work synergistically with vitamin E to protect the rod outer segments and the retinal pigment epithelium from freeradical-induced membrane lipoperoxidation and damage.

Courtesy: National Eye Institute, National Institutes of Health.

preference for zeaxanthin over lutein. A quality supplement should contain at least 4mg of zeaxanthin. RPE65 is the key enzyme needed to convert lutein to the centrally located meso-zeaxanthin. Thus, adequate intake of lutein is critical for macular protection. Many commercial formulations use beta-carotene as the source of vitamin A. However, excessive amounts of betacarotene interfere with absorption of lutein and zeaxanthin. Research also has linked beta-carotene to increased rates of lung cancer in smokers who also consume alcohol. Keep in mind that body mass index plays a factor in eye health. Specifically, the amount of body fat an individual has affects the amount of lutein and zeaxanthin in the retina. These nutrients are stored in fat tissue and are not available to the eye, even when needed. So, you should probably discuss weight factors with your patients who have AMD.

Advanced AMD cases such as this might be prevented by different supplement formulas.

A third antioxidant, coenzyme Q10, regenerates circulating antioxidants and provides nutritional support for the vascular system. It is also essential for producing adenosine triphosphate (ATP) energy from the mitochondria in our cells. Patients who take statin medications such as Lipitor (atorvastatin) and Zocor (simvastatin) are likely to have a deficiency of this enzyme. Given that drusen appear in the RPE, we should see why disruption of this membrane occurs. Peer-reviewed studies strongly suggest that acetyl-l-carnitine and lipoic acid, also known as alpha lipoic acid, greatly enhance nutrient cellular delivery while providing increased ATP energy to the cells of the RPE. This data was confirmed in an Italian study that found a combination of acetyl-lcarnitine, coenzyme Q10 and fish oils actually reversed some of the physical manifestations of AMD.

supplements to prevent or halt the progress of macular degeneration. Many studies support the inclusion of a wellrounded combination of antioxidants to slow macular degenerative changes. For AMD patients, it is prudent to offer a multiple vitamin and mineral supplement that contains potent amounts of full-spectrum supplemental nutrients and antioxidants. Remember that the eyes are not only an integral part of the body but directly connected to the brain, which is the most biologically active tissue in the body. So, we cannot underestimate the role of nutrients in maintaining the patientâ&#x20AC;&#x2122;s ocular and overall health. OO

SUPPLEMENTS

WHERE TO FIND IT:

Many eyecare practitioners recommend that their older patients take antioxidant

ArcticDx Inc. 866.964.5182 | ArcticDx.com

Jeffrey Anshel, OD, FAAO, is founding president of the Ocular Nutrition Society and is in private practice in Encinitas, CA. Anshel also serves on the advisory board for Optometric Office.

O p tometr ic O ffic e. c om | Se pt ember 2017 23

OO September2017.indd 23

8/25/17 2:46 PM

PHARMACEUTICAL

An Rx for Dry Eye Disease By Carl H. Spear, OD, MBA, FAAO When counseling and OTC methods don’t offer relief, it’s time to write a prescription. If I were to open a new practice today, I would specialize in the diagnosis and management of dry eye disease (DED). The need is there, and several factors would allow the development of a successful practice. Consider: More than 30 million Americans suffer from the disease, many of whom are untreated. Some of the treatment and services are covered by third-party payers. Initial diagnosis requires little or no increased investment in equipment. And, it is a chronic and progressive disease process for which more treatment options continue to become available. In May, the Tear Film & Ocular Surface Society (TFOS) presented the conclusions and recommendations of the TFOS Dry Eye Workshop II (DEWS II), creating new discussion and adding a global standardization and definition to the disease process. The TFOS DEWS II is the sequel to the original TFOS DEWS of 10 years ago. The report, available for free atTearFilm.org, updated the definition of dry eye as “a multifactorial disease of the ocular surface characterized by a loss of homeostasis of the tear film, and accompanied by ocular symptoms, in which tear film instability and hyperosmolarity, ocular surface inflammation and damage, and neurosensory abnormalities play etiological roles.”

MAKING THE DIAGNOSIS For treating patients with dry eye, I use as my guide the local coverage determination (LCD) from First Coast Service Options, Inc., the Medicare Administrative Contractor in Florida, which offers a clear and simple path for determining medical necessity and implementing step therapy. To make the diagnosis, you’ll need a history of the disease signs and symptoms along with any environmental conditions or medications that may be contributing factors. To classify the severity of DED, use one of these questionnaires: the Ocular Surface Disease Index, the Standard Patient Evaluation of Eye Dryness Questionnaire, and the 5-Item Dry Eye Questionnaire. Other available questionnaires include the McMonnies Questionnaire and Subjective Evaluation of Symptoms of Dryness. The LCD doesn’t require testing for mild DED, but if the patient has moderate to severe DED, as indicated from the questionnaire, then additional testing is necessary. This includes the Schirmer test, vital dye staining (fluorescein, rose bengal, lissamine green), tear film breakup time (TFBUT), and slit lamp evaluation with particular attention to conjunctiva and cornea, tear meniscus height, and eyelid and meibomian glands. Additionally, testing of tear osmolarity and inflammatory markers is indicated

Restasis MultiDose is indicated to help increase the eye’s ability to produce tears.

for making the initial diagnosis and possibly at one follow-up visit. For testing inflammatory markers, the LCD specifies using InflammaDry, which Quidel Corp. acquired from Rapid Pathogen Screening. This test identifies elevated levels of matrix metallopeptidase 9 (MMP-9) protein in tear fluid samples taken from the palpebral conjunctiva. Once you diagnose the patient, the LCD offers a definitive regimen of step therapy. This starts with eliminating any environmental factors and medications, when feasible, that may be contributing to the patient’s DED. This is followed by artificial tears, treatment of blepharitis or meibomianitis, treatment of lid abnormalities, medications, and punctal occlusion

THE RX ROUTE We now have several medications available, all of which are considered conservative interventions for DED. These include corticosteroids, systemic omega-3 fatty

24 Se p t e mb e r 2 0 1 7 | O p to m e tri c O f f i c e .c o m

OO September2017.indd 24

8/25/17 2:46 PM

acids (docosahexaenoic acid, eicosapentaenoic acid, and alpha-linolenic acid), RESTASIS (cyclosporine ophthalmic emulsion) 0.05% from Allergan, and Xiidra (lifitegrast ophthalmic solution) 5% from Shire Pharmaceuticals. I follow the step therapy outlined in the Florida LCD. However, when a patient has moderate-to-severe dry eye that has not been alleviated with environmental modification and counseling along with artificial tears and concurrent management of lid disease, it’s time to add a topical Rx.

RESTASIS RESTASIS is an immunomodulator that limits T lymphocyte activity and prevents the release of cytokines, thus reducing inflammation. RESTASIS is indicated to help increase the eye’s ability to produce tears—an ability likely suppressed by ocular inflammation. Advantages of RESTASIS: It has a long track record—the FDA approved RESTASIS in 2002—and is covered by numerous third-party payers. RESTASIS has been available in preservative-free single-use vials, and last year, the FDA approved RESTASIS MultiDose, a 5.5ml bottle with a 30-day supply. Dosage is twice daily. Because patients may not notice immediate improvement, I consider it critical to schedule the patient for a follow-up visit about four to six weeks later. That way, I can reassure them and prevent them from stopping the medication before it has had time to start providing noticeable symptomatic relief. Burning is the most common complaint I hear about Restasis. Other side effects include eye redness, discharge, watery eyes, eye pain, foreign-body sensation, itching, stinging and blurred vision.

Xiidra works by blocking the interaction between ICAM-1 and LFA-1.

XIIDRA In July 2016, the FDA approved Xiidra, the first prescription eye drop approved for treating both signs and symptoms of DED in adults. Xiidra is the first medication in a new class of drugs, called lymphocyte function-associated antigen 1 (LFA-1) antagonist. Xiidra’s active ingredient, lifitegrast, is designed to specifically block the interaction of intercellular adhesion molecule-1 (ICAM-1) and LFA-1, which plays important roles in the inflammation behind DED. In clinical trials, Xiidra demonstrated significant reduction in both signs and symptoms of DED by week 12 compared with the vehicle, with symptom improvement observed at Day 14. Xiidra comes in single-dose containers. Dosage is twice daily. Xiidra is generally well tolerated. The most common adverse reactions reported include instillation site irritation, an unusual taste (dysgeusia) and reduced visual acuity.

It’s important to educate your patients that either treatment will be long-term when dealing with the chronic and progressive nature of DED. Follow patients regularly and reassure them when initiating therapy so that they continue the use of the medication to allow for the therapeutic benefit. Coverage of these medications by patients’ insurance will also be a determining factor in their continuing use to treat this chronic disease. I have been successful with both Rx medications. Be aware of each patient’s insurance, and be diligent at getting approvals or writing the Rx in the specific manner required for coverage by the insurer. OO Carl Spear, OD, MBA, FAAO, practices in the Panhandle of Florida. Dr Spear is a lecturer, writer and consultant specializing in practice management and strategic eyecare industry analysis. WHERE TO FIND IT:

DECISION DRIVERS Clinically, the decision to use Xiidra or Restasis is driven by the severity of the patient’s DED. Personal experience has shown that each one may work better in certain patients than in others.

Allergan 844.469.8327 | Restasis.com Quidel 800.874.1517 | Quidel.com Shire Pharmaceuticals 800.828.2088 | Xiidra-ECP.com

O p tometr ic O ffic e. c om | Se pt ember 2017 25

OO September2017.indd 25

8/25/17 2:46 PM

THE | OPTOMETRIC TECHNICIAN BY ROBERTA BEERS, CPOT HERE’S WHAT YOU SHOULD KNOW ABOUT THE OPTIONS FOR DIAGNOSING AND TREATING KERATOCONUS. Keratoconus affects a small segment of the U.S. population—an estimated 1 in 2,000, according to the National Eye Institute— but those individuals with the disorder experience blurring and distortion and, in some cases, may eventually require corneal transplant. When the OD asks you to assist in the diagnosis of this disorder, you need to know why and what to expect.

THINNING AND BULGING In keratoconus, the cornea progressively thins and starts to bulge slightly in the center, eventually taking on a cone shape. Keratoconus is bilateral, but it is usually asymmetrical, with one eye more involved that the other. It may be so asymmetrical that only one eye needs to be treated. In its earliest stages, keratoconus causes slight blurring and distortion of vision and increased sensitivity to light. These symptoms usually appear when individuals are in their late teens and early 20s. Keratoconus may progress for 10 to 20 years and then slow or stabilize, usually when individuals are in their early 30s.

A symptom of keratoconus is a painless decrease of vision over time. It may manifest as intolerance to contact lenses or inability to wear soft lenses. The cause of keratoconus is unknown. Patients may have a family history, yet the disease is not inherited. Also, keratoconus is not associated with other serious ocular or systemic conditions. Although the cause of keratoconus is unknown, it is easy diagnose and treat. A corneal topographer provides different maps to show changes indicative of keratoconus. Keratometry, or K, readings are another important part in diagnosing keratoconus. If the mean K is less than 50.00D, the cone can be considered early stage. A mean Kreading of 50.00D to 55.00D is advanced, a reading greater than 55.00D is severe.

Eyeglasses or soft contact lenses may be used to correct the mild nearsightedness and astigmatism that occur during the early stages for keratoconus. As the disorder progresses and cornea continues to thin and change shape, gas permeable contact lenses become the preferred treatment. The gas permeability enables these lenses to vault over the cornea, replacing its irregular shape with a smooth, uniform refracting surface to improve vision. Fitting contact lenses on a keratoconic cornea is challenging and time-consuming. Patients often must make follow-up visits to fine-tune the fit, especially if the keratoconus continues to progress. However, there have been many developments in contact lenses for individuals who have keratoconus.

CUSTOM SOFT LENSES MORE TREATMENTS In the past, optometrists treated keratoconus in the following order: eyeglasses, gas permeable contact lenses and corneal transplant. Today, there are more treatments available.

The center of the UltraHealth contact lens vaults over the cornea for added comfort.

Custom soft contact lenses for correcting mild-to-moderate keratoconus are madeto-order based on detailed measurements of the individual’s keratoconic eye(s). For some individuals, these may be more comfortable than gas permeable or hybrid contact lenses. Custom soft contacts for the correction of keratoconus include KeraSoft IC from Art Optical Contact Lens Inc. and NovaKone Lenses from Alden Optical, a division of Bausch + Lomb Specialty Vision Products. KeraSoft IC is a high-water-content silicone hydrogel lens with a power range of –20.00D to +20.00D and cylinder powers of –0.25D to –12.00D. NovaKone lenses are medium-water hydrogel lenses and come in powers of –30.00D to +30.00D and cylinder powers up to –10.00D. Both lenses have an extensive range of fitting parameters for a customized fit and are typically larger in diameter than conventional

26 Se p t e mb e r 20 1 7 | O p to m e tri c O f f i c e .c o m

OO September2017.indd 26

8/25/17 2:46 PM

SCLERAL AND SEMI-SCLERAL LENSES

Custom soft toric lenses, such as the NovaKone Toric, are an option for part-time wear.

soft lenses for greater rotational stability on a keratoconic eye. Custom soft toric lenses are an option for part-time wear for individuals with keratoconus who cannot tolerate wearing gas permeable lenses full-time. For example, an individual might wear GP lenses during work and while driving and the soft lenses during leisure activities or as a short break from the GP lenses.

HYBRID CONTACT LENSES Hybrid contact lenses are designed to provide the crisp optics of a gas permeable contact lens and the wearing comfort of soft lenses. The UltraHealth, SynergEyes KC and ClearKone hybrid contact lenses, manufactured by SynergEyes, combine a highly oxygen-permeable rigid center with a soft peripheral skirt. UltraHealth uses silicone hydrogel material for the soft lens skirt, providing greater oxygen transmissibility than SynergEyes KC’s and ClearKone’s hydrogel skirt. UltraHealth, SynergEyes KC and ClearKone are available in a wide range of parameters to fit the irregular shape of a keratoconic eye. These lenses were designed specifically for keratoconus, with the central GP zone of the lens vaulting over the cone-shaped cornea for increased comfort.

These are large-diameter gas permeable lenses in which the periphery and edge of the lens rest on the sclera of the eye. Scleral lenses cover a larger portion of the sclera, whereas semi-scleral lenses cover a smaller area. Because the center of scleral and semiscleral lenses vaults over the irregularly shaped cornea, these lenses don’t apply pressure to the eye’s cone-shaped surface, allowing for a more comfortable fit. And, these larger lenses are more stable than conventional gas permeable contact lenses, which move with each blink because they cover only a portion of the cornea.

ADDITIONAL TREATMENTS In the past few years there have been new treatments for keratoconus in the hope of delaying and possibly preventing the need for corneal transplant. In 2004, the FDA approved Intacs, which Addition Technology, Inc. acquired from KeraVision, for treating keratoconus and for which OASIS Medical, Inc., is the distributor for the U.S. The surgeon inserts these polymethylmethacrylate, or PMMA, segments in the periphery of the cornea to help reshape the cornea for clearer vision. Intacs may be needed when patients no longer can obtain functional vision with contact lenses or eyeglasses. Studies have shown that Intacs can improve best spectacle-corrected visual acuity of a keratoconic eye by an average of two lines. Also, the implants can be removed and exchanged. Intacs might delay but can’t prevent a corneal transplant if keratoconus continues to progress. More recently, Avedro, Inc., received FDA approval in 2016 for Photrexa Viscous

and Photrexa riboflavin solutions and the KXL System for corneal cross-linking, or CXL, in patients with keratoconus and with corneal ectasia following refractive surgery. In CXL, the doctor instills the drug formulations onto the ocular surface, and then applies the ultraviolet light to strengthen corneal tissue. This, in turn, halts the bulging of the eye’s surface. There are two different of corneal cross-linking: FDA-approved epitheliumoff cross-linking, in which the outer layer of the cornea is removed to allow penetration of the drug; and epithelium-on (also called transepithelial crosslinking), in which the epithelium is left intact. The epithelium-on method requires different drug formulations and often, more time for the drug to penetrate the cornea, but potential advantages include less risk of infection, less discomfort and faster visual recovery. Epithelium-on CXL has not been approved by the FDA. The most important thing to remember about keratoconus is that it is treatable and most patients enjoy good vision. OO Roberta Beers, CPOT, is an optometric assistant in Erie, PA.

WHERE TO FIND IT: Addition Technology, Inc. 847.297.8419 | AdditionTechnology.com Alden Optical, Inc. 800.253.3669 | AldenOptical.com Art Optical Contact Lens, Inc. 800.253.9364 | ArtOptical.com Avedro, Inc. 844.528.3376 | Avedro.com SynergEyes, Inc. 877.733.2012 | SynergEyes.com

O p tometr ic O ffic e. c om | S e pt ember 2017 27

OO September2017.indd 27

8/25/17 2:47 PM

AT-A- GLANCE TONOMETERS TONOMETER

TYPE

MEASUREMENT RANGE

METHOD

BENEFITS

Contact tip

•G ravity Offset Technology provides precise measurements with less calibration •T akes average of 9 readings and accounts for corneal thickness • No fluorescein required • Inexpensive AccuTip disposable tip covers

Accutome | 800.979.2020 | Accutome.com AccuPen

Handheld

5-60 mmHg

BiCOM Inc. | 877.342.8667 | TonometerDiaton.com Diaton

Handheld

5-60 mmHg

Non-Contact (No corneal contact)

•T akes measurement through the eyelid and sclera, so reading is CCT independent •C an take reading in seated or supine positions •N o sterilization or replacement covers required

Patented rebound technology

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

Air Puff

•P uff automatically adjusts for the next measurement in patients with high readings • Takes average of 4 readings to 0.1º

Air Puff

•T hree-in-one device: non-contact tonometer, autorefractor and autokeratometer • Completely automatic, using three axes: alignment, tracking and focus • Automatic Pressure Control for a softer air puff

Air Puff Non-Contact Tonometry and Pachymetry

• Video of air puff with visualization •P rovides 4330 frames/second with high speed camera • Takes optical pachymetry measurements

Air Puff

• Measures corneal hysteresis •P rovides Corneal Compensated Intraocular Pressure

Non-contact

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

Icare | 888.422.7313 | Icare-USA.com Icare ic100

Handheld

7-50 mmHg

Keeler | 800.523.5620 | KeelerUSA.com Pulsair Desktop

Tabletop

5-50 mmHg

Marco | 800.874.5274 | Marco.com M3 TONOREF II ARK & NonContact Tonometer

Tabletop

1-60 mmHg

OCULUS, Inc. | 425.670.9977 | OCULUSUSA.com Corvis STL

Tabletop

6-60 mmHg

Reichert | 888.849.8955 | Reichert.com Ocular Response Analyzer G3

Tabletop

6-60 mmHg

Tomey | 888.449.4045 | TomeyUSA.com FT-1000

Tabletop

0-60 mmHg

FOR AN EXPANDED LIST OF TONOMETERS, GO TO OPTOMETRICOFFICE.COM 28 Se p t e mb e r 20 1 7 | O p to m e tri c O f f i c e .c o m

OO September2017.indd 28

8/25/17 2:47 PM

VISIONARY IN VISION L

R AT

ANYWHERE, ANYTIME

years

THE INTELLIGENT CHOICE

VISIT VEW 2017 BOOTH #MS7045 FOR PROBE SPECIAL! Learn more: info@icare-usa.com or www.icare-usa.com

Untitled-5 1

8/23/17 4:28 PM

NEW PRODUCT | GALLERY EXPANDED INDICATION FOR BOSTON MATERIALS The U.S. Food and Drug Administration has granted Bausch + Lomb 510(k) clearance for the therapeutic use of its Boston XO and Boston XO2 gas permeable contact lens materials. The expanded indication enables you to use scleral lenses manufactured with the Boston XO and Boston XO2 materials in the treatment of such conditions as dry eye disease, limbal stem cell deficiencies, skin disorders with ocular surface manifestations, neurotrophic keratitis and corneal exposure (pictured). For information, call 800.828.9030, or go to Bausch.com.

EPITHELIAL MAPPING FOR DIAGNOSING CORNEAL DISEASE Optovue has received clearance from the FDA for its epithelial thickness mapping software, or epi-mapping, a non-contact method that lets you obtain epithelial and stromal measurements for the diagnosis and management of ocular diseases. Optovue says epi-mapping can also help you determine whether patients are suitable for refractive procedures and monitor healing after refractive and corneal surgery. Epi-mapping is commercially available on the iVue and iFusion optical coherence tomography systems. For information, call 866.344.8948, or go to Optovue.com.

A PHONE APP FOR MULTILINGUAL EXAMS Dmitriy Richer, an optometry student at NECO, New England College of Optometry, and classmates have developed OpTranslate, a mobile app to help you conduct eye exams on non-English-speaking patients. It features the full, comprehensive eye exam split into six sections; additional sections for contact lens exams, binocular vision testing and pre-written diagnoses; and written explanations, patient education resources and labeled diagrams. Available languages include Spanish, French, Portuguese and Haitian Creole languages, with a Mandarin update planned for October and Russian, Hindi, Korean and Vietnamese updates in development. You can find OpTranslate on the App Store and Google Play. For information, go to OpTranslate.com.

30 Se p t e mb e r 20 1 7 | O p to m e tri c O f f i c e .c o m

OO September2017.indd 30

8/25/17 2:47 PM

2018NYC EDUCATION MARCH 15-18 EXHIBIT HALL MARCH 16-18 JAVITS CENTER NEW YORK CITY

EVERYTHING VISION. BECAUSE VISION IS EVERYTHING.

SAV E T HE DAT E

Bring your vision to New York—the city where things change in the blink of an eye—for the event of the year, where eyecare meets eyewear, and education, fashion and innovation mingle.

YOUR VISION. YOUR WORLD—VISION EXPO. BROUGHT TO YOU BY

Untitled-5 1

PROUD SUPPORTER OF

PRODUCED BY

VI S IO N EXP O.C O M / N YC #VIS IO N EXP O

8/23/17 4:32 PM

DOCS | SPEAK OUT DRY EYE DISEASE Ocular surface disorders take many forms, including dry eye disease (DED). It is an area that has benefited from decades of research to alleviate patient suffering. New pharmaceuticals provide even greater benefits for treating DED. This issue’s Docs Speak Out survey will explore caring for patients with DED.

Have you diagnosed more patients with DED this year than a few years ago?

What diagnostic tests do you routinely use to help diagnose DED? (Check all that apply.) 100

YES 88%

60 40

96% 97% 90% 22% 22%

12%

Do you plan to add any of the following diagnostic tests to your office? (Check all that apply.) 50 40 30 20

29%

49%

10 0

p ian cy ace ku rity tory rea UT) l surf ma sment bompaten smola t i b m e r a a B n s m and ro e nfl se tea e (T orne ing tea sessm tear i ker as gl c ain tim r as st a m

49%

rity

ola

m r os tea sting te

ato

mm nfla i r tea sting te

ion n of s initinatio gland f e h-d m an hig ansillu ibomi tr e me th

DESCRIBE THE PROCESS BY WHICH YOU EXPLAIN TO PATIENTS THAT THEIR TEARY EYES ARE CAUSED BY AN UNDERLYING DRY EYE DISEASE? “Explanation through discussion, and a single illustration piece posted in the exam room.” “The majority of dry eye is caused by meibomian glands that are not functioning properly. These glands secrete oil that mixes with your tears, provides lubrication to the eye and controls how fast your tears evaporate. Without this oil you will have eyes that get red, itch, burn and water uncontrollably at times. Treatment needs to be done now because these glands do not regenerate, so once lost are gone for good.” “I use an eyelid model and explain the importance of the oily layer of the tears.”

“I explain that reflex tearing occurs in dry eye patients routinely, but those are not good tears. Tears are made up of several layers, and if the layers are not in the right proportion, the eyes will still be dry. Therefore, adding the correct regimen will slow or stop the reflex tearing.”

“I draw out on paper the different layers of the tear film and explain why tearing takes place.” “I run a dry eye specialty practice. Education is via meibography and discussion. I happen to like the non-branded brochure by Allergan.” “I use my LipiScan.”

“I show them a photo of lid anatomy and explain how mild changes can cause significant symptoms. A short iPad video would be helpful.” “I use educational videos and personal verbal explanations. The videos really do a good job.”

“Explanation. Two types of tears: one viscous and the other watery, the kind that washes grit out of your eyes. Once the viscous tears can no longer keep the eye moist, the watery tears take over—so your wet eyes are due to dry eye disease.”

32 Se pt e mb e r 20 1 7 | O p to m e tri c O f f i c e .c o m

OO September2017.indd 32

8/25/17 2:47 PM

W H 2O 2A ! Patients Love Our Bubbles

Go Beyond MPS. Upgrade your patients to the bubbling power of CLEAR CARE® PLUS for: • Unsurpassed disinfection

1,2

• Better comfort and cleaner feeling lenses Winner Eye Care Category Survey of 40,000 consumers by TNS

• No preservatives to be more like natural tears

Pick the winner that makes loving lenses easy for your patients. Recommend the bubbling power of CLEAR CARE® PLUS. To learn more, visit clearcareprofessional.com.

PERFORMANCE DRIVEN BY SCIENCE™

CLEAR CARE® PLUS formulated with

MPS, multipurpose solution. *Compared to MPS in symptomatic users. References: 1. Gabriel M, Bartell, J, Walters R, et al. Biocidal efficacy of a new hydrogen peroxide contact lens care system against bacteria, fungi, and Acanthamoeba species. Optom Vis Sci. 2014;91:E-abstract 145192. 2. Alcon data on file, 2014. 3. Alcon data on file, 2015. © 2016 Novartis 04/16 US-CCS-16-E-1913

Untitled-2 1 94820_US-CCS-16-E-1913.indd 1

8/29/16 AM 7/27/16 10:12 1:16 PM

For work play and

everyday Patients want multiple pairs of eyewear to enhance the way they live. Help make them easier to purchase from your practice with promotional financing options* available through the CareCredit credit card. Visit booth #13058 at Vision Expo West. Or call for more information and enroll at no cost today^.

866.853.8432

www.carecredit.com

visioninfo@carecredit.com

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

Untitled-5 1

OO0917OA

8/23/17 4:26 PM