OptometryTimes.com

By Justin Bazan, OD

A person coming into your practice asking for a glasses adjustment is a daily occurrence in many of our offices. In years past, it was com-monplace to have the optician take care of the patient “on the house” as a gesture of goodwill. If he was a current patient—great; if he wasn’t—well, maybe your kind gesture just made such a positive impression on him that he might sched-ule his next exam with you.

While this system has seemingly worked well in the past, the landscape has changed—and is continuing to change. Gone are those simple days when nearly all patients purchased glasses from their eye doctors’ offices. Online eyewear vendors have exploded onto the scene, and the fallout includes the doctor/patient relationship.

By Greg Hill

las Vegas—Glaucoma isn’t being treated aggres-sively enough, and eyecare practitioners (ECPs)are too cautious when it comes to treating and diagnosing the disease—often at the patient’s expense. Eric Schmidt, OD, FAAO, in Wilming-ton, NC, gave the warning at a lecture at Vision Expo West 2016.

Detectable glaucoma has evolved over the years, changing the way ECPs are approaching care. Glaucoma is a silent disease; by the time symptoms are visible, the damage has already been done. Worse yet, the more advanced the disease is, the faster it degenerates vision, lead-ing to eventual blindness. The problem is one of identification—glaucoma patients must be identified early for treatments to be effective. To

Handling patients who want you to adjust glasses purchased online

ECPs don’t treat glaucoma aggressively enough

see ECPs and glaucoma on page 7

see Glasses purchased online on page 14

eyecare practitioners who work with pa-tients in the perioperative period are well aware of the need for topical ther-apy. In most cases, a combination of a

steroid, a nonsteroidal anti-inflammatory drug (NSAID), and an antibiotic will be used for a few days before the day of surgery and then for a period afterward.

However, how these agents are used, in what combination, as well as which partic-ular agents are selected is a matter of much debate. Understanding the role and rationale of each may provide a basis for making an in-formed decision about which agent may be most beneficial in a given scenario.

Topical antibioticsThe role of an antibiotic during the periopera-tive period is relatively straightforward. Infec-tion control and prevention are of critical im-portance, even if the risk of developing sight-threatening sequelae is low. Endophthalmitis following cataract surgery occurs in about 1 in every 1,000 surgeries.1-3 It is likely that only a fraction of these are truly infectious in na-

ture with potential to affect vision; however, infectious endophthal-

mitis can have devastating consequences in terms of vision loss (Figures 1 and 2).

Most cataract surgeons use a preoperative preparation of povidone-iodine to achieve a sterile ocular surface.

The role of intracameral antibiotics is con-sidered off-label and gaining in popularity in the United States, although it is routinely used in Europe.4 In addition, several studies have suggested a benefit for this practice.5-7

Selection of the agent used in intracameral preparations, should they be used, requires some forethought. The emergence of fluoro-quinolone resistance patterns is concerning, and studies have indicated that prior systemic use of a fluoroquinolone may increase the risk.8 There is also recent evidence of hemor-rhagic occlusive retinal vasculitis (HORV) as-sociated with intracameral vancomycin use.9

More typically, patients undergoing cata-ract surgery are started on a topical antibiotic formulation a few days before surgery as pro-phylaxis, which is continued through the post-operative period. Again, resistance patterns become important because resistance to one or more antibiotics is prevalent in ocular iso-

see Topical cataract regimen on page 20

By Walter O. Whitley, OD, MBA, fAAO

OCTOBER 2016VOL . 8 , NO. 10

PRACTICAL CHAIRSIDE ADVICE

TOPICAL reGIMenSFOR CATARACT PATIENTS

An evidence-based approach to choosing agents used during the perioperative period

&Q a | DR. PHILIP AITSEBAOMO RUNNING FOR OFFICE, DIVERSITY IN OPTOMETRY, & MENTORING STUDENTS see Page 34

FIGURES 1 AND 2.Grade 1.5+ cells one day after femtosec-ond cataract surgery.

1 2

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OptometryTimes.com

By Justin Bazan, OD

A person coming into your practice asking for

a glasses adjustment is a daily occurrence in

many of our offices. In years past, it was com-

monplace to have the optician take care of the

patient “on the house” as a gesture of goodwill.

If he was a current patient—great; if he wasn’t—

well, maybe your kind gesture just made such a

positive impression on him that he might sched-

ule his next exam with you.

While this system has seemingly worked well

in the past, the landscape has changed—and is

continuing to change. Gone are those simple

days when nearly all patients purchased glasses

from their eye doctors’ offices. Online eyewear

vendors have exploded onto the scene, and the

fallout includes the doctor/patient relationship.

By Greg Hill

LAS VEGAS—Glaucoma isn’t being treated aggres-

sively enough, and eyecare practitioners (ECPs)

are too cautious when it comes to treating and

diagnosing the disease—often at the patient’s

expense. Eric Schmidt, OD, FAAO, in Wilming-

ton, NC, gave the warning at a lecture at Vision

Expo West 2016.

Detectable glaucoma has evolved over the

years, changing the way ECPs are approaching

care. Glaucoma is a silent disease; by the time

symptoms are visible, the damage has already

been done. Worse yet, the more advanced the

disease is, the faster it degenerates vision, lead-

ing to eventual blindness. The problem is one

of identification—glaucoma patients must be

identified early for treatments to be effective. To

Handling patients who want you to adjust glasses purchased online

ECPs don’t treat glaucoma aggressively enough

See ECPs and glaucoma on page 7

See Glasses purchased online on page 14

Eyecare practitioners who work with pa-

tients in the perioperative period are

well aware of the need for topical ther-

apy. In most cases, a combination of a

steroid, a nonsteroidal anti-inflammatory drug

(NSAID), and an antibiotic will be used for a

few days before the day of surgery and then

for a period afterward.

However, how these agents are used, in

what combination, as well as which partic-

ular agents are selected is a matter of much

debate. Understanding the role and rationale

of each may provide a basis for making an in-

formed decision about which agent may be

most beneficial in a given scenario.

Topical antibioticsThe role of an antibiotic during the periopera-

tive period is relatively straightforward. Infec-

tion control and prevention are of critical im-

portance, even if the risk of developing sight-

threatening sequelae is low. Endophthalmitis

following cataract surgery occurs in about 1

in every 1,000 surgeries.1-3 It is likely that only

a fraction of these are truly infectious in na-

ture with potential to affect vision;

however, infectious endophthal-

mitis can have devastating consequences in

terms of vision loss (Figures 1 and 2).

Most cataract surgeons use a preoperative

preparation of povidone-iodine to achieve a

sterile ocular surface.

The role of intracameral antibiotics is con-

sidered off-label and gaining in popularity in

the United States, although it is routinely used

in Europe.4 In addition, several studies have

suggested a benefit for this practice.5-7

Selection of the agent used in intracameral

preparations, should they be used, requires

some forethought. The emergence of fluoro-

quinolone resistance patterns is concerning,

and studies have indicated that prior systemic

use of a fluoroquinolone may increase the

risk.8 There is also recent evidence of hemor-

rhagic occlusive retinal vasculitis (HORV) as-

sociated with intracameral vancomycin use.9

More typically, patients undergoing cata-

ract surgery are started on a topical antibiotic

formulation a few days before surgery as pro-

phylaxis, which is continued through the post-

operative period. Again, resistance patterns

become important because resistance to one

or more antibiotics is prevalent in ocular iso-See Topical cataract regimen on page 20

By Walter O. Whitley, OD, MBA, FAAO

OCTOBER 2016VOL . 8 , NO. 10

PRACTICAL CHAIRSIDE ADVICE

TOPICAL REGIMENSFOR CATARACT PATIENTS

An evidence-based approach to choosing agents used during the perioperative period

&Q A | DR. PHILIP AITSEBAOMO RUNNING FOR OFFICE, DIVERSITY IN OPTOMETRY, & MENTORING STUDENTS SEE PAGE 34

FIGURES 1 AND 2.Grade 1.5+ cells one day after femtosec-ond cataract surgery.

1 2

Focus On TECHNOLOGY

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NIICE TO

Xiidra improved patient-reported symptoms of eye dryness and improved signsof inferior corneal staining. So help your patients get to know Xiidra.

Check it out at Xiidra-ECP.com

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MEET YOU/�i����Þ�«ÀiÃVÀ�«Ì����iÞi�`À�«���Ƃ�>««À�Ûi`�Ì��ÌÀi>Ì�L�Ì��Ì�i�Ã�}�Ã�>�`�ÃÞ�«Ì��Ã��v��ÀÞ� Þi���Ãi>Ãi

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For additional safety information, see accompanying Brief Summary of Safety Information on the following page and Full Prescribing Information on Xiidra-ECP.com.

BRIEF SUMMARY:Consult the Full Prescribing Information for complete product information.

INDICATIONS AND USAGE:KKFTCv�NKƂVGITCUV�QRJVJCNOKE�UQNWVKQP�����KU�KPFKECVGF�for the treatment of the signs and symptoms of dry eye FKUGCUG�&'&��

DOSAGE AND ADMINISTRATIONInstill one drop of Xiidra twice daily (approximately 12 JQWTU�CRCTV��KPVQ�GCEJ�G[G�WUKPI�C�UKPING�WUG�EQPVCKPGT��Discard the single use container immediately after using in each eye. Contact lenses should be removed prior to VJG�CFOKPKUVTCVKQP�QH�:KKFTC�CPF�OC[�DG�TGKPUGTVGF����minutes following administration.

ADVERSE REACTIONSClinical Trials ExperienceBecause clinical studies are conducted under widely varying conditions, adverse reaction rates observed in clinical studies of a drug cannot be directly compared to rates in the clinical trials of another drug and may PQV�TGƃGEV�VJG�TCVGU�QDUGTXGF�KP�RTCEVKEG��+P�ƂXG�ENKPKECN�UVWFKGU�QH�FT[�G[G�FKUGCUG�EQPFWEVGF�YKVJ�NKƂVGITCUV�ophthalmic solution, 1401 patients received at least ��FQUG�QH�NKƂVGITCUV������QH�YJKEJ�TGEGKXGF�NKƂVGITCUV������6JG�OCLQTKV[�QH�RCVKGPVU������JCF�Ű��OQPVJU�QH�VTGCVOGPV�GZRQUWTG������RCVKGPVU�YGTG�GZRQUGF�VQ�NKƂVGITCUV�HQT�CRRTQZKOCVGN[����OQPVJU��6JG�OCLQTKV[�QH�VJG�VTGCVGF�RCVKGPVU�YGTG�HGOCNG�������6JG�OQUV�EQOOQP�CFXGTUG�TGCEVKQPU�TGRQTVGF�KP��������QH�RCVKGPVU�were instillation site irritation, dysgeusia and reduced XKUWCN�CEWKV[��1VJGT�CFXGTUG�TGCEVKQPU�TGRQTVGF�KP����VQ����QH�VJG�RCVKGPVU�YGTG�DNWTTGF�XKUKQP��EQPLWPEVKXCN�hyperemia, eye irritation, headache, increased lacrimation, eye discharge, eye discomfort, eye pruritus and sinusitis.

USE IN SPECIFIC POPULATIONSPregnancy6JGTG�CTG�PQ�CXCKNCDNG�FCVC�QP�:KKFTC�WUG�KP�RTGIPCPV�women to inform any drug associated risks. Intravenous +8��CFOKPKUVTCVKQP�QH�NKƂVGITCUV�VQ�RTGIPCPV�TCVU��HTQO�RTG�OCVKPI�VJTQWIJ�IGUVCVKQP�FC[�����FKF�PQV�RTQFWEG�teratogenicity at clinically relevant systemic exposures. +PVTCXGPQWU�CFOKPKUVTCVKQP�QH�NKƂVGITCUV�VQ�RTGIPCPV�rabbits during organogenesis produced an increased incidence of omphalocele at the lowest dose tested, ��OI�MI�FC[�����HQNF�VJG�JWOCP�RNCUOC�GZRQUWTG�CV�the recommended human ophthalmic dose [RHOD], DCUGF�QP�VJG�CTGC�WPFGT�VJG�EWTXG�=#7%?�NGXGN���5KPEG�JWOCP�U[UVGOKE�GZRQUWTG�VQ�NKƂVGITCUV�HQNNQYKPI�ocular administration of Xiidra at the RHOD is low, the CRRNKECDKNKV[�QH�CPKOCN�ƂPFKPIU�VQ�VJG�TKUM�QH�:KKFTC�WUG�KP�humans during pregnancy is unclear.

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Pediatric Use 5CHGV[�CPF�GHƂECE[�KP�RGFKCVTKE�RCVKGPVU�DGNQY�VJG�CIG�QH����[GCTU�JCXG�PQV�DGGP�GUVCDNKUJGF��

Geriatric Use No overall differences in safety or effectiveness have been observed between elderly and younger adult patients.

NONCLINICAL TOXICOLOGYCarcinogenesis, Mutagenesis, Impairment of Fertility Carcinogenesis: Animal studies have not been conducted VQ�FGVGTOKPG�VJG�ECTEKPQIGPKE�RQVGPVKCN�QH�NKƂVGITCUV� Mutagenesis: .KƂVGITCUV�YCU�PQV�OWVCIGPKE�KP�VJG�in vitro #OGU�CUUC[��.KƂVGITCUV�YCU�PQV�ENCUVQIGPKE�KP�VJG�in vivo mouse micronucleus assay. In an in vitro chromosomal aberration assay using mammalian cells (Chinese JCOUVGT�QXCT[�EGNNU���NKƂVGITCUV�YCU�RQUKVKXG�CV�VJG�JKIJGUV�concentration tested, without metabolic activation. Impairment of fertility: .KƂVGITCUV�CFOKPKUVGTGF�CV�KPVTCXGPQWU�+8��FQUGU�QH�WR�VQ����OI�MI�FC[� �����HQNF�VJG�JWOCP�RNCUOC�GZRQUWTG�CV�VJG�TGEQOOGPFGF�JWOCP�QRJVJCNOKE�FQUG�4*1&��QH�NKƂVGITCUV�QRJVJCNOKE�UQNWVKQP������JCF�PQ�GHHGEV�QP�fertility and reproductive performance in male and female treated rats.

5Chief Optometric EditorFROM THE

| PRACTICAL CHAIRSIDE ADVICE

I recently had the opportunity to do some-

thing I’d never done before: attend a con-

ference that had absolutely nothing to do

with optometry. Now some of you will ask,

“Don’t you go to enough of those things as

it is?” Well, yes, but this one appealed to

my creative side, it was an easy drive, so

I decided to make this a belated birthday

present to myself.

Boy, was that a mistake.

There is a certain acquired comfort at

optometric conferences. Let’s face it, we’ve

all been to so many that we know what

to expect when we trudge off to whatever

exotic locale the meeting organizers have

chosen. We see people we know and hear

lectures that interest us by speakers who

are knowledgeable, informed and—if we’re

lucky—entertaining. Lectures that are sci-

ence-based and free of commercial content.

That last statement is included for a rea-

son. The conference I attended had abso-

lutely nothing to do with science and was

essentially a series of infomercials. Every

presentation was tied to some book or blog

the presenter had generated, and every pre-

sentation ended with, “Here’s my website,

here’s my blog page, and I have book(s)

for sale out in the hallway. You need to

buy one!” Which may well be the norm;

as I said, it was my first experience with a

non-optometric conference. At least no one

asked me to walk barefoot over hot coals.

Still, the shameless hucksterism really left

a sour taste.

I recall with some irony a meeting was

taking place in Dallas that very weekend

where the future of optometric continuing

education was being discussed. Now, I do

not claim to be well-connected politi-

cally. I am, though, a willing and

enthusiastic consumer of optomet-

ric continuing education. Some-

times change can be good. But

change for the sake of change

rarely ever is.

I am of the opinion that the cur-

rent regulatory body overseeing optometric

continuing education does an outstanding

job on a limited budget navigating the myr-

iad state requirements for CE while keeping

the courses as free as possible from com-

mercial content and bias. That last part is

particularly important, especially having

seen firsthand what a free-for-all presenta-

tion with no guidelines looks like.

Everything I ever needed to know about

life I learned from my grandmother. Once,

my grandfather brought me a bright shiny

new Trailways toy bus that lit up when you

ran it across the floor. Obsessed with dis-

covering what made it run, that six-year-old

took a screwdriver and a ball-peen hammer

to the toy in a feeble attempt to get to its

inner workings.

When my grandmother asked me what

I was doing, without a ready answer I said

meekly, “I’m fixing it.” She replied with

words of wisdom I have never for-

gotten: “If it ain’t broke, son, don’t

fix it.”

I try to apply that lesson to most

endeavors. Perhaps the optometric

powers-that-be might want to apply

it to optometric continuing education.

Why I’m thankful for optometric conferences

All about

compounding pharmacies...See page 25.

Jeffrey Anshel, OD, FAAOOcular Nutrition SocietyEncinitas, CA

Sherry J. Bass, OD, FAAOSUNY College of OptometryNew York, NY

Justin Bazan, ODPark Slope EyeBrooklyn, NY

Marc R. Bloomenstein, OD, FAAOSchwartz Laser Eye CenterScottsdale, AZ

Crystal Brimer, OD, FAAOCrystal Vision ServicesWilmington, NC

Michael Brown, OD, FAAO U.S. Department of Veterans Affairs Huntsville, AL

Mile Brujic, OD, FAAOPremier Vision Group Bowling Green, OH

Dori Carlson, OD, FAAOHeartland Eye CarePark River, ND

Benjamin P. Casella, OD, FAAOCasella Eye CenterAugusta, GA

Michael A. Chaglasian, OD, FAAOIllinois Eye InstituteChicago, IL

A. Paul Chous, OD, MA, FAAOChous Eye Care AssociatesTacoma, WA

Michael S. Cooper, ODWindham Eye GroupWillimantic, CT

Melanie Denton, OD, FAAOSalisbury Eyecare and EyewearSalisbury, NC

Douglas K. Devries, ODEye Care Associates of NevadaSparks, NV

Steven Ferucci, OD, FAAOSepulveda VA Ambulatory Care Center and Nursing HomeSepulveda, CA

Lisa Frye, ABOC, FNAOEye Care AssociatesBirmingham, AL

Ben Gaddie, OD, FAAOGaddie Eye CentersLouisville, KY

David I. Geffen, OD, FAAOGordon Weiss Schanzlin Vision InstituteSan Diego, CA

Jeffry D. Gerson, OD, FAAOWestGlen EyecareShawnee, KS

Alan Glazier, OD, FAAO Shady Grove Eye and Vision Care Rockville, MD

Milton M. Hom, OD, FAAOAzusa, CA

David L. Kading, OD, FAAOSpecialty Eyecare GroupKirkland, WA

Danica J. Marrelli, OD, FAAOUniversity of Houston College of OptometryHouston, TX

Katherine M. Mastrota, MS, OD, FAAOOmni Eye SurgeryNew York, NY

John J. McSoley, OD, FAAOUniversity of Miami Medical GroupMiami, FL

Ron Melton, OD, FAAOEducators in Primary Eye Care LLCCharlotte, NC

Pamela J. Miller, OD, FAAO, JDHighland, CA

Brittany Mitchell, ODAlabama Vision CenterBirmingham, AL

Patricia A. Modica, OD, FAAOSUNY College of OptometryNew York, NY

Leslie O’Dell, OD, FAAODry Eye Treatment Center Hanover, PA

Laurie L. Pierce, LDO, ABOMHillsborough Community CollegeTampa, FL

Mohammad Rafi eetary, OD, FAAOCharles Retina InstituteMemphis, TN

Michael Rothschild, ODWest Georgia Eye CareCarrollton, GA

John Rumpakis, OD, MBA, FAAOPractice Resource ManagementLake Oswego, OR

John L. Schachet, ODEyecare Consultants Vision SourceEnglewood, CO

Leo P. Semes, OD, FAAOUniversity of Alabama at BirminghamSchool of OptometryBirmingham, AL

Peter Shaw-McMinn, ODSouthern California College of OptometrySun City Vision CenterSun City, CA

Diana L. Shechtman, OD, FAAONova Southeastern UniversityFort Lauderdale, FL

Joseph P. Shovlin, OD, FAAO, DPNAPNortheastern Eye InstituteScranton, PA

Kirk Smick, OD, FAAOClayton Eye CentersMorrow, GA

Joseph Sowka, OD, FAAONova Southeastern University College of OptometryFort Lauderdale, FL

Loretta B. Szczotka-Flynn, OD, MS, FAAOUniversity Hospitals Case Medical CenterCleveland, OH

Marc B. Taub, OD, MS, FAAO, FCOVDSouthern College of OptometryMemphis, TN

J. James Thimons, OD, FAAOOphthalmic Consultants of Fairfi eldFairfi eld, CT

William D. Townsend, OD, FAAOAdvanced Eye CareCanyon, TX

William J. Tullo, OD, FAAOTLC Laser Eye Centers/Princeton Optometric PhysiciansPrinceton, NJ

Walter O. Whitley, OD, MBA, FAAOVirginia Eye ConsultantsNorfolk, VA

Kathy C. Yang-Williams, OD, FAAORoosevelt Vision Source PLLCSeattle, WA

Editorial Advisory BoardErnie Bowling, OD, FAAO Chief Optometric Editor

Editorial Advisory Board members are optometric thought leaders. They contribute ideas, offer suggestions, advise the editorial staff, and act as industry ambassadors for the journal.

By Ernie Bowling, OD, FAAOChief Optometric EditorHe is in private practice in Gadsden, AL, and is the Diplomate Exam Chair of the American Academy of Optometry’s Comprehensive Care Section

erniebowling@icloud.com 256-295-2632

@Digit l6

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OCTOBER 2016 t VOL. 8, NO. 10

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CHECK OUT THE LATEST OPTOMETRY TIMES BLOGSIn 2016, Optometry Times is offering blogs from some of the leaders in the optometric profession. Haven’t read them yet? Here’s what you’re missing.

How to get non-symptomatic dry eye patients to comply with treatment Dr. Scott Schachter offers advice on how to better manage non-symptomatic dry eye patients and encourage them to comply with your treatment plan.

Top 10 qualities of engineer patients Dr. Tracy Schroeder Swartz lives near a space center, so many of her friends and patients are engineers or married to engineers. She outlines characteristics of engineers and what they look like in your exam chair.

3 ways to reasses your goals heading into Q4 Drs. David Kading and Mile Brujic encourage readers to step back to reevaluate goals set at the beginning of 2016.

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OptometryTimes.com/beatblepharitis

MISSION STATEMENT Optometry Times delivers easily digested, practical information by ODs for ODs. This information can be immediately applied to improve the clinical experience of the next patient in your chair as well as your practice performance. In partnering with our readers, Optometry Times provides data, analysis, tools, and resources which are available whenever and wherever our readers want them.

4 steps to beating blepharitis

| PRACTICAL CHAIRSIDE ADVICE In Focus 7

accomplish this, ECPs must use cutting-edge

research and detection tools to find and begin

treating glaucoma early.

“In general, I don’t think eye doctors treat

glaucoma aggressively enough,” Dr. Schmidt

says. “Glaucoma is not an equal opportunity

offender.”

He says that certain individuals are more at

risk than others. Regular monitoring through

OCT, visual fields, and gonioscopy is necessary

for ECPs to stay on top of patient health, partic-

ularly when conflicting data from day to day

clouds potential glaucoma diagnoses.

Risk factorsKnowing when to consider treatment can be a

challenge. Monitoring progression is key in indi-

viduals at risk for glaucoma or who have already

been diagnosed with glaucoma.

“Treat early, treat often, and treat aggres-

sively,” says Dr. Schmidt. “I think there are a lot

of people who are under diagnosed and under

treated—they’re controlled, but their pressure

is too high.”

He recommends the acronym FINDACAR to

understand the breadth of variables that may

put a patient at risk for glaucoma:

– Family history

– Intraocular pressure (IOP)

– Myopia

– Diabetes and cardiovascular disease

– Age

– Corneal thickness

– Asymmetry

– Race

He adds that the more risk factors present,

the more susceptible the optic nerve is to dam-

age and the more likely a glaucoma diagnosis.

IOP and serial tonometryAlthough OCTs and visual fields are used to

“prove” glaucoma, regular IOP checks are the

best way to obtain data on how internal pressure

fluctuates over time. Dr. Schmidt highlights the

importance of testing during each patient evalu-

ation, noting that overall trends are more impor-

tant than individual numbers.

“You need to have lots of pressure readings,”

he says. “The more numbers you get, the more

value your data gives you.”

In his view, serial tonometry is critical for un-

derstanding a patient’s ocular pressure across

each year.

“It’s better to get extended IOP readings on

different days, different months, over the course

of time,” he says. “The more untreated pressure

readings you can acquire, the better your deci-

sion making.”

Keep in mind that any single IOP measure-

ment taken between 7 a.m. and 9 p.m. has a

higher than 75 percent chance to miss the high-

est point of the diurnal curve.

“The greater the variability [in IOP] over that

person’s life, the more likely he is to progress,”

he says.

Thin corneasOne of the most important factors in patients

with high pressures is thin corneas. For every

40 μm thinner a cornea measures, the risk of

developing glaucoma increases by 71 percent.

Corneal history is the leading risk factor for

disease progression because thinner corneas

are more susceptible to pressure stress. Corneal

thickness via pachymetry is an important mea-

sure to determine rate of progression in patients

already diagnosed with glaucoma.

Using OCTs and visual fieldsAccording to Dr. Schmidt, OCT is the best way

to diagnose glaucoma and the quickest way to

detect changes in retinal nerve fiber layers, and

both treatments have their place.

“OCTs are more reliable early in the disease,”

he says, “but once you make the decision to treat,

and the patient has glaucoma, visual fields be-

come very important. Visual fields are subjec-

tive measurements of how well the optic nerve

is working. It’s a performance-related index.”

Most ECPs perform fewer visual fields than

they should, he says. Although visual fields

are still the standard of care, it’s important to

note that if ECPs wait for a glaucoma confirma-

tion from visual field testing alone, it may al-

ready be too late. Visual fields should be used

to determine progression, rather than the ini-

tial diagnosis.

“Multiple pre-treatment readings are needed

to make a decision,” Dr. Schmidt says, “and mul-

tiple post-treatment readings are needed to make

a decision for treatment changes. Also, multiple

visual field tests are needed before you decide

whether there’s progression.”

CompliancePatients must be compliant with the therapies

recommended by their ECPs.

“Compliance is everything,” says Dr.

Schmidt. “You can’t make patients use drops,

but we know compliance gets better with the

fewer drops we use. We know that compliance

improves when you talk to the patient about the

importance of his eye drops.”

He stresses the value of keeping patients in-

formed about their condition, including showing

them how to use the drops themselves. When

patients feel confident in their abilities to man-

age their own treatments, medication compli-

ance will likely increase.

The everyday ODAt the end of the day, regular monitoring of glau-

coma signs and symptoms is still the best way to

improve health outcomes for patients. Glaucoma

may be evolving, but it’s still a slow-moving dis-

ease. With glaucoma, ECPs don’t follow the in-

dividual phenomena, they follow the trends.

ECPs and glaucomaContinued from page 1

S15294 09/16©2016 Shire All Rights Reserved

A Closer Look At Eye Health

Source: “Half the World Could Be Nearsighted by 2050," Scientific American. June 2016

By 2050, almost half of the world

could be nearsighted and require some kind of corrective lens, an increase from a quarter of the global population in 2000.

50%

OCTOBER 2016 | 8 Focus On DRY EYE

The use of these innovative in-

struments and therapeutics,

coupled with advancing medi-

cal research, allows us to forge

ahead attaining a new clinical

understanding of OSD. However,

we must not forget nor forgo our

early evidence-based manage-

ment options for dry eye.

Traditional methods to treat dry eyeBasic to overall health and well-

being, nutritional balance should

be considered as an integral part of every

patient’s eyecare plan. It is fundamental

that our bodies remain fueled with the

appropriate and balanced intake. This

ensures that each bodily microenviron-

ment can access those nutrients neces-

sary for peak performance.

Dietary supplements are available to

support most ocular disease states from

dry eye to diabetes. For dry eye patients,

the addition of GLA-rich omega products

such as HydroEye (Science Based Health)

may enhance quality meibom production

and reduce ocular surface inflammation.

Ocular inflammation and discomfort are

part of the symptom spectrum of our oc-

ular surface disease patients.

We can retreat much further into pain

management when considering options

for our OSD patients. Omni Eye Surgery

in New York and New Jersey expanded

its facilities to include a dry eye specialty

care service. We are exploring acupunc-

ture as a viable resource for our dry eye

patients, especially for those who expe-

rience sensations of discomfort, includ-

ing headache.

Acupuncture and CAM therapiesStudies surrounding acupuncture and

dry eye are by no means con-

clusive; however, the sugges-

tion of symptom relief should

not be dismissed. A 2015 evi-

dence-based meta-analysis con-

cluded that acupuncture therapy

is more effective than artificial

tears for dry eye syndrome.1 Acu-

puncture was noted to increase

tear break-up time and Schirmer

measurements, as well as im-

prove corneal staining scores as

compared to artificial tear use.

Additionally, Fourier-domain

optical coherence tomography (OCT) for

monitoring the lower tear meniscus in dry

eye after acupuncture showed the treat-

ment increased the low tear meniscus

parameters for lipid-deficient and non-

Sjögren’s dry eye patients.2

Of interest, dry eye symptoms appear

to be extremely prevalent in chronic mi-

graine patients. Migraine and dry eye are

both thought to have an inflammatory

pathogenesis, and dry eye may present

in migraine patients with greater pres-

ence of auras and longer disease and at-

tack durations.3 Also, Sjögren’s patients

demonstrate more chronic tension-type

headaches vs. controls.4

It is important to note that from a purely

comparative effectiveness perspective, the

evidence from clinical trials and meta-

analyses makes a compelling case in

support of a potentially important role

for acupuncture as part of a treatment

plan. Patients with migraine, tension-type

headaches, and several different types of

chronic headache disorders may benefit

from such treatment.5

Acupuncture is included in complemen-

tary and alternative medicine (CAM) with

homeopathy, naturopathy, chiropractic,

massage, yoga, and Ayurvedic medicine,

among others.

Patients willing to try CAM therapiesAccording to the National Institutes of

Health’s (NIH) National Center for Comple-

mentary and Integrative Health reports,

more than one third of adults in the U.S.

use CAM therapies. Usage is greater among

women and people with higher levels of

education and higher incomes.6

According to a 2007 government survey,

U.S. consumer spending on CAM thera-

pies is about $33.9 billion annually.7 It is

clear that our patients embrace CAM in

health and disease management.

I look forward to the outcomes of acu-

puncture for our select dry eye patients.

I am eager to learn if this practice, in

conjunction with current therapy, affects

positive change in our dry eye patients.

REFERENCES1. Yang L, Yang Z, Yu H, Song H. Acupuncture therapy is more effective than artificial tears for dry eye syndrome: evidence based on a meta-analysis. Evid Based Complement Alternat Med.

2015;2015:143858.

2. Lin T, Gong L, Liu X, Ma X. Fourier-domain optical coherence tomography for monitoring the lower tear meniscus in dry eye after acupuncture treatment. Evid Based Complement Alternat Med.

2015;2015:492150.

3. Celikbilek A, Adam M. The relationship between dry eye and migraine. Acta Neurol Belg. 2015 Sep;115(3):329-33.

4. Tjensvoll AB1, Harboe E, Gøransson LG, Beyer MK, Greve OJ, Kvaløy JT, Omdal R. Headache in primary Sjøgren’s syndrome: a population-based retrospective cohort study. Eur J Neurol. 2013 Mar;20(3):558-63. doi: 10.1111/ene.12033. Epub 2012 Nov 28. Accessed 9/12/16.

5. Coeytaux RR, Befus D. Role of Acupuncture in the Treatment or Prevention of Migraine, Tension-Type Headache, or Chronic Headache Disorders. Headache. 2016 Jul;56(7):1238-40. doi: 10.1111/head.12857. Epub 2016 Jul 13. Accessed 9/12/16.

6. National Center for Complementary and Integrative Health. The Use of Complementary and Alternative Medicine in the United States. Available at: https://nccih.nih.gov/research/statistics/2007/camsurvey_fs1.htm#use. Accessed 9/12/16.

7. National Center for Complementary and Integrative Health. Americans Spent $33.9 Billion Out-of-Pocket on Complementary and Alternative Medicine. 2009 Jul 30. Available at: https://nccih.nih.gov/news/2009/073009.htm. Accessed 9/12/16.

Complementary and alternative medicine help dry eye patientsConsider therapies such as acupuncture to augment your clinical toolsWith the exponential increase of interest in dry eye or

ocular surface disease (OSD) among physicians and the

industry, we are fortunate to have access to exciting new

diagnostic and imaging technology as well as new treat-

ment options and therapeutics for some of our most frus-

trated patients.

BY KATHERINE M. MASTROTA, MS, OD, FAAO Clinical director of Omni Center for Dry Eye Specialty Care in New York City

We Will Pay You From $6,000 To $10,000 A Month, Every Month, Starting Now, For The Legal, HIPPA-Compliant, Ethical Use Of Your Patient Lists - And Together, We’ll Actually Be Saving The Lives Of

Some People, Improving The Lives Of Many MoreYOUR IMMEDIATE "RSVP", EXPRESSION OF INTEREST IS NEEDED.

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OCTOBER 2016 | 10 Focus On RETINA

The patient was neurologically

intact, had intraocular pressures

(IOP) in the statistically normal

range, anterior segments were un-

remarkable for her age, and she

had age-appropriate lens changes.

Except for the refractive correc-

tion (low-degree hyperopic astig-

matism, presbyopia) and fundus

findings, the remaining ocular

history and findings were non-

contributory. At baseline, the

drusen presentation was mini-

mal, and the patient was asked

to self-monitor for vision changes and re-

turn in one year (Figure 1).

Follow-up and treatmentOne year later, at the follow-up examina-

tion, the right eye showed some

minimal advancement of drusen

in the macula. However, he left

eye had developed wet age-related

macular degeneration (AMD), and

VA had deteriorated to 20/200

(Figure 2). The patient claimed to

be unaware of the visual deficit. 

The patient was sent for con-

sultation with a retina specialist

who administered an anti-VEGF

agent in each eye based on a fluo-

rescein angiography (FA) study. 

As expected, the clinical pic-

ture in the left eye was not altered, nor

was VA. Strikingly, at our follow-up visit

which took place two years from the base-

line fundus photograph of the right eye,

the drusen landscape showed significant

improvement (Figure 3). 

Over the next four years, the clinical

picture in the right eye had deteriorated to

the point of requiring repeated anti-VEGF

injections. The VA in the left eye has re-

mained stable (20/200), but the VA of the

right eye had slowly declined to 20/60

despite repeated anti-VEGF treatments.

Lasers assist in treatmentDrusen disappearance had been docu-

mented in an earlier clinical trial of laser

treatment.1 This classic investigation from

nearly two decades ago found that ap-

proximately half of eyes treated showed

abatement of clinical findings. In terms

of specification (physical appearance in

this case), the trial was successful.

Unfortunately, there was no demonstra-

ble improvement in visual performance

(acuity). More recently, drusen regression

as measured by fundus autofluorescence

(FAF) has been reported. Drusen regression

was documented over a two-year period

without any intervention.2 The authors

speculated that the phenomenon may be

associated with physiological changes in

the outer retina but offered no explanation. 

A consolidated review of clinical tri-

als concerning laser treatment for dru-

sen was unable to demonstrate efficacy to

prevent conversion to neovascular AMD,

progression to geographic atrophy, or vi-

sual acuity loss.3 Trials are ongoing to

evaluate the efficacy of anti-VEGF treat-

ment for drusen.

REFERENCES1. Figueroa MS, Regueras A, Bertrand J, Aparicio MJ, Manrique MG. Laser photocoagulation for macular soft drusen. Updated results. Retina. 1997;17(5):378-84.

2. Toy BC, Krishnadev N, Indaram M, Cunningham D, Cukras CA, Chew EY, Wong WT. Drusen regression is associated with local changes in fundus autofluorescence in intermediate age-related macular degeneration. Am J Ophthalmol.

2013 Sep;156(3):532-42.e1.

3. Virgili G, Michelessi M, Parodi MB, Bacherini D, Evans JR. Laser treatment of drusen to prevent progression to advanced age-related macular degeneration.  Cochrane Database Syst Rev. 2015 Oct 23;(10):CD006537. 

The case of the disappearing drusenAnti-VEGF therapy leads to significant improvement in drusenAt her periodic eye examination, a female patient in her

early 70s was discovered to have low-risk macular degen-

eration in each eye. Further evaluation revealed that her

visual acuity (VA) was correctable to 20/25 in each eye.

Her medical history was remarkable for systemic hyper-

tension treatment she received for at least 10 years. 

BY LEO SEMES, OD, FAAO Professor of optometry at the University of Alabama-Birmingham

Dr. Semes is a founding member of the Optometric Glaucoma Society and a founding fellow of the Optometric Retina Society.

Drusen regression may be associated with physiological changes in the outer retina

Figure 1. Baseline fundus appearance of the patient’s left eye. Note the minimal presence of drusen throughout the macula.

Figure 2. Fundus appearance of the patient’s left eye, which has developed the fibrovascular scarring of wet AMD.

Figure 3. Fundus photograph of the right eye two years from baseline showing disappearance of drusen. Visual acuity=20/40.

1

2

3

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OCTOBER 2016 | 12 Focus On PRACTICE MANAGEMENT

I might spend all of my time

getting my accounts receivables

to go down or diligently work

on our processes and scripts to

get my anti-reflective lens sales

to go up.

This narrowly-focused ob-

session almost always brings

good results. Yet this success

typically comes at the expense

of some other neglected area of

the office. Inevitably, when we

completely dive into filling our sched-

ules, we fail to work on efficiencies in

the office and our newly-filled schedule

overwhelms us. When all hands are on

deck for improvement of our meaningful

use documentation, we drop the ball on

following up on insurance claims that

aren’t paid properly.

True success comes from consistently

giving attention to every part of the prac-

tice, not focusing all of your attention on

one area at a time. This requires that you:

– Identify the zones of your practice

– Create a system to consistently eval-

uate and measure each zone

– Make small, daily improvements to

each zone

While every practice is unique, most

eye care practices can fit into these five

zones.

PATIENT CAREOften called “clinic,” most of

this zone’s work is done in the

exam room with the doctor’s in-

volvement. But it also involves any com-

munication involving the patient’s care.

As we become more included

into the healthcare system, our

input to and from other profes-

sionals becomes more critical

to the overall well-being of our

patients. As managed care dic-

tates what we say, who we say it

to, and when we say it, check-

ing it off the list is important.

But we must not let the qual-

ity of the communication slip.

Templates need to make sense

and be helpful to all providers.

FRONT OF HOUSEThis zone is the “public” area of

your practice, typically the front

desk. This is the space that does

not require special permission to enter.

Most places of business have a front of

house, and the rules are fairly univer-

sal. In our practices, the front of house

includes the check-in area, the optical

dispensary, and the check-out area. It

is normal to find these areas compet-

ing for attention in this conflicted zone.

SCHEDULINGThis zone pertains to everything

that controls the flow of patients

into your practice. It includes—

but is not limited to—appointment strate-

gies, recall, reminders, communications

with patients, and all marketing.

DISTRIBUTIONThe term “lab” is outdated in

most eyecare practices. An op-

tical lab reminds me of where

you would have had glasses and

contact lenses made like my grandfather

did. Some practices still do lab work, but

many of us buy inventory, sort it, and

sell it. This all falls under distribution.

FINANCIAL FOUNDATIONThis zone continues to get more

and more complicated, and many

of the parties that we deal with want it

to be complicated. For the overall health

of our practices, we must stay in good

financial health. We have to keep a keen

eye on income and expenses and act

quickly when something gets out of line.

Working the zonesThese specific zones may not work for

every practice, but something like them

might. All that matters is that you iden-

tify four to six zones within your prac-

tice and group every activity that you

do into one of those zones.

After each zone is identified, implement

a process so that you will give some at-

tention to each zone on a regular basis.

Just saying you are going to do it will not

work over the long haul—a system must

be put into place. The system doesn’t

have to be elaborate or perfect; it just

has to be a system.

Here’s how it works in our office.

We close the office every Monday at

1:00 p.m. for a one-hour staff meeting.

We have been doing this for almost 20

years, and it is at the core of how our

office is run. Getting together, face-to-

face, once per week to discuss the prac-

tice has been invaluable.

At each meeting, we hear the five zone

reports that give pre-determined mea-

5 zones of your practice that need TLCPut a system in place to manage your practice and maximize its potentialIn my practice, I can obsess over only one management

area at a time. I may decide that I want the best optical

or the highest percentage of annual supply of contact lens

sales. I may put all my energy into giving the best exams

in the most efficient manner.

Implement a process so that you will give some attention to each zone on a regular basis

BY MICHAEL ROTHSCHILD, OD Director of What’s Next-Leadership OD

ZON E

2

ZON E

4

ZON E

5

ZON E

1

ZON E

3

1 Patient care2 Front of house3 Scheduling4 Distribution5 Financial foundation

ZONES IN MY PRACTICE

| PRACTICAL CHAIRSIDE ADVICE 13PRACTICE MANAGEMENT Focus On

surements with a trend up or down. For

instance, on the first Monday of every

month, the Scheduling report includes

a section on recall success rates, and we

hear about marketing plans on the sec-

ond Monday of each month. The Distri-

bution reports share promise date per-

centages in Week One and returns per-

centages in Week Two. In Week One, the

Clinic report shares the results from our

EHR record audit (Revolution RevAssure)

and our plans to improve our billing and

coding , and Week Two includes current

standing with meaningful use.

About every three months, we will have

a fifth Monday in the calendar. Those

extra Mondays are reserved for topics

that don’t need to be looked at monthly

but can’t be forgotten or ignored. For

Scheduling, every fifth Monday we talk

about why our goal is to be booked at

80 percent rather than 100 percent. The

fifth Monday Front of House report is a

reminder about the value in our luxury

lines of eyewear and why it is important

that all patients see our best products.

Rounding out our fifth Monday reports

are Financial (cost of goods overview),

Distribution (activity on our online store),

and Clinic (overall net promoter score).

Small change adds upIn a culture where improvement is nor-

mal, there must also be an acceptance

of less than perfect. If you are already

perfect, then what is there to improve?

An objective view of real data as a rule

along with trending information is valu-

able when those reporting feel safe to

share the truth.

By facing the facts as a group together

on a routine basis, everyone sees their

contributions to the team and under-

stands that we all have room to improve.

It also gives the leaders a chance to ask,

“So, what are we going to work on this

week to get better?” Before you know it,

it is just what you do.

Dr. Rothschild is also a consultant for Alcon, Optos, and Vision Source; a member of the speakers’ bureau for VSP; and a clinical researcher for CIBA Vision.

True success comes from consistently giving attention to every part of the practice, not all of your attention to one area at a time

MORE ARTICLES ABOUTHEAD_MORE ARTICLES

Understanding millennial patients and staff OptometryTimes.com/millennialpatients

3 steps to staff empowermentOptometryTimes.com/staffempowerment

OCTOBER 2016 | 14 Focus On TECHNOLOGY

The value of optical servicesAfter years of devaluing the crucial and vital

services of eyewear selection, veri-

fication, and adjustments, it’s no

wonder that we are often faced

with scenarios in which our pa-

tients feel very comfortable com-

ing in with Internet-purchased

eyewear and expecting our op-

ticians’ services for free. When

we initially encountered this sce-

nario, the legacy policies of good-

will were applied. However, over

time, many offices, including my

own felt the need to develop policies that

were fair to us as well as the patient.

It is time to bring the perceived value of

our opticians to the forefront and highlight

the benefits of buying from our offices in-

stead of online. Our practices simply can-

not be successful if services are being given

away. We all know that often when some-

thing is given away, it is not valued the same

as if it were purchased.

Online purchasers need our helpIf you haven’t had a patient ask you to ad-

just frames bought online, request his PD

in order to buy on the Internet, or complain

that glasses from your Rx purchased online

don’t work, you will soon.

The 2015 Vision Council Internet Influ-

ence Report found that 30.7 percent of re-

cent eyewear buyers with easy access to the

Internet indicated that they may possibly

or probably will use the Internet to directly

purchase eyewear in the future.1 With more

people buying online, we will see more of

them in our offices needing assistance. In-

ternet-purchased eyewear unfortunately

seems to be plagued with errors, and our

patients will need us.

In fact, the American Optometric Associa-

tion (AOA) bought 200 pairs of glasses from

the 10 most popular online eyewear vendors

and tested them. The results are shocking.

They found nearly half of the eyeglasses

(44.8 percent) had incorrect prescriptions

or safety concerns.1

Bewildering to me is the fact that patients

will proudly present their online glasses to

me and often with a statement such as, “Can

you adjust them for me, please?” or “Some-

thing seems off; would you check them

for me, please.” In our office, we do often

note the politeness of the

request, but we also note

their sense of entitlement

because patients never

seem to inquire about the

charge for such a service.

Like several other cur-

rent concerns in optom-

etry related to the Internet (on-

line exams, anyone?), we are par-

tially at fault. If we fail to adapt

and change, these situations will

only get worse.

So, what solutions have been found?

Create eyewear service plansAs optical industry experts, we know that

there is often a huge difference in both the

service and products between brick-and-

mortar and online vendors. Unfortunately,

our patients do not. We are often provided

with multiple opportunities to educate them.

We need to find out if our pa-

tients plan on purchasing eye-

wear. If so, we need to find out

where. If it is online, we need

to thoroughly educate them

on the benefits of purchasing

from their eyecare practitioner

vs. online. Some patients don’t

want to hear it, and while that is frustrating,

we can’t give up. Let them know that you

want them to bring in their online eyewear

so you can ensure they received glasses that

were made correctly, along with whatever

additional benefits such as adjustments and

maintenance you want to provide in your

“online glasses care package.”

Developing such an eyewear service plan

(ESP) has tremendous short-term and long-

term value to your practice and your pa-

tient—and some would also argue to our

profession. Most important, these plans help

patients see the value and worth in your op-

tician. Patients realize there are just some

things that can’t be done online, such as

glasses adjustments, and they need the ser-

vices of an expert.

For example, Warby Parker knows this,

which is why it will reimburse its custom-

ers up to $50 for a pupillary distance mea-

surement (PD). If after asking, you find out

your patient is dead set on spectacles from

Warby Parker, then this is the perfect op-

portunity to inform your patient about your

ESP. While the circumstances not ideal, it is

an easy discussion to have that helps to so-

lidify your value to your patient.

If the request for a prescription comes in,

you also have an opportunity. In our prac-

tice, emailing the patient our ESP in this

situation works well. We are often thanked

and see the patient come in with their new

glasses. Ideally, because we include informa-

tion about our “$99 special” and benefits of

working with us, we do find that some pa-

tients will decide to come in and forget about

ordering online. The point is that we have

to be proactive.

The mindset of many consumers today

is that they can get practically anything on-

line. That may be true, but we need to edu-

cate our patients about certain truths. Inter-

net-purchased eyewear is here to stay, so it’s

important to develop strategies about how

best to address the challenges that surround

them. Ensure that your patients have all of

the facts about purchasing eyewear online

and know the value that you can provide.

If they do, you can expect your relationship

with them to strengthen instead of dissi-

pate.

REFERENCES1. The Vision Council. VisionWatch Internet Influence Report. 2015 Nov;7. Available at: https://www.thevisioncouncil.org/sites/default/files/research/2015-Internet-Influence-Report-FINAL.PDF. Accessed 9/6/16.

2. American Optometric Association. A Closer Look at Ordering Eyeglasses Online. Available at: https://www.aoa.org/documents/public/A_Closer_Look_at_Ordering_Eyeglasses_Online.pdf. Accessed 9/6/16.

Glasses purchased onlineContinued from page 1

BY JUSTIN BAZAN, OD Owner of Park Slope Eye in Brooklyn

Dr. Bazan is a 2004 SUNY grad. Reach him on his Facebook page.

Our practices simply cannot be successful if services are being given away

of 200 pairs of eyeglasses purchased online had incorrect prescriptions or safety concerns

44.8 %

of recent eyewear buyers with easy access to the Internet indicated that they may possibly or probably will use the Internet to directly purchase eyewear in the future

30.7 %

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OCTOBER 2016 | 16 Dry Eye

By Scott G. Hauswirth, OD, FAAO

Sjögren syndrome is a chronic inflam-

matory disorder that affects 0.1 percent

to 0.6 percent of the popula-

tion and is estimated to affect

as many as four million people in

the United States. This is roughly

equivalent to the same number of

patients with rheumatoid arthritis.

However, only just over one million

individuals have been diagnosed

with Sjögren syndrome.1

This gap alludes to the difficulty

in identifying the disease because it

has an incipient course and initially

presents with non-specific symp-

toms. Many of the symptoms pres-

ent early in the disease may be con-

fused with other matters common to such

items as menopause, medication side effects,

and non-specific aging changes. As a result,

the time between initiation of symptoms as-

sociated with the disease and a confirma-

tory diagnosis is often 3.5 years or longer.1

Sjögren syndrome may also present as a

primary disease, meaning it occurs alone,

or as a secondary disorder, occurring along

with other chronic inflammatory disorders—

most commonly rheumatoid arthritis (RA),

systemic lupus erythematosus (SLE), sclero-

derma, or polymyositis.2 The disease is found

in both sexes, affects females roughly nine

times more than males, and occurs in virtu-

ally any age range. The “typical” patient is

female, Caucasian, and of middle to older age.3

Sjögren pathophysiologyThe key factor of the disease is exocrine gland

dysfunction in which the body’s immune sys-

tem begins to attack several key secretory

glands, including the lacrimal and salivary

glands. As such, two of the primary clinical

features are keratoconjunctivitis sicca and xe-

rostomia, hallmark of the clinical diagnosis.

However, this is only the tip of the iceberg.

The disease often also affects other organ

systems, including the nervous system, skin,

lungs, and kidneys. In primary Sjögren syn-

drome, up to 75 percent of patients mani-

fest with extraglandular disease.4 As such,

the list of other symptoms associated with

Sjögren syndrome involves dental decay, de-

bilitating fatigue, dry skin, periph-

eral neuropathy, arthropathy, and

gastrointestinal problems.

The cumulative risk of a Sjögren

patient to develop non-Hodgkin’s B-

cell lymphoma within 15 years of

her diagnosis is 9.8 percent—sig-

nificantly higher than that of the

general population.5 In addition, 20

to 30 percent of patients with pri-

mary Sjögren syndrome have clini-

cal pulmonary involvement, which

is associated with lower quality of

life and increased 10-year mortality.6

PathogenesisSjögren syndrome is a complex and poorly

understood mechanism, which appears to

be directed by both genetic and epigenetic

controls7,8 and involves several different key

aspects of the immune system. Animal mod-

els suggest that the disorder begins in the

lacrimal and submandibular salivary glands,

then progresses to include involvement of

other secretory glands.

Sjögren is characterized by B-

cell hyperactivity, manifested by

hypergammaglobulinemia and

the presence of multiple serum

autoantibodies,9 the production

of which is mediated via an antigen-driven

process. It has been observed that the epi-

thelial cells within labial salivary glands of

Sjögren patients bear the characteristics of

antigen-presenting cells. This may lead to a

breakdown in the negative feedback regula-

tion of inflammation, with increased expres-

sion and production of autoantigens,9 with

autoimmunogenic activity being propagated

in lymphoid germinal centers.10

Studies examining genetics have identified

several targets, including those involved in

B-cell activation and activated B-cell Nf-kB

signaling, which emphasize the role of B

cells in the process of disease development.

In addition, T follicular helper cells (TFH),

which mediate the selection and survival

of B-cells and differentiation into plasma

cells and memory B cells, may have a sig-

nificant role—TFH cells have been discov-

ered in the structural components of labial

salivary gland tissue.11

Diagnosing SjögrenThe diagnosis of Sjögren syndrome has under-

gone attempts at simplification over time. The

American-European Consensus Classification

Criteria guidelines were published in 2002.12

They incorporate different aspects of clinical

presentation, serology, and histopathology.

Clinical diagnostic guidelines consist of:

– At least one ocular symptom of the

following:

t�Dry eyes >3 mo

t�Foreign body sensation

t�Use of artificial tears >TID

– At least one oral symptom of the following:

t�Dry mouth >3 mo

t�Recurrent or persistently swollen sali-

vary glands

t�Need liquids to swallow dry foods

– At least one ocular sign of the following:

t�Shirmer’s I test (without anesthesia) <=

5 mm/5 min

t�Positive vital dye stain (van Bijsterveld

>=4)

– Histopathology of lip biopsy showing

focal lymphocytic sialodenitis

t�(focus score >=1 per 4 mm2)

– At least one oral sign of the following:

t�Unstimulated whole salivary flow (+

1.5 mL in 15 minutes)

t�Abnormal parotid sialography

t�Abnormal salivary scintigraphy

– Positive autoantibodies for Anti-SSA (Ro)

or Anti-SSB (La)

The American College of Rheumatology

proposed the following classification criteria

TAKE-HOME MESSAGE Sjögren’s syndrome is underdiagnosed and seriously impacts the ocular surface and quality of life and places the patient at risk for multisystem involvement. Optometry’s role in identification, diagnosis and collaborative long-term manage-ment is an important one. Earlier attention to symptoms leading to diagnosis and collabora-tion with other health professionals will ensure better quality of life for our patients

Diagnosing and treating Sjögren syndromeManaging these patients requires a collaborative effort among subspecialists

BY SCOTT G. HAUSWIRTH, OD, FAAO, leads the optometric student externship program at Minnesota Eye Consultants

See Diagnosing Sjögren on page 18

The number of years between initiation of symptoms associated with the disease and a confirmatory diagnosis3.5

Optometrists and cheer coaches would seem to have little in common, but both groups want to give their patients/athletes the tools to perform to the best of their abilities, and both understand how much happier patients/athletes are when they feel confident in their appearance. Because I have spent nearly 10 years coaching impressionable athletes, I take special pride in applying this unique perspective to my optometric practice. Prescribing contact lenses is an important part of the vision care I provide.

DAILIES® AquaComfort Plus® contact lenses are often my first choice to help patients see, look, and feel their best, particularly for younger patients and those considering contact lenses for the first time. For patients new to contact lens wear, Alcon provides a DAILIES® AquaComfort Plus® New Wearer Kit to help them make the transition to daily disposable lenses. This kit includes, among other things, contact lens application and removal instructions, a mirror, and a lens carrying case (Figure 1). Applying and

removing contact lenses can seem daunting to those unaccustomed to it, and this kit goes a long way toward making patients feel confident and comfortable with the process. The kits also include information on an annual supply rebate, which is helpful for demonstrating the value of these lenses to my patients and building long-term loyalty to my practice.

DAILIES® AquaComfort Plus® contact lenses feature a unique design that provides a form of “built-in” compliance. When patients wear DAILIES® AquaComfort Plus® contact lenses, every blink throughout the day provides a sustained release of a moisturizing agent (polyvinyl alcohol) for all-day comfort.1 In addition, this lens provides built-in compliance to remind patients not to wear them a second day.

In fact, a 2009 survey has shown that 93% of patients who wore DAILIES® brand contact lenses were compliant with the wearing schedule.2 This is par ticularly im-portant for my younger patients and new wearers who may struggle a

bit with compliance issues. Studies have shown that patients are most compliant with a daily disposable wearing schedule,3-5 so I’m pleased to be able to offer this modality to my patients,

with the additional benefits of blink-activated moisture and built-in compliance.

In my experience, DAILIES® AquaComfort Plus® contact lenses are a great option for patients with an active lifestyle, especially my younger patients and new lens wearers who want to avoid the hassle of spectacles for sports and exercising, and also want to improve their appearance for social activities. Both the optometrist and coach in me (Figure 2) are happy to see how DAILIES® AquaComfort Plus® lenses are helping my patients see, look, and feel their best every day!

See product instructions for complete wear, care, and safety information.

References 1. Wolffsohn JS, Hunt OA, Chowdhury A. Objective clinical performance of ‘comfort-enhanced’ daily disposable soft contact lenses. Cont Lens Anterior Eye. 2010;33:88-92. 2. Alcon data on file, 2009. 3. Dumbleton K, Woods C, Jones L, et al. Patient and practitioner compliance with silicone hydrogel and daily disposable lens replacement in the United States. Eye Contact Lens. 2009;35:164-171. 4. Dumbleton K, Richter D, Bergenske P, Jones LW. Compliance with lens replacement and the interval between eye examinations. Optom Vis Sci. 2013;90:351-358. 5. Guthrie S, Dumbleton K, Jones L. Financial implications of patient compliance. Contact Lens Spectrum. December 2014. 6. Marx S, Müller C, Sickenberger W. Subjective pre-lens tear film stability of daily disposable contact lenses using ring mire projection. Cont Lens Anterior Eye. 2015;38:e1-e12. 7. Belda-Salmerón L, Ferrer-Blasco T, Albarrán-Diego C, et al. Diurnal variations in visual performance for disposable contact lenses. Optom Vis Sci. 2013;90:682-690. 8. Montés-Micó R, Belda-Salmerón L, Ferrer-Blasco T, et al. On-eye optical quality of daily disposable contact lenses for different wearing times. Ophthalmic Physiol Opt. 2013;33:581-591.

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OCTOBER 2016 | Dry Eye18

10 years later in 2012,13 which will be met if

patients have at least two of the following

three objective features:

– Positive serum anti-SS-A/Ro and/or anti-

SS-B/La or (positive rheumatoid factor and

ANA>=1:320)

– Labial salivary gland biopsy exhibiting

focal lymphocytic sialadenitis with a focus

score >1 focus/4 mm2

– Keratoconjunctivitis sicca with ocular

staining score >=3 (assuming the patient

is not currently using daily eye drops for

glaucoma and has not had corneal surgery

or cosmetic eyelid surgery in the previous

five years)

Serological studies may detect the pres-

ence of autoantibodies SS-A and SS-B, and

are commonly tested along with complete

blood count with differential, ANA, rheu-

matoid (Rh) factor, ESR, and CRP.

Biomarkers present in early stages of Sjögren

syndrome may allow for earlier detection of

the disease. The presence of anti-salivary

protein-1 (SP1), anti-carbonic anhydrase 6

(CA6), and parotid secretory protein (PSP)

have been linked to an earlier stage of disease

than the presence of SSA and SSB.14 These

biomarkers are utilized as part of the testing

in the Sjö test (Bausch + Lomb) in which

a simple finger prick test can be performed

within a few minutes in a clinical setting.

Biopsy of the salivary glands has been con-

sidered the gold standard for confirming the

diagnosis of Sjögren syndrome;15 however,

salivary gland imaging via ultrasonography

may also be useful in earlier stage detection

and improving the diagnostic performance

of the American classification criteria.16 Stud-

ies of human saliva show elevations in the

levels of TH1, TH2, and TH17 cytokines,17 in

addition to significantly altered protein sig-

natures in Sjögren patients.18 This approach

may eventually shift diagnosis to include

saliva analysis vs. serology or the more in-

vasive biopsy methods.

Managing Sjögren patientsPatients with Sjögren syndrome require a

collaborative effort by several subspecial-

ists to appropriately manage the different

aspects of the disease. Rheumatology, op-

tometry, ophthalmology, and dentistry are

important contributors to disease manage-

ment.19 Because there is no cure for Sjögren

syndrome, primary goals for these providers

are to reduce symptoms of exocrinopathy and

to minimize damage to the organ systems

supported by the secretory glands as well

as those affected by extraglandular disease.

Rheumatologists employ several different

systemic medications with varying effects,

guided by the organ system involved as well

as the severity of disease. Hydroxychloro-

quine and methotrexate are two of the more

common medications utilized for pain man-

agement, along with prednisone.19 Manage-

ment of fatigue and other aspects of organ

system involvement are also addressed by

rheumatology.

Ophthalmic care involves aggressive man-

agement of dry eye, a hallmark symptom due

to the primary involvement of the lacrimal

gland. A workup involving examination and

quantification of symptoms with a standard-

ized dry eye symptoms questionnaire such

as the Ocular Surface Disease Index (OSDI)20

may be combined with objective findings

and measurement of the components of the

tears and ocular surface.

Standard diagnostic techniques involve

quantification of tear production as a means of

assessing lacrimal gland function via Schirm-

er’s tests, as well as monitoring integrity of

the cornea and conjunctival epithelium via

vital dye staining.

Treatment varies depending on severity,

but consists of artificial tears and more vis-

cous lubricants.

As an autoimmune disorder, the impact

of inflammation and its elevated role in pro-

gressive ocular surface disease stresses the

importance of anti-inflammatory agents such

as cyclosporine-A and topical steroids in long

term management strategies. Also, with ad-

vancing disease, nutritional support such as

autologous serum to maintain ocular surface

health becomes increasingly likely. Punctual

occlusion or cautery may also be performed

as secretory capacity diminishes.

Oral care significantly helps Sjögren syn-

drome patients. They patients have increased

dental caries, tooth extractions, and den-

tal costs.21 The use of secretogogues such

as pilocarpine and cevimeline and salivary

stimulation via gum-chewing and lozenges

are often employed by dental care provid-

ers in an attempt to improve salivary func-

tion, and potentially reduce the chances of

tooth decay.

Diagnosing SjögrenContinued from page 16

Figure 1. Sjogren’s patient with punctate epithelial keratopathy.

1

Figure 2. Sjogren’s patient with punctate epithelial keratopathy.

2

| PRACTICAL CHAIRSIDE ADVICE Dry Eye 19

ConclusionSjögren syndrome is a disorder that is underdiagnosed and seriously im-

pacts the ocular surface and quality of life and places the patient at risk

for multisystem involvement. Given the role of optometry as primary

eyecare providers for the community, our role in identification, diagno-

sis and collaborative long-term management is an important one. Earlier

attention to symptoms leading to diagnosis and collaboration with other

health professionals will ensure better quality of life for our patients.

REFERENCES1. Sjögren’s Syndrome Foundation. Available at: www.sjogrens.org. Accessed 07/09/16.

2. Beckman KA, Luchs J, Milner MS. Making the diagnosis of Sjogren’s syndrome in patients with dry eye. Clin Ophthalmol. 2015 Dec 24;10:43-53.

3. Patel R, Shahane A. The epidemiology of Sjögren’s syndrome. Clin Epidemiol. 2014 Jul 30;6:247-55

4. Baldini C, Pepe P, Quartuccio L, et al. Primary Sjogren’s syndrome as a multi-organ disease: impact of the serological profile on the clinical presentation of the disease in a large cohort of Italian patients. Rheumatology (Oxford). 2014 May;53(5):839-44.

5. Solans-Laque R, Lopez-Hernandez A, Bosch-Gil JA, Palacios A, Campillo M, Vilardell-Tarres M. Risk, predictors, and clinical characteristics of lymphoma development in primary Sjogren’s syndrome. Semin Arthritis Rheum. 2011 Dec;41(3):415-23.

6. Palm O, Garen T, Berge Enger T, et al. Clinical pulmonary involvement in primary Sjogren’s syndrome: prevalence, quality of life and mortality – a retrospective study based on registry data. Rheumatology (Oxford). 2013 Jan;52(1):173-9.

7. Lessard CJ, Li H, Adrianto I, et al. Variants at multiple loci implicated in both innate and adaptive immune responses are associated with Sjogren’s syndrome. Nat Genet. 2013 Nov;45(11):1284-92.

8. Li Y, Zhang K, Chen H, et al. A genome-wide association study in Han Chinese identifies a susceptibility locus for primary Sjogren’s syndrome at 7q11.23. Nat Genet. 2013 Nov;45(11):1361-5.

9. Routsias JG, Tzioufas AG. Autoimmune response and target autoantigens in Sjogren’s syndrome. Eur J Clin Invest. 2010 Nov;40(11):1026-36.

10. Salomonsson S, Jonsson MV, Skarstein K, Brokstad KA, Hjelmstrom P, Wahren-Herlenius M, Jonsson R. Cellular basis of ectopic germinal center formation and autoantibody production in the target organ of patients with Sjogren’s syndrome. Arthritis

Rheum. 2003 Nov;48(11):3187-201.

11. Szabo K, Papp G, Dezso B, Zeher M. The histopathology of labial salivary glands in primary Sjogren’s syndrome: focusing on helper T cells in the inflammatory infiltrates. Mediators Inflamm. 2014;2014:631787.

12. Vitali C, Bombardieri S, Jonsson R, et al; European Study Group on Classification Criteria for Sjögren’s Syndrome. Classification criteria for Sjogren’s syndrome: a revised version of the European criteria proposed by the American-European consensus group. Ann Rheum Dis. 2002 Jun;61(6):554-8.

13. Shiboski SC, Shiboski CH, Criswell L, et al; Sjögren’s International Collaborative Clinical Alliance (SICCA) Research Groups. American College of Rheumatology classification criteria for Sjogren’s syndrome: a data-driven, expert consensus approach in the Sjogren’s International Collaborative clinical alliance cohort. Arthritis Care Res (Hoboken). 2012 Apr;64(4):475-87.

14. Suresh L, Malyavantham K, Shen L, Ambrus JL., Jr. Investigation of novel autoantibodies in Sjogren’s syndrome utilizing Sera from the Sjogren’s international collaborative clinical alliance cohort. BMC Ophthalmol. 2015 Apr 10;15:38.

15. Kassan SS, Moutsopolous HM. Clinical manifestations and early diagnosis of Sjögren syndrome. Arch Intern Med. 2004 Jun 28;164(12):1275-84.

16. Cornec D, Jousse-Joulin S, Marhadour T, et al. Salivary gland ultrasonography improves the diagnostic performance of the 2012 American College of Rheumatology classification criteria for Sjögren’s syndrome. Rheumatology (Oxford). 2014 Sep;53(9):1604-7.

17. Ohyama K, Moriyama M, Hayashida JN, Tanaka A, Maehara T, Ieda S, Furukawa S, Ohta M, Imabayashi Y, Nakamura S. Saliva as a potential tool for diagnosis of dry mouth including Sjögren’s syndrome. Oral Dis. 2015 Mar;21(2):224-31.

18. Katsiougiannis S, Wong DT. The proteomics of saliva in Sjögren’s syndrome. Rheum Dis

Clin North Am. 2016 Aug;42(3):449-56

19. Vivino FB, Carsons SE, Foulks G, Daniels TE, Parke A, Brennan MT, Forstot SL, Scofield RH, Hammitt KM. New treatment guidelines for Sjögren’s disease. Rheum Dis Clin North

Am. 2016 Aug;42(3):531-51.

20. Walt JG, Rowe MM, Stern KL. Evaluating the functional impact of dry eye: the Ocular Surface Disease Index [abstract]. Drug Inf J. 1997;31:1436.

21. Christensen LB, Petersen PE, Thorn JJ, Schiødt M. Dental caries and dental health behaviors of patients with primary Sjögren syndrome. Acta Odontol Scand. 2001 Jun;59(3):116-20.

Dr. Hauswirth is a subinvestigator for numerous refractive, glaucoma, and dry eye studies. He is adjunct faculty at the Southern California College of Optometry as well as the Illinois College of Optometry. sghauswirth@mneye.com

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lates.10,11 Newer generation fluoroquinolones,

such as moxifloxacin (Vigamox, Alcon) and

gatifloxacin (Zymar, Allergan) are

generally preferred for this reason.

Another topical agent, besifloxacin

(Besivance, Bausch + Lomb) is the

only fluoroquinolone specifically de-

veloped for ocular use.

Anti-inflammatory drugsThe reason for using anti-inflamma-

tory drugs in the perioperative pe-

riod is easy to understand: any surgi-

cal procedure performed on the eye

will induce inflammation, which, in

turn, can lead to pain, light sensitiv-

ity, redness, and other symptoms.

Modern cataract surgery techniques,

including the use of femtosecond

laser for several of the steps, are in-

tended to induce less inflammation.

Still, ocular surgery by its very nature is inva-

sive and therefore carries potential to instigate

an inflammatory response. Certain underly-

ing risk factors may elevate the risk, includ-

ing diabetes, uveitis, epiretinal membrane,

and history of cystoid macular edema (CME)

in the fellow eye.12,13

Most eyecare practitioners recognize the

need for some form of anti-inflammatory pro-

phylaxis, although opinions differ on whether

a combination of NSAIDs and corticosteroids

are needed. In addition to their anti-inflamma-

tory properties, NSAIDs also address pain fol-

lowing surgery and prevent mydriasis during

cataract surgery.14 Use of NSAIDs specifically

for mydriasis is off label, although recently

approved is Omidria (ketorolac and

phenylephrine, Omeros), a fixed-

combination drug that can be placed

in the irrigating solution to bathe the

intraocular tissues throughout the

surgical procedure. In clinical trials,

this intracameral formulation dem-

onstrated the ability to reduce pain

and maintain miosis.15 There is also

suggestion in animal studies that it

provides benefit for reducing inflam-

mation at the retina.16

In addition to addressing pain, the

use of NSAIDs and/or corticosteroids

in the perioperative cataract period

is for the prevention of CME. Most

eyecare practitioners are in agree-

ment that prevention is a more ef-

fective strategy than treatment, and

there are ample studies demonstrating that

combination corticosteroids and NSAIDs ef-

fectively prevent CME.17-31

The actual rate of CME following cataract

surgery is a matter of some debate with studies

suggesting rates between 0.1 percent and 2.33

percent when small-incision techniques and

phacoemulsification are used.32,33 However,

subclinical CME may be apparent on OCT in

4 percent to 11 percent of cases. (Figure 3)34,35

Some eyecare practitioners have looked at

the low rates of CME and concluded that ex-

posing patients to additional risks with sep-

arate medications may be unjustifiable. Yet,

whereas corticosteroids more generally act

at various points of the inflammatory cas-

cade, NSAIDs specifically target the cyclo-

oxygenated pathway and shut down later

prostaglandin activity that may lead to mac-

ular swelling or CME. Thus, pairing the two

classes of medications is synergistic in reduc-

ing inflammation.

While FDA labeling for NSAIDs indicates

that they are off label for prevention of intra-

operative miosis, several agents are indicated

for the management of postoperative pain

and inflammation, such as Ilevro (nepafenac

ophthalmic suspension 0.3%, Alcon) and Pro-

lensa (bromfenac ophthalmic solution 0.07%,

Bausch + Lomb).

Factors affecting agent selectionIn my practice, we follow the prevailing sen-

timent to use both NSAIDs and a corticoste-

roid drop. In patients deemed not at high risk

for CME, we start NSAIDs one day preopera-

tively and use them for four weeks postop.

In patients at high risk, we start NSAIDs one

Comanagement

Topical cataract regimenContinued from page 1 TAKE-HOME MESSAGE The weight

of evidence suggests that both NSAIDs and corticosteroids should be used for prevention of inflammation in the postoperative period, even as the field has moved toward less invasive surgeries with lower potential to induce complications. Selecting the particular agents to use in the perioperative regimen may not be as straightforward as the dosing frequency; bioavailability and retention time on the ocular surface may be additional factors to consider.

WALTER O. WHITLEY OD, MBA, FAAO, is the director of optometric services at Virginia Eye Consultants in Norfolk, VA, and a member of the Optometry Times Editorial Advisory Board

FIGURE 3. Cystoid macular edema after un-eventful cataract surgery.

3

About 30 percent of the population is steroid responders, and about 5 percent are severe steroid responders who have an IOP elevation above 31 mm Hg

| PRACTICAL CHAIRSIDE ADVICE 21

week preop and continue their use

for several weeks postop.36 Rarely,

we will drop the NSAID component

when patients exhibit hypersensitiv-

ity to the NSAID class. It is more likely

(although still rare) that we will sus-

pend use of the corticosteroid, which

may occur if there is an IOP spike

during use or in the presence of ac-

tive infection.

About 30 percent of the popula-

tion is steroid responders, and about

5 percent are severe steroid respond-

ers who have an IOP elevation above

31 mm Hg.37 Those rates are informa-

tive, but they do not necessarily dic-

tate how we will manage a patient

with a steroid response.

We are following cataract patients

on the first day postop, and we will

see the patient back at one week and

one month—there are ample clinical

visits already built into the follow-up

in which to measure and follow IOP.

More to the point, the health of the

optic nerve and other glaucoma risk

factors strongly influence how we re-

spond to a pressure elevation, even

one that rises into the 30s. We may

add a glaucoma medication or we may

switch agents: difluprednate (Du-

rezol, Alcon) is much more likely to

induce a steroid response than either

prednisolone acetate 1% (Pred Forte,

Allergan) or loteprednol etabonate

0.5% (Lotemax, Bausch + Lomb).38,39

With NSAID selection, patients’

compliance with the medication is

an important consideration. As a rule

of thumb, adherence to prescription

protocols declines as the complexity

of the regimen increases—including

number of drops and number of ad-

ministrations.40 A once-a-day formu-

lation may be preferable to an agent

used twice a day; however, dosing

frequency is only one part of the

story. Other factors, including the

drug’s bioavailability and residence

time on the ocular surface, will de-

termine if there are adequate levels

of drug to have a meaningful effect

while the lipophilicity and solubility

factor in whether the drug will pen-

etrate the ocular surface.

A new NSAID slated to launch

commercially later this year is a low-

dose bromfenac formulation (0.075%;

BromSite, Sun Pharma) formulated

in DuraSite (Sun Pharma), which is

a synthetic polymer-based formula-

tion that extends the time of a drug

in the eye relative to conventional

topical therapies.41 Bromfenac is al-

ready a well-known ophthalmic and

frequently prescribed NSAID. As for

Durasite, many of us are already fa-

miliar with this vehicle, which is

utilized in other ocular medications

such Azasite (Merck) and Besivance

(Bausch + Lomb).

BromSite was approved for both

management of postoperative in-

flammation and for prevention of oc-

ular pain, the only NSAID to gain that

specific indication. In a study of 407

patients, significantly more patients

treated with BromSite were 100 per-

cent inflammation free as compared

to vehicle (57 percent and 38 percent

in separate studies vs. 19% and 22%,

respectively).41

The potential to prevent pain adds

something to the role of the NSAID

in the pre- and postop period. In the

Phase 3 study, more patients were

100 percent pain-free as compared

to vehicle in the BromSite group (77

percent and 82 percent vs. 48 percent

and 62 percent, respectively).41 This

aspect should not be undervalued

because, in my experience, pain is a

frequent concern of patients under-

going ocular surgery.

In our practice, wherever possible,

we try to use branded drugs because

FDA labeling indicates that the drugs

had to have been rigorously tested in

clinical trials, a criterion that does

not apply to generic alternatives. In

fact, in our practice, if patients state

a preference for generic formulations,

Comanagement

we make them sign a waiver

indicating that they have been

informed about the potential

effects of their choice. Generics

certainly can play a role, and

they sometimes offer a lower

cost alternative depending on

the insurance status, but pa-

tients should be made aware

that they can be associated

with unpredictable efficacy

and the potential to induce dif-

ferent side effects than their

branded comparators.

See Cataract on page 22

Ocular surgery by its very nature is invasive and therefore carries potential to instigate an inflammatory response

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Choosing topical agentsThe weight of evidence suggests that both

NSAIDs and corticosteroids should be used

for prevention of inflammation in the postop

period, even as the field has moved toward

less invasive surgeries with lower potential to

induce complications. Selecting the particu-

lar agents to use in the perioperative regimen

may not be as straightforward as the dosing

frequency because the bioavailability and re-

tention time on the ocular surface may be ad-

ditional factors to consider. Formulations with

vehicles designed to improve ocular retention

may become an important part of the arma-

mentarium if they prove as useful in routine

clinical practice as they appear to be in clini-

cal trials.

A final consideration in selecting agents

for use in the perioperative regimen relates

to patients’ preference. Specifically, patients

opting for premium IOLs tend to have higher

expectations for their outcome.

Although this article deals specifically

with the use of topical medications, I would

be remiss to not mention the potential to add

OCT as a potential consideration in premium

IOL patients as an added safeguard. As noted

above, the rate of subclinical CME is much

higher than clinically apparent CME, but the

residual inflammation still has potential to

lead to negative outcomes. In such cases, of-

fering treatment in conjunction with a steroid

will typically provide therapeutic benefit. Note

that this is considered off-label usage.

REFERENCES1. Packer M, Chang DF, Dewey SH, et al. Prevention, diagnosis and management of acute postoperative bacterial endophthalmitis. J Cataract Refract Surg. 2011 Sep;37(9):1699-714.

2. Miller JJ, Scott IU, Flynn HW Jr, et al. Acute–onset endophthalmitis after cataract surgery (2000–2004): incidence, clinical settings, and visual outcomes after treatment. Am J Ophthalmol. 2005 Jun;139(6):983–7.

3. Keay L, Gower EW, Cassard SD, et al. Postcataract surgery endophthalmitis in the United States: analysis of the complete 2003 and 2004 Medicare database of cataract surgeries. Ophthalmology. 2012 May;119(5):914-22.

4. Endophthalmitis Study Group, European Society of Cataract & Refractive Surgery. Prophylaxis of postoperative endophthalmitis following cataract surgery: results of the ESCRS multicenter study and identification of risk factors. J Cataract Refract Surg. 2007 Jun; 33(6):978–88.

5. Shorstein NH, Winthrop KL, Herrinton LJ. Decreased postoperative endophthalmitis rate after institution of intracameral antibiotics in a Northern California eye department. J Cataract Refract Surg. 2013 Jan;39(1):8–14.

6. Tan CSH, Wong HK, Yang FP. Epidemiology of postoperative endophthalmitis in an Asian population: 11-year incidence and effect of intracameral antibiotic agents. J Cataract Refract

Surg. 2012 Mar;38(3):425-30.

7. Montan PG, Wedje G, Koranyi G, et al. Prophylactic intracameral cefuroxime; efficacy in preventing endophthalmitis after cataract surgery. J Cataract Refract Surg. 2002 Jun;28(6): 977–81.

8. Fintelmann RE, Hoskins EN, Lietman TM, et al. Topical fluoroquinolone use as a risk factor for in vitro fluoroquinolone resistance in ocular cultures. Arch Ophthalmol. 2011 Apr;129(4):399-402.

9. ASCRS. ASCRS and ASRS issue clinical alert on HORV association with intraocular vancomycin. Available at: http://www.ascrs.org/node/26102. Accessed 9/20/2016.

10. Haas W, Pillar CM, Torres M, et al. Monitoring antibiotic resistance in ocular microorganisms: results from the Antibiotic Resistance Monitoring in Ocular micRorganisms (ARMOR) 2009 surveillance study. Am J Ophthalmol. 201 Oct1;152(4):567-574.e3.

11. Asbell PA, Sanfilippo CM, Pillar CM, et al. Antibiotic resistance among ocular pathogens in the United States: five-year results from the Antibiotic Resistance Monitoring in Ocular Microorganisms (ARMOR) Surveillance Study. JAMA

Ophthalmol. 2015 Dec;133(12):1445-54.

12. Henderson BA. Clinical pseudophakic cystoid macular edema. Risk factors for development and duration after treatment. J Cataract Refract Surg. 2007 Sep;33(9):1550-8.

13. Gass JDM. Macular dysfunction caused by epiretinal membrane contraction. In: Stereoscopic Atlas of Macular Diseases: Diagnosis and Treatment. Vol 2, 4th ed. St Louis, Mo: Mosby; 1997:938-950.

14. Drews RC, Katsev DA. Ocufen and pupillary dilation during cataract surgery. J Cataract Refract Surg. 1989 Jul;15(4):445-8.

15. Hovanesian JA, Sheppard JD, Trattler WB, et al. Intracameral phenylephrine and ketorolac during cataract surgery maintains intraoperative mydriasis and reduces postoperative ocular pain–integrated results from two pivotal phase 3 studies. J Cataract Refract Surg. 2015;41(10):2060-8.

16. Florio V, Cowan L, Prusakiewicz JJ, et al. Ocular tissue distribution of ketorolac after administration of OMS302 to dogs during IOL replacement. Poster presented at: 2015 ASCRS-ASOA Symposium and Congress; April 17-21, 2015; San Diego, CA.

17. Rosetti L, Bujtar E, CastoldiD, et al. Effectiveness of diclofenac eye drops in reducing inflammation and the incidence of cystoid macular edema after cataract surgery. J Cataract Refract Surg. 1996;22 (Suppl l):794-9.

18. McColgin AZ, Raizman MB. Efficacy of topical Voltaren in reducing the incidence of post operative cystoid macular edema. Invest Ophthmol Vis Sci. 1999;40:S289.

19. Miyake K, Masuda K, Shirato S, et al. Comparison of

Comanagement

Topical cataract regimenContinued from page 21

There are ample studies demonstrating that combination corticosteroids and NSAIDs effectively prevent CME

IN BRIEF

J&J acquires Abbott Medical OpticsNEW BRUNSWICK, NJ—Johnson & Johnson entered

into a definitive agreement to acquire

Abbott Medical Optics (AMO), a wholly-

owned subsidiary of Abbott Laboratories,

for $4.325 billion in cash. Abbott reported

sales of $1.1 billion for 2015. The acquisi-

tion will include ophthalmic products in

three business segments: cataract surgery,

laser refractive surgery, and consumer eye

health.

“Eye health is one of the largest, fastest

growing and most underserved segments

in health care today,” says Ashley McE-

voy, company group chairman, responsi-

ble for Johnson & Johnson’s Vision Care

Companies.

“With the acquisition of Abbott Medi-

cal Optics’ strong and differentiated surgi-

cal ophthalmic portfolio, coupled with our

world-leading Acuvue contact lens busi-

ness, we will become a more broad-based

leader in vision care,” she says. “Impor-

tantly, with this acquisition we will enter

cataract surgery—one of the most com-

monly performed surgeries and the num-

ber-one cause of preventable blindness.”

Abbott is known for intraocular lenses

used in cataract surgery. The World Health

Organization estimates that approximately

20 million people are blind from age-related

cataracts and that there are at least 100 mil-

lion eyes with compromised visual acuity

caused by cataracts. These numbers are

steadily rising due to population growth

and increasing life expectancy.

In addition to the cataract business, Ab-

bott has advanced laser vision (LASIK) tech-

nologies designed to enhance surgeon pro-

ductivity and correct near sightedness, far

sightedness and astigmatism.

The acquisition also includes Abbott’s

consumer eye health products: over-the-

counter drops for dry eye, as well as mul-

tipurpose solutions and hydrogen perox-

ide cleaning systems for patients who wear

contact lenses.

The transaction is expected to close in the

first quarter of 2017. The closing is subject

to antitrust clearance and other customary

closing conditions. Following the expected

closing, sales will be reported in the Medi-

cal Devices segment as a separate platform

within Vision Care.See Topical cataract regimen on page 24

Daily lid and lash hygiene.

AV E N O VA . C O M |

� � � � � � � � � � � � |

R X O N LY

Add Avenova® with Neutrox®

(Pure Hypochlorous Acid 0.01% as a

preservative), the only Rx lid hygiene

product with pure hypochlorous acid,

to the lid & lash hygiene regimen

for all your patients.

HWbWc�@^eM3Mh�Mc�6MbcIRbc�6hR�4^]SRaR]PR�O^^cV����

OCTOBER 2016 | 24

edema. Invest Ophthmol Vis Sci. 1999;40:S289.

19. Miyake K, Masuda K, Shirato S, et al. Comparison of diclofenac and fluorometholone in preventing cystoid macular edema after small incision cataract surgery: a multicentered prospective trial. Jpn J Ophthalmol. 2000 Jan-Feb;44(1):58-67.

20. Efficacy of diclofenac eyedrops in preventing postoperative inflammation and long-term cystoid macular edema. Italian Diclofenac Study Group. J Cataract Refract Surg. 1997 Oct;23(8):1183-9.

21. Donnenfeld ED, Perry HD, Wittpenn JR, et al. Preoperative ketorolac tromethamine 0.4% in phacoemulsification outcomes: pharmacokinetic-response curve. J Cataract

Refract Surg. 2006 Sep;32(9):1474-82.

22. Tauber S, Gessler J, Scott W, et al. The effect of topical Ketorolac 0.4% on cystoid macular edema following routine cataract surgery. Association for Research in Vision and Ophthalmology (ARVO) Meeting, Fort Lauderdale, Florida, April 30-May 4, 2006. 683.

23. Fry EL, Fry LL. Nepafenac versus Ketorolac tromethamine in the prevention of postoperative cystoid macular edema. American Society of Cataract & Refractive Surgery (ARCRS) Meeting, San Diego, CA, April 27 – May 2, 2007. R26B. May; 114(5):881-9.

24. Henderson BA, Kim JY, Ament CS, et al. Clinical pseudophakic cystoid macular edema. Risk factors for development and duration after treatment. J Cataract Refract

Surg. 2007 Sep;33(9):1550-8.

25. Wolf EJ, Braunstein A, Shih C, et al. Incidence of visually significant pseudophakic macular edema after uneventful

phacoemulsification in patients treated with nepafenac. J Cataract Refract Surg. 2007 Sep;33(9):1546-9.

26. Shimura M, Nakazawa T, Yasuda K, et al. Diclofenac prevents an early event of macular thickening after cataract surgery in patients with diabetes. J Ocul Pharmacol Ther. 2007 Jun;23(3):284-91.

27. Miyake K, Nishimura K, et al. The effect of topical diclofenac on choroidal blood flow in early postoperative pseudophakias with regard to cystoid macular edema formation. Invest

Ophthalmol Vis Sci. 2007 Dec;48(12):5647-52.

28. Wittpenn. Relationship of retinal thickening and contrast sensitivity in low-risk cataract patients. American Academy of Ophthalmology, New Orleans, LA, November 10-13, 2007. PO010.

29. Yung CW, et al. The effect of topical ketorolac tromethamine 0.5% on macular thickness in diabetic patients after cataract surgery. American Academy of Ophthalmology, New Orleans, LA, November 10-13, 2007. PO257.

30. Asano S, Miyake K, Ota I, et al. Reducing angiographic cystoid macular edema and blood-aqueous barrier disruption after small-incision phacoemulsification and foldable intraocular lens implantation: multicenter prospective randomized comparison of topical diclofenac 0.1% and betamethasone 0.1%. J Cataract Refract Surg. 2008 Jan;34(1):57-63.

31. Heier JS, Topping TM, Baumann W, et al. Ketorolac versus prednisolone versus combination therapy in the treatment of acute pseudophakic cystoid macular edema. Ophthalmology. 2000 Nov;107(11):2034-8;discussion 2039.

32. Henderson BA, Kim JY, Ament CS, et al. Clinical pseudophakic cystoid macular edema. Risk factors for development and duration after treatment. J Cataract Refract

Surg. 2007;33(9):1550-8.

33. Loewenstein A, Zur D. Postsurgical cystoid macular edema.

Dev Ophthalmol. 2010;47:148-59.

34. Belair ML, Kim SJ, Thorne JE, et al. Incidence of cystoid macular edema after cataract surgery in patients with and without uveitis using optical coherence tomography. Am J

Ophthalmol. 2009 Jul;148(1):128-35.

35. Perente I, Utine CA, Ozturker C, et al. Evaluation of macular changes after uncomplicated phacoemulsification surgery by optical coherence tomography. Curr Eye Res. 2007 Mar;32(3):241-7.

36. O’Brien TP. Emerging guidelines for the use of NSAID therapy to optimize cataract surgery patient care. Curr Med

Res Opin. 2005 Jul;21(7):1131-7.

37. Jonas JB, Degenring RF, Kreissig I, et al. Intraocular pressure elevation after intravitreal triamcinolone acetonide injection. Ophthalmology. 2005 Apr;112(4):593-8.

38. Cable MM. Intraocular pressure spikes using difluprednate 0.05% for postoperative cataract inflammation. Inves

Ophthalmol Vis Sci. 2010 Apr;51:1981.

39. Pleyer U, Ursell PG, Rama P. Intraocular pressure effects of common topical steroids for post-cataract inflammation: are they all the same? Ophthalmol Ther. 2013 Dec;2(2):55-72.

40. Claxton AJ, Cramer J, Pierce C. A systemic review of the associations between dose regimens and medication compliance. Clin Therapeutics. 2001 Aug;23(8):1296-310.

41. Hutcheson J, McMullen D, Hosseini K. Clinical Response of 0.075% Bromfenac in DuraSite on Ocular Inflammation and Pain Post Cataract Surgery. Invest Ophthalmol Vis Sci. 2014 Apr;55:1473.

Comanagement

Dr. Whitley is director of optometric services at Virginia Eye Consultants in Norfolk, VA. He serves as a consultant or serves on the advisory boards for Alcon, Allergan, Bausch + Lomb, Shire, and TearLab. wwhitley@vec2020.com

Topical cataract regimenContinued from page 22

JENA, GERMANY, AND DUBLIN, CA—The Medical Technol-

ogy Business Group of Zeiss has been granted

U.S. Food and Drug Administration (FDA)

approval for VisuMax Small Incision Lenti-

cule Extraction (SMILE) procedure. SMILE

is a refractive procedure for the correction

of myopia.

Study results submitted to the U.S. FDA in

Zeiss’ premarket approval (PMA) application

demonstrated excellent visual acuity and re-

fractive predictability outcomes for the 336

eyes treated at five investigational sites in the

U.S., according to the company.

SMILE, a femtosecond laser-based, mini-

mally-invasive vision correction procedure, is

already established in global markets such as

Europe, China, Australia, Canada, and India.

In addition to predictable results and excel-

lent visual outcomes, surgeons reported that

the ReLEx SMILE procedure on the ZEISS Vi-

suMax femtosecond laser exhibited fast visual

recovery with minimal discomfort for their

patients, according to Zeiss.

Dr. Jon D. Dishler, refractive surgery spe-

cialist of Dishler Laser Institute in Denver, CO,

and U.S medical monitor for the VisuMax IDE

Study, says, “We are thrilled that this exciting

new technology is available for surgeons and

patients in the United States. I was very im-

pressed with the excellent refractive outcomes

in our clinical study, especially in those pa-

tients who were most dependent on their spec-

tacles for daily life. SMILE will become an im-

portant addition to our offerings for patients,

and a new and appealing option for those who

have concerns about existing choices for sur-

gical vision correction.”

In the SMILE procedure, surgeons correct

patients’ refractive errors using the Zeiss Vi-

suMax femtosecond laser to create a thin disc-

shaped lenticule within the cornea, which is

then removed by the surgeon through a small

incision on the surface of the cornea, also cre-

ated by the laser.

SMILE is a flapless procedure, which re-

quires only one laser to perform the entire

treatment. The outer corneal layer remains

largely intact, contributing to the eye’s stabil-

ity—both biomechanical and refractive —and

to fast visual recovery.

SMILE is currently available in approxi-

mately 500 clinics in 61 countries around the

world. More than a half a million SMILE pro-

cedures have been performed internationally

since its introduction in 2011, according to the

company, with extensive study results demon-

strating high levels of safety and effectiveness.

Zeiss is also conducting an investigational

device exemption (IDE) trial in the United

States on astigmatic myopia to further broaden

the spectrum of SMILE for more patients.

The VisuMax SMILE procedure is indicated

for use in the reduction or elimination of myo-

pia -1.00 D to -8.00D, with ≤ -0.50D cylinder

and manifest refraction spherical equivalent

(MRSE) -8.25 D in the eye to be treated in pa-

tients who are 22 years of age or older with

documentation of stable manifest refraction

over the past year.

Zeiss gets FDA nod for VisuMax SMILE refractive procedureIN BRIEF

| PRACTICAL CHAIRSIDE ADVICE Primary Care 25

By Jill Autry, OD, RPh

Although the need for mixing

medications is rare in today’s

world of mass-manufactured

pharmaceuticals, there are

still patients and circumstances that

require us to turn to our neighbor-

hood compounding pharmacist.

Why compounding pharmacy?There are four reasons to opt for a

compounding pharmacy instead of

your Rx pad: strength, form, ingredi-

ents, and function. Let’s take a look at each one.

Different strength. The most common need

for a compounded drug is when the prescribed

agent is not manufactured in a strength deemed

necessary for the patient’s condition—the doc-

tor needs a higher or lower concentration than

what can be found in stock. For example, a ca-

chectic patient may need a medication delivered

at half the typically prescribed strength, or a pa-

tient with severe eczema may need a cream that

is twice as strong as those made commercially.

In such cases, the compounding pharmacist

can purchase the raw materials and make the

medication to match the needs of the patient.

Different form. Another cause for calling

upon a compounding pharmacist is when the

prescribed medication does not come in the dos-

age form needed by the patient. This is common

when making adult medications into suspen-

sions for children or for a cancer patient who

cannot swallow a pill or capsule. The mixing of

oral and intravenous medications into alternate

dosage forms is also common in making ocu-

lar preparations, rectal or vaginal suppositories,

topical creams and lotions, or oral rinses.

Different ingredients. Some instances require

the compounding pharmacist to remove or

change the manufactured formulation. Inactive

ingredients, such as preservatives or buffers,

may cause toxicity or allergy in susceptible in-

dividuals. The pharmacist uses the active ingre-

dient in the dosage required but removes the of-

fending agent from the preparation without al-

tering the medication’s pharmacological profile.

Different formulation. Some compounds are

formulated to ease administration or promote

compliance. This is an option when two or more

medications are mixed together into a single

dosage. The most common of these combina-

tions include dermatological prepara-

tions, prescribed separately but more

effective when applied together.

Dry eyeIn its mildest form, dry eye causes ep-

isodic symptoms of burning, tearing,

foreign body sensation, and intermit-

tent blur. For these patients, artificial

tears and/or environmental changes

may be all they need to relieve symp-

toms. For patients with moderate dry

eye, treatments such as Restasis (cy-

closporine 0.05%, Allergan), Xiidra

(lifitegrast 5%, Shire), topical ste-

roids, and doxycycline are often added.

When we exhaust these more conventional

treatments for a patient with moderate to severe

dry eye, we can look to additional therapeutic

options that need to be compounded:

– Cyclosporine ophthalmic ointment. This

ointment, applied q.h.s. in severe dry eye pa-

tients, typically is used to supplement Restasis

topical emulsion. It can be formulated as a 0.1%

to 2% concentration. In severely damaged, low

vision, and/or phthisical eyes, the ointment may

be substituted for the topical cyclosporine drop

b.i.d. to q.i.d. for more contact time without the

concern of associated blur.

– Autologous serum. This is used in severe

aqueous-deficient dry eye to provide patient-

specific protein-based protection to the ocular

surface. Serum and normal tears have many

of the same components, including vitamin A,

various growth factors, and proteins (such as

lactoferrin and lysoszyme). To create the serum,

the patient must make three to four blood do-

nations a year; most clinicians ask for a 20- to

50-percent diluted serum to be instilled q.i.d. or

more. Investigators also have tested this treat-

ment for persistent corneal defects.1

– Albumin drops. Although not the preferred

autologous serum described above, albumin

5% artificial tears may be a suitable alternative

tear supplement for several reasons. For one, it

is easier to compound than autologous serum.

Also, it avoids the need for the patient to make

a blood donation. Last, but not least, it’s much

cheaper than autologous serum. Albumin may

improve the tear film by providing mucin-like

protection as well as anti-inflammatory action.

Research on patients with Sjögren’s syndrome

found that albumin therapy inhibited the apop-

totic enzyme caspase-3, and improved fluores-

cein and rose bengal scores in just four weeks.2

(However, it was not statistically significant for

tear break-up time or subjective symptoms.)

– Transdermal testosterone cream. Androgens

play a role in dry eye through receptor activ-

ity in lacrimal glands, meibomian glands, and

conjunctiva. Because androgen production de-

creases in older men and women as well as in

autoimmune patients, clinicians are increas-

ingly using topical, transdermal testosterone in

a vanishing cream as a treatment for refractive

dry eye in these populations. Various clinicians

recommend a 3% to 5% concentration applied

to the upper eyelids b.i.d. initially, then q.h.s.3

Investigators also are testing compounded tes-

tosterone solution applied directly to the eye.4

– Preservative-free steroids. Many commer-

cially available products for dry eye are available

without preservatives, such as artificial tears

and Restasis. Steroids are often an unavoidable

part of our treatment regimen for dry eye, but

they unfortunately do not come in a preserva-

tive-free preparation. For patients who cannot

tolerate preservatives (or if preservative-con-

taining medications exacerbate their dry eye),

the compounding pharmacist can make preser-

vative-free products, such as 1% methylprednis-

olone ophthalmic drops. When necessary, other

chronic medications, such as glaucoma drops or

allergy treatments, can also be prepared preser-

vative-free through compounding.

– Acetylcysteine solution. In various chronic

ocular conditions—most notably severe dry

eye—mucous filaments can form and attach

to the cornea. This results in pain, foreign body

sensation, photophobia, and decreased vision.

Initial treatment is to remove the filaments with

forceps and, if necessary, apply bandage con-

tact lenses. Next, aggressively treat the underly-

TAKE-HOME MESSAGE Even though today we live in a world of mass-manufactured pharmaceuticals, there are still patients and circumstances that require doctors to turn to neighborhood compounding pharmacies. Reasons include clinical conditions such as dry eye, band keratopathy, and amoebic keratitis. Practitioners may also require a different strength, form, ingredients, or formulation from commercial products.

4 reasons to use a compounding pharmacy Some clinical conditions or patient circumstances require mixing it up

BY JILL AUTRY, OD, RPH, is a partner at Eye Center of Texas in Houston and lectures nationally on eye disease and pharmaceuticals

See Compounding pharmacy on page 26

OCTOBER 2016 | Primary Care26

ing dry eye and consider an ophthalmic solution

of acetylcysteine drops. Mucomyst (acetylcys-

teine, Bristol-Myers Squibb) is used in patients

with pulmonary conditions to reduce excess

bronchial mucus. The compounding pharma-

cist can convert it into a 5% or 10% ophthalmic

solution, which can be helpful in treating and

preventing recurrences when used b.id. to q.i.d.

Corneal bacterial keratitisMost practitioners will encounter a bacterial

keratitis that is so large, central, or vision-threat-

ening that empirical treatment with topical flu-

oroquinolones does not meet standard of care.

The majority of these ulcers are contact lens-re-

lated and, although we tend to think Pseudomo-

nas in these cases, they can be caused by either

gram-positive or gram-negative organisms. First

culture the ulcer, and then initiate fortified topi-

cal antibiotic therapy with one of the following:

– Vancomycin 25 mg/ml. This covers a wide

range of gram-positive organisms, includ-

ing methicillin-resistant Staphylococcus aureus

(MRSA). It should be alternated every half hour

or hour with a gram-negative medication, such

as ceftazidime or tobramycin.

– Cefazolin 50 mg/ml. Like vancomycin, this

first-generation cephalosporin also covers a

wide range of gram-positive organisms but is

not effective against MRSA. It is well tolerated

and is a good choice for pregnant patients who

need intense antibiotic therapy (because fluoro-

quinolones are contraindicated).

– Tobramycin 14 mg/ml. Although generally

considered a medication that is active against

gram-negative species, this aminoglycoside also

works well against gram-positive organisms. It

is often paired with vancomycin or cefazolin for

comprehensive coverage. Also, it is FDA Preg-

nancy Category B (no known risk to the fetus),

so it can be compounded for the treatment of

severe corneal infections in pregnant patients.

– Ceftazidime 50 mg/ml. This third-genera-

tion cephalosporin is known for outstanding

gram-negative coverage. Like tobramycin, cef-

tazidime is paired with gram-positive vancomy-

cin or cefazolin and is alternated every 30 min-

utes to an hour for initial treatment.

The aforementioned are just a few of the most

common fortified antibiotics. Other choices in-

clude amikacin, gentamicin, and ceftriaxone.

Amoebic keratitisAcanthamoeba, one of the more formidable

causes of keratitis, often results in the need for

corneal transplantation. The infection is almost

exclusive to contact lens wearers. Its diagnosis

is often delayed because it can mimic bacterial,

fungal or, more commonly, herpetic keratitis.

The amoeba can be resistant to treatment.

This is why therapy requires a compounding

pharmacist because the current recommended

preparations are not commercially available in

the U.S. Often treatment involves a combined

approach, including a biguanide (either poly-

hexamethylene biguanide 0.02% or chlorhexi-

dine 0.02%) combined with a diamidine (either

hexamidine 0.1% or propamidine 0.1%).5,6

Band keratopathyThis degeneration is characterized by a 3 to 9

o’clock band deposition of calcium across the

cornea. It is found just under the epithelial sur-

face and tends to be concentrated in the intra-

palpebral area due to increased tear tonicity and

evaporation in this area. Band keratopathy can

occur due to a variety of etiologies but is most

often seen in chronic inflammatory conditions,

both systemic and ocular. The band can cause

visual acuity loss as well as chronic foreign

body sensation depending on its severity.

Treatment involves an ophthalmic solution

of ethylenediaminetetraacetic acid (EDTA), an

effective treatment due to its chelating effect.7

Therapy involves first debriding the epithelium

and then applying a 2% EDTA compounded so-

lution to the cornea for three to five minutes.

Lastly, the calcium deposits are scraped away

and a bandage contact lens applied. Depending

on severity, multiple applications and scrapings

may be necessary to control the keratopathy.

Intravitreal injections Although intravitreal injections for macular de-

generation are commonplace today, compound-

ing pharmacists have been supplying various

preparations of antibiotics and steroids for in-

traocular injection for years. Today, the off-label

use of the anti-VEGF Avastin (bevacizumab, Ge-

nentech), a systemic cancer therapy reformu-

lated for intraocular use, is the most commonly

compounded intravitreal preparation. It contin-

ues to be prescribed in lieu of the FDA-approved

Lucentis (ranibizumab, Genentech) due to the ex-

treme cost difference between the two products.

(A single Lucentis injection costs approximately

$2,000 while a shot of Avastin is closer to $50.)

However, a 2011 outbreak of endophthalmitis

cases in Avastin-treated patients was traced to a

single compounding pharmacy. This instance

serves as a lesson on the importance of demand-

ing strict adherence to sterility protocols from

your compounding pharmacies.

Ophthalmic preparations must be made

under sterile conditions following the U.S.

Pharmacopeia Chapter 797 guidelines. Phar-

macists and technicians must use asep-

tic techniques to preserve sterility when

preparing these products and keep cur-

rent on the techniques they have learned.

Further, the medications must be prepared in a

clean room inside a laminar flow hood to avoid

contaminants or bacteria and then sterilized

by using a micron filter or autoclave to ensure

a quality product. The clean room and laminar

flow hood must be tested regularly by an out-

side source for bacteria and endotoxins.

Watch for the use of intravitreal injections to

become even more commonplace in the future

as they bypass topical administration concerns,

take compliance challenges out of the hands of

Compounding pharmacyContinued from page 25

Find a compounding pharmacist and develop a relationship before a unique case occurs so you’ll be prepared if—or more likely when—the patient presents to your practice.

SO, HOW DO YOU FIND ONE? – Ask your local dermatologist, oncologist, or local retail pharmacist where they send com-

pounded prescriptions.– Check professional websites, such as those for the Professional Compounding Centers of

America (www.pccarx.com) or the International Academy of Compounding Pharmacists (www.iacprx.org), where you can enter your city/state/zip code to find a compounding pharmacist near you.

– When you do locate one, don’t forget to make sure the compounding pharmacist makes ocu-lar preparations; many are willing to mix common creams, ointments, and oral dosage forms but may decline to make the more involved ophthalmic preparations, which must meet more stringent guidelines.

There are also commercial compounding pharmacies which are now mass producing com-pounded ophthalmic preparations. For example, Imprimis Pharmaceuticals makes various com-binations of topical drops such as prednisolone with moxifloxacin, prednisolone with ketorolac, and prednisolone with moxifloxacin and ketorolac combinations. These are generally used perioperatively to increase compliance and decrease cost around cataract surgery but could be prescribed for individual patients for other conditions. Imprimis also makes intravitreal injections for dropless cataract surgery.

Finding a compounding pharmacist

| PRACTICAL CHAIRSIDE ADVICE Primary Care 27

patients, and are direct to the intended target site.

Currently, the use of anti-VEGF treatments is in-

creasing as both on-label and off-label indications

expand beyond age-related macular degeneration

(AMD). For other chronic disease states, particularly

glaucoma, novel intravitreal injections could some-

day replace and/or supplement current standard-of-

care topical medications or laser treatments. For in-

stance, a brimonidine intravitreal implant is now in

two Phase II studies—one for glaucomatous optic

neuropathy and one for the treatment of geographic

atrophy due to AMD.8,9 Other intravitreal injections

are being studied for intraocular pressure (IOP), in-

flammation, and dropless cataract surgery.

AntifibrosisMitomycin-C is an antitumor antibiotic used in can-

cer chemotherapy. It is also commonly employed in

various ophthalmological surgical procedures—such

as pterygium removal, trabeculectomy, and photore-

fractive keratectomy—to prevent vascularization,

scar formation, and haze. Most physicians ask a com-

pounding pharmacist to make a solution of 0.02% to

0.05% concentration and apply it directly to the surgi-

cal site for 20 seconds to five minutes, depending on

the surgical or clinical situation.10,11

Corneal collagen crosslinking Riboflavin (vitamin B

2) 0.1% drops are compounded

and used in conjunction with application of UV-A

light during corneal crosslinking. This technique was

off label in the U.S. before its April 2016 FDA approval

and is used routinely in many other countries for the

treatment of keratoconus, corneal ectasia, and even

some cases of bacterial keratitis. The riboflavin acts

as a photosensitizer that strengthens the collagen fi-

bers. It is applied topically five minutes before UV-A

light exposure and every five minutes thereafter dur-

ing the 30-minute ultraviolet light exposure.12-14

In-office compoundingIn-office dilutions are off-label and anecdotal. But that

doesn’t mean off label is off limits. One example in eye

care includes diluting a sample bottle of brimonidine

with artificial tears for a quick red eye remedy.

Practitioners most often use a ratio of two drops of

brimonidine per 1 ml of artificial tears, using the mix-

ture b.i.d. until empty. Any concentration of brimoni-

dine will work; however, samples of Alphagan P (bri-

monidine 0.1%, Allergan) are most common. Place

six drops in a 3 ml sample bottle of Allergan’s Optive

artificial tears (because the top easily pops off).

Be aware that long-term use can result in rebound

hyperemia, which is typical with alpha-agonists.

Also, don’t use it on immediate post-LASIK patients

because it might cause slippage of the flap.15

Another in-office dilution includes adding 10 to 20

drops of topical anesthetic, such as proparacaine, to a

sample bottle of artificial tears. This weak anesthetic

is useful following refractive surgery, such as photore-

fractive keratectomy (PRK), to provide pain relief for

24 to 48 hours.16 This dilution should never be used

for pathologic pain, such as corneal abrasions associ-

ated with contact lens wear or of unknown etiology.

REFERENCES1. Poon AC, Geerling G, Dart JK, et al. Autologous serum eyedrops for dry eyes and epithelial defects: clinical and in vitro toxicity studies. Br J Ophthalmol. 2001 Oct; 85(10):1188-97.

2. Shimmura S, Ueno R, Matsumoto Y, et al. Albumin as a tear supplement in the treatment of severe dry eye. Br J Ophthalmol.

2003 Oct; 87(10):1279-83.

3. Conner CG. Treatment of Dry Eye with a Transdermal 3% Testosterone Cream. Invest Ophthalmol Vis Sci. 2003 May;44:2450.

4. A single-center, double-masked, randomized, vehicle controlled study to evaluate the safety and efficacy of testosterone 0.03% ophthalmic solution compared to vehicle for the treatment of meibomian gland dysfunction. Clinicaltrials.gov. Bethesda, MD: National Library of Medicine. Available at: http://clinicaltrials.gov/ct2/show/NCT00755183 Accessed: 06/18/2012.

5. Kumar R, Lloyd D. Recent advances in the treatment of Acanthamoeba keratitis. Clin Infect Dis. 2002 Aug 15; 35(4):434-41.

6. Seal DV. Acanthamoeba keratitis update—incidence, molecular epidemiology and new drugs for treatment. Eye (Lond). 2003 Nov;17(8):893–905.

7. Najjar DM, Cohen EJ, Rapuano CJ, et al. EDTA chelation for calcific band keratopathy: results and long-term follow-up. Am J

Ophthalmol. 2004 Jun;137(6):1056-64.

8. Safety and efficacy of brimonidine intravitreal implant in patients with geographic atrophy due to age-related macular degeneration (AMD). Clinicaltrials.gov. Bethesda, MD: National Library of Medicine. Available at: http://clinicaltrials.gov/ct2/show/NCT00658619 Accessed: 06/13/2012.

9. Safety and effects of brimonidine intravitreal implant in patients with glaucomatous optic neuropathy. Clinicaltrials.gov. Bethesda, MD: National Library of Medicine. Available at: http://clinicaltrials.gov/ct2/show/study/NCT00693485. Accessed: 06/13/2012.

10. Hashemi H, Taheri SM, Fotouhi A, et al. Evaluation of the prophylactic use of mitomycin-C to inhibit haze formation after photorefractive keratectomy in high myopia: a prospective clinical study. BMC Ophthalmol. 2004 Sep 14;4:12.

11. Bindlish R, Condon GP, Schlosser JD, et al. Efficacy and safety of mitomycin-C in primary trabeculectomy: five-year follow-up. Ophthalmology. 2002 Jul;109(7):1336-41.

12. Wollensak G, Spoerl E, Seiler T. Riboflavin/ultraviolet A induced collagen crosslinking for the treatment of keratoconus. Am J Ophthalmol. 2003 May;135(5):620-7.

13. Spoerl E, Mrochen M, Sliney D, et al. Safety of UVA riboflavin cross-linking of the cornea. Cornea. 2007 May;26(4):385-9.

14. Iseli HP, Thiel MA, Hafezi F, et al. Ultraviolet A/riboflavin corneal cross-linking for infectious keratitis associated with corneal melts. Cornea. 2008 Jun;27(5):590-4.

15. Muñoz G et al. Increased risk for flap dislocation with perioperative brimonidine use in femtosecond laser in situ keratomileusis. J Cataract Refract Surg. 2009;35(8):1338-42.

16. Bethke W. Secrets to better surface procedures. Rev

Ophthalmol. 2011 Jul;18(7):64-6.

Dr. Autry received her pharmacy degree from the University of North Carolina at Chapel Hill. She practiced in critical care before returning for her optometry degree at the University of Houston. jill_autry@hotmail.com

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SPECIAL SECTION28 OCTOBER 2016 |

Lens Care

By Mile Brujic, OD, FAAO

As a profession, we have seen

the benefits of transitioning

patients to contact lens mo-

dalities that are replaced frequently.

Soft lenses that were replaced on

a yearly basis were at one point in

time the standard of care, but daily,

two-week and monthly disposable

contact lenses have quickly taken

over the market. Innovations in ma-

terial technologies have allowed advanced

designs, including greater oxygen permea-

bility, to provide a healthier, more comfort-

able wearing experience.

CDC and lens careHowever, poor compliance can negate many

of the benefits that contact lens wear can

provide our patients. Recently, the Centers

for Disease Control (CDC) released its Mor-

bidity and Mortality Weekly Report (MMWR),1

which reviewed Contact Lens Medical De-

vice Reports and assessed the data for risk

factors, outcomes, and any microorganisms

identified. The report highlighted the need

for ongoing education to our patients about

proper contact lens wear and care habits.

According to the MMWR report, nearly one

out of every five reports of adverse events

described a patient who had a scarred cor-

nea, needed a corneal transplant, or had re-

duced vision after a contact-lens related eye

infection. The true proportion of

contact lens-associated infections

that result in eye damage unfortu-

nately cannot be determined from

the medical device report database.

More than one out of every four

reports described patients who

weren’t caring for their lenses

properly, were wearing them for

too long, or wearing them while

sleeping. Contact lens wear and care

behaviors that increase the chance

of getting an eye infection—yet are easily

avoided—include wearing contact lenses

while sleeping and wearing lenses for lon-

ger than recommended.

Look to your practiceTwo suggestions incorporated into clinical

practice can give you insights into how pa-

tients wear and care for their lenses.

First, simply have patients bring in their

contact lens case, solution, and any other

products they use to care for their eyes or

their lenses. Also, have them bring in any

remaining contact lenses that they may

have. If the lenses were purchased from

your practice, you will be able to quickly

determine how frequently the lenses are

being replaced and ultimately how compli-

ant—or non-compliant—patients are with

their lens wear.

Second, ask patients to remove their lenses

in the exam room and see what they do when

they remove them. Do they wash their hands

or do they simply take their lenses out? Do

they top off solution or simply place lenses

in the case that contains solution? Or do

they fill the lens case with fresh solution?

When they place the lenses back on their

eyes, do they wash their hands?

Observing these behaviors in the office

along with inspecting what they bring into

the practice will give you insights into the

true care habits that these patients pursue

with their contact lenses and lens care.

CDC recommendationsThe CDC’s healthy contact lens wear and

care recommendations focus on hygiene hab-

its, proper use of lenses and supplies, and

annual appointments with an eyecare pro-

vider. The recommendation advocate avoid-

ing behaviors related to contact lens wear

that can increase the chance of getting an

eye infection.

Three habits are commonly reported as

risky and can be easily remedied. Instruct

your patients to:

– Don’t sleep in contact lenses without

discussing with their eyecare practitioner.

Sleeping in contact lenses has been shown

to increase the chance of an eye infection

by six to eight times.1

– Don’t top off, or add new contact lens

solution to old solution that has been sitting

in the case. Adding new solution to used

solution can lower antimicrobial activity

of the solution. 1

– Replace your contact lenses as often as

recommended by your eyecare practitioner.

Studies have shown that contact lens wear-

ers who do not replace their lenses as often

as recommended have more complications

and report more eye problems than contact

lens wearers who follow the replacement

recommendations.1

What it means to youIt is refreshing to see reports encourag-

ing appropriate lens care and advocating for

regular eye care. When worn appropriately,

contact lenses provide a remarkable opportu-

nity for our patients. But when abused, they

can alter the normal physiological health

of the ocular surface, including the cornea.

Knowing this information about our pa-

TAKE-HOME MESSAGE Contact lens wear can provide patients with healthy, com-fortable vision when worn correctly. Noncompli-ance with lens wear and care can lead to poor outcomes. Help your patients fix risky habits by not sleeping in lenses without doctor approval, avoiding topping off solution, and wearing lenses as directed. Eyecare practitioners should educate patients on how to wear and clean lenses, the importance of handwashing before lens handling, and replacing lenses on time.

6 contact lens wear and care habits for patients and ODsFollow these three habits yourself, and advise your patients on another three

MILE BRUJIC, OD, FAAO, practices in Bowling Green and Lima, OH

Figure 1. A corneal scar as a result of a patient who was wearing his contact lenses four times longer than the manufacturer’s recommended replacement schedule. This overwear led to a corneal infection and the resulting scar.

1

29S P E C I A L S E C T I O N

| PRACTICAL CHAIRSIDE ADVICE

Lens Care

tients and understanding the potential ram-

ifications to ocular health, what is an ap-

propriate defense in arming our patients

with best chances to effectively and com-

fortably wear contact lenses in a safe and

healthy manner?

Adopt these three habits to encourage

safe and healthy lens wear:

– Appropriately educate the patient on the

supplies that she has brought into the office.

This gives you a firsthand look at what she

is actually using to care for her lenses and

the condition of her supplies, including her

case. It also gives you the opportunity to see

if she is in fact utilizing the solution that you

recommended for her and provides oppor-

tunities to educate her on appropriate care.

– Encourage appropriate use of contact lens

solutions and handwashing. Just as impor-

tant as using the appropriately recommended

solution is making sure that patients com-

pletely replace the solution in their contact

lens cases prior to storing their lenses in the

solution. Additionally, make sure that you

educate your patients to clean their hands

prior to lens handling.

– Encourage appropriate replacement sched-

ules for your lens wearers. This is particularly

important for those patients who wear lenses

longer than the approved wear schedules.

Consider educating all patients on the value

of an annual supply of contact lenses. Not

only are there often financial advantages

to an annual supply, having such a supply

encourages patients to replace their lenses

when they are supposed to because they

have a ready supply of lenses.

Although there are potential dangers to

wearing contact lenses inappropriately, when

worn correctly contact lenses can provide

patients with healthy, comfortable vision.

Through increased awareness of inappro-

priate behaviors and then proper education

to counter these behaviors, our patients can

enjoy the benefits of contact lenses while

minimizing their risk.

REFERENCE1. Centers for Disease Control and Prevention. Contact Lens–Related Corneal Infections—United States, 2005–2015. MMWR. 2016 Aug 19; 65(32);817–820.

Nearly one out of every five reports of adverse events described a patient who had a scarred cornea, needed a corneal transplant, or had reduced vision after a contact-lens related eye infection

Dr. Brujic is cofounder of Optometric Insights, a service providing career coaching to optometry students. He graduated from the New England College of Optometry in 2002.

brujic@prodigy.net

30S P E C I A L S E C T I O N

OCTOBER 2016 |

Lens Care

By Katy McDermott

You can’t walk into a big-box

store, drugstore, or even gro-

cery store without seeing an

aisle dedicated to contact lens solu-

tions. Is it any wonder patients are

often confused?

Reinforce your lens care recom-

mendation by knowing what your

patients will be seeing when they’re

shopping for solutions.

Here are some of the most common types

of solution and the most common brands

within each type. Information was gath-

ered from product and company websites.

MULTIPURPOSE SOLUTIONMultipurpose solution (MPS) is the most

popular method of contact lens care in the

U.S. and is used for cleaning, rinsing, disin-

fecting, and storing soft contact lenses. Pa-

tients use MPS to mechanically clean their

lenses as they would with daily cleaner, then

rinse (if directed) and disinfect, all with

the same solution. Alternatively, they can

rinse the lenses twice, then place them in

the clean lens case with solution to clean

and disinfect. When they are ready to wear

the lenses, they rinse again. With multipur-

pose solutions, no other lens care products

are necessary.

Some MPS are indicated for “no-rub” care

because they are designed to adequately

clean and disinfect lenses with a simple

rinse-and-store method, eliminating the

need to mechanically rub the lenses to re-

move lens deposits. However, patients may

not properly follow rinsing instructions; the

required rinse may last as long as 30 sec-

onds. Some companies are moving away

from the no-rub indication for this reason.

BioTrue (Bausch + Lomb)– Up to 20 hours of moisture using hyaluro-

nan, a lubricant found throughout the body

– Dual disinfection system

– Protein management

– Same pH as healthy tears to enhance

performance of dual disinfectants

– Tear proteins that are kept in their na-

tive state, active as they are naturally in

the eye, carrying out antimicrobial activi-

ties on their own

– Carton and bottle are 100 per-

cent recyclable

renu fresh (Bausch + Lomb)

– Stand-alone testing efficacy

against Acanthamoeba

– Efficacy against broad spec-

trum of clinical isolates, includ-

ing MRSA

–Poloxamine to provide sustained

wettability and conditioning of lens surface

– Unique ingredient Hydranate effectively

cleans and removes protein deposits

renu sensitive (Bausch + Lomb)– Formulated to work with the eyes’ nat-

ural tears

– Carton and bottle are 100 percent

recyclable

RevitaLens OcuTec (Abbott Medical Optics)

– Peroxide-quality, broad-spectrum dis-

infection protects patients from emerging

pathogens

– Super ior d i s i n fec t ion aga ins t

Acanthamoeba

– Protection from lens case contamina-

tion for non-compliant patients

– Low incidence of corneal infiltrates,

corneal staining, and adverse events

– Protein removal, lens cleaning, lens con-

dition for increased patient comfort (more

than 16 hours per day)

– Designed for silicone hydrogel and all

other soft contact lenses

Complete Easy Rub (Abbott Medical Optics)

– Disinfection promoted by removing

and killing a broad range of bacteria and

microorganisms on lenses to help protect

against infection

– Protein and debris removal

– Contains Poloxamer 237, an effective

cleaner that is also gentle on the eyes

– Four beneficial electrolytes

Opti-Free Express (Alcon)– Dual disinfectants Polyquad and Aldox

remove microorganisms that can cause eye

infections

– Approved for all soft contact lenses

Opti-Free Replenish (Alcon)– Dual disinfectants Polyquad and Aldox

remove microorganisms that can cause eye

infections

– TearGlyde reconditioning system works

with tears to create a moisture shield

– Debris and particle removal keeps con-

tact lenses clean

Opti-Free Puremoist (Alcon) – Dual disinfectants Polyquad and Aldox

remove microorganisms that can cause eye

infections

– HydraGlyde Moisture Matrix surrounds

lenses in moisture cushion and creates bar-

rier that reduces deposits and debris

Hydrogen peroxide care systemsHydrogen peroxide lens care systems can

be used to clean, disinfect, and store both

soft and gas permeable (GP) contact lenses.

Patients place their lenses in the provided

basket and rinse them, then place the bas-

ket in its cup and fill the cup with hydro-

gen peroxide solution to clean and disinfect.

Some lens holders for hydrogen peroxide

systems have a built-in neutralizer to con-

vert the hydrogen peroxide to saline, but

others require patients to add a neutralizing

tablet. After the disinfection and neutraliz-

ing step is completed, patients are able to

safely wear the lenses. They should never

rinse their lenses with hydrogen peroxide

solution or apply them directly to the eyes

without completing the entire disinfecting

and neutralizing step. Doing so can cause

a painful chemical burn.

Hydrogen peroxide systems may help

TAKE-HOME MESSAGE Even prescribing a specific lens care product won’t prevent your patients from facing an overwhelming retail display when they go to buy. Help your patients better navigate the aisles by knowing what’s available yourself. Review MPS, peroxide, and saline choices.

Contact lens solution roundupKnow what your patients see when they purchase lens care products

KATY MCDERMOTT is a freelance writer based in the Philadelphia suburbs

See Solution roundup on page 32

ModernMedicineTopic-BasedResource Centers Resource Center

modernmedicine.com/resource-center/contact-lenses-and-lens-care

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32S P E C I A L S E C T I O N

OCTOBER 2016 |

Lens Care

wearers who are sensitive to preservatives

used in multipurpose solutions. However,

many eyecare professionals are prescribing

hydrogen peroxide care systems as a first

choice for cleaning.

PeroxiClear (Bausch + Lomb) – Triple-Moist Technology, a combination

of 3 moisturizing ingredients that attract,

spread, and retain moisture on lens surfaces

– Up to 20 hours of moisture

– Peroxide neutralized with lenses ready

to wear in only four hours

– Can be used for soft, silicone hydrogel,

and gas permeable lenses

Clear Care (Alcon)– Uses effervescent properties of hydro-

gen peroxide to clean and disinfect lenses

– Tr iple Ac t ion Clean ing power

avoids harsh preservat ives found in

many multi-purpose solutions

Clear Care Plus (Alcon)– Uses effervescent properties of hydro-

gen peroxide to clean and disinfect lenses

– After cleaning and disinfecting, neu-

tralizes into a saline solution much like

natural tears

– Doesn’t use preservatives and chemi-

cals found in other solutions

– Surrounds lenses with long-lasting mois-

ture due to HydraGlyde

GAS PERMEABLE LENS CAREIn the past, GP lenses often were rinsed with

tap water after cleaning. Eyecare profes-

sionals now recommend against this prac-

tice, however, because microorganisms in

tap water can cause eye infections, includ-

ing Acanthamoeba keratitis. In addition, the

U.S. Food and Drug Administration (FDA)

recommends that no type of water (other

than that contained in approved contact

lens solutions) come in contact with con-

tact lenses. Rinse gas permeable contacts

done only with multi-purpose solution or

sterile saline.

Lens care systems for GP lenses are simi-

lar to those for soft lenses, and usually con-

sist of either the combined use of separate

cleaning and disinfecting/storage solutions

or the use of a single multi-purpose solu-

tion for cleaning, disinfecting and storage.

Boston Advance Cleaner and Conditioning Solution (Bausch + Lomb)

– Two-bottle system

– Cleaner removes debris and deposits

from GP lenses, leaving lenses clean, clear,

and ready for disinfection and conditioning

– Cleaner is visibly tinted for faster rising.

The red tip on the cleaner bottle indicates

that the cleaner is not to be put in the eye

– Conditioning Solution dual disinfecting

system delivers protection against harm-

ful microorganisms and includes patented

cushioning system to soothe eyes

Unique pH (Menicon)– Multi-purpose solution

– Simple soaking mechanism removes

dirt, protein deposits, and debris with no

separate daily cleaner required

– Lens conditioning occurs via adjusting

to eye’s natural tear pH to enhance wetta-

bility and comfort of GP contact lenses on

application and during lens wear

– Lens disinfection uses antimicrobial

agents which destroy harmful microorganisms

commonly found on the surfaces of lenses

– May also be used to dilute a daily pro-

tein remover for simultaneous enzymatic

cleaning during conditioning

Optimum (Lobob)– Sterile cleaning, disinfecting, and stor-

ing solution for use with fluorosilicone ac-

rylate and silicone acrylate gas permeable

(GP) and hard contact lenses

– Prevents warpage of lens and adherence

of contaminants to lens surface

– Not for use directly in eye

– Not for use with soft (hydrophilic) lenses

Hybrid contact lens careThe standard of care for hybrid contact lenses

recommends using a daily cleaner approved

for both soft and GP lenses. This can be ei-

ther a multi-purpose solution or a hydrogen

peroxide solution. Note that in some pa-

tients, their tear chemistry may react with

the hydrogen peroxide to cause a perma-

nent white ring at the junction of the rigid

center and soft skirt. This ring does not af-

fect vision or comfort.

If needed, instruct your patients to use

rewetting drops approved for both soft and

gas permeable lenses. Based on patients’

individual needs, you may recommend ad-

ditional products or procedures. 

SALINE SOLUTIONSaline solution is for rinsing and storing

contact lenses only when patients are using

a heat or UV disinfection system. Patients

also may use saline with enzymatic clean-

ing tablets or devices which both clean and

disinfect. Be sure your patients are aware

that they should never use a saline product

for cleaning and disinfection.

Sensitive Eyes Saline Solution (Bausch + Lomb)

– pH-balanced formula containing potas-

sium, found in natural tears

– For use in rinsing after daily cleaning

and before insertion

– Safe for rinsing before or after heat,

chemical, or hydrogen peroxide disinfection

– Can also be used for diluting enzy-

matic cleaning tablets and storing soft con-

tact lenses after thermal disinfection

PuriLens Plus (LifeStyle Company, Inc.)

– Preservative-free saline solution in com-

bination with special cleaning chamber that

uses UV light to kill germs and bacteria

– Saline solution component similar to

Unisol 4 in chemical component and could

be safely used to rinse or fill lenses

– Purilens Plus Ultra PF sterile saline avail-

able separately from rest of cleaning system 

Clear Care Rinse & Go (Alcon)– Launched in spring 2016 as replace-

ment for Unisol

– Made specifically for contact lens wear-

ers using peroxide care systems.

Katy McDermott has written for the medical and pharmaceutical industries. She has authored four mysteries and is working on her third children’s book.

kmcdermott@linguapharmacontent.com

Solution roundupContinued from page 30

In the past, GP lenses often were rinsed with tap water after cleaning. Eyecare professionals now recommend against this practice, however, because microorganisms in tap water can cause eye infections, including Acanthamoeba keratitis

OCTOBER 2016 / OptometryTimes.com MarketplaceMarketplace 33

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OCTOBER 2016 | 34 A&Q

 When did you become interested in optome-

try? When I was in Nigeria,

the federal government de-

cided to target certain pro-

fessions by giving people

scholarships. I wanted to

do architecture. I figured I

could go out of the country

for architecture, but the only

way I could do that was to

pick one of the scholarship

courses. I picked ophthal-

mic optics. In my first year,

I realize this is something

that could pique my inter-

est. I still didn’t think it was

a good path for me until one

day I was studying in the li-

brary and this young Asian

gentleman came by—he had

the personality that I thought

was awesome. This gentle-

man is young, he’s a doc-

tor, he spoke so well, he car-

ried himself so well. That

moment made me feel, “Oh

my God, this is great!” and

I could see myself talking to

students about the profession

I enjoy. That was the mo-

ment that told me this was a

good thing to pursue.

 What would you ad-vise someone moving

from academia to private prac-tice? If you are going from

academia to private practice,

make sure you differentiate

yourself. There are ODs ev-

erywhere. We are opening

new schools—we’re up to 22

schools now—and more will

be on the way, and they are

graduating more and more

students. Just putting your

name out there doesn’t make

people come. Find a niche.

It could be contact lenses

or prosthetic eyes. We don’t

have a whole lot of patients

who need prosthetic eyes,

have choices. Also plan on

delivering exceptional cus-

tomer service. If you can do

that and find a niche, I think

you will be OK.

What’s something your colleagues don’t know

about you? [Laughs] A lot of

people don’t know I’m into

politics. I did run for county

judge. [Laughs] I call myself

a Democrat, and Fort Bend

County (Texas) is heavy Re-

publican, so you know how

that went. [Laughs]. But it

was a good experience.

How quickly is cultural diversity growing in op-

tometry? It’s not growing

fast enough. A school must

weigh a lot of things: stu-

dents who can actually grad-

uate, who will become good

optometrists, who would

be able to get a license. We

get that. But lots of things

come into play. In terms of

cultural diversity, we don’t

have enough of some groups.

I will say for example, the

African American groups,

to really mimic the popula-

tion that we live in. There

are lots of areas where you

do not have anybody practic-

ing. It doesn’t mean that if

you graduate someone who

lives in a lower income area,

that person will necessar-

ily go back to that area but

he is likely to, and somebody

will see him, just like I saw

the Asian doctor,

We are trying to work with the optometry school in Berkley to see if Association of Schools and Colleges of Optometry (ASCO) might be able to hire somebody to go out there and recruit for all of the schools. This project is to find one person to reach the Af-rican American  and Hispanic populations all over the country to recruit good students. We are not looking for students who cannot compete, that would kill the whole system. We’re looking for peo-ple who can compete, but those students typ-ically go to medical or dental school because they have not seen a role model in optome-try. So this person will advocate to qualified students to say, “Here is a different profes-sion.” We have to el-evate the profession ourselves to let peo-ple know that this is a viable profession something we can all be proud of.

QQWhat ways are in place to attract more people of

color?

but when that patient

needs one he doesn’t

Running for office, diversity in optometry, and mentoring studentsPhilip Aitsebaomo, OD, PhD, FAAO President of the National Optometric Association, assistant professor at UIW Rosenberg School of Optometry

and say, “This is what I want

to do.” I’m very proud of the

NOA, and we are doing a lot

of work. We do community

work so that communities

can see us and say, “Wow,

I’m going to be an optome-

trist.” We need more doctors

from minority groups.

What’s one thing you would change about

optometry as it stands now?[Laughs] Most states have a

fairly good prescribing au-

thority. We are too quick to

go to samples. So, when the

pharmaceutical industry is

looking at who is prescrib-

ing, they don’t see us mea-

suring up. They see a pri-

mary care physician pre-

scribing more eye drops

than we do, even though we

see the bulk of the patients.

I think we really ought to

work hard at prescribing to

our patients.

—Vernon Trollinger

Phot

o co

urte

sy P

hilip

Aits

ebao

mo,

OD,

PhD

, FAA

O

To hear the full interview with Dr. Aitsebaomo, listen

online: optometrytimes.com/

DrAitsebaomo

http://coopervision.com/

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