INSIDE
-Understanding scleral topography: p.5
-A handy guide to ophthalmic medications: p. 6
-When is neuroimaging necessary: p. 8
pacificu.edu
Pacific University College of Optometry
EYE ON PACIFIC
As vision subspeciales connue to grow, we can ensure that paents connue to get the care they deserve.
Spring | 2016
When It’s Not Obvious:
Finding Ocular Surface Disease
TRACY DOLL, OD, FAAO | DRY EYE SOLUTIONS CLINIC COORDINATOR
Characteristicsoffrankmeibomianglanddysfunction
(MGD)areveryeasytospot:thickenedeyelidmargins
withtelangiectasia,cappedglandopenings,and
toothpaste-likesecretionsonexpression.Athorough
medicalhistorymayshowunderlyingacnerosaceaor
sebaceousglanddisorder.Commonsymptomsinclude
burning,stinging,visionfluctuation,reflextearing,and
fatigue.However,thereisadistinctsubsetofpatients
whosufferfromMGDthatdonotdisplaytheabove
characteristics.Thedysfunctionishappeningdeeper
insidetheglandandisnotdisplayedonthesurface.In
fact,theeyelidmarginscanbelargelyunremarkable.
Inthesecases,themeibomianglandsareeithernot
producinglipidortheoilistrappeddeepintheglands.
YoucanstillidentifythissubtleMGDifyouarelooking
forthesigns.Properscreeningtoolscanleadtoa
clinicalexplanationofMGDsymptomsdespitethelack
ofclassicsigns.
Ocular Surface Disease (continued)
TheKorbMeibomianGlandEvaluator™
(Figure1)isahandhelddevicethatcanbe
usedtogentlyexpresstheglandswiththe
samepressureasanaverageblink.The
practitionercanapplythisgentlepressureto
theeyelidsandscreenforlowsecretionofthe
glandsinunderaminute.
Acompleteblinkisnecessarytostimulate
thereleaseofthemeibumandspreadthe
oilytearlayerevenlyacrosstheeye.Greater
thana40%partialblinkrateisindicativeof
daytimeexposureandstagnationofthe
lipidsontheeyelidmargin.TheLipiView®II
canquantifyincompleteorpartialblinkrates
(Figure3).
Figure 1: The Korb Meibomian Gland Evaluator™
Figure 3: LipiView® II printout showing a greater
rate of par#al blinks in the le% eye (86%)
compared to the right eye (47%).
Amoreadvanceddiagnosticdeviceavailable
atournewPaci.icDryEyeSolutionsclinicis
theLipiViewII®(Figure2).Thisinstrument
con.irmssubtleMGDbymeasuringthe
thicknessofthelipidlayerusingnoninvasive,
whitelightinterferometry.Alipidlayer
thinnerthan60nmcorrelateswellwith
symptomaticMGD.
Figure2:A.Dullappearanceofadecreasedlipid
layer(38nm).B.Normallipidlayer(greaterthan
100nm)producesabrightre#lection.
A
B
Anincompleteblinkcanoccurasasideeffect
ofcertainmedicationsorasaresultof
occupationaldemands.Theoverallblinkrate
candropupto75%whenlookingata
computerizeddevice.Patientswithalow
blinkrateandhighnumberofincomplete
blinkscanbene.itfromblinktraining.Paci.ic
DryEyeSolutionsprovidesblinktraining
regimenstopatientswithpoorblinkratesvia
theuseofcommerciallyavailablecomputer
andsmartphoneapps.
Ocular Surface Disease (continued)
Imagingofthemeibomianglandsthemselves
canshowunderlyingblockage,aswellas
damageandlossoftheglands.AtPaci.icDry
EyeSolutionsweofferDynamicMeibomian
Imaging™(DMI™)utilizinginfrared
photographycombinedwithtransillumination
(Figure4).Meibomianglandsshouldappearas
twolinesofadjacentclusters.Obstruction
causesthebasesoftheglandstoseparateand
widen.Thisisknownasductdilation.Chronic
obstructionandin.lammationleadtogland
dropout.Becauseglanddropoutisirreversible,
earlydiagnosisandmanagementiscrucialto
avoidpermanentmeibomianglanddamage.
NewtreatmentoptionsareavailableforMGD.
Paci.icDryEyeSolutionsofferstreatmentwith
theLipiFlow®.Thistreatmentmethodusesa
disposableactivatortodelivervectored
thermalpulsetherapy.Theactivatorisplaced
betweentheglobeandtheeyelid(Figure5),
whilethecorneaisprotectedbyashellthatis
similarindiametertoascleralcontactlens.
Theactivatorappliesconstantheatand
pulsatilepressuretotheeyelids.Itisimportant
tonotethattheactivatorheatsthroughthe
backsideoftheeyelid,closertowherethe
meibomianglandsarelocated.The12-minute
treatmentispainlessduetothecombinationof
heat,pressure,andcornealprotection.Fully
expressingstagnantglandcontentallows
restorationofthenormalmeibomiangland
function,improvingtearqualityandreducing
thein.lammatorycascade.
Excellentnewsforpatients:thecostofthe
LipiFlow®activatorsdroppedsigni.icantlyat
theendof2015,resultinginsavingsbeing
passedontopatients.LipiFlow®issuperiorto
classicmeibomianglandexpression(useof
paddlesandforceps)inthatitiscompleteand
painless.
ItisimportanttonotethatMGDcanaffectany
portionofthepopulation,whichiswhyhaving
thenecessarydiagnosticequipmentiscrucial.
Thefollowingcasesdemonstratethatpoint.
Figure 4: Images from Dynamic Meibomian Imaging.
A. Healthy glands extending the en#re length of the eyelid
(blue arrow). B. Dila#on of the meibomian ducts (yellow
arrow). C. Impac#on of the meibomian glands (orange
arrows), best imaged with transillumina#on meibography.
D. Dropout of the meibomian glands (red arrow).
A
B
C
D
Figure 5: Setup of the LipiFlow®
IllustrativeCases:
Case1:Figure6showsglanddropoutanda
verylowlipidlayermeasuredona56-year-old
malewithacnerosacea.Afterinitialdiagnosis
andcon.irmationofsevereglandloss,hewas
placedonahometherapyregimenthat
includedhotcompresses,lidscrubs,and
vegetarian-basedomega-3fattyacid
Ocular Surface Disease (continued)
supplementationinordertolowerin.lammation
andachieveacleanocularsurface.Onthis
therapy,thepatientachieveddecreased
symptomsandclearingofhislidsofscurfdebris.
Hisglandlossremainedstable,asdidthelipid
layerthicknessandincompleteblinkrate
demonstratedwiththeLipiView®II.MGE
scoreshadincreasedbytwoglandsineacheye,
andLipiFlowtreatmentwasperformedto
furtherimprovethemeibomianglandfunction.
Figure 6: Case 1
Case2:Figure7showsasimilarlypoorlipid
layerandglanddropoutina24-year-old
professionalstudent.Thehighincompleteblink
ratewasalargeareaofconcern.Hertreatment
regimenvaried,inthatblinktrainingwith
computerappswereprescribed.Shealsowas
abletoundergoLipiFlowtreatmentwith
dramaticimprovementinsymptoms.
Figure 7: Case 2
Figure 8: Case 3
Ocular Surface Disease (continued)
Case3:Figure8demonstratesa12-yearoldpatientwithsymptomsoffatiguewith
nearworkthatcouldnotbeexplainedbya
binocularorrefractivedisorder.Hewas
referredtoPaci.icDryEyeSolutionswith
suspecteddryness.Hislipidlayerthickness
was27nmODand32nmOS,lessthan1/3of
normal.Meibographyshowedmoderateto
advancedglandlossofthelowereyelids.He
hasbeenscheduledforLipiFlowtreatment
andreferredforVitaminAde.iciencytesting.
Themodernpractitionerhasnewtoolstoboth
discoverandmanagetheunderlyingcauseof
oculardrynessassociatedwithmeibomiangland
dysfunction.Newmethodsofscreeningcanhelp
to.indevensubtlecasesandallowfortreatment
priortopermanentdamagetotheglands.
Paci.icDryEyeSolutionsoffersadvancedinof.icediagnosticandtreatmentoptions.Ifwe
canbeofservicetoyouoryourpatientsdon’t
hesitatetocallusat503-352-1699.
Advances in Contact Lenses
SHEILA MORRISON, OD, MS | CORNEA AND CONTACT LENS RESIDENT
Innovationsincontactlenslathing
technologyandcontemporarycontactlensmaterialshavegreatlyimprovedtheperformanceofmodern
sclerallenses.Sclerallensesare
indicatedwhencornealdiseaseor
irregularityprohibittheuseoftraditionalcornealgaspermeable
lenses.Asclerallenscanvaultthe
irregularcornealsurface,allowing
thefullweightofthelenstoreston
thesclera.
Understandingthescleralshapeis
imperativetosuccessful.ittingof
thesespecialtycontactlenses.This
ispossibleusingtheanteriorsegmentOCT(Zeiss),Scheimp.lugimaging(Pentacam),andpro.ilometry
(sMap3D&Eaglet).
Withtheincreasinguseofscleral
lenses,practitionersandresearchersarebeginningtounderstand
theimportanceoffurtherresearch
elucidatingtheoptimal.ittingrelationshipbetweencontactlenses
andthecorneo-scleraljunction.
OurstudiesatPaci.icUniversity
ScleralshapedisplaygeneratedbythesMap3Dscleraltopographysystem.
indicatethatthescleraisasymmetricinmostpatients.The
asymmetryincreasesasyoumoveperipherallyfromthelimbus.
Becauseofthisasymmetry,scleraldesignsof14.5mmorless,
whichlandclosetothelimbus,maybene.itfromtraditional,
rotationallysymmetricsclerallandingzones,whereaslens
designslargerthan14.5mmmaybene.itfromatorichaptic
and/oraquadrantspeci.icdesigninanattempttomatchthe
moreasymmetricperipheralsclera.
Modi.icationsavailableinmodernsclerallensdesignsinclude
theabilitytocreateatoricperiphery.Thesecustomizable
sclerallandingzonesallowforbetter.ittinglensesandoffer
greatercomfortforpatients.
Advances in Medical Eye Care
LORNE YUDCOVITCH, OD, MS, FAAO | MEDICAL EYE CARE SERVICE CHIEF
Ophthalmicmedicationsareanintegralpartof
optometricpractice,andeachyeardrugupdates
occur.Recenthighlightsfrom2015includethe
introductionofPazeo(olopatadine0.7%),as
wellastheintroductionofgenericalternatives
forLumigan(bimatoprost0.03%),Travatan
(travoprost0.004%),Vigamox(moxi.loxacin
0.5%),andPataday(olopatadine0.2%).Currently,topicalophthalmichomatropineandscopolamineareunavailable;hopefullytheywillbe
re-introduced.
Foraneasy-to-usesourceforthemainophthalmicmedications,pleasefeelfreetoaccessthe
OphthalmicDrugs2016chart(Figure).This
chartshowcasesthemostcommonophthalmic
drugs,updatedasofthebeginningof2016.Both
topicalophthalmicandoralmedicationsareincluded,withFoodandDrugAdministration/
AmericanAcademyofOphthalmologycapcolor
representationwhenindicated.Commonbottle
sizes,concentrations,anddosagesareincluded.
Medicationswithgenericversionsarenotedwith
anasterisk(*).Pleasedownloadthechartforyour
personalusefromPaci.icUniversity’sCommonKnowledge.Gotohttp://
commons.paci.icu.edu/coofac/38andselect
“download.”
Wearehappytoconsultwithyouregardingophthalmicmedications.Pleasefeelfreetocontactthe
MedicalEyeCareServiceatanyofourEyeClinics.
Advances in Binocular Vision
HANNU LAUKKANEN, OD, MEd, FAAO | VISION THERAPY/PEDIATRICS SERVICE
IreneArroyo,ForestGroveVTCoordinator
Inthisissuewewouldlikeyoutomeettwoof
themostimportantpeopleinourVision
TherapyServices.MeganandIrene,ourvision
therapypatientandschedulecoordinators,
serveasourpublicrepresentatives.Without
thesetwowonderfullycapablepeople,our
VisionTherapyServiceswouldnotfunction
well.WeaskedIreneandMegantowriteabrief
introduction.
MynameisIreneArroyo,andIamtheVision
TherapyCoordinatorforourForestGroveClinic.
IstartedwithPaci.icUniversityin2002asthe
MedicalRecordsCoordinatorandmovedtothe
VTCoordinatorpositionfouryearsago.
Myfavoritepartofthevisiontherapyjobis
workingcloselywiththedoctorsandinterns,as
wellasgettingtoknowthepatientsona
personallevel.Ilovetoseehowinvolvedthe
parentsareintheirchildren’ssuccess.Ihaveto
behonestandsaythattheotherbestpartofmy
jobisthelittletreatsIgetfromthekidsand
internsattheendofthesemester.Ihave
receivedhomemadebookmarks,cards,cookies,
candy,andanendlessamountoflove!Themost
challengingpartofmyjobishavingtowear
manyhatsonanygivenday.Igofrombeingthe
visiontherapycoordinatortothecredentialing
specialist,totranslatingorbeingthebackupfor
thefrontdeskstaff.AttimesI’meventhecleaning
lady!But,Iwouldn’thaveitanyotherway.
WhenIamnotatwork,Ilovetospendtimewith
myfamily,whichincludesmyhusband,mytwo
daughtersandtheirspouses,andmythree
granddaughters.Ienjoybeinginvolvedinmy
church,playingsoftballandkickball,longwalks,
thebeach,andhappyhourwithfriends.
Youcanalwaysreachmeviae-mail@
iarroyo@paci.icu.eduorbyphone@503-3522174.Pleasefeelfreetocontactmeifyouever
haveanyquestionsaboutourservices!
MeganChapman-Rexford,PortlandVTCoordinator
MynameisMeganChapman-Rexford,andIamthe
VisionTherapyCoordinatorforourPortland
Clinic.IstartedatPaci.icEyeTrendsin2010asa
.loatingopticiananddidthisthroughoutmy
undergraduateyears.Iacceptedthispositionin
Septemberof2015.Mygoalistobecomean
optometrystudentnextautumn.
Ihavebeendeeplymovedbyhowhardour
wonderfulattendingdoctorsandinternsworkto
rehabilitateourpatients.Iwouldhavetosaythat
myfavoriteaspectofthispositionisthedetective
workIwitnessfromeveryoneinvolvedinthecare
ofourpatients.Conversely,themost
challengingaspectisthefactthatIhaveto
eventuallywatchourpatientsandinternsleave.
Wegettoknowthem-theirsuccessesand
challenges-andwatchthemgrow.Itistruly
dif.icultsayinggoodbye.
WhenI’mnotatwork,Icareformyelderly
parents,binge-watchTVshows,andcrochet
somemeanafghans!Ienjoyspendingtimewith
mynewfamily,whichincludesmyhusbandand
mynine-yearoldstepdaughter.
Ikeepmydooropentoeveryone,notjusttheVT
crew,andIprovidetastycandywhenIcan.Itis
prettyeasytocontactmeviaemailat
chap9064@paci.icu.edu.Callingmeat503-3522504isalittlemoredif.icultasIamalways
runningaround.Pleasefeelfreetocontactmeif
youeverhaveaquestionaboutourservices!
Advances in Neuro-Ophthalmic Disease
DENISE GOODWIN, OD, FAAO| NEURO-OPHTHALMIC DISEASE CLINIC
ToImageorNottoImage
Whetherornottoperformneuroimagingona
patientwithanisolatedextraocularmotor
nervepalsyiscontroversial.Anisolatedcranial
nerve(CN)palsyinanolderpatientisoften
vasculopathicinnature.However,some
patientshaveamoreseriousunderlying
condition.Weoftenfacethedilemmaof
exposingthepatienttothecostsof
neuroimagingorriskmissingaseriousand
potentiallytreatablecondition.
Arecentprospective,multicenterstudy
suggestedthatupto5%ofpatientsthoughtto
haveavasculopathicCN4orCN6palsyended
uphavinganon-vasculopathiccause,including
aneurysm,tumor,orstroke.Thisincreasedto
16%ifCN3palsieswereincluded.Inaddition,
vasculopathicriskfactorswerepresentin61%
ofpatientsfoundtohaveanon-vasculopathic
causeforthepalsy.Thistellsusthatjust
becauseapatienthasvasculopathicriskfactors
doesnotmeanthatthepalsyisalways
vasculopathic.
Advantagesofimagingearlyincludeimproved
clinicaloutcomeandpsychologicalbene.its.
Treatmentofdemyelination,tumors,stroke,
andotherneurologicdiseasehasimproved
greatlyinrecentyears.Thismakesearly
diagnosismorecriticalinthesepatients.A
normalMRIcanalsoallayfearsassociatedwith
neurologicdiseasewhich,inturn,canimpact
socialandpsychologicalhealth.
BothcompleteandpartialCN3palsiesshouldbe
imagedduetotheriskofaneurysm.Whetherto
imagethosewithaCN4orCN6palsyismore
debated.Althoughweliveinatimewherecost
constraintsareparamount,wemustask
ourselvesifwearewillingtotaketheriskof
missingapotentiallyseriouscausethatmaybe
treatable.Ultimatelythedecisiontoobtain
neuroimagingmustbemadeonanindividual
basis.Performingathoroughhistoryand
recognizingsubtlesignsorsymptomsarecritical
indetermineifneuroimagingwouldbe
advantageoustothepatient.
Feelfreetocontactusat503-352-7300ifyou
haveaquestionregardingwhetherornotto
orderneuroimagingforyourpatient.
Pacific EyeClinics Updates
CAROLE TIMPONE, OD, FAAO, FNAP | ASSOCIATE DEAN OF CLINICAL PROGRAMS
CindiRapp,DirectorofClinicOperations
OurnewestadditiontothePaci.icUniversity
EyeClinicteamisCindiRapp,RDH,Directorof
ClinicalOperations.Cindibringsenergyanda
newperspectivetoourclinicalsystem,having
spentherearliercareeratKaiserPermanentein
theDentalCareProgram.Thereshehad
opportunitiestobeinclinicalpractice,workas
consultantandtrainer,andserveasareamanager
forKaiser’smanydentalof.ices.Althoughnewto
theCollegeofOptometry,Cindibecameinvolved
withPaci.icUniversityduringtheinitial
developmentphaseofitsdentalhygienedegree
program,havingbeenaskedtoserveonits
advisoryboard.Cindirecalls,“Itwasexcitingto
seetheworkoftheadvisory/curriculum
committeecometofruitionwhentheDental
HygieneStudiesProgramopenedwiththe.irst
class,in2007.”Shewassubsequentlyrecruited
asanadjunctclinicfacultymemberand
thoroughlyenjoyedheryearsworkingwiththe
students.
HernewroleinclinicaloperationsfortheCollege
ofOptometryenableshertocontinuetointeract
withstudents,whilereturningtoherpassionof
healthcareadministration.InCindi’sownwords,
“Itisaprivilegetocontinueworkingwith
students,staffandfacultyandtooverseethe
operationsofoureyeclinics.Iamdelightedtobe
partoftheCollegeofOptometry!Havingspent
manyyearsindentistry,bothinmanagementand
asaregistereddentalhygienist,Iamexcitedto
learnabouttheworldofvision.Icanalreadyfeel
thepositiveenergyandseeacommitted,cohesive
teamwhichissoimportant,aswecanallachieve
somuchmoretogetherthanwhatwecan
accomplishalone.Ilookforwardtobeinga
contributingmemberoftheoptometryteam!”
Whennotatwork,Cindienjoysspendingtime
withherfamily—husband,Greg,of25years;her
daughter,Meg(ajunioratGonzagaUniversity);
andherson,Chris(ajunioratValleyCatholicHS).
Shelikestogarden,cook,enjoytheoutdoors,and
watchherkidsplaysports.
Ourclinicalfacultyandstaffareheretohelpyou
withpatientconsultationsandreferrals.Pleaselet
usknowhowwecanbestserveyourneeds!
CE Opportunities
April 2016:
-Coeur d’Alene CE; Coeur d’Alene Golf and Spa
Resort, Coeur d’Alene, ID; Apr. 15-16.
-Teplick Vision’s 22nd Annual Blockbuster 5 hour
CE Event; NVision Eye Center, Portland, OR;
April 30, 7:30-2:30. Click here to register.
May 2016:
-Oregon’s Meeting; Sunriver Resort; Sunriver,
OR; May 19-22.
June 2016:
-Northwest Residents Conference; Jefferson Hall,
Forest Grove, OR; June 10-11.
July 2016:
-Victoria Conference; Delta Victoria Ocean
Pointe Resort, Victoria, Canada; July 21-24.
Referral Service Contact Numbers
Pacific EyeClinic Forest Grove
2043CollegeWay,ForestGrove,OR97116
Phone:503-352-2020
Fax:503-352-2261
VisionTherapy:ScottCooper,OD;GrahamErickson,OD;HannuLaukkanen,OD;JPLowery,OD
Pediatrics:ScottCooper,OD;GrahamErickson,OD;HannuLaukkanen,OD;JPLowery,OD
MedicalEyeCare:RyanBulson,OD;TracyDoll,OD;LorneYudcovitch,OD
LowVision:KarlCitek,OD;JPLowery,OD
ContactLens:MarkAndre;TadBuckingham,OD;PatrickCaroline;AmieeHo,OD;BethKinoshita,OD;
HannahShinoda,OD
Pacific EyeClinic Cornelius
1151N.Adair,Suite104Cornelius,OR97113
Phone:503-352-8543
Fax:503-352-8535
Pediatrics:JPLowery,OD
MedicalEyeCare:TadBuckingham,OD;SarahMartin,OD;CarolineOoley,OD;LorneYudcovitch,OD
Pacific EyeClinic Hillsboro
222SE8thAvenue,Hillsboro,OR97123
Phone:503-352-7300
Fax:503-352-7220
Pediatrics:RyanBulson,OD
MedicalEyeCare:TracyDoll,OD;DinaErickson,OD;MichelaKenning,OD;CarolineOoley,OD
Neuro-ophthalmicDisease:DeniseGoodwin,OD
Pacific EyeClinic Beaverton
12600SWCrescentSt,Suite130,Beaverton,OR97005
Phone:503-352-1699
Fax:503-352-1690
3DVision:JamesKundart,OD
Pediatrics:AlanLove,OD
MedicalEyeCare:SusanLittle.ield,OD
ContactLens:MattLampa,OD
DryEyeSolutions:TracyDoll,OD
Pacific EyeClinic Portland
511SW10thAve.,Suite500,Portland,OR97205
Phone:503-352-2500
Fax:503-352-2523
VisionTherapy:BradleyCoffey,OD;BenConway,OD;ScottCooper,OD;JamesKundart,OD
Pediatrics:BradleyCoffey,OD;BenConway,OD;ScottCooper,OD;JamesKundart,OD
MedicalEyeCare:RyanBulson,OD;CandaceHamel,OD;ScottOverton,OD;CaroleTimpone,OD
ContactLens:MarkAndre;CandaceHamel,OD;MattLampa,OD;ScottOverton,OD;SarahPajot,OD
Neuro-ophthalmicDisease/Strabismus:RickLondon,OD
LowVision:ScottOverton,OD
Whenschedulinganappointmentforyourpatient,pleasehavethepatient’sname,address,phonenumber,
dateofbirth,andinsuranceprovider,aswellasthetypeofserviceyouwouldlikePaci.icUniversityeye
clinicstoprovide.