AUGUST 2015
VOL. 7, NO. 8
OptometryTimes.com
PRACTICAL CHAIRSIDE ADVICE
SPECIAL SECTION
Pediatrics
Using OCT for your
younger patients
Urine in pools
causes red eyes
By Colleen McCarthy
Content Specialist
Atlanta—The Centers for Disease Control and Prevention (CDC) recently told Women’s Health
magazine that the reason some swimmers
get red eyes after a dip in the pool isn’t the
chlorine—it’s the urine in the water.
Michael J. Beach, PhD, associate director
1,2 tells the
of
the
** CDC’s Healthy Water Program,
magazine that chlorine binds with sweat and
urine produced by swimmers and forms chemical irritants. That irritant is also to blame for
the cough many swimmers get from an indoor pool after the chemicals enters the lungs.
“This report will make you think before
ever getting in a public pool,” says Chief Optometric Editor Ernie Bowling, OD, FAAO.
“Remember, even though you’re there for
fun, you are potentially sharing body fluids
with the entire2%!(,
populace. I recommend no
one ever open their
underwater, and I
8 | 4™eyes
%**!%"'*#%**
recommend swimming
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sick or have any open wounds.
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ourapplications
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future
gives your patients clear, stable vision and comfort.
1
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8
3
PRECISION BALANCE 8 | 4™
LENS DESIGN
6
Visit MYALCON.COM to learn why AIR OPTIX® for
Astigmatism contact lenses are the lenses of choice
By Rachel
A.practitioners.
Coulter, OD, MS, FAAO, and Erin Jenewein, OD, MS, FAAO
for many
eye care
4
the optometrist
with
to make miye disease is relatively uncommon in
SCRIBE MARKS
ATthe
3, 6 ability
AND 9 O’CLOCK
croscopic retinal abnormalities clearly evichildren. When it is present, however,
dent and to quantify and replicate measures
optometrists may find the tasks of seof tissue structure. Patients are better able
lecting tests, obtaining findings, and
to tolerate OCT testing than other diagnosinterpreting results to be more difficult. Chiltic tests—OCT is not invasive and does not
dren are often moving targets. They quickly
require a probe contact or use of an immerbegin to fatigue or resist testing. The opBy Colleen McCarthy
1
sion medium.™
tometrist may be more dependent on objecContent Specialist
OCT also does not require
DRIVEN
SCIENCE
tivePERFORMANCE
tests, due to limitations in
obtaining aBY radiation
exposure, which may be a parcomplete or detailed history. Young pediatticular concern in the pediatric population.2
Seattle—Bob Prouty, OD, FAAO, educated a packed
ric patients frequently cannot describe their
house at the American Optometirc AssociaOCT creates high-quality cross-section
symptoms, and the parent who accompanies
tion’s Optometry’s Meeting on marijuana’s
images of tissue structure using interferthem to their eye examination may or may
use in and outside of eye care.
ometry.1 It originally developed in its time
not be present as the*Dk/t
symptoms
unfolded.
Because his father was a police officer,
domain
form
that
uses
a
time
comparison
= 108 @ -3.00D -1.25 x 180. Other factors may impact eye health. **Based on subjective vision ratings and investigator-graded surface deposits. † Compared
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The potential of optical
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with^ aPureVision,
moving
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arm
to determine
ADVANCE,^ PureVision,^ Biofinity^ and Avaira^ contact lenses. ^Trademarks 3are the property of their respective owners.
raphy (OCT) to support
diagnosis
and
mancally
or
otherwise.
But
that
doesn’t
mean he
the
depth
of
retinal
tissue.
Stratus OCT was
Important information for AIR OPTIX® for Astigmatism (lotrafi lcon B) contact lenses: For daily wear or extended wear up to 6 nights for near/far-sightedness and
Risk of serious
eye problems
(i.e., corneal
is greater
for extended
wear.More
In rare cases,
may result.
like discomfort,
mild burning
agement of pediatricastigmatism.
ocular disease
is pardoesn’t
seeSide
theeffects
potential
benefits—or
harms—
designed
asulcer)
a time
domain
OCT.
re- loss of vision
or stinging may occur.
ticularly intriguing.
OCT
provides
See OCT study
on page
26lcon B lenses comparing 2 weeks versus 4 weeks
SeeofMarijuana
on page 6
References: 1. Alcon data on file, 2008. 2. Eiden SB, Davis R, Bergenske P. Prospective
of lotrafi
wear for objective
E
Marijuana’s role in
optometry and beyond
Q&A
and subjective measures of health, comfort and vision. Eye & Contact Lens. 2013;39(4):290-294. 3. In vitro measurement of contact angles on unworn spherical lenses;
significance demonstrated at the 0.05 level; Alcon data on file, 2009. 4. Nash W, Gabriel M, Mowrey-McKee M. A comparison of various silicone hydrogel lenses; lipid and
protein deposition as a result of daily wear. Optom Vis Sci. 2010;87:E-abstract 105110.
See product instructions for complete wear, care and safety information.
© 2014 Novartis 1/14 AOT14005JAD
| DR. JOAN HANSEN talks optometry politics, C E junkie, and hairdressing
SEE PAGE 46
AUGUST 2015
VOL. 7, NO. 8
OptometryTimes.com
PRACTICAL CHAIRSIDE ADVICE
SPECIAL SECTION
Pediatrics
Using OCT for your
younger patients
Current and future applications
1
Figure 1.
OCT of optic
disc drusen.
By Rachel A. Coulter, OD, MS, FAAO, and Erin Jenewein, OD, MS, FAAO
ye disease is relatively uncommon in
children. When it is present, however,
optometrists may find the tasks of selecting tests, obtaining findings, and
interpreting results to be more difficult. Children are often moving targets. They quickly
begin to fatigue or resist testing. The optometrist may be more dependent on objective tests, due to limitations in obtaining a
complete or detailed history. Young pediatric patients frequently cannot describe their
symptoms, and the parent who accompanies
them to their eye examination may or may
not be present as the symptoms unfolded.
The potential of optical coherence tomography (OCT) to support diagnosis and management of pediatric ocular disease is particularly intriguing. OCT provides
E
Q&A
the optometrist with the ability to make microscopic retinal abnormalities clearly evident and to quantify and replicate measures
of tissue structure. Patients are better able
to tolerate OCT testing than other diagnostic tests—OCT is not invasive and does not
require a probe contact or use of an immersion medium.1 OCT also does not require
radiation exposure, which may be a particular concern in the pediatric population.2
OCT creates high-quality cross-section
images of tissue structure using interferometry.1 It originally developed in its time
domain form that uses a time comparison
with a moving reference arm to determine
the depth of retinal tissue.3 Stratus OCT was
designed as a time domain OCT. More reSee OCT on page 26
Urine in pools
causes red eyes
By Colleen McCarthy
Content Specialist
Atlanta—The Centers for Disease Control and Prevention (CDC) recently told Women’s Health
magazine that the reason some swimmers
get red eyes after a dip in the pool isn’t the
chlorine—it’s the urine in the water.
Michael J. Beach, PhD, associate director
of the CDC’s Healthy Water Program, tells the
magazine that chlorine binds with sweat and
urine produced by swimmers and forms chemical irritants. That irritant is also to blame for
the cough many swimmers get from an indoor pool after the chemicals enters the lungs.
“This report will make you think before
ever getting in a public pool,” says Chief Optometric Editor Ernie Bowling, OD, FAAO.
“Remember, even though you’re there for
fun, you are potentially sharing body fluids
with the entire populace. I recommend no
one ever open their eyes underwater, and I
recommend swimming goggles. And of course
remove contact lenses before swimming.”
Heading to the pool? Take a shower and
a bathroom break first. Don’t ever pee in
the water (and, no—we know what you’re
thinking—you’re not safe to do it in a lake
or ocean, either). The CDC also recommends
that people refrain from swimming if they’re
sick or have any open wounds.
Marijuana’s role in
optometry and beyond
By Colleen McCarthy
Content Specialist
Seattle—Bob Prouty, OD, FAAO, educated a packed
house at the American Optometirc Association’s Optometry’s Meeting on marijuana’s
use in and outside of eye care.
Because his father was a police officer,
Dr. Prouty has never used marijuana, medically or otherwise. But that doesn’t mean he
doesn’t see the potential benefits—or harms—
See Marijuana on page 6
| DR. JOAN HANSEN talks optometry politics, C E junkie, and hairdressing
SEE PAGE 46
| PRACTICAL CHAIRSIDE ADVICE
FROM
THE
Chief Optometric Editor
3
The doctor becomes the patient
By Ernie Bowling, OD, FAAO
Chief Optometric Editor
He is in private practice in Gadsden, AL, and
is the Diplomate Exam Chair of the American
Academy of Optometry’s Primary Care Section
erniebowling@icloud.com
256-295-2632
aring for patients day after day, we become desensitized to the discomfort we
inflict on them during an eye exam. I
recognize that everyone has their own fears
regarding doctor’s visits. For me, it’s the snap
of the rubber gloves over my family physician’s hands during my annual physical.
Even understanding these personal qualms,
I have little sympathy for the patient who
struggles with tonometry (air puff or applanation—they hate ‘em all) or fights to avoid
the BIO light during a dilated retinal exam.
Come on, people. This ain’t that bad. Multiply that by the dozens of times we perform
those procedures every week, and we can
easily become numb to our actions.
Recently, I was strikingly reminded of those
discomforts. While at the AOA meeting in
Seattle, I noticed a sudden onset of flashes
and floaters in my right eye. I saw the reti-
C
to hurt? That nurse lied. It hurt. And this
nal specialist upon my return home and was
doctor is recommending I have an injection
subjected to those same tortures I routinely
for the pain prior to the procedure. I politely
administer to my patients. We’ve all heard
declined. It can’t be that bad, I told myself,
the adage that doctors make the worst paand I still had a full afternoon of patients
tients, and I’m certain I fully measured up.
scheduled in my office.
Those anesthetic drops do really sting.
Girding my loins, I held my head tight
The dilating drops do make your near vision
against the forehead rest and looked where
blurry, and you really are sensitive to light.
he told me, as at that moment I had an irraThe dazzling lights of the slit lamp are nothtional fear of an aberrant laser burn striking
ing compared to the light of the BIO. Wow,
my macula. The surgeon placed 384 laser
just how damn bright can that device be?
spots in the affected area. This gave me a
Let’s not forget scleral depression. I got the
new appreciation for my patients’ pain threshfull-bore treatment, which I am grateful for
old. When he finished, he grinned and said,
now but wasn’t so much at the time. After
“You’re one tough SOB.” Then he asked, “So,
several minutes, my toes had curled, and
how did that feel?”
I’m certain I left a permanent indentation in
How did it feel? Like someone stuck me with
his exam chair from my white-knuckle grip.
a pin…384 times. Individually, it wouldn’t
His very thorough evaluation revealed a
have been so bad, but the never-ending onsmall flap tear in an area of lattice degeneraslaught of the laser magnified the experience.
tion. He recommended a laser repair, which
Afterward, I trudged back to the office
I agreed to immediately. I’ve seen many paand saw my afternoon schedule—
tients undergo this procedure without much
but with a greater appreciation of
regard for what they were experiencmy patient’s trepidations. And
ing. I should’ve gotten a clue when the
We have
top VT tools
in the future, when that patient
retinal surgeon suggested a subconfrom Dr. Marc
tries to climb out of the chair
junctival anesthetic injection.
Taub. See page
because of a test I’m doing, I’ll
You remember back when you were
30 for more.
try to be more empathetic.
little, the nurse told you it wasn’t going
Editorial Advisory Board
Ernie 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.
Jeffrey Anshel, OD, FAAO
Michael P. Cooper, OD
Alan G. Kabat, OD, FAAO
Mohammad Rafieetary, OD, FAAO
Joseph Sowka, OD, FAAO
Ocular Nutrition Society
Encinitas, CA
Chous Eye Care Associates
Tacoma, WA
Southern College of Optometry
Memphis, TN
Charles Retina Institute
Memphis, TN
Sherry J. Bass, OD, FAAO
Douglas K. Devries, OD
David L. Kading, OD, FAAO
Michael Rothschild, OD
Nova Southeastern University College
of Optometry
Fort Lauderdale, FL
SUNY College of Optometry
New York, NY
Eye Care Associates of Nevada
Sparks, NV
Specialty Eyecare Group
Kirkland, WA
West Georgia Eye Care
Carrollton, GA
Justin Bazan, OD
Steven Ferucci, OD, FAAO
Danica J. Marrelli, OD, FAAO
John Rumpakis, OD, MBA
Park Slope Eye
Brooklyn, NY
Sepulveda VA Ambulatory Care
Center and Nursing Home
Sepulveda, CA
University of Houston College
of Optometry
Houston, TX
Practice Resource Management
Lake Oswego, OR
Lisa Frye, ABOC, FNAO
Katherine M. Mastrota, MS, OD, FAAO
Eye Care Associates
Birmingham, AL
Omni Eye Surgery
New York, NY
Eyecare Consultants Vision Source
Englewood, CO
Ben Gaddie, OD, FAAO
John J. McSoley, OD
Gaddie Eye Centers
Louisville, KY
University of Miami Medical Group
Miami, FL
University of Alabama at Birmingham
School of Optometry
Birmingham, AL
David I. Geffen, OD, FAAO
Ron Melton, OD, FAAO
Peter Shaw-McMinn, OD
Gordon Weiss Schanzlin
Vision Institute
San Diego, CA
Educators in Primary Eye Care LLC
Charlotte, NC
Southern California College of Optometry William D. Townsend, OD, FAAO
Sun City Vision Center
Advanced Eye Care
Sun City, CA
Canyon, TX
Jeffry D. Gerson, OD, FAAO
Highland, CA
Diana L. Shechtman, OD, FAAO
William J. Tullo, OD, FAAO
Patricia A. Modica, OD, FAAO
Nova Southeastern University
Fort Lauderdale, FL
TLC Laser Eye Centers/
Princeton Optometric Physicians
Princeton, NJ
Marc R. Bloomenstein, OD, FAAO
Schwartz Laser Eye Center
Scottsdale, AZ
Crystal Brimer, OD
Crystal Vision Services
Wilmington, NC
Mile Brujic, OD
Premier Vision Group
Bowling Green, OH
Benjamin P. Casella, OD
Casella Eye Center
Augusta, GA
Michael A. Chaglasian, OD
Illinois Eye Institute
Chicago, IL
WestGlen Eyecare
Shawnee, KS
Milton M. Hom, OD, FAAO
A. Paul Chous, OD, MA
Azusa, CA
Chous Eye Care Associates
Tacoma, WA
Renee Jacobs, OD, MA
Practice Management Depot
Vancouver, BC
Pamela J. Miller, OD, FAAO, JD
SUNY College of Optometry
New York, NY
Laurie L. Pierce, LDO, ABOM
Hillsborough Community College
Tampa, FL
John L. Schachet, OD
Leo P. Semes, OD
Joseph P. Shovlin, OD, FAAO, DPNAP
Northeastern Eye Institute
Scranton, PA
Kirk Smick, OD
Clayton Eye Centers
Morrow, GA
Loretta B. Szczotka-Flynn, OD, MS, FAAO
University Hospitals Case Medical Center
Cleveland, OH
Marc B. Taub, OD, MS, FAAO, FCOVD
Southern College of Optometry
Memphis, TN
Tammy Pifer Than, OD, MS, FAAO
University of Alabama at
Birmingham School of Optometry
Birmingham, AL
J. James Thimons, OD, FAAO
Ophthalmic Consultants of Fairfield
Fairfield, CT
Walter O. Whitley, OD, MBA, FAAO
Virginia Eye Consultants
Norfolk, VA
Kathy C. Yang-Williams, OD, FAAO
Roosevelt Vision Source PLLC
Seattle, WA
Digit@l
4
AUGUST 2015
t VOL. 7, NO. 8
Content
CHECK OUT THE LATEST OPTOMETRY TIMES BLOGS
In 2015, Optometry Times is offering weekly blogs from some of the leaders in the
optometric profession. Haven’t read them yet? Here’s what you’re missing.
Dr. Mark Uhler says patients are often experience anxiety during their eye
exams—especially when it comes time for the “One or two?” question. Some
fear that if they give the “wrong” answer, they will jeopardize the prescription.
Check out his tips for calming your patient’s fears about giving the wrong
answer.
Dr. Tracey Schroeder Swartz is the parent of a teenager and recently learned
the meaning of the slang term “on fleek.” (Translation: on point, perfect.) The
revelation inspired her to come up with her own optometry-inspired slang
terms. Let’s just say her latest blog is totally “20/10.”
Dr. Leslie O’Dell says noncompliance will ruin even the most perfect treatment
plans. She shares her tips for making sure your patients are staying on the right
track with their medications and treatment plans.
optometrytimes.com/tag/odt-blog
TOP HEADLINES Check out
what your colleagues are reading.
1
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Optometry on fleek
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Blue eyes linked
to alcoholism
What your patients are
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JULY 20157
VOL. 7, NO.
OptometryTimes.com
CHAIR
PRACTICAL
E
SIDE ADVIC
Optic neuropathy ion
diagnosed via hypertens
correlates
blood pressure
Although low other risk factors exist
with NA-ION,
AFTER
BEFORE
of ONH
OCT 3D visualization OCT 3D
BEFORE Cirrus
AFTER Cirrus
at fivenear onset of NA-AION.
ONH edema resolution
visualization of
visit.
week follow-up
Managing
myopia with es
contact lens
FAAO
Bailey, NCLC,
Director
By Gretchyn
Content Channel
Editor in Chief,
n
Lens Associatio
British Contact its 2015 conferof
the first day
man(BCLA) opened
on myopia
day-long focus
Brien Holden,
ence with a
agement. Professor chief execuDSc,
BAppSc, PhD,
Holden
of the Brien
to
tive officer
offers points
Vision Institute,
managing myoremember when lenses.
pia with contact
increase in
There is a massive and high
myopia
of
the prevalence
to Dr. Holden.
myopia, according
of myopes increase,
unAs the number
of people with
the number
error will
corrected refractive
Liverpool, UK— The
increase.
myopia is mea.
Traditiona lly,
both meridians
D in one or
at –0.50
sured as -0.75
should be considered
Today, myopia
to Dr. Holden. child is -0.50
D, according
if a
knows that
on page 5
“Everyone
See Myopia
OD, RPh, FAAO
6
Bruce Onofrey,
use.
y, OD, and
inhibitor (PDE5) long
By Pierce Kenworth
phosphod iesterase
y
remains stable
optic neuropath 1
NA-AION generally unlikely to show any
fields
nterior ischemic described in 1974.
ent
first
term with visual spontaneous improvem
of the
(AION) was
but
non-perfusion
improvement,
acuity has been
It results from blood supply to the
lines of visual
The
of up to three
of patients.
anposterior ciliary
to 40 percent
makes
symptoms of
2
shown in up
resolves and
head. Classic
y include
head edema
optic nerve
optic nerve
weeks following
optic neuropath
in six to 11
terior ischemic vision loss, mild to severe
within
way for pallor
episode. Also,
fell field defect,
sudden, painless
the acute NA-AIONeye involvement, the
inferior altitudina
resolves
loss,
initial
vision
usually
five years of
become involved
edema, which
is
ral eye can
5
months and
and optic disc
low contralate
in about two
generalpercent of patients.
spontaneously
more often
in 15 to 19
sectoral or
replaced by
3
an
ized optic atrophy. particularly a small cup,
first noticed
Case report
size,
for
d Hispanic male left eye while
Optic nerve
a risk factor
A 49-year-ol
his
thought to be
case
shadow in
4
has long been
Though this
at work durinferior nasal
of NA-AION.
from the fridge
as a major risk
development
as painless
lifting a cooler
hypertension
It was described seek mediare also many
will represent
day.
there
the
ing
disorder,
He did not
at
and developfactor for the
and fairly sudden. the visual complaint
blood pressure
for
ive study
cases of low
5
y on page 20
One retrospect
cal evaluation
See Neuropath
ment of NA-AION. that there is a two-fold
showed
with
of NA-AION
increase risk
A
MISSION STATEMENT
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Frameri
After Shark Tank, success
online optical finds
E. McCarthy
By Colleen
Content Specialist
of
a recent episode a
you caught
Cincinnati, OH— If
may have gotten
Tank, you
company.
ABC’s Shark
latest startup
ofretailer that
look at eyewear’s
online optical
t
Frameri is an
and lenses—bu
priced frames
are
fers moderately
that the lenses
it different is
The wearer
what makes
between frames.
a
interchangeable
snap them into
the lenses and
Or the
can pop out
of seconds.
in a matter
opt
frame
and
different
optical lenses
pop out the
frames
wearer can
turning his
tinted lenses,
instead for
s.
page 6
into sunglasse
Frameri on
IN
Q&A | AGUST
GONZALES
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PAGE 41
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| PRACTICAL CHAIRSIDE ADVICE
In Focus
5
Glaucoma market to grow to $3 billion by 2023
By Colleen McCarthy
Content Specialist
London—The glaucoma treatment market is ex-
pected to grow across from $2.4 billion in
2013 to $3 billion by 2023, according to recent projections from research and consulting firm GlobalData.
The growth—which is projected for the
seven major markets: U.S., France, Germany,
Italy, Spain, UK, and Japan—was described
as moderate, with a compound annual growth
rate (CAGR) of 2.4 percent.
According to the report, the growth will
be driven by first-in-class drugs—such as
Rhopressa/Roclatan (Aerie), Vesneo (latanoprostene bunod, Bausch + Lomb), and trabodenoson (Inotek)—and the introduction
of additional fixed-dose combination (FDC)
products, such as Tapcom/Taptiqom (tafluprost/timolol maleate, Santen) and Simbrinza
(brinzolamide/brimonidine tartrate ophthalmic suspension, Alcon).
“The six products anticipated to enter the
seven major markets during the forecast period will collectively generate sales of $672
million by 2023, constituting a 22.2 percent
share of the global market,” says Catherine
Daly, PhD, senior analyst with GlobalData.
“Aerie’s Roclatan is forecast to achieve the
highest sales and is expected to generate
approximately $262 million in 2023. Significant uptake of Roclatan in the U.S., due to
the drug’s enviable position of becoming the
first prostaglandin, analog-containing FDC
product available in this large arena, will be
the main overall market driver.”
The GlobalData report also states that the
U.S. will consolidate its position as the dominant country for glaucoma treatment within
the major markets. U.S. sales
are expected to
increase from
$1.7 billion in
2013 to $2.2
billion by 2023
at a CAGR of
2.5 percent,
with its overall
market share
80
rising slightly
from 70.7 percent to 71.6 percent over the
same period.
“This increase is mainly attributed to the
expected introduction of several new products between 2013 and 2023, and the overall increase in glaucoma prevalence that is
mostly due to an aging society in the U.S.,”
says Dr. Daly. “However, Allergan will lose
patent protection for its FDC drug Combigan in 2022, allowing generic brimonidine
+ timolol FDC products to enter the arena.
This will negatively impact the U.S. market
value and slow the overall growth rate in
the last two years of the forecast period.”
PRODUCTS SOLD
ONLINE
70
71.6
73.9
IN BRIEF
Optovue launches Optovue Academy
FREMONT, CA—Optovue recently launched Optovue Academy, an
online learning portal offering clinical education, technician
training, and practice development tracks. Content will be
delivered via video PowerPoint presentations, recordings of
live presentations, a library of research documents, a forum
where learners can comment, and a calendar of live events
supported or hosted by Optovue Academy.
“Optovue Academy was created to give eyecare professionals the clinical knowledge they need to offer a higher level
of medical eye care with OCT,” says Larry Alexander, OD,
FAAO, senior director of clinical education for Optovue. “In
addition, this program supports the practice as a whole by
providing training for technicians and resources for growing
the practice with advanced imaging technology.”
“This program demonstrates that commitment by giving
eyecare professionals the tools they need to enhance patient
care with their Optovue OCT, improve operator scan acquisition skills and maximize the return on their investment
in the instrumentation,” says Christina Kirby, marketing
director for Optovue.
To learn more or request login credentials, visit www.OptovueAcademy.com.
% of Practices Selling on Website
60
50
47.3
47.3
41.3
40
41.3
28.4
30
21.7
20
13.5 13.0
10
0
Contact
Lenses
2013 n=325; 2014 n=46
Eyeglasses Sunglasses Accessories
Other
2013
2014
Source: Jobson 2014 ECP Internet Usage Study
6
In Focus
Marijuana
Continued from page 1
of medical marijuana.
His eyes were opened to the drug’s potential
medical benefits after seeing Sanjay Gupta’s
report on CNN about Charlotte Figi, a small
child from Colorado who was suffering from
Dravet Syndrome, a rare, severe form of intractable epilepsy. As a toddler, Figi suffered
from 300 grand mal seizures a week. Her
parents found a type of marijuana that was
high in cannabidiol (CBD) but low in tetrahydrocannabinol (THC), the intoxicant. They
were able to use the oil from this strain of
marijuana to greatly reduce Figi’s seizures.
At a federal level, marijuana remains a
Schedule I drug. While the attitudes about
marijuana seem to be shifting across the country, to date only four states have completely
legalized marijuana—Colorado, Washington,
Oregeon, and Alaska—which has made studying the drug and its effect on various diseases
and conditions rather difficult.
In 1997, the Institute of Medicine released a
report on medical marijuana. (http://www.nap.
edu/openbook.php?record_id=6376&page=1)
“While there was a remarkable conscientious about the potential of cannabinoid drugs
for medical use, there was far less convincing
data about the proven medical benefits about
whether this should be utilized at all,” he says.
“A review of the science behind marijuana
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Wilmington, NC
AUGUST 2015
and cannabinoids suggests that the debate
has been very misunderstood. Medical use
of potent, controlled psychoactive drugs has
not led to abuse, based on that report. Rather
than focusing on the drug control policy, the
medical marijuana debate should really be
more about future drug development.”
Under the guidance of a well-educated and
involved doctor, there are certain cases in
which medical marijuana can be used proactively and appropriately, says Dr. Prouty.
But does that extend to eye care?
Marijuana as a glaucoma
treatment
Glaucoma is currently listed as a condition
that can be treated with medical marijuana,
but Dr. Prouty asserts that there is no evidence that it is a better treatment than the
traditional medicines currently available.
|
efits of lowering IOP are outweighed by the
potential harm.
“So, they’re having a good time going
blind,” he says.
Is it helping or hurting?
Marijuana is often written off as a gateway
drug, leading its users down a path toward
much more addictive and dangerous drugs.
“Because it’s the most widely-used illegal
drug, marijuana is predictably the first one
that most people are going to encounter, including people who are going to experiment
with other substances. The vast majority of
them, however, are first acquainted with alcohol and nicotine, usually when they were
too young to participate with that legally,” he
says. “It is a gateway drug in that it generally
precedes other forms of illicit drugs. On the
other hand, marijuana does not appear to be
There are many reasons to worry that for
people who choose to use marijuana as
medicine, the drug could add to their health
problems—not be helping but hurting.
When medical marijuana advocates discuss the drug’s use as a glaucoma treatment
to lower intraocular pressure (IOP), they refer
to a study from the 1970s (http://www.ncbi.
nlm.nih.gov/pubmed/?term=Flom+MC%2C+
Adams+AJ%2C+Jones+RT.+Marijuana+smo
king+and+reduced+pressure+in+human+ey
es%3A+drug+action+or+epiphenomenon%3F
+Invest+Ophthalmol+1975%3B+14%3A52-5.)
when glaucoma treatment was nothing compared to what is available today.
“The first such reports generated considerable interest at the time because conventional
medications had such an adverse side-effect
profile,” says Dr. Prouty. “Currently, other treaments of the disorder have massively eclipsed
what marijuana-based medicines can do.”
While we know that marijuana does lower
IOP, researchers are not yet sure how or why it
does so. And in most trials, marijuana maintains IOP reduction for only three to four hours.
“How many times is that smoking in a
day? Eight times a day. So, you’ve got to be
dosed out of your gourd for this to have any
effect,” says Dr. Prouty.
Marijuana lowers blood pressure, and reduced blood pressure could decrease the blood
flow to the optic nerve, thereby contracting
from the benefits of lowering IOP. Without
further researcher, Dr. Prouty says the ben-
a gateway to the extent that it causes or even
is a significant predictor of hard drug abuse.”
Instead, the better predictor that someone
will move onto hard drugs is his intensity of
use of marijuana and other predispositions
for addiction.
“There are many reasons to worry that
for people who choose to use marijuana as
medicine—especially those who smoke it—
the drug could add to their health problems—
not be helping but hurting,” says Dr. Prouty.
Whether or not marijuana is addictive is
a hot topic, says Dr. Prouty.
“Yet, when you have candid discussion
with most marijuana users, they’ll tell you
they quickly develop a tolerance to its effects
and tend to want to use it more,” he says.
“That’s akin to addiction.”
Active marijuana users experience some
degree of withdrawal symptoms, including
restlessness, irritability, agitation, insomnia,
sleep disturbances, nausea, and cramping—
uncomfortable, but far milder than those withdrawal symptoms of alcohol or hard drugs,
says Dr. Prouty.
“For certain patients—particularly adolescents, people with psychological problems,
those with inherent disposition toward substance abuse—marijuana-based medications
may not be worth the work,” he says.
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07/15
8
Focus On
TECHNOLOGY
AUGUST 2015
|
5 ways to improve in-office purchasing
Tips for keeping your patients from hitting the online and big box retailers
Your patients are conditioned to believe that if they
take their Rx and just buy it online, they are going to
get the best deal. That may have been a partial truth
in the past, but today, you are often times able to offer
your patients the best deal.
find a better deal, no matter where they
When it comes down to it,
go. This includes online and offline big
your patients probably
box retailers. Remind them that
want to see your
you offer the best price.
practice succeed.
They know that
supporting you
STEP Use exclusive
with their busiproducts
ness w i l l en able
There are awesome
you to do so. However,
products that are sold
your patients are probably not
primarily offline. Leverage these
BY JUSTIN BAZAN, brands that don’t have a huge
willing to spend a whole heck
OD Owner of Vision
of a lot more in your office on
online presence. Reinforce their
Source Park Slope
products they can find online
exclusiveness and quality to enEye in Brooklyn.
for less—even with your specsure that your patients undertacular service included.
stand the value of them.
When it comes to glasses, contact lenses,
and other eyecare products, there are a
STEP Be first
few things you can do to provide your
You should have the first chance
to help your patients get the vision-related products they need
or want. The reality is that as an eyecare provider, your patients are in your
office, and you are able to have the opportunity to be the first to provide help
1. Use exclusive offers/rebates
to meet their needs. You are the most
convenient—let alone knowledgeable —
2. Use exclusive products
option they have because they can take
3. Be first
care of things on the spot before they
4. Optimize annual supply sales
walk out of your office.
Help
your staff
to work as a
team See page
36 for tips on
making it
happen.
2
3
How to improve
in-office purchasing
5. Offer competitive packages
STEP
patients with the best deals and service
possible. Here are five ways to keep your
patients buying from you, not from other
sources—including online.
STEP
1
Use exclusive
offers/rebates
You can help ensure that your
patients are getting the absolute
best price for their products by making
sure to take advantage of these exclusive manufacturer offers and rebates. You
can also help to start to recondition your
patients to understand that they cannot
4
Optimize annual supply
sales
When it comes to contact lenses,
helping your patients get their
annual supply is of utmost importance.
Purchasing an annual supply helps to
thwart end-of-the-box stretching, which
will help prevent contact lens abuse-related problems. It will also help to ensure
that patients don’t hop online to quickly
and easily re-up their supply through an
online vendor. We all know that once
patients are in the database of an online
vendor, they will receive near-constant
marketing, reducing the chances of them
purchasing from your office.
STEP
5
Offer competitive
packages
Online eyewear has evolved since
its inception. There are many
companies out there that are offering
products and service that your patients
find appealing. There are many people
out there who would buy from you if
only you were to offer them something
similar. If you want to retain these shoppers, provide them with what they are
looking for.
People —your patients—love the ease
of buying things online. They have also
learned that they can often find what
they need online for less money. However, you can provide your patients with
the best possible deals on the products
they need by keeping these five tips in
mind. You also get first chance at helping them do so.
Dr. Bazan is a 2004 SUNY grad.
Reach him on his Facebook page.
WANT MORE CONTENT
FROM DR. BAZAN?
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POWERFULLY
BREAKS THE CHAIN
IN PATHOGENS
OF GREATER
CONCERN 1-4
Indication
BESIVANCE®1;)9=167476-)6<151+:7*1)416,1+)<-,.7:<0-<:-)<5-6<7.*)+<-:1)4
+762=6+<1>1<1;+)=;-,*A;=;+-8<1*4-1;74)<-;7.<0-.7447?16/*)+<-:1)Aerococcus
viridans,*+7:A6-.7:5/:7=8Corynebacterium pseudodiphtheriticum,*
Corynebacterium striatum,* Haemophilus influenzae, Moraxella catarrhalis,*
Moraxella lacunata,* Pseudomonas aeruginosa,* Staphylococcus aureus,
Staphylococcus epidermidis, Staphylococcus hominis,* Staphylococcus lugdunensis,*
Staphylococcus warneri,* Streptococcus mitis group, Streptococcus oralis, Streptococcus
pneumoniae, Streptococcus salivarius*
* .E+)+A.7:<01;7:/)61;5?);;<=,1-,16.-?-:<0)6
16.-+<176;
Important Risk Information about BESIVANCE®
B$'® is for topical ophthalmic use only, and should not be injected
subconjunctivally, nor should it be introduced directly into the anterior chamber
of the eye.
B;?1<07<0-:)6<116.-+<1>-;8:7476/-,=;-7.$'® may result in
7>-:/:7?<07.676;=;+-8<1*4-7:/)61;5;16+4=,16/.=6/1.;=8-:16.-+<176
occurs, discontinue use and institute alternative therapy.
B!)<1-6<;;07=4,67<?-):+76<)+<4-6;-;1.<0-A0)>-;1/6;7:;A58<75;7.
*)+<-:1)4+762=6+<1>1<1;7:,=:16/<0-+7=:;-7.<0-:)8A?1<0$'®.
B%0-57;<+75576),>-:;-->-6<:-87:<-,167.8)<1-6<;<:-)<-,?1<0
BESIVANCE®?);+762=6+<1>)4:-,6-;; <0-:),>-:;-->-6<;:-87:<-,168)<1-6<;
receiving BESIVANCE®7++=::16/16)88:7@15)<-4A7.8)<1-6<;16+4=,-,
blurred vision, eye pain, eye irritation, eye pruritus and headache.
B$'®1;67<16<-6,-,<7*-),5161;<-:-,;A;<-51+)44A"=167476-;),5161;<-:-,;A;<-51+)44A0)>-*--6);;7+1)<-,?1<0
0A8-:;-6;1<1>1<A:-)+<176;->-6.7447?16/);16/4-,7;-!)<1-6<;;07=4,*-),>1;-,<7,1;+76<16=-=;-155-,1)<-4A)6,+76<)+<
their physician at the first sign of a rash or allergic reaction.
B$).-<A)6,-..-+<1>-6-;;1616.)6<;*-47?76-A-):7.)/-0)>-67<*--6-;<)*41;0-,
Please see the Brief Summary of the BESIVANCE® full prescribing information on the adjacent page.
References: 1. BESIVANCE®!:-;+:1*16/6.7:5)<176$-8<-5*-:
2.%-8-,167-44-:(&;6-:(-<)4!0);--.E+)+A)6,;).-<A;<=,A7.
*-;1F7@)+16780<0)451+;=;8-6;176
16<0-<:-)<5-6<7.*)+<-:1)4+762=6+<1>1<1;Curr Med Res Opin
3.-7:A75;<7+3%
-):16/-:$7::1;%(4161+)4-.E+)+A7.*-;1F7@)+16780<0)451+;=;8-6;176
)/)16;<#$)6,#$!7;<-:8:-;-6<-,)<66=)4--<16/7.
<0-;;7+1)<176.7:#-;-):+016'1;176)6, 80<0)45747/A)A
7:<)=,-:,)4-4.)<)76E4-)=;+075*6+7:87:)<-,
7:8:7,=+<:-4)<-,9=-;<176;)6,+76+-:6;+)441-800-323-0000 or visit www.bausch.com.
BESIVANCE is a registered trademark of Bausch & Lomb Incorporated or its affiliates.
©2014 Bausch & Lomb Incorporated.
US/BES/14/0003
| PRACTICAL CHAIRSIDE ADVICE
ALLERGY
Focus On
A new player to in-office allergy testing
Is point-of-care testing shotgun empiricism or diagnostic logic?
The scope of ocular surface disease is a vast territory
which can be treacherous and confusing for even the most
skilled clinician posed by a dry eye or “allergic conjunctivitis” case—or combination thereof. Why the quotation
surrounding this popular condition? The simple reason is
that until recently, the eyecare community utilized subjective data collection to diagnosis this multifaceted disease, albeit with great success.
What if I told you that prescribing an allergy medication
outright was a bandage or kneejerk approach? Before everyone
comes after me with pitchforks,
hear me out. I am not stating
that you have violated the sacred
Optometric Oath by mistreating
the patient. The thought is to expand our horizons as a profession
beyond its current bounds in a
more objective manner.
lergy, allergens interact with IgE
bound to sensitized mast cells
and after two rounds of exposure,
result in a massive hypersensitivity reaction characterized by
mast-cell degranulation. Consequent increased levels of histaMICHAEL S.
mine, prostaglandins, leukotriCOOPER, OD
enes, and other pro-inflammais in an OD/
tory molecules in the tear film
MD practice in
in these mast cells trigger the
Willimantic, CT
expression of chemokines, adhesion molecules, and other chemoattractive
proteins that recruit and activate T-cells
Scoping it out
and macrophages in the conjunctival muStatistically, 60 million Americans are afcosa, characterizing the late-phase Type
fected by allergies, of which 24 million (40
IV delayed reaction.6
percent) have some form of ocular etiol-
What would be the response if I
told you that prescribing an allergy
medication outright was a bandage or
knee-jerk approach?
ogy.1-3 From a public health standpoint, this
is a emerging epidemic for which population-based studies show that the rate of
allergenic disease is increasing in magnitude. The many faces of allergy encompass patients with classic seasonal and
perennial allergic conjunctivitis to vernal
keratoconjunctivitis, atopic keratoconjunctivitis, and giant papillary conjunctivitis.4
Seasonal and perennial allergies are
linked directly to the expression of specific immunoglobulin E (IgE) antibodies to environmental allergens making
up the most common form of ocular allergy, affecting up to 15 to 20 percent of
the population.5 In this type of ocular al-
In the huddle, be the
quarterback
In my ocular surface disease practice, allergic conjunctivitis comprises a rolling average of 25 percent of my cases, depending
on the season. With the heavy snowpack
and pollen boom in Spring 2015, many
emergent patients forced me to be creative
with the increased workload.
How did I do it? I took a step back and
delegated to my technical staff an arsenal
of objective (and painless) tests such as
TearLab Osmolarity Test, LipiView, and
now Doctor’s Allergy Formula. With a methodical point-of-care approach taking fewer than 12 minutes to
collect, I was able to optimize the patient
experience, leading to efficient diagnosis
and fewer symptomatic patients. This approach has exponentially grown my practice and created a gateway to facilitate dialogue with my fellow colleagues in the
allergy, rheumatology, and endocrinology
specialties. Furthermore, I make it a priority to share the information I collect in
a cordial and succinct summary through
my electronic health records to provide
the highest level of patient care.
Doctor’s Allergy Formula
Ocular surface disease hinges on identifying the unknown etiology. Doctor’s Allergy
Formula (DAF) fits right into this mold
by providing a non-invasive, no-needle,
proprietary U.S. Food and Drug Administration-approved diagnostic test designed
to objectively diagnose specific allergies.
When I was researching this test strategy,
a component I found interesting was that
it included both positive and negative controls in order to diminish false readings.
In addition, with the scientific team’s assistance, you are able to build an antigen database with up to 58 allergens that
are regionally specific for higher yield depending on the practice’s geographic location. A pearl that I have gleaned from
an esteemed ophthalmology colleague of
mine is that you must alert the patient to
stop his allergy treatment five days prior
to administering DAF to get a properly
calibrated and meaningful result.
Results can be interpreted within 10 to
15 minutes, allowing for immediate patient education on the sensitive allergens
and methods of avoidance. From my perspective, the ability to customize DAF is
powerful and can be life altering for some
severe allergy sufferers.7
In the practice management realm, the
test is covered and reimbursed by all major
medical insurances and Medicare using
the well-established CPT-4 billing code of
95004, described as “percutaneous tests
with allergenic extracts, immediate type
reactions.” Information provided by the
company suggests when billing the procedure to use a quantity modifier of 60.
Finally, there is a one significant caveat:
even though the code is multidisciplinary,
See Point-of-care testing on page 12
11
12
Focus On
ALLERGY
Point-of-care testing
AUGUST 2015
|
1
Figure 1. Close-up of antigen
applicator. (Photos courtesy Doctor’s
Allergy Formula)
2
Figure 2. A sample of colorcoded antigen database.
3
Figure 3. Administration of the
antigen applicator to a patient’s
forearm.
Continued from page 11
an OD-only practice setting cannot yet
participate unless associated with a MD
or DO. If you want to perform the DAF
analysis, reach out to your ophthalmology peers for assistance.
Taking the next step
Revisiting the question regarding the bandage or knee jerk response approach to medication administration—the call to action
is to truly identify the specific offending
allergens in order to properly manage each
case. In-office allergy testing will instill
confidence in the clinician to know what
role allergy plays in the ocular surface disease and also what the best treatment(s)
might be for the patient. Consequently,
this new paradigm shift in ocular surface
disease management will allow patients
not only physical but psychological relief
from their allergy symptoms by providing
them a sense of knowing that their condition has been addressed in a compassionate and disciplined manner.
REFERENCES
1. Singh K, Bielory L. Epidemiology of ocular
allergy symptoms in United States adults (19881994). American College of Allergy, Asthma &
Immunology Annual Meeting; Nov 9-15, 2006;
Philadelphia, PA. Abstract 34.
2. Austin JB, Kaur B, Anderson HR, et al. Hay
fever, eczema, and wheeze: a nationwide UK study
(ISAAC, international study of asthma and allergies
in childhood). Arch Dis Child. 1999 Sep;81(3):22530.
3. Nathan RA, Meltzer EO, Seiner JC, et al.
Prevalence of allergic rhinitis in the United States. J
Allergy Clin Immunol. 1997;99:S808-14.
4. Barbee RA, Kaltenborn W, Lebowitz MD, et al.
Longitudinal changes in allergen skin test reactivity
in a community population sample. J Allergy Clin
Immunol. 1987 Jan;79(1):16-24.
5. Wong AH, Barg SS, Leung AK. Seasonal and
perennial allergic conjunctivitis. Recent Pat Inflamm
Allergy Drug Discov. 2009 Jun;3(2):118-27.
6. Leonardi A, De Dominicis C, Motterle L.
Immunopathogenesis of ocular allergy: A
schematic approach to different clinical
entities. Curr Opin Allergy Clin Immunol. 2007
Oct;7(5):429-35.
7. Doctor’s Allergy Formula. “Ocular Allergy Testing.
(Physician Area).” Doctor’s Allergy Formula.
2013. Available at http://drsallergyformula.com/
Dr. Cooper is a consultant to Allergan, BioTissue, Johnson
& Johnson Vision Care, Alcon Surgical, Valean/B+L,
TearLab, Epocrates, and has received past honoraria from
Alcon Vision Care and inVentiv Health.
coopadre@gmail.com
4
Figure 4. Varying degrees of allergenic response to
DAF.
14
Focus On
REFRACTIVE SURGERY
AUGUST 2015
|
Corneal inlays offer new advantages
Femtosecond and material advances allow another option for patients
Corneal inlays to correct refractive errors are not new—
various materials have been tried for more than 50 years
to correct blurred vision. The greatest barriers to success
of corneal inlays have been a lack of biocompatibility with
the cornea, the difficulty of placing them within the corneal stroma safely, and refractive predictably.1
More recently, several attempts
at correcting hyperopia with corneal inlays failed primarily due to
difficulty changing the anterior
curvature of the cornea while
maintaining a healthy cornea.
Deep placement of the inlays
was able to maintain corneal
physiology but had little to no
effect on anterior curvature.2
vestigational device called the
Raindrop Near Vision Inlay (ReVision Optics). Raindrop is a
transparent plano non-refractive hydrogel inlay, 2.0 mm in
diameter and 32 μm thick, that
is inserted in the anterior corBY WILLIAM
neal stroma (130-150 μm deep)
TULLO, OD Vice
under a flap created with a fempresident of clinical
tosecond laser. It alters the eye’s
services for TLC
refractive power by increasing
Vision.
the central radius of curvature
New technology,
of the anterior cornea. The goal
presbyopia focus
of this inlay is to produce a hyperproFemtosecond lasers have revolutionized
late shape, which results in an aspheric
the ability to create smooth precise pockmultifocal effect with minimal disrupets into the corneal stroma at specific
tion to distance vision.
depths to place corneal inlays. AdditionThe second approach uses concentric
ally, advances in material biocompatoptics and is called Flexivue Microlens
ibility and manufacturing technology
(Presbia Cooperatief U.A.) Flexivue is
to produce highly permeable hydrogel
still investigational in U.S. A small 1.8
polymers and ultra-thin corneal inlays
mm diameter, 15-20 μm thick transparent
have contributed to the success of curmethacrylate copolymer with a central
rent generation corneal inlays.
plano zone and peripheral annular near
Presbyopia is the most common refraczone of specific power (+1.25 D to +3.00
tive error with an estimated more than
D) is implanted in an intrastromal pocket
2.1 billion people affected worldwide by
20202 with 80 million adults between 45
and 64 years old in the U.S. There are
billion people worldmore than 11 million estimated emmewide will be presbyopic
3
tropic presbyopes currently in the U.S.
by 2020
Corneal inlays are placed in the nondominant eye at a specific depth within
280-300 μm deep. It incorporates a central
a femtosecond laser-created pocket in the
0.15 mm hole to facilitate the transfer of
corneal stroma. The surgical procedure
oxygen and metabolites to maintain noris fast, typically less than 10 minutes,
mal corneal physiology. Similar to conand is performed under topical anesthecentric design contact lenses, patients
sia. The inlay is carefully centered over
must adapt to the simultaneous images
the visual axis to maximize the optical
on the retina of the non-dominant eye.
effect and minimize visual side effects
The third approach is the only U.S.
such as blur, diplopia, and loss of bestFood and Drug Administration (FDA)corrected vision.
approved device for the correction of near
vision blur called the Kamra Inlay (Acu3 approaches to reading
Focus). AcuFocus uses a hyperthin micorrection
croperforated aperture to increase depth
The first approach is found in the in-
2.1
TABLE 1 Contraindications for
Kamra Inlay
1. Severe dry eye syndrome
2. Active eye infection or inflammation
3. Keratoconus or keratoconus suspect
4. Abnormal corneal topography
5. Less than 250 μm below stromal
pocket
6. Active herpes eye infection
7. Uncontrolled glaucoma
8. Uncontrolled diabetes
9. Active autoimmune or connective
tissue disease
10. Cataracts
11. Reduced BCVA
of focus. Kamra is a single piece of polyvinylidene fluoride (PVDF), with 3.8 mm
diameter opaque (carbon black) annulus,
a 1.6 mm transparent central hole, and
is 6 μm thick. The inlay is perforated
with 8,400 holes randomized from 5.5 to
11.5 μm in size to allow for transport of
metabolites to maintain the health and
integrity of the cornea.
More on Kamra
Recent U.S approval specifies that the
Kamra inlay is indicated for the improvement of near vision by extending the
depth of focus in the non-dominant eye
of phakic presbyopia patients between
the ages of 45 and 60 years old with refractive error +0.50 D to -0.75 D with ≤
0.75 D of refractive astigmatism.3 Additionally, patients must not be wearing
glasses or contact lenses for distance vision and have near correction between
+1.00 D and +2.50 D. Kamra is placed
in a femtosecond laser-created intrastromal pocket 220 μm or deeper. Outside
the U.S., it is not uncommon to create a
pocket 100 μm below a previously created LASIK flap for Kamra. Patients with
a refractive error of -0.75 D to -1.00 D
seem to have the best results due to optimal placement of the range of depth of
See Inlay on page 16
100% PRESERVATIVE-FREE
Learn more at zioptan.com and cosoptpf.com
Cosopt PF is a registered trademark of Merck Sharp & Dohme Corp and is used under license. ZIOPTAN is a registered trademark of Merck Sharp & Dohme Corp and is used under license.
ZIOPTAN is licensed by Santen Pharmaceutical Co., Ltd.
©2015 Akorn, Inc. All rights reserved. P455
Rev 06/15
16
Focus On
REFRACTIVE SURGERY
Inlay
Continued from page 14
focus provided by the artificial pinhole.
Contraindications and complications
of the Kamra inlay are summarized in
Tables 1 and 2. Because Kamra does
not split light, it does not interfere with
normal binocular summation, requiring
less neuroadaptation than monovision
correction.
While approved only for natural emmetropes in the U.S., more than 20,000
Kamra inlays have been implanted in
pseudophakes and post-LASIK emmetropes, and performed in combination
with other refractive surgeries to provide improved near vision in more than
50 countries outside the U.S.
Very little peer-reviewed literature
is available for Flexivue Microlens and
Raindrop. More than 29 clinical studies are currently published on Kamra
Inlay, showing:
Reading speed and acuity are significantly improved after inlay
implantation6
Post-inlay implantation patients are
able to read at a significantly closer
reading distance6
Visual field is unaffected6
K a m r a d o e s n’t a f fe c t o c u l a r
assessments6
Cataract surgery is possible with the
inlay in place7
TABLE 2 Complications reported
with Kamra Inlay
1. Night vision disturbances
2. Dryness
3. Blurry vision
4. Double vision
5. Pain and burning
6. Temporary visual illusions (Puftrich
Effect)
7. Decrease contrast sensitivity
8. Infection
9. Corneal thinning or scarring
10. Endothelial cell loss
11. Ectasia
12. Increased IOP (steroid drops)
Inlay advantages and
disadvantages
The biggest advantage of corneal inlays
is the reduction of dependence on reading glasses. The fact that they are additive and do not remove any tissue from
the cornea enhance their safety profile
as compared to ablative laser vision correction procedures. Other key advantages
include:
Easy removability
Not an intraocular procedure
Maintenance of contrast acuity
Extended range of vision
The biggest disadvantage of corneal
inlays is the mild to moderate loss of
distance vision (one to two lines uncorrected distance vision (UCDV) that can
occur in the non-dominant eye. Additionally, the dry eye that often accompanies the inlay can lead to fluctuating
vision and patient dissatisfaction. Some
patients also require prolonged use of
topical steroids, increasing the risk of
IOP spikes.
In the FDA study of 508 eyes implanted with the Kamra inlay, 83.5 percent achieved uncorrected near visual
acuity (UCNVA) of 20/40 (eight-point
font) or better at 12 months in the implanted eye, representing an average of
three lines of vision improvement.3 About
three percent of the enrolled patients with
a modern femtosecond pocket had the
inlay removed, mostly due to a hyperopic refractive shift affecting distance
vision in the implanted eye.3
Patient selection, follow up
An ideal patient has mild myopia (-0.75
D to -1.00 D) with -0.50 D or less astigmatism, a good tear film with no dryness symptoms, and an easy-going personality willing to tolerate common visual symptoms associated with inlay.
AcuTarget HD, a new device from AcuFocus, may also assist with patient selection by measuring intraocular light
scatter and evaluating subtle lenticular
opacities not evident on slit lamp examination that may cause reduced patient satisfaction with Kamra. AcuTarget
HD also helps determine visual axis and
pupil center, allowing precise centering
of the Kamra inlay, necessary for best
visual performance.
Post-operative medications include
topical antibiotics for one week (similar to LASIK) and topical steroids for
AUGUST 2015
|
one-month taper (similar to PRK). Additional testing includes checking uncorrected near vision OD, OS, OU, and distance corrected near vision OD, OS, OU.
AcuFocus also recommends a midpoint
refraction—midpoint between maximum
plus to blur and maximum minus to blur
at distance—in the implanted eye.
Other surgical options for the correction of presbyopia in the U.S. include
LASIK or PRK monovision and multifocal/accommodating IOLs. Problems such
as reduced distance vision, reduced near
vision, reduced stereopsis, reduced contrast sensitivity, and poor quality of vision has limited these options for our
patients.
Hopefully, the addition of the first corneal inlay will expand the options for
patients with blurred near vision. Due
to the less invasive nature of the corneal
inlay procedure and its reversibility, it
is even possible that corneal inlays may
serve as a bridge for patients who are
not ready for the intraocular placement
of an IOL.
REFERENCES
1. Binder PS, Lin L, van de Pol C. Intracorneal Inlays
for the Correction of Ametropias. Eye Contact Lens.
2015 Jul;41(4):197-203.
2. Lindstrom RL, Macrae SM, Pepose JS, et al.
Corneal Inlays for presbyopia correction. Curr Opin
Ophthalmol. 2013 Jul;24(4):281-7.
3. AcuFocus KAMRA Inlay US FDA
Ophthalmic Devices Committee June
6, 2014. Available athttp://www.fda.
gov/downloads/AdvisoryCommittees/
CommitteesMeetingMaterials/MedicalDevices/
MedicalDevicesAdvisoryCommittee/
OphthalmicDevicesPanel/UCM400439.pdf.
Accessed 7/13/2015.
4. Alarcon A, Anera RG, Villa C, et al. Vision Quality
after Monovision LASIK in presbyopic patients. J
Cataract Refract Surg. 2011 Sep;37(9):1629-35.
5. Yilmaz OF, Alagoz N, Azman E, et al. Intracorneal
Inlay to Correct Presbyopia: Long-term Results. J
Cataract Refract Surg. 2011 Jul;37(7):1275-81.
6. Kamra. Available at kamra.com. Accessed
7/14/2015.
7. Tan TE, Mehta JS. Cataract Surgery following
Kamra presbyopic implant. Clin Ophthalmol.
2013:7;1899-1903.
8. Dexl AK, Jell G, Strohmaier C, et al. Longterm outcomes after monocular corneal inlay
implantation for the surgical compensation
of presbyopia. J Cataract Refract Surg. 2015
Mar;41(3):566-75.
Dr. Tullo is also adjunct assistant clinical professor at
SUNY College of Optometry.
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18
Focus On
LENS CARE
AUGUST 2015
|
Pros and cons of selling lens care solution
Solution may not bring in the big bucks, but it pays off with patient perception
For years, contact lens solutions have been available to
sell in office, but relatively few of us have pursued that
stream of revenue. Perhaps because it’s more of a driedup creek? But recently, there’s been a heightened buzz
around the topic, so maybe it’s time to consider the pros
and cons once more.
are purposeful. First, don’t charge significantly more than what other retailers
charge. Second, offer something different
than the other retailers whenever possible. For example, Alcon’s Pro line allows
you to sell bottles with more ounces than
typically found on the shelf. This adds
value to the patient’s purchase, avoids a
direct price per bottle comparison, and
allows you to charge the same price per
ounce relative to the everyday prices in
a big box store. Or if you carry another
brand, you might consider throwing in
a complimentary travel-size bottle with
the purchase. Another example is the
Sauflon model, in which solutions were
offered for sale only within the doctor’s
office. Since CooperVision’s recent acquisition of Sauflon, there has been no
public announcement about continuation
or development of the previous in-office
program. A third, more drastic way to convince patients of your genuine intentions
is to donate the proceeds of the solution
sales to a national eye charity or possibly a local community cause. After all,
the profits are negligible—or are they?
Historically, we know that competing
free, as an added value, with the purwith big box stores for profit is an upchase of an annual supply or color lens
hill battle—like trying to fight the Ebola
add-on. Others include lens care as a benvirus with a Z-pack. When you include
efit offered in their contact lens maintethe potential capital outlay for
nance program. Some doctors
the bottles, as well as the space
sell the solution, but charge even
requirements for their storage
less than other retailers, hopand display, the aggravations
ing to build trust and credibility
start to add up.
with the patient. Any of these
But with some of the new prooptions increase the patient’s
perception of value. No matter
grams, these previous objections
are neutralized. A more difficult
how you choose to distribute
BY CRYSTAL M.
debate to defuse is whether or
BRIMER, OD, FAAO it, having solution in the office
In private practice in
not having retail bottles in the
allows you to provide for all of
Wilmington, NC.
office creates a pressure—and
their eyecare needs. Even if they
choose to purchase elsewhere,
potential discomfort—on the staff
to sell. We don’t want to exhaust
they realize that you are strivtheir sales energy on a low-profit item
ing to offer them complete eye care and
or divert their efforts from some other
convenience. And, ultimately, you have
The profit margins
their best interests in mind.
high-benefit product we sell. And could
Bausch + Lomb recently partnered with
it create a perception that we are greedy,
Vision Source to offer an in-office pronickel and diming the patient? gram. Alcon recently released a full-blown
Offer something different
business strategy around in-office soWhat we want to avoid is the perlution sales. CooperVision is curception that we are selling soIncreasing patients’ perception
Help
rently maintaining the availability
lution out of greed, simply to
of value
your staff
of Sauflon solution. AMO continacquire every eyecare dime
What if we remove the question of profit
members
work as a
ues to make its solutions availthe patient spends. We can
and competition from the equation? Some
team. See page
able to the doctor. Depending
escape that perception if we
offices give lens care products away for
36 for more.
on the company, you can expect
to see a profit margin of 20 to 40
percent per bottle. Using Alcon’s new
program as an example, the difference
between the unit cost and manufacturer’s
suggested retail price (MSRP) is about
– Expect 20 to 40 percent profit margin and free shipping
30 percent. But if you qualify for end-of– Expect a relatively small price differential for the patient
year quantity rebates, it can boost your
profit up to 40 percent. Meanwhile, the
– Try to offer something a little different that what’s on the shelf
patient is paying the same relative price
– Consider bundling solution with annual supply purchase or other in-office
per ounce as an every day price at a big
program
box retailer and less than a typical gro– Add patient convenience and/or value
cery store. Of course, retailers often have
sales or rollbacks and may use solution
– Lessen patient exposure to the competition
as a “loss leader” to get consumers’ at– Create an image as a complete eye care destination
tention, decreasing the price per ounce.
Key points to in-office lens care sales
| PRACTICAL CHAIRSIDE ADVICE
Increase compliance and remain competitive
Whether it’s a corporate strategy or not, there are great benefits to
having access to solutions from all four companies. You won’t be
limited to a specific brand just because you wish to provide solution
to your patients in office. We know the need for patient direction
and the power of the recommendation. Now you cansell what you
would typically recommend, thereby ensuring compliance with
your recommendation. And compliance may lead to a positive effect
on the patient’s contact lens comfort and
difference between unit
cost and the manufacturwearing success. Furer’s suggested retail price thermore, it reduces
the potential of the
patient being exposed to a competitor while buying solution—a
company that also sells contacts and offers eye exams. It keeps
them from associating another store with eye care!
The goal is to maximize convenience to the patient without
minimizing our own. Luckily, corporations are catching on. Cur-
30%
Historically, we have known
that competing with big
box stores for profit is an
uphill battle—like trying to
fight the Ebola virus with a
Z-pack. When you include
the potential capital outlay
for the bottles, as well as
the space requirements, the
aggravations start to add up.
rently, there is only one company that allows you to order solution straight from your contact lens distributor, as needed. But regardless of where you get it, there is now no reason to keep large
amounts of solution on hand. You get the same price, buying it
one case at a time—or even one bottle at a time, in some cases.
And there are no shipping costs to the doctor with any of the four
companies. Some brands will ship bottles directly to the patient,
even free of charge with a minimum purchase. This opens up the
option to sell solution on your website, if desired. Remember, it’s
about convenience and perception, not sales.
Keep in mind: you are not likely to change the habits of those
who buy their solution at club stores. So, don’t try! That’s not the
goal. The goal is to create a patient perception that you have gone
out of your way for their convenience, and there is no need to go
elsewhere for their eyecare needs. While a profit margin of 20 to
40 percent pales in comparison to the profit margin of a frame,
it keeps patients in the office and adds value. This is a moment
where the focus must be on the big picture.
Dr. Brimer has special interests in contact lenses and dry eye.
drbrimer@crystalvisionservices.com
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20
Practice Management
AUGUST 2015
|
How our office is preparing
for ICD-10
A 6-step plan and post-implementation evaluation keep us on track
By Carl H. Spear, OD, MBA, FAAO
What’s the rush?
The World Health Organization (WHO) is a
specialized agency within the United Nations
ne of the buzzwords that is very pop(UN) that focuses on international public
ular in corporate and leadership dehealth. The 10th edition of the International
velopment circles over the past few
Classification of Diseases (ICD-10)
years is “change managecoding was initially endorsed by
ment.” We can all agree that the
the World Health Assembly in 1990
need to change and the speed of
and first used by World Health Orchange both continue to increase.
ganization member states in 1994.
Change was once a way for companies to thrive or gain a competitive
If it seems that the United States
is rushing to implement ICD-10, we
advantage—now it is a necessity in
CARL H. SPEAR,
are actually more than fashionably
order to survive.
OD, MBA, FAAO
late to the implementation party.
Over the past few years, we have
owns a multi-location The system, already adopted by
seen rapid change in health care
group practice with
most UN member states, is a way
and specifically in eye care. Unforhis wife Dr. Katie
to universally collect and monitor
tunately, changes are often slower
Gilbert Spear in
Pensacola, FL.
health information across member
than the demand or need, and we
states. The ICD system in general
often have mediocre results at best.
provides a way for member states to moniAs the October 1 implementation date of the
tor national rates of morbidity and mortalnew ICD-10 coding system rapidly approaches,
ity, the primary indications of health status.
our offices like many others are scrambling to
Within each country, the ICD system is used
make sure we are ready. Our ability to manas a standardized way to allocates resources
age the change will be critical to our survival.
and reimbursements.
I have talked with many doctors across the
The Department of Health and Human
Services published its final ruling to adopt
ICD-10 in the United States on January 15,
2009, with an implementation date of October 1, 2013. That date has been delayed twice
with a new implementation date of October
1, 2015. It looks like ICD-10 is finally going
to be implemented, so it is time to get ready.
O
Starting now may
even be a benefit
because you will
have a sense of
urgency and
access to the latest
and most reliable
information.
country, and the overwhelming sense is that
no one is fully ready for the change. More
troubling, many doctors have not even started
the process. For those of you in this situation,
hope is not a strategy, and the time to start
is now. No matter where you are in preparing for ICD-10, the countdown has started.
Barring some miracle delay, the change is
inevitable. At least we know what needs to
be done, and we have a deadline.
6 steps to prepare for ICD-10
Below is our step-by-step approach to ICD10 preparedness and implementation.
STEP
Do your homework
For us, the first step in preparing
for ICD-10 implementation has been
doing the homework and trying to
understand the real obstacles to implementation. When a systematic change as big as
ICD-10 conversion happens, there is a tremendous amount of information and misinformation being propagated. Finding credible and
reliable sources for information is critical.
I am skeptical of the multitude of e-mails
that I receive from companies touting how
1
TAKE-HOME MESSAGE Preparing a
six-step plan, with key players in billing and
IT, help a multi-location practice ensure it is
ready for ICD-10 implementation. The six steps
are: Do your homework, identify and assign
key roles, train your doctors and staff, practice
in your EHR, use your resources, and plan for
financial backup. A final yet important step is a
post-implementation evaluation: Be sure your
claims are going through in a timely fashion
and you are paid the correct amounts.
they can prepare us for ICD-10 with fees ranging from $199-$2,999. My mantra is always,
“Go to the source.” In this case, the Centers
for Medicare and Medicaid Services (CMS)
is the authoritative source for ICD-10. If you
want the real deal and the history of ICD-10,
go to CMS.gov, and everything is available
to you. The next time you are in a lecture
or presentation and hear some wild comment or claim regarding ICD-10, ask for the
1994
The year ICD-10 was first
used by World Health Organization (WHO) member states
reference. If it is anything other than CMS,
caveat emptor (buyer beware).
STEP
Identify and assign key roles
Our second step in preparing for
ICD-10 was basic project management of identifying and assigning
key roles. The two key people in our preparation have been my billing manager and
IT manager.
I am blessed with a talented and conscientious billing manager who is the spearhead
of our preparation for ICD-10 billing. She has
been diligently working toward ICD-10 conversion for the past two and a half years. We
were gearing up for the initial implementation date of October 2013 before the reprieve
that delayed implementation until October
2014, then it became October 2015.
2
| PRACTICAL CHAIRSIDE ADVICE
If you have not been working at it that long, not to worry. You
have time but need to assign the roles and get started today. Most
of our preparation has been in watching videos and webinars on
the basics of ICD-10 and preparing a training plan for the rest of
the staff and doctors. If you have a smaller office, you may want to
put together your training plan so that everyone watches the videos and training materials at the same time.
The second key person in our preparation has been our IT manager. Again, I am blessed with an IT person who has a wide range
of knowledge and expertise. He has diligently kept our systems
Hope is not a strategy, and the
time to start is now.
updated so that when the time comes to upgrade our software to
the ICD-10 compatible version, we will be ready. For me, this is the
most difficult piece in the puzzle. Understanding how overnight
we switch from ICD-9 to ICD-10 and how much of the coding will
occur in the system is the great unknown at this point. Making
sure your system is compatible with new software that incorporates ICD-10 is a must-do now!
STEP
Train doctors and staff
We have now started our full-on training for all doctors
and staff. Our training plan is twofold.
When we train, we want everyone in the office to have
a baseline working knowledge of everything going on in the office.
Whether it is a new piece of equipment or a new lens in optical,
everyone needs the big picture. Our staff meetings are now very
heavy on ICD-10 training that is primarily overview on what will
happen during implementation.
The second piece of training is in-depth job-specific training required for each person or department. Obviously, our billing team
is ahead of the curve and already working to understand what is
needed both from them and also what they need from everyone else.
Over the next months leading up to ICD-10, we have a detailed
training plan for each section so that we can be as ready as possible. Many resources are available online for training, including the
Medical Learning Network hosted by CMS (see “ICD-10 resources”
page 25 for more information).
3
See ICD-10 on page 24
Hidden benefit of ICD-10
Over the past three years, I have worked with numerous practices
that have been targets of recovery contractor audits (RACS). One
of the potential hidden benefits of the ICD-10 coding system is the
level of specificity that is required.
ACCURACY
“I have used various autorefractors in
my career, many have provided a good
starting point for subjective refraction.
However, with the OPD-Scan III and
TRS-5100, I now have the accuracy
of wavefrontguided refractive data
to quickly and precisely generate the
best refractive endpoints and visual
satisfaction. Compared to traditional
refraction, Wavefront Optimized
Refraction (the ‘XFRACTION process’),
represents a new age in digital
refractions.”
Benjamin Gaddie, OD | Louisville, KY
This may turn out to be a blessing for many practices because
they are forced to provide more details in order to be reimbursed.
Many of the audits we have assisted with result from poor documentation of medical necessity and failure to demonstrate the
need for special testing. While we all are skeptical of how well the
ICD-10 implementation will go, the potential to reduce audit risk
could be a real benefit.
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eye problems. Consult the package insert for complete information. Complete information is also available from Johnson & Johnson Vision Care, Inc., by calling 1-800-843-2020 or
by visiting acuvueprofessional.com.
Educate your patients about ACUVUE® Brand Contact Lenses—
the only major brand to block at least 97% of UVB and 81% of
UVA rays as standard across the entire line.*†
To learn more, visit acuvueprofessional.com.
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Helps protect against transmission of harmful UV radiation to the cornea and into the eye.
WARNING: UV-absorbing contact lenses are NOT substitutes for protective UV-absorbing eyewear such as UV-absorbing goggles or sunglasses, because they do not completely cover the eye and
surrounding area. You should continue to use UV-absorbing eyewear as directed. NOTE: Long-term exposure to UV radiation is one of the risk factors associated with cataracts. Exposure is based on a
number of factors such as environmental conditions (altitude, geography, cloud cover) and personal factors (extent and nature of outdoor activities). UV-blocking contact lenses help provide protection
against harmful UV radiation. However, clinical studies have not been done to demonstrate that wearing UV-blocking contact lenses reduces the risk of developing cataracts or other eye disorders.
Consult your eye care practitioner for more information.
References: 1. The big picture: eye protection is always in season. The Vision Council Website. http://www.thevisioncouncil.org/sites/default/files/VCUVReport2013FINAL.pdf. Accessed
May 7, 2014. 2. Chandler H. Ultraviolet absorption by contact lenses and the significance on the ocular anterior segment. Eye Contact Lens. 2011;37(4):259-266.
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ACU-43878-J
July 2015
Practice Management
24
ICD-10
Continued from page 21
STEP
Practice in your EHR
In early July, our IT manager was
able to obtain an advanced copy of
the ICD-10 version of our EHR system. We are now in the process of getting
our hands dirty playing with the software
trying to understand the capabilities of the
system. This in turn helps us plan more targeted and real-word training for staff and
4
Our ability to
monitor, evaluate,
and readjust after
implementation
will be paramount.
doctors. I highly recommend pushing your
EHR provider to get you access as soon as
possible so you can determine the limitations and capabilities in order to have focused training and realistic expectations.
STEP
Use your resources
We have utilized the resources
available from our affiliation with
an optometric network, organized
optometry, and peer-to-peer collaboration.
Although CMS is the authoritative source
for all things ICD-10, that does not mean we
are not watching, talking, and listening to
a multitude of other sources for tidbits and
best practices.
5
Like many of you, we are part of a national group of affiliated optometrists in an
optometric network. The resources, thought
leadership, and value of knowing others are
in the same boat as we are is invaluable. We
have taken advantage of training programs
and materials as well as sharing best practices within this group. Organized optometry
at both a national and state level has also
provided valuable resources and forums to
assist with implementation. Finally, we are
members in a study group with six other
offices from around the country. We get together every six months to share ideas and
best practices. Our next meeting in August
will be geared around ICD-10 and a sharing
of thoughts, ideas, and counseling around
ICD-10 and the way forward.
STEP
Plan for financial backup
In preparation for ICD-10, we made
a visit to the bank. Despite bestlaid plans by our entire team, it is
prudent to have a contingency plan in case
things are not as smooth as we would like.
To that end, we have worked with our bank
to establish a specific line of credit for each
office just in case we see a significant decrease in revenue from a disruption in the
payment cycle as ICD-10 is implemented. We
hope this is not necessary, but when October 1 arrives, I will sleep better knowing
that we do have a plan to maintain cash
flow just in case.
6
Looking ahead to
implementation
By the time you read this article, we will
AUGUST 2015
6
|
STEPS TO
PREPARE
FOR ICD-10
1 Do your homework
2 Identify and assign key roles
3 Train doctors and staff
4 Practice in your EHR
5 Use your resources
6 Plan for financial backup
be in the 45-day countdown toward ICD10 implementation. At that point, you will
still have time to do all of the things I mentioned above and get prepared for ICD-10.
In all honesty, starting now may even be
a benefit because you will have a sense of
urgency and access to the latest and most
reliable information.
As we look forward and execute our training plan and system upgrades, the next big
milestone will actually be implementation
day on October 1. Our plan is to go all out
and treat it as just another clinic day—albeit
with an all-hands-on-deck mentality. Initial
focus will be on maintaining continuity of
patient care and realizing if our EHR system
is not responding to patient information input
or coding. We cannot dwell on that during
clinic but must remain patient focused and
sort out the problems at the end of the day
when patient care is completed. We anticipate challenges and will approach the day
IN BRIEF
CMS, AMA announce efforts to help ICD-10 transition
WASHINGTON, DC—The Centers for Medicare & Medicaid Services (CMS) and the American Medical Association (AMA) recently announced
efforts to help physicians get ready for the
October 1 deadline for ICD-10 transition. In
response to requests from the provider community, CMS is releasing additional guidance
that will allow for flexibility in the claims
auditing and quality reporting process as
the medical community gains experience
using the new ICD-10 codes.
Reaching out to health care providers
all across the country, CMS and AMA will
educate providers through webinars, onsite training, educational articles, and na-
tional provider calls to help providers learn
about the updated codes and prepare for
the transition.
CMS’s free help includes the “Road to 10”
aimed specifically at smaller physician practices with primers for clinical documentation,
clinical scenarios, and other specialty-specific resources to help with implementation.
CMS has also released provider-training videos that offer ICD-10 implementation tips.
The AMA also has a range of materials
available to help physicians prepare.
CMS detailed its operating plans for implementation, including:
t4FUUJOHVQBDPNNVOJDBUJPOTBOEDPPS-
dination center, learning from best practices
of other large technology implementations
to identify and resolve problems.
t4FOEJOHBMFUUFSJO+VMZUPBMM.FEJDBSF
fee-for-service providers encouraging ICD10 readiness and notifying them of these
flexibilities.
t$PNQMFUJOHUIFGJOBMXJOEPXPG.FEJcare end-to-end testing for providers in July.
t0GGFSJOHPOHPJOH.FEJDBSFBDLOPXMedgement testing for providers through September 30.
t)PTUJOHBO.FEJDBSF-FSOJOH/FUXPSL
(MLN) Connects National Provider Call on
August 27.
| PRACTICAL CHAIRSIDE ADVICE
with a positive mindset and fallback plan. Past
the stress of “flipping the switch” and being
ready for October 1, the next big milestone
will be in the days following implementation.
No matter how good the plan, EHR, and
implementation on October 1, a key to success
will be a post-implementation evaluation. We
will gauge success as the billing department
starts scrubbing the first claims to see if they
are done correctly. The next step will be to
see if the claims transmit through the clearinghouse without glitches. Finally and most
Making sure your
system is compatible
with new software
that incorporates
ICD-10 is a must-do
now!
Practice Management
tional and delusional to think we will get
it all right, and everything will be perfect.
Our ability to monitor, evaluate, and readjust after implementation will be paramount.
I hope this is much to do about nothing,
and we all have a simple and easy transition
to ICD-10. Our ability to manage the change
will be a test to our practices, our profes-
25
sion, and our healthcare system.
By the way, ICD-11 is ready to be released
by the World Health Organization in 2017.
Dr. Spear is commander of the 919th Special Operations
Medical Squadron at Duke Field in Florida and chairman of
the American Academy of Optometry Exhibits Committee. He
consults for Alcon and Vision Source. chspear@gmail.com
As your dedicated partner in eye care
We Re-Envision Vision
important will be close monitoring for timely
payments for the correct amounts. We always
monitor our insurance and patient accounts
receivable, but on September 30 we will run
a baseline accounts receivable to benchmark
against in the weeks and months that follow.
Ultimately, the post-implementation evaluation is more critical than all of the work that
leads up to implementation. It would be irra-
ICD-10 resources
For the full language and ICD-10
Final Rule, see the January 16, 2009,
Federal Register: http://www.gpo.gov/
fdsys/pkg/FR-2009-01-16/pdf/E9-740.
pdf
For CMS memorandums and a host
of useful resources: http://www.
cms.gov/Medicare/Coding/ICD10/
index.html?redirect=/ICD10/
To sign up for e-mails to receive
updates on changes and to view videos: http://www.cms.gov/Outreach-andEducation/Medicare-Learning-NetworkMLN/MLNGenInfo/index.html
Meeting the need.
An increasing aging and diabetic population gives way to an
increased number of patients diagnosed with retinal diseases. Regeneron is committed
to delivering targeted therapies that can impact your patients’ vision.
Learn more about our science to medicine approach at Regeneron.com.
ICD-10 resources from the AOA:
http://www.aoa.org/news/practice-management/ready-resources-forthe-icd-10-rollout?sso=y
science to medicine is a registered trademark of Regeneron Pharmaceuticals, Inc.
©2015, Regeneron Pharmaceuticals, Inc.,
777 Old Saw Mill River Road, Tarrytown, NY 10591
All rights reserved
02/2015
RGN-0271
SPECIAL SECTI O N
26
AUGUST 2015
Pediatrics
OCT
cupping reversal. Findings of one
retrospective study suggest that in
Continued from page 1
some cases, even when intraocular
pressure (IOP) is lowered and ONH
cently, spectral domain OCT was decupping reverses, RNFL continued
veloped. Spectral OCT assesses the
to thin postoperatively.6
interferometric signal as a function
of optical frequencies.3 This enables
In non-glaucomatous optic neua faster scanning speed and density RACHEL A.
ropathy, SD-OCT has been used to
of scanning while reducing artifacts COULTER, OD,
diagnose and monitor pediatric paMS, is an associate
from eye motion. This combination professor at Nova
tients. When SD-OCT is combined
of increased speed with fewer arti- Southeastern
with eye tracking technology, it can
facts from eye movements is advan- University. She has obtain reproducible RNFL measuretageous when working with pediatric published multiple
ments, even in patients with depatients.3 Clinicians and researchers articles and book
creased vision.7 In optic disc elevachapters on topics
have reported the use of OCT in chil- related to pediatric tion, OCT can be helpful in completdren as a diagnostic tool, to monitor optometry.
ing a careful assessment. Optic disc
treatment outcomes, and to investielevation can be caused by serious
gate normal ocular tissue structure. and progressive conditions such as
optic nerve edema or benign, stable
conditions such as ONH drusen.
Diagnostic advantages
Traditionally, B-scan ultrasonograDiagnostically, OCT may be helpful
phy has been the tool of choice in
to supplement visual field informadiagnosing ONH drusen. More retion or to provide information when
cently, OCT has been used to evaluvisual field findings are not availERIN JENEWEIN,
ate patients with an elevated ONH
able. Visual field testing is commonly OD, MS, FAAO,
used to evaluate the visual system is joining the faculty to differentiate between optic disc
edema and ONH drusen.2,9 In paand to diagnose and monitor pathol- of Salus University
ogy. To obtain reliable visual field as an assistant
tients with ONH drusen, OCT can
results, however, the patient needs professor. She is an be used to monitor changes in RNFL
active member of
to understand the test, sustain at- the Pediatric Eye
thickness that may be associated
tention, and respond accurately. Re- Disease Investigator with the condition. OCT may also
search suggests that children under Group (PEDIG).
be useful in evaluating tilted disc
the age of eight years old are not resyndrome.10 This condition can
liable visual field test takers.4
cause visual field defects. OCT can confirm a structural change that corresponds
with measured field defects.
OCT in optic neuropathy
For children suspected of having optic nerve
pathology conditions such as glaucoma, optic
Pediatric retinal conditions
nerve head (ONH) drusen, and optic neuropIn addition to use in optic neuropathy, OCT
athy, OCT can help in diagnosis and moniis helpful in the diagnosis and monitoring of
toring treatment outcomes. In pediatric glaupediatric retinal conditions. Examining the
coma cases, Spectral Domain SD-OCT has
retinae, particularly the maculae, of chil-
OCT provides the OD with the ability to
make microscopic retinal abnormalities
clearly evident and to quantify and
replicate measures of tissue structure.
been shown to produce reproducible measurements of pediatric retinal nerve fiber
layer (RNFL) and macular thickness.5 This
makes it a useful tool in for diagnosing pediatric glaucoma and monitoring structural
changes in glaucoma progression. In addition, OCT also may shed light on mechanisms of disease. In the condition of pediatric glaucoma, OCT has been used to study
dren can be difficult. Detecting and documenting subtle changes in macular structure may be difficult or impossible in the
fundus evaluation. In a variety of retinal
pathologies, pediatric patients may present with decreased visual acuity and subtle retinal findings. OCT has been used in
the diagnosis of oculocutaneous albinism,
epiretinal membranes, foveal hypoplasia, fo-
|
TAKE-HOME MESSAGE While eye
disease is relatively uncommon in children,
optometrists often find the tasks of selecting
tests, obtaining findings, and interpreting
results to be more difficult for their younger
patients. But pediatric patients are better able
to tolerate OCT testing than other diagnostic
tests for optic neuropathy or retinal diseases.
OCT for pediatric patients does have its
limitations due to the lack of pediatric normal
reference values.
veal retinoschisis, and Stargardt disease.10-14
OCT can enable the determination of a
definitive diagnosis more quickly and lead
to earlier treatment and better visual outcomes. In epiretinal membranes, OCT has
shown significant differences between the
pediatric condition and its adult counterpart. In addition to diagnostic uses, OCT
has helped to manage outcomes. OCT has
proven useful in predicting the surgical outcome of epiretinal membranes removal.12 In
retinopathy of prematurity, OCT has proven
useful in young patients receiving laser treatment. Macular edema is an associated complication, and SD-OCT can be used to detect
subtle macular changes that may occur.15
OCT limitations
A limitation of OCT has been the lack of pediatric normal reference values. Work has
begun, however, to report findings in specific pediatric populations,16,17 such as reference values of RNFL thickness in Chinese
children and teenagers.18
Reports using Stratus OCT-3 (Carl Zeiss
Meditec) suggest that macular volume, foveal thickness, and RNFL thickness may
vary by race and age in pediatric populations.19 In fact, OCT may prove useful in expanding our understanding of normal ocular structure characteristics and how they
differ in children from adults and among
different subgroups of patients. For example, several studies have found that myopic
children had significantly thinner macular
thickness and smaller macular volumes.19, 20
OCT may be useful in understanding functional limitations in patients who present
with residual amblyopia or traumatic brain
injury. Preliminary findings suggested that
OCT may be helpful in localizing the cause of
complaints associated with traumatic brain
injury such as blurred vision, increased light
sensitivity, double vision, visual field loss
See OCT on page 28
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SPECIAL SECTI O N
28
AUGUST 2015
Pediatrics
OCT
|
2
Continued from page 26
or reduction, and difficulties with eye movements. In some cases, these symptoms may
due to photoreceptor injury and not due to
damage in the optic nerve or visual cortex..21
In amblyopia, both time-domain and spectral-domain OCT have been used to investigate macular volume and retinal thickness in
amblyopic and non-amblyopic eyes.22-27 Many
but not all of these reports have found differences in macular structure, retinal layer
thickness, and RNFL. Though more investigation is needed, OCT may help optometrists in the future to determine if decreased
visual acuity is linked to structural differences and if the maximal visual acuity has
been obtained in treating an amblyopic eye.
Diagnosing and managing pediatric eye
disease is not always easy. OCT is a promising tool that provides objective data quickly
and is non-invasive. In evaluating suspicious
optic nerves and maculae in children, ODs
should consider OCT as a primary or supplemental test. As pediatric normal reference
values become available and additional studies are reported, its use in the pediatric population is likely to increase in the future.
REFERENCES
1. Costa RA, Skaf M, Melo LA, et al. Retinal assessment
using optical coherence tomography. Prog Retin Eye Res.
2006 May;25(3):325-53.
2. Shah A, Szirth B, Sheng I, et al. Optic Disc Drusen in a
child: Diagnosis using noninvasive imaging tools. Optom
Vis Sci. 2013 Oct;90(10):269-73.
3. Forte R, Cennamo GL, Finelli ML, et al. Comparison of
Time Domain Stratus OCT and Spectral Domain SLO/
OCT for assessment of macular thickness and volume.
Eye (Lond). 2009 Nov;23(11):2071-8. Figure 2. OCT of Stargardts disease.
disc syndrome. Graefes Arch Clin Exp Ophthalmol. 2014
Oct;252(10):1661-7.
10. Wilk M, McAllister J, et al. Relationship between foveal
cone specialization and pit morphology in albinism. Invest
Ophthalmol Vis Sci. 2014 May;55(7):4186-98.
11. Sisk R, Leng T. Multimodal imaging and multifocal
electroretinography demonstrate autosomal recessive
Stargardt Disease may present like occult macular
dystrophy. Retina. 2014 Aug;34(8):1567-75.
12. Rothman A, Folgar F, Tong A, et al. Spectral domain
OCT characterization of pediatric epiretinal membranes.
Retina. 2014 Jul;34(7):1323-34.
13. Karaca EE, Cubuk MO, Ekici F, et al. Isolated foveal
hypoplasia: Clinical presentation and imaging findings.
Optom Vis Sci. 2014 Apr;91(4 Suppl 1):S61-5.
4. Akar Y, Yimaz A, Yucel I. Assessment of an effective
visual field testing strategy for a normal pediatric
population. Ophthalmologica. 2008;222(5):329-33.
14. Kyung SE, Lee M. Foveal retinoschisis misdiagnosed
as bilateral amblyopia. Int Ophthalmol. 2012
Dec;32(6);595-8.
5. Ghasia F, El-Dairi M, Freedman S, et al. Reproducibility
of Spectral-Domain Optical Coherence Tomography
measurements in adult and pediatric glaucoma. J
Glaucoma. 2015 Jan;24(1):55-63.
15. Narang S, Singh A, Jain S, et al. Optical coherence
tomography of fovea before and after laser treatment in
retinopathy of prematurity. Middle East Afr J Ophthalmol.
2014 Oct-Dec;21(4):302-6.
6. Ely A, El-Dairi M, Freedman S. Cupping Reversal in
Pediatric Glaucoma—Evaluation of the Retinal Nerve
Fiber Layer and Visual Field. Am J Ophthalmol. 2014
Nov;158(5):905-15.
16. Al-Haddad C, Barikian A, Jaroudi M, et al. Spectral
domain optical coherence tomography in children:
normative data and biometric correlations. BMC
Ophthalmology. 2014 Apr 22;14:53.
7. Rajjoub R, Trimboli-Heidler C, Packer R, et al.
Reproducibility of retinal nerve fiber layer thickness
measures using eye tracking in children with
nonglaucomatous optic neuropathy. Am J Ophthalmol.
2015 Jan;159(1):71-7.
17. El-Dairi MA, Asrani SG, Enyedi LB, et al. Optical
coherence tomography in the eyes of normal children.
Arch Ophthalmol. 2009 Jan;127(1):50-8.
8. Lee K, Woo S, Hwang J. Differentiation of optic nerve
head drusen and optic disc edema with Spectral-Domain
optical coherence tomography. Ophthalmology. 2011
May;118(5):971-7.
9. Pichi, F, Romano S, Villani E, et al. Spectral-domain
optical coherence tomography findings in pediatric tilted
18. Qian J, Wang W, Zhang X, et al. Optical Coherence
Tomography measurements of Retinal Nerve Fiber
Layer Thickness in Chinese Children and Teenagers. J
Glaucoma. 2011 Oct;20(8):509-13.
19. Lim HT, Chun BY. Comparison of OCT Measurements
between high myopic and low myopic children. Optom Vis
Sci. 2013 Dec;90(12):1473-8.
20. Luo HD, Gazzard G, Fong A, et al. Myopia, axial length,
and OCT characteristics of the macula in Singaporean
children. Invest Ophthalmol Vis Sci. 2006 Jul;47(7):277381.
21. Flatter JA, Cooper RF, Dubow MJ, et al. Ocular retinal
structure after closed-globe blunt ocular trauma. Retina.
2014 Oct0;34(10):2133-46.
22. Silva F, Alves S, Pina S, et al. Comparison of macular
thickness and volume in amblyopic children using time
domain optical coherence tomography. Oftalologica.
2012;36:231-6.
23. Agrawal S, Singh V, Singhal V. Cross-sectional study
of macular thickness variations in unilateral amblyopia. J
Clin Ophthalmol Res. 2014;2:15-7.
24. Szigeti A, Tatrai E, Szamosi A, et al. A morphological
study of retinal changes in unilateral amblyopia using
optical coherence tomography image segmentation. PLoS
ONE. 2014 Feb 6;9(2): e88363.
25. Miki A, Shirakashi M, Yaoeda K, et al. Retinal nerve
fiber layer thickness in recovered amblyopia. Clin
Ophthalmol. 2010 Sep 20;4:1061-4.
26. Al Haddad E, Mollayess GM, Mahfoud ZR, et al.
Macular ultrastructural features in amblyopia using highdefinition optical coherence tomography. Br J Ophthalmol.
2013 Mar;97(3):318-22.
27. Yen MY, Cheng CY, Wang AG. Retinal nerve fiber layer
thickness in unilateral amblyopia. Invest Ophthalmol Vis
Sci. 2004 Jul;45(7):2224-30.
Dr. Stacey Coulter is a diplomate in Binocular Vision,
Perception, and Pediatric Optometry and graduate of the
Pennsylvania College of Optometry (PCO) and completed a
residency in Pediatric Optometry and Vision Therapy at PCO.
staceyco@nova.edu
Dr. Erin Jenewein graduated from Nova Southeastern
University (NSU) and completed a residency in pediatric
optometry at NSU. In 2009, she won the Dr. Terrance Ingraham
Pediatric Optometry Residency Award. jenewein@nova.edu
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ACUVUE® Brand Contact Lenses are indicated for vision correction. As with any contact lens, eye problems, including corneal ulcers, can develop. Some wearers may experience mild
irritation, itching or discomfort. Lenses should not be prescribed if patients have any eye infection, or experience eye discomfort, excessive tearing, vision changes, redness or other eye
problems. Consult the package insert for complete information. Complete information is also available by visiting acuvueprofessional.com or by calling 1-800-843-2020.
†
Helps protect against transmission of harmful UV radiation to the cornea and into the eye.
§
WARNING: UV-absorbing contact lenses are NOT substitutes for protective UV-absorbing eyewear such as UV-absorbing goggles or sunglasses, because they do not completely cover the
eye and surrounding area. You should continue to use UV-absorbing eyewear as directed. NOTE: Long-term exposure to UV radiation is one of the risk factors associated with cataracts.
Exposure is based on a number of factors such as environmental conditions (altitude, geography, cloud cover) and personal factors (extent and nature of outdoor activities). UV-blocking
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ACU-10352273-D
June 2015
SPECIAL SECTI O N
30
AUGUST 2015
Pediatrics
|
Vision therapy: 10 more
tools for your practice
Devices and gadgets to help you provide the best services
By Marc B. Taub, OD, MS, FAAO, FCOVD
STEP
MFBF Matching Game
While this version of this activity is new on the market, the conecause the response to my first top
cept is not a new one. This activity
10 activities for vision therapy was
uses the concept of monocular fixation in a
positive (“Vision therapy: A top 10
binocular field, or bi-ocular, as some refer
must-have list,” August 2014), I have
to it. This means that both eyes
decided to once again revisit the
consensually react to the stimulus,
topic. On the first list were some of
but only one eye at a time actually
the mainstays in the vision therapy
sees the given stimulus. This is an
room as well as a bonus item. In this
intermediate step in accommodainstallment, I will present a second
tive techniques between monocuset of 10 items that are essential to
lar and binocular therapies.
every vision therapy practice and
In this set, there are clear aceexpound in greater detail on one or
MARC B. TAUB,
tates with black targets (pictures,
two items from the first list.
OD, MS, FAAO,
numbers, and three grade levels
In the Vision Therapy & RehaFCOVD is the chief
of words), a red acetate that sits
bilitation Service at Southern Colof Vision Therapy
lege of Optometry, there is no one
and Rehabilitation at under the chosen acetate, and corthe Southern College responding sets of white domino
way to perform vision therapy; this
of Optometry in
style tiles with red targets (see Figlist and the previous are reflective
Memphis, TN
ure 1). While previous iterations
of that point. Some doctors prefer
computer programs and technical
required a specific viewer on which
instruments, while others perform activito perform the activity, this one can be used
ties in free space. I like a bit of both, as you
with a standard lighted vectogram holder.
can tell. Regardless of which approach you
While wearing red/green glasses, the patient locates and places the matching tiles
may take, you are not wrong.
on top of the red/clear acetate in the cor-
B
Figure 1. MFBF Matching Game red targets.
1
rect location (see Figure 2). If she cannot
see either target or during the activity the
targets start to disappear, the patient is suppressing and a larger target should be used.
This activity can be made more challenging
with the addition of plus and minus lens
on opposite eyes to turn up the burner on
relaxing and stimulating accommodation.
STEP
Lens blanks
I bet you never thought of using your
lens blanks for more than spectacles,
but in vision therapy, we put them
to good use. In a technique I learned from
the Optometric Extension Program’s Curriculum Courses called Mental Minus, the
lenses are used to create conscious control
in three-dimensional space involving accommodation. Starting with high minus lenses,
we use the activity to establish the foundations for the concepts of smaller, larger and
closer and farther. SILO (small in, large out)
is built off of this activity and is crucial to
successful vision therapy. Once the higher
powers like 8.00 D/+6.00 D is completed
successfully, the trick is to obtain a consistent response with lower powers. These
2
Figure 2. The patient locates and places the matching tiles on top of the red/clear acetate in the
correct location.
SPECIAL SECTI O N
| PRACTICAL CHAIRSIDE ADVICE
lenses are not expensive and can be issued
for home-based support. A traditional plastic lens with no coating is recommended.
STEP
Walking rail
A walking rail is useful for patients
with tracking problems and/or perceptual difficulties. The level of the
activity can easily be adjusted up or down
to suit the patient’s ability, and kids love
showing off to their therapist and parents.
Starting with a military-type walk, the addition of a fixation target such as a Marsden
ball and a metronome can increase the challenge (Figure 3). Next, make the ball swing
side to side and even around the patient as
he walks, and the challenge increases. Oh,
did I mention that he has to go forward and
backward? The walking rail should be performed with shoes off to provide a challenge
to balance and increase the tactile feedback
in all parts of the foot. I can personally attest that sensory feedback is crucial to proper
balance and walking! 3
STEP
Facility Rock Set
While these concepts have been on
the market for many years, this is
the first set to bring all the pieces
of facility testing and therapy, accommodative and vergence, together into one package. Also, this includes a greater variety of
targets (pictures, numbers, Landolt Cs, and
three grade levels of words), rows of targets
designed to match up under red/green (see
Figure 4) and polarized bar readers (see Figure 5) and cards made of a durable material. Accommodative and vergence facility are
crucial in testing and therapy because they
mirror daily activities of looking from distance to near and the opposite. So much
of our testing is static and smooth; facility
activities are dynamic in nature. The set
comes with ±2.00 D and 12 base-out/three
base-in flippers for use in testing or therapy. These are the standard powers used in
research studies on these topics. Therapy
can be performed either using the included
cards or with any appropriate print material. 4
STEP
5
Pediatrics
gence, tracking, anti-suppression, and perceptual components to the program. One
bonus is that you can generate your own
Hart charts with a variety of rows and columns to suit your patients’ abilities.
Home Therapy Systems has multiple programs depending on your patient’s needs.
There are programs for both in-office and
home-based therapy that focus on accommodation/vergence, amblyopia, and perception.
I love the home-based version because the
results are sent to a main system, and I can
log in to evaluate the patients’ performances
and confirm that they are actually doing the
work assigned. Because patients can travel
from up to several hours away, this program
allows for controlled home-based therapy.
Even though I push for office-based vision
therapy as a first approach, Home Therapy
Systems eases my mind in regard to homebased treatment. STEP
Prism flippers/loose lenses
Prism, like lenses, is so important
for therapy. For strabismic patients,
using loose prism in the opposite
direction of the eye turn will allow the patient to feel that eye move (see Figure 6). You can’t expect the patient to eventually
control the eye and move it in a way that
he cannot feel or understand. The use of
loose prism makes that possible. Prism flippers are used toward the end of
therapy and in a fashion similar to accommodative flippers with plus and minus lenses.
6
See Vision therapy on page 32
Figure 3. Walking rail.
Vision Builder/Home
Therapy Systems
As I discussed in the first top 10
activities list, computer programs
are a great addition to a standard vision
therapy program. The two sets of programs I
use frequently are Vision Builder and those
produced by Home Therapy Systems. Vision
Builder is an all-in-one program and can be
used in-office and at home. There are ver-
Figure 4. Family Rock Set red/green readers.
Figure 5. Family Rock Set polarized bar readers.
31
SPECIAL SECTI O N
32
AUGUST 2015
Pediatrics
Figure 6. Prism flippers/loose lenses.
Figure 7. Chalkboard circles.
keeping the vergence demand static. Even
though it is a difficult technique for the
patient to master, it is super simple for the
therapist. There are numbers on each card
that instruct the therapist on card and aperture placement. Each target also contains
a suppression check to ensure binocularity. Vision therapy
Continued from page 31
Starting with low, symmetrical amounts of
base out and in, have the patient read for
five minutes, flipping every sentence. To
increase the difficulty, have him flip every
few words or increase the powers of the
prism. There is no need to go too high on
the prism power—you need to emphasize
quality over quantity. STEP
STEP
7
STEP
8
Aperture rule
The aperture rule is used toward the
end of vision therapy and is used
to train both convergence and di-
New vectograms
Everyone knows the old stalwarts
like the quiot, spirangle, and clown,
but Vision Assessment Corporation
manufactures new vectograms that just pop
off the page. The chain and gem are simple
peripheral targets and should be used earliest (see Figure 10). The vortex is both peripheral and central and contains letters of
equal demand along the design (see Figure
11). The bear and popcorn have detailed targets placed over the entire vectogram, and
the demand changes based on what or where
you are fixating (see Figure 12). The popcorn
is my new personal favorite because the kernels literally pop off the change. I get hungry just thinking about it! When doing vectograms, the quality or the response trumps
the quantity of the level patients can achieve.
Don’t forget that two vectograms—one base
out on the bottom and another base in on
the top—can be used as a jump duction.
Lenses can also be added; the patient flips
between plus and minus lenses, increasing
the accommodative demand of the activity. 9
Chalk/whiteboard
Even though wall space can be considered a premium in many offices,
the chalk or whiteboard is a must
have. When it comes to hand-eye coordination activities, having a large, clean surface
is key. Some vision therapy doctors prefer
the traditional chalkboard for the tactile
support of the chalk on the board vs. the
smooth sensation of the marker on the whiteboard. Each is useful, and I am spoiled to
have both. The whiteboard has the added
bonus of being used for anti-suppression activities when using red/green glasses with
the same color markers. Chalkboard circles
(see Figure 7), racetrack, CP saccades, and
flashlight tag are just some of the activities
that can be performed with these boards. If
you get the chalkboard, make sure to use
dustless chalk or the floor, walls, and you
will be covered quickly.
|
Figures 8
A and B. Jump vergences.
vergence depending on the set-up; one aperture is convergence, and two apertures are
for divergence. Once you master each side
separately, you can use two and do jump
vergences (see Figures 8A and 8B). Another
option is to use plus and minus flippers
to alter the accommodative demand while
STEP
Dowel/stick
Yes, a stick! I use the dowel two
ways. In ball bunting, I use different colored tape along the dowel
(see Figure 13). The patient bunts the ball
10
SPECIAL SECTI O N
| PRACTICAL CHAIRSIDE ADVICE
Pediatrics
Figure 9. Plus and
minus flippers to alter the
accommodative demand
while keep the vergence
demand static.
33
aspects along with recalling the pattern. The dowel can be used
with the CP saccades activity to point to different letters on the
board while keeping fixation on a central point. This is great
for peripheral awareness. Bonus item: ReadAlyler eye movement recording system
The ReadAlyzer is more for testing than for therapy, but I want
See Vision therapy on page 34
Digital Photography
Solutions
for Slit Lamp
Imaging
Figure 10. Vectograms:
Chain and gem are simple
peripheral targets and should
be used earliest.
Digital
SLR Camera
Figure 11. Vectograms:
Vortex is both peripheral and
central and contains letters
of equal demand along the
design.
Figure 12. Vectograms:
The bear and popcorn have
detailed targets placed over
the entire vectogram and
demand changes based on
where you are fixating.
Universal
Smart Phone
Adaptor for
Slit Lamp
Imaging
Made in USA
forward and repeats the process. Using the tape, he can alternate left
and right of the central line and even call out left/right. He can move
his hands inward and attempt the activity using the outer colors—the
further from the center, the more challenging. Memory can be challenged by calling out a pattern; now, he has to perform the eye-hand
TTI Medical
Transamerican Technologies International
Toll free: 800-322-7373
email: info@ttimedical.com
www.ttimedical.com
SPECIAL SECTI O N
34
AUGUST 2015
Pediatrics
Figure 13. Ball bunting using a dowel.
Vision therapy
|
Figure 14. ReadAlyzer.
IN BRIEF
Continued from page 34
to espouse its benefits nonetheless. Using infrared goggles, the patient’s eye movements
are tracked while reading age-appropriate
materials. Passages range from kindergarten to adult levels. They come in both short
and long versions. For younger kids, I prefer short passages, but for teens and adults,
the longer passages mirror real-life reading (see Figure 14). Some patients appear
to have good quality eye movements with
short passages but fall apart when asked to
read something longer. The passages come
in over 14 languages, including Mexican
Spanish, Hebrew, Arabic, and Italian. I love
showing parents what their children’s eyes
are actually doing when reading. It is amazing to see parents’ reactions when they see
it, and it allows immediate understanding
on their parts. This product can be purchased only through the Optometric Extension Program Foundation.
I hope you enjoyed this second list of
equipment for vision therapy that I consider
must haves. You don’t have to buy them all
at once, but I promise they are worth every
penny and will make your vision therapy
state of the art and a rousing success.
Dr. Taub has financial interested in the
MFBF Matching Game and the Facility Rock Set.
Dr. Taub is supervisor of the residency program in Pediatrics
and Vision Therapy at the Southern College of Optometry in
Memphis, TN.
mtaub@sco.edu
Allegro shares Luminate Phase 2 results
SAN JUAN CAPISTRANO—Allegro Ophthalmics recently
announced that the Phase 2 clinical trial of
Luminate (ALG-1001) in patients with vitreomacular traction (VMT) or vitreomacular
adhesion (VMA) met its primary endpoint.
In the Phase 2, prospective, randomized,
double-masked, placebo-controlled trial evaluating the safety and efficacy of intravitrealinjections of Luminate in 106 study subjects,
65 percent of eyes treated with the 3.2 mg
dose of Luminate achieved release of VMT
or VMA by Day 90, compared to 9.7 percent
of those in the placebo control group.
The study, which included three Luminate groups (2.0, 2.5, or 3.2 mg) and a balanced salt solution (BSS) placebo group, also
foundthat Luminate was well tolerated with
no drug toxicity or intraocular inflammation noted with repeated intravitreal injections. These safety results are consistent with
previously conducted Luminate studies on
human subjectswhere there were no rod or
cone photoreceptor dysfunction on full-field
electroretinogram testing, no afferent pupillary defects, and no evidence of retinal tears
or detachments.
“These findings appear to be very promising,” says Michael Tolentino, MD, associate
professor of ophthalmology at the University of Central Florida, director of research
for the Center for Retina and Macular Disease, and clinical investigator of this Phase
2 VMT study. “It is a very positive outcome
to have 65 percent of eyes treated with the
3.2 mg dose of Luminate achieve VMT/VMA
release by Day 90. These statistically significant findings, as assessed by the Duke
Reading Center, coupled with the fact that
Luminate has been shown to be well-tolerated, makes me optimistic that Luminate
will provide meaningful clinical benefit to
patients with VMT or VMA.”
“These positive results continue to affirm
the safety and efficacy of Luminate,” says
Vicken Karageozian, MD, chief technical officer, Allegro Ophthalmics. “The vitreolytic
properties confirmed in this study and the
anti-angiogenic properties demonstrated in
earlier DME and neovascular AMD studies
continue to validate our clinical development
approach of advancing Luminate across multiple vitreoretinal indications.”
Luminate, a first-in-class integrin peptide
therapy, treats vitreoretinal diseases by targeting integrin receptors involved in cell signaling and regulation and in the construction of new and aberrant blood vessels. By
utilizing two mechanisms of action (vitreolysis and anti-angiogenesis), Luminate has
been shown to effectively regress and inhibit
new blood vessel formation as well as reduce
vascular leakage. Luminate is an investigational drug not approved by the U.S. Food
and Drug Administration. Allegro maintains
commercial rights to Luminate in all territories outside of Japan, Korea, and China.
For patients who want to
start and end the day
with more moisture1,2
Recommend Biotrue® ONEday
daily disposable contact lenses
Now available for Presbyopia
Biotrue® ONEday HyperGel™ material forms a
Dehydration Barrier
2 Stays moist
up to 16 hours2
2 Retains more than
98% moisture
through the day2
UVA/UVB Protection*
Biotrue® ONEday Cross-section
Poloxamer
407
POLOXAMER
407
PVP
PVP
H2O
PVP binds to SAM
SAM is concentrated at surface
Hydrophilic polymer molecules —
PVP — are bound to the molecules of
the Surface Active Macromer (SAM)
Poloxamer 407.
The polymer-bound Surface Active
Macromer (SAM) Poloxamer 407,
increases in concentration at the
surface forming a permanent
component of the lens material.
For more information, call 1-800-828-9030, contact your Sales Representative or Bausch.com/ecp
* WARNING: UV-absorbing contact lenses are NOT substitutes for protective UV-absorbing eyewear, such as UV-absorbing goggles or sunglasses,
because they do not completely cover the eye and surrounding area. The effectiveness of wearing UV-absorbing contact lenses in preventing or
reducing the incidence of ocular disorders associated with exposure to UV light has not been established at this time. You should continue to use
UV-absorbing eyewear as directed. NOTE: Long-term exposure to UV radiation is one of the risk factors associated with cataracts. Exposure is based
on a number of factors such as environmental conditions (altitude, geography, cloud cover) and personal factors (extent and nature of outdoor
activities). UV-blocking contact lenses help provide protection against harmful UV radiation. However, clinical studies have not been done to
demonstrate that wearing UV-blocking contact lenses reduces the risk of developing cataracts or other eye disorders.
REFERENCE: 1. Multiple-Packaged Lenses Comparison, Tyler’s Quarterly – Professional Edition, September 2013 2. Twenty-two subjects participated
in a randomized, double masked, contralateral eye study to evaluate water loss of Biotrue ONEday, 1-Day Acuvue Moist, 1-Day Acuvue TruEye contact
lenses. After 4,8,12, and 16 hours of wear, lenses were removed and immediately weighed (wet weight). The lenses were then completely dried and
reweighed (dry wet). The percent water loss was then calculated for each lens from the wet and dry weights.
Biotrue, HyperGel and inspired by the biology of your eyes are trademarks of Bausch & Lomb Incorporated or its affiliates.
All other product/brand names are trademarks of their respective owners. ©2015 Bausch & Lomb Incorporated. US/BOD/15/0011
InDispensable
36
AUGUST 2015
|
How to cultivate teamwork
in your practice
Three steps for leading your staff to success by combining the talents of all
By Lisa Frye, ABOC, FNAO
here is an old adage that states that
there is no “I” in team. The most successful results can be achieved only
when we all work together to obtain a
common goal. I cannot express enough the
importance of having strong leadership followed by dedicated staff members who are
all in when it comes to running a thriving
practice or business. While individual performance is important, combining the talents of each individual in areas best suited
to utilize those talents can yield amazing
growth and reach higher levels in providing patient satisfaction.
T
STEP Define the culture
How can a practice develop a successful team? Step one is setting a
vision and a culture that can be adopted by all members. Have you ever visited
a business and quickly understood the cul-
1
ture? Some offices feel warm and inviting,
but others can leave you without a personal
connection. Taking care of patients involves
making positive connections. Staff members
are following the example set by leadership
or the management of the practice.
STEP Build your best team
Step two is making certain the right
person is in the position that best
utilizes her personality and talents.
If someone prefers tasks rather than working with people, then that individual would
thrive when matched to a task-oriented job
that enables her to happily apply her skills
without distractions. While individuals who
are task oriented accomplish tasks single
mindedly, the people-oriented team members are out there interacting with patients
and loving every minute of it. Useful team
exercises or personality testing can lend
insight about the best matchup of personalities to positions.
2
Have you ever visited a business and quickly
understood the culture? Some offices feel
warm and inviting, but others can leave you
without a personal connection.
MyWoodi
eyewear
introduces
Madrid and
Amsterdam
styles
MILAN—MyWoodi eyewear
recently introduced two new
opitcal styles—Madrid for
women and Amsterdamn for
men, both seen at left.
MyWoodie eyewear is manufactured in Italy using wood
from around the world. These
latest styles join a collection
of 12 styles available in six
different types of wood and a
varity of colors.
TAKE-HOME MESSAGE Define your
culture, set your vision and goals, and identify
the staff and the positions needed to succeed
in reaching your goal. In recruiting staff, clearly
relay what you hope to achieve, and create
your team. Lead by example with equity and
fairness. Keep the staff rewarded, motivated,
educated, but most of all ready to show up
daily, play all out, and be a valid contributing
player on your team. Reevaluate the employees
and positions periodically to keep forward
momentum.
I find it better to wait for the right employee to fill a staff opening. Never settle
just to get the vacancy filled by hiring the
first available person. Having the qualifications for a position is good, but having
the right attitude, work ethic, and team approach that lines up with practice culture
and fits into the existing team is great!
Cross training is the ultimate team approach. When everyone can flow to an area
of immediate need—such as those times
when there are more patients in optical waiting for assistance and the optical staff are
MADRID
| PRACTICAL CHAIRSIDE ADVICE
already working with patients—you demonstrate the team approach in action. Each
team member may primarily work in areas
that best utilize her strengths, but can also
contribute in areas outside her comfort zone.
You are only as strong as your weakest
link. In larger practices with a large staff,
often jobs become compartmentalized. The
entire team shares the common objective of
taking care of patients. We must not become
shortsighted and fail to see beyond an individual department or a single employee but
look to the greater picture. If we are going to
achieve success overall, then we must understand and respect each individual and realize
that every link must be strong and bonded
together. The sum is greater than the parts.
Sometimes the fit may not work out if an
employee fails to keep a good attitude or cannot buy into the desired goal and vision of
Negativity can stall
the forward progress
of the team, and
drama has no place
in a professional
setting.
a practice. It is better to break ties with an
employee unwilling to foster the right care
for fellow team members or patients. Negativity can stall the forward progress of the
team, and drama has no place in a professional setting. Sometimes, an employee who
truly cares will join a team only to later discover that she carries the load and no one
else cares about achieving success. When this
InDispensable
occurs, good help is lost, and this directly
impacts revenue and patient care.
Steps to better
teamwork
1
Define the culture
2
Build your best team
3
Be intentional
Imagine a team of staff that work to earn
a living, but also truly care about the quality of work, about one another, and each
patient. I am not talking about those who
just show up for a paycheck but about folks
with a passion for success. Successful team
members exhibit a great work ethic. Educate
staff of exact objectives and share with individuals how you expect them to contribute
in their roles.
STEP Be intentional
Step three is to remember that good
teamwork is intentional, not incidental. An employer once shared with
me his desire for his practice to reach the
next level. I joined his staff with the intention of doing my part to achieve that goal. It
started with the managing doctor being intentional in reaching that benchmark. The greatest part was that our philosophies matched:
take care of every patient every time, and
success will follow. I was not initially hired
into a management role, but my willingness
to serve others along with displaying good
work ethics led to a promotion. It is the at-
3
37
titude, not the title, that counts.
The success that followed that endeavor
was accomplished by a joint effort of the entire team. Record growth and expansion followed. This was achieved by word-of-mouth
referrals from patients. These patients were
cared for in an environment that truly gave
them excellent care in a warm and inviting
culture. Happy and successful workplaces
typically have low staff turnover rates.
Dedication to growth and change
Over the course of my career, I have been
privileged to hear many wonderful motivational speakers and educators and to be a
part of various practices and companies. The
most important message when it comes to
application is that each team member is dedicated to growth and change, and willing to
be a team player.
I watched some business models thrive
while others failed. Some individuals who
strive to perform and make a difference get
frustrated when other staff do not care for
change. Change is a vital part of growth. To
stagnate means you are stuck in the same
place as yesterday, afraid to go forward or
try something new. A business will not reach
success if there is not a clear vision and effective communication from the leadership.
Without direction, you can find staff members working with completely different goals
and agendas that are not common or in sync.
Try applying this advice to improve teamwork among your staff. A well-synced staff
helps your practice operate like a well-oiled
machine. They’ll feel it, you’ll feel it, and most
importantly, your patients will feel it.
Lisa Frye is certified by the American Board of Opticians and is a
Fellow of the National Academy of Opticians.
AMSTERDAM
38
InDispensable
AUGUST 2015
|
Frameri eyewear launches Prose
Cincinnati, OH—Frameri eyewear recently launched
its latest collection, Prose, inspired by literature and features styles named for iconic
writers.
Harper is a new interpretation of the classice cat-eye frame. This frame is available
in a variety of frame color options including
Carbon, Cheetah, Ruby, Cobalt, Lilac, and
Ember.
While all of Frameri’s styles can be worn
by men or women, the company says Harper is its most female-friendly frame to date.
Twain is a modern frame with clean lines
an dmemorable drop-down bridge. Twain
is available in a variety of colors including
Smoke, Ember, Black, Oxford, Havana, and
Granite.
Austen features traditional design elements including an arched top and rounded
bridge—a combination known as a smile.
Austen offers a variety of frame color options including Honey, Black, Clear, and
Cheetah.
Frameri allows wearers to quickly and easily change their look by popping out the lenses and putting them in a different frame. Or
a wearer can switch from optical to sunwear
by simply switching out the lenses.
The wearer can purchase her favorite
frame in a variety of colors or stick with one
TWAIN
HARPER
AUSTEN
AUSTEN
frame and change up her look with different
tinted lens options.
All frames are $99 with $50 for plano and
single-vision lenses or $250 for progressive lenses. Lenses are polycarbonate, ARcoated, EMI-coated, scratch resistant, and
smudge resistant. Frameri offers 10 different
tints for sunglasses lenses.
While Frameri began as an online-only
optical retail company, the eyewear brand
recently began expanding into traditional
optical shops.
For more information on Frameri, check
out our July 2015 cover story, “After Shark
Tank, Frameri online optical finds success.”
Published as a promotional supplement to the June 2015 issue of
DIABETIC EYE DISEASE:
Diagnosis and Management Strategies for Patients
t
Challenges in diagnosing DME
t
Referral and patient monitoring
t
The evolving treatment of DME
Did you miss this must-read promotional supplement in the June issue of Optometry Times?
Download the supplement at: http://optometrytimes.com/diabetic-eye-disease
40
InDispensable
AUGUST 2015
|
Spine eyewear introduces new styles
SUN VALLEY, CA—Spine eyewear recently released two new sunglass styles,
avialable in a variety of frame colors and lens options. According to the
company, Spine frames feature hinges that grip all day to fit any face
shape or head size. The hinges were inspired by the vertebrae of the
spine, which allows the frame’s temples open and close smoothly and
gradually.
SP3003 is a vintage-styled, handmade acetate frame with a retro
keyhole bridge detail. This frame is avialable in tortoise with green
lenses, as seen here.
SP3002 is a classic aviator shape finished in handmade acetate.
The frame is featured here in black and tortoise with smoke lenses.
SP3002 is available in crystal with green lenses, seen at left,
and tortoise with green lenses. All Spine lenses are fitted with an
interior AR coating.
SP3003 is also avialable in black and havana with brown
lenses, seen at right, and crystal with smoke lenses.
Coburn Technologies launches improved website with chat feature
South Windsor, CT—Coburn Technologies announced the launch of the new and improved CoburnTechnologies.com website.
This website will provide visitors with a
more custom and interactive experience
for viewing Coburn Technologies’ optical
equipment, product videos, and the latest
news.
A feature new to the website is the ability to chat with a Coburn Technologies
representative. Customer service staff
is readily available to answer any and all
questions. Visitors may start a session on
any page and continue their conversation
if they navigate to another page on the
website.
At any time during the chat, the visitor
has the ability to send the transcript to
his e-mail for future reference. The chat
feature also works on any mobile device or
tablet. Customer service staff will be available Monday thru Friday, 8 a.m. to 6 p.m.
Eastern time.
Coburn Technologies’ mobile-friendly
site gives the growing number of consumers using mobile devices and tablets an
easier and more comprehensive way of
interacting with the website. Site speed
and load times have been enhanced to
allow rapid communication with little to no
wait time.
CoburnTechnologies.com includes a
list of popular optical equipment from the
former website, as well as a growing list of
new products, which are continually added
to the website.
AUGUST 2015 / OptometryTimes.com
Go to:
41
products.modernmedicine.com
Products & Services
SHOWCASE
PRODUCTS
Search for the company name you see in each of the ads in this section for FREE INFORMATION!
AUGUST 2015 / Optometry Times
42
Products & Services
SHOWCASE
Go to:
products.modernmedicine.com
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Akorn Pharmaceuticals
Fax: 267-483-4010
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Alcon Laboratories Inc
Tel: 800-862-5266
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Bausch + Lomb
Tel: 800-227-1427
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9, 10, 35
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CV2
Heidelberg Engineering
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Tel: 914-345-7400
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Shire Ophthalmic
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InDispensable
45
Transitions launches social content aggregator
Pinellas Park, FL—Transitions Optical is making it
easier for eyecare professionals to join the
#ThroughANewLens discussion and engage
their patients with social media content. The
web page, found at TransitionsPRO.com/
NewLens, gives eyecare professionals the
ability to view and share a series of consumer videos that are available through its “See
Life Through a New Lens” campaign.
The socially-shareable videos feature fashion tips and trends from style maven Sarah
Evans at South by Southwest (SXSW); content from Rolling Stone’s “Dawn to Dusk”
editorial series sponsored by Transitions; and
a way to showcase Transitions Trial Decals.
Simple share buttons make it possible for
eyecare professionals to share an item directly
with their patients on their Twitter, Facebook,
LinkedIn, or Google+ accounts. As activities
surrounding Transitions Optical’s consumer
campaign and high-profile media partnerships continue to unfold, new content will be
uploaded.
“Even though we are already sharing these
digital assets on our brand’s social pages,
Costa releases Playa, Pawleys
Daytona Beach, FL—Costa recently introduced
two new styles to its lifestyle sunglasses
collection, Playa and Pawleys.
Playa, seen here, features a sleek construction in a medium fit with co-injected
molded nylon frames and hypoallergenic
rubberized no-slip nose pads. Playa is
available in a variety of colors, including
honey tortoise; coconut fade; matte Car-
PLAYA
ribbean fade; black and amber; black,
white, and aqua; and light tortoise, white,
and aqua.
Pawleys features a combination frame
comprised of Monel metal and nylon. This
large frame has a lightweight fit and optical spring hinge.
All Costa sunglasses can be customized with a variety of 560 lenses.
we are also housing them on our professional website so that our partners can visit
one place and easily pick and choose from
the most up-to-date activities related to our
consumer campaign,” says Patience Cook,
director, North America marketing, Transi-
tions Optical. “Our goal with the page is to
provide our partners with unique messages
that will encourage more consumers to reconsider how a new lens–like Transitions
adaptive lenses–can fit into their personal
style and offer rich visual experiences.”
BRIEF SUMMARY
PAZEO (olopatadine hydrochloride ophthalmic solution) 0.7%.
For topical ophthalmic administration.
The following is a brief summary only; see full prescribing
information for complete product information.
CONTRAINDICATIONS
None.
WARNINGS AND PRECAUTIONS
Contamination of Tip and Solution
As with any eye drop, care should be taken not to touch the eyelids
or surrounding areas with the dropper tip of the bottle to prevent
contaminating the tip and solution. Keep bottle tightly closed when
not in use.
Contact Lens Use
Patients should not wear a contact lens if their eye is red.
The preservative in PAZEO solution, benzalkonium chloride, may
be absorbed by soft contact lenses. Patients who wear soft
contact
lenses and whose eyes are not red, should be instructed to wait
at least five minutes after instilling PAZEO before they insert their
contact lenses.
ADVERSE REACTIONS
Clinical Trials Experience
Because clinical trials are conducted under widely varying
conditions, adverse reaction rates observed in the clinical trials of
a drug cannot be directly compared to rates in clinical trials of
another drug and may not reflect the rates observed in practice.
In a randomized, double-masked, vehicle-controlled trial, patients
at risk for developing allergic conjunctivitis received one drop of
either PAZEO (N=330) or vehicle (N=169) in both eyes for 6 weeks.
The mean age of the population was 32 years (range 2 to 74 years).
Thirty-five percent were male. Fifty-three percent had brown iris
color and 23% had blue iris color. The most commonly reported
adverse reactions occurred in 2-5% of patients treated with either
PAZEO or vehicle. These events were blurred vision, dry eye,
superficial punctate keratitis, dysgeusia and abnormal sensation
in eye.
USE IN SPECIFIC POPULATIONS
Pregnancy
Risk Summary
There are no adequate or well-controlled studies with PAZEO in
pregnant women. Olopatadine caused maternal toxicity and
embryofetal toxicity in rats at levels 1,080 to 14,400 times the
maximum recommended human ophthalmic dose (MRHOD). There
was no
toxicity in rat offspring at exposures estimated to be 45 to 150 times
that at MRHOD. Olopatadine should be used during pregnancy only
if the potential benefit justifies the potential risk to the fetus.
Animal Data
In a rabbit embryofetal study, rabbits treated orally at 400 mg/kg/
day during organogenesis showed a decrease in live fetuses. This
dose is 14,400 times the MRHOD, on a mg/m2 basis.
An oral dose of 600 mg/kg/day olopatadine (10,800 times the
MRHOD) was shown to be maternally toxic in rats, producing
death and reduced maternal body weight gain. When administered
to rats throughout organogenesis, olopatadine produced cleft
palate at 60 mg/kg/day (1080 times the MRHOD) and decreased
embryofetal viability and reduced fetal weight in rats at 600 mg/
kg/day. When administered to rats during late gestation and
throughout the lactation period, olopatadine produced decreased
neonatal survival at 60 mg/kg/day and reduced body weight gain
in offspring at 4 mg/kg/day. A dose of 2 mg/kg/day olopatadine
produced no toxicity in rat offspring. An oral dose of
1 mg/kg olopatadine in rats resulted in a range of systemic plasma
area under the curve (AUC) levels that were 45 to 150 times higher
than the observed human exposure [9.7 ng∙hr/mL] following
administration of
the recommended human ophthalmic dose.
Nursing Mothers
Olopatadine has been identified in the milk of nursing rats following
oral administration. Oral administration of olopatadine doses at
or above 4 mg/kg/day throughout the lactation period produced
decreased body weight gain in rat offspring; a dose of 2 mg/kg/
day olopatadine produced no toxicity. An oral dose of 1 mg/kg
olopatadine in rats resulted in a range of systemic plasma area
under the curve (AUC) levels that were 45 to 150 times higher
than the observed human exposure [9.7 ng∙hr/mL] following
administration of the recommended human ophthalmic dose. It is
not known whether topical ocular administration could result in
sufficient systemic absorption to produce detectable quantities in
the human breast milk. Nevertheless, caution should be exercised
when PAZEO is administered to a nursing mother.
Pediatric Use
The safety and effectiveness of PAZEO have been established in
pediatric patients two years of age and older. Use of PAZEO in
these
pediatric patients is supported by evidence from adequate and
well-controlled studies of PAZEO in adults and an adequate and
well controlled study evaluating the safety of PAZEO in pediatric
and adult patients.
Geriatric Use
No overall differences in safety and effectiveness have been
observed between elderly and younger patients.
NONCLINICAL TOXICOLOGY
Carcinogenesis, Mutagenesis, Impairment of Fertility
Carcinogenicity
Olopatadine administered orally was not carcinogenic in mice and
rats in doses up to 500 mg/kg/day and 200 mg/kg/day, respectively.
Based on a 35 μL drop size and a 60 kg person, these doses are
approximately 4,500 and 3,600 times the MRHOD, on a mg/m2 basis.
Mutagenesis
No mutagenic potential was observed when olopatadine was
tested in an in vitro bacterial reverse mutation (Ames) test, an
in vitro mammalian chromosome aberration assay or an in vivo
mouse micronucleus test.
Impairment of fertility
Olopatadine administered at an oral dose of 400 mg/kg/day
(approximately 7,200 times the MRHOD) produced toxicity in male
and female rats, and resulted in a decrease in the fertility index
and reduced implantation rate. No effects on reproductive function
were observed at 50 mg/kg/day (approximately 900 times the
MRHOD).
PATIENT COUNSELING INFORMATION
H".804+B439&2.3&9.43@);.8*5&9.*3989434994:(-)7455*79.594
eyelids or surrounding areas, as this may contaminate the dropper
tip and ophthalmic solution.
HB43(42.9&39E8*4+B439&(9C*38*8@);.8*5&9.*39834994
wear contact lenses if their eyes are red. Advise patients that
PAZEO should not be used to treat contact lens-related irritation.
Advise patients to remove contact lenses prior to instillation
of PAZEO. The preservative in PAZEO solution, benzalkonium
chloride, may be absorbed by soft contact lenses. Lenses may
be reinserted 5 minutes following
administration of PAZEO.
Patents: 8,791,154
ALCON LABORATORIES, INC.
Fort Worth, Texas 76134 USA
© 2015 Novartis.
6/15 PAZ15093JAD
46
Q&A
AUGUST 2015
Joan Hansen, OD
|
Co-owner of Tsawwassen Optometry, Tsawwassen, BC, Canada
Optometry politics, CE junkie, and hairdressing
Did the U.S. Affordable
Care Act affect the number of cross-border patients you
see? We see a number of people who live down in Point
Roberts, WA. They have to
go so far to find care; they
don’t have anybody there.
They have to drive over the
border, through Tsawwassen, drive through Canada,
go back again through the
border, and down to Blaine
or Bellingham for eye care.
They pay with cash; we can’t
bill their insurance. Nor do
we bill any in Canada; it’s no
different for our Canadian
patients. When we need to
send somebody off for, say,
cataract treatment, if he has
Medicare we try to set him
up with an ophthalmologist
down on the Seattle side. What’s something your
colleagues don’t know
about you? Before optometry
school, I was a hairdresser.
[Laughs] When I finished
high school, I wasn’t ready
to go to university. I took a
hairdressing course for 10
months at our local community college. I wanted to
make enough money so I
could go traveling. I worked
as a hairdresser for only a
couple of years and saved up
enough money to go to Europe. That started my travel
bug. I knew it wasn’t going
to be forever—it would be
hard to make the kind of
money for the independence
and intellectual challenge
that I wanted. I knew I was
going to university, but I had
to be ready to buckle down.
How did you begin offering CE yourself? I had
always liked running the
Q
What attracted
you to
professional
leadership?
All the people I went
to optometry school
with—there was 57
in our class so you
got to know everyone
pretty well—were very
involved in activities
around the school, organizing things. Over
the years, my class has
been very involved with
optometry leadership
across the country as
well. When I moved to
British Columbia, one
of my classmates who
was here said, “I’m
glad you’re here. I’ve
got a job for you on
our BCA council.” So, I
was put to work immediately when I got here.
That got me into going
through the chairs at
the BC Association of
Optometrists, then I
moved on to the Canadian Association of
Optometrists.
continuing education seminars for the BC association.
It was getting to know the
speakers who came to speak
to us. So, I went to other seminars like AOA, SECO, or Academy and listened to the top
speakers and found people I
would like to bring up to British Columbia. Once you tell
them you’re in Vancouver,
it’s not hard to get somebody
to come here. Prior to that,
I was very disappointed in
what the BC association was
giving us as education. It
didn’t fill my niche of what
I wanted to listen to, and I
found myself not going. So I
thought, “I can’t be the only
one,” so I tried offering some
CE on my own. I figured
out how to put one together,
found a venue, and have
been doing it ever since.
Why are you a CE
junkie? I like to know
what’s going on. Being a part
of optometric politics, I always want to be at the table
when something new is
being discussed or a decision
was being made. I feel the
same way about CE. I want
to know what’s new. Maybe
I can’t do it in my own clinic
today with lasers or cataract
surgery, but I want to know
what’s new so that I can
help my patients make the
best decisions. When I was
in university, I sat in the
back of the classroom.
Now I sit at the front
and direct it.
many things within the office that I don’t know what
they do because it’s their responsibility. I empower them
so that they have an interest
in how we’re doing. I have
no qualms about sharing
how much money is coming
into the office. I think this
makes them feel they are an
important part of the team.
What’s the craziest
thing you’ve ever done?
Trying to ride a hand-pump
train car with a bunch of my
friends when I was in high
school. We weren’t even
drunk. [Laughs] The part of
Winnipeg where I lived was
right along the main railway
track. It was the railway yard
where they repaired all the
cars for the railway. We went
not quite half a mile. Somehow we made it back. I’m not
even sure how we even got
into the yard.
—Vernon Trollinger
Many of your staff
have been with you
for a long time. What’s
your secret? I treat
them like I would
want to be treated.
I encourage them to
be part of the decisionmaking in the
office. There are
To hear the full
interview with Dr.
Joan Hansen, listen
online:
optometrytimes.com/
JoanHansen
Photo courtesy Joan Hansen, OD
Once-Daily PAZEOTM Solution
24 HOURS OF OCULAR ALLERGY
ITCH RELIEF
IN ONE DROP
Once-Daily PAZEO™ Solution
for relief of ocular allergy itch:
The first and only FDA-approved once-daily drop with
demonstrated 24-hour ocular allergy itch relief1
Statistically significantly improved relief of ocular itching
compared to PATADAY® (olopatadine hydrochloride
ophthalmic solution) 0.2% at 24 hours post dose
(not statistically significantly different at 30-34 minutes)1
Statistically significantly improved relief of ocular itching
compared to vehicle through 24 hours post dose1
Study design: Two multicenter, randomized, double-masked, parallel-group, vehicle- and
active-controlled studies in patients at least 18 years of age with allergic conjunctivitis using the
conjunctival allergen challenge (CAC) model (N=547). Patients were randomized to receive study
drug or vehicle, 1 drop per eye on each of 2-3 assessment days. On separate days, antigen challenge
was performed at 27 (±1) minutes post dose to assess onset of action, at 16 hours post dose (Study
1 only), and at 24 hours post dose. Itching scores were evaluated using a half-unit scale from
0=none to 4=incapacitating itch, with data collected 3, 5, and 7 minutes after antigen instillation.
The primary objectives were to demonstrate the superiority of PAZEO™ Solution for the treatment
of ocular allergy itch. Study 1: PAZEO™ Solution vs vehicle at onset of action and 16 hours. Study 2:
PAZEO™ Solution vs vehicle at onset of action; PAZEO™ Solution vs PATADAY® Solution, PATANOL®
(olopatadine hydrochloride ophthalmic solution) 0.1%, and vehicle at 24 hours.1-3
PAZEO™ Solution: Safety Profile
Give your patients 24 HOURS
OF OCULAR ALLERGY ITCH
RELIEF with once-daily
PAZEO™ Solution1
Well tolerated1
The safety and effectiveness of PAZEO™ Solution have been established in patients two years of age and older1
The most commonly reported adverse reactions, occurring in 2% to 5% of patients, were blurred vision, dry eye,
superficial punctate keratitis, dysgeusia, and abnormal sensation in eye1
Once-daily dosing1
INDICATION AND DOSING
PAZEO™ Solution is indicated for the treatment of ocular itching associated with allergic conjunctivitis. The recommended dosage
is to instill one drop in each affected eye once a day.
IMPORTANT SAFETY INFORMATION
As with any eye drop, care should be taken not to touch the eyelids or surrounding areas with the dropper tip of the bottle to
prevent contaminating the tip and solution. Keep bottle tightly closed when not in use.
Patients should not wear a contact lens if their eye is red. PAZEO™ Solution should not be used to treat contact lens-related
irritation. The preservative in PAZEO™ Solution, benzalkonium chloride, may be absorbed by soft contact lenses. Patients
who wear soft contact lenses and whose eyes are not red should be instructed to wait at least five minutes after
instilling PAZEO™ Solution before they insert their contact lenses.
The most commonly reported adverse reactions in a clinical study occurred in 2%-5% of patients
treated with either PAZEO™ Solution or vehicle. These events were blurred vision, dry eye,
superficial punctate keratitis, dysgeusia, and abnormal sensation in eye.
For additional information on PAZEO™ Solution, please refer to the brief summary of
the full Prescribing Information on the following page.
References: 1. PAZEO™ Solution Package Insert. 2. Data on file, 2011. 3. Data on file, 2013.
From Alcon, committed to providing treatment options for patients.
Olopatadine is licensed from Kyowa Hakko Kirin Co., Ltd. Japan
©2015 Novartis
6/15
PAZ15093JAD
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cleaning and disinfection of CLEAR CARE ® – and now with our exclusive
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1
Gabriel M, Bartell J, Walters R, et al. Biocidal efficacy of a new hydrogen peroxide contact lens care system against bacteria, fungi, and Acanthamoeba species.
Optom Vis Sci. 2014; 91: E-abstract 145192. © 2015 Novartis 5/15 CCS15069AD-B
®