Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
Download What`s trending in ocular allergy treatment
Document related concepts
Transcript
FEBRUARY 2015 VOL. 7, NO. 2 Practical Chairside Advice OptometryTimes.com What’s trending in ocular allergy treatment Many AMD supps do not meet AREDS standards Prevalence of disease is increasing, and so should your knowledge patients can THIS IS WHY enjoy refreshing comfort with every Figure blink—no matter 1. A patient with what the day may bring. giant papillary BLINK-ACTIVATED MOISTURIZING AGENTS + conjunctivitis. While not a true ocular allergic condition, it is commonly seen in patients wearing soft contact lenses or those with exposed suture barbs. Treatment is the same as for patients suffering from allergic conjunctivitis. See Supplements on page 1 = Experts issue vision screening recommendations BLINK-ACTIVATED MOISTURE MOISTURIZING AGENTS TEAR FILM STABILITY Moisture is released with every PVA, PEG and HPMC help Tear film stability helps blink, which helps result in a deliver comfort from insertion support clear vision. stable tear film. to the end of the day. By Colleen E. McCarthy By Ernie Bowling, OD, FAAO Offer your patients innovative technologies that provide outstandingContent all-day Specialist comfort. he advent of spring yields the annual Visit of myalcon.com pilgrimage patients into our offices Chicago—The National Expert Panel to the Nacomplaining of the itchy, watery eyes tional Center for Children’s Vision and Eye of allergy. As any eyecare practitioner Health at Prevent Blindness has issued new can attest, ocular allergy is one of the most recommendations to provide an evidence-based common presentations to an eyecare pracapproach to screening children from 36 to 72 tice. The ocular conjunctiva is particularly months old. The recommendations include syssusceptible to airborne allergens and is a tem-based public health strategies to ensure very common site of allergic inflammation.1 ™ improved surveillance and program accountOcular allergy presents in conjunction with PERFORMANCE DRIVEN BY SCIENCE ability as it relates to children’s vision in the other systemic atopic manifestations, includU.S. The new recommendations were recently ing rhinoconjunctivitis (hay fever), rhinopublished in Optometry and Vision Science. sinusitis, asthma, urticaria (hives), and/or T See Allergy prevalence on page 1 *Based on DAILIES ® AquaComfort Plus ® sphere contact lenses. Reference: 1. Wolffsohn J, Hunt O, Chowdhury A. Objective clinical performance of ‘comfort-enhanced’ daily disposable soft contact lenses. Cont Lens Anterior Eye. 2010;33(2):88-92. See product instructions for complete wear, care, and safety information. © 2014 Novartis 12/14 Q A DAF15001JAD & | DR. See Screening on page 1 DORI CARLSON discusses Nor th Dakota , leadership, weightlif ting, and ice S e e p a g e 4 2 FeBRUaRY 2015 VOL. 7, NO. 2 PRACTICAL CHAIRSIDE ADVICE optometrytimes.com What’s trending in ocular allergy treatment Many aMD supps do not meet aReDS standards Prevalence of disease is increasing, and so should your knowledge By colleen e. Mccarthy Content Specialist figurE 1. a patient with giant papillary conjunctivitis. While not a true ocular allergic condition, it is commonly seen in patients wearing soft contact lenses or those with exposed suture barbs. treatment is the same as for patients suffering from allergic conjunctivitis. T Q&a magenta cyan yellow black See Supplements on page 5 experts issue vision screening recommendations By ernie Bowling, OD, fAAO he advent of spring yields the annual pilgrimage of patients into our offices complaining of the itchy, watery eyes of allergy. As any eyecare practitioner can attest, ocular allergy is one of the most common presentations to an eyecare practice. The ocular conjunctiva is particularly susceptible to airborne allergens and is a very common site of allergic inflammation.1 Ocular allergy presents in conjunction with other systemic atopic manifestations, including rhinoconjunctivitis (hay fever), rhinosinusitis, asthma, urticaria (hives), and/or atopic dermatitis (eczema).1 Ocular allergy includes a spectrum of sAn frAnCisCO— A study recently published in Ophthalmology found that nutritional supplements marketed to help treat age-related macular degeneration (AMD) may not be backed by scientific evidence. According to the study, researchers examined the five top-selling brands of ocular nutritional supplements in the U.S. according to dollar sales tracked by SymphonyIRI (Waltham, MA) from June 2011 to June 2012. The study reviewed the ingredients and manufacturer claims of 11 ocular nutritional supplements on the companies’ consumer information websites. Those ingredients were compared with those contained in the Age-Related Eye Disease Study (AREDS) and Age-Related Eye Disease Study 2 (AREDS2) formulas. The researchers determined that some of disorders with overlapping symptoms and progressing in severity; these disorders include seasonal allergic conjunctivitis (SAC) and perennial allergic conjunctivitis (PAC), atopic keratoconjunctivitis (AKC), and vernal keratoconjunctivitis (VKC). SAC and PAC are the most common forms of ocular allergy. By colleen e. Mccarthy Content Specialist Approximately 15-20 percent of the world population is affected by some form of allergic disease. Ocular symptoms present in about 40-60 percent of allergic patients2 and contribute significantly to poor qual- CHiCAgO—The National Expert Panel to the National Center for Children’s Vision and Eye Health at Prevent Blindness has issued new recommendations to provide an evidence-based approach to screening children from 36 to 72 months old. The recommendations include system-based public health strategies to ensure improved surveillance and program accountability as it relates to children’s vision in the U.S. The new recommendations were recently published in Optometry and Vision Science. See Allergy prevalence on page 26 See Screening on page 6 Prevalence of allergy | DR. DORI CARLSON discusses Nor th Dakota , leadership, weightlif ting, and ice See paGe 42 ES558388_OP0215_CV1.pgs 01.23.2015 03:41 ADV THIS IS WHY 4 out of 5 patients 1 agree their lenses feel like new. The scientifically proven formula of CLEAR CARE® Solution deeply cleans, then neutralizes, to create a gentle saline similar to natural tears. The result is pure comfort and is why CLEAR CARE® has the most loyal patients of any lens care brand.2 The Science Behind a Pristine, Clean Lens: Pluronic 17R4 Triple-Action Cleaning Pristine, Clean Lens • Patented formula deeply cleans • Carries away dirt & debris • Pluronic^ 17R4 lifts away protein • Less residual H2O23-5 • Irritant-free comfort • No added preservatives Range of Residual H2O2 on Lens: 0 5 20 40 60 80 RESIDUAL H 2 O 2 IN PARTS 100 PER MILLION (PPM) CLEAR CARE® Solution1 SOFTWEARTM Saline 2 OCULAR AWARENESS THRESHOLD3 Recommend CLEAR CARE® Solution and learn more at MYALCON.COM PERFORMANCE DRIVEN BY SCIENCE ™ ^Trademarks are the property of their respective owners. References: 1. A market research study conducted amongst 107 US contact lens wearers representative of CLEAR CARE® purchasers in the United States, 2007. 2. Based on third party industry report 52 weeks ending 12/29/12; Alcon data on file. 3. Alcon data on file, 2009. 4. SOFTWEAR™ Saline package insert. 5. Paugh, Jerry R, et al. Ocular response to hydrogen peroxide. American Journal of Optometry & Physiological Optics: 1988; 65:2,91–98. © 2014 Novartis 02/14 CCS14004ADi magenta cyan yellow black ES558311_OP0215_CV2_FP.pgs 01.23.2015 03:38 ADV | PRACTICAL CHAIRSIDE ADVICE FROM THE 3 Chief Optometric Editor Embracing new contact lens technology 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 [email protected] 256-295-2632 recently attended our webinar “Increasing your successful multifocal fits,” presented by Editorial Advisory Board member David Geffen, OD, FAAO. David is one of the sharpest ODs I know, and his mastery of the subject matter was evident. I consider myself to be up to speed on this topic and was amazed at what I didn’t know! The webinar is available on our website (http://www.modernmedicine.com/webinars#eyecare). After the presentation, I wondered: with the outstanding multifocal options for our contact lens patients, why would anyone still choose monovision as a primary selection? Monovision is an antiquated technology dating back at least to the 1960s1 and goes against almost every tenet we’ve been taught regarding binocular vision. At its inception, it was the only method we had to keep our presbyopic patients in their contact lenses. Not a week I goes by where I don’t see a patient wearing this modality. Many come to my office on the recommendation of a family member or friend who raved about their improved vision after I fitted them with multifocals. I understand the attraction of monovision, especially in a busy practice: it requires no special lens, fitting is no more complicated than traditional lenses, and it is generally accepted visually by more than 70 percent of patients.2 Likewise, some practitioners shy Why would anyone still choose monovision as a primary selection? away from multifocals due to a perceived complexity of the fit and increased chair time. Not saying that monovision doesn’t have a place. It still does, albeit for those few rare cases when I just can’t get them comfortable in a multifocal. I am also a firm subscriber to grandma’s old adage: if it ain’t broke, Ernie, don’t fix it. But not when it comes to monovison. Many patients have simply gone along with that modality. They may not be aware of other options. That’s where we come in. Let’s face it: today’s presbyopes aren’t our grandparents. They are more active with more visual demands and more disposable income. This cohort is growing and is seriously underserved regarding presbyopic correction.3 These patients want the best correction we have to offer, do not want to compromise their vision, and are willing to pay for better technology. Today, that means multifocals. So, if you haven’t given multifocals a whirl lately, consider them. These new multifocal designs have resulted in increased success rates and patient satisfaction vs. monovision.3 Your patients will appreciate your efforts at bringing them the latest in contact lens technology. REFERENCES 1. Fonda G. Presbyopia corrected with single vision spectacles or corneal lenses in preference to bifocal corneal lenses. Trans Ophthalmol Soc Aust. 1966:25;70-80. 2. Westin E, Wick B, Harrist RB. Factors influencing success of monovision contact lens fitting: survey of contact lens diplomates. Optometry. 2000 Dec;71(12):757–63. 3. Bennett ES. Contact lens correction of presbyopia. Clin Exp Optom. 2008 May;91(3):265-78. Read more from Dr. Bowling. Turn to page 26 for his take on allergy. 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 magenta cyan yellow black 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 ES556137_OP0215_003.pgs 01.20.2015 20:59 ADV Digit@l 4 FEBRUARY 2015 • VOL. 6, NO. 02 Content CONTENT CHANNEL DIRECTOR Gretchyn M. Bailey, NCLC, FAAO [email protected] 215/412-0214 CONTENT SPECIALIST Colleen McCarthy [email protected] 440/891-2602 VIDEO GALLERY Follow us to stay up-to-date with the latest news GROUP CONTENT DIRECTOR Mark L. Dlugoss [email protected] 440/891-2703 GROUP ART DIRECTOR Robert McGarr • ART DIRECTOR Lecia Landis Publishing/Advertising and advice, then join in the conversation and share with your peers. EXECUTIVE VICE PRESIDENT Georgiann DeCenzo [email protected] 440/891-2778 USING QUESTIONNAIRES TO IDENTIFY DRY EYE VP, GROUP PUBLISHER Ken Sylvia [email protected] 732/346-3017 GROUP PUBLISHER Leonardo Avila [email protected] 302/239-5665 In this video, Dr. Leslie O’Dell discusses how asking the right questions can help identify dry eye patients who may not realize that they have a problem. Dr. O’Dell utilizes the Standard Patient Evaluation of Eye Dryness (SPEED) questionnaire. To read more from Dr. O’Dell, turn to page 34. http://ow.ly/HIr43 ASSOCIATE PUBLISHER Erin Schlussel [email protected] 215/962-5399 NATIONAL ACCOUNT MANAGER Cherie Pearson [email protected] 609/636-0172 DIR. OF BUSINESS DEVELPMENT, HEALTHCARE TECHNOLOGY SALES Margie Jaxel [email protected] 732/346-3003 ACCOUNT MANAGER, CLASSIFIED/DISPLAY ADVERTISING Karen Gerome [email protected] 440/891-2670 WHAT’S TRENDING IN ALLERGY TREATMENT STAYING HIPAA COMPLIANT ONLINE HOW TO GET SAMPLES Dr. Ernie Bowling talks about the latest treatments for ocular allergies in this new video. Dr. Justin Bazan shares his tips for staying HIPPA compliant on social media platforms. http://ow.ly/HIrC7 http://ow.ly/HIrXA Dr. Scott Schachter explains the best ways to get samples for your patients from pharma reps. ACCOUNT MANAGER, RECRUITMENT ADVERTISING Joanna Shippoli [email protected] 440/891-2615 http://ow.ly/HIshA BUSINESS DIRECTOR, EMEDIA Don Berman [email protected] 212/951-6745 SPECIAL PROJECTS DIRECTOR Meg Benson [email protected] 732/346-3039 DIRECTOR OF MARKETING & RESEARCH SERVICES Gail Kaye [email protected] 732/346-3042 SALES SUPPORT Hannah Curis [email protected] 732/346-3055 REPRINTS 877-652-5295 ext. 121, [email protected] Outside US, UK, direct dial: 281-419-5725. Ext. 121 LIST ACCOUNT EXECUTIVE Renée Schuster [email protected] 440/891-2613 PERMISSIONS/INTERNATIONAL LICENSING Maureen Cannon [email protected] 440/891-2742 TOP HEADLINES Check out what your colleagues are reading. 1 2 3 Production Optometry Times app user breakdown: Vision therapy: A top 10 must-have list 38% Two-way communication is essential to patient care One door vs. two door debate continues OptometryTimes.com/onedoorvstwodoor 62% FEMALE OPTOMETRY TIMES does not verify any claims or other information appearing in any of the advertisements contained in the publication, and cannot take responsibility for any losses or other damages incurred by readers in reliance of such content. Get access to all the benefits Optometry Times offers at your fingertips. The Optometry Times app for iPad and iPhone is now free in the iTunes store. OPTOMETRY TIMES cannot be held responsible for the safekeeping or return of unsolicited articles, manuscripts, photographs, illustrations or other materials. Library Access Libraries offer online access to current and back issues of Optometry Times through the EBSCO host databases. To subscribe, call toll-free 888-527-7008. Outside the U.S. call 218/740-6477. OPTOMETRY TIMES (Print ISSN: 0890-7080, Digital ISSN: 2328-3904) is published monthly (12 issues) by UBM Advanstar, 131 W. First Street, Duluth, MN 55802-2065. Subscription rates: $49 for one year in the United States & Possessions; $59 for one year in Canada and Mexico, and $89 for one year for all other countries. Periodicals Postage paid at Duluth MN 55806 and additional mailing offices. POSTMASTER: Please send address changes to OPTOMETRY TIMES, P.O. Box 6089, Duluth, MN 55806-6089. Canadian G.S.T. number: R-124213133RT001, PUBLICATIONS MAIL AGREEMENT NO. 40612608, Return Undeliverable Canadian Addresses to: IMEX Global Solutions, P. O. Box 25542, London, ON N6C 6B2, CANADA. Printed in the U.S.A. MISSION STATEMENT Optometry Times is an optometry-driven publication that disseminates news and information of a clinical, socioeconomic, and political nature in a timely and accurate manner for members of the optometric community. In partnership with our readers, we will achieve mutual success by: CHIEF EXECUTIVE OFFICER Joe Loggia EXECUTIVE VICE-PRESIDENT, CAO & CFA Tom Ehardt EXECUTIVE VICE-PRESIDENT Georgiann DeCenzo EXECUTIVE VICE-PRESIDENT Chris DeMoulin EXECUTIVE VICE-PRESIDENT, BUSINESS SYSTEMS Rebecca Evangelou EXECUTIVE VICE-PRESIDENT, HUMAN RESOURCES Julie Molleston EXECUTIVE VICE-PRESIDENT, STRATEGY & BUSINESS DEVELOPMENT Mike Alic SR VICE-PRESIDENT Tracy Harris VICE-PRESIDENT, GENERAL MANAGER PHARM/SCIENCE GROUP Dave Esola VICE-PRESIDENT, LEGAL Michael Bernstein VICE-PRESIDENT, MEDIA OPERATIONS Francis Heid VICE-PRESIDENT, TREASURER & CONTROLLER Adele Hartwick UBM Advanstar provides certain customer contact data (such as customers’ names, addresses, phone numbers, and e-mail addresses) to third parties who wish to promote relevant products, services, and other opportunities that may be of interest to you. If you do not want UBM Advanstar to make your contact information available to third parties for marketing purposes, simply call toll-free 866/529-2922 between the hours of 7:30 a.m. and 5 p.m. CST and a customer service representative will assist you in removing your name from UBM Advanstar’s lists. Outside the U.S., please phone 218/740-6477. OPTOMETRY TIMES APP Optometry Times is part of the ModernMedicine Network, a Webbased portal for health professionals • Being a forum for optometrists to communicate their clinical knowledge, insights, and discoveries. offering best-in-class content and • Providing management information that allows optometrists to enhance and expand their practices. tools in a rewarding and easy-to-use environment for knowledge-sharing • Addressing political and socioeconomic issues that may either assist or hinder the optometric community, and reporting those issues and their potential outcomes to our readers. among members of our community. magenta cyan yellow black Circulation CORPORATE DIRECTOR Joy Puzzo DIRECTOR Christine Shappell MANAGER Molly Tomfohrde MALE OptometryTimes.com/visiontherapy OptometryTimes.com/communication SENIOR PRODUCTION MANAGER Karen Lenzen ©2015 Advanstar Communications Inc. All rights reserved. No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical including by photocopy, recording, or information storage and retrieval without permission in writing from the publisher. Authorization to photocopy items for internal/educational or personal use, or the internal/educational or personal use of specific clients is granted by Advanstar Communications Inc. for libraries and other users registered with the Copyright Clearance Center, 222 Rosewood Dr. Danvers, MA 01923, 978-750-8400 fax 978-646-8700 or visit http://www.copyright.com online. For uses beyond those listed above, please direct your written request to Permission Dept. fax 440-756-5255 or email: [email protected]. ES558256_OP0215_004.pgs 01.23.2015 02:41 ADV In Focus | praCtiCal ChairSide adviCe Supplements Continued from page 1 the top-selling products do not contain identical ingredient dosages to formulas proven effective in clinical trials. Addressing AREDS2 controversies “All of the ocular nutritional supplements contained the ingredients from the AREDS or AREDS2 formula; 36 percent (4/11) of the supplements contained equivalent doses of AREDS or AREDS2 ingredients; 55 percent (6/11) included some information about the AREDS on their consumer information websites,” the study’s authors write. “Product descriptions from four of the 11 supplements (36 percent) stated that the supplements were important to maintain general eye health; none of these supplements duplicated the AREDS or AREDS2 formula. All the individual supplements claimed to ‘support,’ ‘protect,’ ‘help,’ or ‘promote’ vision and eye health, but none specified that there is no proven benefit in using nutritional supplements for primary prevention of eye disease.” The study’s authors say their findings emphasize the importance of eyecare professionals educating their patients on the evidence-based role of supplements in the management of eye health. Optometry Times Editorial Advisory Board member Steven Ferrucci, OD, FAAO, agrees. “This article, in my mind, underscores the importance of patient education regarding vitamin supplements and the eye, specifically AMD,” he says. “The doctor should recognize which patients are candidates for nutritional supplementation, and exactly what supplement is most appropriate for that given patient.” Dr. Ferrucci says that the doctor’s recommendation is key in ensuring the patient is taking the correct supplement for their condition. “Just like we as optometrists recommend specific contact lenses, contact lens solutions, or progressive lenses, we should be recommending specific nutritional supplements that contain the correct ingredients for the appropriate patients,” he says. “Products that adhere to the AREDS2 formulation are the most appropriate because they have been the most validated by studies, most notably the AREDS2 study that was released last May.” The study also mentioned that a noted side effect in AREDS was the increase in genitourinary hospitalizations, a known side effect of high dosages of zinc. “Since AREDS2 found no significant difference in progression to advanced AMD using 80 mg vs. 25 mg of zinc, the practitioner should be aware of this when counseling AMD patients about ocular vitamins,” says Optometry Times Editorial Advisory Board member Sherry Bass, OD, FAAO. “There are other formulations available—not studied here—with AREDS ingredients but with low-dose zinc. “ “Bausch + Lomb fully supports the efforts of researchers and organizations to study the role of vitamins in eye health and to help clarify their benefits for clinicians and patients,” says Kristy Marks, manager, product public relations at Bausch + Lomb. Marks noted that three of the four supplements that were found to have the same ingredients in the same concentra- magenta cyan yellow black tion as those used in the AREDS and AREDS2 studies were Bausch + Lomb products— PreserVision Eye Vitamin AREDS Formula Tablets, PreserVision Eye Vitamin AREDS Formula Soft Gels, and PreserVision AREDS2 Formula. Donna Lorenson, spokesperson for Alcon, said the company is evaluating study results. Alcon’s ICaps AREDS Formula supplement represented the fourth supplement that had the same ingredients in the same concentrations as AREDS and AREDS2. “As stated in this study, there are currently no regulations for the vitamin industry,” says Dr. Bass. “Regulation may be needed, not only to prevent wasteful spending, but more 5 importantly, to reduce the risk of side effects from the unnecessarily high dosages of some ingredients.” Unproven is not disproven Commentary from Dr. Stuart Richer This meticulously written, but narrowly focused article concerns ocular nutritional supplements for the primary prevention of eye disease. While there’s a dearth of long-term multi-year studies on the efficacy of nutritional supplements on progression of early AMD, there are several international placebo controlled, doublemasked, randomized controlled trials evaluating improvement of vision function in these same patients. That See Supplements on page 6 Income limiters for the eyecare practitioner 30% Reimbursement 12% 11% 8% decreases Changes from healthcare reform Personal choice (work less, etc.) Patient volume/ patient load 7% 6% 4% 4% 2% 16% Payer mix Overhead increases Competition with other ODs Inefficiency Malpractice premium costs Other Source: Opthalmology Times ES558391_OP0215_005.pgs 01.23.2015 03:42 ADV 6 In Focus Screening Continued from page 1 “It would be great if every preschool child received a comprehensive eye exam, but that is not the current reality,” says Susan Cotter, OD, MS, FAAO, lead author of the recommendations, speaking exclusively to Optometry Times. “However, many kids undergo a vision screening in their pediatricians’ offices or at a Head Start or community screening. Opinions vary widely regarding which techniques should be used.” The panel and recommendations The National Expert Panel consists of leading professionals in optometry, ophthalmology, pediatrics, public health, and other related fields. Dr. Cotter says the panel reviewed the current scientific literature to explore best practices for vision screenings for children in this age range. The panel recommends that children 36 to 72 months be screened annually (best practice) or at least once using one of the best-practice approaches (accepted minimum standard). There are two best practice vision-screen- Supplements Continued from page 5 is not a trivial issue, as early AMD indeed affects vision, and macular re-pigmentation through dietary carotenoid supplementation (lutein/zeaxanthin) quickly improves night driving visual ability.1,2 Higher-dosed zeaxanthin has also been shown to lengthen the treatment cycle between anti-VEGF injections and other invasive procedures. When 20 mg of dietary zeaxanthin (Z-RR) was added to patients receiving triple therapy for exudative AMD (PDT, dexamethasone, and bevacizumab), the number of treatment cycles required to achieve stabilization with comparable visual acuity results was reduced by about 25 percent.3 Nonetheless, the question of supplementation efficacy for an aging population, in terms of disease progression, requires further insight and study. The authors’ conclusions exemplify another failure of the evidence-based medicine scientific model to provide solutions for actual patients concerned about individual chronic medical conditions, including AMD as well as those who do not respond to antiVEGF injections.4,5 Statistical medicine pro- magenta cyan yellow black February 2015 ing methods for preschool-aged children. The first, according to the experts, is monocular visual acuity testing using single HOTV letters or LEA Symbols surrounded by crowding bars at a 5-ft test distance, with the child responding by either matching or naming. The second is instrument-based testing using the Retinomax autorefractor or the SureSight Vision Screener with the Vision in Preschoolers (VIP) Study data software installed (version 2.24 or 2.25 set to minus cylinder form). AOA survey finds parents are unaware of infant vision needs | “If a child undergoes a vision screening, then we want it to be a good one—that is, a screening that has a high likelihood of correctly identifying the kids in need of professional eye care. With the best tests, lay or nurse screeners can identify 78 to 88 percent of preschool children with the most severe vision conditions,” she says. “Finally, there also must be mechanisms in place to ensure that the children who fail the screenings receive appropriate follow-up care with an optometrist or ophthalmologist.” Collecting screening data The recommendations say that using the Plusoptix Photoscreener is acceptable practice, as is adding stereoacuity testing using the Preschool Assessment of Stereopsis with a Smile (PASS) stereotest as a supplemental procedure to visual acuity testing or auto-refraction. “Our goal was to determine the methods expected to provide the ‘most bang for your buck’ in identifying amblyopia, strabismus, significant refractive error, and their associated risk factors, when used by a nurse or lay screener in educational, community, public health, or primary healthcare settings,” says Dr. Cotter. The National Expert Panel also calls for the creation of the development and implementation of an integrated data system for recording vision screening and eyecare follow-up outcomes in preschool-aged children. “Currently, there is a lack of data on the proportion of children screened and no effective system to ensure that children who fail screenings access appropriate comprehensive eye examinations and follow-up care,” the authors write. The panel also recommends a standardized approach to measuring progress toward viding an exact AREDS2 formulation of a few high-dosed nutrients to high-risk AMD patients at best reduces the overall risk of catastrophic visual loss by only one third. Moreover, recent AREDS2 data provide little guidance for the unfortunate AMD patient with geographic atrophy.6 Isn’t it our individual moral imperative as doctors to attempt to save vision with nutrients “not on the list?” This has been accomplished in individual cases with a resveratrol-based supplement at our medical center.7 Unfortunately, the authors draw the conclusion that ophthalmologists need not consider supplementation for chronic eye disease prevention beyond “evidence-based” publications. This conveniently leaves open only the possibility for drug-based treatment(s) and “detect–collect” protocols. What we are really interested in is an AMD prevention diet, along with a wider array of nutrients and environmental measures to shift the discussion to “prevention-cure.” I applaud manufacturers large and small and private entrepreneurs who are moving beyond the narrow constraints of evidencebased medicine in providing doctors and patients with choices where none now exist. In summary, this publication provides little direction and little room for innovation, discretion, and medical judgment. See Screening on page 13 RefeRences 1. Richer S, Park D-W, Epstein R, et al. Macular Re-pigmentation Enhances Driving Vision in Elderly Adult Males with Macular Degeneration. J Clin Exp Ophthalmology. 2012 April. 2. Yao Y, et al. Lutein supplementation improves visual performance in Chinese drivers: 1 -year randomized, double-blind, placebo-controlled study, Nutrition. 2013 Jul-Aug;29 (7-8):958-64. 3. Peralta E, Olk RJ, et al. Oral zeaxanthin improves anatomic and visual outcome of triple therapy for subfoveal CNV in age-related macular degeneration. Retina Society Meeting, poster Sept 21th-25th, 2011, Rome, Italy. 4. Hickey S and Roberts H, Tarnished Gold: The Sickness of Evidence-based Medicine, ISBN 9781466397293. 5. The NNT. Quick summaries of evidence-based medicine. Available at: www.the nnt.com Accessed 01/07/2015. 6. Age-Related Eye Disease Study 2 (AREDS2) Research Group, Chew EY, Clemons TE, Sangiovanni JP, Danis RP, Ferris FL 3rd et al, Secondary analyses of the effects of lutein/zeaxanthin on age-related macular degeneration progression: AREDS2 report No. 3. JAMA Ophthalmol. 2014 Feb;132(2):142-9. 7. Richer S, Stiles W, Ulanski L, Carroll D, Podella C, Observation of human retinal remodeling in octogenarians with a resveratrol based nutritional supplement. Nutrients. 2013 Jun 4;5(6):1989-2005. ES558389_OP0215_006.pgs 01.23.2015 03:41 ADV RELIEF AT THE MAIN SOURCE of dry eye symptoms Target Lipid Layer Deficiency: Soothe XP ® With Restoryl® Mineral Oils Recommend Soothe XP as your first choice for dry eye patients. To request samples, please call 1-800-778-0980. Now available at major retailers nationwide. Distributed by Bausch + Lomb, a Division of Valeant Pharmaceuticals North America LLC, Bridgewater, N.J. © 2014 Bausch & Lomb Incorporated. Soothe and Restoryl are trademarks of Bausch & Lomb Incorporated or its afliates. All other brand/product names are trademarks of their respective owners. PNS07316 US/SXP/14/0006 magenta cyan yellow black ES558313_OP0215_007_FP.pgs 01.23.2015 03:38 ADV 8 Opinion FEBRUARY 2015 | Treat rosacea by treating the cause—demodex I now believe rosacea can be treated by battling demodex with tea tree oil By Milton M. Hom, OD, FAAO, FACAAI (Sc) no cure. Prescribing several treatments in clinical practice with little to no success is almost the norm. Based on the studies, I really do think the demodex mite causes rosacea. Our patterns of frustration with rosacea pretty much follow the patterns with demodex. Try this, try that. ears ago, Mark Dunbar, OD, FAAO, of Bascom Palmer shared with me some cases about rosacea. I was a little taken aback because the cases he MILTON M. HOM, OD, FAAO, FACAAI shared concerned Hispanic patients, (SC) not the usual patients of Northern English isles descent we read about Tea tree oil treatment in school. The skeptic in me was doubtful, We know that the best treatment for demoeven though Mark had great pictures and dex is tea tree oil.9 Tea tree oil is merciless detailed data from the cases. against the mite. It comes in pads, ointments, Fast forward to today. Dry eyes and lid soaps, shampoos, etc. We have noticed it disease are the main buzzwords in ocular is also effective against rosacea. Typically, surface. In the past, everyone had aqueous we recommend the patient to use the tea tear deficiency, now everyone has meibomian gland dysfunction (MGD)/evaporative/ blepharitis. With respect to blepharitis, Gary Gerber, OD, says it seems like staphylococcus has left the planet and demodex has taken its place.1 Y Demodex and rosacea So, let’s look at the demodex prevalence studies. Three studies posit the rates of demodex in blepharitis: 62.9 percent, 88 percent, 97 percent of patients with blepharitis have demodex.2-5 The figures are not exactly the same, but they all represent the majority. There was a time when I believed 97% of patients with blepharitis have demodex; other studies posit 63% or 88% there was blepharitis and, on a rare occasion, demodex blepharitis. Now, I believe that most blepharitis is actually caused by demodex. Yes, it is that prevalent. What does this have to do with rosacea? Recent research has pointed to an undeniable link between rosacea and demodex. Meta-analysis of several studies bears this out.5 Demodex even shares the same bacteria as rosacea patients.7,8 We are aware of the treatments for rosacea, and we know it is a chronic disease. Most of the treatments are palliative; there is magenta cyan yellow black 3. Alejo RL, Valenton MJ, Abendanio R. Demodex folliculorum infestation of the lids in Filipinos. Philipp J Ophthalmol. 1972;4:110Y3. 4. De Venecia AB, Siong RL. Demodes sp. infestation in anterior blepharitis, meibomian gland dysfunction, and mixed blepharitis. Philipp J Ophthalmol. 2011;36:15Y22. 5. Zhao YE, Wu LP, Hu L, et al. Association of blepharitis with Demodex: a meta-analysis. Ophthalmic Epidemiol. 2012 Apr;19(2):95-102. 6. Zhao YE, Wu LP, Peng Y, et al. Retrospective analysis of the association between Demodex infestation and rosacea. Arch Dermatol. 2010 Aug;146(8):896-902. 7. Li J, O’Reilly N, Sheha H, et al. Correlation between ocular Demodex infestation and serum immunoreactivity to Bacillus proteins in patients with facial rosacea. Ophthalmology. 2010 May;117(5)870877. There was a time when I believed there was blepharitis and, on a rare occasion, demodex blepharitis. Now, I believe that most blepharitis is actually caused by demodex. tree oil wipes on their face after using on the lids. The results have been excellent. Patients for the first time have the redness in their cheeks resolve. The mite does not only reside in the lashes, it also resides in the skin. Our luck in treating rosacea has increased when we think of it as a demodex problem first. Since learning more about demodex, I am seeing much more rosacea than ever, even in places I would never expect, like my own clinical practice. Because my patient demographic is mostly Hispanic, I am seeing lots of rosacea and demodex in, of course, mostly Hispanics. Mark Dunbar, you were right all along. REFERENCES 1. Power Hour. http://powerhour.info/demodex-andblepharitis-where-were-you-5-years-ago. Accessed 1/5/15. 2. Sumer Z, Arıcı MK, Topalkara A, et al. Incidence of Demodex folliculorum in chronic blepharitis patients. Cumhuriyet Univ Tıp Fak Dergisi. 2000;22:69Y72. 8. Jarmuda S, O’Reilly N, Zaba R, et al. Potential role of Demodex mites and bacteria in the induction of rosacea. J Med Microbiol. 2012 Nov;61(Pt. 11):150410. 9. Hom M, Mastrota K, Schachter SE. Demodex. Optom Vis Sci. 2013 Jul;90(7):e198-205. Dr. Hom receives research support from, or serves as a consultant to, Abbott Medical Optics, Allergan, Bausch + Lomb, CibaVision/Alcon, CooperVision, Essilor, and Inspire Pharmaceuticals. [email protected] WANT MORE STORIES ON DEMODEX? WE GOT ‘EM! A different approach to treating demodex blepharitis OptometryTimes.com/treatdemodex Diagnosing demodex OptometryTimes.com/diagnosedemodex Why has demodex gone viral? OptometryTimes.com/viraldemodex ES556135_OP0215_008.pgs 01.20.2015 20:59 ADV SYMPTOMATIC VITREOMACULAR ADHESION (VMA) SYMPTOMATIC VMA MAY LEAD TO VISUAL IMPAIRMENT FOR YOUR PATIENTS1-3 IDENTIFY REFER Recognize metamorphopsia as a key sign of symptomatic VMA and utilize OCT scans to confirm vitreomacular traction. Because symptomatic VMA is a progressive condition that may lead to a loss of vision, your partnering retina specialist can determine if treatment is necessary.1-3 THE STEPS YOU TAKE TODAY MAY MAKE A DIFFERENCE FOR YOUR PATIENTS TOMORROW © 2014 ThromboGenics, Inc. All rights reserved. ThromboGenics, Inc., 101 Wood Avenue South, Suite 610, Iselin, NJ 08830 – USA. THROMBOGENICS and the THROMBOGENICS logo are trademarks or registered trademarks of ThromboGenics NV. 9/14 OCRVMA0220 References: 1. Sonmez K, Capone A, Trese M, et al. Vitreomacular traction syndrome: impact of anatomical configuration on anatomical and visual outcomes. Retina. 2008;28:1207-1214. 2. Hikichi T, Yoshida A, Trempe CL. Course of vitreomacular traction syndrome. Am J Ophthalmol. 1995;119(1):55-56. 3. Stalmans P, Lescrauwaet B, Blot K. A retrospective cohort study in patients with diseases of the vitreomacular interface (ReCoVit). Poster presented at: The Association for Research in Vision and Ophthalmology (ARVO) 2014 Annual Meeting; May 4-8, 2014; Orlando, Florida. magenta cyan yellow black ES558312_OP0215_009_FP.pgs 01.23.2015 03:38 ADV Opinion 10 February 2015 | Looking back at a year of Energeyes success O our success lies. By Mark J. Uhler, OD In the 16 months the Energeyes n September 1, 2013, life was Association has now been in busibreathed into this idea we ness, we have garnered the support now call the Energeyes Asof 422 dues-paying members. Our sociation. I am humbled by members, risk takers and adventhe experience to have completed turers each and every one, have our first full calendar year of operaBy MArK J. supported our nascent organizations. It is no longer about launchuHlEr, Od tion, shaped so many of our deciing or “getting off the ground” but co-founder and sions and provided the motivation the true operationalizing, the impresident of and impetus for all of us to conplementation, and the hard part energeyes, the tinue to make this journey a realof putting a great idea into action. association of corporate-affiliated ity. Our members are pioneers in I am reminded of what it must optometrists their own right. have been like for the forefathers of our country. I think for George Washington, our reluctant first president, it Taking a look back wasn’t so much about being the first presiMuch of our best learning is conducted dent but that we had ourselves a new counthrough reflection. As I reflect on this past try with new ideals and plans. How exciting calendar year, the staff, leadership, vendors, that must have been. I have been privileged and members of the Energeyes Association to lead a different revolution that I believe have accomplished so much. Remember back is having, and will continue to have, a proto your first year of practice. Hopefully you found effect on the future of optometry and took a moment to reflect on what that first the provision of eye care from coast to coast. year was like. Our Association’s first year of practice had the following elements: From the ground up 422 corporate optometrists are now duespaying ($250 per year) members. Creating something where there is nothing is never easy, no matter how great that idea Our members come from Walmart, Sam’s is. Read the stories of great innovators who Club, LensCrafters, Costco, Sears, Pearle, today we celebrate and applaud—the Wright and Target. We are truly reaching corBrothers, Thomas Edison, Henry Ford, George porate optometry. Washington Carver—all fought uphill batOur members reside in 44 different states, tles to bring new ideas to life. Some were making us a true, national organization. even laughed at for their innovations. EnThe programming we have developed, ergeyes has also experienced our requisite and continue to develop, includes free In the 16 months the Energeyes Association has been in business, we have garnered the support of 422 dues-paying members. share of starts and stops, steps backward, delays, and all manner of obstacles for each and every step we took forward. Part of the secret of our success to date is our Board of Directors—a courageous, resilient, innovative, professional group of people I have ever had the privilege to serve with. I use the word serve because these doctors are volunteers generously giving of their talents and time. It is in this generosity where magenta cyan yellow black professional websites for all members (150+ have been implemented to date, bringing an average of 5 new patients per month to the participating practices; 60 new patients per year per practice!). Our national meeting in Colorado Springs in April 2014 was a huge success with 50 members attending (18 percent of active membership), 22 vendors, and 12 speakers. Our mentoring program has served 3 new members. Our monthly webinar series is attended by 30 to 50 members each month, with an educational focus of the move to the medical model. Our Product Purchasing Program created a competitive bidding process for three products to date: OCT, anterior segment cameras, and patient communication tools. Our newsletter is published monthly and is read by over 1,000 optometrists. We launched a new student program in July designed to educate optometry students on the choices they have (including corporate optometry) upon graduation. We have turned our Board. I list this as an accomplishment because it was done seamlessly without a misstep. Those doctors who helped get the Association off the ground did not see their skills fitting with a Board poised for growth. Our additional Board members have raised the bar on our Board, and I expect great things from the entire Board in the coming year. We are piloting products to ensure their efficacy and appropriateness for a corporate practice and continue to have vendors approach our association with new product and service ideas. I was fortunate to be recognized on behalf of the Association as one of the top influencers in the industry by Jobson Optometric Business Innovator’s program. This is a great illustration of the positive impact we are having. My colleague Dr. Eric Botts and I were featured earlier this year on Dr. Gary Gerber’s Power Hour radio show. Of course these accomplishments sit atop a legal, accounting, marketing, membership, and operations structure that one year later we all seem to take for granted. Suffice it to say, that for this young start-up in our first year of practice, we have accomplished much and have laid a strong foundation for our future. dr. uhler is a pittsburgh native and leases space next to two Walmart Vision centers in pittsburgh and carnegie, pa. [email protected] ES558387_OP0215_010.pgs 01.23.2015 03:41 ADV For allergic conjunctivitis1 THE POWER TO CALM THE ITCH BEPREVE® — FIRST-LINE, YEAR-ROUND, WITH BROAD-SPECTRUM ALLERGEN COVERAGE Scan this QR code or visit beprevecoupon.com to • Order samples • Learn about the automatic co-pay program • Help your patients find participating pharmacies INDICATION AND USAGE BEPREVE® (bepotastine besilate ophthalmic solution) 1.5% is a histamine H1 receptor antagonist indicated for the treatment of itching associated with signs and symptoms of allergic conjunctivitis. IMPORTANT RISK INFORMATION BEPREVE® is contraindicated in patients with a history of hypersensitivity reactions to bepotastine or any of the other ingredients. BEPREVE® is for topical ophthalmic use only. To minimize risk of contamination, do not touch the dropper tip to any surface. Keep the bottle closed when not in use. BEPREVE® should not be used to treat contact lens–related irritation. Remove contact lenses prior to instillation of BEPREVE®. The most common adverse reaction occurring in approximately 25% of patients was a mild taste following instillation. Other adverse reactions occurring in 2%‐5% of patients were eye irritation, headache, and nasopharyngitis. Made by the trusted eye-care specialists at Please see the accompanying prescribing information for BEPREVE® on the following page. Reference: 1. BEPREVE [package insert]. Tampa, FL: Bausch + Lomb, Inc; 2012. For product-related questions and concerns, call 1-800-323-0000 or visit www.bepreve.com. ®/TM are trademarks of Bausch & Lomb Incorporated or its affiliates. ©2014 Bausch & Lomb Incorporated. US/BEP/12/0026a(1) 1/14 magenta cyan yellow black ES558309_OP0215_011_FP.pgs 01.23.2015 03:38 ADV BEPREVE® (bepotastine besilate ophthalmic solution) 1.5% HIGHLIGHTS OF PRESCRIBING INFORMATION These highlights do not include all the information needed to use BEPREVE® (bepotastine besilate ophthalmic solution) 1.5% safely and effectively. See full prescribing information for BEPREVE®. BEPREVE® (bepotastine besilate ophthalmic solution) 1.5% Initial U.S. Approval: 2009 -------------RECENT MAJOR CHANGES-------------Contraindications (4) 06/2012 --------------INDICATIONS AND USAGE-------------BEPREVE® is a histamine H1 receptor antagonist indicated for the treatment of itching associated with allergic conjunctivitis. (1) -----------DOSAGE AND ADMINISTRATION---------Instill one drop into the affected eye(s) twice a day (BID). (2) ----------DOSAGE FORMS AND STRENGTHS-------Solution containing bepotastine besilate, 1.5%. (3) -----------------CONTRAINDICATIONS----------------Hypersensitivity to any component of this product. (4) ------------------ADVERSE REACTIONS---------------The most common adverse reaction occurring in approximately 25% of patients was a mild taste following instillation. Other adverse reactions which occurred in 2-5% of subjects were eye irritation, headache, and nasopharyngitis. (6) To report SUSPECTED ADVERSE REACTIONS, contact Bausch & Lomb Incorporated. at 1-800-3230000, or FDA at 1-800-FDA-1088 or www.fda.gov/ medwatch. See 17 for PATIENT COUNSELING INFORMATION Revised: 10/2012 FULL PRESCRIBING INFORMATION: CONTENTS* 1 INDICATIONS AND USAGE 2 DOSAGE AND ADMINISTRATION 3 DOSAGE FORMS AND STRENGTHS 4 CONTRAINDICATIONS 5 WARNINGS AND PRECAUTIONS 5.1 Contamination of Tip and Solution 5.2 Contact Lens Use 5.3 Topical Ophthalmic Use Only 6 ADVERSE REACTIONS 6.1 Clinical Trial Experience 6.2 Post-Marketing Experience 8 USE IN SPECIFIC POPULATIONS 8.1 Pregnancy 8.3 Nursing Mothers 8.4 Pediatric Use 8.5 Geriatric Use 11 DESCRIPTION 12 CLINICAL PHARMACOLOGY 12.1 Mechanism of Action 12.3 Pharmacokinetics 13 NONCLINICAL TOXICOLOGY 13.1 Carcinogenesis, Mutagenesis and Impairment of Fertility 14 CLINICAL STUDIES 16 HOW SUPPLIED/STORAGE AND HANDLING 17 PATIENT COUNSELING INFORMATION 17.1 Topical Ophthalmic Use Only 17.2 Sterility of Dropper Tip 17.3 Concomitant Use of Contact Lenses FULL PRESCRIBING INFORMATION The most common reported adverse reaction occurring in approximately 25% of subjects was a mild taste following instillation. Other adverse reactions occurring in 2-5% of subjects were eye irritation, headache, and nasopharyngitis. 1 INDICATIONS AND USAGE BEPREVE® (bepotastine besilate ophthalmic solution) 1.5% is a histamine H1 receptor antagonist indicated for the treatment of itching associated with signs and symptoms of allergic conjunctivitis. 2 DOSAGE AND ADMINISTRATION Instill one drop of BEPREVE into the affected eye(s) twice a day (BID). 3 DOSAGE FORMS AND STRENGTHS Topical ophthalmic solution containing bepotastine besilate 1.5%. 4 CONTRAINDICATIONS Bepreve is contraindicated in patients with a history of hypersensitivity reactions to bepotastine or any of the other ingredients [see Adverse Reactions (6.2)]. 5 WARNINGS AND PRECAUTIONS 5.1 Contamination of Tip and Solution To minimize contaminating the dropper tip and solution, care should be taken not to touch the eyelids or surrounding areas with the dropper tip of the bottle. Keep bottle tightly closed when not in use. 5.2 Contact Lens Use Patients should be advised not to wear a contact lens if their eye is red. BEPREVE should not be used to treat contact lens-related irritation. BEPREVE should not be instilled while wearing contact lenses. Remove contact lenses prior to instillation of BEPREVE. The preservative in BEPREVE, benzalkonium chloride, may be absorbed by soft contact lenses. Lenses may be reinserted after 10 minutes following administration of BEPREVE. 5.3 Topical Ophthalmic Use Only BEPREVE is for topical ophthalmic use only. 6 ADVERSE REACTIONS 6.1 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 the clinical trials of another drug and may not refect the rates observed in clinical practice. black -----------WARNINGS AND PRECAUTIONS---------• Tominimizetheriskofcontamination,donot touch dropper tip to any surface. Keep bottle tightly closed when not in use. (5.1) • BEPREVEshouldnotbeusedtotreatcontact lens-related irritation. (5.2) • Removecontactlensespriortoinstillationof BEPREVE. (5.2) *Sections or subsections omitted from the full prescribing information are not listed 6.2 Post Marketing Experience Hypersensitivity reactions have been reported rarely during the post-marketing use of BEPREVE. Because these reactions are reported voluntarily from a population of unknown size, it is not always possible to reliably estimate their frequency or establish a casual relationship to drug exposure. The hypersensitivity reactions include itching, body rash, and swelling of lips, tongue and/or throat. 8 USE IN SPECIFIC POPULATIONS 8.1 Pregnancy Pregnancy Category C: Teratogenicity studies have been performed in animals. Bepotastine besilate was not found to be teratogenic in rats during organogenesis and fetal development at oral doses up to 200 mg/kg/day (representing a systemic concentration approximately 3,300 times that anticipated for topical ocular use in humans), but did show some potential for causing skeletal abnormalities at 1,000 mg/kg/day. There were no teratogenic effects seen in rabbits at oral doses up to 500 mg/kg/day given during organogenesis and fetal development (>13,000 times the dose in humans on a mg/kg basis). Evidence of infertility was seen in rats given oral bepotastine besilate 1,000 mg/kg/day; however, no evidence of infertility was observed in rats given 200 mg/kg/ day (approximately 3,300 times the topical ocular use in humans). The concentration of radiolabeled bepotastine besilate was similar in fetal liver and maternal blood plasma following a single 3 mg/kg oral dose. The concentration in other fetal tissues was one-third to one-tenth the concentration in maternal blood plasma. An increase in stillborns and decreased growth and development were observed in pups born from rats given oral doses of 1,000 mg/kg/day during perinatal and lactation periods. There were no observed effects in rats treated with 100 mg/kg/day. There are no adequate and well-controlled studies of bepotastine besilate in pregnant women. Because animal reproduction studies are not always predictive of human response, BEPREVE® (bepotastine besilate ophthalmic solution) 1.5% should be used during pregnancy only if the potential beneft justifes the potential risk to the fetus. 8.3 Nursing Mothers Following a single 3 mg/kg oral dose of radiolabeled bepotastine besilate to nursing rats 11 days after delivery, the maximum concentration of radioactivity in milk was 0.40 mcg-eq/mL 1 hour after administration; at 48 hours after administration the concentration was below detection limits. The milk concentration was higher than the maternal blood plasma concentration at each time of measurement. It is not known if bepotastine besilate is excreted in human milk. Caution should be exercised when BEPREVE (bepotastine besilate ophthalmic solution) 1.5% is administered to a nursing woman. 8.4 Pediatric Use Safety and effcacy of BEPREVE (bepotastine besilate ophthalmic solution) 1.5% have not been established in pediatric patients under 2 years of age. Effcacy in pediatric patients under 10 years of age was extrapolated from clinical trials conducted in pediatric patients greater than 10 years of age and from adults. 8.5 Geriatric Use No overall difference in safety or effectiveness has been observed between elderly and younger patients. 11 DESCRIPTION BEPREVE (bepotastine besilate ophthalmic solution) 1.5% is a sterile, topically administered drug for ophthalmic use. Each mL of BEPREVE contains 15 mg bepotastine besilate. Bepotastine besilate is designated chemically as (+) -4-[[(S)-p-chloro-alpha -2-pyridylbenzyl]oxy]-1piperidine butyric acid monobenzenesulfonate. The chemical structure for bepotastine besilate is: Bepotastine besilate is a white or pale yellowish crystalline powder. The molecular weight of ® bepotastine besilate is 547.06 daltons. BEPREVE ophthalmic solution is supplied as a sterile, aqueous 1.5% solution, with a pH of 6.8. The osmolality of BEPREVE (bepotastine besilate ophthalmic solution) 1.5% is approximately 290 mOsm/kg. Each mL of BEPREVE® (bepotastine besilate ophthalmic solution) 1.5% contains: Active: Bepotastine besilate 15 mg (equivalent to 10.7 mg bepotastine) Preservative: benzalkonium chloride 0.005% Inactives: monobasic sodium phosphate dihydrate, sodium chloride, sodium hydroxide to adjust pH, and water for injection, USP. 12 CLINICAL PHARMACOLOGY 12.1 Mechanism of Action Bepotastine is a topically active, direct H1receptor antagonist and an inhibitor of the release of histamine from mast cells. 12.3 Pharmacokinetics Absorption: The extent of systemic exposure to bepotastine following topical ophthalmic administration of bepotastine besilate 1% and 1.5% ophthalmic solutions was evaluated in 12 healthy adults. Following one drop of 1% or 1.5% bepotastine besilate ophthalmic solution to both eyes four times daily (QID) for seven days, bepotastine plasma concentrations peaked at approximately one to two hours post-instillation. Maximum plasma concentration for the 1% and 1.5% strengths were 5.1 ± 2.5 ng/mL and 7.3 ± 1.9 ng/mL, respectively. Plasma concentration at 24 hours post-instillation were below the quantifable limit (2 ng/mL) in 11/12 subjects in the two dose groups. Distribution: The extent of protein binding of bepotastine is approximately 55% and independent of bepotastine concentration. Metabolism: In vitro metabolism studies with human liver microsomes demonstrated that bepotastine is minimally metabolized by CYP450 isozymes. In vitro studies demonstrated that bepotastine besilate does not inhibit the metabolism of various cytochrome P450 substrate via inhibition of CYP3A4, CYP2C9, and CYP2C19. The effect of bepotastine besilate on the metabolism of substrates of CYP1A2, CYP2C8, CYP2D6 was not studied. Bepotastine besilate has a low potential for drug interaction via inhibition of CYP3A4, CYP2C9, and CYP2C19. Excretion: The main route of elimination of bepotastine besilate is urinary excretion (with approximately 75-90% excreted unchanged in urine). 13 NONCLINICAL TOXICOLOGY 13.1 Carcinogenesis, Mutagenesis and Impairment of Fertility Long-term dietary studies in mice and rats were conducted to evaluate the carcinogenic potential of bepotastine besilate. Bepotastine besilate did not signifcantly induce neoplasms in mice receiving a nominal dose of up to 200 mg/kg/day for 21 months or rats receiving a nominal dose of up to 97 mg/kg/day for 24 months. These dose levels represent systemic exposures approximating 350 and 200 times that achieved with human topical ocular use. The no observable adverse effect levels for bepotastine besilate based on nominal dose levels in carcinogenicity tests were 18.7 to 19.9 mg/kg/day in mice and 9.6 to 9.8 mg/kg/day in rats (representing exposure margins of approximately 60 and 20 times the systemic exposure anticipated for topical ocular use in humans). There was no evidence of genotoxicity in the Ames test, in CHO cells (chromosome aberrations), in mouse hepatocytes (unscheduled DNA synthesis), or in the mouse micronucleus test. When oral bepotastine was administered to male and female rats at doses up to 1,000 mg/kg/day, there was a slight reduction in fertility index and surviving fetuses. Infertility was not seen in rats given 200 mg/kg/day oral bepotastine besilate (approximately 3,300 times the systemic concentration anticipated for topical ocular use in humans). 14 CLINICAL STUDIES Clinical effcacy was evaluated in 2 conjunctival allergen challenge (CAC) studies (237 patients). BEPREVE (bepotastine besilate ophthalmic solution) 1.5% was more effective than its vehicle for relieving ocular itching induced by an ocular allergen challenge, both at a CAC 15 minutes postdosing and a CAC 8 hours post dosing of BEPREVE. The safety of BEPREVE was evaluated in a randomized clinical study of 861 subjects over a period of 6 weeks. 16 HOW SUPPLIED/STORAGE AND HANDLING BEPREVE® (bepotastine besilate ophthalmic solution) 1.5% is supplied in a white low density polyethylene plastic squeeze bottle with a white controlled dropper tip and a white polypropylene cap in the following size: 5 mL (NDC 24208-629-02) 10 mL (NDC 24208-629-01) STORAGE Store at 15º – 25ºC (59º – 77ºF). 17 PATIENT COUNSELING INFORMATION 17.1 Topical Ophthalmic Use Only For topical ophthalmic administration only. 17.2 Sterility of Dropper Tip Patients should be advised to not touch dropper tip to any surface, as this may contaminate the contents. 17.3 Concomitant Use of Contact Lenses Patients should be advised not to wear a contact lens if their eye is red. Patients should be advised that BEPREVE should not be used to treat contact lens-related irritation. Patients should also be advised to remove contact lenses prior to instillation of BEPREVE. The preservative in BEPREVE, benzalkonium chloride, may be absorbed by soft contact lenses. Lenses may be reinserted after 10 minutes following administration of BEPREVE. Manufactured by: Bausch & Lomb Incorporated Tampa, FL 33637 Under license from: Senju Pharmaceutical Co., Ltd. Osaka, Japan 541-0046 ®/TM are trademarks of Bausch & Lomb Incorporated or its affliates © 2012 Bausch & Lomb Incorporated. US/BEP/13/0028 4/13 ES558310_OP0215_012_FP.pgs 01.23.2015 03:38 ADV Opinion | praCtiCal ChairSide adviCe LetterS To the Editor More darndest patient stories Chief Optometric Editor Ernie Bowling invited readers to share their funny patient stories (“Patients say the darndest things,” November 2014). Following are two responses we received. I refit a patient from one bifocal contact lens to another. Me: How do you feel with this new pair? Patient: These aren’t as comfortable. My hair gets into my eyes more with this brand. Me: (what I was thinking): You need a haircut. I examined a gentleman and found significant hemorrhagic changes in his right eye. I sent him directly to my buddy the retina specialist. His tech called to ask who was the referring doctor. I said it was myself, of course. She told me the gentleman said he was seen by the male doctor in my office. I am the only doctor, and I am female. The optician, a man, did have the patient sign insurance forms. I guess this patient will need some glasses after the retinal treatment! Thanks for letting me vent. Anne Rafal, OD Brooklyn, NY My father-in-law was monocular. He would wear only an executive bifocal. When I first examined him in the UABSO clinic, he obtained new glasses. I was so proud that he liked them. Later on a visit home, I walked in his room to find him laid back in his recliner watching television with the new glasses perched on his nose upside down. I was embarrassed! After a few minutes, he told me this was the best pair of glasses he ever had because he could turn them upside and see television perfectly—a balance lens with moderate cylinder axis 90 degrees. Mike Parker, OD Fort Payne, AL We Want to hear from you! like something we published? hate something we published? have a suggestion? We want to hear from you! Send your comments to [email protected]. letters may be edited for length or clarity. Screening Continued from page 6 national goals to improve the eye health of preschool-aged children. “Currently, providers of vision screening and eye examinations lack a system to provide national- or state-level estimates of the proportion of children who receive either a vision screening or an eye examination,” the authors write. The panel developed a system to measure the rates of children who completed a vision screening in a medical or community setting using a recommended method, or received an eye examination by an eyecare practitioner at least once between the ages of 36 and 72 months old. The panel also developed a separate measure for children with neurodevelopmental disorders and measures for eye magenta cyan yellow black OE Tracker update I am the current chair of OE tracker. I was very pleased to read your positive comments on COPE and OE Tracker (“COPE makes CE easy,” December 2014). Thank you! OET is examination and follow up. The American Optometric Association recently responded to the new recommendations, stating that the organization remains committed to ensuring more children have direct access to early and periodic comprehensive eye examinations provided by an eyecare practitioner. “While schools or pediatricians may provide periodic vision screenings, these screenings often miss more than they find,” the AOA stated. “Because of vision screenings’ particularly low sensitivity and selective testing, many children may pass the screening while having undetected vision disorders, delaying further examination and profoundly affecting children’s quality of life.” States vary in their requirements for children’s screenings or eye exams. For example, in Kentucky, all children ages 3-6 are re- 13 nearing 50,000 QR scans and has proven to be efficient and reliable. One of the proposed updates to the app will be the ability to download lecture PowerPoint notes directly to your mobile device. I became involved with OE Tracker after our State Board of North Dakota decided to perform a 100 percent audit at the end of each three-year CE cycle and pay the OET fee for all ND licensed optometrists. I believe there are currently five states and two provinces which pay for all optometrists in their jurisdictions. I hope many more will see the value of OET after reading your comments. Jeff Yunker, OD Grand Forks, ND my favorite app Zite My favorite new app is Zite. it is a news app that you can customize for areas of interest, such as sports, travel, movies, etc. Zite pulls in articles from other sites that match your areas of interest. —Steven ferrucci, oD, faao Sepulveda, CA quired to have an eye exam by an optometrist or ophthalmologist before entering school. “The Affordable Care Act has recognized that full coverage for eye exams is essential, and that’s why it’s included in the essential benefit package,” says Richmond, KY OD William T. Reynolds, who is also a member of the AOA Board of Trustees. “It is a doable thing to get an eye exam for every child. So many parents believe that a screening takes the place of an eye exam. When Kentucky had just screening laws before 2001, we would get kids in who were age 14 or 15 who had been screened over and over but had amblyopia. We know that the earlier you catch it, the easier it is to treat. In Kentucky, we don’t have that problem now.” For more information on the recommendations, visit visionsystems.preventblindness.org. ES558385_OP0215_013.pgs 01.23.2015 03:41 ADV 14 Focus On RETINA FEBRUARY 2015 | Anti-VEGF treatment helps diabetic patient Visual acuity improves and pre-retinal hemorrhage almost completely resolves A 76-year-old white female presented for her periodic diabetic eye examination at UAB Eye Care in July 2014. She A admitted to blurry vision in her left eye for approximately one week. Her significant medical history included diabetes of at least 15 years duration for which she was treated with Humalog (insulin lispro, Lilly), Lantus (insulin glargine, Sanofi), and metformin. retinal hemorrhage. She quoted her most recent A1C as 8.2 percent. She was treated with hydrochlorothiazide for sysAnti-VEGF treatment temic hypertension of unknown She had a consult with a retina duration. Blood pressure was not specialist that day and was adminassessed at this visit. She has istered Avastin (bevacizumab, Genever smoked and was appronentech) via intravitreal injection BY LEO SEMES, priately oriented with respect to and was scheduled for follow-up OD, FAAO Professor time, place, person, mood, and in one month. At the four-month of optometry at affect. Body mass index (BMI) follow-up visit, best-corrected vithe University was greater than 30. sual acuity OS improved to 20/40, of AlabamaBirmingham Best-corrected visual acuity and the pre-retinal hemorrhage was 20/25 OD and 20/400 OS resolved almost completely (botwith minimal correction. She was tom right). Fortunately, she is free pseudophakic in each eye with a clear capof other diabetic retinal complications. sule in the right and S/P capsulotomy in Among the lessons from this case are the left. Dilated fundus evaluation of the the significant disparity in visual aculeft eye revealed the presentation top right. ity between the two eyes with apparently Presence of the pre-retinal hemorrhage minimal patient awareness as well as the Presence of the pre-retinal hemorrhage is consistent with her history of diabetes despite the absence of apparent diabetic changes within the visible portion of the posterior pole. is consistent with her history of diabetes despite the absence of apparent diabetic changes within the visible portion of the posterior pole. There is macular swelling, which accompanies the juxtapapillary pre- Lucentis FDA approvals 2006 Neovascular AMD 2010 Macular edema following CRVO and BRVO 2012 Diabetic macular edema magenta cyan yellow black significant hemorrhagic response secondary to minimal attendant diabetic fundus changes. There was no evidence of proliferative retinopathy throughout either fundus. With resolution of the hemorrhage and a brighter exposure, asteroid bodies become evident in the left eye. The family of anti-VEGF agents, of which Avastin is a member, is intended to restore the integrity of the circulatory system. Since the introduction of Lucentis (ranimizubab, Genentech) with FDA approval in June 2006 for the treatment of neovascular age-related B A Fundus photo of the left eye focused at the plane of the RNFL showing striations of blood within that layer of the retina. There is macular swelling, which accounts for the reduced visual acuity. B Fundus photo of the left eye demonstrating almost complete resolution of the pre-retinal hemorrhage. The visibility of the macula has improved consistent with her improvement in visual acuity. Note the presence of asteroid bodies, as well. macular degeneration (AMD), many additional applications have been reported. In 2010 and 2012, respectively, the FDA granted approval for Lucentis to treat macular edema following retinal vein occlusion (central [CRVO] and branch [BRVO]) as well as diabetic macular edema. The safety and efficacy of these agents makes the future bright for this and other neovascular complications. Dr. Semes is a founding member of the Optometric Glaucoma Society and a founding fellow of the Optometric Retina Society. [email protected] ES556134_OP0215_014.pgs 01.20.2015 20:59 ADV magenta cyan yellow black ES558327_OP0215_015_FP.pgs 01.23.2015 03:39 ADV 16 Focus On Technology February 2015 | HIPAA in the age of social media Ensuring you and your practice stay compliant on social media platforms Human beings are social creatures. We take tremendous pleasure in sharing our world with others. There is no better evidence than to look at the social media revolution that has taken place over the last few years. Often, when we see something cool, we want to share it with other people. As healthcare providers in an age where digital information can be just as viral as the viruses we treat, it is of the utmost importance to understand the implications of our social media posts. “(B) relates to the past, presSo where does sharing someent, or future physical or mental thing cool become troublesome? health or condition of an indiWhen you violate Health Insurvidual, the provision of health ance Portability and Accountabilcare to an individual, or the past, ity Act of 1996 (HIPAA). Social present, or future payment for media has the power to amplify the provision of health care to somebody’s lapse of judgment BY JUSTIn BAZAn, an individual.”1 to the point where the content OD Owner of Vision is seen by millions around the Source Park Slope world in just a matter of minutes. What does this mean Eye in Brooklyn. Prior to social media, the error for you? may have not spread to much So for the average OD, what does more than a handful of people—often HIPAA mean? Most impactful, the Priavoiding implications—it now is often vacy Rule will require optometrists to brought front and center to the public’s inform patients about how their informaregulatory eye. It becomes very easy for a potential HIPPA violation to occur and get noticed. It is quite impressive that upon HIPAA creation, disks were floppy and websites were rag tag, and we now find ourselves in the midst of massive multi-million dollar penalties served to entities violating the act. According to U.S. Department of Health and Human Services, HIPAA called for the establishment of standards and requirements for transmitting certain health information to improve the efficiency and tion can be used and what their privacy effectiveness of the healthcare system while rights are. It also means setting up and protecting patient privacy. This means implementing privacy procedures for our that because protected health information practices that outline and detail how a (PHI) is a major HIPAA theme, it needs patient’s PHI is appropriately used and to be accurately defined. Defined in the adequately protected. An employee will law, “health information” means any inneed to take responsibility that this proformation, whether oral or recorded in cedure is adopted and adhered to. For any form or medium, that: most of our small private practices, an “(A) is created or received by a healthoffice manager or other responsible emcare provider, health plan, public health ployee will work fine. This person can authority, employer, life insurer, school or also serve as a contact for handling comuniversity, or health care clearinghouse; and plaints and HIPAA concerns. An employee must review these policies and document he understands. For most small private practices, this will suffice as adequate employee training. Finally, the patient’s records need to be secured. The authoritative source for guidance is http://www. hhs.gov/ocr/privacy.2 How to avoid a HIPAA violation What are the basic things an OD should do to avoid HIPAA trouble? The best way to avoid trouble is to always and above all else protect and secure a person’s health information. Regarding social media, the rule is simple: unless you have informed consent, never post enough personal information, such as the medical condition involved and office, for anyone to recognize who is being described. The best policy is to eliminate all info that can be used to identify the patient. The patient-doctor relationship is built upon trust. There is no quicker way to break that bond than to publically disrespect a patient, intentionally or not. The top three HIPAA violations fall into three categories: impermissible uses and disclosures of PHI, lack of safeguards of PHI, and a lack of patient access to their PHI.3 It’s of note that private practices are Social meida has the power to amplify somebody’s lapse of judgment to the point where the content is seen by millions around the world in just a matter of minutes. magenta cyan yellow black the most common type of covered entity that have been required to take corrective action to achieve voluntary compliance.4 Hypothetical social media HIPAA violations example An employee at your office tweets to her followers “OMG! James Franco was in for an eye exam today! Even with pink eye, he is still so cute!” Although this was not directly on any of the office’s social media 1 See HIPAA on page 18 ES556136_OP0215_016.pgs 01.20.2015 20:59 ADV magenta cyan yellow black ES558328_OP0215_017_FP.pgs 01.23.2015 03:39 ADV 18 Focus On Technology HIPAA February 2015 because you sent it to a person in confidence doesn’t mean he will respect that. Continued from page 16 pages, it is still a HIPAA violation because personal info, the patient’s name, was directly linked to medical info, his pink eye, and broadcast where unauthorized people had access to the info. The employee might have thought that since James Franco is a celebrity and he is all over social media, that it was OK to tweet about him. An in-office social media policy, backed with proper training and follow-up, might have been helpful in preventing this. However, if James Franco signed an informed consent form and was cool with the post, then all is well. example A technologically progressive and social media savvy office uses Facebook (FB) to correspond with its patients. Most commonly, messages are exchanged using the messenger feature, which is HIPAA compliant because you are directly and privately communicating. However, if you do use FB for correspondence, be very careful. One might think posting to a patient’s timeline on FB is OK, when in reality, his timeline may be public, making it a violation. Furthermore, be cognizant that digital content can easily spread. Just 2 example Healthcare providers can partake in consultation over social media provided the network meets security protocols. Direct, private messaging between two healthcare providers in consultation, utilizing the minimum necessary HPI, is OK. However, disclosing PHI in a social media group is not. Popular FB groups like ODs on Facebook need to be utilized in ways that safeguard against HIPAA breaches. 3 example A patient writes a user review and includes his PHI. It is of the utmost importance to not breach HIPAA despite the apparent public airing of PHI. Simply do not disclose anything that has not been already publicly disclosed. The patient is free to say what he wants about himself; however, you are not. Develop and implement your own social media policy, but be sure to frame it around HIPAA guidelines. HIPAA requires substantial research, time, and effort to correctly abide. Social media represents one area that has the potential for HIPAA violations to easily occur. However, one can avoid most problems by getting direct informed consent. If you want to risk it and post HPI 4 | without it, you must be sure to remove all information that can be used to identify the patient. RefeRences 1. U.S. Department of Health & Human Services. Health Insurance Portability and Accountability Act of 1996. Available at: http://www.hhs.gov/ ocr/privacy/hipaa/administrative/statute/index. html#1171. Accessed 11/25/2014. 2. U.S. Department of Health & Human Services. Generally, what does the HIPAA Privacy Rule require the average provider or health plan to do? Available at: http://www.hhs.gov/ocr/privacy/ hipaa/faq/privacy_rule_general_topics/189.html. Accessed 11/25/2014. 3. U.S. Department of Health & Human Services. Top Five Issues in Investigated Cases Closed with Corrective Action, by Calendar Year. Year. Available at: http://www.hhs.gov/ocr/privacy/hipaa/ enforcement/data/top5issues.html. Accessed 11/25/2014. 4. U.S. Department of Health & Human Services. Enforcement Highlights. Available at: http:// www.hhs.gov/ocr/privacy/hipaa/enforcement/ highlights/2009/01092009.html. Accessed 11/25/2014. 5. State of Rhode Island Department of Health Board of Medical Licensure and Discipline No. C10-156. Available at: http://www.health.ri.gov/ discipline/MDAlexandraThran.pdf. Accessed 11/25/2014. Dr. Bazan is a 2004 SUNY grad. Reach him on his Facebook page. In BrIef Shire acquires NPS New antibiotic may be Pharmaceuticals for $5.2 billion less prone to resistance DUBlIn—Shire PLC acquired all outstanding shares of NPS Pharmaceuticals Inc. for $46 per share in cash, for a total of approximately $5.2 billion. NPS Pharmaceuticals, headquartered in Bedminster, NJ, is a rare disease-focused biopharmaceutical company. According to Shire, the company plants to accelerate growth of NPS’ portfolio through its market expertise in gastrointestinal disorders, core capabilities in rare disease patient management, and global footprint. “The acquisition of NPS Pharma is a significant step in advancing Shire’s strategy to become a leading biotechnology company,” says Shire CEO Flemming Ornskov, MD, MPH. “We look forward to accelerating the growth of the NPS Pharma portfolio based on our proven track record of maximizing value from acquired assets and commercial execution. The NPS Pharma organization will be a welcome addition to Shire as we continue to help transform the lives of patients with rare diseases.” magenta cyan yellow black Researchers have isolated a novel antimicrobial compound which may be the first in a new class of antibiotics. Teixobactin is safe and effective in mice and may not induce antimicrobial resistance. It may translate into a shorter course of treatment and a better adverse effect profile for patients. The discovery is a result of collaboration between academia and NovoBiotic Pharmaceuticals. The reseachers’ approach to identify teixobactin and the early efficacy data were published in Nature in January. “We did not obtain any mutants of Staphylococcus aureus or Mycobacterium tuberculosis resistant to teixobactin,” the authors write. “The properties of this compound suggest a path toward developing antibiotics that are likely to avoid development of resistance.” The team expects the novel antibiotic to go to clinical trials in two years. If it makes it through clinical trials and is approved, teixobactin will be the first of a new class of antibiotics. medical sales representatives expected to be in place in 2015. ES556133_OP0215_018.pgs 01.20.2015 20:59 ADV What we do every day matters. AvenovaTM with NeutroxTM (pure hypochlorous acid) removes microorganisms and debris from the lids and lashes. Avenova is an ideal addition to any daily lid and lash hygiene regimen, including for use by patients with Blepharitis and Dry Eye. Avenova may also be used after make-up removal as well as pre and post contact lens wear. Daily lid and lash hygiene. OPHTHALMOLOGIST AND OPTOMETRIST TESTED A V E N O VA . C O M magenta cyan yellow black | | RX ONLY 1-800-890-0329 ES558329_OP0215_019_FP.pgs 01.23.2015 03:38 ADV 20 Focus On Allergy FeBrUarY 2015 | 3 tips for discussing allergy with kids Rise to the pediatric allergy challenge with these top six questions How often do you ask a child in the exam chair if her eyes were “ever” itchy or watery? When I started to ask this question to every patient in my pediatric population, it was quite evident that there was an undiscovered gold mine in my anterior segment practice. Allergies in the pediatric population are trending upward in a startling and truly dangerous manner. 1 2 3 4 might seem simplistic, but they Statistically, epidemiological have streamlined and improved studies and surveys in the U.S. chair time in my busy clinical have illustrated approximately setting. Furthermore, parents are 50 million patients suffer from both impressed with the clear some form of allergy and 20 to responses from their children 25 percent with ocular allergies.1 and in many cases shocked that Dissecting these numbers furBY MICHAEL S. the children have any symptoms ther, Abelson et al found that COOPER, OD of allergies. Once the child acapproximately 40 percent of is in an OD/ knowledges the symptoms of children were affected by alMD practice in the condition, the parent will lergic conjunctivitis.2 After digWillimantic, CT begin to engage you. This beging through the literature, my comes your platform to educate the parmission statement became how to effect ent about chronic allergy treatment and change today in the hearts and minds of management, whether it is seasonal aloptometric physicians to start treating lergic conjunctivitis (SAC), perennial alpediatric patients in a more aggressive lergic conjunctivitis (PAC), or vernal kermanner in their practices. atoconjunctivitis (VKC). At this moment, the doctor has waged the adherence war What’s in it for me? and achieved a significant victory. The short answer is everything to lose but immensely more to gain! Although children can take more time to examine The pharmacy conundrum and be confounding in their history, I Now that you have the diagnosis, the next have found easy open-ended questions logical step is selecting your medication helpful to slice through for the purpose of of choice. Let me take a moment to emtime management (See box). The queries phasize this tremendous opportunity to Figure 1. Dr. Cooper’s 4-year-old daughter Hannah. She suffers from severe seasonal allergies. magenta cyan yellow black Top 6 questions for pediatric patients 5 6 Do your eyes ever itch? Do your eyes ever water? Do you ever rub your eyes in the morning when you wake up? Do you keep your window open at night? Do you have trouble breathing inside in the morning or when you are outside? Does your brother or sister rub his or her eyes? diffuse a bomb: be the doctor and use your power of the electronic pen. We all live in an age where the pharmacy benefit manager makes many calls beyond our wishes, but let me share a pearl. If you 40% of children are affected by allergic conjunctivitis desire to prescribe a specific product, it is within your doctoral right to specify “brand medically necessary.” These words essentially bar pharmacists from substituting a generic product of their choice without your permission. In addition, I would suggest looking at your state laws for further guidance because there are always slight differences in legal doctrine. Another hurdle is who carries the purse strings, the parent or caregiver. We might think we captured them hook, line, and sinker with education, but ultimately in some cases there are financial obstacles. I do not take these situations lightly, yet I don’t harp on them either to hemorrhage valuable chair time. Once you have stated your case and actively suggested a rebate card to defray a substantial amount of the cost for products such as Lastacaft (alcaftadine, Allergan), Pataday (olopatadine hydrochloride, Alcon), and Bepreve (bepotastine besilate, Bausch + Lomb), ES557436_OP0215_020.pgs 01.22.2015 04:35 ADV | practical chairside advice Allergy Focus On 21 Figure 2. Papillary reactionin 4-year-old child suffering from seasonal allergies. your job is mostly done. I say mostly done because the “rub” is step therapies with certain generic products that might be dictated by the patient’s Rx benefit for which you must once again be flexible. A quick takeaway in your decision tree is patient comfort when given the typical popular choice between generic forms of Elestat (epinastine, Allergan) and Optivar (azelastine, Meda). The ratio of ocular burning and stinging is highly in favor with epinastine with 1 to 10 percent of patients expe- I never tell a pediatric patient the following words: medication, drop, or pill. riencing these symptoms comparatively to 30 percent with azelastine.3,4 Finally, Allergy apps Apps to embrace for allergy sufferers. – – – – – magenta cyan yellow black Zyrtec AllergyCast WebMD Allergy Allergy Alert EyeDROPS Free or Pro Kids Eye Doctor Lite or Pro if there is a tremendous financial burden below the poverty level, I have utilized the RxHope patient assistance program as a viable alternative. Figure 3. Closer look at papillary reaction in seasonal allergies. Images courtesy Michael S. Cooper, OD The lion, the drop, and the wardrobe I never tell a pediatric patient the following words: medication, drop, or pill. From the eyes and ears perspective of a young child, including my 4-year-old daughter Hannah, and even younger adolescents, the thought of taking any medicinal therapy is emotionally upsetting and confusing.5 How do I confront these situations? The chief golden rule is to have a cheerful and positive attitude while explaining how the medication will help them improve their allergy symptoms.6 Additionally, with a huge assist from fairy tales and fictional characters, I utilize the following vocabulary in place of drops and pills: magic potions and magic beans. I find that children feel more at home with these analogies, which leads to far less resistance when it is time to take their medication at night before bedtime. Finally, I encourage parents to empower their child to include them in the experience by holding the bottle together to instill the “potion” into their eyes. Although allergic conjunctivitis might seem annoying and not as glamorous as glaucoma and macular degeneration; nonetheless, it can truly change a patient’s life. From my clinical experience, it astonishes me time and again where my pediatric population will come back for a follow up or a comprehensive examination with a smile on their face in order to tell me that they did not miss school due to their “itchy and scratchy” eyes. Personally, these moments are gratifying and have increased my drive to treat more in this disease state. RefeRences 1. Centers for Disease Control and Prevention. “CDC Fast Facts A-Z,” Vital Health Statistics, 2003. Asthma and Allergy Foundation of America. http://www.aafa.org/display.cfm?id=9&sub=30. Accessed 10/1/14. 2. Abelson MB, Granet D. Ocular allergy in pediatric practice. Curr Allergy Asthma Rep. 2006; 6(4):30611. 3. Elestat [package insert]. Irvine, CA; Allergan; December 2011. 4. Optivar [package insert]. Somerset, NJ; Meda Pharmaceuticals; April 2009. 5. Iliades, Chris, Bass PF ed. “10 Ways to Get Kids to Take Medicine.” everyday HEALTH. Everyday Health Media, 3 February 2011. http://www. everydayhealth.com/kids-health/10-ways-to-getkids-to-take-medicine.aspx. Accessed on 1/10/15 6. Food and Drug Administration. “Giving Medicine to Children.” FDA. US Department of Health and Human Services, 12 March 2013. http://www. fda.gov/ForConsumers/ConsumerUpdates/ ConsumerUpdatesEnEspanol/ucm291741.htm. Accessed on 1/10/15. 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. [email protected] ES557435_OP0215_021.pgs 01.22.2015 04:34 ADV Exceptional all-day lens wear, every day, for every eye UNSURPASSED COMFORT Clinically unsurpassed in overall comfort and rated superior to Dailies® AquaComfort Plus® in beginning to end-of-day comfort EXCELLENT SAFETY PROFILE1 ¶ Confirmed in an unprecedented, year-long, observational study of 570 wearers— no other lens has published this kind of safety data, including Dailies® AquaComfort Plus® UV PROTECTION† Blocks approximately 97% UVB & 82% UVA rays.‡ Dailies® AquaComfort Plus® does not meet ANSI/ISO standards for UV blocking 1-DAY ACUVUE® MOIST® Brand Contact Lenses for ASTIGMATISM SAME COMFORT, SAFETY, AND UV PROTECTION WITH ENHANCED STABILITY — BLINK STABILIZED™ Design creates equal/opposite forces to limit rotation and better stabilize vision — Nearly 200 more parameters than Dailies® AquaComfort Plus® Toric Lenses|| REALIGNS WITH EVERY BLINK Stabilization zones magenta cyan yellow black Stabilization zones ES558673_OP0215_022_FP.pgs 01.23.2015 19:40 ADV ANSI=American National Standards Institute; ISO=International Organization for Standardization. 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 from VISTAKON® Division of Johnson & Johnson Vision Care, Inc., by calling 1-800-843-2020 or by visiting acuvueprofessional.com. † 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. ‡ UV-blocking percentages are based on an average across the wavelength spectrum. ¶ This observational/surveillance registry relied on patient reports of symptomatic adverse events that led them to seek clinical care. These results should be considered in conjunction with other clinical results on the safety and efficacy of daily disposable etafilcon A contact lenses, which also generally show low rates of such events. Although no symptomatic infiltrative events were reported in this study, such events can occur with daily disposable lenses, including 1-DAY ACUVUE® MOIST®, as noted in the product labeling. || Based on Tyler’s Quarterly Soft Contact Lens Parameter Guide; June 2014. 1. Chalmers RL, Hickson-Curran SB, Keay LJ, Gleason W. Safety of hydrogel and silicone hydrogel daily disposables in a large post-market surveillance registry—the TEMPO registry. Presented at: ARVO 2014 Annual Meeting: May 4-8, 2014; Orlando, FL. The third party trademarks used herein are trademarks of their respective owners. ACUVUE®, 1-DAY ACUVUE® MOIST®, BLINK STABILIZED™, and VISTAKON® are trademarks of Johnson & Johnson Vision Care, Inc. © Johnson & Johnson Vision Care, Inc. 2015 ACU-A44519-B January 2015 magenta cyan yellow black ES558672_OP0215_023_FP.pgs 01.23.2015 19:40 ADV 24 Focus On RefRactive SuRgeRy FeBrUarY 2015 | Are those eyes healthy enough for LASIK? Ocular conditions to consider when identifying candidates for laser correction Before recommending laser vision correction for your patient, there are a number of factors you as an eyecare practitioner must consider. In a previous issue (“Is your patient healthy enough for LASIK surgery?” February 2014), we discussed how your patient’s systemic health can affect the safety and efficacy of refractive surgery. Today, I would like to look at the ocular conditions that must be considered before making a patient candidacy decision. Most refractive surgeons base their criteria for patient candidacy on the original criteria described in the original FDA approval of LASIK more than a decade ago (Table 1). Keratoconus Keratoconus is a progressive thinning disorder of the cornea that results in irregular astigmatism causing impairment of visual function. Corneal refractive surgery is associated with an increased risk of progressive ectasia and loss of vision.1 While moderate to severe keratoconus can often be diagnosed with a biomicroscope, early subclinical forms of keratoconus can often be detected only with corneal topography (Figure 1) or corneal tomography (Figure 2).2,3 Additionally, recent evidence suggests that elevated corneal wavefront analysis (vertical coma) and biomechanical analysis may improve the early detection of corneas susceptible to the development of keratoconus.4,5 The FDA classification of keratoconus as an absolute contraindication to laser vision correction is currently being questioned by many surgeons. Outside of the U.S., it has become more common to uti- Corneal herpes simplex and herpes zoster Reports of reactivation of herpes simplex and herpes zoster virus after excimer refractive surgery can be found in the literature.7,8 Recent evidence suggests that LASIK is safe in patients with a history of ocular herpes that has been inactive for more than one year.9 Perioperative use of systemic antiviral prophylaxis is recommended to reduce the risk of virus reactivation. Any active eye disease History of prior corneal surgery Thin cornea History of glaucoma Cataracts Large pupils Severe dry eye Both LASIK and PRK are known to increase dryness symptoms after surgery. Possible mechanisms include loss of neurotrophic effect, damage of goblet cells, and altered corneal shape. Despite the fact that most dryness symptoms are usually temporary and resolve in the first six to 12 months after surgery, significant preoperative dry eye signs and symptoms should be resolved prior to corneal refractive surgery to reduce the risk of patient’s dissatisfaction.10 Overall, most surgeons agree that any patient with active eye disease should not be considered a candidate for an elective refractive procedure due to increased risk of sightthreatening complications and poor visual outcome. taBLe 1 FDA approval of LASIK: Ocular health considerations Absolute contra-indications Relative contra-indications Keratoconus Corneal herpes simplex Corneal herpes zoster Significant dry eye magenta cyan yellow black Unstable Rx (any change by more than 0.50 D) Corneal scars lize photorefractive keratectomy combined with corneal collagen cross-linking to improve vision and stabilize the cornea of patients with keratoconus.6 BY WILLIAM TULLO, OD Vice president of clinical services for TLC Vision. taBLe 2 Precautions prior to LASIK Surgery Other considerations In addition to these contraindications, several other precautions are recommended when screening your patients for corneal refractive surgery (Table 2). Overall, most surgeons agree that any patient with active eye disease should not be a considered candidate for an elective refractive procedure due to increased risk of sightthreatening complications and poor visual outcomes. The transient significant rise in intraocular pressure (IOP) with femtosecond and mechanical microkeratome used in LASIK surgery may not be safe for patients with glaucomatous visual field loss or optic nerve compromise. Corneal scars and prior corneal surgery ES556953_OP0215_024.pgs 01.21.2015 22:55 ADV RefRactive SuRgeRy | practical chairside advice can reduce the safety, efficacy, and predictability of corneal refractive surgery. Patients with thin corneas may be at increased risk of corneal destabilization due to LASIK flap creation and excimer ablation. Many surgeons use a cutoff of 480-500 µm for LASIK and 460-480 µm for PRK when screening patients for surgery. Evidence shows that LASIK and PRK in patients with thin corneas (less than 500 µm) is safe and predicable providing no other risk factors such as abnormal topography exist.11 Patients with early crystalline lens changes should be cautioned about corneal refractive surgery, which can reduce the accuracy of intraocular lens (IOL) power selection. The unpredictable progression of crystalline lens changes makes it impossible to accurately predict the timing of significant vision loss. Visually The FDA classification of keratoconus as an absolute contraindication to laser vision correction has currently being questioned by many surgeons outside of the U.S. significant cataracts are best addressed with lens extraction and IOL implantation, which can also accurately correct long-standing refractive error. Early forms of corneal refractive surgery were often associated with night vision disturbances. Early evidence suggested that large scotopic and mesopic pupil size may play a role in patient symptoms. Most experts agree that modern excimer lasers and ablation patterns have eliminated the majority night vision disturbances including glare, halo, and starbursts. In a recent study of 10,944 eyes of 5,563 myopic patients treated with wavefront-guided LASIK, low-light pupil diameter was not predictive of surgery satisfaction, ability to perform activities or visual symptoms magenta cyan yellow black 1 Focus On 25 Figure 1. Early subclinical forms of keratoconus can often be detected onlly with corneal topography. 2 Figure 2. Corneal tomography is another way to detect early subclinical forms of keratoconus. Moderate to severe keratoconus can be detected with a biomicroscope. (Images courtesy of Dr. William Tullo) at one-month postoperatively.12 Having a thorough understanding of your patient’s ocular health is necessary to determine if your patient is a good candidate for refractive surgery. refractive surgery. Curr Opin Ophthalmol. 2012 Jul;23(4):264-8. RefeRences 1. Binder PS. Risk factors for ectasia after LASIK. J Cataract Refract Surg. 2008 Dec;34(12):2010-1. 8. Jarade EF, Tabbara KF. Presumed reactivation of herpes zoster ophthalmicus following laser in situ keratomileusis. J Refract Surg. 2002 JanFeb;18(1):79-80 2. Ramos-López D, Martínez-Finkelshtein A, Castro-Luna GM, et al. Screening subclinical keratoconus with placido-based corneal indices. Optom Vis Sci. 2013 Apr;90(4):335-43. 3. Belin MW, Villavicencio OF, Ambrósio RR Jr. Tomographic parameters for the detection of keratoconus: suggestions for screening and treatment parameters. Eye Contact Lens. 2014 Nov;40(6):326-30. 7. Levy J, Lapid-Gortzak R, Klemperer I, et al. Herpes simplex virus keratitis after laser in situ keratomileusis. J Refract Surg. 2005 JulAug;21(4):400-2 9. de Rojas Silva V, Rodríguez-Conde R, CoboSoriano R, et al. Laser in situ keratomileusis in patients with a history of ocular herpes. J Cataract Refract Surg. 2007 Nov;33(11):1855-9 10. Nettune GR, Pflugfelder SC. Post-LASIK tear dysfunction and dysesthesia. Ocul Surf. 2010 Jul;8(3):135-45 4. Saad A, Gatinel D. Evaluation of total and corneal wavefront high order aberrations for the detection of forme fruste keratoconus. Invest Ophthalmol Vis Sci. 2012 May 17;53(6):2978-92. 5. Ahmadi Hosseini SM, Abolbashari F, Niyazmand H, et al. Efficacy of corneal tomography parameters and biomechanical characteristic in keratoconus detection. Cont Lens Anterior Eye. 2014 Feb;37(1):26-30. 6. Pasquali T, Krueger R. Topography-guided laser 11. Kymionis GD, Bouzoukis D, Diakonis V, et al. Long-term results of thin corneas after refractive laser surgery. Am J Ophthalmol. 2007 Aug;144(2):181-185. 12. Schallhorn S, Brown M, Venter J, et al. The role of the mesopic pupil on patient-reported outcomes in young patients with myopia 1 month after wavefront-guided LASIK. J Refract Surg. 2014 Mar;30(3):159-65 Dr. Tullo is also adjunct assistant clinical professor at SUNY College of Optometry. ES556952_OP0215_025.pgs 01.21.2015 22:55 ADV Special Secti o n Allergy 26 allergy prevalence Continued from page 1 ity of life. Most recent estimates suggest that 15–25 percent of the U.S. population, or between 50 and 85 million Americans, suffer from ocular allergy and/or allergic conjunctivitis.4,5 Other studies have estimated the prevalence of allergic conjunctivitis to range between 15 and 40 percent of the U.S. population.6 Here in the United States, the National Health and Nutrition Examination Survey III (NHANES III) found that 40 percent of the ErniE BOWling, adult population had ocuOd, fAAO chief optometric editor lar symptoms, defined as “episodes of tearing and ocular itching, with no significant differences according to age, though there was a predominance in the south vs. other regions 3 20% the increase of prescriptions for allergic conditions from 1993 to 2008 of the country.7 The prevalence of allergic conjunctivitis is similar in Europe, Japan, and Australia, and is increasing worldwide.6 According to an analysis from 1993 to 2008, prescribing medications for allergic conditions has similarly accelerated by about 20 percent.8 This likely reflects an increasing prevalence of allergic disease in developed countries. Although the exact reason for this increase is not known, February 2015 taKe-home meSSaGe Given the worldwide increase in ocular allergy prevalence, you may see an increase in allergy patients in your chair. itch is the hallmark of ocular allergy, but other signs and symptoms may be present. ocular allergy may mimic other conditions, so the exam and history is important. a three-step treatment plan is determined by the severity of the patient’s presentation. many factors are thought to play a role, including air pollution, industrialization and urbanization, climate change, and the “hygiene hypothesis,” which in essence attributes immune hypersensitivity among city dwellers to low microbial exposure during childhood.1,9 While not life threatening, the symptoms of ocular allergy as suffered by affected individuals have a significant impact on their productivity and quality of life.10 Ocular allergy symptoms can produce patient discomfort and interfere with visual tasks, including computer work and recreational activities. The quality of life of patients dealing with allergic conjunctivitis can be affected by intense itching, which produces sensation of dryness, vision fatigue and reading difficulties. Some 20 percent of allergy suffers report missing some time from work due to allergy symptoms.11 More severe forms of the ocular allergy, such as AKC12 or VKC,13 are rare yet can be sight threatening. Similar to other allergic conditions, allergic con- | junctivitis may demonstrate both an early, acute phase triggered by mast cell degranulation and a late, chronic phase involving allergic inflammation.14 SAC and PAC have seen a worldwide trend of increased prevalence over the past few decades.6 For example, increases in SAC and PAC in children have been well documented by the International Study of Asthma and Allergies in Childhood (ISAAC).15 Earlier studies suggest a difference between children from developed countries and those from more rural countries: while the overall health of children from underdeveloped countries may be worse, their risk of develop- The symptoms of ocular allergy as suffered by affected individuals have a significant impact on productivity and quality of life. ing allergic disease was substantially lower than that seen in Europe, North America, or Japan.16 Nations undergoing substantial economic growth report spikes in the prevalence of allergic conjunctivitis and symptoms associated with rhinitis or allergic conjunctivitis.16 Another factor in the rise in allergic disease prevalence receiving considerable attention in recent literature is the role of air figurE 2. Note conjunctival redness, eyelid edema, and watery discharge in this patient with seasonal allergic conjunctivitis magenta cyan yellow black ES558393_OP0215_026.pgs 01.23.2015 03:42 ADV Special Secti o n | praCtiCal ChairSide adviCe Corticosteroids remain among the most potent pharmacologic agents used in the more severe presentations of ocular allergy. A diagnosis of allergic conjunctivitis should be questioned if a patient isn’t complaining with an itch.23 Itching may be particularly aggravating in the nasal aspect of the eye and may range from mild to severe. Other symptoms include burning, stinging, photophobia, tearing, watery or mucoid discharge, chemosis, or dry eye.22 The discharge may contain a small amount of mucus, rendering it stringy or ropy, which could occasionally lead to a misdiagnosis of bacterial conjunctivitis. Because the nasal and ocular mucosa tissues have a similar reaction to allergens, Allergic conjunctivitis can look most patients with ocular like these conditions: complaints also have nasal – bacterial conjunctivitis symptoms. Among patients – rhinitis whose ocular symptoms – dry eye appear isolated, mild nasal – Meibomian gland disease (resulting in and/or lower respiratory tear film abnormality or insufficiency) symptoms can often be dis– blepharitis covered during the patient interview.23 The ocular exam for allergy should focus primarily on the conwere fed milk other than breast junctiva because the conjunctival milk during the first 4 months of membrane is an active immunolife20 have an increased risk of delogic tissue that responds to allergic veloping allergies. stimuli.24 Papillary hypertrophy of the upper tarsal conjunctiva is a Diagnosing ocular allergy sign generally not observed in the Allergic conjunctivitis is caused by SAC or PAC sufferer and indicates an allergen-induced inflammatory a more chronic and severe form of response in which allergens interallergic conjunctivitis.1 act with IgE bound to sensitized mast cells, producing the clinical Differential diagnosis of allergic ocular allergic presentation. Enviconjunctivitis can be challenging ronmental allergens trigger both because of the wide array of disorSAC and PAC. 21 Symptoms of alders that can mimic or mask the condition, including dry eye and lergic conjunctivitis may fluctumeibomian gland disease (resulting ate throughout the year, but they in tear film abnormality or insufworsen during times of highest ficiency), blepharitis, rhinitis and allergen exposure and in weather bacterial conjunctivitis.5 that is warm, windy, and dry. The hallmark signs and symptoms of When the signs and symptoms both SAC and PAC are itching and are consistent with SAC and the redness,22 but the hallmark symptom patient history does not indicate some other disease, allergy testing of allergic conjunctivitis is itching. pollution as an exacerbating factor in allergic signs and symptoms.17 About 89 percent of the world’s population lives in areas where the levels of airborne particulate matter exceed the World Health Organization’s (WHO) guidelines for air quality.18 There is also evidence that suggests some allergic resistance is passed passively from mother to child. Children born by Caesarean section19 and those who Allergy 27 is usually not required.25 However, in stubborn and recurrent cases, allergists can perform skin testing for specific allergens by scratch tests or intradermal allergen injections. In-vitro tests for allergen-specific IgE antibodies are also widely used.26 If a causative agent can be determined by either skin prick tests or allergen challenge, then avoiding the allergen can greatly lessen the severity and symptom frequency. See Allergy prevalence on page 28 Rely on something that STAYS PUT AllErgy diffErEnTiAl diAgnOsis magenta cyan yellow black Parasol® 92% We’ve taken the worry out of plug retention, so you can concentrate RE TENTION on patient retention. The Parasol Punctal Occluder trumps the competition with an unprecented 92% retention rate. Use the Parasol Punctal Occluder, designed for easy insertion and guaranteed to stay put. TO ORDER: 866-906-8080 [email protected] odysseymed.com or beaver-visitec.com Beaver-Visitec International, Inc. | 411 Waverley Oaks Road Waltham, MA 02452 USA | BVI, BVI Logo and all other trademarks (unless noted otherwise) are property of a Beaver-Visitec International (“BVI”) company © 2015 BVI ES558390_OP0215_027.pgs 01.23.2015 03:41 ADV Special Secti o n Allergy 28 allergy prevalence Continued from page 27 Allergy treatment The management of ocular allergy includes patient education and allergen avoidance (if possible), topical therapies, and immunotherapy. Avoidance of the offending antigen is the primary behavioral modification for all types of allergic conjunctivitis. However, the eyes present a large surface area, so it is often impossible to avoid ocular exposure to airborne allergens. Sunglasses should be worn to reduce direct ocular exposure to airborne allergens. Treatment options will February 2015 Alternatively, or concurrently, over the counter anti-allergy medications or an ocular antihistamine/mast cell stabilizer may be utilized. STEP Treatment with a topical ocular antihistamine/mast cell stabilizer is recommended for patients with itching (ranging from mild to severe and from intermittent to prolonged) who do not have significant redness or concurrent ocular conditions. However, steroids are commonly used. Corticosteroids remain among the most potent pharmacologic agents used in the more severe 2 With the treatment options available to eyecare practitioners, the prognosis for ocular allergy is quite good. often depend on the symptom severity and the nature of the ocular allergy, and treatment should follow a stepwise approach.27 Following are three steps to design an allergy treatment plan. STEP Patients with mild, intermittent itching should use nonpharmaceutical measures like cold compresses, ice packs, and lubricating ophthalmic drops. Cold compresses provide relief from symptoms (especially itching). Artificial tear substitutes provide an allergen barrier and help to dilute the various allergens and inflammatory mediators present on the ocular surface—they help flush away these agents from the ocular surface. 1 presentations of ocular allergy and are also effective in the treatment of acute and chronic forms of allergic conjunctivitis. STEP Treatment with a topical ocular antihistamine/mast cell stabilizer and/or a topical ocular corticosteroid is indicated for allergic conjunctivitis for seasonal allergy patients with moderate-to severe symptoms of allergic conjunctivitis and redness. Patients placed on a topical ocular steroid should receive careful follow-up to assess its effect and rule out adverse events, such as drug-induced intraocular pressure (IOP) elevation. IOP should be checked before steroid therapy is begun and rechecked at two weeks 3 | if the steroid is continued that long. A slit lamp examination of the ocular surface before steroid therapy should be done to rule out opportunistic infections (e.g., with herpes simplex virus or fungi).28 In severe cases, it may be necessary to get symptoms under control quickly by using a more aggressive approach and then reducing to a maintenance program. Many allergic conditions tend to be chronic in nature, so long-term control with agents such as mast cell stabilizers and antihistamines rather than a steroid may be preferred. Allergen-specific immunotherapy is an effective treatment for patients with allergic rhinoconjunctivitis who have allergenspecific IgE antibodies. The main objective of this treatment is to induce a clinical tolerance to the specific allergen, which reduces the seasonal increases of IgE specific for that allergen. However, immune responses to allergen administration are not predictive of the therapy’s effectiveness. The therapy itself can produce systemic reactions, the incidence and severity of which can vary dependent on the type of allergen administered.29 Traditionally, immunotherapy is delivered via subcutaneous injection. However, sublingual (oral) immunotherapy (SLIT) is gaining momentum among allergists. Recent large-scale trials have focused on SLIT therapy for grass and ragweed allergies, and trials are underway using allergens from dust mites.30 SLIT requires further evaluation for ocular allergy relief; it has been shown to control ocular signs and symptoms, although ocular symptoms do not respond as well as nasal symptoms.31 figurE 2. another patient with red, itchy eyes secondary to SaC magenta cyan yellow black ES558392_OP0215_028.pgs 01.23.2015 03:42 ADV Special Secti o n | praCtiCal ChairSide adviCe Conclusion The prevalence of allergies is increasing worldwide. Ocular allergies are a very common presentation in an optometric practice, especially in the spring of the year when the plants burst forth in bloom. Fortunately, with the treatment options available to eyecare practitioners, the prognosis for the disease is quite good. Familiarity with the condition and the many treatments available enable us to better care for our patients presenting with those itchy, watery eyes. RefeRences 1. Bielory L. Ocular allergy overview. Immunol Allergy Clin North Am. 2008 Feb;(1): 1–23. 2. Petricek I, Prost M, Popova A. The differential diagnosis of red eye: a survey of medical practitioners from Eastern Europe and the Middle East. Ophthalmologica. 2006;220(4):229–237. 3. Palmares J, Delgado L, Cidade M, et al. Allergic conjunctivitis: a national crosssectional study of clinical characteristics and quality of life. Eur J Ophthalmol. 2010 Mar-Apr;20(2):257-64. 4. Miraldi V, Kaufman AR. Allergic eye disease. Pediatr Clin North Am. 2014 Jun;61(3):607-20. 5. O’Brien TP. Allergic conjunctivitis: an update on diagnosis and management. Curr Opin Allergy Clin Immunol. 2013 Oct;13(5):543-9. 6. Rosario N, Bielory L. Epidemiology of allergic conjunctivitis. Curr Opin Allergy Clin Immunol. 2011 Oct;11(5):471-6. 7. Singh K, Bielory L. The epidemiology of ocular allergy symptoms in United States adults (1988-1994). Ann Allergy Asthma Immunol. 2010 Oct;126(4):778-783.e6. 8. Origlieri C, Bielory L. Emerging drugs for conjunctivitis. Expert Opin Emerg Drugs. 2009 Sep;14(3):523-36. 9. Bielory L, Lyons K, Goldberg R. Climate change and allergic disease. Curr Allergy Asthma Rep. 2012 Dec;12(6):485-94. 10. Virchow JC, Kay S, Demoly P, et al. Impact of ocular symptoms on quality of life (QoL), work productivity and resource utilisation in allergic rhinitis patients: an observational, cross sectional study in four countries in Europe. J Med Econ. 2011;14(3):305-14. Acad Dermatol 2014; 70:569–575.8. safety during a 4-year follow-up study. Allergy 1995; 50: 405–413. 13. De Smedt S, Wildner G, Kestelyn P. Vernal keratoconjunctivitis: an update. Br J Ophthalmol 2013; 97: 9–14. 30. Gomes PJ. Trends in prevalence and treatment of ocular allergy. Curr Opin Allergy Clin Immunol 2014,14: 451–456. 14. Leonardi A. Allergy and allergic mediators in tears. Exp Eye Res 2013; 117:106–117. 15. Ait-Khaled N, Pearce N, Anderson HR, et al. Global map of the prevalence of symptoms of rhinoconjunctivitis in children: the International Study of Asthma and Allergies in Childhood (ISAAC) Phase Three. Allergy 2009; 64: 123– 148. 16. Mallol J, Crane J, von Mutius E, et al. The International Study of Asthma and Allergies in Childhood (ISAAC) Phase Three: a global synthesis. Allergol Immunopathol (Madr) 2013; 41:73–85. 31. Vitaliti G, Leonardi S, Miraglia Del Giudice M, et al. Mucosal immunity and sublingual immunotherapy in respiratory disorders. J Biol Regul Homeost Agents 2012; 26(1 Suppl): S85-93. dr. Ernie is in private practice in Gadsden, al, and is the Diplomate exam chair of the american academy of optometry’s primary care Section [email protected] Digital Photography Solutions 17. Guarnieri M, Balmes JR. Outdoor air pollution and asthma. Lancet 2014; 383: 1581–1592. for Slit Lamp Imaging 18. Brauer M, Amann M, Burnett RT, et al. Exposure assessment for estimation of the global burden of disease attributable to outdoor air pollution. Environ Sci Technol 2012; 46:652–660. 19. Renz-Polster H, David MR, Buist AS, et al. Caesarean section delivery and the risk of allergic disorders in childhood. Clinical & Experimental Allergy 2005; 35:1466-72. Digital SLR Camera 20. Halken S. Prevention of allergic disease in childhood: clinical and epidemiological aspects of primary and secondary allergy prevention. Pediatric Allergy & Immunology Suppl 2004; 16: 4-5, 9-32. 21. American Academy of Ophthalmology Cornea/External Disease Panel. Preferred practice pattern guidelines. Conjunctivitis: limited revision. San Francisco, CA: American Academy of Ophthalmology; 2011. 22. Moloney G, McCluskey PJ. Classifying and managing allergic conjunctivitis. Med Today 2007; 8: 16–21. 23. Bielory L. Ocular allergy. Mt Sinai J Med 2011; 78: 740 –758. 24. Bielory L, Friedlaender MH. Allergic conjunctivitis. Immunol Allergy Clin North Am 2008; 28: 43–58. 25. Kari O, Saari KM. Updates in the treatment of ocular allergies. J Asthma Allergy 2010; 3: 149–158. Universal Smart Phone Adaptor for Slit Lamp Imaging 26. La Rosa M, Lionetti E, Reibaldi M, et al. Allergic conjunctivitis: a comprehensive review of the literature. Italian Journal of Pediatrics 2013, 39: 18. 27. Bielory L, Meltzer EO, Nichols KK, et al. An algorithm for the management of allergic conjunctivitis. Allergy Asthma Proc 2013; 34: 408-420. 11. Smith AF, Pitt AD, Rodruiguez AE, et al. The economic and quality of life impact of seasonal allergic conjunctivitis in a Spanish setting. Ophthalmic Epidemiology 2005; 12: 233-42. 28. Ilyas H, Slonim CB, Braswell GR, et al. Long-term safety of loteprednol etabonate 0.2% in the treatment of seasonal and perennial allergic conjunctivitis. Eye Contact Lens 2004; 30:10–13. 12. Chen JJ, Applebaum DS, Sun GS, et al. Atopic keratoconjunctivitis: a review. J Am 29. Walker SM, Varney VA, Gaga M, et al. Grass pollen immunotherapy: efficacy and magenta cyan yellow black Allergy 29 Made in USA TTI Medical Transamerican Technologies International Toll free: 800-322-7373 email: [email protected] www.ttimedical.com ES558386_OP0215_029.pgs 01.23.2015 03:41 ADV Contact Lenses 30 FeBrUarY 2015 | Relieve migraines with tinted lenses Color can offer relief for those struggling from visual disabilities By Paul Harris, OD, FCOVD, FACBO, FAAO, FNAP, and Christina Esposito, OD, FAAO O ptometric practices offer tinted and colored contact lenses to aid in cosmetic enhancement; however, many eyecare practices are unaware of the therapeutic effects that tinting a lens (contact or spectacle) can offer. Fluorescent migraines D.B., a 57-year-old male presented to The Eye Center at Southern College of Optometry with severe migraines, including auras that triggered when exposed to fluorescent lighting for as briefly as 15 minutes. At the time of first presentation, he wore very dark sunglasses and a baseball cap at work to help prevent the onset of migraines. To reduce overall brightness, he removed half of the tubes in each fixture. Occasionally, he needed to shut off all the lighting. D.B. was seen by a neurologist for his headaches, but his medical and ocular histories were otherwise unremarkable. D.B. was experienc- PAUL HARRIS, OD, FCOVD, FACBO, FAAO, FNAP is a professor at Southern College of Optometry after being in private practice in Baltimore for more than 30 years. CHRISTINA ESPOSITO, OD, FAAO works in vision therapy and rehabilitation at the Midwestern University Eye Institute. ing migraines daily which would last for up to four hours. These migraines were so debilitating that he remained in bed, losing days of his life. He takes 100 mg of Imitrex (sumatriptan, GlaxoSmithKline) to help with the pain. He is allergic to aspartame, caffeine, cheese, monosodium glutamate, and tryptophan. Upon examination, his uncorrected distance visual acuities was 20/20 OU, and all other preliminary testing was normal. Refraction revealed OD: +0.50 -0.75 x 110 OS: +0.25 -0.50 x 110 with an add of +2.00 D OU. Anterior and posterior segment health is unremarkable. We performed color sensitivity testing using the Intuitive Colorimeter (Cerium Optical Products). This logically and sequentially explored color space and helps find the optimal precision tint for the relief of perceptual distortions, or in this case, migraines. The Intuitive Colorimeter changes three parameters of color: hue, saturation, and brightness. The patient views colors, which are projected onto text or other targets, through the Figure 1. Output from the Excel spreadsheet for the hue of 180 and saturation of 30. The lower left part of the figure shows which lenses are used to produce the final filter; Turquoise A5 and D2 and Green B4. The lower-right portion of the figure shows the transmission curve of the final tint. magenta cyan yellow black TAKE-HOME MESSAGE Tinting lenses and contact lenses can help treat a variety of visual disabilities. In this case, a patient suffered from debilitating fluorescent lightinginduced migraines. He was first treated with a pair of custom tinted glasses. Ultimately, practitioners were able to create customtinted contact lenses for the patient which helped to relieve him of migraines. instrument while the examiner changes the parameters and records subjective responses. Based on the responses, a computer program helps to determine which combinations of filters will produce a color unique to the patient’s needs. There are 42 different reference filters, which can be used one at a time or, in rare cases, in combinations of four to five different reference lenses. The program gives a specific transmission curve for the lens combination, which is testable and reproducible. Using the filters allows the patient to see the color suggested for him before tinting. Treating with tinting With D.B., testing indicated a preference with the spectrum narrowed to 180 at 30 saturation. Producing the right tint for D.B. required three reference lenses, one from the green set and two from the turquoise set (Figure 1). This produces an overall 36 percent transmission with a peak at 500 nanometers. The first step was to make a pair of glasses to this specification. The preferred color was then called into the lab (Figure 2). The lenses still did not provide enough coverage, and he was still experiencing the migraines. We decided to try placing the tint closer to the surface of the eye using contact lenses to more effectively block light. Using the SoftChrome In-Office Tint System, the lenses were tinted in house. The tinting system kit includes a choice of patterned templates to create pupil and iris combinations, dyes, tinting equipment, and instructions. The lens used was CooperVision Biomedics XC (omafilcon). A blue tint was applied using the system instructions. A dark tint was required to relieve the migraine symptoms. ES557478_OP0215_030.pgs 01.22.2015 04:56 ADV Contact Lenses | practical chairside advice 31 of color through filters and/or lenses should be considered for those who are struggling from visual disabilities. Dr. Harris serves as the president of the Optometric Extension Program Foundation and lectures on topics of behavioral vision care, vision therapy, and acquired brain injury. [email protected] Dr. Esposito graduated from the Arizona College of Optometry in 2013, then served as a vision therapy/rehabilitation resident at the Southern College of Optometry. [email protected] Figure 2. The actual pair of glasses made for D.B. as a first attempt to help him with his migraines. Figure 3. The final tinted contact on D.B.’s right eye. The lens was an excellent fit with good limbal to limbal coverage and with 1 mm to 2 mm of movement with a blink. He achieved 20/20 acuity with these lenses in all normal lighting situations. It took about five iterations of making the lenses progressively darker before we attained an appropriate transmission level. We combined 2 ml of activator solution with 15 drops of blue dye. The lenses were left to tint for 45 minutes, then put into a neutralizing solution to restore pH balance to them. The lenses were then transferred to a multi-purpose solution for storage, which was changed several times to be sure no dye was coming out of the lenses. We tinted only the pupil with the first lenses in order to improve cosmesis. Though these were promising, it turned out that they still did not provide enough coverage. The most successful tint pattern was a full diameter very dark tint (Figure 3). The result was a profound change in the patient’s life. Benefits of in-house tinting The benefits to tinting contact lenses in-house include faster delivery time, color modification options, and the ability to apply a tint for therapeutic use to any available lenses. You can buy lenses that are already tinted; however, if darker or lighter colors are needed, you would need to order many different lenses, increasing the turnaround time. For a patient that is suffering the way D.B. was, the sooner the lenses were finished, the better. The patient was able to wear the tinted contact lenses full time during the day in any lighting condition without experiencing headaches, though it should be noted that he removed them once he got home. His acuity through the lenses is 20/20 OU. The patient stated, “I am not tired at the end of my work day due to the exposure to the fluorescent lighting, nor do I get migraines as easily. I can tolerate being at work, and I do not have to consider quitting my job. It is amazing, and I thank you again for what you have done for me—giving me a normal life back.” Tinting contact lenses and/or glasses for therapeutic reasons can be time consuming, but it can be a rewarding experience for both the clinician and patient. Many people struggle with visual disturbances on a daily basis. Whether it is light sensitivity, reading problems, or even visual sequelae related to vestibular issues, color helps many of these patients live a normal life. The use Better comfort. Better retention. Better results. Take the VeraPlug™ challenge. Compare the new VeraPlug to the plug you’re using now and see the diference for yourself. Visit lacrivera.com/challenge for your free sample A FRESH PERSPECTIVE™ lacrivera.com 2500 Sandersville Rd ■ (855) 857-0518 Lexington KY 40511 USA © 2014 Lacrivera, a division of Stephens Instruments. All rights reserved. magenta cyan yellow black ES557477_OP0215_031.pgs 01.22.2015 04:56 ADV Contact Lenses 32 FeBrUarY 2015 | Corneal size does matter in lens fit Case shows even subtle size abnormality can make lens wear difficult By David Kading, OD, fAAO, fcLSA, and Jeanette Strommen, OD C to lens movement during contact sports performance. Furthermore, glasses temples are caught in between the head and a tight-fitting helmet, which consequently applies extra pressure on the sides of the athlete’s head. Contact lenses eliminate all of these variables and permit athletes to focus on the game rather than being annoyed at their glasses. orneal size does matter. In fact, it can turn a simple soft contact lens fitting into a complex DAVID KADING, OD, clinical puzzle. With increased corFAAO, FCLSA neal size, the sagittal depth does not owns a threematch the size of the standard sagphysician, twoittal depth of off-the-rack soft conlocation practice in tact lenses, making custom contact the Seattle area. lenses a necessary means to an end. Looking at the cornea We encountered this clinical coOur patient was a seemingly nundrum when a 13-year-old young straightforward contact lens fit with man complained of an inability to -2.00 D OU. Upon further evaluawear contact lenses throughout the tion of his eye, we noticed his K day. He had been to several eyecare readings were 43.1/43.5 @ 017 OD practitioners, all of which resulted in and 43.4/43.7 @125 OS, indicating unsuccessful attempts soft contact that he had essentially spherical BY JEANETTE lens fittings. He was eager to trancorneas. All other aspects of his STROMMEN, OD sition into contact lenses because ocular health were unremarkable. is the anterior he is an active athlete, participatWe applied a soft contact lens of segment disease/ ing in lacrosse and football, both contact lens resident standard diameter and noticed that at Davis Duehr Dean of which require helmets. the contact lens was decentering Eye Clinic in Madison, uncomfortably. Noting the size of The use of spectacles can often WI. inhibit performance in sports with the cornea compared to the size of helmet requirements. In comparison the contact lens, we were further to contact lenses, spectacles limit the field able to evaluate that his corneal size was of view and provide less steady optics due beyond normal. TAKE-HOME MESSAGE In this case, a teenage boy had not been successfully fit with soft contact lenses and discomfort caused him to discontinue all-day wear. K readings revealed the patient had essentially spherical corneas. Topography revealed his corneas had a diameter of 12.04 mm OD and 12.10 mm OS—just slightly larger than normal, but enough that it was preventing a correct fit. Custom contact lenses were ordered and the patient’s discomfort resolved. We performed topography on his eyes and noted that his corneas had a diameter of 12.04 mm OD and 12.10 mm OS. The standard corneal size is 11.8 mm.1 Thus, although the size is not significantly outside of the normal range, we have concluded that the size of the patient’s corneas and the associated increased sagittal depth are the cause to the long history of soft contact lens fitting challenges in this patient. In this particular patient’s case, the size abnormality was subtle, but significant enough to have threatened his desire to wear lenses. Thus, we elected to order a custom soft note how both eyes show HVID that is larger than 11.8 mm. Patients who have corneal sizes that are smaller or larger may need custom lenses with custom diameters. magenta cyan yellow black ES557597_OP0215_032.pgs 01.22.2015 05:40 ADV | practical chairside advice contact lens with a diameter that is larger than standard. In our particular case, we would order a contact lens with at least 1.5 mm of limbal coverage, so we will order a contact lens that is 14.5 to 15 mm in diameter. If solely customizing the diameter is not enough to stabilize the contact lens on particu- In this case, the size abnormality was subtle, but significant enough to have threatened his desire to wear lenses. Don’t be afraid to customize your lenses It is very common for patients who are wearing soft contact lenses to occasionally not find the comfort that they desire. They may present with uncomfortable contact lens wear, irritation throughout the day, or possibly hyperemia that develops after several hours of lens wear. We are very fortunate to have access to many custom contact lens laboratories. There are several retailers on the market that are able to customize soft contact lenses to our patients’ individual needs. Our industry partners’ lenses offers custom soft contact lenses with a customizable base curve, power, and diameter which suits the contact lens needs of atypical corneas and prescriptions. Several laboratories suggest ordering a contact lens with a diameter of 3.0 to 3.5 mm greater than the patient’s horizontal visible iris diameter (HVID). Using our Contact Lenses 33 RefeRence 1. Caroline P, Andre M. The effect of corneal diameter on soft lens fitting, part 1. Contact Lens Spectrum 2002;17(4)56. Dr. Kading disclosed speaking, research, or consulting relationships with Alcon, Allergan, Bausch + Lomb, Contamac, CooperVision, Paragon Vision Sciences, SynergEyes, Unilens, Valley Contax, Vistakon, and Visionary Optics. [email protected] Dr. Jeanette Strommen plans to settle in the Minneapolis-St. Paul area after completing her residency and plans to practice full-scope optometry with a niche in anterior segment disease and contact lenses. [email protected] Building the Ophthalmic Tech’s Community of Practice modernmedicine.com/iTech Resource Center for Technician Education WEB EXCLUSIVE CONTENT Know what sports your patients play: keep contact lenses in mind Related Articles Continuing Education With the welcomed safety requirements that we are seeing come into play with more and more of today’s sports, it is important for us to identify the sports that our patients play. eyeglasses are very difficult to wear under helmets. this is extremely critical for our patients who are children. these patients often will remove their glasses out of convenience and may not mention to their parents the significance of their visual problems. larly large corneas, then the base curve comes into play. These parameters work synergistically to increase the sagittal depth of the contact lens significantly when the base curve is decreased. The diameter will also increase. The result is a contact lens with a far greater sagittal depth, one that may better match the sagittal depth of the larger than average cornea, permitting a more harmonious contact lens experience. magenta cyan yellow black Often, parents are aware of the significance that a child’s refractive error can have on his daily life. this is even more important with high-intensity sports like football and lacrosse. look closely at your patient’s hobbies and remember to keep contact lenses in mind for patients who play sports. sports with helmets include hockey, football, baseball, softball, lacrosse, snowboarding, snowskiing, waterskiing, bobsled, etc. patient as an example, we would then order his contact lenses with a diameter of around 15.60 mm. Turn to your local custom soft contact lens provider for further recommendations in ordering its particular lens. In our clinic, we have found that corneal size is a major factor that needs to be followed and monitored. Corneal size variations can be a significant marker for contact lens comfort and success. Clinical Tools & Tips iTech provides educational presentations and information for ophthalmic and optometric technicians, helping them work effectively with their doctors to enhance the practice. 1 AND SUPPLEM ENT TO IM ERY T AY, Ee V Y Dpr tic , EVl EfoR ery ac N ev A r E sentia IT CL E is hygiene Hand important just as rument as inst tion steriliza comes it when solid ing a to hav n control infectio m. progra G program is es KEEioPnIN control Infect ros ent only elem said be the m, uld not progra ents sho ction control Instrum infe ctice’s , CRNO. Health of a pra RN, MN ty and Lamb, ters for al Safe Patricia the Cen upation versal Occ and The lined uni (OSHA) tration have out ction (CDC) Adminis s for infe every Control caution Disease nt for dard pre are importa day, se and stan e, every , and the every practic nt of the control in side er, pre mb past istered team me who is the ic Reg b, cialist. hthalm said Lam Society of Op ical nurse spe er an clin Americ ) and a ne in ord od, dici ORN (AS cly to blo into me Nurses ted infe y goes tions app ons -associa , to practice “Nobod d precau , and excreti lthcare less s standar ons vent hea b. “Neverthe prevent mucou These secreti to pre Lam e to skin, and y fuids, abl said intact all bod tions,” must be ctions.” at, non A or caune, you s, OSH ept swe ments ion ted infe sal pre yee exc medici ver plo ocia detach ial em A uni an ranes. eous the opt es, are-ass tion of a potent or vitr surgery is memb cas healthc ing to the OSH certain hum protec s with some lmic posteri ur, be nd in For the all employee to be When breaks occ Accord an blood and y fluids Ophtha age—a known d by other and bod s that retinal the dam lost vision. some of all hum treated as if air s, and blood dictate tion, pai tions, to viru cina re to rep even restore be aware of B are vac osu atitis fuids atitis B for exp it may ans should body HIV, hep . the hep uire nici us for s and req red ens tech s ctio ure offe yee ced infe t pathog ployer. the pro rations tha h emplo borne limited the em ition, all suc bloodbut not conside lmologists rd ens, g uding In add standa the concept of pathog ophtha n choosin l g, incl borne ed versal to trainin s. surgica face whe annual owing: bloodFrom uni CDC expand changed theed ir etinal onomic vitreor ches for the and erg n control 6, the s” and lain the foll lence, In 199 s,” exp caution s to approa lace vio Lamb, infectio that cause sal pre deline ts. caution nts patien rd pre “univer tion gui uce workp ing to “standa in of eve precau red Accord the cha term to se standard followed to 3 ak Page bre and n. The IONS on uld be borne aims to infectio Lamb. INFECT all bloodCDC sho ead of See of to n the spr lied the app from smissio ir of tran must be of the the risk ens and regardless , pathog n status. other ng care ts receivi sumed infectio patien sis or pre diagno Mesza By Liz E: ocedures INSIDetina l pr to treat es ks approach Surgicalments and brea detach Vitreor PAGE 11 Brought to you by e 01 | volum issue 04 | Winter 2012 ES557598_OP0215_033.pgs 01.22.2015 05:40 ADV Dry Eye 34 FeBrUarY 2015 | SPEED questionnaire identifies dry eye Asking the right questions can lead to successful tailored treatment plans By Leslie e O’Dell, OD, fAAO mation. I’ve learned the phrase, “No complaints of dry eye” can’t always be accepted as gospel. ne of the challenges we face As I start my exam, there are sevin diagnosing our patients eral important signs I look for that with dry eye disease is that indicate I may be dealing with a dry clinical findings and the patient’s eye patient who doesn’t know she symptoms often do not correlate.1,2 BY LESLIE E is one—yet. A quick introduction There’s simply no definitive “one O’DELL, OD, FAAO will show me any signs of redness size fits all” approach. is the director of the to the eyelid margin or the ocular In lieu of improving diagnostic Dry Eye Treatment surface, and even the appearance tests, symptoms have been shown Center at May Eye Care Center in of the patient’s face might show to be more repeatable than clinical Hanover, PA. redness associated with rosacea. findings.3 The challenge is our paDuring my refraction, visual tients’ perception of dryness when fluctuations before and after blink can be using a subjective measure. This challenge apparent. From there, I get into the most in diagnosing dry eye parallels the chalcrucial element of my evaluation: a thorlenges eyecare practitioners face when diough slit lamp exam. agnosing glaucoma. We evaluate subjective I evaluate the lid, tear meniscus, tear breakand objective measures to develop a risk/ up time, corneal and conjunctiva staining, benefit ratio for each patient that guides and meibomian glands. I then take time to our clinical decision on when to treat. We step back from the slit lamp and begin to ask do not and cannot use one test for making questions that can quickly reveal if a patient this diagnosis; rather, the best diagnosis is is suffering from ocular surface disease. made using a culmination of data points I ask questions such as: over time. How long can you read before your eyes fatigue or blur? Defining normal for each patient During a typical day seeing patients in our How do you feel after a day in the ofbustling practice, it’s surprising how many fice on the computer? dry eye patients I encounter, but you wouldn’t How do your eyes feel in the morning know it by reviewing patient intake inforwhen you are waking? O MEIOBOGRAPHY can now be done easily in office with the introduction of dynamic transillumination available in lipiview ii from tearscience. this image shows truncation and atrophy of the meibomian glands of a lower lid. these images speak volumes to patients and enhance their understanding of this chronic condition. Image courtesy of TearScience magenta cyan yellow black TAKE-HOME MESSAGE Often, a patient may come to accept dryness or discomfort as the “new normal,” and he may not come to you to seek a solution if he does not know there is a problem. A simple set of questions, like the Standard Patient Evaluation of Eye Dryness (SPEED) survey, can help evaluate the severity and frequency of dry eye symptoms. Do your eyes water, look red, or feel irritated? How do your eyes feel when you outdoors, especially in the wind? While optometrists are trained to know what dry eye symptoms are, we need to be cognizant that patients suffering these symptoms often accept them as a “new normal” and may not realize that dry eye disease is the cause. Implementing a questionnaire This disconnect with patient perception led our practice to shift from simply asking the patient if she have dry eyes to utilizing a detailed questionnaire that the patient fills out when he is checking into the office. Several years back, I developed my own questionnaire based on past experience and would occasionally use the Ocular Surface Disease Index (OSDI) for patients already being treated for dry eye, aqueous deficient or evaporative. About two years ago, we started to implement the Standard Patient Evaluation of Eye Dryness (SPEED) survey, a validated dry eye survey that like its name is fast.4,5 This helps immensely with patient (and staff) compliance. SPEED evaluates both the frequency and severity of symptoms in just eight questions. The patient grades the severity of her symptoms on a scale of zero to four with zero being no symptoms and four being intolerable symptoms. The numeric value for each answer is simply added with scores ranging from zero to 28. The questionnaire is set up to ask patients about their symptoms in the present and up to three months due to the variability of symptoms over time.6 The symptoms Korb and Blackie used for ES556431_OP0215_034.pgs 01.21.2015 00:34 ADV Dry Eye | practical chairside advice the survey help to quickly identify possible underlying causes. Grittiness is a common complaint of patients with lid wiper epitheliopathy, while burning is often found in patients with partial blinks.6 The SPEED questionnaire is able to differentiate symptomatic from asymptomatic patients.7 Having a number from a questionnaire quickly helps me to identify and categorize dry eye patients. For those with many symptoms greater than 8 on the SPEED, their current treatment should be re-evaluated to gain better symptom control. For those asymptomatic, clinical signs that might indicate early stages of dry eye, especially meibomian gland dysfunction, should be evaluated. Start educating patients even when they are not complaining, less than 6 on the SPEED. Current treatments may be more effective if we initiated them in early stages. We are in an evolving role presently; raising public awareness of ocular surface wellness starts with the optometrist. This challenge harkens back to the uphill battle dentistry faced years ago before annual and biannual evaluation were standard of care to Quick quiz after the slit lamp exam, i ask patients these questions to determine if dry eye might be a problem for them. – How long can you read before your eyes fatigue or blur? – How do you feel after a day in the office on the computer? – How do your eyes feel in the morning when you are waking? – Do your eyes water, look red, or feel irritated? – How do your eyes feel when you outdoors, especially in the wind? prevent tooth decay and even that of dermatology prior to public awareness of the importance for sunscreen to prevent skin cancer. Changing public perception and industry practices related to dry eye disease will not be an easy or short-term process, but is a critical element in helping dry eye sufferers avoid symptoms and find relief. Validated questionnaires There are a wide variety of options of validated questionnaires to use in a clinical setting. OSDI, Dry Eye Questionnaire (DEQ), McMonnies Questionnaire (MQ), Subjective Evaluation of Symptoms of Dryness (SESoD), and now, SPEED. Studies have shown the magenta cyan yellow black 35 Figure 1. The Standard Patient Evaluation of Eye Dryness (SPEED) survey can help evaluate the frequency and severity of dry eye syptoms. To download a free copy of this questionnaire to use in your practice, go to www.OptometryTimes.com/ SPEEDdryeye. SPEED questionnaire to be similar to the OSDI in determining symptomatic from asymptomatic patients.6 The OSDI is a great tool for assessing the quality of life impact dry eye is having for a patient, which is a critical consideration. Using a validated questionnaire as a routine part of your routine eyecare evaluation is one more tool that will guide your diagnosis and treatment. With the proven repeatability of these questionnaires, the results can also show outcomes for the treatment you have implemented. If the number on the SPEED survey is going down, rest assured your treatment is effective for the time being. If the number from the SPEED is stationary or on the rise, step back and re-evaluate. The challenge Start using a questionnaire for every patient you see, it’s fast and you may be surprised with the hidden number of dry eye patients. Then the real challenge begins. Take the extra time to talk to your patients and develop a treatment plan to not only relieve their symptoms but also slow the progression of the disease. And schedule a follow-up, even if you are simply starting artificial tears. A follow-up not only allows you to re-evaluate the therapy and repeat the SPEED but also validates the problem to your patients. RefeRences 1. Begley CG, Chalmers RL, Abetz L, et al. The relationship between habitual patient-reported symptoms and clinical signs among patients with dry eye of varying severity. Invest Ophthalmol Vis Sci. 2003 Nov;44(11):4753-61. 2. Sullivan BD, Crews LA, Sonmez B, et al. Clinical utility of objective test for dry eye disease: variability over time and implications for clinical trials and disease management. Cornea. 2012 Sep;31(9):10008. 3. Nichols KK, Nichols JJ, Mitchell FL. The lack of association between signs and symptoms in patients with dry eye disease. Cornea. 2004 Nov;23(8):762770. 4. Korb DR, Herman JP, Greiner JV, et al. Lid wiper epitheliopathy and dry eye symptoms. Eye Contact Lens. 2005 Jan;31(1):2-8. 5. Korb DR, Scaffidi RC, Greiner JV, et al. The effect of two novel lubricant eye drops on tear film lipid layer thickness in subjects with dry eye symptoms. Optom Vis Sci. 2005 Jul;82(7):594-601. 6. Blackie C, Albou-Ganem C, Korb D. Questionnaire assists in dry eye disease diagnosis. Four-question survey helps evaluate patients’ dry eye symptoms to improve screening. Ocular Surgery News Europe Edition. November 2012. 7. Ngo W, Situ P, Keir N, et al. Psychometric properties and validation of the Standard Patient Evaluation of Eye Dryness questionnaire. Cornea. 2013 Sep;32(9):1204-10. Dr. O’Dell lectures throughout the East Coast and internationally on dry eye-related topics. She is a graduate of the Pennsylvania College of Optometry and University of Delaware and served her residency at the Baltimore VA Hospital. [email protected] ES556926_OP0215_035.pgs 01.21.2015 22:50 ADV InDispensable 36 FEBRUARY 2015 Nearsights offers monocles for women | PURITI DURAHINGE PuriTi and DuraHinge launch styles for women RALEIGH, NC—Nearsights has introduced a new line geared specifically toward women with its smallest monocle. The new diameter makes Nearsights the only monocle company to provide consumers with a full range line: 34 mm (small), 37 mm (medium), and 40 mm (large). The 34 mm is available in the classic, tinted, and mirrored models for comfortable hands-free correction. Monocles can be adapted to multiple magnifier strengths (plano to +4.00 D) and written to prescription. The polycarbonate lens and polished stainless steel frame fits neatly in pockets or can be worn around the neck with the included lanyard. magenta cyan yellow black HAUPPAGE, NY—ClearVision recently expanded two of its private label collections, PuriTi 100 percent titanium eyewear and DuraHinge, to include new styles for women. PuriTi for women offers the ultra lightweight, hypoallergenic, and anti-corrosive benefits associated with titanium, in classic to contemporary designs. The four introductory styles feature pierced temple designs, metallic pearl temple tips, jewelry-inspired details, and integrated spring hinges. All four styles are offered in feminine colorations. Created and designed for women who need a little more durability in their eyewear, DuraHinge for women offers strength and comfort with a touch of feminine style. The collection is designed with the DuraHinge five-barrel hinge construction, providing strength with the added flexibility of a spring hinge without being too heavy or bulky on the face. The six introductory styles feature decorative stone accents and marble temples. The styles are offered in jewel tone colors like gold, purple, and wine. To celebrate the introduction of PuriTi for women and DuraHinge for women, ClearVision is offering special programs available to eyecare professionals through February 27, 2015. In addition, in-store merchandising materials, including counter cards and custom displays, are available for both collections. ES557513_OP0215_036.pgs 01.22.2015 05:04 ADV VISIONARIES IN EDUCATION, FASHION AND TECHNOLOGY Are you practicing full-scope medical eyecare? International Vision Expo offers advanced education focused on the core competencies of your practice: management of eye disease, contact lens technology, practice management and optical topics. By expanding your knowledge base, you’ll enhance the scope of your practice and patient offerings to the maximum extent of your license. It’s no surprise that more Optometrists and Opticians choose to continue their education at International Vision Expo than at any other conference globally. After all, the conference offers more than 330 hours of education and has added tracks to address Retail, Wearable Technology and Ocular Wellness, plus clinical, business solutions and interactive crowd-source learning. International Vision Expo has created the Young Professionals Club, offering tools to jump-start your career. Optometrists who have graduated within the past five years are invited to join. Enjoy six hours of complimentary education, free exhibit hall registration, resources to help you start a practice and networking opportunities with other young ODs. INTERNATIONAL VISION EXPO 2015 EDUCATION: THURSDAY, MARCH 19–SUNDAY, MARCH 22 EXHIBITION: FRIDAY, MARCH 20–SUNDAY, MARCH 22 JAVITS CENTER | NEW YORK, NY | VisionExpoEast.com | #VisionExpo PROUD SUPPORTER OF: magenta cyan yellow black ES558669_OP0215_037_FP.pgs 01.23.2015 19:39 ADV 38 InDispensable FEBRUARY 2015 | Via Spiga debuts new styles Zyloware recently expanded the Via Spiga Eyewear Collection with five new optical styles, three of which are seen below, and two sun- glasses. These are inspired by Via Spiga’s latest trends including sporty styling, stones, studs, and animal prints. Snap-in logo nosepads are a special feature of the frames with a plastic core that prevents oxidation and discoloring in a shape for comfort and feminine styling. Via Spiga Graziella is a rectangularshaped frame with sheet metal accents on the metal front. The temple features a studded faceted rectangular plaque with the Via Spiga logo. The wide zyl temples allow for a comfortable fit for the wearer. The black frame features a spotted black and grey tortoise zyl temple. Via Spiga Frederica has a full rim zyl front in a rectangular shape, and the zyl endpiece features a diamond-shaped shield. This frame has metal temples that have a two-toned look and feel. The black turquoise frame has a black zyl front and milky light blue layer on the inside with tortoise zyl temple tips infused with turquoise blue. The multi crystal stripe color frame features shiny brown temples with brushed tan, and finishing with dark brown zyl temple tips. Via Spiga Raffaella is a full rim zyl frame in a square shape. The Tortoise frame features zyl green marble temples with a metal and laser accent. The black frame incorporates an eyecatching mosaic pattern with a chic black metal and laser accent. Costa introduces Cortez sunglasses DAYTONA BEACH, FL—Costa’s new Cortez sunglasses offer a large fit with a wrap shape, meant to block glare from entering from the sides. The linear venting system alleviates lens fogging, and the temple tips feature open magenta cyan yellow black slots for a retainer cord. The frames are built of co-injected molded nylon with sturdy integral hinge technology. The hypoallergenic rubberized interior lining and nose pads keep the sunglasses comfortably in place. Cortez frame color options include blackout, tortoise, shiny black, Realtree Xtra camo, crystal bronze, and white with a blue Costa logo. All Costa sunglasses can be customized in its full array of patented color-enhancing po- larized 580 lenses. Costa’s 580 lens technology selectively filters out yellow and high-energy ultraviolet blue light. Filtering yellow light enhances reds, blues and greens, and produces better contrast and definition while reducing glare and eye fatigue. Absorbing high-energy blue light cuts haze. Costa’s 580 lenses are available in either glass or impact-resistant polycarbonate. Lens color options include: gray, copper, amber, sunrise, blue mirror, green mirror, and silver mirror. Cortez is also available in customized Rx sun lenses. ES557514_OP0215_038.pgs 01.22.2015 05:04 ADV February 2015 / OptometryTimes.com Go to: 39 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! magenta cyan yellow black ES558687_OP0215_039_CL.pgs 01.23.2015 20:33 ADV 40 Marketplace February 2015 / Optometry Times PRODUCTS & SERVICES DISPENSARY magenta cyan yellow black ES558685_OP0215_040_CL.pgs 01.23.2015 20:33 ADV Marketplace February 2015 / OptometryTimes.com 41 PRODUCTS & SERVICES CONFERENCES & EVENTS PRACTICE MANAGEMENT Advertisers Index American Academy of Optometry New Jersey Chapter Advertiser 13t h Annual Educational Conference April 22-26, 2015 Myrtle Beach, South Carolina Alcon Laboratories Inc Tel: 800-862-5266 Web: www.alcon.com Hilton Embassy Suites at Kingston Plantation Dr. Mark Friedberg, M.D. Founding Editor of the Wills Eye Manual 16 HOURS COPE CE Dr. Alan Kabat, OD., F.A.A.O. Registration: $475.00 One, Two or Three Bedroom Suites Accommodations Include a Daily Breakfast Buffet and Evening Cocktail Reception PACK YOUR CLUBS! Golf details to follow. For Accommodation and Additional Information, contact: Dennis H. Lyons, OD, F.A.A.O. QUIKEYES ONLINE WEB-BASED OPTOMETRY EHR • $99 per month after low cost set-up fee • Quick Set-Up and Easy to Use • No Server Needed • Corporate and Private OD practices • 14 Day Free Demo Trial • Users Eligible for 44K incentives www.quikeyes.com Phone: (732) 920-0110 E-Mail: [email protected] CLASSIFIED WORKS! Content Licensing for Every Marketing Strategy Page CVTIP, CV2, CV4 Allergan Inc Tel: 714-246-4500 Fax: 714-246-4971 Customer Service: 800-433-8871 Web: www.allergan.com 15 Bausch + Lomb Tel: 800-227-1427 Customer Service: 800-323-0000 Web: www.bausch.com 7, 11, 12 Beaver Visitec Tel: 781-906-7941 Web: www.beaver-visitec.com 27 Cooper vision Web: www.coopervision.com CV3 Heidelberg Engineering Tel: 800-931-2230 Fax: 760-598-3060 Web: www.heidelbergengineering.com 17 Lacrivera Tel: 855-857-0518 Web: www.lacrivera.com 31 Nova Bay Pharmaceuticals Web: [email protected] 19 Thrombogenics Tel: 732-590-2900 Web: www.thrombogenics.com Marketing solutions fit for: Outdoor | Direct Mail | Print Advertising Tradeshow/POP Displays | Social Media Radio & TV TTI Medical Tel: 800-322-7373 Web: www.ttimedical.com 29 Vision Expo Web: www.visionexpoeast.com 37 Vistakon Web: www.acuvueprofessional.com Leverage branded content from Optometry Times to create a more powerful and sophisticated statement about your product, service, or company in your next marketing campaign. Contact Wright’s Media to fnd out more about how we can customize your acknowledgements and recognitions to enhance your marketing strategies. 9 22, 23 This index is provided as an additional service. The publisher does not assume any liability for errors or omissions. Call Karen Gerome to place your Products & Services ad at For information, call Wright’s Media at 877.652.5295 or visit our website at www.wrightsmedia.com magenta cyan yellow black 800-225-4569, ext. 2670 [email protected] ES558686_OP0215_041_CL.pgs 01.23.2015 20:33 ADV 42 Q&A FEBRUARY 2015 Dori Carlson, OD | Former AOA president, owner of Heartland Eye Care of Park River and Grafton, ND North Dakota, leadership, weight lifting, and ice How does your practice differ from your colleagues in different areas of the country? We end up taking care of a lot of different things, which makes the day more interesting. I really don’t have anyone to refer to—my husband and I and our associates tend to be the go-to folks. How did you get interested in optometry leadership? I got asked to do a few things, I saw a need. To be really honest, I was frustrated with our therapeutic bill and limitations on what we were able to do and prescribe when I moved to North Dakota. When I did my residency in the VA, I treated glaucoma, there weren’t a lot of limitations within the normal range for that time period. When I moved to North Dakota, suddenly I couldn’t prescribe medications for glaucoma, and when I worked part-time across the border in Minnesota, I couldn’t even prescribe an antibiotic. So I found myself calling local ophthalmologists and being frustrated that because I moved across a state I didn’t know how to do something I did on a daily basis beforehand. It was more geography than anything else, so I wanted to get involved because I wanted to get that changed. As they say, one thing leads to another. What advice about leadership do you have for other women in the profession? Do something that scares you. By doing that, you grow magenta cyan yellow black Q What one thing did you learn from AOA leadership? Oh, I’ve changed as a person. My leadership skills are much better. I used to be terrified of public speaking. That was a baptism by fire, and now I’ve learned what speaking style works for me, so I’ve gotten past that. I think that I’m a little more forthright and definitely stronger as a person for having gone through that experience. as a person and as a leader. I cannot explain how much it’s brought to the practice or my life in general. When I look back at the times I had to speak in public prior to coming onto the AOA board, I shake my head laughing, I wish I could go back and re-do some of those. You learn what your speaking style is, and what works for one person doesn’t work necessarily for another. Obviously, the more comfortable and more prepared you are, the easier it is to deliver a message. What’s one thing your colleagues don’t know about you? Only my close friends know this, but I love weight lifting. Three times a week I go to the gym, and I lift weights for an hour. I started weight lifting with videos at my house, and then a woman opened a fitness gym with group fitness classes and I signed up. Ever since, I’ve been going to her classes pretty regularly, which has been a blast. Where do you see the future of optometry? I think optometry has a lot of positive things going for it. As changes happen, and the jury’s still out with what will happen with the Affordable Care Act, I think we’ve got our toe in the door for access to patients much better than what we had before. If you look at the other aspects of health in general, the increasing number of diabetics, increasing number of macular degeneration, they’re going to need care. The number of ophthalmology residents are not increasing to accommodate that care, so I think there’s incredible opportunities for optometry if optometry wants to embrace them this little family-owned resort that we go to, they usually cut a hole in the lake. You sit in a sauna at about 108°F until you can hardly stand it anymore. Then you’re finally ready to run out on to the lake ice and— for safety reasons there’s a ladder so you don’t just jump into the hole—but go down on the ladder and put your body into this freezing cold water. You wear wool socks or tennis sandals or something so your feet don’t stick to the ice. The worst one was a 30 mph wind and it was below zero—it was pretty chilly out there! No, we had not been drinking. You know it’s for the photo opportunity to claim that you did it. —Vernon Trollinger What’s the craziest thing you’ve ever done? I’ve jumped in a hole in the ice in a lake with the polar plunge! We go crosscountry skiing every winter. As part of Photo courtesy Dori Carlson, OD To hear Dori’s full interview, listen online: optometrytimes.com/ DoriCarlson ES556393_OP0215_042.pgs 01.21.2015 00:20 ADV All eyes deserve clariti. clariti 1 day—now available for practices everywhere. The world’s first and only family of silicone hydrogel daily disposable contact lenses designed for every patient type—sphere, toric and multifocal. High Oxygen Transmissibility High Water Content Low Modulus UV Protection Afordable Upgrade Now you can prescribe all of your patients with healthy, comfortable, afordable silicone hydrogel 1 day lenses— which will make all eyes very happy indeed. To learn more, contact your CooperVision representative today or visit CooperVision.com/practitioner. magenta cyan yellow black ES558330_OP0215_CV3_FP.pgs 01.23.2015 03:38 ADV THIS IS WHY our daily disposable multifocal contact lens is designed to perform at every distance and refreshes with every blink—no matter what the day may bring. PRECISION PROFILE Design WITH BLINK-ACTIVATED MOISTURE DAILIES® AquaComfort Plus® Multifocal NEAR IN E T E R M E D I AT contact lenses are designed to deliver clear binocular vision and refreshing comfort. D I S TA C E N PRECISION PROFILE DESIGN Smooth, uninterrupted transitions from near to intermediate, to distance. Visit myalcon.com BLINK-ACTIVATED MOISTURE Moisture is released with every blink, which helps result in a stable tear flm. SUCCESSFUL WEAR Clear vision and comfort throughout the day. Featuring the same Precision Profile Design as AIR OPTIX® AQUA Multifocal— the #1 multifocal contact lens.1 PERFORMANCE DRIVEN BY SCIENCE™ Reference: 1. Based on third-party industry report, 12 months ending March 2013, Alcon data on file. See product instructions for complete wear, care, and safety information. © 2015 Novartis 1/15 DAM13014JAD-A magenta cyan yellow black ES558314_OP0215_CV4_FP.pgs 01.23.2015 03:38 ADV
