Download fact or fiction and the eye the truth behing old husband

10/15/2013
Disclosure Larry Alexander
• CONSULTANT TO
– OPTOVUE, INC
– PRN OMEGA HEALTH
– MACULAR HEALTH
• OWNER
LARRY J ALEXANDER, OD FAAO
eyelessons.com
Have You Sent Out Your Glaucoma HEDIS
Letters to PCPs?
http://www.eyelessons.com/letters-brochures/item/glaucoma-letterto-gps
The National Committee for Quality
Assurance (NCQA). HEDIS 2012:
Healthcare Effectiveness Data and
Information Set. Vol. 1, narrative.
Washington (DC): National Committee for
Quality Assurance (NCQA); 2011 has
determined that any patient over 67 years of
age must receive a glaucoma test every 2
years.
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THEY WANT ME TO SAY.
Have You Sent Out Your Diabetes HEDIS
Letters to PCPs?
http://www.eyelessons.com/letters-brochures/item/diabetic-letterto-gps
The National Committee for Quality
Assurance (NCQA). HEDIS 2012:
Healthcare Effectiveness Data and
Information Set. Vol. 1, narrative.
Washington (DC): National Committee for
Quality Assurance (NCQA); 2011 has
determined that any patient over 18 – 75
years of age must receive a dilated eye
examination every year to facilitate the early
detection of diabetic retinopathy.
A foolish consistency is the hobgoblin of little
minds, adored by little statesmen and
philosophers and divines. With consistency a
great soul has simply nothing to do. He may as well
concern himself with his shadow on the wall. Speak
what you think now in hard words, and tomorrow
speak what tomorrow thinks in hard words again,
though it contradict every thing you said today. — ‘Ah,
so you shall be sure to be misunderstood.’ — Is it so
bad, then, to be misunderstood? Pythagoras was
misunderstood, and Socrates, and Jesus, and Luther,
and Copernicus, and Galileo, and Newton, and every
pure and wise spirit that ever took flesh. To be great is
to be misunderstood.
Ralph Waldo Emerson Essay on Self Reliance
1
10/15/2013
Excessive salt consumption
causes hypertension, heart
attacks, strokes….foolish
consistency?????
American Journal of Hypertension 24, 843-853 (August 2011) | doi:10.1038/ajh.2011.115
Reduced Dietary Salt for the Prevention of Cardiovascular Disease: A Meta-Analysis of Randomized
Controlled Trials (Cochrane Review)
Rod S. Taylor, Kate E. Ashton, Tiffany Moxham, Lee Hooper and Shah Ebrahim
Scientific American July 8, 2011. It's Time to End the War on Salt. The zealous drive by politicians to limit
our salt intake has little basis in science By Melinda Wenner Moyer
Despite collating more event data than previous systematic reviews
of RCTs (665 deaths in some 6,250 participants) there is still
insufficient power to exclude clinically important effects of reduced
dietary salt on mortality or CVD morbidity. Our estimates of benefits
from dietary salt restriction are consistent with the predicted small
effects on clinical events attributable to the small BP reduction
achieved.
Salt restriction increased the risk of all-cause mortality in those with
heart failure (end of trial RR 2.59, 1.04–6.44, 21 deaths).
A 2003 Cochrane review of 57 shorterterm trials similarly concluded that
"there is little evidence for long-term
benefit from reducing salt intake."
Fact
IODINE DEFICIENCY IS CONSIDERED THE
MOST COMMON CAUSE OF
PREVENTABLE BRAIN DAMAGE IN THE
WORLD.
Iodine is present naturally in soil and seawater. The
availability of iodine in foods differs in various regions of the
world. Individuals in the United States can maintain
adequate iodine in their diet by using iodized table salt
(unless they have to restrict the amount of salt in their
diet), by eating foods high in iodine, particularly dairy
products, seafood, meat, some breads, and eggs, and by
taking a multivitamin.. However, the amount of iodine in
foods is not listed on food packaging in the U.S., and it can
be difficult to identify sources of iodine in foods.
NUTRITION AND EYE DISEASE
?
?
IS THERE ABSOLUTE PROOF?
APRIL 2012
Recommending Nutritional
Supplementation is an Ethical
Crime….foolish consistency?????
Dietary supplements are wildly popular. About 114 million
Americans — roughly half the adult population — take at
least one supplement, running up a collective tab of over
$28 billion in 2010 alone. But manufacturers do not need to
prove the purity, strength, safety, or effectiveness of
supplements. And the law does not require proof that claims on
the label are true.
Despite their popularity, there is no evidence that multivitamins
enhance health or prevent illness. In fact, both the U.S.
Preventive Services Task Force and a National Institutes of
Health State-of-the-Science Conference concluded that
multivitamins do not offer protection against heart disease or
cancer. In contrast, research suggests that fish oil
supplements may be beneficial for people with heart
disease.
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10/15/2013
APRIL 2012
Vitamin D. About 70% of Americans lack sufficient amounts
of the "sunshine vitamin. Current guidelines call for 600 IU
(international units) a day below age 71 and 800 IU a day
thereafter. But many experts recommend 800 to 1,000 IU a day
for most adults; daily doses up to 4,000 IU are considered safe,
but more can be toxic. If you want to be sure you need this
supplement, ask for a blood test; levels of at least 30
nanograms per milliliter are considered best.
APRIL 2012
Antioxidants. Vitamin E, vitamin A, beta carotene, and
vitamin C were the favorites of the 1980s and early '90s. But
many careful randomized clinical trials have not shown any
benefit against heart disease, cancer, or other illnesses. In
fact, even moderately high doses of vitamin A increase
the risk of hip fractures, and high levels of vitamin A
have been linked to an increased risk of prostate cancer;
beta carotene increases lung cancer risk in smokers;
and vitamin E increases the risk of prostate cancer and
has been linked to an increase in respiratory infections,
heart failure, and the overall death rate.
Do not take antioxidant supplements. One exception: people
with moderate or advanced age-related macular
degeneration (AMD) benefit from special antioxidant
supplements that also contain zinc.
APRIL 2012
Fish oil. The American Heart Association now
recommends 1,000 mg a day of the marine fatty acids
DHA and EPA for people with coronary artery disease. It's
also reasonable advice for people with major cardiac risk
factors such as high blood pressure, abnormal cholesterol
levels, and diabetes. People who eat fish at least twice a week
are not likely to benefit from extra fish oil.
While fish oil does appear to protect the heart, its other
advertised benefits — ranging from treating depression and
bowel inflammation to helping with arthritis — have not been
validated. In high doses, fish oil can reduce triglyceride
levels; a prescription formulation is now available. If you
decide to take fish oil, don't choose fish liver oil, which has too
much vitamin A.
APRIL 2012
Calcium. The Recommended Dietary Allowance (RDA) of
calcium for men is 1,000 milligrams (mg) before age 71 and
1,200 mg thereafter. If your diet falls short, supplements
make sense; calcium carbonate and calcium citrate are
best. Although many doctors routinely recommend calcium
supplements for women, who have a high risk of osteoporosis,
men should limit themselves to the RDA since some
evidence suggests very high levels may increase the risk of
prostate cancer. And a 2011 report linked calcium
supplements, with or without vitamin D, to an increased
risk of heart disease. It's not a proven risk, but it underlines
the need for careful study of the risks and benefits of
supplements, including the popular items that "everybody
knows are good for you."
APRIL 2012
Homocysteine issues and B6, B12, and folate
supplementation are now being questioned in the research
literature.
Although normal amounts of folic acid appear to protect cells
from malignant transformation, high amounts may fuel the
growth of rapidly dividing tumor cells. And some recent
studies suggest that even modest doses of supplementary
folic acid, when added to the folic acid in fortified food and the
natural folate in food, may increase the risk of colon cancer,
prostate cancer, and breast cancer. A typical multivitamin
provides just 400 mcg of folic acid, only 40% of the dose
that has been shown to promote the growth of
precancerous adenomas in the colon.
I WOULD POSIT THE
FOLLOWING
AN EGG A DAY CAN HELP
KEEP THE ANTI VEGF AWAY
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10/15/2013
Wenzel AJ, Gerweck C, Barbato D, et al. A 12-wk egg intervention
icreases serum zeaxanthin and macular pigment optical density in
women. J Nutr 2006;136:2568-2573.
CONSUMPTION OF EGGS INCREASES
SERUM LUTEIN, ZEAXANTHIN AND
MPOD WITHOUT NEGATIVELY
AFFECTING SERUM CHOLESTEROL
www.eyefoods.com $22.95 US
OMEGA 3 CONSUMPTION
INCREASES THE RISK OF
PROSTATE CANCER
SELECT STUDY
• The study reports a 71 percent increased risk of
advanced state prostate cancer; a 44 percent
increase in the risk of early prostate cancer and
an overall 43 percent increase in risk for total
prostate cancer.
• There is no evidence that anyone in the SELECT
study took fish oil dietary supplements. There is
also no documentation of fish oil or fish intake in
the study group.
• http://www.drweil.com/drw/u/QAA401331/DoesFish-Oil-Cause-Prostate-Cancer.html
J Natl Cancer Inst. 2013 Aug 7;105(15):1132-41. doi:
10.1093/jnci/djt174. Epub 2013 Jul 10.
Plasma phospholipid fatty acids and prostate cancer
risk in the SELECT trial.
• This study confirms previous reports of
increased prostate cancer risk among
men with high blood concentrations of
LCω-3PUFA. The consistency of these
findings suggests that these fatty acids
are involved in prostate tumorigenesis.
Recommendations to increase LCω3PUFA intake should consider its
potential risks.
SELECT STUDY
• This study could have simply been measuring
a marker reflecting recent intake of fish or fish
oil in a group of high risk cancer patients that
have been told to increase their EPA and
DHA levels, as compared to a group of noncancer patients that have not been told to
consume more EPA and DHA.
• The authors are concluding that men are at
higher risk of aggressive prostate cancer if the
plasma level of omega-3 is 4.7% versus
4.5%.
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10/15/2013
VITAMIN E CONSUMPTION
INCREASES THE RISK OF
PROSTATE CANCER
Nutrients. 2013 Apr 3;5(4):1122-48. doi: 10.3390/nu5041122.
Selenium and prostate cancer prevention: insights from the
selenium and vitamin E cancer prevention trial
• neither selenium nor vitamin E reduced
the incidence of prostate cancer after
seven years and that vitamin E was
associated with a 17% increased risk of
prostate cancer compared to placebo.
THE FACTS
THE FACTS
• Most people do not experience any side
effects when taking the recommended
daily dose, which is 15 mg.
Vitamin E is
POSSIBLY UNSAFE if taken in high
doses. If you have a condition such as
heart disease or diabetes, don’t take doses
of 400 IU/day or more.
• All-rac-alpha-tocopherol (synthetic vitamin
E) 400 IU seems to speed vision loss in
people with retinitis pigmentosa. However,
much lower amounts (3 IU) don’t seem to
produce this effect. If you have this
condition, it’s best to avoid vitamin E.
THE FACTS
Cancer Prev Res (Phila). 2012 May;5(5):701-5.
• There is some concern that vitamin E might
increase the chance of having a serious stroke
called hemorrhagic stroke, which is bleeding into
the brain. Some research shows that taking
vitamin E in doses of 300-800 IU each day might
increase the chance of this kind of stroke by
22%. However, in contrast, vitamin E might
decrease the chance of having a less severe
stroke called an ischemic stroke.
• On the basis of these results as well as information
from the literature, we suggest that vitamin E, as
ingested in the diet or in supplements that are rich
in γ- and δ-tocopherols, is cancer preventive;
whereas supplementation with high doses of αtocopherol is not.
• The recently finished follow-up of the Selenium and
Vitamin E Cancer Prevention Trial (SELECT) even
showed higher prostate cancer incidence in
subjects who took α-tocopherol supplementation.
http://www.webmd.com/vitaminssupplements/ingredientmono-954VITAMIN+E.aspx?activeIngredientId=954&activeIngredient
Name=VITAMIN+E&source=2#vit_sideeffects
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OMEGA 3 CONSUMPTION
DECREASES THE RISK OF
PANCREATIC CANCER
Int J Cancer. 2010 Oct 15;127(8):1893-904. Intake of fatty acids and
antioxidants and pancreatic cancer in a large population-based
case-control study in the San Francisco Bay Area.
J Nutr Biochem. 2012 May;23(5):452-7. Docosahexaenoic acid inhibits invasion
of human RT112 urinary bladder and PT45 pancreatic carcinoma cells via
down-modulation of granzyme B expression.
Am J Epidemiol. 2013 Jan 15;177(2):152-60. Types of fish
consumed and fish preparation methods in relation to
pancreatic cancer incidence: the VITAL Cohort Study.
• DHA can reduce the invasive phenotype
of bladder and pancreatic carcinoma
cells, and we provide the first evidence
for a possible causative role of GrB in
DHA-induced inhibition of cancer cell
invasion. The potential use of fish oil as
adjuvant antibladder and antipancreatic
cancer agent may be suggested.
HPB (Oxford). 2013 Jun;15(6):428-32. Reduction in
circulating pro-angiogenic and pro-inflammatory factors is
related to improved outcomes in patients with advanced
pancreatic cancer treated with gemcitabine and
intravenous omega-3 fish oil.
• There is a well-established link between
pro-inflammatory circulating cytokines and
growth factors (CAF), and the development
of neoplasia.
• Treatment with gemcitabine plus IV n-3FA
may reduce concentrations of CAF which
may be associated with an improved
outcome.
• These results support the hypotheses
that a high intake of saturated and
certain monounsaturated fatty acids
may increase the risk of pancreatic
cancer, whereas greater intake of
omega-3 fatty acids, vitamins C and E
may reduce the risk.
• DHA showed a greater inverse association
with pancreatic cancer than EPA. The
potential health impact of fish consumption
may depend on the types of fish consumed
and fish preparation methods. LC-PUFAs,
particularly DHA, and nonfried fish, but not
shellfish or fried fish, may be beneficial in
the primary prevention of pancreatic
cancer.
J Cell Biochem. 2013 Jan;114(1):192-203. EPA, an omega-3
fatty acid, induces apoptosis in human pancreatic cancer
cells: role of ROS accumulation, caspase-8 activation, and
autophagy induction.
• In a recent study, we showed that (EPA) and
(DHA) can cause ROS accumulation and
subsequently induce caspase-8-dependent
apoptosis in human breast cancer cells
(Kang et al. [2010]
• It is therefore suggested that combination of
EPA with an autophagy inhibitor may be a
useful strategy in increasing the therapeutic
effectiveness in pancreatic cancer.
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10/15/2013
HIGH LEVELS OF ZINC
CONSUMPTION ARE TOTALLY
SAFE
http://www.webmd.com/vitamins-supplements/ingredientmono982ZINC.aspx?activeIngredientId=982&activeIngredientName=ZIN
C
• High doses above the recommended
amounts might cause fever, coughing,
stomach pain, fatigue, and many other
problems.
• Taking more than 100 mg of supplemental
zinc daily or taking supplemental zinc for 10
or more years doubles the risk of developing
prostate cancer. There is also concern that
taking large amounts of a multivitamin plus a
separate zinc supplement increases the
chance of dying from prostate cancer.
AM J CLIN NUTR 1990;1:225-227
• adverse effects on the ratio of lowdensity-lipoprotein to high-densitylipoprotein (LDL/HDL) cholesterol have
been reported. Even lower levels of zinc
supplementation, closer in amount to
the RDA, have been suggested to
interfere with the utilization of copper
and iron and to adversely affect HDL
cholesterol concentrations.
http://ods.od.nih.gov/factsheets/
Zinc-HealthProfessional/
Table 1: Recommended Dietary Allowances (RDAs) for
Zinc [2]
Age Male Female
Pregnancy Lactation
0–6 months 2 mg* 2 mg*
7–12 months 3 mg 3 mg
1–3 years
3 mg 3 mg
4–8 years
5 mg 5 mg
9–13 years 8 mg 8 mg
14–18 years 11 mg 9 mg 12 mg 13 mg
19+ years
11 mg 8 mg 11 mg 12 mg
• Taking 450 mg or more of zinc daily can
cause problems with blood iron. Single
doses of 10-30 grams of zinc can be fatal.
• Zinc nose sprays (Zicam, Cold-Eeze) are
POSSIBLY UNSAFE. These products may
cause loss of ability to smell.
• Do not take zinc if you have HIV/AIDS. Zinc
might shorten your life.
http://www.mayoclinic.com/health/zinc/NS_patientzinc/DSECTION=safety
• Zinc may increase the risk of bleeding
• Zinc may lower blood sugar levels.
• Avoid in patients who are homozygous for
hemochromatosis
• Use cautiously in patients with high cholesterol or blood fats,
a high risk of developing heart disease, various skin
disorders, gastrointestinal disorders, liver disease,
genitourinary conditions, blood disorders, neurological
disorders, pulmonary or respiratory disorders, immune
disorders, or kidney disease, or in patients taking
antidepressants, potassium-sparing diuretics, antibiotics
(particularly tetracyclines and quinolones), iron,
penicillamine, thyroid hormones, or copper
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TO KNOW WHAT ONE DOES
NOT KNOW
IS THE BEGINNING OF
WISDOM
Socratic Philosophy
AREDS II
NOT EVEN GOING TO GO
THERE.
WHAT IS THE NEWEST
TREATMENT FOR EXUDATIVE
ARM?
Larry J Alexander, OD FAAO
You Have to Constantly Be In
The State of Becoming
Bob Dylan Philosophy
REMEMBER IF THIS DOESN’T WORK
Acupuncture Treatment
of Exudative Central
Chorioretinopathy
A Preliminary Report of
600 Cases, Department
of Ophthalmology, The
First Hospital, Zhejiang
Medical College
Compiled by Ye Linmei
Analysis of 600 cases with exudative central chorioretinopathy
undergoing acupuncture therapy showed an overall results of
cured or improved in 586 cases (97.66%) and unsatisfactory in
14 cases (2.34%).
SUPPLEMENTATION WON’T WORK
IS THE CAUSE
http://www.healingtheeye.com
Glucosamine is a Great
Nutriceutical for Arthritis With No
Side Effects
….foolish consistency?????
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10/15/2013
Marijuana is an Excellent Tool for
Managing Glaucoma
….foolish consistency?????
IS THERE ABSOLUTE PROOF?
=
CONTROLLED
IOP
http://www.eyelessons.com/articles/item/marijuanaand-glaucoma
Nasal and Inhaled Steroids
Significantly Increase the Risk of
Elevated IOP/Glaucoma
….foolish consistency?????
STUDIES REPORTING IOP RISE WITH
NASAL AND INHALED STEROIDS
•
•
•
•
•
•
•
•
•
•
•
•
Opatowsky I, Feldman RM, Gross R, Feldman ST. Intraocular pressure elevation associated with inhalation
and nasal corticosteroids. Ophthalmology. 1995 Feb;102(2):177-179.
Garbe E, LeLorier J, Boivin JF, Suissa S. Inhaled and nasal glucocorticoids and the risks of ocular
hypertension or open-angle glaucoma. JAMA. 1997 Mar 5;277(9):722-727.
Garbe E, Suissa S, LeLorier J. Association of inhaled corticosteroid use with cataract extraction in elderly
patients. JAMA. 1998 Aug 12;280(6):539-543.
Sapir-Pichhadze R, Blumenthal EZ. [Steroid induced glaucoma]. Harefuah. 2003 Feb;142(2):137-140, 157.
Clark AF, Wordinger RJ. The role of steroids in outflow resistance. Exp Eye Res. 2009;88:752–759.
Podos SM, Becker B, Morton WR. High myopia and primary open-angle glaucoma. Am J Ophthalmol. 1966
Dec;62(6):1038-1043.
Mitchell P, Cumming RG, Mackey DA. Inhaled corticosteroids, family history, and risk of glaucoma.
Ophthalmology. 1999 Dec;106(12):2301-2306.
Bui CM, Chen H, Shyr Y, Joos KM. Discontinuing nasal steroids might lower intraocular pressure in
glaucoma. J Allergy Clin Immunol. 2005 Nov;116(5):1042-1047.
Peridis S, Hopkins C, Lekakis G, Roberts D. Re: Discontinuing nasal steroids might lower intraocular
pressure in glaucoma. Clin Otolaryngol. 2010 Feb;35(1):72. doi: 10.1111/j.1749-4486.2009.02058.x.
Bollinger KE, Crabb JS, Yuan X, et al. Proteomic similarities in steroid responsiveness in normal and
glaucomatous trabecular meshwork cells. Mol Vis. 2012; 18: 2001–2011. Published online 2012 July 20.
Kersey JP, Broadway DC. Corticosteroid-induced glaucoma: a review of the literature. Eye (Lond)
2006;20:407–416.
Jones R, 3rd, Rhee DJ. Corticosteroid-induced ocular hypertension and glaucoma: a brief review and update
of the literature. Curr Opin Ophthalmol. 2006;17:163–167.
“SHOULD THERE BE MORE CONCERN
REGARDING THE UBIQUITOUS USE OF
NASAL AND INHALED
CORTICOSTEROIDS”
EYELESSONS.COM 2013
More than 20% of Americans suffer from allergic
rhinitis and is present in up to 75% of patients
with asthma. Blaiss MS. Safety considerations of intranasal corticosteroids for the
treatment of allergic rhinitis. Allergy Asthma Proc 2007;28;145-152
There is the suggestion that there is a doserelated risk of open-angle glaucoma with inhaled
corticosteroids for treating moderate to severe
COPD. Gartlehner G, Hansen RA, Carson SS, Lohr KN. Efficacy and safety of inhaled
corticosteroids in patients with COPD: a systematic review and meta-analysis of health outcomes. Ann
Fam Med 2006;4:253-262.
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Patients Taking Oral Glucocorticoids
Should Have Their IOPs Checked Every
6 Months (Brit Med J 1997;314:695)
STUDIES REPORTING NO IOP RISE WITH
NASAL AND INHALED STEROIDS
•
•
•
•
With a Strong Family History of Glaucoma
Inhaled Steroids Increase the Risk
(Ophthalmology 1999;106:2301)
•
•
•
•
•
IOP was Reduced With the
Discontinuation of Nasal Steroids in
Patients with Glaucoma (J Allergy Clin Immunol
2005;116:1042)
•
•
•
•
Oztürk F, Yücetürk AV, Kurt E, et al. Evaluation of intraocular pressure and cataract formation following the longterm use of nasal corticosteroids. Ear Nose Throat J. 1998 Oct;77(10):846-848, 850-851.
Duh MS, Walker AM, Lindmark B, Laties AM. Association between intraocular pressure and budesonide inhalation
therapy in asthmatic patients. Ann Allergy Asthma Immunol. 2000 Nov;85(5):356-361.
Marcus MW, Müskens RP, Ramdas WD, et al. Corticosteroids and open-angle glaucoma in the elderly: a populationbased cohort study. Drugs Aging. 2012 Dec;29(12):963-970.
Miller DP, Watkins SE, Sampson T, Davis KJ. Long-term use of fluticasone propionate/salmeterol fixed-dose
combination and incidence of cataracts and glaucoma among chronic obstructive pulmonary disease patients in the
UK General Practice Research Database. Int J Chron Obstruct Pulmon Dis. 2011;6:467-476.
Ozkaya E, Ozsutcu M, Mete F. Lack of ocular side effects after 2 years of topical steroids for allergic rhinitis. J
Pediatr Ophthalmol Strabismus. 2011 Sep-Oct;48(5):311-317.
Emin O, Fatih M, Mustafa O, et al. Evaluation impact of long-term usage of inhaled fluticasone propionate on ocular
functions in children with asthma. Steroids. 2011 May;76(6):548-552.
Behbehani AH, Owayed AF, Hijazi ZM, et al. Cataract and ocular hypertension in children on inhaled corticosteroid
therapy. J Pediatr Ophthalmol Strabismus. 2005 Jan-Feb;42(1):23-27.
Bergmann J, Witmer MT, Slonim CB. The relationship of intranasal steroids to intraocular pressure. Curr Allergy
Asthma Rep. 2009 Jul;9(4):311-315.
Gonzalez AV, Li G, Suissa S, Ernst P. Risk of glaucoma in elderly patients treated with inhaled corticosteroids for
chronic airflow obstruction. Pulm Pharmacol Ther. 2010 Apr;23(2):65-70.
Peters SP. Safety of inhaled corticosteroids in the treatment of persistent asthma. J Natl Med Assoc. 2006
Jun;98(6):851-861.
Gartlehner G, Hansen RA, Carson SS, Lohr KN. Efficacy and safety of inhaled corticosteroids in patients with COPD:
a systematic review and meta-analysis of health outcomes. Ann Fam Med. 2006 May-Jun;4(3):253-262.
Rossi GA, Cerasoli F, Cazzola M. Safety of inhaled corticosteroids: room for improvement. Pulm Pharmacol Ther.
2007;20(1):23-35.
Buys YM, Yuen D, Jin Y, et al. The Effect of Nasal Steroids on Intraocular Pressure in Ocular Hypertension or
Controlled Glaucoma. AGS 2011. Abstract.Control Number:148.
There is NO RISK of Glaucoma with
Inhaled Steroids
(JAMA 1997;277:722)
In a large cohort of elderly patients treated for
airways disease, it was found that current use
and continuous use of high-dose ICS did not
result in an increased risk of glaucoma or raised
intra-ocular pressure requiring treatment.
There is INCR RISK (44% MORE LIKELY)
of Glaucoma with High Dose Inhaled
Steroids > 3 Months of Use (Ear Nose Throat J
1998;77:846)
Gonzalez AV,
Li G, Suissa S, Ernst P. Risk of glaucoma in elderly patients treated with inhaled corticosteroids for chronic airflow obstruction. Pulm
Phamacol Ther 2010;23:65-70.
5-8 % of the General Population are
Steroid Responders While 95% of
POAG Patients are Steroid Responders
(Ann Allergy 1989;62:375, Dermatol Clin 1998;16:277)
SO WHAT DOES EVIDENCEBASED MEDICINE SAY TO DO?
TAKE
Actually….nothing. The studies leave you hanging.
But if you read this study…..
“Inhalation steroid therapy can cause ocular hypertension or
open angle glaucoma. The authors describe the case of a
young girl who presented with raised intraocular pressure
and headaches due to the prolonged administration of nasal
and inhalation steroids. The ophthalmologist should monitor
the intraocular pressure in patients who use inhalation or
nasal steroid therapy on a regular base. The physician or
paediatrician should be aware of this complication in
children with headaches or diminished visual acuity.” 27
Desnoeck M, Casteels I, Casteels K. Intraocular pressure elevation in a child due to the use of
inhalation steroids--a case report. Bull Soc Belge Ophtalmol. 2001;(280):97-100.
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WHAT ARE THE AT RISK
GROUPS?
Myopia Increases the Risk of
Elevated IOP/Glaucoma
….foolish consistency?????
Prevalence of Glaucoma as
Related to Axial Length
Surv Ophthalmol 1970;15:1
Axial Length in Total Subjects
mm
Total Subjects
with Glaucoma
20.0 to 26.4
mm
192
3.125%
26.5 to 33.6
mm
196
11.224%
GLAUCOMA IS MORE PREVALENT IN LONGER EYES
Pigmentary Glaucoma and Refractive Error
POAG LTG and Refractive Error
Trans Am Acad Ophthalmol Otolaryngol 1970;74:984
Refractive Error
+3 D
+.5 to +2 D
-.25 to +.25 D
-.50 to -2.00 D
-2.25 to -4.00 D
-4.25 to -6.75 D
-7.00 to -9.00 D
-10.00 to -13.50 D
Br J
Ophthalmol 1973;57:499
% of Eyes with
Pigmentary Glaucoma 78.22 % Myopic
0.49%
6.44%
14.85%
31.19%
23.27%
19.80%
1.98%
1.98%
PIGMENTARY GLAUCOMA HIGHER IN MYOPES
POAG
LTG
Mean Age
71
63
Mean Refract
0.0D
-5.1 D
Mean AL
22.9 mm
25.2 mm
Mean Max IOP 34.3 mm Hg
19.8 mm Hg
LTG HIGHER IN MYOPES AND LONG EYES
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10/15/2013
TAKE
WHAT ARE THE TARGET
GROUPS FOR STEROIDS?
• Patients who currently are being treated for
glaucoma
• Patients who have been identified as being at
risk for glaucoma
• Patients who are offspring of patients who were
identified with glaucoma
• Patients with siblings with glaucoma
• Patients with myopia over 5 diopters
• Patients who are known steroid responders
• Patients who are required to use higher
dosages for a prolonged period of time…
SEE EVERY 6 MONTHS
WHAT ELSE?
TAKE
• LETTER TO MDS/HEALTH CARE
PROVIDERS
• LETTER TO PHARMACISTS
• EDUCATE PATIENTS
Dr. or Mr./Dr. (pharmacist) or Nurse Practitioner or other ODs in the immediate surround
Dear Dr./Mr. _____________,
I am pleased to announce that our practice is equipped to follow and manage patients who are prescribed nasal and inhaled
corticosteroids. These medications have the potential to increase intraocular pressure and create glaucoma in a subgroup of
patients. Dr. Rick Wilson in the Wills site http://willsglaucoma.org/steroid-use-and-iop reports in a discussion that 5% of the
general population of patients are steroid responders while 95% of Glaucoma patients are steroid responders. He further states
that if steroid use is prolonged, 50% or more of the population are steroid responders. What is of most concern is the fact that
the majority of the time the steroid responders are asymptomatic until significant damage has occurred.
The characteristics of the patient groups at greatest risk are:
Oral Mirtogenol is the Way to
Effectively Manage
Glaucoma….foolish
consistency?????
Patients who currently are being treated for glaucoma or
Patients who have been identified as being at risk for glaucoma
Patients who are offspring of patients who were identified with glaucoma
Patients with siblings with glaucoma
Patients with nearsightedness over 5 diopters
Patients who are known steroid responders
Patients who are required to use higher dosages for a prolonged period of time…there appeared to be a
dosage/duration connection in some of the reports. Note that a number of the studies that report no relationship are
short-term studies, even the latest Clinical Trial reported as an AGS abstract.
For those patients outside of these characteristics an intraocular pressure/glaucoma evaluation yearly would be an effective
conservative approach. Our office is equipped to perform pre-treatment evaluation and post-treatment follow-up. Additionally
we will provide you a report of the patient’s status including spectral domain OCT analysis. Termination of the steroid usually
allows the pressure to go back down and structural damage is minimized. Included will be recommendations for appropriate
follow-up care. We are delighted to be able to provide these services to your patients.
Sincerely,
Larry J Alexander, OD
Downloadable from eyelessons.com
12
10/15/2013
2008 Controlled Study
.
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2447819/
• 160 mg Mirtoselect
• 80 mg Pycnogenol
2010 Controlled Study
.
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2447819/
• 80 mg Mirtoselect
• 40 mg Pycnogenol
• 1gtt Latanoprost
The Results-IOP
40
8
35
The Results-Diastolic Blood
Flow
7
40 % Decrease
30
25
6
192 % Increase
5
I
O 20
P 15
Mirtogenol
10
C 4
M/ 3
S 2
5
1
Latanoprost
Both
0
Mirtrogenol
Latanoprost
Both
0
0
5
10
15
20
Weeks of Treatment
25
0
4
6
12
16
20
24
Weeks of Treatment
13
10/15/2013
Schönlau F, Rohdewald P. Pycnogenol® for diabetic retinopathy. A review. Int Ophthal. 2001;24:161–171.
30
The Results-Systolic Blood
Flow
25
39 % Increase
20
Mirtrogenol
15
C
M/ 10
S
Latanoprost
Both
Perossini M, Guidi G, Chiellini S, Siravo D. Diabetic and hypertensive retinopathy therapy with Vaccinium myrtillus
anthocyanosides (Tegens®):Double blind placebo-controlled clinical trial. Ann Ottalmol Clin Ocul. 1987;113:1173–1190.
Repossi P, Malagola R, De Cadilhac C. The role of anthocyanosides on vascular permeability in diabetic retinopathy. Ann
Ottalmoll Clin Ocul.1987;113:357–361.
Ehrlich R, Kheradiya NS, Winston DM, Moore DB, Wirostko B, Harris A. Age-related ocular vascular changes. Graefes
Arch Clin Exp Ophthalmol. 2009;247:583–591.
Nishioka K, Hidaka T, Takemoto H, et al. Pycnogenol® ®, French maritime pine bark extract, augments endotheliumdependent vasodilation in humans. Hypertens Res 2007;30:775–780.
Virno M, Pecori Giraldi J, Auriemma L, Antocianosidi di mirtillo e permeabilità dei vasi del corpo ciliare. Boll Ocul.
1986;65:789–795.
Steigerwalt RDJr., Gianni B, Paolo M, et al. Effects of Mirtogenol™on ocular blood flow and intraocular hypertension in
asymptomatic subjects. Mol Vis. 2008; 14: 1288–1292.
Cellini M, Versura P, Zamparini E, et al. Effects of endothelin-1 and flunarizine on human trabecular meshwork cell
contraction. Exp Biol Med (Maywood) 2006;231:1081–1084.
Schmetterer L, Krejcy K, Kastner J, et al. The effect of systemic nitric oxide-synthase inhibition on ocular fundus
pulsations in man. Exp Eye Res. 1997;64:305–312.
5
Liu X, Wei J, Tan F, et al. Antidiabetic Effect of Pycnogenol® French Maritime Pine Bark Extract in patients with diabetes
type II. Life Sci. 2004;75:2505–2513.
0
0
4
6
12
16
20
24
Colantuoni A, Bertuglia S, Magistretti MJ, Donato L. Effects of Vaccinium Myrtillus anthocyanosides on arterial
vasomotion. Arzneimittelforschung. 1991;41:905–909.
Steigerwalt RD Jr, Belcar G, Morazzoni P, et al. Mirtogenol® potentiates latanoprost in lowering intraocular pressure and
improves ocular blood flow in asymptomatic subjects. Clinical Ophthalmology 2010; 4: 471–476.
Weeks of Treatment
Summary of Facts
• At around 4-6 weeks the synergistic
effects of a Prostaglandin and
Mirtrogenol (120 mg )
Sleep Deprivation Can Contribute
to Vision Compromise….foolish
consistency?????
– Increases systolic blood flow 39 % Increase
– Increases diastolic blood flow 192 % Increase
– Decreases intraocular pressure 40 % Decrease
• 120 mg of Mirtrogenol costs about $1
Nutr Rev. 2007 Dec;65(12 Pt 2):S244-52.
Simpson N, Dinges DF.
A number of recent studies have reported
associations between disrupted sleep/sleep
deprivation and inflammatory responses, although
the physiological mechanisms underlying these
relationships remain unclear.
Alterations in sleep due to lifestyle factors, the aging
process, and disease states have all been
associated with increases in a range of
inflammatory markers. Several of these
inflammatory processes have been associated
with reduced health status (e.g., C-reactive
protein and cardiovascular disease).
Altering free radicals with steroids, which
paradoxically could increase intraocular
pressure, may block lipid peroxidation.. This
is primarily achieved through suppression
of inflammation.
Invest Ophthalmol 1996;37:2744, J Glaucoma 1996;5:427
Immune System influences including
antibodies generated by B-cells within the
rubric of the general inflammatory process
lead to cell death in glaucoma. Protection
also occurs through the immune system
pointing to the importance of proper
modulation of the immune system.
Cell Mol Neurobiol 2001;21:617
14
10/15/2013
C-reactive protein (CRP) elevation is also
associated with CSVD indicating an
inflammatory process, and the elevated CRP
levels are also found in NTG patients. The
CRP increases endothelin which has been
implicated in the proliferation of astrocytes
in the nerve head and changes in the
trabecular meshwork and has been found to
be elevated in glaucoma and NTG after
exposure to cold temperatures.
Autoimmunity is at the root of most
disorders and is defined as an attack on the
host cell by activated T cells. It has actually
been shown that survival of RGCs after
optic nerve injury is facilitated by the
autoimmune response via activated T cells.
This response can either be by active
immunization with a protein or by transfer of
activated T cells.
Cell Mol Neurobiol 2001;21:617, J Neurosci 2000;20:6421, J Neuroimmunol 2000;106:189, Nat Med
1999;5:49, Am J Ophthalmol 2006;141:1105, Surv Ophthalmol 2001;45:S256, Invest Ophthalmol Vis Sci
2003;44:407, Proc Natl Acad Sci USA 2001;98:3398, Proc Natl Acad Sci USA 2000;97:7446
Circulation 2005;112:900, J Glaucoma 2005;14:384, Circ Res 2004;95:877, Invest Ophthalmol Vis Sci
2002;43:2704, J Glaucoma 2002;11:259, J Glaucoma 1997;6:83, Br J Ophthalmol 2005;89:60, Invest
Ophthalmol Vis Sci 2003;44:2565
IS SLEEP DEPRIVATION THE
RESULT OF SLEEP APNEA?
TNF- alpha is a pro-inflammatory cytokine
that is present during excitotoxic and
ischemic brain injury. Among other
functions, it binds to the death receptor and
can induce caspase components of the
mitochondrial cell death pathway. TNFalpha has been implicated as a mediator in
RGC death.
Mol Med 1997;3:765, Stroke 1994;25:1481, Stroke 1997;28:1233, Invest Ophthalmol Vis Sci 2001;42:1787
TNF- α inhibitors (GLC756) are being
investigated for the treatment of glaucoma.
Exp Eye Res 2006;83:1335, Exp Eye Res 2006;83:1246
WHAT ARE ISSUES THAT
CREATE INFLAMMATION?
TAKE
•
•
•
•
•
•
•
OBESITY
LACK OF EXERCISE
LACK OF SLEEP
POOR DIET
LACK OF ENOUGH OMEGA 3
SMOKING AND AIR POLLUTION
STRESS
THIS IS THE “AMERICAN PROFILE”
15
10/15/2013
I Want You to Think and
Question.
What if I told you that men with erectile
dysfunction have a nearly 3X risk for
having POAG than men with normal
erectile function?
Ophthalmology 2012:119:289-293
I Want You to Think and Question
There is a clear beneficial effect of the
use of glaucoma medication on the
likelihood of death. Patients taking
topical PGAs, a-agonists and Bblockers for confirmed POAG
associated with a 74% reduction in
death.
Arch Ophthalmol 2010;128:235-240
WHY?
MEN TAKING ED MEDS HAVE A HIGHER RISK OF ION AS
WELL
WHY?
Screening VF Based on FDT
Technology May Miss Neurological
Lessions….foolish
consistency?????
56 YO
MILD DISC ASYMMETRY
•
•
•
•
COMPLAINS OF MILD DECR VA
IOP 15/16
FAILED FDT
ANGLES 20-23 DEGREES WITH
SLIGHT NARROWING NASALLY
• BCVA 20/25 OU
EXPLAINED BY DISC
SIZE DIFFERENCES
16
10/15/2013
VF DEFECT
ON
SCREENING
VERY THIN CORNEAS
PRETTY MUCH NORMAL NUMBERS EVERYWHERE
PRETTY MUCH NORMAL NUMBERS EVERYWHERE
LET’S TRY A THRESHOLD VF
SO WHAT’S UP???
•
•
•
•
GLAUCOMA
NA-AION
SUB ACUTE ANGLE CLOSURE
NOTHING
INCONGRUOUS LEFT UPPER QUADRANTANOPSIA
17
10/15/2013
LET’S TAKE A LOOK HERE
MAGNOCELLULAR
VS
PARVOCELLULAR
PATHWAY
SO WHAT IS THE BASIS OF THE CONTROVERSY?
IT IS THE MAGIC OF PERCEPTION
..the magnocellular (fast conducting) stream, which
carries information useful for motion analysis, and the
parvocellular (slow conducting) stream, which carries
information useful for analyses of shape and
color…higher cortical areas that receive input either
directly or indirectly from layer 4B are likely to be more
strongly influenced by the parvocellular pathway than
previously believed
Nature 380, 442 - 446 (04 April 1996)
The PC pathway accounts for approximately 80% of
optic nerve fibers…loss of visual acuity and color
vision are two visual functions thought to be mediated
by the PC pathway…Optic neuritis produced large
sensitivity losses mediated by the MC pathway and
contrast gain losses in the inferred PC pathway. (Invest
Ophthalmol Vis Sci. 2011;52:8900–8907)
The M ganglion cells in the retina, so called because of their
larger cell body,3 project to layers one and 2 in the lateral
geniculate nucleus (LGN). The P cells in the retina project to
layers 3 through 6 in the LGN. The projections of the M and P
cells appear to be distinct in the LGN4,5 and remain so from
the LGN to the primary visual cortex (V1), with the M pathway
terminating primarily in layer 4C of V1 and the P pathway
terminating primarily in layers 4A and 4C of V1.6.
Because of the different physiologic responses of the M
and P pathways, a common strategy to preferentially
activate the pathways is to use a stimulus that is colorneutral, low in contrast, large in grid size, and reverses
contrast at a fast rate for the M pathway. Conversely, the P
pathway responds preferentially to stimuli that are
different in color, high in contrast, small in grid size, and
reverses contrast at a slow rate. These two pathways
have different blood oxygen level dependencies.
Frequency doubling technology perimetry
demonstrates high sensitivity and specificity for
detection of early, moderate, and advanced
glaucomatous visual field loss.
Am J Ophthalmol 2000;129:314–322.
FDT appears more sensitive to axonal injury reflected
by the extent of optic disc pallor in altitudinal NAION
than SAP and in some patients reveals visual
dysfunction in the hemifield that appeared relatively
uninvolved when evaluated using SAP.
Br J Ophthalmol 2004;88:1274-1279
Am J Neuroradiol 27:1628 –34 Sep 2006
18
10/15/2013
FDT was developed based on the belief that the
magnocellular (M) cells in the retina are preferentially
stimulated. With few M cell fibers distributed throughout the
retina, it was argued that FDT perimetry would be more
sensitive in detecting early glaucomatous field loss.
However, more recent evidence has suggested that the FDT
effect is mediated by many neural cell types.
No difference was found suggesting that neurologic disease
affects FDT similarly whether the insult is pre- or
postchiasmal. However, it should be noted that in roughly
10% of cases (anterior and posterior) SAP and FDT did
not correlate well. Our study was not designed to
address this and the significance of this occasional
discordance remains unknown.
However, defects in patients with hemianopias
may be missed because of the presence of scattered abnormal
test locations and failure to detect test locations along the
vertical meridian…This suggests FDT may not be isolating the
magnocellular (M) cells with nonlinear responses to stimulus
contrast (My cells) in patients with visual loss.
Comparison of Sensitivity and Specificity of CAP to FDT
Type
CAP Sens/Spec
FDT Sens/Spec
Optic Neuropathy
86/81
78/76
Hemianopia
92/81
48/76
(Invest Ophthalmol Vis Sci. 2002;43:1277–1283)
Middle East Afr J Ophthalmol 2012;19:211-5
The new Humphrey Matrix 24-2 testing strategy
provides a visual field testing method for optic nerve and
chiasmal disorders that has fair to good concordance with the
Humphrey SITA Standard 24-2 program. Both tests have
similar sensitivity and specificity.
TAKE
Invest Ophthalmol Vis Sci. 2008;49:917–923
The FDT screening test can fail to demonstrate complete
hemianopic and quadrantanopic field defects. Users should be
aware of this deficiency when using FDT to screen for field
defects.
Eye (2003) 17, 330–333.
The Humphrey Matrix was released in April 2005 with the aim
of providing significant enhancements to the diagnostic
capabilities. Additional tests having smaller targets and
increased number of tested locations to improve the spatial
resolution of VF defects have been created without greatly
effecting the variability and sensitivity resolution
FDT
Wide Field Fundus Imaging and
SDOCT are the Standard of
Care..foolish consistency?????
parvocellular (slow conducting) stream, which carries information
useful for analyses of shape and color…higher cortical areas that
receive input either directly or indirectly from layer 4B are likely to
be more strongly influenced by the parvocellular pathway than
previously believed
19
10/15/2013
61 YO
THE WOW FACTOR..WHAT DO YOU SEE?
• ROUTINE EXAM
• NOTICED REDUCED VISION OD
RECENTLY
THE WOW FACTOR..WHAT DO YOU SEE?
VITREOUS LIFTED
CYSTIC MACULOPATHY
EPIRETINAL MEMBRANE
VITREOUS SEPARATION
NORMAL BLOOD VESSEL SHADOWING
20
10/15/2013
61 YO
• ROUTINE EXAM
• NOTICED REDUCED VISION OD
RECENTLY
• OPHTHALMOSCOPIC VIEW
APPEARS NORMAL
• EPIRETINAL MEMBRANE OD
AND EVOLVING HOLE. PVD OS
THE WOW FACTOR..WHAT DO YOU SEE?
57 YO
• ROUTINE EYE EXAM
• RELATIVELY YOUNG PATIENT
WITH MILD VISION REDUCTION
THE WOW FACTOR..WHAT DO YOU SEE?
VITREOUS SEPARATION
RPE DISEASE
RPE DISEASE
21
10/15/2013
VITREOUS SEPARATION
RPE DISEASE
RPE DISEASE
64 YO
57 YO
• ROUTINE EYE EXAM
• RELATIVELY YOUNG PATIENT WITH MILD
VISION REDUCTION
• NO OPHTHALMOSCOPIC SIGNS, YET RPE
DISEASE INDICATIVE OF EARLY AGE
RELATED MACULAR DEGENERATION.
• RPE DISEASE DISCOVERED WITH SDOCT
AFFORDING THE OPTION OF MORE
CAREFUL FOLLOWUP AND INTERVENTION
THE WOW FACTOR..WHAT DO YOU SEE?
• ROUTINE EXAM
• COMPLAINING OF SLIGHT
REDUCTION IN VISION OD
THE WOW FACTOR..WHAT DO YOU SEE?
ASTEROID HYALOSIS
22
10/15/2013
VITREORETINAL TRACTION
RETINAL SWELLING
RPE DISEASE
64 YO
• ROUTINE EXAM
• COMPLAINING OF SLIGHT REDUCTION
IN VISION OD
• OPHTHALMOSCOPICALLY NO SIGN
OF ANY DISEASE OR DISORDER
EXCEPT ASTEROID HYALOSIS OS
• SDOCT SHOWS VITREORETINAL
TRACTION AND RETINAL SWELLING
OD AND SIGNIFICANT RPE DISEASE
OS, THE HARBINGER OF AGE
RELATED MACULAR DEGENERATION
72 YO
• ROUTINE EXAM
• COMPLAINS OF REDUCING
VISION
• OPHTHALMOSCOPIC VIEW
SHOWS ASTEROID HYALOSIS
OD AND “SOFT DRUSEN”
ASTEROID HYALOSIS
“SOFT DRUSEN”
THE WOW FACTOR..WHAT DO YOU SEE?
“SOFT DRUSEN”
THE WOW FACTOR..WHAT DO YOU SEE?
23
10/15/2013
NOTE RETINAL THINNING OVER THE
DETACHMENT
RPE DETACHMENT
NOTE RETINAL THINNING OVER THE DETACHMENT
RPE RIP
72 YO
• ROUTINE EXAM
• COMPLAINS OF REDUCING VISION
• OPHTHALMOSCOPIC VIEW SHOWS
ASTEROID HYALOSIS OD AND
“SOFT DRUSEN”
• SDOCT REVEALS VERY
SIGNIFICANT BILATERAL RPE
DETACHMENTS
RPE DETACHMENT
LANDMARK STUDY IN THE PREEMPTIVE STRIKE
Awad C, Slotnick S, Nath S, Sherman J. Sensitivity and specificity of the iVue
iWellnessExam™ in detecting retinal and optic nerve disorders
http://www.dovepress.com/articles.php?article_id=12215 2013
Loss of Photoreceptors
Neurosensory Retinal
Detachment
Early RPE Compromise and
Small Drusen
RPE Detachment and RPE
Dystrophy
Early Choroidal Neovascular
Membranes
Ganglion Cell Loss
RNFL Loss..Unless Quite
Dramatic
Epi-retinal Membranes
Vitreoretinal Traction, Evolving
Macular Holes
Retinal Edema and Cysts
Retinal Schisis
Small Micro Aneurysms and
Exudates
Vitreous Issues
• 125 of 126 normal… identified as normal…
99% specificity
• 97 of 101 with disease…identified as
disease 96% sensitivity
– 64 or 67 with retinal disease identified…
95.5% sensitivity
– 45 of 50 with optic nerve disease identified…
90% sensitivity
24
10/15/2013
TAKE
What this means is that you
can identify “normals” over
90% of the time and “disease”
over 90% of the time even
before you see the patient.
WITH THIS PLAN YOU
CAN PRACTICE IN YOUR
BED WITH YOUR
JAMMIES ON
America and Optometry Must
Institute Health Care
Reform….foolish
consistency?????
THE WRONG ATTITUDE
I have a great optical model business,
Why should I worry about any of this?
= $1200 with the Family Discount
This is why!
This is Why!
http://www.fatwallet.com/forums/hot
-deals/231255/
They have glasses from $7 - $30.
$5.00 more for anti-reflective
coating and free uv and scratch
coatings. $5 flat shipping for all
orders. The orders usually take
about 10-15 days. Special orders
can take up to 1 month.
Zenni Optical
27 Sunny Oaks Dr.
San Rafael, Ca.94903
Phone 1-800-211-2105
Fax 1-415-491-4516
[email protected]
25
10/15/2013
PQRS BONUSES 2011
MEDICARE PHYSICIAN QUALITY REPORTING
SYSTEM
• 32,404 OD ELGIBLE FOR PQRS 27.7 %
PARTICIPATION
• 18.7 % ODS WHO SAW MEDICARE
PARTICIPATED
• 22 ODS GOT PQRS MAINTENANCE OF
CERTIFICATION BONUSES
• 26.4 % OF ALL ELGIBLE HEALTH CARE
PRACTIONERS PARTICIPATED IN PQRS
• 79.4 % OMD ELGIBLE FOR PQRS REPORTED
PQRS WITH 36.9 % RECEIVING BONUSES
SO WHAT
• 2015 CMS WILL REDUCE MEDICARE
PAYMENTS TO ELGIBLE
PROFESSIONALS WHO DO NOT
REPORT
• 2015 PENALTIES WILL BE BASED ON
PQRS PARTICIPATION IN 2013. NO
REPORTING WILL REDUCE PAYMENT
BY 1.5 %
SO WHAT?
Arch Ophthalmol. 2004 Apr;122(4):477-85.
Causes and prevalence of visual impairment among adults in the United States.
Congdon N, O'Colmain B, Klaver CC, Klein R, Muñoz B, Friedman DS, Kempen J, Taylor
HR, Mitchell P; Eye Diseases Prevalence Research Group.
RESULTS:
Based on demographics from the 2000 US Census, an
estimated 937 000 (0.78%) Americans older than 40 years
were blind (US definition). An additional 2.4 million Americans
(1.98%) had low vision. The leading cause of blindness
among white persons was age-related macular
degeneration (54.4% of the cases), while among black
persons, cataract and glaucoma accounted for more than
60% of blindness. Cataract was the leading cause of low
vision, responsible for approximately 50% of bilateral vision
worse than 6/12 (20/40) among white, black, and Hispanic
persons. The number of blind persons in the US is
projected to increase by 70% to 1.6 million by 2020, with a
similar rise projected for low vision.
One of the main changes we will see is an increased
ability for patients to compare cost and quality of care
against published measures.
The Medicare pay-for-performance measures represent
a major change in the position of Congress to address
this issue. Every sign in the political arena points to
rapidly growing support for health care reform as a
renewed national priority.
We might easily conclude that the health care reform
process has stopped and therefore we need not be
concerned with it. On the contrary, the financial crisis
in health care is growing rapidly and, with federal
funding stalled, insurers and organizations
responsible for health care have begun themselves to
initiate cost and quality control measures.
A core concept behind pay-for-performance is to change
reimbursement and pay only for what are deemed to be
industry and clinical best practices.
If we estimate 72 million CT scans are performed
a year at very low $1,000 average and 20 million
(28%) of them are judged as unnecessary that
amounts to $20,000,000,000. If we apply that
arbitrary CT percentage of 28% to the 6,010,610
OCTs of 2011 reimbursed at an average of
$44/scan we have 1,682,970 potential unnecessary
scans at a cost of $74,050,680. That cost is 0.37%
or $19,925,949,320 less than the verifiable
unnecessary CT scans.
26
10/15/2013
Executive Order signed August 22, 2006 by President George W. Bush.
“Promoting Quality & Efficient Health Care in Federal Government
Administered or Sponsored Health Care Programs.”
Once patient health information is maintained electronically and
requirements are in place for electronic transmission, records
reviews for both quality and cost become quick, easy and practical.
A complex problem that resulted in an internal-medicine diagnosis, it
had involved approximately $20,000 of testing at hospital A, following
which the attending physician gave the patient recommendations for
care. The patient decided to seek another opinion at hospital B. The
same tests were repeated with no difference in the recommended
care, no improvement in care. Mandatory portability of patient health
information would have required all test results from hospital A to
follow the patient to hospital B. Compared to the actual total cost of
$40,000, a second opinion could have been obtained for about $130.
Official government estimates are that portability will directly save
$360 billion dollars per year out of the current $1.7 trillion annual
healthcare costs in the United States.
Plaquenil Toxicity is Real….foolish
consistency?????
DO YOU SEE ANY
PROBLEM IN THE
PLAQUENIL ZONE?
DO YOU SEE ANYTHING
WRONG?
The Four Cornerstones of Value-Driven Health
Care
1) Utilizing health information technology to
ensure that all patient health information is
electronic and can be efficiently and
effectively moved anywhere the information
is needed
2) Measuring and publishing health care
quality information
3) Measuring and publishing health care
pricing information
4) Creating incentives for high-quality,
efficient health care
54 yo
• ROUTINE EYE EXAM
• DRY GRITTY EYES
• HX SLE AND MEDS INCLUDE:
ALEVE, PREMARIN,
PROTEINEX, AND PLAQUENIL
• BCVA 20/20 OU
DO YOU SEE ANY
PROBLEM IN THE
PLAQUENIL ZONE?
DO YOU SEE ANYTHING
WRONG?
27
10/15/2013
DO YOU SEE ANY
PROBLEM IN THE
PLAQUENIL ZONE?
PERIFOVEAL THINNING
DO YOU SEE ANY
PROBLEM IN THE
PLAQUENIL ZONE?
EARLIEST SIGN OF PERIFOVEAL GCC THINNING
DO YOU SEE ANY
PROBLEM IN THE
PLAQUENIL ZONE?
PERIFOVEAL THINNING
DO YOU SEE ANY
PROBLEM IN THE
PLAQUENIL ZONE?
EARLIEST SIGN OF PERIFOVEAL GCC THINNING
28
10/15/2013
NO
APPARENT
VF DEFECT
NO
APPARENT
VF DEFECT
54 yo
• ROUTINE EYE EXAM
• DRY GRITTY EYES
• MEDS INCLUDE: ALEVE,
PREMARIN, PROTEINEX, AND
PLAQUENIL 200 MG QD X 14
YEARS- CUMULATIVE DOSE
1,022,000 MG
• BCVA 20/20 OU
• TOTALLY DIFFERENT APPROACH
TO PATIENT MANAGEMENT
49 YO
• ROUTINE PLAQUENIL CHECK
• HX SLE AND ASSOCIATED LIVER
DYSFUNCTION
• HX OF DRY EYES
• MEDS INCLUDE: NAPROXEN, AND
PLAQUENIL 200 MG QD X 2 YEARSCUMULATIVE DOSE 146,000 MG
• BCVA 20/20 OU
VERY LATE STAGE EFFECTS
WAY OUTTA THE BARN
DO YOU SEE ANY
PROBLEM IN THE
PLAQUENIL ZONE?
29
10/15/2013
OD GRID
DO YOU SEE ANY
PROBLEM IN THE
PLAQUENIL ZONE?
O.S. GRID
DO YOU SEE ANY
PROBLEM IN THE
PLAQUENIL ZONE?
DO YOU SEE ANY
PROBLEM IN THE
PLAQUENIL ZONE?
DO YOU SEE ANY
PROBLEM IN THE
PLAQUENIL ZONE?
30
10/15/2013
Dr. Larry’s Recommendations to
Minimize Blindness in Your Office
•
•
•
•
•
CHOOSE YOUR PARENTS CAREFULLY
HAVE THEM EAT HEALTHY/BMI
HAVE THEM NOT SMOKE OR DRINK ALCOHOL
HAVE THEM DO EVERYTHING IN MODERATION
HAVE THEM EXERCISE AND SLEEP 8 HOURS A
DAY
• TELL THEM TO HAVE NO STRESS
• DON’T STEP IN FRONT OF MOVING VEHICLES OR
LARGE ANIMALS
• DON’T DELIBERATELY ANTAGONIZE BIG,
STRONG, MEAN PEOPLE
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