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CliniCal news & analysis grand rOUnds // what is diagnosis? plus+ CHALLENGES In This Issue May 1, 2013 Vol. 38, No. 9 glaucoma 15 On the intricacy of uveitic glaucoma Management requires aggressive therapy of infammation, elevated IOP refractive 32 Crosslinking best option for iatrogenic ectasia Choosing visual rehabilitation method presents another management issue OF StrAbISMUS SUrGEry CORRELATION RNFL THICKNESS: VISUAL FIELD CHANGES DRy EyE not a cut-and-dried issue Surgeons’ approach to condition, identifying candidates varies cataract 34 Device guides IOL selection in certain patient groups Challenging cases achieve good refractive outcomes with aberrometry follow us online: OphthalmologyTimes.com pediatrics gene therapy targets inherited retinal diseases By Cheryl Guttman Krader IOWA CIt y, IA :: RECENT RESEARCH progress provides reason for clinicians to assume an optimistic posture toward patients with inherited retinal diseases. “It is hard to imagine all of the progress that has occurred in gene therapy research for inherited retinal diseases during the 5 years since the first human RPE65 gene therapy,” said Edwin M. Stone, MD, PhD, director of the Institute for Vision Research at the University of ( See story on page 10 ) magenta cyan yellow black keratopathy after LaSIk Severe superfcial punctate keratopathy 8 days after LASIK as demonstrated by fuorescein staining. The patient complained of signifcant foreign body sensation and poor vision. (Photo courtesy of Christopher J. Rapuano, MD) THE APPROPRIATENESS of laser refractive surgery in patients with dry eye is not without debate. From the perspective of Christopher J. Rapuano, MD, the two don’t mix. Dry eye is an important cause of patient dissatisfaction after LASIK, is a risk factor for regression, and may be a persistent complaint, he says. ScreenIng for dry eye Dr. Donnenfeld tests for ocular surface damage. Shown here, marked corneal and conjunctival staining with lissamine green. (Photo courtesy of Eric D. Donnenfeld, MD) Providing a different vantage, Eric D. Donnenfeld, MD, notes that dry eye is not an absolute contraindication to LASIK. Affected patients can often be acceptable candidates if they are managed intelligently with appropriate preoperative, intraoperative, and postoperative techniques, he says. Both perspectives are presented in a point/counterpoint beginning on page 30. NO LASER SELEctivE LASER “Consider surgery only if the ocular surface is normalized,” says Christopher J. rapuano, MD on page 30 “the majority of patients with dry eye are excellent candidates for LASIK,” says Eric D. Donnenfeld, MD on page 31 ES237069_OT050113_cv1.pgs 04.24.2013 23:47 ADV ONE INJECTION, EARLY INTERVENTION. TAKE ACTION WITH JETREA® (ocriplasmin) Intravitreal Injection, 2.5 mg/mL The FIRST and ONLY pharmacologic treatment for symptomatic Vitreomacular Adhesion (VMA).1 Indication JETREA (ocriplasmin) Intravitreal Injection, 2.5 mg/mL, is a proteolytic enzyme indicated for the treatment of symptomatic vitreomacular adhesion. Important Safety Information Warnings and Precautions • A decrease of ≥ 3 lines of best-corrected visual acuity (BCVA) was experienced by 5.6% of patients treated with JETREA and 3.2% of patients treated with vehicle in the controlled trials. The majority of these decreases in vision were due to progression of the condition with traction and many required surgical intervention. Patients should be monitored appropriately. • Intravitreal injections are associated with intraocular inflammation/infection, intraocular hemorrhage and increased intraocular pressure (IOP). Patients should be monitored and instructed to report any symptoms without delay. In the controlled trials, intraocular inflammation occurred in 7.1% of patients injected with JETREA vs 3.7% of patients injected with vehicle. Most of the post-injection intraocular inflammation events were mild and transient. If the contralateral eye requires treatment with JETREA, it is not recommended within 7 days of the initial injection in order to monitor the post-injection course in the injected eye. Please see Brief Summary of full Prescribing Information on adjacent page. Reference: 1. JETREA [package insert]. Iselin, NJ: ThromboGenics, Inc.; 2012. ©2013 ThromboGenics, Inc. All rights reserved. ThromboGenics, Inc., 101 Wood Avenue South, Suite 610, Iselin, NJ 08830 – USA. JETREA and the JETREA logo are trademarks or registered trademarks of ThromboGenics NV in the United States, European Union, Japan, and other countries. THROMBOGENICS and the THROMBOGENICS logo are trademarks or registered trademarks of ThromboGenics NV in the United States, European Union, Japan, and other countries. magenta cyan yellow black ES236269_OT050113_CV2_FP.pgs 04.24.2013 00:29 ADV • Potential for lens subluxation. Adverse Reactions • In the controlled trials, the incidence of retinal detachment was 0.9% in the JETREA group and 1.6% in the vehicle group, while the incidence of retinal tear (without detachment) was 1.1% in the JETREA group and 2.7% in the vehicle group. Most of these events occurred during or after vitrectomy in both groups. • The most commonly reported reactions (≥ 5%) in patients treated with JETREA were vitreous floaters, conjunctival hemorrhage, eye pain, photopsia, blurred vision, macular hole, reduced visual acuity, visual impairment, and retinal edema. • Dyschromatopsia (generally described as yellowish vision) was reported in 2% of all patients injected with JETREA. In approximately half of these dyschromatopsia cases there were also electroretinographic (ERG) changes reported (a- and b-wave amplitude decrease). VISIT JETREACARE.com FOR REIMBURSEMENT AND ORDERING INFORMATION LEARN MORE AT JETREA.com (ocriplasmin) Intravitreal Injection, 2.5 mg/mL 04/13 OCRVMA0072 JA2 F magenta cyan yellow black ES236267_OT050113_003_FP.pgs 04.24.2013 00:29 ADV black ES236268_OT050113_004_FP.pgs 04.24.2013 00:28 ADV May 1, 2013 :: ophthalmology times 5 contents Special Report DRY EYE 16 dRy eye commoN, but compLicated Making a diagnosis is only the frst step in treating patients with dry eye syndrome 38 Composite fundus photos demonstrating multifocal chorioretinal scars involving posterior pole OU and optic disc pallor OD. Pediatrics Cataract 10 geNe theRapy taRgets iNheRited RetiNaL diseases 33 timiNg, LocatioN, caLcuLatioN Phase III study of RPE65 for Leber's congenital amaurosis under way 12 peaRLs addRess stRabismus suRgeRy Avoiding hypotropia, excylotropia after augmented transposition surgery among tips 17 compLetiNg the dRy eye theRapeutic stoRy Advances in technology, understanding of dry eye will generate future therapies 20 puNctaL occLusioN aids muLtiFocaL ioL satisFactioN Two cases illustrate benefts in managing dry eye before, after surgery with implant Here are three important factors in treating traumatic cataract in pediatric patients 24 a New poiNt oF caRe FoR dRy eye Expanded array of diagnostic platforms target identifcation of dry eye disease 34 device guides ioL seLectioN iN ceRtaiN patieNt gRoups Challenging cases achieve good refractive outcomes with aberrometry Glaucoma 14 RNFL thickNess coRReLates with visuaL FieLd chaNges SLO-MP shows higher structure/function correlation compared with perimetry 15 oN the iNtRicacy oF uveitis gLaucoma Management requires aggressive therapy of infammation, medical therapy of elevated IOP Refractive 32 cRossLiNkiNg best optioN FoR iatRogeNic ectasia 36 gRadiNg system pRomisiNg FoR impRoved eFFicieNcy Lens assessment with femtosecond laser imaging offers opportunity for outcomes 26 ’tis the seasoN FoR ocuLaR suRFace disease Grand Rounds Pre-emptive strategies for exacerbations guided by seasonal fuctuations 38 patieNt has paiN, visioN Loss Man has 3-day hisory of OD pain, decreased vision,other symptoms: What is diagnosis? 28 why patieNt educatioN is key to compLiaNce An effective campaign must be readily available for physicians to implement Choosing a visual rehabilitation method after CXL presents management issue In Every Issue magenta cyan yellow black 6 Editorial 8 ophthalmic nEws 39 markEtplacE ES237079_OT050113_005.pgs 04.24.2013 23:50 ADV 6 May 1, 2013 :: Ophthalmology Times editorial MaY 1, 2013 ◾ Vol. 38, no. 9 CONTENT It’s the ‘law’ Why unintended consequences can have bad results By Peter J. McDonnell, MD director of the Wilmer Eye institute, Johns hopkins University School of Medicine, baltimore, and chief medical editor of Ophthalmology Times. he can be reached at 727 Maumenee building 600 n. Wolfe St. baltimore, Md 21287-9278 Phone: 443/287-1511 Fax: 443/287-1514 E-mail: [email protected] HUBERT HORATIO HUMPHREY, making a mistake that harms a patient. Anecdotes of patients dying in hospitals and emergency rooms under the care of reportedly exhausted young doctors appeared in the media and lawyers pursued damages in courts. In response to this (legitimate, in my opinion) concern, new laws were passed by state legislators and new rules were promulgated by regulatory bodies limiting the number of hours that house officers could work (consecutively and over the course of a week). So strongly was this considered the right thing to do, that training institutions that failed to comply were threatened with being shut down (the death penalty). Who could be against the idea of happier, better-rested, and healthier residents who, more alert, would be better learners and providing better care to sick people? Teaching hospitals scrambled to obey—hiring workforces of technicians, nurse practitioners, and physician assistants to get the work done. former U.S. Senator from Minnesota, Vice President, and unsuccessful candidate for the presidency, is famous for his observation that “the Senate is a place filled with goodwill and good intentions, and if the road to hell is paved with them, then it’s a pretty good detour.” This saying about good intentions is thought to have originated with Saint Bernard of Clairvaux who wrote, “L’enfer est plein de bonnes volontés et désirs” (Hell is full of good wishes and desires). The concept that apparently rational people, in an effort to make the world a better place, make decisions or rules that inadvertently — Peter J. McDonnell, MD screw things up even more is fairly evident. This common but troublesome little scenario, the law of unA decade later, what have been the conseintended consequences, rears its ugly head in quences of these new rules? According to two many situations, both within and outside of recently published studies, the interns training medicine. under this new regimen “make more mistakes and learn less” (emphasis added). The trainYELLOW LIGHTS, R ED LIGHTS ees did not sleep more, did not report being less This month, I read about a study of the effect depressed, and did not report a better sense of of red light cameras placed at intersections acwell being. They did, however, report that they cording to a law passed in the (laudable) effort were more concerned that they had made a seto decrease the number of crashes caused by rious medical error (with the percentage inmotorists running red lights. After considerable creasing from 19.9% to 23.3%). time had passed, some wise guy performed a “Our results suggest that the negative uninretrospective analysis of the number of accitended consequences of the reforms may outdents at these intersections. The number of acweigh any positives,” says an author of one of cidents, rather than decreasing, had actually the studies. increased (because of rear-end collisions from drivers hitting the brakes in response to yellow HOW DO W E EXPLAIN THIS BAD lights so they don’t get tickets). R E SU LT ? On a medical note, legislators and regulaOne theory is that the increased transfer of care tory bodies became concerned some years ago for patients from one house officer to the next, about the problem of house officers being on duty for extended periods, getting tired, and Continues on page 8 : Editorial It would not be diffcult to beta test proposed new rules. magenta cyan yellow black Chief Medical Editor Peter J. Mcdonnell, Md Group Content Director Mark l. dlugoss [email protected] 440/891-2703 Content Channel Manager Sheryl Stevenson [email protected] 440/891-2625 Content Specialist helen thams [email protected] 440/891-2639 Digital & Interactive Content Manager brandon glenn Content Coordinator Miranda hester Group Art Director Robert Mcgarr Art Director nicole davis-Slocum Anterior Segment Techniques Ernest W. kornmehl, Md Cataract Corner Richard S. hoffman, Md and Mark Packer, Md coding.doc l. neal Freeman, Md, Mba Money Matters John J. grande, traudy F. grande, and John S. grande, CFPs® Neuro-Ophthalmology andrew g. lee, Md Ophthalmic Heritage norman b. Medow, Md Panretinal View allen C. ho, Md Plastics Pearls Richard anderson, Md Tech Talk h. Jay Wisnicki, Md Uveitis Update Emmett t. Cunningham Jr., Md, Phd, MPh What’s New at the AAO John gallagher P U B L I S H I N G /A DV E R T I S I N G Executive Vice President georgiann deCenzo [email protected] 440/891-2778 VP, Group Publisher ken Sylvia [email protected] 732/346-3017 Group Publisher leonardo avila [email protected] 302/239-5665 Associate Publisher Erin Schlussel [email protected] 215/886-3804 National Account Manager Rebecca a. hussain [email protected] 415/932-6332 Account Manager, Classifed/ Display Advertising darlene balzano [email protected] 440/891-2779 Account Manager, Recruitment Advertising Jacqueline Moran [email protected] 440/891-2762 Director, Sales Data gail kaye Sales Support hannah Curis 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 PRODUCTION Senior Production Manager karen lenzen AUDIENCE DEV ELOPMEN T Corporate Director Joy Puzzo Director Christine Shappell Manager Wendy bong Chief Executive Offcer: Joe loggia Chief Executive Offcer Fashion Group, Executive Vice-President: tom Florio Executive Vice-President, Chief Administrative Offcer & Chief Financial Offcer: tom Ehardt Executive Vice-President: georgiann deCenzo Executive Vice-President: Chris deMoulin Executive Vice-President: Ron Wall Executive Vice-President, Business Systems: Rebecca Evangelou Sr Vice-President: tracy harris Vice-President, Media Operations: Francis heid Vice-President, Legal: Michael bernstein Vice-President, Human Resources: nancy nugent Vice-President, Electronic Information Technology: J. Vaughn Advanstar Communications Inc. 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 advanstar Communications inc. 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 advanstar’s lists. outside the U.S., please phone 218-740-6477. Ophthalmology 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. Ophthalmology Times cannot be held responsible for the safekeeping or return of unsolicited articles, manuscripts, photographs, illustrations or other materials. Ophthalmology Times is a member of the association of independent Clinical Publications inc. Library Access libraries offer online access to current and back issues of Ophthalmology Times through the EbSCo host databases. To subscribe, call toll-free 888-527-7008. outside the U.S. call 218-740-6477. PRintEd in U.S.a. ES235816_OT050113_006.pgs 04.23.2013 03:43 ADV May 1, 2013 :: Ophthalmology Times 7 editorial advisory board Official publication sponsor of Editorial advisory Board Chief Medical Editor Anne L. Coleman, MD Jules Stein Eye Institute/UCLA Los Angeles, CA Peter J. McDonnell, MD Wilmer Eye Institute Johns Hopkins University Baltimore, MD Allen C. Ho, MD Wills Eye Institute, Thomas Jefferson University, Philadelphia, PA Associate Medical Editors Dimitri Azar, MD University of Illinois, Chicago, Chicago, IL Ernest W. Kornmehl, MD Harvard & Tufts Universities, Boston, MA Robert K. Maloney, MD Los Angeles, CA Joan Miller, MD Massachusetts Eye & Ear Infirmary Harvard University, Boston, MA Ophthalmology Times Mission Statement Ophthalmology Times is a physician-driven publication that disseminates news and information of a clinical, socioeconomic, and political nature in a timely and accurate manner for members of the ophthalmic community. Randall Olson, MD University of Utah, Salt Lake City, UT In partnership with our readers, we will achieve mutual success by: ◾ Being a forum for ophthalmologists to communicate their clinical knowledge, insights, and discoveries. Robert Osher, MD University of Cincinnati, Cincinnati, OH ◾ Providing management information that allows ophthalmologists to improve and expand their practices. ◾ Addressing political and socioeconomic issues that may either assist or hinder the ophthalmic community, and reporting those issues and their potential outcomes to our readers. Anterior Segment/Cataract Cornea/External Disease Ashley Behrens, MD Wilmer Eye Institute, Johns Hopkins University Baltimore, MD Rubens Belfort Jr., MD Federal University of São Paulo São Paulo, Brazil Elizabeth A. Davis, MD University of Minnesota, Minneapolis, MN Kuldev Singh, MD Stanford University, Stanford, CA Theo Seiler, MD University Hospital of Zurich, Zurich, Switzerland George L. Spaeth, MD Wills Eye Institute, Thomas Jefferson University Philadelphia, PA Jonathan H. Talamo, MD Harvard University, Boston, MA Robert N. Weinreb, MD Hamilton Glaucoma Center University of California, San Diego Neuro-Ophthalmology Andrew G. Lee, MD Methodist Hospital, Texas Medical Center Houston, TX Uday Devgan, MD Jules Stein Eye Institute/UCLA Los Angeles, CA I. Howard Fine, MD Oregon Health & Science University Portland, OR Oculoplastics/ Reconstructive Surgery George Theodossiadis, MD Athens, Greece Kazuo Tsubota, MD Keio University School of Medicine, Tokyo, Japan George O. Waring III, MD Atlanta, GA Retina/Vitreous Mark S. Blumenkranz, MD Stanford University, Stanford, CA Neil M. Bressler, MD Wilmer Eye Institute, Johns Hopkins University Baltimore, MD Richard L. Anderson, MD Center for Facial Appearances, Salt Lake City, UT Stanley Chang, MD Columbia University, New York, NY Robert Goldberg, MD Richard S. Hoffman, MD Oregon Health & Science University, Portland, OR Jules Stein Eye Institute/UCLA, Los Angeles, CA David Chow, MD University of Toronto, Toronto, Canada John T. LiVecchi, MD Jack T. Holladay, MD, MSEE, FACS St. Luke’s Cataract & Laser Institute Baylor College of Medicine, Houston, TX Sharon Fekrat, MD Tarpon Springs, FL Duke University, Durham, NC Manus Kraff, MD Shannath L. Merbs, MD Northwestern University, Chicago, IL Stuart Fine, MD Wilmer Eye Institute, Johns Hopkins University University of Pennsylvania, Philadelphia, PA Samuel Masket, MD Baltimore, MD Jules Stein Eye Institute/UCLA, Los Angeles, CA Julia Haller, MD Wills Eye Institute, Thomas Jefferson University Bartly J. Mondino, MD Pediatric Ophthalmology Philadelphia, PA Jules Stein Eye Institute/UCLA, Los Angeles, CA Hilel Lewis, MD Norman B. Medow, MD Mark Packer, MD Columbia University, New York, NY Oregon Health & Science University, Portland, OR Manhattan Eye, Ear & Throat Hospital New York, NY Carmen A. Puliafito, MD Walter J. Stark, MD Keck School of Medicine, USC, Los Angeles, CA Jennifer Simpson, MD Wilmer Eye Institute, Johns Hopkins University University of California, Irvine Baltimore, MD Carl D. Regillo, MD Irvine, CA Wills Eye Institute, Thomas Jefferson University Philadelphia, PA Glaucoma H. Jay Wisnicki, MD New York Eye & Ear Infirmary, Beth Israel Medical Lawrence J. Singerman, MD Robert D. Fechtner, MD Center/Albert Einstein College of Medicine Case Western Reserve University, Cleveland, OH University of Medicine & Dentistry of New Jersey New York, NY Lawrence Yannuzzi, MD Newark, NJ Manhattan Eye, Ear & Throat Hospital Neeru Gupta, MD Refractive Surgery New York, NY University of Toronto, Toronto, Canada Eric D. Donnenfeld, MD Jeffrey M. Liebmann, MD Uveitis New York University Medical Center Manhattan Eye, Ear & Throat Hospital New York, NY New York, NY Emmett T. Cunningham Jr., MD, PhD Daniel S. Durrie, MD Stanford University, Stanford, CA Richard K. Parrish II, MD Kansas City, KS Bascom Palmer Eye Institute, University of Miami Kenneth A. Greenberg, MD Miami, FL Chief Medical EditorsDanbury Hospital, Danbury, CT/ New York Emeritus Harry A. Quigley, MD University, New York, NY Wilmer Eye Institute, Johns Hopkins University Jack M. Dodick, MD Peter S. Hersh, MD Baltimore, MD University of Medicine & Dentistry of New Jersey New York University School of Medicine Robert Ritch, MD New York, NY (1976-1996) Newark, NJ New York Eye & Ear Infirmary, New York, NY David R. Guyer, MD Ioannis G. Pallikaris, MD Joel Schuman, MD New York, NY (1996-2004) University of Crete, Crete, Greece University of Pittsburgh Medical Center Pittsburgh, PA Howard V. Gimbel, MD Gimbel Eye Centre, Calgary, Canada John Bee Rhein Medical Inc. President and CEO Mark Newkirk Reichert Technologies Director of Global Marketing and Sales Daina Schmidt Bausch + Lomb Surgical Global Executive Director of Product Strategy William Burnham, OD Carl Zeiss Meditec Inc. Director of Market Development, Americas Giulia Newton Abbott Medical Optics Inc. Head of Commercial Operations Canada and Latin America Kelly Smoyer Essilor of America Product Director Bob Gibson Topcon Medical Systems Inc. Vice President of Marketing B A D C Pr ob an Gl e In Meibomian d A) Maskin ® Meibomian Gland Intraductal (76um OD) Probe – For Popping Through MG Obstructions. B) Maskin ® 1mm Meibomian Gland Intraductal (110um OD) Tube – For Delivering A Pharmaceutical. # Maskin ® MG Orifice & Duct 2mm Dilator (150um OD) – For Opening Up The Glands. Ophthalmology Times Industry Council Alastair Douglas Alcon Laboratories Inc. Director of U.S. Commercial Support Maskin® MGD Surgical Treatment System* Ram Palanki ThromboGenics, Inc. Global Head - Marketing & Sales D) Maskin ® MG Large Bore 2mm Tube (150um OD Cannula) – For Intraductal Injection Of Small Particle Therapeutic Suspensions. John Snisarenko Genentech USA Inc. Vice President, Sales & Marketing Ramin Valian Allergan Inc. Vice President of Marketing Scan The Code To See A Surgery Or Call 727-209-2244 For More Information. How to Contact Ophthalmology Times Editorial Subscription Services Advertising 24950 Country Club Blvd., Toll-Free: 888/527-7008 or 218/740-6477 Suite 200 North Olmsted, OH 44070-5351 FAX: 218/740-6417 440/243-8100 FAX: 440/756-5227 485 Route 1 South Building F, First Floor Iselin, NJ 08830-3009 732/596-0276 FAX: 732/596-0003 Production 3360 Scherer Drive, Suite B, St. Petersburg, FL 33716 s4ELs&AX %MAIL)NFO 2HEIN-EDICALCOMs7EBSITEWWW2HEIN-EDICALCOM $EVELOPED)N#OORDINATIONWITH3TEVEN,-ASKIN-$ 131 W. First St. Duluth, MN 55802-2065 800/346-0085 FAX: 218/740-7223, 218/740-6576 3TYLIZED%YE2HEIN-EDICAL 1330 Rev.A magenta cyan yellow black ES235818_OT050113_007.pgs 04.23.2013 03:43 AHBC ADV ophthalmic news 8 ( in Brief ) FROM STAFF REPORTS Vision and public health PBA hosts second Focus on eye heAlth summit C h i C ago :: PrevenT BLindness AMeriCA (PBA) will host the second annual Focus on Eye Health National Summit, to be held June 18. The event, which highlights advances in vision and public health, will take place at the Marriott at Metro Center in Washington, DC. This event will include the release of PBA’s Economic Impact of Vision Problems, a new report featuring cost data related to vision matters across the age spectrum. The summit will also include presentations on the role of surveillance in vision and public health; women’s eye health; vision benefits for children; advances in low vision; and public health systems of care for vision. Among presenters scheduled so far: > Janine Austin Clayton, Md, director, National Institutes of Health Office of Research on Women’s Health > Mary frances Cotch, Phd, chief, Division of Epidemiology and Clinical Applications, Epidemiology Branch, National Eye Institute > John Crews, dPA, Vision Health Initiative, Centers for Disease Control and Prevention > Paul Lee, Md, Jd, University of Michigan Kellogg Eye Center > Joe touschner, senior health policy analyst, Georgetown University Health Policy Institute Center for Children and Families editoriAl ( Continued from page 6 ) the logical outcome of shorter workdays, increases the risk that a newly arriving doctor will know the details of his/her patient less well and something is more likely to fall through the cracks. It seems to me that the careful scientific rigor with which new medical drugs and devices are evaluated is the model that we should follow whenever a significant change is being contemplated in how we train our young doctors. With all of the training programs in our country and the many faculty who are steeped in the scientific method of clinical trials, it would not be difficult to magenta cyan yellow black May 1, 2013 :: Ophthalmology Times > John Wittenborn, NORC at the University of Chicago For more information go to www.preventblindness.org/eyesummit or call 800/331-2020. AllergAn commemorAtes World glAucomA Week Headlines you migHt Have missed As seen in Ophthalmology Times’ weekly eReport. Sign up at http://www.modernmedicine. com/OphthalmologyTimes/enewssignup BAUSCH + LOMB RECEIVES APPROVALS BAUsCH + LOMB AnnOUnCes several updates including bromfenac ophthalmic solution 0.07% prescription eye drops (Prolensa); a new CE mark for its Victus femtosecond laser platform; and an FDA advisory panel has recommended approval of its Trulign Toric posterior chamber IOL. http://bit.ly/15m8Cp2 (Photo courtesy of Allergan) bangkok, t hail and :: Margot Goodkin, MD, PhD, and Michael Rowe from Allergan (front and second rows, left) along with Ron Gross, MD, Clifton R. McMichael Chair of Ophthalmology from the Cullen Eye Institute at Baylor College of Medicine (last row, left) commemorated “World Glaucoma Week” this past March in Thailand along with local leaders and physicians. For this event, Allergan worked in collaboration with Chulalongkorn Hospital as well as Udon Thani Hospital to provide free consultations and eye health exams. The next event will be held in Free State Province, South Africa, where an estimated 600 patients will be screened for glaucoma. beta test proposed new rules for 1 year or 2 to determine whether they actually help our trainees become better and healthier doctors and make our patients safer. ■ LEnSAR EARnS CLEARAnCE fOR ARCUAtE InCISIOnS THe LensAr LAser sysTeM for refractive cataract surgery (Lensar Inc.) has received 510(k) clearance from the FDA for the execution of arcuate incisions during cataract surgery. http://bit.ly/Z33hPL BVI BUyS ASSEtS fROM OdySSEy BeAver-visiTeC inTernATiOnAL has purchased the ophthalmic assets from Odyssey Medical Inc., which specializes in dry eye solutions. http://bit.ly/11fLjGD Facebook Poll Trending nOW To what degree are ophthalmic infections caused by drug-resistant organisms a problem in your practice? Reference • Ammer C. The American Heritage dictionary of idioms. 1997. ISBN 9780395727744. • Morin M. Limiting hospital intern shifts may not cut errors, studies find. Los Angeles Times, March 25, 2013. http://articles.latimes.com/2013/mar/25/science/ la-sci-medical-interns-hours-20130326. Accessed April 16, 2013. ES235814_OT050113_008.pgs 04.23.2013 03:43 ADV Brien Holden Vision Institute is one of the largest and most successful social enterprises in the history of eye care. By applying commercial strategies to vision research and product development the Institute has generated income for research and public health programs that provide quality eye care solutions and sustainable services for the most disadvantaged people in our world. The concern for the devastating shortfall in eye care education in developing communities, especially for correction of refractive error, became action in 1998 for those at the Institute. The lack of training institutes and educational opportunities was creating a human resource gap and a critical eye care shortage for hundreds of millions of people in need of services. The concern and willingness to address the issue gave rise to the International Centre for Eyecare Education (ICEE). Almost 15 years later, and acknowledging that 640 million people are still without access to permanent eye care, concern has galvanised into action again. To advance the process of addressing the challenge, both ICEE and Brien Holden Vision Institute will more closely align, share one common purpose and one name. Together, we believe if we harness our efforts and broaden our scope we can achieve much more. Together, we aim to drive, innovate, educate, collaborate, advocate and negotiate what is needed so that hundreds of millions of people worldwide can enjoy the right to sight. Whether it’s research to develop the technology to slow the progress of myopia, investment in new systems for diagnosis of disease, delivery of sustainable access to services or provision of eye care education in the most marginalised and remote communities in the world, the Institute will focus on the quality of vision people experience and equity in eye care access worldwide. vision for everyone... everywhere Share the vision brienholdenvision.org We believe in vision for everyone...everywhere. The Durban community in South Africa arrives in hundreds to support the Brien Holden Vision Institutes initiative Drive for Sight, part of the World Sight Day celebrations in October 2012. All attendees were offered free eye examinations, access to free or affordable low cost spectacles and referrals for further eye care where necessary. . Photo by Graeme Wyllie. Education Research Technology Public Health Brien Holden Vision Institute Foundation (formerly ICEE) is a Public Health Division of Brien Holden Vision Institute magenta cyan yellow black ES236021_OT050113_009_FP.pgs 04.23.2013 19:49 ADV 10 May 1, 2013 :: Ophthalmology Times pediatrics Gene therapy trials offer hope for inherited retinal diseases Phase III study of RPE65 for Leber’s congenital amaurosis under way, among other research By cheryl Guttman Krader; Reviewed by Edwin M. Stone, MD, PhD; Budd Tucker, PhD; and Arlene V. Drack, MD Take-Home A phase III trial of RPE65 gene therapy for Leber’s congenital amaurosis is under way. Phase I gene therapy trials for several other inherited retinal diseases are in progress or being planned. Iowa CI t y, Ia :: ecent research progress provides reason for clinicians to assume an optimistic posture toward patients with inherited retinal diseases. “It is hard to imagine all of the progress that has occurred in gene therapy research for inherited retinal diseases during the 5 years since the first human RPE65 gene therapy,” said Edwin M. Stone, MD, PhD, director of the Institute for Vision Research at the University of Iowa, Iowa City. “Now, multiple trials are under way, many others are planned, and this is really just the beginning. Dr. Stone “Fur thermore, affordable genetic testing is available for the conditions being considered for future clinical trials,” he said. “Patients should be undergoing testing now to determine their genotype so that they will be ready to participate once trials begin recruitment. “In the future, we hope that gene therapy might also be used in a genetically corrected cell replacement approach to help patients with advanced stages of disease, and we also need to think about electronic retinal prostheses that can allow people who have become completely blind from their inherited degenerative disease to function more effectively,” he added. R magenta cyan yellow black Ge n e r epl acem e n t t h er a py Reviewing the current status of gene replacement therapy trials for inherited retinal disorders, Dr. Stone noted that the phase I/II trials of adeno-associated virus (AAV)-mediated RPE65 gene replacement for Leber’s congenital amaurosis (LCA) are finishing up and a phase III trial is underway in Philadelphia and Iowa City. Additionally, numerous other trials are being organized to treat other forms of LCA and numerous other retinal degenerations. “Sixteen genes account for more than 75% of patients with the clinical findings of LCA and molecular testing for these genes is excellent today,” Dr. Stone said. He added that Project 3000 (www.project3000. org) is a philanthropically funded project at the University of Iowa’s Carver Laboratory that can help defray the cost of genetic testing for LCA patients whose families are uninsured and cannot afford the cost. “Thanks in part to this project, it is estimated that fewer than 150 individuals with LCA in the United States who are under the age of 20 years have not yet had genetic testing,” Dr. Stone said. Other gene therapy trials underway for inherited retinal diseases include a phase I trial of ABCA4A gene replacement therapy for Stargardt’s disease, which is being conducted at sites in Portland, OR, and Paris, France, and a phase I trial of MY07A gene therapy for Usher syndrome in Portland. In addition, a phase I trial of AAV-mediated CHM gene therapy for choroideremia is ongoing in Oxford, UK, and a gene therapy trial for patients with retinitis pigmentosa (RP) due to MERTK mutations was recently launched in Saudi Arabia. “A trial of AAV-mediated gene transfer of the soluble VEGF receptor Flt-1 for treatment of exudative age-related macular degeneration is being conducted in Framingham, MA, and Perth, Australia,” Dr. Stone said. “While this therapy is not relevant to pediatric ophthalmology, it has huge potential importance for ophthalmology in general.” Other studies of gene therapy in animal models that are being considered for future clinical trials include: X-linked retinoschisis; X-linked, autosomal recessive, and autosomal dominant RP; achromatopsia; Leber hereditary optic neuropathy, Bardet Biedl Syndrome, MAK-associated RP and GUCY2D-, RPGRIP1-, and CEP290-associated LCA. cell r epl acem e n t t h er a py Ongoing research to develop patient-derived induced pluripotent stem cells to replace lost photoreceptors and RPE cells aims to help individuals with more advanced stages of inherited retinal diseases. In this approach, pluripotent stem cells are generated from autologous skin, then are induced to develop into retinal precursor cells. These cells may be transfected with a normal copy of the patient’s defective gene using the same types of gene therapy vectors currently being used in vivo in clinical trials. Research conducted at the University of Iowa provides proof of principle for this type of genetically engineered cell replacement therapy [Tucker BA, et al. PLoS One. 2011]. In this study performed in an immune-compromised retinal degenerative mouse model, pluripotent stem cells were derived from the skin of red fluorescent mice and induced to generate photoreceptor precursor cells. The latter cells were then injected into the eyes of adult, nonfluorescent, rhodopsin null mice that had lost all of their photoreceptors. Follow-up testing confirmed that the injected cells differentiated into photoreceptors that made synaptic connections to the inner retina, resulting in restoration of electroretinal function. ■ edwin m. STone, md, PHd e: [email protected] Dr. Stone has no fnancial interest in the subject matter. This article is based on Dr. Stone’s presentation during Pediatric Ophthalmology 2012 at the annual meeting of the American Academy of Ophthalmology. ES236596_OT050113_010.pgs 04.24.2013 20:21 ADV magenta cyan yellow black ES235982_OT050113_011_FP.pgs 04.23.2013 19:48 ADV 12 MAy 1, 2013 :: Ophthalmology Times pediatrics Pearls address challenges of strabismus surgery Avoiding hypotropia, excyclotropia after augmented transposition surgery among tips by Cheryl guttman Krader; Reviewed by Jonathan M. Holmes, MD Roches t eR, MN Maintaining a high index of suspicion for tight superior oblique involvement in patients with strabismus due to thyroid eye disease, and then monitoring intraoperative torsion to detect its presence, can help strabismus surgeons avoid postoperative A-pattern exotropia and incyclotropia, according to Jonathan M. Holmes, MD. This was one of the practical solutions offered Dr. Holmes by Dr. Holmes. I n add it ion, he discussed avoiding hypotropia and excyclotropia after augmented transposition surgery and a posterior fixation suture modification incorporating adjustable recession for addressing incomitant deviations. Tips for sT r a bismus surgery “Surgeons who operate on enough patients with thyroid eye disease may have encountered postoperative A-pattern exotropia and incyclotropia, and one mechanism may be a mechanical effect from over-recession of the inferior rectus muscles,” said Dr. Holmes, Joseph E. and Rose Marie Green Professor of Visual Sciences, Mayo Clinic, Rochester, MN. “However, I would propose that, in some cases, this problem is due to the involvement of magenta cyan yellow black the superior oblique muscle by the thyroid eye disease that is masked by coexistent inferior rectus muscle involvement.” To identify involvement of a tight superior oblique muscle intraoperatively, Dr. Holmes recommended assessing the torsional position of the eye before and after disinserting the inferior rectus muscle and performing an exaggerated traction test of the superior oblique muscle after disinserting the inferior rectus muscle. To help with the assessment of the torsional position of the eye, he suggested placing dots on the limbus at the 6 and 12 o’clock positions using a surgical skin marking pen. If tightness of the superior oblique muscle is detected, the superior oblique tendon should be recessed to weaken it. Preoperatively, the presence of superior oblique involvement by the thyroid eye disease may be suspected clinically by measuring cyclotropia using double Maddox rods or the synoptophore, Dr. Holmes said. “In the context of a tight inferior rectus muscle, if there is only a small amount of excyclotropia, between 0° and 5° (less than expected with a very tight inferior rectus muscle), or frank incyclotropia, surgeons should suspect coexistent superior oblique muscle involvement,” he explained. (Further details are published in Holmes JM et al. J AAPOS. 2012;16:280-285.) ES235809_OT050113_012.pgs 04.23.2013 03:43 ADV 13 MAy 1, 2013 :: Ophthalmology Times pediatrics take-hoMe Jonathan M. Holmes, MD, discusses practical solutions for addressing selected problems encountered by strabismus surgeons. av o i d i n g v e r T i C a l deviaTion Monitoring torsion intraoperatively may also help surgeons avoid hypotropia and excyclotropia after augmented transposition surgery, for example, with Foster sutures. Again, Dr. Holmes recommended monitoring the torsional position of the eye intraoperatively using preplaced limbal markings with a skin marking pen. Showing that incyclotropia occurs after initial tightening of the superior rectus Foster suture, he said that surgeons can monitor the torsion while tying the inferior rectus Foster suture. “With this technique, surgeons can still use an adjustable hangback recession to titrate the alignment in straight ahead gaze, while still having the advantage of posterior fixation to address the incomitance,” Dr. Holmes said. (Further details are published in Holmes JM et al. J AAPOS. 2010;14:132-136.) ■ Jonathan M. holMes, MD e: [email protected] Dr. Holmes has no fnancial interest in the subject matter. This article is adapted from Dr. Holmes’ presentation during Pediatric Ophthalmology 2012 at the annual meeting of the American Academy of Ophthalmology. Arita Meibomian ‘I use a bow tie for the inferior rectus Foster suture.’ — Jonathan M. Holmes, MD “I use a bow tie for the inferior rectus Foster suture, starting by tying the suture with the inferior rectus muscle belly 2 mm from the lateral rectus, and then I check the torsional position of the eye, adjusting the tension of the Foster suture and the position of the inferior rectus muscle belly, until the torsional position is neutral, to protect against the hypotropia, which tends to be associated with the excyclotropia,” Dr. Holmes explained. (Further details are published in: Holmes JM et al. J AAPOS. 2012;16:136-140.) posTerior fix aTion The third technique he discussed was the use of a posterior fixation suture with adjustable recession to address the situation of a small deviation in primary gaze with a large deviation in eccentric gaze. Here, the surgeon disinserts the inferior rectus muscle (for example) from the sclera, places the posterior fixation suture 15 mm back from the insertion centrally, and passes the double-armed 6-0 Mersilene suture through the muscle at onethird of the muscle width from each of its edges. The inferior rectus muscle is reattached with 6-0 Vicryl using a sliding noose adjustment, and the Mersilene suture is then tied over the belly of the muscle, opposed to sclera, but not so tight to preclude adjustment of the recession. This new instrument has been designed by Dr. Reiko Arita of Saitama City, Japan to gently express meibum from dysfunctional meibomian glands (MGD). The special angles of the forceps allow the surgeon to easily insert and position the tips over the eyelid parallel to the lid margin. The broad, smoothly polished jaws are then used to atraumatically compress the glands – relieving any occlusions with minimal pain to the patient. This instrument is user-friendly while Watch it! addressing an upper or lower eyelid and working from either a temporal or nasal approach. K5-5900 ® 973-989-1600 U 800-225-1195 U www.katena.com magenta cyan yellow black ES235815_OT050113_013.pgs 04.23.2013 03:43 ADV glaucoma 14 May 1, 2013 :: Ophthalmology Times RNFL thickness correlates with changes in visual field SLO-MP shows higher structure/function correlation compared with standard perimetry By lynda charters; Reviewed by Sadhana V. Kulkarni, MD Take-Home The thickness of the retinal nerve fber layer at the macula is a good predictor of reductions in retinal sensitivity in advanced glaucoma. t Ot tawa, Canada :: hinning of the retinal nerve fiber layer (RNFL) with corresponding reduction in retinal sensitivity are good predictors of progression of glaucoma. However, there seems to be a higher structure/function correlation when using scanning laser ophthalmoscopy microperimetry (SLO-MP) compared with Humphrey 10-2 (H-10) standard perimetry in making these inferences. “Patients with advanced glaucoma likely have dense central 10° field defects that split fixation and make monitoring of progression inaccurate,” said Sadhana V. Dr. Kulkarni Kulkarni, MD, who is affiliated with the University of Ottawa Eye Institute and the Ottawa Hospital Research Institute, Ottawa, Canada. “It has been shown that the correlation between structure and function is a better diagnostic tool than following visual fields alone,” Dr. Kulkarni said. “Evaluating the RNFL sensitivity in areas with RNFL defects might help detect progression earlier in advanced glaucoma.” S o m e a dva n t ag e S Microperimetry may have some advantages over Humphrey perimetry, she explained, in that the same retinal locus is tested by tracking the blood vessels, there is precise localization of each stimulus with real-time tracking of fixation and better reliability indices, and therefore, a good structure/function correlation. Dr. Kulkarni and colleagues conducted a single-center, nonrandomized, prospective, magenta cyan yellow black longitudinal study in which they compared the efficacy of standard automated perimetry (SAP) with that of SLO-MP for predicting glaucomatous progression at 3 years in 12 patients (18 eyes) with advanced primary angleclosure glaucoma who had central 10° visual field defects and to correlate the changes with corresponding sectoral RNFL loss measured by SLO-optical coherence tomography (OCT). The investigators used a modified 52-points 10-2 SLO-MP grid to evaluate patients within 3 months after their last reliable SAP H-10 test. A Goldmann size III, 200-millisecond stimulus at 1-second intervals was used to administer the SLO-MP test. Ambient illumination was photometrically standardized with the Gossen Starlite instrument to justify the absence of a bowl in SLO-MP test. A standard 3.5-mm CSME (clinically significant macular edema) grid was superimposed on the SLO-MP data and the 52 points were divided into three rings that were 1, 2, and 3 mm, respectively from the center of the macula. The same CSME grid was used to divide the 68 points on the H-10 raw scale into three rings and then compared with the SLO-MP rings by flipping it over the horizontal meridian to maintain retinal topography, Dr. Kulkarni explained. The primary outcome measure was the correlation of the retinal sensitivity to the mean baseline macular RNFL thickness; the secondary outcome measure was the comparison of the decline in the mean retinal sensitivities of the SLO-MP and Humphrey-10 at 3 years. The results showed that for ring segment 1 there was no correlation between retinal sensitivity and the mean baseline macular RNFL thickness using the two instruments. However, Dr. Kulkarni noted that with rings 2 and 3 there were significant correlations between the two parameters for both instruments (ring 2, SLO-MP, p <0.04 and H-10, p <0.05; ring 3, SLO-MP, p <0.12 and H-10, p <0.03). Interestingly, she showed that the decline in overall threshold macular sensitivities measured with the SLO-MP instrument was “impressively more” compared with the H-10 (SLO-MP = –6.12 ± 2.0, H-10= –1.87 ± 2.23), although the decrease with both instruments reached significance. Since 98% of eyes with advanced glaucoma have perimacular RNFL changes, Dr. Kulkarni commented, early diagnosis of progression in these patients with advanced glaucoma through evaluation of the ganglion cell complex, which constitutes 35% of the retinal thickness at the macula, rather than the peripapillary RNFL, makes sense. Explaining the results further, she said that no correlations were found between the retinal sensitivity and the baseline RNFL thickness in ring 1 by either instrument, probably because even though the retinal ganglion cell thickness correlates well with H-10 loss for the central 7.2° from the fovea; there is a great deal of ganglion cell displacement within 1 mm of the center of the fovea. However, correlations were significant in rings 2 and 3 with SLO-MP than H-10 as SLO-MP detects glaucomatous change better in areas with advanced RNFL thinning that can go undetected by H-10. ImplIcatIonS ar e ‘huge’ The clinical implications of early detection of progression are “huge,” she noted. “Early detection of progression in these advanced cases could help preserve the severely compromised visual fields,” Dr. Kulkarni emphasized. “If the exact location of the preferred retinal locus could be identified, precise residual visual field mapping could aid in the development of low-vision aids.” The thickness of the retinal nerve fiber layer by SLO-OCT and retinal sensitivity measurements obtained with SLO-MP together are good predictors for progression of glaucoma compared with the Humphrey 10-2 perimetry evaluation. There is a trend toward higher structure/function correlation with SLO-OCT and SLO-MP, she concluded. ■ SadHana V. kulkarni, md e: [email protected] Dr. Kulkarni has no fnancial interest in the subject matter. This article is adapted from Dr. Kulkarni’s presentation at the 2012 annual meeting of the American Academy of Ophthalmology. ES235813_OT050113_014.pgs 04.23.2013 03:43 ADV MAY 1, 2013 :: Ophthalmology Times 15 glaucoma On the intricacy of uveitic glaucoma Management requires aggressive therapy of infammation, medical therapy of elevated IOP By Lynda Charters; Reviewed by Sumru Onal, MD, FEBOphth TAKE-HOME Glaucoma is a frequent complication of uveitis arising from the infammatory disease process itself or from corticosteroid use or both. IS TANBUL, T URK E Y :: MANAGEMENT OF GLAUCOMA in patients with uveitis should aggressively target intraocular inflammation and the underlying systemic disease. Sumru Onal, MD, FEBOphth, discussed the numerous medical, laser, and surgical options available to manage these complicated cases. “Glaucoma develops in from 20% to 40% of patients Dr. Onal with uveitis, although historically, the diagnosis has often been made on the basis of IOP elevation alone,” said Dr. Onal, associate professor of ophthalmology, Department of Ophthalmology, Koc University School of Medicine, Istanbul, Turkey. “Uveitic glaucoma is more common in some uveitides, and numerous mechanisms are involved in its pathogenesis,” Dr. Onal said. “Almost all patients with uveitis with elevations in IOP require treatment with anti-inflammatory and antiglaucoma medications. Thirty percent of these patients will require a glaucoma surgery and the percentage increases to almost 60% in pediatric patients.” A wide range of therapies (i.e., medical, laser, and surgical) are involved in the management of uveitic glaucoma. MEDICAL THER APY The management of uveitic glaucoma requires treatment of the primary disease and glaucoma. Corticosteroids are still the mainstay of treatment of acute intraocular inflammation, but many patients are at risk of steroid-induced ocular hypertension, she commented. Cycloplegics are used to prevent posterior synechiae. The offlabel use of immunomodulatory therapy (IMT) is the standard of care in the uveitis practice today. Apart from controlling the inflammation, IMT has a steroid-sparing effect and has magenta cyan yellow black the potential to induce long-term remissions. In patients with no response to IMT, biological response modifiers are an option. Antiviral drugs are used for anterior uveitis associated with herpes simplex virus and cytomegalovirus. Medical therapy of elevated IOP includes the first-line choices of topical beta-blockers and topical carbonic anhydrase inhibitors (CAIs); alpha-2 agonists can be used but should be avoided in young patients because of adverse effects on the central nervous system; prostaglandin agonists can lower IOP without increasing uveitic flare-ups in patients with controlled uveitis treated with IMT. Oral CAIs can be used when the disease is refractory to topical CAIs. Oral intravenous hyperosmotic agents can be beneficial for patients with acutely elevated IOP. Patients with uveitic glaucoma often need more than one drug to manage the IOP. LASER THER APY Laser iridotomy is indicated for patients with pupillary block glaucoma. In cases in which the laser iridotomy closes, a surgical iridectomy may be needed; surgical iridectomy also might be required in pediatric patients with uveitis and pupillary block glaucoma. Argon laser trabeculoplasty generally is not beneficial in eyes with uveitis. Transscleral laser cyclophotocoagulation can be used to treat patients in whom IOP lowering cannot be achieved by any other means. However, the risk of permanent hypotony increases with this treatment. SURGICA L M A NAGEMEN T Glaucoma filtration surgery is indicated in patients with elevated IOP refractory to maximum tolerated medical therapy. The conjunctiva in these patients should have no or minimal scarring. “Well-controlled inflammation during surgery decreases the risk of bleb encapsulation and failure,” Dr. Onal said. Trabeculectomy can be performed with or without the use of antimetabolites to treat uveitic glaucoma. The success rates of achieving an IOP below 21 mm Hg vary (i.e., 50% to 100% at 1 and 2 years postoperatively and from 50% to 76% at 5 years postoperatively). The success rates with unaugmented trabeculectomy have been modest. Dr. Onal noted that the risk of failure in the long term is substantial. Trabeculectomy with mitomycin C (MMC) is associated with a significant increase in the long-term success of the surgery. A study that compared the short-term (1- and 2-year rates) success of trabeculectomy with MMC in patients with uveitic glaucoma and those with high-risk primary open-angle glaucoma (POAG) showed no difference between the groups in the short term when the procedures were the initial surgeries. However, the failure rate at 2 years was higher in eyes with uveitis. Studies of the longer-term success of an initial trabeculectomy with MMC procedure showed no significant difference at 5 years between patients with uveitis and POAG. The results of trabeculectomy with 5-fluorouracil were found to be comparable to those of trabeculectomy with MMC over the long term. However, both drugs are associated with ocular adverse effects. Bleb and filter failure are associated with younger age, African-American descent, perioperative/postoperative inflammation, and the need for more surgery among others. Glaucoma drainage devices are indicated for patients with extreme conjunctival scarring, active/recurrent uveitis, and those in whom trabeculectomy has failed. In eyes with uveitis, shunt failure and corneal complications are the most common problems associated with glaucoma drainage devices. Goniotomy is minimally invasive and may be consider for pediatric patients before trabeculectomy with its excessive scarring and implant surgery. Dr. Onal concluded, “Treatment of patients with uveitic glaucoma should first attempt aggressive and comprehensive control of intraocular inflammation and the underlying systemic disease. Uncontrolled IOP can be managed with medical therapy first and then surgical intervention in refractory cases. Glaucoma drainage devices have increased long-term success rates. Randomized controlled trials should assess the safety and efficacy of new procedures and implants in patients with uveitic glaucoma.” ■ SUMRU ONAL, MD, FEBOPHTH E: [email protected] Dr. Onal has no fnancial interest in the subject matter. This article is adapted from Dr. Onal’s presentation during Uveitis Subspecialty Day at the 2012 annual meeting of the American Academy of Ophthalmology. ES235817_OT050113_015.pgs 04.23.2013 03:43 ADV 16 Special Report ) DRY EYE making a diagnosis is only the first step Dry eye common, but complicateD Making a diagnosis is only the frst step in treating patients with dry eye syndrome By Liz Meszaros; Reviewed by Christina Rapp Prescott, MD, PhD D Balt imore :: take-home Despite the fact that dry eye is a very common complaint and a very common symptom, ophthalmologists must be familiar with its various signs, be able to assess severity, and treat it effectively. ry eye is a common complaint. Therefore, ophthalmologists must be familiar with its various signs, be able to assess severity, and treat it effectively. “No matter what your specialty is or what your area of interest is, you will see patients who come in with a chief complaint of dry eye,” said Christina Rapp Prescott, MD, PhD, assistant professor of ophthalmology, cornea, external disease & refractive surgery, Wilmer Eye Institute, Johns Hopkins University School of Medicine. “It is therefore important for everyone to have a framework of how to approach these patients.” Despite the fact that dry eye is a very common complaint and Severity Level 1 2 3 4 Symptoms Mild to moderate Mild to moderate Severe Extremely severe Conjunctival Signs Mild to moderate Staining Staining Scarring Corneal Staining Mild punctate staining Marked punctate staining, central staining, flamentary keratitis Severe staining, corneal erosions Other Signs Tear flm, decreased vision(blurring) • Treatment Options • Patient education Environmental modifcation • Preserved tears • Control allergy • • • • • If not improvement, add level 2 treatments If not improvement, add If not improvement, add level 3 treatments level 4 treatments Nonpreserved tears Gels, ointments • Cyclosporine A • Topical steroids • Secretagogues • Nutritional support Oral tetracyclines Punctal plugs (once infammation is controlled) Systemic antiinfammatory therapy • Oral cyclosporine Acetylcysteine • Moisture goggies • Surgery (punctual cautery) The International Dry Eye Workshop (DEWS) defned four categories of dry eye severity. (Adapted from Behrens A, Doyle JJ, Stern L, et al. Dysfunctional tear syndrome: A Delphi approach to treatment recommendations. Cornea. 2006;25:900-907) Dry eye evaluation & management magenta cyan yellow black a very common symptom, the definition of dry eye is something that has been quite controversial, Dr. Prescott said. Not until 2007 was an official definition developed, as a result of the International Dry Eye Workshop Study Group (DEWS), which defined four categories of dry eye severity. Dry eye is currently defined as “a multifactorial disease of the tears and ocular surface Dr. Prescott that results in symptoms of discomfort, visual disturbance, and tear film instability, with potential damage to the ocular surface. It is accompanied by increased osmolarity of the tear film and inflammation of the ocular surface.” The prevalence of dry eye disease is quite high and on the rise, Dr. Prescott continued. In the United States, 7.5% of men aged ≥80 years, and 10% of women aged ≥75 years have dry eye complaints and symptoms that meet the official definition of dry eye. “This prevalence is even higher in other countries, most notably in Asia, where [more than] one-third of the population (33.7%) meets the definition for dry eye syndrome,” she said. “This is really quite epidemic in proportion throughout the world.” The most common dry eye symptoms patients complain of include dryness, ocular fatigue, grittiness, redness, and soreness. To assess symptoms of dry eye, two questionnaires— the “Ocular Surface Disease Index” and the “Symptom Assessment in Dry Eye”—may be helpful, Dr. Prescott said. “Unfortunately, no questionnaire has really proven itself to be the best option,” she said. “Symptoms are very subjective and often not correlated with the severity of disease that you will see on the exam, and this makes [a diagnosis] quite challenging. Further complicating the diagnosis is the fact that symptoms can also vary depending on the time and the day, or season to season. Many different treatments exist for patient with dry eye and these include: artificial tears, lubricating ointment, oral omega-3 fatty acid supplementation, punctal occlusion, warm compresses, topical cyclosporine, lid scrubs, humidifier use, eye wash, erythromycin, moisture Continues on page 18 : Complicated Marguerite McDonalD, MD, discuses symptoms in the dry eye diagnosis and management, the role of osmolarity, variability as a marker for disease severity, and strategies for improving pre-and post-op management of dry eye following refractive surgery. View the webinar at eyecare on demand. go to: http://bit.ly/11egfk3 ES236610_OT050113_016.pgs 04.24.2013 20:31 ADV 17 MAy 1, 2013 :: ophthalmology times Special Report ) DRY EYE Working to complete the dry eye therapeutic story By George W. Ousler iii; Special to Ophthalmology Times We’ve spent years evaluating each intricate detail of dry eye disease in order to find treatments for those plagued by the gritty, burning, stinging symptoms. As novel treatments advance at a rapid pace through the pipeline, it’s no doubt a tribute to the development of both our enhanced understanding of the disease and the improved technologies that, used in conjunction, will help to complete the dry eye therapeutic story. While each dry eye story is different, we’ve learned for most dry eye sufferers, their symptoms tend to fluctuate as the seasons change, which makes conducting environmental studies especially challenging. One way to minimize the environmental factors is to conduct a clinical trial during a single season. Even doing so, however, does not account for additional situational factors that may influence an individual patient’s dry eye symptoms, such as extended visual tasking or certain medications that cause ocular drying. The Controlled Adverse Environment (CAE) model was designed to reduce both the environmental and situational factors by controlling humidity, temperature, air flow, lighting conditions, and visual tasking.1 Using a clinical model that reproduces a standard ocular challenge equally for all patients is a valuable tool for investigating treatments for dry eye. One key aspect of the CAE is its utility in distinguishing subpopulations of patients with dry eye, making it especially useful for screening and enriching patient populations. Our understanding of dry eye and the way it is assessed in the clinic has become more precise, yielding information essential to advancing potential treatments. What was once thought to be a condition due solely to insufficient tear production is now recog- magenta cyan yellow black nized as a multifactorial disease with a variety of therapeutic approaches. This is a result of significant strides in ocular surface research and improvements in clinical assessment techniques. The concept of tear-film breakup time (TFBUT) in particular has come a long way since the pioneering work of Lemp in the 1970s. No longer are large or varying amounts of sodium fluorescein used, artificially lengthening breakup time, but rather very precise microquantities in order to obtain more accurate values.2 t e a r f i L M a n a Ly s e s While TFBUT remains a common measure used in clinical research for measuring the properties of the tear film, we’ve also learned that it does not say enough about the overall ocular tear film dynamics. Recognizing that blink also plays a role in the health and stability of the ocular surface, the Ocular Protection Index (OPI) was developed. As a ratio of the interblink interval (IBI) and tear-film break-up time (TFBUT/IBI), lower OPI values, particularly those less than one, are associated with increased risk of signs and symptoms of dry eye, since it is likely that corneal exposure occurs prior to the next blink. While the OPI took the concept of TFBUT one step further in assessing ocular surface health, the tool did not account for a more dynamic ocular surface assessment, that of tear-film breakup area. The development of the OPI 2.0 System provides clinicians with a fully automated, real-time measurement of corneal surface exposure, as the system is designed to evaluate ocular surface protection under a normal blink pattern and normal visual conditions, two key concepts necessary for accurate, realistic measurements. In an initial study, the OPI 2.0 system distinguished between dry eye and normal by way of the added area metrics (corneal surface exposure).3 This method was validated in a second study that demonstrated that the fully automated system was able to provide accurate, reliable measures of corneal surface exposure while distinguishing between normal subjects and subjects with dry eye.4 In a study published late last year utilizing the CAE, the corneal surface exposure metric of mean breakup area (MBA) was able to detect changes in the ocular surface induced by the CAE.5 Following CAE exposure, subjects experienced a decrease in MBA, demonstrating a possible compensatory mechanism. BLi n K Pat t er ns Do you know how many times you’ve blinked since you started reading this article? Wouldn’t it be interesting if you did? Despite appearing to be an incredibly simple action, blinking is actually quite complicated, as are the implications of blink physiology for patients with dry eye. Continuing research on blink patterns is essential in order to explore fully the impact blinking has on dry eye, and moving forward, what benefits therapies may have by Continues on page 18 : dry eye ES236657_OT050113_017.pgs 04.24.2013 21:01 ADV 18 MAy 1, 2013 :: ophthalmology times Special Report ) DRY EYE Dry eye ( Continued from page 17 ) considering the effect blink has on the tear film of patients with dry eye. In a recent study, for example, IBI was significantly shorter for patients with dry eye performing a visual task compared with normal subjects.6 Utilizing digital imaging to track natural blink patterns offers an advantage over the more invasive, traditionally used measures. In a study examining lid contact time, or lid closures, of up to multiple seconds, termed “extended blinks,” a concept heavily studied in fatigue research, subjects with dry eye had longer lid contact times than normal subjects.7 In addition to having longer durations of extended blinks, IBIs were significantly longer after an extended blink for dry eye subjects (potentially indicating a compensatory response), and blinks of longer than 1 second occurred almost exclusively in subjects with dry eye. Other research considering extended blinks has found that subjects with dry eye are more than 10 times more likely than normal subjects to exhibit blinks of 1 second duration or longer (Lafond A, et al. IOVS 2013;54:ARVO E-Abstract 962). Blink, while perhaps appearing inconsequential, should be carefully considered when studying dry eye. By gaining a more comprehensive understanding of patterns, we may be better able to diagnose subjects with dry eye, and determine duration of CoMpLICateD ( Continued from page 16 ) goggles, cevimeline, and pilocarpine. “When we see this many different treatments for one disease, it makes us wonder if these treatments are effective. Why are there so many different options? Why is there so much variability if we are treating only one disease?” Dr. Prescott said. Is there a standard treatment for dry eye? In 2006 the Delphi Treatment Algorithm was developed for patients with dry eye disease. It categorizes patients into four levels according to disease severity. “But this only addresses dry eye according to severity, not according to the underlying cause,” Dr. Prescott said. U n De r Ly i nG c aU s e s “What if dry eye is not just dry eye? What if magenta cyan yellow black disease, underlying ocular discomfort, and tear film stability, as well as assess other therapeutic effects. Further, examining variations of blink patterns may help to categorize subgroups of patients who may have a different response to treatment. aU t OM at e D a n a Ly s e s The integration of automated analyses has been quite useful in enhancing our understanding of dry eye. Numerical scales are the mainstay used by most practitioners and clinical researchers to quantify and classify the extent and quality of ocular redness in patients with dry eye. In order to supplement the subjective evaluation of a clinical grader, however, automated detection of hyperemia has been utilized to provide increased repeatability and sensitivity. Dry eye is particularly well suited for automated detection of redness because hyperemia occurs as horizontal banding over the conjunctiva.8 Computerized technologies are also showing their utility in assessing lissamine green staining severity (Lane K, et al. IOVS 2013;54: ARVO E-Abstract 6045). As of late, there has also been buzz within the industry regarding mucins and their impact on the tear film of the ocular surface. Being able to measure levels of mucin in the tear film may give way to additional therapies targeted at stimulating mucin secretion. Any defect in the aqueous, lipid, and/or mucin layers of the tear film can cause and/or exacerbate dry eye symptoms, so targeting these layers for potential treatments is of utmost importance. Advancements in technology and our ever- there is an underlying cause?” Dr. Prescott asked. In these patients, she said, first look for a systemic cause of disease, and look especially at the skin. Systemic causes can include Sjögren’s syndrome, Stevens-Johnson syndrome, and thyroid disease. “Any kind of underlying autoimmune problem will be quite challenging to deal with,” Dr. Prescott said. “Work with the patient’s rheumatologist to treat the underlying cause. These patients need aggressive treatment of inflammation as well as lubrication.” Once systemic causes have been addressed, you can continue to look for specific ocular causes of dry eye symptoms. These can include: > Eyelid position, which can be affected by floppy eyelid syndrome, post-surgical effects, thyroid eye disease, and neurotrophic problems caused by past herpetic infection or a neurologic event. Treatments include ointment, taping worse eye at night, temporary or permanent tarsorhaphy, eyelid surgery, or PROSE lenses (Boston Foundation for Sight). “Bandage lenses are also an option, but these growing understanding of dry eye will surely help generate future therapies for those plagued by the symptoms of the disease. What we don’t know, we will seek to learn, and what we do know, we will capitalize on in the hopes of coming full circle with our attempts to combat dry eye. ■ References 1. Ousler GW, Gomes PJ, Welch D, Abelson MB. Methodologies for the study of ocular surface disease. The Ocular Surface. Vol 3; 2005:143-154. 2. Abelson MB, Ousler GW III, Nally LA, Welch D, Krenzer K. Alternative reference values for tear film break up time in normal and dry eye populations. Adv Exp Med Biol. 2002;506(Pt B):1121-1125. 3. Abelson R, Lane KJ, Angjeli E, Johnston P, Ousler G, Montgomery D. Measurement of ocular surface protection under natural blink conditions. Clin Ophthalmol. 5:1349-1357. 4. Abelson R, Lane KJ, Rodriguez J, et al. Validation and verification of the OPI 2.0 System. Clin Ophthalmol. 6:613-622. 5. Abelson R, Lane KJ, Rodriguez J, et al. A single-center study evaluating the effect of the controlled adverse environment (CAE(SM)) model on tear film stability. Clin Ophthalmol. 6:1865-1872. 6. Johnston PR, Rodriguez J, Lane KJ, Ousler G, Abelson MB. The interblink interval in normal and dry eye subjects. Clin Ophthalmol. 7:253-259. 7. Rodriguez JD, Ousler GW, 3rd, Johnston PR, Lane K, Abelson MB. Investigation of extended blinks and interblink intervals in subjects with and without dry eye. Clin Ophthalmol. 7:337-342. 8. Gomes PLK, Abelson MB, Rodriguez J, Angjeli E. Clinical evaluation of automated detection and grading of conjunctival hyperemia in dry eye and allergic conjunctivitis patients. TFOS Asia. Kamakura, Japan; 2012. GeorGe W. ouSLer III is vice president of dry eye at Ora Inc., Andover, MA. patients need to be treated with antibiotic prophylactically and followed closely for infection,” Dr. Prescott said. > Eyelid margin problems, such as blepharitis, conjunctivitis, or excessive conjunctiva. > Episcleritis and scleritis. > Limbal stem cell deficiency. > Corneal dystrophy or recurrent erosion syndrome. “If you cannot find an underlying cause, treat the dryness using the Delphi Treatment Algorithm,” Dr. Prescott concluded. ■ Reference • Behrens A, Doyle JJ, Stern L, et al. Dysfunctional tear syndrome: a Delphi approach to treatment recommendations. Cornea. 2006;25:900-907. ChrIStIna rapp preSCott, MD, phD P: 410/836-7010 or 410/893-0480 F: 410/877-9796 Dr. Prescott did not indicate any proprietary interest in the subject matter. This article is adapted from Dr. Prescott’s presentation at the 25th annual Current Concepts in Ophthalmology meeting, held in association with the Wilmer Eye Institute and Ophthalmology Times. ES236611_OT050113_018.pgs 04.24.2013 20:31 ADV magenta cyan yellow black ES236001_OT050113_019_FP.pgs 04.23.2013 19:48 ADV 20 May 1, 2013 :: Ophthalmology Times Special Report ) DRY EYE How punctal occlusion improves multifocal IOL satisfaction Two cases illustrate benefts in managing dry eye before, after surgery with implantation By Craig F. McCabe, MD, PhD, FaCs, and shannon e. McCabe, Bsc, Special to Ophthalmology Times Patients undergoing cataract surgery who choose multifocal or estingly, it has been reported that 50% to 60% of patients with cataracts have significantly abother premium IOLs have high expectations normal tear break-up time and central corneal that are quite similar to those of younger pa- staining, despite being asymptomatic.7 If surtients undergoing LASIK. In order to meet those geons miss treating dry eye in these patients, the expectations, it is imperative to treat dry eye likelihood of selecting the incorrect IOL power disease before and after surgery. or the wrong axis for placement of a toric IOL Dry eye disease is strongly correlated with or corneal relaxing incision (CRI) increases. age, so ophthalmologists can expect a relatively Although one might consider treating dry high incidence in a cataract surgery popula- eye with steroids or cyclosporine, punctal oction. Even in patients with no history of dry clusion can be a useful modality for patients eye complaints, the condition is with cataracts. In this age group, very common after cataract surdry eye often results from a pergery.1 Post-surgical dry eye may manent decrease in lacrimal gland aqueous production secondary to be due to pre-existing subclinical fibroblast infiltration causing padryness, ocular surface irritation Patients undergoing renchymal destruction.8 Thus, pacaused by topical anesthesia and cataract surgery who preservatives in eye drops used tients with cataracts may have an choose multifocal during surgery, and/or the disrupinflamed dry eye as a symptom of or other premium tion in corneal innervation from their dry ocular surface from an IOLs have high surgical incisions.2 age-related decrease in the tear expectations. It is film’s aqueous component, rather Regardless of the cause, evidence imperative to treat dry than from a primary inflammasuggests that ocular surface diseye disease before and tory disease. ease has a significant effect on after surgery. Two recent cases in which puncpatient satisfaction following cortal occlusion was beneficial to paneal or lens refractive surgery.3,4A suboptimal tear film may lead to an increase in tients with multifocal IOL illustrate the importotal and higher-order aberrations and, conse- tance of addressing dry eye both preoperatively quently, a reduction in retinal image quality.5,6 and postoperatively. In both of these cases, had Dry eye can also affect the accuracy of pre- failed a trial of artificial tears had failed. Puncoperative keratometry and topography. Inter- tal occluders (Parasol Punctal Plug Occluders, take-home Figure 1. NIDEK OPD-Scan of the left cornea before punctal plug therapy magenta cyan yellow black Odyssey Medical) were inserted in the lower puncta of each of these patients. Case 1 A 75-year-old white female was referred for progressive vision loss and red eyes. She complained of glare and difficulty driving at night as well as painful, gritty eyes. These problems forced her to cut back on activities she enjoyed, and she wanted to “get her life back.” Her exam demonstrated a decreased tear meniscus, 2+ inferior corneal punctate epithelial erosions, and a 3+ nuclear sclerotic cataract OU. The lid margin was normal. A scan (Nidek OPDScan, Marco) of her left eye revealed a placido image with the characteristic dull corneal light reflex and wavy, irregular mires, especially inferiorly, of a dry ocular surface (Figure 1). Six weeks after punctal occlusion, her dry eye symptoms were greatly improved. Compared with the first scan, there was a noticeable improvement in the placido image of the axial map (Figure 2). Also, spherical aberration decreased significantly from 0.241 to 0.136 µm. Lastly, the K-values changed from 42.61/43.27 @ 41° to 42.88/43.72 @ 53° (a difference in average K of 0.36 D and in axis of 12°) and 0.8 D increase in average pupil power. In both eyes, dry eye treatment resulted in a 0.5-D change in the IOL power selected to Continues on page 22 : Occlusion Figure 2. Preoperative NIDEK OPD-Scan after punctal plug therapy ES237209_OT050113_020.pgs 04.25.2013 02:01 ADV The new OCULUS Keratograph 5M Visit us at ARVO – Booth #1314 More than a topographer! Topography and advanced external imaging for dry eye assessment • High-resolution color camera • Imaging of the upper and lower meibomian glands • Non invasive tear film break up time and tear meniscus height measurements facebook.com/OCULUSusa Toll free 888 - 519 - 5375 [email protected] www.oculususa.com magenta cyan yellow black ES236020_OT050113_021_FP.pgs 04.23.2013 19:49 ADV 22 May 1, 2013 :: Ophthalmology Times Special Report ) DRY EYE occlusion ( Continued from page 20 ) achieve a plano result (Table 1). It also revealed that her corneal astigmatism was significant enough to warrant CRIs. One month after cataract surgery with a multifocal IOL and CRIs, her uncorrected visual acuity (UCVA) OS was 20/20 and J1+ with a manifest refraction of –0.25 + 0.25 × 006°. She was very satisfied with her new vision and enthusiastically looked forward to having surgery on her right eye. Had we based the surgical plan on initial data without the benefit of punctal occlusion, the patient would likely have ended up with a manifest refraction of –0.75 +0.75 × 045 at best. Thus, preoperative treatment can mean the difference between needing to perform an enhancement procedure on an unsatisfied patient and having a very satisfied patient with a premium lens. Case 2 A 65-year-old white female presented 1 week after uncomplicated cataract surgery with a multifocal IOL (Tecnis Multifocal IOL, Abbott Medical Optics) in the left eye. She complained that the eye felt “sandy” and that her vision had worsened after postoperative day 1. Her manifest refraction was –0.50 +1.50 × 175° yielding UCVA of 20/50 and J3. Postopera- tive dry eye and irregular astigmatism were diagnosed (Figure 3). A punctal plug was easily inserted into her left lower eyelid, and the potential need for corneal relaxing incisions was discussed. One month later, UCVA had improved to 20/25 and J1. Her MR was –0.25 +0.75 × 178°, and the ocular foreign body sensation had resolved. The total wavefront error improved from 1.089 to 0.580 µm, while the root mean square (RMS) for a 3-mm pupil improved from 0.93 to 0.31 D, corresponding to a much sharper and more regular placido image (Figure 4). Three months later, she was offered the option of a small CRI that further improved her UCVA to 20/20 and J1+, residual MR to +0.25 D sphere, total wavefront error to 0.349 µm, and RMS to 0.22 D. Pat i e n t s at i s FaC t ion In this case, treatment of postoperative dry eye using punctal occlusion turned an unhappy patient with a multifocal IOL into a happy one. The improvement in her refraction with treatment demonstrates the importance of optimizing the ocular surface before performing costly and/or invasive corrective procedures that may further stress an already compromised ocular surface. Ultimately, the goal of multifocal lens implantation is patient satisfaction with the visual outcome. Punctal occlusion before and after premium IOL surgery is a fast, safe, effective, and affordable treatment Figure 3. Postoperative NIDEK OPD-Scan before punctal plug therapy magenta cyan yellow black oD Formula: Holladay II Alcon SN6AD1 Procedure: Std Phaco MFG ACD(US): 5.49 os Alcon SN6AD1 Procedure: Std Phaco MFG ACD(US): 5.49 IOL Pred.Ref. IOL Pred.Ref. 24.00 0.25 23.50 0.30 24.50 -0.09 24.00 -0.04 24.51 -0.10 24.09 -0.10 25.00 -0.44 24.50 -0.39 25.50 -0.80 25.00 -0.74 oD Formula: Holladay II Alcon SN6AD1 Procedure: Std Phaco MFG ACD(US): 5.49 os Alcon SN6AD1 Procedure: Std Phaco MFG ACD(US): 5.49 IOL Pred.Ref. IOL Pred.Ref. 23.00 0.53 23.00 0.37 23.50 0.19 23.50 0.03 23.92 –0.10 23.68 –0.10 24.00 –0.15 24.00 –0.32 24.50 –0.50 24.50 –0.67 Table 1. Holladay II printout before and after punctal plug therapy to improve both patient and physician satisfaction greatly. ■ References 1. Roberts CW, Elie ER. Dry eye symptoms following cataract surgery. Insight. 2007;32:14-23. 2. Kohlhaas M. Corneal sensation after cataract and refractive surgery. J Cataract Refract Surg. 1998;24:1399–1409. 3. Woodward MA, Randleman JB, Stulting RD. Dissatisfaction after multifocal intraocular lens implantation. J Cataract Refract Surg. 2009;35:992-997. 4. Levinson BA, Rapuano CJ, Cohen EJ, Hammersmith KM, Ayres BD, Laibson Figure 4. Postoperative NIDEK OPD-Scan one month after punctal plug therapy ES237210_OT050113_022.pgs 04.25.2013 02:01 ADV 23 May 1, 2013 :: Ophthalmology Times Special Report ) PR. Referrals to the Wills Eye Institute Cornea Service after laser in situ keratomileusis: reasons for patient satisfaction. J Cataract Refract Surg. 2008;34:32-39. 5. Lin YY, Carrel H, Wang IJ, Lin PJ, Hu FR. Effect of tear film break-up on higher order aberrations of the anterior cornea in normal, dry, and post-LASIK eyes. J Refract Surg. 2005;21:S525-S529. 6. Hofer H, Chen L, Yoon GY, Singer B, Yamauchi Y, Williams DR. Improvement in retinal image quality with dynamic correction of the eye’s aberrations. Opt Express. 2001; 8:631-463. Corneal transplants use pre-loaded tissue From staf Reports 7. Trattler W, Reilly C, Goldberg D, et al. Prospective health assessment of cataract patients’ ocular surface study. Poster presented at: Annual meeting of the American Society of Cataract and Refractive Surgery; March 2011; San Diego, CA. 8. Ogawa Y, Yamazaki K, Kuwana M, Mashima Y, Nakamura Y, Ishida S, et al. A significant role of stromal fibroblasts in rapidly progressive dry eye in patients with chronic GVHD. Invest Ophthalmol Vis Sci. 2001;42:111–119. STABILITY | DRY EYE craig F. Mccabe, MD, PhD, Facs, is a clinical instructor at Vanderbilt University and is in private practice at McCabe Vision Center, Murfreesboro, TN. Readers may contact him at 615/904-9024 or [email protected]. shannon e. Mccabe, bsc, is a medical student at Northeast Ohio Medical University, Rootstown, OH, and can be reached at [email protected]. The authors did not indicate any fnancial interest in the subject matter. CONTROL | VISUALIZATION DESIGNED SPECIFICALLY FOR MIGS AND INTRAOPERATIVE GONIOSCOPY PROCEDURES Tampa, F L :: cartridges Pre-loaded by an eye bank (EndoGlide, Angiotech Pharmaceuticals Inc.) have been successfully used in corneal transplantation, according to the Lions Eye Institute for Transplant and Research (LEITR). The cartridges were selected for initial endothelial keratoplasty transplant procedures utilizing donor endothelial tissue that was precut, trephined, and pre-loaded into the device at LEITR in Tampa, FL. The loaded cartridges were then transported to the Massachusetts Eye and Ear Infirmary, Boston, where the procedures were performed by Roberto Pineda II, MD, associate professor of ophthalmology at Harvard Medical School. “Tissue preparation and device pre-loading by eye banks not only simplifies the surgery [but] may provide increased reproducible outcomes for endothelial keratoplasty,” said Dr. Pineda. In a pre-clinical study presented at the 2012 Association for Research in Vision and Ophthalmology (ARVO) annual meeting, LEITR reported that eye banks are able to prepare and load corneal tissue safely into the cartridges; corneal buttons pre-loaded by LEITR sustained an average of 9.07% endothelial cell damage, compared with 36.2% in control group tissue that was loaded into the insertion system on site, a statistically significant difference (p = 0.004). ■ FLOATING LENS STABILIZATION RING MULTIPLE DEGREES OF FREEDOM DEVELOPED IN COLLABORATION WITH STEVEN VOLD, MD IwantmyTVG.com Volk Optical Inc.: Tel: 440-942-6161 - Email: [email protected] © 2013 Transcend Medical, Inc. and Volk Optical Inc. Patent Pending. PM-01022 Rev. A Caution: Federal law (USA) restricts this device to sale by or on the order of a physician. For a complete listing of indications,contraindications, precautions, and warnings, please refer to the Instructions For Use which accompany each product. magenta cyan yellow black ES237208_OT050113_023.pgs 04.25.2013 02:01 ADV 24 May 1, 2013 :: Ophthalmology Times Special Report ) DRY EYE Dry eye has new point of care Expanded array of diagnostic platforms target identifcation of dry eye disease By cheryl guttman Krader; Reviewed by Stephen C. Pfugfelder, MD Hous ton :: There are a varieTy of new diagnostic tests for dry eye and a number of reasons why clinicians should consider incorporating these technologies into practice, said Stephen C. Pflugfelder, MD. “The addition of certain tests appears to improve the ability to diagnose and classify tear dysfunction and may help identify patients with tear dysfunction who are poor candidates for LASIK or multifocal IOL surgery,” said Stephen C. Pflug felder, MD, Professor and James and Margaret Elkins Chair, Department of Ophthalmology, Baylor College of Medicine, Houston, Dr. Pfugfelder TX. “These tests may also prove valuable for guiding therapeutic decision making and for monitoring therapeutic efficiency.” Thr ee caTegories The new diagnostic technologies represent three categories: tests for evaluating tear composition, techniques for tear film imaging, and a method for sampling ocular surface cells for impression cytology. The devices for measuring tear composition include one instrument that measures tear osmolarity (TearLab, TearLab) by sodium ion conductivity in a 50 nl sample collected from the inferior tear meniscus. “It is well know that tear composition is altered in eyes with tear dysfunction due to lacrimal gland disease where there are reduced concentrations of factors secreted by the lacrimal glands and increased osmolarity,” Dr. Pflugfelder said. “However, osmolarity is also increased in aqueous-sufficient dry eye conditions, such as meibomian gland dysfunction (MGD) and conjunctivochalasis.” In a study where the device was used to measure tear osmolarity in 314 consecutive subjects classified as normal or with mild, moderate, or severe dry eye based on the Dry Eye Workshop composite severity score, a cutoff of 308 mOsm/l was the most sensitive threshold for discriminating between normal and mild subjects versus moderate Continues on page 26 : Tests magenta cyan yellow black ES236476_OT050113_024.pgs 04.24.2013 02:14 ADV SPECIFY LOTEMAX® GEL Dispense as written when prescribing Discover more at www.lotemaxgel.com ®/TM are trademarks of Bausch & Lomb Incorporated or its affliates. ©2013 Bausch & Lomb Incorporated. US/LGX/13/0042 [4/13] magenta cyan yellow black ES236517_OT050113_025_FP.pgs 04.24.2013 16:55 ADV 26 May 1, 2013 :: Ophthalmology Times Special Report ) DRY EYE To everything there is a season (for ocular surface disease) Pre-emptive strategies for exacerbations guided by seasonal fuctuations By cheryl guttman Krader; Reviewed by Christopher E. Starr, MD ne w York :: Taking inTo accounT seasonal variation in disease severity of ocular surface disease can help clinicians optimize care for patients with allergic conjunctivitis and dry eye disease. “Ophthalmologists are well aware that due to changing environmental conditions, patients with dry eye disease generally experience exacerbations during the late fall and winter while those with seasonal allergic conjunctivitis (SAC) can develop flares in the early spring and fall,” said Christopher E. Starr, MD, associate professor of ophDr. Starr thalmology, Weill Cornell Medical College, New York. “Adapting management strategies to these calendar fluctuations can help minimize the intensity of disease-related signs and symp- TESTS ( Continued from page 24 ) and severe, whereas 315 mOsm/l had the greatest specificity. In another study evaluating six different diagnostic tests, tear osmolarity showed the greatest correlation with the DEWS composite disease severity score. However, other researchers reported no differences in mean tear osmolarity comparing normal eyes and those with non-Sjögren’s syndrome aqueous tear deficiency or Sjögren’s syndrome aqueous tear deficiency, nor correlations between tear osmolarity and any other clinical tests. “The value of this device may be to identify tear dysfunction, especially if osmolarity is consistently high,” Dr. Pflugfelder said. He added that results of other studies suggest it may be used to monitor ocular surface toxicity from chronic use of glaucoma drops with preservatives and to monitor the therapeutic effect of cyclosporine treatment. magenta cyan yellow black toms,” Dr. Starr said. “It is far better to try to prevent an exacerbation than to have to treat one with more aggressive therapy.” empow er i ng paT ie n T s Rather than instituting office-generated reminders for patients to schedule follow-up visits, Dr. Starr said he prefers to empower patients to take charge of their care. When a patient’s disease shows a pattern of recurrent flares at certain times of the year, he discusses establishing a reminder and even asks patients to take out their smartphones to oversee their cooperation in creating an alert. “Contacting patients to set up seasonal followup visits or to initiate seasonal management strategies for allergy or dry eye is a time- and resource-intensive task, whereas with today’s electronic tools, patients can easily create their own reminders,” explained Dr. Starr, who is A second device analyzing tear composition is a semiquantitative immunoassay that detects elevated levels (>40 ng/ml) of matrix metalloproteinase-9 (MMP-9) in tear fluid (InflammaDry Detector, RPS). It is a single-use disposable assay and is approved in Europe and Canada but pending FDA approval. According to its manufacturer, the test has 85% sensitivity and 94% specificity for identifying dry eye diagnosed by “clinical truth.” “Both the concentration and activity of this inflammatory protease have been shown to be increased in eyes with aqueous tear deficiency and MGD,” Dr. Pflug felder explained. “Furthermore, elevated tear MMP-9 activity correlates with a number of objective and subjective clinical parameters of tear dysfunction.” Te a r film im aging The techniques for tear film imaging include a system that noninvasively analyzes tear stability (Tear Stability Analysis System, Tomey). A study evaluating its use found that the rate of increase of irregular points over 6 seconds also director, refractive surgery service, and director of the cornea, cataract and refractive surgery fellowship, and director of ophthalmic education at Weill Cornell Medical Center, New York-Presbyterian Hospital, New York. “Furthermore, patients who are motivated to be more involved in their health care may be more likely to adhere to their physician’s recommendations,” he said. “Nevertheless, it is still the physician’s responsibility to initiate the process.” For patients with a history of recurring seasonal allergic conjunctivitis, Dr. Starr recommends initiating treatment a few weeks prior to the start of the fall or spring allergy seasons with a dual-acting mast cell stabilizer/antihistamine. In addition, these individuals are reminded about non-pharmacologic strategies for reducing allergen exposure, including wearing sunglasses and brimmed caps when out- was very low in normal eyes and progressively increased with severity level of dry eye. Another tear film imaging unit noninvasively measures tear breakup time and location in reflected placido rings (Keratograph 5M, Oculus), The data are presented in a color-coded map. A third device using white light interferometry (LipiView, TearScience) provides data on the thickness and quality of lipid in the tear layer and is useful for diagnosing meibomian gland dysfunction, Dr. Pflugfelder said. There are also two anterior segment-OCT platforms (Visante Omni, Carl Zeiss Meditec; RTVue, Optovue) that can be used for noncontact tear film imaging and to determine the inferior and superior tear meniscus height, width, and area. In addition, they calculate tear volume by extrapolation and are sensitive enough to detect tear meniscus debris. ■ STEphEn C. pflugfEldEr, Md e: [email protected] Dr. Pfugfelder receives research support from and is a consultant for Allergan, Bausch + Lomb, and GSK. This article is adapted from Dr. Pfugfelder’s presentation during Cornea 2012 at the annual meeting of the American Academy of Ophthalmology. ES236477_OT050113_026.pgs 04.24.2013 02:14 ADV 27 May 1, 2013 :: Ophthalmology Times Special Report ) However, Dr. Starr noted that the latter interventions are usually maintained year-round because dry eye is a chronic disease and it is important to try to optimize the ocular surface even in the absence of aggravating environmental factors. Keeping an eye on flares While initiating pre-emptive measures according to a patient’s history of disease flares can help reduce the likelihood of an extreme exacerbation of dry eye and SAC, it is not a guarantee. Therefore, patients must also be instructed to call for an appointment if they are experiencing a severe flare that may be an indication for a short course of a topical cor ticosteroid to control surface inflammation. Dr. Starr also noted that when managing dry eye and ocular allergy to(figurE 1) A female patient presents gether, clinicians should keep in mind with red eyes and complaints of that each of these conditions may masburning, dryness, and itching. Tear querade as the other or they may coosmolarity was normal and testing was negative for adenovirus. She exist, which may partly explain the had a similar episode at the same frequent disconnect between signs and time last year in early April. Her symptoms in ocular surface disorders. symptoms improved with a topical “Traditionally, we think of allergy antihistamine/mast cell stabilizer when patients have a chief complaint drop, and she was reminded to mark her calendar to prevent future of ocular itching, and we think dry exacerbations. eye when a patient complains of grit(Photos courtesy of Christopher E. Starr, MD) tiness or foreign body sensation,” Dr. side, washing their clothes frequently, Starr said. However, he added, recent studies keeping windows closed, and leaving have shown a significant overlap of outerwear outside of the house. Artificial tears are also a useful ad- these symptoms with almost 58% of junct because they can flush the ocu- allergy patients with itch also comlar surface of allergens and inflamma- plaining of dryness in a study by Hom tory mediators, and preservative-free et al. (Ann Allergy Asthma Immunol. 2012;108:163-166). preparations are preferred It is also important to for patients needing freremember that some medquent instillation. ications used to treat alPatients with dry eye lergy will secondarily and who have a history of Seasonal fuctuations cause or exacerbate eye developing exacerbations in ocular surface dryness, with antihistain the late fall and early disease severity provide mines being among the winter coinciding with dea rationale for initiating biggest culprits. New declining humidity indoors pre-emptive strategies velopments in point-ofand outside are counseled to avoid signifcant care diagnostic tests are about the use of humidiexacerbations. helping to overcome some fiers at home and in the workplace, keeping themselves hy- of the diagnostic challenges, he said. “Tests, such as one available for drated, and healthy computer habits. Some patients may also find it useful measuring tear osmolarity (TearLab, to increase the frequency with which TearLab Corp.) and another for detectthey are instilling artificial tears in ing adenovirus (AdenoPlus, Nicox), addition to twice daily topical cyclo- help me on a daily basis to distinguish sporine emulsion (Restasis, Allergan). between common causes of red eyes,” take-home magenta cyan yellow black Dr. Starr said. “In the future, we will have other point-of-care diagnostics for identification of MMP-9, IgE, and other markers that will further help clinicians with the differential diagnosis of ocular surface disorders.” ■ DRY EYE ChriSTophEr E. STarr, Md e: [email protected] Dr. Starr is a consultant and speaker for Alcon Laboratories, Allergan, Bausch + Lomb, Merck, and TearLab Corp., and has done research for Allergan, Rapid Pathogen Screening, TearLab Corp. PARASOL ® 92% Retention Rate † ORDER NOW You have patients. They have Dry Eye. We have the Parasol. THE 1 APP # FOR THE TREATMENT OF CHRONIC DRY EYE ES236475_OT050113_027.pgs 04.24.2013 02:14 ADV 28 MAy 1, 2013 :: Ophthalmology Times Special Report ) DRY EYE Why patient education is critical to dry eye disease compliance An effective campaign must be readily available for physicians to implement By Marguerite B. Mcdonald, Md, Special to Ophthalmology Times ChroniC dry eye disease, also topic, we have iPads available so that the techknown as keratoconjunctivitis sicca, is a condition nicians and coordinators can show them speinvolving abnormalities and deficiencies in the tear cific segments again. Video segments are also film, which may be initiated by a variety of causes. available for placement on one’s website; they The incidence of chronic dry eye has been can be e-mailed to patients, allowing them to estimated by many authors; it is thought to watch as many times as they want or share affect at least 5 million people over the age with family members. of 50 in the United States,1,2 but I believe that We physicians often think that we have explained a pathology or treatment very clearly, this is a low estimate. At least 75% of the patients who come to my and inevitably, there will be patients that did not cornea referral practice have dry eye disease. In understand or ask questions. Frequently, new pathe past, dry eye was a difficult disease to quantify tients will present who have been taking a drug, and measure, and treatment options were some- such as brimonidine tartrate (Alphagan, Allergan) for 10 years, and when I ask them what limited. However, diagnostic and if their glaucoma is controlled, they treatment modalities have improved will respond that they did not know dramatically, making it a dynamic they even had glaucoma. and profitable practice focus. The dry eye educational mateThe number of patients with dry Compliance rates rials take concepts that are diffieye who experience serious com- increase signifcantly cult to understand in the abstract, plications, such as corneal scarring when patients and use images and animation to and significant vision loss, is small. understand what their explain aqueous deficient versus However, the number of patients medication does, how evaporative dry eye and the roles whose cataract or laser vision cor- to take it properly, and of the lid margins and the meiborection surgery will be negatively what will happen if they mian glands. They employ easy-toaffected, or that are miserable due do not take it. understand language where each to fluctuating vision or red and irritated eyes, is incredibly high. Untreated ocular word is selected so that it is meaningful withsurface disease makes pre-surgical refractive out being overly technical. This saves a great measurements less accurate and affects sur- deal of time for our physicians and technical gical outcomes; thus, we have always had a staff. When we sit down to talk with patients focus on ocular surface disease in our practice. about their pathology, they already understand the anatomy of the eye, the disease pathology, and some of the treatment options. Cen ter of e xCellenCe Several years ago we decided to make our praceduCation is pow er tice a center of excellence for dry eye disease. We invested in several diagnostic and treatment tools Treatment compliance rates increase signif(including tear osmolarity testing, TearLab; LipiV- icantly when people understand what their iew Ocular Surface Interferometer, TearScience; medication does, how to take it properly, and LipiFlow Thermal Pulsation System, TearScience; what will happen if they do not take it. The treatment regimen for dry eye disease includes and Oculus Keratograph 5M, Oculus Inc.). In addition, we invested in patient education medications and cleansing techniques that take software (LUMA and ECHO, Eyemaginations). time, technique, and money. Many patients are on a fixed income and These animated patient education programs make complex topics understandable to the are spending hundreds of dollars per month patient. We often play a loop with a variety on co-payments. Unless they understand why of topics in the waiting room as well as in the they need a particular medication, they are dilation area, making sure that information not going to spend their money. Even with great insurance coverage, dry eye medications on dry eye is always included. If patients have any trouble understanding a such as cyclosporine (Restasis, Allergan) are take-home magenta cyan yellow black often high-ticket items. Patients must understand why the drug is prescribed as well as the need to take it consistently and long term in order to feel relief. In another example, patients with blepharitis are often instructed to perform lid scrubs twice a day. Patients that have not been educated properly will come for a follow-up visit and report that they have been doing the scrubs, but their lids will reveal oily scurf and inspissated meibomian glands. When asked to demonstrate, although their intentions are good, they are missing the mark in most cases. We often take for granted that people know where their lid margin is and how to scrub it, but in truth, they often do not; education is key in the treatment of this form of ocular surface disease. An effective educational campaign must be easy and readily available for the physicians and technicians to implement. Whether the technicians have iPads available at the nurses’ station, in each exam lane, or wear a uniform with big pockets to carry them around, they must have quick access without searching or they will not work it into their day. Printed educational brochures are also very useful, if the physician or technician sits down and walks patients though the material. However, we have found the higher-tech options to be a great option that lends our practice an image of advanced technology with a high level of concern for patients. When patients understand the pathology of the disease, and then they see their tear osmolarity score decreasing and their lipid layer improving, they are more satisfied and their compliance rates are higher. ■ References 1. Schaumberg DA, Sullivan DA, Buring JE, Dana MR. Prevalence of dry eye syndrome among U.S. women. Am J Ophthalmol. 2003;136:2318-2326. 2. Schaumberg DA, Dana R, Buring JE, Sullivan DA. Prevalence of dry eye disease among U.S. men. Archiv Ophthalmol. 2009;127:763-768. Marguerite B. McDonalD, MD, is clinical professor of ophthalmology at NYU, adjunct clinical professor of ophthalmology at Tulane University, and in private practice with the Ophthalmic Consultants of Long Island, Lynbrook, NY. She did not indicate any proprietary interest in the subject matter. ES235819_OT050113_028.pgs 04.23.2013 03:44 ADV 44th Annual Doheny Days Conference JUNE 14 & 15, 2013 Registration fee is $180 For more information contact: Wilma McConnell, DEI/CME TEL 323 442 6427 FAX 323 442 6517 [email protected] www.doheny.org The Irvine Memorial Lecture: Health Care Reform 2013 George A. Williams, MD Professor and Chairman Department of Ophthalmology William Beaumont Hospital Royal Oak, Michigan The Doheny Memorial Lecture: CCT, Corneal Biomechanics & Glaucoma How Do They All Fit Together? James D. Brandt, MD Professor, Director Glaucoma Service Department of Ophthalmology University of California, Davis Eye Center Sacramento, California Cataract Surgery • Refractive Surgery • Corneal/External Disease • Pediatric Ophthalmology Neuro-Ophthalmology • Ocular Oncology • Retina/Vitreous • Glaucoma • Oculoplastics Accreditation Statement: The Doheny Eye Institute is accredited by the Institute for Medical Quality/California Medical Association to provide continuing medical education for physicians. The Doheny Eye Institute takes responsibility for the content, quality and scientific integrity of this CME activity. Credit Designation Statement: The Doheny Eye Institute designates this live educational activity for a maximum of 12 AMA PRA Category 1 Credits™. Physicians should only claim credit commensurate with the extent of their participation in the activity.This credit may also be applied to the CMA Certification in Continuing Medical Education. magenta cyan yellow black ES236266_OT050113_029_FP.pgs 04.24.2013 00:28 ADV 30 May 1, 2013 :: ophthalmology times Special Report ) DRY eYe Dry eye not a cu t-anD-DrieD issue Point Laser refractive surgery has no place in dry eye Pre-existing dry eye should be identifed and controlled before surgery is considered By cheryl Guttman Krader; Reviewed by Christopher J. Rapuano, MD PHIL ADEL PHIA :: Other research findings highlight the potential persistence of postrefractive surgery dry eye. In don’t mix, in the view of one ophthalmologist. a retrospective study, investigators reviewed data “Careful preoperative evaluation is needed to from the preoperative visit and from 1 week, 1 identify patients with active dry eye disease who month, 3 months, and 6 months postsurgery for should not undergo surgery,” a group of 190 LASIK-treated eyes. The study said Christopher J. Rapuano, found significant worsening in Schirmer scores MD, chief, cornea service, Wills and tear film breakup time for the duration of Eye Institute, and professor follow-up and that symptoms of dry eye were of ophthalmology, Jefferson present at 6 months in 20% of eyes. The risk for Medical College of Thomas dry eye was higher in eyes treated for higher Jefferson University, Phila- refractive errors as well as in women. Dr. Rapuano Findings were similar in a prospective study delphia. “Treat the dry eye first; consider surgery only comparing dry eye symptoms in patients unif the ocular surface is normalized, and per- dergoing LASIK with a superior-hinged femform the procedure only with an appropriate tosecond laser flap versus a nasal-hinged mechanical microkeratome. Overall, preoperative discussion and thor50% of patients had dry eye sympough informed consent.” toms after 1 week and 20% were Results from published studies prostill bothered at 6 months. While vide evidence that dry eye is a leadhinge location was not associated ing cause of patient dissatisfaction Dry eye is with dry eye, higher refractive error after LASIK. One such study underan important was again a risk factor. taken by Dr. Rapuano and colleagues cause of patient In a prospective study of 48 eyes at Wills Eye Hospital included 109 dissatisfaction after of 48 patients undergoing LASIK, postLASIK patients representing 157 LASIK, is a risk significantly decreased conjunctival operated eyes. Poor distance vision factor for regression, and corneal sensitivity along with was the most common chief comand may be a worsened symptom scores were plaint (63%) among these patients persistent complaint. found present at 1 week and perseen on referral, but 20% of patients sisted at 16 months after LASIK. were unhappy because of dry eye. On clinical examination at the time of consulta- Another retrospective study compared 20 eyes tion, 28% of patients had dry eye or blepharitis. of postLASIK patients seen 2 to 5 years after A second study included 161 eyes of 101 pa- surgery for high myopia with 10 age-matched tients who sought consultation because they controls. The researchers found no difference were dissatisfied after refractive surgery; the between groups in signs of tear insufficiency majority had undergone LASIK (83%) and a or hypoesthesia, but dry eye symptoms were smaller proportion had PRK (14%). Similar to significantly worse in the postLASIK group. the findings from the Wills Eye Study, 59% of patients complained about poor distance Qua lit y of life affected vision, 21% were dissatisfied because of dry Other research highlights the negative effect eye, and 30% were diagnosed with dry eye. of dry eye on quality of life. Data from partici- DRy EyES AND laser refractive surgery take-home magenta cyan yellow black pants in the Women’s Health Study and Physician’s Health study found those with dry eye were significantly more likely than their unaffected counterparts to have difficulty with reading, professional work, computer use, and daytime and nighttime driving. The adverse consequences of dry eye also include an increased risk for refractive regression. As reported in a study of 565 eyes followed for 1 year postLASIK. Among the subgroup of 45 patients with dry eye, 27% experienced regression compared with only 7% of eyes without dry eye. concer ns , complic ations Concerns about patient dissatisfaction and complications after LASIK, including dry eye, were the impetus for the FDA to convene an advisory committee meeting in 2008. The proceedings from that meeting should raise a red flag for surgeons. “Disturbingly, a review of the minutes of this meeting showed suicide was mentioned 15 times, and a clinical psychologist interviewing 300 patients with LASIK complications reported 100 had suicidal ideation that was strongly associated with dry eye,” Dr. Rapuano said. “Laser refractive surgery is an elective cosmetic procedure to enhance a patient’s lifestyle and well-being,” he said. “It is highly successful in the majority of patients. However, surgeons do not want to turn a patient who is mildly unhappy with having to wear glasses or contact lenses into somebody who is miserable because of dry eye.” ■ ChristOpher J. rapUanO, Md e: [email protected] dr. rapuano has no relevant fnancial interests to disclose. this article is adapted from dr. rapuano’s presentation during refractive Surgery 2012 at the annual meeting of the american academy of ophthalmology. ES237067_OT050113_030.pgs 04.24.2013 23:47 ADV May 1, 2013 :: ophthalmology times 31 Special Report ) DRY eYe Dry eye not a cu t-anD-DrieD issue CounterPoint Dry eye not an absolute contraindication to LASIK laSIK can be an option after management to normalize ocular surface By cheryl Guttman Krader; Reviewed by Eric D. Donnenfeld, MD rOCK VIL L E CEN t rE, N y :: AlTHOugH lASIK cAN exacerbate cluded from LASIK, but they are the rare exception rather than the rule. The majority of patients with dry eye are excellent candidates for LASIK.” Citing a 2005 paper by Smith and Maloney, Dr. Donnenfeld added that even patients with autoimmune disease and dry eye can undergo LASIK with excellent results if they are managed appropriately. pre-existing dry eye, affected patients can often be acceptable surgical candidates if they are managed intelligently with appropriate preoperative, intraoperative, and postoperative techniques. Eric D. Donnenfeld, MD, addressed the question of whether to perform LASIK in patients with dry eye. He dr . d on n e n f e l d’s a pproach cited data presented during In screening for dry eye, Dr. Donnenfeld said Dr. Donnenfeld the 2008 meeting of the FDA he evaluates patients for eyelid margin disease Ophthalmic Devices Panel and does testing for ocular surface damage, on LASIK safety showing that the procedure tear stability, tear osmolarity, and tear producis not associated with a signifition. He performs lissamine green, cant increase in dry eye. fluorescein, and rose bengal stainIn addition, Dr. Donnenfeld reiting. Any positive staining identifies erated the panel’s conclusions that patients who will have irregular refractive surgeons should be vigtopography, are at risk for a poor LASIK can be an ilant in identifying LASIK candi- option for patients outcome, and who should not have dates who have symptoms or signs with dry eye and LASIK until the condition of the of dry eye during the preoperative eyelid margin cornea is improved. evaluation as these individuals are disease, but only “I like to look at the Hartmannat greater risk for developing prob- after management Shack image as well, and if there is lems after surgery and their iden- to normalize the dropout, it means the ocular surtification allows appropriate coun- ocular surface face is damaged enough that the seling, pretreatment, and in some and with use of reading is not good,” Dr. Donnenrare cases, exclusion from LASIK. surgical techniques feld said. “However, patients with dry eye are usually excellent canand postoperative didates for LASIK if the Hartmannmajor it y ar e excellent interventions that Shack image is normal.” c a ndidates minimize dry eye. In addition to identifying pa“LASIK is not a big cause of dry eye, but rather it is a procedure done predomi- tients at risk for dry eye, Dr. Donnenfeld emnantly in patients who have dry eye because phasized the need to maximize the tear film they can’t wear contact lenses,” said Dr. Don- stability preoperatively, develop a surgical plan nenfeld, clinical professor of ophthalmology, that minimizes dry eye, and intervene with New York University, and founding partner, appropriate postoperative therapy. His approach to dry eye management inOphthalmic Consultants of Long Island and Connecticut, Rockville Centre, NY. “There are cludes use of topical lubricants, immunothersome patients with dry eye that should be ex- apy, omega-3 supplements, and interventions take-home magenta cyan yellow black for meibomian gland disease as indicated. For omega-3 supplementation, Dr. Donnenfeld noted patients should be instructed to use products where the fatty acids are in the triglyceride form as this formulation provides better bioavailability than the ester form. A short course of a topical corticosteroid will help control inflammation and improve tear production and can be used as induction with topical cyclosporine ophthalmic emulsion (Restasis, Allergan). Loteprednol gel (Lotemax, Bausch + Lomb) is particularly good as an immunomodulator with a great safety profile and a vehicle that supports the ocular surface, Dr. Donnenfeld noted. His surgical technique involves a small (8.3 mm) thin flap created with a bevel-in sidecut as these flap characteristics have all been shown to reduce the incidence of dry eye. “Previously, my standard flap diameter was 9.5-mm, which has almost 50% more surface area than an 8.3-mm flap, and it was associated with much more dry eye,” Dr. Donnenfeld said. “The bevel-in side cut improves corneal nerve apposition.” ■ WHAT DO yOu THINK? What's your take on laser refractive surgery in patients with dry eye? Join the discussion on Facebook. eriC d. dOnnenfeld, Md e: [email protected] dr. donnenfeld is a consultant, receives grant support, and/or receives lecture fees from several companies that market devices used for LaSIk or for the management of dry eye and eyelid margin disease, including abbott Medical optics, alcon Laboratories, allergan, Bausch + Lomb, tearlab, and tearscience. this article is adapted from dr. donnenfeld’s presentation during refractive Surgery 2012 at the annual meeting of the american academy of ophthalmology. ES237068_OT050113_031.pgs 04.24.2013 23:47 ADV refractive 32 May 1, 2013 :: Ophthalmology Times Crosslinking best option for iatrogenic ectasia Choosing a method for visual rehabilitation after CXL presents another management issue by Cheryl Guttman Krader; Reviewed by Ernest W. Kornmehl MD Take-Home Collagen crosslinking using the original Dresden protocol halts progression in eyes with iatrogenic ectasia, and the beneft seems to be sustained for at least 7 years. c Zurich, Swi t Zerl and :: ollagen crosslinking (CXL) is mandatory for the primary management of iatrogenic ectasia, and appears to stop progression long-term. However, the CXL procedure must be performed using the original standard technique, said Theo Seiler, MD, PhD, professor of ophthalmology, University of Zurich, Switzerland, and chairman, IROC, Zurich. “Other than CXL, a keratoplasty procedure is the only option for these eyes,” Dr. Seiler said. “Once CXL is performed, visual rehabilitation is needed, and that can be much more difficult than the CXL itself.” Discussing long-term experience with CXL for eyes with ectasia following laser vision Dr. Seiler correction surgery, Dr. Seiler began by reviewing the first case he performed. The patient was a 32-yearold female who had LASIK in 2003 for moderate myopia. Preoperatively, she had normal topography and a calculated residual stromal bed thickness of 315 µm. However, within 6 months she presented with central corneal steepening that worsened during follow-up. “Although we had already used CXL in diseased eyes with keratoconus, at first we were unsure about performing CXL in cases of iatrogenic ectasia,” Dr. Seiler said. “Initially, therefore, we waited to document progression. However, after finding more than 1 D of progres- magenta cyan yellow black sion in true net power within 6 months in a series of 16 eyes, we decided we should proceed with CXL immediately after diagnosing iatrogenic ectasia.” The patient’s worse eye was treated first. Seven years later, it has shown no progression whereas the fellow eye progressed within the first 5 months of follow-up. To date, Dr. Seiler and his colleagues at IROC have 1-year follow-up data for 24 eyes treated with CXL for iatrogenic ectasia. Two eyes had developed ectasia after PRK and the rest were postLASIK. The 1-year data documented that progression of the disorder was halted in all eyes, and maximum K was reduced by more than 2 D in 13 eyes (54%). No eyes lost more than 2 lines of best spectacle-corrected visual acuity (BSCVA) while 8 eyes (33%) had an improvement of more than 2 lines in uncorrected visual acuity (UCVA). Twelve of the 24 eyes had follow-up to 5 years, at which time all continued to show no evidence of progression and 8 (67%) maintained a K max reduction exceeding 2 D. Again, no eye had a loss of more than 2 lines of BSCVA and 5 eyes (42%) had more than a 2-line gain in UCVA. Compared with standard CXL for keratoconus, there were no unexpected safety issues except for the development of endothelial damage in an eye with a thin cornea that did not swell even after pure riboflavin (without dextran) was applied onto the de-epithelialized cornea. The only other option for the patient was a keratoplasty procedure, and with informed consent the patient agreed to undergo CXL, Dr. Seiler said. concentration of riboflavin applied for just 2 minutes instead of 0.1% riboflavin for 30 minutes, there is no place for these techniques in treating iatrogenic ectasia because of their more superficial effect, Dr. Seiler said. “The original volume type of CXL is needed in order to stop the progression of ectasia when biomechanical integrity of the cornea is impaired. The other approaches do not create adequate strength,” he explained. V isua L r ehabiLitation Despite undergoing a successful CXL procedure, patients may still be unhappy because of decreased vision. Options for visual rehabilitation include rigid contact lenses, intrastromal corneal rings, or surface ablation. ‘Other than CXL, a keratoplasty procedure is the only option for these eyes.’ — Theo Seiler, MD, PhD C X L Va r i a t i o n s While alternative protocols for CXL have emerged in which the procedure is performed either without epithelial removal or using a very high However, patients who have already had a complication after laser vision correction may be reluctant to have another laser procedure, Dr. Seiler observed. “There has been some discussion about performing surface ablation in these eyes, and it can be done safely because the ablation is only to the flap that does not contribute to the cornea’s biomechanical integrity,” Dr. Seiler said. “However, while laser ablation is possible, many patients don’t want to hear the word ‘laser’ anymore.” ■ THeo Seiler, mD, PHD e: [email protected] Dr. Seiler is equity owner of IROC. This article is adapted from Dr. Seiler’s presentation during Refractive Surgery 2012 at the annual meeting of the American Academy of Ophthalmology. ES236815_OT050113_032.pgs 04.24.2013 22:22 ADV cataract May 1, 2013 :: Ophthalmology Times 33 Timing, location, calculation Here are three important factors in treating traumatic cataract in pediatric patients By lynda charters; Reviewed by Edward G. Buckley, MD Take-Home Timing, location, and IOL calculations are important factors in treating traumatic cataract in pediatric patients. m Durham, NC :: anaging traumatic cataracts in children requires attention to three issues when implanting an IOL: the timing of the lens implantation, the lens type, and the lens calculations. Edward G. Buckley, MD, discussed the specifics of IOL implantation in this patient population. Some controversies regarding IOL implantation in children include whether to implant the lens in the sulcus or capsule, whether the surgery is primary or secondary, and how to deal with the lack of capsular support. “All of the issues surrounding IOL implantation in children concern the anterior segment and what it looks like at the time of intervention,” Dr. Buckley said Dr. Buckley, professor of ophthalmology and pediatrics and vice dean of medical education, Duke University School of Medicine, Durham, NC. Timing The general rule, according to Dr. Buckley, is “the later the better.” If surgery in an inflamed eye can be avoided, the surgery will be easier, the cornea will be clearer, the tissue will be less reactive, the IOL calculations will be more accurate, there is a better chance of in-the-bag placement, and there will be fewer postoperative issues, he noted. The surgeon must determine if the IOL is inserted during the primary surgery or during a secondary procedure. “The answer depends on the anterior chamber,” he said. “If the chamber is not in good shape after the initial surgery, waiting is likely a better option to avoid a rocky postoperative magenta cyan yellow black course with further complications. The general rule is when in doubt, don’t do it.” locaTion Regarding capsular implantation or sulcus fixation, there are no long-term data that suggest a difference in children with traumatic cataract. “Exerting heroic efforts to put the IOL in the bag is probably not a good idea, especially in the presence of a poor anterior segment,” Dr. Buckley said. In the absence of adequate capsular support, the surgeon is faced with the choice of an anterior chamber IOL or suturing an IOL in the posterior chamber. “In children, the anterior chamber IOLs do not have a good track record because of pupil problems, persistent inflammation, hyphema, and glaucoma,” he said. A new lens, the Artisan Iris Clip Lens (Ophtec), may be advantageous, but the long-term performance is unknown. IOLs that are sutured in place are associated with complications during the initial surgery. The long-term safety is a question that centers around the 10-0 Prolene suture material, which tends to break (average time to breakage, 6 years) in the long term in up to 33% of patients, Dr. Buckley said. This can be avoided by using 9-0 Prolene. iol Types There are two IOL options for use in children. A single-piece polymethylmethacrylate (PMMA) IOL is the hallmark IOL for use in inflamed eyes, according to Dr. Buckley. This IOL is implanted through a 7-mm incision and is more suitable in the sulcus. The other lenses are the acrylic single-piece AcrySof IOL (MA60AC, Alcon) that iol calculaTions is foldable and implantable through a 4-mm incision and the SA60AT (Alcon) that is inject- There is a myopic shift in children over time that extends into the teen years. “Surgeons able through a 2.75-mm incision. The acrylic SA60AT IOL is by far the IOL of need to consider the myopic shift ahead of choice by 93.3% of pediatric ophthalmologists time. The eye should be undercorrected early for in-the-bag fixation and not for implanta- to avoid very high myopia later,” he advised. tion in the sulcus. The MA60AC IOL should be considered for eyes with a great deal of inflammation. When sulcus fixation is desired, a three-piece acrylic IOL or a single-piece PMMA IOL is the best choice. — Edward G. Buckley, MD A rule to follow to determine if a PMMA IOL can be implanted in the sulcus is to determine The formula used to calculate IOL powers the degree of optic support that is available, does not matter. Dr. Buckley said. If the capsule can support “Because timing is an issue, waiting until the optic, an MA60AC IOL is “perfectly sat- the eye is quiet is best. The IOL type depends isfactory.” In the absence of optic support, a on the implant location, which dictates the opPMMA IOL may be a better choice because it is timal lens material. The myopic shift must be sufficiently rigid to achieve adequate support. considered when doing the IOL calculations,” Inflammation is a big factor when choosing Dr. Buckley concluded. ■ the appropriate lens in these cases. The acrylic IOLs can develop a great deal of deposits and are not a good choice in an eye that may have edward G. Buckley, md severe inflammation. In contrast, the PMMA e: [email protected] IOLs are easier to clean than the acrylic IOLs. Dr. Buckley has no fnancial interest in the subject matter. ‘The IOL type depends on the implant location, which dictates the optimal lens material.’ ES236816_OT050113_033.pgs 04.24.2013 22:22 ADV 34 May 1, 2013 :: Ophthalmology Times cataract Device guides IOL selection in certain patient groups Challenging cases achieve good refractive outcomes with intraoperative aberrometry by cheryl Guttman Krader; Reviewed by Mark Packer, MD Take-Home Mark Packer, MD, describes how he uses a proprietary intraoperative aberrometer to guide IOL selection in patients with cataract surgery with a history of keratorefractive surgery. I Por t l and, or ntraoperative wavefront aberrometry has been a helpful tool for refining refractive outcomes after cataract surgery in the difficult group of eyes with previous keratorefractive surgery. Mark Packer, MD, described his method of IOL power calculation in these challenging cases, and he reported outcomes demonstrating good accuracy. His technique involves first inputting all of the preoperative data available for each case into the online ASCRS IOL calculator. Depending on the amount of information entered, the calculator generally suggests several lenses with different powers that can vary by 2 to 3 D. Then, all of the suggested lenses are brought into the OR, and after the cataract is removed, the aphakic refraction is performed with the intraoperative aberrometer (ORA, WaveTec Vision Systems). Generally the lens power chosen by the intraoperative aberrometer is within the range suggested by the ASCRS IOL calculator, and in that situation Dr. Packer uses the aberrometer-determined power and the lens that he has the most experience with because it will have the best A-constant optiDr. Packer mization. When the aberrometer suggests a power outside of the range of the IOL calculator, the difference has been 0.5 D at most, and then he chooses the IOL calculator-suggested lens with the power closest to that determined by the aberrometer. “There is still some art involved in my approach, but it is more scientific than randomly picking from the options offered by the IOL magenta cyan yellow black calculator,” said Dr. Packer, clinical associate professor of ophthalmology, Oregon Health & Science University School of Medicine, Portland. Refractive outcomes in a series of 12 eyes with a history of myopic LASIK support use of the technique. Dr. Packer noted that postoperative SE at 1 month averaged 0.30 ± 0.22 D, was within 0.5 D of intended in 75% of the eyes, and within 1 D of intended in all 12 eyes. In addition, he discussed its use in a patient who presented for bilateral cataract surgery with a history of LASIK moORA aphakic measurement specifes the appropriate IOL novision. The patient’s left eye was cor- power and also measures the total corneal astigmatism, rected for near, and he wanted to main- including both anterior and posterior surfaces. (Illustration tain monovision after cataract surgery. courtesy of Mark Packer, MD) The ASCRS IOL calculator generated a list of IOL options for each eye with powers measured with the ORA. Among 131 postmyranging from 18 to 21 D for the right eye and opic LASIK eyes measured with the ORange 16 to 21 D for the left eye, and the intraopera- 2.6, the mean 1-month postoperative refraction tive aphakic refraction determined that 21 D was 0.51 ± 0.38 D, 60% of eyes were within was the proper IOL power for each eye. Postop- 0.5 D of intended SE and 92% were within 1 D. Interim data from a prospective multicenter eratively, the patient achieved 20/25 distance uncorrected visual acuity (UCVA) in his right study evaluating refractive outcomes using the eye and J1 near UCVA in his left eye. Spheri- aberrometer for intraoperative aphakic refraction cal refractions were –0.50 D OD (target plano) in postkeratorefractive surgery eyes show that the and –2.25 D OS (target –2.25 D) with some re- SE was within 0.5 D of intended in 68% of 45 eyes. “This outcome compares well with published sidual astigmatism in both eyes. results for series where the IOL power was selected using various empirical formulas,” Dr. New platfor m, Packer said. better performaNce Dr. Packer noted he also uses intraoperative The first generation of the intraoperative aberrometry platform used by Dr. Packer was first aberrometry to guide treatment of astigmatism introduced by the manufacturer in April 2009 at the time of cataract surgery in both toric IOL as the ORange. The current device, which was recipients and limbal relaxing incision cases. He released in 2011, represents a 70% hardware presented a case where the system was used to change and offers a greater dynamic range (–5 to determine optimal positioning of a toric lens, but +20 D) as well as increased speed and accuracy. noted it can also be used in toric IOL recipients Pooled data from standard cases (not post- to determine the aphakic spherical power and LASIK eyes) derived from multiple investigators aphakic cylinder power and axis. ■ show increased accuracy was achieved with the changeover to the new system. Dr. Packer mark Packer, mD noted that among 295 eyes that underwent ine: [email protected] traoperative aberrometry using the ORange 2.6, Dr. Packer is a consultant to WaveTec Vision Systems. This article is adapted from Dr. mean postoperative SE at 1 month was 0.36 ± Packer’s presentation during the Spotlight on Cataract session during the 2012 annual 0.29 D compared with 0.32 ± 0.29 D in 82 eyes meeting of the American Academy of Ophthalmology. ES237230_OT050113_034.pgs 04.25.2013 02:05 ADV 2013 eyecare webinar series MAY 8th 2013 7:00 PM EST MAY 22nd 2013 9:00 PM EST New Perspectives in Anti-Inflammatory Dr ugs in Cataract Surgery FEATURING » Dr. Terry Kim • 4rendsortYpesinanti-inmaMMatorYdrUGs • DebatebetweenNSAIDsandsteroids • Newperspectivesandbestpracticesfor post-operativecare • ,atestanti-inmaMMatorYdrUGs Register TODAY. magenta cyan yellow black http://ophthalmologytimes.modernmedicine.com/ 2013-eyecare-webinar-series ES236036_OT050113_035_FP.pgs 04.23.2013 19:49 ADV 36 May 1, 2013 :: Ophthalmology Times cataract Grading system holds promise for improved efciency, safety Lens assessment with femtosecond laser imaging offers opportunity for cataract outcomes by cheryl Guttman Krader; Reviewed by Harvey Uy, MD Take-Home The high-resolution Scheimpfug images obtained with a cataract surgery femtosecond laser were used to grade lens density and determine surgical technique. Que zon CI t y, PhIl IPPInes :: HigH-resolution scHeimpflug imaging (HRSi) technology incorporated in a proprietary cataract surgery femtosecond laser system (LensAR) provides unique information on lens anatomy that can help surgeons tailor their approach to achieve optimal results. “Evaluation of lens anatomy with HRSi can allow surgeons to choose the appropriate nuclear disassembly technique and phaco machine settings, Dr. Uy and it requires no extra effort because the imaging is built into the process of the femtosecond laser-assisted cataract surgery,” said Harvey Uy, MD, consultant at St. Luke’s Medical Center, image-guided caTaracT surgery VideO Go to http://ow.ly/koiZe for a demonstration of high-resolution scheimpfug imaging of a cataract using the lensar system. Based on this image, the surgeon visualizes the anatomy of a dense cataract with suffcient cortex which allows passing of an uy femtosecond combo manipuator (asICo) to the equator in order to execute the counter prechop maneuver. (Video courtesy of Harvey Uy, MD) magenta cyan yellow black Quezon City; Pacific Eye and Laser Institute, Makati City; and clinical associate professor of ophthalmology, University of the Philippines. “In the future, I envision a new world of cataract surgery in which the femtosecond laser imaging software will automatically export Scheimpflug image measurements to the phaco machine that will then automatically call up the appropriate parameters for the surgery. Just as MRI guidance has revolutionized neurosurgery, I foresee the Scheimpflug images will revolutionize cataract surgery into an imageguided procedure,” he said. Dr. Uy presented the results of a study in which 52 eyes underwent HRSi-guided femtosecond laser-assisted cataract surgery using the LensAR system. All cataracts were graded preoperatively by a certified LOCS III grader assessing slit-lamp images. Intraoperatively cataract grading was performed based on the lens appearance in the Scheimpflug images. Using the images, the eyes were categorized into three groups, and surgical technique was based on the categorization. Eyes with a soft/ moderate cataract underwent a prechop technique (40%), those with a dense cataract and adequate cortical space to use a chopper underwent counter prechop (50%), and eyes with a dense cataract with inadequate space had stop and chop (10%). “In eyes where there is no cortical space visible on the Scheimpflug image, the second instrument used for a prechop technique may inadvertently cause capsular damage, and so a stop and chop technique is considered safer,” Dr. Uy said. All of the eyes had a successful outcome after undergoing the HRSi-guided femtosecond laser-assisted cataract surgery. The only complication was a small posterior capsular tear that occurred with a postocclusion surge. However, it was still possible to place the IOL in the bag and the patient had a good visual outcome, Dr. Uy noted. c or r e l at ioN a N a ly s e s In addition to the grading of the cataracts from the slit-lamp images using the LOCS III sys- A B C D A) Dense nucleus with adequate cortical space for counter prechop. B) HRSI image of posterior polar cataract and dense nucleus. C) Soft nucleus for prechopping. D) Very dense nucleus for stop and chop. ES237229_OT050113_036.pgs 04.25.2013 02:05 ADV May 1, 2013 :: Ophthalmology Times 37 cataract “Detection of the posterior polar cataract allowed us to achieve successful surgery by adjusting our technique, including lowering the machine settings and avoiding hydrodissection,” he said. ■ HarVeY UY, mD e: [email protected] Dr. Uy is a consultant to LensAR and Alcon Surgical. This article is adapted from Dr. Uy’s presentation during Refractive Surgery 2012 at the annual meeting of the American Academy of Ophthalmology. Advertiser Index Advertiser Posterior polar cataract with dense nucleus. (Photos courtesy of Harvey Uy, MD) tem, a grader masked to those scores categorized the density of the cataracts based on the Scheimpflug images using a scale of 1 (very soft) to 6 (very dense). There was a high positive correlation between the HRSi-based cataract grading and the preoperative LOCS III nuclear opalescence scores. However, an analysis of the relationship between cataract grade and utilized ultrasound energy, represented by the Cumulative Dissipated Energy value on the phacoemulsification machine (Infiniti Vision System, Alcon Laboratories), showed a stronger correlation with the Scheimpflug image cataract rating than with the preoperative LOCS III grading. Because of this strong correlation, the surgeon can adjust ultrasound, vacuum, and flow settings to suit the HRSi-measured nuclear grading, Dr. Uy said. “For example, for a soft cataract, the ultrasound power can be minimal with low vacuum and flow essentially to aspirate the nucleus,” he said “For a very dense cataract, higher phaco power, vacuum, and bottle height may be utilized together with more extensive chopping maneuvers to minimize utilized ultrasonic energy. “Also, a femtosecond laser feedback loop can be created where the imaging software selects the optimal laser treatment algorithm for lens fragmentation,” Dr. Uy added. “In the future, the imaging, lens fragmentation, and phaco machine software will be merged together to create seamless, customized treatment algorithms for femtosecond laser-guided cataract surgery.” HiGH-r esolUtioN im aGes Dr. Uy presented Scheimpflug images showing eyes where a prechop procedure could and could not be used based on visibility of the cortical space. In addition, he showed the Scheimpflug image from an eye with a moderately dense nuclear cataract and a posterior polar cataract that was not identified on the slit-lamp image. magenta cyan yellow black Alcon Laboratories Inc. Page Advertiser Page CV4 Oculus Inc. 21 Tel: 425/670-9977 Fax: 425/670-0742 Internet: www.oculususa.com Tel: 800/862-5266 Internet: www.alcon.com Allergan Inc. 11-12 Odyssey Medical Inc. Tel: 714/246-4500 Customer Service: 800/433-8871 Fax: 714/246-4971 Internet: www.allergan.com Bausch + Lomb 27 Tel: 901/383-7777 Fax: 901/382-2712 Internet: www.odysseymed.com CV3-25 Regeneron Pharmaceuticals 14A-B* Tel: 914/345-7400 Internet: www.regeneron.com Tel: 800/227-1427 Customer Service: 800/323-0000 Internet: www.bausch.com Rhein Medical Brien Holden Vision Institute 7 9 Tel: 800/637-4346 Internet: www.rheinmedical.com Tel: 612/9385-7441 Internet: www.brienholdenvision.org TearLab Corp. Doheny Eye Institute Tel: 855/832-7522 Web: http://www.tearlab.com Internet: www.doheny.org ICHE 41 ThromboGenics CV2, 3-4 Tel: 732/590-2900 Internet: www.thrombogenics.com Web: www.bizmedicine.org Katena Products Inc. 19 29 13 Transcend Medical Tel: 973/989-1600 Fax: 973/989-8175 Internet: www.katena.com Tel: 650/223-6600 Internet: www.transcendmedical.com World Glaucoma Congress Lacrimedics 23 24 17 Internet: www.worldglaucoma.org Tel: 800/367-8327 E-mail: [email protected] *Indicates demographic advertisement. This index is provided as an additional service. The publisher does not assume any liability for errors or omissions. OPHTHALMOLOGY TIMES (Print ISSN 0193-032X, Digital ISSN 2150-7333) is published semi-monthly (24 issues yearly) by Advanstar Communications Inc., 131 W First Street, Duluth, MN 55802-2065. Subscription rates: $200 for one year in the United States & Possessions, Canada and Mexico; all other countries $263 for one year. Pricing includes air-expedited service. Single copies (prepaid only): $13 in the United States & Possessions, Canada and Mexico; $20 all other countries. Back issues, if available are $25 in the U.S. $ Possessions; $30 in Canada and Mexico; $35 in all other countries. Include $6.50 per order plus $2 per additional copy for U.S. postage and handling. If shipping outside the U.S., include an additional $10 per order plus $5 per additional copy. Periodicals postage paid at Duluth, MN 55806 and additional mailing offices. POSTMASTER: Please send address changes to OPHTHALMOLOGY TIMES, P.O. Box 6009, Duluth, MN 55806-6009. Canadian G.S.T. number: R-124213133RT001, Publications Mail Agreement Number 40612608. Return undeliverable Canadian addresses to: IMEX Global Solutions PO Box 25542 London, ON N6C 6B2 CANADA. Printed in the U.S.A. ©2013 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]. ES237228_OT050113_037.pgs 04.25.2013 02:05 ADV 38 grand rounds May 1, 2013 :: Ophthalmology Times with Kellogg Eye Center Patient has pain, vision loss Man has 3-day history of OD pain, decreased vision, other symptoms: What is diagnosis? By travis C. rumery, Do; Blake V. Fausett, mD, phD; Jonathan D. trobe, mD; shahzad i. mian, mD Take-Home A 79-year-old Hispanic man presented with a 3-day history of right periocular pain and decreased vision in the right eye. He also had new-onset nausea, vomiting, fevers, chills, and confusion. What is your diagnosis? 79-year-old Hispanic man presented with a 3-day history of right periocular pain and decreased vision in the right eye. He also had new-onset nausea, vomiting, fevers, chills, and confusion. The patient’s medical history included transient ischemic attack, hypertension, hyperlipidemia, iron-deficiency anemia, and coronary artery disease with coronary artery bypass grafting. His ocular history was significant only for pseudophakia. A retired construction worker, he had been a previous smoker, having quit more than 20 years prior. Consultation by a neurologist found only slight inattentiveness. The ophthalmology service was consulted. A Ex amination Visual acuity with correction was 20/200 OD and 20/20 OS. Pupils were equal in size and constricted to light but with a right relative afferent pupillary defect. Motility and alignment exams were normal. Confrontation visual field testing revealed constriction inferiorly OD and was full OS. Anterior segment exam disclosed only pseudophakia OU. Fundus examination revealed only vitreous syneresis overlying the posterior pole OD. CliniCal CoursE MRI of brain and orbits was normal. Lumbar puncture showed glucose 52 mg/dl, protein 61 mg/dl; white cells 86/mm3 with 43% neutrophils, 29% lymphocytes, and 22% histiocytes. VDRL, AFB, flow cytometry, cytology, PPD, RPR, toxoplasmosis IgM and IgG, and Lyme titers were negative. magenta cyan yellow black (Figure 1) Retcam fundus photos demonstrating numerous round, whitish, deep choroidal lesions involving the posterior pole OD and normal fundus OS. For a diagnosis of bacterial meningitis or possibly herpes simplex encephalitis, he was treated with intravenous vancomycin, ceftriaxone, and ampicillin as well as intravenous acyclovir. On hospital day 2, dilated fundus examination of the OD showed a slightly swollen optic disc and many round, whitish, deep choroidal lesions, attenuated retinal arterioles, and 3-4 dot-blot hemorrhages in the superior retinal periphery (Figure 1). Fundus examination of the OS was normal. Chorioretinitis in the setting of meningitis was diagnosed. As causes, we considered syphilis, tuberculosis, histoplasmosis, coccidioidomycosis, Bartonella, Toxoplasma, diffuse unilateral sub-acute neuroretinitis (DUSN), Lyme disease, Nocardia, Aspergillus, Cryptococcus, Meningococcus, ophthalmomyiasis, onchocerciasis, cysticercosis, non-Hodgkin’s large-cell lymphoma, and sarcoidosis. But on further questioning, the patient’s family reported he was an avid camper and that on occasion he slept outside in a tent in his own back yard. Arbovirus IgM (West Nile Virus) titer was positive. Antibiotics were discontinued and he was treated supportively. He was discharged after 6 days of hospitalization. Follow-up When he was seen as an outpatient 15 days after presentation, both eyes were involved (Figure 2, Page 42). Visual acuity was 20/500 OD and 20/40 OS. The vitreous of both eyes showed rare cells. Optic disc pallor was present OD. t wo-month Follow-up Visual acuity was 20/80 OD and 20/40 OS. Trace vitreous debris was still present OU. Atrophic chorioretinal lesions were now present OU (Figure 3, Page 42). DisCussion a nD Di agnosis WNV is a single-stranded RNA arbovirus belonging to the Flaviviridae family, which involves Japanese encephalitis, St. Louis encephalitis (SLE), yellow fever, dengue, Murray Valley encephalitis, Kunjin encephalitis, and Western equine encephalitis viruses.1 Wild birds serve as the primary natural hosts.2 Mosquitos are responsible for transmission from birds to humans and other mammals.2,3 The WNV was first detected in the United States in 1999 during an outbreak in New York. Only 20% of infected individuals experience systemic symptoms, including malaise, fever, rash, anorexia, and lymphadenopathy.4 Continues on page 42 : Grand Rounds ES236597_OT050113_038.pgs 04.24.2013 20:21 ADV May 1, 2013 :: Ophthalmology Times marketplace 39 For Products & Services advertising information, contact: Karen Gerome at 800-225-4569, ext 2670 • Fax 440-756-5271 • Email: [email protected] For Recruitment advertising information, contact: Jacqueline Moran at 800-225-4569, ext 2762 • Fax 440-756-5271 • Email: [email protected] PRODUCTS & SERVICES BILLING SERVICES PM Medical Billing & Consulting Exclusive Ophthalmology Billers Expert Ophthalmology Billers Excellent Ophthalmology Billers Triple E = Everything gets Paid Concentrating on one Specialty makes the difference. We are a Nationwide Ophthalmology Billing Service. We have been in business over twenty years. Our staff consists of billers who are certifed Ophthalmic Techs, Ophthalmic assistants, and fundus photographers who are dual certifed ophthalmic coders and billers. This combination of clinical backgrounds in ophthalmology with the certifed coding degree is the ideal combination of expertise that you need to dramatically increase your revenue. We will get you paid on every procedure every single time. No more bundling, downcoding or denials… Primary, Secondary, Tertiary and Patient Billing Relentless and meticulous follow up. • Experts in Forensic Billing .Specializing in old AR cleanup • Credentialing and Re credentialing our Specialty. We have a separate Credentialing Department who has cultivated years of contacts to expedite the process as well as getting providers on plans that are technically closed. • We can offer you our own Practice Management software at no cost to you or we can VPN into your system if that is what you prefer. • Totally Hippa compliant. 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Post a job today www.modernmedicine.com/physician-careers Jacqueline Moran RECRUITMENT MARKETING ADVISOR (800) 225-4569, ext. 2762 [email protected] FUNDUS PHOTO DOES! Learn more at www.itsthisgood.com 314.533.6000 LASERS Repeating an ad ENSURES it will be seen and remembered! magenta cyan yellow black ES236570_OT050113_040_CL.pgs 04.24.2013 19:03 ADV CME CE PATIENT CONSIDERATIONS IN THE TREATMENT OF DRY EYE DISEASE A Unique Series of CME/CE Articles and Online Case-Based Activities Returning in July 2013, the Institute for Continuing Healthcare Education will continue its popular CME/CE journal article series in Ophthalmology Times and Optometry Times. This year, the certified-CME/CE articles will be accompanied by online virtual patient cases where additional CME/CE will be offered. Get introduced to a patient with dry eye disease and learn more about the condition in the article, then follow the patient into the virtual clinic. Topics include: Faculty includes: • Increasing awareness of the prevalence, chronicity, and burden of dry eye disease MARc BLOOMEnSTEIn, OD, FAAO Schwartz Laser Eye Center, Scottsdale, AZ • Improving rates of routine screening and early, accurate diagnosis of dry eye disease • Optimizing management of dry eye disease to prevent possible complications Provided by MARk T. DUnBAR, OD, FAAO University of Miami Miller School of Medicine, Miami, FL STEPHEn c. PFLUGFELDER, MD Baylor College of Medicine, Houston, TX kELLY k. nIcHOLS, OD, MPH, PhD University of Houston, Houston, TX nEDA SHAMIE, MD University of Southern California, Los Angeles, CA cLARk SPRInGS, MD Indiana University School of Medicine, Indianapolis, IN Supported by an unrestricted educational grant from Allergan Inc. Keep an eye out for this unique CME/CE series coming soon! magenta cyan yellow black ES236261_OT050113_041_FP.pgs 04.24.2013 00:28 ADV 42 May 1, 2013 :: Ophthalmology Times grand rounds (Figure 2) Composite fundus photos demonstrating multifocal chorioretinal scars involving posterior pole OU and optic disc pallor OD. (Illustrations courtesy of Richard E. Hackel, MA, CRA) grand rounds ( Continued from page 38 ) Reported ocular symptoms include photophobia, retrobulbar pain, and diplopia.5 Approximately 1 in 150 infections results in meningitis or encephalitis6 with a mortality rate of 5% to 10% in this group.7 Ages more than 50 years and diabetes have been identified as risk factors for severe neurologic disease and death.3,8 Common intraocular manifestations include bilateral, multifocal chorioretinitis with circular “target-like” lesions scattered in the midperiphery and often arranged in a radial linear pattern.9 Other intraocular findings include mild iridocyclitis, anterior uveitis, vitritis, occlusive retinal vasculitis, optic disc edema, and optic neuritis.6,9 While patients may suffer an initial significant decline in vision, visual acuity tends to recover to near-baseline levels, with chorioretinal involvement not typically extensive.9 However, the less-frequent ocular lesions, including optic neuritis and occlusive vasculitis, frequently induce persistent and likely permanent visual deficit.7 The diagnosis of systemic WNV infection relies on a high index of clinical suspicion and specific laboratory test results. The most efficient diagnostic method is detection of IgM antibody to WNV in serum or CSF using the IgM antibody-capture ELISA assay. Because IgM antibody does not cross the blood-brain barrier, its presence in CSF strongly suggests infection of the central nervous system.6 The pathogenesis of WNV-associated chorioretinitis remains speculative. It has been hypothesized that hematogenous dissemination of WNV to the choriocapillaris during viremia may seed the choroid to produce a multifocal granulomatous chorioretinitis with scattered magenta cyan yellow black (Figure 3) Optos fundus photos demonstrating numerous areas of chorioretinal atrophy OU, with linear pattern of atrophic chorioretinal lesions superior to optic disc OS, and optic disc pallor OD > OS. or linear distribution of chorioretinal lesions.10 One report showed mononuclear perivascular inflammation in pathologic specimens of neuro-invasive cases with WNV infections.11 However, Khairallah et al.12 argue that the linear pattern of WNV-associated chorioretinitis is related to retinal nerve fiber organization. Their findings suggest a contiguous spread of WNV from central nervous system via the optic nerve fibers into the eye, rather than a hematogenous dissemination to the choriocapillaris. Treatment of WNV infection is supportive. ConClusion WNV disease must be included in the differential diagnosis of a patient experiencing an acute febrile illness associated with symptoms suggestive of encephalitis or meningitis.13 The unique pattern of multifocal chorioretinitis in patients with systemic symptoms of WNV infection can help to establish the diagnosis while serologic testing is pending, highlighting the importance of the dilated fundus examination in patients who are suspected of having WNV infection.6 To understand and manage better the full spectrum of ocular disease caused by WNV virus infection, all patients who have suffered a WNV-induced meningoencephalitis should be referred for ophthalmologic evaluation.14 ■ References 1. Mukhopadhyay S, Kuhn RJ, Rossman MG. A structural perspective of the Flavivirus life cycle. Nat Rev Microbiol. 2005;3:13-22. 2. Craven RB, Roehrig JT. West Nile virus. JAMA. 2001;286:651-653. 3. Petersen LR, Marfin AA. West Nile virus: a primer for the clinician. Ann Intern Med. 2002;137:173-179. 4. Mostashari F, Bunning ML, Kitsutani PT, et al. Epidemic West Nile Virus encephalitis, New York, 1999: results of a household-based seroepidemiological survey. Lancet. 2001;358:261-264. 5. Weiss D, Carr D, Kellachan J, et al. Clinical findings of West Nile virus infection in hospitalized patients, New York and New Jersey, 2000. Emerg Infect Dis. 2001;7:654-658. 6. Khairallah M, Ben Yahia S, Ladjimi A, et al. Chorioretinal involvement in patients with West Nile Virus. Ophthalmology. 2004;111:2056-2070. 7. Chan CK, Limstrom SA, Tarasewicz DG, Lin SG. Ocular features of West Nile virus infection in North America. Ophthalmology. 2006;113:1539-1546. 8. Nash D, Mostashari F, Fine A, et al. 1999 West Nile Outbreak Response Working Group. The outbreak of West Nile virus infection in the New York City area in 1999. N Engl J Med. 2001;344:1807-1814. 9. Myers, J, Leveque, T, Johnson MW. Extensive chorioretinitis and severe vision loss associated with West Nile virus meningoencephalitis. Arch Ophthalmol. 2005;123:1754-1756. 10. Garg S, Jampol LM. Systemic and intraocular manifestations of West Nile virus infection. Surv Ophthalmol. 2005;50:3-13. 11. Sampson BA, Armbrustmacher V. West Nile encephalitis: the neuropathology of four fatalities. Ann N Y Acad Sci. 2001;951:172-178. 12. Khairallah M, Ben Yahia S, Attia S, et al. Linear pattern of West Nile virus-associated chorioretinitis is related to retinal nerve fiber organization. Eye (Lond). 2007;21:952-955. 13. Hershberger VS, Augsburger JJ, Hutchins RK, et al. Chorioretinal lesions in nonfatal cases of West Nile Virus infection. Ophthalmology. 2003;110:1732-1736. 14. Anninger WV, Lomeo MD, Dingle J, et al. West Nile virus-associated optic neuritis and chorioretinitis. Am J Ophthalmol. 2003;136:1183-1185. Travis C. rumery, do, is Clinical Lecturer, Ophthalmology and Visual Sciences, University of Michigan. Blake v. FauseTT, md, PHd, is Resident, Ophthalmology and Visual Sciences, University of Michigan. JonaTHan d. TroBe, md, is Professor, Ophthalmology and Visual Sciences; Professor, Department of Neurology, University of Michigan. sHaHzad i. mian, md, is Associate Professor, Ophthalmology and Visual Sciences; Residency Program Director, Ophthalmology and Visual Sciences, University of Michigan. riCHard e. HaCkel, ma, Cra, Photography: No fnancial interests for anyone listed above. ES236595_OT050113_042.pgs 04.24.2013 20:21 ADV NOW APPROVED ®/™ are trademarks of Bausch & Lomb Incorporated or its affiliates. ©2013 Bausch & Lomb Incorporated. Printed in USA US/PRA/13/0043a 4/13 magenta cyan yellow black ES236265_OT050113_CV3_FP.pgs 04.24.2013 00:28 ADV Some SurfaceS are worth protecting THE OCULAR SURFACE IS ONE. The SYSTANE® portfolio includes products that are engineered to protect, preserve and promote a healthy ocular surface1-5. See eye care through a new lens with our innovative portfolio of products. References 1. Christensen MT, Blackie CA, Korb DR, et al. An evaluation of the performance of a novel lubricant eye drop. Poster D692 presented at: The Association for Research in Vision and Ophthalmology Annual Meeting; May 2-6, 2010; Fort Lauderdale, FL. 2. Davitt WF, Bloomenstein M, Christensen M, et al. Effcacy in patients with dry eye after treatment with a new lubricant eye drop formulation. J Ocul Pharmacol Ther. 2010;26(4):347-353. 3. Data on fle, Alcon. 4. Wojtowica JC., et al. Pilot, Prospective, Randomized, Double-masked, Placebo-controlled Clinical Trial of an Omega-3 Supplement for Dry Eye. Cornea 2011:30(3) 308-314. 5. Geerling G., et al. The International Workshop on Meibomian Gland Dysfunction: Report of the Subcommittee on Management and Treatment of Meibomian Gland Dysfunction. IOVS 2011:52(4). Surface Protection and More © 2012 Novartis 10/12 SYS13100JAD magenta cyan yellow black ES235969_OT050113_CV4_FP.pgs 04.23.2013 19:46 ADV
