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july 2015 VOL. 7, NO. 7 Practical Chairside Advice OptometryTimes.com Optic neuropathy diagnosed via hypertension Although low blood pressure correlates with NA-ION, other risk factors exist before after EXCELLENT OVERALL CHOLESTEROL DEPOSIT RESISTANCE 1,2 SUPERIOR WETTABILITY 3† Resists cholesterol deposits throughout the lens better than other two-week or monthly replacement SiHy lenses tested.** BEFORE Cirrus OCT 3D visualization of ONH near onsetSmooths of NA-AION. Cirrus 3D andAfter protects theOCT lens. Providing a hydrophilic environment visualization of ONH edema resolution at fivethat helps week follow-up visit.maintain lens moisture. Managing myopia with contact lenses By Gretchyn Bailey, NCLC, FAAO Editor in Chief, Content Channel Director Liverpool, UK— The British Contact Lens Association (BCLA) opened the first day of its 2015 conference with a day-long focus on myopia management. Professor Brien Holden, BAppSc, PhD, DSc, chief executive officer of the Brien Holden Vision Institute, offers points to remember when managing myopia with contact lenses. There is a massive increase in4,5the prevaTEAR FILM STABILITY lence of myopia and high myopia, according to Dr. Holden. As the number of myopes increase, the number of people with uncorrected refractive error will increase. Traditionally, myopia is measured as -0.75 D in one or both meridians. Today, myopia should be considered at –0.50 D, according to Dr. Holden. stableiftear film, is -0.50 “EveryoneProvides knowsa that a child which is important for consistent D, at the end of the year she won’t5 be -0.50 comfort and visual acuity. D,” he says. Dr. Holden proposes to control myopia by See Myopia on page 5 Ask your sales representative about the AIR OPTIX® family of contact lenses or visit MYALCON.COM By Pierce Kenworthy, OD, and Bruce Onofrey, OD, RPh, FAAO A phosphodiesterase inhibitor (PDE5) use.6 nterior ischemic optic neuropathy (AION) was first described in 1974.1 NA-AION generally remains stable long It results from non-perfusion of the term with visual fields unlikely to show any posterior ciliary blood supply to the improvement, but spontaneous improvement optic nerve head.2 Classic symptoms of anof up to three lines of visual acuity has been By Colleen E. McCarthy shown in up to 40 percent of patients. The terior ischemic optic neuropathy include Content Specialist optic nerve head edema resolves and makes sudden, painless vision loss, mild to severe TM way for pallor in six to 11 weeks following vision loss, inferior altitudinal field defect, PERFORMANCE DRIVEN BY SCIENCE Cincinnati, OH— If you caught a recent episode of the acute NA-AION episode. Also, within and optic disc edema, which usually resolves ABC’s Shark Tank, you may have gotten a five years of initial eye involvement, the felspontaneously in about two months and is at eyewear’s latest startup company. low contralateral eye can become involved replaced by sectoral or more often general*AIR OPTIX® AQUA (lotrafilcon B), AIR OPTIX® AQUA Multifocal (lotrafilcon B) and AIR OPTIX® COLORS (lotrafilcon B) contact lenses: Dk/t = 138 @ -3.00D. AIR OPTIX® NIGHT & look DAY® AQUA (lotrafilcon A) contact lenses: Dk/t = 175 @ -3.00D. AIR OPTIX® for Astigmatism (lotrafilcon B) contact resistance compared to ACUVUE^ OASYS^, ACUVUE^ ADVANCE^, PureVision^, Biofinity^ and Avaira^ 3 lenses: Dk/t = 108 @ -3.00D -1.25 x 180. Other factors may impact eye health. **Superior overall lipid deposit 5 Frameri is an online optical retailer that ofin 15 to 19 percent of patients. ized optic atrophy. contact lenses. †Compared to ACUVUE^ OASYS^, ACUVUE^ ADVANCE^, PureVision^, Biofinity^ and Avaira^ contact lenses. ^Trademarks are the property of their respective owners. Important information for AIR OPTIX AQUA (lotrafi lcon B), AIR OPTIX AQUA Multifocal (lotrafi lcon B), and AIR OPTIX for Astigmatism (lotrafi lcon B) contact lenses: For daily wear or extended wear up to 6 nights for near/farfers moderately priced frames and lenses—but Optic nerve size, particularly a small cup, sightedness, presbyopia and/or astigmatism. Risk of serious eye problems (i.e. corneal ulcer) is greater for extended wear. In rare cases, loss of vision may result. Side effects like discomfort, mild burning or stinging may occur. it different isthat that lenses are has long been for thought be a (lotrafi risk lcon factor forlenses:Case report Important information AIR OPTIXto COLORS B) contact For daily wear only for near/far-sightedness. Contact lenses, even if worn for cosmeticwhat reasons, makes are prescription medical devices mustthe only be worn under the prescription, direction and supervision of 4 an eye care professional. Serious eye health problems may occur as a result of sharing contact lenses. Although rare, serious eye problems can develop while wearing contact lenses. Side effects interchangeable between frames. The wearer development of NA-AION. A 49-year-old male first noticed an care instructions provided by their eye doctor. like discomfort, mild burning or stinging mayThough occur. To helpthis avoid case these problems, patients must followHispanic the wear and replacement schedule and the lens Important information hypertension for AIR OPTIX NIGHT AQUA risk (lotrafilcon inferior A) contact lenses: Indicated for vision for eye daily wear (worn only while awake) extended while awake asleep) for upinto to 30 a can or pop out wear the(worn lenses and and snap them will represent as& aDAY major nasal shadow incorrection his left while nights. Relevant Warnings: A corneal ulcer may develop rapidly and cause eye pain, redness or blurry vision as it progresses. If left untreated, a scar, and in rare cases loss of vision, may result. The risk of serious problems is greater for extended wear vs daily wear and smoking this risk. A one-year post-market found 0.18% (18 the out offridge 10,000) ofat wearers developed infection, with 0.04%in (4 out of 10,000) of of wearers experiencing a different frame a matter seconds. Or the factor for the disorder, thereincreases are also many lifting astudy cooler from work dur- a severe corneal permanent reduction in vision by two or more rows of letters on an eye chart. Relevant Precautions: Not everyone can wear for 30 nights. Approximately 80% of wearers can wear the lenses for extended wear. About two-thirds of wearer can pop out the optical lenses and opt cases of low blood pressure and developing the day. It was described as painless wearers achieve the full 30 nights continuous wear. Side Effects: In clinical trials, approximately 3-5% of wearers experience at least one episode of infiltrative keratitis, a localized inflammation of the cornea which may be accompanied by mild to severe pain and may5require the use of antibiotic eye drops for up to one week. Other less serious side effects were conjunctivitis, lid irritation or lens discomfort including dryness, mild burning or stinging. Contraindications: instead fordisease tinted turning hislens frames mentlenses of NA-AION. and fairly sudden. He did seek One Contact should not be worn if youretrospective have: eye infection or study inflammation (redness and/or swelling); eye disease, injury not or dryness thatmedical interferes with contact lens wear; systemic that lenses, may be affected by or impact wear; certain allergic conditions or using certain medications (ex. some eye medications). Additional Information: Lenses should be replaced every month. If removed before then, lenses should be cleaned and disinfected before wearing again. into sunglasses. evaluation for the visual complaint at that showed that there is a two-fold Always follow the eye care professional’s recommended lens wear, care and replacement schedule. Consult package insert for complete information, available without charge by calling (800) 241-5999 or go to myalcon.com. References: 1. Nash W, Gabriel M. Ex vivo analysis of cholesterol with deposition for commercially available silicone hydrogel contact lenses using a fluorometric enzymatic assay. Eye Contact Lens. 2014; 40(5): 277-282. 2. Ex vivo measurement increase risk of NA-AION See Neuropathy on page 1 See Frameri on page 6 After Shark Tank, Frameri online optical finds success ® ® ® ® ® ® of lipid deposits (total cholesterol) on lenses worn daily wear through manufacturer-recommended replacement period; CLEAR CARE® Cleaning & Disinfecting Solution used for cleaning and disinfection; significance demonstrated at the 0.05 level; Alcon data on file, 2008. 3. Ex vivo measurement of contact angles on lenses worn daily wear using Clear Care for cleaning and disinfection; significance demonstrated at the 0.05 level; Alcon data on file, 2009. 4. Guillon M, Maissa C, Wong S, Patel K, Lemp J. Tear film dynamics over silicone hydrogel contact lenses with different lipid deposition profiles. Optom Vis Sci. 2014; 91: E-abstract 145196. 5. Alcon data on file, 2014. Q& A product | agustin gonzales oninformation. owl vision, generic vs. branded, and going to private practice See page 41 See instructions for complete wear, care and safety © 2015 Novartis 2/15 AOA15014JAD JULY 2015 VOL. 7, NO. 7 OptometryTimes.com PRACTICAL CHAIRSIDE ADVICE Optic neuropathy diagnosed via hypertension Although low blood pressure correlates with NA-ION, other risk factors exist BEFORE AFTER BEFORE Cirrus OCT 3D visualization of ONH near onset of NA-AION. AFTER Cirrus OCT 3D visualization of ONH edema resolution at fiveweek follow-up visit. Managing myopia with contact lenses By Gretchyn Bailey, NCLC, FAAO Editor in Chief, Content Channel Director Liverpool, UK— The British Contact Lens Association (BCLA) opened the first day of its 2015 conference with a day-long focus on myopia management. Professor Brien Holden, BAppSc, PhD, DSc, chief executive officer of the Brien Holden Vision Institute, offers points to remember when managing myopia with contact lenses. There is a massive increase in the prevalence of myopia and high myopia, according to Dr. Holden. As the number of myopes increase, the number of people with uncorrected refractive error will increase. Traditionally, myopia is measured as -0.75 D in one or both meridians. Today, myopia should be considered at –0.50 D, according to Dr. Holden. “Everyone knows that if a child is -0.50 See Myopia on page 5 By Pierce Kenworthy, OD, and Bruce Onofrey, OD, RPh, FAAO nterior ischemic optic neuropathy (AION) was first described in 1974.1 It results from non-perfusion of the posterior ciliary blood supply to the optic nerve head.2 Classic symptoms of anterior ischemic optic neuropathy include sudden, painless vision loss, mild to severe vision loss, inferior altitudinal field defect, and optic disc edema, which usually resolves spontaneously in about two months and is replaced by sectoral or more often generalized optic atrophy.3 Optic nerve size, particularly a small cup, has long been thought to be a risk factor for development of NA-AION.4 Though this case will represent hypertension as a major risk factor for the disorder, there are also many cases of low blood pressure and development of NA-AION.5 One retrospective study showed that there is a two-fold increase risk of NA-AION with A phosphodiesterase inhibitor (PDE5) use.6 NA-AION generally remains stable long term with visual fields unlikely to show any improvement, but spontaneous improvement of up to three lines of visual acuity has been shown in up to 40 percent of patients. The optic nerve head edema resolves and makes way for pallor in six to 11 weeks following the acute NA-AION episode. Also, within five years of initial eye involvement, the fellow contralateral eye can become involved in 15 to 19 percent of patients.5 After Shark Tank, Frameri online optical finds success By Colleen E. McCarthy Content Specialist A 49-year-old Hispanic male first noticed an inferior nasal shadow in his left eye while lifting a cooler from the fridge at work during the day. It was described as painless and fairly sudden. He did not seek medical evaluation for the visual complaint at Cincinnati, OH— If you caught a recent episode of ABC’s Shark Tank, you may have gotten a look at eyewear’s latest startup company. Frameri is an online optical retailer that offers moderately priced frames and lenses—but what makes it different is that the lenses are interchangeable between frames. The wearer can pop out the lenses and snap them into a different frame in a matter of seconds. Or the wearer can pop out the optical lenses and opt instead for tinted lenses, turning his frames into sunglasses. See Neuropathy on page 20 See Frameri on page 6 Case report Q&A | AGUSTIN GONZALES on owl vision, generic vs. branded, and going to private practice SEE PAGE 41 | PRACTICAL CHAIRSIDE ADVICE FROM THE Chief Optometric Editor 3 Optometry’s future is in good hands By Ernie Bowling, OD, FAAO Chief Optometric Editor He is in private practice in Gadsden, AL, and is the Diplomate Exam Chair of the American Academy of Optometry’s Primary Care Section [email protected] 256-295-2632 n the last day of January, I had the distinct honor to lecture at the Georgia Optometric Association’s Super CE meeting in Atlanta. Having practiced in northwest Georgia for the majority of my career, I got to see a lot of old friends and make many new ones. The highlight of the weekend for me personally was getting to spend some time catching up with Ben Casella, OD, FAAO. Ben is a third-generation optometrist from Augusta, GA. He is a graduate of the UAB School of Optometry, and I’m proud to say one of my former students. After completing an ocular disease residency at SUNY, he returned to the family practice started in 1948 by his grandfather. Ben is a member O Dr. Bowling shares why ODs like Ben Casella make the future bright OptometryTimes.com/BenCasella to view. Dr. Bowling and Dr. Casella smile for the camera at the GOA meeting in Atlanta. of our Optometry Times Editorial Advisory Board and authors the magazine’s glaucoma column (see page 14). I do not know a more clinically savvy young optometrist. He is also very active politically on behalf of our profession. Ben is currently the trea- surer of the Georgia Optometric Association, working his way through the officer chairs. Ben was named the Young OD of the South by SECO International in 2014. I’m certain his father Thomas is very proud of his son’s accomplishments. Talking with Ben, he obviously has a great pride in the family practice that is now in his charge, but you really see his eyes brighten when he talks of his wife Laura and their two children Carter and Elisabeth. The future of our profession is in the hands of these young optometrists. They are going to stand on—and expand upon—the hardfought gains by the generations of ODs who came before them. They know from where our profession has come but more importantly know where our profession is now and have a vision of where our profession needs to be in the years to come so optometrists everywhere can better care for their patients. When I see Dr. Ben Casella and many of the young ODs at these meetings—optometrists who are passionate about our profession and willing to put Provide their time and treasure culturally toward its betterment—I competent care See page know optometry’s future 16 for more on is in good hands. this story. Editorial Advisory Board Ernie Bowling, OD, FAAO Chief Optometric Editor Editorial Advisory Board members are optometric thought leaders. They contribute ideas, offer suggestions, advise the editorial staff, and act as industry ambassadors for the journal. Jeffrey Anshel, OD, FAAO Michael P. Cooper, OD Alan G. Kabat, OD, FAAO Mohammad Rafieetary, OD, FAAO Joseph Sowka, OD, FAAO Ocular Nutrition Society Encinitas, CA Chous Eye Care Associates Tacoma, WA Southern College of Optometry Memphis, TN Charles Retina Institute Memphis, TN Sherry J. Bass, OD, FAAO Douglas K. Devries, OD David L. Kading, OD, FAAO Michael Rothschild, OD Nova Southeastern University College of Optometry Fort Lauderdale, FL SUNY College of Optometry New York, NY Eye Care Associates of Nevada Sparks, NV Specialty Eyecare Group Kirkland, WA West Georgia Eye Care Carrollton, GA Justin Bazan, OD Steven Ferucci, OD, FAAO Danica J. Marrelli, OD, FAAO John Rumpakis, OD, MBA Park Slope Eye Brooklyn, NY Sepulveda VA Ambulatory Care Center and Nursing Home Sepulveda, CA University of Houston College of Optometry Houston, TX Practice Resource Management Lake Oswego, OR Lisa Frye, ABOC, FNAO Katherine M. Mastrota, MS, OD, FAAO Eye Care Associates Birmingham, AL Omni Eye Surgery New York, NY Eyecare Consultants Vision Source Englewood, CO Ben Gaddie, OD, FAAO John J. McSoley, OD Gaddie Eye Centers Louisville, KY University of Miami Medical Group Miami, FL University of Alabama at Birmingham School of Optometry Birmingham, AL David I. Geffen, OD, FAAO Ron Melton, OD, FAAO Peter Shaw-McMinn, OD Gordon Weiss Schanzlin Vision Institute San Diego, CA Educators in Primary Eye Care LLC Charlotte, NC Southern California College of Optometry William D. Townsend, OD, FAAO Sun City Vision Center Advanced Eye Care Sun City, CA Canyon, TX Jeffry D. Gerson, OD, FAAO Highland, CA Diana L. Shechtman, OD, FAAO William J. Tullo, OD, FAAO Patricia A. Modica, OD, FAAO Nova Southeastern University Fort Lauderdale, FL TLC Laser Eye Centers/ Princeton Optometric Physicians Princeton, NJ Marc R. Bloomenstein, OD, FAAO Schwartz Laser Eye Center Scottsdale, AZ Crystal Brimer, OD Crystal Vision Services Wilmington, NC Mile Brujic, OD Premier Vision Group Bowling Green, OH Benjamin P. Casella, OD Casella Eye Center Augusta, GA Michael A. Chaglasian, OD Illinois Eye Institute Chicago, IL WestGlen Eyecare Shawnee, KS Milton M. Hom, OD, FAAO A. Paul Chous, OD, MA Azusa, CA Chous Eye Care Associates Tacoma, WA Renee Jacobs, OD, MA Practice Management Depot Vancouver, BC Pamela J. Miller, OD, FAAO, JD SUNY College of Optometry New York, NY Laurie L. Pierce, LDO, ABOM Hillsborough Community College Tampa, FL John L. Schachet, OD Leo P. Semes, OD Joseph P. Shovlin, OD, FAAO, DPNAP Northeastern Eye Institute Scranton, PA Kirk Smick, OD Clayton Eye Centers Morrow, GA Loretta B. Szczotka-Flynn, OD, MS, FAAO University Hospitals Case Medical Center Cleveland, OH Marc B. Taub, OD, MS, FAAO, FCOVD Southern College of Optometry Memphis, TN Tammy Pifer Than, OD, MS, FAAO University of Alabama at Birmingham School of Optometry Birmingham, AL J. James Thimons, OD, FAAO Ophthalmic Consultants of Fairfield Fairfield, CT Walter O. Whitley, OD, MBA, FAAO Virginia Eye Consultants Norfolk, VA Kathy C. Yang-Williams, OD, FAAO Roosevelt Vision Source PLLC Seattle, WA Digit@l 4 JULY 2015 t VOL. 7, NO. 7 Content CONTENT CHANNEL DIRECTOR Gretchyn M. Bailey, NCLC, FAAO [email protected] 215/412-0214 CONTENT SPECIALIST Colleen McCarthy [email protected] 440/891-2602 VP, CONTENT & STRATEGY Sara Michael GROUP CONTENT DIRECTOR Mark L. Dlugoss DIRECTOR, DESIGN AND DIGITAL PRODUCTION Nancy Bitteker ART DIRECTOR Lecia Landis CHECK OUT THE LATEST OPTOMETRY TIMES BLOGS In 2015, Optometry Times is offering weekly blogs from some of the leaders in the optometric profession. Haven’t read them yet? Here’s what you’re missing. Dr. Tracy Schroeder Swartz, the newest blogger for Optometry Times, shares some lessons that she’s learned as the owner of a jet ski that apply to her life as an optometrist, too. Dr. Michael Brown lays out the laws of the optometric jungle for the recentlygraduated class of 2015. Whether you earned your OD this year or 20 years ago, Dr. Brown has some good advice on remembering what it’s all about. Dr. Scott Schachter says that vision begins at the tear film—so why aren’t we objectively evaluating this critical layer? Dr. Steve Nelson, another new blogger on the Optometry Times block, responded to an Ophthalmology Times blog written by a first-year resident who argued against expanding OD scope of practice in California. optometrytimes.com/tag/odt-blog TOP HEADLINES Check out what your colleagues are reading. Best and worst places to practice 2015 1 OptometryTimes.com/BestandWorst2015 What is your patients’ interest level in cosmetic lenses? 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OptometryTimes.com PRACTICAL CHAIRSIDE ADVICE MD resident rn cks ODs y What we can leases atta blog—ODs repl from diabetic ca important ation just as Patient educ ful ocular exam as a care C A in McCarthy By Colleen Content Specialist logy Times, , Ophthalmo Zack Oakey, Our sister publication two blogs from Unirecently featured logy resident at the a MD, an ophthalmo , Irvine, that created versity of Californiaof the OD/MD aisle. sides defends opbuzz on both blog, Dr. Oakey s and In his first medical procedure such allowing tometrist-performed he thinks not explains why hinder patients and create practices would . monopoly ic two weeks an ophthalm blog, published In his second OD-performed explains that be legal. He not later, Dr. Oakey should s remedical procedure first blog, he writing the desays that after from both sides of the ’s attempts ceived reactions believes optometryare best debate and now scope of practice 5 at expanded Blog on page See noted associated aneurysm C l to macula with toward the fovea. of exudates infratempora around the foveal and edema encroaching shows the ring FAAO d the exudate area, the capillaries , OD, A Fundus photograph B OCT demonstrate normal. ad Rafieetary within the highlighted Mohamm center of circinate. athy within the By remain essentially at the the field shown shows microangiop areas within Angiography and most other avascular zone MISSION STATEMENT SONSINO ce Patent s, insuran OPTOMETRY TIMES cannot be held responsible for the safekeeping or return of unsolicited articles, manuscripts, photographs, illustrations or other materials. called Blink ra’s new service d viNew York City—EyeNet at-home, on-deman has begun offeringYork City. New sion tests in week seven days a appointments company will Blink offers to 9 p.m. The the from 9 a.m. home and performcosts The test come to a patient’s 20 minutes. ,” not testing in about by a “visioneer performed $75 and is st. t that an optometri a bunch of equipmenpage 8 “We’ve shrunk See Blink on How it works Library Access Libraries offer online access to current and back issues of Optometry Times through the EBSCO host databases. Optometry Times is an optometry-driven publication that hiking e, and scary time machin To subscribe, call toll-free 888-527-7008. Outside the U.S. call 218/740-6477. SEE PAGE 46 disseminates news and information of a clinical, socioeconomic, and political nature in a timely and accurate manner for members of the optometric community. In partnership with our readers, we will achieve mutual success by: Y Q&A | DR. 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Several eyecare and the neglect their patient with sual acuity any diabetics I asked a diabeticwas suffering and/or misunyears ago, if he due to not knowing diabetes reretinopathy the effects of disease. He significant derstanding Much lated kidney visual system. functioned any diabetic-re to the eyes and that his kidneys conveyed education can plied by saying ies in patient t if this was then asked or insufficien of the inadequac any kidney perfectly. I to the absence providphysician through but went be attributed no, to him by his among healthcarepatients. He replied our testing. communication and kidneys were function optometrists, assesshe knew his page 21 ers, including on to say that tion is our patients’ diabetes on See Managing One misconcep the possibility of having ment of t eye disease— any significan M Get access to all the benefits Optometry Times offers at your fingertips. The Optometry Times app for iPad and iPhone is now free in the iTunes store. In-home, vision on-demand test is coming B By Mohamm OPTOMETRY TIMES APP CHIEF EXECUTIVE OFFICER Tim Cobbold GROUP OPERATIONS DIRECTOR Andrew Crow CHIEF FINANCIAL OFFICER Robert Gray CHAIRMAN Dame Helen Alexander Optometry Times is part of the ModernMedicine Network, a Webbased portal for health professionals Being a forum for optometrists to communicate their clinical knowledge, insights, and discoveries. t offering best-in-class content and t Providing management information that allows optometrists to enhance and expand their practices. tools in a rewarding and easy-to-use environment for knowledge-sharing t Addressing political and socioeconomic issues that may either assist or hinder the optometric community, and reporting those issues and their potential outcomes to our readers. among members of our community. OPTOMETRY TIMES (Print ISSN: 0890-7080, Digital ISSN: 2328-3904) is published monthly (12 issues) by UBM Medica 131 W. First Street, Duluth, MN 55802-2065. Subscription rates: $49 for one year in the United States & Possessions; $59 for one year in Canada and Mexico, and $89 for one year for all other countries. Periodicals Postage paid at Duluth MN 55806 and additional mailing offices. POSTMASTER: Please send address changes to OPTOMETRY TIMES, P.O. Box 6089, Duluth, MN 55806-6089. Canadian G.S.T. number: R124213133RT001, PUBLICATIONS MAIL AGREEMENT NO. 40612608, Return Undeliverable Canadian Addresses to: IMEX Global Solutions, P. O. Box 25542, London, ON N6C 6B2, CANADA. Printed in the U.S.A. ©2015 Advanstar Communications Inc. All rights reserved. No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical including by photocopy, recording, or information storage and retrieval without permission in writing from the publisher. Authorization to photocopy items for internal/educational or personal use, or the internal/educational or personal use of specific clients is granted by Advanstar Communications Inc. for libraries and other users registered with the Copyright Clearance Center, 222 Rosewood Dr. Danvers, MA 01923, 978-750-8400 fax 978-646-8700 or visit http://www.copyright.com online. For uses beyond those listed above, please direct your written request to Permission Dept. fax 440-756-5255 or email: [email protected]. | PRACTICAL CHAIRSIDE ADVICE Myopia Continued from page 1 D, at the end of the year she won’t be -0.50 D,” he says. Dr. Holden proposes to control myopia by not using standard spectacles and contact lenses which promote myopia, delaying the onset of myopia, and using interventions that will reduce the rate of myopia. The eyecare community needs to identify and treat the young, faster growing, at-risk myopes. Two questions need to be answered: Can we control the progress of a child destined for high myopia? Does myopia control reduce pathological consequences? The World Health Organization (WHO) and the Brien Holden Vision Institute (BHVI) recently held a global scientific meeting on myopia to review scientific evidence and create recommendations to prevent blindness from myopia. In addition, BHVI is launching The Myopia Institute, which will provide evidence-based information about myopia, educate society about the adverse influence of myopia, and develop strategies for reducing vision impairment caused by myopia. In Focus der aberrations are manipulated via mathematical algorithms to optimize retinal image quality across a wide range of distances. These lenses show a 40-48 percent reduction in axial length. 7 Dose matters Wearing myo- pia control contact lenses on a consistent basis and remaining compliant increases success. Such contact lenses worn 10 hours a day showed a 47 percent reduction, lenses worn 12 hours a day showed a 58 percent reduction, and lenses worn 14 hours a day showed a 66 percent reduction. Key myopia management points We need to change our attitudes Any myopia in a 1 2 young child is a major risk factor. The only soft contact lens available today that does not have a myopia-provoking spherical aberration in the periphery of the optic is lotrafilcon A Power profiles of lenses vary; some have a negative spherical aberration profile that exacerbates myopia. 3 Outdoors is good Increasing the time outdoors de- 4 Ortho-k works “Ortho-k lenses are the most success- 5 Peripheral plus lenses work Peripheral plus contact lays the onset of myopia and reduces the rate of progression. Children today are spending more time indoors, especially with digital devices. Taiwan recently proposed a new law which would ban children under the age of 2 from using electronic devices, levy a fine on parents who allow children to use iPads and/ or smartphones, and allow digital device use for children under age 18 for a “reasonable” length of time. ful myopia control treatment that we have,” says Dr. Holden. Overall, ortho-k lenses provide a 30 percent reduction in axial length increase. lenses bring the peripheral image forward toward the retina; correcting peripheral hyperopia helps to control myopia. The lenses consistently reduce the rate of progress of myopia by 40 percent each year. “If you want to do something tomorrow,” Dr. Holden says, “fit every kid aged 7 to 27 with peripheral plus lenses.” 6 Stepped anti-myopia (SAM) and extended depth of focus (EDOF) contact lenses work Higher-or- 2013 n=325; 2014 n=263 8 5 Fear, handling, and discomfort are concerns Confidence in these contact lenses from both public and eyecare professionals is needed. 9 Myopia is both a challenge and an opportunity Myopia is a challenge to eye health. Myopia is also an opportunity for: Contact lenses Eyecare practitioners to prevent high myopia Contact lens industry Health and welfare of children and adults Prevention of global blindness 6 In Focus Frameri Continued from page 1 Frames run at $99 per pair. The frames come in three different shapes with a wide range of color options. Plano and single vision lenses are $50, while progressive lenses run $250. The lenses are polycarbonate, ARcoated, EMI-coated, scratch resistant, and $99 The cost of a pair of Frameri frames. Single-vision lenses are $50, and PALs are $250 smudge resistant. Frameri offers 10 different tints for sunglasses lenses. Frameri runs its own optical lab in-house. Founder Konrad Billetz says that even after wearing glasses since he was a kid, he didn’t know much about eyewear. But the price, the inconvenience, and the limited choices were always a problem, so he set to find a way to improve the experience for glasses wearers. “We put together a team of industrial designers, computer nerds, and smart geeks, and we figured it out,” he says. “We want to make glasses for people who wear them. JULY 2015 Frameri plans to offer its frames in traditional optical shops. How can we make them better? What are the problems that people run into?” After a year of research and design, the company officially launched last July. From the beginning, Billetz says, it was about coming up with the best design to meet the needs of the wearer. But what further differentiates Frameri from its online optical competition is that the company has plans to offer its frames in traditional optical shops. Bridging the gap between optical and e-commerce “We view ourselves as the bridge between traditional optical shops or independent opticals and e-commerce,” Billetz says. “For a long time, e-commerce has had that horrible reputation because it takes away from the opticians. We don’t want to conflict with | the opticians—we want to work with them.” Not only will opticals be able to carry Frameri products, Billetz says that if a patient makes any future purchases on the Frameri site, the eyecare professional will be compensated. “The product is all about owning multiple frames. Well, if they don’t get the frames at your shop, and they get them from Frameri, you should be compensated, as well,” he says. “Instead of conflicting with the way eyewear is done, we want to be that bridge.” Several ODs told Optometry Times they actually loved the idea behind Frameri. “I think it is a fantastic idea to have the same set of lenses be used in multiple frames of different styles,” says Optometry Times Editorial Advisory Board member Justin Bazan, OD. “Most people seem to have one or maybe two primary pairs that they wear on a regular basis. By utilizing the same set of lenses, you are greatly reducing the cost associated with multiple pairs, which helps to facilitate the purchase of them. “I think this innovative concept will be incorporated into other manufacturers’ frame See Frameri on page 8 IN BRIEF Oraya’s IRay wins silver for medical design excellence NEWARK, CA—Oraya Therapeutics and Bridge Design announced that the the company’s Oraya IRay Radiotherapy System has won the silver award in the radiological and electromechanical devices category of the 18th Annual Medical Design Excellence Awards (MDEA). The MDEA is the medtech industry’s premier design competition committed to searching worldwide for the highest caliber finished medical devices, products, systems, or packaging available on the market. The awards program celebrates the achievements of the medical device manufacturers, their suppliers, and the many people behind the scenes—engineers, scientists, designers, and clinicians—who are responsible for the cutting-edge products that are savings lives, improving patient healthcare, and transforming medtech. The 2015 MDEA Juror Panel selected 45 exceptional finalists in 10 medical technology product categories. Products were judged based on design and engineering innovation; function and user-related in- novation; patient benefits; business benefits; and overall benefit to the healthcare system. “We, alongside our partner Bridge Design, are honored to be recognized with this prestigious award,” says Jim Taylor, president and CEO of Oraya Therapeutics. “Our goal in designing and developing the IRay system was to offer eyecare practitioners and their patients an innovative, comfortable and non-invasive treatment option for wet AMD. We believe that physician ease-of-use and patient comfort have played a significant role in the rapidadoption of Oraya Therapy in Europe and its continued integration into standard clinical care.” The IRay Radiotherapy System delivers low-voltage X-rays for the treatment of wet age-related macular degeneration (AMD). Oraya says theIRay system’s relatively small footprint is designed for installation in a clinic or hospital, without the need for added room shielding, and to be easy to operate. The key proprietary elements of the system consist of a low-energy X-ray tube, a self-contained automated beam positioning system, Oraya Therapy software, the I-Guide eye stabilization device and an eye tracking system. Combining these elements into a product that would be patient friendly as well as providing reliability and efficiency with patient workflow was critical. Bridge Design worked in close collaboration with Oraya to design and engineer the IRay system from conception to commercialization. Extensive ergonomic studies were undertaken to gain a clear understanding of physicians’ and patients’ needs, and to inform the development of the product for an international market. Oraya Therapy is available at 11 sites in three countries including the United Kingdom, Germany and Switzerland, and additional sites are in the active planning stages. The IRay system is CE marked in Europe. In the U.S., the IRay System is an investigational device and is not available for sale. ACRYSOF IOL VISION SIMULATOR ® YOUR ROADMAP TO IOL EDUCATION NOW CATARACT PATIENT EDUCATION IS JUST A CLICK AWAY. With the AcrySof ® IOL Vision Simulator app, you can quickly and easily show patients the simulated impact of IOL selection on their vision: Download it free on the iTunes store Works with iPads Search “AcrySof ” in the iPad apps section Helps patients visualize their treatment options, including astigmatism correction DOWNLOAD THE ACRYSOF® IOL VISION SIMULATOR APP FOR YOUR IPAD TODAY! Patients can compare the simulated post-surgical vision of each IOL at near, intermediate and far distances based on their unique vision needs. See adjacent page for important product information. © 2015 Novartis 3/15 IOL15005JAD 8 In Focus Frameri Continued from page 6 designs,” he says. “Personally, I have really loved a frame style and wanted to get it in other colors, but would hesitate because the cost of the lenses. Being able to just swap out the lenses is a great solution for that.” Eric White, OD, says he’d be interested in Frameri as an alternative for online optical retailers. “E-commerce is here, and we have to find a way to expand and $1.2 billion, the value of five-year old Warby Parker, one of the innovators of online optical retailing and has expanded to brick-and-mortar stores introduce our patients to it without loosing them,” he says. “I feel this would be a good alternative, especially if they are willing to work with the independent OD.” While Ryan Powell, OD, says he has not had experience with Frameri, he’s intrigued by the concept. “I think that patients and customers purchasing glasses in my opticals would be interested in an interchangeable lens option. That would be something new to the market that is interesting,” he says. Dr. Powell does have his concerns with online optical companies. “When you say ‘inexpensive, online,’ my first thought is poor quality,” he says. “A poor quality frame with low-end lenses would not be something we would be interested in offering our patients. JULY 2015 | We want to be able to provide eyeglasses that we can stand behind. We want to feel confident that the buyer of the eyeglasses at our practice is getting a quality product and that the value of the product is found in the longevity of the lenses and frame and the quality of his vision.” Why eye care has become a hot spot for startups Frameri is just one of many new startups to hit the eyecare space in the last few years. Companies like Warby Parker, Blink, and Opternative have all attempted to change aspects of the eyecare experience in one way or anther. So, what makes this industry so attractive to startup companies? The startup community is growing in all industries, Billetz says, but eye care has been a very promising space because there hasn’t been a lot of innovation in the industry in the past. “This is a marketplace that is very ripe for disruption,” he says, using Warby Parker’s massive success as an example. “I don’t want to say that what’s currently done is broken, but I think that there’s a lot of areas for improvement. The difficult part has been working in such a traditional field while still trying to create new things.” Billetz says that you would never look down upon innovations in the tech world, but that’s how the eyecare industry tends to react to these startups’ new ideas. There is a sense that change is bad, he says. “I would hope that the industry begins to understand that this is a collaborative movement to improve things. We’re looking at making these better, and let’s embrace that and accept that, really see what works, and make things better for the customer,” he says. “It should be everybody’s goal at the end of the day.” Online optical becomes big business ACRYSOF® IQ TORIC INTRAOCULAR LENSES IMPORTANT PRODUCT INFORMATION CAUTION: Federal (USA) law restricts this device to the sale by or on the order of a physician. INDICATIONS: The AcrySof® IQ Toric posterior chamber intraocular lenses are intended for primary implantation in the capsular bag of the eye for visual correction of aphakia and pre-existing corneal astigmatism secondary to removal of a cataractous lens in adult patients with or without presbyopia, who desire improved uncorrected distance vision, reduction of residual refractive cylinder and increased spectacle independence for distance vision. WARNINGS/PRECAUTIONS: Careful preoperative evaluation and sound clinical judgment should be XVHGE\WKHVXUJHRQWRGHFLGHWKHULVNEHQHWUDWLREHIRUHLPSODQWLQJDOHQVLQDSDWLHQWZLWKDQ\RIWKH conditions described in the Directions for Use labeling. Toric IOLs should not be implanted if the posterior capsule is ruptured, if the zonules are damaged, or if a primary posterior capsulotomy is planned. Rotation can reduce astigmatic correction; if necessary lens repositioning should occur as early as possible prior to lens encapsulation. All viscoelastics should be removed from both the anterior and posterior sides of the lens; residual viscoelastics may allow the lens to rotate. Optical theory suggests that high astigmatic patients (i.e., > 2.5 D) may experience spatial distortions. Possible toric IOL related factors may include residual cylindrical error or axis misalignments. Prior to surgery, physicians should provide prospective patients with a copy of the 3DWLHQWΖQIRUPDWLRQ%URFKXUHDYDLODEOHIURP$OFRQIRUWKLVSURGXFWLQIRUPLQJWKHPRISRVVLEOHULVNVDQGEHQHWV associated with the AcrySof® IQ Toric Cylinder Power IOLs. Studies have shown that color vision discrimination is QRWDGYHUVHO\DHFWHGLQLQGLYLGXDOVZLWKWKH$FU\6RI ®1DWXUDOΖ2/DQGQRUPDOFRORUYLVLRQ7KHHHFWRQYLVLRQ of the AcrySof® Natural IOL in subjects with hereditary color vision defects and acquired color vision defects secondary to ocular disease (e.g., glaucoma, diabetic retinopathy, chronic uveitis, and other retinal or optic nerve diseases) has not been studied. Do not resterilize; do not store over 45° C; use only sterile irrigating solutions such as BSS® or BSS PLUS® Sterile Intraocular Irrigating Solutions. ATTENTION: Reference the Directions for Use labeling for a complete listing of indications, warnings and precautions. © 2015 Novartis 3/15 IOL15005JAD Frameri joins the ranks of online optical retail companies like Warby Parker, which just raised $100 million to expand its brick and mortar stores from 12 to 20 by the end of the year. Just five years old, Warby Parker is now valued at $1.2 billion. And Frameri, while not even a year old yet, has been getting a lot of attention. Last year, a month before the company even launched, the company appeared on the ABC show Shark Tank to pitch to the show’s lineup of investors. Frameri didn’t walk away with a deal, but that was OK, says Billetz. In between the time the show approached the company about appearing and the time he went to shoot the episode, Frameri had already secured some significant investments. Last summer, Frameri won a $100,000 investment from America Online co-founder Steve Case. And Billetz, 28, made Forbes’ 2015 30 under 30 list in the manufacturing and industry category. What you can learn from online optical companies Dr. Bazan says ODs can learn from the growth of online optical companies. “It is becoming more apparent from the popularity of companies like Frameri that more and more consumers are looking for trendy eyewear that is in the $100 to $200 range,” says Dr. Bazan. “The average Main Street OD should be studying these companies and finding ways to be competitive in their own offices.” When his patients request their prescription with plans to use it at an online optical retailer, Dr. Bazan says he uses it as an opportunity to bring their attention to his moderately-priced frames. “Often, they will find something they love, and we can get it done for them on the spot,” he says. “Other times, they learn the differences between that eyewear and the premium eyewear we have in our optical. They key was to have something competitive in our optical, which gave us an opportunity to do business with them.” | PRACTICAL CHAIRSIDE ADVICE Opinion 9 Lutein and zeaxanthin: Beyond retinal health By Stuart Richer, OD, PhD placebo-controlled study. Nutrition. 2013 JulAug;29(7-8):958-64. O 5. Richer S, Park D-W, Epstein R, et al. Macular Re-pigmentation Enhances Driving Vision in Elderly Adult Males with Macular Degeneration. J Clin Exp Ophthalmology. ISSN: 2155-9570, 2012, 3(3)1000217. severe cataract.6 Separately, it been determined that for every 300-mcg (about 1/3 ptometrists like to think about of a milligram) increase in dietary ocular nutritional supplements lutein and zeaxanthin, there was a in narrow terms, focusing on statistically significant three perAREDS2 or the carotenoids’ visual cent decrease in nuclear cataract benefits. For example, it is now well STUART RICHER, risk.7 The dietary carotenoids also established by the AREDS2 study OD, PHD, FAAO, that dietary lutein and zeaxanthin promote cardiovascular health and is director of ocular reduce the risk of developing adhave anti-inflammatory effects.8 preventive medicine vanced catastrophic vision loss in Further properties of dietary caat James Lovell Federal Health Care patients with high-risk retinopathy.1 rotenoids leading to a potential reFacility in Chicago. duction of cardiovascular risk inWe also know that the lack of the He is also associate clude lowering of blood pressure, ocular carotenoids in the diet can professor of family reduction of pro-inflammatory cyinfluence visual function through and preventative tokines, markers of inflammation optical as well as biological mechmedicine at Chicago Medical School (such as C-reactive protein), and anisms.2,3 This includes mitigating and assistant improvement of insulin sensitivglare disability and improving glare clinical professor ity in muscle, liver, and adipose recovery time, contrast sensitivity, at University of tissues.9 Most exciting of all, luchromatic contrast, visual range, Illinois at Chicago and neural processing speed and tein and zeaxanthin promote betdepartment of ophthalmology and efficiency. Notably, macular re-pigter brain health. Within our own visual science. mentation with lutein in Chinese laboratory, in the Zeaxanthin and drivers or zeaxanthin in U.S. drivVision Function study, zeaxanthin ers, as shown in our lab, improves night has been found to promote better long term driving vision.4,5 delayed memory.10 All of these extra–retinal health factors should be taken into account when choosing Other optical enhancements an ocular supplement. While supplemental How many of us appreciate that dietary lumesozeaxanthin (and endogenous lutein detein and zeaxanthin also support the health rived mesozeaxanthin) can build macular of the human lens beyond optical enhancepigment and enhance retinal pigmentation ment through biological mechanisms? In and vision, mesozeaxanthin has not been AREDS2, dietary lutein and zeaxanthin found in the ocular lens, brain, and extrawere found to have anti-cataract properocular tissues—thus far offering no added ties.In subjects in the lowest quintile of diprotection to systemic and brain health. Dietary carotenoids promote cardiovascular heath and provide antiinflammatory and emerging neurocognitive benefits. etary lutein and zeaxanthin intake, there was a 32 percent reduction in progression to cataract surgery, a 30 percent reduction in development of any cataract, and a 36 percent reduction in development of any REFERENCES 1. Age-Related Eye Disease Study 2 (AREDS2) Research Group, Secondary analyses of the effects of lutein/zeaxanthin on age-related macular degeneration progression: AREDS2 report No. 3. JAMA Ophthalmol. 2014 Feb;132(2):142-9. 2. Hammond BR, Fletcher LM, Roos F, et al. A doubleblind, placebo-controlled study on the effects of lutein and zeaxanthin on photostress recovery, glare disability, and chromatic contrast. Invest Ophthalmol Vis Sci. 2014 Dec 2;55(12): 8583-9. 3. Bovier ER, Renzi LM, Hammond BR, et al. A double-blind, placebo-controlled study on the effects of lutein and zeaxanthin on neural processing speed and efficiency. PLoS One. 2014 Sep 24; 9(9). 4. Yao Y, Qiu QH, Wu XW, Cai ZY, Xu S, Liang XQ. Lutein supplementation improves visual performance in Chinese drivers: 1-year randomized, double-blind, 6. Age-Related Eye Disease Study 2 (AREDS2) Research Group, Lutein/zeaxanthin for the treatment of age-related cataract: AREDS2 randomized trial report no. 4. JAMA Ophthalmol. 2013 Jul;131(7):84350. 7. Ma L, Hao ZX, Liu RR, et al. A dose-response meta-analysis of dietary lutein and zeaxanthin intake in relation to risk of age-related cataract. Graefes Arch Clin Exp Ophthalmol. 2014, 252(1):63-70. 8. Gammone MA, Riccioni G, D’Orazio N, Carotenoids: potential allies of cardiovascular health? Food Nutr Res. 2015 Feb 6;59:26762. 9. Vishwanathan R, Schalch W, Johnson EJ. Macular pigment carotenoids in the retina and occipital cortex are related in humans. Nutr Neurosci. 2015 Mar 9. 10. Hoffman K, Richer SP, Wrobel J, et al. A prospective study of neuro-cognitive enhancement with carotenoids in elderly adult males with early age related macular degeneration. Science Domain International Ophthalmology. 2015;4(1):1-8. Dr. Richer is president of the Ocular Nutrition Society (ONS). He is associate editor of Journal of the American College of Nutrition and a Physician Information & Education Resource (PIER) consultant to the American College of Physicians. [email protected] MY FAVORITE APP Golf Pad I like Golf Pad for keeping score, yardage per shot, and courses played. The GPS feature reports to the center of the green, which is not the same as distance to the pin, yet it suits my needs in a single device. The one drawback is the appearance of using a phone during golf. —Renee Jacobs, OD, MA Vancouver 10 Focus On CO-MANAGEMENT JULY 2015 | How technology changed optometry’s role in cataract comanagement The cataract surgery landscape is ever evolving, and so must our role Times—they are a changing. Look mom, no hands! Look, no wires! No ethernet connection necessary. No phone cord needed. No wires. No need to remove the corneal flap. No key to open my door. No reason to remove the whole capsule. No reason to actually even use drops for cataract surgery. Driverless cars. Pilotless planes. No sugar in my soda. No meat in my burger. Wait, back up. No drops for cataract surgery? What you talkin’ ‘bout, Willis? salt solution in the surgery is important to wash out the nucleus, yet it also washes away the preoperative drops. Omidria has the opportunity to maintain a stable pupil size that will decrease complications associated with diameter-related complications. The concern some surgeons have is the use of ketorolac and its long-term effects on macula edema. Thus, management of these patients should include a close analysis of the macula and early signs of any cystoid changes. Simplifying post-op Changing landscape but can you look at him before he goes blind, or worse, his insurance runs out?” Newer technology adds simplicity but also potentially adds new challenges for management, like your battery dying on your PDA. Dropless cataract surgery falls into that category—just no batteries. Cataract surgery has entered that technology zone enabling surgeons the opportunity to provide sutureless and bladeless surgery, in vivo axis orientation and aberrometry measurements, and BY MARC R. now, remove the drops from this BLOOMENSTEIN, procedure. The advent of techOD, FAAO Director nology creates a changing landof optometric scape for the comanaging OD. services at Schwartz New therapy I remember a time when I Omidria (phenylephrine and keLaser Eye Center in Scottsdale, AZ. saw a perfectly round anterior torolac injection, Omeros) is the capsulotomy performed by the first FDA-approved medication for femtosecond. I was astounded anterior segment surgery to be and marveled at the precision of the cut. delivered intracamerally. Omidria, which However, the capsule was adhering to contains the mydriatic phenylephrine 1% The advent of technology creates a changing landscape for the optometrist who is following his patients after surgery. the endothelial cells of the patient’s eye. This particular patient was seeing 20/15 and had absolutely no visual problems, yet the optometrist who was following this patient had some concerns. The capsule eventually folded on itself and left a triangular flap of tissue on the superior corneal endothelium. The call I got sounded like this: “Dude, I think the cornea is breaking up from in the inside. The patient is only visiting, and the nonsteroidal anti-inflammatory drug (NSAID) ketorolac 0.3%, is added to 500 ml of balanced salt solution to irrigate the anterior chamber during cataract surgery. It is indicated to maintain the pupil’s size by inhibiting intraoperative miosis and to reduce postoperative ocular pain. This medication creates an opportunity to provide a constant mydriasis during the whole procedure. The use of balanced In another opportunity to break the shackles of drops, a movement is growing to place the antibiotic and steroid in the eye during cataract surgery. Yes, truly making the post-operative management more simplified and cost effective. Evidence has grown to support this use in other countries, where over 400,000 surgeries had been performed with this alternative drop method with a 0.029 percent endophthalmitis incidence.1 Impress Pharmaceuticals is the first company to bring to market a commercially available combination of triamcinolone and moxifloxacin. The combo drug is delivered transzonularly using a bent cannula. The goal of the anterior vitreous placement is designed to delay the drug clearance and aid in any postoperative cystoid macular edema. Thus a dropless management of cataract surgery will help the patients who have difficulties with drop placement, lowering the patient cost and compliance. Yet, this also means a new way for optometrists to manage the cataract patient. The bolus of medication needs to be placed in the region between the equator and the capsular bag. Although some surgeons have reported that 95 percent of their patients healed without any topical therapy,2 there is a learning curve that is needed so that the surgeon can ensure the sufficient dose makes its way through the zonules. The patient will present with inflammation that will necessitate the use of topical steroid instillation. The comSee Technology in cataract on page 12 %AEFABD7>;78;E3SAD634>78ADKAGDB3F;7@FE $#(!(%$'($%&(*#!""($##%#!*"%&''$# 3x 2x ?AD753F3D35FB3F;7@FE35:;7H76L7DA;@R3??3F;A@A@BAEFAB7D3F;H73KE3@6HEB>3574A M* HEA@3K*HEA@3K Nearly 3E?3@K53F3D35FB3F;7@FE35:;7H76L7DAB3;@A@BAEFAB7D3F;H73KE3@6HEB>3574A M*HEA@3K*HEA@3K +#(&(##$#$)'#(&$&)*(')&.$!N")!'$#+'#$##&$&($ %&$&(^)&.$!N")!'$#,!-*'%&$&(^,!- MBETTERAD5A?B3D34>78AD?G>3DK5AH7D397HE97@7D;5BD76@;EA>A@7357F3F7 A@EA?7"76;53D7%3DFB>3@E MNOF:7D3B7GF;57CG;H3>7@FFA)&.$!N?G>E;A@ *%AA>7663F38DA?B>3574A5A@FDA>>76FD;3>E;@B3F;7@FEG@67D9A;@953F3D35FEGD97DKP< HEB>3574A ^(D367?3D=;EF:7BDAB7DFKA8;FEAI@7D CORTICOSTEROID COVERAGE IS NOT THE SAME LEARN MORE ABOUT DUREZOL® EMULSION FORMULARY ACCESS IN YOUR AREA AT MYALCON.COM/FORMULARY INDICATIONS AND USAGE: DUREZOL® Emulsion is a topical corticosteroid that is indicated for: M(:7FD73F?7@FA8;@8>3??3F;A@3@6B3;@3EEA5;3F76I;F:A5G>3DEGD97DK M(:7FD73F?7@FA87@6A97@AGE3@F7D;ADGH7;F;E Dosage and Administration MADF:7FD73F?7@FA8;@R3??3F;A@3@6B3;@3EEA5;3F76I;F:A5G>3DEGD97DK;@EF;>>A@7 6DAB;@FAF:75A@<G@5F;H3>E35A8F:73S75F767K7F;?7E63;>K479;@@;@9:AGDE 38F7DEGD97DK3@65A@F;@G;@9F:DAG9:AGFF:78;DEFI77=EA8F:7BAEFAB7D3F;H7 B7D;A68A>>AI764KF;?7E63;>K8AD3I77=3@6F:7@3F3B7D43E76A@F:7D7EBA@E7 MADF:7FD73F?7@FA87@6A97@AGE3@F7D;ADGH7;F;E;@EF;>>A@76DAB;@FAF:7 5A@<G@5F;H3>E35A8F:738875F767K7F;?7E63;>K8AD63KE8A>>AI764KF3B7D;@9 3E5>;@;53>>K;@6;53F76 IMPORTANT SAFETY INFORMATION Contraindications: )&.$!N?G>E;A@3EI;F:AF:7DAB:F:3>?;55ADF;5AEF7DA;6E ;E5A@FD3;@6;53F76;@?AEF35F;H7H;D3>6;E73E7EA8F:75AD@733@65A@<G@5F;H3;@5>G6;@9 7B;F:7>;3>:7DB7EE;?B>7J=7D3F;F;E67@6D;F;5=7D3F;F;EH355;@;33@6H3D;57>>3 3@63>EA;@?K5A435F7D;3>;@875F;A@A8F:77K73@68G@93>6;E73E7EA8A5G>3DEFDG5FGD7E Warnings and Precautions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®?G>E;A@(:7 BD7E7DH3F;H7;@)&.$!N?G>E;A@?3K4734EAD4764KEA8F5A@F35F>7@E7E!7@E7E ?3K47D7;@E7DF7638F7D ?;@GF7E8A>>AI;@936?;@;EFD3F;A@A8)&.$!®?G>E;A@ Most Common Adverse Reactions M%AEF$B7D3F;H7$5G>3D@R3??3F;A@3@6%3;@P$5G>3D36H7DE7D735F;A@EA55GDD;@9 ;@A8EG4<75FE;@5>G6765AD@73>767?35;>;3DK3@65A@<G@5F;H3>:KB7D7?;37K7 B3;@B:AFAB:A4;3BAEF7D;AD53BEG>7AB35;Q53F;A@3@F7D;AD5:3?47D57>>E3@F7D;AD 5:3?47DR3D75A@<G@5F;H3>767?33@64>7B:3D;F;E M@F:77@6A97@AGE3@F7D;ADGH7;F;EEFG6;7EF:7?AEF5A??A@36H7DE7D735F;A@E A55GDD;@9;@ A8EG4<75FE;@5>G6764>GDD76H;E;A@7K7;DD;F3F;A@7K7B3;@ :73635:7;@5D73E76$%;D;F;E>;?43>3@65A@<G@5F;H3>:KB7D7?;3BG@5F3F7 =7D3F;F;E3@6GH7;F;E For additional information about DUREZOL® Emulsion, please refer to the brief summary of Prescribing Information on adjacent page. For more resources for eye care professionals, visit MYALCON.COM/DUREZOL. References: 1.)&.$!6;RGBD76@3F7AB:F:3>?;57?G>E;A@/B35=397;@E7DF0ADF+ADF:(,>5A@!34AD3FAD;7E@5 &7H;E76"3K 2. AD7@87>6"'';>H7DEF7;@'"AA=7!*A97>&DA5=7FF&';RGBD76@3F7$B:F:3>?;5?G>E;A@ GD7LA>'FG6KDAGB;RGBD76@3F7AB:F:3>?;57?G>E;A@ 8ADBAEFAB7D3F;H7;@R3??3F;A@3@6B3;@J Cataract Refract Surg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ocus On CO-MANAGEMENT Technology in cataract Continued from page 10 bination medication will create a visual disturbance that may take days to clear. Snow globe medication That wow factor, as well as the drops, is replaced with a dose of verbal Valium needed to assure the normality of the scenario. The medication breaks up in the vitreous and resembles floaters, most notably in the first few days following the surgery. Although each patient is different, the typical asteroid field will last for the few weeks following the surgery. I should be taken when appropriate. Topical Ophthalmic Use Only DUREZOL® Emulsion is not indicated for intraocular administration. BRIEF SUMMARY OF PRESCRIBING INFORMATION INDICATIONS AND USAGE Ocular Surgery DUREZOL® (difluprednate ophthalmic emulsion) 0.05%, a topical corticosteroid, is indicated for the treatment of inflammation and pain associated with ocular surgery. Endogenous Anterior Uveitis DUREZOL® Emulsion is also indicated for the treatment of endogenous anterior uveitis. DOSAGE AND ADMINISTRATION Ocular Surgery Instill one drop into the conjunctival sac of the affected eye 4 times daily beginning 24 hours after surgery and continuing throughout the first 2 weeks of the postoperative period, followed by 2 times daily for a week and then a taper based on the response. Endogenous Anterior Uveitis Instill one drop into the conjunctival sac of the affected eye 4 times daily for 14 days followed by tapering as clinically indicated. DOSAGE FORMS AND STRENGTHS DUREZOL® Emulsion contains 0.05% difluprednate as a sterile preserved emulsion for topical ophthalmic administration. CONTRAINDICATIONS The use of DUREZOL® Emulsion, as with other ophthalmic corticosteroids, is contraindicated in most active viral diseases of the cornea and conjunctiva including epithelial herpes simplex keratitis (dendritic keratitis), vaccinia, and varicella, and also in mycobacterial infection of the eye and fungal disease of ocular structures. WARNINGS AND PRECAUTIONS IOP Increase Prolonged use of corticosteroids may result in glaucoma with damage to the optic nerve, defects in visual acuity and fields of vision. Steroids should be used with caution in the presence of glaucoma. If this product is used for 10 days or longer, intraocular pressure should be monitored. Cataracts Use of corticosteroids may result in posterior subcapsular cataract formation. Delayed Healing The use of steroids after cataract surgery may delay healing and increase the incidence of bleb formation. In those diseases causing thinning of the cornea or sclera, perforations have been known to occur with the use of topical steroids. The initial prescription and renewal of the medication order beyond 28 days should be made by a physician only after examination of the patient with the aid of magnification such as slit lamp biomicroscopy and, where appropriate, fluorescein staining. Bacterial Infections Prolonged use of corticosteroids may suppress the host response and thus increase the hazard of secondary ocular infections. In acute purulent conditions, steroids may mask infection or enhance existing infection. If signs and symptoms fail to improve after 2 days, the patient should be re-evaluated. Viral Infections Employment of a corticosteroid medication in the treatment of patients with a history of herpes simplex requires great caution. Use of ocular steroids may prolong the course and may exacerbate the severity of many viral infections of the eye (including herpes simplex). Fungal Infections Fungal infections of the cornea are particularly prone to develop coincidentally with long-term local steroid application. Fungus invasion must be considered in any persistent corneal ulceration where a steroid has been used or is in use. Fungal culture JULY 2015 Contact Lens Wear DUREZOL® Emulsion should not be instilled while wearing contact lenses. Remove contact lenses prior to instillation of DUREZOL® Emulsion. The preservative in DUREZOL® Emulsion may be absorbed by soft contact lenses. Lenses may be reinserted after 10 minutes following administration of DUREZOL® Emulsion. ADVERSE REACTIONS Adverse reactions associated with ophthalmic steroids include elevated intraocular pressure, which may be associated with optic nerve damage, visual acuity and field defects; posterior subcapsular cataract formation; secondary ocular infection from pathogens including herpes simplex, and perforation of the globe where there is thinning of the cornea or sclera. Ocular Surgery Ocular adverse reactions occurring in 5-15% of subjects in clinical studies with DUREZOL® Emulsion included corneal edema, ciliary and conjunctival hyperemia, eye pain, photophobia, posterior capsule opacification, anterior chamber cells, anterior chamber flare, conjunctival edema, and blepharitis. Other ocular adverse reactions occurring in 1-5% of subjects included reduced visual acuity, punctate keratitis, eye inflammation, and iritis. Ocular adverse reactions occurring in < 1% of subjects included application site discomfort or irritation, corneal pigmentation and striae, episcleritis, eye pruritis, eyelid irritation and crusting, foreign body sensation, increased lacrimation, macular edema, sclera hyperemia, and uveitis. Most of these reactions may have been the consequence of the surgical procedure. Endogenous Anterior Uveitis A total of 200 subjects participated in the clinical trials for endogenous anterior uveitis, of which 106 were exposed to DUREZOL® Emulsion. The most common adverse reactions of those exposed to DUREZOL® Emulsion occurring in 5-10% of subjects included blurred vision, eye irritation, eye pain, headache, increased IOP, iritis, limbal and conjunctival hyperemia, punctate keratitis, and uveitis. Adverse reactions occurring in 2-5% of subjects included anterior chamber flare, corneal edema, dry eye, iridocyclitis, photophobia, and reduced visual acuity. USE IN SPECIFIC POPULATIONS Pregnancy Teratogenic Effects Pregnancy Category C. Difluprednate has been shown to be embryotoxic (decrease in embryonic body weight and a delay in embryonic ossification) and teratogenic (cleft palate and skeletal) anomalies when administered subcutaneously to rabbits during organogenesis at a dose of 1–10 mcg/kg/day. The no-observed-effect-level (NOEL) for these effects was 1 mcg/kg/day, and 10 mcg/kg/day was considered to be a teratogenic dose that was concurrently found in the toxic dose range for fetuses and pregnant females. Treatment of rats with 10 mcg/kg/day subcutaneously during organogenesis did not result in any reproductive toxicity, nor was it maternally toxic. At 100 mcg/kg/day after subcutaneous administration in rats, there was a decrease in fetal weights and delay in ossification, and effects on weight gain in the pregnant females. It is difficult to extrapolate these doses of difluprednate to maximum daily human doses of DUREZOL® Emulsion, since DUREZOL® Emulsion is administered topically with minimal systemic absorption, and difluprednate blood levels were not measured in the reproductive animal studies. However, since use of difluprednate during human pregnancy has not been evaluated and cannot rule out the possibility of harm, DUREZOL® Emulsion should be used during pregnancy only if the potential benefit justifies the potential risk to the embryo or fetus. Nursing Mothers It is not known whether topical ophthalmic administration of corticosteroids could result in sufficient systemic absorption to produce detectable quantities in breast milk. Systemically administered corticosteroids appear in human milk and could suppress growth, interfere with endogenous corticosteroid production, or cause other untoward effects. Caution should be exercised when DUREZOL® Emulsion is administered to a nursing woman. Pediatric Use Safety and effectiveness in pediatric patients have not been established. Geriatric Use No overall differences in safety or effectiveness have been observed between elderly and younger patients. Nonclinical Toxicology Carcinogenesis, Mutagenesis, and Impairment of Fertility Difluprednate was not genotoxic in vitro in the Ames test, and in cultured mammalian cells CHL/IU (a fibroblastic cell line derived from the lungs of newborn female Chinese hamsters). An in vivo micronucleus test of difluprednate in mice was also negative. Treatment of male and female rats with subcutaneous difluprednate up to 10 mcg/ kg/day prior to and during mating did not impair fertility in either gender. Long term studies have not been conducted to evaluate the carcinogenic potential of difluprednate. Animal Toxicology and/or Pharmacology In multiple studies performed in rodents and non-rodents, subchronic and chronic toxicity tests of difluprednate showed systemic effects such as suppression of body weight gain; a decrease in lymphocyte count; atrophy of the lymphatic glands and adrenal gland; and for local effects, thinning of the skin; all of which were due to the pharmacologic action of the molecule and are well known glucocorticosteroid effects. Most, if not all of these effects were reversible after drug withdrawal. The NOEL for the subchronic and chronic toxicity tests were consistent between species and ranged from 1–1.25 mcg/kg/day. PATIENT COUNSELING INFORMATION Risk of Contamination This product is sterile when packaged. Patients should be advised not to allow the dropper tip to touch any surface, as this may contaminate the emulsion. Use of the same bottle for both eyes is not recommended with topical eye drops that are used in association with surgery. Risk of Secondary Infection If pain develops, or if redness, itching, or inflammation becomes aggravated, the patient should be advised to consult a physician. Contact Lens Wear DUREZOL® Emulsion should not be instilled while wearing contact lenses. Patients should be advised to remove contact lenses prior to instillation of DUREZOL® Emulsion. The preservative in DUREZOL® Emulsion may be absorbed by soft contact lenses. Lenses may be reinserted after 10 minutes following administration of DUREZOL® Emulsion. | have a snow globe that I use to represent the suspension of the steroid in a bottle, although I have a Shake Weight to serve the same purpose, “Shake it before you take it!” The snow globe is a great way to demonstrate the visual obstructions. It is equally important to realize the commonality of these visual changes and differentiate them from a possible retinal detachment, though rare, that may occur. These tramicinolne particles may make their way into the anterior chamber and thus resemble anterior cells. The eyes may be quiescent, yet it is still a challenge to know the exact makeup of the particle. Thus, treat these as possible inflammatory cells, and start the patient on a topical therapy. Another drop that may have to be added is a topical hypotensive medication following the surgery. Steroid responders make up a large percent of the population, and a steroid is injected into the vitreous creates a risk of prolonged intraocular pressure (IOP) elevation. Managing doctors should follow the IOP of these patients closely and most notably patients who have been diagnosed as steroid responsive. Time will tell if droplets will go the way of wireless tech or driverless cars. Reduction of out-of-pocket expenses and compliance sure do make a droplets cataract surgery seem appealing. Perhaps when I am sitting in my car writing the next article, while my car is taking me to Laguna Beach, I will feel differently, much like when you get over the hurdle of a new drop regimen. REFERENCES 1. Friling E, Lundstrom M, Stenevi U, Montan P. Six-year incidence of endophthalmitis After cataract surgery: Swedish national study. J Cataract Refract Surg 2013. Jan;39(1):15-21. 2. Liegner JT. “Better surgery through chemicals: topical and intracameral agents for the anterior segment surgeon.” ASCRS/ASOA Symposium. Washington, DC. 27 April 2014. [email protected] WANT MORE CONTENT ON COMANAGEMENT? Revised: June 2012 U.S. Patent 6,114,319 Manufactured For Earning a spot on the medical team Alcon Laboratories, Inc. 6201 South Freeway Fort Worth, Texas 76134 USA 1-800-757-9195 [email protected] Manufactured By: Catalent Pharma Solutions Woodstock, IL 60098 © 2015 Novartis 1/15 DUR14090JAD-PI OptometryTimes.com/earningaspot Why wait to recommend cataract surgery? OptometryTimes.com/waitcatsurg | PRACTICAL CHAIRSIDE ADVICE CONTACT LENSES Focus On Prevent dropout by asking the right questions Uncovering the problems with patients who say their contact lenses feel fine The main reason for contact lens dropout is discomfort and dryness, according to a survey done by Richdale.1 The latest data on contact lens dropouts is approximately 16 percent annually. 2 Given these two statistics, one may assume that dryness and discomfort are the primary cause of our patients dropping out of contact lens wear. Patients do not decide suddenly to drop out of lens wear. It is a progression that may occur over months or years. The strugglers they have not returned in 13-14 months do we call and find out The progression of contact lens where they are? Whose fault is it? discomfort starts with those paMost of us say the patients’, but tients we will call strugglers. These I believe we, as doctors, need to are the patients who come in to take more responsibility for this. the office and will tell you their We need to be proactive in our contact lenses feel “fine.” Unless BY DAVID I. practices to insure our patients we ask more in-depth questions, GEFFEN, OD, FAAO are receiving the most up-to-date we will not discover that these Director of technology, which may be better patients may have some fluctuatoptometric and ing vision. They may be noticing refractive services in to address the changing lifestyles of our patients. Keeping the pasome visual disturbances. San Diego, CA. tient in the same lenses year in Next, we move on to the paand year out because it’s not broken is not tient who may still say his contact lenses in the patient’s or the practice’s best interfeel “fine,” but if we ask the right quesest. We know the patient will come in and tions, we may uncover that the patient is tell us his lenses feel “fine.” If we do not experiencing reduced comfortable wearing change anything after three or four years, time. He will tell you he wears his lenses patients may feel that they will just buy all day, but unless we ask the right questheir lenses online the next year because tions, you may not find out the last three the doc isn’t changing anything, and they hours of wearing time is dry and uncommight as well save some money. fortable. The next step in the progression is reduced wearing time. The patient may still say her lenses feel Stop progression to dropout “fine,” but she takes her lenses out the minWhat we ask our patients about their lenses ute she gets home from work. Next is the is critical to stop the progression of the temporary discontinuation of lens wear. dropout. If we ask more probing questions, Now, the patient may tell you her lenses we will find out about the visual disturare not as comfortable, and she doesn’t bances early on in the process, and we can wear them to work and may wear them make the necessary adjustments to bring only on weekends or going out. Finally, the patient back to the comfort she wants we have the total discontinuation of lens and deserves. A few examples: wear and the dreaded contact lens dropout. Do you feel like you want to remove your lenses as soon as you get home from work? Taking responsibility The process may take months or even years, Are your contact lenses as comfortbut the result is often the loss of a patient able at the end of the day as when and tens of thousands of dollars of reveyou put them in? nue to the practice. Most of us do not even How would you rate your contact lens realize the patient has stopped wearing comfort on a scale from 1-10 at the his lenses. How would we know? Do we beginning of the day as compared to look at our patient recall numbers, and if the end of the day? Do you think your contact lenses are as comfortable as they could be? These questions are much more likely to tell us the patient is on the road to discomfort or dropout. Why do patients tell us their lenses feel “fine?” Our patients often think this is how lenses should feel—they don’t know any better. Also, the patient may be afraid if she complains, we will tell her to stop wearing her lenses. By asking the right questions, we will give patients confidence that we are looking to help them feel the best possible with lenses. Another disconnect is the fact that 97 percent of patients are interested in trying a new contact lens technology. However, only 20 percent expect to learn about new technology during their visit to their eye doctor.3 This I find to be an amazing statistic in doctors’ failure to be more proactive Patients do not decide suddenly to drop out of lens wear. It is a progression that may occur over months or years. for our patients. So, go in to work tomorrow, and start asking the right questions! REFERENCES 1. Richdale K, Sinnott LT, Skadahl E, et al. Frequency of and factors associated with contact lens dissatisfaction and discontinuation. Cornea. 2007 Feb;26(2):168-174. 2. Rumpakis J. New Data on Contact Lens Dropouts: An International Perspective. Rev Optometry. Available at: http://www.revoptom. com/content/d/contact_lenses_and_ solutions/c/18929/. Accessed 4/21/15. 3. Rah, MJ, Reindel, W, Mosehauer, G. Interest and acceptance of a new contact lens technology in today’s practice. Poster session presented at: 118th Annual AOA Congress; 2015 Jun 34-28; Seattle, WA. Dr. Geffen sits on the advisory board and speaks for Alcon, Bausch + Lomb, and Vmax and sits on the advisory board for TearLab and Accufocus. He speaks for Allergan and AMO. [email protected] 13 14 Focus On GLAUCOMA JULY 2015 | Is glaucoma a neurological disease? Examining the plausible correlation between glaucoma and cerebrospinal fluid For years now, there has been considerable evidence indicating that glaucoma should be considered a neurological disease and not an entity isolated to the eyes alone.1 Perhaps the most compelling evidence for such a characterization is the fact that the retinal ganglion cells affected by glaucoma do not synapse until they arrive at the midbrain (specifically, the lateral geniculate nucleus). Evidence of damage in the midbrains of simian models after induction of ocular hypertension2 furthers the evidence for glaucoma to be classified as a neurological disease. One other (rather contemporary) notion regarding glaucoma and its relationship to the brain is a plausible correlation between glaucoma and low cerebrospinal fluid (CSF). Eye and brain pressure low CSF pressure is a risk factor for glaucoma. Further, high IOP combined with low CSF pressure would seemingly be a greater risk factor for the development of glaucoma than the first two scenarios. BY BENJAMIN P. CASELLA, OD, FAAO Practices in Augusta, GA , with his father in his grandfather’s practice. As the optic nerve exits the globe and begins its journey through the retrobulbar space, it fenestrates through the lamina cribrosa. It is at this point that there exists a pressure gradient between intraocular pressure (IOP) within the globe and CSF pressure within the subarachnoid space (or, as I tell my patients, “eye pressure and brain pressure”). If this trans-laminar pressure gradient is high (specifically meaning a higher drop in pressure as the optic The causal relationship between CSF and IOP This causal relationship between CSF pressure and IOP at the location of the lamina cribrosa does well to possibly (and at least in part) explain a few aspects of glaucoma that remain somewhat elusive. First, we have thin central corneal thickness as a strong and independent risk factor for the development of glaucoma.4 The cornea and lamina cribrosa both derive from the neuro-ectoderm in utero. So, perhaps a thin central cornea (along with other hysterics) correlates with a lamina cribrosa that isn’t as apt to handling a significant pressure gradient between IOP and CSF pres- Whatever the reason, we understand that high IOP doesn’t automatically mean glaucoma, and low IOP doesn’t automatically mean not glaucoma. nerve goes from the globe to the retrobulbar space), then there is a greater chance for glaucomatous optic nerve damage to occur.3 There is more than one way for this scenario to occur. First, if IOP is high and CSF pressure is normal, then there would be a drop in pressure along this gradient. Second, if IOP is normal and CSF pressure is low, the net effect would be the same drop in pressure. So, overall net is a relatively sure. Second, we have the separate clinical entity known as normal or low-tension glaucoma (NTG) in which glaucomatous damage occurs in the presence of statistically normal IOP. Perhaps the presence of relatively low CSF pressure would at least partially explain the pathogenesis in this disease entity. Third, we have ocular hypertension with no signs or symptoms that would lead us to suspect glaucoma (i.e. la- beling a patient as having ocular hypertension rather than labeling that patient as a glaucoma suspect). We all know that ocular hypertension is the number-one risk factor for the development of glaucoma. Yet, we all have patients with this condition (and some with markedly high IOP) who just never go on to develop any signs of glaucoma. Perhaps some of these patients also have protectively high CSF pressures, thus lowering their trans-laminar pressure gradients between IOP and CSF pressure Whatever the reason, high IOP doesn’t automatically mean glaucoma, and low IOP doesn’t automatically mean not glaucoma. While more research is needed to explore low CSF pressure and its potentially causal relationship with glaucoma, the implications seem rational. The fact that patients are typically diagnosed with NTG at older ages points to vascular and hemodynamic dysfunction as another contributing factor. Yet, low CSF pressure as a potential risk factor might explain why some patients develop glaucoma at lower IOPs than others. The future of glaucoma holds considerable promise of new horizons on both the diagnostic and therapeutic sides of this increasingly common disease. However, the future will also entail an increasingly more common discussion of non-IOP risk factors, whether those factors can be modified or not. The notion of CSF pressure and its relationship with glaucoma, at the very least, continues a conversation about glaucoma as a neurological disease and not something contained solely within the eyes. REFERENCES 1. Yu L, Xie L, Dai C, Xie B, Liang M. Progressive thinning of visual cortex in primary open-angle glaucoma of varying severity. PLoS One. 2015 Mar 27;10(3):e0121007. 2. Dai Y1, Sun X, Yu X, et al. Astrocytic responses in the lateral geniculate nucleus of monkeys with experimental glaucoma. Vet Ophthalmol. 2012 Jan;15(1):23-30. 3. Jonas JB, Wang N. Cerebrospinal fluid pressure and glaucoma. J Ophthal Vis Res. 2013 Jul;8(3): 257-263. 4. Brandt JD, Beiser JA, Kass MA, et al. Central corneal thickness in the Ocular Hypertension Treatment Study (OHTS). Ophthalmology. 2001 Oct;108(10):1779-88. [email protected] #&"1'*"' % long days '#!$'%#!#%'#% long-term eye health. For patients who wear their lenses intensely* and put a priority on the long-term health of their eyes /!!!&'!("#"#''#%""+ !"!," "&+"'%'#"'#!0%(+0 %"#"''"&&nearly invisible'#'+'& / " +&#*"'##!$% '#'"'(% +#"#!#%'" #!&(%&##( % ''%+&# +*%2 /&' ) # #"†§) "#"'' "& PVP=polyvinylpyrrolidone. *Intense wear=Patients who wear lenses ≥14 hours a day, ≥5 days a week. ‡ Comparable to no lens wear on comfort and 5 out of 6 measures of ocular health (limbal hyperemia, corneal vascularization, corneal staining, bulbar conjunctival hyperemia, and papillary conjunctivitis. The sixth measure was conjunctival staining.) ACUVUE® Brand Contact Lenses are indicated for vision correction. As with any contact lens, eye problems, including corneal ulcers, can develop. Some wearers may experience mild irritation, itching or discomfort. Lenses should not be prescribed if patients have any eye infection, or experience eye discomfort, excessive tearing, vision changes, redness or other eye problems. Consult the package insert for complete information. Complete information is also available by visiting acuvueprofessional.com or by calling 1-800-843-2020. † Helps protect against transmission of harmful UV radiation to the cornea and into the eye. § WARNING: UV-absorbing contact lenses are NOT substitutes for protective UV-absorbing eyewear such as UV-absorbing goggles or sunglasses, because they do not completely cover the eye and surrounding area. You should continue to use UV-absorbing eyewear as directed. NOTE: Long-term exposure to UV radiation is one of the risk factors associated with cataracts. Exposure is based on a number of factors such as environmental conditions (altitude, geography, cloud cover) and personal factors (extent and nature of outdoor activities). UV-blocking contact lenses help provide protection against harmful UV radiation. However, clinical studies have not been done to demonstrate that wearing UV-blocking contact lenses reduces the risk of developing cataracts or other eye disorders. Consult your eye care practitioner for more information. Reference: 1. Morgan PB, Chamberlain P, Moody K, Maldonado-Codina C. Ocular physiology and comfort in neophyte subjects fitted with daily disposable silicone hydrogel contact lenses. Cont Lens Anterior Eye. 2013;36(3):118-125. Study conducted over 365 days. ACUVUE®, 1-DAY ACUVUE® TruEye®, and HYDRACLEAR® are trademarks of Johnson & Johnson Vision Care, Inc. Third-party trademarks used herein are trademarks of their respective owners. © Johnson & Johnson Vision Care, Inc. 2015 ACU-10352273-D June 2015 16 Primary Care July 2015 | Creating culturally competent care Doctors and staff must understand the forces at work outside the exam room By edwin c. Marshall, OD, Ms, MPH, fAAO Accepting the cultural realities of your practice Optometrists are educated in what n the 4th century BC, Hippocrates we consider to be the traditional understood that illness has—in constructs of health and illness. addition to its biomedical conHowever, many of our patients text—an environmental, social, and today may subscribe to a differbehavioral context.1 Today, we unent “traditional” construct that deEDWIN C. derstand that access to vision and fines their needs, informs their perMARSHALL, OD, eye care can be influenced by a ceptions of health and illness, and MS, MPH, FAAO, variety of non-biomedical factors, establishes their attitudes toward is professor emeritus including health literacy, language, seeking and receiving health care. of optometry and public health at race and ethnicity, patient percepWhat is considered traditional or Indiana University. tions, trust, and cultural values and usual in one culture may be conbeliefs.2 Both patients and optomsidered non-traditional or alternative in another culture. Our biomedical etrists are more likely today to bring to the construct may associate a certain morbidity clinical encounter a complex cross-cultural to a biomedical etiology—such as a metaarray of attitudes, customs, preferences, bolic dysfunction or bacterial infection— assumptions, expectations, practices, and whereas a cultural construct may attribute fears that help decode experiences, form the same illness to spiritual imbalance, maperspectives, influence decisions, and drive levolent spirits, susto (loss of soul), mal de behavior. ojo (evil eye), punishment, the wind, fatalism, or God’s will. Why understand culture Similarly, the reliance on traditional Having an understanding of cultural norms practices—such as healing rituals, prayer, can help identify and mitigate many of the meditation, herbs, massage, coining, and cultural barriers that negatively impact qualcupping—may be more of a cultural norm ity and perpetuate disparities in health and than the willing acceptance of some biohealth care, especially among racial and medical therapies, such as the long-term ethnic populations who frequently are at use of medications for chronic conditions increased risk for certain ocular morbidilike open-angle glaucoma. Cultural beliefs, ties like glaucoma and diabetic retinopalike the belief that talking about a specific thy. With the racial and ethnic population illness will cause the illness to occur, could in the U.S. expected to increase from 37 present roadblocks to effective and efficient percent to 57 percent by the year 2060, the patient-doctor communication. Likewise, need for cultural competency as a compounderestimating the role of the extended nent of quality health care becomes more compelling each day.3 Each of us represents a blend of cultures that are conditioned by the collective and diverse experiences of our age, race, ethnicity, gender, sexual orientation, education, religion, socioeconomic status, geographic – Showing respect when addressing the patient by residence, and even our occupation or prousing the patient’s title and family name (e.g., Señor fession. Cultural diversity can introduce an Gonzalez) and not the first name (respecto) unexpected dimension into the traditional – Taking a personal and friendly approach (personalbiomedical paradigm of ophthalmic care. ismo) to appreciating how cultural perspectives can Conflicts can arise and interpersonal relainfluence patient perceptions about the diagnosis and tionships can suffer when cultural-based treatment of ocular conditions dynamics clash. Such conflicts in health – Considering patient perceptions and traditions care can adversely affect communication, (curanderismo) as helpful guides to clinical decisions understanding, compliance, satisfaction, – Maintaining a professional appearance in and of the and ultimately the opportunity to achieve office (esmero) the most optimal health outcomes. I Keys to culturally competent care magenta cyan yellow black TAKE-HOME MESSAGE Cultural perspectives about health and illness can influence patient behavior and impact quality of care. More today than ever before it is important for optometrists to understand and respect the cultural perspectives of their patients in adapting care that is clinically, culturally, and linguistically appropriate. Cultural competence is an attribute of patient-centered care that helps build concordance between the cultural traditions of the patient and the biomedical traditions of the optometrist. family in discussions, decision making, and therapeutic care (familismo) could create unforeseen challenges, such as reconciling patient privacy with the decision-making traditions of family-centered care. It is critically important that optometrists be nonjudgmental in accepting the cultural realities of their practices—that the diversity of perceptions and beliefs about health and illness are potential quality-of-care issues that can impact both the delivery of services and their clinical outcomes. Non–English-speaking patients With 21 percent of the U.S. population aged 5 years and over currently speaking a language other than English at home, linguistic competence becomes an integral aspect of the cultural competence paradigm.4 The enhanced National Standards on Culturally and Linguistically Appropriate Services (CLAS), published by the U.S. Office of Minority Health, target cultural and linguistic barriers to healthcare delivery. For example, the CLAS standards call for competent language assistance and recommend against the use of untrained persons and/or minors as ad hoc interpreters for patients who have limited English proficiency and/or other communication needs. The CLAS guidelines also call for the use of multilingual print and multimedia materials and signage that would be easily understood by patients who have limited English ability. Responding to a congressional directive, the National Eye Institute launched the Nasee Cultural care on page 18 ES632980_OP0715_016.pgs 06.23.2015 23:58 ADV Broad Managed Care Coverage1 THE NUMBER OF DAILY DOSES DECLINES, BUT THE EFFICACY DOESN’T Once-daily post-op dosing when you're managing patients after cataract surgery. ILEVRO® Suspension dosed once daily post-op has been shown to be noninferior to NEVANAC® (nepafenac ophthalmic suspension) 0.1% dosed three times daily for the resolution of inflammation and pain associated with cataract surgery.2,3 One drop of ILEVRO® Suspension should be applied once daily beginning 1 day prior to cataract surgery through 14 days post-surgery, with an additional drop administered 30 to 120 minutes prior to surgery.2 Use of ILEVRO® Suspension more than 1 day prior to surgery or use beyond 14 days post-surgery may increase patient risk and severity of corneal adverse events.2 Available in 1.7 mL and new 3 mL fill sizes INDICATIONS AND USAGE ILEVRO® Suspension is a nonsteroidal, anti-inflammatory prodrug indicated for the treatment of pain and inflammation associated with cataract surgery. IMPORTANT SAFETY INFORMATION Contraindications ILEVRO® Suspension is contraindicated in patients with previously demonstrated hypersensitivity to any of the ingredients in the formula or to other NSAIDs. Warnings and Precautions 6*.!/! (!! %*#%)!8%0$/+)!*+*/0!.+% (*0%%*9))0+.5 drugs including ILEVRO® Suspension there exists the potential for increased bleeding time. Ocularly applied nonsteroidal antiinflammatory drugs may cause increased bleeding of ocular tissues (including hyphema) in conjunction with ocular surgery. 6!(5! !(%*#8+,%(*+*/0!.+% (*0%%*9))0+.5 .1#/ (NSAIDs) including ILEVRO® Suspension may slow or delay healing. Concomitant use of topical NSAIDs and topical steroids may increase the potential for healing problems. 6+.*!(""!0/8/!+"0+,%(/)5.!/1(0%*'!.0%0%/ In some patients, continued use of topical NSAIDs may result in !,%0$!(%(.!' +3*+.*!(0$%**%*#+.*!(!.+/%+*+.*!( 1(!.0%+*+.+.*!(,!."+.0%+*$!/!!2!*0/)5!/%#$0 threatening. Patients with evidence of corneal epithelial .!' +3*/$+1( %))! %0!(5 %/+*0%*1!1/! Patients with complicated ocular surgeries, corneal denervation, corneal epithelial defects, diabetes mellitus, ocular surface diseases (e.g., dry eye syndrome), rheumatoid arthritis, or repeat ocular surgeries within a short period of time may be at increased .%/'"+.+.*!( 2!./!!2!*0/3$%$)5!+)!/%#$00$.!0!*%*# +,%(//$+1( !1/! 3%0$10%+*%*0$!/!,0%!*0/ /!)+.!0$* 5,.%+.0+/1.#!.5+.1/!!5+* 5/ ,+/0/1.#!.5)5%*.!/!,0%!*0.%/'* /!2!.%05+"+.*!( adverse events. 6+*00!*/!.8® Suspension should not be administered while using contact lenses. Adverse Reactions $!)+/0".!-1!*0(5.!,+.0! +1(. 2!./!.!0%+*/"+((+3%*# 0.0/1.#!.5+1..%*#%*,,.+4%)0!(50++",0%!*0/ were capsular opacity, decreased visual acuity, foreign body sensation, %*.!/! %*0.+1(.,.!//1.!* /0%'5/!*/0%+* For additional information about ILEVRO® Suspension, please refer to the brief summary of prescribing information on adjacent page. References: 1. Formulary data provided by Pinsonault Associates, LLC, PathfinderRx, June 2014. 2. ILEVRO® Suspension prescribing information. 3. NEVANAC® Suspension prescribing information. For more resources for eye care professionals, visit MYALCON.COM/ILEVRO ® © 2014 Novartis 7/14 ILV14058JAD 18 Primary Care Cultural care Continued from page 16 tional Eye Health Education Program, which provides culturally and linguistically appropriate, evidence-based materials for eyecare professionals. (Available at: http://www. nei.nih.gov/nehep) JULY 2015 More resources The concept of cultural and linguistic competency in health care is not new. In setting goals for the “preferred future” of the optometric profession, the 2007 Optometry 2020 Summit called for optometrists and their staff to have the knowledge, skills, and attitude to serve patients of different times human plasma exposure at the recommended human topical ophthalmic dose for rats and 20 and 180 times human plasma exposure for rabbits, respectively. In rats, maternally toxic doses ≥10 mg/kg were associated with dystocia, increased postimplantation loss, reduced fetal weights and growth, and reduced fetal survival. Nepafenac has been shown to cross the placental barrier in rats. There are no adequate and well-controlled studies in pregnant women. Because animal reproduction studies are not always predictive of human response, ILEVRO® Suspension should be used during pregnancy only if the potential benefit justifies the potential risk to the fetus. BRIEF SUMMARY OF PRESCRIBING INFORMATION INDICATIONS AND USAGE ILEVRO® Suspension is indicated for the treatment of pain and inflammation associated with cataract surgery. DOSAGE AND ADMINISTRATION Recommended Dosing One drop of ILEVRO® Suspension should be applied to the affected eye one-time-daily beginning 1 day prior to cataract surgery, continued on the day of surgery and through the first 2 weeks of the postoperative period. An additional drop should be administered 30 to 120 minutes prior to surgery. Use with Other Topical Ophthalmic Medications ILEVRO® Suspension may be administered in conjunction with other topical ophthalmic medications such as beta-blockers, carbonic anhydrase inhibitors, alpha-agonists, cycloplegics, and mydriatics. If more than one topical ophthalmic medication is being used, the medicines must be administered at least 5 minutes apart. CONTRAINDICATIONS ILEVRO® Suspension is contraindicated in patients with previously demonstrated hypersensitivity to any of the ingredients in the formula or to other NSAIDs. WARNINGS AND PRECAUTIONS Increased Bleeding Time With some nonsteroidal anti-inflammatory drugs including ILEVRO® Suspension, there exists the potential for increased bleeding time due to interference with thrombocyte aggregation. There have been reports that ocularly applied nonsteroidal anti-inflammatory drugs may cause increased bleeding of ocular tissues (including hyphemas) in conjunction with ocular surgery. It is recommended that ILEVRO® Suspension be used with caution in patients with known bleeding tendencies or who are receiving other medications which may prolong bleeding time. Delayed Healing Topical nonsteroidal anti-inflammatory drugs (NSAIDs) including ILEVRO® Suspension, may slow or delay healing. Topical corticosteroids are also known to slow or delay healing. Concomitant use of topical NSAIDs and topical steroids may increase the potential for healing problems. Corneal Effects Use of topical NSAIDs may result in keratitis. In some susceptible patients, continued use of topical NSAIDs may result in epithelial breakdown, corneal thinning, corneal erosion, corneal ulceration or corneal perforation. These events may be sight threatening. Patients with evidence of corneal epithelial breakdown should immediately discontinue use of topical NSAIDs including ILEVRO® Suspension and should be closely monitored for corneal health. Postmarketing experience with topical NSAIDs suggests that patients with complicated ocular surgeries, corneal denervation, corneal epithelial defects, diabetes mellitus, ocular surface diseases (e.g., dry eye syndrome), rheumatoid arthritis, or repeat ocular surgeries within a short period of time may be at increased risk for corneal adverse events which may become sight threatening. Topical NSAIDs should be used with caution in these patients. Postmarketing experience with topical NSAIDs also suggests that use more than 1 day prior to surgery or use beyond 14 days post surgery may increase patient risk and severity of corneal adverse events. Non-teratogenic Effects. Because of the known effects of prostaglandin biosynthesis inhibiting drugs on the fetal cardiovascular system (closure of the ductus arteriosus), the use of ILEVRO® Suspension during late pregnancy should be avoided. Nursing Mothers ILEVRO® Suspension is excreted in the milk of lactating rats. It is not known whether this drug is excreted in human milk. Because many drugs are excreted in human milk, caution should be exercised when ILEVRO® Suspension is administered to a nursing woman. Pediatric Use The safety and effectiveness of ILEVRO® Suspension in pediatric patients below the age of 10 years have not been established. Geriatric Use No overall differences in safety and effectiveness have been observed between elderly and younger patients. NONCLINICAL TOXICOLOGY Carcinogenesis, Mutagenesis, Impairment of Fertility Nepafenac has not been evaluated in long-term carcinogenicity studies. Increased chromosomal aberrations were observed in Chinese hamster ovary cells exposed in vitro to nepafenac suspension. Nepafenac was not mutagenic in the Ames assay or in the mouse lymphoma forward mutation assay. Oral doses up to 5,000 mg/kg did not result in an increase in the formation of micronucleated polychromatic erythrocytes in vivo in the mouse micronucleus assay in the bone marrow of mice. Nepafenac did not impair fertility when administered orally to male and female rats at 3 mg/kg. PATIENT COUNSELING INFORMATION Slow or Delayed Healing Patients should be informed of the possibility that slow or delayed healing may occur while using nonsteroidal anti-inflammatory drugs (NSAIDs). Avoiding Contamination of the Product Patients should be instructed to avoid allowing the tip of the dispensing container to contact the eye or surrounding structures because this could cause the tip to become contaminated by common bacteria known to cause ocular infections. Serious damage to the eye and subsequent loss of vision may result from using contaminated solutions. Use of the same bottle for both eyes is not recommended with topical eye drops that are used in association with surgery. Contact Lens Wear ILEVRO® Suspension should not be administered while wearing contact lenses. Intercurrent Ocular Conditions Patients should be advised that if they develop an intercurrent ocular condition (e.g., trauma, or infection) or have ocular surgery, they should immediately seek their physician’s advice concerning the continued use of the multi-dose container. Concomitant Topical Ocular Therapy If more than one topical ophthalmic medication is being used, the medicines must be administered at least 5 minutes apart. Shake Well Before Use Patients should be instructed to shake well before each use. U.S. Patent Nos. 5,475,034; 6,403,609; and 7,169,767. Contact Lens Wear ILEVRO® Suspension should not be administered while using contact lenses. ADVERSE REACTIONS Because clinical studies are conducted under widely varying conditions, adverse reaction rates observed in the clinical studies of a drug cannot be directly compared to the rates in the clinical studies of another drug and may not reflect the rates observed in practice. Ocular Adverse Reactions The most frequently reported ocular adverse reactions following cataract surgery were capsular opacity, decreased visual acuity, foreign body sensation, increased intraocular pressure, and sticky sensation. These events occurred in approximately 5 to 10% of patients. Other ocular adverse reactions occurring at an incidence of approximately 1 to 5% included conjunctival edema, corneal edema, dry eye, lid margin crusting, ocular discomfort, ocular hyperemia, ocular pain, ocular pruritus, photophobia, tearing and vitreous detachment. Some of these events may be the consequence of the cataract surgical procedure. Non-Ocular Adverse Reactions Non-ocular adverse reactions reported at an incidence of 1 to 4% included headache, hypertension, nausea/vomiting, and sinusitis. USE IN SPECIFIC POPULATIONS Pregnancy Teratogenic Effects. Pregnancy Category C: Reproduction studies performed with nepafenac in rabbits and rats at oral doses up to 10 mg/kg/day have revealed no evidence of teratogenicity due to nepafenac, despite the induction of maternal toxicity. At this dose, the animal plasma exposure to nepafenac and amfenac was approximately 70 and 630 ALCON LABORATORIES, INC. Fort Worth, Texas 76134 USA © 2014 Novartis 7/14 ILV14058JAD | ethnicities, native languages, age, gender, religions, and cultural backgrounds and to be linguistically competent by providing care in multiple languages and/or providing interpretation services.5 In 2008, the Association of Schools and Colleges of Optometry (ASCO) approved the ASCO Guidelines for Culturally Competent Eye and Vision Care to assist optometric institutions with preparing clinicians to understand and respect diverse values, beliefs, and expectations in addressing the vision and eyecare needs of a multicultural community. In 2012, Transitions Optical introduced the Transitions Cultural Connections initiative with a complimentary package of multicultural resources for eyecare practitioners, which includes the recently released consensus paper from its hosted roundtable discussion on the topic of improving the eye health of culturally diverse populations. (Available at: http://www.mymulticulturaltoolkit.com) The cultural competency continuum There is no cookbook or shortcut to cultural competence. It is a continuous and progressive process. The cultural competence continuum involves a series of steps from “cultural destructiveness” and “cultural incapacity” through “cultural blindness” and “cultural pre-competence” to “cultural competence” and “cultural proficiency.”6 More simplistically, the continuum can be viewed as a progression from “unconscious incompetence” in which there is an absence of awareness of cultural differences to “unconscious competence” and the ability to provide culturally appropriate care spontaneously.7 Culturally competent practitioners are not expected to understand and respond to every cultural aspect of every patient; they are asked simply to challenge their own cultural assumptions and preconceptions while embracing a patient-centered culture of care. The amalgam of knowledge, skills, and attitudes that define cultural competence encompass both the clinician’s understanding of and respect for individual patient values, beliefs, and needs and the clinician’s awareness of her own values, assumptions, and needs in adapting care that is clinically, culturally, and linguistically appropriate.8 It is like looking at patients through their cultural lens and integrating their perspectives into their personalized care. | PRACTICAL CHAIRSIDE ADVICE Benefits of cultural competency According to a recent survey, 95 percent of eyecare professionals believe that a good understanding of a patient’s cultural background is constructive to a better patient experience.9 Cultural competence: Increases patient-doctor communication and flow of diagnostic and therapeutic information Enhances interpersonal understanding and trust Facilitates greater patient access to and timely use of appropriate healthcare services Creates opportunities for a more positive understanding of and compliance with both traditional biomedical practices as well as traditional cultural practices Cultural competency improves the quality of the healthcare experience. Conversely, culturally-blind care can lead to less than optimal and possibly negative outcomes among diverse patient populations. The ultimate goal of optometric practice is to provide quality healthcare practices and achieve optimal eye and vision health for our patients. While we provide the best clinical care with the intention for quality in all cases, the impact of our unconscious actions may generate unintended consequences. Cultural competence is a current day necessity for a quality response to traditional healthcare practices and to fostering patient-centered climates of respect and trust for the values, needs, and expectations of both the patient and the doctor. Primary Care 7. Campinha-Bacote, J. Many faces: addressing diversity in health care. Online J Issues Nurs. 2003;8(1):3. 8. Mutha S, Allen C, Welch M. Toward Culturally Competent Care: A Toolbox for Teaching Communication Strategies. San Francisco, CA: Center for the Health Professions, University of California, San Francisco, 2002. 9. Online survey among a nationally representative 19 sample of 241 eye care professionals conducted by Jobson Optical Research on behalf of Transitions Optical, Inc. March 2014. Dr. Marshall serves on the National Eye Health Education Program Planning Committee of the National Eye Institute and the Diversity Advisory Board of Transitions Optical, Inc. [email protected] As your dedicated partner in eye care We Re-Envision Vision REFERENCES 1. Lasker RD. Medicine & Public Health: The Power of Collaboration. Committee on Medicine & Public Health. New York, NY: The New York Academy of Medicine, 1997. 2. ORC/Macro. Identification of variables that influence access to eye care: final report. National Eye Institute, National Institutes of Health. July 28, 2005. 3. U.S. Census Bureau. U.S. Census Bureau projections show a slower growing, older, more diverse nation a half century from now. Available at: http://www.census.gov/ newsroom/releases/archives/population/cb12-243. html. Accessed: 11/25/2014. 4. Ryan C. Language use in the United States: 2011. U.S. Census Bureau, August 2013. Available at: http://www.census.gov/prod/2013pubs/acs-22.pdf. Accessed: 11/25/2014. Meeting the need. An increasing aging and diabetic population gives way to an increased number of patients diagnosed with retinal diseases. Regeneron is committed to delivering targeted therapies that can impact your patients’ vision. Learn more about our science to medicine approach at Regeneron.com. 5. American Optometric Association. Optometry 2020 Summit. 2007. 6. Cross TL, Bazron BJ, Dennis KW, et al. Towards a Culturally Competent System of Care: A Monograph on Effective Services for Minority Children Who Are Severely Emotionally Disturbed. Washington, DC: Georgetown University Child Development Center, 1989. science to medicine is a registered trademark of Regeneron Pharmaceuticals, Inc. ©2015, Regeneron Pharmaceuticals, Inc., 777 Old Saw Mill River Road, Tarrytown, NY 10591 All rights reserved 02/2015 RGN-0271 Case Report 20 JULY 2015 Neuropathy Continued from page 1 that time, but one week later, he presented to the emergency room with a headache and dizziness. He was not currently taking any medications but reported previous medical treat- PIERCE ment one year prior for hypertension, KENWORTHY, OD is a graduate of the which was discontinued due to fi- Arizona College of nancial constraints. The patient de- Optometry. nied smoking and alcohol. His ocular history was unremarkable, and his family medical and ocular histories were non-contributory. No allergies were reported. At the initial hospital visit, the patient’s blood pressure was significantly elevated at 212/115 mm Hg. BRUCE ONOFREY, CT, MRI, and blood work were or- OD, RPH, FAAO dered and all returned normal for is clinical professor his age. During his four-day hospital at the University of stay, the patient was assessed by an Houston College of ophthalmologist with pertinent find- Optometry. ings including an afferent pupillary defect (APD) of the left eye, normal 2 right optic nerve head (ONH), 3+ edema ity of J10 in the left eye, compared to J7 near acuity in the right. Distance acuity was not assessed due to convenience testing in a hospital setting. The plan at discharge was to initiate antihypertensive treatment with amlodipine (Norvasc, Pfizer), hydralazine (Apresoline, Novartis), and lisinopril (Prinivil, Merck). He was then instructed to return in one week for a dilated fundus exam and visual field. The patient did not return to the hospital but instead arrived at the University Eye Institute 10 days after discharge, complaining of a persistent inferior nasal shadow in the vision of his left eye. He reported good compliance with clonidine (Kapvay, Concordia) 0.1mg tid, hydralazine (generic only) 100 mg tid, Lisinopril (Prinivil, Merck) qam, and aspirin 81 mg bid. Blood pressure was measured at 140/105 mm Hg in-office | TAKE-HOME MESSAGE Non-arteritic anterior ischemic optic neuropathy (NA-AION) is the most common type of ischemic optic neuropathy and results from non-perfusion of the posterior ciliary blood supply to the optic nerve head. Classic symptoms of anterior ischemic optic neuropathy include sudden, painless, mild to severe vision loss, inferior altitudinal field defect and optic disc edema, which usually resolves spontaneously in about two months and is replaced by sectoral or more often generalized optic atrophy. Few treatments are available, but many systemic risk factors such as hypertension can be treated to help prevent the visual sequelae associated with NA-AION. with an arm cuff. Best-corrected visual acuity (BCVA) at distance was 20/20 OD and 20/30 OS. Slit lamp examination was unremarkable, reSee Neuropathy on page 22 AION results from non-perfusion of the posterior ciliary blood supply to the optic nerve head of the left ONH, normal right eye confrontation visual fields (CVF), nasal field loss both superior and inferior of the left eye assessed with CVF, and reduced near acu- 1 Figure 1. Fundus photograph ONH edema secondary to NA-AION. Figure 2. 30-2 Humphrey Visual Field SITA Standard Inferior altitudinal defect explains inferior nasal shadow in patient’s vision OS. For patients who want to start and end the day with more moisture1,2 Recommend Biotrue® ONEday daily disposable contact lenses Now available for Presbyopia Biotrue® ONEday HyperGel™ material forms a Dehydration Barrier 2 Stays moist up to 16 hours2 2 Retains more than 98% moisture through the day2 UVA/UVB Protection* Biotrue® ONEday Cross-section Poloxamer 407 POLOXAMER 407 PVP PVP H2O PVP binds to SAM SAM is concentrated at surface Hydrophilic polymer molecules — PVP — are bound to the molecules of the Surface Active Macromer (SAM) Poloxamer 407. The polymer-bound Surface Active Macromer (SAM) Poloxamer 407, increases in concentration at the surface forming a permanent component of the lens material. For more information, call 1-800-828-9030, contact your Sales Representative or Bausch.com/ecp * WARNING: UV-absorbing contact lenses are NOT substitutes for protective UV-absorbing eyewear, such as UV-absorbing goggles or sunglasses, because they do not completely cover the eye and surrounding area. The effectiveness of wearing UV-absorbing contact lenses in preventing or reducing the incidence of ocular disorders associated with exposure to UV light has not been established at this time. You should continue to use UV-absorbing eyewear as directed. NOTE: Long-term exposure to UV radiation is one of the risk factors associated with cataracts. Exposure is based on a number of factors such as environmental conditions (altitude, geography, cloud cover) and personal factors (extent and nature of outdoor activities). UV-blocking contact lenses help provide protection against harmful UV radiation. However, clinical studies have not been done to demonstrate that wearing UV-blocking contact lenses reduces the risk of developing cataracts or other eye disorders. REFERENCE: 1. Multiple-Packaged Lenses Comparison, Tyler’s Quarterly – Professional Edition, September 2013 2. Twenty-two subjects participated in a randomized, double masked, contralateral eye study to evaluate water loss of Biotrue ONEday, 1-Day Acuvue Moist, 1-Day Acuvue TruEye contact lenses. After 4,8,12, and 16 hours of wear, lenses were removed and immediately weighed (wet weight). The lenses were then completely dried and reweighed (dry wet). The percent water loss was then calculated for each lens from the wet and dry weights. Biotrue, HyperGel and inspired by the biology of your eyes are trademarks of Bausch & Lomb Incorporated or its affiliates. All other product/brand names are trademarks of their respective owners. ©2015 Bausch & Lomb Incorporated. US/BOD/15/0011 22 Case Report Neuropathy Continued from page 20 vealing both conjunctiva were clear and quiet, both corneas were clear, the anterior chambers were free of cells and flare, and the iris was flat and intact. Fundoscopy revealed clear crystalline lenses in both eyes as well as clear vitreous. The macula was flat with even pigment and showed a positive foveal reflex OU. The optic nerve head of the right eye appeared normal, but the left eye showed optic nerve head edema, with the superior portion of the nerve affected more than the inferior portion (see Figure 1). Both eyes demonstrated mild arteriovenous nicking of the blood vessels. Humphrey visual fields were overall normal in the right eye and showed an inferior altitudinal defect in the left eye, which respected the horizontal midline (see Figure 2). Optical coherence tomography (OCT) demonstrated significant retinal nerve fiber layer (RNFL) thickening of the left eye, particularly JULY 2015 was 20/20 OD and 20/25-2 OS. The patient had been recording his blood pressure at 5 p.m. every day for the previous four weeks and continued his antihypertensive treatment regimen. Blood pressure was measured in office at 118/90 mm Hg. The edema of 40% of patients show spontaneous improvement of up to three lines of visual acuity the left optic nerve head appeared almost entirely resolved upon funduscopic examination (see Figure 6), but a 30-2 Humphrey visual field indicated that the inferior altitudinal field loss remained (see Figure 7). OCT showed a decrease in retinal nerve fiber layer (RNFL) thickness superior tem- poral (see Figure 8), which corresponded with a GCC loss superior temporal as well (see Figure 9). A 3-D visualization shows regression of swelling of the optic nerve head compared to five weeks prior (see Figure 10). The right eye was also assessed and determined to be stable and normal, with no signs of NA-AION or other hypertensive complications noted. The patient was educated again regarding the nature of his vision loss and the importance of continued blood pressure control and management with his internist. He was instructed to return for another dilated fundus exam in four months. That visit was still pending at the time this report was prepared. Discussion The term “anterior ischemic optic neuropa- 3 Optic nerve size, particularly a small cup, has long been thought to be a risk factor for the development of NA-ION superiorly (see Figure 3). The ganglion cell complex (GCC) thickness was normal OD, with possible thinning superior temporal OS (see Figure 4). A 3-D visualization also helped to view the extent of swelling of the optic nerve head (see Figure 5). The assessment at this visit was probable non-arteritic anterior ischemic optic neuropathy with hypertension as a major risk factor. The patient was educated regarding the likely permanent nature of his vision loss and counseled regarding continued management of systemic risk factors. The patient was instructed to continue blood pressure management with his internist and return for a follow-up dilated fundus exam in one month for a repeat visual field. Follow-up visit He returned five weeks later reporting only minimal improvement in his vision. BCVA | Figure 3. Cirrus OCT quantifying ONH edema OS near onset of NA-AION. | PRACTICAL CHAIRSIDE ADVICE 4 Case Report Figure 4. GCC relatively normal at onset of NA-AION. 23 thy” (AION) was coined by Sohan Singh Hayreh, MD, MS, PhD, FRCS, FRCOphth, DSc, in 1974.1 It results from nonperfusion of the posterior ciliary blood supply to the optic nerve head.2 Non-arteritic anterior ischemic optic neuropathy (NA-AION) is the most common type of ischemic optic neuropathy and is the most common acute optic nerve disease of adults over age 50 years.7,8 See Neuropathy on page 24 Digital Photography Solutions for Slit Lamp Imaging Digital SLR Camera 5 6 Figure 5. Cirrus OCT 3D visualization of ONH near onset of NA-AION Figure 6. Fundus photograph ONH edema resolution at five-week follow-up visit. Universal Smart Phone Adaptor for Slit Lamp Imaging Made in USA TTI Medical Transamerican Technologies International Toll free: 800-322-7373 email: [email protected] www.ttimedical.com 24 Case Report Neuropathy JULY 2015 | 7 Continued from page 23 Though variations exist, classic symptoms of AION have been outlined by Dr. Hayreh to include: Sudden, painless visual deterioration in one eye, usually discovered on waking in the morning Visual acuity may vary from better than 20/20 to no light perception Perimetry usually reveals relative or absolute inferior altitudinal defect, inferior nasal sectoral defect or central scotoma Optic disc edema, which usually resolves spontaneously in about two months and is replaced by sectoral or more often generalized optic atrophy.3 The research of Hoyt and his colleagues from 1963-1974 provided insight into the topographic localization of the optic nerve fibers in monkeys by photocoagulating the retinal nerve fibers. The ganglion cell defect 70% of eyes treated with oral corticosteroids showed improvement in visual acuity may appear weeks after the initial ischemic event, and it should correspond with a specific topographic region of the optic nerve head where atrophy may be visualized.9-11 Though controversial, oral corticosteroids have been proposed as one of the few treatment options available for NA-AION. In a non-randomized cohort study of 613 eyes, improvement in visual acuity was seen in 70 percent of treated eyes, whereas only 40 percent of untreated eyes showed improvement.5 Contrary to those findings, however, other smaller studies have found no statis- Figure 7. 30-2 Humphrey Visual Field SITA Standard, Inferior altitudinal defect persists at five-week follow-up visit. development of NA-AION, but the resultant after effect of an ischemic event on the size of the optic nerve was not quantified until recently. Hayreh and colleagues determined that following an NA-AION, there was no NA-AION generally remains stable, with visual fields unlikely to show improvement, but spontaneous improvement of up to three lines of vision has been shown in up to 40 percent of patients. tically significant difference in visual acuity or visual fields between treated and untreated individuals.6 Optic nerve size, particularly a small cup, has long been thought to be a risk factor for statistically significant difference among the cup-to-disc ratio, parapapillary atrophy, or overall disc size between the affected eye vs. the patient’s non-affected eye. This information provides the clinician with an additional differentiation from other optic nerve head disorders such as glaucoma.4 The previously presented case is interesting as it demonstrates NA-AION in a patient with uncontrolled high blood pressure. There are also many cases of low blood pressure and development of NA-AION. Use of phosphodiesterase five inhibitors (PDE5), such as sildenafil (Viagra, Pfizer), has been considered a possible risk factor because the therapeutic dose has been shown to reduce blood pressure by at least 10 mm Hg, thus producing systemic hypotension.5 One retrospective study concluded that there is a two-fold increase risk of NA-AION with PDE5 use.6 A recent 2015 article summarized the natural course of NA-AION into the following valuable points: NA-AION generally remains stable, with visual fields unlikely to show See Neuropathy on page 26 Make upg wearers a rading easy for n ew nd 2-wee k patients Daily disposables are growing by leaps and bounds,1 and SofLens® daily disposable contact lenses are the right start to growing this side of your practice. Offer your patients the benefits of daily disposables— for less than the leading 2-week lens. For more information, call 1-800-828-9030, contact your Sales Representative or visit SofLens.com Reference: 1. Nichols J. Contact Lenses 2014. Contact Lens Spectrum. 2014;30:22-27. SofLens is a trademark of Bausch & Lomb Incorporated or its affi liates. © 2015 Bausch & Lomb Incorporated. US/SDD/15/0008 Case Report 26 JULY 2015 | 8 9 Figure 8. Cirrus OCT five-week follow-up visit showing decrease in overall swelling with more specific superior temporal RNFL loss OS. Figure 9. GCC, decrease in ganglion cell thickness five weeks after NA-AION. Codes and Fees FPS Exam Visual Field OCT Fundus Photo OD/Med Exam TOTAL 92014 92083 92133 92250 99213 10 Figure 10. Cirrus OCT 3D visualization of ONH edema resolution at five-week follow-up visit. $151 $113 $57 $96 $89 $ 506 Neuropathy Continued from page 24 Conclusion improvement, but spontaneous improvement of up to three lines of vision has been shown in up to 40 percent of patients. The optic nerve head edema resolves and makes way for pallor in six to 11 weeks following the acute NA-AION episode. Lastly, within five years of initial eye involvement, the fellow contralateral eye was involved in 15 to 19 percent of patients.5 This case demonstrates an example of a patient who was living with untreated systemic disease and whose first symptom of advancing hypertension was a visual field defect. That symptom was followed by symptoms of headache and dizziness, which finally prompted a visit to the hospital. NA-AION has an unknown etiology, but many risk factors have been exhibited. Though a clini- cian will often correlate NA-AION with low blood pressure, nocturnal hypotension, and medications used to treat erectile dysfunc- 15% of patients experienced fellow contralateral eye involvement within 5 years tion, the clinician must not forget that high blood pressure is itself a major risk factor | PRACTICAL CHAIRSIDE ADVICE for the ischemic event. Unfortunately, few options are available for the treatment of NA-AION, but careful co-management with primary-care doctors and internists can have a profound impact in treating the systemic diseases such as diabetes and hypertension that can contribute to NA-AION development. In the case of this 49-year-old Hispanic male, the most valuable treatment for his ocular condition was tight blood pressure control. REFERENCES 1. Hayreh SS. Anterior ischaemic optic neuropathy. I. Terminology and pathogenesis. Br J Ophthalmol. 1974 Dec;58(12):955-63. 2. Hayreh SS. Ischemic optic neuropathy. Prog Retin Eye Res. 2009 Jan;28(1):34-62 3. Hoyt WF. Anatomic considerations of arcuate scotomas associated with lesions of the optic nerve and chiasm. A nauta axon degeneration study in the monkey. Bull Johns Hopkins Hosp. 1962 Aug;111:57–71. Case Report Dr. Kenworthy is currently a family practice resident at the University of Houston College of Optometry and is joining a private practice in the Houston Medical Center following completion of residency. Dr. Onofrey is executive director of continuing education programs at the University of Houston College of Optometry. [email protected] [email protected] 27 INTERESTED IN MORE CASE REPORTS? Managing a partial thickness laceration OptometryTimes.com/managinglaceration Decreased vision on the left side leads to hemianopia OptometryTimes.com/visionhemianopia HELP FOR YOUR PATIENTS WITH Ocular Surface Disorders 4. Jonas JB, Hayreh SS, Tao Y, et al. Optic Nerve Head Change in Non Arteritic Anterior Ischemic Optic Neuropathy and Its Influence on Visual Outcome. PLoS One. 2012;7(5):e37499. 5. Miller NR, Arnold AC. Current concepts in the diagnosis, pathogenesis and management of nonarteritic anterior ischaemic optic neuropathy. Eye (Lond). 2015 Jan;29(1):65–79. 6. Campbell UB, Walker AM, Gaffney M, et al. Acute Nonarteritic Anterior Ischemic Optic Neuropathy and Exposure to Phosphodiesterase Type 5 Inhibitors. J Sex Med. 2015 Jan;12(1):139–51. 7. Hattenhauer MG, Leavitt JA, Hodge DO, et al. Incidence of Nonarteritic Anterior Ischemic Optic Neuropathy. Am J Ophthalmol. 1997Jan;123(1):103-7. 8. Hayreh SS. Anterior ischemic optic neuropathy: differentiation of arteritic from non-arteritic type and its management. Eye (Lond). 1990;4:25-41. 9. Hoyt WF, Luis O. Visual fiber anatomy in the infrageniculate pathway of the primate. Arch Ophthalmol. 1962; 68:94–106. 10. Hoyt WF, Tudor RC. The course of parapapillary temporal retinal axons through the anterior optic nerve. A Nauta degeneration study in the primate. Arch Ophthalmol. 1963 Apr;69:503–7. 11. Hoyt WF, Kommerell G. Der Fundus oculi bei homonymer Hemianopie. (Fundus oculi in homonymous hemianopia). Klin Monbl Augenheilkd. 1973 Apr;162(4): 456–64. ADDITIONAL RESOURCES 1. Hayreh SS, Joos KM, Podhajsky PA, et al. Systemic diseases associated with nonarteritic anterior ischemic optic neuropathy. Am J Ophthalmology. 1994 Dec 15;118(6);766-80. 2. Hayreh SS, Zimmerman MB. Non-arteritic anterior ischemic optic neuropathy: role of systemic corticosteroid therapy. Graefes Arch Clin Exp Ophthalmol. 2008 Jul;246(7):1029–46. 3. Rebolleda G, Perez-Lopez M, Casas-LLera P, et al. Visual and anatomical outcomes of non-arteritic anterior ischemic optic neuropathy with high-dose systemic corticosteroids. Graefes Arch Clin Exp Ophthalmol. 2013 Jan;251(1):255–60. Do you treat patients with ocular surface issues? Do you see patients with chronic dry eye, corneal erosions, or epithelial defects? Have you ever considered using IOP AmbioDiskto help your patients? SAFE COMFORTABLE r1BUFOUFE1VSJPO¡1SPDFTTHFOUMZ EFIZESBUFTBOEUFSNJOBMMZTUFSJMJ[FT UIFBNOJPUJDNFNCSBOFXIJMF QSFTFSWJOHFTTFOUJBMHSPXUIGBDUPST QSPUFJOTBOEDZUPLJOFT r8FMMUPMFSBUFECZQBUJFOUT EFFECTIVE rFZFTTVDDFTTGVMMZUSFBUFE XJUIPVUBOZBEWFSTFFGGFDUT r1SPWFO1VSJPO¡5FDIOPMPHZSFUBJOT NPSFFTTFOUJBMHSPXUIGBDUPSTQSPUFJOT BOEDZUPLJOFTUIBOPUIFSQSPEVDUT r/PGPSFJHOCPEZTFOTBUJPO WELL REIMBURSED r$PWFSFEJOUIFPGGJDFFOWJSPONFOU VOEFS$15DPEF$BMMPVS GSFFIPUMJOFUPEFUFSNJOFUIF SFJNCVSTFNFOUJOZPVSBSFB r/PTQFDJBMTIJQQJOHPSIBOEMJOHDPTUT rZFBSTIFMGMJGFBUSPPNUFNQFSBUVSF SIMPLE r&BTJMZBQQMJFEPOUPBESZDPSOFBBOE DPWFSFEXJUIBCBOEBHFDPOUBDUMFOT r1FSGPSNFEEVSJOHBCSJFGPGGJDFWJTJU XJUIPVUUIFOFFEGPSUBQJOHUIFFZFTIVU INSTRUMENTS BIOLOGICS DEVICES 4-rrXXXLBUFOBDPN Why not help your patients today with IOP AmbioDisk™? 28 SPECIAL SECTION JULY 2015 | Contact Lenses Clinical performance of a new silicone hydrogel cosmetic lens Better comfort, less dryness with new addition to the color lineup osmetic lenses in Europe and the U.S. typically account for <10 percent of all new fits today, but they are more commonly used in Asian countries such as China (15%), Indonesia (31 percent), South Korea (41 percent), DOERTE or Taiwan (63 percent).1,2 Despite LUENSMANN, this growing market, lenses with PHD, DIPL ING cosmetic tints are primarily avail(AO), FAAO able in pHEMA (poly(2-hydroxyethyl methacrylate))-based materials, which have a relatively low oxygen permeability compared with modern silicone hydrogel (sihy) materials.2 A new cosmetic sihy contact lens has been recently released by Alcon (Air Optix Colors), which LYNDON JONES, is manufactured with lotrafilcon PHD, FCOPTOM, B and has an oxygen permeabilFAAO ity (Dk) of 110. The application of the color print is distinctive. While the color print on hydrogel lenses is often applied to the anterior surface of the 1 lens, Air Optix Colors sihy lenses incorporate a printing technique in which ink layers are encapsulated within the material, near the back surface of the lens, which are then covered with an additional clear coat before plasma treatment. C ers initially wore the company’s lotrafilcon B sihy non-color lens (Air Optix Aqua; Alcon) bilaterally for one week to adapt to the lens material and design. This adaptation phase was followed by four weeks of daily lens wear of Air Optix Colors and FreshLook, in which each lens was worn in one eye only, in a randomized contralateral eye design. Both lens types had the same color pattern (color Grey) and the Air Optix Colors contact lens was replaced after four weeks and the FreshLook contact lens after was replaced two weeks (Figure 1). During each study visit, visual acuity, subjective ratings, and biomicroscopy data were collected. After 1, 13, and 27 days of lens wear, study participants completed a variety of subjective ratings at home. TAKE-HOME MESSAGE Air Optix Colors cosmetic silicone hydrogel lenses were compared to FreshLook ColorBlends lenses. Overall, study participants preferred Air Optix Colors for comfort and less dryness during wear as well as visual acuity. This new lens offers practitioners a silicone hydrogel lens option for their patients interested in cosmetic lens wear. Study participants Forty-seven participants were screened, of which nine discontinued due to a variety of non-study lens concerns, including discomfort with the FreshLook lens during the screening visit, inconvenience, loss to followup, lens mix-up of OD/OS at the two-week visit, or conjunctivitis. The mean age of the remaining 38 participants included in the 2 day washout prior to screening Screening and fitting Dispense: Non-color lotrafilcon B (bilateral) Air Optix Colors vs. FreshLook Patient satisfaction and clinical performance with the new cosmetic sihy lens were assessed in a clinical study comparing it to a long-standing, successful conventional color hydrogel lens, FreshLook ColorBlends, also manufactured by Alcon. Ethics approval was obtained through a Research Ethics Committee at the University of Waterloo prior to the start of the study, and the study was conducted following the tenets of the Declaration of Helsinki. RMANOVA and Tukey Post-hoc comparisons were used for the analysis (p<0.05 was considered significant). In this study, habitual soft lens wear- 1 week adaptation 1 week assessment 1 month color lens wear Dispense Air Optix Colors, FreshLook ColorBlends (contralateral) 2 week assessment 4 week assessment Figure 1. Study flow chart Subjective ratings: Day 1, Day 13, Day 27 SPECIAL SECTI O N | PRACTICAL CHAIRSIDE ADVICE analysis was 29.7±10 years (ranging from 18 to 52 years) and included 34 female and four male participants. At the final study visit, six participants had a mix-up of OD/ OS lenses, and that data was not included in the analysis. Figure 2 shows the appearance of the study lens on two participants with different iris colors. Contact Lenses 2A 29 Figure 2. Example image of a light green eye (a) and a brown eye (b) wearing Air Optix Colors (color Grey for both). Visual acuity High-contrast visual acuity (VA) at high illumination and low-contrast VA at high and low illumination was measured at the dispensing visit and after two and four weeks of cosmetic lens wear. After the assessment, participants were asked to rate their satisfaction with vision using a 0-100 scale (100=completely satisfied). Both lenses provided acceptable VA, and the subjective vi- 2B Cosmetic lenses are used more commonly in Asia than in the U.S. and Europe sion ratings reflected that (Figures 3 and 4). For high-contrast VA, a difference between lenses was found after four weeks of wear, indicating that FreshLook performed marginally better compared to Air Optix Colors (p=0.004), but this two-letter difference was not considered clinically relevant (Figure 3). Low-contrast VA ranged between +0.17 and +0.19 logMAR with high illumination and between +0.21 and +0.24 logMAR with low illumination for both lenses with no differences found between lenses or over time (all p>0.05). Overall satisfaction with vision at high and low illumination was rated higher with Air Optix Colors compared to FreshLook (p≤0.016); however, post-hoc comparisons indicated significant differences only at the two-week visit (p≤0.02) (Figure 4). Biomicroscopy findings Biomicroscopy findings were clinically acceptable—no serious adverse events, either related or unrelated to the study products occurred—and only one significant event was noted (conjunctivitis). Corneal staining as determined using the global staining score3 was overall slightly higher with FreshLook compared to Air Optix Colors (p=0.037), while the opposite was found for conjunctival staining (0-100 scale), which was mar- ginally higher after wearing Air Optix Colors compared to FreshLook (p<0.001) (Figures 5 and 6). The eye wearing FreshLook showed slightly more bulbar hyperaemia compared to Air Optix Colors (p=0.002), but this difference was negligible and not of clinical significance. Palpebral conjunctival hyperemia and roughness were clinically normal between 22 and 31 units (0-100 scale), and no changes were seen throughout the study or between lenses (p>0.05). Comfort and dryness ratings Participants completed at-home ratings for comfort and dryness on Days 1, 13, and 27 using a 0-100 scale (100=excellent comfort/ not dry at all). Ratings were completed following lens application, after four and eight hours of lens wear, and prior to lens removal (Figure 7). When combining all ratings, Air Optix Colors was rated more comfortable compared to FreshLook (p=0.002). As seen in previous studies, lower comfort scores were found at the end of the day (prior to lens removal) compared to all other time points (p<0.008).4,5 The comfort for Air Optix Colors did not change over the four-week study period; however, comfort ratings increased significantly for FreshLook, with no difference between lens types on Day 27 (p>0.05). Ocular dryness ratings followed a similar trend compared to the comfort results, indicating that both lenses felt drier toward the end of the day. It was not surprising to find similar results for comfort and dryness ratings because this has been shown previously.6 On Day 1 and Day 13, participants rated Air Optix Colors less dry than FreshLook (p<0.01), but they noted no difference on Day 27 (p>0.05). See Cosmetic lenses on page 30 SPECIAL SECTI O N 30 JULY 2015 Contact Lenses Cosmetic lenses Continued from page 29 3 High contrast visual acuity — high illumination Peripheral vision and halo During the four-week period, participants were also asked to indicate whether their | 0.00 Air Optix Colors FreshLook ColorBlends 13% of participants noted color print on FreshLook; 0% noted for Air Optix Colors -0.02 -0.04 -0.06 LogMAR peripheral vision was affected by the color in the lens. The majority of participants enrolled in this study had no previous experience with cosmetic lens wear, and an impact in peripheral vision with at least one lens was reported by 12 (32 percent) participants after lens application on the first day. On Day 27 prior to lens removal, only four (13 percent) participants noted the -0.08 -0.10 -0.12 See Cosmetic lenses on page 32 -0.14 IN BRIEF ENGLEWOOD, CO—Ampio Pharmaceuticals announced that a recent study found Optina (low-dose danazol) to be safe and offers significant improvements in visual acuity as well as reductions in central retinal thickness (CRT) in patients with diabetic macular edema (DME) when given the optimal dose. A review of a representative set of images of the eye from the trial identified positive changes in Optina-treated patients compared to placebo, including the reversal of complications such as cystic lesions andsubretinal fluid. Analysis revealed that 69 percent of the patients in the study received a medication that manages kidney-induced high blood pressure. When this group received the optimal Optina dose, patients showed a sixletter improvement compared to placebo, regardless of whether or not they previously had anti-VEGF eye injections. There was a significant 34-micron reduction in CRT over placebo. Sixty percent of these eyes showed a restoration of at least one line of vision compared to only 27 percent of placebo. Dispense 4 2 weeks 4 weeks Subjective vision ratings — high illumination 100 Air Optix Colors FreshLook ColorBlends 90 Score Ampio shares Optina DME study results -0.16 80 70 60 Dispense 2 weeks 4 weeks Figures 3 and 4. High contrast visual acuity (logMAR; Figure 3) and subjective vision ratings (0-100 scale; 0=completely dissatisfied, 100=completely satisfied; Figure 4) were collected during each visit. * indicates statistically significant differences. Vertical bars denote 95 percent confidence interval. Superior Coverage for Complete Dry Eye Relief Fourth Generation Tear Film Enhancement Improves Tear Film Stability | Decreases Ocular Discomfort | Reduces Ocular Surface Staining For more information and to order, call (800) 233-5469 or visit www.ocusoft.com Clinical Study Results as Published in Clinical Ophthalmology * * Ousler III, George, et al. “An evaluation of Retaine ophthalmic emulsion in the management of tear film stability and ocular surface staining in patients diagnosed with dry eye.” Clinical Ophthalmology 9 (2015): 235-43. Web. 5 Feb. 2015. © 2015 OCuSOFT, Inc., Rosenberg, TX 77471 USA SPECIAL SECTI O N 32 JULY 2015 Contact Lenses Cosmetic lenses 5 Continued from page 30 Participants rated Air Optix Colors as more comfortable than FreshLook ColorBlends Corneal staining 500 Air Optix Colors FreshLook ColorBlends 450 400 Global staining score (0 - 10 000) color print in the periphery with FreshLook, but no participant indicated this with Air Optix Colors. It can be expected that lens wearers who habitually wear clear lenses may go through an adaptation period and are likely to become less aware of the color print over time. Halo scores were rated by the participants on a 0-4 scale (0=no halo). In an at- | 350 300 250 200 150 100 50 74% of participants preferred Air Optix Colors; the remainder had no preference Colors and FreshLook, respectively. Both lens types showed an improved halo score over time between the dispensing visit and the four-week visit (p<0.05). Overall lens preference Study participants were asked whether they had a lens preference over the course of the study (Figure 8). After lens application on the first lens wear day, 74 percent (28) of participants preferred Air Optix Colors, and the remainder of the participants had no preference; no one preferred FreshLook. At the end of the four-week study period, only one participant preferred FreshLook, while all other participants had either no preference (41 percent; 13) or preferred Air 0 Dispense 2 weeks 4 weeks 6 Conjunctival staining 40 Air Optix Colors FreshLook ColorBlends Conjunctival staining score tempt to test this in the clinic, a small LED light of moderate intensity was placed in the center of a large, square, black chart. Participants viewed this light at three meters under dim illumination and rated how far the halo around the light spread using four reference points of equal distance away from the light source. Overall, subjective halo scores for Air Optix Colors were significantly lower, compared to FreshLook, indicating less halo disturbance with Air Optix Colors (p<0.001). Ratings at the dispensing visit were 0.50 vs. 0.84 and 0.31 vs. 0.61 at the four-week visit for Air Optix 30 20 * 10 * 0 Dispense 2 weeks 4 weeks Figures 5 and 6. Corneal staining (global staining score; Figure 5) and conjunctival staining (0-100 rating score; Figure. 6) were assessed during each visit. * indicates statistically significant differences. Vertical bars denote 95 percent confidence interval. Optix Colors (47 percent; 15). This shift in preference suggests that participants took longer to adapt to FreshLook, while no such adaptation period was needed for Air Optix Colors. Conclusion Participants preferred Air Optix Colors over FreshLook and rated it more comfortable and less dry. At the four-week visit, logSee Cosmetic lenses on page 34 REGISTER TODAY! INTERNATIONAL VISION EXPO 2015 EDUCATION: WEDNESDAY, SEPTEMBER 16–SATURDAY, SEPTEMBER 19 EXHIBITION: THURSDAY, SEPTEMBER 17–SATURDAY, SEPTEMBER 19 SANDS EXPO & CONVENTION CENTER | LAS VEGAS, NV VisionExpoWest.com | #VisionExpo PROUD SUPPORTER OF: SPECIAL SECTI O N 34 JULY 2015 Contact Lenses Cosmetic lenses Continued from page 32 MAR acuity was marginally lower with Air Optix Colors compared to FreshLook; however, participants rated visual satisfaction Participants found color lens adapation time shorter for Air Optix Colors 7 | Subjective comfort ratings 100 DAY 1 DAY 13 DAY 27 95 90 85 80 Research funded by Alcon; editorial and financial support for this article provided by Alcon. The authors want to thank Drs. Ping Situ, Amir Moezzi and Krithika Nandakumar for helping with the data collection in this study. 75 Air Optix Colors FreshLook ColorBlends 70 8 Removal Lens preference 100 2. Snyder C. A primer on contact lens materials. Contact Lens Spectrum. 2004;19(2):34-9. Air Optix Colors No preference 80 3. Sorbara L, Peterson R, Woods C, Fonn D. Multipurpose disinfecting solutions and their interactions with a silicone hydrogel lens. Eye Contact Lens. 2009 Mar;35(2):92-7. FreshLook ColorBlends Invalid/missing data % 60 40 5. Fonn D, Situ P, Simpson T. Hydrogel lens dehydration and subjective comfort and dryness ratings in symptomatic and asymptomatic contact lens wearers. Optom Vis Sci. 1999 Oct;76(10):700-4. 20 6. Fonn D, Dumbleton K. Dryness and discomfort with silicone hydrogel contact lenses. Eye Contact Lens. 2003 Jan;29(1 Suppl):S101-4; discussion S15-8, S92-4. val mo rs Re rs 8h er Aft 4h er ert ins 27 Re Da y Aft ion val mo rs rs 4h 8h er Aft er ion ert ins 13 Da y Aft val mo rs Re rs 8h er Aft 4h er Aft y1 ins ert ion 0 Da Dr. Luensmann is a clinical scientist Centre for Contact Lens Research, School of Optometry and Vision Science, University of Waterloo, Canada. Dr. Jones is director of the Centre for Contact Lens Research, School of Optometry and Vision Science, University of Waterloo, Canada. [email protected] [email protected] 8 hours Figure 7. Subjective ratings for lens comfort were completed at home using a 0-100 scale 0 = completely dissatisfied, 100 = completely satisfied. Participants rated their lenses 4x on the first lens wear day (Day 1) and on the days prior to each assessment visit (Days 13 and 27). * indicates statistically significant differences. Vertical bars denote 95 percent confidence interval. REFERENCES 1. Morgan PB, Woods C, Tranoudis IG, Helland M, Efron N, Teufl M, et al. International Contact Lens Prescribing in 2013. Contact Lens Spectrum. 2014;29(January):30-5. 4. Varikooty J, Keir N, Richter D, Jones LW, Woods C, Fonn D. Comfort response of three silicone hydrogel daily disposable contact lenses. Optom Vis Sci. 2013 Sep;90(9):945-53. 4 hours Insertion Removal 8 hours 4 hours Insertion Removal 4 hours 8 hours 65 Insertion higher with Air Optix Colors. Both contact lenses were clinically acceptable as determined by biomicroscopy. Because color contact lens wear was new to most study participants, they were more aware of the color in their lenses and experienced minor halo appearances at the beginning of the study; however, the adaptation time for Air Optix Colors was typically shorter compared to FreshLook. Figure 8. Subjective ratings of lens preference completed at home on Days 1, 13, and 27 of lens wear. Ratings were completed immediately after lens application, after four and eight hours of lens wear, and prior to lens removal. | PRACTICAL CHAIRSIDE ADVICE InDispensable 35 Skechers Eyewear releases 2015 Kids collection SOMERVILLE, NJ—Marcolin USA recently debuted the Skechers Eyewear 2015 Kids collection, just in time for families preparing for back to school. The new collection consists of 10 new optical styles with a blend of fun and sporty accents. Marcolin says this collection is perfect for today’s kids who are driven by brand awareness. Highlights from the girls’ collection include stud and stone embellishments with denim-patterened finishes on styles like SE1569 and SE1570, seen at left, which are both crafted in acetate. The new optical styles for boys are designed with today’s boys’ active lifestyle with sporty rubber accents and tech materials. The addition of aluminum 180-degree spring hinged temples on SE1092, seen at left, and SE1093 provides flexibility. An epoxy-filled SKECHERS “SPX” logo treatment adds color to the temples that are equipped with rubberized tips for added comfort and support. SE1569 SE1570 SE1092 Coburn Technologies introduces SGX Pro Generator SOUTH WINDSOR, CT—Coburn Technologies recently introduced and begun shipments of its latest generation surface generator, SGX PRO. The SGX Pro is equipped with new electronics and operating on a Windows 7 platform. According to Coburn, this generator’s touch screen interface and USB capabilities makes lens processing easier. Like its predecessor, SGX Plus, the SGX Pro generator delivers high performance,dry-cut milling technology for processing Trivex, CR39, polycarbonate, and high-index lenses. The SGX Pro is the fourth generation of the SGX series of generators. According to Coburn, SGX Pro has one of the widest curve ranges on the market and has been proven to provide the same dependability and accuracy of earlier SGX models. Coburn has discontinued production of its SGX Plus generator at its world headquarters assembly plant. The company will continue to provide support and service to existing SGX Plus generators and, in addition, offer an SGX Pro upgrade kit for users looking to update that equipment. See InDispensable on page 36 36 InDispensable JULY 2015 | Kenneth Cole releases Spring/Summer 2015 collection NEW YORK CITY—Kenneth Cole recently released its Spring/Summer 2015 collection. The latest collection featues optical and sun styles for both men and women in a range of sophisticated shapes and sizes inspired by the urban lifestyle of the brand. The tones of the collection range from milky color palettes to gradient colorations. In addition to the four styles featured below, the collection also features seven additional styles, including one women’s sun style, three men’s sun styles, one women’s optical style, and two men’s optical styles. KC0226 is a women’s optical style with a sleek metal profile with two-tone colorations and crafted stainless steel. It is complete with textured temples and enhanced by a raised metal border. Color combinations include satin black, brown, or burgundy with gold or satin navy with silver. KC0230 is a men’s optical style with a modified rectangular profile and updated metal temple detail. This style is offered in several colors, including soft gradient fades, including grey to brown and blue to brown, as well as solid matte black. KC7170 is a women’s sun style that features flat metal styling coupled with sleek acetate temples adorned with clean metal detailing. Shiny hematite-colored temples are paired with shiny gold or shiny burgundy metal fronts or offered in a contrasting shiny black/shiny gold option, combined with gradient or smoke-colored lenses. KC7173 is a men’s sun style that offers an iconic screw and metal wrap-around detail accents the front of this handmade acetate frame. This style is offered in a neutral palette ranging from black fade to tortoise, translucent grey or translucent stone, and shiny black. See InDispensable on page 42 JULY 2015 / OptometryTimes.com Go to: 37 products.modernmedicine.com Products & Services SHOWCASE PRODUCTS Search for the company name you see in each of the ads in this section for FREE INFORMATION! JULY 2015 / Optometry Times 38 Products & Services SHOWCASE Go to: products.modernmedicine.com CONFERENCES EastWest Eye Conference October education 2015 s discovery 1-3 Cleveland Convention C e n t e r team building p Experience the Premier Eye Conference in the Midwest p World-class Education Courses p An Expansive and Innovative Vendor Marketplace networking p Network with Friends and Colleagues p Enjoy Major Attractions and Entertainment in Cleveland innovation vision Cleveland, Ohio p Collaboration and Team Building Opportunities Visit www.eastwesteye.org for more information. >VUKLY^OH[[OLZLHYL& COMPANY NAME Go to products.modernmedicine.com and enter names of companies with products and services you need. marketers, find out more at: advanstar.info/searchbar Bringing Eye Health into Focus Search for the company name you see in each of the ads in this section for FREE INFORMATION! JULY 2015 / OptometryTimes.com Marketplace PRODUCTS & SERVICES DISPENSARY 39 40 JULY 2015 / Optometry Times Marketplace Advertisers Index PRODUCTS & SERVICES Advertiser PRACTICE MANAGEMENT Page Alcon Laboratories Inc Tel: 800-862-5266 Web: www.alcon.com QuikEyes Web-Based Optometry EHR t $198 per month after low cost set-up fee t Quick Set-Up and Easy to Use t No Server Needed t Corporate and Private OD practices t 14 Day Free Demo Trial t Email/Text Communications www.quikeyes.com PRACTICE FOR SALE OPTOMETRY PRACTICES FOR SALE 1$7,21:,'(&DOLIRUQLD&RORUDGR )ORULGD0DVVDFKXVHWWV0LQQHVRWD 7HQQHVVHH7H[DV1HZ-HUVH\ 9HUPRQW:LVFRQVLQ 100% OPTOMETRY PRACTICE FINANCING )RU0RUH,QIR&DOO3UR0HG)LQDQFLDO,QF 3KRQH LQIR#SURPHGILQDQFLDOFRP ZZZSURPHGILQDQFLDOFRP Call Karen Gerome to place your Products & Services ad at 800-225-4569, ext. 2670 [email protected] CAREERS MARYLAND )XOOWLPH RSSRUWXQLW\ DV DVVRFLDWH RSWRPHWULVW LQ '& 0HWUR $UHD 0' DQG 9$ :H SUDFWLFH IXOO VFRSH RSWRPHWU\ 2XWVWDQGLQJ FRPSHQVDWLRQ SDFNDJHEHQHÀWVDQGLQFHQWLYHV 6HQG&9WR VFKZDUW]EHUJ#GRFWRUVRQVLJKWFRP RUFDOO(G Content Licensing for Every Marketing Strategy Marketing solutions fit for: Outdoor | Direct Mail Print Advertising Tradeshow/POP Displays Social Media | Radio & TV Leverage branded content from Optometry Times to create a more powerful and sophisticated statement about your product, service, or company in your next marketing campaign. Contact about how we can customize your acknowledgements and recognitions to enhance your marketing strategies. CVTIP, 7, 8, 11, 12 17, 18, 42, CV4 Bausch + Lomb Tel: 800-227-1427 Customer Service: 800-323-0000 Web: www.bausch.com 21, 25 Cooper vision Web: www.coopervision.com CV2 Katena Products Inc. Tel: 973-989-1600 Fax: 973-989-8175 Web: www.katena.com 27 Ocusoft Tel: 281-239-9871 Web: www.ocusoft.com 31 Regeneron Pharmaceuticals Tel: 914-345-7400 Web: www.regeneron.com 19 TTI Medical Tel: 800-322-7373 Web: www.ttimedical.com 23 Vision Expo Web: www.visionexpoeast.com 33 Vistakon Web: www.acuvueprofessional.com CV3, 15 This index is provided as an additional service. The publisher does not assume any liability for errors or omissions. RECRUITMENT ADVERTISING WORKS! Call Joanna Shippoli to place your For information, call Wright’s Media at 877.652.5295 or visit our website at www.wrightsmedia.com Recruitment ad at 800-225-4569 ext. 2615 [email protected] Q&A | PRACTICAL CHAIRSIDE ADVICE Agustin Gonzalez, OD, FAAO, ABCMO 41 Clinic director of Eye & Vision, Richardson, TX Owl vision, generic vs. branded, going to private practice How did you become interested in the vision of Q How did you decide to go into private practice? owls? When I was in optometry school, a Cornell professor came to visit. We studied the refractory aspects of the owl’s eyes. That fascinated me because the eyes are simple yet complex organs—it’s simple in the way it works but very complex in the way things have to happen for it to work. I became very interested in that. Back then, it was a big thing for me. At one time I was managing a number of Pearle Vision offices in the Dallas area. As with anything in retail, you are the poster child for how to do things right and then you become the poster child of part of the problem, of not doing things the way they wanted. So, pressure mounted for me to get rid of the operations, which I did. That moment in time I said I wanted to move the largest into a private practice. There was a moment there, year number two, where your amount of commercial patients starts dwindling down because your prices are going up, but your amount of prior patients starts going up because of the quality of services you’re delivering. That happened 10 years ago, and I’ve never looked back. What sparked your interested in generic Photo courtesy Agustin Gonzalez, OD, FAAO, ABCMO meds? A long time ago, when generic Tobradex hit the market, I understood that it wasn’t as effective as brandname Tobradex. So, I looked more closely into what made the products different. Then with price increases in medications within the last five years, it’s become a hot topic. I realized that there is a big gap between outcomes and using the right medications. That got me interested in the biochemistry and molecular pharmacology of medications. I tell all my students that just because a drug is labeled by the FDA to be in a category doesn’t mean that they all work the same. You have to find the unique properties in the molecule or formulation that are better suited for a particular patient, and that’s going to improve your clinical outcomes. We all have great backgrounds in pharmacology— we take more pharmacology hours than the MDs. But if we do not discern how to properly use a medication, it becomes very difficult to attain the desired outcome. sional. My first opera was Rigoletto in Verona, and I’ve seen it seven times. Do you have any regrets? I should have started in private practice sooner. I’ve been an optometrist for 28 years, and I’ve been in private practice for 10 of those years. On the other hand, if I didn’t go through a cycle of commercial practice or having worked in a hospital environment, there are a lot of things I would not be doing nowadays. You know, I think no. I’ve had a good path, I’ve had a good grip on different modes of practice. I think that I am in the moment of time where I should be So, do I have any regrets? No, not really. What social media advice you have for ODs? Get involved and learn the nuts and bolts. Social media is so personalized. Delegating social media to another person is very inefficient. In order for social media to work, you need to understand your needs and how to voice them to your patients. Being able to voice that you’re the expert in this particular part of eye What do you do for down time? I’ve been a Dal- las Opera season ticket holder for about 12 years. My favorite opera is Iolanta. It’s about a blind princess, so that’s one that resonates for a profes- To hear the full interview with Dr. Gonzalez, listen online: optometrytimes.com/ AgustinGonzalez care is more effective than delegating to somebody else. What’s the craziest thing you’ve ever done? Have kids. [laughs] When I was in college, we used to cave dive in sink holes in Florida to collect albino crawfish. We would go out about 120 feet, below sea level, diving for these little boogers to collect for research. I grew up diving in Puerto Rico, and at the time we didn’t need certification. More recently, I went zip lining in Puerto Rico on one of the longest zip lines in the world called Toro Verde or “green bull.” For a guy who’s not seeking adventure, I enjoy tipping my hat every once in a while. —Vernon Trollinger | PRACTICAL CHAIRSIDE ADVICE InDispensable 42 ClearVision releases new kids styles HAUPPAUGE, NY—ClearVision Optical introduces its 2015 Kids Collection, featuring new styles from Op Kids, Jessica McClintock for Girls, and IZOD Boys. The Jessica McClintock for Girls collec- BRIEF SUMMARY PAZEO (olopatadine hydrochloride ophthalmic solution) 0.7%. For topical ophthalmic administration. The following is a brief summary only; see full prescribing information for complete product information. CONTRAINDICATIONS None. WARNINGS AND PRECAUTIONS Contamination of Tip and Solution As with any eye drop, care should be taken not to touch the eyelids or surrounding areas with the dropper tip of the bottle to prevent contaminating the tip and solution. Keep bottle tightly closed when not in use. Contact Lens Use Patients should not wear a contact lens if their eye is red. The preservative in PAZEO solution, benzalkonium chloride, may be absorbed by soft contact lenses. Patients who wear soft contact lenses and whose eyes are not red, should be instructed to wait at least five minutes after instilling PAZEO before they insert their contact lenses. ADVERSE REACTIONS Clinical Trials Experience Because clinical trials are conducted under widely varying conditions, adverse reaction rates observed in the clinical trials of a drug cannot be directly compared to rates in clinical trials of another drug and may not reflect the rates observed in practice. In a randomized, double-masked, vehicle-controlled trial, patients at risk for developing allergic conjunctivitis received one drop of either PAZEO (N=330) or vehicle (N=169) in both eyes for 6 weeks. The mean age of the population was 32 years (range 2 to 74 years). Thirty-five percent were male. Fifty-three percent had brown iris color and 23% had blue iris color. The most commonly reported adverse reactions occurred in 2-5% of patients treated with either PAZEO or vehicle. These events were blurred vision, dry eye, superficial punctate keratitis, dysgeusia and abnormal sensation in eye. USE IN SPECIFIC POPULATIONS Pregnancy Risk Summary There are no adequate or well-controlled studies with PAZEO in pregnant women. Olopatadine caused maternal toxicity and embryofetal toxicity in rats at levels 1,080 to 14,400 times the maximum recommended human ophthalmic dose (MRHOD). There was no toxicity in rat offspring at exposures estimated to be 45 to 150 times that at MRHOD. Olopatadine should be used during pregnancy only if the potential benefit justifies the potential risk to the fetus. Animal Data In a rabbit embryofetal study, rabbits treated orally at 400 mg/kg/day during organogenesis showed a decrease in live fetuses. This dose is 14,400 times the MRHOD, on a mg/m2 basis. An oral dose of 600 mg/kg/day olopatadine (10,800 times the MRHOD) was shown to be maternally toxic in rats, producing death and reduced maternal body weight gain. When administered to rats throughout organogenesis, olopatadine produced cleft palate at 60 mg/kg/day (1080 times the MRHOD) and decreased embryofetal viability and reduced fetal weight in rats at 600 mg/kg/day. When administered to rats during late gestation and throughout the lactation period, olopatadine produced decreased neonatal survival at tion, featured below, has transformed to a more grown-up collection and is offered in colorful styles, edgy eye shapes, translucent and fade materials, and clean, sculpted temples. 60 mg/kg/day and reduced body weight gain in offspring at 4 mg/kg/day. A dose of 2 mg/kg/day olopatadine produced no toxicity in rat offspring. An oral dose of 1 mg/kg olopatadine in rats resulted in a range of systemic plasma area under the curve (AUC) levels that were 45 to 150 times higher than the observed human exposure [9.7 ng∙hr/mL] following administration of the recommended human ophthalmic dose. Nursing Mothers Olopatadine has been identified in the milk of nursing rats following oral administration. Oral administration of olopatadine doses at or above 4 mg/kg/day throughout the lactation period produced decreased body weight gain in rat offspring; a dose of 2 mg/kg/day olopatadine produced no toxicity. An oral dose of 1 mg/kg olopatadine in rats resulted in a range of systemic plasma area under the curve (AUC) levels that were 45 to 150 times higher than the observed human exposure [9.7 ng∙hr/mL] following administration of the recommended human ophthalmic dose. It is not known whether topical ocular administration could result in sufficient systemic absorption to produce detectable quantities in the human breast milk. Nevertheless, caution should be exercised when PAZEO is administered to a nursing mother. Pediatric Use The safety and effectiveness of PAZEO have been established in pediatric patients two years of age and older. Use of PAZEO in these pediatric patients is supported by evidence from adequate and well-controlled studies of PAZEO in adults and an adequate and well controlled study evaluating the safety of PAZEO in pediatric and adult patients. Geriatric Use No overall differences in safety and effectiveness have been observed between elderly and younger patients. NONCLINICAL TOXICOLOGY Carcinogenesis, Mutagenesis, Impairment of Fertility Carcinogenicity Olopatadine administered orally was not carcinogenic in mice and rats in doses up to 500 mg/kg/day and 200 mg/kg/ day, respectively. Based on a 35 μL drop size and a 60 kg person, these doses are approximately 4,500 and 3,600 times the MRHOD, on a mg/m2 basis. Mutagenesis No mutagenic potential was observed when olopatadine was tested in an in vitro bacterial reverse mutation (Ames) test, an in vitro mammalian chromosome aberration assay or an in vivo mouse micronucleus test. Impairment of fertility Olopatadine administered at an oral dose of 400 mg/kg/day (approximately 7,200 times the MRHOD) produced toxicity in male and female rats, and resulted in a decrease in the fertility index and reduced implantation rate. No effects on reproductive function were observed at 50 mg/kg/day (approximately 900 times the MRHOD). PATIENT COUNSELING INFORMATION H ,6.2)B217$0,1$7,21@'9,6(3$7,(17672127728&+'5233(5 7,372(<(/,'6256855281',1*$5($6$67+,60$<&217$0,1$7( 7+('5233(57,3$1'23+7+$/0,&62/87,21 HB21&20,7$17E6(2)B217$&7C(16(6@'9,6(3$7,(176127 72:($5&217$&7/(16(6,)7+(,5(<(6$5(5(''9,6(3$7,(176 7+$7#6+28/'127%(86('7275($7&217$&7/(165(/$7(' ,55,7$7,21'9,6(3$7,(176725(029(&217$&7/(16(635,2572 ,167,//$7,212)#!+(35(6(59$7,9(,1#62/87,21 %(1=$/.21,80&+/25,'(0$<%($%625%('%<62)7&217$&7 /(16(6C(16(60$<%(5(,16(57('0,187(6)2//2:,1* $'0,1,675$7,212)# Patents: CBC ! DB 257"257+!(;$6 ED I 29$57,6 5/15 PAZ15011JAD JMC4800 The Op Kids is inspired by the brand’s tween/teen apparel and offers cool shapes with a tropical beach vibe. The collection has three new styles and features patterned designs, like camouflage and colorblocking, along with metallic and mixed materials styles. The IZOD Boys collection offers sportinfused designs with racing-inspired accents and textures and pops of color. The latest release features four new styles, two of which offer memory metal bridges for enhanced durability. JCM4802 What she’s really searching for is comfort. What happens when she looks at digital screens all day long? She blinks 5 times less, her tear film is destabilized, and she experiences dryness.1 HYDRACLEAR® PLUS Technology helps stabilize the tear film by mimicking the eye’s natural mucins, allowing her to live more of the digital life she wants. It’s no wonder patients like her report ACUVUE OASYS® Brand Contact Lenses has superior comfort vs Air Optix® Aqua and Biofinity® after 8 hours on digital screens. Provide exceptional performance for her digital life with ACUVUE OASYS® Brand. Reference: 1. Patel S, Henderson R, Bradley L, Galloway B, Hunter L. Effect of visual display unit use on blink rate and tear stability. Optom Vis Sci. 1991;68(11):888-892. ACUVUE® Brand Contact Lenses are indicated for vision correction. As with any contact lens, eye problems, including corneal ulcers, can develop. Some wearers may experience mild irritation, itching or discomfort. Lenses should not be prescribed if patients have any eye infection, or experience eye discomfort, excessive tearing, vision changes, redness or other eye problems. Consult the package insert for complete information. Complete information is also available from Johnson & Johnson Vision Care, Inc., by calling 1-800-843-2020 or by visiting www.acuvueprofessional.com. ACUVUE®, ACUVUE OASYS®, and HYDRACLEAR® are trademarks of Johnson & Johnson Vision Care, Inc. Third-party trademarks used herein are trademarks of their respective owners. © Johnson & Johnson Vision Care, Inc. 2015 ACU-10337497-A June 2015 INTRODUCING New Once-Daily PAZEOTM Solution 24 HOURS OF OCULAR ALLERGY ITCH RELIEF IN ONE DROP New Once-Daily PAZEO™ Solution for relief of ocular allergy itch: The first and only FDA-approved once-daily drop with demonstrated 24-hour ocular allergy itch relief1 Statistically significantly improved relief of ocular itching compared to PATADAY® (olopatadine hydrochloride ophthalmic solution) 0.2% at 24 hours post dose (not statistically significantly different at 30-34 minutes)1 Statistically significantly improved relief of ocular itching compared to vehicle through 24 hours post dose1 Study design: Two multicenter, randomized, double-masked, parallel-group, vehicle- and active-controlled studies in patients at least 18 years of age with allergic conjunctivitis using the conjunctival allergen challenge (CAC) model (N=547). Patients were randomized to receive study drug or vehicle, 1 drop per eye on each of 2-3 assessment days. On separate days, antigen challenge was performed at 27 (±1) minutes post dose to assess onset of action, at 16 hours post dose (Study 1 only), and at 24 hours post dose. Itching scores were evaluated using a half-unit scale from 0=none to 4=incapacitating itch, with data collected 3, 5, and 7 minutes after antigen instillation. The primary objectives were to demonstrate the superiority of PAZEO™ Solution for the treatment of ocular allergy itch. Study 1: PAZEO™ Solution vs vehicle at onset of action and 16 hours. Study 2: PAZEO™ Solution vs vehicle at onset of action; PAZEO™ Solution vs PATADAY® Solution, PATANOL® (olopatadine hydrochloride ophthalmic solution) 0.1%, and vehicle at 24 hours.1-3 PAZEO™ Solution: Safety Profile Give your patients 24 HOURS OF OCULAR ALLERGY ITCH RELIEF with once-daily PAZEO™ Solution1 Well tolerated1 The safety and effectiveness of PAZEO™ Solution have been established in patients two years of age and older1 The most commonly reported adverse reactions, occurring in 2% to 5% of patients, were blurred vision, dry eye, superficial punctate keratitis, dysgeusia, and abnormal sensation in eye1 Once-daily dosing1 INDICATION AND DOSING PAZEO™ Solution is indicated for the treatment of ocular itching associated with allergic conjunctivitis. The recommended dosage is to instill one drop in each affected eye once a day. IMPORTANT SAFETY INFORMATION As with any eye drop, care should be taken not to touch the eyelids or surrounding areas with the dropper tip of the bottle to prevent contaminating the tip and solution. Keep bottle tightly closed when not in use. Patients should not wear a contact lens if their eye is red. PAZEO™ Solution should not be used to treat contact lens-related irritation. The preservative in PAZEO™ Solution, benzalkonium chloride, may be absorbed by soft contact lenses. Patients who wear soft contact lenses and whose eyes are not red should be instructed to wait at least five minutes after instilling PAZEO™ Solution before they insert their contact lenses. The most commonly reported adverse reactions in a clinical study occurred in 2%-5% of patients treated with either PAZEO™ Solution or vehicle. These events were blurred vision, dry eye, superficial punctate keratitis, dysgeusia, and abnormal sensation in eye. For additional information on PAZEO™ Solution, please refer to the brief summary of the full Prescribing Information on the following page. References: 1. PAZEO™ Solution Package Insert. 2. Data on file, 2011. 3. Data on file, 2013. From Alcon, committed to providing treatment options for patients. Olopatadine is licensed from Kyowa Hakko Kirin Co., Ltd. Japan © 2015 Novartis 5/15 PAZ15011JAD
