ON PATIENT CARE - Review of Optometry

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ON PATIENT CARE - Review of Optometry
24th edition

ON PATIENT CARE
    Formerly “The Clinical Guide to Ophthalmic Drugs”

                                                See the practice of
                                            optometry through the
                                             eyes of three experts.

                                                          Ron Melton, OD

                                                   Randall Thomas, OD, MPH

                                                        Patrick Vollmer, OD
                    A Supplement to

 Supported by an unrestricted grant from Bausch + Lomb
ON PATIENT CARE - Review of Optometry
FROM THE AUTHORS

                                                                                                             CLINICAL
   On the Virtues of Change                                                                                PERSPECTIVES
                                                                                                             ON PATIENT CARE
   In a tumultuous year, we still have much to be excited about.
                                                                                                                   Section I:
   T    he COVID-19 virus has unequivocally altered all of our lives and practices. Two
        of us (Drs. Melton and Thomas) have tested positive for the virus—and survived.
   Once this terrible storm passes, however, our patients will once again be in need of
                                                                                                             Strategies for Success
                                                                                                                    Page 3                                       See the practice of
                                                                                                                                                             optometry through the
                                                                                                                                                              eyes of three experts.
   our professional services. We hope the clinical information in this supplement will
   further equip you to more fully care for your patients in the post-COVID era.                                  Section II:
                                                                                                            Anterior Segment Care
                                                                                                                                                                             Ron Melton, OD

      You’ll also notice some radical changes to this annual publication. We are
   broadening our scope of topics this year. Why? Because optometric practice has                                  Page 18                                               Randall Thomas, OD, MPH

   broadened, too. Simply giving a run-down of drug categories, as we did when this
   started back in the 1990s, just doesn’t live up to the present moment for optometry.                           Section III:                                             Patrick Vollmer, OD

                                                                                                            Posterior Segment Care
                                                                                                                                A Supplement to

   After nearly 25 years of producing a “drug guide,” we want you to get an up-close                             Supported by an unrestricted grant from Bausch + Lomb

   look at how we three clinicians actually practice, and think about, all facets of                                Page 34
   optometric care. Thus, Clinical Perspectives on Patient Care is born!
      Imagine this supplement as a chance to sit alongside us as we consider literally                         Supported by an
   hundreds of different day-to-day challenges. We’ll give you our unvarnished take                         unrestricted grant from
                                                                                                                Bausch + Lomb
   on all of them. If there is no literature reference, consider the statement to be our
   professional opinion. Other doctors will no doubt have their own approaches, and
   that’s fine. Our aim is not to present every conceivable idea—just our own, earned
   through countless hours in the clinic.
      For better or worse, we have now managed to accumulate over 80 combined years
   of intensive clinical experience. Our practice pattern has always been to care for
   patients with non-surgical eye conditions ourselves. We hold ophthalmic surgeons
   in high regard, and are most happy to work collegially with them in caring for our
   patients with surgical needs; otherwise, we manage the extensive gamut of medical eye                      Randall K. Thomas,
   conditions within our own optometric practices.                                                             OD, MPH, FAAO
      Rather than chapters per se, this new approach will share a somewhat random
   selection of topics germane to bringing you up to date on a wide variety of eye
   conditions and issues, organized in three main sections. Note that we cannot condense
   four years of clinical training into a single supplement. We are assuming a strong
   foundation of clinical knowledge by the reader, and are only attempting to add
   succinct, salient “pearls” to this foundation.
      Our goal in writing this guide is to help further equip our colleagues with
   knowledge to provide a broader range of top-quality patient care services. Of all the                         Ron Melton,
   conditions we need to master, the two most important ones are glaucoma and dry eye                            OD, FAAO
   disease. We encourage you to attentively read these discussions, pay attention to the
   professional journals and exhaustively seek lectures on glaucoma.
      As always, we are grateful to Bausch + Lomb Pharmaceuticals for their unwavering
   support of this optometric educational product through the years, and to the editorial
   team at Review of Optometry for helping shape this supplement into a highly readable
   work.
      We hope and pray that each of you and your loved ones endure this viral assault,
   and come out of this disaster stronger and more resolute than ever before.                                 Patrick M. Vollmer,
                                                                                                                  OD, FAAO
   With our best wishes,
   Drs. Melton, Thomas and Vollmer

Disclosure: Drs. Melton and Thomas are consultants to, but have no financial interests in, the following
companies: Bausch + Lomb and Icare. Dr. Vollmer has no financial interests in any company.
                                                                                                             A PEER-REVIEWED
Note: The authors present unapproved and “off-label” uses of specific drugs in this publication.                SUPPLEMENT
ON PATIENT CARE - Review of Optometry
SECTION I: STRATEGIES FOR SUCCESS

Warning: Major Changes Coming to Optometry
If you think you can rely on dispensary income and routine eye exams, you may be
in for a rude awakening.

A
             quick look at the profes-    upon this reality, one could rationally
                                                                                        MEDICAL EYE CONDITIONS
             sional literature clearly    and accurately assume that the pub-
                                                                                        ALL ODs SHOULD MANAGE
             shows major sea changes      lic’s quest for competent, thorough,
                                                                                        • Assessing hydroxychloroquine
             in how eye care is being     medically-oriented eyecare is valued            (Plaquenil) retinotoxicity risk
delivered. Online refractions, eye-       far more than just “refraction.” This
                                                                                        • Diabetic retinopathy
glasses and contact lenses are already    is a powerful observation, and one
available in many places of the world,    that we should take to heart.                 • The glaucomas
and are now available in the United                                                     • Acute symptomatic posterior
                                                                                          vitreous detachments
States. The 3-D printers are making       NO TIME TO WASTE
complete eyeglasses, and this technol-    A comprehensive consensus of these            • Acute red eyes: allergic, bacterial,
                                                                                          viral, chlamydial
ogy will only improve. Drugs to push      observations should compel think-
back presbyopia will also be here         ing optometrists to reevaluate their          • Injuries and abrasions
soon, thus dampening the bifocal          practice modus operandi and develop           • Blepharitis
market. Autorefractors and auto-          strategies to remain viable in the face       • Meibomian gland dysfunction
mated subjective systems are already      of these tidal waves of changes com-          • Dry eye disease
here, and they too, will continue to      ing our way.                                  • Zoster ophthalmicus
improve. Eyeglasses are heavily pro-         Our relatively straightforward             • Eye pain: trichiasis, ectropion,
moted for as little as $6.95!             plan is to simply begin keeping all             entropion, lagophthalmos
   The Department of Veterans             the patients who present to us. Stated        • Bell’s palsy
Affairs (VA) now has operational          another way, it is imperative that we         • Corneal dystrophies
programs in place in which layper-        stop hemorrhaging patients through
                                                                                        • Optic neuritis
sons are trained to perform essen-        referrals, and that we provide a much
                                                                                        • Macular degeneration
tially full eye examinations, including   broader base of comprehensive medical
refraction, and patient satisfaction is   care services; this is critical to our sur-   • Presurgical cataract care
reported to be “high.” For decades,       vival as a profession. For perspective,       • Epiphora
ophthalmologists have had high            the table at right is a near-comprehen-       • Post-op care for numerous surgeries
school graduates performing their              sive list of medical eye conditions      • Lid infections: acute hordeola, styes
refractions, and people                                 that attentive and caring       • The gamut of contact lens
flock to their prac-                                            ODs can readily           complications
tices. Based                                                              address.      • Episcleritis/scleritis
                                                                                        • Giant cell (temporal) arteritis
                                                                                        • Recurrent corneal erosion
    THREATS TO OPTOMETRY                                                                • Contact blepharodermatitis
                                                                                        • Superior limbic keratoconjunctivitis
    • Bargain-basement tactics by
                                                                                                                                      STRATEGIES FOR SUCCESS
                                                                                        • Phlyctenular keratoconjunctivitis
      eyewear discounters
                                                                                        • Eroding tarsal concretions causing
    • Online refractions                                                                  foreign body sensation
    • Online contact lens sales                                                         • Thygeson’s superficial punctate
    • Bottom line: dispensary is                                                          keratopathy
      dying                                                                             • Transient vision loss from carotid
                                                                                          artery disease
                                                                                        • Ocular migraines
                                                                                        • Corneal infiltrates and ulcers/CLARE
                                                                                        • Giant papillary conjunctivitis
                                                                                        • Epithelial basement membrane
                                                                                          assessment and monitoring

                                                                                        REVIEW OF OPTOMETRY JUNE 15, 2020         3
ON PATIENT CARE - Review of Optometry
SECTION I: STRATEGIES FOR SUCCESS

                                                 radical some of these changes and              Another resource to keep you
                                                 approaches may seem, but we im-             attuned to the latest research is the
                                                 plore you to begin to become proac-         website www.practiceupdate.com.
                                                 tive and not find yourselves scram-         You can sign up to have a daily
                                                 bling to play “catch-up” when you           email newsletter sent to you each
                                                 are faced with technological advance-       morning with important studies in
                                                 ments; they indeed are coming.              eye care.
                                                                                                Yet another way to increase your
                                                 KEEP UP WITH RESEARCH                       professional abilities is to call upon
                                                 A very enriching way to fast-forward        a colleague to gain his or her advice.
                                                 your expertise in these areas is to         There is nothing wrong in asking for
    If you want to insulate your practice from
    the threat of online refraction services,
                                                 subscribe (as we do) to the following       help, or getting an opinion, but keep
    evolve to a medical foundation.              journals. These can be readily ac-          your patients in your practice.
                                                 cessed via a simple Google search:             What about being “on call”?
       Caring for patients with these               1. Ophthalmology                         Doctors like to receive after-hours
    conditions, especially the glaucomas,           2. American Journal                      calls about as much as patients like
    holds massive potential for building               of Ophthalmology                      undergoing air-puff tonometry; how-
    a dynamic practice, and possesses a             3. JAMA Ophthalmology                    ever, as doctors we need to develop a
    strong firewall against technological           4. Survey of Ophthalmology               system whereby optometric patients
    advancements into traditional op-               You can read these journals solely       have at least consultative access to
    tometry. “Refraction” is a technical         on your own, but perhaps a wiser            optometric care outside of normal
    procedure, and bright, sharp, friendly       way to increase your knowledge base         office hours.
    high school graduates can be rapidly         would be to develop monthly “jour-             Here again is where coming to-
    trained to perform this data-collec-         nal clubs” where four of you each           gether as teams provides the perfect
    tion task, thus freeing the doctor up        subscribe to one of these journals,         solution. Find six or seven like-
    to have more time doing those tasks          then get together over a nice dinner        minded, patient-centric colleagues
    only a doctor can do. As doctors, it         one weekday per month to review             and form a formal call group. In
    is our duty and responsibility to have       salient, relevant articles. The four of     this way, an OD is available to meet
    quality-assurance oversight on the           you will grow exponentially! Trying         the needs of our collective opto-
    final refraction; thus, looking at the       to feed yourselves via continuing edu-      metric patient population. If you
    current eyeglasses prescription, the         cation meetings provides a very low         consider your fellow ODs only as
    autorefraction, and the technician’s         yield in professional growth, whereas       competitors, that is a shallow, rather
    performance of subjective refraction         perusing optometric and ophthalmo-          desperate view, and quite simply, is
    accomplishes such.                                    logical journals is a high-yield   pitiable. We should all work together
       Now, we are keenly                                          professional growth       as colleagues in an effort to enhance
    aware of how                                                           exercise.         patient care, and to keep optometric
                                                                                             patients as optometric patients! Your
                                                                                             practices will thrive, your patients
                                                                                             will be well served, and public health
        REFRACTIONIST OR DOCTOR?                                                             will be enhanced. Remember, above
                                                                                             all, you are your brother’s keeper.
        • A new world of vision testing and eye wear sales is dawning now
          that refractions and prescription fulfillment are being offered online.            OUR PRACTICAL ADVICE
        • These developments may not be a negative for ophthalmology                         Now that we have comprehensively
          practices and patients.                                                            laid the groundwork and have made
             » Visibly                » Myeyelab.com           » Vmax Vision                 the case for expanded care by ODs,
                                                                                             we turn to sharing the knowledge
             » EyeNetra               » Smart Vision           » Warby Parker
                                        Labs
                                                                                             gleaned from the literature and
             » MyVisionPod                                                                   our combined 80 years of clinical
        • Optometrists: Expand your scope of patient care services to protect                practice. It is our hope that what we
          your future!                                                                       share herein enables you to fur-
        • The AOA is aggressively fighting for optometry: Join the AOA!                      ther enhance your competence as a
                                                                                             patient-centric caregiver and medical
                                                                                             practitioner of the eye.

4   REVIEW OF OPTOMETRY JUNE 15, 2020
ON PATIENT CARE - Review of Optometry
Optometry “On Call”: A Not-So-Novel Concept
It’s commonplace in other fields, yet somewhat rare in our profession. Patients who
need urgent care deserve the attention and expertise that ODs can provide.

A
             s we all know, eye care           ner—that is, form such a call group        no matter the time of day or night.
             provided by anyone                with your colleagues to provide            For perspective, the vast majority of
             outside of optometry or           emergency patient care. To allow           these calls can be dealt with by phone;
             ophthalmology is abysmal.         your office phone to simply ring           only rarely is there a need to meet the
Whether one practices in a group,              and ring after hours is completely         patient in the office in the middle of
private practice, a retail/commercial          irresponsible; instructing your after-     the night. Most emergencies can wait
setting or in any other setting, there         hours answering service to direct the      until office hours to be seen.
should be one uncompromising goal:             caller to an emergency department or          Let’s understand our role as a pa-
providing optometric patient access to         urgent care center is even worse.          tient caregiver, and develop a creative,
optometric care 24/7.                             We are a healthcare profession,         collaborative system to meet our pa-
   First, it is the rare individual who        doctors, and our collective patients       tients’ after-hours emergency medical
enjoys being “on call.” It is encum-           deserve to be seen by an optometrist       needs. We would want nothing less
bering, but the cases are usually              when an ocular emergency arises,           for ourselves!
stimulating and can stretch your clini-
cal confidence.
   It is our collective perspective
that patients should have access to
emergency medical optometric care
whenever the need arises. When a pa-
tient calls her or his optometrist, there
should be an answering machine/ser-
vice guidance as to how to contact the
optometrist on call!
   Here we share a parallel example
of how many dental practices meet
the needs of their patients: six to eight
dentists come together and form a call
group, such that a single dentist is on
call for the group every six to eight
weeks. By spreading the responsibil-
ity, they move from being “always on
call” (which, in reality, we all are), to
being on call only every six or eight
weeks. With this shared call system,
emergency patients always have ready
                                                                                                                                         STRATEGIES FOR SUCCESS

access to a dentist. If we had a dental
emergency, called our dentists and the
answering machine said “Our office
is now closed,” or if we were directed
to contact an emergency department/
urgent care, the three of us would be
finding other dentists!
   We urge our optometric colleagues
to become proactive in a like man-
    Vision Source supports its members by                                          (Practice Name)
                                                                              (Practice Phone Number)
      offering this promotional flyer on the
         vital emergency care ODs provide.

                                                                                            REVIEW OF OPTOMETRY JUNE 15, 2020        5
ON PATIENT CARE - Review of Optometry
SECTION I: STRATEGIES FOR SUCCESS

    Ophthalmologic                                   PATIENTS ARE READY FOR REMOTE EYE EXAMS—ARE YOU?
    Perspective on                                   A company called DigitalOptometrics is offering full-time and part-
    Emergency Eye Care                               time positions to optometrists who are willing to perform remote
                                                     comprehensive eye

    N
              ow that more and more                  examinations during
              eye surgeons have (or have             the day, evenings and/
              access to) outpatient surgery          or weekends from their
    centers, and use those rather than               home office or other
    hospital operating rooms, there is a             location of choice.
    shrinking need for such surgeons to                 DigitalOptomet-
    serve on-call for hospital emergency             rics, which operates in
    departments. This leaves a vacuum                the United States and
    relative to emergency eye care. An               Canada, uses live video-
    article in EyeNet magazine (December             conferencing technology
    2019) shed light on the matter:                  to enable comprehensive
        “If ophthalmologists continue                eye health and vision analysis remote eye examinations performed
    removing themselves from emergency               by licensed optometrists. The goal, according to the company, is
    medicine and remain unwilling to                 to make comprehensive eye exams convenient to patients in both
                                                     urban and remote locations by having exams performed remotely
    provide care outside of their offices
                                                     by licensed optometrists.
    […] it is only creating a void that oth-
                                                        Our take: These technologies are in their infancy and will only
    ers will be more than happy to fill.”
                                                     grow. Refraction-centric practices will be hurt. Medically-centric
        “Optometrists and non-ophthalmic             practices should be protected. Give this great contemplation.
    providers are organized and ready to                Fortunately, our colleagues at the AOA already have. The AOA
    jump in. They see the gap in care. If            kicked off a national public awareness campaign this year on the
    a hospital can’t depend on ophthal-              importance of an annual, in-person, comprehensive eye examination
    mologists, why wouldn’t they send                with an AOA family doctor of optometry—turning a moment (the
    patients elsewhere? Why wouldn’t                 tie-in of year 2020 and 20/20 vision) into a movement.
    optometrists become gatekeepers?”
        Everywhere else in medicine, non-         can say with authority that the need          If both optometrists and ophthal-
    surgeons are the gatekeepers, thus            for an eye surgeon is exceedingly rare.    mologists would proactively educate
    it seems perfectly appropriate for               As there is always the remote           their collective patients to “call us
    optometrists to fill this role. Having        possibility for surgical need, an eye      first” before going to an emergency
    been on-call for our respective                       surgeon needs to always be         department, several things could hap-
    hospital emergency                                            available, and this just   pen:
    departments, we                                                       makes sense.           • Patient care would be greatly
                                                                                             enhanced.
                                                                                                 • Patients would save significant
                                                                                             time and money.
        THE EYE AND THE ED                                                                       • Those caring practices would
                                                                                             enjoy enhanced revenue.
        • Most common ICD diagnoses:
                                                                                                • Emergency department physi-
           Conjunctivitis ..................33%
                                                                                             cians, who have a variably limited
           Corneal injury...................13%
                                                                                             skill set for eye problems, would
           Corneal foreign body ...... 8%
           Hordeolum .........................4%                                             become unencumbered from eye
        • Mean ED charge: $989.30 for eye visit                                              emergencies.
        • Eye visits: 1.5% of all visits                                                        We all need to step up to the
        —Vazini K, et al. Ophthalmology 2016;123(4):917-19
                                                                                             plate and reach out to this subset of
                                                                                             patients with urgent eye care needs.
        • “Approximately 387,000 patients per year present to US emer-
                                                                                             We applaud those optometrists
          gency departments with eye injuries, and children represent up
          to one-third of those injured.”
                                                                                             already providing such emergency eye
                                                                                             services, and to our friends at Vision
        —JAMA Ophthalmology, August 2018
                                                                                             Source for being formally proactive in
                                                                                             this regard.

6   REVIEW OF OPTOMETRY JUNE 15, 2020
ON PATIENT CARE - Review of Optometry
Optometrists Can Rise to the Occasion
Build your practice around caring for your patients—especially those with emergency
medical needs—and you’ll be ready for anything, even a global pandemic.

T
        his year, the world has been               response. They don’t
        overwhelmed by the corona-                 want to deal with eye
        virus pandemic, which filled               issues right now. A
hospitals with COVID-19 patients                   lot of these patients
and ground the everyday workings of                are getting funneled
society to a halt. Like most doctors,              into my clinic day and
the majority of optometrists closed                night.”
their offices to routine care. Some                   He sees each
opened to emergency cases, but only                patient one at a
if they had the clinical skills and com-           time, so there is
munity reputation to make it work.                 never more than one
Practices that rely too heavily on                 patient in the clinic.
refractions and are mostly perceived               To further ensure
as an outlet for glasses fared poorly.             safety, Dr. Vollmer
    One of our number—Patrick                      wears an N-95 mask
Vollmer, OD—made the transi-                       and gloves, and all
tion easily. Urgent care was nothing               patients also receive
new to Dr. Vollmer, who provided                   masks and gloves
emergency eye care the first day he                at the door. When
walked in the door of his practice,                the patient leaves,
long before COVID-19 struck.                       everything is disin-
    “I worked tirelessly in my com-                fected. The procedure
munity to establish medical and                    is a bit tedious “but it
emergency eye care,” he says. “This                works,” he says.
has proven to be a virtuous deci-                     Many of Dr.
sion. To my knowledge, pretty much                 Vollmer’s current
all of the hospitals, Urgent Cares                 emergency patients
and primary care offices are a bit                 tell him they would’ve Dr. Vollmer and his patient each wear masks and gloves to
                                                                             minimize risk of contagion.
overwhelmed with the COVID-19                      normally gone to the
                                                   ER or Urgent Care, but they were            nice to be appreciated, but I get more
                                                   worried about being in a hospital set- fulfillment in knowing I helped some-
  COMORBIDITIES AND
                                                   ting currently. “I take this opportuni- one in need.”
  COVID-19 DEATHS
                                                   ty to educate these new patients that          Continuing to see patients who
  In a large study, the most                       they shouldn’t go the ER anyway.            called in for urgent issues filled a
  common comorbidities were                        A lot of patients simply don’t know         critical patient care need and kept
                                                                                                                                              STRATEGIES FOR SUCCESS
  hypertension (57%), obesity                      this despite going to their eye doctors Dr. Vollmer’s practice busy during
  (42%) and diabetes (34%)—all                     for years. Optometry cannot assume          the downtime. “One of the important
  conditions that in most cases can
                                                   patients know to come to their clinics aspects that I learned,” he explains,
  be mitigated by lifestyle changes,
                                                   for ocular emergencies,” he says.           “is how important it is to diversify
  and/or medications. Something
                                                      Patients are appreciative of             your practice. If it wasn’t for emer-
  to ponder as we, as a society,
                                                   emergency care regardless, but they         gency patients and ‘urgent’ needs, life
  prepare for future pandemics.
                                                   are especially grateful during this         would have been pretty slow.” Now
  1. Richardson S, Hirsch JS, Narasimhan M, et     outbreak, Dr. Vollmer says. “I don’t        that the practice is seeing routine care
  al. Presenting characteristics, comorbidities,
  and outcomes among 5700 patients hospital-       charge an after-hours fee right now,        again, patients are more motivated
  ized with COVID-19 in the New York City area.
  JAMA 2020; April 22. [Epub ahead of print].
                                                   and the most I charge for any office        than ever to come in because they
  Published online April 22, 2019.                 visit is around $150 if they have no        know this is a doctor they can count
                                                   insurance or a high deductible. It’s        on even in the toughest times.

                                                                                                REVIEW OF OPTOMETRY JUNE 15, 2020         7
ON PATIENT CARE - Review of Optometry
SECTION I: STRATEGIES FOR SUCCESS

    Clinical Pearls You Can Count On
    Heed these time-honored insights gleaned through 80+ years of patient visits.

    E
             very patient is unique, and          • Unless the cause for foreign
             deserves to be treated as such,   body sensation is clearly evident (and
             but these tips have proven        sometimes even when it is), always
    correct again and again in numer-          evert the upper eyelid after instilling
    ous encounters the three of us have        fluorescein dye. There is always a
    amassed throughout our careers.            cause for foreign body sensation, so
        • If there is any unexplained al-      look for things like:
                                                                                          Eyes in primary gaze appear healthy.
    teration of visual function, always do        – subtle epithelial basement mem-
    a retrospective review of any changes      brane dystrophy
    of the patient’s medicines, especially        – Thygeson’s superficial punctate
    if they are on any new medicines or        keratopathy
    changes to dosing have been made.             – eroding tarsal conjunctival con-
    By doing so, often a cause-and-effect      cretions
    relationship can be established that          – occult trichiasis
    provides a rational explanation for           – a loose lash in the puncta
    the change in visual status.                  For conjunctival foreign bodies, we     Upon downgaze, the diagnosis of SLK is
                                                                                          obvious, thus emphasizing the necessity
        • Studies have confirmed that          try not to use an anesthetic, so once      of lifting the eyelids to search for the
    patients prefer their doctors to wear a    the foreign body has been removed,         cause of his presenting symptoms.
    lab coat with their nametag on it. We      the patient can give immediate con-
    prefer our nametags to have our first      firmation of relief, rather than having
    and last names, then OD, rather than       to wait 20 to 30 minutes while the
    “Dr. Last Name.” We are proud to           anesthetic wears off before making
    be ODs, and on occasion, it provides       such a determination.
    an opportunity to explain to our              • If the eye is pretty much white
    patients exactly what an OD is. To         yet the patient has miserable, irritated
    display our degree allows us to share      eyes with foreign body sensation,          These eroding calcific bodies caused this
    our unique expertise in eye care, and      always think about superior limbic         patient’s foreign body sensation.
    to confirm to our patients that they       keratoconjunctivitis (SLK). Confirm-
    are, indeed, seeing the right                       ing this diagnosis takes two      that you can examine the superior
    doctor. Be proud to be                                      steps: have the patient   bulbar conjunctiva, and then stain the
    an OD!                                                              look down so      globe with lissamine green dye. Allow
                                                                                          30 to 60 seconds for adequate stain-
                                                                                          ing. If these bulbar and tarsal conjunc-
                                                                                          tival tissues have become idiopathical-
        SUPERIOR LIMBIC KERATOCONJUNCTIVITIS                                              ly keratinized, the mechanical rubbing
                                                                                          of these two interfacing tissues is the
        • Both sexes affected, women more                                                 cause for the distressing symptoms.
        • Main symptoms: distressingly irritated eyes                                        We initially use 0.5% silver nitrate
                                                                                          compounded solution to help diminish
        • Dry eyes common companion finding                                               these keratinized tissues. After the
        • Symptoms disproportionate to clinical findings                                  patient takes your prescription to a
                                                                                          known ophthalmic compounding
        • Spontaneous exacerbations and remissions
                                                                                          pharmacy and obtains the solution,
        • 25% to 40% have some thyroid dysfunction                                        have him or her bring the drop back
        • Tx (difficult): 0.5% silver nitrate, optimum lubrication, pressure              to the office where topical propara-
          patching, therapeutic soft lenses, surgical resection, cryotherapy              caine is instilled twice (about 30
                                                                                          seconds between each drop). We then
                                                                                          dip a sterile cotton swab into the com-
                                                                                          pounded solution, flick off the excess,

8   REVIEW OF OPTOMETRY JUNE 15, 2020
ON PATIENT CARE - Review of Optometry
and have the patient look down, evert
the upper eyelid(s) and “paint” the
superior tarsal tissues.                         EYELID CLEANSING TREATMENTS FOR BLEPHARITIS
   This is just like painting a wall
with a paint roller; do this for about           • Study compared “dedicated eyelid cleanser to diluted baby
20 seconds. Then un-evert the eyelid               shampoo”
and have the patient look down. Now
                                                 • Cleaning was done BID for four weeks
perform the same procedure to the
affected superior bulbar conjunctival            • Conclusion: improvements occurred with both treatments
tissues.
                                                 • “However, only the dedicated eyelid cleanser proved
   We then instill a moderate amount
                                                   effective in reducing inflammation and was the preferred
of generic Maxitrol (neo-poly-dex)
ophthalmic ointment, which we keep                 therapy.”
in our lab coat pockets. We encour-              —The Ocular Surface, October 2017
age these patients to frequently instill
lipid-based artificial tears to the eye(s)
over the course of the day and to use
a preservative-free artificial tear oint-
ment at bedtime until they return to us      agnosed condition. Being thorough            dystrophy. Instillation of fluorescein
in one month, at which time we repeat        in your diagnostic pursuit will easily       dye can help uncover these two subtle
the “painting” procedure. We keep            reveal the cause for the patient’s visit.   presentations. There is always an
the patient’s silver nitrate solution in     While rare, SLK is yet another oppor-       explanation for monocular diplopia;
our refrigerator, clearly marked with        tunity to care for our patients.            our duty is to find the correct cause
the patient’s name, date of birth and           • Baby shampoo for treatment of          and treat it appropriately.
medical record # until that time.            blepharitis has gone the way of the            • Ethambutol is commonly used to
   While this process is highly benefi-      horse and buggy. There are numerous         treat tuberculosis, but it can lead to
cial, there may be occasional recalci-       commercially prepared “eyelid cleans-       toxic optic neuropathy. Color vision
trant-to-treatment patients. If, after       ers” readily available over-the-coun-       is commonly compromised in this
this two-step therapeutic intervention,      ter, and we exclusively recommend           situation, so, if possible, be sure to
the patient is still not below symptom-      these when eyelid scrubs are indicated      perform a color vision test to establish
atic threshold, a consult with a cornea      in the care of patients with symptom-       a baseline prior to starting therapy
and external disease surgical subspe-        atic blepharitis.                           for tuberculosis. The general toxic
cialist for a conjunctival resection of         • Monocular “diplopia” can               threshold is 30mg/kg per day, so the
these afflicted tissues is in order.         result from a couple of subtle corneal      greater the dose, the higher the risk of
   Superior limbic keratoconjunctivitis      conditions: unilateral Thygeson’s SPK       neuronal toxicity. Beyond color vision
is a commonly missed and/or misdi-           and epithelial basement membrane            testing, certainly establish best visual
                                                                                         acuity and baseline 10-2, as well.
  MIND YOUR MEDICINES                                                                    Depending upon dosage, follow these
                                                                                         patients quarterly and repeat testing as
  An OD recently encountered a woman in her late 20s whose chief                         deemed necessary.1
  complaint was near blur. She did not have                                                 • A recent review in a cardiology
  hyperopia nor did she have latent hyper-                                               journal notes that diagnoses of COPD
                                                                                                                                        STRATEGIES FOR SUCCESS
  opia on cycloplegic refraction. Her exam
                                                                                         were incorrect in about 62% of cases.
  was normal except for “presbyopia.”
                                                                                         The authors caution, “Physicians
  With a +2.50, she saw a crisp 20/20.
                                                                                         need to do a better job of identifying
  Reviewing her medical record, it was
  seen that she was taking Qbrexa for
                                                                                         patients with COPD and not over-
  her axillary sweating which has a                                                      diagnosing it. Performing spirometry
  significant anticholinergic effect,                                                    before and after administration of
  thus causing her symptom. This                                                         a bronchodilator is essential before
  perfectly illustrates the impor-                                                       making a diagnosis.”2
  tance of being attentive to any new                                                       Our take: This seems to be
  medicines when encountering an unusual                                                 somewhat parallel to the challenges
  patient complaint.                                                                     that eye doctors face with regard to
                                                                                         glaucoma. Obviously, it is essential to

                                                                                          REVIEW OF OPTOMETRY JUNE 15, 2020         9
ON PATIENT CARE - Review of Optometry
SECTION I: STRATEGIES FOR SUCCESS

     perform an appropriate and compre-         coming down the road. Anticipate the
     hensive workup prior to initiating         emergence of these innovative drugs           THE BENEFITS OF
     therapy.                                   and how they might impact your                DRINKING WATER
        • An internal medicine journal          practices.4                                   “Clinicians should use simple,
     notes “soft drink consumption has             • Looking into resolution of               clear messaging on the role
     been associated, not only with weight      congenital nasolacrimal duct obstruc-         of water as the primary drink
     gain and obesity, but also with excess     tion, JAMA Ophthalmology recently             for all children, adolescents,
     mortality in US studies. Associations      stated, “The rate of spontaneous reso-        and young adults when
     were found for both sugar-sweetened        lution plateaued after nine months,           discussing healthy habits
     and artificially sweetened drinks.”3       and initial probing success declined          with families.”
        Our take: Play outside and be           after 15 months.”5                            Rosinger AY, Bethancourt H, Francis
     active. For the most part, try to eat a       Of course, different articles seem to      LA. Association of caloric intake from
                                                                                              sugar-sweetened beverages with water
     plant-based diet; wear your seat belts;    consistently find different outcomes.         intake among us children and young
     don’t drink alcohol (or soft drinks)       This is always so frustrating. A study        adults in the 2011-2016 National Health
     excessively; sleep adequately; certainly   from the December 2019 British                and Nutrition Examination Survey. JAMA
                                                                                              Pediatric. 2019;173(6):602-04.
     do not smoke; and if you wear contact      Journal of Ophthalmology found that
     lenses, do not sleep in them!              “spontaneous resolution occurred in
        • Presbyopia-“correcting” eye           45% of patients at a mean of 17.8          ignorance of the professional litera-
     drops are coming. The bifocal market       months of age.”                            ture seems to fail to deter sales-centric
     is about to take a hit! This first            Our take: We would recommend            opticals. Because blue light can
     sentence is to get your attention; the     appropriate lacrimal sac massage for       modify our circadian rhythms, all of
     following discussion is to explain the     several weeks, but if treatment is not     these articles advise us not to work
     pharmacologic mechanisms to reduce         successful, we would recommend a pe-       at a screen two to three hours before
     the demand for bifocal lenses.             diatric ophthalmological consultation      bedtime, however.
        There are two primary approaches:       at about nine to 10 months of age.            • In a similar vein, the alleged ben-
     (1) miotic induction to create a pin-      While we still hold to this recommen-      efit of wearing yellow-tinted glasses
     hole effect in a non-dominant eye, and     dation, if the parent(s) prefer to con-    to enhance contrast has been found
     (2) restoration of crystalline lens in-    tinue to try massage up to 15 months       to be a myth.6 Now, we all have
     trinsic elasticity. The former approach    of age, that may well be reasonable.       patients who swear by these, and we
     may come to market first; however,            • Blue light protection glasses.        see no practical reason to rain on their
     we are excited for the latter approach.    There have been a number of articles       parades. However, it is important that
        It’s a year or two too early to get     published regarding blue light protec-     we are all aware of this research—
     into the details, but we feel an obliga-   tion of late. There is no consensus        that’s why we read the journals!
     tion to put our colleagues                         that such “protection” serves         • Topical antibiotics play a very
     on notice that mega-                                       any humanitarian           limited role in contemporary eye care,
     changes are                                                        purpose, yet       as their only indication is for the treat-
                                                                                           ment of bacterial infection, which is
                                                                                           relatively uncommon as compared to
                                                                                           inflammatory eye conditions.7 There
         YELLOW-TINTED GLASSES AND NIGHT DRIVING                                           are three prime uses for antibiotics:
                                                                                              − children with bacterial conjunc-
         • “Wearing yellow-lens glasses                                                    tivitis
           did not improve (i.e., more likely                                                 − prophylaxis when using a ban-
           worsened) performance either                                                    dage contact lens
           with or without headlight glare.”
                                                                                              − bacterial corneal ulcers
                                                                                              When we encounter adults with
         • “These findings do not appear                                                   acute bacterial infections, we treat
           to support having eye-care                                                      with a combination antibiotic-steroid
           professionals advise patients to                                                such that we address the infection and
           use yellow-lens night-driving
                                                                                           the secondary inflammation simulta-
           glasses.”
                                                                                           neously. For more advanced bacte-
         —JAMA Ophthalmol., August 2019                                                    rial infections, we most commonly
                                                                                           prescribe generic moxifloxacin or
                                                                                           Besivance. Note that Besivance is an

10   REVIEW OF OPTOMETRY JUNE 15, 2020
ophthalmic suspension and needs to
be shaken before each instillation. For
this reason, when used for prophy-              HOW IMPORTANT IS IT TO BE “PRESERVATIVE-FREE”?
laxis in the setting of a bandage soft
contact lens, we would choose generic           • “Published studies have not demonstrated any clear benefits of
moxifloxacin, since it is a solution.             the BAK-Free formulations.”
For corneal ulcers, we would use be-            • “There is a lack of evidence of clinically significant harm from
sifloxacin because of it superiority as           a small number of BAK preserved drops in patients without
demonstrated in the ARMOR study                   OSD. This means that generally more expensive PF glaucoma
(see p. 29 for the 2020 ARMOR                     medications should only be recommended for those on poly
data).                                            pharmacy or those with OSD but are not necessarily required for
   • Some patients with migraine                  all patients.”
headaches, blepharospasm and post-              —Br J Ophthalmol, July 2018
concussion suffer from quality-of-life
–altering photophobia. An FL-41 (FL
stands for fluorescent) spectacle lens
coating can filter out certain wave-
lengths of blue/green light that have
been shown to contribute to light           study, neomycin allergy developed          man medical care, these sites will im-
sensitivity.8 Of course, it is important    in only 1.5% of subjects. When such        prove over time, and while they may
to rule out ocular surface disease, so      does occur, it is only a mild annoy-      be helpful adjunctively to clinic-based
conduct a trial of topical corticoste-      ance or aggravation. Discontinuation      care, nothing will replace the care and
roids QID for two weeks to address          of the offending drop, optional use of    attention of a face-to-face doctor visit.
any inflammatory component before           cool compresses and/or triamcinolone         • Thankfully, newer, better and
suggesting FL-41 coating. Address-          0.1% cream can be used for two to         easier to use antithrombotic medi-
ing severe photophobia may require          three days.                               cines are dampening the prevalence
multiple approaches, but do be aware           An article in the British literature   of Coumadin (warfarin). However,
of such options.                            provides a more practical perspective     there is still an abundance of people
   • Steroids are simple: we prescribe      on BAK (see slide above).                 on warfarin for stroke prevention. A
Durezol (Novartis) for advanced cases          Further, it is well known that the     blood assay known as the Internation-
of anterior uveitis and episcleritis; for   original 0.3% Lumigan (Allergan)          al Normalized Ratio (INR) quantifies
everything else, we prescribe Lotemax       caused a fair amount of conjunctival      thrombotic control. It is yet another
SM (Bausch + Lomb). As emulsions,           and eyelid irritation. It was refor-      blood test beyond CBC, sed rate and
neither require shaking prior to instil-    mulated to a much more tolerable          C-reactive protein (CRP) with which
lation. There are times when regula-        0.1%. However, there is four times        we all need to be familiar. In our tire-
tory formularies limit us to generic        more BAK in the 0.1% formulation.         less pursuit of simplicity, just know
prednisolone acetate, which must be         Deductive reasoning will now soften       INR generally needs to be between
shaken well before each use.                the accusations against this maligned     2 and 3 for warfarin patients. This
   • Regarding eyedrops, we our-            preservative.                             metric is not applicable to any other
selves personally demonstrate to our           • What about online “symptom-          drug. Essentially, if the INR is 3, the risk of hemorrhagic events is
                                                                                                                                       STRATEGIES FOR SUCCESS

ceiling while pulling down the lower        interesting article in the June 2019      increased.
eyelid, and having the bottle tip about     JAMA Ophthalmology found that                • There are three commonly used
a half-inch away from the eye. This         the WebMD site listed the correct         antibiotic-steroid combinations. From
is especially important for our new         diagnosis as the first diagnosis in 26%   oldest to newest, these are: Maxitrol
glaucoma patients. Most people have         of cases. The correct diagnosis was       (neomycin, polymyxin-B and dexa-
an incomplete understanding of the          not on the list at all in 43% of cases.   methasone, Novartis), which comes in
proper technique, and giving them a         Their euphemistic conclusion: “There      both suspension and ointment forms;
live demonstration greatly enhances         is room for improvement in the            TobraDex suspension and ointment
the efficacy of therapy.                    domain of online symptom-checkers         (tobramycin with dexamethasone,
   • While neomycin and benzalko-           for ophthalmic symptoms.” Bottom          Eyevance); and Zylet (tobramycin and
nium chloride (BAK) suffer much             line—just see an optometrist!             loteprednol, Bausch + Lomb), which
abuse, neither merit it. In a large            Like all technologies affecting hu-    is only available as a suspension.

                                                                                       REVIEW OF OPTOMETRY JUNE 15, 2020          11
SECTION I: STRATEGIES FOR SUCCESS

        − From least to most expensive,         not fully control the allergic response,    wear time are significant maneuvers in
     these are: generic Maxitrol (about         then “an intranasal antihistamine such      the ultimate resolution of symptoms.
     $25), Zylet (with a coupon it is about     as azelastine can be added, albeit at the   According to Mathea Allansmith,
     $35) and generic TobraDex (about           expense of dysgeusia.”9                     MD, a renowned ocular allergist at
     $60-80). These prices may vary                • Giant papillary conjunctivitis         Harvard, and our esteemed colleague
     depending upon insurance plans and         continues to be a menace. It could be       Jimmy Bartlett, OD (professor emeritus
     geographic location of the patient.        relegated to history if everyone could/     at UAB), loteprednol is the steroid of
        − From safest to least safe (all are    would wear daily disposable contact         choice in treating this condition.
     relatively safe): Zylet, Maxitrol and      lenses. For symptomatic patients, such         • An FDA program called “Rx to
     TobraDex. All three suspensions            as in the image below, we have them         OTC” recently brought both 0.1%
     need to be shaken before instillation.     cease contact lens wear for at least a      olopatadine (Patanol, Alcon) and
     Regarding antibiosis, these medicines      week, and preferably for two weeks.         0.2% olopatadine (Pataday, Alcon)
     are all clinically effective. There is                                                 OTC. These drops can no longer be
     no debate that Zylet is the “pick of                                                   prescribed. This will bring two more
     the litter” here, especially for chronic                                               products onto the already-crowded
     conditions such as staphylococcal                                                      OTC shelves. Since all these histamine
     blepharitis, because of the ester-based                                                type 1 receptor blockers perform simi-
     steroid. When cost is truly imperative,                                                larly, the advice we give our patients is
     generic Maxitrol is the best choice,                                                   to select a 10mL bottle when it costs
     but only for acute conditions that                                                     about the same as a 5mL competitor.
     generally need treatment for no more                                                   Use any of these drops BID for a week,
                                                GPC remains common among the contact
     than seven to 10 days, because of the      lens population but is easily managed.      then try to drop back to once daily use
     dexamethasone.                                                                         as needed to control ocular itching.
        These combination drugs are real        (Every contact lens wearer with a func-        Different insurance plan formularies
     workhorses in routine clinical care.       tionally significant prescription needs a   may mean that, cost-wise, you provide
     Do bear in mind, however, that unless      backup pair of eyeglasses!)                 a better service to your patient by
     there is a breach in the integrity of         We prescribe Lotemax SM for these        prescribing a brand name–protected
     the corneal epithelium, an antibiotic      patients QID for one to two weeks,          Rx anti-allergy drop, such as Bepreve
     is generally not needed, and only a        then BID for two more weeks. During         (bepotastine, Bausch + Lomb), rather
     straight steroid should be employed.       the last two weeks, we instruct the         than asking them to purchase an OTC
        • Intranasal steroids are the treat-    patient to instill a drop 10 minutes        product. By being attentive to this
     ment of choice for allergic rhinitis in    prior to lens application and a second      cost-saving maneuver, you can wisely
     patients over age 12; adding an oral       drop at the end of the work or school       and compassionately keep down out-
     antihistamine confers no ben-                      day when lenses are removed.        of-pocket expenses for your patients!
     efit. If the intranasal ste-                                Getting new lenses            • A young man presented to
     roid alone does                                                     and decreasing     us with his third episode of some
                                                                                            sort of dermatitis to the eyelid and
                                                                                            periocular tissues in six months. He
                                                                                            had seen his internist twice before,
         TREATMENT OF OCULAR ALLERGIES                                                      about three months apart, and was
                                                                                            treated successfully (albeit temporarily)
                                                                                            with oral prednisone. This time, the
                                                                                            patient wanted to try an eye doctor.
                                                                                            It appeared to be a 4+ case of contact
                                                                                            dermatitis so severe that he was getting
                                                                                            secondary ectropion from the epider-
                                                                                            mal inflammation.
                                                                                               He was treated with 40mg of
                                                                                            prednisone (it was not known what his
                                                                                            prior dosage had been) for five days,
                                                                                            along with 0.1% triamcinolone cream
                                                                                            applied to the affected tissues QID for
                                                                                            five days. The cynical saying “no good
                                                                                            deed goes unpunished” applies here,

12   REVIEW OF OPTOMETRY JUNE 15, 2020
in that the patient never returned for
follow-up, and his phone mailbox was
full or his phone simply rang and rang.         BILATERAL PERIORBITAL IMPETIGO — DERMATITIS
    Finally, after about four months,
we were able to see him. He shared              • Impetigo is a Staph. aureus infection, often seen in patients with
with us that his condition had quickly            eczema
resolved and had not recurred during            • Usually seen in children and young adults
this four-month period. That’s great,
                                                • Can cause a secondary inflammatory dermatitis
but we still only had a presumptive di-
agnosis of contact dermatitis. This was         • Can create cicatricial ectropion
in May 2018. Fortuitously, in the June
                                                • Tx with oral antibiotic and topical antibiotic/steroid or steroid
2018 issue of Ophthalmology, there                ointment
was an article that grabbed our atten-
tion. Looking at the pictures, it clearly       —Ophthalmol, June 2018
reminded us of this patient. Well, it
turns out that the diagnosis was more
than contact dermatitis—it was impe-
tigo! Because we consistently read the
literature, we were able to grow our        and seasonal allergic conjunctivitis.”           • Festoons. These are fluid-filled,
clinical knowledge. Should this patient     However, their use in prevention              “squishy” pockets gravitationally
ever return with similar symptoms, we       of postoperative cystoid macular             exacerbated by age-related laxity of
now know to how to address his issue        edema is central in their prescribing        the upper facial muscles. They can also
more definitively and competently. In       frequency.                                   accompany inflammatory dermatolog-
addition to the steroid, we will also          – “Alarmingly, topical NSAIDs             ic diseases; most relevant to us, herpes
prescribe an oral antibiotic such as        may be used by eyecare practitioners         zoster ophthalmicus. These non-tender
cephalexin 500mg BID or Augmentin           for extended periods of time without         festoons look bad but carry no patho-
875mg BID, depending upon our clini-        a clear diagnosis or indication.”            logical relevance. The treatment is pa-
cal judgment; it’s an art.                     – “Corneal complications of topical       tient reassurance, or if he/she desires, a
                                            NSAIDs include superficial punctate          referral for facial plastic surgery.
                                            keratopathy (punctate epithelial                • Medicines that can cause dysgeu-
                                            erosions), corneal infiltrates, and epi-     sia: prednisolone acetate, lifitegrast,
                                            thelial defects; the most severe of all is   topical carbonic anhydrase inhibitors
                                            corneal melt.”                               and azelastine.
                                               – “An intriguing aspect of such
                                                                                         1. Stuart A. Drug Toxicity to the Retina and Optic Nerve: Are You
                                            melt is the apparent requirement for a       Missing It? EyeNet Magazine. September 2019. Available at: https://
                                            compromised cornea for it to occur.”         www.aao.org/eyenet/article/drug-toxicity-to-the-retina-and-optic-
                                                                                         nerve?september-2019 (last accessed April 14, 2020).
                                            It appears that compromised epithelial       2. Sator L, Horner A, Studnicka M, et al. Overdiagnosis of COPD in
                                                                                         subjects with unobstructed spirometry: a BOLD analysis. Chest. 2019
Note the secondary ectropion to this        cells respond differently to NSAIDs          Aug;156(2):277-88.
patient with impetigo.                      than healthy ones.                           3. Mullee A, Romaguera D, Pearson-Stuttard J, et al. Association be-
                                                                                         tween soft drink consumption and mortality in 10 European countries.
                                               – “Some ocular surface diseases           JAMA Intern Med. 2019;179(11):1479-90.
                                                                                         4. Thompson V. Examining presbyopia treatments. Eye World.
   • What’s the risk for corneal melt       such as dry eye are considered rela-         December 2019. Availablee at: https://www.eyeworld.org/examining-
with the use of topical nonsteroidal        tive—and for most experts—absolute           presbyopia-treatments (last accessed April 14, 2020).
                                                                                                                                                                        STRATEGIES FOR SUCCESS
                                                                                         5. Sathiamoorthi S, Frank RD, Mohney BG. Spontaneous resolution
anti-inflammatory drugs (NSAIDs)?           contraindications to the use of ocular       and timing of intervention in congenital nasolacrimal duct obstruction.
Anti-inflammatory drops are routinely       NSAIDs.”                                     JAMA Ophthalmol. 2018; Nov 1;136(11):1281-6.
                                                                                         6. Hwang AD, Tuccar-Burak M, Peli E. Comparison of pedestrian
used postoperatively, and only rarely                                                    detection with and without yellow-lens glasses during simulated night
                                                                                         driving with and without headlight glare. JAMA Ophthalmol. 2019;
do they cause problems. An important                                                     Aug 1.
recent article in Survey of Ophthal-                                                     7. Keen M, Thompson M. Treatment of acute conjunctivitis in the
                                                                                         united states and evidence of antibiotic overuse: isolated issue or a
mology offers these insights:10                                                          systematic problem? 2017; Aug; 124(8):1096-8.
                                                                                         8. Migraines & FL-41 Tinted Lenses. University of Utah Health/Moran
   – “The FDA has approved oph-                                                          Eye Center. Available at: https://healthcare.utah.edu/moran/optom-
thalmic NSAIDs for use in four areas:                                                    etry/fl41-lenses.php (last accessed April 14, 2020).
                                                                                         9. Wallace DV, Dykewicz, Oppenheimer J, et al. pharmacologic treat-
pain and inflammation associated                                                         ment of seasonal allergic rhinitis: synopsis of guidance from the 2017
                                                                                         Joint Task Force on Practice Parameters. Annals of Internal Medicine.
with cataract surgery, pain associ-                                                      2017; Dec. 19.
ated with corneal refractive surgery,       Patients may be anxious about festoons
                                                                                         10. Rigas B, Huang W, Honkanen R. NSAID-induced corneal melt:
                                                                                         Clinical importance, pathogenesis, and risk mitigation. Surv Ophthal-
inhibition of intraoperative miosis,        but they are harmless.                       mol. 2020 Jan-Feb;65(1):1-11.

                                                                                           REVIEW OF OPTOMETRY JUNE 15, 2020                                       13
SECTION I: STRATEGIES FOR SUCCESS

     Perspective on Pupillary Dilation
     Patients may not like this experience but that’s no excuse for avoiding a vital step
     that can make or break a diagnosis.

      N
                o one enjoys being dilated;
                no woman enjoys having a
                Papanicolaou (Pap) smear;
     no man enjoys a prostate examina-
     tion; however, all three examina-
     tion procedures are important and
     represent excellent healthcare. Face
     it—in life, many vitally important
     functions, procedures and activities
     are just not fun.
        Certainly, there are technologies
     to image the retina without phar-
     macologic dilation, and in some          This case of synechial anterior uveitis finally yielded to atropine, Durezol and 10%
     cases, these can be useful. However,     phenylephrine. The residual lens face “tattooing” of iris pigments will largely
     community standards of care and          dissipate over the years.
     prestigious medical centers fully
     embrace the dilated eye examina-         countless other conditions                   to dilate most of our patients is
     tion. In most cases, a dilated exam is       We explain to our patients that          the instillation of Paremyd (0.25%
     essential to:                            if they were being seen at any               tropicamide with 1% hydroxyam-
        – diagnose pseudoexfoliation          prestigious medical center, their            phetamine hydrobromide, Akorn).
        – meticulously examine for dia-       eyes would be dilated; thus, why             This combination drug provides
     betic retinopathy and maculopathies      should we provide our patients with          rapid, short-lived dilation with a
        – search for subtle retinal tears     anything less than the very best of          considerably truncated cycloplegic
     (for example, associated with symp-      care? We rarely have patients ada-           effect.
     tomatic posterior vitreous detach-       mantly decline dilation, and when               For older, diabetic patients
     ments)                                   we do, we document in our medical            (who typically are more difficult to
        – identify pars planitis or ciliary   record that the patient refused AMA          achieve dilation), we revert back
     body tumors                                      (against medical advice).            to the traditional use of 1% tropi-
        – assist with visu-                                    One maneuver we             camide and 2.5% phenylephrine.
     alization of                                                   typically use          Post-mydriatic sunglasses are always
                                                                                           provided. As healthcare profes-
                                                                                           sionals, we have an obligation to
                                                                                           provide our patients the highest
        PAREMYD OPHTHALMIC SOLUTION                                                        levels of care, and pharmacological
                                                                                           dilation represents the gold standard
        • A combination of tropicamide 0.25% and 1%                                        in this regard.
          hydroxyamphetamine HBr, an indirect acting                                          Given that “failure to diagnose”
          sympathomimetic (adrenergic agonist).                                            is by far the most common reason
        • An excellent, less intrusive dilating drug we use                                optometrists are successfully sued,
          for routine dilation.                                                            we have yet another good reason
                                                                                           (beyond our desire to provide
        • For patients who are of African origin and/or
                                                                                           excellent patient care) to embrace
          patients with diabetes, we commonly use 1%
                                                                                           the inconvenient virtue of pupillary
          tropicamide with 2.5% phenylephrine.
                                                                                           dilation.
        • Marketed by Akorn in a 15ml bottle                                                  During one of Dr. Thomas’s
                                                                                           externships, the brilliant ophthal-
                                                                                           mologist’s routine dilation protocol
                                                                                           was use of 1% tropicamide and

14   REVIEW OF OPTOMETRY JUNE 15, 2020
10% phenylephrine. There was
no adverse event with any of these
hundreds upon hundreds of mostly                SAFETY OF PHENYLEPHRINE
elderly patients.
   We share this to provide a                   “Phenylephrine 2.5% leads to no clinically
perspective on the safety of both               meaningful change in blood pressure or heart
phenylephrine concentrations. Since             rate and can be considered safe to use in clinical
the 2.5% formulation (in combina-               routine. The changes in BP and HR seen with
tion with 0.5% or 1% tropicamide)               phenylephrine, 10%, are short lived and of
provides ample dilation, we rarely              uncertain clinical relevance.”
have a practical need to use the                Stavert B, McGuinness MB, Harper CA, Guymer RH, Finger RP.
10% concentration. However, we                  Cardiovascular Adverse Effects of Phenylephrine Eyedrops:
                                                A Systematic Review and Meta-analysis. JAMA Ophthalmol.
do find the 10% concentration can               2015;133(6):647–652. doi:10.1001/jamaophthalmol.2015.0325
be adjunctively helpful in breaking
some recalcitrant synechiae, and for
subsequent visits of patients known
to dilate poorly.

 GUEST COMMENTARY, by Richard Edlow, OD

 The Not-So-Secret Strategy to Turbocharging Practice Growth
 We were certainly right in thinking the year 2020 would be special for all of us—just not the way we anticipated.

 T   he world and the way we inter-
     act is changing, perhaps forever.
 Optometry’s practice patterns must
                                            age 64 and under is only 1.9%, while
                                            the 65-and-older increase is 30.5%.
                                               The demand for medical eye care
                                                                                          will produce approximately 460 new
                                                                                          entrants each year, and 420 practitio-
                                                                                          ners will be exiting, for a net increase
 also change, but not in the ways one       services will grow 20 times more rap-         of 400 ophthalmologists over the
 might be thinking.                         idly than the demand for vision exams.        entire decade—just 40 each year for
    I will share a number of data points    The latter are defined as ICD-10 refrac-      the entire country. To just provide
 that should be a wake-up call for all      tive diagnosis codes, while medical           for the increase in cataract surgical
 optometrists, regardless of practice       eye care exams are those that have a          procedures, we would require 3,500
 environment, to fully embrace provid-      medical diagnosis. Eye care providers         surgeons.
 ing medical eye care services. The data    (ECPs) will need to collectively deliver         Ophthalmologists will find them-
 is a compilation from sources includ-      two million additional vision exams per       selves more and more in the operating
 ing CMS/Medicare, Census Bureau,           year, 10.8 million additional diagnostic
                                                                                          room, less and less in the office setting.
                                            tests per year, 16 million additional
 National Eye Institute, optometric and                                                      The message is clear: Optometry
                                            medical eye exams per year and 1.4
 ophthalmology training programs and                                                      must rapidly embrace providing
                                            million additional cataract surgeries
 insurance utilization statistics.                                                        medical eye care services in their prac-
                                            per year—all above and beyond what
    The following projection (net                                                         tices. If one uses Medicare Provider
                                            we are providing today in 2020. For
 changes from 2020 to 2030) reveals a                                                     Utilization & Payment data as a proxy
                                            perspective, current levels are 111.4 mil-
 unique opportunity for the growth of       lion vision exams, 64 million diagnostic      for how engaged optometry is in pro-
                                                                                                                                            STRATEGIES FOR SUCCESS

 optometric practice over the next 10       tests, 60.4 million medical eye exams         viding medical eye care, it is at a very
 to 20 years. An aging population, the      and 4.2 million cataract surgeries.           low level—less than 28% of optom-
 prevalence of age-related eye condi-                                                     etrists provide any level of care.
 tions and a relative shrinking supply      SUPPLY OF ECPs                                   It is incumbent upon the entire
 of ophthalmologists presents a once-       The supply of optometrists will               eye care industry to rapidly increase
 in-a-lifetime open window to embrace       increase at a pace somewhat greater           optometry’s involvement in medical
 medical eye care.                          than overall population growth but            services and turbocharge practices,
                                            much slower than the 65 and older             regardless of practice setting. n
 GROWING DEMAND & MARKET SIZE               demographic.
 The US population is expected to grow         The game-changer is that the sup-             Dr. Edlow, AKA “The Eyeconomist,”
 6.7% this decade. Of greater signifi-      ply of ophthalmologists is almost flat.       practices in Catonsville, MD, and is
 cance: projected growth among those        Ophthalmology residency programs              known for strategic trend analysis.

                                                                                            REVIEW OF OPTOMETRY JUNE 15, 2020          15
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