INTERESTING EYE NEWS & CLINICAL PEARLS

British Journal of Ophthalmology 2006;90:29-32 It has been suggested that sun exposure may be a risk factor for AMD and that skin sensitivity to sunlight and iris colour could be confounding factors. According to this study: " No significant association between AMD and sun exposure, iris colour, change in iris colour, or hair colour was demonstrated ."

Cicatricial Conjunctival Inflammation With Trichiasis as the Presenting Feature of Wegener Granulomatosis. Granulomatosis. Ophthalmic Plastic & Reconstructive Surgery. 22(1):69-71, January/February 2006. Wegener Granulomatosis symptoms: According to Kanski, Wegener granulomatosis is mostly in males in their 40's with upper respiratory tract symptoms, joint pains, weakness, and tiredness. Symptoms include sinus pain, discolored or bloody fluid from the nose, and, occasionally, nasal ulcers. A common sign of the disease is almost constant rhinorrhea ("runny nose") or other cold symptoms that do not respond to usual treatment In the eyes people may develop conjunctivitis, scleritis, episcleritis, or a mass lesion behind the eye globe. Eye symptoms include redness, burning, or pain. Wegener Granulomatosis responds well to systemic steroids and cyclophosphamide. So, if you have an unexplained conjunctivitis and a patient with an runny nose that won't go away, consider...

According to this article in the Washington Post , Pfizer Inc. hopes to begin selling Exubera , the first inhalable version of insulin to win federal approval, by midyear. Use of rapid-acting inhaled insulin will not replace the need to inject the hormone occasionally. In clinical trials, Exubera managed blood sugar levels just as well as injected insulin. An FDA review expressed concern about some patients who experienced coughing or a slight decrease in lung capacity when using the drug. Diabetics with asthma, poorly controlled or unstable lung disease, or a smoking habit shouldn't use Exubera, the FDA said. A daily supply of Exubera will cost about $4 to $5. Treatment with injected insulin costs $1 to $1.50.

From Review of Ophthalmology December 2005 : "The NeuroVision system, currently FDA-approved for the treatment of amblyopia in individuals nine years or older, is a non-invasive, patient-specific computerized treatment that forces the patient to identify fine details in visual stimuli. In a prospective, randomized, double-masked study conducted in Israel for the FDA involving 44 amblyopic patients, mean visual acuity improved more than 80 percent (2.5 lines); all ages showed improvement."

Current Opinion in Ophthalmology. 17(1):94-98, February 2006. This is a study of the Implantable Miniature Telescope for end-stage macular degeneration. It is implanted in the posterior chamber to improve the patient's ability to perform everyday activities. 89% of patients implanted with the device gained two or more lines of BVA.

This month's EyeWorld Magazine has an excellent article on how to handle leaking blebs.

Ophthalmic Plastic & Reconstructive Surgery. 22(1):53-55, January/February 2006. According to this study: "...one drop of 0.5% apraclonidine reverses the anisocoria of Horner syndrome. In addition, 0.5% apraclonidine leads to a complete resolution of the ptosis associated with Horner syndrome, a finding reported once in the literature. Apraclonidine is a safe and readily available alternative to cocaine for the diagnosis of Horner syndrome."

Ophthalmic Plastic & Reconstructive Surgery. 22(1):13-19, January/February 2006 This study was undertaken to evaluate the potential usefulness of measured thyroid-stimulating immunoglobulin (TSI) values in following and treating patients with Grave's Disease. It was found that changes in eye signs of Grave's Disease statistically correlate with changes in measured TSI. The study concludes: "These findings suggest that serial TSI measurements may be an adjunct in assessing clinical inflammatory activity of Thyroid-Associated Orbitopathy and may help direct clinical decision making regarding treatment decisions."

I received the following advice from our contact lens consultant, whom I highly respect, when I asked him what the best RGP material and cleaning system is for heavy depositors: " Optimum Classic or Hydro 2 are two good materials for heavy depositors and dry eye patients. I would use Optimum Care (by Lobob) for the best cleaning system. "I often recommend the cleaning and storage from Lobob/Optimum , and then use the Boston wetting solution for rinsing and rewetting of the lenses...this used in conjunction with the Lobob storage and cleaning solutions works very well. The Optimum storage solution is a cleaner and needs to be rinsed before the lenses are inserted. "The other product you might consider using is Progent . Progent is an in office cleaner that takes the place of polishing the lenses, and removes even the most stubborn deposits. You just soak the lenses in the cleaning system for 20 minutes. If you do this in office treatment with progent then I would sugge...

This is Alcon's most recent multi-purpose disinfecting solution that is designed to be compatible with silicone hydrogel lenses. It contains "Tearglyde" which supposedly enhances wettability. Alcon's website, www.alconinc.com, has yet to release research. But check out "Health and Medicine Week" for more information.

Thanks to Dr. Kris Owens for sending me the link to the fitting guide for Synergeyes. According to the web site: "The SynergEyes lens has the advantages of rigid lens optics and soft lens comfort, without the disadvantages (low Dk, and skirt dehiscence) of prior-generation hybrid lenses." Sounds like it is a great alternative to the old Saturn lens.

CooperVision will launch Biomedics XC in February 2006. According to the FDA, it "may provide improved comfort for contact lens wearers who experience mild discomfort or symptoms relating to dryness during lens wear." Biomedics XC is a two-week daily-wear lens with an aspheric design with a deposit-resistant surface. For more information, go to http://www.coopervision.com/ .

According to the FDA's research , this implant is a good alternative for myopes who were poor candidates for Lasik either because of thin corneae or myopia outside the currently treatable range. "The approval was based on data from a clinical study (n = 294) showing that 95% of patients had 20/40 vision or better and 59% had 20/20 vision or better at 3 years postimplantation." "The ICL remains our most significant opportunity for profitable growth going forward and receipt of FDA approval represents a critical milestone," said David Bailey, President and CEO of STAAR Surgical . "Throughout the approval process, doctors' interest in our state-of-the-art lens has continued to build, driven by superior clinical outcomes, the stability and safety of the procedure and the high patient satisfaction rate.

Here's an update on the use of some W codes. I put it here so I can reference it in the future. These are proprietary for our clinic only, not generally accepted Medicare codes, as I understand it right now. W9997 will be used when an OD determines the calculation of IOL for an MD W9998 will be used for paperwork only W9999 will be used for actual LASIK pre op eliminating the use of the 76516R W99601 is used for the actual LASIK screening

I received this e-mail from a refractive surgeon: "I have noticed that several of my crystalens patients have developed large PVDs with central floaters in the visual axis, and this seems to be at a higher rate than what I would see with standard catarct surgery. Has anyone else noticed this? If you see a few cases let me know, we might want to study the situation and possibly report it. It may be that the patient population is younger, or different in some way, or it may be related to the IOL and that it shifts back and forth in the eye causing more vitreous movements." Anybody seen anything on this?

Eye & Contact Lens: Science & Clinical Practice. 32(1):8-11, January 2006. According to this study that compared cytotoxicity of Renu Multi-Plus, Optifree, and Complete Moisture Plus contact lens care solutions: "ReNu has frequently been cited as being more cytotoxic. We propose that when used at a high frequency, ReNu preservatives and additives are adverse." The authors did not investigate Renu with MoistureLoc.

Nascent Pharmaceuticals has announced positive results of a Phase IIb clinical trial of iDESTRIN (NP50301), a topical drop for treating dry eye in postmenopausal women. In patients with moderate-to-severe disease, researchers noted a significant Schirmer's Test improvement of more than 75 percent from baselin, a significant improvement at 12 weeks for superficial punctuate keratopathy and corneal staining. Significant improvement was achieved for foreign body sensation at four weeks, compared to vehicle in both eyeS. No drug-related serious adverse events were reported.

SOURCE: Fraser-Bell S, Wu J, Klein R, et al. Smoking, alcohol intake, estrogen use, and age-related macular degeneration in Latinos: The Los Angeles Latino Eye Study. Am J Ophthalmol. 2006;141(1):79-87. This study assessed the associations between smoking, alcohol intake and estrogen use and early and advanced age-related macular degeneration (AMD) among Latinos. CONCLUSION: Smoking and heavy alcohol consumption, particularly beer, was associated with a greater risk of having advanced AMD; exogenous estrogen use appeared to have a weak protective effect in Latino participants.

This article in EyeWorld Magazine reports that: "A new case report published in the August 2005 issue of the Journal of Cataract & Refractive Surgery indicates that as long as four years after surgery, patients need to remain vigilant." The article suggests: "to forewarn patients of long-term risk, particularly those that may be prone to eye injuries, such as military personnel, boxers, or police officials, and possibly discuss refractive choices to consider other than LASIK."

One thing I found interesting in this month's article, New Calculator Predicts Glaucoma Risk in Review of Optometry is that the author states: "Clinicians should note that diabetes is protective against conversion from ocular hypertension to glaucoma, say Dr. Semes and his colleague, Paul Schacknow, M.D., Ph.D., from Lake Worth, Fla. If patients are diabetics, their glaucoma risk goes down. “This may be misleading because it contradicts other studies, and therefore may limit the interpretation of the results of the calculator,” Dr. Schacknow says" Studies seem to point both ways. It kind of makes it a non -factor...for now until there are more conclusive studies.

Below are some pearls taken from Arthritis as Seen Through the Eyes in January 2006 Review of Optometry · Symptoms of RA : stiffness in multiple joints, morning stiffness in the joints for more than one hour and generalized fatigue. Clinical signs of RA include joint swelling and tenderness. · Lab Testing for RA includes CBC (shows normochromic-normocytic anemia in 80% of cases, ESR & C-reactive protein, and Rheumatoid Factor (RF). · At plaquenil follow-ups perform color vision testing, photodocumentation of the macula and automated perimetry of central vision (e.g., Humphrey central 10-2) every six months to one year. · Ocular complications of RA include Keratoconjunctivitis sicca (KCS), episcleritis, scleritis, keratitis and peripheral corneal. Retinal detachment, choroiditis, episcleral nodules, retinal vasculitis and cystoid macular edema have also been associated with RA. · You may need to educate the comanaging rheumatologist that liver enzymes do not need to be monitored wh...

OSN SuperSite - The Voice of Ophthalmology According to this article: "Before administering the drug intravitreally for treatment of retinal disease, the physician should first give patients who are Medicare beneficiaries an Advance Beneficiary Notice informing them that the procedure will likely not be covered by Medicare, Dr. Williams said. "

Below is a review of some of the more interesting (although perhaps debatable) points from the article "Develop a Flare for Uveitis" in this month's Review of Optometry : "If the attack is not broken early, a longer duration of therapy becomes necessary." The authors insist on using Pred Forte and not generic as they've had less success with generic and other steroids. I've seen this before in Review of Optometry. The Pred Forte dosing at presentation is every 15 minutes for 6 hours followed by hourly dosing while awake until follow-up. They recommend instilling one drop every minute for five minutes before retiring. Cyclogel does not provide adequate cycloplegia. Instead they use scopolmine .25%, atropine 1%, or homatropine 5% (in mild cases). Use 10% phenylephrine if synechia are not breaking with cycloplegia. If patient is responding to therapy, reduce steroid to q2h. They do not taper steroids unti there are zero cells visible in the anterior chamber...

EyeWorld Magazine: January�2006 This article discusses the use of a mixture of kenalog and antibiotics during cataract surgery to eliminate the need for drops post-operatively.

I've noticed lately, clinically, that going from BID to TID with Alphagan-P or Azopt/Trusopt seems to be giving slightly better results. I still start them off BID, but if they're just slightly above borderline pressure, than it may be worth trying TID.

According to this review in Eye World Magazine of a study published in the Journal of Allergy and Clinical Immunology: "Discontinuation of nasal steroids in glaucoma patients resulted in significant intraocular pressure (IOP) reduction". The authors of the original study concluded: "nasal steroids might contribute to an increase in IOP, and they recommend that further studies should review whether a patient has glaucoma before medication initiation."

This study in this month's Archives of Ophthalmology suggests that there is an association between increased retinal vein diameter and systemic inflammation, indicated by higher C-reactive protein, interleukin 6, and amyloid A levels. The study concludes: "These data show an association of inflammatory markers with larger retinal venular diameter, suggesting that retinal venular caliber may be a marker of systemic inflammation." Perhaps larger retinal vein diamter is something to look for in patients with unusual symptoms that may indicate, for example, giant cell arteritis.

This study in this month's Archives of Ophthalmology is yet another indicating that rapid blood sugar control increases the risk of diabetic macular edema. This one particularly evaluated progression of diabetic retinopathy and macular edema in patients who underwent rapid glycemic control vs. those with uncontrolled and already controlled blood sugars, post-cataract surgery. I think this is another study that makes the case for slow, steady improvements in blood sugar levels as opposed to rapid correction of blood sugar levels.

Arch Ophthalmol -- Abstract: Development of Cataract and Associated Risk Factors: The Visual Impairment Project, January 2006, Mukesh et al. 124 (1): 79 This article lists risk factors for NS, CS, and PSC cataracts. Among the risk factors for NS is smoking.

Arch Ophthalmol -- Abstract: Characteristics of Peripapillary Detachment in Pathologic Myopia, January 2006, Shimada et al. 124 (1): 46 This study suggests that nearly 5% of highly myopic eyes have a localized peripapillary retinal detachment. It's "pathogenesis and pathologic significance require further classification, (it) might be another indicator of visual field defects in high myopia."

Avandia's manufacturer, Glaxo-Smith-Kline, has determined that this drug may increase the incidence of macular edema. Here is the letter GSK sent to health care providers. .

This article discusses Memantine, a glutamate antagonist (glutamate is toxic to the optic nerve), being developed by Allergan and undergoing phase III FDA clinical trials. It is touted as a neuroprotectant.

According to this study in Retina , elevated homocysteine is a risk factor for early-onset CRVO.

According to this press release : "AlphaRX, an emerging biopharmaceutical company ...is pleased to announce that the development of the formulation for Acusolin™, ...has been completed and in vivo studies are underway as scheduled. "The Company will investigate Acusolin™ using an established cataract animal model. This model is designed to demonstrate Acusolin™'s ability to prevent and treat senile cataracts." I'll believe it when I see it.

According to this article in Ocular Surgery News : "Isotretinoin, a topical medication commonly prescribed for acne, should be contraindicated for patients after LASIK surgery, a recent commentary in a dermatology publication suggests. Just as patients should stop using the acne medication at least 6 months before LASIK surgery, they also should not be given the medication for 6 months after surgery."

Proof that Marvin Zindler may have it wrong (Eyewitness News anchor in Houston that wears blue lenses). According to this article in Retina (Retina. 26(1):1-4, January 2006.) : "Epidemiologic and experimental evidence suggests that blue light-blocking lenses could theoretically benefit patients with age-related macular degeneration. Clinical trials are needed to determine the effect of yellow lenses in preventing the progression of age-related macular degeneration."

Bored? Too many no shows and not enough paperwork? Try Oculus Invaders to help the time pass (but don't show it to your staff or they'll never get anything done).

This article in EyeWorld Magazine talks about successful treatment of fungal keratitis using subconjunctival injection of Fluconazole. Historically, subconjunctival injections have not been used because of toxicity, and topical treatment has not always been reliable. In this study, all 13 eyes treated responded to therapy within 2 weeks without any resulting toxicity reaction.

This article in Review of Ophthalmology gives some tips on fitting progressives in small frames.

The Press Release is out: "VISTAKON®, a division of Johnson & Johnson Vision Care, Inc., today announced that the U.S. Food & Drug Administration has granted an additional indication for ACUVUE® OASYS ™ Brand Contact Lenses with HYDRACLEAR™ PLUS, approving the daily wear contact lens for up to six consecutive nights/seven days of extended wear ." I'm going to have to start fitting this lens more. Has anybody tried this lens? Does it really work better for dry eye patients? Anybody out there?

This study published in EyeWorld Magazine concludes that there is greater penetration of 1% tropicamide through post-LASIK eyes. It attributes this to a thinner cornea. Makes sense to me.

Optometry & Vision Science. 82(12):1014-1021, December 2005. According to this study : "A greater proportion of the corneas wearing flat-fitting contact lenses were scarred (43% compared with 26% for the steep-fitted eyes)" But then it says: "After controlling for corneal curvature, the association of rigid contact lens fit and corneal scarring at baseline did not persist. 32% percent of unscarred eyes at baseline fitted flat had developed an incident corneal scar by the eighth year follow-up visit compared with 14% of eyes fitted steep." And the study concludes: "The data reported here indicate that, after controlling for disease severity in the form of corneal curvature, keratoconic eyes fitted with a rigid contact lens resulting in an apical touch fluorescein pattern did not have an increased risk of being scarred centrally at baseline." Huh? Conclusion does not seem to match the results. What does it mean when it says: "after controlling for...

Soon we may just be hooking electrodes up to the heads of patients and having them look at a target. According to this article in Ocular Surgery News, Multifocal VEP: "requires no patient response except to monitor fixation. It is noninvasive, and it can be done in patients with undilated pupils with low stress and a minimal learning curve." Also: "mfVEP may be helpful in patients with unreliable visual field results and may detect changes before they are seen in white-on-white perimetry, the study authors said." Hook me up!

Pellucid Marginal Degeneration is somewhat like keratoconus but begins later (usually 20's to 40's) and doesn't have Fleischer rings or Vogt stria. It is characterized by a 1-2mm wide arc of corneal thinning extending from 4 o'clock to 8 o'clock, and with increasing severe flattening in the vertical meridian. Best spectacle-corrected VA on average is a little worse than 20/30. According to this article in the December Ocular Surgery News , these patients are able to obtain nearly 20/20 vision on average with: "bitoric gas-permeable contact lenses with a larger overall diameter" Sounds like another case for Jim Slightom at ABBOptical!

This article in The Review of Ophthalmology discusses a novel treatment to improve contrast sensitivity in adults with amblyopia. According to the article: "The NeuroVision system , currently FDA-approved for the treatment of amblyopia in individuals nine years or older is a computerized treatment that forces the patient to identify fine details in visual stimuli. "After each session, the relevant information is uploaded to a data center where treatment for the next session is customized. Sessions generally last about 30 minutes, with two to four sessions per week, depending on the amount of visual impairment and pace of progression. The company recommends 45 sessions for treating amblyopia and 30 sessions for low myopia. If a patient doesn’t show improvement after 12 consecutive sessions, treatment is terminated. "In the clinical trial for amblyopia, the improvement was maintained after two years with no further sessions, except for adults with strabismus who continued ...

J Glaucoma. 2005 Dec;14(6):504-7 According to this study that was published in December: "Participants with open-angle glaucoma (OAG) who reported regular coffee drinking had significantly higher mean IOP (19.63 mm Hg) than participants who said that they did not drink coffee (16.84 mm Hg). Participants consuming > or = 200 mg caffeine per day had higher mean IOP (19.47 mm Hg) than those consuming "No association between coffee or caffeine consumption and higher IOP was found in participants with ocular hypertension and those without open-angle glaucoma. "CONCLUSIONS: In participants with open-angle glaucoma, this study identified a positive cross-sectional association between coffee consumption/higher caffeine intakes and elevated intraocular pressure." I mentioned this study in December to a COAG patient who was about 2-3mmHg over his target IOP. I kept him on his Lumigan and he said he'd try to cut back on coffee. When I saw him this morning his IOP ...

I was reading the November 2005 issue of AOA News, pg 20, and came across this article about erectile dysfunction drugs and ischemic optic neuropathy. I've gotten questions from patients before about the safety of these drugs, and up until now I've told them it may cause visual changes. But this article suggests something more serious. In this article, Howard D. Pomeranz, M.D. published a study linking these drugs to blindness. According to Bruce Onofrey, O.D., who is also a pharmacist, Viagra has been connected to NAION. "The number of case reports of ION per million prescriptions was 25 times higher for Cialis and 18 times higher for Viagra compared to...medication used by people with similar cardiovascular risk factors". "Dr. Onofrey advises patients taking the drugs to discontinue use if they experience a TIA, visual distortion, migraines, or color-tinged vision." I guess that's where I'll stand on this until I learn otherwise. Anybody have ...