A weekly e-journal by Art Epstein, OD, FAAO


Volume 19, Number 16

Monday, April 22, 2019


Inside this issue: (click heading to view article)
######### Off the Cuff: Ignorance Isn’t Always Bliss
######### Early Diagnostic Parameters of Glaucoma in High Myopes
######### Hyaluronic Acid Combined with Serum Rich in Growth Factors in Corneal Epithelial Defects
######### Mobile Telephone Use and Reaction Time in Drivers With Glaucoma
######### News & Notes

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Off the Cuff: Ignorance Isn’t Always Bliss

As the primary provider of eye care in the US, optometry increasingly finds itself between the rock of the profit-driven, bought-and-paid-for “consumer” lobby and the hard place of our profession’s core mission of protecting the public’s health and sight. Joining a number of other states, Indiana recently passed legislation banning online eye examinations. Visibly (formerly Opternative) was visibly upset by what was patient protective legislation, but they were not alone.

In the Thursday online edition of Forbes, “Indiana Legislature Stopped Optometrists' Competition in the Blink of An Eye” by Andrew Wimer, assistant communications director at the Institute for Justice, totally misconstrued our concerns. The Institute for Justice is a non-profit that Wimer describes as a “public interest law firm,” one that received nearly $24 million in contributions in 2017 and has more than $80 million in assets. While no financial relationship was disclosed, the Institute has worked closely and openly with Visibly in the past and, according to Wimer in the Forbes article, Visibly is again “teaming up with the Institute for Justice” to sue Indiana to overturn the new law.

To the unsophisticated or those with an obvious economic agenda, optometry’s support of strict controls on unsupervised online eye examinations may seem to be protectionism. The reality is that it is simply protection. Anyone who understands eye care and places patient needs first recognizes that vision and eye health are inseparable. Without a healthy eye, sight is endangered. Realizing this more than a half-century ago, optometry transformed itself from a refractive profession into one that focuses on primary comprehensive care of the eye. Going backwards makes absolutely no sense.

In our practice, we routinely discover ocular and systemic diseases that threaten vision and health in patients who come in for “routine exams” and thought they just needed a new prescription. This week alone, we found patients with narrow and open-angle glaucoma, MS, macular degeneration, an epiretinal membrane, iritis, cataracts and retinal ischemia from low blood pressure. A busy week perhaps, but ours is only one practice of thousands. Without comprehensive eye examinations, an untold number of patients would remain unaware and suffer potentially serious eye and health damage.

Despite this clear truth, it is all too easy to argue that Visibly offers cutting-edge telemedicine for patients who would otherwise be deprived or forced to pay for what they don’t need. While telemedicine will undoubtedly be an important part of the future of eye care, current technology is still in a nascent and potentially dangerous stage. To better convince those who would naively think otherwise, perhaps it’s time that we studied ocular and systemic disease in a primary care practice setting among patients who present for routine eye exams. This would be a worthy project for collaboration between our AOA and AAO.

Happy and safe holidays to all of our readers!  



Arthur B. Epstein, OD, FAAO
Chief Medical Editor


Want to share your perspective? Write to Dr. Epstein at artepstein@optometricphysician.com.

The views expressed in this editorial are solely those of the author and do not necessarily represent the opinions of the editorial board, Jobson Medical Information LLC (JMI), or any other entities or individuals.


Early Diagnostic Parameters of Glaucoma in High Myopes
The goal of this study was to assess changes in OCT parameters occurring in high myopic glaucoma patients, so as to enable early diagnosis and prevention of progressive glaucomatous damage. It was performed at the department of ophthalmology, Kasr Alainy Hospital, Cairo University, over a 20-month period. This study was a cross-sectional, randomized, single-blinded study. It included 62 eyes of highly myopic individuals. Patients were divided into two groups: Group A included myopic non-glaucomatous individuals, and Group B included the myopic glaucoma patients. All patients had a full ophthalmological examination, as well as OCT assessment of the RNFL, GCC and ONH parameters. The VF was tested as well as AXL and CCT. Correlation of the data was performed.

Regarding the GLV, its mean in group A was 11.88% ± 6.71% vs. 19.69% ± 9.69% in group B; the difference between both groups was statistically significant (p=0.001). Regarding the cup area, the mean in group A was 0.51mm2 ± 0.41mm2, while that in group B was 1.25mm2 ± 0.72mm2; the difference between both groups was statistically significant (p<0.001).

The ONH parameter, cup area and the GCC parameter GLV were key parameters in supporting the diagnosis of glaucoma in myopic patients. Researchers added that other parameters measured by OCT, such as inferior RNFL thickness, FLV and C/D ratio, could aid in diagnosis as well.

SOURCE: Mohammad Noureldine A, Hashem Fouad P, Magdy Ahmed H, et al. Early diagnostic parameters of glaucoma in high myopes. J Fr Ophtalmol. 2019; Apr 9. [Epub ahead of print].

Hyaluronic Acid Combined with Serum Rich in Growth Factors in Corneal Epithelial Defects
The aim of this study was to assess if an adhesive biopolymer, sodium hyaluronate (NaHA), had synergistic effects with s-PRGF (a serum derived from plasma rich in growth factors and a blood derivative that has already shown efficacy in corneal epithelial wound healing) to reduce time of healing or posology. In vitro proliferation and migration studies, both in human corneal epithelial (HCE) cells and in rabbit primary corneal epithelial (RPCE) cultures, were carried out. In addition, investigators performed studies of corneal wound healing in vivo in rabbits treated with s-PRGF, NaHA or the combination of both. They performed immunohistochemistry techniques (CK3, CK15, Ki67, ß4 integrin, ZO-1, α-SMA) in rabbit corneas seven and 30 days after a surgically induced epithelial defect.

In vitro results show that the combination of NaHA and s-PRGF offered the worst proliferation rates in both HCE and RPCE cells. Addition of NaHA to s-PRGF diminished the re-epithelializing capability of s-PRGF. In vivo, all treatments, given twice a day, showed equivalent efficacy in corneal epithelial healing.

Investigators concluded that the combined use of s-PRGF and HaNA as an adhesive biopolymer did not improve the efficacy of s-PRGF alone in the wound healing of corneal epithelial defects.

SOURCE: Suárez-Barrio C, Etxebarria J, Hernáez-Moya R, et al. Hyaluronic acid combined with serum rich in growth factors in corneal epithelial defects. Int J Mol Sci. 2019;20(7).



Mobile Telephone Use and Reaction Time in Drivers With Glaucoma
Combining mobile telephone use with driving is not unusual. However, distracted driving limits driving performance because of limited capacity for persons to divide attention. Researchers investigated the frequency of mobile telephone use while driving and to assess whether patients with glaucoma had a disproportionate decrease in driving performance while conversing on a mobile telephone compared with healthy participants. The cross-sectional study included surveys collected from 112 patients with glaucoma and 70 control participants to evaluate mobile telephone use while driving. A randomly selected subgroup of 37 patients with glaucoma and 28 controls drove in a driving simulator to investigate peripheral event detection performance during distracted driving at the Visual Performance Laboratory, Duke University, Durham, N.C. Data collection was performed from Dec. 1, 2016, through April 30, 2017. Participants answered a survey and submitted to a driving simulation test with and without mobile telephone use. Survey answers were collected, and distracted driving performance—assessed by reaction time to peripheral stimuli—was analyzed.

Of the 182 participants who answered the survey, the 112 participants with glaucoma included 56 women (50.0%) and had a mean (SD) age of 73.6 (9.6) years. The 70 controls included 49 women (70.0%) and had a mean (SD) age of 68.4 (10.9) years. When asked about mobile telephone use while driving, 30 patients with glaucoma (26.8%) admitted to rarely and two (1.8%) admitted to sometimes using it. In the control group, 20 participants (28.6%) admitted to rarely and two (2.9%) admitted to sometimes using the telephone while driving (p=.80). Reaction times to peripheral stimuli were significantly longer among patients with glaucoma compared with controls during mobile telephone use (median [interquartile range], 1.86 [1.42 to 2.29] seconds vs. 1.14 [0.98 to 1.59] seconds; p=.02). Compared with driving performance while not using a mobile telephone, the mean (SD) increase of 0.85 (0.60) second in reaction time while conversing on the mobile telephone among patients with glaucoma was significantly greater than the mean (SD) increase of 0.68 (0.83) second for controls (p=.03).

This study's findings indicate that patients with glaucoma used mobile telephones while driving as frequently as healthy participants. However, the findings also suggested that patients with glaucoma might experience a greater decline than healthy participants in their ability to detect peripheral events while driving when also talking on a mobile telephone. Patients with glaucoma should be informed that they might have a higher driving risk that might be worsened by distractions, such as mobile telephone use.

SOURCE: Ogata NG, Daga FB, Jammal AA, et al. Mobile telephone use and reaction time in drivers with glaucoma. JAMA Netw Open. 2019;2(4):e192169.

News & Notes
SilkTech IND Submission Cleared by FDA
SilkTech Biopharmaceuticals announced the company received clearance of its FDA Investigational New Drug submission for its SDP-4 eye drop product. In addition, the company initiated a Phase II clinical trial for its first-in-class drug to assess the safety and efficacy of the use of the product in treating the signs and symptoms of DED. The trial (SDP-4-CS201) is a 300-patient, multicenter, double-masked, randomized, vehicle-controlled, dose-response, parallel-group study designed to evaluate the ocular safety and efficacy of SDP-4 ophthalmic solution in subjects with moderate to severe dry eye disease over a 12-week treatment period. Topline results from this study are expected in late 2019 and will be used to inform the design of future Phase III studies. Learn more.

Novartis Announces FDA Filing Acceptance & Priority Review
Novartis announced that the FDA accepted the company's Biologics License Application for brolucizumab (RTH258) for the treatment of wet age-related macular degeneration. Seeking to make brolucizumab available as quickly as possible, Novartis used a priority review voucher to expedite FDA review. If approved by the FDA, Novartis anticipates launching brolucizumab by the end of 2019. The regulatory application is primarily based on Phase III data from the HAWK and HARRIER trials—prospective, randomized, double-masked multi-center studies. The primary endpoint of these studies was non-inferiority to aflibercept in mean change in best-corrected visual acuity from baseline to week 48. HAWK and HARRIER are the first and only global head-to-head trials in patients with wet AMD that prospectively demonstrated efficacy at week 48 starting with a 12-week dosing regimen. Read more.

Essilor Instruments USA Launches PRO-B 300 Blocker
Essilor Instruments launched the PRO-B 300 blocker for high-volume labs. The PRO-B 300 blocker offers an ergonomic design with robust and fast operation to enhance efficiency. The PRO-B 300 is compatible with Essilor and Weco posiblock designs and is available with or without an embedded heavy-duty tracer. Essilor showcased the PRO-B 300 blocker alongside its PRO-E 700 edger at the recent Vision Expo East. Read more.


Optometric Physician™ Editorial Board

Chief Medical Editor
Arthur B. Epstein, OD, FAAO

Journal Reviews
Shannon Steinhäuser, OD, FAAO

Contributing Editors
• Katherine M. Mastrota, MS, OD, FAAO
• Barry A. Weissman, OD, PhD, FAAO (Dip CL)

Editorial Board
• William Jones, OD, FAAO
• Alan G. Kabat, OD, FAAO
• Bruce Onofrey, RPh, OD, FAAO
• John Schachet, OD, FIOS
• Joseph Shovlin, OD, FAAO



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