Optometric Physician

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


Volume 20, Number 35

Monday, August 17, 2020


Inside this issue: (click heading to view article)
######### Off the Cuff: Express Yourself

######### Perceptions of Marijuana Use for Glaucoma from Patients, Cannabis Retailers and Glaucoma Specialists
######### Effect of High Add Power, Medium Add Power or Single-Vision Contact Lenses on Myopia Progression in Children: The BLINK Randomized Clinical Trial
######### Clinical Predictors of the Region of First Structural Progression in Early Normal-tension Glaucoma
######### News & Notes

Click on the image for upcoming Conferences and Meetings.


Off the Cuff: Express Yourself

As our practices slowly get back to normal despite the continued onslaught of COVID, I realize that I have been losing myself in the clinical. I think it is intentional, as the real world is too depressing to really think about. The office has been busy, but there has also been a significant and odd shift in the complexity of the patients we’re seeing. From very esoteric retinal disease to huge sterile central corneal melts to honest-to-goodness Munchhausen’s, the daily beat goes on. This deep dive into the clinically challenging has provided constant food for thought and clearer insight into how things work in healthy eyes, and why and how they fail in sick ones. Some of these realizations were d’oh slap-in-the-head moments, while others were true epiphanies.

I’ll be sharing a lot in the coming months, but let’s start with something simple. At least something that seems simple like meibomian gland expression. Conventional wisdom and the early and still brilliant insights of Donald Korb suggest that gland obstruction defines MGD and that clearing obstructed glands is therapeutic. While many readers probably don’t perform expression of any kind, some will manually express while other colleagues will express using advanced technologies like iLux, LipiFlow or TearCare (in alphabetical order to not upset anyone).

From my own experience, gland expression can be very effective in restoring tear function and reducing both signs and symptoms of “dry eye.” So, what is it that expression actually does? I bet that most, if not all, of you said, it increases meibum flow by clearing gland blockage. If I am wrong, email to let me know, as I am curious. However, in truth, clearing obstruction is only part—and likely a small part—of what gland expression actually does.

As with virtually everything associated with the ocular surface, except perhaps for reflex tearing, gland function is controlled centrally. When glands become obstructed, they are commanded to reduce production of meibum as back pressure increases. Thus, down regulation is likely a major part of the pathogenesis of meibomian gland dysfunction as it results in stagnation of lipids within the glands, worsening obstruction as the lipids become more saturated, and increasing tear lipid deficiency. This reduces tear stability and progressively causes inflammation and the subsequent loss of gland tissue and structure.

This complex process plays a major role in what we simplistically and incorrectly call dry eye, and yet is more often than not completely ignored. It is also only the tip of the ocular surface iceberg. So, fasten your seatbelts as there is a lot more to come. In truth I would rather share clinical insights than talk about COVID any day.


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.


Perceptions of Marijuana Use for Glaucoma from Patients, Cannabis Retailers and Glaucoma Specialists

As marijuana's popularity continues to grow, patients with glaucoma will encounter conflicting opinions on marijuana's role in glaucoma therapy. This study seeks to define the differing perceptions among glaucoma specialists, medical marijuana dispensaries and glaucoma patients in a state with legalized marijuana. The study included medical marijuana dispensaries in Colorado, members of the American Glaucoma Society (AGS) and patients with glaucoma at the University of Colorado glaucoma clinic. First, medical marijuana dispensary employees were surveyed using a mystery call approach and a brief phone script. Dispensary employees were questioned as to whether marijuana was recommended and whether marijuana was safe and effective. Second, a self-administered survey was distributed to AGS members to determine the history of recommending marijuana and influencing factors for or against this recommendation. Third, the self-administered glaucoma patient survey assessed demographics, history of glaucoma, knowledge and rate of marijuana use, and perceptions of marijuana use. All surveys were conducted from October 2018 to March 2019. The proportion of medical marijuana dispensaries and glaucoma specialists recommending marijuana for the treatment of glaucoma, and the proportion of patients with glaucoma using marijuana as a treatment for glaucoma were evaluated.

A total of 203 of the 300 medical marijuana dispensaries called were successfully contacted (68%). Of these, 103 respondents (51%) recommended marijuana products for the treatment of glaucoma. The remaining 100 (49%) deferred making a recommendation or were unsure. Of the 1,308 AGS members, 290 (22%) responded to the survey. Twenty-two respondents (7.6%) reported that they had recommended marijuana for the treatment of glaucoma, with the majority of these (86.4%) having done so infrequently. Among the 231 respondents with glaucoma, most (58.9%) had heard about the possible use of marijuana for glaucoma, but only 2.6% had used marijuana as a treatment for glaucoma.

Few glaucoma specialists have recommended marijuana as a treatment for glaucoma, and an even smaller percentage of patients report its use as a treatment for their glaucoma. In contrast, many marijuana dispensary employees endorse its use. The authors wrote that, as legal access and public acceptance of marijuana escalate, physicians should be aware of these perceptions when educating patients.

SOURCE: Weldy EW, Stanley J, Koduri VA, et al. Perceptions of marijuana use for glaucoma from patients, cannabis retailers, and glaucoma specialists. Ophthalmol Glaucoma. 2020; July 3. [Epub ahead of print].


Effect of High Add Power, Medium Add Power or Single-Vision Contact Lenses on Myopia Progression in Children: The BLINK Randomized Clinical Trial

Slowing myopia progression could decrease the risk of sight-threatening complications. To determine whether soft multifocal contact lenses slow myopia progression in children and whether high add power (+2.50D) slows myopia progression more than medium (+1.50D) add power lenses, a double-masked randomized clinical trial took place at two optometry schools located in Columbus, Ohio, and Houston, Texas. A total of 294 consecutive eligible children ages seven to 11 years with -0.75D to -5.00D of spherical component myopia and less than 1.00D astigmatism were enrolled between September 22, 2014, and June 20, 2016. Follow-up was completed June 24, 2019. Participants were randomly assigned to wear high add power (n=98), medium add power (n=98), or single-vision (n=98) contact lenses. The primary outcome was the three-year change in cycloplegic spherical equivalent autorefraction, as measured by the mean of 10 autorefraction readings. There were 11 secondary endpoints, four of which were analyzed for this study, including three-year eye growth.

Among 294 randomized participants, 292 (99 percent) were included in the analyses (mean [SD] age, 10.3 [1.2] years; 177 [60.2 percent] were female; mean [SD] spherical equivalent refractive error, -2.39 [1.00]D). Adjusted three-year myopia progression was -0.60 D for high add power, -0.89D for medium add power, and -1.05D for single-vision contact lenses. The difference in progression was: 0.46D for high add power vs. single vision; 0.30D for high add vs. medium add power; and 0.16D for medium add power vs. single vision. Of the four secondary endpoints, no statistically significant differences were found between the groups for three of the end points. Adjusted mean eye growth was 0.42mm for high add power, 0.58mm for medium add power and 0.66mm for single vision. The difference in eye growth was: -0.23mm for high add power vs. single vision; -0.16mm for high add vs. medium add power; and -0.07mm for medium add power vs. single vision.

Researchers wrote that, among children with myopia, treatment with high add power multifocal contact lenses significantly reduced the rate of myopia progression over three years compared with medium add power multifocal and single-vision contact lenses. However, they added, further research is needed to understand the clinical importance of the observed differences.

SOURCE: Walline JJ, Walker MK, Mutti DO, et al. Effect of high add power, medium add power, or single-vision contact lenses on myopia progression in children: the BLINK randomized clinical trial. JAMA. 2020;324(6):571-80.




Clinical Predictors of the Region of First Structural Progression in Early Normal-tension Glaucoma

This study aimed to compare the clinical characteristics of patients who showed structural progression in the peripapillary retinal nerve fiber layer (RNFL) first against those who showed progression in the macular ganglion cell-inner plexiform layer (GCIPL) first, and to investigate clinical parameters that help determine whether a patient exhibits RNFL or GCIPL damage first. A retrospective review of medical records of patients diagnosed with early-stage normal-tension glaucoma was performed. All eyes underwent intraocular pressure measurement with Goldmann applanation tonometer, standard automated perimetry and Cirrus optical coherence tomography at six-month intervals. Structural progression was determined using guided progression analysis software. Blood pressure was measured at each visit.

Forty-one eyes of 41 patients (mean age, 52.6 ± 16.7 years) were included in the study. In 21 eyes, structural progression was first detected in the RNFL at 54.2 ± 14.8 months, while structural progression was first observed at the macular GCIPL at 40.5 ± 11 months in 20 eyes. The mean intraocular pressure following treatment was 13.1 ± 1.8 mmHg for the RNFL progression first group and 13.4 ± 1.8 mmHg for the GCIPL progression first group. The GCIPL progression first group was older and had thinner RNFL at baseline. The logistic regression analyses indicated that both age and follow-up duration until first progression predicted the region of structural progression.

Investigators wrote that age of glaucoma patients and time until progression were associated with the region of the first structural progression in normal-tension glaucoma. They added that further studies exploring the association between glaucomatous progression and the location of damage would be needed.

SOURCE: Lee JS, Lee K, Seong GJ, et al. Clinical predictors of the region of first structural progression in early normal-tension glaucoma. Korean J Ophthalmol. 2020;34(4):322-33.

News & Notes
Academy 2020 Moves Online
As a result of the COVID-19 pandemic and the American Academy of Optometry’s continued focus on the health and well-being of its constituents, the organization announced that Academy 2020 Nashville will now be held as a virtual meeting renamed Academy 2020 At Home. “We listened to our stakeholders and watched the national health situation very carefully including the impact on Nashville, and we absolutely believe this is the best decision for everyone,” said Academy Chief Executive Officer Peter Scott. “While we’re disappointed that we can’t hold this show in person, I’m extremely excited to announce that we’ve found a dynamic and robust online platform that will be able to deliver an unbelievably innovative experience.” Academy 2020 At Home will offer “live” COPE continuing education approval, including nearly 300 hours of CE; participants will be able to earn up to 80 hours of CE credits as opposed to the traditional, in-person meeting limit of 34 hours. Because Nashville is nicknamed “the Music City” and features world-renowned artisans, restaurants and culture, the Academy is aiming to bring these elements to the virtual experience. Academy 2020 At Home will be available Oct. 7 to 22 during select periods. The broadcast schedule is in development and will be available soon. This year’s virtual meeting will feature a Plenary Session titled “Today’s Research, Tomorrow’s Practice,” looking at how care and diagnostic standards have changed over recent years, and the impacts of hypertension, hyperlipidemia, diabetes and other common ailments on patient care. The Academy will also host a special symposium on diversity, equity and inclusion. Additional headlining virtual events will include the 2020 Monroe J. Hirsch Research Symposium, offering insights on how robotics and smart technology are increasingly important in optometry. The symposium will dive into the growing science of optometric issues in space, with a presentation by U.S. Navy Captain Tyson Brunstetter, OD, PhD, FAAO, from the Space and Occupational Medicine Branch at NASA Johnson Space Center. Registration is now open. Learn more.

X-Cel to Offer Unlimited Exchanges and Elimination of Add-on Fees
X-Cel Specialty Contacts implemented two key components of the Bounce Back program by launching a new and simplified warranty and returns policy. The new policy, which will be effective September 1, will allow for unlimited exchanges within 120 days on all warranted custom soft and gas permeable products (including the Atlantis scleral). Under this new policy, X-Cel will also move from a return fee upon credit to an exchange fee upon reorder, which will allow for simpler reconciliation of account statements. Additionally, add-on fees have been eliminated, including charges for truncation, fenestration, lenticular, notching and prism among others. Tangible HydraPEG, PlasmaEYEZ treatment and material surcharges remain in effect. Learn 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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