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


Volume 18, Number 34

Monday, August 20, 2018


Inside this issue: (click heading to view article)
######### Off the Cuff: Students, Debt and the Future of Optometry
######### Unexpected Cause for Eyelid Swelling and Ptosis: Rigid Gas Permeable Contact Lens Migration Following a 28-year-old Trauma
######### Corneal Sensitivity After Ocular Surgery
######### Early Macular Changes After Phacoemulsification in Eyes with High Myopia
######### News & Notes

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Off the Cuff: Students, Debt and the Future of Optometry

Student debt is a steadily escalating problem for health care professionals. It has gotten so bad that this past week, the NYU School of Medicine announced that it is waving tuition for all new and existing medical school students. Their action is in response to growing debt among young doctors and the trend away from lower-paying, but much-needed, primary care practice. The school reportedly views this as a public health issue. The hope is that other medical schools will follow suit.

Unfortunately, optometry doesn’t appear that fortunate or farsighted. To my knowledge, no optometric program is planning to wave tuition or even reduce it to more affordable levels. In sad fact, optometry school graduates have a higher debt-to-income ratio than any other health care professionals with an earning capability far lower than most. With even more new schools on the already crowded horizon, it’s difficult to not view additional optometry programs as predatory, preying on increasingly less-qualified students who have dreams of becoming a doctor.

For many of these young ODs, I fear that their dreams may quickly turn into a nightmare. The glut of new graduates will eventually exceed demand, if it hasn’t already. With continuing advances in technology and too many practices still mired in traditional refractive care, OD salaries are likely to tank while competition for a shrinking number of positions grows exponentially. More and more of these young ODs will be working just to pay off their student loans, and some may not be able to pay them off at all. If reimbursements drop to fuel Medicare for all, it won’t be pretty for any of us, but especially painful for young and in-debt grads.

Unfortunately, there is no simple answer. By the time the law of supply and demand kicks in, it will be too late. Some have suggested that we actively discourage prospective new ODs from pursuing optometry as a career. The only thing that will accomplish is to deprive the profession of a greater number of quality candidates rather than dissuade the poor ones.

Eventually, some existing schools will have to close and new ones not open, but that will never happen as long as there are students willing to pay, and schools are making money from minting new ODs. The one solution that would work and might actually save the profession is the hardest. Raise entry and training standards to almost painful levels. That would ensure qualified candidates and well-prepared ODs, and force the worst schools to close. Ultimately, the future of optometry lies in the hands of the AOA and its Accreditation Council on Optometric Education.

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.



Unexpected Cause for Eyelid Swelling and Ptosis: Rigid Gas Permeable Contact Lens Migration Following a 28-year-old Trauma
A patient presented with left upper eyelid swelling and ptosis. The MRI reported a cyst with proteinaceous content. On surgical excision of the cyst, a rigid gas permeable (RGP) contact lens was found. The RGP lens was encapsulated within the upper eyelid soft tissue. It was later revealed that the patient had experienced childhood trauma while wearing RGP contact lenses 28 years previously. The patient had assumed that the RGP lens had fallen out and was lost; however, researchers inferred that the lens had migrated into the eyelid and resided there asymptomatically for 28 years.

SOURCE: Patel S, Tan LL, Murgatroyd H. Unexpected cause for eyelid swelling and ptosis: rigid gas permeable contact lens migration following a 28-year-old trauma. BMJ Case Rep. 2018;10;2018.

Corneal Sensitivity After Ocular Surgery
Authors wrote that the cornea is densely innervated with free nerve endings to provide a high level of sensitivity to foreign bodies or noxious substances, which also provide trophic support to the tissues of the cornea and facilitate their repair and replacement. Any reduction in the function of the nerve endings through disease, contact lens wear or surgery may lead to corneal disease, damage or reduced healing. Assessment of the corneal nerve function can be made by the use of specialized instruments (aesthesiometers) that stimulate the corneal nerves using different modalities—mechanical, chemical or thermal. Each modality assesses the function of a different cohort of corneal nerve type.

Ocular surgery, particularly corneal surgery, can produce significant damage to the corneal innervation. However, for the majority of surgical procedures, corneal sensation eventually returns to preoperative levels, given enough time. The principal exceptions to this are penetrating keratoplasty, epikeratophakia and cryo-keratomileusis, where sensation rarely returns to normal.

Authors concluded that, for all types of surgery, the pattern of corneal sensation loss and recovery depends on the type, depth and extent of incision because these influence the number of nerve fibers severed and the healing response of the patient.

SOURCE: Lum E, Corbett MC, Murphy PJ. Corneal Sensitivity After Ocular Surgery. Eye Contact Lens. 2018; Aug 7. [Epub ahead of print].




Early Macular Changes After Phacoemulsification in Eyes with High Myopia
This prospective cohort enrolled patients with high myopia (axial length ≥26mm) who underwent phacoemulsification with intraocular lens implantation. Spectral-domain optical coherence tomography (OCT) scans were obtained at baseline, and two and six months after the operation. Postoperative macular changes on OCT scans were regarded as the main outcome measure.

Thirty-four eyes of 31 patients with high myopia were included (age, 60 years ±10 years [mean ±SD]); of these, 14 patients (45.2%) were male. The mean axial length was 27.8mm ±1.5mm. Epiretinal membrane (one eye, 2.9%), lamellar hole (one eye, 2.9%), myopic foveoschisis (two eyes, 5.9%) and vitreomacular traction associated with foveoschisis (one eye, 2.9%) were notable findings at baseline examination; no eyes showed cystoid macular edema (CME) at this time. At the two-month examination, three eyes (8.8%) developed CME. At the six-month follow-up, one eye with CME at two months improved, and a new case of CME (5.6%) was detected. The characteristics of epiretinal membrane, lamellar hole, vitreomacular traction and foveoschisis did not change at the two- and six-month examinations, and no new cases occurred.

Investigators determined that uncomplicated phacoemulsification had no significant effect on the prevalence or characteristics of pre-existing macular abnormalities in eyes with high myopia at up to six months of follow-up. The incidence of CME two months after uncomplicated cataract surgery in eyes with high myopia was about 9%.

SOURCE: Ashraf H, Koohestani S, Nowroozzadeh MH. Early macular changes after phacoemulsification in eyes with high myopia. J Ophthalmic Vis Res. 2018;13(3):249-52.

News & Notes

Sun Pharma Receives FDA Approval for CEQUA to Treat DED
Sun Pharma received FDA approval for CEQUA (cyclosporine ophthalmic solution) 0.09%. CEQUA is indicated to increase tear production in individuals with keratoconjunctivitis sicca. CEQUA provides the highest FDA-approved concentration of cyclosporine A and is the first approved CsA product that incorporates a nanomicellar technology enabling the CsA molecule to overcome solubility challenges, penetrate the eye’s aqueous layer and prevent release of the active lipophilic molecule prior to penetration. Read more.

Ivantis Gets FDA Nod for Hydrus Microstent Device for MIGS
Ivantis received FDA approval for the Hydrus Microstent, a microinvasive glaucoma surgery device used to treat individuals with mild to moderate primary open-angle glaucoma in conjunction with cataract surgery. The approval is based on the HORIZON Trial, which included 556 mild to moderate glaucoma patients undergoing cataract surgery, randomized to either receive cataract surgery plus the Hydrus Microstent (treatment) or cataract surgery alone (control). More than three-quarters (77.2 percent) of individuals in the Hydrus Microstent group achieved a statistically significant decrease (≥20 percent reduction in unmedicated intraocular pressure) at 24-months postoperative compared with 57.8 percent in the cataract surgery alone group, meeting the primary effectiveness endpoint. Read more.


2018 Ophthalmology Update

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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