Optometric Physician



Vol. 24, #32 •   Monday, August 7, 2023


Off the Cuff: Invisible Disability of Keratoconus

I treat a fairly large keratoconus population. Taking these patients from levels of visual disability or legal blindness to functionally sighted creates a huge and immediate positive change in the quality of their lives. Monitoring and fitting these individuals with medically necessary specialty lenses are some of the most rewarding patient interactions I have. Once their sight has been restored though, the level of disability these individuals have is not so obvious to others. You would think this would be a good thing, but the stories I hear regarding their employers and supervisors are just heartbreaking.


Letters to employers and filling out Family Medical Leave Act paperwork for keratoconus patients is a common occurrence. Annually I have to ask for accommodations for lighting, work from home requests, and computer setups so these individuals can do their jobs as well as time off requests so they can come to their appointments. I get the distinct impression some employers utilize this as a seemingly punitive measure. For one of my keratoconus patients that I needed to have out of her lenses for a few days to get ESP Eaglet profilometry measurements, it felt like we were having to move mountains to get those days off for her.

Another one of my keratoconus patients is a police officer. With his scleral lenses he meets all the vision requirements for his position, but the night glare off his corneal scarring makes it impossible for him to safely do night patrols. Every year I have to write a letter asking for an accommodation that he only works day shifts. He then told me how his direct supervisor harasses him about it in front of other officers so his co-workers have the same bad attitude of “must be nice” to never have to work night shifts. He gets mocked on the shooting range because they believe his vision couldn’t be that bad if he’s shooting that well. This has created a toxic work environment for him. Every time I see him I can tell he’s getting closer and closer to leaving his chosen profession.

I was taught the definition of visually disabled is 20/70 or worse with a patient wearing their best glasses or contact lenses. That got me thinking. If I fit these individuals with specialty contact lenses and get them better than 20/70, am I in a catch 22? They need the specialty lenses for their visual disability, but then don’t meet the definition of disability when wearing “their best contact lenses?” Turns out, no they’re not. In the American with Disabilities Act, it clearly states the level of disability is measured through “ordinary eyeglasses or contact lenses” and not through the measures taken to get them sighted (29 CFR §§1630.2(j)(1)(vi)). Interestingly, I found these supervisors/employers were in violation of all kinds of ADA requirements. I highly recommend taking a peruse.

I have now added a line to the end of my employer letters that seems to have made all the difference. “Please let me know if you need any assistance in navigating the Americans with Disabilities Act regulations and necessary accommodations as they apply to (insert patient name here).” Even though the disability of keratoconus is invisible to some, we’re in the position to make sure the patient protections in place shine bright.

Shannon L. Steinhäuser, OD, MS, FAAO
Chief Medical Editor


Want to share your perspective?
Write to Dr. Shannon L. Steinhäuser, OD, MS, FAAO at ssteinhauser@gmail.com. The views expressed in this editorial are solely those of the author and do not necessarily represent the opinions of Jobson Medical Information LLC (JMI), or any other entities or individuals.



Causes of Punctal Plug Loss in Sjögren's Syndrome

The purpose of this study was to evaluate the long-term maintenance rate and associated factors of silicone punctal plugs in patients with Sjögren's syndrome (SS).

The medical records of 163 patients with SS who underwent silicone punctal plug insertion between December 2013 and July 2021, at Severance Hospital in Seoul, South Korea, were retrospectively reviewed. The status of punctal plug insertions was classified into the following three categories by the clinician: maintenance, spontaneous loss, and intended removal. Cox proportional hazards model was used to evaluate the risk factors for spontaneous loss. The mean maintenance period was 12.8±15.3 (median 7.07) months. The rate of spontaneous loss was 58%, and the rate of punctal plug removal by the clinician was 14%. The number of prior plug insertions was a risk factor for spontaneous loss [hazard ratio (HR) 1.055]. The upper eyelid punctum was at a higher risk than the lower one. Small-sized plugs showed a significantly higher risk for spontaneous loss than large-sized ones (HR 1.287). Flow-controller type plugs were more vulnerable to spontaneous loss than complete occluders [Micro Flow™ vs. EagleFlex® (HR 2.707) and Micro Flow™ vs. Ultraplug™ (HR 3.402)]. The most common reason for removal was tear overflow (5.6%).

Researchers concluded that repeated insertion, characteristics of the punctal plug, including the type and size, and location of plug insertion, influenced the spontaneous loss of plugs. They added that the management of punctal plugs, including insertion, maintenance, and removal, requires personalized strategies for versatile situations.

SOURCE: Kim NE, Ahn H, Jun I, et al. Causes of punctal plug loss in Sjögren's Syndrome. Yonsei Med J. 2023 Aug;64(8):505-10.



The Short-term Effect of 1% Tropicamide Drop on Pupillary Diameter and Intraocular Pressure Change in Patients With Pseudoexfoliation Material

This study was designed to evaluate pharmacological dilation with one drop of 1% tropicamide on pupillary diameter and intraocular pressure (IOP) changes in patients with pseudoexfoliation syndrome (PXS) and glaucoma (PXG).

Eighty-two patients with PXS, 78 patients with PXG, and 35 healthy subjects were included in the study. PXG and PXS were diagnosed based on IOP assessment, corneal pachymetry, optic disc examination, visual field testing, and peripapillary retinal nerve fiber analysis. IOP and the diameter of pupil size were measured before dilation and at post dilatation 1st hour, 2nd, and 4th hours.

The mean pupillary diameter values at post-dilatation 2nd and 4th hours were statistically significantly different between the patients with PXS and PXG. Also, there were significant differences between PXS group and control group in terms of the mean pupillary diameter values at pre-dilatation and post-dilatation at 1st hour and post-dilation 2nd hour. The mean pupillary diameter at all times was statistically significantly different between PXG and control groups. Significant IOP increases were observed in all groups after dilation. The mean IOP at pre-dilation and post-dilation 4th hour were statistically significantly different between PXG and PXS groups. Whereas the mean IOP at pre-dilation, post-dilatation 1st hour, post-dilatation 2nd hour, and post-dilation 4th hour were statistically significantly different between PXG and control group.

Investigators wrote that significant IOP increases were observed with 1% tropicamide in the PXG and PXS groups, with the peak effect at the 2nd hour in the post-dilation period. Furthermore, the mean pupil diameter was found to be significantly lower in PXG patients compared to the control group.

SOURCE: Ural Fatihoğlu Ö, Vural E, Çelebi ARC. The short-term effect of 1% Tropicamide drop on pupillary diameter and intraocular pressure change in patients with pseudoexfoliation material. J Glaucoma. 2023 Jul 25. Epub ahead of print.

Iris Color as a Predictive Factor for Intraoperative Floppy Iris Syndrome

The purpose of this study was to assess the influence of iris color on the predisposition for intraoperative floppy iris syndrome (IFIS) during cataract surgery.

The medical records of patients who underwent cataract surgery in two medical centers between July 2019 and February 2020, were reviewed. Patients younger than 50 years, with preexisting ocular conditions affecting pupillary size or anterior chamber depth (ACD), and combined procedures were excluded. The remaining patients were questioned via telephone regarding their iris color. The association of IFIS occurrence and severity with iris color was tested using univariant and multivariant analyses. Overall, 155 eyes of 155 patients were included, 74 with documented IFIS and 81 without. The mean age was 74.03 ± 7.09 years, and 35.5% were female. The most common iris color among study eyes was brown (110/155, 70.97%), followed by blue (25/155, 16.13%) and green (20/155, 12.90%). Compared to brown-colored eyes, blue irises exhibited a 4.50-fold risk for IFIS (OR=4.50, 95% CI: 1.73-11.70), and green irises 7.00-fold risk (OR=7.00, 95% CI: 2.19-22.39). After adjusting for possible confounders, the results remained statistically significant. Light-colored irises tended to exhibit a more severe IFIS compared to the brown iris group. IFIS bilaterality was also affected by iris color, with a 10.43-fold risk for fellow eye IFIS in the green iris group compared to eyes with brown irises (OR=10.43, 95% CI: 3.35-32.54).

Researchers concluded that light iris color was associated with a significantly increased risk of IFIS occurrence, severity, and bilaterality on univariate and multivariate analysis in this study.

SOURCE: Safir M, Greenbaum E, Vardi MA, et al. Iris color as a predictive factor for intraoperative floppy iris syndrome. Graefes Arch Clin Exp Ophthalmol. 2023 Jun 21. Epub ahead of print.



Industry News

American Academy of Optometry Announces 2023 Award Recipients

View the recipients.

Art Optical Announces Specialty Contact Lens Travel Grant Recipient

View the recipient.

Harrow Launches Vigamox in the US

Harrow completed the transfer to Harrow of the New Drug Application for Vigamox (moxifloxacin hydrochloride ophthalmic solution) 0.5%, a fluoroquinolone antibiotic eyedrop for the treatment of bacterial conjunctivitis caused by susceptible strains of organisms. Harrow purchased the U.S. commercial rights to Vigamox in January 2023. Read more.

Euclid Vision & Visionary Optics Announce Scholarships for Optometric Residents

Learn more.

Okyo Pharma Plans to Initiate Phase II Trial of OK-101

Okyo Pharma announced a new agreement with Tufts Medical Center to conduct a 40-patient open-label clinical trial evaluating the efficacy and safety of OK-101 in patients with neuropathic corneal pain. Read more.

Prevent Blindness Launches New “Eyes on Capitol Hill” Online Advocacy Resource, Declares August as Children’s Eye Health and Safety Month

View the new advocacy resource.

Learn about Children’s Eye Health and Safety Month.










Journal Reviews Editor:
Katherine M. Mastrota, MS, OD, FAAO

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