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


Volume 18, Number 52

Monday, December 17, 2018


Inside this issue: (click heading to view article)
######### Off the Cuff: The Power and Sometimes the Agony of What We Do
######### Determination of Central Corneal Clearance in Scleral Lenses with an Optical Biometer and Agreement with Subjective Evaluation
######### Non-linear Relationship Between Blood Pressure and Glaucoma in US Adults
######### Comparing Spectacle and Toric Contact Lens Prescribing Trends for Astigmatism
######### News & Notes

Click on the image for upcoming Conferences and Meetings.


Off the Cuff: The Power and Sometimes the Agony of What We Do

While I sometimes marvel at the incredible power we possess for changing people’s lives for the better, it’s easy to forget that sometimes things go wrong. In some cases, very wrong. Earlier this week, Jessica Starr, a 35-year-old mother of two young children and a popular meteorologist on Fox News in Detroit, took her own life after a reportedly failed SMILE procedure.

Having spent a good deal of my career dealing with refractive surgery complications, I’ve come to believe that most of these disasters start long before the patient even sits for the pre-op examination. However, by all accounts, Jessica Starr was healthy, well-adjusted, outgoing and as normal as a patient could be. Getting a glimpse of her life on Facebook and watching her colleagues on Fox 2 Detroit talk about her loss was incredibly heart-wrenching.

Jessica chronicled her SMILE issues on social media. Especially poignant for me as a clinician was her plea for help. A call that apparently tragically remained unheeded. I couldn’t help but wish I had seen her video before it was too late or that someone noticed how seriously bad things were for her and how terrified she was. I so wish that someone had been there to bring her back from the abyss.

It is so easy to think that what we do has only positive consequences. But that is really naive. Sometimes, even the most competent among us screw up, and the marginally competent and incompetent skate by on the thin ice of luck and the body’s ability to heal itself. It’s likely we’ll never fully understand what went wrong with Jessica Starr’s surgery or if anything actually did go wrong. While I suspect there is more to this story, the reality is that refractive surgery can be disastrous for some patients, even today, even with the most advanced technology, even when performed by the most skilled surgeon.

I have seen that same look of helplessness and hopelessness in other patients’ eyes, especially in those with severe, debilitating disease who have not yet found someone who cared enough, understood their problem or could help them. So far, I have been able to intercede and help many of my own patients. I now realize that for some, help won’t come in time. If there is something to be learned from this tragedy it’s how powerful our impact on patients can be, how fragile life is, and how precarious what we do can sometimes be.

Arthur B. Epstein, OD, FAAO
Chief Medical Editor

Editor’s Note: Please join us this coming Wednesday at 9pm EST when I will be appearing on Gary Gerber’s Power Hour discussing The Challenging Future of Optometry. You can tune in at http://www.powerhour.info/ or by calling in 646-716-8746. See you then.

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.


Determination of Central Corneal Clearance in Scleral Lenses with an Optical Biometer and Agreement with Subjective Evaluation
This study compared three methods to measure central corneal clearance (CCC) during scleral lens wear: subjective (slit lamp), image processed (ImageJ) and with an optic biometer. The optic biometer technique was validated in comparison to an OCT in the first part of the study. Twenty-two eyes (11 subjects) with healthy corneas were recruited. Three measures of OCT with scleral lenses and ten measurements of axial length (AL) with IOLMaster with and without lens were performed. For the second part, 61 eyes (35 subjects) enrolled in a clinical study were selected. Measurements of CCC were done with IOLMaster, SlitLamp and ImageJ.

The measurements of CCC indirectly obtained with IOLMaster had a strong correlation with AS-OCT measurements (r=0.981), showing a mean difference of 122.18μm  ± 46.05μm (higher with IOLMaster). Regarding the second part, measurements of CCC were 238.66μm  ± 95.94μm, 250.16μm  ± 124.31μm and 263.15μm  ± 90.60μm, for the IOLMaster, SlitLamp and ImageJ, respectively. The correlations were higher for ImageJ vs. subjective measure (r=0.891) than for IOL vs. subjective (r = 0.748) and IOL vs. ImageJ (r=0.745). Analysis of differences and correlations between SlitLamp and ImageJ through time showed a mean difference of -32.28μm  ± 89.95μm (r=0.683) at V1month, 12.53μm  ± 59.46μm (r=0.850) at V6months and 11.57μm  ± 32.95μm (r=0.940) at V12months.

Researchers determined that it was possible to measure CCC with IOLMaster, considering AL measured with and without lens and lens thickness. The three methods tested had good correspondence, showing that IOLMaster and ImageJ could be objective techniques to measure CCC. Also, the researchers added, it was possible to improve the agreement of subjective measures when compared to objective measures trough time.

SOURCE: Macedo-de-Araújo RJ, Amorim-de-Sousa A, Queirós A, et al. Determination of central corneal clearance in scleral lenses with an optical biometer and agreement with subjective evaluation. Cont Lens Anterior Eye. 2018; Nov 28. [Epub ahead of print].

Non-linear Relationship Between Blood Pressure and Glaucoma in US Adults
Previous studies have reported that vascular disease is associated with glaucoma. However, the relationship between blood pressure (BP) and glaucoma has been inconsistent. Investigators looked at whether there is a non-linear association between BP and glaucoma in an adult population of the United States. From the 2005-2008 National Health and Nutrition Examination Surveys (NHANES) data, 4,137 participants ages 40 and older were chosen. BP was assessed based on a standard protocol. Glaucoma was determined using fundus photographs. Age, sex, race/ethnicity, education, poverty, anti-hypertensive medication and history of cardiovascular disease were also considered in analyses.

The prevalence of glaucoma was 1.2%. In the multivariate analysis, both high (≥ 161mm Hg) and low (≤ 110mm Hg) levels of systolic BP were positively associated with glaucoma in those without antihypertensive medications: their prevalence ratios (95% CIs) for glaucoma were 6.42 (1.01 to 40.81) and 5.46 (1.77 to 16.53), respectively, when compared to the reference levels of systolic BP (111mm Hg to 120mm Hg). Also, both high (≥ 91mm Hg) and low (≤ 60mm Hg) levels of diastolic BP were positively associated with glaucoma in those without antihypertensive medications. The prevalence of glaucoma was lowest in those having systolic BP levels of 111mm Hg to 120mm Hg and diastolic BP levels of 81mm Hg to 90mm Hg. However, there were no such U-shaped relationships in those with antihypertensive medications.

There was a non-linear (U-shaped) relationship between BP and the glaucoma in those without anti-hypertensive medications. Investigators concluded that future longitudinal studies would be warranted to confirm their findings, including the optimal BP levels for the prevention of glaucoma.

SOURCE: Kim H, Choi B. Non-linear relationship between blood pressure and glaucoma in US adults. Am J Hypertens. 2018; Dec 8. [Epub ahead of print].




Comparing Spectacle and Toric Contact Lens Prescribing Trends for Astigmatism
The purpose of this study was to investigate and compare spectacle and contact lens (CL) prescription trends, with an emphasis on astigmatic refractive error prescribing differences for patients who purchase spectacles or CLs in South Korea. A retrospective study of patient records of a major optical chain in South Korea was conducted. De-identified data of age, gender, power of prescribed spectacles and/or CLs were extracted from the practice database. Inclusion criteria were: being within the first 10,000 purchasers of spectacles or CLs, or both.

The first 10,000 purchases included spectacles (59%) and CLs (41%) (male-to-female ratio, 4:6). The proportion of purchasers who were female was significantly higher for CLs (88% female, 12% male) than spectacles (43% female, 57% male) (χ 2 =4480.36). There was a significant difference in the proportions of purchases by age group for spectacles and CLs (χ 2 =3246.69). Spherical power distribution of prescribed lenses was similar between the groups; however, cylinder power and axis were significantly different. CL astigmatic powers were more likely to be 1.00DC or greater, whereas the majority of spectacle lenses had astigmatic power of 0.75DC or less. In total, 90% of toric CLs were prescribed ×180 and 9% at other meridians, unlike spectacles where 50% were prescribed ×180, 14% ×90 and 40% at oblique meridians.

Investigators wrote that there was scope for providing increased toric lens correction among CL wearers and increasing the proportion of wearers who are male. The estimated gap for toric lens prescription among CL wearers who had clinically significant astigmatism ≥0.75 DC was about 59%.

SOURCE: Chu BS, Boon MY, Noh DH. Comparing spectacle and toric contact lens prescribing trends for astigmatism. Clin Optom (Auckl). 2018;10:119-127.

News & Notes

Avedro's Announces Anthem Joins Commercial Plans Covering Corneal Cross-Linking & CMS Issues J Code for Photrexa Drug Formulations
Avedro announced that Anthem, the largest member of the Blue Cross Blue Shield Association, issued a positive coverage policy for Avedro’s FDA-approved corneal cross-linking procedure, bringing the total number of commercial plans covering the Photrexa drug formulations and the KXL System to 60. The addition of the nation’s second largest commercial plan affects 31 million beneficiaries. Read more.
In addition, the Centers for Medicare and Medicaid Services recently issued a product-specific J code for Photrexa Viscous (riboflavin 5’-phosphate in 20% dextran ophthalmic solution) and Photrexa (riboflavin 5’-phosphate ophthalmic solution). The new J code, J2787, will become effective on Jan. 1, 2019. Read more.

Miru 1month Menicon Monthly Replacement Silicone Hydrogel Lenses Launch in US
Menicon America announced the US launch of Miru 1month Menicon, a monthly replacement silicone hydrogel lens available as spheres for myopia and hyperopia, as a toric for astigmatism and as a multifocal for treating presbyopia. Starting with Dk/t of 161, the lenses optimize oxygen transmissibility by using unique geometry to control and minimize lens thickness in sphere, toric and multifocal designs across the whole lens surface and entire power range. Miru 1month Menicon obtained FDA approval in February 2018. Learn more.

Number of Practices Offering neurolens Contoured Prism Lenses More Than Quadrupled in 2018
Neurolens announced that adoption among US optometric practices more than quadrupled in 2018. neurolenses are the first and only prescription lenses that add a contoured prism to bring the eyes into alignment. When the eyes are not aligned, the visual system must work constantly to compensate for the misalignment. By year’s end, 31 states will carry neurolenses and the neurolens measurement device. Read more.

Alcon Introduces Medical Affairs Website in North America
Alcon launched AlconScience.com for US- and Canadian-based eye care professionals and academic institutions. The website consolidates information about Alcon’s scientific, academic and related activities in one portal. Visitors may download clinically focused publications, submit grant applications for Investigator-Initiated Trials, apply for independent medical education support and for educational equipment donations, among other activities. 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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