Optometric Physician

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


Volume 21, Number 6

Monday, February 15, 2021


Inside this issue: (click heading to view article)
######### Off the Cuff: An Open Letter to Ophthalmology

######### Short-term Effects of COVID-19-Related Deferral of Intravitreal Injection Visits
######### Corneal Penetration of Low-dose Atropine Eye Drops
  Effect of Steroid Eye Drops After Trabeculectomy in Glaucoma Patients: a Keratograph Analysis
######### News & Notes

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Off the Cuff: An Open Letter to Ophthalmology

Over the past few years, despite the dogged determination of some in our respective professions to the contrary, optometry and ophthalmology have grown closer together. Advances in optometric education, the impact of COVID, the combined forces of technology, economics, government overreach and overregulation have made it increasingly apparent that optometry and ophthalmology are headed for a collaborative nexus.

When I began my career, optometry was almost exclusively a refractive profession. Some brave souls ventured into contact lens fitting, vision therapy or low vision, but medical eye care was a far-off aspiration at best. Moves to incorporate diagnostic drugs into the optometric domain, despite enhanced education and training, were met by organized ophthalmology with predictions of patients dying in the streets from misuse of mydriatics and cycloplegics.

As optometry ventured increasingly into the therapeutic management of ocular disease, every move forward in every state was fought tooth and nail by organized ophthalmology. Despite the effort and cost, today, every OD in every state routinely prescribes a broad variety of pharmaceutical agents. A few months ago, the lone glaucoma holdout, Massachusetts, granted ODs glaucoma-prescribing privileges. Again, despite years of warnings about dire consequences, no one has died and the public has greater access to eye care than ever before.

From the back of jewelry shops and peddler’s wagons a century ago, optometry has evolved to provide the majority of routine and medical eye care in the US today. Optometric malpractice rates remain incredibly low, and catastrophic medical mishaps are exceedingly rare. Perhaps unexpectedly, ophthalmology has been among the greatest beneficiaries of optometric scope expansion. That assertion may leave some fuming, but ophthalmologic specialties have flourished, and many of the most successful practices have ODs and MDs working side-by-side.

History and experience teach that some things simply cannot be stopped. As optometry continues to broaden its focus to better serve the needs of its patients, its continued advances are certain. Yes, the advances may be delayed temporarily, but they never will be stopped. I have said this before, but now more than ever, it is time for optometry and ophthalmology to begin a dialogue of reconciliation, and to find a path forward based on cooperation and trust. I call on the AOA and the American Academy of Ophthalmology to initiate this dialogue by cosponsoring a summit to chart a collaborative future for eye care.


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.



Short-term Effects of COVID-19-Related Deferral of Intravitreal Injection Visits

In this cross-sectional, retrospective analysis of a single-provider outpatient clinic across multiple satellites, consecutive patients returning for intravitreal injections (IVIs) of anti-vascular endothelial growth factor or corticosteroids were identified as "delayed" or "undelayed" during a six-week study interval during the COVID-19 pandemic to determine secondary effects of the closure period on injection-based retina care and outcomes. A "delayed" encounter was defined as having a follow-up interval exceeding 33% of the recommended cycle. Patients seen for IVIs during the corresponding six-week interval a year previously were identified for study as pre-COVID-19 controls. Main outcome measures included best-corrected visual acuity (BCVA) and optical coherence tomography (OCT) assessment based on findings of intraretinal or subretinal fluid consistent with new or recurrent neovascular events.

The study included 183 eyes of 144 patients who underwent IVI-based care from June 18, 2020, through August 7, 2020, compared to 193 eyes of 154 patients injected during the corresponding interval one year before. There were 62 eyes of 46 patients seen in the study period later than scheduled (among 144 patients of 183 eyes in total), which represented a larger proportion of delayed patients compared to the previous year (31.9% vs. 14.9%). Considering the patterns from the control group, the attributed delay due to COVID-19 was 15.0% of patients. The delayed return eyes had a greater decline in BCVA (three letters), higher rates of worsened OCT results (48%) and prompted reduction in previously prescribed injection intervals.

Researchers wrote that the unintended consequence of delayed care of patients on established care regimens should be anticipated, and mitigate strategies considered if similar restrictions are mandated in the future.

SOURCE: Ashkenazy N, Goduni L, Smiddy WE. Short-term effects of COVID-19-related deferral of intravitreal injection visits. Clin Ophthalmol. 2021; Feb 3. [Epub ahead of print].


Corneal Penetration of Low-dose Atropine Eye Drops

Major studies demonstrating the inhibition of myopia in children and juveniles by low-dose atropine eye drops provide little information on the manufacturing process and the exact composition of the atropine dilutions. However, corneal penetration might significantly vary depending on preservatives such as benzalkonium chloride (BAC) and the atropine concentration. Since there is a tradeoff between side effects, stability and optimal effects of atropine on myopia, it is important to gain better knowledge about intraocular atropine concentrations. Researchers performed an ex vivo study to determine corneal penetration for different formulations. Atropine drops (0.01%) of different formulations were obtained from pharmacies and applied to the cornea of freshly enucleated pig eyes. After 10 minutes, a sample of aqueous humor was taken, and atropine concentrations were determined following liquid-liquid extraction followed by high-performance liquid chromatography-tandem mass spectrometry (LC-MS/MS).

The variability that originated from variations in applied drop size exceeded the differences between preserved and preservative-free formulations. The atropine concentration in the anterior chamber measured after 10 minutes was only 3.8 × 10-8 of its concentration in the applied eye drops, corresponding to 502.4 pM.

Researchers reported that the preservative did not facilitate corneal penetration, at least ex vivo. They added that, in the aqueous humor of children's eyes, similar concentrations, including higher variability, may be expected in the lower therapeutic window of pharmacodynamic action.

SOURCE: Austermann H, Schaeffel F, Mathis U, et al. Corneal penetration of low-dose atropine eye drops. J Clin Med. 2021; Feb 4;10(4):588.




Effect of Steroid Eye Drops After Trabeculectomy in Glaucoma Patients: a Keratograph Analysis

A total of 31 eyes of 31 glaucoma patients were studied to investigate the use of preoperative steroid drops in glaucoma patients undergoing trabeculectomy for ocular surface disease. Only glaucoma patients who had been using at least three topical intraocular pressure-lowering medications for longer than six months were included. All patients were treated with loteprednol etabonate ophthalmic suspension 0.5% four times per day for one week before trabeculectomy. Data from baseline (day of surgery) and the follow-up visit (two weeks after surgery) were included. All patients underwent a detailed ophthalmologic exam. Ocular surface disease was evaluated using the Ocular Surface Disease Index questionnaire and clinical measures, including tear breakup time, conjunctival hyperemia, and biomicroscopy to detect the presence or absence of keratitis. Ocular Surface Disease Index scores greater than 13 indicated a clinically relevant presence of ocular surface disease. In addition, all patients underwent keratograph analysis. The comparison of ocular surface disease before and after trabeculectomy was assessed using a paired test.

The mean age of the glaucoma patients was 69.90 ± 10.77 years. The average visual acuity was 0.40 ± 0.34 logMAR. The overall Ocular Surface Disease Index prevalence rate was 27.20 ± 17.56 units. Clinical assessment revealed no significant difference in bulbar redness, breakup time or keratitis before and after surgery. Keratograph analysis showed that the only two parameters that were significantly different before and after trabeculectomy were the bulbar redness by keratograph (BR-K) and the average noninvasive tear breakup time. Patients presented more conjunctival hyperemia and shorter noninvasive tear breakup time after trabeculectomy compared with before surgery.

Investigators wrote that the study not only confirmed the high prevalence of clinical findings of ocular surface disease in glaucoma patients but also revealed new objective parameters measured by keratograph analysis. Apart from using loteprednol etabonate ophthalmic suspension 0.5% one week before the surgery, the sample demonstrated a worsening of conjunctival hyperemia (bulbar redness by keratograph) and also a shorter noninvasive tear breakup time postoperatively.

SOURCE: Fares NT, Portela RC, Machado LF, et al. Effect of steroid eye drops after trabeculectomy in glaucoma patients: a keratograph analysis. Arq Bras Oftalmol. 2021; Feb 3. [Epub ahead of print].


News & Notes
  Prevent Blindness to Hold Annual Eyes on Capitol Hill Advocacy Event
Prevent Blindness will be holding its sixteenth annual Eyes on Capitol Hill advocacy event virtually Feb. 24 and 25. The program brings together patients, caregivers, public health workers and medical professionals with their elected officials to educate lawmakers and their staff on vision issues, including equitable access to quality eye care, health disparities in the prevalence of vision disorders, and the importance of sight-saving research and surveillance. Learn more.


  Euclid Systems Announces Expansion of Leadership Team
Euclid Systems, a global provider of advanced orthokeratology and proactive myopia management, expanded of its leadership team over the last six months, to include the following individuals:
Barry A. Rhein, vice president of manufacturing, was most recently vice president of global supply chain at Bausch + Lomb
Guanrong (Gary) Ding, vice president of sales, China, formerly served as commercial director at Abbott Medical Optics and Johnson & Johnson Surgical Vision
Jackson Lau, OD, FAAO, FSLS, manager of clinical and scientific affairs, is a cornea and contact lens residency-trained optometrist with clinical research experience
Jim Rackley, senior director, product engineering, previously served in the role of continuous improvement manager at Zimmer Biomet
Linda Chang, chief financial officer, was the chief financial and chief operating officer of Science and Medicine Group
Nitin Jain joined in August 2020 as global vice president of marketing after serving as senior director of Johnson & Johnson Vision, where he led the global Acuvue contact lens portfolio marketing team
Zhang (Neo) Zhixang, vice president of marketing, China, joined from Essilor, where he was senior marketing director








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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