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


Volume 18, Number 9

Monday, February 26, 2018


Inside this issue: (click heading to view article)
######### Off the Cuff: Guest Author Jeffrey Cooper
######### Patient Acceptance of Sustained Glaucoma Treatment Strategies
######### Review of Nitric Oxide for the Treatment of Glaucomatous Disease
######### Ocular Biometry in Primary Angle-Closure Glaucoma Associated with Retinitis Pigmentosa
######### News & Notes

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Off the Cuff: Guest Author Jeffrey Cooper

I almost never run guest editorials. However, after last week's Off The Cuff, this note from old friend and fellow SUNY colleague Jeffrey Cooper really resonated. A recognized thought leader and extraordinary clinician, he captures some of the major challenges facing our profession today and how different things are from when he and I were trained. His comments about SUNY optometry apply to many other schools. I thought it important to share this sad but accurate commentary:

It was important to me be a good clinician, teacher and researcher. I strived to be like our senior role models, and they were abundant in the old SUNY model. It was a time of growth and development not only individually, but for the profession. This was true for both optometry and medicine. It was fun and exciting. Now fast forward, it has all changed.

The mentoring system, at least at SUNY, has been abandoned. Doctors are treated like factory workers, research is only geared to clinical trials and the number of optometric students has expanded without the corresponding ability to train them. At SUNY, experienced part-time clinical faculty have been eliminated, and teaching is performed by young, inexperienced faculty who only want to work 9 to 5. Look at our journals (we eliminated the JAOA), and you'll find no research from American schools of optometry.

The insurance companies and government want non-deviating clinical guidelines to dictate care. The art of medicine and optometry is being lost. Our mentors are dying and not being replaced. Add this to the debt of education and low reimbursements, and we have to ask who will be tomorrow’s doctors?

Jeffrey Cooper OD, FAAO
New York, NY

Editors Note: I just learned of the passing of Steve Grant, a friend, a leader in the contact lens community and a true giant in our profession. Steve never failed to turn up whenever I spoke in Southern California. His devotion to our profession was unparalleled and he always spoke his mind. I am truly saddened by his loss.

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.


Patient Acceptance of Sustained Glaucoma Treatment Strategies
Electronic surveys were administered to 150 individuals at two glaucoma clinics to assess patient acceptance of different methods for delivering sustained-release, intraocular pressure-lowering medications. Participants were questioned on their willingness to accept drug-eluting contact lenses, ring inserts, punctal plugs and subconjunctival injections as alternatives to IOP-lowering eye drops based on various success levels. Multivariable logistic regression models determined the association between device type and treatment acceptance, adjusting for age, gender, study site, cost burden of drops and previous contact lens use.

The majority (69%) of participants were 55 to 74 years of age and white (65%), and half were female. The majority of participants would accept contacts (59%), rings (51%), plugs (57%) and subconjunctival injections (52%) if they obviated glaucoma surgery; fewer would accept these devices if they reduced (23% to 35%) or eliminated (27% to 42%) drops. Most participants would also accept contacts (56%), plugs (55%) and subconjunctival injections (53%) if they were more effective than eye drops, while only 47% would accept a ring; fewer would accept any device if it were equally or less effective than drops. Participants were also 36% less likely to accept rings and 32% less likely to accept subconjunctival injections as compared to contacts.

Researchers determined that most glaucoma patients considered sustained drug-delivery modalities acceptable alternatives to IOP-lowering eye drops, but only when they were said to obviate surgery or demonstrate greater efficacy than eye drops.

SOURCE: Varadaraj V, Kahook MY, Ramulu PY, et al. Patient acceptance of sustained glaucoma treatment strategies. J Glaucoma. 2018; Feb 16. [Epub ahead of print].


Review of Nitric Oxide for the Treatment of Glaucomatous Disease
Glaucoma is the leading cause of irreversible blindness worldwide, affecting 64.3 million people, authors wrote. An estimated 60.5 million people are affected by primary-open angle glaucoma globally, and this will increase to 111.8 million by 2040, they added. Furthermore, the definition of glaucoma has evolved greatly over time. Although multiple risk factors such as ischemia, inflammation, myopia, race, age and low ocular perfusion pressure may play a role, intraocular pressure (IOP) is still the main risk factor easily identified and modified. Currently, both medical and surgical interventions aim to reduce IOP. Effective IOP reduction controls and prevents the progression in many cases of glaucoma, the authors continued.

Although this multifactorial disease's true pathophysiology is difficult to elucidate, physiologic mediators including nitric oxide (NO) are being evaluated as novel ways to impact progression by both lowering IOP and improving optic nerve head perfusion. Latanoprostene bunod 0.024% is an emerging therapeutic agent that has shown promise in clinical trials, authors wrote. As a nitric oxide-donating prostaglandin F2-alpha receptor agonist, it has proven to effectively, and with good tolerability, reduce IOP in glaucoma and ocular hypertensive patients, they wrote further. Latanoprostene bunod capitalizes on NO's ability to modulate the conventional aqueous humor outflow system, directly improving outflow through the trabecular meshwork, Schlemm's canal and distal scleral vessels, authors explained.

Authors concluded that targeting the conventional outflow tissues with NO-donating drugs represents an opportunity to restore outflow function, which will most likely have a beneficial consequence of additional IOP-lowering effects with dampening of diurnal and other IOP fluctuations, the benefit of a healthy trabecular meshwork.

SOURCE: Aliancy J, Stamer WD, Wirostko B. A review of nitric oxide for the treatment of glaucomatous disease. Ophthalmol Ther. 2017;6(2):221-32.



Ocular Biometry in Primary Angle-Closure Glaucoma Associated with Retinitis Pigmentosa
Retinitis pigmentosa (RP) comprises a group of inherited disorders in which patients typically lose night vision in adolescence and then lose peripheral vision in young adulthood before eventually losing central vision later in life. A retrospective, case-control study was performed to evaluate differences in ocular biometric parameters in primary angle-closure glaucoma (PACG) patients with and without concomitant RP to determine whether a relationship exists between PACG and RP.

Investigators used ultrasound biomicroscopy (UBM) to measure anterior chamber depth (ACD). A-scan biometry was carried out to measure lens thickness (LT) and axial length (AL). Propensity score matching and mixed linear regression model analysis were conducted. A total of 23 patients with chronic primary angle-closure glaucoma (CPACG) associated with RP, 21 patients with acute primary angle-closure glaucoma (APACG) associated with RP, 270 patients with CPACG and 269 patients with APACG were recruited for this study.

Investigators found no significant differences on ACDs, ALs and relative lens position (RLP) between patients with PACG associated with RP and patients with PACG; however, patients with APACG associated with RP had a significantly greater LT than patients with APACG. In addition, individuals with PACG associated with RP had the same biometric parameter characteristic as patients with CPACG and APACG. Investigators wrote that these finding suggest that RP might be a coincidental relationship with angle-closure glaucoma.

SOURCE: Xu J, Ouyang Z, Yang Y, et al. Ocular biometry in primary angle-closure glaucoma associated with retinitis pigmentosa. J Ophthalmol. 2017; Dec 31. [Epub ahead of print].

News & Notes
Eyenovia Advances MicroPine for Myopia into Phase III Clinical Development
Eyenovia announced, following discussions with the U.S. Food and Drug Administration, it received clear feedback on its pivotal trial protocol design, as well as confirmation to advance its MicroPine therapeutic program for the treatment of progressive myopia into Phase III clinical development. Based on the growing clinical evidence from academic and collaborative trials, Eyenovia has received feedback that only one Phase III pivotal study will be required for registration instead of two trials. The Phase III trial is planned to start in the first half of 2019. MicroPine is Eyenovia’s proprietary micro-therapeutic formulation of atropine to slow the progression of myopia. Read more.

VSP Global Launches Level Smart Glasses
VSP Global introduced Level smart glasses, featuring activity-tracking technology embedded inside the temple of an optical frame. The technology tracks activity via an accompanying smartphone app; as users reach daily step goals, they earn points redeemable for a donation of vision care services to individuals in need. Level smart glasses began in 2015 as the Project Genesis prototype within VSP Global's innovation lab. A partnership and academic study with USC Center for Body Computing followed in 2016, with results published September 2017 in the NEJM Catalyst. The Level technology, located inside the left temple of the frame, tracks steps, calories burned, distance and total activity time. Level will be sold through hundreds of independent optometry practices participating in the VSP Global Premier Program within select U.S. markets. Read more.

Review of Optometry's New Technologies and Treatments in Eye Care in Nashville, April 6-8, 2018, at the Nashville Marriott at Vanderbilt University
Review of Optometry's New Technologies and Treatments in Eye Care



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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