Optometric Physician

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


Volume 21, Number 2

Monday, January 18, 2021


Inside this issue: (click heading to view article)
######### Off the Cuff: Some Secret Sauce

######### The Distribution of Retinal Venous Pressure and Intraocular Pressure Differs Significantly in Patients with Primary Open-angle Glaucoma
######### Clinical Effectiveness of Laser-induced Increased Depth of Field for the Simultaneous Correction of Hyperopia and Presbyopia
  Depression Among Keratoconus Patients
######### News & Notes

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Off the Cuff: Some Secret Sauce

One of the basic tenets of medicine is sharing knowledge freely. It is a principle I hold dear and a large part of the reason for the existence of Optometric Physician. Over the past year, I’ve made some huge advances in understanding and treating dry eye. In this issue, I’ll share some of what I’ve figured out—what some call my “secret sauce.” Hopefully you will find it helpful. Note that some of it is off-label; also, I have no financial interest in any of the products mentioned.

Nocturnal exposure is a frequently underrecognized cause or associated finding in dry eye patients. More often than not, the patient will actually tell you that they have exposure if you simply ask. Patients will describe a dry, gritty, sandpaper feeling and difficulty opening their eyes on waking. Exposure can be easily confirmed by having the patient tilt their head back about 30 degrees, and from below, looking for glistening conjunctiva or cornea using a penlight or transilluminator. A mainstay treatment has been Eye Eco’s Eyeseals 4.0 or Onyix and Quartz hydrating silicone masks. An alternative that I’ve been using more and more of late is VitA-POS, a paraffin-based ointment containing Vitamin A. Manufactured by URSAPHARM and distributed by Scope Opthalmics, VitA-POS or HYLO NIGHT, as it has been renamed, is not directly available in the US since paraffin is not on the FDA OTC monograph. However, it can be found on Amazon or eBay. A small titratable 2-5mm ribbon in the lower cul-de-sac creates an effective moisture barrier and does not leave the gooey morning mess that petrolatum-based products do.

Since discovering Regener-Eyes five or six years ago, I rarely prescribe autologous serum tears any more. I’ve had good success with the “full strength” product, now called Regener-Eyes Professional Strength. For some patients, the biologic was transformative, promoting dramatically improved comfort, decreased staining and, in a few cases, recovery of meibomian gland structure. The two issues that limited use were the need for refrigeration and cost. Last year the company came out with Regener-Eyes LITE. So far, I am very impressed with it, and because of lower cost and no need for refrigeration, I am using it for a broader range of patients. I’ll report back when we have more experience, but even at this early stage I recommend you consider adding it to your dry eye OSD armamentarium.

EBMD and RCE effect many patients. Treatment has evolved over the years, yet remains subject to debate. When a patient presents with epithelial erosion, debriding loose, poorly adherent epithelium and applying a Prokera amniotic membrane can work wonders. The erosion usually heals quickly and, in many patients, does not return. For others, RCE occurs so often and is so painful that the patient may actually dread going to sleep. About six months ago, I discovered that Xiidra, a novel surface-active anti-inflammatory FDA approved for the signs and symptoms of dry eye, used twice daily was highly effective in reducing and possibly eliminating RCE. I hypothesize that Xiidra blocks T-cell adhesion and subsequent surface inflammation that damages epithelial adhesion complexes resulting in subsequent erosion. Keep in mind that this is an off-label indication and an early observation. However, I’ve had enough success to share it with you. I welcome hearing about your experience if you try it.

This has been a rough week in America. No matter what side of the political aisle you are on, it was hard not to see the events that occurred in our nation’s capital and the disturbing ripple effects it caused as a sad moment in our nation’s history. It is my sincere wish that we find our way to hearing and treating each other with open minds and hearts, and mutual respect. Now more than ever, we need to realize that as Americans, we have much more in common than the issues that separate us.


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.



The Distribution of Retinal Venous Pressure and Intraocular Pressure Differs Significantly in Patients with Primary Open-angle Glaucoma

Until now, venous pressure within the eye has widely been equated with intraocular pressure (IOP). Measurements with dynamometers calibrated in instrument units or in force showed that the retinal venous pressure (RVP) may be higher than the IOP in glaucoma patients. In this study, the RVP was measured with a contact lens dynamometer calibrated in mmHg. Fifty consecutive patients ages 69 ± 8 years with primary open-angle glaucoma (POAG) who underwent diurnal curve measurement under medication were included. RVP was measured via contact lens dynamometry, and IOP measurement was measured via dynamic contour tonometry.

In all 50 patients, the IOP was 15.9 mmHg [median (Q1; Q3)] (13.6 mmHg; 17.1 mmHg), and the RVP was 17.4 mmHg (14.8 mmHg; 27.2 mmHg). The distribution of the IOP was normal, and that of the RVP was right skewed. In the subgroup of 34 patients with spontaneous pulsation of the central retinal vein (SVP), the IOP and therefore, by definition, the RVP was 16.5 mmHg (13.7 mmHg; 17.4 mmHg). In the subgroup of 16 patients without SVP, the IOP was 14.8 mmHg (13.3 mmHg; 16.4 mmHg), and the RVP was 31.3 mmHg (26.2 mmHg; 38.8 mmHg). In systemic treatment, the number of patients for the prescribed drugs were: ACE inhibitors (20), β-blockers (17), angiotensin II-receptor blockers (13), calcium channel blockers (12), diuretics (7). No difference in RVP was observed between patients receiving these drugs and not receiving them, except in the β-blocker group. Here, the 17 patients with systemic β-blockers had a median RVP of 15.6 mmHg and 20.2 mmHg without. In the 16 patients with a higher RVP than IOP, only one patient received a systemic β-blocker. The median IOP was 15.7 mmHg with systemic β-blockers and 16.1 mmHg without.

In a subgroup of 16 of the 50 patients studied, the RVP was greater than the IOP by a highly statistically and clinically significant degree. According to the widely accepted thinking on the pathophysiology of retinal and optic nerve head circulation, the blood flow in these tissues may be much more compromised in this group of patients than has been assumed, the researchers wrote. They may be identified by a missing SVP. Topical and systemic medications showed no statistically significant influence on the RVP, except for the systemic β-blockers, in which the RVP was lower by 4.6 mmHg than for the patients who did not receive these drugs.

SOURCE: Stodtmeister R, Koch W, Georgii S, et al. The distribution of retinal venous pressure and intraocular pressure differs significantly in patients with primary open-angle glaucoma. Klin Monbl Augenheilkd. 2021; Jan 12. [Epub ahead of print].


Clinical Effectiveness of Laser-induced Increased Depth of Field for the Simultaneous Correction of Hyperopia and Presbyopia

These researchers evaluated the visual outcomes of patients with presbyopic hyperopia, comparing the current standard of monovision treatment with a novel bilateral presbyopic LASIK (Custom-Q mode) technique. This prospective comparative study of consecutive eligible patients with presbyopic hyperopia undergoing a bilateral presbyopic laser in situ keratomileusis technique was conducted between January 2018 and February 2019. After contact lens-simulated monovision measurements were obtained, the non-dominant eyes had a negative aspheric ablation profile planned using the Custom-Q nomogram (Alcon Laboratories). The dominant eye was operated on with a positive aspheric ablation profile. Visual acuity testing, refraction, corneal asphericity (▵Q), higher order aberrations and a satisfaction questionnaire (National Eye Institute Refractive Error Quality of Life) were evaluated after the monovision trial and postoperatively.

Twenty-eight patients, with a mean age of 56.03 ± 4.31 years, were included in the study. At six months, 100% of patients achieved 20/20 or better binocular uncorrected distance visual acuity (UDVA) vs. 57% in the monovision group, 100% of patients achieved 20/25 or better binocular uncorrected intermediate visual acuity vs. 32% in the monovision group, and 92.86% of patients achieved 20/25 or better binocular uncorrected near visual acuity (UNVA) in both groups. In contact lens monovision simulation, no patient reached a UDVA of 20/50 or better, with only 3.6% having a UNVA of 20/40 or better. The questionnaire demonstrated high patient satisfaction.

The outcomes confirmed the superiority of increased depth of focus using negative spherical aberration modulation in the non-dominant eye compared with contact lens monovision. They also demonstrated the effectiveness of positive spherical aberration induction to improve intermediate and near vision in the dominant eye.

SOURCE: Rahmania N, Salah I, Rampat R, et al. Clinical effectiveness of laser-induced increased depth of field for the simultaneous correction of hyperopia and presbyopia. J Refract Surg. 2021; Jan 1;37(1):16-24. [Epub ahead of print].



Depression Among Keratoconus Patients

Depression is a highly prevalent disorder globally and locally in Saudi Arabia. Individuals with chronic conditions are more liable to develop depression. Keratoconus is a chronic progressive corneal disorder that markedly affects the vision and quality of life, making its sufferers liable to developing depression. This was a descriptive cross-sectional study that was conducted using 9-item Patient Health Questionnaire (PHQ-9) to screen for depression among adults ages 18 to 60 years old only. The participants in this study were patients who were previously diagnosed with keratoconus by their ophthalmologists. The structured questionnaire was distributed using Google Forms through various social media platforms. After extracting the data, it was revised, coded and then analyzed using the Statistical Packages for Social Sciences (SPSS), version 21 (IBM Corp.).

A total of 330 keratoconus patients living in Saudi Arabia were recruited in this study. The modal age group was 31 to 40 years old (44.5%), and the male to female ratio was 3:2. The most frequently reported concurrent eye diseases of the patients were astigmatism (48.5%) and myopia (36.7%). The prevalence of depression among patients with keratoconus was 40.6% (n=134). The use of corrective contact lenses (both: hybrid and rigid lens) in both eyes contributed to a significantly higher depression rate among its wearers compared to users in one eye and non-users.

Researchers wrote that depression is highly prevalent among keratoconus patients. They added that this is especially true among corrective contact lens wearers of both eyes. Keratoconus is associated with depression regardless of disease severity and socio-demographic characteristics.

SOURCE: Al-Dairi W, Al Sowayigh OM, Al Saeed AA, et al. Depression among keratoconus patients in Saudi Arabia. Cureus. 2020; Dec 6;12(12):e11932.

News & Notes

Haag-Streit Introduces Lenstar Myopia
Haag-Streit introduced Lenstar Myopia, consisting of the Lenstar 900 optical biometer and EyeSuite Myopia software, developed in close cooperation with myopia experts Thomas Aller, OD, and Pascal Blaser, founder and developer of myopia.care. Aside from precise axial length measurements, Lenstar 900 offers a wide range of data including keratometry metrics for making accurate predictions about myopia’s onset and progression,. Read more.

  Eye Health Organizations Unveil New Recommendations for Myopia
Johnson & Johnson Vision announced a new guide with recommendations for eye care professionals to assess, monitor and treat myopia in children. “Managing Myopia: A Clinical Response to the Growing Epidemic,” is the result of a year of collaboration with the American Optometric Association, American Academy of Optometry, Association of Schools and Colleges of Optometry, and Singapore Optometric Association. This marks the latest milestone to address the growing myopia epidemic following the establishment of a strategic research partnership between Johnson & Johnson Vision, the Singapore National Eye Centre and the Singapore Eye Research Institute. 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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