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


Volume 19, Number 25

Monday, June 24, 2019


Inside this issue: (click heading to view article)
######### Off the Cuff: What’s Happening in Arkansas Endangers Optometry in Every State
######### Association Between Radiation, Glaucoma Subtype, and Retinal Vessel Diameter in Atomic Bomb Survivors
######### Effect of Trabeculectomy on Corneal Endothelial Cell Loss
######### Ciliochoroidal Effusion Syndrome with Central Serous-like Chorioretinopathy and Secondary Angle Closure Following Exogenous Testosterone Use
######### News & Notes

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Off the Cuff: What’s Happening in Arkansas Endangers Optometry in Every State

Last week, Arkansas lawyer/lobbyist Alex Gray filed a referendum petition on behalf of Safe Surgery Arkansas, a coalition of MDs touting patient safety concerns to thinly mask an aggressive anti-OD agenda. The referendum, if passed, would overturn recently enacted Act 579, which amended the definition of optometric practice in Arkansas to include local injection, incision and curettage of chalazia, removal of superficial peri-ocular skin lesions, and limited laser procedures after appropriate training and certification.

Arkansas is a largely rural state with many communities having limited access to specialty care, including ophthalmology. This results in an unnecessary and costly burden for patients who either do without or are forced to travel significant distances, despite trained practitioners being available locally who can provide appropriate care. It was this need for greater access that prompted overwhelming support by Arkansas legislators for Act 579. And as is almost always the case when optometry seeks to expand its scope to better serve our patients, the legislation met with intense opposition, scrutiny and lengthy debate before it was wisely and fairly enacted into law.

While a growing number of ophthalmologists have embraced interprofessional cooperation and work closely with ODs, there remains a small, but virulent, segment more interested in protecting their own turf and income than the wellbeing of their patients. The Safe Surgery Coalition is well-funded and well-organized. In the past, most of their efforts have focused on lobbying, PR and press. However, with this latest move, the game has suddenly taken a very dangerous turn.

The referendum process, created to give citizens a greater and more direct voice in government, exists in 24 states. Recently, it has increasingly been co-opted by outsiders with agendas and lots of money. Often distant from the states and communities where the actual battles are being fought, large amounts of dark money are being used to thwart the legislative process. This not only poses a threat to our democratic process as Americans, but closer to home, if the oxymoronic Safe Surgery Arkansas is successful in overturning Act 579, all future optometric scope expansion legislation as well as existing optometric regulations become vulnerable in many states.

I believe it is likely that this referendum will make it to the ballot. If it does, a tremendous amount of money will be spent on convincing the people of Arkansas, especially those in more densely populated areas with a bigger share of voice, into voting to overturn Act 579. If that happens this won’t just be a problem for the AROA and Arkansas ODs. No optometric practice act will be safe just about anywhere in the US.

From past experience I don’t expect the AOA to do much to fend off this threat (more on that later), so it will be up to us to come together to form a national force against such a travesty. Think about it. If just half the ODs in the US donated $50, a million dollars could be raised in a matter of days. I will be keeping a very close eye on this referendum petition and will likely have a lot more to say in the coming weeks and months.



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.


Association Between Radiation, Glaucoma Subtype, and Retinal Vessel Diameter in Atomic Bomb Survivors
Researchers examined the relationship between glaucoma subtype and retinal vascular caliber as markers of ocular circulation. Subjects were Japanese atomic bomb survivors in Hiroshima and Nagasaki. After a screening examination, potential cases were further examined. The diameters of central retinal artery and vein equivalents (CRAE and CRVE) on digitized retinal photographs were measured using an established method. Generalized linear regression analyses were used to examine the associations among vessel diameters, radiation exposure and prevalence of glaucoma subtypes among the study subjects.

Researchers identified 196 cases of glaucoma (12%) based on optic disc appearance, perimetry results and other ocular findings. The main subtypes were primary angle-closure glaucoma, primary open-angle glaucoma and normal-tension glaucoma (NTG). NTG was the dominant subtype (78%). NTG was negatively associated with CRAE and CRVE, and positively associated with radiation dose. CRVE was negatively associated with radiation dose, and the association was unclear for CRAE.

Researchers concluded that the smaller retinal vessel caliber in NTG patients than in subjects without glaucoma might indicate an association between ocular blood flow and the pathogenesis of NTG. However, they added that significant relationships among vessel calibers, NTG and radiation exposure were not clear.

SOURCE: Kiuchi Y, Yanagi M, Itakura K, et al. Association between radiation, glaucoma subtype, and retinal vessel diameter in atomic bomb survivors. Sci Rep. 2019;9(1):8642.

Effect of Trabeculectomy on Corneal Endothelial Cell Loss
This prospective, observational study followed 117 eyes of 117 patients for two years after trabeculectomy to investigate changes in corneal endothelial cell density (CECD) after trabeculectomy. The central cornea was examined by corneal specular microscopy prior to, and at every six months after, the surgery. Survival analysis of patients who exhibited a 10% or less reduction of the postoperative CECD compared with preoperative levels was assessed using the Kaplan-Meier survival curve. A Cox proportional hazards model was used to evaluate prognostic factors for decreasing CECD.

At baseline, the mean CECD was 2,420 ± 357cells/mm2, while at six, 12, 18 and 24 months after surgery, the mean CECD was 2,324 ± 373cells/mm2, 2,276 ± 400cells/mm2, 2,290 ± 398cells/mm2 and 2,267 ± 446cells/mm2, respectively. At six, 12, 18 and 24 months after surgery, the results of the Kaplan-Meier survival analysis of the 10% loss of CECD from baseline were 91%, 85%, 83% and 77%, respectively. Uveitic glaucoma was a significant prognostic factor for decreasing CECD.

Investigators found that CECD significantly and continuously decreased after trabeculectomy.

SOURCE: Hirooka K, Nitta E, Ukegawa K, Sato S, Kiuchi Y. Effect of trabeculectomy on corneal endothelial cell loss. Br J Ophthalmol. 2019; Jun 14. [Epub ahead of print].



Ciliochoroidal Effusion Syndrome with Central Serous-like Chorioretinopathy and Secondary Angle Closure Following Exogenous Testosterone Use
A 37 year-old man presented with a two-week history of blurred vision, elevated intraocular pressure and myopic shift in his right eye. Gonioscopy showed angle closure. After YAG iridotomy, ultrasound biomicroscopy (UBM) showed ciliochoroidal effusion and anterior rotation of the ciliary processes. Subsequent color fundus photography, enhanced depth imaging optical coherence tomography (EDI-OCT) and near-infrared reduced-illuminance autofluorescence imaging (NIR-RAFI) showed macular striae, choroidal folds, and increased choroidal thickness without presence of subretinal fluid (SRF) or pigment epithelial detachment (PED). Further questioning revealed the patient was using dermal testosterone gel for six months for treatment of hypogonadism. The patient stopped using the testosterone gel, and his visual acuity and intraocular pressure significantly improved six weeks later. Follow-up UBM showed significant improvement of the ciliochoroidal effusion, and repeat multimodal images demonstrated resolution of the macular striae and choroidal folds, and slightly improved choroidal thickness.

This patient demonstrated a rare case of ciliochoroidal effusion, central serous-like chorioretinopathy and secondary angle closure that dramatically improved with cessation of testosterone. Researchers wrote that they believed that this unique clinical constellation was the first to be reportedly associated with exogenous testosterone use.

SOURCE: Brill D, Albert D, Fields T, et al. Ciliochoroidal effusion syndrome with central serous-like chorioretinopathy and secondary angle closure following exogenous testosterone use. Am J Ophthalmol Case Rep. 2019;15:100482

News & Notes
B+L Ultra Multifocal for Astigmatism CLs Now Available as Standard Offering in Fit Sets
Bausch + Lomb announced the U.S. launch of Bausch + Lomb Ultra Multifocal for Astigmatism contact lenses, the first multifocal toric lens available as a standard offering in the eye care professional’s fit set. The monthly silicone hydrogel lens, designed to address the lifestyle and vision needs of patients with both astigmatism and presbyopia, combines the company’s 3-Zone Progressive multifocal design with the stability of its OpticAlign toric design to provide eye care professionals and patients an advanced contact lens technology with the convenience of same-day fitting during the initial lens exam. Eye care professionals can offer patients a broad range of parameters from +4.00D to -6.00D with two add powers and three cylinders of around-the-clock astigmatism correction. Read more.

EyePromise Introduces Screen Shield Pro
EyePromise introduced Screen Shield Pro to its eye vitamin line. The screen shield is designed to protect and relieve the associated symptoms of digital eye strain of adults (ages 18 and up) who spend eight-plus hours staring at digital screens while working, gaming or watching television. It follows the recent introduction of Screen Shield Teen, an ocular nutrition supplement specially formulated to preserve and support visual comfort and wellness for children ages four to 17. Read more.

IDOC to Provide Members with IDOC Insider Advanced Analytics
IDOC is offering unlimited access to state-of-the-art business analytics and reporting as a complimentary benefit to members with GPN-compatible practice management systems. It is adding a customized Report Card feature to the Insider benefit package, which provides data-driven practice performance feedback in dashboard format. IDOC Insider is powered by EDGEPro by GPN Technologies, a provider of data and analytics software for the eye care industry, and combines data and sell-through analytics technology with customized, metrics-driven business recommendations based on practice data. IDOC Insider Report Card will display clinical and optical revenue, sales volume by product type, performance benchmarks compared to participating IDOC member averages and other key performance indicators. Those KPIs are then interpreted by IDOC practice management experts, who provide actionable steps to help members identify and act on market opportunities. Learn more.

RightEye, USA Baseball and Optometrists Team Up
RightEye is working with USA Baseball for the third consecutive year to provide baseline sports vision assessment to all athletes entering the Prospect Development Pipeline, a collaboration between USA Baseball and Major League Baseball. For the first time, RightEye will also recommend local optometrists who can help athletes correct functional vision issues and improve performance on the field. At 34 events taking place across the country, prospective collegiate and professional baseball players will be screened with RightEye Sports Vision and Functional Vision EyeQ, a set of objective eye-tracking tests that measures and analyzes eye movement, brain processing and reaction time, and compares scores to those of peers, amateurs and pro athletes. Read 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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