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


Volume 18, Number 26

Monday, June 25, 2018


Inside this issue: (click heading to view article)
######### Off the Cuff: On Improving Our Ability to Detect Glaucoma
######### Macular Choroidal Thickness in Highly Myopic Women During Pregnancy and Postpartum: a Longitudinal Study
######### Patient Characteristics and Outcomes of Retained Lens Fragments in the Anterior Chamber After Uneventful Phacoemulsification
######### Efficacy of Toric Intraocular Lens Implantation in Eyes with High Myopia: a Prospective, Case-controlled Observational Study
######### News & Notes

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Off the Cuff: On Improving Our Ability to Detect Glaucoma: Guest Author Don Hood

As regular readers know, we don’t often run guest editorials, but from time to time important topics arise that demand broad attention. Don Hood is the James F. Bender Professor of Psychology and Professor of Ophthalmic Science in Ophthalmology at Columbia University. He currently serves as Editor-in-Chief of Investigative Ophthalmology and Visual Science and on the Editorial Board of the Journal of Glaucoma. Don received the Research Excellence Award from the Optometric Glaucoma Society in 2014 and is among the world’s brightest minds in understanding visual system function and physiology. He has a special interest in glaucoma. What Don has to say is very important:

On Improving Our Ability to Detect Glaucoma

Over the past decade, my laboratory has been able to show that macular vision is affected early in the glaucomatous process. This finding goes against conventional wisdom, which holds that that glaucoma affects the peripheral field first and the macular region last. Our work has demonstrated that arcuate field defects near fixation are common, can affect reading and often progress toward fixation. Most importantly, macular field defects can be missed by 24-2 visual fields as well as by conventional OCT scans of the optic disc and simple analyses of peri-papillary circle scans of the retinal nerve fiber layer (RNFL).

Today, the best OCT test for detecting macular glaucomatous damage is a cube scan that includes the central ±10° (corresponding approximately to a 6mm x 6mm square of retina). Thus, we believe that best practice is to obtain OCT images of both the macula and the optic nerve and surrounding tissues. In some OCT instruments, this requires two cube scans, one centered on the macula and one centered on the disc, while in others the scan is wide enough to include both disc and macula. In either case, our OCT instruments are up to the task.

However, it still is important to confirm and stage glaucoma with visual fields. The commonly used 24-2 test pattern of the Humphrey Visual Field Analyzer (Carl Zeiss Meditec) may miss and/or underestimate macular damage simply because its test points are spaced 60 apart, leaving room for scotomas to fall between the points. The Humphrey 10-2 test pattern covers the central 100 with its points spaced 20 apart and can typically detect these defects. But, here is the problem: Because of testing time and billing considerations, many clinicians find it difficult to obtain both a 24-2 and 10-2 visual field. Based upon our research, we and colleagues have helped Zeiss select points to add to the 24-2 to create a 24-2C pattern that would test both the central and macula region. Now we can have our 24-2 and pick up most macular defects as well!

Or so we thought. The latest word from Zeiss is that the 24-2C will only be available on the new HFA3. Perhaps Zeiss does not yet understand the importance of the 24-2C to their customers and to our patients. Recent knowledge has improved our ability to detect glaucomatous damage, and it is important that as many patients as possible enjoy the benefits of this improvement. Zeiss should reconsider making the 24-2C test pattern available on older models of the HFA. 

- Don Hood, PhD

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.

Macular Choroidal Thickness in Highly Myopic Women During Pregnancy and Postpartum: a Longitudinal Study
High myopia, a cause of serious visual impairment, is a significant global public health concern. Researchers investigated longitudinal changes in macular choroidal thickness (CT) during pregnancy and six-months postpartum in women with high myopia (HM). A prospective longitudinal study was conducted in highly myopic (HM) pregnant women during the course of pregnancy (n=42 eyes, 42 patients) and six months postpartum (n=40 eyes, 40 patients, two cases lost). Macular CT was measured via enhanced-depth imaging (EDI)-optical coherence tomography (OCT) (EDI-OCT). Intraocular pressure (IOP), axial length (AL), refractive error, mean arterial pressure (MAP), mean ocular perfusion pressure (MOPP) and body mass index (BMI) were also measured.

Macular CTs of HM pregnant women (214.3μm ± 52.3μm) increased significantly during the third trimester of pregnancy compared with postpartum women (192.7μm ± 51.9μm). No significant differences in AL, refractive error or MAP were found between pregnant and postpartum groups. During pregnancy, macular CT was negatively correlated with AL and positively correlated with refractive error. No correlations between macular CT and age, IOP, MOPP, MAP or BMI were found.

The study revealed the presence of a significantly thicker choroid during the third trimester of pregnancy compared with six-months postpartum in HM women. Macular CT positively correlated with refractive error and negatively correlated with AL during pregnancy, but did not correlate with gestational age, MOPP, IOP, MAP or BMI.

SOURCE: Chen W, Li L, Zhang H, et al. Macular choroidal thickness in highly myopic women during pregnancy and postpartum: a longitudinal study. BMC Pregnancy Childbirth. 2018;18(1):220.

Patient Characteristics and Outcomes of Retained Lens Fragments in the Anterior Chamber After Uneventful Phacoemulsification
Using Current Procedural Terminology codes 2006 to 2018, patients with a diagnosis of retained nuclear fragment in the anterior chamber after uncomplicated phacoemulsification cataract extraction were identified to determine patient characteristics and outcomes for developing retained nuclear fragments in the anterior chamber after phacoemulsification in at-risk populations. Patient demographics, ocular biometrics, treatments and clinical management were recorded. Main outcome measures were visual outcomes and visual acuity at regular follow-up appointments.

Nineteen patients (13 with myopia) were identified. Most patients (n=15) presented with corneal edema and anterior chamber inflammation, and the fragments were diagnosed on slit-lamp exams in most patients (n=18). Seventeen retained fragments were found in the inferior angle. The mean axial length, keratometry and anterior chamber depth (ACD) values were 23.58mm, 44.93D and 2.97mm, respectively. The mean time from cataract extraction to fragment removal was 34.7 days. The final corrected distance visual acuity ranged from 20/20 to 20/400. Three patients developed cystoid macular edema, and two patients had corneal complications after fragment removal.

A comparison between the patients in this study and cited cases indicated that long eyes, steep corneas and a shallow ACD might be risk factors for retained nuclear fragments in patients having cataract extraction. Prompt identification and surgical removal provided the best visual outcomes because most cases proved refractory to steroid treatment.

SOURCE: Norton JC, Goyal S. Patient characteristics and outcomes of retained lens fragments in the anterior chamber after uneventful phacoemulsification. J Cataract Refract Surg. 2018; Jun 13. [Epub ahead of print].


Efficacy of Toric Intraocular Lens Implantation in Eyes with High Myopia: a Prospective, Case-controlled Observational Study
This prospective, clinical observational study aimed to evaluate the efficacy of toric intraocular lenses (IOL) to achieve rotational stability and astigmatism correction in eyes with high myopia. A total of 27 consecutive cataract patients (39 eyes) with pre-existing corneal astigmatism (1.5D to 3.5D) were divided into two groups according to their refractive status: one group of 18 eyes with high myopia (-12.5D to 6.0D) and another group consisting of 21 eyes with emmetropia or low myopia (-3.0D to 0.0D). All eyes underwent cataract phacoemulsification surgeries by the same surgeon, with the implantation of an AcrySof Toric IOL at the pre-designed degree. Uncorrected visual acuity, best-corrected visual acuity and phoropter examination results were recorded at the 1st day, 1st week, 1st month and 3rd month after the surgery. By analyzing digital images from slit-lamp photography with a self-designed software, the rotational stability was observed. The contrast sensitivity was also measured.

No significant difference in the baseline and postoperative residual astigmatism was identified between the two groups. In addition, no significant difference in the degree of rotation was observed between the two groups. All patients had significantly improved visual quality after the surgery.

Investigators observed an equal astigmatism-correction efficiency and rotational stability in the two groups. They concluded that a second auxiliary spot-penetrating incision, removal of visco-elastic substances and tight adherence of the IOL to the posterior capsular membrane were essential for a successful surgery.

SOURCE: Guo T, Gao P, Fang L, et al. Efficacy of toric intraocular lens implantation in eyes with high myopia: a prospective, case-controlled observational study. Exp Ther Med. 2018;15(6):5288-94.

News & Notes

FDA Approves iDESIGN Refractive Studio
Johnson & Johnson Vision announced FDA approval of the iDESIGN Refractive Studio, the only system to use topography-integrated, wavefront-guided technology. The platform is approved for myopia, hyperopia and mixed astigmatism. Additionally, it is the only available LASIK platform indicated for monovision LASIK in presbyopic myopic patients. Monovision is a procedure designed for patients over 40 years old who are experiencing blurry near vision due to aging of their eyes. Each treatment plan begins with a wavefront analysis to measure how light travels inside the eye, detailing the imperfections in a patient’s vision. The corneal topography scans the outside surface of the eye, measuring and analyzing tiny variations in curvature and elevation. The combination of the two measurements delivers a custom LASIK procedure tailored for each eye. The new system will be marketed by Johnson & Johnson Surgical Vision and be commercially available in the third quarter. Read more.



B+L Ultra For Astigmatism Contact Lenses Offer -2.75D Cylinder Power, Company Receives Pre-Market Approval for Envista Toric MX60T IOL
Bausch + Lomb Ultra for Astigmatism contact lenses are now available in a cylinder power of -2.75D, across all power ranges in the portfolio, from +6.00D to -9.00D. The lenses combine MoistureSeal technology, which helps to maintain 95 percent of lens moisture for a full 16 hours and OpticAlign design, engineered for stability to promote a successful first fit. This latest expansion will allow eye care professionals to fit more of their astigmatic patients with these lenses to provide all-day comfort, stability and consistently clear vision. Read more.
In addition, the company received FDA pre-market approval for the enVista toric MX60T, the company’s first hydrophobic acrylic intraocular lens for astigmatism correction. The IOL features a one-piece, aberration-free, aspheric optic with fenestrated, step-vaulted, modified C-loop haptic design to deliver exceptional rotational stability and ensure predictable astigmatism correction. Additionally, the optic’s posterior square edge provides a 360-degree barrier to posterior capsular opacification. Read more.

Avedro Enrolls First Patient in Phase III Epi-on Corneal Cross-Linking Trial for Progressive Keratoconus
Avedro began enrolling patients in a Phase III clinical trial to evaluate the safety and efficacy of an epithelium-on corneal collagen cross-linking procedure to treat patients with progressive keratoconus. The multicenter, randomized, controlled trial of a novel corneal cross-linking procedure involves 275 patients with progressive keratoconus across approximately 20 sites in the United States. Read more.

EyePromise Hires New President & CFO
EyePromise announced the appointments of Andreas Wolf as president and Peggy Stohr as chief financial officer. Wolf previously served as vice president and general manager of Young Dental, and before that, in various roles at Novus International. At EyePromise, Wolf takes responsibility for all of the company’s business activities and growth strategies. Stohr comes with a strong strategic financial and administrative background, having served at public and private medical device organizations.

RightEye Unveils Computer-based Vision Training for Visual Dysfunction
RightEye unveiled its new EyeQ Trainer computer-based vision rehabilitation program at Optometry's Meeting 2018, which takes place June 20 to 24 in Denver, (booth #611). EyeQ Trainer gives optometrists a tool their patients can use at home to rehabilitate eye-movement issues. Through a series of simple exercises conducted on a personal computer or tablet with an internet connection during which patients engage in specific eye movements, RightEye EyeQ Trainer activates the eyes' muscles, as well as key elements of brain circuitry. The circuitry activation is intended to yield better functional vision, and smoother and more accurate eye movements that directly impact quality of life. Read more.

Orasis Closes $13 Million Series B Financing
Orasis Pharmaceuticals closed a $13 million Series B financing, led by Visionary Ventures, with participation from Sequoia Capital, SBI (Japan) Innovation Ventures, LifeSci Venture Partners and other private investors. Proceeds will advance the company’s lead product candidate, CSF-1, an eye drop in development for the treatment of presbyopia symptoms, through completion of its Phase IIb clinical trial. 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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