Optometric Physician

Vol. 21, #8   •   Monday, March 1, 2021


Off the Cuff: COVID - The Coming Months

Over the past year I have tried my best to compile the latest news and science so I could share what I figured out with readers. The usual sources for guidance, like the FDA, CDC and NIH, have been sadly disappointing. My early analyses have largely held up and my conclusions and recommendations mostly validated. COVID-19 never learned to walk, it infects primarily through airborne transmission, and the masks, antisocial distancing and HEPA filtration I recommended early on remain sage advice.

While I am elated by ramped-up vaccine production and increasing access around much of the world, I am distressed by the lack of interest in the US in Ivermectin, an apparently effective, low-cost and easily accessible treatment that is rapidly gaining in acceptance in other countries.

The burden of social isolation and lingering uncertainty has certainly taken its toll, and I suspect that all of us, Shannon and I included, would love nothing more than to get back to the lives we had before March 2020. I miss the meetings, the personal contacts, the friends and even the travel. Despite Shannon and I being like two peas in a pod, we are both starting to go a bit stir crazy.

This is where I would like to say, “Hey everyone, I have some great news. The worst is over and things will get back to normal any day now.” I so wish I could say that, but I can’t. While the pandemic is definitely showing signs of retreat for the moment, I suspect that this is only a lull in a still-dangerous storm. Even now, we are seeing more transmissible, virulent and possibly-more lethal mutations. These strains will continue to emerge in areas of low inoculation and spread to more populous areas just as we’re seeing with the UK, South African and other variants now spreading through the US. While I hope I’m wrong, I expect to see another spike in infections by early summer, despite the growing numbers of vaccinated. I also expect vaccine booster shots targeting new strains to be introduced by late summer or early fall.

All of this does not bode well for meetings and resumption of normalcy. I know normalcy will eventually come, but I don’t think it will come as fast as all of us would like. In the interim, as a profession, we need to consider how we will deal with educating our students, supporting our organizations—especially those that depended on CE-related income—and educating our colleagues. We also need to consider that, for the foreseeable future, we will likely remain, at least in part, in a virtual reality.

Editor’s note: Thanks to the many of your who wrote to share perspective, thoughts and friendship after last week’s OTC. It was not an easy one to write, and I was touched and moved by your words. I also wanted to thank Scott Jens. Many of you know Scott from his volunteer work with the AOA or perhaps as the developer of RevolutionEHR software. Scott currently and generously shares his uncanny ability to succeed with others through Sandbox Coaching. Scott also produces a blog, chock filled with wisdom and interviews of colleagues who have had interesting or unusual professional careers.

I was humbled when he asked if I would consent to an interview. It was an incredible experience, one that helped put me in touch with who I am, where I came from and why I do what I do. It also led to last week’s piece. I highly recommend you visit Sandbox stories. Scott has managed to capture the best of the best of us. If you want to hear my interview, you can catch it here. If you like OP and want to know what makes me tick, you’ll enjoy it. Thanks Scott!


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 Jobson Medical Information LLC (JMI), or any other entities or individuals.



Case Report: Crying Blood

Hemolacria (bloody tears) is a rare clinical presentation with varied underlying etiologies. Thorough clinical evaluation is essential to diagnosis and management. This study aimed to report unilateral hemolacria in a known contact lens wearer with an occult, palpebral, conjunctival pyogenic granuloma and review the literature.

A 21-year-old female contact lens wearer presented to the clinic after three episodes of sudden painless bloody tears from the right eye. She was referred to the oculoplastic clinic for evaluation. On everting her right upper lid, a fleshy, nontender, ovoid, pedunculated mass was found attached to the palpebral conjunctiva of the right, nasal, upper tarsus. Surgical excision was performed in the office, and pathological examination of the lesion was consistent with pyogenic granuloma.

Researchers wrote that unilateral hemolacria should raise clinical suspicion for a hidden conjunctival lesion such as pyogenic granuloma, although other more sinister causes of hemolacria must also be considered. They added that thorough evaluation including eyelid eversion is critical in identifying and managing occult conjunctival lesions.

SOURCE: Idowu OO, Kaidonis G, Husain S, et al. Case Report: Crying Blood. Optom Vis Sci. 2021; Feb 26. [Epub ahead of print].


Multiple Penetrating Eye Wounds Due to Suspected Self-Injury

Researchers presented a case of a 29-year-old male night watchman complaining of sudden decreased vision, redness and tearing of the left eye. On anamnesis, trauma was denied and personal past history was relevant for right eye enucleation due to an "eye injury" eight years prior. At presentation, his visual acuity was 20/200 and intraocular pressure (IOP) was 10 mmHg. Slit-lamp examination revealed a 1-mm inferonasal corneal wound and a localized lens opacity associated with extrusion and posterior extension of cortical material in the same quadrant. Echography confirmed posterior lens capsular bag puncture with hyperechogenic material in the anterior vitreous. Intraocular foreign body was ruled out.

Topical anti-inflammatory and cycloplegic treatment was initiated with partial visual recovery, IOP rise, moderate anterior chamber inflammatory reaction and an emergent posterior subcapsular cataract. A pars plana vitrectomy and lensectomy were performed. After surgery and recovery, best-corrected visual acuity with contact lens was 20/15. The patient was followed for six years, during which he returned six more times with a variety of new findings, such as new corneal leukoma, leaking corneal wounds, hypotony, choroidal folds and choroidal detachments, each time with full visual acuity recovery.

Researchers wrote that some cases of ocular injury and self-mutilation have been described in the context of various psychiatric disorders. Self-inflicted injuries were suspected due to substance abuse, although the patient denied doing so. Referral to a psychiatrist was insisted on in several occasions without success. However, potentially life-threatening complications may arise; therefore, psychiatric referral is imperative.

SOURCE: Dalma-Weiszhausz J, Alvarado JAO, Licona AMS, et al. Multiple penetrating eye wounds due to suspected self-injury. Turk J Ophthalmol 2021; Feb 25;51(1):58-61.


Comparative Study of Lamina Cribrosa Thickness Between Primary Angle-Closure and Primary Open-Angle Glaucoma

A comparative cross-sectional study was conducted to compare lamina cribrosa thickness (LCT) of primary angle-closure glaucoma (PACG) and primary open-angle glaucoma (POAG) using the enhanced depth-imaging mode of the Heidelberg Spectralis spectral-domain optical coherence tomography (EDI-OCT). Investigators enrolled 34 patients with PACG, 38 with POAG and 62 controls, testing only one eye of each participant. Lamina cribrosa thickness was determined at the center of the optic nerve head using EDI-OCT. Nine points of LCT were measured, and LCT averages were analyzed.

Mean age, number of glaucoma medications, current intraocular pressure (IOP), cup to disc ratio and visual field indices were not significantly different between PACG and POAG eyes. The maximum IOP (SD) was higher in PACG than in POAG, at 32.5 (10.46) vs. 25.05 (6.42) mmHg, and LCTs were significantly different among the PACG, POAG and control groups. Mean (SD) LCTs were 226.99 (31.08), 257.17 (19.46) and 290.75 (28.02) μm, respectively. Lamina cribrosa thickness was correlated with mean deviation of the visual field, while it was inversely correlated with maximum IOP. Linear regression analysis revealed that LCT was inversely related to age, female and maximum IOP. LCT was marginally related to visual field MD.

Investigators reported that glaucomatous eyes had thinner LCT than controls, and maximum IOP was inversely correlated to the LCT. They added that PACG eyes had higher maximum IOP and thinner LCT than POAG ones. Investigators concluded that EDI-OCT emphasized the pressure-dependent mechanism of glaucoma on lamina cribrosa deformation and the higher IOP-loaded stress, which led to a greater lamina cribrosa strain.

SOURCE: Wanichwecharungruang B, Kongthaworn A, Wagner D, et al. Comparative study of lamina cribrosa thickness between primary angle-closure and primary open-angle glaucoma. Clin Ophthalmol 2021; Feb 18;15:697-705.





Industry News

Allergan Submits NDA for Investigational AGN-190584 Presbyopia Treatment

Allergan submitted a New Drug Application to the FDA for investigational AGN-190584 (pilocarpine 1.25%) ophthalmic solution for the treatment of presbyopia. The FDA is expected to act on the NDA by the end of 2021. The NDA is based primarily on data from two Phase III GEMINI I and GEMINI II clinical studies, which evaluated the efficacy, safety and tolerability of AGN-190584 (pilocarpine 1.25%). In both studies, AGN-190584 met the primary endpoint reaching statistical significance in improvement in near vision in mesopic conditions without a loss of distance vision vs. the vehicle. No serious adverse events were observed in any AGN190584 treated participants. Read more.




B+L Launches Alaway Preservative Free Antihistamine Eye Drops

Bausch + Lomb announced the U.S. launch of Alaway Preservative Free (ketotifen fumarate ophthalmic solution 0.035%) antihistamine eye drops, the first over-the-counter preservative-free antihistamine eye itch relief drop approved by the FDA. Alaway Preservative Free is a new, OTC prescription-strength formula formulated to block the release of histamines and reduce allergic inflammation. Alaway provides relief within minutes and lasts up to 12 hours with one dose. Read more.

Prevent Blindness Declares March Workplace Eye Wellness Month, 13th Swing Fore Sight Golf Tournament at Vision Expo East

Prevent Blindness declared March as Workplace Eye Wellness Month. Because one of the many negative effects of the ongoing COVID-19 pandemic is increased digital screen time for many remote workers, Prevent Blindness is raising awareness of digital eye strain and providing tips on ways to decrease the effects of increased screen time. Symptoms of digital eye strain, also referred to as computer vision syndrome, include tired, burning or itching eyes, dry eyes, blurred vision and/or headache. Prevent Blindness also recently launched its Screen Time-Out awareness campaign to educate individuals on the effects of increased screen time. Learn more.
In addition, Prevent Blindness announced the 2021 Prevent Blindness Swing Fore Sight Golf Tournament will take place June 2 at the Orange County National Golf Center and Lodge, Orlando, Fla., in conjunction with Vision Expo East registration and lunch. All proceeds from the event will go to support Prevent Blindness and its sight-saving mission. The Swing Fore Sight golf committee is co-chaired by Michael Block of Block Business Group and Joe Savarese of Jobson Interactive. All sponsorship levels are now available. Read more.



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