Optometric Physician



Vol. 23, #10  •   Monday, March 14, 2022


Off the Cuff: Bad Luck

Some patients are complex and complicated. Some are simple and straightforward. Since COVID began, our practice increasingly looks more like a cross between a MASH unit and a conglomeration of university tertiary specialty clinics.

A few weeks ago, a pleasant 70-something gentleman was referred for severe dry eye by a local colleague. The patient shared that his symptoms were much worse in the morning and had become quite bothersome, but had resisted a variety of treatments. The history was especially interesting. The patient reported having developed Bell’s palsy shortly after receiving a Moderna COVID vaccine booster shot. While uncommon, Bell’s palsy has been reported after different vaccinations, not just for COVID. In his case, the partial paralysis caused lagophthalmos and nocturnal exposure. It was being managed with Muro 128 ointment, which I thought a bit unusual.

On examination, he still had a small amount of persistent lid gap in the affected eye. On slit lamp exam, instead of an area of dense SPK I expected, I observed a broad area of inferior corneal edema with a small amount of overlying SPK. The edema was significant and was confirmed by anterior segment OCT.

As I shared these findings with the patient, he told me that he had forgotten to mention that he had cataract surgery in that eye shortly before the booster vaccination and that the surgeon had to subsequently perform a second procedure to retrieve a piece of the lens that had “broken off” during the original operation. At that point what had happened was pretty obvious. While the “blame” for his worsening symptoms had been placed on the vaccination and subsequent Bell’s palsy, much of the problem was due to a surgical mishap—either from the retained lens fragment or, more likely, from phaco damage during the second surgery.

As you can imagine, explaining this to a patient delicately is not an easy task, especially as he continued to decompensate with painful bullae forming over the damaged area. We tried a number of increasingly aggressive approaches from bandage lenses to amniotic membrane with all ultimately failing. After a frank conversation about options, we referred him to a skilled local corneal surgeon for evaluation for DSEK or DMEK. For this poor gentleman, if he didn’t have bad luck he might not have had any luck at all. For clinicians, this case serves as an important reminder that seemingly simple things can quickly turn into complex challenges.



Arthur B. Epstein, OD, FAAO
Chief Medical Editor

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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.




Evaluation of Corneal Staining With an Antihistamine-Releasing Contact Lens

Practitioners can be reassured that this antihistamine-releasing contact lens has no additional effect on corneal epithelial integrity. To evaluate the effect of an antihistamine-releasing soft contact lens on corneal epithelium integrity when worn on a daily disposable modality for 12 weeks. Two clinical trials using the same randomized, double-masked, placebo-controlled, parallel-group design enrolled healthy contact lens wearers. Participants wore either etafilcon A with 0.019 mg ketotifen (test; n=374) or etafilcon A with no added drug (placebo; n=186). Assessments were conducted at baseline, one week and four, eight, and 12 weeks. Slit-lamp evaluations of corneal staining (using sodium fluorescein) in all regions of the corneas of both eyes were graded on a 0 to 4 scale. Data from all randomized participants were analyzed.

Corneal staining was infrequent and, where present, was mild (Grade 2) or trace (Grade 1). There were no Grade 3 or 4 findings of corneal staining. The overall proportion of findings of Grade 0 corneal staining was 95.86% with the test lens and 95.88% with the placebo lens. The odds of no staining were not statistically different between the test and placebo lenses (odds ratio: 0.96, 95% confidence intervals: 0.76 to 1.20). There were no serious ocular adverse events or signs of ocular surface medicamentosa.

Both test and placebo lenses were well-tolerated by subjects during the three months of wear. The antihistamine-releasing contact lens did not significantly impact corneal epithelial integrity.

SOURCE: Pall B, Sun CK. Evaluation of corneal staining with an antihistamine-releasing contact lens. Clin Exp Optom. 2022 Mar 9:1-6.





Diabetic Corneal Neuropathy As a Surrogate Marker for Diabetic Peripheral Neuropathy

Diabetic neuropathy is a prevalent microvascular complication of diabetes mellitus, affecting nerves in all parts of the body including corneal nerves and the peripheral nervous system, leading to diabetic corneal neuropathy and diabetic peripheral neuropathy, respectively. Diabetic peripheral neuropathy is diagnosed in clinical practice using electrophysiological nerve conduction studies, clinical scoring, and skin biopsies. However, these diagnostic methods have limited sensitivity in detecting small-fiber disease so they do not accurately reflect the status of diabetic neuropathy. More recently, analysis of alterations in the corneal nerves has emerged as a promising surrogate marker for diabetic peripheral neuropathy. In this review, the authors discussed the relationship between diabetic corneal neuropathy and diabetic peripheral neuropathy, elaborating on the foundational aspects of each: pathogenesis, clinical presentation, evaluation, and management. They further discussed the relevance of diabetic corneal neuropathy in detecting the presence of diabetic peripheral neuropathy, particularly early diabetic peripheral neuropathy; the correlation between the severity of diabetic corneal neuropathy and that of diabetic peripheral neuropathy; and the role of diabetic corneal neuropathy in the stratification of complications of diabetic peripheral neuropathy.

SOURCE: So WZ, Qi Wong NS, Tan HC, et al. Diabetic corneal neuropathy as a surrogate marker for diabetic peripheral neuropathy. Neural Regen Res. 2022; Oct;17(10):2172-8.




Topographic Relationships Among Deep Optic Nerve Head Parameters in Patients With Primary Open-Angle Glaucoma

Researchers investigated the topographic relationships within the deep optic nerve head (ONH) parameters representing myopic axial elongation or changes in the lamina cribrosa (LC) in patients with primary open-angle glaucoma (POAG). Among patients with POAG who visited the clinic between January 2015 and March 2017, the following deep ONH parameters were measured using spectral-domain optical coherence tomography (SD-OCT): externally oblique border tissue (EOBT) length, ONH tilt angle, optic canal (OC) obliqueness, and anterior LC insertion depth (ALID). In addition, the angular locations of the maximal value of each parameter were measured. Researchers analyzed the correlations between the parameters, correlations with axial length (AL), and the spatial correspondence with glaucomatous ONH damage.

A total of 100 eyes with POAG were included in the analysis. The EOBT length, ONH tilt angle, and OC obliqueness were correlated with each other and with AL, whereas ALID showed less correlation with the other parameters and AL. The angular location where the three AL-related parameters had maximum values was also correlated with the predominant region of the glaucomatous ONH damage, while the angular location of the deepest ALID showed less correlation.

Among the deep ONH parameters, the AL-related parameters of EOBT length, ONH tilt angle, and OC obliqueness showed strong spatial correspondence with glaucomatous ONH damage, whereas the LC-related parameter ALID was less correlated with both AL and the region with glaucomatous ONH damage. Researchers reported that further studies were needed to determine how these differences affect glaucomatous ONH change.

SOURCE: Park DY, Noh H, Kee C, et al. Topographic relationships among deep optic nerve head parameters in patients with primary open-angle glaucoma. J Clin Med. 2022; Feb 27;11(5):1320..






Industry News

SECO Announces 2022 Award Winners

SECO International named the recipients of its 2022 awards. They are:
Southern Council of Optometrists’ Optometrist of the South Award: Dr. Sidney Stern of Miami
Southern Council of Optometrists’ Young Optometrist of the South Award: Dr. Tiffany Li McElroy of Madison, MI
Southern Council of Optometrists’ Paraoptometric of the South: Samantha Denton, CPO, CPOA of Oklahoma City, OK
Southern Council of Optometrists’ President’s Award: Dr. Stan Dickerson, of Columbia, TN
Distinguished Service Award: Dr. Tammy Than of Sun City, AZ
Read more.






Théa Acquires Akorn’s Branded Ophthalmic Products

Théa Pharma announced completion of its previously announced acquisition of seven branded ophthalmic products from Akorn Operating Company. Read more.

Kala Announces Eysuvis Now Covered on UnitedHealthcare Commercial and Cigna Medicare

Kala Pharmaceuticals announced that UnitedHealthcare added Eysuvis (loteprednol etabonate ophthalmic suspension) 0.25% as a covered brand on its commercial formularies. In addition, Cigna Medicare added Eysuvis as a preferred brand, adding an additional 1.9 million Medicare patients. Learn more.

NovaSight Announces Positive Findings on Amblyopia Treatment

NovaSight announced positive data from its multicenter randomized controlled trial of CureSight, an eye-tracking based, digital treatment device for amblyopia. The study, which randomized 103 participants ages four to nine, compared the improvement in visual outcomes achieved by CureSight digital treatment vs. eye patching, the standard-of-care treatment. The digital device treatment was shown to be non-inferior to eye patching for amblyopia treatment in children. Read more.

IDOC Has Record Conference Attendance

IDOC’s national conference this year, The Connection 2022, drew a record 800 attendees, including IDOC members, sponsor representatives and other industry professionals. After a virtual Connection in 2021, this year’s event marked the return to an in-person format. Learn more about the IDOC.





















Journal Reviews Editor:
Shannon Steinhauser, OD, MS, FAAO

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