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


Volume 18, Number 20

Monday, May 14, 2018


Inside this issue: (click heading to view article)
######### Off the Cuff: How to Become a Dry Eye Guru Without Paying Through the Nose
######### Microbial Keratitis-Induced Endophthalmitis: Incidence, Symptoms, Therapy, Visual Prognosis and Outcomes
######### Recurrent Corneal Erosion Caused by Retained Sutures in Blepharoplasty
######### A Pilot Study Investigating the Impact of Topical Nasal Steroid Spray in Allergic Rhinitis Patients with Dry Eye
######### News & Notes

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Off the Cuff: How to Become a Dry Eye Guru Without Paying Through the Nose

It seems that rarely a week goes by where I don’t hear of yet another dry eye program or protocol. Some of these courses cost hundreds, some thousands of dollars, and all imply that you will be turned into a dry eye expert when they are done. What is especially interesting is that unlike most other clinical specialty areas, where most learning comes through traditional low- or no-cost CE education, there seems to be a lot of money being charged to achieve true dry eye enlightenment.

While I absolutely believe that dry eye is one of the greatest opportunities in eye care today, and an effective and essential entrance into medical eye care for optometry, is developing knowledge in this specialty area that different from other clinical areas? Is necessary expertise something that can be conveyed by a simple protocol or taught in a single course? Should this knowledge be shared freely, or is it something that should be sold for profit?

I guess the bottom line is, is it worth attending one of these courses? How much is a reasonable amount to spend? And will you learn enough to justify the time and cost? Here is what I tell friends who ask: First, make sure that the educators are qualified. Have they published? Do they present at meetings? What do their patients say? Speak to colleagues who have attended the program, and examine the course format. Is most of it clinical or more advertising pitch from sponsors?

For many, I think these courses may be a waste of time and money. Good clinical skills, a thorough understanding of the science in the literature and DEWS-II report, attending lectures by topical thought leaders, and, most of all, listening to patients and focusing on outcomes will lead to clinical skill and practice success. For those who feel more comfortable seeing how a successful dry eye practice works, some of these courses may have some value. Just make sure you are getting what you pay for.

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.

Microbial Keratitis-Induced Endophthalmitis: Incidence, Symptoms, Therapy, Visual Prognosis and Outcomes
This retrospective study with 11 patients treated between 2009 and 2014 evaluated symptoms, therapies and outcomes in rare microbial keratitis-induced endophthalmitis. Clinical findings, corneal diseases, history of steroids and trauma, use of contact lenses, number and type of surgical interventions, determination of causative organisms and visual acuity (VA) were evaluated.

The incidence of transformation from microbial keratitis to an endophthalmitis was 0.29% (n=11/3773). In 90.9% (n=10/11), there were pre-existent eyelid and corneal problems; in 45.5% (n=5/11), rubeosis iridis with increased intraocular pressure and corneal decompensation; and in 18.2% (n=2/11), ocular trauma. Specimens could be obtained in 10 of 11 samples: 33.3% of those 10 specimens were gram-positive coagulase-negative Staphylococci (n=3/10) or gram-negative rods (n=3/10), and 10.0% were Staphylococcus aureus (n=1/10). In 30% (n=3/10), no pathogens were identifiable. In keratitis-induced endophthalmitis cases, 72.7% (n=8/11) were treated with vitrectomy, 9.1% (n=1/11) with amniotic-membrane transplantation. In 27.3% (n = 3/11), the infected eye had to be enucleated: 18.2% (n=2/11) primarily, 9.1% (n=1/11) secondarily. No patient suffered from sympathetic ophthalmia. The median initial VA was 2.1 logMAR (n=11/11). At one month, median VA was 2 logMAR (n=7/11); after three months, 2 logMAR (n=6/11); and after one year, 2.05 logMAR (n=6/11). The change in VA was not significant. Of all of the cases, 36.4% (n=4/11) resulted in blindness.

Researchers concluded that the overall outcome was poor with rare microbial keratitis-induced endophthalmitis. The added that enucleation should be weighed against the risk of local and systemic spread of the infection, prolonged rehabilitation and sympathetic ophthalmia.

SOURCE: Zapp D, Loos D, Feucht N, et al. Microbial keratitis-induced endophthalmitis: incidence, symptoms, therapy, visual prognosis and outcomes. BMC Ophthalmol. 2018;18(1):112.


Recurrent Corneal Erosion Caused by Retained Sutures in Blepharoplasty
Four patients with unilateral recurrent corneal erosion (RCE) were found to have previous blepharoplasty associated with late suture exposure. The clinical courses, characteristics, methods to identify the suture exposure and treatment were presented.

The clinical presentations—including local erosion of upper bulbar conjunctiva, corneal abrasion lines, local corneal epithelial defects with rough border and subepithelial opacity—were noticed in all four patients. RCE symptoms were exaggerated with eye blinking and did not respond to artificial tears treatment. Erosion recurred soon after the removal of therapeutic contact lenses. Individuals underwent blepharoplasty one two 10 years before RCE emerged, and the RCE lasted one to eight months before suture exposure was found. RCE healed within one week after suture removal.

Investigators wrote that suture exposure might occur several years after blepharoplasty and could cause RCE. They added that a thorough exploration of the fornix by double eyelid eversion might identify the hidden sutures in such patients.

SOURCE: Ma IH, Kuo BI, Hou YC. Recurrent corneal erosion caused by retained sutures in blepharoplasty. Int Ophthalmol. 2018; Apr 27. [Epub ahead of print].


A Pilot Study Investigating the Impact of Topical Nasal Steroid Spray in Allergic Rhinitis Patients with Dry Eye
The aim of this study was to demonstrate the effect of nasal steroid treatment on intraocular pressure and dry eye in allergic rhinitis patients with dry eye. Twenty-nine patients with a diagnosis of allergic rhinitis and dry eye were included. Symptoms and findings of patients before and after nasal steroid therapy were compared.

Researchers found that Ocular Surface Disease Index scores for dry eye symptoms showed significant improvement after nasal steroid treatments. On the Schirmer’s test, no significant change was observed in the right or left eye. For the tear film break-up time, no significant changes were observed in the right or left eye. No significant changes were observed in the right eye or the left eyes in an intraocular pressure test.

In this study, symptoms of dry eye with allergic rhinitis were significantly improved with nasal steroid therapy, without affecting the intraocular pressure.

SOURCE: Yenigun A, Elbay A, Dogan R, et al. A Pilot study investigating the impact of topical nasal steroid spray in allergic rhinitis patients with dry eye. Int Arch Allergy Immunol. 2018; May 7:1-6. [Epub ahead of print].

News & Notes
B+L Launches Lumify OTC Redness-relieving Eye Drop With Low-dose Brimonidine
Bausch + Lomb introduced Lumify (brimonidine tartrate ophthalmic solution 0.025%), the first over-the-counter eye drop developed with low-dose brimonidine tartrate for the treatment of eye redness. In clinical trials, Lumify eye drops demonstrated a strong safety and efficacy profile with low risk for rebound redness and 95 percent symptom improvement seen at one minute and lasting up to eight hours. The ophthalmic solution is an alpha-2 (α2)-adrenergic receptor agonist with a unique method of action designed to selectively constrict venules, while maintaining the availability of oxygen to surrounding tissue. Six clinical studies were conducted in over 600 individuals to evaluate the safety and efficacy of Lumify, including studies with both pediatric and geriatric subjects. Read more.

Takeda to Acquire Shire, Executes $30.85 Billion Bridge Loan Agreement for the Purchase
Takeda Pharmaceutical Company reached an agreement with Shire to acquire the company, and entered into a bridge credit agreement for an aggregate principal amount of up to $30.85 billion to finance funds necessary for the acquisition. The transaction was approved by both companies’ boards of directors, and is expected to close in the first half of calendar year 2019. Upon the closing of the transaction, Takeda shareholders will own approximately 50 percent of the combined group. JP Morgan Chase Bank is serving as administrative agent and an initial lender of the bridge credit agreement, with Sumitomo Mitsui Banking Corp. and MUFG Bank Ltd. also serving as initial lenders. Read more on the agreement. Read more on the bridge credit agreement.

Optos Unveils Next-generation UWF with OCT Capabilities for U.S.
Optos, part of Nikon Corp., announced that it launched Monaco, the first ultra-widefield imaging device combined with OCT, in the United States. Monaco, a new compact desk-top UWF retinal imaging device, provides greater imaging functionality and represents the company’s first imaging device with ultra-widefield color imaging, three-in-one color depth imaging and autofluorescence modalities combined with OCT. The device is designed to enhance pathology detection and disease management, and improve clinical flow. Read more.

Essilor & American Academy Announce Academic Student Challenge
Essilor of America and the American Academy of Optometry announced a new event for students at the Academy’s annual meeting: Essilor Academic Challenge @ Academy Stadium. The competition will include teams at each school and college of optometry, culminating in a final showdown on Nov. 8 at Academy 2018 San Antonio. School teams will be made up of of three students at varying points in their academic career and one faculty coach. The teams will compete against each other in an entertaining environment, and all meeting attendees are invited to attend the live competition. Read more.

OcuSoft Reiterates That Zoria Lash Intensifying Serum is Drug-Free
In light of recent news reports, OcuSoft reiterated that Zoria Lash Intensifying Serum, part of the Zoria skin care line from OcuSoft, is completely drug-free. Recent reports have shown that prostaglandin or prostaglandin analog-based lash enhancement products, both prescription and over-the-counter, can cause serious side effects to the eyes and surrounding areas. OcuSoft explained in a press release that, presently, there is confusion in the marketplace, due to FDA regulation, about cosmetic ingredients and drug ingredients. The company wrote further that many cosmetic over-the-counter formulas continue to use unapproved prostaglandin analog ingredients such as isopropyl proclostenate, decloro dihydroxy difluoro ethycloprostenolamide and cloprostenol isopropyl ester, which are closely linked chemically to approved prescription drug ingredients, which potentially subject users to possible side effects. However, the company emphasized that non-prescription Zoria Lash Intensifying Serum is a drug-free OTC formula designed to be non-irritating and to deliver noticeable results without potential side effects. Learn more.

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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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