Optometric Physician



Vol. 23, #16  •   Monday, May 2, 2022


Off the Cuff: The Processes of Clinical Thought and Understanding

As our practice has grown and evolved, our patient population has become increasingly complicated and challenging. Many patients are referred by colleagues, both OD and MD. Some cases are fairly straightforward, and while we may not learn much from uncomplicated patients, helping them is always gratifying. However, some patients have problems that are so complicated that unraveling their issues takes tremendous thought and effort. In extreme cases, actual epiphany is possible and can result in complete changes in our understanding and approach.

As I have figured out more and more, it’s made a massive difference in how I approach clinical care. It has also helped me understand colleagues who ask questions either directly or sometimes by posting on web boards. As a closet psychologist, I have become increasingly interested in the processes of clinical thought and decision making. Most clinicians rely on what can best be described as linear thinking in clinical problem solving. A good example would be prescribing one artificial tear after another with minimal if any thought about why the preceding attempts failed, and then switching to Restasis or punctal plugs without considering possible benefits, risks or even expected outcomes of these interventions. Oddly, strict adherence to evidence-based medicine often leads to linear thinking.

Recently, I wrote about critical thinking, a more advanced approach to clinical problem solving. Critical thinking requires the analysis of existing knowledge of both patient and treatment options, available evidence, expectation for the clinical intervention, clinical observation of the effect on the problem, and careful review of the outcome and likely reason for it. Critical thinking is essentially an ongoing learning process whereby understanding grows and therapeutic strategies are refined after careful observation and introspection. Caring about both patient and outcome is essential. An unexpected example of this was a significant improvement in corneal endothelial function in a 50-year-old congenital cataract patient with dry eye who was treated with IPL. The explanation—and there is an explanation—would take too long to get into here.

Fascinated by the thought processes themselves, I have been observing how clinicians both inside and outside of eye care function at their highest levels. I have identified a novel thought process that I call creative clinical thinking. At least as complex as the aforementioned critical thinking strategy, the process adds a creative element facilitating rapid integration of non-linear individualized clinical elements. Some old timers may recognize this as clinical intuition, which was essential in the early days of medicine when GPs knew little but cured a lot.

If you need a doctor, you don’t want a linear thinker but you do want a creative critical thinker. It can make the difference between sight and blindness, and life and death. More to come…


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.


The Short-Term Effect of Contact Lens Wear on Blink Characteristics

The aim of this pilot study was to investigate the initial effect of contact lens wear on spontaneous blink characteristics. This was a randomized, crossover pilot study. Spontaneous blinking was recorded using a high-speed infrared camera in 10 subjects with three different soft contact lenses (spherical hydrogel, spherical silicone hydrogel and toric hydrogel), one rigid contact lens and without contact lenses. Custom semi-automated software was used to determine palpebral aperture height, interblink interval (IBI), blink speed, blink completeness and blink duration.

The IBI was significantly greater for non-lens wear compared with the silicone hydrogel [ratio (95% CI): 1.34 (1.16, 1.55), p<0.0001], toric hydrogel [1.28 (1.10, 1.48), p=0.0001] and rigid corneal lenses [1.48 (1.27, 1.73), p<0.0001]. The spherical silicone hydrogel lens showed greater closing-phase speed than non-lens wear [mean difference (95% CI): 27.4 (5.6, 49.1) mm/s, p=0.006]. Shorter total blink duration was found for non-lens wear compared with any of the lens types [spherical hydrogel: ratio 0.89 (0.81, 0.98), p=0.01; spherical silicone hydrogel: 0.87 (0.80, 0.95), p=0.0001; toric hydrogel: 0.90 (0.83, 0.98), p=0.004; and rigid corneal: 0.88 (0.82, 0.96), p=0.0004]. Opening-phase speed (p=0.12) and blink completeness metrics (all p>0.5) were not influenced by wearing condition.

This work showed that short-term contact lens wear influenced the palpebral aperture height, IBI, speed and duration of the blink, and the effect was dependent on the contact lens type. The completeness of the blink was not altered by contact lens wear. Researchers wrote that future work should be conducted to assess the effect of long-term wear of different contact lens types on blink characteristics. The measurement of spontaneous blinking characteristics represents an immediate, sensitive and non-invasive evaluation of the impact of a contact lens on the ocular surface.

SOURCE: Navascues-Cornago M, Sun T, Read ML, et al. The short-term effect of contact lens wear on blink characteristics. Cont Lens Anterior Eye. 2022; Apr 21. [Epub ahead of print].




Impact of COVID-19-Related Lockdown on Glaucoma Patients

This retrospective chart review included all glaucoma patients who were either examined and/or underwent emergency surgery between March 11, 2020, and May 31, 2020, a period of complete COVID-19-related lockdown in Turkey, to analyze emergency and outpatient admissions of glaucoma patients during complete lockdown and to assess the effect of pandemic-related complete lockdown on glaucoma patients. The data were compared with data from patients seen during the same time period in 2019. Visual acuity and intraocular pressure data from patients examined after the lifting of the lockdown were also evaluated.

According to Turkish Ministry of Health guidelines, only emergency examinations and surgeries could be performed during the 82 days of the COVID-19 lockdown. During this period, a total of 11 eyes of 10 patients underwent procedures, and 123 patients were examined in the outpatient clinic. During the same period in 2019, 122 surgeries were performed, 39 of which were emergencies. In the first four weeks after the lockdown ended, 163 patients were examined at the outpatient clinic, and marked visual loss was detected in 10 eyes of 9 (5.5%) patients who did not attend follow-up visits due to the pandemic.

During the lockdown, emergency surgeries related to glaucoma decreased by 71.7%, and marked visual loss was detected in 5.5% of the patients examined after the lockdown. These findings suggested that some patients were unable to present to clinics despite needing emergency care.

SOURCE: Barış ME, Çiftçi MD, Güven Yılmaz S, et al. Impact of COVID-19-related lockdown on glaucoma patients. Turk J Ophthalmol. 2022; Apr 28;52(2):91-5.



Effects of Contact Lens Wear on Tear Inflammatory Biomarkers

This review article intended to critically review the available literature relating to the behavior of tear-borne inflammatory biomarkers during contact lens wear. The workflow protocol followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement recommendations. An exhaustive search was carried out using the PubMed database. The analysis included a list of 34 eligible clinical trials: Thirty addressed the use of soft contact lenses, three focused on rigid gas permeable lenses, and one focused on scleral lenses. The biomarkers' presence was described as changes in the molecular concentration compared to control groups—non-contact lens wearers—or baseline measurements.

Contact lens wear inflates the concentration of several inflammatory molecules in tears. Most relevant changes were found for IL-1β, IL-6, IL-8, IL-17, LTB4, and MMP-9. The use of rigid gas permeable lenses seemed to produce a more robust subclinical inflammatory response than soft contact lenses, with significant contributions of IL-8, MMP-9, and EGF. Investigators wrote that reusable lenses worn continuously or on a daily modality were more likely to raise the expression of biomarkers compared to daily disposables.

Investigators reported that mechanical trauma, hypoxia, and wearing schedules may be associated with a distinct sub-clinical inflammatory response in contact lens wearers. They added that the relationship between these responses and contact lens-induced discomfort remain unclear, as existing scientific evidence is still scarce. Furthermore, they wrote, more clinical studies are needed to prove the impact of reverse geometry and scleral lens wear on the behavior of tear-borne biomarkers.

SOURCE: Insua Pereira E, Sampaio AP, Lira M. Effects of contact lens wear on tear inflammatory biomarkers. Cont Lens Anterior Eye. 2022; Apr 21. [Epub ahead of print].






Industry News

Academy Announces ARVO Student Travel Fellowship Grant Recipients

The American Academy of Optometry named recipients of the 2022 ARVO Student Travel Fellowship Grants. View the recipients.






J&J Vision Introduces TearScience Activator for MGD Treatment

Johnson & Johnson Vision announced availability of the next-generation TearScience Activator Clear. Building on the foundation of the LipiFlow Thermal Pulsation System, an automated treatment for meibomian gland dysfunction, TearScience Activator design features a single-piece eye cup and translucent design enabling more efficient and accurate positioning for more consistent delivery of heat and pressure across the entire lid. Read more.

Théa Introduces iVIZIA OTC Products in United States

Théa Pharma announced availability of the iVIZIA line of over-the-counter eye care products in the United States, including lubricating eye drops, lubricating eye gel and three options for daily hygiene of sensitive eyelids. iVIZIA eye drops offer preservative-free extended relief and ocular surface protection to patients with any type of dry eye, including those who wear contact lenses. Learn more.

NORA Registration Open

Registration is now open for the Neuro-Optometric Rehabilitation Association, International (NORA) 32nd annual conference, September 8 to 11, at the Hyatt Regency Columbus, Columbus, Ohio. Learn more.

Bostonsight Announces Patient Marketing Campaign

BostonSight launched a patient marketing campaign for BostonSight Scleral. The intent of the campaign is to provide patients with easily accessible content about scleral lenses and to promote confidence that scleral lenses might be the right solution for their eye condition. Read more.

Prevent Blindness Teams with Regeneron Unite, Offers UV Awareness Month Resources

Prevent Blindness and Regeneron Pharmaceuticals, are uniting to increase education on the impact diabetes can have on vision and eye health through an expanded Diabetes and the Eyes program. With the support of Regeneron, the program will now include a video series relevant for both English and Spanish speakers, community-level health education and support, and updated materials to increase awareness of diabetes’ impact on vision. Learn more.
In addition, the group is offering a dedicated webpage for May’s Ultraviolet Awareness Month along with other resources. Learn more.















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

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