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


Volume 18, Number 46

Monday, November 13, 2017


Inside this issue: (click heading to view article)
######### Off the Cuff: Empowering the Future
######### Evaluation of the Effect of Moist Chamber Spectacles in Patients with Dry Eye Exposed to Adverse Environment Conditions
######### Coordination of Gaze Behavior and Foot Placement During Walking in Persons with Glaucoma
######### Comparison of Noncycloplegic and Cycloplegic Autorefraction in Categorizing Refractive Error Data in Children
######### News & Notes

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Off the Cuff: Empowering the Future

Over the past few years I’ve cautioned that optometry is in for a wild ride. I speak to a lot of colleagues, and it has become increasingly obvious to all but those in deep denial that traditional optometric practice is serious trouble. We sit squarely in the crosshairs of well-funded adversaries that are intent upon deracinating traditional patient care models—especially our more mercantile elements.

Longtime vision care provider allies will eventually succumb to the financial pressures and forge alliances that focus on their own survival rather than ours. Insurance busywork will skyrocket while reimbursements will plummet. Large corporate practices will find technology and automation to be far more cost effective than helping a young OD pay off his or her student debt.

As I see it, if you have an independent practice you have three choices. The first is to grow your practice to a size sufficient to withstand the coming financial pressures while making sure you stay on the leading edge of the inevitable tech wave. If you can’t grow quickly enough, you can sell your practice to an equity capital firm. I suggest you get a lot of cash upfront, take as little stock as possible and make sure you have a favorable buyback, in case these practice consolidators fail to put something together to attract a bigger fish.

The third alternative, and the one I will be focusing on in the coming months, is to develop niche expertise in areas where patient demand will be greatest and insurance coverage will be smallest. Dry eye is an obvious example, with a growing population of young digital-device-addicted patients, an uptick in post-LASIK dry eye and more effective treatments. Esthetic optometry will also offer fertile ground, with advances in scopes and an aging, but esthetically aware, patient population. Add myopia control and even traditional vision therapy, and you can see where I am going.

As the insurance industry continues to collapse, services and devices that are currently covered will suffer significant reimbursement cuts. OCT was an early example of how easily insurance reimbursements can be cut. Given the current economic reality, the future of health care will undoubtedly include more uncovered and out-of-pocket services. If our profession is to survive we must move quickly to anticipate these changes and prepare for our future.

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.


Evaluation of the Effect of Moist Chamber Spectacles in Patients with Dry Eye Exposed to Adverse Environment Conditions
This study evaluated the effect of moist chamber spectacle wear on the ocular surface and tear functions in a controlled wind exposure environment. Twenty-eight eyes of 14 probable dry eye subjects (four men, 10 women; mean age: 34.5 years) underwent constant wind exposure for 10 minutes without spectacles, with conventional spectacle wear and with moist chamber spectacle wear. Dryness Visual Analog Scale (VAS) scores, tear evaporation, blink rate, tear-film breakup testing and fluorescein staining were performed before and after wind exposure.

The mean dryness VAS score after wind exposure was significantly higher when no spectacles were worn or when conventional spectacles with no moist chambers were worn compared with after exposure scores when moist chamber spectacles were worn. The mean of tear evaporation rate from the ocular surface and blink rate increased significantly with wind exposure when no spectacles were worn or when conventional spectacles with no moist chambers were worn. There were no significant changes before and after wind exposure when the moist chamber spectacles were worn.

Moist chamber spectacles appeared to have favorable effects on dry eye symptomatology, tear stability and blink rates in adverse environment conditions such as wind exposure.

SOURCE: Ogawa M, Dogru M, Toriyama N, et al. Evaluation of the effect of moist chamber spectacles in patients with dry eye exposed to adverse environment conditions. Eye Contact Lens. 2017; Oct 31. [Epub ahead of print].

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Coordination of Gaze Behavior and Foot Placement During Walking in Persons with Glaucoma

Vision normally provides environmental information necessary to direct the foot to safe locations during walking. Peripheral visual field loss limits what a person can see, and may alter how a person visually samples the environment. Researchers tested the hypothesis that the spatial-temporal coupling between gaze and stepping in a precision-based walking task is altered in persons with glaucoma, particularly under dual-task situations, and results in reduced foot-placement accuracy. Twenty people with glaucoma and 20 normally sighted controls performed a precision walking task that involved stepping to the center of four targets under three conditions: targets only, walking and counting backwards to simulate a conversation, and walking while performing a concurrent visual search task to simulate locating a landmark. Researchers quantified foot placement error and error variability with respect to the targets, as well as saccade and fixation timing with respect to foot placement.

Compared with controls, people with glaucoma looked earlier at future stepping targets (with respect to toe-off of the foot) in the targets only and count conditions, and transferred gaze away sooner from the current stepping target in all conditions. Persons with glaucoma also had increased foot placement error, particularly in the count condition, and increased foot placement error variability compared with normally sighted controls.

Glaucoma significantly disrupted gaze-foot coordination and resulted in less accurate foot placement when precision wass required during walking. Researchers wrote that this finding suggests that the risk of trips and falls might be heightened in this population.

SOURCE: Miller AB, Lajoie K, Strath RA, et al. Coordination of gaze behavior and foot placement during walking in persons with glaucoma. J Glaucoma. 2017; Nov 7. [Epub ahead of print].



Comparison of Noncycloplegic and Cycloplegic Autorefraction in Categorizing Refractive Error Data in Children
To systematically analyze the differences between cycloplegic and noncycloplegic refractive errors (RE) in children and to determine if the predictive value of noncycloplegic RE in categorizing RE could be improved, random cluster sampling was used to select 6,825 children four to 15 years of age. Autorefraction was performed under noncycloplegic and cycloplegic (induced with 1% cyclopentolate drops) conditions. Paired differences between noncycloplegic and cycloplegic spherical equivalent (SE) RE were determined. A general linear model was developed to determine whether cycloplegic SE could be predicted using noncycloplegic SE, age and uncorrected visual acuity (UCVA).

Compared with cycloplegia, noncycloplegia resulted in a more myopic SE (paired difference: -0.63D ± 0.65D, 95% CI: -0.612 to -0.65D, 6017 eligible right eyes), with greater differences observed in younger participants and in eyes with more hyperopic RE and smaller AL. Using raw noncycloplegic data resulted in only 61% of the eyes being correctly classified as myopic, emmetropic or hyperopic. Using age and uncorrected VA in the model, the association improved, and 77% of the eyes were classified correctly. However, predicted cycloplegic SE continued to show large residual errors for low myopic to hyperopic RE. Applying the model to only those eyes with uncorrected VA <6/6 resulted in an improvement (R2 =0. 93), with 80% of the eyes correctly classified. A higher VA cutoff (i.e., ≤20/60) resulted in 97.5% of eyes classified correctly.

Noncycloplegic assessment of RE in children overestimated myopia and resulted in a high error rate for emmetropic and hyperopic RE. Investigators wrote that adjusting for age and applying uncorrected VA cutoffs to noncycloplegic assessments improved detection of myopic RE, and might help in identifying myopic RE in situations where cycloplegia is not available. However, they added that it did not help in identifying the magnitude of refractive error, and, therefore, is of limited value.

SOURCE: Sankaridurg P, He X, Naduvilath T, et al. Comparison of noncycloplegic and cycloplegic autorefraction in categorizing refractive error data in children. Acta Ophthalmol. 2017;95(7):e633-e640.

News & Notes
SCO Honors Farias with Lifetime Achievement Award
Southern College of Optometry recently awarded its lifetime achievement award to Fred Farias III, OD, CEO of 20/20 Vision Care in McAllen, Texas. Dr. Farias was previously named 2015 Optometrist of the Year by the Texas Optometric Association and 2016 Optometrist of the Year by the American Optometric Association. He focuses his Texas practice on therapeutic optometry and optometric glaucoma, and is a member of SCO’s Alumni Council, the AOA Board of Trustees, and the AOA Federal Legislative Action and Keyperson committees. He is the immediate past president of the Texas Optometric Association and was a charter member of Optometry Cares - The AOA Foundation. Texas Governor Greg Abbott appointed Dr. Farias to the Texas Higher Education Coordinating Board. In addition, Dr. Farias organizes/sponsors vision screenings for underserved communities throughout south Texas and volunteers for the AOA Foundation’s InfantSEE program.

Tear Film Innovations Completes $9 Million Series A Funding
Tear Film Innovations completed a $9 million Series A Preferred Stock funding round led by Visionary Ventures Fund and Tigris Ventures. TFI’s flagship product, the iLux system, is an investigational device under review by the U.S. Food and Drug Administration that enables eye care professionals to provide in-office treatment of blocked meibomian glands through targeted heating and compression of affected eyelids. TFI recently completed a multi-site clinical study demonstrating the safety and efficacy of the system. Read more.


AAO Honors Dr. Choi with Career Development Award
Stacey S. Choi, PhD, was named by the American Academy of Optometry as the 2018 Academy Career Development Award recipient. The Academy will provide a maximum of $50,000 in direct costs per year for up to two years, potentially renewable once for a total of up to four years of funding. The Ohio State University will provide matching funds up to $50,000 per year. The funding will help support Dr. Choi’s research on cellular level structural changes in the retina associated with the onset and progression of myopia. Read more.

2018 Winter Ophthalmic Conference

IDOC Hosts Its Fall Optometry Conference in Denver
IDOC, a privately held alliance of U.S. independent optometrists, hosted more than 300 people during its fall national conference at the Grand Hyatt in Denver (Oct. 25 to 28). The conference kicked off with a welcome ceremony and talk from IDOC CEO and President Dave Brown, who presented “Focused on What Matters.” Other highlights included a celebration of the 10-year anniversary of Essilor Vision Foundation and World Sight Day. Read more.

Review of Optometry's New Technologies and Treatments in Eye Care in Philadelphia, November 3-5, 2017 at Loews Hotel Philadelphia

AAO Makes Donation in Honor of Brien Holden Humanitarian Awardee Dr. Potter
The American Academy of Optometry contributed $5,000 to VOSH/International in honor of C. Ellis Potter, OD, FAAO, the 2017 inaugural recipient of the Brien Holden Humanitarian Award. Dr. Potter was recognized for his lifetime record of humanitarianism and distinguished career with VOSH/International, where he played a significant role in helping the organization evolve from its model providing care in weeklong clinic trips to developing countries to one that works with local optometry and health care organizations to create sustainable models.

AAOF Announces Vincent Salierno Scholarship Recipients
The American Academy of Optometry Foundation named the 2017 Vincent Salierno Scholarship recipients. First- through fourth-year students pursuing a Doctorate of Optometry degree are nominated by their institutions. They must be enrolled in a full-time course of study and must have a 3.0 average for all course work taken so far in optometry school. View the recipients.


LumiThera Unveils LIGHTSITE I Dry AMD Clinical Interim Data
LumiThera announced topline interim results from the LIGHTSITE I trial for treatment of dry age-related macular degeneration trial utilizing its LT-300 device. The 30-subject pilot study funded by a Small Business Innovation Research grant is testing each subject's vision and examining disease pathology in the eye following PBM treatments for up to one year. Data will be presented at the 2017 American Academy of Ophthalmology Conference in New Orleans on Nov. 12. 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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