Optometric Physician

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


Volume 20, Number 48

Monday, November 16, 2020


Inside this issue: (click heading to view article)
######### Off the Cuff: COVID When Will It End?

######### Acute Corneal Edema Decades After Penetrating Keratoplasty for Keratoconus in Eyes Wearing Scleral Contact Lenses
######### Association of Ocular Antihypertensive Medications and the Development and Progression of Age-related Macular Degeneration in a US Insurance Claims Database
  Assessment of a Novel Lens Surface Treatment for Scleral Lens Wearers with Dry Eye
######### News & Notes

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Off the Cuff: COVID When Will It End?

Although I spend a significant amount of time following SARS COVID-2 from an epidemiology, infectious disease and practical perspective, it has been a while since I covered it. I think my track record has been pretty good so far. I quickly realized that transmission was airborne, strongly advocated mask wearing and antisocial distancing, recognized obsessive surface disinfection for the theatre it is and recommended the use of high-capacity HEPA filters in exam rooms. So far, my approach has been successful in our practice with no employee becoming infected despite extremely high levels of community infection in Phoenix.

Right now, there is enough new information to revisit the outbreak prognosis. COVID remains widespread throughout the US and likely to get worse. The pattern of infection in the US and many Western countries has been sinusoidal, with peaks and valleys spaced fairly evenly apart. Economically devastating restrictions drive case numbers and deaths down, while reopening drives cases up in fairly predictable fashion. Some countries have avoided this pattern, notably China, where a miniscule number of new cases have been reported since early April, quite odd considering the densely packed population and the virus’ pattern of rapid and often uncontrolled spread in other countries.

Despite media optimism about the recently announced Pfizer COVID vaccine, keep in mind Pfizer’s CEO sold off $5.6 million in stock the day the vaccine was announced. One reason for his cashing out may be that the vaccine’s long-term effectiveness remains a huge question mark, a critical bit of data considering COVID can apparently reinfect a few months after previous infection. A virus that doesn’t prompt a robust and sustained immune response—typical of the coronaviruses that cause the common cold or strains of influenza—will likely thwart efforts at creating an effective vaccine. That considered, effective treatments will be critical.

I recently received a note from a Utah colleague who shared information about treatments such as ivermectin that he felt were purposely being kept under the radar by the media and pharmaceutical industry, which he noted stands to make billions selling vaccines. Ivermectin is an inexpensive and widely used antiparasitic that has shown impressive promise for both prophylaxis and treatment of COVID in a several trials. There are a number of other drugs currently under investigation that you will hear little if anything about from the mainstream media for reasons you are welcome to speculate about.

As a healthcare professional, I highly recommend you subscribe to Whiteboard Doctor, a brilliant open-access medical education YouTube channel that has been extensively covering SARS COV-2. This episode is a good place to start. Another good source of COVID information is drbeen. Stay informed to keep yourself, your staff and your patients safe.


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.



Acute Corneal Edema Decades After Penetrating Keratoplasty for Keratoconus in Eyes Wearing Scleral Contact Lenses

This retrospective chart review of three scleral contact lens (ScCL) wearers presenting for sudden onset pain and blurred reported three cases of acute corneal edema occurring decades after penetrating keratoplasty (PK) for keratoconus. Data extracted included clinical presentation, year and reason for PK, ocular medications and comorbidities, contact lens wearing history; and results of any ancillary testing available including corneal topography, anterior segment optical coherence tomography (OCT) and specular microscopy surrounding the event; treatment and outcomes of intervention. The number of PK eyes fit with ScCLs in the author's practice was determined to estimate the prevalence of this event.

The three patients each had a longstanding PK for keratoconus performed between 33 and 35 years prior to presentation and recurrent ectasia. Each patient presented with an acute, painful eye and reduced vision either three days, four months or nine years after refitting into ScCLs. Each eye had well-demarcated focal microcystic epithelial and stromal edema within the graft and crossing the wound margin onto the host cornea. Although a definitive break or detachment of Descemet's membrane was not visualized, the presentations suggested these were episodes of acute hydrops.

Longstanding PKs with recurrent ectasia and acute focal edema suggestive of corneal hydrops was demonstrated in this case series of ScCL wearers. Researchers wrote that, although similar events have occurred as part of the natural history of post-PK corneas for keratoconus, the proximity of ScCL refitting to two of the events suggested some association.

SOURCE: Murillo SE, Shariff A, Lass JH, et al. Acute corneal edema decades after penetrating keratoplasty for keratoconus in eyes wearing scleral contact lenses. Cont Lens Anterior Eye. 2020; Nov 4:S1367-0484(20)30179-X.


Association of Ocular Antihypertensive Medications and the Development and Progression of Age-related Macular Degeneration, in a US Insurance Claims Database

In this retrospective, observational cohort study using healthcare claims data from a US nationwide managed care network between January 1, 2006 and December 31, 2016, which included enrollees ≥40 years old with primary open-angle glaucoma with or without a diagnosis of nonexudative AMD at the index date, researchers assessed whether ocular antihypertensives were associated with development and progression of age-related macular degeneration (AMD). Hazard ratios (HR) for developing AMD or progressing from nonexudative to exudative AMD with exposure to ocular antihypertensive medications were analyzed.

Of 132,963 eligible enrollees, 118,174 (87.5%) had no diagnosis of AMD at baseline, while 14,789 (12.5%) had a diagnosis of nonexudative AMD. Prostaglandin analog exposure had a decreased hazard of AMD development among individuals without baseline disease (HR, 0.90), while topical alpha2-agonist exposure demonstrated an increased hazard of AMD development (HR, 1.08). Among patients with baseline nonexudative AMD, topical carbonic anhydrase inhibitor exposure was associated with a decreased hazard of progressing to exudative disease (HR, 0.84), while topical alpha2-agonists had increased hazard (HR, 1.17).

Researchers reported that certain ocular antihypertensive medications may be associated with development or progression of AMD. They added that their role in AMD pathogenesis should be better understood as they are considered for therapeutics in this disease.

SOURCE: Eton EA, Wubben TJ, Besirli CG, Wang SY. Association of ocular antihypertensive medications and the development and progression of age-related macular degeneration in a U.S. insurance claims database. Curr Eye Res. 2020 Nov 11.Epub ahead of print.




Assessment of a Novel Lens Surface Treatment for Scleral Lens Wearers with Dry Eye

Investigators compared lens comfort and dry eye (DE) symptoms of DE scleral lens (SL) wearers’ fit with polyethylene glycol (PEG)-based surface-treated and untreated SLs. Dry eye signs, comfortable SL wearing time (WT), vision quality and lens-related ocular surface changes were also assessed. Twenty-one SL wearers with DE and SL discomfort were enrolled in a double-masked crossover study. Participants were randomized to wear untreated or PEG (Tangible Hydra-PEG, Tangible Science) surface-treated SL of the same parameters first for 30 days. Lens comfort, DE symptoms and ocular surface assessments were measured at baseline, after the first test period and after the crossover. Comfortable lens WT and frequency of foggy vision were recorded. Comparisons were assessed using paired T tests or Wilcoxon signed-rank tests.

Polyethylene glycol-treated SL wear resulted in significantly improved lens comfort, DE symptoms, corneal sodium fluorescein staining, temporal conjunctival lissamine green staining, lid wiper epitheliopathy, conjunctival papillae, frequency of foggy vision, tear break-up time (TBUT) and comfortable lens WT compared with untreated wear. No significant changes were found between treated and untreated lens wear for TBUT over the SL and nasal conjunctival lissamine green staining.

Investigators wrote that polyethylene glycol surface-treated SLs provided improved comfort, reduced DE symptoms and reduced ocular surface compromise compared with untreated SLs for participants with DE.

SOURCE: Mickles CV, Harthan JS, Barnett M. Assessment of a novel lens surface treatment for scleral lens wearers with dry eye. Eye Contact Lens. 2020; Nov 3. [Epub ahead of print.]


News & Notes

B+L: Nearly 27 Million Units of CL Materials Recycled by One By Ones
Bausch + Lomb announced that its One By One Recycling program has recycled nearly 27 million used contact lenses, top foils and blister packs since launching in November 2016. The program, made possible through a collaboration with TerraCycle, a leader in the collection and repurposing of hard-to-recycle post-consumer waste, has diverted more than 162,000 pounds of contact lens waste from oceans, lakes, streams and landfills. Read more.


  X-Cel Provides Eliminates Add-on Fees
X-Cel’s new and simplified warranty and returns policy now includes the elimination of add-on fees, including charges for truncation, fenestration, lenticular, notching and prism, among others. Derrell James, vice president and general manager, said in a press release: “Permanently eliminating add-on fees provides that extra bit of breathing space eye care practitioners deserve now and in the future. Our customers don’t want to be nickel and dimed for every little thing when ordering their specialty contact lenses. We want to make their experience seamless, simple, cost effective and consistent.” Under this new policy, X-Cel also moved from a return fee upon credit to an exchange fee upon reorder to allow for simpler reconciliation of account statements. These changes were added to the existing Bounce Back program. Learn more.

ScienceBased Health Expands Optometry Clinical Advisory Panel
ScienceBased Health announced the addition of Tracy Doll, OD, FAAO; Scott Hauswirth, OD, FAAO; and Justin Schweitzer, OD, FAAO to its Clinical Advisory Panel. Dr. Doll is an assistant professor at Pacific University College of Optometry, and established and coordinates Pacific Dry Eye Solutions, an ocular surface dryness center of excellence at PUCO. Dr. Hauswirth is an assistant professor of ophthalmology at the University of Colorado School of Medicine, and coordinating director of the Ocular Surface Clinic. Justin Schweitzer, OD, FAAO, specializes in advanced glaucoma, refractive surgical clinical care and anterior segment pathology at Vance Thompson Vision.









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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