VOL. 13, NO.

6 JUNE 2021

GLAUCOMA

IOP-LOWERING
MEDICATION REVIEW
STAY UP-TO-DATE
ON AVAILABLE
GLAUCOMA
THERAPIES
Glaucoma
By Stacy Potwin, OD, FAAO drug class

M
meds chart
edical therapy for the treat- See page 31
ment of glaucoma has come
a long way in recent decades,
yielding several classes of medica-
tions and combinations from which to

Issue Highlights
choose. This will serve as a review of available top-
ical medications in the United States for the treat-
ment of glaucoma. It will also update the clinician
on the newer therapeutics that have recently become RETINA
available.
How to differentiate between choroidal
See Glaucoma medications on page 31
nevus and choroidal melanoma

TECHNOLOGY
Top 10 digital resources for ODs
OCULAR SURFACE DISEASE

How to address face

REFRACTIVE
Know the basics of a pediatric eye exam

mask–associated dry eye

CONTACT LENSES
Ocular hygiene: The good and the bad
during COVID-19

Face coverings are causing individuals to experience ocular

irritation and dryness OptometryTimes.com
By Melissa Barnett, OD, FAAO, FSLS, FBCLA

THE USE OF FACE MASKS has exponentially increased during the COVID-19 pan-
demic. Face masks are worn to reduce disease transmission and prevent infection.
Because mask use is expected to continue for the foreseeable future, ODs need to
be aware of the impact on the ocular surface. A recent study found a corresponding
increase in ocular irritation and dry eyes among regular mask users.1
See MADE on page 7
 RELY ON THE
~ 7.6 M
PATIENTS
PRESCRIBED 3

#
1
EXPERIENCE RESTASIS® helps more of your
DISPENSED patients make their own real tears.1,2*
BRANDED For patients with decreased tear production
EYE DROP 4
presumed to be due to ocular inflammation
associated with chronic dry eye

17
YEARS
OF TEARS AND
COUNTING

Individual results may vary.

94% AND 95% OF COMMERCIAL AND PART D PATIENTS ARE COVERED 5†

*Increased tear production was seen at 6 months when used as directed.1,2
†
Source: Managed Markets Insight & Technology, LLC TM, a trademark of MMIT Database, as of March 2020. Data are subject to change. Data are not guarantee of coverage, or partial or full payment,
by any payers. Actual benefits determined by respective plan administrators, insurer plans, coverage criteria, and formularies are subject to change without notice. Check each patient’s coverage
with applicable insurer. Allergan does not endorse any individual plan. Formulary coverage does not imply efficacy or safety.

INDICATIONS AND USAGE: RESTASIS® and RESTASIS MultiDose® ophthalmic emulsion are indicated to increase tear production in
patients whose tear production is presumed to be suppressed due to ocular inflammation associated with keratoconjunctivitis sicca.
Increased tear production was not seen in patients currently taking topical anti-inflammatory drugs or using punctal plugs.
IMPORTANT SAFETY INFORMATION
CONTRAINDICATIONS: RESTASIS® and RESTASIS MultiDose® are contraindicated in patients with known or suspected
hypersensitivity to any of the ingredients in the formulation.
WARNINGS AND PRECAUTIONS
POTENTIAL FOR EYE INJURY AND CONTAMINATION: Be careful not to touch the container tip to your eye or other surfaces to
avoid potential for eye injury and contamination.
USE WITH CONTACT LENSES: RESTASIS® and RESTASIS MultiDose® should not be administered while wearing contact lenses. If
contact lenses are worn, they should be removed prior to the administration of the emulsion. Lenses may be reinserted 15 minutes
following administration of RESTASIS® and RESTASIS MultiDose® ophthalmic emulsion.
ADVERSE REACTIONS: In clinical trials, the most common adverse reaction following the use of cyclosporine ophthalmic emulsion
0.05% was ocular burning (upon instillation)—17%. Other reactions reported in 1% to 5% of patients included conjunctival hyperemia,
discharge, epiphora, eye pain, foreign body sensation, pruritus, stinging, and visual disturbance (most often blurring).
PLEASE SEE NEXT PAGE FOR A BRIEF SUMMARY OF THE FULL PRODUCT INFORMATION.
REFERENCES: 1. RESTASIS® (cyclosporine ophthalmic emulsion) 0.05% [prescribing information]. Irvine, CA: Allergan, Inc; 2017. 2. RESTASIS Multidose® (cyclosporine ophthalmic
emulsion) 0.05% [prescribing information]. Irvine, CA: Allergan, Inc; 2016. 3. Symphony Health, PHAST Prescription Monthly, data through October 2019. 4. IQVIA, Xponent
PlanTrak, January 2019- October 2019. 5. Managed Markets Insight & Technology, LLC. Yardley, PA: Managed Markets Insight & Technology, LLC; March 2020.

© 2020 Allergan. All rights reserved. All trademarks are the property of their respective owners. RES134940 06/20
RESTASIS® (Cyclosporine Ophthalmic Emulsion) 0.05% and
RESTASIS MULTIDOSE® (Cyclosporine Ophthalmic Emulsion) 0.05%
BRIEF SUMMARY—PLEASE SEE THE RESTASIS® AND
RESTASIS MULTIDOSE® PACKAGE INSERTS FOR FULL
PRESCRIBING INFORMATION.
INDICATION AND USAGE
RESTASIS® and RESTASIS MULTIDOSE® ophthalmic emulsion are
indicated to increase tear production in patients whose tear production is
presumed to be suppressed due to ocular inflammation associated with
keratoconjunctivitis sicca. Increased tear production was not seen in patients
currently taking topical anti-inflammatory drugs or using punctal plugs.
CONTRAINDICATIONS
RESTASIS® and RESTASIS MULTIDOSE® are contraindicated in patients
with known or suspected hypersensitivity to any of the ingredients in the
formulation. [see Adverse Reactions]
WARNINGS AND PRECAUTIONS
Potential for Eye Injury and Contamination
Be careful not to touch the container tip to your eye or other surfaces to
avoid potential for eye injury and contamination.
Use with Contact Lenses
RESTASIS® and RESTASIS MULTIDOSE® should not be administered while
wearing contact lenses. Patients with decreased tear production typically
should not wear contact lenses. If contact lenses are worn, they should
be removed prior to the administration of the emulsion. Lenses may be
reinserted 15 minutes following administration of RESTASIS® and RESTASIS
MULTIDOSE® ophthalmic emulsion.
ADVERSE REACTIONS
The following serious adverse reactions are described elsewhere in the
labeling: Potential for Eye Injury and Contamination
[see Warnings and Precautions]
Clinical Trials Experience
Because clinical trials are conducted under widely varying conditions,
adverse reaction rates observed in the clinical trials of a drug cannot be
directly compared to rates in the clinical trials of another drug and may not
reflect the rates observed in practice.
In clinical trials, the most common adverse reaction following the use of
cyclosporine ophthalmic emulsion 0.05% was ocular burning (17%).
Other reactions reported in 1% to 5% of patients included conjunctival
hyperemia, discharge, epiphora, eye pain, foreign body sensation, pruritus,
stinging, and visual disturbance (most often blurring).
Post-marketing Experience
The following adverse reactions have been identified during post approval
use of cyclosporine ophthalmic emulsion 0.05%. Because these reactions
are reported voluntarily from a population of uncertain size, it is not always
possible to reliably estimate their frequency or establish a causal relationship
to drug exposure.
Reported reactions have included: hypersensitivity (including eye swelling,
urticaria, rare cases of severe angioedema, face swelling, tongue swelling,
pharyngeal edema, and dyspnea); and superficial injury of the eye (from the
container tip touching the eye during administration).
USE IN SPECIFIC POPULATIONS
Pregnancy
Risk Summary: Clinical administration of cyclosporine ophthalmic emulsion
0.05% is not detected systemically following topical ocular administration
[see Clinical Pharmacology (12.3)], and maternal use is not expected to result
in fetal exposure to the drug. Oral administration of cyclosporine to pregnant
rats or rabbits did not produce teratogenicity at clinically relevant doses
[see Data].
Data
Animal Data: At maternally toxic doses (30 mg/kg/day in rats and 100 mg/
kg/day in rabbits), cyclosporine oral solution (USP) was teratogenic as
indicated by increased pre- and postnatal mortality, reduced fetal weight
and skeletal retardations. These doses (normalized to body surface area) are
5,000 and 32,000 times greater, respectively, than the daily recommended
human dose of one drop (approximately 28 mcL) of cyclosporine ophthalmic
emulsion 0.05% twice daily into each eye of a 60 kg person (0.001 mg/
kg/day), assuming that the entire dose is absorbed. No evidence of
embryofetal toxicity was observed in rats or rabbits receiving cyclosporine
during organogenesis at oral doses up to 17 mg/kg/day or 30 mg/kg/day,
respectively. These doses in rats and rabbits are approximately 3,000 and
10,000 times greater, respectively, than the daily recommended human dose.
An oral dose of 45 mg/kg/day cyclosporine administered to rats from Day
15 of pregnancy until Day 21 postpartum produced maternal toxicity and an
increase in postnatal mortality in offspring. This dose is 7,000 times greater
than the daily recommended human dose. No adverse effects in dams or
offspring were observed at oral doses up to 15 mg/kg/day (2,000 times
greater than the daily recommended human dose).
Lactation
Risk Summary
Cyclosporine is known to appear in human milk following systemic
administration, but its presence in human milk following topical treatment
has not been investigated. Although blood concentrations are undetectable
following topical administration of cyclosporine ophthalmic emulsion 0.05%
[see Clinical Pharmacology (12.3)], caution should be exercised when
RESTASIS® and RESTASIS MULTIDOSE® are administered to a nursing
woman. The developmental and health benefits of breastfeeding should
be considered along with the mother’s clinical need for RESTASIS® and
RESTASIS MULTIDOSE® and any potential adverse effects on the breast-fed
child from cyclosporine.
Pediatric Use
Safety and efficacy have not been established in pediatric patients below the
age of 16.
Geriatric Use
No overall difference in safety or effectiveness has been observed between
elderly and younger patients.
NONCLINICAL TOXICOLOGY
Carcinogenesis, Mutagenesis, Impairment of Fertility
Carcinogenesis: Systemic carcinogenicity studies were carried out in male
and female mice and rats. In the 78-week oral (diet) mouse study, at doses of
1, 4, and 16 mg/kg/day, evidence of a statistically significant trend was found
for lymphocytic lymphomas in females, and the incidence of hepatocellular
carcinomas in mid-dose males significantly exceeded the control value.
In the 24-month oral (diet) rat study, conducted at 0.5, 2, and 8 mg/kg/
day, pancreatic islet cell adenomas significantly exceeded the control rate
in the low-dose level. The hepatocellular carcinomas and pancreatic islet
cell adenomas were not dose related. The low doses in mice and rats are
approximately 80 times greater (normalized to body surface area) than
the daily human dose of one drop (approximately 28 mcL) of cyclosporine
ophthalmic emulsion, 0.05% twice daily into each eye of a 60 kg person
(0.001 mg/kg/day), assuming that the entire dose is absorbed.
Mutagenesis: Cyclosporine has not been found to be mutagenic/genotoxic
in the Ames Test, the V79-HGPRT Test, the micronucleus test in mice and
Chinese hamsters, the chromosome-aberration tests in Chinese hamster
bone-marrow, the mouse dominant lethal assay, and the DNA-repair test in
sperm from treated mice. A study analyzing sister chromatid exchange (SCE)
induction by cyclosporine using human lymphocytes in vitro gave indication
of a positive effect (i.e., induction of SCE).
Impairment of Fertility: No impairment in fertility was demonstrated in studies
in male and female rats receiving oral doses of cyclosporine up to 15 mg/kg/
day (approximately 2,000 times the human daily dose of 0.001 mg/kg/day
normalized to body surface area) for 9 weeks (male) and 2 weeks (female)
prior to mating.
PATIENT COUNSELING INFORMATION
Handling the Container
Advise patients to not allow the tip of the container to touch the eye or any
surface, as this may contaminate the emulsion. Advise patients to not touch
the container to their eye to avoid the potential for injury to the eye.
[see Warnings and Precautions]
Use with Contact Lenses
RESTASIS® and RESTASIS MULTIDOSE® should not be administered while
wearing contact lenses. Patients with decreased tear production typically
should not wear contact lenses. Advise patients that if contact lenses are
worn, they should be removed prior to the administration of the emulsion.
Lenses may be reinserted 15 minutes following administration of RESTASIS®
and RESTASIS MULTIDOSE® ophthalmic emulsion.
[see Warnings and Precautions]
Administration
Advise patients that the emulsion from one individual single-use vial is to be
used immediately after opening for administration to one or both eyes, and
the remaining contents should be discarded immediately after administration.
Advise patients to read the Instructions for Use for detailed first-time use
instructions for the multidose bottle.
Rx Only
Based on package inserts 71876US19 and 72843US12
© 2017 Allergan. All rights reserved.
All trademarks are the property of their respective owners.
RES103567_v3 09/17
Patented. See www.allergan.com/products/patent_notices
Made in the U.S.A.
 JUNE 2021 |
4

Table of contents
12 21
20

Technology Ocular Surface Disease Refractive

TOP 10 DIGITAL RESOURCES HOW TO ADDRESS FACE KNOW THE BASICS
FOR ODS MASK–ASSOCIATED DRY EYE OF A PEDIATRIC EYE EXAM
By Thomas Wong, OD, FNAP By Melissa Barnett, OD, FAAO, FSLS, FBCLA By Nathan Cheung, OD
Consider the case for optometric digital Face coverings are causing individuals to experience Binocular testing, extraocular movements, dilation,
minimalism 12 ocular irritation and dryness 1 and visual acuity are reviewed 21

5 QUESTIONS ANSWERED WHY ODS SHOULD PREPARE

ABOUT ANTIBIOTIC RESISTANCE PATIENTS FOR SURGERY YEARS Contact Lenses
IN EYE CARE BEFORE THEY NEED IT OCULAR HYGIENE:
By Loretta Ng, OD, FAAO By Marc Bloomenstein, OD, FAAO
THE GOOD AND THE BAD
Look to surveillance data to help guide The earlier patients are prepared for surgery, the
treatment decisions 16 better the outcomes will be 11
DURING COVID-19
By Jade Coats, OD
Some patients are more aware of ocular health,

Glaucoma Retina whereas others have worsening habits 20

IOP-LOWERING HOW TO DIFFERENTIATE

MEDICATION REVIEW BETWEEN CHOROIDAL NEVUS
By Stacy Potwin, OD, fAAO AND CHOROIDAL MELANOMA
Stay up-to-date on available glaucoma therapies 1 By Leo Semes, OD, FAAO
Appropriate identification and management of
pigmented fundus lesions can be made clinically 30

CHAIRMAN’S LET TER

HITTING OUR STRIDE IN EARLY SUMMER

By Mike Hennessy Sr Grab a cup of coffee and sit down with us to enjoy this that they keep current on surveillance data, such as the Antibiotic Resistance
early summer issue of Optometry Times®. We have a lot of great stuff for you. Monitoring in Ocular Microorganisms, or ARMOR, study to drive treatment choices.
First, Stacy Potwin, OD, FAAO, offers a comprehensive review on glaucoma Nathan Cheung, OD, refreshes readers on the basics of a pediatric eye exam,
Cover image: eyeadobestock @Adobe Stock

therapies. She also provides prescribing pearls and a list of what to include in a
practice’s glaucoma crash cart. You won’t want to miss this information-rich article.
Although the country is beginning to open up in the wake of COVID-19 vaccine
administration, face mask wearing has not completely disappeared. And neither
has mask-associated dry eye, says Melissa Barnett, OD, FAAO, FSLS, FBCLA,
who explains why patients are experiencing more dry eye and how to combat it.
Tom Wong, OD, FNAP, suggests that ODs have a wealth of clinical resources at
their digital fingertips and should take advantage of them to better understand
conditions and diseases and offer solutions to their patients.
Loretta Ng, OD, FAAO, answers 5 common questions about antibiotic resis-
tance in eye care. ODs have a role to play in preventing it, and she recommends
and Leo Semes, OD, FAAO, offers tips on distinguishing a choroidal nevus and a
choroidal melanoma. Marc Bloomenstein, OD, FAAO, advocates that ODs should
be preparing patients for surgery years before they need it—which means at
today’s visit. Check out his insightful article for his recommendations.
Jade Coats, OD, does double duty in this issue. First, she outlines how the pan-
demic has helped—or worsened—patients’ ocular hygiene and what ODs can do
about it. Next, she joins fellow Intrepid Eye Society members Jacob Lang, OD,
FAAO, and Chris Kruthoff, OD, FAAO, in a deep look at depression and anxiety and
how patients’ mental health might be affected by their ocular conditions.
You might need a coffee refill to read this great issue. As always, thank you for
reading.
 | PRACTICAL CHAIRSIDE ADVICE
5
FROM
THE Chief Optometric Editor

My first 2021 in-person meeting was fantastic

By Benjamin P. Casella, OD, FAAO
Chief Optometric Editor
Practices in Augusta, GA, with his
father in his grandfather’s practice
bpcasella@gmail.com 
706-267-2972
I
t happened. SECO 2021 happened both in per-
son and virtually. From my vantage point, it was
fantastic.
I arrived Wednesday evening in Atlanta, Geor-
gia. It was quiet in the Omni Hotel, and I thought
for a second that this was an indicator of sparse
attendance. I ordered a burger and fries and took
them back to my room because I had a confer-
ence call to join. The call ended at 11:00 pm, and I
went over my lecture slides once more before hit-
ting the sack.
The next morning was an early one with an 8:15
am lecture. I walked through the lobby to a slew
of socially distanced and masked SECO attend-
ees. It was on. SECO was happening. The vitality
was palpable, and I was excited to be a part of it.
I completed a health screening on my phone and
presented it to a SECO staff member upon enter- pany, and then it was off to my last lecture. This
ing the Georgia World Congress Center (GWCC). one was in 2 lecture halls and broadcast virtually
Then, an automated temperature check allowed at the same time. I had questions from the audi-
me past the gates. ence and answered into a camera for the virtual
I could already see that the meeting attendance ones. The lecture was well received, and I hurried
was better than I had anticipated. The GWCC off to our son’s soccer game.
was alive with optometry, and it is a big (I mean
really, really big) building. So, if you are looking
for social distancing of 6 ft, you can find it, and I asked just about
much more, with little effort. In addition, even
though the Georgia governor lifted the mask man- everyone I met with
date for the state, SECO and the GWCC did not
budge from its policies. whether they were
Back to my first lecture. The chairs were spaced
apart accordingly, and attendance was good. The 2
fully vaccinated, and
hours seemed to fly by, and I was feeling so grate- no one said no.
ful to do what I love—lecturing, and in person.
After the lecture, I had several meetings with
industry members over the next 2 days. We were All in all, SECO 2021 was great to attend.
all in agreement over how good it was to see I hope it was as good for everyone else
one another again. For my own personal Jade as it was for me, and hats off to all
edification, I asked just about everyone Coats, the effort that went into it. Hats off
I met with whether they were fully vac- OD, and colleagues to the industry support, as well. My
cinated, and no one said no. dive into mental health. next stop is the American Optometric
Before I knew it, it was Saturday morn- See page 27 to read Association’s Optometry’s Meeting in
ing. I had a meeting with a start-up com- more. Denver, Colorado, and I can’t wait.

Editorial Advisory Board

Benjamin P. Casella, OD, FAAO Chief Optometric Editor Editorial Advisory Board members are optometric thought leaders. They contribute ideas,
Ernest L. Bowling, OD, FAAO Editor Emeritus 2012-2017 offer suggestions, advise the editorial staff, and act as industry ambassadors for the journal.

Jeffrey Anshel, OD, FAAO Clark Y. Chang, OD, MSA, MSc, FAAO David I. Geffen, OD, FAAO Mohammad Rafieetary, OD, FAAO Tracy L. Schroeder Swartz, OD, FAAO
Ocular Nutrition Society Wills Eye Hospital Gordon Weiss Schanzlin Charles Retina Institute Madison Eye Care
Encinitas, CA Philadelphia, PA Vision Institute Memphis, TN Madison, AL
San Diego, CA
Melissa Barnett, OD, FAAO, FSLS A. Paul Chous, OD, MA, FAAO Stuart Richer, OD, PhD, FAAO Marc B. Taub, OD, MS, FAAO, FCOVD
UC Davis Medical Center Chous Eye Care Associates Jeffry D. Gerson, OD, FAAO James Lovell Federal Southern College of Optometry
Tacoma, WA WestGlen Eyecare Health Care Facility Memphis, TN
Sacramento, CA
Shawnee, KS North Chicago, IL

Sherry J. Bass, OD, FAAO Jade Coats, OD William D. Townsend, OD, FAAO
McDonald Eye Associates Scott G. Hauswirth, OD, FAAO John Rumpakis, OD, MBA
SUNY College of Optometry University of Colorado Advanced Eye Care
Rogers, AR Practice Resource Canyon, TX
New York, NY School of Medicine Management
Michaela Crowley, OD Aurora, CO Lake Oswego, OR
Thomas A. Wong, OD
Justin Bazan, OD Lexington Eye Associates
Park Slope Eye Lexington, MA James Hill, OD, FAAO Leo P. Semes, OD, FAAO State University of New York
Brooklyn, NY Medical University University of Alabama College of Optometry
Melanie Denton, OD, MBA, FAAO of South Carolina at Birmingham School New York, NY
Ernest L. Bowling, OD, FAAO Salisbury Eyecare and Eyewear Charleston, SC
of Optometry
Gadsden, AL Salisbury, NC Birmingham, AL Chris Wroten, OD
Milton M. Hom, OD, FAAO Bond-Wroten Eye Clinic
Azusa, CA
Crystal Brimer, OD, FAAO Marta Fabrykowski, OD, FAAO Diana L. Shechtman, OD, FAAO Hammond, LA
Crystal Vision Services Manhattan Eye, Ear and Throat David L. Kading, OD, FAAO Retina Macula Specialists
Wilmington, NC Hospital Ophthalmology Specialty Eyecare Group of Miami
New York, NY Miami, FL
Kirkland, WA
Michael Brown, OD, MHS-CL, FAAO
US Department of Veterans Steven Ferucci, OD, FAAO Katherine M. Mastrota, MS, OD, FAAO Joseph P. Shovlin, OD, FAAO, DPNAP
Sepulveda VA Ambulatory Care Hotel Association of New York Northeastern Eye Institute
Affairs
Huntsville, AL
Center & Nursing Home City Health Center Scranton, PA
Sepulveda, CA New York, NY
Mile Brujic, OD, FAAO Diana Canto-Sims, OD
Barbara Fluder, OD Pamela J. Miller, OD, FAAO, JD Buena Vista Optical
Premier Vision Group Williams Eye Institute Highland, CA Chicago
Bowling Green, OH Merrillville, IN
Andrew S. Morgenstern, OD, FAAO Joseph Sowka, OD, FAAO
Michael A. Chaglasian, OD, FAAO Ben Gaddie, OD, FAAO Walter Reed National Military Nova Southeastern University
Illinois Eye Institute Gaddie Eye Centers Hospital College of Optometry
Chicago, IL Louisville, KY Bethesda, MD Fort Lauderdale, FL
6
Digit@l JUNE 2021 • VOL. 13, NO. 6

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 | PRACTICAL CHAIRSIDE ADVICE
7

Ocular Surface Disease

How to address face mask–associated dry eye
Continued from page 1

Face mask history genesis of the use of face masks to pre-

Just over 100 years ago, Doust and Lyon vent infective droplet transmission at
reported the results of a study on the the time of the Spanish flu pandemic.1 TAKE-HOME MESSAGE Face mask wearing will
effect of face masks on respiratory tract In October 1919, Hurley suggested likely be part of the culture for some time. Many individ-
infections.2 A volunteer was instructed that if everyone were required to uals, even those who previously did not experience dry
to gargle with a suspension of an oppor- wear a face mask during an influ- eyes, are showing signs and symptoms while wearing
tunistic pathogen, the bacterium Bacil- enza epidemic, “the transmission of face masks. ODs should ask patients about dry eye
lus prodigiosus (now called Serratia mar- the infection from those in the incu- symptoms, and encourage proper mask wearing, breaks
cescens). Agar plates were placed at vari- MELISSA bation period, sick, convalescent, or from digital devices, and use of lubricant eye drops.
ous distances from 1 to 10 ft from the vol- BARNETT, OD, from well carriers to the healthy non-
unteer, who was instructed to speak in FAAO, FSLS, infected population would be greatly
an ordinary conversational tone, a loud FBCLA, minimized.” This was the first recom-
tone, or to cough as much as possible. is principal mendation for both the universal use Another solution is wearing an N100 respi-
After the volunteer left the room, plates optometrist at of face masks and face masks for well, rator mask to block 100% of inhaled particles
the University of
were exposed for 10 minutes, then incu- California Davis Eye or asymptomatic, carriers.6 (virus, bacterial droplet, aerosol). N100 respi-
bated for 72 hours. Center in Sacramento, rators are manufactured by the 3M Company
The results demonstrated a “4-ft dan- California. N95 and are designed to block 99.97% of particulate
ger zone about the patient” during nor- Current N95 “respirator” masks have See MADE on page 8
mal or loud speech, which lengthened to “a min- been made to effectively block particle inhala-
imum radius of 10 ft” during coughing. This led tion via a complex microstructure. These masks
to the well-recognized concept of social distanc- are termed 95 because they block 95% of the
ing at approximately 6 ft or 2 m. Presently, laser entry of 0.3-μm particles. Thus, 5% of par-
light scattering and high-speed cameras are used ticles are not trapped, which could lead
2
to study particulate emissions.3-5 to infection.
Early face masks were made of coarse or medium A solution is wearing a surgical
gauze from 2 to 10 layers that did not prevent the mask over an N95 mask to prevent
projection of inhaled material during coughing. infection and keep the surface of
Conversely, “3-layer butter cloth masks were effec- the N95 mask clean. However, this
tive” preventing respiratory diseases. This was the may encumber breathing.

Figure 1.
Lissamine green staining in mask-associated dry eye.

Figure 2.
Consider a daily replacement contact lens to improve comfort.
 JUNE 2021 |
8
Ocular Surface Disease

MADE 3
Continued from page 7

inhalation.7 These masks are ben-

eficial to reduce particle transmis-
sion from approximately 5% (N95)
to approximately 0.03% (N100), an
improvement of approximately 170x
to block particle transmission via
the nose and mouth.1 These num-
bers are significantly improved com-
pared to a surgical mask with vari-
able particle penetration of approx-
imately 30% on average.8
N100 respirator masks are not
generally discussed because they are
even more difficult to obtain than
N95 masks, which remain in short
supply.1 The downside to N95 or
N100 respirator masks is that breath-
ing through them is more difficult
compared with breathing through a
surgical face mask, necessitating a
medical fitting and evaluation prior
to use. A valved respirator is not as
effective blocking exhaled viral or
bacterial infectious droplets because
they can pass straight through the
valve. Of interest, valved respirators
have been prohibited as acceptable
“face coverings” for the public in Figure 3. Mask-associated dry eye. Download available from COVIDEyeFacts.org.
San Francisco, California.9

Mask wear and dry eye
A recent review in Ophthalmology
Therapy described a marked increase
in dry eye symptoms among regu-
lar mask users.10 Dry eye symptoms
may become problematic for a sig-
nificant percentage of the popula-
tion. Even individuals who have not
previously had dry eyes are exhib-
iting dry eye symptoms with mask
usage. Those who wear masks regu-
larly for extended hours each day or
full time exhibit more symptoms.10
All face mask wearers are sus-
ceptible to dry eye symptoms; how-
ever, people at greater risk of dry eye
symptoms are those who are immu-
nosuppressed, have other preexist-
Ensure that
the mask fits
well with a
pliable nose
wire to fit the
mask shape
to prevent air
from being
directed to the
eyes.
ing ocular surface conditions such as Sjögren’s syndrome,
are elderly with reduced tear film quality, contact lens
wearers, and those who wear masks for extended peri-
ods. A worsening of subjective dry eye symptoms assessed
by the Ocular Surface Disease Index was noted in staff
and patients. An objective increase in corneal staining
was found in patients who wore face masks (Figure 1).10
Most individuals described an awareness of air blow-
ing upward from the mask into their eyes. Exhaled air
from breathing out is channeled up, out of the top of the
face mask, and over the ocular surface. The increased air-
flow likely accelerates tear film evaporation, causing ocu-
lar surface irritation or inflammation. Dry eye symptoms
include a feeling of dryness; eyes feeling gritty, sandy,
irritated, itchy, or watery; or redness.10
The tear film is an essential barrier against the inva-
sion of pathogens and may be compromised if face mask
use causes increased evaporation of this barrier.11 Discom-
fort from dry eyes may increase eye rubbing or touch-
ing, which may cause increased viral transmission when
unwashed hands are brought close to the face.12 This
increases the likelihood of coronavirus infection through
mucous membranes such as the mouth, nose, and to a
smaller extent, the eye.
Addressing dry eye
A remedy for mask-associated dry eye is to ensure that
the mask fits well with a pliable nose wire to fit the mask
shape to prevent air from being directed toward the eyes.
The top of the mask can be taped to impede upward air-
flow. However, careful attention is advised to ensure that
lower lid excursion is not inhibited and that a mechani-
cal ectropion is not induced. Frequent breaks on digital
devices and employing the 20-20-20 rule (every 20 min-
utes, look at something 20 ft away for 20 seconds) may
be beneficial. Taking breaks every few hours for mask
removal and the application of lubricant eye drops is help-
ful. Encouraging good eyelid hygiene to maintain tear
film integrity is imperative.
The application of localized heat to the meibomian
glands improves meibum secretion, making warm com-
presses a commonly prescribed treatment.13-15 A recent
publication demonstrated that moist heat compress could
be an effective first-line treatment to improve comfort in
contact lens wearers with contact lens-related dry eye.16
It is also important to limit direct air on the eyes such
as with overhead fans and limit time in air-conditioned
environments.
If parameters allow, consider prescribing a daily replace-
ment contact lens to improve contact lens comfort,17 pre-
vent contact lens discontinuation,18 and reduce corneal
infiltrate events (CIEs; Figure 2). Chalmers reported that
reusable contact lens wearers had a 12.5x increased risk
of CIEs compared with daily disposable wearers.19
Such consideration is particularly important during
the current pandemic, when there may be gaps between
eye examinations.
Blinking is key to maintain a normal ocular surface.
Most blinks have a cycle of secretion, dispersal, evap-
oration, and tear drainage.20 A reduced blink rate with
computer use has been reported in multiple studies and
may be associated with dry eye disease.21-23 One study
described that a blink rate of 18.4 blinks/minute prior to
computer use was reduced to 3.6 blinks/minute during
computer use.21 Recommending and performing blinking
exercises may be useful, especially with face mask wear.
Conclusion
During the current pandemic and beyond, it is import-
ant to ask patients about their face mask–wearing expe-
riences and inquire about dry eye symptoms with mask
wearing. Encourage breaks on digital devices, lubricant
 | PRACTICAL CHAIRSIDE ADVICE

Ocular Surface Disease 9

eyedrop use, good eyelid hygiene, and avoidance of 20. Himebaugh NL, Begley CG, Bradley A, Wilkinson Exp Ophthalmol. 2003;241(11):914-20. doi:10.1007/s00417-
JA. Blinking and tear break-up during four visual tasks. 003-0786-6
touching the face and eyes (Figure 3).
Optom Vis Sci. 2009;86(2):E106-E114. doi:10.1097/
23. Tsubota K, Nakamori K. Dry eyes and video display
OPX.0b013e318194e962
REFERENCES terminals. N Engl J Med. 1993;328(8):584. doi:10.1056/
1. Oldfield E, Malwal SR. COVID-19 and other pandemics: how 21. Patel S, Henderson R, Bradley L, Galloway B, Hunter NEJM199302253280817
might they be prevented? ACS Infect Dis. 2020;6(7):1563-1566. L. Effect of visual display unit use on blink rate and
tear stability. Optom Vis Sci. 1991;68(11):888-892.
doi:10.1021/acsinfecdis.0c00291 Barnett is chair elect of the American Optometric Association Contact Lens
doi:10.1097/00006324-199111000-00010
and Cornea Section and past president of the Scleral Lens Society. Her inter-
2. Doust BC, Lyon AB. Face masks in infections of the
22. Freudenthaler N, Neuf H, Kadner G, Schlote T. ests include dry eye, anterior segment disease, and contact lenses, and spe-
respiratory tract. JAMA. 1918;71(15):1216-1219. doi:10.1001/
Characteristics of spontaneous eyeblink activity during video cialty contact lenses. She enjoys cooking, yoga, and hiking.
jama.1918.26020410011008c
display terminal use in healthy volunteers. Graefes Arch Clin drbarnett@ucdavis.edu
3. Anfinrud P, Stadnytskyi V, Bax CE, Bax A. Visualizing speech-
generated oral fluid droplets with laser light scattering. N Engl J
Med. 2020;382(21):2061-2063. doi:10.1056/NEJMc2007800
4. Tang JW, Settles GS. Images in clinical medicine. Coughing
and aerosols. N Engl J Med. 2008;359(15):e19. doi:10.1056/
NEJMicm072576
5. Bourouiba L, Dehandschoewercker E, Bush JWM. Violent
expiratory events: on coughing and sneezing. J Fluid Mech.
2014;745:537-563. doi:10.1017/jfm.2014.88
6. Hurley JR. Influenza with special reference to the pandemic of
1918. Medical Record. 1919;96(16): 651-664.
7. 3M Particulate Respirator 8233, N100. 3M. Accessed May 5,
2021. https://www.3m.com/3M/en_US/p/d/v000057486/
8. Balazy A, Toivola M, Adhikari A, Sivasubramani SK, Reponen
T, Grinshpun SA. Do N95 respirators provide 95% protection
level against airborne viruses, and how adequate are surgical
masks? Am J Infect Control. 2006;34(2):51-57. doi:10.1016/j.
ajic.2005.08.018
9. Masks and face coverings for the coronavirus pandemic. City
and County of San Francisco. Updated May 8, 2021. Accessed
May 5, 2021. https://sf.gov/information/masks-and-face-
coverings-coronavirus-pandemic
10. Moshirfar M, West WB Jr, Marx DP. Face mask-associated
Change the outlook for dry eye disease
ocular irritation and dryness. Ophthalmol Ther. 2020;9(3):397-
400. doi:10.1007/s40123-020-00282-6
11. Sun CB, Wang YY, Liu GH, Liu Z. Role of the eye in
transmitting human coronavirus: what we know and what we Only CEQUA™ features NCELL™, an innovative technology
do not know. Front Public Health. 2020;8:155. doi:10.3389/ that helps improve the ocular penetration of cyclosporine1-3
fpubh.202000155
12. Lazzarino AI, Steptoe A, Hamer M, Michie S. Covid-19:
important potential side effects of wearing face masks that we
should bear in mind. BMJ. 2020;369:m2003. doi:10.1136/bmj. • NCELL helps improve the delivery of cyclosporine
m2003 to where it is needed2,3
13. Geerling G, Tauber J, Baudouin C, et al. The international • Significant improvement in tear production at 3 months1
workshop on meibomian gland dysfunction: report of the
subcommittee on management and treatment of meibomian • Significant improvement in corneal staining as early
gland dysfunction. Invest Ophthalmol Vis Sci. 2011;52(4):2050- as 1 month2,4
2064. doi:10.1167/iovs.10-6997g
• In a comfort assessment at 3 minutes post instillation, 90% (Day 0)
14. Goto E, Endo K, Suzuki A, Fujikura Y, Tsubota K. Improvement and 85% (Day 84) of patients had no or mild ocular discomfort4 Visit GetCequa.com to learn more.
of tear stability following warm compression in patients with
meibomian gland dysfunction. Adv Exp Med Biol. 2002;506(Pt
B):1149-1152. doi:10.1007/978-1-4615-0717-8_161 INDICATIONS AND USAGE
CEQUA™ (cyclosporine ophthalmic solution) 0.09% is a calcineurin inhibitor immunosuppressant
15. Olson MC, Korb DR, Greiner JV. Increase in tear film lipid indicated to increase tear production in patients with keratoconjunctivitis sicca (dry eye).
layer thickness following treatment with warm compresses in
patients with meibomian gland dysfunction. Eye Contact Lens. IMPORTANT SAFETY INFORMATION
2003;29(2):96-99. doi:10.1097/01.ICL.0000060998.20142.8D WARNINGS AND PRECAUTIONS
16. Tichenor AA, Cox SM, Ziemanski JF, et al. Effect of the Potential for Eye Injury and Contamination: To avoid the potential for eye injury and contamination,
Bruder moist heat eye compress on contact lens discomfort in advise patients not to touch the vial tip to the eye or other surfaces.
contact lens wearers: an open-label randomized clinical trial. Use with Contact Lenses: CEQUA should not be administered while wearing contact lenses. If contact
Cont Lens Anterior Eye. 2019;42(6):625-632. doi:10.1016/j. lenses are worn, they should be removed prior to administration of the solution. Lenses may be reinserted
clae.2019.09.005 15 minutes following administration of CEQUA ophthalmic solution.
17. McConville P, Pope JM. Diffusion limited evaporation rates in ADVERSE REACTIONS
hydrogel contact lenses. CLAO J. 2001;27(4):186-191. The most common adverse reactions reported in greater than 5% of patients were pain on instillation
18. Nichols JJ, Willcox MDP, Bron AJ, et al; members of the TFOS of drops (22%) and conjunctival hyperemia (6%). Other adverse reactions reported in 1% to 5% of patients
International Workshop on Contact Lens Discomfort. The TFOS were blepharitis, eye irritation, headache, and urinary tract infection.
International Workshop on Contact Lens Discomfort: executive Please see brief summary of Full Prescribing Information on the adjacent page.
summary. Invest Ophthalmol Vis Sci. 2013;54(11):TFOS7–
TFOS13. doi:10.1167/iovs.13-13212 References: 1. CEQUA [package insert]. Cranbury, NJ: Sun Pharmaceutical Industries, Inc.; 2018. 2. Data on file. Cranbury, NJ:
Sun Pharmaceutical Industries, Inc. 3. US Patent 9,937,225 B2. 4. Tauber J, Schechter BA, Bacharach J, et al. A Phase II/III,
19. Chalmers RL, Keay L, McNally J, Kern J. Multicenter case- randomized, double-masked, vehicle-controlled, dose-ranging study of the safety and efficacy of OTX-101 in the treatment of dry
eye disease. Clin Ophthalmol. 2018;12:1921-1929.
control study of the role of lens materials and care products
on the development of corneal infiltrates. Optom Vis Sci. © 2019 Sun Ophthalmics, a division of Sun Pharmaceutical Industries, Inc. All rights reserved.
CEQUA and NCELL are trademarks of Sun Pharma Global FZE.
2012;89(3):316-325. doi:10.1097/OPX.0b013e318240c7ff PM-US-CQA-0327 10/2019
Brief Summary of Prescribing Information for An oral dose of 45 mg/kg/day cyclosporine (approximately
CEQUA™ (cyclosporine ophthalmic solution) 0.09%, 4800 times higher than MRHOD) administered to rats from
for topical ophthalmic use Day 15 of pregnancy until Day 21 postpartum produced
CEQUA™ (cyclosporine ophthalmic solution) 0.09% maternal toxicity and an increase in postnatal mortality in
See package insert for Full Prescribing Information. offspring. No adverse effects in dams or offspring were
observed at oral doses up to 15 mg/kg/day (approximately
INDICATIONS AND USAGE 1600 times greater than the MRHOD).
CEQUA ophthalmic solution is a calcineurin inhibitor Lactation
immunosuppressant indicated to increase tear production Risk Summary
in patients with keratoconjunctivitis sicca (dry eye). Cyclosporine blood concentrations are low following topical
CONTRAINDICATIONS ocular administration of CEQUA. There is no information
None. regarding the presence of cyclosporine in human milk following
topical administration or on the effects of CEQUA on breastfed
WARNINGS AND PRECAUTIONS
infants and milk production. Administration of oral cyclosporine
Potential for Eye Injury and Contamination
to rats during lactation did not produce adverse effects in
To avoid the potential for eye injury and contamination, advise
offspring at clinically relevant doses. The developmental and
patients not to touch the vial tip to the eye or other surfaces.
health benefits of breastfeeding should be considered along
Use with Contact Lenses with the mother’s clinical need for CEQUA and any potential
CEQUA should not be administered while wearing contact adverse effects on the breastfed child from cyclosporine.
lenses. If contact lenses are worn, they should be removed
Pediatric Use
prior to administration of the solution. Lenses may be
The safety and efficacy of CEQUA ophthalmic solution have
reinserted 15 minutes following administration of CEQUA
not been established in pediatric patients below the age of 18.
ophthalmic solution.
Geriatric Use
ADVERSE REACTIONS
No overall differences in safety or effectiveness have been
Clinical Trials Experience
observed between elderly and younger adult patients.
Because clinical trials are conducted under widely varying
conditions, adverse reaction rates observed in the clinical PATIENT COUNSELING INFORMATION
trials of a drug cannot be directly compared to rates in the Handling the Vial
clinical trials of another drug and may not reflect the rates Advise patients to not allow the tip of the vial to touch the eye
observed in practice. or any surface, as this may contaminate the solution. Advise
patients also not to touch the vial tip to their eye to avoid the
In clinical trials, 769 patients received at least 1 dose of
potential for injury to the eye.
cyclosporine ophthalmic solution. The majority of the treated
patients were female (83%). Use with Contact Lenses
CEQUA should not be administered while wearing contact
The most common adverse reactions reported in greater than
lenses. Patients with decreased tear production typically should
5% of patients were pain on instillation of drops (22%) and
not wear contact lenses. Advise patients that if contact lenses
conjunctival hyperemia (6%). Other adverse reactions reported
are worn, they should be removed prior to the administration
in 1% to 5% of patients were blepharitis, eye irritation,
of the solution. Lenses may be reinserted 15 minutes following
headache, and urinary tract infection.
administration of CEQUA ophthalmic solution.
USE IN SPECIFIC POPULATIONS
Administration
Pregnancy
Advise patients that the solution from one individual single-use
Risk Summary
vial is to be used immediately after opening for administration
There are no adequate and well-controlled studies of CEQUA
to one or both eyes, and the remaining contents should be
administration in pregnant women to inform a drug-associated
discarded immediately after administration.
risk. Oral administration of cyclosporine to pregnant rats or
rabbits did not produce teratogenicity at clinically relevant doses. Rx Only
Distributed by: Sun Pharmaceutical Industries, Inc.
Data
Cranbury, NJ 08512
Animal Data
Oral administration of cyclosporine oral solution (USP) to
pregnant rats or rabbits was teratogenic at maternally toxic
doses of 30 mg/kg/day in rats and 100 mg/kg/day in rabbits, as
indicated by increased pre- and postnatal mortality, reduced
fetal weight, and skeletal retardations. These doses (normalized
to body weight) were approximately 3200 and 21,000 times
higher than the maximum recommended human ophthalmic
dose (MRHOD) of 1.5 mcg/kg/day, respectively. No adverse
embryofetal effects were observed in rats or rabbits receiving
cyclosporine during organogenesis at oral doses up to
17 mg/kg/day or 30 mg/kg/day, respectively (approximately © 2018 Sun Ophthalmics, a division of Sun Pharmaceutical Industries, Inc. All rights reserved.
CEQUA is a trademark of Sun Pharma Global FZE.
1800 and 6400 times higher than the MRHOD, respectively). PLR-00020 2018
 | PRACTICAL CHAIRSIDE ADVICE

Ocular Surface Disease 11

Why ODs should prepare patients for

surgery years before they need it
The earlier patients are prepared for surgery, the better the outcomes will be
By Marc R. Bloomenstein, OD, FAAO nomodulating anti-inflammatory drops to increase

T
he time to start thinking about preparing tear production (and increase wear time) are efforts
patients for surgery is not when to avoid the exodus of contact lens drop- TAKE-HOME MESSAGE Proactively preparing
they want or need it but rather in out around age 40 or 50 years. patients for surgery that may be needed down the
visits prior. Another way of stating Will using a moist heat mask on the road allows for better outcomes. A proactive mind-set
this obvious and yet seemingly unprac- lids regularly, at a younger age, ward off can ward off obstruction of the meibomian glands
ticed mode of care is to prepare for the obstruction of the meibomian glands? with weapons like lid hygiene, daily disposable contact
worst and hope for the best. Most likely. At best, it may be like lenses, and moist heat masks. Treatment options like
The ocular surface is the refractive brushing your teeth daily while con- topical corticosteroids, microblepharoexfoliation, and
epicenter of the eye, and thus needs suming an oral cornucopia of sugary meibography may also help.
undivided attention at every patient MARC R. treats. To break this point down, any-
encounter. Research has shown that BLOOMENSTEIN, thing we implement now is only going
there is an accumulative effect of OD, FAAO to help in the future.
inflammation and dryness that can not Director of Now, without the opportunity to Conclusion
only impede healing, but also alter sur- Optometric services go all Doc Brown and go back to the ODs exhibit countless examples of proactive pre-
gical calculations.1,2 Additional research at Schwartz Laser future, ODs must become myopic when paredness it without thinking twice. We owe it to
shows that meibomian glands are nega-
Eye Center in preparing a patient for surgery. Fortu- our patients to start a pre-surgery dialogue and
Scottsdale, Arizona.
tively affected at earlier and earlier ages. nately, ODs have treatment tricks. treatment course far in advance of any actual pro-
So, how can ODs combat this? It’s all about cedure. When is a good time to implement this
anticipation. The simplest answer to the ques- Treatment options mind-set? I would set the year in the DeLorean to
tion, “When do we start planning to prepare the This year eyecare practitioners saw the first 1985, or at least to now.
ocular surface for potential surgery?” is, “At your approval of a topical corticosteroid (Eysuvis,
last visit.” loteprednol etabonate ophthalmic suspension REFERENCES
0.25%; Kala Pharmaceuticals) indicated for the 1. Epitropoulos AT, Matossian C, Berdy GJ, Malhotra RP,
Potvin R. Effect of tear osmolarity on repeatability of
Proactive mind-set short-term (up to 2 weeks) treatment of the signs
keratometry for cataract surgery planning. J Cataract Refract
Take the edict that every patient is a dry eye patient and symptoms of dry eye disease (DED). Surg. 2015;41(8):1672-1677. doi: 10.1016/j.jcrs.2015.01.016
until proven otherwise. Every meibomian gland is Another available option is the use of an amni-
2. Tichenor AA, Ziemanski JF, Ngo W, Nichols JJ, Nichols
starting to atrophy or the meibum is altered until otic membrane to improve overt dryness or help
KK. Tear film and meibomian gland characteristics in
eyecare practitioners don’t see those changes. All smooth irregular corneas afflicted with corneal adolescents. Cornea. 2019;38(12):1475-1482. doi:10.1097/
lids have an overabundance of Demodex, most dystrophy. Although the latter may require cor- ICO.0000000000002154
notably cylindrical dandruff, unless you don’t see neal debridement in coordination with cryopre-
it—because you looked. served amniotic membrane, the former can be
mbloomenstein@gmail.com
Eye care clinicians are tasked with protecting treated with a cryopreserved membrane alone.
sight, yet we don’t use our sight or insight when Another quick and important element is cleaning
we need to prevent surface damage. the lid margin of offending inflammatory debris.
As an ideological posture, assuming everyone Microblepharoexfoliation treatments can accom-
has ocular surface disease (OSD) until proven oth- plish this prior to any surgical treatment. Using
erwise works if we lived and worked in a vac- hypochlorous acid to clean the lids has also
uum. However, the eyes of this generation are been very effective at quickly eradicating
taxed greater than any other. It is naive to think pesky bugs.
that OSD will not rear its ugly head if we engage The focus on the lids is easier with mei-
unchecked in pesky OSD-altering habits. In other bography. Akin to using tomography to
words, we can’t expect that continuous use of our assist in refractive surgery, meibogra-
peepers will not erode the OSD faster and sooner phy gives a landscape of the glands. Not
without doing something to slow it down. I tried only does this visual assess the current
that with my teeth, and let me just say that I should and future potential of the glands, but
have been flossing for decades. it is a clear picture from which patients
can understand the consequences of
Preventive care their actions. Meibography, in my opin-
The good news is that eye care practitioners have ion, should be performed at all exam-
scores of unintrusive and intuitive options to help inations regardless of patient age. By
patients start preparing early for a post-OSD era. For using symptoms and glands as a road
Parilov @Adobe Stock

example, a universal battle cry now of every eye map, we can prepare patients for further
clinician is, “Stop, collaborate, and look away from treatments.
your monitor!” That is the former 20/20/20 rule Thermal pulsation may be needed prior to
modified to sound cooler as a 1980s 1-hit wonder. presurgical evaluation. However, when more
Fitting contact lens patients with daily dispos- time is available, an intense pulsed light (IPL) pro-
able lenses, incorporating lid hygiene, using immu- cedure could and should be implemented.
 JUNE 2021 |
12

Technology
Top 10 digital resources for ODs
Consider the case for optometric digital minimalism
By Thomas A. Wong, OD, FNAP as our faculty, residents, and students

A
lthough I remain a strong
advocate for a move to dig-
ital thinking and new tech-
nologies in optometric patient
care,1 I advise colleagues against allow-
ing technology and modern digital life
to consume them in a way that leads
to exhaustion and isolation. The global THOMAS A. WONG,
pandemic has caused a societal fracture OD, FANP, is director
we are only beginning to understand, of new technologies
and I hope it will eventually spark a at SUNY College of
move toward a simpler, more human Optometry in New
way of life. York City.
Fortunately for State University of
New York College of Optometry students, clinics become too distracted by an endless obsession with
have been busy since the summer quarter of 2020 social media, internet images, and a constant need
TABLE 1 Top 10 digital resources
APPS & WEBSITES DESCRIPTION
Available on Skyscape e-book, iOS,
The Wills Eye Manual Google Play. Comprehensive ocular
disease reference guide.
A glaucoma teaching site including
Curriculum. gonioscopy.org and EyeRounds.org—a
iowaglaucoma.org site to find morning rounds, images,
videos, and tutorials.
Easy-to-access drug information
EyeMedsNow.com service. Searchable by condition,
classification, or key word.
Ocular pharmacology and drug
information guide including
EPOCRATES
formularies, dosing guides, and drug
interaction information.
An interactive contact lens resource
ODspecs.com searchable by categories, including all
parameters.
A quality clinical outcome support tool
Parks 3-Step
for use in the management of diplopia.
A multifunctional, ophthalmic app for
Eye Handbook the diagnosis and treatment of eye
disease that is continuously updated.
A global pool of professional videos in
EyeTube
ophthalmology including educational
and surgical videos with free access,
symposia, and dialogues.
Normative optical coherence
tomography reference material
OCTaVIA with corresponding images for the
differential diagnosis of multiple retinal
disorders.
American Academy Education app with latest news
of Ophthalmology and videos, including a weekly case
Related Apps challenge and EyeWiki channel.
have learned to practice in a COVID-
19 world by providing important ser- TAKE-HOME MESSAGE The risk of digital clutter,
vices to the New York City community. exhaustion, and isolation is real, particularly during a
I hope students learn the skills nec- pandemic. ODs who focus on a few meaningful clinical
essary to move the profession into a research tools may push the profession to new heights.
more patient-centric era, such as allow-
ing patients autonomy and collaborating
with fellow ODs for optimal outcomes.
for connection whether it is over the internet or at
Effects of social media association meetings (virtual, hybrid, and live).
Although I contend that the modern OD I was greatly affected by New York magazine
needs to embrace technology to pro- commentator Andrew Sullivan’s September 2016
vide more focused patient care, I am essay, “I Used to Be a Human Being,” with the
concerned that clinicians today have powerful subtitle “An endless bombardment of
news and gossip and images has rendered us
manic information addicts. It broke me. It might
break you, too.”2 I fear
many clinicians have
TABLE 2 Low vision resources update been broken and need to
focus on the significant,
meaningful technologi-
APPS DESCRIPTION cal tools that allow ODs
to improve patient out-
Available on iOS. It describes the environment and
comes instead of creat-
BlindSquare announces points of interest and street intersections as
someone travels. ing meaningless discus-
sion and clutter.
Available for free on iOS and Android. Multiuse app.
As Cal Newport in
Reads printed and handwritten text, barcodes, deciphers
Seeing AI the 2019 book Digi-
currency, names colors, gives scene description, detects
light, and recognizes individuals. tal Minimalism: Choos-
ing A Focused Life in a
Available for a fee on iOS and Android. Multiuse app.
Noisy World3 makes the
Reads printed and handwritten text, barcodes, deciphers
Envision AI
currency, names colors, gives scene description, detects
case for digital mini-
light, and recognizes individuals. malism—my philoso-
phy values new tech-
Available for free on iOS and Android. Connects
nologies for their long-
people who are blind or visually impaired with sighted
Be My Eyes term, significant value
volunteers who provide virtual assistance through a live
video call. over short-term desires
for hyper-connection.
Available for a fee on iOS and Android. Connects people
Let’s look at technology
who are blind or visually impaired with a sighted Aira
Aira resources that allow us
employee who is trained to provide virtual assistance
to focus on empathetic,
through a live video call.
quality patient care.
Available for a fee on iOS and Android. Auditory reading
Voice Dream Reader of downloaded books and documents as well as ability
Can the optometric
profession, its leader-
to increase font size and color.
ship, and associations
Available for a fee on iOS. Optical character recognition
Voice Dream Scanner move more quickly into
to allow auditory reading of printed text.
the future and utilize
NLS BARD: National practice patterns that
Available for free upon approval on iOS, Android,
Library Service Braille
Windows, and Mac. Access to talking books from the are both evidence and
& Audio Reading
Library of Congress. value based? As I tell
Download
all my students, COVID-
Normative optical coherence tomography reference 19 should teach us that
OCTaVIA material with corresponding images for the differential
empathy belongs at the
diagnosis of multiple retinal disorders.
core of optometric care.
American Academy Let’s look at those
Education app with latest news and videos, including a
of Ophthalmology
weekly case challenge and EyeWiki channel. See Resources
Related Apps
on page 14
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when the current medical community recommends the application of
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© 2021 Sight Sciences, Inc. 6/21 TC-1220-US.v2


14
Technology
Resources
Continued from page 12
mobile and technological reference
resources necessary for clinicians to
remain current and updated. With due
respect to colleagues who have spent time
creating the social media and internet sites
mentioned here, this article will focus on
a few clinical and research tools for the
modern optometrist. Plus, my colleagues
helped me compile a table of mobile tech-
nology updates for low vision patients as
a follow-up to my January 2019 Optometry
Times® article “Innovative Mobile Tech-
nology Targets Low Vision.”4
Conclusion
Advances in technology apps and web-
sites allow patients with vision impairment
to interact with their environment as the
COVID-19 crisis changes society. While
Generation Z tends to use social media
more for entertainment, millennials tend
to rely on it for information sharing.5 The
risk of digital clutter, exhaustion, and iso-
lation is real. I think modern clinical ODs
should spend much more time using the
digital resources listed here and less time
on social media.
REFERENCES
1. Wong TA. Hackathon series puts focus on
digital eye care. Optometry Times®. January 23,
2017. Accessed May 10, 2021. https://www.
optometrytimes.com/view/hackathon-series-puts-
focus-digital-eye-care
2. Sullivan A. I used to be a human being. New York
magazine. September 19, 2016. Accessed May 10,
2021. https://nymag.com/intelligencer/2016/09/
andrew-sullivan-my-distraction-sickness-and-yours.
html
3. Newport, C. Digital Minimalism: Choosing A
Focused Life In A Noisy World. Penguin Random
House LLC; 2019.
4. Wong TA, Sukhija S, Bradley M. Innovative mobile
technology targets low vision. Optometry Times®.
January 18, 2019. Accessed May 10, 2021. https://
www.optometrytimes.com/view/innovative-mobile-
technology-targets-low-vision
5. Durfy L. Millennials vs Generation Z on Social
Media. Post Beyond. February 21, 2019. Accessed
May 10, 2021. https://www.postbeyond.com/blog/
millennials-genz-social-media/
taw@georgetown.edu
ACCESSIBILITY
IN SMART DESCRIPTION
PHONES
VoiceOver (screen reader),
VoiceOver+Braille (on external Braille
display), enlarge text (zoom or magnifier),
Apple/iOS
audio scene description for movies,
enhances contrast, dictation, has Siri
(voice activation).
TalkBack (screen reader), Voice
Access (voice activation), enlarges text,
Android
enhances contrast, Lookout (scene
description).
WEARABLES DESCRIPTION
Small wearable camera that magnetically
attaches to the patient’s eyeglasses.
It takes a picture and speaks the
information to the patient. Specific
OrCam MyEye 2
functions include reading printed text;
recognizing people, products, money
notes, and colors; and has tell time
feature.
Enclosed virtual reality design using a
smartphone that magnifies up to 14x
for distance viewing and near tasks.
Iris Vision
Other assistive features include bioptic
or bubble magnified view, retinitis
pigmentosa mode.
Open design using electronic
magnification to enlarge objects up to
eSight 4 24x for distance and near. It includes
other assistive features including
enhanced contrast.
“
I am greatly
concerned that
clinicians today have
become too distracted by an
endless obsession with social
media, internet images,
and a constant need for
connection.
JUNE 2021 |
COMPUTER DESCRIPTION
SOFTWARE
Available for Windows and Mac. Screen
Zoom Text reader that magnifies and enhances
everything on the computer screen.
Available for Windows and Mac. Screen
Job Application with
reader that provides speech and Braille
Speech (JAWS)
output.
MOBILITY /
OBSTACLE DESCRIPTION
DETECTION
Electronic handle that attaches to
patient’s white cane. It uses sensors to
WeWALK Smart
Cane
detect obstacles above chest level and
warns the patient via vibrations. Can be
paired with a smartphone for navigation.
Wearable bracelet that detects and
alerts patients to obstacles at upper
body and head level through vibrations.
Sunu Band Use in conjunction with white cane or
guide dog. Pairs with smartphone to
provide information about location and
directions.
CCTV DESCRIPTION
Portable 10-inch digital magnifier with
speech. Can enhance color contrast. Has
Compact 10 HD
a swing arm design to allow the patient
with Speech
to view items, objects, and their own
handwriting. Enlarges up to 22x.
Portable 5-inch digital magnifier with
Ruby XL HD ability to enhance contrast. Enlarges up
to 14x.
ra2 studio @Adobe Stock
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 JUNE 2021 |
16
Technology

5 questions answered about

antibiotic resistance in eye care
Look to surveillance data to help guide treatment decisions
By Loretta Ng, OD, FAAO What is antibiotic resistance,

T
he world has been plagued by the and how does it develop?
COVID-19 pandemic caused by Good and bad bacteria exist in human TAKE-HOME MESSAGE Antibiotic resistance
a novel pathogen that was pre- bodies. Among them are drug-resistant is a growing global public health concern, and trends
dicted by various public health strains. Use of broad-spectrum antibiot- of antibiotic resistance in common ocular pathogens
specialists, agencies, and even Hol- ics kills beneficial bacteria that protect show high levels of multidrug resistance in certain
lywood years prior.1-3 However, when and pathogenic ones that harm. Unfor- bacteria. This article introduces the causes of antibiotic
COVID-19 appeared, the world was woe- tunately, this selective process benefits resistance, reviews findings from clinical trials and
fully unprepared. those bacteria with antibiotic resistance, nationwide surveillance programs, and discusses their
LORETTA NG, OD,
A possibly larger threat to global and they survive and thrive without clinical application in eye care.
FAAO, is assistant
health, according to the World Health dean of clinical competition.10 Some bacteria are able
Organization (WHO), is antibiotic resis- affairs at Western to share their drug-resistant trait with
tance, a subcategory of antimicrobial University of Health other bacteria that are not its own off-
resistance.4 Alexander Fleming, who Sciences, College spring through a process called hori- viduals seek medical care at clinics and hospi-
of Optometry, in
discovered penicillin in 1928, warned Pomona, California. zontal gene transfer.2,11 tals, health care workers and other patients are
that bacteria can become resistant to exposed to possible community spread.12 Antibi-
this wonder drug during his Nobel Prize accep- How does antibiotic-resistant bacteria otic resistance is not only a personal but a soci-
tance speech in 1945.5 develop in humans? etal concern.2
Since then, doctors have seen bacteria develop These bacteria develop via 2 main methods. One
resistance to many new antibiotics at an alarmingly way occurs when broad-spectrum antibiotics kill How do ODs
faster rate.6 This adaptability of bacteria has led to both helpful and harmful bacteria in the body and combat antibiotic resistance?
the development of superbugs, such as carbape- leave behind resistant bacteria to proliferate in an ODs can help prevent antibiotic resistance through
nem-resistant Enterobacteriaceae, methicillin-re- altered microbiome. Therefore, prophylactic anti- several mechanisms:
sistant Staphylococcus aureus (MRSA), and multi- biotic use can be dangerous. –  Education. Physicians must address educa-
drug-resistant Pseudomonas aeruginosa, that are The second method is tied to the popular farm- tional gaps in proper antibiotic use. For exam-
resistant to numerous categories of antibiotics.7 ing and agricultural habit of adding antibiotics ple, discourage antibiotic use for viral flu
If the rate of antibiotic resistance continues to animal feed with the aim of promoting faster infections; do not discontinue antibiotics early
unabated, the WHO warns that “it is compromis- and larger animal growth. By consuming these or use in low doses; resistance lives at the
ing our ability to treat infectious diseases and put- food-source animals, products made from them, bacterial level not the individual level; and
ting people everywhere at risk.”8 In a report by and vegetative produce grown on the same farms, antibiotic resistance can affect anyone.14
the United Nations, it is estimated that drug-resis- individuals are at risk of contracting antibiotic-re- –  Surveillance. Without rapid bacteria testing
tant diseases could cause 10 million deaths each sistant bacteria if food is not properly prepared.12 options, physicians are not able to use antibi-
year by 2050, outpacing cancer at 8.3 million lives Illnesses spread between animals and people are otic resistance surveillance programs to guide
taken annually.9 called zoonotic diseases.13 When infected indi- prescribing practices.14
–  Antibiotic stewardship. Physicians and patients
must adopt more care when prescribing and
using antibiotics. Inappropriate antibiotic use
in food source animals, which has already
proven effective in other countries, is being
adopted in some states.14,15
–  Hygiene. Proper disinfection and hygiene
protocols reduce community spread.14 With
COVID-19, everyone is more cognizant about
the important role of hygiene in transmission.
–  Lab testing. Rapid and specific lab tests are
needed to quickly identify the cause of an
infection so physicians can target prescrib-
ing based on specific bacteria and their resis-
tance traits (Figure 1).14
–  Investment in new antibiotic treatment and strat-
egy. The last time a new class of antibiotic
was introduced to market was almost 15 years
ago.2,16 New drug research and development
is costly, and antibiotics have a lower return
on investment than chronic-use medications.
Figure 1.
Conjunctival Commitments are needed from private and
culturing. government partners to invest in new anti-
biotic research.14,17
 | PRACTICAL CHAIRSIDE ADVICE

Technology 17

How do ODs’ actions

affect antibiotic
resistance?
Although systemic use of anti-
biotics plays a much bigger role,
resistance occurs in eye care, and
reports exist of increasing ocular DRUG-RESISTANT
infection treatment failures.18-20
One study looked at the effects
DISEASES COULD CAUSE
of topical antibiotics on resistance
patterns of ocular surface flora
10 MILLION DEATHS
after repeated exposure.21 Inves- EACH YEAR BY 2050,
tigators in another study found the
prophylactic use of topical antibi-
OUTPACING CANCER AT
otics after intravitreal injections
in age-related macular degener-
8.3 MILLION
ation (AMD) patients resulted LIVES TAKEN ANNUALLY.
in significant changes in ocular
surface antibiotic resistance pro-
file. The percentage of Staphylo-
coccus epidermidis isolated from
the conjunctival flora surface sig-
nificantly increases after repeated
exposure to different antibiotics
at the expense of other commen-
sal flora.21,22 Although S epider-
midis can have probiotic function,
HOW ANTIBIOTIC RESISTANCE HAPPENS
it is also an opportunistic patho-
gen and one of the most common
causes of endophthalmitis.23 Inves-
tigators concluded that “recom-
mend that routine use of prophy-
lactic antibiotics after [intravitreal]
injection be discouraged.”20
From 2000 to 2006, the Ocular
Tracking Resistance in US Today
(Ocular TRUST) program found Lots of germs and some Antibiotics kill the bacteria The drug-resistant Some bacteria give their
high levels of antibiotic resistance are drug resistant. causing the illness as well as bacteria are now able to drug resistance to other
in certain ocular isolates (approxi- the good bacteria protecting grow and take over. bacteria.
mately 50% S aureus–MRSA, 62% the body from infection.
coagulase-negative Staphylococcus
[CoNS], approximately 20% Strep- Normal bacterium Resistant bacterium Dead bacterium
tococcus pneumonia) with many
strains resistant to multiple drug
categories. The 6-year Ocular
TRUST program discovered a 12.1% increase in ent drugs representing the main categories of anti- tory concentration (MIC90) (2 ug/mL) against
incidence of MRSA strains over the course of the biotics. Overall, “antibiotic resistance may be prev- all CoNS isolates collected and besifloxacin’s
study.19 In 2009 Bausch + Lomb initiated and con- alent among staphylococcal isolates, particularly MIC90 (4 µg/mL) is second to only vancomy-
tinues to support the Antibiotic Resistance Moni- among older patients. In this study, a few small cin (2 µg/mL) for methicillin-resistant CoNS
toring in Ocular Microorganisms (ARMOR) proj- differences in antibiotic resistance were observed (MRCoNS) isolates.25 Given these data, I would
ect that is the only ongoing nationwide antibiotic by geographic region or longitudinally.”25 prescribe commercially available besifloxacin
resistance surveillance program focused on 5 com- 4 times a day for 1 week in stubborn cases
mon ocular pathogens (S aureus, CoNS, S pneumo- How should ODs apply surveillance of blepharitis.
niae, P aeruginosa, and Haemophilus influenzae).24 data to clinical practice? –  Corneal ulcers in contact lens wearers. The
Recently published are ARMOR 10-year cumula- In clinical practice, I use the findings of ARMOR’s most common bacterial agent is P. aerugi-
tive data.25 It reported on the differences in antibi- charts about specific antibiotic resistance rates nosa in this scenario.28 According to ARMOR,
Balint Radu, Christoph Burgstedt @Adobe Stock

otic resistance of the 5 pathogens across 10 differ- for the different pathogens when I make empiri- the antibiotic with the lowest MIC90 against
cal prescribing decisions in initial and subsequent P aeruginosa ciprofloxacin (0.5 µg/mL) fol-
antibiotic treatments. Here are clinical examples. lowed by levofloxacin, gatifloxacin (Zymaxid
–  Blepharitis. I typically treat this condition 0.5%, Zymar 0.3%; Allergan) and tobramy-
with vigorous lid hygiene as first-line ther- cin (Tobrex, Novartis) (all at 1 µg/mL). This
Figure 2. apy (eg, lid scrubs, hypochlorous acid, tea helps to guide my prescribing of ciproflox-
QR code linked to the tree oil, etc.), but if refractory I will prescribe acin (Ciloxan; Novartis) drops every 1 to 2
10-year results of the an effective antibiotic. Several studies have hours, and if that is not available, levoflox-
ARMOR study. Find
reported that up to 95% of blepharitis cases acin or gatifloxacin alternating with tobra-
MIC90 information under
are caused by S epidemidis (CoNS).26, 27 Look- mycin every 1 to 2 hours would be my next
Figures/Tables tab for
the 5 ocular pathogens
ing at the ARMOR chart for CoNS, vanco- best option.25 See Figure 2.
studied. mycin and besifloxacin (Besivance; Bausch Until investigators develop a rapid point-of-care
+ Lomb) have the lowest minimum inhibi- See Antibiotic resistance on page 18
 JUNE 2021 |
18
Technology

Antibiotic resistance
Continued from page 17

test and newer antibiotics, ODs can rely on sur-

veillance data to guide in decisions on which anti-
biotic to prescribe.

Effects of COVID-19
The WHO warned on June 1, 2020, that the “COVID-
19 pandemic has led to an increased use of anti-
biotics, which ultimately will lead to higher bac-
terial resistance rates that will impact the bur-
den of disease and deaths during the pandemic
and beyond.”
Only a small number of COVID-19 patients need
antibiotics to treat subsequent bacterial infections.
The WHO issued guidance to medics to stop pro-
phylaxis antibiotic therapy in patients with mild
to moderate COVID-19 without a clinical suspi-
cion of bacterial infection.29
Antibiotic resistance
occurs in eye care,
and reports exist of
increasing ocular
infection treatment
failures.
G, et al. Horizontal gene transfer and its association
with antibiotic resistance in the genus Aeromonas
spp. Microorganisms. 2019;7(9):363. doi:10.3390/
microorganisms7090363
12. Antibiotic resistance and NARMS surveillance. Centers for
Disease Control and Prevention. Updated November 21, 2019.
Accessed May 6, 2021. https://www.cdc.gov/narms/faq.html
13. Zoonotic diseases. Centers for Disease Control and
Prevention. Updated July 14, 2017. Accessed May 6, 2021.
https://www.cdc.gov/onehealth/basics/zoonotic-diseases.
html
14. Lack of new antibiotics threatens global efforts to contain
drug-resistant infections. News release. World Health
Organization. January 17, 2020. Accessed May 6, 2021.
https://www.who.int/news-room/detail/17-01-2020-lack-
of-new-antibiotics-threatens-global-efforts-to-contain-drug-
1
QUICK
QUIZ
What did Alexander Fleming warn
us about during his Nobel Prize
acceptance speech?
a. Dangers of using steroids while treating
bacterial infections
«
resistant-infections b. Dangers of patients having allergic
reactions to penicillin
15. Martin MJ, Thottathil SE, Newman TB. Antibiotics overuse c. Dangers of bacterial resistances to penicillin
in animal agriculture: a call to action for health care providers. d. Dangers of using fluoroquinolones in
Am J Public Health. 2015;105(12):2409-2410. doi:10.2105/ patients who are allergic to penicillin
AJPH.2015.302870
16. Conly JM, Johnston BL. Where are all the new antibiotics?
the new antibiotic paradox. Can J Infect Dis Med Microbiol.
2005;16(3):159-160. doi:10.1155/2005/892058
2 Which is a misconception about
antibiotic resistance?
a. A person cannot develop antibiotic
17. Lack of new antibiotics threatens global efforts to contact resistance if they take their antibiotics as
prescribed.
drug-resistant infections. World Health Organization. January
17, 2020. Accessed May 6, 2021. https://www.who.int/news- b. Antibiotics are not effective for a viral
infection.
room/detail/17-01-2020-lack-of-new-antibiotics-threatens-
global-efforts-to-contain-drug-resistant-infections c. The bacteria, not the individual, develop
antibiotic resistance.
18. Dang S. Understanding antibiotic resistance and eye
infections. American Academy of Ophthalmology. September
d. You should not discontinue antibiotics early
once you feel better.
21, 2014. Accessed May 6, 2021. https://www.aao.org/eye-
health/news/antibiotic-resistance-eye-infections
e. No one is immune to antibiotic resistance in
the community.
19. Asbell PA, Colby KA, Deng S, et al. Ocular TRUST:

REFERENCES
nationwide antimicrobial susceptibility patterns in ocular
isolates. Am J Ophthalmol. 2008;145(6):951-958.
doi:10.1016/j.ajo.2008.01.025
3 The repetitive use of topical
antibiotics can lead to antibiotic
resistance on the conjunctival
1. Brilliant L. My wish: help me stop pandemics. TED. February
20. Yin VT, Weisbrod DJ, Eng KT, et al. Antibiotic resistance
surface flora.
2006. Accessed April 7, 2021. https://www.ted.com/talks/
of ocular surface flora with repeated use of a topical antibiotic a. True
larry_brilliant_my_wish_help_me_stop_pandemics?utm_
after intravitreal injection. JAMA Ophthalmol. 2013;131(4):456- b. False
campaign=tedspread&utm_medium=referral&utm_
461. doi:10.1001/jamaopthalmol.2013.2379

source=tedcomshare.
2. Xue K. Superbug: an epidemic begins. Harvard
Magazine. May 2014. Accessed April 7, 2021. https://www.
harvardmagazine.com/2014/05/superbug.
3. Shamberg M, Sher S, Jacobs G, Soderbergh S. Contagion.
2011;DVD. Warner Bros. Pictures.
4. Antimicrobial resistance. World Health Organization.
October 13, 2020. Accessed April 7, 2021. https://www.who.
int/news-room/fact-sheets/detail/antimicrobial-resistance
5. Fleming A.. Nobel lecture. The Nobel Prize. December 10,
1945. Accessed April 7, 2021. https://www.nobelprize.org/
prizes/medicine/1945/fleming/speech/
6. About antibiotic resistance. Centers for Disease Control and
Prevention. Updated March 13, 2020. Accessed April 7, 2021.
https://www.cdc.gov/drugresistance/about.html
7. Antibiotic resistance threats in the United States. Centers
for Disease Control and Prevention. Updated December 2019.
Accessed April 7, 2021. https://www.cdc.gov/drugresistance/
pdf/threats-report/2019-ar-threats-report-508.pdf
8. Global action plan on antimicrobial resistance. World Health
Organization. May 2015. Accessed April 7, 2021. https://www.
who.int/antimicrobial-resistance/global-action-plan/en/
9. O’Neill J. Tackling drug-resistant infections globally: final
report and recommendations. Government of the United
Kingdom, Wellcome Trust. May 2016. Accessed April 7,
2021. https://www.biomerieuxconnection.com/wp-content/
uploads/2018/04/Tackling-Drug-Resistant-Infections-
Globally_-Final-Report-and-Recommendations.pdf
10. How antibiotic resistance happens. Centers for Disease
Control and Prevention. Updated February 10, 2020.
Accessed May 6, 2021. https://www.cdc.gov/drugresistance/
about/how-resistance-happens.html
11. Bello-Lopez JM, Cabrero-Martinez OA, Ibáñez-Cervantes
21. Kim SJ, Toma HS. Antimicrobial resistance and
ophthalmic antibiotics: 1-year results of a longitudinal
controlled study of patients undergoing intravitreal injections.
Arch Ophthalmol. 2011;129(9):1180-1188. doi:10.1001/
archophthalmol.2011.213
22. Dave SB, Toma HS, Kim SJ. Changes in ocular flora in
eyes exposed to ophthalmic antibiotics. Ophthalmology.
2013;120(5):937-941. doi:10.1016/j.ophtha.2012.11.005
23. Gentile RC, Shukla S, Shah M, et al. Microbiological
spectrum and antibiotic sensitivity in endophthalmitis: a
25-year review. Ophthalmology. 2014;121(8):1634-1642.
doi:10.1016/j.ophtha.2014.02.001
24. Asbell, PA Sanfilippo CM, Pillar CM, DeCory HH, Sahm
DF, Morris TW. Five-year results from the antibiotic resistance
monitoring in ocular microorganisms (ARMOR) surveillance
study. JAMA Ophthalmol. 2015;133(12):1445-1454.
doi:10.1001/jamaophthalmol.2015.3888
25. Asbell PA, Sanfilippo CM, Sahm DF, DeCory
HH. Trends in antibiotic resistance among ocular
microorganisms in the United States from 2009 to 2018.
JAMA Ophthalmol. 2020;138(5):439-450. doi:10.1001/
jamaophthalmol.2020.0155
26. Groden LR, Murphy B, Rodnite J, Genvert GI. Lid flora in
blepharitis. Cornea. 1991;10(1):50-53.
27. Ficker L, Ramakrishnan M, Seal D, Wright P. Role of
cell-mediated immunity to staphylococci in blepharitis. Am
J Ophthalmol. 1991;111(4):473-479. doi:10.1016/s0002-
9394(14)72383-9
28. Cheng KH, Leung SL, Hoekman HW, et al. Incidence of
contact-lens-associated microbial keratitis and its related
morbidity. Lancet. 1999;354(9174):181-185. doi:10.1016/
S0140-6736(98)09385-4
29. Record number of countries contribute data revealing
4
In the Ocular TRUST, which ocular
isolates had the highest antibiotic
resistance rates?
a. Staphyloccocus aureus
b. Coagulase-negative Staphylococcus
c. Streptococcus pneumonia
5 Studies looking at the prophylactic
use of topical antibiotics after intra-
vitreal injections in patients recom-
mended that the practice be:
a. Enhanced
b. Discontinued
c. Continued
1: C, 2: A, 3: A, 4: B, 5: B
QUIZ ANSWER KEY:
disturbing rates of antimicrobial resistance. News release.
World Health Organization. June 1, 2020. Accessed May 6,
2021. https://www.who.int/news-room/detail/01-06-2020-
record-number-of-countries-contribute-data-revealing-
disturbing-rates-of-antimicrobial-resistance
Ng is also associate professor at Western University of Health Sciences, College
of Optometry. She graduated from the University of Waterloo School of Optom-
etry and Vision Science in Canada and completed an ocular disease/refractive
surgery residency in Oklahoma City. Ng is a coprincipal site investigator for the
Antibiotic Resistance Monitoring in Ocular Microorganisms (ARMOR) surveil-
lance program sponsored by Bausch + Lomb. She has been a consultant and/or
speaker for Akorn, Alcon, Allergan, AMO Pharma, Bausch + Lomb, Bio-
Tissue, and Santen.
ngl@westernu.edu
Why stop at the last page?
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 JUNE 2021 |
20

Contact Lenses
Ocular hygiene: The good and
the bad during COVID-19
Some patients are more aware of ocular health, whereas others have worsening habits
By Jade Coats, OD
unprotected and vulnerable to infec- during the pandemic.7 This is likely because of the

D
uring the COVID-19 pandemic, tion. Additionally, the eyes may be fur- growth in public awareness of hand-washing hab-
ODs have seen shifts, both good ther compromised by irritation from an its. Since the height of the pandemic, many patients
and bad, in ocular hygiene. improperly fitted mask.2 have inquired about lens modalities and daily dis-
Although some patients seem Bacteria exhaled behind ill-fitted face posable options after considering the convenience,
more aware of their ocular health, other masks may have caused worsened ocular comfort, and quality compared with other lenses.
patients’ ocular hygiene and contact lens hygiene and styes during the pandemic.
habits have significantly worsened. The humid environment under masks, Words of advice
JADE COATS, OD, created by our own breath, generates a To further encourage good hygiene, I have been
THE BAD is an associate at perfect breeding ground for organisms diligent in educating patients on the importance
Worsened ocular hygiene an OD/MD multi- including bacteria, fungi, and Demodex of maintaining optimal ocular health. If a symp-
ODs may sometimes think they sound
disciplinary practice mites to grow.2 Styes, blepharitis, and tomatic patient has worn extended wear lenses,
in Rogers, Arkansas.
like broken records when remind- Demodex infestations can grow quickly the pandemic presented the perfect excuse to get
ing patients with dry eye to use artificial tears, out of control when left untreated. to the root of the problem, whether lens fit, modal-
or patients with blepharitis to maintain clean lid ity, materials, or even untreated ocular surface dis-
margins, and other contact lens patients to wear Recommendations ease due to poor ocular hygiene.
contact lenses as directed. Unfortunately, this past Options are available to improve ocular hygiene. Rather than dismissing a patient’s symptoms as
year spent at home in isolation may have been one Avenova (NovaBay), a 0.01% hypochlorous acid normal, consider offering a trial of a daily dispos-
of the worst for ocular hygiene. spray, is available over the counter to kill viruses and able lens to compare with a current extended wear
Although no transmission of COVID-19 via con- bacteria that can lead to MGD and symptoms asso- setup. Providing the opportunity for patients to try
tact lenses has been reported,1 some patients say ciated with blepharitis.3 Sprayed twice daily to clean daily disposables has helped me with conversions
they have avoided touching their eyes for fear of eyelashes and eyelids, Avenova can help patients to daily lenses throughout the pandemic.
causing infection or COVID-19 transmission. Oth- experiencing contact lens intolerance and other To ensure best hygiene practices for patients in
ers say they extend contact lens supplies for various chronic eye conditions. NovaBay claims Avenova an extended wear lens, I recommend hydrogen per-
reasons, including loss of vision insurance, fear of is effective against SARS-CoV-2 on hard surfaces.3 oxide disinfection such as ClearCare (Alcon).8 Edu-
running out of lenses, and having no backup glasses. Eyelid wipes such as OCuSOFT Lid Scrubs can cating patients on proper disinfection has revealed
When one avoids touching the eyes and face, help remove debris, excess oils, and dead skin cells that very few people read the instructions.
staphylococcal bacteria on the eyelids, lashes, and from the lid margin without negative effects on tear Patients need and appreciate a reminder of ocular
biofilm of the lid margins might not be regularly break-up time or ocular surface staining.4 I recom- hygiene basics, including the importance of keep-
removed, resulting in an increased incidence of ocu- mend OCuSOFT Lid Scrub Plus because its formu- ing lids and lashes clean, washing hands before
lar inflammation. To worsen the scenario, contact lation does not require rinsing, increasing conve- lens application and removal, and how to disinfect
lens patients with blepharitis and meibomian gland nience. Cliradex Towelettes are a preservative-free contact lenses. ODs must continue to reiterate the
dysfunction (MGD) typically experience worsened option that includes a tea tree oil ingredient recom- importance of good ocular health, and they may
lipid buildup and deposits on their contact lenses.2,3 mended when Demodex folliculorum is suspected.4 need to offer new advice in the time of a pandemic.
Nearly half of blepharitis cases in the United REFERENCES
Poor ocular and contact lens hygiene States are caused by Demodex mites. Tarsus Pharma- 1. Jones L, Walsh K, Willcox M, Morgan P, Nichols J. The COVID-19 pandemic:
important considerations for contact lens practitioners. Cont Lens Anterior Eye.
When poor ocular hygiene is coupled with poor con- ceuticals’ proposed drop formulation, if approved, 2020;43(3):196-203. doi:10.1016/j.clae.2020.03.012
tact lens hygiene, the result can become a vicious would be the first to treat Demodex-associated bleph- 2. Moshirfar M, West WB Jr, Marx DP. Face mask-associated ocular irritation and
dryness. Ophthalmol Ther. 2020;9(3):397-400. doi:10.1007/s40123-020-00282-6
cycle of local inflammations including bacterial aritis. Tarsus recently announced the start of its 3. Sindt CW. Wash away your old hygiene strategy. Review of Cornea &
hordeolums and noninfectious chalazions attributed phase 3 trials for TP-03.5,6 Contact Lenses. May 15, 2014. Accessed May 10, 2021. https://www.
reviewofcontactlenses.com/article/wash-away-your-old-hygiene-strategy
to clogged meibomian glands. 4. Murphy O, O’Dwyer V, Lloyd-McKernan A. The effect of lid hygiene on the tear film
To make matters worse, patients with or without THE GOOD and ocular surface, and the prevalence of Demodex blepharitis in university students.

contact lenses who were not already treating dry Improved ocular hygiene
eye disease or blepharitis before the pandemic may Although some patients have presented with wors-
also experience additional ocular insults related to ened ocular hygiene during the pandemic, time in
mask-associated dry eye, coupled with a decreased quarantine has shifted the perspectives of others
blink rate from increased digital device usage.2 to the importance of good health. Consequently,
The tear film acts as an essential barrier against some patients have reported more diligent use of
pathogenic invasion, and it may be compromised if artificial tears, lid scrubs, hot compress masks, and
an ill-fitting mask or excess computer use causes other at-home treatment options previously recom-
evaporation to occur more rapidly.2,3 Although uni- mended by their eye care providers.
versal, public mask use has been essential during Interestingly, research shows that contact lens
the COVID-19 pandemic to reduce disease transmis- adherence and hand-washing before contact lens
sion through the mouth and nose, the eye remain application and removal significantly improved
Cont Lens Anterior Eye. 2020;43(2):159-168. doi:10.1016/j.clae.2019.09.003
5. Paulsen AJ, Cruickshanks KJ, Fischer ME, et al. Dry eye in the beaver dam
offspring study: prevalence, risk factors, and health-related quality of life. Am J
Ophthalmol. 2014;157(4):799806. doi:10.1016/j.ajo.2013.12.023
6. Schaumberg DA, Nichols JJ, Papas EB, Tong L, Uchino M, Nichols KK. The
international workshop on meibomian gland dysfunction: report of the subcommittee
on the epidemiology of, and associated risk factors for, MGD. Invest Ophthalmol Vis
Sci. 2011;52(4):1994-2005. doi:10.1167/iovs.10-6997e
7. Vianya-Estopa M, Wolffsohn JS, Beukes E, Trott M, Smith L, Allen PM. Soft
contact lens wearers’ compliance during the COVID-19 pandemic. Cont Lens
Anterior Eye. Published online August 14, 2020. doi:10.1016/j.clae.2020.08.003
8. Contact lens care systems & solutions. Centers for Disease Control and
Prevention. Updated September 11, 2020. Accessed May 10, 2021. https://www.
cdc.gov/contactlenses/care-systems.html#hydrogen-peroxide
Dr. Coats is an advisory board member and speaker for Shire.
cjadecoats2020@gmail.com
 | PRACTICAL CHAIRSIDE ADVICE
21

Refractive
Know the basics of
a pediatric eye exam
Binocular testing, extraocular movements, dilation, and visual acuity are reviewed
By Nathan Cheung, OD
sis and binocularity.

S
ome ODs feel ner- The binocular test result is 1
vous when they see a helpful piece of information
a pediatric patient that builds the child’s clinical
on their schedule. picture. Proceeding through
For several reasons, the exam- the exam sequence, the more
ination sequence for a pediatric information ODs obtain from
eye exam is different from an pediatric patients, the more
adult eye exam. First, the atten- NATHAN CHEUNG, of a clinical picture ODs can
tion span of a child is limited. OD, is a pediatric build. However, situations and
optometrist at Duke
ODs must be quick and selec- University in Durham, times exist when the child is
tive in their exam sequence North Carolina. uncooperative, shy, or unable
to obtain quality information. to participate because of medi-
Second, all new pediatric patients must cal conditions. Thus, gaining stereo infor-
be sufficiently dilated and cyclopleged. mation is helpful but not crucial in the
Unlike adult patients who can be refracted assessment and treatment of pediatric
behind a phoropter, most children will patients.
need their refractive error neutralized by Various stereo books are available. I
retinoscopy. The most accurate way to per- personally do not find the stereo fly to be 2a
form retinoscopy on a child is with relaxed helpful in determining stereopsis because
accommodation. Finally, the most import- it is difficult to ask a 3-year-old to touch
ant items to evaluate in the pediatric pop- or pinch the wings of the fly. Compared
ulation are the presence of amblyopia or to the butterfly, it is more difficult to be
strabismus and ocular health. certain that your pediatric patient has ste-
Let’s review the pediatr ic exam reopsis based on the fly.
sequence. After stereopsis testing, the OD can
transition to the Worth 4 Dot test. The
Binocular testing child switches from wearing the stereo
In a pediatric eye exam, I recommend glasses to the red-green glasses. Ask
performing binocular testing first before how many circles the child sees. How
monocular testing. The binocular tests many green circles? How many red cir-
allow ODs to evaluate the child’s binoc- cles? Remember that the red filter cov-
ular status when the child is most alert. ers the right eye and the green filter cov-
The longer the duration of the exam, the ers the left eye. This test is a fun and
more the child will fatigue and some mon- easy way to subjectively determine sup-
2b
ocular tests will cause the patient’s eyes pression based on the patient’s response.
to dissociate. Therefore, the first test in If the child reports seeing 2 red circles,
my pediatric exam sequence is the Randot then the child is suppressing their left
Stereo test (Figure 1). If a child can cor- eye. Conversely, if the child reports see-
rectly identify the butterfly in this book, ing 3 green circles, then the child is sup-
I know the child has acceptable stereop- pressing their right eye.

TAKE-HOME MESSAGE This article
will review the fundamental methods and
treatments in a pediatric eye examination.
Prescribing is as much as an art as a
science. The goal of this article is to provide
fellow optometrists with the confidence
and comfort in giving eye exams to young
children.
Extraocular movements
Next in the exam sequence is testing
extraocular movements. Finger puppets
or lighted toys (Figure 2) are exciting
fixation targets for the pediatric patient.
Alternatively, a doll’s eye maneuver can
determine a pediatric patient’s extraocu-
lar movements. I play a movie at the other
end of the room, and I ask the patient to
watch the movie as I move their head to Figure 1. Randot Butterfly Stereo book, my preferred stereo book.
determine the range of motion.
Figure 2. Finger puppets and lighted toys make for great fixation targets.
See Pediatric exam on page 22

22
Refractive
Pediatric exam
Continued from page 21
The anatomy of the extraocular mus-
cles with the insertion points on the
eye help determine the eye’s move-
ment. The medial and lateral rectus
adduct and abduct the eye. The supe-
rior and inferior rectus muscles (ver-
tical recti) insert onto the eye at a 23˚
angle from midline. The superior rec-
tus elevates, intorts, and adducts, and
the inferior rectus depresses, extorts,
and adducts. Conversely, the oblique
muscles insert in an anterior to poste-
rior fashion at 51˚ from midline. Thus,
the superior oblique in primary gaze
intorts, depresses, and abducts, and
the inferior oblique extorts, elevates,
and abducts.1
The extraocular muscles move the
eyes in all directions. Test the eye mus-
cles in the H formation. Evaluate each
muscle to see for overaction, under-
action, or misinnervation. When the
patient looks to the right, the left eye’s
superior oblique muscle is sufficiently
isolated because the left eye positions
perpendicular to the superior rectus
muscle. This allows ODs to see a poten-
tial inferior oblique overaction or a
Keys to
success
– Demonstrate the
examination procedure
before performing it. This
eases the patient into
cooperating.
– Allow the patient to touch
and play with some of the
equipment to understand
that will not hurt them.
– Make the exam fun for
them so it feels like a
game.
– Some days will be better
than others. Remember
that some patients will
not cooperate no matter
what.
– Educate the parents
because they are the
OD’s best ally in the
exam room and at
home. Ensuring that the
parents understand the
importance of the eye
exam and follow-ups will
help with adherence.
JUNE 2021 |
superior oblique palsy.
During extraocular muscle testing, 3a
observe the patient for nystagmus or
anomalous head posture. Characteristi-
cally, it has been thought that patients
with a congenital superior oblique
palsy will display a facial asymme-
try or hemifacial microsomia because
of a long-standing head tilt. However,
the reliability of the facial asymmetry
as being pathognomonic for superior
oblique palsy should be used with cau-
tion. Results from one study illustrate
that the anomalous head posture could
arise from superior oblique palsy or a
pulley heterotopy.2
With nystagmus, observe the patient
to determine the presence or absence 3b
of nystagmus. If present, assess the
type, frequency, and amplitude. The
movie at the end of the exam lane helps
when assessing nystagmus and pupils.
It keeps the patient distracted by fixat-
ing into the distance as the OD assesses
the eyes.
Different methods are used to per-
form a cover test: alternate, unilateral,
Hirschberg, and Krimsky. For patients
who are monocular, have poor visual
acuity or are poor fixators, perform-
ing Hirschberg or Krimsky to deter-
mine ocular alignment may be suffi-
cient. For older patients who are more
attentive, perform a unilateral or alter-
nate cover test.
4
Visual acuity
In addition, different methods are used
to test visual acuity. Starting with the
infants and toddlers, obtain visual acu-
ity with Teller Acuity Cards. I set up
the testing as a peek-a-boo game with
patients as I flash the card in front of
the infant and observe their eyes to
see which side of the card they gravi-
tate toward.
Preschool-aged children can per-
form matching games to determine
their visual acuity. I use Lea symbols Figure 3. HOTV and Lea symbols. Preferred method of visual acuity testing for pediatric patients.
for younger patients and HOTV let- Figure 4. Crowded bars for single presentations make the visual acuity testing less daunting for
ters for older ones (Figure 3). I per- pediatric patients.
form visual acuity testing as single let-
ters with crowded bars (Figure 4). The
crowded bars simulate a line of letters movement will be observed. Conversely, if the patient experiences bet-
for the child, but the single-letter pre- ter visual acuity with the prism, a single eye movement will be observed
sentation makes the task seem not as as the patient refixates on the new diplopic image. The induced tro-
daunting. pia test reveals an approximately 2- to 3-line difference in visual acu-
For elementary-aged children and ity between the eyes.3
older, I use standard Snellen symbols. For patients unable to participate in the previously mentioned visual
Evaluate a fi xation preference acuity testing, the central, steady, maintained (CSM) approach can help.
between the eyes with the induced The name relates to the patient’s fixation on a target. If each eye fixates
tropia test. Place a prism of 14 to 16 centrally and not eccentrically, holds steady fixation on that target, and
mm pupillary distance in front of the continues to stay fixated on that target even when occlusion is removed
patient’s eyes. The prism induces dip- from the fellow eye, the vision is noted as “CSM.” Central and steady
lopia. If the patient has equal vision are monocular tests, and maintained is a binocular test.
between the eyes, the patient will move
their eyes between the 2 images. How- Dilation
ever, if the patient experiences worse The dilated portion of the exam sequence is the most important part
visual acuity with the prism, no eye of the exam. There will be days or situations when the patient will not
 | PRACTICAL CHAIRSIDE ADVICE

Refractive 23

cooperate with exam components. The most essen- Optometric clinical practice guideline care of the patient with jaapos.2004.05.004
tial parts of the evaluation are ensuring ocular health amblyopia. American Optometric Association. Accessed May
8. Lyons SA, Jones LA, Walline JJ, et al. A survey of clinical
20, 2021. https://www.aoa.org/AOA/Documents/Practice%20
and determining refractive error. To obtain an accu- prescribing philosophies for hyperopia. Optom Vis Sci.
Management/Clinical%20Guidelines/Consensus-based%20
rate reading of a child’s refractive error, the OD must guidelines/Care%20of%20Patient%20with%20Amblyopia.pdf
2004;81(4):233-237. doi:10.1097/00006324-200404000-
00008
relax the patient’s accommodation. The 3 most com-
6. Wallace DK, Christianse SP, Sprunger DT, et al. Pediatric Eye
mon topical cycloplegic agents are atropine, cyclo- Evaluations PPP – 2017. American Academy of Ophthalmology.
pentolate, and tropicamide.4 Because of the time to November 2017. Accessed May 20, 2021. https://www.aao.org/ Cheung earned his doctor of optometry degree at the University of California,
maximum cycloplegia and cycloplegic effect, cyclo- preferred-practice-pattern/pediatric-eye-evaluations-ppp-2017
Berkeley, School of Optometry. He serves as director of community education
and director of pediatric optometry residency at Duke University in Durham,
pentolate is the agent of choice for many ODs. 7. Donahue SP. How often are spectacles prescribed to “normal” North Carolina.
The most common cause for decreased vision in preschool children? J AAPOS. 2004;8(3):224-229. doi:10.1016/j. nathan.cheung@duke.edu
children, other than uncorrected refractive error, is
amblyopia. Cycloplegic retinoscopy determines the
extent of the patient’s refractive error. The Ameri-
can Academy of Ophthalmology and the American
Optometric Association created amblyogenic refrac-
tive error guidelines.5,6 ®
Prescribing glasses for pediatric patients is as much
an art as a science. Ophthalmologists suggest that
optometrists overprescribe glasses to children, caus-
ing a financial burden on the healthcare system.7
In prescribing for pediatric patients, the first step
is knowing when to prescribe, and the second is
knowing what to prescribe.
I determine glasses prescribing based on the
answers to these questions:
–  Does this refractive error have potential to
cause amblyopia?
–  How did the child perform on visual acuity
testing?
–  How did the child perform on stereoacuity
testing?
–  How old is the child? Is the child attending
Keep it Simple
grade school?
–  What is the parents’ socioeconomic Keep it Preservative-Free
background?

ODs and ophthalmologists differ in their prescrib-

ing patterns. Even among ODs, large variation exists.
The following prescribing guidelines are my opinion.
And NOW Introducing Simple Pricing
Every pediatric patient presenting for a comprehen-
sive eye exam will have a refractive error with cyclo-
plegic retinoscopy.8 My job is to determine the sever-
ity of the refractive error and whether this refrac-
tive error may cause amblyopia. I evaluate the level Any Single Drug:
$19/month*
and magnitude of the refractive error and compare
it to what is normal for a child this age.
For patients with myopia and astigmatism, I pre-
scribe the full value of the refractive error, especially
if the child is school aged. I often monitor low lev-
els of myopia and astigmatism in toddlers and pre-
Any Combo Drug:
school children. For patients with hyperopia, I con-
sider the level of error and its severity for the patient’s $39/month*
age. Unless the patient has esotropia, I prescribe a
symmetrical reduction in hyperopia to both eyes,
rarely giving their full cycloplegic refractive error.

Scan QR code or visit:

REFERENCES
1. Kanski J, Bowling B. Kanski’s Clinical Ophthalmology 8th Edition;
2015.

2. Velez FG, Clark RA, Demer JL. Facial asymmetry in superior

oblique muscle palsy and pulley heterotopy. J AAPOS.
www.SimpleDrops.com
2000;4(4):233-239. doi:10.1067/mpa.2000.105277

3. Nanda KD, Blaha B, Churchfield WT, et al. Induced tropia test and
visual acuity testing in nonverbal children. J Binocul Vis Ocul Motil.
2018;68(4):134-136. doi:10.1080/2576117X.2018.1525235
Important: Patients may need to take more than one eye drop product pursuant to
4. Egashira SM, Kish LL, Twelker JD. Comparison of cyclopentolate multiple dosing regimens, as directed by his or her prescriber, in order for the
versus tropicamide cycloplegia in children. Optom Vis Sci. active ingredients to remain effective throughout the day.
1993;70(12):1019-1026. doi:10.1097/00006324-199312000-00005 *1 Month supply can vary based on the dosing regimen prescribed by the doctor.

5. Rouse MW, Cooper JS, Cotter SA, Press LJ, Tannen BM. ImprimisRx and Simple Drops are registered trademarks of Harrow Health, Inc.
©2021 ImprimisRx. All rights reserved. IMPO0393 Rev4 5/21
 CONTINUING EDUCATION
3
Follow-Up
VISIT
from
Things You Should Know
About Dry Eye Disease
David L. Wirta, MD
Principal Investigator
Medical Director
Eye Research Foundation
Ophthalmologist
Oculoplastic Surgeon
Aesthetic Eyecare Institute
Newport Beach, CA
This activity was written by PER® editorial
staff under faculty guidance and review.
Faculty, Staff, and Planners’ Disclosures
The staff of Physicians’ Education
Resource®, LLC have no relevant financial
relationships with ineligible entities.
Disclosures (Dr Wirta): Grant/Research
Support: Aerie Pharmaceuticals, Allergan,
GreenLight Biosciences, Novaliq, Novartis,
OraPharma, Oyster Point Pharma, TearCare.
PER® mitigated all COI for faculty, staff, and
planners prior to the start of this activity by
using a multistep process.
To learn more about this
topic, including information
on the increasing prevalence
of dry eye disease (DED),
available treatment options,
and emerging novel agents
with unique mechanisms of
action, go to
gotoper.com/online-cme-
activities/medical-crossfire/
mxf-dry21eye
Release Date: June 1, 2021
Expiration Date: June 1, 2022
Learning Objectives
Upon successful completion of this activity, you should be
better prepared to:
• Assess the impact of increased screen time due to
COVID-19 and other factors that may contribute to the
development and prevalence of DED
• Evaluate new mechanisms of action, efficacy, and safety
data for emerging therapies seeking indications for DED
Accreditation/Credit Designation
This activity, COPE Activity Number 121761, is accredited by
COPE for continuing education for optometrists.
Physicians’ Education Resource®, LLC, is accredited by the
Accreditation Council for Continuing Medical Education
(ACCME) to provide continuing medical education for
physicians.
Physicians’ Education Resource®, LLC, designates this enduring
material for a maximum of 0.25 AMA PRA Category 1 Credits™.
Physicians should claim only the credit commensurate with the
extent of their participation in the activity.
Acknowledgment of Commercial Support
This activity is supported by an educational grant from Oyster
Point Pharma, LLC.
Off-Label Disclosure/Disclaimer
This activity may or may not discuss investigational, unapproved
or off-label use of drugs. Learners are advised to consult
prescribing information for any products discussed. The
information provided in this activity is for accredited continuing
education purposes only and is not meant to substitute for the
independent clinical judgment of a health care professional
relative to diagnostic, treatment or management options for a
specific patient’s medical condition. The opinions expressed in
the content are solely those of the individual faculty members,
and do not reflect those of PER® or any company that provided
commercial support for this activity.
Instructions for Participation/
How to Receive Credit
1 Read this activity in its entirety.
2 G o to gotoper.com/go/od-dry21eye-print to access
and complete the post-test.
3 Answer the evaluation questions.
4 Request credit using the drop-down menu.
You may immediately download your certificate.
D
ry eye disease (DED) is a common condition
of the ocular surface that is characterized by
a deficiency of quality or quantity of the tear
fluid.1 Due to its multifactorial nature involv-
ing interrelated underlying pathologies, DED can rapidly
become a chronic refractory condition. Since the onset
of the COVID-19 pandemic, the prevalence of DED has
steadily increased.2 Current treatments for DED might
not work for everyone, and the increasing prevalence
has accelerated the development of novel therapies. Here
are 3 things you should know about DED and emerging
strategies to treat it.
1
The new definition of DED
provides practitioners a
practical tool to diagnose
DED in the clinic.
In the United States, more than 16 million patients have
been diagnosed with DED, and an estimated 6 million
adults have symptoms but have not yet been diagnosed.3
16.4 million
diagnosed with DED
DED, clinically referred to as keratoconjunctivitis
sicca, is defined by the Tear Film and Ocular Surface
Society’s Dry Eye Workshop II (TFOS DEWS II) panel as
a multifactorial disease of the ocular surface characterized
by a loss of homeostasis of the tear film and accompa-
nied by ocular symptoms, such as discomfort and visual
disturbance.4 It involves tear film instability and hyperos-
molarity, ocular surface inflammation and damage, and
neurosensory abnormalities.
DED is often classified into 2 primary subtypes: aque-
ous tear-deficient dry eye, characterized by an inefficiency
or inability of the lacrimal glands to produce tears, and
evaporative dry eye, typically attributed to excessive evap-
oration of the tear fluid.5 The newer definition can help
clinicians to determine the specific DED subtype to guide
and individualize treatment.
The symptoms of DED are heterogeneous and often
include dryness, red eyes, blurred vision, photophobia, oc-
ular discomfort or pain, foreign body sensation, fluctuat-
ing vision, irritation, and burning.6,7 These symptoms can
have a substantial effect on daily activities and can lead to
a reduction in work productivity with a consequently high
impact on quality of life.8
JUNE 2021 OPTOMETRY TIMES ® 25
CE

2
spread use of face masks adds a potential second compo- dnol etabonate (LE) is a corticosteroid with a low risk
The COVID-19 pandemic nent to the DED epidemic. The displacement of a mask or of corticosteroid-related adverse effects such as elevated
has led to a higher its incorrect fitting could disperse air around the eyes, and intraocular pressure.12 The LE ophthalmic suspension
prevalence of DED. the air leakage could cause a rapid evaporation of tears 0.25% was recently approved by the United States Food
leading to mask-associated DED.2 and Drug Administration (FDA) following the completion
Risk factors and exacerbating causes of the STRIDE 3 trial. LE is the first agent indicated for the

of DED include advanced age, female gender, medica-
tions (eg, antihistamines, estrogens, selective serotonin
antagonists), low humidity environments, extended screen
viewing, systemic diseases (eg, Sjögren syndrome, diabetes
mellitus), and prior ophthalmic surgery.9
A common risk factor
for DED is extended
screen time
The COVID-19 pandemic has led to an increase in the
prevalence of DED, especially among the younger popu-
lation. The increase in remote schooling and working has
exposed individuals to greater use of visual display termi-
nals.2 Increased screen time leads to excessive evaporation
of tear fluid because of prolonged blinking intervals, and
gazing is thought to be the main causative factor.
Several studies have shown that 1 hour of tablet or
smartphone use increases eye strain and blur in young
adults by as much as 5 times.10 Furthermore, the wide-
“In the trial, I found there was a significant portion of patients who
would rather not put something in their eyes to help their eyes. Just
doing a quick nasal spray, which many people are comfortable with
already, certainly is a big plus to a subset of patients.” —David L. Wirta, MD
3
Emerging treatments for
DED include a nasal spray
Treatment for DED is aimed at im-
proving symptoms by increasing or
supplementing tear production, slowing tear evaporation,
reducing tear resorption, or reducing ocular surface
inflammation. The TFOS DEWS II management and
treatment recommendations include a 4-step process.4
First-line treatment for most patients with mild or preclin-
ical DED includes artificial tears and lifestyle modifica-
tions, including taking frequent screen breaks by looking
at a distant object and blinking at regular intervals.11 For
moderate to severe cases, additional disease-modifying
prescription drugs may be needed. Surgical intervention
is considered only if these recommendations fail to yield
positive results.
Owing to the inflammatory nature of DED, topical
corticosteroids are an effective treatment option, particu-
larly for moderate to severe DED when first-line treat-
ments such as ocular lubricants are insufficient. Lotepre-
short-term treatment of the signs and symptoms of DED.
In STRIDE 3, ocular discomfort severity was significantly
improved by day 15 in both the intent-to-treat group and
in a predefined subgroup with more severe ocular discom-
fort at baseline, compared with the vehicle group. LE was
well tolerated and had a favorable safety profile.13
Varenicline, a nicotinic acetylcholine receptor agonist,
is an emerging agent for DED with a novel mechanism
of action; this preservative-free nasal spray stimulates
the trigeminal parasympathetic pathway to increase
tear production. The parasympathetic nervous system
controls tear film homeostasis partially via the trigeminal
nerve, which is accessible within the nasal cavity. Results
from the MYSTIC, ONSET-1, and ONSET-2 trials have
demonstrated statistically significant improvements in the
Schirmer score (a measure of natural tear film production)
among individuals treated with varenicline compared with
controls, which was the primary end point in these trials.
Key secondary end points of ONSET-1 and ONSET-2
included change from baseline in symptoms as assessed
by the eye dryness score. Both trials showed statistically
or nominally statistically significant improvement in
symptom scores at day 28, and in ONSET-2, as early as
day 14, among patients treated with varenicline nasal
spray compared with controls. All doses under study were
well tolerated with no serious drug-related adverse events.
The FDA accepted the new drug application (NDA)
for varenicline nasal spray for the treatment of DED in
March 2021.14

KEY REFERENCES
4. Craig JP, Nelson JD, Azar DT, et al. TFOS DEWS II Report Executive Summary. Ocul Surf. 2017;15(4):802-812. doi:10.1016/j.jtos.2017.08.003
5. Agarwal P, Craig JP, Rupenthal ID. Formulation considerations for the management of dry eye disease. Pharmaceutics. 2021;13(2):207.
doi:10.3390/pharmaceutics13020207
For a full list of references go to
10. Jaiswal S, Asper L, Long J, Lee A, Harrison K, Golebiowski B. Ocular and visual discomfort associated with smartphones, tablets and gotoper.com/go/od-dry21eye-print
computers: what we do and do not know. Clin Exp Optom. 2019;102(5):463-477. doi:10.1111/cxo.12851

Claim Your CE Credit at:

CE POST-TEST QUESTIONS
gotoper.com/go/od-dry21eye-print

1 Janice is a 16-year-old high school student who has continued to take online classes since the COVID-19 lockdown in her school district. Besides her regular
course work, she is also studying for the SAT exam; thus, she often spends additional hours on her laptop preparing for the exam and engaging with social
media. Her mother has encouraged her to use lubricant eye drops, but she forgets and frequently complains of dry eyes. Which of the following statements is
true regarding the impact of prolonged screen time leading to visual discomfort?
A. One hour of tablet or smartphone use increases eye strain and blurring in young adults up to 5-fold
B. One hour of computer use increases eye strain and blurring in older adults up to 10-fold
C. Reduced blink rate within minutes of device use is similar for both computer and smartphone or tablet use
D. Reduced tear volume occurs more frequently with smartphone or tablet use
2 In the STRIDE 3 phase 3 study comparing loteprednol etabonate 0.25% to a vehicle in an intent-to-treat (ITT) group and a subgroup with more baseline ocular
discomfort, which of the following is true regarding safety and efficacy?
A. The most common adverse event was corneal verticillata
B. Elevations in intraocular pressure were greater in the vehicle group
C. Ocular discomfort severity (ODS) was significantly improved by day 15 in the ITT and higher baseline discomfort groups
D. ODS was improved at day 15 in the overall intent-to-treat population with less severe ocular discomfort
3 Which of the following phrases describes varenicline, an agent being evaluated to relieve the signs and symptoms of dry eye disease?
A. Lubricant drops preserved with sodium perborate that target the lacrimal functional unit
B. Preservative-free drops that reduce T-cell mediated inflammation
C. Preservative-free nasal spray that targets acetylcholine receptors to activate the trigeminal parasympathetic pathway
D. Nasal spray preserved with an oxychloro complex that targets acetylcholine receptors in the lacrimal functional unit

CE Provider Contact Information

To learn more about this topic, including information on the increasing prevalence of dry eye disease, Physicians’ Education Resource®, LLC
available treatment options, and emerging novel agents with unique mechanisms of action, go to 2 Clarke Drive, Suite 110, Cranbury, NJ 08512
gotoper.com/online-cme-activities/medical-crossfire/mxf-dry21eye Toll-Free: 888-949-0045 | Local: 609-378-3701 |
info@gotoper.com
 JUNE 2021 |
26
Practice Management

5 financial ratios to watch to track

your practice’s financial health
Knowing the level of financial stability helps practitioners make better decisions
a solvency ratio called the current ratio. class. How long does it take for the Centers for
By David Norris, MD, MBA The current ratio is a simple calculation Medicare & Medicaid Services to pay the practice?
Contributing author to perform, but first a few definitions are How long does it take for commercial payers to

P
hysicians are quite familiar with
methods for discovering the
health of their patients. They
use HDL:LDL (high-density lipo-
protein/low-density lipoprotein) ratio,
waist-to-height ratio, waist-to-hip ratio,
needed. When current is used in a finan-
cial report, it indicates the ability to con-
vert the asset into cash within a 1-year
period or the liability is due within
1 year. Current assets can convert to
DAVID NORRIS, cash within 1 year. Current assets are
pay the practice? How long does it take to get paid
by patients with health savings accounts? These
are important questions that can help physicians
make better decisions and plans. The calculation
is performed by dividing accounts receivable by
the revenue and then multiplying by 365.

3
and many other measurements. Not MD, MBA, is an cash, cash equivalents, accounts receiv-
only are they skilled at doing so, but anesthesiologist in able (A/R), bad debt allowance, and Operating margin
they can even use this data to predict Wichita, Kansas. inventory on hand. Current liabilities Operating margin is a measure of what pro-
problems patients will face and even are bills that must be paid within 1 year. portion of the company’s revenue is left over
how long they might live. Current liabilities are all notes and accounts pay- after paying the variable costs of production of the
Accountants and business leaders use similar able due within 1 year, interest payable, wages services or goods. These costs include wages, raw
ratios and methods to determine the financial payable, and income taxes payable. materials, etc. It is important to have a healthy
health of a company. These ratios can tell physi- The current ratio is an indication of the firm’s operating margin so that the company has enough
cians the financial health of their practices. Listed ability to pay back its short-term liabilities. To cash to pay its fixed costs. This is also known as an
below are the top 5 financial metrics every phy- obtain this ratio, divide the current assets by the operating profit margin for the net profit margin.
sician should know how to and use each month. current liabilities. If the current ratio is less than It is calculated by dividing the operating income
These are a few of the financial ratios physicians 1, this indicates the company has more debt due by the net revenue.

4
can determine using income statements and bal- within 1 year than it has assets to pay those debts.
ance sheets provided by their accountants and This is a critical ratio for any company, particularly Working capital
office managers. in medical practice. If a practice’s current ratio is Capital measures the practice’s abilities to
These ratios will help determine the level of less than 1, the physician should seriously con- pay its bills on time. It is another liquidity
financial stability of a practice and help ODs make sider how the practice will survive should some- or solvency ratio. It is calculated by subtracting
better decisions for their future. Financial health thing happen to cash flow. the current liabilities from the current assets. The
is hard work. Just as physicians ask patients to Another ratio is the quick ratio or “acid test.” larger the number, the larger the working capital
keep track of diet and exercise activity, they should This is the same as a current ratio except that and the larger the cushion the firm has should an
also closely monitor the financial health of their inventories are not included in the numerator. It unexpected revenue downturn occur.

5
practices. They must be diligent to actively man- examines the most liquid assets and compares
age their business. them against the current liabilities. If a practice Number of days in accounts
payable

1
does not hold inventory, then its current ratio is
Current ratio a quick ratio or acid test. Like the number of days in A/R, the num-

2
One of the most important
ratios to know is Number of days in
accounts receivable
The number of days in A/R mea-
sure a company’s ability to convert
receivables into cash. A low
number of days in A/R indi-
cates that the practice can
quickly collect on its debts.
This ratio varies by industry.
The important thing to watch is
whether the number increases.
If it is increasing, investigate
why and find ways to bring
the number back down. Every
practice should know its gen-
ber of days in accounts payable (A/P) measures
how long it takes for the practice to pay its bills.
This is an important ratio because it can be a lag-
ging indicator of the financial health and solvency
of the practice.
Also, the number of days in accounts payable
can be a good indicator of how well the practice
is using its cash. Paying bills too soon might strap
the firm for cash in the short term. Paying bills
too late puts the practice in jeopardy of financial
and legal action.
Says in A/P is also a good ratio to know about
those with whom a practice has service contracts
or agreements. If these providers take a long time
to pay their bills, it will give you an indication of
what to expect. This calculation is made by the
Victor Moussa @Adobe Stock

eral number of days ending accounts payable divided by the cost of

in A/R. sales divided by the number of days.
It is equally
important
FROM THE
to know the
PAGES OF
n u m b e r of
days in A/R Norris previously was a business consultant with the Center for Professional
for each payer Business Development.
 | PRACTICAL CHAIRSIDE ADVICE
When times aren’t “20/happy”
Many systemic conditions have higher incidence with depression, anxiety
By Jade Coats, OD; Chris Kruthoff, –  Restlessness
OD, FAAO; and Jacob R. Lang, OD, –  Difficulty concentrating
FAAO
–  Difficulty sleeping or getting out of
A
s primary eye care providers, bed
optometrists may face unsettling –  Changes in appetite
situations in which a patient is –  Suicidal ideations
exhibiting behavioral or mental
health crisis while in the office. Inter- The onset of major depressive disor-
estingly, many of the systemic condi- JADE COATS, OD, der peaks with most patients present-
tions ODs treat regularly have a higher is an associate ing in their 20s, with a second peak of
incidence with mental conditions such at an OD/MD incidence of patients in the 50s.7 Women
as depression and anxiety. multidisciplinary are twice as likely as men to receive a
practice in Rogers,
Early recognition, referral, and treat- Arkansas. diagnosis of depression.8 Risk factors
ment of common mental health condi- for major depressive disorder include
tions such as these can improve qual- divorce or separation, episodes of
ity of life for patients and help prevent depression in the past, increased stress,
complications of cooccurring behav- a history of trauma, and a family his-
ioral health and medical comorbidi- tory of depression in first-degree rela-
ties while reducing overall health care tives.9 Depression can occur at any age,
costs.1 Being familiar with common sys- and as will be discussed later in this
temic and ocular associations with men- article, is often present with other sys-
tal illness along with being more aware CHRIS KRUTHOFF, temic comorbidities. In fact, depression
of a patient’s behavioral health status OD, FAAO, can exacerbate these problems.6
may help to guide an OD to provide is in a group OD/
an appropriate mental health referral. MD practice Golden Anxiety
In the United States, the estimated Valley, Minnesota. All individuals will experience anxiety
lifetime risk of a major depressive epi- in their lives as a response to stressful
sode approaches 30%. The incidence situations. With the ongoing COVID-19
of suicide, which is associated with a pandemic, most individuals have likely
diagnosis of depression more than 50% experienced episodes of anxiety regard-
of the time, has been increasing and is ing concerns about their health and that
the 10th leading cause of death in the of their families and how the pandemic
United States.2-4 might affect their work and livelihood.
Although these anxious responses in
Depression versus anxiety JACOB R. LANG, short duration are normal, anxiety dis-
While mental health focuses on a per- OD, FAAO, orders hold a more chronic presence in
son’s psychological state, behavioral is in a group OD/MD the lives of those who experience them.
practice in Stillwater,
health is a broad umbrella that incor- Minnesota. These disorders fall under several cate-
porates physical and mental struggles, gories according to the National Insti-
including daily eating habits, exercise routines, tute of Mental Health,10 including:
and alcohol consumption. ODs are in a distinctive –  Generalized anxiety disorder: Excess anxiety
position to routinely assess these details reported on a near daily basis for at least 6 months.
by patients; therefore, it may behoove ODs to fur- This persistent anxiety has a profound effect
ther educate themselves on how to identify mental on daily activities and may manifest with
conditions and refer when appropriate. symptoms such as extreme restlessness, loss
To properly identify someone who may need of sleep, difficulty focusing, fatigue, and
further mental health assistance, it is important irritability.10
to better understand the definitions and charac- –  Panic disorder: Recurrent panic attacks that
teristics of depression and anxiety. may be triggered by certain situations or be
unexpected. These episodes may be accompa-
Depression nied by shortness of breath, shaking, sweat-
Clinical depression is a common condition, affect- ing, heart palpitations, and feeling of impend-
ing more than 1 in 6 individuals at some point in ing doom.10
their lives.5 While most encounter periods of sad- –  Phobia-related disorders: Fear of certain situ-
ness or grief during their lives, clinical depression ations or things to the extent that other nor-
is characterized by persistent, and nearly constant, mal activities of daily living are affected.10
states of these emotions. Signs and symptoms of
clinical depression include any of the following Although depression and anxiety represent
being present for 2 or more weeks6: 2 separate clinical entities, they frequently over-
–  Persistent sadness lap. Approximately 85% of patients with depres-
–  Loss of interest in hobbies sion experience anxiety, and 90% of patients with
–  Fatigue anxiety also exhibit signs of depression.11
Clinical 27
Treatment options for each condition involve a
combination of psychological (ie, clinical coun-
seling) and pharmacologic therapies (antidepres-
sants) depending on severity of condition. How-
ever, more than one-third of patients who expe-
rience these conditions seek treatment, and only
half of those are offered helpful interventions.11
Systemic disease and mental health
There is evidence for an association between
depression and anxiety with a multitude of sys-
temic conditions such as diabetes, lung disease,
arthritis, autoimmune disorders, heart disease, and
cancer, to name a few.1,2 As ODs assess patients
with these systemic conditions in their offices daily,
they should consider screening patients to ensure
they are receiving care.
Psychiatric conditions such as depression and
anxiety have been linked to the following sys-
temic conditions.
Diabetes
Patients with diabetes need regular diabetic ret-
inopathy examinations as well as treatment for
common findings in these patients such as dry
eye, cataract, and glaucoma. The diabetes epi-
demic is well known and continues to grow, with a
prevalence estimate of as many as 1 in 11 adults.12
Research shows that depression rates run higher by
as many as 2 to 3 times in comparison to patients
without diabetes, whereas anxiety is present in
as many as 40% of these patients.12 While diabe-
tes may cause or contribute to mental health con-
cerns, evidence shows depression may be a con-
tributing factor in the development of diabetes.
Patients diagnosed with depression have a 60%
increased risk of developing type 2 diabetes com-
pared with control populations.13
Obstructive sleep apnea (OSA)
OSA is tied by causation or exacerbation to many
systemic and eye-related conditions, including dia-
betes and diabetic retinopathy, hypertension, glau-
coma, floppy eyelid syndrome, and nonarteritic
ischemic optic neuropathy.14 Because of the consis-
tent interruption of normal sleep, which can lead
to development of depression, it is not surprising
that a bidirectional relationship exists between
these 2 conditions with nearly 18% of patients
experiencing one also experiencing the other.15
Autoimmune diseases
Autoimmune conditions can be burdensome, with
varying intensity and flares that may lead to con-
cern for short- and long-term complications. This
may contribute to depression and anxiety in these
patients. Correlations are seen in patients with
lupus, rheumatoid arthritis, inflammatory bowel
disease, autoimmune thyroiditis, and multiple scle-
rosis, among others.16-18 Moreover, an increase in
cytokine activation may be a contributing factor
See Mental health on page 28

28
Clinical
Mental health
Continued from page 27
in the cause of depression, suggesting that inflam-
matory factors released in these conditions may
be a primary contributing factor to depression.16
Heart disease
When hospitalized for a cardiac event, such as acute
myocardial infarction or coronary artery bypass
graft surgery, approximately 1 in 5 patients meets
diagnostic criteria for depression and up to 1 in 3
experiences severe anxiety.19 Because patients who
are anxious or depressed after a cardiac event are
at increased risk of a subsequent event and prema-
ture death,19 it is especially important to ensure
that patients recently affected by heart disease are
receiving proper mental health care.
Stroke
Stroke is the third-leading cause of death glob-
ally, affecting 15 million individuals annually.20
Poststroke depression (PSD) has been reported in
nearly 33% of stroke patients and is considered
the most frequent and important neuropsychiat-
ric consequence of a stroke that negatively affects
recovery.20 PSD is characterized as a mood disor-
der with depressive features, major depressive-
like episodes, manic features, or mixed features,
which increases the disease deterioration, causes
further social function defects, and increases the
risk of suicide.20 Screening for mental illness in
poststroke patients is important because adequate
treatment eye-related conditions may be depen-
dent on successful therapy for other comorbid con-
ditions, such depression and anxiety secondary
to stroke.20
Fibromyalgia and migraines
Fibromyalgia and depression share similar patho-
physiology and are targeted by the same drugs with
dual action on serotoninergic and noradrenergic
systems.21 Fibromyalgia is considered an affective
85%
of patients with
depression experience
anxiety, and 90% of
patients with anxiety
also exhibit signs of
depression.8
The prevalence of
depression among
DED patients was
spectrum disorder. This category includes physi-
cal conditions such as migraines and psychiatric
disorders such as21:
–  Attention-deficit/hyperactivity disorder
–  Bulimia nervosa
–  Dysthymic disorder
–  Generalized anxiety disorder
–  Major depressive disorder
–  Obsessive compulsive disorder
–  Panic disorder, posttraumatic stress disorder
–  Premenstrual dysphoric disorder
–  Social phobia
Cancer
The mental health of individuals living with and
surviving cancer is an important factor to consider
as an OD. Although many factors such as the type
and stage of cancer can affect the severity of mental
illness, one meta analysis of several studies found
that the estimated prevalence of depression var-
ied across treatment settings. Depression ranged
from 5% to 16% in outpatients, 4% to 14% in inpa-
tients, 4% to 11% in mixed outpatient and inpa-
tient samples, and 7% to 49% in palliative care.22
More research and a personalized approach to
support the psychological health of individuals
with cancer are needed, as well as proper referral
for treatment of comorbid depression and anxiety.22
Ocular disease and mental health
In addition to considering systemic conditions
when assessing a patient’s overall health status,
it is also important to consider ocular surface dis-
ease, visual impairment from conditions such as
age-related macular degeneration (AMD) and glau-
coma, and chronic inflammatory disease such as
uveitis. All these ocular diseases may further con-
tribute to mental illness.2,4,23,24
An investigation into appropriate treatment strat-
egies, beyond just the eye, may be an important
indirect step in treating the overall ocular disease.
In studies across the globe, patients suffering from
certain ocular conditions have been shown to have
57.9%
of patients reported
believing that
psychological distress
was a trigger for their
relapses.27
Compared with other
eye diseases, the rate of
depression in older adults with
AMD was the highest at
39%. 23
25%,
ranging upward
of 57%.2
JUNE 2021 |
an increased prevalence of depression and anxiety.2
The perception of visual impairment, rather than
objective measures such as visual acuity, has been
shown to be more strongly correlated with depres-
sion. Interestingly, patients who report functional
vision problems, such as difficulty driving, nav-
igating steps, or seeing objects in the periphery,
are 90% more likely to be depressed than patients
who do not report these same problems, indepen-
dent of visual acuity.2,24
Dry eye disease
Depression and anxiety may be a significant but
underrecognized comorbidity in patients with
chronic ocular inflammation such as dry eye dis-
ease (DED).2,4 One meta-analysis demonstrated that
the prevalence of depression among DED patients
was 25%, ranging upward of 57%.2 An increased
frequency of dry eye in patients being treated for
a variety of psychiatric illnesses, including depres-
sion and anxiety, has been observed in a large
population-based study.2
It is thought that patients receiving treatment
for DED would also benefit from treatment for
depression and anxiety.2,4 Depression and anxi-
ety symptoms may also affect other psychologi-
cal systems.4,23 ODs should view DED among the
same group of chronic systemic medical illnesses
with implications for psychiatric disease and be
more cognizant to psychiatric symptoms reported
in patients with DED.
Note that the anticholinergic activity of some
antidepressant medications has been identified as
a risk factor for DED.2 Patients being treated for
depression and or anxiety may need to be further
screened for DED and vice versa.
AMD
AMD is a common cause of visual impairment and
blindness that affects nearly 196 million individu-
als worldwide, which is approximately 9% of the
global population.24 Depression and anxiety are
more common in adults with visual impairment.
Clinically significant subthreshold symptoms of
depression are found in approximately one-third
of older adults with AMD and impaired vision,
which is nearly twice as high as the lifetime prev-
alence rates in the general older population.23,24
Visual impairment worsened by AMD is associ-
ated with increased functional disability and emo-
tional stress, leading to an increased risk of men-
tal health problems in patients with AMD. Com-
pared with other eye diseases, the rate of depres-
sion in older adults with AMD was the highest at
39%.24 The rate of anxiety was variable, but the
prevalence of anxiety among patients with AMD
ranges from 9.6% to 30%.23 It is important to note
that other mental conditions such as agoraphobia
(4.2%) and social phobia (2.4%) were prevalent
among those with visual impairment due to AMD.24
Although research has shown that behavioral
interventions can treat or prevent depression in
AMD, 24 until an AMD-specific behavioral and
ink drop @Adobe Stock
self-management program model is available, tra-
ditional low vision rehab is considered the best
treatment option ODs can provide, coupled with
an appropriate referral for mental health care when
necessary. Because AMD can affect functional and
psychological well-being, ODs should educate AMD
 | PRACTICAL CHAIRSIDE ADVICE
patients that symptoms of anxiety and depression
can be alleviated by treatments such as medica-
tion from their medical providers, psychotherapy,
and low vision rehabilitation.24
Glaucoma
Glaucoma is a chronic, potentially blinding condi-
tion requiring lifelong treatment and regular fol-
low-up visits. Although the condition varies in
severity, the potential threat of irreversible vision
loss can have a significant impact on patient psy-
che. As with chronic systemic disorders, correla-
tion exists between the glaucoma and the pres-
ence of depression and anxiety.25
Research shows potential exacerbation of glau-
coma by these afflictions. Results from one study
showed significant association with anxiety or
concomitant depression and anxiety and conver-
sion from glaucoma suspect to the development
of glaucoma.26 Results from another study showed
patients with anxiety exhibited higher and more
variable intraocular pressure (IOP), faster retinal
nerve fiber layer progression, and increased pres-
ence of disc hemorrhage, postulating that contin-
ued emotional stress has a significant effect on the
autonomic nervous system, which further affects
IOP and blood flow.27 These study results indicate
that the relationship between glaucoma and these
mental health disorders may have 2-way interac-
tion in affecting disease progression.
Uveitis
HLA-B27-associated uveitis (B27-AU) is another
ocular condition in which research has found that
patients with the condition had more depressive
symptoms and negative coping strategies than
patients in the control group. Perhaps implicat-
ing stress and life events as a trigger for relapses,
results from this study demonstrated that female
patients with B27-AU react with depression, and
male patients use negative stress coping strategies.
Some 57.9% of patients reported believing that psy-
chological distress was a trigger for relapses, and
34.5% stated specific life events triggered them.28
Although the prognosis of anterior uveitis is
good, complications of HLA-B27-associated uve-
itis can include posterior synechiae, cataract, glau-
coma and hypotony, although only less than 2%
develop legal blindness and less than 5% have
visual impairment.28 When a patient presents with
recurrent anterior uveitis, ensure the patient seeks
follow-up treatment with a rheumatologist so the
underlying inflammatory cause can be treated.
How ODs can help
Especially during COVID-19, ODs may be the only
health care professionals a patient has seen or will
see for significantly more time compared with
prepandemic. This induced isolation requires all
health care providers to be more connected, and
a team approach is needed to care for patients’
comprehensive health.
Although discussing depression and anxiety
with patients during their eye examination may
be awkward, uncomfortable, and time consuming,
ODs are able to identify vision-related deficiency
and psychiatric symptoms affected by ocular dis-
ease. ODs can play a role in destigmatizing men-
tal illness by emphasizing that depression is com-
mon and an understandable reaction to vision loss.
All health care providers should watch for
identifying signs of mental illness. Results from
one study showed that 38% of individuals who
attempted suicide visited a health care provider
within the previous week.9 The coexistence of
depression and anxiety is frequent with more than
50% of patients with depression also diagnosed
with clinically significant anxiety.9 Coexistence of
both conditions decreases the chance of success
with standard treatments compared with patients
who have depression without anxiety.9
Surveys are commonly used by ODs to screen
patients for mental health diseases. Many are avail-
able, and all have pros and cons, focus, length, and
intended use.9 The Patient Health Questionnaire
has utility in eye care clinics because it is quick,
simple, and accurate.8 This 4-question, 12-point
survey screens for depression and anxiety and
can help facilitate consultation with primary care
and other mental health specialists.8
When concerns about a patient’s mental well-
being arise, a phone call to the patient’s primary
care provider is recommended as the best next
step. If the patient doesn’t have a relationship with
a primary care physician or the situation seems
emergent, it is recommended that ODs work with
emergency department colleagues. In our experi-
ence, emergency department colleagues are happy
to take over care in these situations. In addition,
the National Suicide Prevention Lifeline is avail-
able 24 hours: 1-800-273-8255.
Although mental health conditions are best
treated by primary care, psychology, and psychi-
atry colleagues, ODs play an integral role to get
patients the help they need with an appropriate
and timely referral. Because ODs sometimes spend
more time with their patients due to systemic and
ocular conditions requiring chronic care, an OD
may be the patient’s most trusted and visited health
care provider. Learning the details of systemic
and ocular comorbidities associated with depres-
sion and anxiety is an important step in getting
patients the care they need.
REFERENCES
1. Zheng Y, Wu X, Lin X, Lin H. The prevalence of depression and
depressive symptoms among eye disease patients: a systematic review
and meta-analysis. Sci Rep. 2017;7:46453. doi:10.1038/srep46453
2. van der Vaart R, Weaver MA, Lefebvre C, Davis RM. The association
between dry eye disease and depression and anxiety in a large
population-based study. Am J Ophthalmol. 2015;159(3):470-474.
doi:10.1016/j.ajo.2014.11.028
3. Wen W, Wu Y, Chen Y, et al. Dry eye disease in patients with
depressive and anxiety disorders in Shanghai. Cornea. 2012;31(6):686-
692. doi:10.1097/ICO.0b013e3182261590
4. Kitazawa M, Sakamoto C, Yoshimura M, et al. The relationship of dry
eye disease with depression and anxiety: a naturalistic observational
study. Transl Vis Sci Technol. 2018;7(6):35. doi:10.1167/tvst.7.6.35
5. What is depression? American Psychiatric Association. October 2020.
Accessed May 13, 2021. https://www.psychiatry.org/patients-families/
depression/what-is-depression
6. Depression. National Institute of Mental Health. Updated February
2018. Accessed May 13, 2021. https://www.nimh.nih.gov/health/
topics/depression/index.shtml
7. Burke KC, Burke JD Jr, Regier DA, Rae DS. Age at onset of selected
mental disorders in five community populations. Arch Gen Psychiatry.
1990;47(6):511518. doi:10.1001/archpsyc.1990.01810180011002
8. Kroenke K, Spitzer RL, Williams JBW, Löwe B. An ultra-brief
screening scale for anxiety and depression: the PHQ-4. Psychosomatics.
2009;50(6):613-621. doi:10.1176/appi.psy.50.6.613
9. Mulvaney-Day N, Marshall T, Piscopo KD, et al. Screening for
behavioral health conditions in primary care settings: a systematic review
of the literature. J Gen Intern Med. 2018;33(3):335-346. doi:10.1007/
Clinical 29
s11606-017-4181-0
10. Anxiety disorders. National Institute of Mental Health. Updated
July 2018. Accessed May 13, 2021. https://www.nimh.nih.gov/health/
topics/anxiety-disorders/index.shtml
11. Tiller JW. Depression and anxiety. Med J Aust. 2013;199(S6):
S28-S31. doi:10.5694/mja12.10628
12. Bădescu SV, Tătaru C, Kobylinska L, et al. The association between
diabetes mellitus and depression. J Med Life. 2016;9(2):120-125.
13. Mezuk B, Eaton WW, Albrecht S, Golden SH. Depression and
type 2 diabetes over the lifespan: a meta-analysis. Diabetes Care.
2008;31(12):2383-90. doi:10.2337/dc08-0985
14. West SD, Turnbull C. Obstructive sleep apnoea. Eye (Lond).
2018;32(5):889-903. doi:10.1038/s41433-017-0006-y
15. Jehan S, Auguste E, Pandi-Perumal SR, et al. Depression,
obstructive sleep apnea and psychosocial health. Sleep Med Disord.
2017;1(3):00012.
16. Pryce CR, Fontana A. Depression in autoimmune diseases. Curr Top
Behav Neurosci. 2017;31:139-154. doi:10.1007/7854_2016_7
17. Siegmann EM, Müller HHO, Luecke C, Philipsen A, Kornhuber
J, Grömer TW. Association of depression and anxiety disorders with
autoimmune thyroiditis: a systematic review and meta-analysis. JAMA
Psychiatry. 2018;75(6):577-584. doi:10.1001/jamapsychiatry.2018.0190
18. Boeschoten RE, Braamse AMJ, Beekman ATF. Prevalence of
depression and anxiety in multiple sclerosis: a systematic review and meta-
analysis. J Neurol Sci. 2017;372:331-341. doi:10.1016/j.jns.2016.11.067
19. Murphy B, Le Grande M, Alvarenga M, Worcester M, Jackson A.
Anxiety and depression after a cardiac event: prevalence and predictors.
Front Psychol. 2020;10:3010. doi:10.3389/fpsyg.2019.03010
20. Shi Y, Yang D, Zeng Y, Wu W. Risk factors for post-stroke depression:
a meta-analysis. Front Aging Neurosci. 2017;9:218. doi:10.3389/
fnagi.2017.00218
21. Gracely RH, Ceko M, Bushnell MC. Fibromyalgia and depression.
Pain Res Treat. 2012;2012:486590. doi:10.1155/2012/486590
22. Niedzwiedz CL, Knifton L, Robb KA, Katikireddi SV, Smith DJ.
Depression and anxiety among people living with and beyond cancer:
a growing clinical and research priority. BMC Cancer. 2019;19(1):943.
doi:10.1186/s12885-019-6181-4
23. Cimarolli VR, Casten RJ, Rovner BW, Heyl V, Sörensen S, Horowitz A.
Anxiety and depression in patients with advanced macular degeneration:
current perspectives. Clin Ophthalmol. 2015;10:55-63. doi:10.2147/
OPTH.S80489
24. Brody BL, Gamst AC, Williams RA, et al. Depression, visual acuity,
comorbidity, and disability associated with age-related macular
degeneration. Ophthalmology. 2001;108(10):1893-1900; discussion
1900-1901. doi:10.1016/s0161-6420(01)00754-0
25. Zhang X, Olson DJ, Le P, Lin FC, Fleischman D, Davis RM.
The association between glaucoma, anxiety, and depression in a
large population. Am J Ophthalmol. 2017;183:37-41. doi:10.1016/j.
ajo.2017.07.021
26. Berchuck S, Jammal A, Mukherjee S, Somers T, Medeiros FA.
Impact of anxiety and depression on progression to glaucoma among
glaucoma suspects. Br J Ophthalmol. Published online August 29, 2020.
doi:10.1136/bjophthalmol-2020-316617
27. Shin DY, Jung KI, Park HYL, Park CK. The effect of anxiety and
depression on progression of glaucoma. Sci Rep. 2021;11(1):1769.
doi:10.1038/s41598-021-81512-0
28. Maca SM, Schiesser AW, Sobala A, et al. Distress, depression and
coping in HLA-B27-associated anterior uveitis with focus on gender
differences. Br J Ophthalmol. 2011;95(5):699-704. doi:10.1136/
bjo.2009.174839
Coats received her doctor of optometry degree from Southern College of Optome-
try in Memphis, Tennessee. She serves as a board member of Intrepid Eye Society
and Hope Cancer Resources. She is married to another OD, and in their spare time
they enjoy scuba diving and traveling internationally. Coats has served as a speaker
and/or advisory board member for Allergan, Bausch + Lomb, Kala Pharmaceuticals,
Orasis, Novartis, and Zeiss. cjadecoats2020@gmail.com
Kruthoff focuses on acute and chronic medical care and perioperative manage-
ment of cataract, cornea, and glaucoma procedures. He received his doctor of
optometry degree from the Illinois College of Optometry in Chicago, Illinois. Fol-
lowing optometry school, he completed a residency in ocular disease and surgical
comanagement at Omni Eye Services of Atlanta, Georgia. He is a member of Intrepid
Eye Society. chris.kruthoff@gmail.com
Lang received his doctor of optometry degree from the New England College of
Optometry in Boston, Massachusetts, then completed a cornea and specialty con-
tact lens residency in Boston. He is a Diplomate of the American Board of Optome-
try and program chair of the Anterior Segment Section of the American Academy of
Optometry. Lang is the residency coordinator for his practice’s ocular disease resi-
dency and adjunct clinical faculty at the Illinois College of Optometry, The Ohio State
University, and Salus University. He serves as a board member of Intrepid Eye Soci-
ety. Lang belongs to the speakers’ bureau and/or holds advisory positions for Orasis,
Allergan, Avellino, Dompe, Novartis, Advanced Ophthalmic Systems, Scope, and Sun
Pharma. jlang@associatedeyecare.com
 JUNE 2021 |
30

Retina
How to differentiate between
choroidal nevus and choroidal melanoma
Appropriate identification and management of pigmented fundus lesions can be made clinically
By Leo Semes, OD, FAAO
1

A
64-year-old woman was
referred for consultation
regarding a pigmented fun-
dus lesion. She was asymp-
tomatic and enjoyed good vision
and systemic health. She took no
medications, had no history of ocu-
lar trauma or surgeries, and did not
LEO SEMES, OD, admit to a family history of ocular
FAAO, is a professor or systemic disorders.
of optometry at Visual acuity was correctable
the University
to 20/20 in each eye. The anterior
of Alabama-
Birmingham. segments and intraocular pres-
sures were within age-appropri-
ate norms. The significant view of the ocular fundus is
shown in Figures 1 to 4.
2 3

Discussion
Choroidal nevus (CN) is a frequently encountered pig-
mented lesion. CN is characterized as having a slate-
gray coloration, flat consistency, and somewhat distinct
borders.
The most common differential diagnoses include con-
genital hypertrophy of the retinal pigment epithelium
(CHRPE) and small malignant melanoma. (See more
on CHRPE in “Diagnosing CHRPE Lesions Can Be a
Challenge for ODs” in the June 2017 issue of Optometry
Times®.) Distinct differences from CN include jet black
color and presence when viewed with red-free light.
Small choroidal melanomas have been described as
having certain characteristics by the mnemonic TFSOM
(To Find Small Ocular Melanoma).1 Multimodal imag-
ing shows these features, including thickness less than
2 mm, subretinal fluid, vision loss via Snellen acuity,
orange pigment, melanoma hollowness on ultrasound/
margin (< 3 mm from optic nerve head), and diame-
ter less than 5 mm.1,2
One simple clinical observation for differentiating
CHRPE from CN is based on anatomy. Melanin absorbs
red-free light of 540 nm.3 Therefore, structures deep in
the retinal pigment epithelium are rendered invisible, or
their visibility is significantly attenuated using such a
filter. Often neglected in clinical observations and doc-
umentation by color fundus photography is that the red-
free filter attenuates resolution.3 For this reason, illu-
mination must be increased to preserve the clinician’s
ability to view choroidal nevi.
Another potential differential diagnosis of CN is
categorized as suspicious nevus. Although this has
been somewhat obviated by the TFSOM paradigm, it
remains an intermediate classification between CN,
which is benign and unlikely to transform to malig-
nant melanoma.4,5
Figure 1. Baseline color fundus photograph of choroidal nevus (left) and documented with red-free light. Note the attenuation of the
nevus but persistence of the surface drusen. Figure 2. The same lesion but at different magnification at 2-year follow-up.
Figure 3. The same lesion with greater magnification and exposure at 2-year follow-up. Note from landmarks the consistency of size.
Conclusion 4
With the availability of multimodal imaging
techniques beyond color fundus photography
such as optical coherence tomography and ultra-
sound, identification and management of pig-
mented fundus lesions can be made clinically.
REFERENCES
1. Shields CL, Dalvin LA, Ancona-Lezama D, et al. Choroidal
nevus imaging features in 3806 cases and risk factors for
transformation into melanoma in 2355 cases: the 2020 Taylor
R. Smith and Victor T. Curtin lecture. Retina. 2019;39(10):1840-
1851. doi:10.1097/iae.0000000000002440 Figure 4. Greater magnification with stable size and
2. Shields CL, Kels JG, Shields JA. Melanoma of the eye: configuration 7 years from baseline. The lesion has remained flat.
revealing hidden secrets, one at a time. Clin Dermatol. 237. doi:10.1097/ICU.0000000000000361
2015;33(2):183-196. doi:10.1016/j.clindermatol.2014.10.010
5. Shields CL, Furuta M, Berman EL, et al. Choroidal nevus
3. Bennett TJ. Monochromatic fundus photography. Ophthalmic transformation into melanoma: analysis of 2514 consecutive
Photographers’ Society. Accessed May 10, 2021. https://www. cases. Arch Ophthalmol. 2009;127(8):981-987. doi:10.1001/
opsweb.org/page/monochromatic archophthalmol.2009.151
4. Chien JL, Sioufi K, Surakiatchanukul T, Shields JA, Shields
CL. Choroidal nevus: a review of prevalence, features, genetics,
risks, and outcomes. Curr Opin Ophthalmol. 2017;28(3):228- leopsemes@gmail.com
 | PRACTICAL CHAIRSIDE ADVICE
31

Glaucoma
Stay up-to-date on available glaucoma therapies
Continued from page 1

Prostaglandin analogues Expected IOP decrease with a and reevaluate pulse at follow-up visits.5
Example: Latanoprost (Xalatan; Pfizer) topical BB is 20% to 30%, but Most BB nonselectively block both beta-1
Prostaglandin analogues (PGAs) are the primary efficacy may decrease over (cardio) and beta-2 (lung) receptors. Betaxolol
first-line intraocular pressure (IOP)-lowering drug time in approximately 10% of (Betoptic-S; Alcon) is the only selective topical
class due to their 25-year history of excellent effi- patients. BBs are dosed once BB because it has an affinity for beta-1 receptors.
cacy, safety, and tolerability. They increase aque- or twice a day: often twice Because of this, it is an option for patients with-
ous outflow through the uveoscleral pathway by a day if monotherapy, every out cardiovascular risk factors but with significant
increasing extracellular matrix turnover in the cil- morning if using the gel for- pulmonary risk factors to safely use a topical BB.
iary body.1 A 25% to 35% decrease in IOP is seen STACY POTWIN, mulation or when used as Unfortunately, more beta-2 receptors exist in the
OD, FAAO,
with PGA use, and the maximum effect takes up adjunctive therapy.2,5 Patients eyes, so this drop does not have as significant an
is a staff optometrist
to 2 weeks to be reached. PGAs are dosed once a already on a systemic BB will effect on IOP as nonselective BB.2,5
at the Veterans
day (usually at bedtime, but adherence is more Affairs community- not achieve the maximum
important than time of day used) and show a based outreach clinic effect of the topical BB since Alpha agonists (selective alpha-2
paradoxical increase in IOP when dosed more in Charleston, West the systemic beta blocker adrenergic receptor agonist)
than that.2,3 Virginia. slightly lowers the baseline Example: Brimonidine (Alphagan)
This medication type should be used with cau- IOP by about 2 mm Hg.2 Alpha agonists activate the alpha-2 receptors in
tion in patients with ocular inflammatory con- Beta blockers are indicated for all types of glau- the ciliary body, inhibiting aqueous secretion.7 The
ditions (ie, uveitis, herpes, macular edema) and coma—the state of the angle does not impact their main short-term effect is reduced aqueous pro-
in pregnant patients.1,4,5 No significant systemic effect).5 The most common AEs from topical BB are duction, and chronic treatment leads to increased
adverse events (AEs) exist. Main local AEs of PGAs shortness of breath, reduced blood pressure and aqueous outflow through the uveoscleral path-
include stinging, hyperemia, darkening of the iris heart rate, and fatigue. Less common AEs include way.9 The reduction in IOP is 4 mm Hg to 6 mm
(affecting green-brown eyes the most), eyelid red- decreased libido, depression, and decreased sen- Hg with this class.10
ness, and increased length, thickness, pigmenta- sitivity to symptoms of hypoglycemia in insulin- Up to 20% of users experience an allergy to this
tion, and number of eyelashes and eyelid vellus dependent diabetics.7,8 medication, which can appear soon after initiat-
hairs. All AEs are reversible with discontinuation These drops are contraindicated in patients ing treatment or be delayed up to 8 months and
except iris color changes.1,3,5 An interesting AE of with asthma, severe chronic obstructive pulmo- is concentration and dose dependent. Other than
long-term use is prostaglandin-associated perior- nary disease, sinus bradycardia, heart/atrioven- an allergy to the medication or preservative, other
bitopathy and includes the following changes6: tricular block, congestive heart failure, and myas- common AEs include irritation; burning; head-
–  Upper lid ptosis thenia gravis.2,7 Consider taking a pretreatment ache; dry mouth, nose, and eyes; hypotension;
–  Deepening of the upper lid sulcus pulse on patients being prescribed a topical BB See Glaucoma medications on page 32
–  Shrinkage of dermatochalasis
–  Periorbital fat atrophy
–  Mild enophthalmos
–  Inferior scleral show
TABLE 1 Glaucoma drug classes1-19
–  Increased prominence of eyelid vessels Cap Mechanism Bottle
–  Tightening of the eyelids CLASS Drug Percent Generic Brand Dosing
Color of action size
Prostaglandin Latanoprost 0.005% Yes Xalatan Teal Daily Increases 2.5 mL
Upon discontinuation, partial to full reversal of analog (PGA) (Pfizer) (QPM) uveoscleral
these changes is seen.6 outflow
No Xelpros Teal Daily Increases 2.5 mL
(Sun Pharmaceutical) (QPM) uveoscleral
outflow
Beta blockers are Bimatoprost 0.03% Yes none Teal Daily Increases 2.5, 5, 7.5

indicated for all (QPM) uveoscleral

outflow
mL

types of glaucoma— Bimatoprost 0.01% No Lumigan

(Allergan)
Teal Daily
(QPM)
Increases
uveoscleral
2.5, 5, 7.5
mL

the state of the Bimatoprost 10mcg No Durysta

outflow
Increases Intracameral
angle does not implant (Allergan) uveoscleral
outflow
injection

impact their effect. Travoprost

(BAK preservative)
0.004% Yes none
(Travatan d/c)
Teal Daily
(QPM)
Increases
uveoscleral
2.5, 5m L

outflow
Travoprost 0.004% No Travatan Z Teal Daily Increases 2.5, 5 mL
Beta blockers (beta adrenergic (Sofzia preservative) (Novartis) (QPM) uveoscleral
antagonists) outflow
Example: Timolol (Timoptic) Tafluprost 0.0015% No Zioptan Daily Increases 30
Beta blocker (BB) eye drops work by blocking the (Akorn) (QPM) uveoscleral dropperettes
beta receptors in the ciliary body, reducing aque- outflow
ous production.7 Nocturnal aqueous production Latanoprostene 0.024% nN Vyzulta Teal Daily Increases 2.5, 5 mL
is about half of diurnal, which is why BBs do not bunod (Bausch & Lomb) (QPM) uveoscleral
outflow
control overnight IOP as well as other options.4,5
 JUNE 2021 |
32
Glaucoma

TABLE 1 Glaucoma drug class meds chart (cont.) Glaucoma medications

Continued from page 31

Cap Mechanism Bottle and lethargy, fatigue, and drowsiness.2,9 This med-
CLASS Drug Percent Generic Brand Dosing
Color of action size
ication is contraindicated in children under age
Beta Timolol 0.25, Yes Timoptic Yellow Daily Decreases aqueous generic 2 years and in patients taking a monoamine oxi-
blockers solution 0.5% / Timolol to BID production 0.25%, 0.5%:
(BB) Maleate 5, 10, 15 mL; dase inhibitor.4,7
(Novartis, and Akorn) Timoptic
0.25%: 5 mL, Carbonic anhydrase inhibitors (CAI)
0.5%: 5, 10
mL Example: Dorzolamide (Trusopt; Merck)
0.25, Betimolol Yellow Daily Decreases aqueous 0.25%: 5 mL; Inhibiting the carbonic anhydrase (CA) enzyme
0.5% (Akorn) to BID production 0.5%: 5, 10, reduces aqueous production in the ciliary body,
15 mL
decreasing IOP by 4 mm Hg to 6 mm Hg with this
0.5% Istalol Yellow Daily Decreases aqueous 2.5, 5 mL class.7,10 AEs include a bitter taste, instillation dis-
(Bausch & Lomb) to BID production comfort, diuresis, fatigue, and stomach upset.7,8
Timolol PF 0.25, No Timoptic Daily Decreases aqueous 60 ampules This class is contraindicated in patients with a
0.5% PF Ocudose to BID production sulfa allergy, severe liver or kidney disease, or cor-
(Bausch & Lomb) neal compromise because the CA enzyme is pres-
Timolol gel 0.25, Yes Timoptic-XE Yellow Daily Decreases aqueous 5 mL ent in the corneal endothelium and is involved in
0.5% (Bausch & Lomb); to BID production fluid transport within the cornea.7,11
Timolol The oral CAIs—acetazolamide, Diamox Sequels
Maleate Gel
(Novartis) (acetazolamide XR; Teva Pharmaceuticals), and
Levobunolol 0.25, Yes Betagan Yellow Daily Decreases aqueous 0.25%: 5, 10 methazolamide—can be an option for chronic
0.5% (Allergan) to BID production mL; 0.5%: 5, glaucoma treatment, especially to lower IOP while
10, 15 mL awaiting surgery or for a patient on maximum top-
Betaxolol 0.25% No Betoptic S Light Daily Decreases aqueous 10, 1 5mL ical treatment not at target IOP who is not a candi-
(Novartis) blue to BID production;
Cardio-selective date for surgery. Acetazolamide, however, is usu-
0.5% Yes none Blue or Daily Decreases aqueous 5, 10, 15mL ally used in the treatment of short-term IOP con-
white to BID production; trol in acute angle closure glaucoma. Because of its
Cardio-selective reduced strength, methazolamide has fewer AEs
but is not as effective as acetazolamide.
Oral CAIs have the same contraindications as
topical CAIs, with additional contraindication if
PRESCRIBING PEARLS PGA STORAGE13,14 the patient is taking a thiazide diuretic or digitalis.
- Start with prostaglandin analogues (PGAs), - Store unopened bottles of PGA in the Oral CAIs have a longer list of AEs because of sys-
then consider a fixed-dose combination refrigerator temic administration, including tingling hands and
(FDC; beta blocker [BB]+ carbonic anhydrase - Open bottles at room temperature should be feet, memory problems, increased urination, kid-
inhibitor [CAI] or BB+ adrenergic agonist (AA) discarded after 6 weeks ney and liver effects, gastrointestinal problems,
unless cardiac or pulmonology concerns, then
try CAI+AA) • Tafluprost (Zioptan; Merck) should be depression, impotence, Stevens-Johnson syndrome,
used within 28 days once brought to room
- Consider PGA+ rho-kinase (ROCK) inhibitor and aplastic anemia.7,8,12
temperature
for the only FDC dosed once a day
- During shipment, it is acceptable for the bottles
- Consider adding netarsudil (Rhopressa; Aerie Miotics/cholinergic agonists
to reach up to 104˚ F for up to 14 days
Pharmaceuticals), the only adjunctive therapy
dosed once a day Example: Pilocarpine (Isopto Carpine; Alcon)
This rarely used class stimulates the muscarinic
• Achieve once daily glaucoma care when DURATION OF ACTION receptors, causing pupillary muscle constriction,
dosed at same time of day as PGA (every
night) or BB (every morning) FOR CAI/AA which pulls on and opens the trabecular mesh-
Both have a short duration of action (4 to 6 work (TM) leading to increased aqueous outflow
- Consider switching from a traditional PGA hours), so when used alone or in combination
to latanoprostene bunod (Vyzulta; Bausch + through the TM. Many ocular AEs are related to
with one another (brinzolamide/brimonidine
Lomb) if only a small decrease in IOP is needed [Simbrinza)] they must be dosed 3 times a day. the pupillary constriction of this therapy, includ-
• Latanoprostene bunod may show less If CAI, AA, or FDC is used with any other class, ing dim vision, brow ache, myopia, and retinal
periorbital pigmentation and hypertrichosis twice-daily dosing is acceptable.
tear and detachment.7,13
than other PGAs2
This medication is dosed 4 times a day, giv-
• Switching between different medications in
same class usually does not result in lower
GLAUCOMA CRASH CART20,21 ing approximately a 20% decrease of IOP at that
IOP In case of acute intraocular pressure (IOP) spikes dosing. It is reserved for acute angle closure and
from angle closure, keep on hand a beta blocker, should be used with caution in patients who are
- Don’t hesitate to add a FDC to a PGA as alpha agonist, and carbonic anhydrase inhibitor,
opposed to trying another single entity first all of which reduce aqueous production quickly. pregnant or breastfeeding.2,14
- Maximum medical therapy is considered PGA - PGA not helpful (delayed effect and
+ FDC inflammatory potential) New options
- Separate by 15 minutes any drops used at - Consider pilocarpine when IOP less than 40 Latanoprostene bunod (Vyzulta; Bausch + Lomb)
same time of day mm Hg is 1 of the 2 newest options and is part of the PGA
- No class is approved for use with contact • Constricting the pupil is beneficial for class. The drug is metabolized into 2 active moi-
lenses, but they may be applied 15 minutes peripheral iridotomy
after drop instillation eties; latanoprost acid, which increases uveoscleral
• Beware, pilocarpine paradoxically narrows
the angle in eyes with phacomorphic, outflow, and nitric oxide, which causes the TM to
- Discontinue any PGA before initiating treatment
with latanoprostene bunod or netarsudil/ pseudoexfoliation, or vitreous block relax, leading to increased TM outflow. Research
latanoprost (Rocklatan; Aerie Pharmaceuticals) glaucoma shows an additional IOP drop of about 1 mm Hg
- Undergoing selective laser trabeculoplasty - Oral acetazolamide, not extended release, to 1.23 mm Hg compared to latanoprost.2,15
does not change effectiveness of any drops should be on hand to be given if needed Another new glaucoma drug is netarsudil
after the procedure - Keep in mind contraindications or cautions
before using every drop available to lower IOP (Rhopressa; Aerie Pharmaceuticals), the first
drug in the new class rho-kinase (ROCK) inhibi-
 | PRACTICAL CHAIRSIDE ADVICE

Glaucoma 33

duration of action is short, only about 3 to 4 hours.
For this therapy to be an effective option,
patients would need to smoke about every 3 hours,
around the clock. Not only is this unrealistic, but
the mood-altering effect would cause the user to
be unable to drive or function at maximum men-
tal capacity.
Additionally, hundreds of lung-damaging com-
pounds in marijuana. Other routes (ie, oral, sub-
lingual, drop) have been unsuccessful due to AEs
or ineffective IOP control.18
Future research opportunities exist because
receptors for the active component of marijuana
are found in eye tissues, and this drug may even
have neuroprotective potential. At this time, no
form of this drug is recommended as an option
for IOP-lowering therapy.18
See Glaucoma medications on page 34

TABLE 1 Glaucoma drug classes (cont.)

Cap Mechanism of Bottle
CLASS Drug Percent Generic Brand Dosing
Color action size
Alpha Brimonidine 0.15%, Yes none Purple BID- Decreases aque- 5, 10, 15 mL
agonists / (BAK preservative) 0.2% TID ous production; in-

For marijuana to be Alpha 2

adrenergic
creases uveoscle-
ral outflow
agonists
an effective option, (AA)
Brimonidine
(Purite preservative)
0.1% No Alphagan P
(Allergan)
Purple
(green
BID-
TID
Decreases aque-
ous production; in-
5, 10, 15 mL

bottle) creases uveoscle-

patients would ral outflow
Apraclonidine 0.5% Yes none Purple BID- Decreases aque- 5, 10 mL
need to smoke TID ous production; in-
creases uveoscle-
about every 3 hours, 1% No Iopidine BID-
ral outflow
Decreases aque- 24
around the clock. (Novartis) TID ous production; in-
creases uveoscle-
droperettes
per box
ral outflow

tors. ROCK inhibition decreases TM cell contrac- Carbonic Dorzolamide 2% Yes Trusopt (Merck Orange BID- Decreases aque- 10 mL
anhydrase & Co.) TID ous production
tion, leading to expansion and relaxation of the inhibitor
TM, causing increased aqueous outflow through (CAI)
Dorzolamide 2% Yes none Orange BID- Decreases aque- 10 mL
the TM. Additionally, episcleral venous pressure PF TID ous production
decreases, which also increases outflow through
Brinzolamide 1% No Azopt (Novartis) Orange BID- Decreases aque- 10, 15 mL
the TM. ROCK inhibition also inhibits norepi- (suspension) TID ous production
nephrine transport, leading to decreased blood
flow to the ciliary body, which decreases aque-
Acetazolamide 125, Yes none (Diamox d/c) Acute IOP spike Oral tablet
ous production. 250mg / acute angle
This medication is used only as adjunctive ther- closure
apy and shows approximately 20% additional 500mg No Diamox BID Chronic; Oral
decrease in IOP when added to a PGA or combi- Sequel (Teva not for acute capsule
Pharmaceuticals)
nation drop. Local AEs include hyperemia (42%),
Methazolamide 25, Yes none (Neptazane d/c) BID Chronic; Oral tablet
stinging, corneal verticillate (11%), and subcon- 50mg -TID not for acute
junctival hemorrhages (11%).2,8,16
Rho kinase Netarsudil 0.02% No Rhopressa (Aerie White with daily Increases TM 2.5 mL
inhibitor Pharmaceuticals) orange (QPM) outflow
Fixed-dose combination (FDC) drops (RKI) writing
These are great options for increasing convenience
and adherence, reducing the amount of preser- Miotics / Pilocarpine 1%, Yes Isopto Carpine Green QID Increases TM 15 mL
vative on the eye, and reducing cost.10 Most are cholinergic 2%, 4% (Novartis) outflow
agonists
dosed twice a day.2 Brinzolamide/brimonidine
(Simbrinza; Novartis) is dosed 3 times a day. The COMBINING OPTIONS
newest combination, netarsudil/latanoprost (Rock-
Cap Mechanism Bottle
latan; Aerie Pharmaceuticals), is dosed once a day, CLASS Drug Percent Generic Brand Dosing
Color of action size
typically at bedtime.17 AA + BB Brimonidine + 0.2% / No Combigan Blue BID Decreases aque- 5, 10, 15mL
Timolol 0.5% (Allergan) ous production and
Marijuana (tetrahydrocannabinol) increases uveoscle-
ral outflow
Finally, a few thoughts on a drug many patients
CAI + BB Dorzolamide + 2% / Yes Cosopt (Akorn) Blue BID Decreases aque- 10mL
assume is a treatment for glaucoma. Smoking mar- Timolol 0.5% ous production)
ijuana has been shown to decrease IOP in indi-
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 JUNE 2021 |
34
Glaucoma

Glaucoma medications USFiles/Package%20Inserts/Pharma/vyzulta-

prescribing-information.pdf
June 24, 2020. Accessed May 10, 2021. www.
glaucoma.org/treatment/glaucoma-medications-
Continued from page 33 manufacturers.php
16. Rhopressa. Package insert. Aerie
Pharmaceuticals; Revised March 2019. Accessed 20. Cymbor M. Angle closure glaucoma: are
REFERENCES
May 24, 2021. https://rhopressa.com/hcp/assets/ you ready? Review of Optometry. October 15,
1. Brooks AM, Gillies WER. Ocular beta-blockers in glaucoma management.
pdf/RHOPRESSA-Prescribing-Information.pdf 2016. Accessed May 10, 2021. https://www.
Clinical pharmacological aspects. Drugs Aging. 1992;2(3):208-21.
reviewofoptometry.com/article/angleclosure-
doi:10.2165/00002512-199202030-00005 17. Rocklatan. Package insert. Aerie
glaucoma-are-you-ready
Pharmaceuticals; Revised June 2020. Accessed
2. Dorkowski M, Williamson J, Rixon A. A guide to applying IOP-lowering drugs.
May 24, 2021. https://rocklatan.com/hcp/assets/ 21. Khondkaryan A, Francis BA. Angle closure
Review of Optometry. July 15, 2018. Accessed May 10, 2021. https://www.
pdf/Rocklatan_Prescribing_Information.pdf glaucoma. American Academy of Ophthalmology.
reviewofoptometry.com/article/a-guide-to-applying-ioplowering-drugs
December 18, 2013. Accessed May 10, 2021.
18. Jampel H. American Glaucoma Society
3. Medication review: prostaglandin analogs for glaucoma. Pharmacy Times®. https://www.aao.org/current-insight/angleclosure-
position statement: marijuana and the treatment
October 1, 2015. Accessed May 10, 2021. https://www.pharmacytimes. glaucoma-19
of glaucoma. J Glaucoma. 2010;19(2):75-76.
com/contributor/michelle-smith-pharmd-bcps/2015/10/medication-review-
doi:10.1097/IJG.0b013e3181d12e39
prostaglandin-analogs-for-glaucoma
19. Glaucoma Medication Manufacturers. Potwin has no disclosures.
4. Yee S. Glaucoma therapy: finding the right combination. Review of Optometry.
Glaucoma Research Foundation. Updated stacypotwin@gmail.com
April 15, 2027. Accessed May 10, 2021. https://www.reviewofoptometry.com/
article/glaucoma-therapy-finding-the-right-combination
5. Dexter A. Review of topical glaucoma medications. OptoPrep. February 29,
2016. Accessed May 10, 2021. https://blog.optoprep.com/review-of-topical- EQUIPMENT FOR SALE
glaucoma-medications-prostaglandins-and-beta-blockers
6. Jayaram A. Prostaglandin associated periorbitopathy. American Academy
of Ophthalmology. Updated April 26, 2021. Accessed May 10, 2021. https:// STATE OF THE ART EQUIPMENT FOR SALE
eyewiki.org/Prostaglandin_Associated_Periorbitopathy COMPLETE DRY EYE WORKUP TEST AND TREATMENT SET UP
7. Rhee DJ. Glaucoma: Color Atlas & Synopsis of Clinical Ophthalmology. • Includes lipo view, lipo flow • Everything in unused condition,
McGraw-Hill, Medical Pub. Division. 2003:107-117. treatment and supplies must sell due to sudden illness
8. Radhakrishnan S, Iwach A. Glaucoma medications and their side effects. • Tear osmolarity tester and supplies • Schirmer strips and various
Glaucoma Research Foundation. Updated July 23, 2018. Accessed May 10, • Orbscan 11 and computer accessories including meibomian
2021. https://www.glaucoma.org/gleams/glaucoma-medications-and-their- • Metalloproteinase test kits gland probes and handbooks
side-effects.php • Free standing Zeiss slit lamp
9. Cantor LB. Brimonidine in the treatment of glaucoma and ocular hypertension. and adjustable stand
Ther Clin Risk Manag. 2006;2(4): 337-346. doi:10.2147/tcrm.2006.2.4.337
Equipment is available and boxed for pickup in North Orange County, California.
10. Collins LA, King BJ. Boost your glaucoma drug knowledge. Modern
Optometry. April 2019. Accessed May 10, 2021. https://modernod.com/ Please call 714-813-4883
articles/2019-apr/boost-your-glaucoma-drug-knowledge?c4src=article:infinite- charaparthur46@gmail.com
scroll
11. Reynolds AC. Topical glaucoma treatment and the cornea. Glaucoma Today.
November/December 2014. Accessed May 10, 2021. https://glaucomatoday. PRODUCTS
com/articles/2014-nov-dec/topical-glaucoma-treatment-and-the-cornea
12. Perkins TW. Oral CAIs: still an option worth using. Review of Ophthalmology.
April 12, 2006. May 10, 2021. https://www.reviewofophthalmology.com/article/
oral-cais-still-an-option-worth-using
13. Medication guide. Glaucoma Research Foundation. Updated June 19, 2020.
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guide.php
14. Epocrates. Version 21.1.1. Last updated February 5, 2021.
15 . Vyzulta. Package insert. Bausch + Lomb; Revised May 2019. Accessed May
24, 2021. https://www.bausch.com/Portals/69/-/m/BL/United%20States/

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