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Excerpts from:

INTERNATIONAL GLAUCOMA REVIEW
Volume 14-4 2013

 

The Cost of Glaucoma Care (2002-2009)
Long-term postoperative complications in patients randomized to trabeculectomy in the Collaborative Initial Glaucoma Treatment Study (CIGTS): The risk of blebitis and hypotony was each 1.5% at five years and the risk of endophthalmitis was 1.1% at five years.

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In 2009, office visits comprised nearly one-half of glaucoma-related costs, diagnostic testing was about one-third, and surgical and laser procedures were about 10% of costs each. From 2002 to 2009, glaucoma care costs per person per year rose from $197 to $228, less than 1/200th of all Medicare payments, and increasing at less than the rate of general or medical inflation.

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Large and Sustained Blood Pressure Dips Are Associated With Visual Field Progression and Normal-Tension Glaucoma.
This suggests that 24-hour BP monitoring may be useful in NTG patients.

 

M & T: At the European Society Meeting (June 2014), it was recommended to order a 24-hour blood pressure monitoring for patients with "normal-tension glaucoma" who continue to progress in spite of perceived adequate IOP control. This is most certainly something to be considered when faced with such patients.

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A Prospective Randomized, Multicenter, Single-Masked, Parallel, Dose Ranging Study To Compare the Safety and Efficacy of BOL-303259-X to Latanoprost in Subjects with Open-Angle Glaucoma or Ocular Hypertension
BOL-303259-X is a nitric oxide donating prostaglandin F2a agonist. Following randomization, 413 eligible subjects with a diagnosis of open-angle glaucoma or ocular hypertension were assigned to one of five treatment groups: BOL-303259-X 0.006%, 0.012%, 0.024%, 0.040%, or latanoprost 0.005% ophthalmologic solutions. After 28 days of once-daily treatment, mean diurnal IOP reduction in the BOL-303259-X 0.024% (9mmHg; p= 0.0051) and 0.040% (8.9mmHg; p=0.0089) treatment groups was greater than the latanoprost group (7.8mmHg); on Day 29, a greater mean diurnal IOP reduction was still observed in the BOL-303259-X 0.024% group (7.20 versus 6.25mmHg; p= 0.0056) compared to latanoprost. Conjunctival hyperemia was similar across all treatment options. These results indicate that BOL-303259-X is a safe and effective IOP-lowering agent with greater IOP reduction than latanoprost with the 0.024% concentration, while retaining a similar side effect profile.

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Cataract Surgery to Lower IOP
Recent clinical trials have confirmed earlier reports that modern cataract surgery with phacoemulsification should be considered an intraocular pressure (IOP) lowering procedure. The degree of average IOP lowering is positively related to the level of IOP with greater expected reduction in those with the highest baseline IOP.

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Multifocal IOLs and Glaucoma
It is becoming known that contrast sensitivity is reduced in patients with glaucoma, even those with minimal visual field defects. Diffractive optics multifocal IOLs trade contrast for two simultaneous images. For patients with glaucoma, taking a hit in contrast sensitivity from two different directions may make the long-term placement of a diffractive optics multifocal IOL problematic, with gradually increasing visual disability.

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Establishing Baseline Visual Fields
When establishing a baseline set of visual fields, obtain two and separate them by less than one month. Generally, if you explain to the patient that this is the baseline that they are going to have to compare against for many years, they will endorse the plan.

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Glaucoma Risk Factors Versus Glaucoma Manifestation
The risk factors for glaucoma and glaucoma manifestation have to be discriminated. Risk factors are detectable via medical history of the patient or objective examination (high IOP, thin cornea, gonioscopy). Not even the presence of all of these risk factors is enough for glaucoma diagnosis, the risk factors only enhance it probability.

 

M & T: Glaucoma is definitively diagnosed with a repeatable visual field defect.

 

More on Cataract Surgery to Lower IOP
Modern cataract surgery using phacoemulsification is undoubtedly the most commonly performed IOP-lowering procedure worldwide today. Although a small risk for complications exists, it is hard to argue against the fact that the benefits of early cataract surgery outweigh the risks in most patients with mild, moderate, and, in some cases, advanced glaucomatous disease.

 

Glaucoma Opinion: Prostaglandin-Associated Periorbitopathy (PAP): Clinical Features. Pathophysiology and implications
We have performed a comprehensive search using PubMed to identify all reported cases of Prostaglandin-Associated Periorbitopathy (PAP). Ten articles were found in English literature dating back to 2004, reporting 39 cases of PAP; 23 cases resulting from bimatoprost use, eight cases from travoprost use and eight cases from latanoprost.

 

Clinical Features
The following clinical features of PAP have been described:

  • Upper lid ptosis

  • Deepening of upper lid sulcus

  • Involution of dermatochalasis

  • Orbital fat atrophy​

  • Mild enophthalmos

  • Inferior scleral show

  • Reduction of the interior eyelid bags

  • Tight orbits

 

These effects arise after a period of several weeks to several years on treatment with PGAs.
Most of the anatomical changes of PAP are thought to be due to orbital fat atrophy, while dehiscence of the levator aponeurosis or Muller's muscle may account for the upper lid ptosis.

 

The mechanism of the fat atrophy appears to be related to the effect of the prostaglandin F2alpha (PGF2 alpha) on adipocytes. Studies have shown that PGF2 alpha inhibits adipogenesis by activating mitogen-activated protein kinase.

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In vitro studies comparing the different PGAs showed that bimatoprost had the most anti-adipogenic effect and latanoprost had the least.

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The mechanism for blepharoptosis is less clear, immunohistochemistry studies have shown a decrease in collagen types I, III, and IV in the ciliary body of monkey eyes treated with PGAF2 alpha compared with untreated eyes. It is possible that PGAs could also decrease the amount or weaken the structure of collagen in the levator aponeurosis or Muller's muscle ligament, resulting in ptosis.

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Potency of Onset PAP
Many authors have reported reversal of PAP after discontinuation of bimatoprost and travoprost. Reversal of upper eyelid sulcus deepening has been reported to occur anywhere from four weeks to nine months after cessation of bimatoprost therapy. The signs of travoprost-induced PAP have been reported to resolve anywhere between two and 15 months after discontinuation of travoprost. Of the two existing articles reporting latanoprost-induced PAP, the medication was not discontinued, so reversal could not be noted. It is possible that some cases of PAP after long-term use may not be reversible.

 

Clinical Implications of PAP
The anatomic changes to the periorbital soft tissues should not be taken lightly. It can be cosmetically unappealing and especially noticeable in monocularly treated patients. Asymmetry of the orbits and eyelids has led to unnecessary imaging and workup for causes of unilateral enophthalmos or apparent contralateral proptosis.
The deep orbits and tight eyelids present a challenge to eyecare clinicians when examining the eye and performing procedures. Goldmann applanation tonometry, for instance, is more difficult to perform as both the patient and the clinician have difficulty lifting up the patient's ptotic upper eyelid.

 

Factors Affecting IOP
In the supine position, IOP was significantly higher in the eye with the more advanced visual field loss. In the lateral decubitus position, the IOP was higher than in the supine position, and the IOP of the dependent (lower) eye was higher than the nondependent eye. Interestingly, the IOP difference between the two eyes was greater when the eye with the more advanced visual field loss was in the dependent position that in the non-dependent position. These results suggest that eyes with more advanced glaucoma have a different IOP response to changes in body position than eyes with milder disease. However, the significance of these findings to clinical management is not clear at this time. It is possible that greater IOP rise in the supine and lateral decubitus position is what predisposes to more advanced disease. It is also possible that these IOP changes are incidental findings, and other factors, such as pressure on the dependent eye by the pillow in the lateral decubitus position, are the true causes.

 

IOP Instruments in Children
The iCare rebound tonometer has proven invaluable in the assessment of children with known or suspected glaucoma. Although the device often reports IOP to be slightly higher than measured with Goldmann applanation tonometry in cooperative children, its low rate of 'false low' IOP readings makes it an almost ideal screening tool for the pediatric population requiring IOP measurement.
The results of this study support the general impression that iCare rebound tonometry makes IOP assessment in non-sedated children much easier, and that real benefit ensues, in terms of anesthetic sessions saved and even cost incurred for care of pediatric glaucoma patients.

 

Prostaglandin Side Effects
Prostaglandin-associated periorbitopathy (PAP) has recently gained attention. PAP results from atrophy of periorbital adipocytes, and consists of ptosis, deepening of the upper eyelid sulcus (DUES), involution of dermatochalasis, loss of the inferior orbital fat pads, enophthalmos, inferior scleral show, and tight orbits. The authors found in a former study that switching 25 Japanese patient with OAG being treated in both eyes with latanoprost for more than 12 months to bimatoprost resulted in 15 patients (60%) developing DUES within six months. In the present study, the authors switched 13 of these 15 patients back to latanoprost, and found in 11 of the 13 (85%), DUES had either decreased or disappeared within two months. Further research needs to be done to determine the frequency of PAP, how long it takes to occur, how long it takes to resolve after discontinuation of PGAs, and any differences that may exist based on age, race, and type of PGA used.

 

Eyedrop Formulation
Glaucoma topical therapeutics preserved with BAK have been used chronically by patients for decades and appear to be safe and well-tolerated in the overwhelming majority of those treated. It is possible that the physiologic effect on the eye is not substantial enough to induce measurable damage and/or that the eye can overcome such effects by inherent compensatory mechanisms such as anti-oxidant reserves. Alternatively, the very treatment being prescribed to patients may lead to damage that could potentially worsen disease.

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The Optometric Cardiologist

 

      Cardiologists are superbly trained medical practitioners of the heart, and cardiothoracic surgeons are superbly trained in heart/chest surgeries. These two medical specialties work together as smoothly as a well-oiled machine or as finely tuned instruments in an orchestra. Why, then, is this not the case with ophthalmologists and optometrists in eyecare? There may be several reasons – a couple follow, and the dynamics here can be highly complex: One reason is that general ophthalmologists are by and large heavily focused on cataract and refractive surgeries. Since many have not (through professional “racism”) enjoined the community optometrists as surgical referral sources, ophthalmologists have to see an abundance of general care patients to glean their surgical patients . Ophthalmologists are heavily, procedure-oriented by definition and by choice; they are eye surgeons. Being procedure-oriented, they are not bastions of medical eyecare. There is no analogous medical specialty in ophthalmology, only a surgical residency. Note that it is a high bar to be competent in both medical and surgical aspects of any specialty. To wit:

Neurology and neurosurgery 

Sports medicine and orthopedic surgery  

Rheumatology and orthopedic surgery  

Internal medicine and general surgery 

Gastroenterology and general surgery

Nephrology and urology

Pediatrics and pediatric surgery 

Audiology and otolaryngology 

There has always been a major sequestration between medicine and surgery, as they are clearly two distinct elements of patient care.

 

      Optometrists, at least traditionally, are heavily focused on refractive correction of ametropias with eye glasses and contact lenses. Ophthalmic medicine has not, until recently, held sway in professional training and competency. As a profession, we have not historically been trained to be a medical eye physician. So, from both an ophthalmologic and optometric perspective, “medical eyecare” has been relatively ignored. Now, optometry is continuing to grow in its embrace of medical conditions of the eye, and ophthalmology, though trained in eye medicine and eye surgeries, is now far more keenly focused on surgical procedures.

      If eyecare can continue to evolve in parallel to every other aspect of medicine, optometrists should become the cardiologists of the eye, and ophthalmic surgeons will be fully ophthalmic surgeons. Of course, this will require the continued revision of optometric curriculum to more comprehensively embrace the entire spectrum 

 

The Optometric Cardiologist: Page 2

 

of medical eye disease, and to ophthalmology devoting itself exclusively to meeting the coming “baby boomer” demand for cataract and refractive surgeries.

 

      Finally, in addition to the American Academy of Ophthalmology, there is a huge meeting and journal exclusively dedicated to “cataract and refractive surgery”. There is no huge meeting or journal dedicated to “medical ophthalmology,” nor should there be, especially if the profession of optometry rises to fill this relative void in human patient care. 

 

Optometry as a Commodity

 

      Optometry has experienced glorious growth in the scope of professional practice over the past few decades. Interestingly, those who practice in small towns may have gained more from the broadening of services offered than those in more urban areas. There are many hundreds of optometrists who truly function as comprehensive eyecare physicians delivering state-of-the-art eyecare. There are also many thousands of optometrists who function as glorified refractionists, mostly in urban, retail type settings. These optometrists are relegated (either by choice or by necessity) as “refract and refer” practitioners. Like it or not, most ophthalmology offices have a team of well-trained high school graduates who perform excellent refractions, and the ophthalmologist (s) serve as the “quality control officer” who oversees their findings and performs the balance of the comprehensive eye examination.  

 

      It seems a deplorable waste of four years of postgraduate training, time, talent and money, only to spend one’s professional life doing the same tasks that most high school graduates can be trained to do in six to twelve months.

 

      From an optometric perspective, this situation is likely to worsen as a tide of new optometry schools flood the market, driving up competition for positions while diminishing potential incomes. It may not be long until new graduates, burdened with increasing college debt, will find less opportunity to land desirable positions with desirable remuneration.

 

      Refracting technology devices have rapidly evolved, and their level of accuracy is now well within visual acceptance standards. We can see the day when refraction will be offered at kiosks in shopping malls for $25 to $50; the patron will simply sign an electronic “release from liability” statement that may read something like: “This prescription for eyeglasses does not constitute a comprehensive eye examination. You should be examined by a licensed ophthalmologist or optometrist to assure that an eye disease/condition such as glaucoma, cataract, or macular degeneration, is not present.” I assure you, the statement will be filled with all the correct legal jargon. Currently, tobacco, alcohol, and a myriad of other products and services are sold with similar warnings. All such disclaimers minimally affect human behavior, but medicolegally, these statements in most instances serve well to protect the entrepreneur.      

 

      Physical care doctors – and you have to decide if you bear the honor of such a mantle – should have the patient’s very best interest at heart. Unfortunately, many “doctors” in the eyecare profession  are in essence, “eyeglass salespersons”, and are violators of the Golden Rule. Courses and articles that instruct one on “how to up-sell your optical” are a disservice to the consumer and to the eyecare professions as a whole. These 

 

Optometry as a Commodity: Page 2

 

tactics are not compatible with the concept of “doctor” and they violate our duty and responsibility to be a trusted healthcare provider to other humans who count on us for help. 

 

      One measure of optometric productivity is the “currency” of our patient census. If we measure our productivity in “eye exams,” we will be doomed by technology. If, however, we measure our productivity as the “number of patients seen,” there is hope. Many optometrists see 25 to 30 patients per day, and perhaps half of these patients are indeed, “healthy eye exams,” but the balance are problem-oriented visits for such conditions as posterior vitreous detachments; acute red eyes; dry eyes; blepharitis; shingles; trichiasis; contact lens-related problems; foreign body; abrasions; glaucoma; Plaquenil toxicity; contact dermatitis/rosacea; epiphora; headache; temporal arteritis; optic neuritis; diplopia; cataract; hyphema; glaucoma (repeated with intention);  symptomatic tarsal conjunctival concretions; episcleritis; and the list goes on and on! “Refract and refer” optometrists may wither on several levels, but true comprehensive, patient-centered optometric physicians should flourish. Established optometrists,  and particularly those contemplating optometry as a career, should thoughtfully weigh the concepts and perspectives set forth in this article.

 

      In summary, with excellent externships, it is possible to complete a four-year, doctorate-level, single-organ system program with sound clinical competence. Refractionists will be relegated to “factory work,” while comprehensive optometric physicians can have an exciting, diverse clinical life full of satisfaction and yes, financial success. The former will be sales-oriented; the latter, patient-oriented. The former’s practice could be dampened by refractive technology advancements; the latter can look forward to a career enhanced through advances in diagnostic technology and therapeutic options.  It’s up to you.

 

 

 

Our Perspective on the Future of Our Profession

 

If something unsightly is stuck between your front teeth, it is a true friend who steps outside his or her own comfort zone to tell you, so that further embarrassment is avoided. In like manner, we are stepping outside of our comfort zone to offer our perspective on the future of optometry. There needs to be a clear awakening regarding our collective mode of practice before we cross the threshold into professional disaster.  There are several observations that we share:

  1. Refraction. Once the epicenter of optometric practice, refraction is actually a technical procedure that can easily be delegated to bright high school graduates after several weeks of training.  Let’s put this into real time perspective: ophthalmologists have huge practices, and commonly see twice the number (or more) of patients per day than do optometrists. People flock to ophthalmology practices because there is the strong perception that ophthalmologists are “real eye doctors” and the public harbors great trust in the belief that they receive higher quality of eye care at these practices; although in many of these practices, trained high school graduates do indeed provide the refractive portion of the examination. So, if “refraction” is such a high-value service, how can this procedure be so successfully delivered by high school graduates?! Now, granted, the physician, either optometric or ophthalmologic, has a duty and responsibility to oversee the entire patient care process and provide rock-solid quality assurance. Further, and perhaps even more importantly, “technology” is like a two-edged sword – it has advantages and disadvantages, such as one’s level of competency in the use of that technology. 

Autorefractors are now able to provide highly exact prescriptions.”Online (or kiosk) refractions” are likely to soon become a reality. Of course, these devices/websites will carry a disclaimer stating something like this: “Receiving a glasses prescription from this device/website does not constitute a comprehensive eye examination, and all persons should receive a formal eye examination from an optometrist or ophthalmologist periodically” – or some similar statement that will be largely ignored, as are the health warnings on alcohol and tobacco products. Moreover, 3-D printers can now generate eyeglasses, and this technology will only continue to improve.

 

  1. The American Aging Population. The American population is ageing, while ophthalmology residency programs are being reduced. There will be a growing need for all aspects of medically-related eye care in the coming years.  Ophthalmologists love performing microsurgeries, but many have little or no passion for nonsurgical eye care. Since ophthalmologists will have their hands full providing cataract and refractive surgeries to our older citizens, there will be a major void of clinicians to care for those patients in need of nonsurgical eye care services. The optometric profession could easily fill the gap. 

 

Our Perspective on the Future of Our Profession: Page 2

 

  1. Specialty Contact Lens Care. Specialty contact lens care is likely to endure as a needed professional service, but most of these contacts will likely be purchased online at a competitive price. However, basic soft lens care could be provided by optical dispensaries or contact lens technicians in ophthalmology offices.

 

  1. Optometric Education.  In truth, we probably have way too many optometry schools. Why “probably”? If the educational institute’s purpose is to provide training in medical eye care, then terrific. There will be a huge number of necessary services that their graduates can fulfill. However, if the facility is just another “me, too,” traditional, refractive-centric school, they are pathologically flooding a market in which the mode of refractive eye care services appears to be changing. As schools produce a glut of freshly minted optometrists, the salaries for optometric services will be suppressed. It may be that ophthalmology practices could hire a “basic” optometrist at only a slightly higher salary than that of an ophthalmic technician. However, we believe a well-trained, medically competent optometrist should be and would be a highly valued asset to medical/surgical systems. Just something to think about.

 

  1. Optometric Curricula. Optometric  curricula and our “Board” examinations need to immediately be modified to reflect this new age of need for medical expertise within our profession. These two institutions (the schools and the boards of examination) need to evolve in parallel fashion so that training and testing  share the parallel goal of total competence in specialty contact lenses and comprehensive medical eye care, as we believe these will be critical for our professions meaningful  survival in the future.

 

The time is now for all interested parties in healthcare and optometric care to give actionable thought to these concepts and perspectives we have set forth. We will be retiring in a few years, but we have a deep desire to see our profession continue to advocate for enhanced public health. Our current status is in need of a major paradigm shift. We stress that anything we do to strengthen our profession cannot be self-serving. Our profession will thrive because of our collective effort as well-trained, dedicated doctors of optometry to provide broad-based, expert patient care.  

 

 

 

 The BEST Way to Stay Current (It’s NOT With a Lecture Format!)

 

      The best way to stay current is quite simple: get four to six area colleagues to each subscribe to a single journal or magazine. Then get together over a nice meal once a month to share the pertinent highlights of each month’s journals. This should take about two hours, and will make all of you much better doctors.

      The journals we subscribe to, and recommend are as follows:

  • Ophthalmology 

  • American Journal of Ophthalmology 

  • JAMA – Ophthalmology 

  • Survey of Ophthalmology  

Beyond these essential four, there is Review of Optometry, Primary Care Optometry News, Optometric Management, and many others from which to choose.

Simply Google these publications to subscribe. The meals and subscriptions are tax-deductible; the education and fellowship is priceless!

 

 

 The Eye in Public Health

 

      Politically-oriented ophthalmologists so enjoy railing against optometric scope of practice legislation, alleging potential harm to public health. They are so terribly wrong. We all know how poor eyecare is at “quick care/urgent care” centers, and even in hospital-based emergency departments and primary care offices. All optometrists and ophthalmologists are fully aware of the substandard eyecare rendered in these facilities. Not all urgent or emergent eye problems occur during regular office hours, so we have some sort of general safety net for these after-hour patients –the hospital-based emergency department at least fills the “first responder” role for these events.

 

      Now, regarding protecting the public health, IF the eyecare professions, and especially ophthalmology, truly cared about the public’s health, rather than devote energy to trying to limit optometric services, wouldn’t the common good be better served by developing guidelines, policies and protocols, and legislation advocating that patients with eye and vision problems preferentially be seen by eye doctors? It should be quite obvious that steering eye patients to practitioners who can provide higher levels of care could enhance public health. The time is now to cease such hypocrisy and duplicity, and focus on measures to enhance the eyecare of the citizens we profess to serve. Something to think about.

 

 

CE: Continuing Education or Infomercial?

 

            The reality is that many continuing education lectures are a sham; a commercial for one or more companies.  There are several reasons for this: continuing education would be significantly more expensive were it not for industry sponsorship dollars; some optometrists are present only to “get my hours,” and simply want to get their ticket stamped and get home; state associations may care more about their budgets than they do about the true education of  their members, and these associations therefore tend to seek “sponsored” lecturers. That is, some state associations may be willing to sacrifice the quality of education for financial stability. Some optometrists may not be current with the scientific/medical literature, and so may be easily manipulated by company-sponsored lecturers.

 

      The misleading statement, “the speaker has no financial interest,” is grossly misleading! While the speaker may not own stock in a specific company, she/he is most assuredly under obligation to promote the product/device of the sponsoring company. If the speaker does not perform to the sponsoring company’s expectation, that speaker will rapidly be replaced by a more compliant lecturer. Thus, lecturers speaking for any company have a very real financial interest in the content, purpose, and delivery of the lecture.  For instance, if a sponsored lecturer speaks factually about the virtues of a Lexis, then that is fine because it’s true; but if a lecturer portrays lesser quality care as equal in value or ability, then an egregious disservice is perpetuated against the audience.  As lecturers ourselves, we speak regularly on behalf of Bausch & Lomb Pharmaceuticals, yet we share the truth of the clinical benefits of these products. We do not “sell,” but truly educate our audiences with the goal of enhancing patient care.  It is fully ethical to urge the use of a product when it truly enhances patient care, but when a product has either marginal or no benefit to patient care, such a lecturer is fully unethical.

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