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Excerpts from:

INTERNATIONAL GLAUCOMA REVIEW

Volume 14-1 2012

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Notes from the European Glaucoma Society

  • Preservative-free medical treatments are advocated especially in patients with a long life expectancy, when two or more drugs are required, and in stages of damage close to surgical intervention.
     

  • Primary angle-closure treatment with Laser Peripheral Iridoplasty (LPI) in Asia shows that in 20-30% of subjects, significant appositional closure still remains after the procedure, and only 10% of those with glaucomatous optic neuropathy are effectively controlled.
     

  • A more realistic approach to the patient's self-experience of visual field defects is related to perception of blur or missing areas rather than classical descriptions of dark and opaque scotomas.
     

  • Dynamic response of sclera may be key in glaucoma pathogenesis. Link of central corneal thickness to glaucoma may act through effect of collagen 8 variants on scleral responses to IOP. In the future, potential therapies may aim at scleral state and responsiveness.


Prevention and Screening
A nationwide screening program would reduce the incidence of glaucoma from 50% to 27% and the prevalence of blindness from glaucoma from 4.6% to 4.4%. A major problem in designing a care delivery model for any chronic occult disease is a low adherence to recommended eye examinations. A rigorously designed health education program does not significantly alter adherence with eye examinations.
 

M & T: Honest, eye-to-eye, ongoing discussions with patients is what we do, and we think this is about the best one can hope for.


Risk Factors: Body Mass Index and Cerebrospinal Pressure
Body mass index has a linear relationship with cerebrospinal fluid pressure.

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Berhdal et al. performed a retrospective study to assess the relation between body mass index (BMI) and cerebrospinal fluid opening pressure (CSFP) on lumbar puncture (LP). The recent findings of an inverse relation between BMI and primary open-angle glaucoma (POAG), particularly among women, motivated this study. They are to be congratulated for exploring a novel potential link between BMI and POAG that might involve CSFP, as the optic nerve is a 50mm white matter tract bathed in cerebrospinal fluid. The authors found a positive linear correlation between BMI and CSFP.

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Circadian IOP Patterns and Visual Field Damage in Normal Tension Glaucoma (NTG)
In this well-designed prospective study, Lee and colleagues employed the best possible conditions in collecting 24-hour data of IOP under habitual body positions from newly diagnosed and untreated glaucoma patients whose office sitting IOP readings were in the normal range. The 24-hour variations of IOP in approximately one third of the study patients were rather small and regarded to have no 24-hour IOP peak. For the remaining study patients, the 24-hour IOP peaks appeared more during the nocturnal period, about three times, than during the diurnal period. The authors also showed that the nocturnal IOP elevations were related to the change of habitual body position for sleep. If one considers only the sitting IOP for 24 hours, the nocturnal IOP elevation cannot be demonstrated. Individual IOP elevations during the nocturnal period can be substantial in some patients and make their office IOP readings misleading for glaucoma diagnosis and treatments. There is little doubt that real life IOP peaks in most glaucoma patients, including so-called normal-tension glaucoma patients [and that this peak] would occur outside regular office hours.

 

Trends in Ancillary Diagnosis Tests
While testing with objective imaging devices increased dramatically in the past decade, visual field testing declined meaningfully whereas fundus photography remained fairly steady. Despite small differences between patients assisted by ophthalmologists versus optometrists, the type of eyecare provider followed the same trend. Nonetheless, optometrists were more likely to change from fundus photography and visual field testing to objective imaging technologies than ophthalmologists during the same period.

The most surprising observation, however, was that more than 25% of patients with newly diagnosed suspected or established glaucoma have not undergone visual field testing within two years of diagnosis. Although new imaging technologies have had remarkable improvements in resolution and patients often prefer objective to behavioral testing, visual fields still have a key role in glaucoma diagnosis and monitoring. Moreover, automated achromatic perimetry correlates significantly with vision-related quality of life and has been employed to determine progression endpoints in the main clinical trials in glaucoma, which heightens that much of the current knowledge on risk factors and effectiveness of therapy in glaucoma is based on data obtained from functional tests. Another important point is that the technology behind visual field testing has remained relatively stable over the past decades and given its wide availability, has provided longer and more consistent information regarding the disease process than imaging technologies which are rapidly evolving and often provide results that are not interchangeable with older techniques. All patients with glaucoma or suspected glaucoma should be diagnosed and followed using both structural and functional tests, and these new objective technologies have considerable advantage over fundus photography.

 

M & T: Agreed; let's all do a better job.

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Diagnostic Accuracy of the ISNT (inferior>superior>nasal>temporal) Rule
In many normal eyes, the rim is wider inferior than superiorly, and the difference in the physiological rim width between the superior disc region and the nasal disc region is marginal. The most important part of the ISNT rule is that the smallest part of the rim should be in the temporal disc region (i.e., the 'T' in the ISNT rule).

 

M & T: ISNT isn't perfect, but it helps us be more attentive to optic nerve head anatomy.

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Optical Coherence Tomography: The Role of the Lamina Cribosa in Glaucomatous Optic Neuropathy
The lamina cribosa represents an important site for axonal injury in glaucoma. Glaucomatous excavation of the optic nerve head is related to posterior bowing and collapse of the lamina cribosa which is believed to impede axoplasmic flow and contribute to loss of neuronal functional and subsequent axonal death. Recent advancements in OCT technology using enhanced depth imaging (EDI) has enabled direct in-vivo visualization of the lamina and demonstrated various anatomic changes including laminar thinning, posterior migration into the sclera, loss of laminar beams, and focal disinsertion from the scleral rim. These findings not only provide critical insight regarding glaucoma pathogenesis, but also represent and opportunity for new therapeutic targets.

 

The anatomy of the lamina cribosa is complex and the mechanism by which neuronal damage may occur at the level of the lamina is multifunctional. Deformation of the lamina may produce direct compression of axonal borders within the laminar pores, changes in axoplasmic flow with neurotriptin deficiency, and alterations in axonal perfusion by compression of blood vessels. In addition, the lamina represents the interface between the intraocular pressure (IOP) and intracranial pressure (ICP). Dynamic changes in IOP, ICP, and systemic blood pressure may alter the configuration of the lamina and optic nerve head anatomy and need to be carefully considered when interpreting EDI scans.

 

Novel therapeutic targets may one day be directed at the lamina to provide increased structural support to axons passing through the lamina pores.

 

In-vivo Evaluation of Focal Lamina Cribosa Defects in Glaucoma
Focal lamina cribosa (LC) defects were found in 34 of 38 eyes with glaucoma (89%), while such change was not detected in any of the healthy eyes. The location of the focal LC defects correlated well with the location of structural and functional glaucomatous damage. They mostly occurred in the inferior or inferotemporal far periphery of the LC and presented clinically as neuroretinal rim thinning and notching. These findings suggest that mechanisms of LC deformation in glaucoma include focal loss of laminar beams in addition to the general changes in its thickness or position. These findings underscore the importance of LC evaluation in glaucoma in addition to the conventional structural assessment of the optic nerve head.

 

Glaucoma Progression: Combination of Risk Factors and SAP Data
Visual fields are the most common method used to monitor individuals with glaucoma for progression. Fields are performed over time with the clinician deciding if change has occurred, and if so, what the rate of change is. Analyzing progressing fields for the rate of change (trend analysis) is relatively new, with a regression analysis program commonly used. Measurement variability or noise must be considered as the clinician decides whether the results are real and glaucoma has gotten worse. This is an important decision as it is usually associated with an advancement in therapy, and one the clinician struggles with as he/she decides whether the results are credible. Often additional fields are performed for confirmation, delaying the decision making. Doctors will also incorporate other information as they decide whether to believe the results such as which eye has the higher intraocular pressure (IOP), how high the IOP is, which optic nerve has greater damage, has the optic nerve(s) changed recently, etc.

When a limited number of fields are available, one can still address whether progression has occurred by relying on other clinical measurements.

 

M & T: Always analyze ALL clinically relevant parameters when making clinical decisions.

 

Combination of Structural and Functional Measurements to Improve Estimates of Rates of Glaucomatous Progression
Almost ten years ago, the first consensus meeting of the World Glaucoma Association on Glaucoma Diagnosis recommended that patients with or suspected glaucoma should be monitored with a combination of structural and functional tests. The detection of optic disc and visual field changes simultaneously increases the likelihood that true glaucomatous progression has occurred, as opposed to measurement variability. However, these simultaneous structural and functional changes are not always seen and cases of disagreement pose as a major challenge for clinicians when tailoring glaucoma therapy.

 

Topical Medical Management of Pediatric Glaucoma
Prostaglandin analogues were the most commonly prescribed medication as monotherapy (39%) followed by nonselective beta blockers (21%). When beta blockers were used as monotherapy, they were most commonly prescribed in the lowest concentrations possible (0.1 and 0.25%). As for effectiveness, the median percentage IOP reduction as monotherapy was the same for the prostaglandins and beta blockers (17.2%) with similar responder rates for these groups consistent with the phase 3 latanoprost vs. timolol 12-week, randomized, double-masked, multicenter study. Almost 20% with monotherapy had systemic side effects; the prostaglandin group with the least and brimonidine tartrate 0.2% with the most. Brimonidine tartrate should not be used in children less than six years of age.

 

Adherence to Therapy: The Role of Intensive Patient Counseling
Gray and colleagues randomized 127 newly diagnosed ocular hypertensive or open-angle glaucoma patients who were prescribed topical drop therapy to receive usual care or to have a face-to-face assessment focusing on issues that might affect adherence. The initial meeting lasted a bit more than an hour and about five additional face-to-face or phone meetings were held, but these were shorter. Some patients also received additional contact during the year. A previous publication for these authors had documented that most eye doctors provide limited information to their patients about glaucoma and that patients have a relatively poor understanding of their condition.

 

The intervention was notably effective. In an intention-to-treat analysis, 70% of the intervention arm subjects were fully adherent compared to 43% in the usual care arm. Of note, the intervention arm included ten subjects (out of 64) who did not receive the intervention, nine of whom had poor adherence. As documented previously in the other research on adherence, eye pressure was similar in the two arms, which likely indicates better drop taking at the time of the visits.
Providing intensive counseling can improve patient adherence to therapy and should stimulate interest in identifying how best to integrate this kind of care into routine practice.

 

M & T: Would we not all agree that optometrists spend considerable more fact-to-face time (and talk more with our patients) than our surgical counterparts? This is yet another sound reason why O.D.s should be the primary caretakers of patients with glaucoma. Optometry, from a purely humanitarian perspective, needs to rise to the occasion!

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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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