Optometric Physician

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


Volume 19, Number 38

Monday, September 23, 2019


Inside this issue: (click heading to view article)
######### Off the Cuff: Technology and Shifting Standards of Care
######### Understanding Diagnostic Disagreement in Angle Closure Assessment Between Anterior Segment Optical Coherence Tomography and Gonioscopy
######### Additive Effect of Topical Nepafenac on Mydriasis in Patients With Diabetes Mellitus
######### Microperimetry and OCT Angiography Evaluation of Patients With Ischemic Diabetic Macular Edema Treated With Monthly Intravitreal Bevacizumab: a Pilot Study
######### News & Notes

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Off the Cuff: Technology and Shifting Standards of Care

When we opened our practice a little over six years ago—amazing how time flies—most of our spend was on high-tech equipment. As the practice grew, we added even more technology until we literally ran out of space. From our iVue OCT, Octopus Visual Field, our Oculus Keratograph 5M, our LipiView II and finally our Optos Daytona, each one of these instruments has dramatically improved our ability to diagnose and manage even the most complex and esoteric disorders. A few devices, like the K5M and the Lipiview II, have served as the foundation of our dry eye practice. The other instruments have expanded our clinical abilities beyond what I would have thought possible just a few years ago.

We are currently in the middle of planning a major office expansion, and, as you might expect, we will be adding even more technology in the additional space. That’s prompted me to think about what we’re using, what needs to be updated and what we need to add that we now don’t have. Perhaps more importantly, it’s also gotten me thinking about just how much technology has changed the way Shannon, I and now Cory practice, and maybe, how we all should be practicing.

Of all of the instruments in our clinical arsenal, we all agree that the iVue OCT is the Swiss Army knife of diagnostic instruments. Using OCT, we have been able to diagnose things that, in many cases, would have been difficult if not impossible to identify otherwise. The iVue’s novel iWellness screening mode has made it cost-effective to perform OCT as an added part of a routine exam, and its anterior segment module has made scleral lens fitting precise and more successful. It should be self-evident that OCT has revolutionized glaucoma diagnosis and management. Change analysis lets us track progression or stability of the disease, and assess treatment effectiveness.

Even though I now rarely see non-dry eye patients, I can’t imagine practicing without OCT. I consider it a standard of care. Yet, as I think about it, I have to wonder if everyone sees it as a standard of care. If not, how disastrous a malpractice suit will it take to make that happen? If you’re curious, at the top of our new tech wish list: an angio-OCT.

Arthur B. Epstein, OD, FAAO
Chief Medical Editor


Want to share your perspective? Write to Dr. Epstein at artepstein@optometricphysician.com.

The views expressed in this editorial are solely those of the author and do not necessarily represent the opinions of the editorial board, Jobson Medical Information LLC (JMI), or any other entities or individuals.


Understanding Diagnostic Disagreement in Angle Closure Assessment Between Anterior Segment Optical Coherence Tomography and Gonioscopy
Although it tends to be a more objective tool for assessment and follow-up of angle closure, reliability studies have reported a moderate diagnostic performance for anterior segment optical coherence tomography (OCT) technologies when compared with gonioscopy as the reference standard. Researchers aimed to determine factors associated with diagnostic disagreement in angle closure when assessed by anterior segment swept-source OCT (CASIA SS-1000; Tomey) and gonioscopy. A total of 2,027 phakic subjects ages ≥50 years, with no relevant previous ophthalmic history, were consecutively recruited from a community polyclinic in Singapore. Gonioscopy and SS-OCT (128 radial scans) for the entire circumference of the angle were performed for each subject. A two-quadrant closed gonioscopic definition was used. On SS-OCT images, angle closure was defined as iridotrabecular contact (ITC) to the extent of ≥35%, ≥50% and ≥75% of the circumferential angle. Diagnostic disagreements between both methods, that is, false positives or overcalls and false negatives or under-calls were defined, respectively, as gonioscopic open/closed angles inversely assessed as closed/open by SS-OCT.

Two hundred seventy-two (14.7%) resulted in overcall results (false positives) when ≥50% of the angle circumference was closed using SS-OCT. These eyes had significantly wider (anterior chamber width, 11.7 vs. 11.6 mm) and deeper (anterior chamber depth (ACD), 2.4 vs. 2.2 mm) anterior chambers than eyes assessed by both methods as closed (true positives). Deeper ACD and lower lens vault (LV) were significantly associated with a false-positive diagnosis in the multivariate analysis. Most of these cases had short (52.6%) or irregular (39%) ITC in SS-OCT images.

Researchers found that anterior chamber dimensions, determined by ACD and LV, were factors significantly associated with diagnostic disagreement between anterior segment SS-OCT and gonioscopy in angle closure assessment.

SOURCE: Porporato N, Baskaran M, Tun TA, et al. Understanding diagnostic disagreement in angle closure assessment between anterior segment optical coherence tomography and gonioscopy. Br J Ophthalmol. 2019; Sep 6. [Epub ahead of print].

Additive Effect of Topical Nepafenac on Mydriasis in Patients With Diabetes Mellitus
This prospective comparative study included patients having cataract surgery with and without diabetes mellitus (DM) to evaluate the additive effects of topical nepafenac on pupil diameter (PD) in patients with DM with cataract. Two consecutive PD measurements were taken using an automatic quantitative pupillometry system (Mon Pack One, Metrovision). A baseline measurement was taken, then one drop of nepafenac 0.1% (Nevanac, Alcon) was instilled in the eye to be operated on (study eye). Cyclopentolate 1.0% was instilled to both eyes (study eye/fellow eye) five minutes later. The second measurement was taken at one hour after this application.

The DM group consisted of 43 patients, and the control group consisted of 39 participants. The baseline PDs of both eyes were similar in the DM group and the control group. The change in pupil size from baseline to mydriasis was statistically significantly greater in the study eyes (2.69 ± 0.53) than fellow eyes (2.54 ± 0.61) in the DM group, but there was no statistically significant difference in the control group (2.94 ± 0.63 vs. 2.86 ± 0.58). When the groups were compared, the PD changes were similar in the study eyes between groups, while the PD changes in the fellow eyes were lower in the DM group.

The investigators wrote that nepafenac showed an additive effect on pupil dilation in diabetic patients before cataract surgery.

SOURCE: Kiziltoprak H, Koc M, Yetkin E, et al. Additive effect of topical nepafenac on mydriasis in patients with diabetes mellitus. Eye Contact Lens. 2019; Sep 9. [Epub ahead of print].



Microperimetry and OCTA Evaluation of Patients With Ischemic Diabetic Macular Edema Treated With Monthly Intravitreal Bevacizumab: a Pilot Study
Researchers evaluated the function and anatomy of patients with ischemic diabetic macular edema after monthly injections of bevacizumab. Five eyes from five patients with diabetic macular edema associated with macular ischemia in fluorescein angiography (FA) received six monthly intravitreal injections of bevacizumab. All subjects underwent SD-OCT, FA, OCT angiography (OCTA) and microperimetry at baseline, and after six months of follow-up. Primary outcome measures were improvement of best-corrected visual acuity (BCVA), microperimetry and assessment of macular perfusion (foveal avascular zone size and capillary loss).

Five patients completed the follow-up. BCVA improved from 20/180 to 20/74 and macular sensitivity improved from 11.66 to 16.26 dB. Researchers also observed that areas of ischemia on OCTA represented areas of lower macular sensitivity on microperimetry. No changes in macular perfusion status were noted.

Monthly intravitreal bevacizumab in patients with ischemic diabetic macular edema improved BCVA and macular sensitivity without compromise of perfusion in the macula. Capillary dropout areas in OCTA correlated with lower retinal sensitivity on microperimetry.

SOURCE: Pereira F, Godoy BR, Maia M, et al. Microperimetry and OCT angiography evaluation of patients with ischemic diabetic macular edema treated with monthly intravitreal bevacizumab: a pilot study. Int J Retina Vitreous. 2019;5:24.

News & Notes
Compulink Launches E-Commerce Solution for All-in-one Optometry EHR at Vision Expo West
Compulink Healthcare Solutions, the creator of Advantage SMART Practice, the EHR and practice management system powered by artificial intelligence, officially unveiled its MyEyeStore e-commerce solution at Vision Expo West, (Sept. 19-21) in Las Vegas. The solution enables eye care practices to offer patients the ability to order contact lenses and other recommended products directly from them online. Included is a custom-built and branded web store for the practice, along with management of all order processing, tracking and patient order reminders. MyEyeStore is designed to help increase capture rates and create new revenue streams for the practice. Read more.

RightEye Releases Technology to Helps Uncover & Treat Functional Vision Issues
RightEye releasd its fully commercialized version of EyeQ Trainer, an oculomotor exercise program. Paired with its suite of EyeQ Tests, RightEye now offers a complete solution for addressing functional vision impairments. The product will showcase at Vision Expo West, taking place Sept. 18 to 21 in Las Vegas (booth #LP9109) and is available online for prescribers. RightEye EyeQ Trainer features a completely revamped user experience that is more fun and easier to use through gamified features. The commercialized version incorporates feedback from hundreds of doctors who participated in a year-long beta test of the product. The new product also adds flexibility to workflows and the user experience. Read more.

Vertical Pharmaceuticals to Present Phase III RVL-1201 Clinical Trial Data in Acquired Blepharoptosis
Vertical Pharmaceuticals announced that Phase III clinical trial results for RVL-1201 (oxymetazoline hydrochloride ophthalmic solution, 0.1%) would be presented at multiple global congresses in October and November. RVL-1201 is a novel first-in-class pharmacologic agent in development for the treatment of acquired blepharoptosis (ptosis or droopy eyelid). In the United States, there are currently no approved pharmacologic treatments for acquired blepharoptosis. The current standard of care is surgery, which is often reserved only for severe cases and can carry an increased risk of adverse events such as infection, bleeding and asymmetry. If approved, RVL-1201 (a direct-acting, α-adrenergic agent) will be a noninvasive therapy administered topically to the eye. Read more.

Ennco Display Introduces The Sentry
Ennco Display introduced The Sentry, an individual locking peg system for eyeglasses designed to fit the style and aesthetic of any space while giving the user peace of mind that their frames are secure. With frame theft on the rise in recent years, the system is intended to help practices reduce theft while enabling clients to evaluate the frames. IT comes in two vconfigurations—a peg configuration for holding frames on a wall-mounted panel, and a shelf configuration for any shelving surface present in the space. Read more.

Myco Granted a Preliminary Injunction Against BlephEx and CEO
A Michigan federal judge barred BlephEx from making allegations of patent infringement and threatening litigation against customers of Myco Industries regarding Myco's AB Max. U.S. District Judge Gershwin A. Drain issued a preliminary injunction on Aug. 27, enjoining BlephEx and CEO James Rynerson from making allegations of patent infringement and threatening litigation against potential customers of Myco. BlephEx's product and its related patent are used on the inner edge of the eyelid, whereas Myco's AB Max is applied on the front edge of the eyelid, which Judge Drain stated makes them sufficiently different. Read more.




Optometric Physician™ Editorial Board

Chief Medical Editor
Arthur B. Epstein, OD, FAAO

Journal Reviews
Shannon Steinhäuser, OD, FAAO

Contributing Editors
• Katherine M. Mastrota, MS, OD, FAAO
• Barry A. Weissman, OD, PhD, FAAO (Dip CL)

Editorial Board
• William Jones, OD, FAAO
• Alan G. Kabat, OD, FAAO
• Bruce Onofrey, RPh, OD, FAAO
• John Schachet, OD, FIOS
• Joseph Shovlin, OD, FAAO



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