Optometric Physician


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

#########

Volume 19, Number 39

Monday, September 30, 2019

#########

Inside this issue: (click heading to view article)
#########
######### Off the Cuff: How a Meibomian Gland Conspiracy Theorist Implemented IPL
#########
######### Fast vs. Gradual Adaptation of Soft Daily Disposable Contact Lenses in Neophyte Wearers
#########
######### Corneal Ectasia Following Cataract Extraction Surgery in a Patient With Keratoconus: a Case Report
#########
######### Latanoprost Uptake and Release From Commercial Contact Lenses
#########
######### News & Notes
 

Click on the image for upcoming Conferences and Meetings.
http://www.facebook.com/pages/Optometric-Physician/256126944408439

 

Off the Cuff: How a Meibomian Gland Conspiracy Theorist Implemented IPL

Now that my Lumenis Optima M22 IPL has solidly become a practice mainstay, I thought it might be good time to share what I’ve learned and how I’ve integrated IPL into my dry eye practice. It wasn’t as easy as you might think, but looking back just a few months it was transformative.

Immediately after it was delivered, I stared at it and realized I had bought this expensive thing that looked like R2D2, and I really didn’t know what to do with it other than make R2D2 look-alike jokes. When do I use IPL, and when do I use LipiFlow or TearCare. Did I just purchase something I didn’t really need?

Understand that I had successfully been using LipiFlow since we opened our office a little over six years ago and recently added TearCare to my expression armamentarium. I am a firm believer in MGD being the primary driver of virtually all dry eye, well beyond the oft-quoted Lemp, et al. percentage of 86%. As I see it, obstruction leads to increased intra-gland and intraductal pressure, downregulation of meibum production, lipid stagnation, inflammation and ultimately gland loss. Where does IPL fit into that model? I worried.

I know what you’re thinking—I was overthinking it. IPL is for ocular rosacea while LipiFlow and TearCare are for obstructive MGD. I only wish it were that simple. First, there is a lot of overlap between ocular rosacea and MGD. In many cases, it’s virtually impossible to tell the difference between the two pathoetiologies by simple clinical observation. Are the engorged telangiectatic vessels due to rosacea that then leak inflammatory mediators into the glands and lid tissues, or is MGD and the resulting obstruction and stagnant rancid meibum causing inflammation and subsequent vascular infiltration?

As it turns out, there is a lot more to IPL than just sealing leaky vessels, or heating and melting congealed meibum (which it doesn’t actually do). IPL turned out to be a revelation, increasing patient comfort, improving tear stability and changing the composition of meibum—even without expressing the glands? Lipid layer thickness and tear quality all improved, and the M22 quickly went from a quirky R2D2 clone to closer and closer to a first line treatment for MGD and dry eye.

So where did that leave LipiFlow and TearCare? Actually, better than before. Both are still extremely effective tools for clearing obstruction and restoring function in patients with MGD and dry eye. Patients who have minimal obvious inflammation and lid vascularization are offered LipiFlow or TearCare first. Patients who have rosacea and MGD, lid inflammation or clear-cut ocular rosacea get IPL first. For many patients, the best outcomes occur when these different, but synergistic, technologies are combined. As with many things, they are much more effective used together.

Arthur B. Epstein, OD, FAAO
Chief Medical Editor
artepstein@optometricphysician.com

 

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.

 








Fast vs. Gradual Adaptation of Soft Daily Disposable Contact Lenses in Neophyte Wearers
 
 
Despite the widespread practice of gradually adapting all new soft contact lens wearers (neophytes), researchers wrote that there is little evidence-based research underpinning such practice. This study determined if a gradual adaptation period was necessary for neophytes when fitted with modern hydrogel or silicone-hydrogel daily disposable contact lenses. At four sites, neophytes (19 to 32 years) were randomly assigned to an adaptation schedule: fast (10-hour wear from the first day) or gradual (4-hour on the first day, increasing their wear-time by 2 hours on each subsequent day until they had reached 10 hours) with hydrogel (n=24 fast; n=21 gradual) or silicone-hydrogel (n=10 fast; n=10 gradual) contact lenses. Masked investigators graded ocular surface physiology and non-invasive tear breakup time (NIBUT). A range of subjective scores (using 0 to 100 visual analogue scales) were recorded at the initial visit and after 10 hours of lens wear, four to six days and 12 to 14 days after initial fitting. Subjective scores were also repeated after seven days.

There was no difference in ocular surface physiology between the fast and gradual adaptation groups at any time point in either lens type. NIBUT was similar at all time points for both adaptation groups in both lens types, with the exception that the gradual adaptation silicone-hydrogel wearers had a slightly longer NIBUT than the fast adaptation group at 12 to 14 days. Subjective scores were also similar across the visits and lens types, with the exception of “lens awareness” and “ease of lens removal,” which were better in the fast compared with the gradual adaptation hydrogel lens group at day 7. Additionally, “end-of-day discomfort” was better in the fast compared with the gradual adaptation hydrogel lens group at 12 to 14 days.

Researchers wrote that there appeared to be no benefit in daily disposable soft contact lens adaptation for neophytes with modern contact lens materials.

SOURCE: Wolffsohn JS, Dhirajlal H, Vianya-Estopa M, et al. Fast versus gradual adaptation of soft daily disposable contact lenses in neophyte wearers. Cont Lens Anterior Eye. 2019; Sep 19. [Epub ahead of print].



Corneal Ectasia Following Cataract Extraction Surgery in a Patient With Keratoconus: a Case Report
 
 
According to experimental and clinical published studies, patients with keratoconus have a genetic predisposition to corneal ectasia; however, ectasia might not be activated or reactivated unless an additional stressful event triggers the disease. Triggering factors are sources of reactive oxidative stress; among them, mechanical trauma (vigorous eye rubbing, poorly fit contact lenses), exposure to ultraviolet light and atopy/allergies. The aim of this case report was to present for the first time a case of rapidly progressive corneal ectasia in a patient with keratoconus following uncomplicated phacoemulsification surgery for cataract removal.

A 38-year-old Caucasian man was referred to the investigators’ outpatient service due to bilateral cataract. He also had bilateral keratoconus and had undergone corneal cross-linking in both his eyes five years prior to his referral. Since the corneal cross-linking, keratoconus had been stable. The patient underwent a full ophthalmological examination including slit-lamp biomicroscopy, optical biometry, Scheimpflug tomography, corneal biomechanical assessment and fundus examination. He presented advanced centrally located cataract with count fingers for preoperative best-corrected visual acuity. An uncomplicated cataract extraction surgery was performed. Preoperative flat keratometry reading was 40.5 diopters, steep keratometry reading was 41.8 diopters, astigmatism was 1.3 diopters, corneal hysteresis was 8.2, corneal resistance factor was 7.5 and thinnest corneal thickness was 503 μm. Within three months, the patient demonstrated rapidly progressing corneal ectasia in his operated eye, while six months postoperatively, flat keratometry reading was 45.5 diopters, steep keratometry reading was 48.3D, astigmatism was 2.8D, corneal hysteresis=6.8, corneal resistance factor=7.5 and thinnest corneal thickness=318 μm.

To the best of the investigators’ knowledge, this was the first report to describe corneal ectasia in a patient with keratoconus following phacoemulsification surgery. The investigators wrote that cataract surgeons should provide extra caution to patients with keratoconus and take into consideration this rare, but potentially sight-threatening, complication.


SOURCE: Labiris G, Panagiotopoulou EK, Ntonti P, et al. Corneal ectasia following cataract extraction surgery in a patient with keratoconus: a case report. J Med Case Rep. 2019;13(1):296.

 

 

Latanoprost Uptake and Release From Commercial Contact Lenses
 
 
This study investigated the potential of delivering an anti-glaucoma drug using commercial silicone hydrogel (SiHy) contact lenses. The moderately hydrophobic drug latanoprost was rapidly loaded in four minutes by swelling contact lenses in a solution of the drug in n-propanol. A fraction of the drug was radiolabeled, thus allowing measurement of the uptake and subsequent release of drug into artificial tear fluid. Three questions were addressed: 1) How much drug can be loaded into each type of lens, 2) how fast is drug release and 3) how are these values related to the contact lens chemistry? To examine correlations between lens chemistry, drug chemistry and uptake, and solvent chemistry, the Hansen solubility parameters were calculated using estimates of contact lens chemistry.

The results showed that much more latanoprost could be loaded into SiHy lenses than a conventional contact lens of poly(hydroxyethyl methacrylate). The drug uptake correlated with the amount of swelling in n-propanol, with Galyfilcon lenses having the greatest swelling and highest drug uptake. The drug release from the SiHy lenses occurred over days, whereas the conventional lens released nearly all drug in a burst over a few hours.

These results showed that drug uptake in SiHy lenses correlated with favorable solubility parameter interactions between the n-propanol and the lens material, but did not correlate with interactions between the drug and the lens materials.

SOURCE: Horne RR, Rich JT, Bradley MW, et al. Latanoprost uptake and release from commercial contact lenses. J Biomater Sci Polym Ed. 2019; Sep 17:1-17. [Epub ahead of print].





News & Notes
 
AAOF Announces Beta Sigma Kappa Research Fellowship, Allergan Foundation Research Grant & Korb-Exford Dry Eye Career Development Grant Recipients
The American Academy of Optometry Foundation, in collaboration with the Beta Sigma Kappa International Optometric Honor Society, announced that Sima T. Mozdbar, OD, was the 2019 recipient of the Beta Sigma Kappa Research Fellowship. Dr. Mozdbar is an adjunct clinical professor at the University of Houston College of Optometry. The award will fund Dr. Mozdbar’s project, titled “Cognitive Dysfunction and the 25-Item National Eye Institute Visual Function Questionnaire.” Read more.
In addition, the AAOF, in partnership with the Allergan Foundation, announced Loretta B. Szczotka-Flynn, OD, PhD, FAAO, as the 2019-2020 recipient of the Allergan Foundation Research Grant. Dr. Flynn is a professor of ophthalmology and visual sciences at Case Western Reserve University. She was awarded a $60,000 grant for her project, “Modeling Corneal Endothelial Cell Health Parameters as Predictors of Keratoplasty Stress.” Read more.
As well, the AAOF announced that Laura Downie, BOptom, FAAO, was this year’s recipient of the Korb-Exford Dry Eye Career Development Grant. Dr. Downie is senior lecturer in the Department of Optometry and Vision Sciences and Faculty of Medicine, Dentistry and Health Sciences at the University of Melbourne, Australia. She was chosen for her proposal to develop a novel point-of-care medical device for eye diagnosis, and will receive a $25,000 grant to help her advance eye care and improve outcomes for people with dry eye disease. Read more.



Prevent Blindness Urges Consumers to Seek Expert Advice, Obtain Rx for all CLs
Prevent Blindness has declared October as Contact Lens Safety Awareness Month to educate the public on the best ways to care for their eyes through safe use and care of contact lenses. In a press release, Prevent Blindness wrote that many consumers might not be aware that the FDA regulates contact lenses and certain contact lens care products as medical devices. Additionally, it added that the FDA states that contact lenses are not over-the-counter devices, so companies that sell them as such are misbranding the device and violating Federal Trade Commission regulations by selling contact lenses without having a valid prescription. Prevent Blindness stressed that any time a foreign object or material is placed in the eye, there’s an increased risk of complications and that all contact lens wearers should follow an eye doctor's instructions about care and cleaning of the lenses. Read more.



NORA Presents Awards Neuro-optometric Rehabilitation Contributions
The Neuro-Optometric Rehabilitation Association, International recognized several individuals and a foundation last week at NORA’s 28th Annual Conference in Scottsdale, Ariz., for their important contributions to NORA and the field of Neuro-Optometric Rehabilitation. View the recipients.



EyeJust Announces Blue Light Blocking Screen Protectors for iPhone 11
EyeJust announced the launch of blue light blocking screen protectors for iPhone 11, iPhone 11 Pro and iPhone 11 Pro Max, to help users avoid harmful effects of blue light. The filters were designed to filter the highest amount of harmful blue light without changing the color of the screen. According to the company, the optical clarity screen was tested at the Gavin Herbert Eye Institute at UC Irvine and was ophthalmologist- approved for blue light blocking efficiency. 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


 

 

Optometric Physician™ (OP) newsletter is owned and published by Dr. Arthur Epstein. It is distributed by the Review Group, a Division of Jobson Medical Information LLC (JMI), 11 Campus Boulevard, Newtown Square, PA 19073.

To change your email address, reply to this email. Write "change of address" in the subject line. Make sure to provide us with your old and new address.

To ensure delivery, please be sure to add Optometricphysician@jobsonmail.com to your address book or safe senders list.

Click here if you do not want to receive future emails from Optometric Physician.

HOW TO SUBMIT NEWS
E-mail optometricphysician@jobson.com or FAX your news to: 610.492.1039.

HOW TO ADVERTISE
For information on advertising in this e-mail newsletter or other creative advertising opportunities with Optometric Physician, please click here for advertising information.