PCON brings cutting-edge developments in primary care optometry to the podium

NEW YORK — The Third Annual Primary Care Optometry News Symposium enjoyed nearly 40% growth over last year as attendees from all parts of the country came here Nov. 7 to 9 to enjoy multi-source presentations of topics covering all aspects of primary care.

Course director and moderator, PCON Editor Michael D. DePaolis, OD, FAAO, led nearly 300 participants and 17 lecturers through 20 hours of continuing education over 3 days. Topics ranged from contact lenses to diabetic retinopathy to glaucoma to children’s vision care and were presented by PCON Editorial Board members, columnists and frequent contributors. PCONSuperSite.com provided meeting highlights daily from on-site.

Glaucoma trial results

Presentations on the first day of the symposium focused on glaucoma. PCON Editorial Board members Murray Fingeret, OD, FAAO, and Bruce E. Onofrey, OD, RPh, FAAO, analyzed results of recent glaucoma research.

After about 4 years into the Ocular Hypertension Treatment Study, about twice the number of untreated patients had developed primary open-angle glaucoma as those treated. In addition, about the same number were diagnosed on visual field changes as with optic nerve changes. The study found the predominant risk factor for developing POAG as thinner corneas.

In the Early Manifest Glaucoma Trial, intraocular pressure was lowered in patients by 25% by using either beta-blockers or argon laser trabeculoplasty. Results showed that the treatment group had less progression and that the majority were diagnosed based upon visual field results vs. optic nerve damage.

Dr. Onofrey discussed drug choice. His clinical pearls: “If a patient fails on a beta-blocker, don’t switch to another beta-blocker,” he said. “If a patient fails on a prostaglandin, definitely try another prostaglandin.”

Prostaglandins on the front line

Drs. Fingeret and Onofrey discussed the potential of prostaglandins as first-line glaucoma therapy. Currently, Xalatan (latanoprost, Pharmacia) is the only prostaglandin FDA approved for this indication.

Dr. Onofrey believes that “the prostaglandin analogues have everything you could want in a first-line therapy modality: efficacy, safety and convenience,” he said. “Beta-blockers, in spite of their significant systemic side effects, have very good efficacy and are cost effective medications, particularly in their generic versions.”

“Should we use only Xalatan as first-line therapy?” Dr. Fingeret asked. “It’s always at the doctor’s discretion to prescribe what he or she feels is in the patient’s best interest.”

An audience member asked about using a prostaglandin and Restasis (cyclosporine 0.05% ophthalmic emulsion, Allergan) concurrently. Dr. Onofrey said the two agents work via different mechanisms, so, theoretically, using them together should not be a problem. However, new research is looking at anti-inflammatories for managing dry eye. “In the case of a significant dry eye with chronic inflammation, I would not put that patient on a prostaglandin,” he said. “I believe it would exacerbate the inflammatory phase.”

Diagnostic technologies in glaucoma

PCON board members William L. Jones, OD, FAAO, and J. James Thimons, OD, FAAO, joined Dr. Fingeret to cover new diagnostic technologies in glaucoma.

Dr. Fingeret discussed the HRT II (Heidelberg Engineering). “It is important to realize that any one measurement in isolation is not as important as evaluating the overall data,” Dr. Fingeret said.

Ocular therapeutics: Dr. Thomas (left) and Dr. Melton (right) said NSAIDs are no more beneficial for adenoviral keratoconjunctivitis than artificial tears.

Dr. Thimons covered the VCC (variable corneal compensator) version of the GDx (Laser Diagnostic Technologies). “The normative database and deviation plots are important, but change over time is most important,” he said.

They both agreed that all of the instruments are most useful in mild and moderate glaucoma to track progression. The instruments are synergistic, each providing different information to the practitioner, Dr. Thimons said.

According to Dr. Jones, when using the Stratus OCT (Carl Zeiss Meditec), “It’s always important to compare the two eyes for symmetry,” he added.

He also discussed the Optos Panoramic200, which can identify neuroretinal rim asymmetry — in the same eye — that is associated with POAG.

Dry eye and Restasis

Dr. Thimons started off day 2 of the symposium by discussing the role of Restasis, which is approved for twice-daily dosing to treat inflammation, an underlying cause of dry eye. At 6 months, study patients experienced increased tear production resulting in statistically significant improvements in Schirmer’s wetting, corneal staining and symptoms. Patients also experienced significant reduction in T-cell infiltration and inflammatory cytokines.

Dr. Thimons listed off-label uses for the agent: chronic fulminating uveitis, Thygeson’s disease, rheumatoid melts, vernal keratoconjunctivitis, herpes simplex virus/herpes zoster virus dry eye and in post-LASIK patients.

Ocular therapeutics update

PCON Editorial Board members Ron Melton, OD, FAAO, and Randall Thomas, OD, FAAO, updated their ocular therapeutics lecture. Their antibiotic solutions of choice are tobramycin, polymyxin B/trimethoprim and the fluoroquinolones. Their ointment of choice is polymyxin B. They added that we will soon see two new anti-infective/anti-inflammatory combinations: CiproDex (tobramycin/dexamethasone, Alcon) and Zylet (tobramycin/loteprednol, Bausch & Lomb).

Treating children: Dr. Bartiss recommended childproofing your office as you would childproof your home.

In patients with severe dry eye, use loteprednol etabonate twice to four times daily for 1 month in conjunction with Restasis, they said; the steroid will help quell the inflammation quickly. Then, discontinue the steroid; the Restasis should be able to keep the patient comfortable indefinitely. Artificial tears may still be necessary.

Drs. Melton and Thomas cautioned doctors against assuming an infiltrate is a corneal ulcer until proven otherwise. “Any time you see anything at or near the limbus, it is almost invariably inflammatory in nature,” Dr. Thomas said. TobraDex (tobramycin/dexamethasone, Alcon) is well indicated in these patients. In situations where peripheral infiltrates tend to chronically recur (in non-contact lens wearers), a several-month course of oral doxycycline may re-establish normal eyelid-ocular surface physiology, thus preventing recurrences.

The COX-2 inhibitors Celebrex (celecoxib, Pharmacia/Pfizer) and Vioxx (rofecoxib, Merck) were recommended for recalcitrant uveitis. “Add Celebrex or Vioxx to oral prednisone for a synergistic effect,” they said. As an alternative, they recommended 200 mg of ibuprofen four times daily to suppress inflammation.

Drs. Melton and Thomas recommended the off-label use of povidone iodine 5% for adenoviral keratoconjunctivitis. Use proparacaine first, then Betadine 5% (Alcon) for 1 minute, followed by irrigation. “Add corticosteroids four times daily for a few days to quell the inflammation,” they said. “Betadine, by virtue of lessening the viral load, minimizes the likelihood of viral antigens inducing an infiltrative response, that is, the classic subepithelial infiltrates.”

Examining the pediatric patient

Pediatric ophthalmologist and PCON Editorial Board member Michael Bartiss, OD, MD, FAAO, FAAP, FACS, shared insights on preparing your practice – both clinically and administratively – for treating children.

“Children are not little adults,” he began. During the exam, watch for head tilts or turns that might indicate compensation for a binocularity problem. He suggested covering one eye with paper tape when assessing visual acuities. If the head tilt disappears, it is a binocular problem; if the head position does not change, it is more likely an orthopedic problem. He stressed looking for visual acuity symmetry in preverbal children. He also recommended checking single-letter visual acuity in amblyopic children, as well as near binocular visual acuity and monocular distance visual acuity on all children.

Dr. Bartiss said an infant should be able to recognize Mom at a normal holding distance at about 8 weeks. Normal corneal diameter for infants is 9.5 mm to 10.6 mm. Normal IOP in infants and young children is about 20 mm Hg.

Ocular allergy

During an Alcon-sponsored lunch, Glenn S. Corbin, OD, and Walter S. Ramsey, OD, FAAO, joined Dr. DePaolis to offer advice on keeping allergy patients. Dr. Ramsey suggested asking patients if their eyes ever itch, controlling samples, using pre-printed prescription pads from manufacturers that list drug names and dosages, and learning CPT codes to be sure you receive proper reimbursement.

Diabetic eye disease

Editorial Board member Anthony Cavallerano, OD, FAAO, said that a simplified, clinically useful system for classifying diabetic retinopathy (DR) has been published by the Global Diabetic Retinopathy Project Group. (See www.oacs.mcg.edu/som/eye/files/Ophthalmology%202003%20110%201677.pdf)

He shared an unusual fact: some evidence shows that, for some reason, cigarette smoking may protect against progressive DR in some diabetic patients.

Ongoing research is showing that the oral beta isoform dose of protein kinase-C inhibitors may exhibit short-term benefit for DR and diabetic macular edema, Dr. Cavallerano said. Other experimental and emerging therapies for DR include studies with vitamin E, unoprostone and Envision TD (Bausch & Lomb) for diabetic macular edema, and Celebrex.

Cases in neuro-ophthalmology

Neuro columnist Leonid Skorin Jr., OD, DO, FAAO, FAOCO, shared case reports from medical malpractice cases in which he testified. A 57-year-old man had progressive vision loss over a 4-month period in the right eye. The patient also had paresthesia of the hands. He was diagnosed with retrobulbar optic neuritis and prescribed oral steroids. The patient got worse. Then, an MRI revealed glioblastoma. An MRI should have been done at the beginning, Dr. Skorin said. The Optic Neuritis Therapy trial concluded that oral steroids should never be prescribed for optic neuritis.

Peripheral retinal disorders

Dr. Jones shared his pearls for diagnosing peripheral retinal disorders. Congenital hyperplasia of retinal pigment epithelium (CHRPE) is often circular with or without a halo and usually is flat and jet black in appearance.

Retinal pigment degeneration is very common in seniors, Dr. Jones said. It can have hundreds of peripheral drusen. Patients with lattice degeneration should be followed up every year. About one-third of all retinal detachment patients will have lattice degeneration as an accompanying finding.

Laboratory and imaging studies

Dr. Skorin covered advantages and disadvantages of CT scans and MRIs and made recommendations regarding which imaging tests to order for what conditions: for optic neuritis, order MRI of the brain and orbits, with and without gadolinium, with fat suppression; for orbital tumor, order MRI of the orbits with gadolinium and fat suppression; for orbital trauma, order CT of the orbits, axial and coronal, without contrast; for third nerve palsy with involved pupil, order MRI and MRA of the brain with gadolinium; for homonymous hemianopsia, order an MRI of the brain with and without gadolinium.

Dr. Cavallerano outlined which laboratory tests are typically ordered for a variety of conditions, including cases of granulomatous uveitis, where PPD (purified protein derivative), FTA (fluorescent titer antibody), HLA-B27 and ACE (angiotensin-converting enzyme) can help identify an underlying systemic cause.

New fluoroquinolones, first-line therapy

On day 3, board member Richard Lindstrom, MD, FACS, and contributor Marc Bloomenstein, OD, FAAO, joined Dr. Skorin to debate the new fluoroquinolones’ role as first-line therapy.

According to Dr. Bloomenstein, third-generation agents require only a topo isomerase 4 mutation to become ineffective, while fourth-generation agents require a topo isomerase 2 and 4 mutation. “Continued use of third-generation agents will facilitate an increase in bugs that are just one step away from resistance to fourth generations,” he said.

Dr. Skorin told the audience: “Don’t hesitate to use the strongest agent available to get the greatest benefit.”

Dr. Lindstrom recommended loading the eye prior to surgery with a short course of these agents: four times daily every 3 hours for 3 days preoperatively, then two drops at the time of surgery.

Presbyopia and contacts

Surgery for presbyopia: Dr. DePaolis (far left) moderated the refractive surgery panel, from left, Dr. Catania, Dr. Lindstrom and Dr. Bloomenstein. “The future will lie in refractive lensectomy with an accommodating IOL, particularly for hyperopes and emmetropes,” said Dr. Lindstrom.

Editorial Board member and columnist Jennifer Smythe, OD, FAAO; board member Wayne Wood, OD; and columnist Deepak Gupta, OD, FAAO, joined together to address the management of presbyopia with contact lenses.

Dr. Wood offered his three clinical pearls for monovision: try to obtain maximum visual acuity in both the distance and near eye (“Treat each eye like a separate patient.”); start with the dominant eye for distance, but change if the patient has trouble adapting; a 0.25-D power change can be significant, often the difference between success and failure.

According to Dr. Smythe, other conditions that occur in conjunction with loss of accommodation — lid flacity, dry eye, reduced contrast – make contact lens wear challenging. “However, presbyopes are very, very motivated,” she said.

An ideal simultaneous vision design for presbyopes is one with asphericity on both sides. Larger diameters, such as 10 to 10.5 mm, are very comfortable and perform better because the optics are centered over the pupil. “Remember, really small changes on the front surface can have a profound impact on the add,” she said.

Children and contacts

The trio also addressed pediatric contact lens practice. Dr. Smythe cited a study from the 1970s where 333 myopes, 10 to 15 years old, wearing PMMA lenses were compared to a control group. Myopia in 90% of the spectacle wearers and only 20% of the PMMA wearers increased by at least 0.25 D over 2 years. Another study in 1989 showed that GP wearers changed 0.25 D over 2 years while spectacle wearers progressed 0.75 D. “However, the recent Singapore study showed no difference in progression in two such groups,” she said. “It is hoped that the Contact Lens and Myopia Progression Study results will provide a definitive answer.”

Dr. Wood urged practitioners to discuss compliance, warn children and adolescents about sharing cosmetic lenses, review risks of overnight wear and prescribe contact lens solutions.

Most infants will need prescription changes within the first month and further changes every 3 months, Dr. Gupta said. He recommended overplussing by 3 D for children up to age 2; overplussing by 1.5 D for those 2 to 3 years; and then using the distance prescription and spectacles for older children.

Convenient contact lens options

Dr. Wood said he presents daily disposables “as the safest, most convenient way to wear contacts.” He said the only real drawback is the cost, which should be presented as a daily — not a monthly — expense. Emphasize the greater value in health and convenience.

Dr. Gupta discussed overnight Corneal Refractive Therapy (CRT) from Paragon. “Paragon will give you the initial lens selector – it’s pretty simple; you key in the data, and it will tell you what lens to start with,” he said. “Once you put the lens on, you look at everything you would normally look at when fitting a normal GP lens: visual acuity, centration, mid-periphery, periphery and edge clearance.”

Dr. Smythe addressed extended wear with silicone hydrogels. When fitting this lens, “I look at corneal topography, but I also consider corneal diameter as much as evaluating a patient’s apical radius of curvature,” she said. “If the keratometry readings are 44 D or steeper, I select the 8.4-mm lens. About 70% of my patients are in the 8.4 mm, and the rest are in the 8.6 mm. I said just the opposite last year.

“As far as scheduling, I used to do a 24-hour check,” she continued, “but now I only do it if I have a concern.” Otherwise, she follows up at 1 week.

Dr. Smythe prescribes daily wear for 1 week for new contact lens wearers, but allows experienced wearers to go right into the overnight schedule.

Wavefront technology in optometry

Editorial Board member Louis J. Catania, OD, FAAO, joined Dr. Bloomenstein and Dr. Lindstrom to discuss wavefront technology. According to Dr. Catania, 80% to 83% of visual system imperfections are made up of lower-order aberrations. “First-order (prism) and second-order (sphere/cylinder) aberrations are what we’re correcting now,” he said. “However, addressing the remaining 20%, higher-order aberrations, is essential for maximum vision correction.”

“What we used to call ‘irregular astigmatism’ we are now calling ‘coma, trefoil, secondary astigmatism, etc.,’” said Dr. Lindstrom. “For example, a patient with keratoconus has severe vertical coma.”

Dr. Lindstrom recommended using customized ablation whenever the patient qualifies because a higher percentage will achieve 20/20 or better and fewer have night vision problems.

The trio highlighted what they consider to be the “claim to fame” of each of the FDA-approved wavefront laser platforms. “Visx (Star S4 and CustomVue) prides itself in its PreVue capability (simulation of the correction) and its ability to utilize the manifest refraction to manipulate the wavefront,” said Dr. Catania. “Alcon (LADARVision and LADARWave) prides itself in its ability to capture, register and treat with extreme accuracy.”

According to Dr. Lindstrom, Bausch & Lomb (Technolas and Zyoptix) prides itself on its data (compared to study outcomes with other uses), its larger optical zone capabilities and larger treatment range.

New technologies in refractive surgery

The lecturers discussed some of the newer technologies. The femtosecond (Intralase FS) laser is a noninvasive method FDA approved for keratectomy (creating flaps in LASIK), creating channels for intracorneal rings and anterior lamellar keratectomy. “Intralase flaps are true planar flaps (optically neutral), not meniscus flaps (which induce cylinder) as created by mechanical microkeratomes,” Dr. Catania said. “The Intralase may ultimately be used for intrastromal ablations as well.”

“The Intralase femtosecond laser may ultimately be the best approach to performing LASIK enhancements,” Dr. Lindstrom added, “eliminating the need to lift flaps.”

Results of conductive keratoplasty (CK, Refractec) are very much affected by surgical techniques, Dr. Bloomenstein said. The Tecnis (Pharmacia) aspheric IOL is very good for younger cataract patients with night vision symptoms or larger pupils, he said. And the Light Adjustable Lens from Calhoun Vision can be adjusted up to 4 D postoperatively for refining postsurgical outcomes.

Surgery for presbyopia

The final presentation covered surgical options for presbyopia. According to Dr. Catania, PRELEX, Presbyopic Lens Exchange with the AMO Array lens, is yielding impressive results in hyperopic presbyopes. Scleral expansion surgery is offering very limited results with regression. Twelve accommodating IOLs are in development, he said.

Dr. Bloomenstein discussed the CrystaLens by Eyeonics Inc. (formerly C&C Vision), which received FDA approval Nov. 14. With this hinged-optics lens in place in the capsular bag, when the ciliary body constricts, the vitreous mass pushes on the posterior aspect of the IOL, with attending accommodation.