Benjamin P. Casella, OD, FAAO

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It has been an incredible time for all of us. Besides the social distancing, extra personal protective equipment, Payback Protection Program (PPP) loans, and incredibly light schedules, the psychology of the pandemic has been intense. I needed a mental break from it all, and I got just that recently.

I recently attended the Georgia Optometric Association (GOA) annual conference. Rather than packing up and driving to the beach with the family, my dad and I grabbed a couple of beers and sat down in front of a computer.

Related: Biggest challenges facing optometry schools and students

Of course, it wasn’t the same. I will say, however, that the GOA did the best job it could given these unprecedented circumstances. Our longstanding emcee, Bob McCullough, OD, did another terrific job of presiding over the evening while telling some of the worst jokes humankind has ever heard. Mehrdad Saadat, OD, gave an excellent recap of our last 12 months before being elected to the highly coveted position of immediate past president of the GOA. After becoming the newly elected GOA president, Jeanne Perrine, OD, gave an inspiring speech charging us with the task of getting more ODs involved with organized optometry, and we even had none other than American Optometric Association (AOA) President Barbara Horn, OD, on hand for the swearing in of the newly elected officers.

I left the meeting feeling more energized about optometry in general, and I also left feeling a little heartbroken that it has been so long since I have laid in-person eyes on my optometry family—and it is a family. The GOA really is just one big family. We get together whenever we can. We would do anything for one another. We agree on things and get them done. We argue, sometimes at length, as we strive to reach common ground on concerns. Hats off to Bryan and the GOA staff for pulling off a real winner—albeit a virtual one.

Related: Telemedicine in the face of COVID-19

So, when will our family convene in person again? We have all heard many, many opinions on the matter. I can also tell you that, out of all the chatter I have heard in the media regarding this question, very little of it has come out of the mouths of actual epidemiologists. So, who knows?

I hope it’s soon because I miss you all. I miss seeing you in the hallways between lectures. I miss trading drink tickets at happy hours. I miss catching up. I miss the experience of seeing someone across the room for the first time in a year and the two of us immediately starting to laugh about some funny experience that may have happened years ago. I hope to see colleagues in person soon. However, I will say that Dr. McCullough’s terrible jokes 

In the meantime, hang in there, everybody. Continue to follow the science and be confident that every day brings us one day closer to shaking hands.

More by Dr. Casella: Physical and psychological changes of opening post COVID-19

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Virtual conferences not filling the gap of in-person meetings

I recently came across a paper while performing a search of the world’s peer-reviewed literature with the topic of contact lens compliance in mind. My search was precipitated by two things.

The patient I had just seen 10 minutes prior was a new patient who thought she had scratched her right eye. As it turned out, she had an ulcer that appeared to be bacterial just inferior-temporal to her visual axis. It was small, round, white, and had just a mild amount of staining with sodium fluorescein. Its location being closer to the visual axis rather than the periphery led me to suspect that it was infectious and not “sterile.”

The patient was a 26-year-old female who was not pregnant and had no known medical allergies. A frankly bleak sign was the presence of several old round scars on both corneas: evidence of prior insults. She reported noncompliance with her contact lens-wearing schedule.

I started the patient on Besivance ophthalmic suspension (besifloxacin, Bausch + Lomb) every 30 minutes in the right eye, advised her not to wear a contact lens in that eye, and invited her back the next day at 9:00 a.m.

The second thing that precipitated my search of the world’s literature on this topic was the fact that, with this occurring during a global pandemic, I had oodles of time in between patients to do so (at the time this was written, I was seeing about one patient every hour).

Related: 11 things my patient wished her previous OD had told her

So, in my quest, I came across a very timely paper out of Spain whose lead author was a cornea specialist in a hospital setting.1 The paper, “Characteristics, Behaviors, and Awareness of Contact Lens Wearers Purchasing Lenses Over the Internet,” had a title that intrigued me, especially having recently heard news that several states were dealing with entities attempting to use the COVID-19 pandemic to convince lawmakers to overturn laws banning online eye examinations for the renewal of glasses and contact lens prescriptions.2

The authors of the study sent out a questionnaire regarding contact lens hygiene to clients of an online contact lens service. Through the survey questionnaire, they collected information on demographics, knowledge of proper contact lens hygiene, and compliance. The survey took place over a 6-month period, after which the results were analyzed.

Some 1264 contact lens wearers completed the survey. The mean age of those who participated was 40.8 years, and most participants were female (71.1 percent). As one would expect, the majority (76.4 percent) were myopic. Some 63.3 percent wore monthly disposable contact lenses.

The participants who purchased their contact lenses exclusively online reported a lower frequency of eye examinations. The frequency of eye examinations was also lower among those who had begun contact lens wear on their own (without an eye doctor). The participants who had begun contact lens wear on their own were found to be less experienced.

Of the risk factors isolated from the survey, exposure to water (swimming and/or showering with contact lenses in) was common, as was use of contact lenses and/or contact lens cases beyond the recommended replacement schedule. The reuse of contact lens solution was also common.

The authors found no differences in risk-awareness or compliance between those who purchased their contact lenses exclusively online versus other contact lens wearers. They did, however, find that those who taught themselves how to use contact lenses tended to have less frequent eye examinations, poorer compliance, and increased risks for adverse contact lens related events.

Related: Engineer a specialty contact lens practice

One overt characteristic of this paper that must be pointed out is the fact that this study came out of another country with obvious differences as far as laws relating to contact prescription and purchase are concerned. However, that doesn’t mean that ODs cannot extract meaningful information from it.

Those familiar with reviewing and grading scientific literature would be quick to point out that, while the sample size is sizeable, a self-reported questionnaire tends to have a lower evidence profile than, say, a double-masked randomized controlled trial with thousands of participants and a study period of several years. I would agree with that, as well. However, again, it doesn’t mean that we, in the U.S., cannot get tangible information here.

One may say off the cuff, “You can’t get contact lenses without an eye examination and a prescription in the U.S.” Yes, you can. I hate to say it, but yes, you can.

My mind almost immediately went to a young female several years ago who came in with a near total corneal ulcer from the contact lenses she bought at a flea market that a friend taught her how to wear. I immediately referred her to a cornea specialist and have never heard from her since.

ODs have an obligation to inform the public, our lawmakers, and our patients of the dangers of contact lens misuse. The potential for blinding complications is all too real.

More by Dr. Casella: Dr. Ben Casella COVID-19 wrap-up

1. Mingo-Botín D, Zamora J, Arnalich-Montiel F, Muñoz-Negrete FJ. Characteristics, Behaviors, and Awareness of Contact Lens Wearers Purchasing Lenses Over the Internet. 

. 2020 May 14. doi: 10.1097/ICL.0000000000000702.

2. Georgia Public Policy Foundation. Foundation Joins Plea for Georgia to Allow Online Vision Care. Available at: https://www.georgiapolicy.org/2020/05/foundation-joins-plea-for-georgia-to-allow-online-vision-care/. Accessed 6/10/20.

Patients, contact lenses, and the internet

Contrast sensitivity evaluates how well a person can distinguish an object from its background and it is an often overlooked symptom of glaucoma.

I have spoken to glaucoma patients and suspected glaucoma patients about the risk of visual field loss many times for several reasons. They need to know, they have a right to know, it is part of my fiduciary obligation, and it may improve compliance. I usually end the conversation by saying “if glaucoma goes untreated for long enough, it can affect your central vision, as well”.

A recent conversation with a glaucoma patient of mine led me to the unfortunate conclusion that I really need to rephrase my concluding remarks in this conversation (which I have often).

Related: Know what common glaucoma mistakes to avoid

A Caucasian male who is now 51 years old first presented to me in 2015 for a comprehensive eye examination. He was a low myope and an early presbyope looking to update his current glasses. Best-corrected visual acuity (BCVA) was 20/20 OU. His family history was noncontributory.

Of note, his intraocular pressures (IOP) were 20 mm Hg OD and 21 mm Hg OS in the early afternoon. Upon posterior segment examination through dilated pupils, his right optic nerve head appeared suspicious for glaucoma with a slightly larger cup than his left optic nerve head. I thought his retinal nerve fiber layer, as examined with the use of a pre-corneal lens and a red-free filter, appeared asymmetric as well. There was no frank history of trauma. I took photos of his optic nerves and invited him back in a week or two for baseline glaucoma testing.

Related: Pediatric glaucoma: types, tests and treatments

He eventually returned in October 2019. He apologized and stated he remembered our conversation about the need for glaucoma testing well but that he had just gotten busy and put it off until the present time. At that visit, his BCVA was 20/20 in each eye. IOPs were measured at 32 mm Hg OD and 16 mm Hg OS in the mid-morning.

Unfortunately, his right optic nerve appeared to be obviously glaucomatous with a vertical cup-to-disc ratio of 0.8 and a clearly evident notch superiorly at 11 a.m. His left optic nerve looked unchanged from his previous exam in 2015. Gonioscopy showed relatively symmetric angles open to the ciliary body OU with mid pigment. There was no evidence of angle recession. Central corneal thickness values were 533 μm OD and 537 μm OS.

Spectral-domain optical coherence tomography (OCT) studies OU showed a thin ganglion cell complex and diffuse retinal nerve fiber layer thinning OD. The OS study was essentially clear. Visual field studies were conducted, and the OD showed dense arcuate defects superiorly and inferiorly. OS was unremarkable.

Related: Misdiagnosis when clinical findings don’t make sense

I told the patient that he had unilateral open-angle glaucoma OD and that he needed to be treated. He consented to treatment, and I started him on a prostaglandin analog at bedtime OD with a target of 50 percent pressure reduction in that eye.

When he returned in a month IOPs were 14 mm Hg OD and 17 mm Hg OS at the same time of day. The dense arcuate defects in the OD visual field were repeatable, and the OS field remained unremarkable.

I congratulated him on his right eye’s remarkable response to glaucoma monotherapy and invited him to return again in 3 months for an IOP check. At that visit in February 2020, his IOPs were unchanged. It was at that visit that he intrigued me with a comment and a piece of paper he brought with him.

This man is a highly intelligent and astute observer He is an engineer with a PhD. He told me that he didn’t notice his visual field defect at all but that he did have a noticeable and bothersome change to his contrast sensitivity OD.

In fact, he brought in what he considered to be the quintessential demonstration of his complaint, an example of white writing against a yellow background (Figure 1).

He was kind enough to leave this with me so I could test contrast sensitivity on glaucoma patients. I thanked him and told him I would brush up on the topic. He said he will continue to self-monitor the disparity of contrast sensitivity between OD and OS and let me know if there is improvement in the future.

A pertinent negative finding to note is that this patient does not have a cataract in either eye (a potential lurking variable in patients for whom contrast sensitivity is a concern).

His BCVA is normal and symmetrical, and his cornea, aqueous, and vitreous humor are unremarkable.

The effect of glaucoma on contrast sensitivity is well documented.1-4 This parameter of visual function is related to numerous activities of daily living.5 Contrast sensitivity has been postulated to be a likely culprit of visual complaints in glaucoma patients with good visual acuity.6 Indeed, contrast sensitivity is an often-overlooked aspect of one’s visual quality of life. 

I often talk about contrast sensitivity with patients with cataracts, but I am going to do a better job of addressing this aspect of glaucoma, as well. I am equipped to test for it, and I am going to do so more often after having this conversation with my patient. I am also going to rework how I explain visual function in glaucoma to include something about contrast sensitivity.

 Richman J, Lorenzana LL, Lankaranian D, Dugar J, Mayer J, Wizov SS, Spaeth GL. Importance of visual acuity and contrast sensitivity in patients with glaucoma. 

 Ross JE, Bron AJ, Clarke DD. Contrast sensitivity and visual disability in chronic simple glaucoma. 

 Atkin A, Bodis-Wollner I, Wolkstein M, Moss A, Podos SM. Abnormalities of central contrast sensitivity in glaucoma. 

 Sample PA, Juang PS, Weinreb RN. Isolating the effects of primary open-angle glaucoma on the contrast sensitivity function. 

 Liu J, McAnany JJ, Wilensky JT, Aref AA, Vajaranant TS. M&S Smart System contrast sensitivity measurements compared to standard visual function measurements in primary open angle glaucoma patients. 

 Hawkins AS, Szlyk JP, Ardickas Z, Alexander KR, Wilensky JT. Comparison of contrast sensitivity, visual acuity, and Humphrey visual field testing in patients with glaucoma. 

A comment from a patient prompts a doctor’s change in testing and discussion.

Contrast sensitivity manifests in glaucoma patient with no cataracts

 Chief Optometric Editor, Ben Casella, OD, FAAO sits down with Editor in Chief Gretchyn M. Bailey, NCLC, FAAO to discuss the final phase of his practice's reintegration to normalcy after COVID-19.

Related: Dr. Ben Casella checks in Week 10 of COVID-19

Author | Benjamin P. Casella, OD, FAAO

Articles

Virtual conferences not filling the gap of in-person meetings

Patients, contact lenses, and the internet

Contrast sensitivity manifests in glaucoma patient with no cataracts

Dr. Ben Casella COVID-19 wrap-up