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Dana Shannon, OD, FAAO, shares pearls on spotting red flags in need of referral and enhancing patient care with follow-up compliance.

NOA Midwestern Symposium 2025: Knowing when to refer when post-trabeculectomy complications arise

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The report outlines views and behaviors of US adults regarding vision correction, managed vision care, eye examinations, prescription eyewear, reading glasses, and nonprescription sunglasses.

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3 mental heath conditions to watch for in patients

Dana Shannon, OD, FAAO, detailed a lecture she gave at the NOA Midwestern Symposium earlier this month.

NOA Midwestern Symposium 2025: Hypotony-related complication post-trabeculectomy

Dana Shannon, OD, FAAO, detailed a presentation from the 2025 Midwestern Symposium, sponsored by the National Optometric Association and cohosted by Indiana University, on April 5. Shannon focused on hypotony, specifically its relationship to trabeculectomy, a surgical procedure designed to lower eye pressure in patients with glaucoma. Trabeculectomy creates a new drainage pathway in the eye by making an incision in the conjunctiva and sclera, establishing a bleb (fluid collection area) typically located at 12 o'clock underneath the eyelid. While intended to manage eye pressure, this procedure can lead to various complications, particularly hypotony. Hypotony is defined both statistically (eye pressure below 6.5 mm Hg) and clinically, with the clinical definition being more significant for optometrists. Shannon outlined several potential complications associated with low eye pressure:

Corneal changes: Scleral collapse can cause corneal edema and endothelial compromise.

Choroidal effusions: Fluid-filled dome-shaped packs develop in the suprachoroidal space, potentially mimicking retinal detachment.

Hypotony maculopathy: The choroid and retina can wrinkle and buckle, detectable through OCT scans.

Lens nutrient disruption: Reduced aqueous humor can lead to cataract development.

Optic disc edema: More likely in patients with intact nerve fibers.

Anterior chamber shallowing: Potential flattening that could cause the cornea to touch the iris or lens.

Notably, Shannon emphasized that these complications can occur years after the initial surgery, not just in the immediate postoperative period. Two case studies highlighted hypotony developing 4 to 5 years after trabeculectomy, underscoring the importance of long-term monitoring. For optometrists, Shannon recommended several management strategies, including the use of diagnostic tools like OCT scans and retinal photos, employing bandage contact lenses to manage bleb leaks, using cycloplegic drops and topical steroids to manage choroidal effusions, conducting thorough, extended examinations of posttrabeculectomy patients, and promptly referring patients to ophthalmologists when complications are detected.

The ultimate goal is to help optometrists recognize and address subtle clinical findings, ensuring comprehensive patient care and preventing potential long-term eye health complications.

NOA Midwestern Symposium 2025: Hypotony-related complications post trabeculectomy

CRU 2025 provided the latest insights regarding glaucoma, dry eye disease, retina, myopia, neurotrophic keratitis, and keratoconus.

CRU 2025: What eye care providers took home that is current, relevant, and useful

The rustic landscape of Napa Valley hosted CRU 2025, which allowed optometrists and ophthalmologists to learn the latest in glaucoma, retina, and more. In between wine tastings, eye care providers had the chance to reflect on what they are taking back to their practices that is current, relevant, and useful. 

Melissa Tawa, OD, FAAO, highlighted what she learned about inherited retinal diseases at the conference. "I really learned a lot from Dr [Rachelle] Lin's lecture about the changes in inherited retinal diseases and the available gene therapies that we have, and also what's coming down the pipeline in terms of treatment for these patients who were otherwise told that there was nothing available to them, novel mechanisms of getting cells into the eyes that could create enzymes that our bodies are lacking," Tawa said. "It is a really exciting time for me, and it's so wonderful to be at this type of convention where we're learning from experts in all different areas of optometry, from inherited retinal diseases to glaucoma, but also keratoconus management, which is not something that I am focused on, but I get to come to this conference and learn from experts in the states."

Deborah Ristvedt, DO, has gained a revitalized outlook on glaucoma surgery in her commitment to staying relevant with changing treatment options. "There's so many things now that I continue to push myself and challenge myself as a surgeon," she said. "I think the biggest thing is staying relevant with how glaucoma is changing right now. I wish we had an answer to why some people develop glaucoma and others don't, or why some people progress and others don't. That's where minimally invasive glaucoma surgery, as well as procedural pharmaceuticals, have totally changed my practice and my mindset to say, 'We know that we can control pressure. Why not doing do it earlier in the disease?' 

"Thank you so much for having me at CRU," Ristvedt continued. "It's been such a fun opportunity to be amongst my colleagues who are constantly up to date and looking for useful information."

Other ODs also found value in the insights they gained from MDs at CRU. Cecelia Koetting, OD, FAAO, DipABO; and Melissa Barnett, OD, FAAO, FSLS, FBCLA, took the importance of comanagement and collaborative care back to their practices.

"It's CRU; this is its fourth year. I've been here every year," Koetting said. "This is my first year here as a speaker. I'm really excited to be a part of it, but the reason I've kept coming back, and the reason I came to begin with, was because CRU: current, relevant, useful. I find that every time I leave here, I'm learning new things. Yes, I educate, but I'm also learning always. And the big thing here, especially just sitting on the panel with a couple of ophthalmologists recently, just listening and hearing what they have to say as far as their take on neurotrophic keratitis, the different treatments, and then just putting a spin on my thought for things as well."

"What I'm taking back from CRU, which is current, relevant, and useful, is the importance of collaborative care," Barnett said. "So collaborative care, we're talking about patients who have keratoconus, those who have neurotrophic keratitis, and the importance of great communication in order to be best care for our patients."

Conference

At CRU 2025, Dr. Rachelle Lin and Dr. Quan Dong Nguyen reviewed the latest advancements in retinal care.

Retina updates with Dr. Rachelle Lin

At CRU Eye Symposium 2025, Rachelle Lin, OD, MS, FAAO, and Quan Đông Nguyễn, MD, MSc, presented a “Retina Roundup” presentation. The meeting was held from March 28-30, 2025 in Napa, California. The duo discussed new and proven treatment options for neovascular age-related macular degeneration (nAMD), geographic atrophy (GA), and diabetic retinopathy (DR). Here, Lin shares a few of her thoughts and takeaways from the discussion.

The below transcript has been lightly edited for clarity.

Hi, I'm Dr Rachelle Lin. I'm an optometrist and associate professor at the Southern California College of Optometry at Marshall B. Ketchum University. So we had a great retina updates talk. It was myself as well as Dr [Quan Đông] Nguyễn, who is an ophthalmologist and professor at Stanford University. Some updates from the talk were specifically for diabetic macular edema, treatments for that geographic atrophy and then neovascular AMD. We also went over some new research, as well as an update on the new medication that has been approved for macula telangiectasia type 2, also known as MacTel for short. So with MacTel type 2 and the new treatment that's available, it's very exciting, because this is the first and only treatment available for this condition, and even though most patients with this condition tend to have slight reductions in visual acuity. It's not as serious as some other retinal conditions, if we look at the best corrected visual acuities.

However, it's absolutely debilitating for patients, if it's affecting their central or pericentral vision. So it's something that we definitely want to now be more aware of and make sure that we're referring to our retina surgeons for treatment.

Well, a lot of what I do in low vision rehabilitation is work with patients with AMD, of course, as well as patients with inherited retinal dystrophies. We have our first gene therapy, FDA approved for inherited retinal dystrophy in 2017 and we've really been waiting for new treatments to come out. So any new treatments that can come out for inherited retinal dystrophies, that's going to be really exciting for that community.

I think for optometrists, because there's always so many more new medications coming out for the treatment of diabetic retinopathy and AMD and now a macular telangiectasia, I think we just have to be up to date on what's available and make sure that patients are getting referred for that as soon as possible. With regards to all of those conditions, as well as IRDs, inherited retinal dystrophies, we need to make sure that those patients are also getting those referrals to low vision rehabilitation simultaneously. Because these treatments, most of them, some of them do improve vision, but a lot of them, for example, the ones for geographic atrophy, they're just meant to slow down progression. So these patients, even after treatment, they're still going to have visual impairment. They're still going to have difficulties with their activities of daily living. We want to make sure that even while they're getting this treatment, they're able to successfully and happily live their lives and do the things that they want to do.

Rachelle Lin, OD, MS, FAAO, and Quan Đông Nguyễn, MD, MSc, lectured on retinal updates at CRU 2025. The pair also covered the power of a low vision referral for patients with retinal disease.

CRU 2025: The latest and greatest in retina

Melissa Barnett, OD, FAAO, FSLS, FBCLA, gave 2 presentations alongside other ODs and MDs at CRU 2025. 

CRU 2025: Exploring neurotrophic keratitis cases with Dr Melissa Barnett

In their presentation "Neurotrophic Keratitis: Multidisciplinary Approaches to Enhance Patient Outcomes," Melissa Barnett, OD, FAAO, FSLS, FBCLA; Cecelia Koetting, OD, FAAO, DipABO; Jennifer Li, MD; and Quan Đông Nguyễn, MD, MSc, emphasized the importance of corneal sensitivity testing before any anesthetics, considering various conditions like preservatives, artificial tears, and eye surgeries that can lead to neurotrophic keratitis (NK). Treatment options include bandage lenses, sclera lenses, topical nerve growth factor, medications, occlusion, and corneal neurotization. 

Barnett and Li also gave the presentation "Restoring Connections in Neurotrophic Keratitis," which covered patient cases, stressing the need for early diagnosis and treatment to preserve vision. Patients were advised to monitor for symptoms like redness, pain, and loss of vision and to seek immediate medical attention. The sessions were interactive and appreciated by both in-person and virtual audiences.

Editor's note: The below transcript has been lightly edited for clarity.

We had 2 lectures on neurotropic keratitis. So the first lecture really went into the diagnosis of NK. So the importance of checking corneal sensitivity, checking corneal sensitivity in all quadrants of the cornea, checking the eye that is not affected, the unaffected eye first, and then the affected eye, and checking corneal sensitivity prior to any topical anesthetics, for example, that would numb the cornea. We spoke about all the different conditions that are associated with NK, those like preservatives and artificial tears, any topical anesthetic drugs used chronically, any sort of history of eye surgery. So it could be cataract surgery done many years ago, retinal surgery, glaucoma surgery, refractive surgery, all sorts of autoimmune conditions, multiple sclerosis, diabetes and, of course, herpetic disease. So there are many, many conditions associated with NK. So when you have a patient, and if you're unsure, maybe it's dry eye, maybe it's NK, checking coronal sensitivity is key. We also covered all sorts of treatment options for NK, so those including bandage lenses, scleral lenses, topical nerve growth factor medications for NK, punctal occlusion, and even corneal neurotization. So many different options to treat NK, important to diagnose early, treat patients, and really save their vision.

In the second lecture, we covered all sorts of different patient cases ranging from mild to quite severe, and the complications that can occur with NK. So since patients cannot feel their corneas, informing them to look in the mirror or see if their eyes are red, have someone look at them to see if they have any redness, any pain, loss of vision, and then to come back and giving appropriate information on how to contact you anytime, day or night. So these sessions have been great, very interactive. We appreciate the in-person and the virtual audiences and all the questions that are being asked in the interaction from the sessions.

Deborah Ristvedt, DO, and Melissa Tawa, OD, FAAO, encouraged optometrists and ophthalmologists alike to rethink drops as the first-line therapy for patients with glaucoma in their CRU 2025 presentation “MIGS and DIGS: Glaucoma Devices and Surgery.”

 Presented on March 30 in Napa, California, the presentation overviewed the importance of interventional glaucoma, which prioritizes a proactive vs a reactive approach to prevent disease progression by utilizing early procedural intervention.

“It's a lot for changing the whole algorithm period on how we're treating glaucoma, and we can't do it without collaboration with all of us getting on board to help patients and to improve quality of life,” Ristvedt said.

She noted that a significant challenge that comes with the traditional approach to glaucoma treatment is adherence. Research shows that more than 90% of patients are nonadherent regarding medication use, with about 50% of patients purposely discontinuing their medication(s) within 6 months of initial prescription.

“Let’s remember what drops do long term,” Ristvedt said. “They cause hyperemia, they cause fat atrophy, ocular surface disease. Some can cause pigmentary changes or iris color changes. So are they as benign as we think they are? Medications work, I love medications, but are we taking them in the right manner?”

Ristvedt also noted that stacking drops increases dry eye symptoms in patients, which can also predict nonadherence. In a study evaluating 19,665 patients with glaucoma, dry eye disease prevalence increased from 51% to 60% between taking 1 and 3 drops for glaucoma treatment.

Now, Ristvedt recommended that laser procedures like selective laser trabeculoplasty for patients with ocular hypertension and mild and moderate glaucoma should be offered as first-line therapy. Procedural pharmaceuticals can then be recommended for additional treatment, followed by tissue-sparing minimally invasively glaucoma surgery (MIGS), such as trabecular bypass or canaloplasty. Ristvedt also noted that the future glaucoma treatment algorithm may see topical medications used as a supplement to procedural-based intervention. In the case of “bridge therapy,” drops are to be used as a temporary treatment while a patient waits for procedural intervention.

Ristvedt also stated that through an interventional glaucoma approach, she is also able to deploy the Family, Occupation, Recreation, Dreams (FORD) method of individualizing care. “I really try to cater my [patient] education to the things that I found out about that patient,” she said. “What is it to them that is really important about their vision, about their life? Try to play out that aspect to … get them on board.”

Ristvedt D, Tawa M. MIGS and DIGS: Glaucoma Devices and Surgery. Presented at: CRU 2025; March 28-30; Napa California.

Nordstrom BL, Friedman DS, Mazaffari E, Quigley H, Walker AM. Persistence and adherence with topical glaucoma therapy. 

Erb C, Gast U, Schremmer D. German register for glaucoma patients with dry eye: I. Basic outcome with respect to dry eye. 

2008;246:1593-1601. doi:10.1007/s00417-008-0881-9

Deborah Ristvedt, DO, and Melissa Tawa, OD, FAAO, detail the benefits of interventional glaucoma during their CRU 2025 presentation.

CRU 2025: Rethinking first-line glaucoma therapy

Dr. Rachelle Lin highlights the urgent need for early intervention in childhood myopia, discusses associated retinal and systemic risks, and emphasizes the long-term impact of axial length control in reducing serious ocular complications.

CRU 2025: Managing myopia today to prevent vision loss tomorrow

At the CRU Eye Symposium, Rachelle Lin, OD, FAAO, associate professor at the Southern California College of Optometry at Marshall B. Ketchum University, joined Andrew S. Morgenstern, OD, FAAO, FNAP, to deliver a comprehensive overview of both clinical guidelines and long-term ocular risks associated with 

. The CRU Eye Symposium took place March 28 to 30, 2025, in Napa Valley, California.

Morgenstern opened the session by highlighting the updated American Optometric Association (AOA) guidelines on myopia, which he codeveloped with a team of experts. These guidelines, now available on the AOA website, provide structured recommendations to help clinicians implement effective myopia management strategies in practice.

Lin’s portion of the talk focused on the retinal and systemic implications of myopia. She emphasized that even low levels of myopia can significantly elevate the risk of sight-threatening conditions such as myopic macular degeneration, retinal detachment, posterior subcapsular (PSC) cataracts, and open-angle glaucoma. These risks escalate with increasing myopic severity, underscoring the critical importance of early intervention and axial length control.

A key topic in Lin’s presentation was identifying and managing pediatric patients who are trending toward high myopia. She referenced recent studies indicating that children under age 10 who are projected to reach -6.00 D or higher—whether spherical or cylindrical—should be considered high-risk. These patients may face not only ocular complications but also potential systemic associations, including inherited retinal dystrophies, connective tissue disorders, and complications from prematurity, such as retinopathy of prematurity. Such complex profiles require optometrists to maintain a high index of suspicion and consider multidisciplinary referrals when appropriate.

Lin concluded by acknowledging the vital work of optometrists who are deeply engaged in myopia management. While preventing future pathology often goes unrecognized by patients, she emphasized that the long-term impact is profound. As a low-vision practitioner, she frequently sees the devastating outcomes of unmanaged myopia and affirmed that effective myopia control, especially in managing axial elongation, plays a crucial role in preserving vision and quality of life.

Dr Rachelle Lin highlights the urgent need for early intervention in childhood myopia, discusses associated retinal and systemic risks, and emphasizes the long-term impact of axial length control in reducing serious ocular complications.

Fraser C. Horn, OD, FAAO

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