Taking out a loan is a major financial decision. Whether you own a medical business or are an employed physician, you may need financing for continuing education courses, investing in technology and equipment, funding new initiatives, or growth and expansion. Not all lenders or loans are created equal. Asking the right questions in advance can help you find the best solution.

One of the biggest disadvantages with many loans is that they can be challenging to obtain unless you have valuable collateral. Although some lenders require it, others do not, enabling you to safeguard what you own. You worked incredibly hard to acquire your assets—are you really willing to risk them?

2. WILL THIS LOAN SHOW UP ON MY CREDIT REPORT?

Applying for a loan could put your credit score at risk. During the application process, some lenders will conduct a hard credit pull, which provides a full report of your credit history and credit score. This type of inquiry can hurt your credit score and stay on your report for up to 2 years. Other lenders perform a soft credit pull, which neither affects your credit score nor ends up on your report.

3. DO YOU HAVE EXPERIENCE WORKING WITH OTHERS IN MY INDUSTRY?

Physicians have unique needs, so partnering with a lender experienced in the industry matters. Some lenders have a process that does not differentiate a physician from any other borrower, whereas others specialize in working with physicians or with customers whose profiles are similar.

Each lender or loan is different. Understanding the fundamental components can help you confidently evaluate loan quality and overall experience. By examining a lender’s expectations about timelines, deliverables, and expertise, you will decrease the risk of surprises.

4. HOW LONG DO I HAVE TO REPAY WHAT I OWE?

The length of your loan dictates how much you will pay each month. Longer terms typically mean your monthly payment will be lower and more manageable. If you need more monthly cash flow, look for a loan that offers longer payback terms.

Loans will have a fixed interest rate or variable rate. This dictates whether the rate will stay consistent for its entire term or will fluctuate based on market conditions. With a fixed rate, you will always know what your interest costs will be, making your loan payments and monthly budget more predictable.

6. HOW SOON DO YOU MAKE APPROVAL DECISIONS?

Establishing the approval timeline can help you anticipate whether the process will take days, weeks, or months. This is critical if you urgently need funds.

7. HOW QUICKLY DO YOU FUND UPON APPROVAL?

Some lenders can take weeks or months to deposit funds into your account after loan approval, whereas others can do so in days. If you need funds by a certain time, ensure the lender’s timeline aligns with yours.

As a physician, you deal with a large amount of paperwork. Your time is valuable, so find out how much may be required for the application process. Knowing in advance what paperwork you need to provide can help you estimate the time you will need to commit.

Articles

Put lenders to the test: Before taking out a loan, ask these 8 essential questions

For 1 week out of the year, my hometown of Augusta, Georgia, turns into an international sports spectacle. That week is the first full week of April when the Masters Tournament occurs. Many of the best golfers from around the world compete in this first of 4 Majors played each year.

Well, that’s true most of the time. The tournament was not held for several years in the 1940s because of World War II, and last year, for obvious reasons the Masters was held in November without patrons in attendance. They pulled it off, and their television coverage was second only to being in attendance.

Global pandemic aside, last April felt strange and quiet without the additional tens of thousands of people pouring into our community. The 2021 Masters Tournament will be held again in the first week of April with limited patrons in attendance. It’s certainly a trend in the direction of some sense of normalcy—a sense of normalcy that we are all striving to attain.

Why am I writing about golf? Well, for starters, I’m an avid golf fan. Secondly, I think this is an accurate juxtaposition with optometry meetings because we have another event in April 2021 (one I will be attending): SECO International. SECO will be held as a hybrid meeting of sorts. By that I mean there will be a significant virtual part of the meeting. In fact, at least 1 of my courses is slated to be broadcast online while I give it in person. It’s this type of thinking that will bring us all “together” sooner.

The ODs I have spoken with who plan to attend will be fully vaccinated by the time the end of April rolls around. Additionally, the Georgia World Congress Center is big—really, really big. It seems as though our new normal will be, for the time being, a consummation of the old and the new. Will we ever be again neck and neck in the hallways, lecture halls, restaurants, and bars at our meetings? Of course. Will that happen tomorrow or in the next week? Of course not. However, we are trending in the right direction.

I urge everyone to stay safe and continue to follow Centers for Disease Control and Prevention guidelines as they evolve. In addition, I urge everyone who can to get their coronavirus disease 2019 vaccination. I am not a viral epidemiologist, but the more people get vaccinated, the better chance we will have to build toward a sense of how things were. Remember those times?

Stay safe, and if you are attending SECO, flag me down for a safe and socially distanced air high five

Where golf and optometry meetings intersect

has launched the KDB Glide device for advanced excisional goniotomy treatment of glaucoma. KDB Glide was registered with the FDA in October 2020 and is now commercially available to ophthalmic surgeons across the United States.

The device’s proprietary ramp facilitates lifting and stretching the trabecular meshwork, while the dual blades penetrate the trabecular meshwork and create parallel incisions for precise, controlled excision, according to the company. New features of a rounded heel, tapered sides, and smaller footplate deliver optimal interface with the canal of Schlemm, permitting precise excision, even in variable anatomy.

The Centre for Ocular Research & Education (CORE) 

has published issue number 58 of its free online education magazine, 

. This edition launches a new case record feature that shares research-relevant yet patient-centered insights as experienced by practicing eye care professionals.

Along with other content, Andrea Lasby reviews a recent publication that investigates the potential for meibomian gland changes to distinguish dry eye from normal eyes in young adult wearers.

Plus, Andrew Pucker’s editorial addresses commonly asked questions about meibomian gland dysfunction, weighing the evidence and clinical implications for each.

provides a global platform for unbiased clinical insights based in current research. The publication receives support from the educational arms of Alcon, CooperVision, and Johnson & Johnson Vision.

announced that pharmacy benefit manager Express Scripts has added Eysuvis (loteprednol etabonate) 0.25% to its National Preferred, Basic, and High Performance Formularies, effective February 5, 2021.

Eysuvis was approved in October 2020 for the short-term treatment of the signs and symptoms of dry eye disease and became commercially available in the United States in January 2021.

CooperVision has expanded the range of Biofinity XR 

toric contact lenses stocked at its global distribution center in New York. The following parameter ranges are now available to ship next day to customers:

Although Biofinity XR toric remains a made-to-order product for many prescriptions, the expanded inventories will speed access.

CooperVision is also stocking trial lenses in the same parameters. Orders placed directly through CooperVision and select authorized distributors will ship the following business day.

Biofinity XR toric lenses are available in sphere powers from +10.00 D to -10.00 D (0.50 D steps after ±6.00 D), with cylinder powers from -2.75 D to -5.75 D (0.50 D steps) and axes of 5˚ to 180˚ in 5˚ steps.

from 4 phase 3 studies of its investigational bispecific antibody faricimab showing it allowed a significant number of patients to go up to 4 months between treatments for 2 common causes of vision loss, diabetic macular edema and neovascular age-related macular degeneration.

According to the company, key findings from all 4 studies include:

Approximately half of people receiving faricimab could be treated every 4 months in the first year while achieving similar vision gains compared with aflibercept given every 2 months.

Approximately 75% of people receiving faricimab in the studies could be treated every 3 months or longer in the first year.

Faricimab demonstrated rapid and consistent improvements in anatomical outcomes including central subfield thickness across all studies.

Faricimab was generally well tolerated, with no new or unexpected safety signals identified.

Visionary Optics launched its VibrantVue 

product line in collaboration with ABB Optical Group.

VibrantVue Contact Lens Hand Prep is the only product marketed as a “no rinse” hand cleanser specifically for all soft and gas permeable contact lens wearers. It is available in 8-oz and 2-oz sizes.

VibrantVue Scleral Saline solution is the most recently FDA-approved scleral filling solution. It comes in 100-count, single-use 5-mm vials. The company is offering samples for eye care practitioners to provide to their new scleral lens patients.

VibrantVue Lid and Lash Care products include a hydrogel formulation for in-office treatment and liquid spray for at-home maintenance by patients. The 3-oz bottles, on average, will last a patient 3 months.

shares that US phase 3 pivotal trial results for its next-generation corneal cross-linking iLink therapy for the treatment of keratoconus, called Epi-on, met the study’s primary efficacy end point. Epi-on demonstrated a statistically significant improvement in maximum corneal curvature (Kmax) at 6 months from baseline between the treated and placebo-controlled arms.

Epi-on is designed to reduce procedure times, improve patient comfort, and shorten recovery time, according to the company. It utilizes a proprietary, novel drug formulation to penetrate the epithelial layer of the cornea, a stronger UV-A irradiation protocol, and the ability to deliver increased levels of supplemental oxygen to enhance cross-linking. If approved, the company anticipates Epi-on would be the first FDA-approved, noninvasive corneal cross-linking therapy that does not require removal of the epithelium.

The phase 3 trial results are expected to support Glaukos’ NDA submission in 2022, and the company is targeting FDA approval for Epi-on in 2023.

announced that the FDA has accepted its investigational new drug (IND) application to proceed with the clinical development program for Brimochol. A proprietary combination of carbachol and brimonidine tartrate, Brimochol is designed to be a once-daily eye drop to correct for the loss of near vision associated with presbyopia. Under this IND, Visus will immediately initiate its planned phase 2 clinical trial in the United States.

Six clinical studies have been conducted in more than 200 patients to evaluate the safety and efficacy of Brimochol, according to the company. These studies demonstrated an average near visual acuity improvement of 5 lines or more on the Jaeger eye chart, with a minimum duration of 8 hours post dose.

introduced Acuvue Oasys Multifocal Contact Lenses With Pupil Optimized Design for patients with presbyopia. The new lens is available in the United States and Canada. Acuvue Oasys Multifocal is built on the Acuvue Oasys 2-Week platform. It includes the Pupil Optimized Design technology used in 1-Day Acuvue Moist Multifocal.

Acuvue Oasys Multifocal combines 3 technologies—Pupil Optimized Design, Hybrid Back Curve Technology, and a proprietary embedded wetting agent—to create a lens designed for performance and comfort, according to the company.

(SUNY) College of Optometry has received a $30,000 gift from CooperVision. In recognition, SUNY Optometry named a specialized myopia examination room located in the college’s University Eye Center in the company’s honor.

In 2020, CooperVision introduced MiSight 1 day, the only FDA-approved daily soft contact lens designed to slow the progression of myopia in children aged 8 to 12 years. The company’s interest in myopia is a shared area of expertise with SUNY Optometry that offers a myopia management clinic for pediatric patients and adults.

shared its 2021 Best Practices honorees. Now in its sixth year, CooperVision’s Best Practices program highlights optometric practices in the US that advance the profession through innovation, industry leadership, and exceptional patient experience. The new honorees join a group of 50 other optometry practices that have supported the initiative.

Bellaire Family Eye Care in Bellaire, Texas

Broad View Eye Center in Broadview Heights, Ohio

Carbon Valley Eye Care in Frederick, Colorado

Clearvue Vision Center in Kent, Washington

The other reassures patients of common steps being taken to ensure safety during in-office exams. Both are available for download from COVIDeyefacts.org and may be used at no cost if the content is not altered.

of lab growth. On March 15, 1996, Essilor acquired 3 lab groups—Omega, Southern Optical, and Duffen—to accelerate growth for independent eye care professionals, laboratories, and the industry as a whole.

The acquisition prompted Essilor to create a network of labs across the country that offers value for customers, according to the company. Today, Essilor creates access to innovation and elevates patient care for its customers through several optical labs: Essilor Labs, which delivers consistent quality on time; Partner Labs, which benefits from the partnership of Essilor while maintaining their own qualities and strengths; and Independent Labs, which distributes and produces Essilor’s lens innovations.

says it has entered a partnership with Plastic Bank, which makes its clariti 1 day family the first net plastic-neutral contact lenses.

Plastic Bank builds ethical recycling ecosystems in coastal communities, reprocessing the materials for reintroduction into the global supply chain. Collectors receive a premium for the materials they collect, helping them provide basic family necessities such as groceries, cooking fuel, school tuition, and health insurance. For every box of clariti 1 day distributed in the US, CooperVision funds the collection, processing, and reuse of general plastic waste that is equal to the weight of the plastic in clariti 1 day lenses and packaging.

A recent survey commissioned by CooperVision revealed that 93% of US eye care professionals said that keeping plastic out of the oceans is important to them, and 84% agree that manufacturers need to take responsibility for the waste they create.

News updates April 2021

of visual impairment and irreversible blindness worldwide.

 Primary open-angle glaucoma (POAG) accounts for 74% of all cases. There were approximately 57.5 million cases globally in 2015,

 and glaucoma is projected to affect 65.5 million individuals by 2021.

 Intraocular pressure (IOP) is the sole modifiable risk factor.

 It has been well documented that a 20% to 30% decrease in IOP can consistently reduce the risk and trajectory of progression.

Glaucoma is diagnosed when a correlation exists between structural and functional findings in the setting of relevant risk factors.

 Structural findings include optic disc cupping with evidence of nerve fiber layer infarction. Functional findings include relative perimetric losses (scotomata) directly attributable to areas of damaged axons (of ganglion cells) identified through structural mapping. Circumstantial risk factors include raised IOP (>24 mm Hg), increased age, family history of glaucoma, decreased central corneal thickness (<510 μm), female sex, and the presence of comorbidities such as migraine headache, sleep apnea, coagulopathy, hypertension, diabetes, and alpha-beta zone atrophy.

Increased IOP results from poor aqueous humor egress (common) or aqueous humor over production (rare).

 Because altering genetic markers, blood flow, vascular pressure, and heart rate is not possible without profound risks, IOP is the only modifiable risk factor. Lowering the IOP via topical or oral medications or surgical procedures is the only means of arresting the disease’s progression.

The word “myth” is derived from the Greek word 

.15 It means “a widely held but false belief; a misrepresentation of the truth and exaggerated conception; an unfounded notion.”

 Whether these “stories” occur because of misinterpreted data; loosely supported, perpetuated anecdotes (the whisper-down-the-lane effect); held traditions; or misguided beliefs, when encountered in medicine, they should be exposed, discussed, and debated. Sometimes the narrative, albeit not generally believed, is true with individuals forming erroneous conclusions.

television series attempted to test unusual claims for validity. When a myth was proved to be a misrepresentation of the truth, it was “busted.” In the case of the claim being possible, the myth was deemed plausible or supported.

Here, we provide evidence along with debates for 5 “myths” often discussed regarding glaucoma management.

A topical beta-blocker is a good choice for patients with normal tension glaucoma (NTG).

Three etiologies, sometimes 1 alone and sometimes multiple etiologies in combination, create the pathology of glaucoma. They are 

Biomechanical mechanism (pressure dependent; raised IOP creates laminar bowing, crushing the axons that pass through it while also increasing resistance to nerve tissue perfusion)

Vascular mechanism (non–pressure dependent; vascular dysregulation and poor oxygenation create nerve ischemia resulting in segmental destruction)

Genetic mechanism (signaled apoptosis of axons of ganglion cells results in segmental loss)

The only modifiable risk factor for reducing glaucomatous progression is IOP lowering.

 Current guidelines for initial intervention suggest medical therapy with topical ocular hypotensives or selective laser trabeculoplasty (SLT).

For cases in which the surgical option is undesirable, topical medications are required. In most instances, prostaglandin analogue (PGA) topical medications are selected first because of their efficacy and ease of use. Because topical beta-blocker medications can be absorbed by the conjunctiva, producing sympatholytic effects on the heart and lungs (decreased heart rate, bronchoconstriction), clinicians may be apprehensive to use them as a primary or adjunctive therapy. Some are reticent to use the agents in cases of NTG for fear of worsening the disease secondary to the possibility of reduced perfusion.

Two separate studies evaluated pulse rates and IOP lowering in patients placed on the topical beta-blocking preparation timolol.

 The reports demonstrated statistically significant reductions in the pulse rates of both groups.

 During sleep, an individual’s pulse reduces, naturally lowering perfusion to the optic nerve. Adding an agent capable of lowering the heart rate over a 24-hour period can further lower perfusion. In combination with the diurnal fluctuation of IOP (highest during sleep), anything that reduces perfusion has the potential to worsen glaucomatous disease.

Timolol is considered the gold standard for topical IOP lowering. It is a first-line topical anti-glaucoma agent and an excellent supplemental agent when surgical or topical treatment has not provided the optimal target pressure. Because the agent has the capability to induce bronchoconstriction and pulse lowering, it should not be a first choice in cases with lung concerns, such as asthma or chronic obstructive pulmonary disease, or in cases of NTG.

 The most popular first-line topical agents are PGA medications.

Today, with the data provided by the LIGHT study, SLT is a legitimate first option. Topical beta-blockers are generally considered the very last line or not an option at all for NTG cases because of the central nervous system, cardiac, and respiratory adverse effects they may produce; safer topical and surgical alternatives exist.

Brimonidine provides neuroprotection against glaucomatous damage.

Brimonidine tartrate is a sympathomimetic alpha agonist. It reduces IOP by enabling the trabecular meshwork and uveoscleral tissues to filter aqueous humor at a faster rate and by suppressing production of aqueous humor.

 Several studies have demonstrated that the pharmaceutical has a reparative/regenerative effect on optic nerve tissue.

Investigators of another study concluded the compound was capable of reducing ganglion-cell death at a far greater rate than timolol.

 However, some unanswered questions of that study include the following:

Did the brimonidine cohort perform better because of neuroprotection?

Did it perform better because of its dual mechanism of action (IOP suppression and facilitation of uveoscleral/trabecular meshwork outflow)?

Did it perform better because it provided better 24-hour IOP-lowering coverage?

Did the timolol group suffer secondary to reduced perfusion at the nerve in the setting of reduced IOP suppression during sleep?

Investigators have demonstrated in the laboratory that crushed animal optic nerves regenerate when 2 nM of brimonidine was physically applied to the tissue.

Whether these data can be applied to optic nerves sustaining glaucomatous damage in living persons remains in question.

Experimental data have demonstrated that brimonidine may be able to stimulate increased neural activity in the laboratory.20-24 Scientists were able to locate receptors in the retina and optic nerve capable of binding with the compound and making positive use of it. Results of laboratory experiments show that concentrations of as little as 2 nM can produce the beneficial effects. Recent work 

has revealed that when brimonidine is applied to the eye, up to 200 nM can be distributed into the vitreous humor, making it available for this sort of rehabilitation. Further research will determine whether this type of therapy should be considered for all patients with glaucoma, both controlled and in need of control.

With scientific evidence supporting the benefit of neuroprotection added to the known capability of IOP lowering, practitioners should consider brimonidine an excellent first choice in cases of NTG in which pressure reduction is required without lowering vascular perfusion. It would also be an excellent second-line choice for other cases of glaucoma requiring deeper IOP suppression.21-23

If research can prove brimonidine plays a direct role in nerve preservation or repair, IOP will no longer be the only modifiable risk factor. Further, if this is the case, ophthalmologic applications besides glaucoma may be on the horizon. Finally, although there is no detriment to using the medication and evidence has demonstrated a neuroprotective element to its use, clearly it does not provide healing that outpaces the rate of loss.

PGA preparations increase risk of macular edema after cataract surgery and in cases of uveitis.

PGA preparations are efficacious at lowering IOP. They work primarily by increasing uveoscleral outflow.25 Uveoscleral outflow accounts for approximately 10% to 20% of aqueous humor outflow under normal conditions. The traditional pathway of the trabecular meshwork accounts for 80% of aqueous humor drainage.7,29 A single drop of PGA places approximately 1.5 μg of active agent into ocular circulation. Investigators have successfully measured the levels of PGA in the posterior segment and found penetration into the vitreous to be minimal.26-28,30

PGAs rarely produce macular edema. They should not be discontinued unless macular edema is detected or is non-remitting.

Although the mechanism is well understood and the literature is clear in describing this phenomenon, clinical data demonstrate that macular edema is generally not attributable to the use of PGAs.26-28,30 In cases in which macular edema was found after cataract surgery in the setting of concurrent PGA use, the most common contributing factor was the untimely withdrawal of the topical steroid (fast taper), according to one study.28 Further, multiple clinical trials have demonstrated that these agents neither have a high propensity to reactivate old ocular inflammations nor produce macular edema when used in cases with active ocular inflammation.26-28

PGAs lower IOP effectively and are easy to use. These agents create great stability for patients who require them. The literature does not encourage blind cessation following cataract surgery or discontinuation in the event of uveitis acquisition.26-28 The literature recommends that it is not unreasonable to continue use with successfully treated patients who have not realized any complications.

PGA preparations take too long to work to be considered for acute IOP lowering.

As mentioned, the prostaglandin class of medications works to increase the efficiency of the secondary aqueous outflow pathway (uveoscleral outflow pathway).7,25,29 To a lesser degree, PGAs also increase the traditional outflow pathway. The agents have 2 distinguishable ocular interactions26-28,31-33:

Long-term, improved extracellular matrix spacing over time with episcleral venous effects

In a head-to-head study, PGAs were compared with timolol for lowering IOP in cases of chronic 

angle closure glaucoma and found to be at least as effective as timolol as a monotherapy solution.33

Eye care practitioners absolutely can use these agents as part of their armamentarium for lowering acutely raised IOP.

Although practitioners should not judge the long-term maximum effect of PGAs for weeks, the agents have been documented in the literature and anecdotally (the authors’ experience) as having the ability to play a significant role in acute IOP reduction. Application may be considered for cases of poorly adherent open-angle glaucoma and cases of pupil block angle-closure glaucoma. PGAs have a role in lowering acutely elevated IOP from any cause. If measured head-to-head against topical apraclonidine and timolol, a topical PGA would not outperform them. However, because PGAs clearly can have a positive impact on IOP lowering with virtually no adverse effects, they should be considered as an excellent addition if required.26-28,31-33

The incidence of glaucoma will continue to rise. The more ammunition provided to the armamentarium of risk reduction, the better. All practitioners should seek to base clinical management algorithms on scientific platforms created by data supported by evidence-based documentation. Medical myths should be discussed, debated, and dispelled when detected so a clear and uncontroversial path of disease management can be advertised and maintained.

Quigley HA. New paradigms in the mechanisms and management of glaucoma. 

2005;19(12):1241- 1248. doi: 10.1038/sj.eye.6701746

Quigley HA, Broman AT. The number of people with glaucoma worldwide in 2010 and 2020. 

2006;90(3):262-267. doi: 10.1136/bjo.2005.081224

Tham YC, Li X, Wong TY, Quigley HA, Aung T, Cheng CY. Global prevalence of glaucoma and projections of glaucoma burden through 2040: a systematic review and meta-analysis. 

. 2014;121(11): 2081-2090. doi: 10.1016/j. ophtha.2014.05.013

Kapetanakis VV, Chan MP, Foster PJ, Cook DG, Owen CG, Rudnicka AR. Global variations and time trends in the prevalence of primary open angle glaucoma (POAG): a systematic review and meta-analysis. 

2016;100(1):86-93. doi: 10.1136/bjophthalmol-2015-307223

Weinreb RN, Aung T, Medeiros FA. The pathophysiology and treatment of glaucoma: a review. 

. 2014;311(18):1901- 1911. doi: 10.1001/jama.2014.3192

Janssen SF, Gorgels TG, Ramdas WD, et al. The vast complexity of primary open angle glaucoma: Disease genes, risks, molecular mechanisms and pathobiology. 

2013;37(11):31-67. doi: 10.1016/j. preteyeres.2013.09.001

Alm A, Nilsson SF. Uveoscleral outflow--a review. 

2009;88(4):760-768. doi: 10.1016/j.exer.2008.12.012

Brubaker, RF. Targeting outflow facility in glaucoma management. 

2003;48(suppl 1):S17-S20. doi: 10.1016/s0039-6257(03)00003-1

Stamer WD, Braakman ST, Zhou EH, et al. Biomechanics of Schlemm’s canal endothelium and intraocular pressure reduction. 

2015;44:86-98. doi: 10.1016/j. preteyeres.2014.08.002

. Goel M, Picciani RG, Lee RK, Bhattacharya SK. Aqueous humor dynamics: a review. 

2010;4(9):52- 59. doi: 10.2174/1874364101004010052

6th ed. Elsevier Butterworth- Heinemann; 2007:1-100.

. Bucolo C, Platania CBM, Drago F, et al. Novel therapeutics in glaucoma management. 

2018;16(7):978-992. doi: 10.2174/1570159X15666170915 142727

. Gazzard G, Konstantakopoulou E, Garway-Heath D, et. al. Selective laser trabeculoplasty versus drops for newly diagnosed ocular hypertension and glaucoma: the LiGHT RCT. 

2019;23(31):1-102. doi: 10.3310/ hta23310

. Myth. Merriam-Webster. Accessed March 10, 2021. https://www.merriam-webster.com/dictionary/myth

. Keller KE, Acott TS. The juxtacanalicular region of ocular trabecular meshwork: a tissue with a unique extracellular matrix and specialized function. 

. Brubaker RF. Introduction: three targets for glaucoma management. 

2003;48(suppl 1):S1-S2. doi: 10.1016/s0039-6257(03)00002-x

. Tattersall C, Vernon S, Singh R. Resting pulse rates in a glaucoma clinic: the effect of topical and systemic beta-blocker usage. 

. 2006;20(2):221-225. doi: 10.1038/ sj.eye.6701859

. Mizoue S, Nitta K, Shirakashi M, et al. Multicenter, randomized, investigator-masked study comparing brimonidine tartrate 0.1% and timolol maleate 0.5% as adjunctive therapies to prostaglandin analogues in normal-tension glaucoma. 

2017;34(6):1438-1448. doi: 10.1007/s12325-017-0552- 5

. Donella JE, Padilla EU, Webster ML, Wheeler LA, Gil DW. Alpha(2)-adrenoceptor agonists inhibit vitreal glutamate and aspartate accumulation and preserve retinal function after transient ischemia. 

. Saylor M, McLoon LK, Harrison AR, Lee MS. Experimental and clinical evidence for brimonidine as an optic nerve and retinal neuroprotective agent: an evidence-based review. Arch Ophthalmol. 2009;127(4):402-406. doi: 10.1001/ archophthalmol.2009.9

. Kent AR, Nussdorf JD, David R, Tyson F, Small D, Fellows D. Vitreous concentration of topically applied brimonidine tartrate 0.2%. 

. 2001;108(4):784-787. doi: 10.1016/s0161-6420(00)00654-0

. Wheeler LA, Lai R, Woldemussie E. From the lab to the clinic: activation of an alpha-2 agonist pathway is neuroprotective in models of retinal and optic nerve injury. 

. Krupin T, Liebmann JM, Greenfield DS, Ritch R, Gardiner S; Low-Pressure Glaucoma Study Group. A randomized trial of brimonidine versus timolol in preserving visual function: results from the low-pressure glaucoma treatment study. 

2011;151(4):671-681. doi: 10.1016/j. ajo.2010.09.026

. Parrish RK, Palmberg P, Sheu WP, XLT Study Group. A comparison of latanoprost, bimatoprost, and travoprost in patients with elevated intraocular pressure: a 12-week, randomized, masked-evaluator multicenter study. 

2003;135(5):688-703. doi: 10.1016/s0002- 9394(03)00098-9

. Horsley MB, Chen TC. The use of prostaglandin analogs in the uveitic patient, seminars in ophthalmology. 

2011;26(4-5):285-289. doi: 10.3109/08820538.2011.588650

. Peyman GA, Bennett TO, Vlchek J. Effects of intravitreal prostaglandins on retinal vasculature. 

. Chang JH, McCluskey P, Missotten T, et al. Use of ocular hypotensive prostaglandin analogues in patients with uveitis: does their use increase anterior uveitis and cystoid macular oedema? 

2008;(92);7:916-921. doi: 10.1136/ bjo.2007.131037

. Tamm ER. The trabecular meshwork outflow pathways: structural and functional aspects. 

2009;88(4):648-655. doi: 10.1016/j.exer.2009.02.007

. Wand M, Shields BM. Cystoid macular edema in the era of ocular hypotensive lipids. 

2002;133(3):393- 397. doi: 10.1016/s0002-9394(01)01412-x

. Toris CB, Gabelt BT, Kaufman PL. Update on the mechanism of action of topical prostaglandins for intraocular pressure reduction. 

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. Winkler NS, Fautsch MP. Effects of prostaglandin analogues on aqueous humor outflow pathways. 

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2009;18(9):652-657. doi: 10.1097/IJG.0b013e31819c49d4

Find out which myths are busted and which are plausible

5 glaucoma management myths

In 2015, the FDA approved the first optical coherence tomography angiography (OCTA) in the United States. Since then, many optical coherence tomography (OCT) manufacturers have integrated angiography technology into their devices. This technology allows for non-invasive visualization of retinal and choroidal blood vessels and enhances patient management. This article will review the optical concepts of OCTA, including benefits of standard fluorescein angiography (FA), and provide a comprehensive discussion of 2 common retinal conditions in which OCTA is extremely useful in clinical practice: age-related macular degeneration (AMD) and diabetic retinopathy (DR).

OCT uses light rays to construct cross-sectional views of the retina.

 The retinal layers are differentiated because of their reflective properties. Simply, OCTA uses light rays to detect change in OCT images over a short period. The variation identified corresponds to red blood cell movement within normal or abnormal vascular networks.

 This noninvasive imaging technique allows for visualization of many types of vascular pathology including retinal and choroidal neovascularization, macular telangiectasia, retinal ischemia, and retinal macro/ microaneurysms (MAs).

Standard OCT analysis has been able to provide eye care practitioners with qualitative and quantitative analysis of the retina, the optic nerve, and the anterior segment. Qualitative images provide detailed anatomical views. When practitioners are evaluating patients for retinal disease, these scans are helpful for detecting anatomical variations such as intraretinal and subretinal edema, changes to the vitreoretinal interface, and outer retinal atrophy. Quantitative analysis of the retina provides retinal thickness measurements. Retinal thickness variations can be useful for detecting disease and monitoring progression and/or response to therapy.

OCTA provides qualitative images that allow for visualization of vasculature. With OCTA, practitioners do not acquire temporal images as they do with typical FA; instead, 1 vascular image is acquired. The image can be segmented into en face layers (vitreoretinal interface, superficial retina, deep retina, avascular, choriocapillaris, and choroid) to enhance vascular analysis (

). A color-coded depth map of the en face images is created to provide an overview of the vascular network.

As with other imaging techniques, practitioners must understand normal OCTA images to ensure that subtle abnormalities are found when pathology is present.

In 2018, the FDA approved the first quantitative analysis for one of the commercially OCTA devices (AngioVue; Optovue). Instead of providing a thickness measurement as standard retinal OCT does, OCTA quantitative analysis provides measurements of vascular density and the total area of the foveal avascular zone. These measurements can be helpful for identifying and monitoring retinal ischemia.

Using OCTA has several benefits. As mentioned, obtaining OCTA images is non-invasive. Acquisition of 1 image typically takes 3 to 6 seconds, and unlike standard FA, it is performed without an injected dye. This quick acquisition and the reduced risk of anaphylactic allergy are 2 benefits of using the technology. Another benefit over FA is the ability to segmentally visualize vascularization (Figure 1).

Understanding OCTA’s downfalls can aid in interpretation and allow providers to determine when a standard FA is warranted. Scan quality can be altered because of media opacifications, eye movements creating motion artifacts, or segmentation errors. OCTA is unable to image low-flow areas, although newer OCT devices using swept-source technology may offer enhanced capability of imaging these areas. OCTA also cannot detect leakage from vessels because of slow leakage rate—this can make differentiating between retinal neovascularization and intraretinal microvascular abnormalities difficult.

 Lastly, OCTA imaging cannot determine vascular filling times, which is helpful when evaluating patients for vascular occlusions.

Systematic analysis of OCTA starts with a generalized overview of the color-coded map to help identify areas of abnormalities (

). Next, retinal segmentation should be analyzed to ensure that the en face vascular images are accurate (

The technology can diagnose age-related macular degeneration and diabetic retinopathy


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