When a 24-year-old female with moderate headaches and a body mass index (BMI) of 40 is sitting in your chair, the optic nerve head evaluation is the moment of truth. The presence of latent hyperopia may not be enough to quiet your concern if you note bilateral optic nerve head elevation and an absent spontaneous retinal venous pulsation (SVP). If you can provide yourself with physical evidence of optic disc drusen as the cause, unnecessary tests and referrals may be avoided, and the sense of urgency eliminated.

Optic nerve head drusen are commonly seen during the dilated fundus exam, occurring in 2 percent to 4 percent of the population,

 but given their perceived benign nature and lack of management options, drusen are most notable for the diagnostic dilemma they can create. According to a histological study of 1713 eyes with disc drusen, 54 percent caused elevated optic discs.

 This not only highlights that many cases will lead doctors down a rabbit hole of expensive and invasive testing to rule out a brain mass but also how many cases are out there that ODs are not noticing at all.

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While there is some debate regarding their natural history, it is agreed that disc drusen, buried and physically invisible in early stages, are made up of acellular, calcified deposits of nucleic acids and mucopolysacharides. It is also well-established that disc drusen occur in genetically predisposed individuals—who might otherwise be at risk for damage to optic nerve head tissues—from conditions such as small scleral canals. These deposits are known to occur anterior to the lamina cribosa and can make their way to a more anterior position over the years, displacing and damaging adjacent tissues, subsequently disrupting axonal transport.

During childhood, disc drusen are uncalcified and often missed or difficult to diagnose. When pronounced, these optic nerves can paint the picture of papilledema. With a child in the chair and a concerned parent as well, the optometrist’s confidence in the latest technology can be a game changer in this tedious situation. In later adulthood, the condition tends to stabilize with the most progression and possible loss of visual field occurring during adolescence. Experts agree that the progressive clinical visibility of disc drusen into adolescence is likely due to a combination of growing size and/or number of the deposits, anterior migration of the deposits, and normal age-related retinal nerve fiber layer (RNFL) thinning superficial to the deposits.

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Because disc drusen are bilateral most of the time, and because many cases of drusen cause elevated discs,

 bilateral cases of suspiciously elevated optic discs should always be differentiated from disc drusen.

While buried, or when the condition is mild, a firm diagnosis of disc drusen often requires the assistance of advanced imaging. However, once the condition becomes more clinically obvious with age, the diagnosis is more clear and technology may not be needed at all.

Given the potential urgency of an elevated optic disc, the optometrist who suspects disc drusen should always ask and answer two questions:

Can it be ruled out that papilledema (bilateral disc edema with an etiology of increased intracranial pressure) is present?

Utilization of each of the imaging modalities discussed below will be addressed with this approach.

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Can it be ruled out that papilledema is present?

The diameter of the scleral canal just posterior to the optic disc can be measured and approximated using an ultrasound, providing insight to the anatomy and potential vulnerability to the optic nerve.

Clinical literature suggests taking this measurement at 3 mm posterior to the optic disc. Scleral canals greater than 5 mm in diameter at this location should prompt further investigation for increased intracranial pressure (ICP).

A scleral canal narrower than 3 mm, on the other hand, may be suggestive of an anatomically crowded optic disc.

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B-scan ultrasonography has long been considered the standard approach for confirming a diagnosis of disc drusen with its ability to detect subtle hyperreflections at the disc,when the visual “noise” (gain measured in decibels) is reduced.

Figure 2 demonstrate an eye with optic disc drusen.

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Spectral domain OCT (SD-OCT) can also be useful in determining presence of drusen and also in monitoring related structural damage to the inner retinal layers.

Advanced visualization of optic disc topography can be somewhat subjective; however, is nevertheless often useful in correlation of data. Carefully consider other etiologies to a non-uniform elevation, such as superficial disc vasculature, which can mimic drusen.

High-definition raster scans using enhanced depth imaging (EDI) can produce images of both disc topography and also the deeper retinal layers, including Bruch’s membrane. Using a longer scan (9 mm), the peripapillary retinal pigment epithelium (RPE) and therefore contour of the globe can be evaluated.

SD-OCT with EDI allows for the highest sensitivity near the inner sclera and can be utilized clinically for improved visibility in many other clinical conditions occurring in the deeper retinal layers and choroid, including choroidal nevi, central serous retinopathy, and age-related macular degeneration (AMD).

SD-OCT with EDI can detect disc drusen structure and location, allowing it to be a strong differentiator for drusen versus papilledema. Some have reported a higher detection rate than with B-scan.

High-definition raster scans using EDI can produce images of the deeper optic nerve head where the drusen occur. Drusen are visualized as signal-poor areas anterior to the lamina cribosa, whose borders (most easily appreciated anteriorly) are hyperreflective. Smaller, individual drusen, or larger clusters may be present.

Of note, disc drusen can appear similarly as blood vessels on the OCT; however, blood vessels are often perfectly oval shaped and tend to create more shadowing beneath. Furthermore, the adjacent enface image of any B-scan on OCT can be referenced for anatomical consistency of suspected findings.

In addition, the RNFL thickness report can be useful in management of disease progression and structural loss. Based on histopathological studies, RNFL thickening is often present with large, deeply positioned drusen, while thinning is present with drusen of the same size but a less deep position.

 Progressive RNFL thinning which stabilizes later in adulthood, along with the disc drusen position and size, is expected.

Not as often clinically noted, on the other hand, acute change in the condition and disease activity may actually cause RNFL thickening. This of course can create further confusion in a cloudy diagnostic picture.

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Lastly, FAF can be utilized to detect the presence of drusen. In contrast to B-scan and OCT, FAF does not offer information specific to the presence or absence of papilledema. It does, however, have the potential to provide physical evidence of disc drusen. FAF uses an extremely bright light flash to capture evidence of fluorescence tissues. While lipofuscion is its common target, indicating RPE disruption, disc drusen themselves will hyperfluoresce when superficial enough. Unfortunately, the deeply buried, and/or most subtle of cases are when the need for confirmation is greatest and also when FAF is least likely to deliver a positive result.

Table 2 summarizes the clinical tools that can be utilized in both the exam room and with specialty imaging equipment if differentiating disc drusen from other causes of a bilaterally elevated discs.

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While ODs are relieved to determine that elevated discs are in fact disc drusen (versus the scary and often urgent alternative), it is important to bear in mind when discussing the condition with the patient and planning management that drusen are not entirely benign.

As disc drusen expand and move anteriorly, unfortunately there comes a higher risk of subsequent overlying RNFL damage along with visual field loss. Frequency of visual field defects varies based on study; however, most recently defects were reported to occur in approximately 

of patients with confirmed disc drusen. Defects range from enlarged blind spots to nasal, arcuate or partial arcuate, consistent with RNFL defects, and can impeded visual function in advanced cases, as seen in Figure 7.

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Disc drusen may be associated with other clinical findings, highlighting their impact of anatomical structures. Vascular changes associated with the disc include disc and adjacent retinal hemorrhages, typically flame-shaped. Nonarteritic anterior ischemic optic neuropathy (NAION), retinal artery occlusions, and deeper choroidal neovascular membranes have also been reported. Disc drusen are thought to crowd the axonal fibers, leading to vascular compression.

 In patients who have optic nerve head tumors, disc drusen are more prevalent. In this case, tumor compression of optic nerve fibers may promote disc drusen formation.

It is suggested, given their predilection to occur together, that disc drusen and papilledema may in fact be associated, reminding the clinician that multiple diagnoses can be present. Even in the most clear pictures of drusen, papilledema may still need to be ruled out.

While the relationship is unclear, it is suggested that in these patients who have suffered from an increase in intracranial pressure (ICP), and therefore mechanical obstruction and ischemia leading to eventual axoplasmic stasis, there is impaired axoplasmic metabolism and therefore a risk for drusen development. Or, could it be the other way around in which case the disc drusen cause crowding at the optic nerve, creating a vulnerability to disc edema?

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Multiple treatment options for disc drusen have been explored; however, unfortunately we are left with little to none when it comes to preventing vision loss.

The possible benefit of decreasing intraocular pressure (IOP) has long been debated, but is perhaps the most commonly recommended attempt at preventing RNFL damage. Various studies demonstrate conflicting evidence regarding the benefit of hypotensive measures, ranging from increasing retinal ganglion cell function and stabilization of RNFL thickness with a possible delay in optic neuropathy to no association.

 Reports of treatment with vasoactive therapy such as pentoxifylline as well as neuroprotective measures are anecdotal but show some promise.

 Further investigation is clearly needed.

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Auw-Haedrich C, Flemming S, Heinrich W. Optic disk drusen. 

Hamann S, Malmqvist L, Costello F. Optic disc drusen: understanding an old problem from a new perspective. 

Skougaard M, Heegaard S, Malmqvist L, Hamann S. Prevalence and histopathological signatures of optic disc drusen based on microscopy of 1713 enucleated eyes. 

Malmqvist L, Lund-Andersen H, Hamann S. Long-term evolution of superficial optic disc drusen. 

Kimberly HH, Shah S, Marill K, Noble V. Correlation of optic nerve sheath diameter with direct measurement of intracranial pressure. 

Stone MB. Ultrasound diagnosis of papilledema and increased intracranial pressure in pseudotumor cerebri. 

Kupersmith MJ, Sibony P, Mandel G, Durbin M, Kardon RH. Optical coherence tomography of the swollen optic nerve head: deformation of the peripapillary retinal pigment epithelium layer in papilledema. 

Malmqvist L, Bursztyn L, Costello F, Digre K, et al. The optic disc drusen studies consortium recommendations for diagnosis of optic disc drusen using optical coherence tomography. 

Silverman AL, Tatham AJ, Medeiros FA, Weinreb RN. Assessment of optic nerve head drusen using enhanced depth imaging and swept source optical coherence tomography. 

. Gaier ED, Rizzo 3rd JF, Miller JB, Cestari DM. Focal capillary dropout associated with optic disc drusen using optical coherence tomographic angiography. 

. Loft FC, Malmqvist L, Wessel Lindberg AS, Hamann S.The influence of volume and anatomic location of optic disc drusen on the sensitivity of autofluorescence. 

. Lee KM, Woo SJ, Hwang JM. Factors associated with visual field defects of optic disc drusen. 

. Purvin V, King R, Kawasaki A, Yee R. Anterior ischemic optic neuropathy in eyes with optic disc drusen. 

. Lee KM, Hwang JM, Woo SJ. Hemorrhagic complications of optic nerve head drusen on spectral domain optical coherence tomography. 

. Lee KM, Hwang JM, Woo SJ. Optic disc drusen associated with optic nerve tumors. 

. Birnbaum FA, Johnson GM, Johnson LN, Jun B, Machan JT. Increased prevalence of optic disc drusen after papilloedema from idiopathic intracranial hypertension: on the possible formation of optic disc drusen. 

. Pojda-Wilczek D, Wycisło-Gawron P. The effect of a decrease in intraocular pressure on optic nerve function in patients with optic nerve drusen. 

. Nolan KW, Lee MS, Jalalizadeh RA, Firl KC, Van Stavern GP, McClelland CM. Optic Nerve Head Drusen: The relationship between intraocular pressure and optic nerve structure and function. 

. Cybulska-Heinrich AK, Mozaffarieh M, Flammer J. Ginkgo biloba: an adjuvant therapy for progressive normal and high tension glaucoma. 

Articles

B-scan, fundus autofluoresence, and OCT inform diagnosis

Imaging to differentiate disc drusen from papilledema

ODs perform gonioscopy all the time. Glaucoma patients, glaucoma suspects, and patients who have ocular hypertension undergo gonioscopes as well as trauma patients to rule out recession, patients with retinal vascular occlusions, diabetics, and the list goes on from there.

I recall vividly when I first learned the procedure. A significant portion of what I learned while in optometry school (both about gonioscopy and other aspects of clinical care) came from conversations in the hallway and tips on the fly when I was interning in the clinic.

I remember one attending told me that if I wanted to become really proficient at gonioscopy, then I should do it on everyone. “Do it on all diabetics, but also do it on the 20-year-old -2.00 D myope who just needs more contact lenses. Really practice it.” Man, was he ever right.

I entered clinic as a third-year intern being able to perform gonioscopy but frankly afraid of it. Hey, I was a kid. Further, it is akin to a bad joke that the internal reflective properties of the cornea (which is a clear tissue) make mirrors necessary to view the structures of the anterior chamber angle. By the end of a couple of weeks with this attending who was, I’ll stop just short of “trial by fire,” the procedure became second nature to me. Diagnostic contact lenses frightened me no more!

To this day, I am still a fan of performing dilated fundoscopy of the posterior pole through the center lens of a 3-mirror lens when views are difficult to attain. I am not sure, but I would guess that’s a dying art.

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Speaking of times when it is difficult to get a good view of a fundus, let me share with you another clinical pointer which has continued to be of great help through the years. When I was a fourth-year intern, I had a patient who was particularly squeamish about having bright light directed at her macula (and rightfully so, I might add). Unfortunately, she also had moderate cataracts. I should also mention that this was her cataract evaluation to determine if she was a good candidate for cataract extraction. I sheepishly went in and asked my attending to check my exam findings as I was having a difficult time viewing her maculas. He did, but not before saying 4 words that proved to be of great and lasting service: “Go take some photos.”

I did, and the photos I took complemented my examination of the patient greatly. I recall later on in my residency being in a room with maybe half a dozen interns when the attending asked if anyone had ever missed something in a retina and later picked it up on a retinal photograph. The sole hand that went up was mine. He looked at me and said, “Honest man.” Well, I suppose I am nothing if not honest.

No one can argue the fact that it is pointedly simpler to sit back and look at a high-quality photo and digest all of its details and characteristics while sipping coffee than it is to fight the remarkably strong orbicularis muscles of a patient whose eyes instinctively undergo a complete Bell’s phenomenon when his lids are pried open for fundoscopy.

No, I do not think photos take the place of live fundoscopy (not even stereo photos), but they do have their place. Some clinicians have techniques which are more proficient than others, but no one is superhuman.

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So, what do gonioscopy and photography have in common? With that question in mind, I turn to a review on anterior chamber angle assessment.

This review paper goes through several different methods by which the anterior chamber angles can be assessed. Several different examples of gonio-photographic technology are discussed, as are other technologies such as anterior segment optical coherence tomography (AS-OCT) and ultrasound biomicroscopy (UBM).

Acquiring high-quality photographic images of the anterior chamber angles has obvious advantages. The ability to assess a static image of an angle is a luxury I do not currently have, but I am envious of those who do. As for UBM, it is a relatively simple procedure which can quickly determine a narrow angle. As its name implies, UBM technology makes use of sound waves to “view” the structures of the angle.

AS-OCT is a quick procedure that is simple to perform and good at identifying narrow angles. Instead of sound waves, AS-OCT makes use of electromagnetic radiation (of course, at safe levels) in order to acquire its images. However, there are aspects of the anterior chamber angle beyond the position and configuration which need to be assessed. When adding up all of these “qualitative” variables, such as pigment, glaucomflecken, blood, and subtle neovascularization, I am afraid we will have to continue performing gonioscopy for some time.

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Examining patients with both gonioscopy and imaging can reveal potential concerns

Gonioscopy and imaging work in tandem

Every day, I see patients who have been referred for cataract surgery—but have unfortunately been sent to us without any of the preparation that will ensure a smooth and satisfactory experience for the patient, and a painless postoperative management experience for the referring optometrist.

Here are 5 things I wish every doctor discussed with their patients before referring them for surgery.

Discuss the existence of lifestyle lenses

A surgical practice has to provide true informed consent, so we will certainly talk to every patient who is a candidate about presbyopia- and astigmatism-correcting intraocular lens (IOL) options. But the reality is that this topic is best introduced early on, while the patient has the time and energy to think about what is important for their lifestyle and budget.

The preoperative consultation is a long one. The patient will see several different doctors, counselors, and technicians; go through a lot of diagnostic testing; and will likely be tired and somewhat overwhelmed by the end of the visit.

That’s a terrible time to introduce a major decision for the first time. That doesn’t mean that we want everyone to get a lifestyle lens. But we don’t want them to throw up their hands and say “Oh, just give me the standard!” and then later regret a decision made in haste.

A primary eyecare provider who has an established relationship with the patient knows so much more about that patient than the surgeon can learn in a short appointment.

Consider and share all the elements that are relevant to the IOL choice and refractive targets, including:

History of astigmatism and presbyopia correction in glasses or contact lenses

Most important distances for the patient’s daily activities

How easily satisfied the patient is with his spectacle or contact lens prescription

Unusual avocations that require specialized lenses or have non-negotiable distance requirements

For example, as an instrument-rated private pilot I have to be able to see the instrument panel clearly (Figure 1). If my IOL doesn’t allow for that, I will need glasses for the cockpit.

This isn’t about telling the patient, “Hey, I want you to have XYZ lens.” Ultimately, the surgeon will determine which lens type and lens power to implant, but she needs information to make the best choice.

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When talking to patients about how important near vision is for them, it is important to be very, very clear because this is easily misunderstood. “Near” is a very subjective term.

I like to hand patients a near card upside down. The need to turn it around will force them to naturally reposition the card where they like to hold reading material. Depending on patients’ height and arm length, where they typically position devices, and what their hobbies are, “near” can mean anything from embroidery at 6 inches to a computer screen at 36 inches.

A simple way to explain the concept to patients is this: “If you have a standard lens implanted, you won’t be able to see anything clearly that you can touch. There are lens options (such as Tecnis Symfony [Johnson & Johnson Vision]) that can provide a natural range of high-quality vision that will satisfy most patients.”

Someone with short arms or a fine-detail hobby may need a lens that is designed for a closer near-point (such as PanOptix [Alcon] or Tecnis Multifocal IOLs).

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It is really important to physically demonstrate to low myopes what their vision will be like with a standard IOL. These patients will almost certainly discount whatever you say about this if you don’t 

them. Low myopes have breezed through presbyopia just by removing their glasses to see up close. They believe they will retain this natural ability!

So, ODs need to put lenses with their full correction in front of their eyes and ask them to look at a near target, explaining that it will always be this way once they have cataract surgery. With a demonstration like this, I have found that many low myopes would much rather have a presbyopia-correcting lens that offers the range of vision they expect to have.

Similarly, if the patient has always had astigmatism correction in his glasses and is excited to be able to see at distance after cataract surgery, he needs to understand that no matter how good the surgeon is, he will still need glasses unless he opts for astigmatism correction at the time of surgery.

Related: Treatments for presbyopia coming soon

Evaluate and treat ocular surface disorders

Patients with dry eye—whether symptomatic or not—must be treated before preoperative measurements are taken, to ensure that the biometry and IOL power selection are accurate. If they come in for a consult with undiagnosed and untreated dry eye, that slows down the process tremendously because the surgical practice must postpone measurements and start treatment.

The first question a patient always asks is, “Why didn’t Dr. Smith tell me I had this?”

It is an awkward situation for the surgical practice to manage, and it generally causes the patient to lose confidence in the referring doctor. Moreover, it means the referring doctor has ignored the practice opportunity to offer billable treatment services.

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Every IOL offers advantages and disadvantages, including standard monofocal IOLs. A prepared patient understands what she is getting into, regardless of the direction she chooses.

Patients who choose a presbyopia-correcting IOL, and especially if they might get a multifocal IOL, need to understand the potential for night vision symptoms. You can explain that the starbursts they currently see at night (because of the cataract) won’t entirely go away, but they will be less noticeable.

I like to explain neuroadaptation to patients by demonstrating physiological diplopia. Tell the patient to hold a finger about 12 inches from his face. Then hold a pencil at arms’ length. Tell the patient, “When you look at your finger, you are still aware of the pencil, right?” While looking at his finger but being aware of the pencil, he will now see 2 pencils.

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I explain, “Your brain naturally adapts to this phenomenon so you don’t go around seeing double when focused at a specific distance, but if you concentrate, you can see it. Night vision symptoms are a lot like that. The blurred image is there, but your brain will tune it out.”

And of course, if the patient chooses a standard monofocal IOL, he needs to know to expect that he will need glasses for some or all tasks, as discussed in the third point.

The most important factor in maintaining your patients’ trust after surgery—and having a smooth and trouble-free postoperative course—is taking the time to educate patients preoperatively so they are not unpleasantly surprised by the results.

Educate patients preoperatievly, evaluate their needs, and set appropriate expectations

5 things to get your patients ready for cataract surgery

To sum it up, 2020 has been an interesting year of practicing optometry. Optometrists across the nation have stepped up to do their part in helping to decrease unnecessary ocular emergencies from clogging emergency rooms, freeing up space for COVID-19 patients.

In addition to the increase in certain ocular problems seen during the pandemic (such as computer- and mask-induced dry eye, corneal abrasions, central serous chorioretinopathy, and more), there also seems to have been a shift in trends regarding how contact lenses are prescribed and worn. As noted by several optometrists across the nation, there has been an increase in requests for first-time contact lensfits but also simultaneously an increase in contact lens dropout.

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When asking first-time contact lens wearers in 2020 their motivations for wanting to try contact lenses, their reasons often include wanting to minimize the bulkiness of glasses on the face with the mask, the inevitable fogging of lenses, and “wanting another option while on virtual meetings.”

The dreaded fogging of lenses is not enjoyable for anyone. First-time contact lens fit requests have ranged from medical professionals, to chief executive officers (CEO), and office workers on the computer all day to those who had not considered contact lenses before the pandemic. The common goal is to have the option to eliminate the dependency on spectacle correction while performing important work-related tasks.

 The COVID-19 pandemic has seen an increase in what some are calling the “Zoom effect.” With millions of people utilizing virtual chat platforms across the world (such as Zoom), there has been an increase in the willingness to undergo cosmetic procedures and enhancements since the pandemic began.

 Although it has not been studied, it is interesting to note that a portion of patients who have requested first-time contact lens training may be doing so for cosmetic purposes to improve their selfie views.

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In addition, after time in quarantine to reflect on the importance of good health, many patients have asked about daily disposable lens options after (re)considering the improved convenience, comfort, and quality compared to other extended-wear lenses. Daily disposable lenses have been my preferred choice for new soft contact lens wearers well before 2020; however, an added problem during the pandemic was accessibility to contact lens solutions. Rivaling toilet paper in some areas of the country during the pandemic, contact lens solution supplies were reportedly low and demand high, forcing some optometrists and patients to switch to a daily disposable modality for a period of time in 2020.

Also likely contributing to some of the increase in contact lens fits and sales, many patients have unused insurance benefits and/or excess health savings accounts (HSA) due to remaining at home most of 2020. In some cases, patients may have also been driven to purchase contact lenses from their hometown provider in an effort to support local businesses during this COVID-19 pandemic. Educating patients on their benefits and how to use them in conjunction with available rebates and discounts offered in-office have contributed to this trend of increased contact lens fits for new wearers.

2020 also simultaneously saw an increase in contact lens dropout of many established wearers. Some reasons that patients reportedly decreased or completely stopped contact lens wear include wanting to avoid touching the face, concern for increased risk of infections, worsened dry eye, and a decreased need for contact lenses since “working from home and none of my colleagues see me.”

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 Although many patients reportedly discontinued contact lens use due to fear of receiving an infection, there has been no statistical evidence that wearing contact lenses increase risk of COVID-19 infection.

 Interestingly, contact lens compliance and recommended hand-washing before application and removal was significantly improved during the COVID-19 pandemic because people were more cognizant of their hand-washing habits.

Further contributing to contact lens dropout among patients is the increased risk of mask-associated dry eye (MADE) as well as incomplete blinking and decreased blink rate due to excess computer use.

 Millions of people across the world, including many optometrists, have pivoted to virtual events and increased daily digital use. Along with the millions of children now attending virtual school and millions of adults now spending 40 to 60 hours per week staring at multiple digital devices, many patients are at a higher risk for dry eye problems, increasing the likelihood of contact lens dropout.

Adding to the dropout rates, for some, the global pandemic may have meant loss of vision insurance or means to afford an expense such as contact lenses. Unfortunately, COVID-19 has caused widespread financial burdens, and it seems that for some patients, the luxury of wearing contact lenses is sometimes one of the first expenses cut from the budget.

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In other cases, established patients are not willing to give up completely on contact lens wear; therefore, optometric practices may be seeing patients switch from an extended-wear lens to a daily-wear lens. Especially in the midst of a global pandemic, it is important for ODs to educate patients that contact lens wear can be an affordable, safe and healthy option.

Increase in requests for refractive surgeries

Some patients have decided that they would rather take a different refractive route, and a global pandemic encouraged them to finally take the leap. In practice, patients have inquired about refractive surgery options more frequently, which has led to more screenings across refractive facilities. I am curious to see the retrospective studies on the general trends in refractive surgery over the next few years after the COVID-19 pandemic.

Incidentally, in my experience more requests for refractive surgery screenings have yielded more undiagnosed keratoconus and other corneal dystrophies that have excluded patients from being candidates for surgery. Instead, we have been able to steer them toward the specialty contact lens route, thus contributing to the rise in specialty contact lens fittings during the COVID-19 pandemic.

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If the COVID-19 pandemic revealed anything in the practice of Micaela Crowley, OD, and other specialty lens practices across the nation, it is the impact that scleral contact lenses have on a patient’s quality of life.

In the majority of cases, scleral lenses are medically necessary therapeutic devices that provide comfortable and functional vision for a patient to perform activities of daily living. Per Dr. Crowley, whether it was due to worry of a mishap with a lost, broken, or poorly fitting speciality lens or worry from a news source (falsely) suggesting contact lenses unsafe to wear, she saw an increase in scleral lens fits throughout 2020.

“Scleral lens patients were at the front of our minds early in the pandemic and our office made sure these patients knew that we were there for them,” Dr. Crowley says. “Many telehealth meetings were scheduled with scleral lens patients to ensure best hygiene practices and switching to a hydrogen peroxide disinfection system6 if it wasn’t already part of their daily routine. Depending on the concern, in-person exams were considered urgent for some of these specialty lens patients.

“Despite their undeniably life-changing potential, scleral lenses have the reputation of being time consuming and a logistical nightmare in a busy office setting. Reduced schedule spots and increased demand forced us to evaluate protocols and immediately adapt to remain successful during the COVID-19 pandemic. For scleral lenses in particular, it meant implementing a direct ship-to-patient delivery system, adding members to our scleral lens team, and bringing on new technology such as profilometry to streamline the fit process.”

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1. Gelidan AG, Mrad MA, Kattan AE, AlEnazi TH, Bakraa RM, Barry MA. The Public’s awareness and willingness to undergo plastic surgery procedures during the COVID-19 pandemic. 

2. Osborn G, Dumbelton K. Eye care professionals’ perception of the benefits of daily disposable silicone hydrogel contact lenses. 

3. Vianya-Estopa M,Wolffsohn JS,Beukes E, Trott M, Smith L, Allen PM. Soft contact lens wearers’ compliance during the COVID-19 pandemic. 

4. Vianya- Estopa M, Garcia-Porta N, Piñero D, Mannion LS, Beukes EW, Wolffsohn JS, Allen PM. Contact lens wear and care in Spain during the COVID-19 pandemic. 

5. Portello JK, Rosenfield M, Chu CA. Blink rate, incomplete blinks and computer vision syndrome. 

6. Centers for Disease Control and Prevention. Contact Lens Care Systems and Solutions. Available at: https://www.cdc.gov/contactlenses/care-systems.html#hydrogen-peroxide. Accessed 12/21/20.

From daily disposables to increased refractive surgeries, dropout and more

Contact lens trends during COVID-19

Do I have pink eye?” How many times have ODs heard that question from their patients? The answer is usually, “Yes, you do have a pink eye and that’s why you came to see us today.”

The pink eye question gives me an opportunity to explain to the patient that not all eyes become “pink” for the same reason. I tick off the extensive list of differentials of conjunctivitis.

The patient generally exhibits amazement at the depth and breadth of causes of “pink eye” and is pleased that she has come to a specialist to tease out the preferred treatment plan rather than experimenting in self-prescribed folk, over-the-counter (OTC), or internet-search remedies. After all, does not witch hazel cure everything, (said tongue in cheek).

As I practice, the same educational segue sparks when blepharitis is the diagnosis at hand (often associated with conjunctivitis, keratitis, or both). Types of blepharitis include but are not limited to:

Eyelash mites or lice (demodex/pediculus)

Of course, there may be overlap of some of these conditions as one may initiate or potentiate the other. Treatment strategies for blepharitis vary and target the root cause of eyelid infection/inflammation.

Causes of blepharitis differ depending on whether it is an acute or chronic process, and in the case of chronic, the location of the problem.

Acute blepharitis may be ulcerative or non-ulcerative. An infection causes ulcerative blepharitis. This is usually bacterial and most commonly staphylococcal. A viral etiology such as infection with herpes simplex and varicella zoster is also possible. Non-ulcerative is usually an allergic reaction such as atopic or seasonal.

Its location best classifies the chronic form of blepharitis. In anterior blepharitis, an infection, usually staphylococcal, or seborrheic disease process is involved. Also, blepharitis may be associated with rosacea. Meibomian gland dysfunction (MGD) causes posterior blepharitis. Commonly, this is associated with acne rosacea, and hormonal causes are suspect.

) blepharitis. Their role is not well established because asymptomatic individuals have also been found to harbor the mites at approximately the same prevalence.

Assessing eyelid health is important because there is a close association with blepharitis and MGD in ocular surface disease.

Rynerson and Perry coined the new term of dry eye blepharitis syndrome (DEBS).

 A biofilm structure is a target for colonizing bacteria. The invasion initiates quorum-sensing gene activation, subsequently producing inflammatory “virulence factors,” including super-antigens, which persist for a lifetime.

These factors cause follicular inflammation, infected eyelash bases, MGD, aqueous deficiency (lacrimalitis), with lid damage and destruction sustained in the long term. In more advanced stages, eyelid destruction can be accompanied by an ectropion or entropion or may cause an eyelid to become floppy.

Eyelid hygiene and elimination of triggers that exacerbate symptoms remains the foundation of most treatment regimens for blepharitis.

In-office microblepharoexfoliation of the lid margin (BlephEx, Rysurg) removes cellular/makeup/other debris from the eyelid margins, promoting a more normal lid/eyelash environment.

Patient maintenance of the eyelid margin includes daily lid margin cleansing (with a doctor recommended eyelid hygiene product, makeup remover, micellular water, hypochlorous acid solution, tea tree oil-containing product).

Hygiene products include wipes or foams or daily at-home lid/eyelash cleaning/debridement with a NuLids motorized unit (NuSight Medical) or the novel, multi-use iLidClean wand (Optego Vision). Similarly, Bruder has introduced a pre-surgical prep kit targeted to improve pre- and post-surgical eye health by eyelid hygiene.

Of note, Tarsus Pharmaceuticals will initiate a Phase 2b/3 trial in the United States of its lead product TP-03 for demodex. It is estimated 20 million Americans suffer from blepharitis, and approximately 45 percent of them have clinical signs of demodex.

I encourage anyone interested in better lid margin hygiene and treating blepharitis to read my favorite lid margin article of all time, 

How to promote and preserve eyelid health

 by Jose Benitez-del-Castillo, my eyelid margin guru.

1. Eberhardt M, Rammohan G. Blepharitis. 

 Available at: https://pubmed.ncbi.nlm.nih.gov/29083763/. Accessed 12/30/20.

2. Rynerson JM, Perry HD. DEBS—a unification theory for dry eye and blepharitis. 

3. Verjee MA, Brissette AR, Starr CE. Dry Eye Disease: Early Recognition with Guidance on Management and Treatment for Primary Care Family Physicians. 

4. Duncan K, Jeng BH. Medical management of blepharitis. 

5. Tarsus Pharmaceuticals. Tarsus Pharmaceuticals Raises $60 Million in Series B Financing. Available at: https://www.prnewswire.com/news-releases/tarsus-pharmaceuticals-raises-60-million-in-series-b-financing-300983254.html. Accessed 12/30/20.

6. Benitez-del-Castillo J. How to promote and preserve eyelid health. 

Type and cause of the condition are important to discuss during the examination

Blepharitis requires patient education

Over the years, I have developed a state-of-the-art holistic dry eye clinic where I use an array of diagnostic modalities and treatment options to develop effective, individualized treatment plans. Many patients have benefited from thermal massage, exfoliation of scurf and demodex, nutraceutical supplements, and homeopathic medicine for stress, which exacerbates dry eye disease.The missing essential element was a way to address the inflammatory component.

In the last few years, I read more and more about ocular rosacea, inflammation, and the growing movement toward treating dry eye with intense pulsed light (IPL) therapy. I was interested in adding IPL to my clinic, but I still had questions. I checked with my state board, which confirmed it is permitted in my state (CA) because ODs can treat for the indication of inflammation related to dry eye.

I began the process of implementing IPL in my practice, starting with an in-depth trial of two different systems.

I wanted to trial IPL systems in my practice so I could determine which one I would purchase and get an idea if my patients would be willing to pay out of pocket for this procedure. If patients were reluctant, the return on investment (ROI) would not justify the purchase.

From choosing a system to picking candidates, the process exceeded expectations

January digital edition 2021

Imaging to differentiate disc drusen from papilledema

Gonioscopy and imaging work in tandem

5 things to get your patients ready for cataract surgery

Contact lens trends during COVID-19

Blepharitis requires patient education

How to implement IPL into an optometry practice

How ODs can address patients lost to follow up

What ODs need to know about the new COVID-19 relief package

ODs look to what 2021 will bring