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Myopia- Management

Ahmad Fahmy, OD, FAAO, DIPL, ABBO, highlights intense pulsed light (IPL) therapy for the treatment of ocular surface disease at the second annual Twin Cities Ocular Surface Disease Symposium in Minneapolis.

Related: Ahmad Fahmy checks in at the Twin Cities Ocular Surface Disease Symposium 2019

Articles

Twin Cities Ocular Surface Disease Symposium

IPL and dry eye

Ahmad Fahmy, OD, FAAO, DIPL, ABBO, kicks off the second annual Twin Cities Ocular Surface Disease Symposium with an introduction to the 2019 conference.

Related: Highlights from Twin Cities Ocular Disease Symposium  2019

Ahmad Fahmy kicks off the second annual Twin Cities Ocular Surface Disease Symposium

Whitney Hauser, OD, and Jacob Lang, OD, FAAO, discuss highlights of the Twin Cities Ocular Surface Disease Symposium in Minneapolis, MN.

Related: Identify common dry eye masqueraders

Highlights from Twin Cities Ocular Disease Symposium 2019

Jacob Lang, OD, FAAO, explains the interactions between glaucoma and ocular surface disease and how to approach treatment at Twin Cities Ocular Surface Disease Symposium 2019.

Related: How contact lenses affect OSD, dry eye

How to treat OSD in glaucoma patients

Attendees participate in hands-on workshops for dry eye diagnosis and treatment tools at Twin Cities Ocular Surface Disease Symposium in Minneapolis.

Related: Highlights from Twin Cities Ocular Disease Symposium 2019

Twin Cities Ocular Disease Symposium 2019: Workshops

Many conditions mimic dry eye and ocular surface disease. Whitney Hauser, OD, arms optometrists and ophthalmologist with tools to identify dry eye masqueraders and accurately diagnose it at Twin Cities Ocular Surface Disease Symposium in Minneapolis.

Related: Comanage dry eye for best results

Identify common dry eye masqueraders

Melissa Barnett, OD, FAAO, FSLS, makes the argument for why patients with severe eye disease should be using scleral lenses to provide ocular surface relief.

Related: How to treat OSD in glaucoma patients

How to use scleral lenses with OSD

Scott Hauswirth, OD, FAAO, highlights a discussion on neurosensory deficits, dry eye and ocular surface disease at Twin Cities Ocular Surface Disease Symposium in Minneapolis.

Related: How to use scleral lenses with OSD

Impact of neurosensory deficits, DED on OSD

Eric Donnenfeld, MD, highlights his talk from Twin Cities Ocular Surface Disease Symposium on the importance of optometry and ophthalmology working together to improve patient care, particularly with dry eye disease.

Why comanagement matters

Eric Donnenfeld, MD, discusses how to manage the moderate to severe dry eye disease patient at Twin Cities Ocular Surface Disease Symposium 2019.

Surgical therapy for dry eye disease

Eric Donnenfeld, MD, overviews simple and complex surgical therapy options for dry eye disease.

Related: Surgical therapy for dry eye disease

Surgical therapy’s role in dry eye disease

Brooke Messer, OD, FAAO, FSLS, shares contact lens tips for ODs and patients with dry eye and ocular surface disease at Twin Cities Ocular Surface Disease Symposium in Minneapolis.

Related: Compounded medications, injections in OSD

How contact lenses affect OSD, dry eye

David Hardten MD, discusses the important role comanagement plays in the care of ocular surface disease patients from his talk at Twin Cities Ocular Surface Disease Symposium.

Comanaging OSD patients

Various factors, including a compounded reduction in contrast sensitivity and reduced reading speed, mean that multifocal IOLs are not ideal for patients with early or subclinical AMD. It is therefore imperative to identify such patients-using a simple practice tool-and enable them to make an informed choice preoperatively. 

The symptoms of age-related macular degeneration (AMD) and cataract are quite similar, with night vision difficulties being a common finding in both conditions. A standard comprehensive eye exam will usually determine which disease is driving the symptomatology in patients with intermediate to late-stage AMD.


	However, it is easy to overlook early and subclinical AMD when looking only for drusen. This could put these patients who are considering a multifocal intraocular lens (IOL) at significant risk of less than optimal surgical outcomes.

How inflammation may play a role in retinal disease


	Here, we discuss why patients who have early AMD may not be ideal candidates for a multifocal IOL and present a simple practice tool for identifying early disease so that patients and surgeons can make better informed choices preoperatively.

Multifocals compound risk in AMD patients

Multifocal lenses help patients see at different distances by splitting light into multiple foci. The tradeoff for visual improvement at both distance and near is an expected (but hopefully mild) reduction in contrast sensitivity. However, because macular degeneration and multifocal IOLs both reduce patients’ contrast sensitivity, one would face a compounded reduction in contrast sensitivity and perhaps decreased visual outcomes.


	Beyond contrast sensitivity, good macular function is also required to achieve normal reading speed with multifocal IOLs,

 which again should urge us to look more carefully for any signs of AMD.


	In short, implanting a multifocal in a patient with AMD is risky and the outcomes may not be acceptable to patients who likely have very high expectations because they are paying out of pocket for a premium procedure.


	At the very least, these patients deserve more in-depth counseling, and ODs should carefully consider and emphasize the informed consent.

Minimize risk by assessing macular function

Structural signs of macular degeneration, at any stage, can be difficult to view or detect,

 and through a cloudy cataract this task is likely to be even more difficult. However, the need to identify these patients using any means necessary cannot be overstated.


	In a 2014 report, the American Society of Cataract and Refractive Surgeons (ASCRS) Cataract Clinical Committee noted that photostress testing is useful for assessing macular function in multifocal IOL candidates.


	Since the publication of this report, the AdaptDx dark adaptometer (MacuLogix) has been commercialized, improving the objectivity of this type of testing and providing measurable data to further assist in patient selection. The test is easy for technicians to learn, no pupil dilation is needed, and test results are not impacted by the presence of cataracts. While continuously focusing on a fixation light, patients are exposed to a mild bleaching flash and then asked to indicate when a progressively dimmer stimulus light appears.


	The AdaptDx can detect subclinical AMD at least three years earlier than it is clinically evident.

 It works by measuring a patient’s rod intercept (RI) time: the number of minutes it takes for the eye to adapt from bright light to darkness. This RI number provides a clear and objective measurement of retinal function with 90 percent sensitivity and specificity.

 Basically, an RI of less than 6.5 minutes indicates a healthy dark adaptation function and no signs of AMD.  However, an RI higher than 6.5 indicates impaired dark adaptation.

What we know about blue light science and research in 2020


	Shortly after the first AdaptDx was put in practice, Marta McKeague, MD, and Mark Pyfer, MD, conducted a study and presented the results at the XXXIV Congress of the European Society of Cataract and Refractive Surgeons.

 Asserting that screening is needed since multifocal intraocular lenseIOLs may reduce contrast sensitivity and impair visual function in patients with subclinical macular disease, the researchers set out to determine whether dark adaptation could be used as a screening method in patients undergoing cataract surgery evaluation.


	Their retrospective chart review was conducted in a comprehensive ophthalmology practice and identified 193 patients who underwent dark adaptation testing within a 13-month period. A total of 27 patients had both a normal fundus exam and normal corneal topography, making them candidates for multifocal IOLs.

Macular diseases: Emerging best practices for diagnosis, management and follow-up protocols


	Of these 27 eyes, 17 (63 percent) had normal dark adaptation and 10 (37 percent) had abnormal dark adaptation. In other words, if all 27 of these patients opted to undergo cataract surgery with a multifocal IOL, more than one-third of them would potentially experience problems that could not have been anticipated if dark adaptation had not been measured preoperatively. 


	These results are consistent with research in our own practices. For example, at Grin Eye Care, we looked at a series of 100 consecutive patients over the age of 60 with no clinical findings of AMD based on dilated fundus exam and optical coherence tomography (OCT). At the end of the study, 61 participants had normal dark adaptation, and 39 participants had impaired dark adaptation, meaning that almost 40 percent of seemingly healthy patients over the age of 60 had macular function disorders that could affect their candidacy for a multifocal IOL.


	Loss of contrast sensitivity is present even in mild forms of AMD, making implantation of a multifocal IOL a relative contraindication6-or at least a reason to proceed with extreme caution. As these studies indicate, structural testing alone is not sufficient to screen patients for early AMD that will likely impact cataract outcomes. For this reason, macular function testing using the AdaptDx dark adaptometer can provide optometrists with essential information prior to referring patients for premium cataract surgery.

Why the periphery matters in DR progression

1. Braga-Mele R, Chang D, Dewey S, Foster G, Henderson BA, Hill W, Hoffman R, Little B, Mamalis N, Oetting T, Serafano D, Talley-Rostov A, Vasavada A, Yoo S; ASCRS Cataract Clinical Committee. `Multifocal intraocular lenses: relative indications and contraindications for implantation. J Cataract Refract Surg. 2014 Feb;40(2):313-22.
	2. Neely DC, Bray KJ, Huisingh CE, Clark ME, McGwin G Jr, Owsley C. Prevalence of Undiagnosed Age-Related Macular Degeneration in Primary Eye Care. JAMA Ophthalmol. 2017 Jun;135(6):570-575.
	3. Owsley C, McGwin G Jr, Clark ME, Jackson GR, Callahan MA, Kline LB, Witherspoon CD, Curcio CA. Delayed Rod-Mediated Dark Adaptation Is a Functional Biomarker for Incident Early Age-Related Macular Degeneration. Ophthalmology. 2016 Feb;123(2):344-5.
	4. Jackson GR, Scott IU, Kim IK, Quillen DA, Iannaccone A, Edwards JG. Diagnostic sensitivity and specificity of dark adaptometry for detection of age-related macular degeneration. Invest Ophthalmol Vis Sci. 2014 Mar;55(3):1427-31.
	5. McKeague M, Pyfer M. Using dark adaptation time to assess macular function prior to cataract surgery. Paper presented at XXXIV Congress of the European Society of Cataract and Refractive Surgeons Free Paper Session. September 12, 2016.
	6. Chakrabarti M, Chakrabarti A. IOL Selection for Patients With Age-Related Macular Degeneration. CRST Europe. Available at: https://crstodayeurope.com/articles/2015-mar/iol-selection-for-patients-with-age-related-macular-degeneration/. Accessed 2/9/20.

Identifying patients with early AMD is necessary to avoid suboptimal surgical outcomes

Use dark adaptation to screen before multifocal IOL implantation

Shelby Temple, PhD, a visual neuroscientist, has spent the last two decades investigating the way the visual system detects and responds to light.

He began his research looking at polarized light detection in cuttlefish, a species whose vision does not identify color wavelengths of light but whose vision depends on detecting different polarizations of light. In the process of his research, he looked at polarization detection in humans. He learned that the mechanism by which humans can perceive polarized light is caused by molecular components in the retina that protect the eye from high-energy blue wavelength light. He has devoted his career to researching and educating the public about blue light science and the impact it can have on ocular health.

Do digital devices really put our eyes at risk? This is the question that Dr. Temple is most commonly asked when he speaks with eyecare professionals.

“On their own, individual devices probably aren’t putting out high enough amounts of energy that they are going to cause immediate damage,” Dr. Temple says. “But in the long-term, that’s more interesting. It’s not about the intensity; it’s about the exposure.”

Length of time of the computer, dilation of the pupil during device use-these factors could make a difference over a lifetime of blue light exposure.


	One thing Dr. Temple feels strongly about is that the existing blue light research done on animal models should not be disregarded.

 Animal studies have long been used to explore how the human body works and are important when investigating long-term, chronic conditions like retinal damage from blue light exposure where it would be impossible to follow candidates for 65+ years and control for environment and medical history.

“This type of study is not feasible; it’s never going to happen,” he says. “What we can do is look at animal studies and epidemiological studies in humans, and all of these studies show without question that blue light can damage the retina.”

Why AMD supplementation should not be casual

Dr. Temple uses an illuminating analogy for the acceptance of animal and epidemiological research in understanding how environmental exposures can affect human health.

“Everyone today accepts that smoking causes lung cancer, but before 1964 it was up in the air,” he says.

 “The evidence that was put forward by the surgeon general to link smoking to lung cancer then is the same type of evidence we have about blue light damage today. There has never been a double-blind placebo-controlled study in humans that proved smoking causes cancer, nor should there be. We will never have a placebo-controlled study in humans that proves blue light causes macular degeneration.”

Dr. Temple encourages optometrists not to wait for research that is not feasible to make changes to how they educate patients about risks for macular disease.

Resveratrol may be key in AMD stroke patient treatments


	An estimated 14 to 24 percent of people have age-related macular degeneration by age 65, with that number jumping to 33 percent after age 75.

 With Americans living longer, eyecare providers’ focus is to delay the onset of this condition.

What can ODs recommend to patients at every exam to help protect long-term ocular health?

• Educate patients about the dangers. Every time you go outside, you expose yourself to ultraviolet (UV) and high-energy blue light. Daily protection from childhood is essential to long-term ocular health
	• Prescribe quality sunglasses for every patient
	• Educate the importance of a balanced diet. Dark leafy greens and brightly colored fruits and vegetables are full of carotenoids which support macular pigmentation. These macular pigments block up to 80 percent of blue light from the retina.

The International Organization for Standardization (ISO) has established standards for UV and blue light protection in eyewear.

 Using data from over 50 years of research, ISO recommends protection for specific wavelengths of high-energy blue light in the ranges of 380 to 455 nm to lower the risk of retinal damage.

Not all blue light is dangerous, and in fact certain wavelengths of blue light are essential to regulating the sleep/wake cycle. The correct eyewear will not block the 480 nm range that is important to melanopsin function for circadian rhythm regulation.

The specific wavelength of blue light matters, according to Dr. Temple.

“Light with 433 nm wavelength is 20 times more damaging to retinal cells than 500 nm blue wavelength light,” he says.


	• Sunlight exposure, antioxidants, and age-related macular degeneration


	This study showed that people with a poor diet and low levels of carotenoid intake had a much higher risk of developing age-related macular degeneration (AMD).

Dr. Shelby considers this study fundamental in linking how our own natural, internal protection against blue light (macular pigmentation) is essential to protecting against AMD.

• Elevated fundus autofluorescence in monkeys deficient in lutein, zeaxanthin, and omega fatty acids

In this study macaque monkeys were divided into two groups: one group was starved of carotenoids, and another group had a normal diet. These monkeys were followed over 28 years, and their retinas were assessed regularly for the presence of drusen.

Results showed that the segment of monkeys whose diet was deprived of carotenoids had much lower levels of macular pigmentation, and they developed AMD at half the age of the monkeys with normal diets and normal macular pigmentation.

Dr. New Mom: Planning for baby and returning to work

• Benedictine monastery on the Island of Rab hides the mystery of sunlight influence on development of macular degeneration (AMD). Is a harmful sunlight risk factor or cause of macular degeneration?

This study looked at 15 Benedictine sisters who lived a secluded lifestyle in a very dark monastery. Despite the age of these monks (average in their 60s), they had the retinas of much younger patients, except for two sisters with evidence of macular degeneration. These were the only two sisters who were responsible for gardening, so they spent significant time outside.

Because of the very unusual conditions in which the sisters had a controlled diet and daily routine, it is the closest to a placebo-controlled study in humans that proves sunlight exposure is a harmful risk factor in developing macular degeneration.

1. Nakamura M, Yako T, Kuse Y, Inoue Y, Nishinaka A, Nakamura S, Shimazawa M, Hara H. Exposure to excessive blue LED light damages retinal pigment epithelium and photoreceptors of pigmented mice. Exp Eye Res. 2018 Dec;177:1-11.
	2. Krigel A, Berdugo M, Picard E, Levy-Boukris R, Jaadane I, Jonet L, Dernigoghossian M, Andrieu-Soler C, Torriglia A, Behar-Cohen F. Light-induced retinal damage using different light sources, protocols and rat strains reveals LED phototoxicity. Neuroscience. 2016 Dec 17;339:296-307.
	3. Song JA, Choi CY. Effects of blue light spectra on retinal stress and damage in goldfish (Carassius auratus). Fish Physiol Biochem. 2019 Feb;45(1):391-400.
	4. Narimatsu T, Ozawa Y, Miyake S, Kubota S, Yuki K, Nagai N, Tsubota K. Biological effects of blocking blue and other visible light on the mouse retina. Clin Exp Ophthalmol. 2014 Aug;42(6):555-63.
	5. Wu J, Seregard S, SpÃ¥ngberg B, Oskarsson M, Chen E. Blue light induced apoptosis in rat retina. Eye (Lond). 1999 Aug;13 ( Pt 4):577-83.
	6. Auerbach O, Stout AP, Hannond EC, Garfinkel L. The role of smoking in the development of lung cancer. Proc Natl Cancer Conf. 1964;5:497-501.
	7. American Federation for Aging Research. Age-related Macular Degeneration. Available at: https://www.afar.org/infoaging/disease-center/age-related-macular-degeneration/. Accessed 2/26/20.
	8. El-Sayed M. Abdel-Aal, Humayoun Akhtar, Khalid Zaheer, and Rashida Ali. Dietary sources of lutein and zeaxanthin carotenoids and their role in eye health. Nutrients. 2013 Apr; 5(4): 1169–1185.
	9. International Organization for Standardization Online Browsing Platform. Short wavelength visible solar radiation and the eye. Available at: https://www.iso.org/obp/ui/#iso:std:iso:tr:20772:ed-1:v1:en. Accessed 2/26/20.
	10. Fletcher AE, Bentham GC, Agnew M, Young IS, Augood C, Chakravarthy U, de Jong PT, Rahu M, Seland J, Soubrane G, Tomazzoli L, Topouzis F, Vingerling JR, Vioque J. Sunlight exposure, antioxidants, and age-related macular degeneration. Arch Ophthalmol. 2008 Oct;126(10):1396-403.
	11. McGill TJ, Renner LM, Neuringer M. Elevated Fundus Autofluorescence in Monkeys Deficient in Lutein, Zeaxanthin, and Omega-3 Fatty Acids. Invest Ophthalmol Vis Sci. 2016 Mar;57(3):1361-9.
	12. VojnikoviÄ B, VojnikoviÄ D. Benedictine monastery on the Island of Rab hides the mystery of sunlight influence on development of macular degeneration (AMD). Is a harmful sunlight, risk factor or cause of macular degeneration? Coll Antropol. 2010 Apr;34 Suppl 2:5-8.

ODs should take a measured approach to glaucoma management that considers the big picture, treat the disease carefully, assess all known risk factors, interpret results carefully, and more than anything else, use clinical evidence as a guide.

There is a commonly held but false belief within the general public that 

 only affects individuals over the age of 50. Experience has taught optometrists (ODs) to spot that myth from a mile away, but other untruths catch even the most practiced ODs off guard.

Edward Chu, OD, FAAO, and David Hicks, OD, FAAO, explored glaucoma facts and myths with research and evidence-based theories for glaucoma management during their lecture at the 

Related: Year in review of optometric advancements

, it is important to keep in mind that while optic nerve size and shape matter, they do not indicate an increased risk for glaucoma, and normal variations in disc size can explain normal variations in cup-to-disc (C/D) ratios. Asymmetry in C/D values doesn’t necessarily indicate glaucoma either, Dr. Chu says.

When it comes to diagnosing glaucoma itself, it is important to note that glaucoma definitions fall on a spectrum. 

According to Dr. Hicks, there are many ways to define and diagnose glaucoma. Optical coherence tomography (OCT) imaging, visual fields, and physical inspections of the optic nerve heads all contribute to variations.

Most glaucoma cases detected by ODs fall within the asymptomatic disease category in which progression can be detected by imaging tools.

Related: ODs: Redefine your role in glaucoma collaborative care

ODs need to understand a range of conditions to make the correct 

assessment. For example, traumatic glaucoma is not as common as secondary glaucomas and features two peak incidences:

– Within one year of the initial trauma

– More than 10 years after the initial trauma

Related: Look at more than the optic nerve head in glaucoma patients

 is complex with a myriad of risk factors, though some are less known than others.

Research suggests that obstructive sleep apnea is a risk factor r glaucoma. One study showed that 47.6 percent of patients with primary open-angle glaucoma had sleep-disordered breathing.

Perhaps surprisingly, research on erectile dysfunction shows a link to open-angle glaucoma.

These lesser-known risk factors underscore the need for ODs to take extensive case histories from patients during their initial evaluation before making glaucoma care decisions.

Related: Your glaucoma patients also have ocular surface disease

ODs are well aware of visual fields’ varying results. However, false positives are a particular point of concern because they have a significant effect on visual field reliability. Patients may worry that they are underperforming visually. This could cause them to overcompensate and become trigger happy, leading to skewed test results.

This is just one contributing factor to another unfortunate glaucoma fact: determining progression through visual field tests is a challenge. Aside from reliability and variability concerns, rates of visual field change are often inconsistent. 

As a result, available classification systems, event analyses, and trend analyses, are used to determine progression.

Clinicians must use their own judgement and apply evidenced-based approaches to their decisions, Dr. Hicks says.

Related: ODs must raise awareness about glaucoma

More knowledge helps dispel myths in diagnosing and treating this sight-stealing disease.

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