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Dermatologic Therapy-Topical.ppt

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					Using New Technology to Improve
Quality of Care & Profit

  John A. McGreal Jr., O.D.
  Missouri Eye Associates
McGreal Educational Institute
          Excellence in Optometric Education
      John A. McGreal Jr., O.D.
 Missouri Eye Associates
 11710 Old Ballas Rd.
 St. Louis, MO. 63141
 314.569.2020
 314.569.1596 FAX
 jamod1@aol.com




                                  JAM
                             Antaging
 Calorie restriction (CR) – cutting normal calorie intake
  by 1/3rd boosts animal lifespans by 30-40%
 Resveratrol – proven at Harvard & National Institute on
  Aging to extend lifespan by 20%, slow aging process,
  even with high calorie diet
    –   Studies in fruit flies, mice, fish, now humans
    –   Present in red wine
                       Cardiovascular
   New Guidelines for Blood Cholesterol Treatment
    –   Heart disease is the number 1 killer in this country
    –   65 million Americans should change life-style & diet (50)
    –   36 million should take medications to lower cholesterol (13)
    –   Many more patients are now candidates for drug treatment
        than previous
    –   many recent studies confirm a dramatic decrease in mortality
        and morbidity associated with decreased cholesterol levels
    –   Framingham Heart Study “risk calculator”
                       Cardiovascular
   National Cholesterol Education Program Adult
    Treatment Panel (NCEP ATP-III) – lipid management
    in USA is less than desirable
    –   <50% of even highest risk patients receive lipid lowering
        treatment
    –   1/3rd of treated patients achieve LDL goal
    –   <20% of CHD patients achieve LDL goal
    –   <50% of patients who are prescribed lipid lowering drugs are
        still taking it six months later, 30-40% after 12 months
    –   1 in 8 MI patients quit drugs only 1 month after discharge
        and are 3 times more likely to die in the year after MI
        New Cardiovascular Concepts
   >20 years old = lipoprotein profile
    –   LDL, HDL, Triglycerides, total cholesterol, and BP
   Guidelines
    –   Total cholesterol   <200        <200 (175)
    –   LDL                 <130        <130
    –   LDL (high risk)     <130        <100 (70)
    –   HDL                 >35         >40
   Risk Factors
    –   Gender, age, smoking, high total cholesterol or LDL, low
        HDL, HTN, family history premature heart disease, &
        obesity
            New Cardiovascular Concepts
   Risk Factors
    –   Diabetes now singled out as so potent risk factor and assumes
        high risk category (same as for previous MI)
    –   “metabolic syndrome” - new risk factor
          requires   three or more of the following
            –   abdominal obesity - 40 in men/35in women
            –   low HDL -<40 men/<50 women
            –   fasting triglycerides >150
            –   HTN
            –   fasting glucose >110

   New Concepts – C reactive protein, apolipoproteins,
    adiponectin protein, treat HDL & LDL together
             Cholesterol Guidelines
 More than half of the coronary artery disease in the
  U.S. is attributable to abnormalities in the levels and
  metabolism of plasma lipids and lipoproteins.
  Diabetes, alcohol consumption, OCs, renal disease,
  hepatitic disease, hypothyroidism can worsen
  hypercholesterolemia or worsen underlying
  hyperlipoproteinemia.
 LDL = total cholesterol – HDL – triglycerides / 5.
 Every 1% reduction in TC yields a 2% reduction in
  CAD risk!
                       Prehypertension
   New Guidelines for Blood Pressure Control
    –   JAMA 5.21.03 National Heart, Blood, Lung Institute
    –   45 million Americans have “prehypertension”
    –   BP = 120-139/80-90
    –   Risks are MI, kidney failure, stroke, CHF
    –   Many more patients are now candidates for drug treatment
        than previous
    –   Many recent studies confirm a dramatic decrease in mortality
        and morbidity associated with decreased BP levels. Systolic
        blood pressure is far more important risk factor > age 50.
        Damage occurs at 115/75, with each 20/10 increase doubling
        mortality!
                   Thrombolytics for MI
   Acute Coronary Syndromes
    –   Reteplace (Retavase)
    –   Eptifibatide (Integrilin)
    –   Tirofiban (Aggrastat)
    –   ASA (Bayer) 325mg chewed STAT
    –   Drug-eluting stents
   Prevention
    –   ASA 81mg (only 1/3rd of 62 milllion at risk in US use ASA)
          Reduces 1st   MI risk by 32%, 2nd MI risk by 20%
    –   Caution in “vigorous” exercise which can contribute up to
        17% of all sudden cardiac deaths
                  Diabetes Mellitus (DM)
   Diagnosis of DM
    –   Fasting glucose >126mg/dl
    –   Symptoms of diabetes and a random blood glucose of >200mg/dl
        after a 75g oral glucose tolerance test
   Intermediate categories (“Prediabetes”) – not DM but at
    substantial risk of developing type II DM and cardiovascular
    disease in the future
    –   Impaired fasting glucose (IFG) - (110-126mg/dl)
    –   Impaired glucose tolerance (IGT) – (140-200mg/dl)
   Screening with fasting blood glucose – every 3 years
    >45years, or sooner if additional risk factors
        Treatment - Diabetes Mellitus
 Education, control of multisystem complications
 Target HbA1c <7.0% (trending lower to 6.0-6.6%)
 Type I DM require 1.0U/kg/D insulin divided into
  multiple doses, typically combining intermediate and
  short acting insulins, given before morning and
  evening meals or continuous subcutaneous insulin
  infusion device
 Type II DM controlled with diet and exercise alone or
  in combination with oral agents, insulin or
  combinations of oral and insulin.
          Insulin Sensitizing Agents - DM
   Thiazolidinedione – these new insulin sensitizing drugs
    allow dosages of insulin to be decreased and
    combination therapy with oral agents to achieve better
    glycemic control in pts with HA1c >8, on >30U of
    insulin/day
    –   Troglitazone (Rezulin)
    –   Rosiglitazone (Avandia) *
    –   Pioglitazone (Actos) *
    –   Repaglinide (Prandin)
   New combination – Avandaryl qd
    –   Rosiglitazone (Avandia) & Glimepiride (Amaryl)
           “Artificial Pancreas” for DM
   Paradigm system (Medtronic) – combination insulin
    pump and glucose monitoring system
    –   Helps type 1 diabetics to avoid dangerous episodes of
        hypoglycemia, reduce risks of death
    –   Worn like a pager taped to the abdomen, continuously reads
        blood sugar transmits data to pump which beeps or vibrates if
        sugar drops to dangerous levels
          Avoids   “dead in the bed syndrome” in young
    –   Eliminates need for needle use to administer or test sugar
        levels
    –   $7,000. cost
                             Future Directions
   Insulin Eye Drops *****
   Insulin nasal sprays – Exubera (Sanofi & Pfizer)
   Diabetic Retinopathy Treatment – DRS & ETDRS established
    photocoagulation as standard of care for retinopathy since 1974,
    BUT….
    –   Fluocinolone acetonide implant (Envision TD/B&L)
    –   Vascular endothelial growth factor (VEGF) studies in PDR and ARMD
            Lucentis (Genentech)
            Macugen (Pfizer)
   DPP-4 inhibitors – new class of diabetes medications
    –   Januvia (Merck) - type 2 DM highly effective !!
    –   Galvus (Novartis) – (phase 3)
     Blepharitis Therapy – Topical/Oral
   Cleeravue – M Convenience Kit
    –   Minocycline hydrochloride 50mg tablets
    –   SteriLid Eyelid Cleanser (Advanced Vision Research)
            Foam container
            60 tablets of antibiotic
    –   StoneBridge Pharma, LLC
   SteriLid Eyelid Cleanser (Advanced Vision Research)
    –   Linalool – naturally occurring liquid distilled from plant oils
            Found in many flowers and spice plants, tea tree oils
            Outstanding kill – time data for eight eyelid organisms
            Pump onto clean fingertips and apply directly to eyelids for 60 seconds
            Recommended dosing is bid
            Preoperative dosing should begin 3 days before surgery
Endophthalmitis Organism Library at
Mass Eye & Ear

     19 strains of S. epidermidis,
     8 strains of S. aureus,
     4 strains of Pseudomonas aeruginosa,
     3 strains of methicillin-resistant S. aureus,
     3 strains of S. warneri,
     3 strains of Serratia marcescens
    Blepharitis Therapy – Topical/Oral
   ALODOX Convenience Kit
    –   Doxycycline 20mg (low dose) tablets
          Below  antimicrobial level, safer for prolonged use
          Sustains collagenolytic activity, reducing inflammation

    –   Ocusoft Lid Scrub Plus (Cynacon/Ocusoft)
         1  box of pre-moistened pads
          60 tablets of antibiotic
          1 bottle of 50ml Ocusoft Lid Scrub Original Formula
          Covered by most insurances as tier 3 co-pay
              –   $25.00 rebate
              –   Assistance program through www.rxhope.com
    Blepharitis Therapy – Topical/Oral
   ALODOX Convenience Kit
    –   Doxycycline 20mg (low dose) tablets
          Below  antimicrobial level, safer for prolonged use
          Sustains collagenolytic activity, reducing inflammation

    –   Ocusoft Lid Scrub Plus (Cynacon/Ocusoft)
         1  box of pre-moistened pads
          60 tablets of antibiotic
          1 bottle of 50ml Ocusoft Lid Scrub Original Formula
          Covered by most insurances as tier 3 co-pay
              –   $25.00 rebate
              –   Assistance program through www.rxhope.com
    Blepharitis Therapy – Topical/Oral
   ALODOX Convenience Kit
    –   Doxycycline 20mg (low dose) tablets
          Below  antimicrobial level, safer for prolonged use
          Sustains collagenolytic activity, reducing inflammation

    –   Ocusoft Lid Scrub Plus (Cynacon/Ocusoft)
         1  box of pre-moistened pads
          60 tablets of antibiotic
          1 bottle of 50ml Ocusoft Lid Scrub Original Formula
          Covered by most insurances as tier 3 co-pay
              –   $25.00 rebate
              –   Assistance program through www.rxhope.com
    Blepharitis Therapy – Topical/Oral
   ALODOX Convenience Kit
    –   Doxycycline 20mg (low dose) tablets
          Below  antimicrobial level, safer for prolonged use
          Sustains collagenolytic activity, reducing inflammation

    –   Ocusoft Lid Scrub Plus (Cynacon/Ocusoft)
         1  box of pre-moistened pads
          60 tablets of antibiotic
          1 bottle of 50ml Ocusoft Lid Scrub Original Formula
          Covered by most insurances as tier 3 co-pay
              –   $25.00 rebate
              –   Assistance program through www.rxhope.com
     Dermatologic Therapy - Topical
   Low Potency Corticosteroids
    –   Hydrocortisone Cream 1.0% (Hytone)
    –   Triamcinolone 0.025% (Aristocort-A)
   Higher Potency Corticosteroids
    –   Betamethasone Valerate 0.1% (Valisone)
    –   Triamcinolone 0.1%, 0.05% (Aristocort-A)
    –   Mometasone 0.1% 15g/45g (Elocon)
   Non-steroidal anti-inflammatory
    –   Pimecrolimus 1% cream (Elidel)
    –   Tacrolimus 1% (Protopic)
   Antifungal
    –   Metronidazole 0.75% (MetroCream, Gel/Galderma)
    –   Azelaic acid 15% gel / 15g (Finacea/Berlex) bid
    Autologous Serum for PED
 Tears contain EGF, vitamin A, TGF-B, fibronectin and
  other cytokines…..all found in serum
 40ml of blood from venipuncture centrifuged for 5 min
    –   diluted to 20% by physiologic saline (empiric)/UV bottle
    –   Dosed at 6-10 X/D with additional AFTs
   Results
    –   43% healed within 2 wks, all within several months
    –   Serum accelerates migration of corneal epithelial cells
    –   Serum upregulates mucin expression of corneal epithelium
        Amniotic Membrane
        Transplantation (AMT)
 Ocular surface reconstruction in SJS, severe dry eye,
  and severe chemical burns
 Human amniotic membrane prepared from placenta of
  elective cesarean section in seronegative (HIV, HepB
  &C, syphilis)
 Facilitates epithelialization, reduces inflammation,
  vascularization and scarring
 Limbal stem cell transplantation is needed in concert
  with AMT in the most severe chemical burns
 RPS Adeno Detector™
Test Procedure

Assembling the Detector
1. Locate the Test Cassette
2. Assemble the detector by gently
   placing the sampling pad of the
   Sample Collector into the
   sample transfer window of the
   Test Cassette body.
                                                   Transfer Window
3. Press firmly where indicated until
   the detector is secure.


Note: A double auditable click means the detector
      is properly assembled, transferring the sample to the test strip.
RPS Adeno Detector™
Test Procedure

Running the Test
1. Open the buffer vial. Remove
   the Protective Cap from the
   Test Cassette. Do not allow
   any portion of the detector
   besides the absorbent tip to
   touch the buffer vial.
2. Immerse the Assembled
   Detector’s Absorbent Tip into
   the buffer vial for 15 seconds.
RPS Adeno Detector™
Reading & Interpreting the Results

Positive Results:
The Results Line and Control Line are RED in the result window,
indicating that Adenovirus antigen is present.

       Results Line




                               Control Line
                           Control Line
 RPS Adeno Detector™
Reading & Interpreting the Results

Positive Results:
 Note:
 An uneven or incomplete test
 line is due to an uneven
 distribution of eye fluid on the
 sample pad.
 Even if the test line is faint in
 color, incomplete over the width
 of the test strip, or uneven in
 color, it must be interpreted as
 positive.
                                    Results Line
RPS Adeno Detector™
Reading & Interpreting the Results

Invalid Results:
If the Control Line does not appear, the test must be interpreted
as invalid and discarded.

                                                  Note:
                                                  The Patient should be
                                                  re-tested with a new
                                                  RPS Adeno Detector
                                                  kit.




                             NO Control Line
    Antiviral Therapy - Oral
   Acyclovir (Zovirax 200/400/800mg)
    –   Primary Herpes Simplex: 400mg- 5x/D x10D
    –   Chronic Suppressive: 400mg bid qd
    –   Varicella: 20mg/kg- 4x/D x 5D
    –   Herpes Zoster: 800mg- 5x/D x 10D
 Famciclovir (Famvir 500mg tid x 7D)
 Valacyclovir (Valtrex 1000mg tid x 7D)
 Vaccine for Zoster prevention
    –   Zoster Vaccine Live (Zostavax)
     Levofloxacin
 Fluoroquinolone
 Indications
    –   Conjunctivitis, injuries, pre and post operative care,
        pneumonia, sinus, skin and skin structure, GI, GU
   Action – DNA gyrase
    –   Prevents bacterial replication
    –   Broadest spectrum, low toxicity, low resistance
    –   Left stereoisomer of ofloxacin, therefore similar solubility and actions
   Side effects – taste perversion
   Available as
    –   Quixin 0.5%/1.5% (topical) – q2h x 4 days, then q4h for
        conjunctivitis
    –   Levaquin 500mg, Leva-pak 750mg, 25mg/ml q24h
        Antimicrobial Therapy – 2008
   Expanded spectrum fluoroquinolones
    –   Levofloxacin 1.5% (IQUIX / Santen/Vistakon)
          Levofloxacin (L-stereoisomer of ofloxacin)
            –   Dual mechanism of action
            –   Excellent solubility / penetration into cornea
          Indication  – treatment of bacterial corneal ulcer
          Side effects are headache & taste disturbance 8-10%
          Dosage Day 1-3: q30m to 2 hrs while awake and every 4-
           6 hrs after retiring
          Dosage Day 4 through completion: q1-4h
          Supplied: 5ml white bottle with tan top
Ophthalmic Azithromycin: AzaSite
 AzaSite™ pairs DuraSite® drug delivery
  technology with azithromycin (1.0%)
 Azithromycin has not been previously
  used in ophthalmology
    –   A stable aqueous formulation is difficult
   AzaSite™: A stable, easily delivered
    formulation of azithromycin
    –   All the advantages of topical ophthalmic
        delivery
          Glaucoma Evolution

                 POAG




                                Future
Diagnostics   Therapeutics
                             Considerations
Glaucoma Evaluation is Transforming
    In the past, detection & management relied on
     functional assessment
     –   Visual fields (white-on-white)
                       for detecting early POAG
           Insensititve
           High degree of variability

    Recently, structural change over time longitudinal
     studies have validated the role of structural
     imaging
     –   Are structural defects with normal functional tests
         false positives or POAG?
                                                               JAM
        Glaucoma Suspect
   CPT / ICD
    –   99214 / Glaucoma Suspect (365.01) = $80.00
    –   92020 / (365.01) = $25.00
    –   76514 / (365.01) = $15.00
    –   92250 / (365.01) = $70.00
    –   92083 / (365.01) = $70.00
   CPT / ICD
    –   99213 or 92012 / (365.01) = $50.00 or $63.00
    –   92235-RT, 92235-LT / (365.01) = $90.00
    –   Total $400.00 or $413.00
   Rx: Initiate or continue treatment or observe
   Use V58.69 in addition to ICD code when changing medications
    in a glaucoma patient

                                                          JAM
                          Gonioscopy
                             92020
 Bilateral
 Requires documentation
    –   describe visible angle structures
 No limitations to diagnostic groups in most states
 Fee      $25.71-




                                                       JAM
                   Digital Gonioscopy
                           92020
   SL-OCT (Heidelberg)
    –   Integrated Slit lamp & digital gonioscopy system
    –   Haag-Streit BD 900 slit lamp, OCT scanning unit
    –   High resolution grey scale or false color reports
    –   Fast, easy, non-contact OCT at any position
    –   Stores data
    –   Measures angle, angle opening distance, angle recess area,
        trabecular iris contact length, trabecular iris space area
    –   Measures pachymetry and biometry
                                                              JAM
             TM
SL-OCT Hardware Features
   Non-contact
   Fast and easy to use
   Simultaneous
       optical and OCT exam
   Color or gray-scale images
Limitations of Manual
Gonioscopy
   Patient discomfort – full globe contact
   Time consuming
   Subjective
   Requires considerable skill and experience

                      Statement of Assoc. of International Glaucoma Societies (AIGS)
                                           3rd Global Consensus Meeting, May 2006
Computerized Corneal Topography
             92025
 Bilateral or unilateral
 Requires interpretation & report
 No limitations to diagnostic groups in most states
 Fee       $23.12- / $28.47




                                                       JAM
        92025 Corneal Topography
   ICD-9 Codes that Support Medical Necessity
    –   367.22* Irregular astigmatism
    –   371.00 Corneal Opacity Unspecified
    –   371.23 Bullous Keratopathy
    –   371.50 Hereditary Corneal Dystrophy Unspecified
    –   371.52 Other Anterior Corneal Dystrophy
    –   371.57 Endothelial Corneal Dystrophy
    –   371.60 Keratoconus Unspecified
    –   371.61 Keratoconus Stable Condition

                                                          JAM
         92025 Corneal Topography
   ICD-9 Codes that Support Medical Necessity
    –   371.62 Keratoconus Acute Hydrops
    –   372.40 Pterygium Unspecified
    –   996.51 Mechanical Complication Prosthetic Corneal Graft
    –   V42.5 Cornea Replaced by Transplant
    –   V45.61* Cataract Extraction Status
    –   V45.69* Other States Following Surgery of Eye /Adnexa
    –   *367.22 must be accompanied by V45.61 or V45.69
    –   *V45.61 must be accompanied by 367.22
    –   *V45.69 must be accompanied by 367.22
                                                            JAM
Special Anterior Segment Photography
               92286
   With specular endothelial microscopy and cell count
    –   Ex: Konan specular microscope
 Bilateral
 Not Bundled
 Requires Interpretation and report
 Fee       $101.04



                                                     JAM
Special Anterior Segment Photography
               92286
   364.00-364.04 iridocyclitits
   364.10-364.11 chronic iridocyclitis
   364.21 Fuch’s heterochromic iridocyclitis
   364.22 glaucomatocyclitic crisis
   364.23 lens induced iridocyclitis
   364..24 VKH syndrome
   364.51 essential iris atrophy
   364.52 iridoschisis
   364.53 pigmentary iris degeneration
   364.54 pupillary margin degeneration
                                                JAM
Special Anterior Segment Photography
               92286
 364.55 Miotic Cysts of pupil margin
 364.56-364.61 degenerative changes of anterior
  structures
 366.21-23 Traumatic cataract
 366.32 cataract in inflammatory disorder
 366.33 cataract in ocular neovascularization
 371.20-24 corneal edemas
 371.32-33 folds or rupture in descemet’s membrane
 371.50, -.57,-.58, corneal dystrophy
                                                 JAM
Special Anterior Segment Photography
               92286
   371.82 corneal edema due to contact lens
   379.31 aphakia
   379.32 subluxation of lens
   379.32 anterior displacement of lens
   743.20-23 buphthalmos
   906.5 late effect of burn of eye/face
   940.2 alkaline burn of cornea/conj
   940.3 acid burn of cornea/conj
   940.4 other burn of cornea/conj
   V42.5 cornea replaced by transplant
                                               JAM
Special Anterior Segment Photography
               92286
   996.51 mechanical complication of prosthetic corneal graft
   996.60 infection/inflammation due to unspecified implant and
    graft
   996.69 complication of other implant or graft
   998.89 complication of other transplanted organ
   998.59 other postoperative infection
   998.82 cataract fragments in eye following cataract surg
   V53.1 fitting & adjusting specs or CL after intraocular surgery


                                                              JAM
        B Scan Ultrasonaography

   Ocular ultrasound
    –   Ex: Accutome B Scan Plus
 Unilateral
 Not Bundled
 Requires Interpretation and report
 Fee      $



                                       JAM
        Accutome B Scan Plus
 Model 24-6100
 Portable
 High definition
 0.015mm resolution (highest in industry)
 State-of-art probe design
    –   Plugs into any laptop or PC
 2X full zoom
 Excellent software data analysis
                                             JAM
                  Pachymetry
                     76514
 Bilateral
 Measurement of central corneal thickness (CCT) proven
  by Ocular Hypertension Treatment Study (OHTS) to be
  standard of care in diagnosis and management of
  glaucoma, glaucoma suspect and ocular hypertension
 Also billable for keratoconus, corneal transplants,
  cataracts with corneal dystrophies, guttata, edema
 Requires Interpretation & Report
 Fee       $11.92
                                                 JAM
CCT Assessment
   Has become standard
   Equipment widely available
     – DGH was used in OHTS
     – Low cost
   Consider potential effect of
    LASIK on IOP findings
   Also billable for non-
    glaucoma ICD-9 codes
    –   Corneal edema, keratoconus
Reichert IOPac
    Portable, battery op.
    Stores up to 1000 pats.
    USB and infrared interface
    Down load to PC and printer
  Detachable       probe
      –   Easily replaced if necessary
  Download        PDR into Palm
                            Pachymetry
   IOP correction by correlation to corneal thickness is NOT
    POSSIBLE!
    –   A linear relationship does not exist!
    –   Careful examination of regression analysis (scatter graph of IOP
        relative to CCT) demonstrates huge bandwidth
   Adjusting IOP by CCT instills a degree of accuracy into an
    inaccurate measurement
   It is possible to adjust the IOP in the WRONG direction
   Barbados study of black patients shows no correlation of
    CCT/IOP
   “Trying to be more precise than this is not supported by the data
    and may be harmful to patient care” Jamie Brandt, MD Dir
    Glauc Src, UCD / OHTS investigator
                                                                           JAM
                  Serial Tonometry
                          92100
 Bilateral
 Requires Interpretation & Report
    –   Example: Angle closure glaucoma
    –   multiple measurements over time
   Fee       $55.91-




                                          JAM
PASCAL at work:
   Slit lamp mounted
   Technique similar to
    GAT but…
   Constant light pressure
   No fluorescein
   Self-calibrating
   Battery operated
          Pascal DCT
   Measures
    –   Ocular Pulse Amplitude
    –   (OPA)
    –   IOP
    –   Quality (Q)
    –   Heart Pulse (H)
   Stores data
The PASCAL SensorTip
   Contour-matched concave tip
    surface (7mm)
     –   Accurate for corneal radius 5.5-
         9.2mm and CCT 300-700
   built-in pressure sensor (1.2mm)
   transparent tip permits view of
    cornea interface for centering and
    control
Comparison of DCT With the GAT
 Univ. Of Zurich
 228 eyes measure with DCT and GAT
 Compared IOP measurements
 Looked at effects of:
   –   CCT
   –   Corneal curvature
   –   Astigmatism
   –   AC Depth
   –   Axial length
 Intra-observer    and Inter-observer variability
    DCT vs. GAT
 DCT median difference: DCT +1.7mm higher than
  GAT
 GAT: Affected by CCT, curvature, astigmatism, AC
  depth and axial length
 DCT: NO EFFECT with any parameters
     DCT vs. GAT
   Intra-observer variability
    –   GAT 1.1mm
    –   DCT 0.65mm
   Inter-observer variability
    –   GAT 1.28mm
    –   DCT 0.44mm


               Kaufman et. al. IOVS 2004; 45:3118-3121
    IOP Measurements Using DCT After
    LASIK
   “Corneal ablation of 90.0+/-49.18microns reduced
    IOP as measured by GAT by 3.0+/-mm. ..no
    significant change in IOP was recorded by DCT(-
    0.2MM)”




                  Kaufmann C, et al IOVS 2003; 44:9:3790-3794
Biomechanical Properties in Tonometry
   Flatter corneas = lower IOP
   Thinner corneas = Lower IOP
   Softer corneas = lower IOP
   Stiffer IOP = higher IOP
   How accurate is Goldmann in thick, soft cornea?
   How accurate is Goldmann in thin, stiff cornea?
   Pascal DCT removes biomechanical properties from
    measurements
   Cannot correct IOP using thickness alone!
    –   Linear correction factors of GAT will not accurately correct IOP
DCT in Ectatic Corneas
 Study of 53 eyes at Will’s by Ozbek & Cohen
 Included eyes with keratoconus, Pellucid Marginal
  Degeneration and penetrating keratoplasty
    –   Topography = 54.7 X 43.6
    –   CCT = 482
    –   DCT = 16.1 / GAT = 14.3 / TP = 13.8
 DCT were not different between PMD, KC, PK
 DCT were not affected by corneal steepening
     Conclusions
   “IOP measurements by DCT are highly concordant with
    IOP readings obtained by GAT but do not vary in CCT
    and have a lower intra- and inter-observer variability.
    DCT seems to be an appropriate method of tonometry
    for routine clinical use”
 James Brandt, MD
 Director Glaucoma Services
 UC Davis

“Assuming that CCT can be used
 as a correction factor for GAT is
 a misinterpretation of the results
 of OHTS… that couldn’t be
 further from the truth. Adjusting
 IOP based on CCT is attempting
 to instill a degree of precision
 into a flawed measurement. You
 may actually correct in the
 wrong direction. The issues
 related to the most accurate
 tonometry need to include the
 material properties of the
 cornea”
Ocular Pulse Amplitude (OPA)
 Amplitude  and shape of OPA are easily observed with DCT
 OPA is a function of
  –   Vascular geometry & flexibility
  –   Ocular rigidity
  –   Systemic blood pressure
 Can  be used to assess ocular perfusion
 Data now suggests a correlation between OPA & Ocular
  rigidity…and hence between OPA & risk of glaucoma
  progression
           A. Harris, PhD (Indiana University)
    Latino Eye Study
 How often is GAT significantly low?
 Median difference between DCT & GAT studied

    – >4.5mmHg = 10.6%
    – >5.5mmHg = 4.4%
    – >6.5mmHg = 2.5%

 Increased   IOP still most common factor
    in optometric practice converting
    normals to glaucoma suspects
IOP Measurements By DCT After LASIK
  “Corneal ablation of 90.0 +/- 49.18u reduced IOP
   as measured by GAT by 3.0mm...no significant
   change in IOP was recorded by DCT (-0.2MM)”
  Clinically validated by manometric studies of
   true intracameral pressure
  LASIK case volume in US is 7,401,400
     –   GAT DOES NOT WORK!

                  Kaufmann C, et al IOVS 2003; 44:9:3790-3794
Case of “I Have A Peculiar Nerve”
 45yowm CC: “OD wants R/O Papilledema”, Indistinct
  optic discs, IOP 20-25 range, pach 637
 PH: Hodgkin’s disease, R hip replacement, 3 vessel
  CABG, HTN, Hyperlipidemia
 FH: + POAG paternal aunt
 Meds: Darvocet,Amitryptilline, nitrate, isosorbide,
  norvasc,toprol, plavix, lipitor, ASA
 VA 20/20 OU PERRL-APD
 IOP: 26/23     Pach: 639
 SLE: Nl OU      Fundus : As shown
    What is the diagnosis?
 1.   Normal optic nerves
 2.   Papilledema
 3.   Optic nerve drusen
 4.   Ocular histoplasmosis
 5.   Choroidal nevus
    What tests are indicated?
 1.   VF / Pach / SCODI / Stereo disc photos
 2.   MRI
 3.   MRI / VF
 4.   Histoplasmosis titres
 5.   IVFA / VF
Case of “I Have A Peculiar Nerve”
   45yowm CC: “OD wants R/O Papilledema”,
 DCT OD: 24.9 / OPA 4.4 / Q3
 DCT OS: 23.1 / OPA 3.8 / Q3
 SLE: Nl OU Fundus : As prev
 VF OD: Superior and inferior nasal defects
 VF OS: minor changes
 SCODI: Confirms disc elevation limited to disc itself
                   Visual Field 9208x
 Bilateral
 Requires Interpretation
    –   separate report form
    –   narrative in body of medical record, on date of service
   Fee $43.88- (-81)       $57.37+ (-82)       $65.92- (-83)




                                                                  JAM
       Oculus Easy Field Perimeter
 Screening   AND Threshold
  fields
 Color LCD-Display
 Fixation monitoring
   –   CCD camera
 Stores up to 40,000 exams
 Built-in printer
        FDT Perimetry Abnormalities as
        Predictors of Glaucomatous VF Loss
   105 eyes of 105 glaucoma suspects
    –   IOP 23mm+ or disc damage on photos
    –   SAP VF normal
 Baseline FDT obtained
 Mean follow-up 41 months




           Medeiros FA, et al AJO 137:863-871, 2004
FDT as Predictor of VF Loss

 16% (17 pats.) converted on SAP VF
 In pats. with abnl. FDT at baseline:
    –   Probability of developing abnl. SAP:
    –   30%
   Pats. With NL FDT at baseline:
    –   Probability of developing abnl. SAP:
    –   4%
FDT as Predictor of VF Loss

 Location of the FDT and SAP defects corresponded
  in 14 of 17 patients
 FDT defects in 59% of the converters occurred as
  much as 4 years before SAP
    –   Mean: 21 months
However…..

 Only 59% of SAP defects were previously
  identified by abnl. FDT
 24% had SAP defects BEFORE FDT
 18% of converters NEVER developed FDT
  defect
 24% of normal SAP’s showed abnl. FDT but
  never developed abnl. SAP
    –   False positives?
    Other Important VF Studies
 Paczka (2001) - found FDT better overall performance
  in detecting damage than RNFL photographs
 Kondo (1998), Wu (2001) - In patients with SAP VFDs
  restricted to 1 hemifield, FDT has shown to be able to
  detect functional losses in the other hemifield
 Medeiros (2004) – functional defects in FDT predict
  future defects on SAP
    Other Important VF Studies
   Kim (2007/AAO) – when SAP is normal, some patients
    with VFD detected by FDT showed decreased NFL
    thickness (OCT)
    –   Provide evidence that coincident FDT & OCT abnormalities
        may be an early sign of glaucoma
    Visual Field Testing for Specific
    Functions
   Short wavelength autoperimetry (SWAP)
    –   Bistratified ganglion cell (9%) short-wavelength cones
   Frequency doubling technology (FDT)
    –   Magnocellular ganglion cells
   Motion automated perimetry (MAP)
    –   Magnocellular ganglion cells (3%)
   High pass resolution perimetry (HPRP)
    –   Parvocellular ganglion cells
     Visual Field Testing for Specific
     Functions
   Standard Autoperimetry (SAP)
    –   Achromatic perimetry
    –   Non-specific for ganglion cell type
    –   Appreciable portion of nerve fibers lost before defect measured
   Short wavelength autoperimetry (SWAP)
    –   440nm, 1.6degree tartget @ 200ms yellow background
    –   More sensitive by 3-5 years to early loss
            UCD studied for over decade
    –   Disadvantages – time consuming, variable, not bright enough to
        threshold in advanced POAG
    Visual Field Testing for Specific
    Functions
   Frequency doubling technology (FDT)
    –   0.25 cycle/sec sinusoidal grating with 25Hz counterphase
        flicker
    –   View grating at low spatial frequency and high temporal rate
    –   Percept is double frequency illusion attributable to subset of
        magnocellular ganglion cells
    –   Portable, fast, reproducible
    Visual Field Testing for Specific
    Functions
   Motion automated perimetry (MAP)
    –   Tests Magnocellular ganglion cells (3%)
    –   Present random dot kinematogram with coherent motion on
        uniform grey background in 14 locations
    –   Computer controlled stimulus (1024x768), 30degree field, 7
        frames in rapid succession (420ms), 20 dots/frame, in circular
        7.3 degree angle, moving at 8 degree/sec
    –   Superior to SAP in early detection, but time consuming and
        high variability
    Visual Field Testing for Specific
    Functions
   High pass resolution perimetry (HPRP)
    –   Parvocellular ganglion cells system detection
    –   Test presents spatially filtered rings, 50 test locations in
        30degree field, 14 different ring sizes used @165 ms
    –   6 minutes, easy
    –   Very useful in following progression
    –   Lacks standardization
    A Comparison of Humphrey SITA-
    Standard Perimetry With Both Screening
    Oculus Easyfield Perimetry And With
    Screening FDT
   Seitzman,G.D., Robin,A.L., et al
    –   Dept. of Oph., Johns Hopkins University
    Objective
   To determine the sensitivity and specificity of the
    screening modes of the Oculus Easyfield Perimeter and
    Frequency Doubling Testing when compared with SITA
    standard threshold perimetry.
     Methods
   One hundred one subjects had the following perimetric
    testing: Frequency Doubling Technology (screening
    mode), Oculus Easyfield Perimetry (suprathreshold
    mode), and Zeiss Humphrey SITA Standard C-24-2
    threshold perimetry.
     Results
   The sensitivity and specificity of detecting any
    glaucomatous visual field defect using an abnormal
    Glaucoma Hemifield Testing criterion was 76% and
    89% for the FDT and 86% and 98% of the Oculus
    Perimeter, respectively.
     Conclusions
   Both smaller screening perimeters were relatively quick.
    Although the Oculus was just 30 seconds slower than
    the FDT, its increased sensitivity and specificity could
    be much more cost effective in the treatment of
    glaucoma.
    Octopus 301 Perimeter
 Motorized   auto eye tracking
 100% fixation control
 Blazing fast speed
 Ergonomic design patient friendly
 Blue yellow testing in 3 min/eye
 Critical fusion testing
 One min screen
 Three min full threshold
 PeriTrend Analysis
 LAN ethernet
 800.787.5426
 www.haag-streit.com
     Current Perimeters are Highly
               Variable
   After one abnormal visual
    field test:                                                % Patients Returning to "Normal"
     – 86% of patients test within
                                                                   86%
       normal limits on next                                                        66%
       exam

   After two consecutive
    abnormal test results:                                           1                2
     – 66% of patient test within                              Number of Consecutive VF Tests
       normal limits on next
       exam1
         3.Keltner JL, et al. Arch Ophthalmol 2003; 121:643.
    Heidelberg Edge Perimeter
 New “Flicker Defined Form” Stimulus
 Overcomes limitations in Frequency Doubling
  Technology
 True targeting of M-cell visual pathway
 Less test-retest variability
 Direct link to HRT optic disc assessment
    Flicker Defined Form (FDF)
            Targets M-cells
 The magnocellular (M-cell) pathway is one of the three
  main neural pathways from the retina to the primary
  visual cortex
 M-cells may be the first to sustain damage in
  glaucoma2,3
 There are fewer M-cells so selective testing can find
  defect to all cells earlier4
 FDF selectively targets the M-cells which are sensitive
  to high frequency and high contrast stimuli

    5. Glovinsky et al. Retinal ganglion cell loss is size dependent in experimental glaucoma. IOVS. 1991;32:484-491
    6. Kerrigan-Baumrind et al. The number of ganglion cells in glaucoma eyes… IOVS. 2000;41:741-748
    7. Johnson CA. Psychophysical measurement of glaucomatous damage. Surv Ophthalmol. 2001;45:313-318
     How is Flicker Defined Form (FDF)
     Different ?
   Frequency Doubling Technology is not as selective at
    stimulating the M-cell pathway as previously thought5

   Standard Automated Perimetry stimulates all retinal cells
    (broadband stimulus)

   FDF is more selective and targets the M-cell pathway

   FDF studies show less test-retest variability
      8..Quaid PT, Simpson TL and Flanagan JG. Frequency Doubling Illusion: Detection vs. Form Resolution. Optom Vis Sci. 82(1): 36-42, 2005.
    HEP: The New Perimeter for
    Glaucoma Management
 New FDF stimulus for
  early signs of glaucoma
 Less test-retest variability
  for improved diagnosis
 Structure-Function Map
  for combined assessment
 Network-ready
 Test types
   – Contrast sensitivity
   – Letter tests
   – Driving test
     Closing Statements
    Advances in perimetry are continuing
    –   Faster third generation algorithms reduce test time by 50%
   Customization for specific needs
    –   Early detection / established glaucoma / screening
   Early VF loss is often selective, with specific types of axons
    disturbed
    –   SWAP allows early recognition, HPRP follows progression
   SAP perimetry will continue to be preferred for established
    glaucoma with VFDs
    –   Considerably improved methods of computer-assisted interpretations
        of serial VFs
   Screening methods will sacrifice sensitivity for specificity and
    ease of use to detect the half of glaucoma patients who have
    undiagnosed disease
    –   Deployed in non-professional environments
    Closing Statements
 Perimetry is a robust method of examination, a cornerstone of
    glaucoma management and will remain so
   It will become more user and patient friendly
   VF testing is easy to administer (technician)
   VF instruments are not expensive
   VF testing can still be performed in cataract patients
   Computer-assisted analysis (ie Glaucoma Hemifield Test)
    performs as well as trained observers and are extremely
    specific
    –   Asman Arch Ophthalmol 1992
   Closing Statements
 Standard SAP testing is not optimal
 Combination testing of 2 or more modalities improves
  detection
 Glaucomatous optic atrophy may precede currently
  measurable functional loss in some
 Functional loss with specific tests may precede
  detection of glaucoma disc changes on stereo
  photograph review
 Most sensitive test may be different for each stage of
  the disease
                  Fundus Photography
                        92250
   Bilateral
   Not Bundled
   Stereo disc photography
   Requires Interpretation
   Fee $73.67+




                                       JAM
    Fundus Retinal Photos ROI
   Synemed (Canon)
   Cost $24,500.00
   Lease $543.90
   Breakeven 2 photos / wk
   6 MP digital non-mydriatic
   10 images / wk – lease =
    $22,273.20 annual revenue
            Extended Ophthalmoscopy
               92225 / 92226
 Unilateral
 Initial (-225) vs. Subsequent (-226)
 Implies detailed, extra ophthalmoscopy
    –   document fundus lenses used
 Modifiers RT /LT
 Requires retinal drawings & interpretation
    –   sizes, colors and dimensions carrier specific
   Fee        92225 ($22.23+)         92226 ($20.01+)
                                                         JAM
Scanning Computerized Ophthalmic
          Diagnostic Imaging
             92135
 Unilateral
 Applies to glaucoma and retinal evaluations
    –   Retinal Thickness Analyzer (RTA)
    –   Heidelberg Retinal Topography (HRT3)
    –   Humphrey Optical Coherence Tomography (OCT)
    –   Laser Diagnostic Technology (GDX VCC)
 Requires Interpretation & report
 Fee     $45.59-
                                                      JAM
                 Scanning Laser
              Covered Diagnosis List
 362.85 retinal nerve fiber bundle defects 377.00-377.04
 364.22 glaucomatocyclitic crisis           Papilledema
 364.53 pigmentary iris degeneration
 364.73 goniosynechiae
 364.74 pupillary membranes
 364.77 recession of the angle
 365.00-365.9 glaucoma
 368.40-368.45 visual field defects
 377.9 unspecified disorder of optic nerve or pathways
                                                     JAM
                             Scanning Laser
                                92135
   Moderate Damage - payable once or twice per year, not
    with a field
    –   Visual field examples
           moderate reduction in retinal sensitivity
          temporal wedge

    –   Optic Nerve examples
          enlarged cup with sloped or pale rim
          focal notch
          rim/disc >0.1 but <0.2
          prominent lamina cribrosa
                                                        JAM
                            Scanning Laser
                               92135
   Advanced Damage - rarely payable, fields more
    valuable
    –   Visual field examples
          lossof central vision
          temporal island remains
          severe reduction in retinal sensitivity
          absolute defects to within 3 degrees of fixation

    –   Optic Nerve examples
          rim destroyed
          rim/disc ratio<0.1
                                                              JAM
       GDx VCC
   Image acquisition in less than
    1 second
   Uses internal fixation device
   Compact, table-top design
   Portable
   Easiest to use
   Comfortable, objective test for
    patients
   Easy interpretation
     What’s NEW in the HRT3
   OHTS Ancillary Study Results
   GPS Glaucoma Probability Score
   Enhanced Glaucoma Analysis
   Enhanced Progression Software
   Portable Design
   More operator friendly
   Choose from four packages
    Top 5 Stereometric Parameters
 Rim Area
 Rim Volume
 Cup Shape Measure
 Height Variation Contour
 Mean RNFL Thickness
DIAGNOSE: CUP, RIM & RNFL
                Optic disc size measure and
                 “small”, “average” and
                 “large”
                Parameters adjusted for disc
                 size
                Largest normative database
                Ethnic-selectable
                OU asymmetry
                RNFL normative data
                Quality Indicator
                Conclusion:
                 Complete Assessment
Monitor Change Over Time
 Baseline   compared to follow-up images
  –   Absolute change calculated
 Progression   Change Probability Analysis
  – Pixel by pixel comparison
  – Independent of reference plane
  – No contour line is needed

 Progression   Trend Report
  –   Normalized stereometric parameters graphically displayed
 How Predictive is the HRT?
 Moorfields   Regression Analysis – measures
  rim area & adjusts for disc size
 40% of patients flagged at baseline as “outside of
  normal limits” by Moorfields Temporal Superior sector
  analysis developed glaucoma.
 26% of patients flagged at baseline as “outside normal
  limits” by Moorfields Global analysis developed
  glaucoma
 90% of those with normal HRTs did not develop
  glaucomatous damage over the next 5 years
    Glaucoma Probability Score (GPS)
 What if we could take the world’s leading glaucoma
  experts and use their combined knowledge to help you
  diagnose your patients?
 The Glaucoma Probability Score takes the first step in
  this direction by applying machine learning to glaucoma
  diagnostics.
GPS Advanced Artificial Intelligence
 "Find a bug in a program, and fix it, and the program
  will work today. Show the program how to find and
  fix a bug, and the program will work forever."

- Oliver G. Selfridge, in AI's Greatest Trends and
  Controversies
    Glaucoma Probability Score
 A new approach to optic disc analysis
 6 years in development
 Applies the latest in artificial intelligence to glaucoma
  diagnostics – “Relevance Vector Machine”
 Produces an understandable indicator - probability of
  disease
 Eliminates the need for contour lines or reference planes
    GPS How It Works
   Uses same HRT scan as in the past
   Performs 3-dimensional shape
    analysis
   Relevance Vector Machine is              Healthy

    “trained” to look for glaucoma
   Measures 5 key parameters
   3 parameters represent cup shape and
    2 represent RNFL
                                           Glaucomatous
    Case of the “Ocular migraine?”
 Age: 43yowm CC: “Flashes of light”
 HPI: 20mins / OU / once / 3L soda/Day / -HA, nausea,
  vomiting / overweight
 Meds: synthroid    Allergy: none
 BVA: OU 20/20 Pupils: PERRL-APD          EOM: full
  EXT: NL, CA auscultation Nl
 Pach: 528/532 SLE: Nl OU IOP 24/24,17/17
 VF: normal Optic N: OD 0.80 OS 0.65
 OcHx: Mother & brother susp ONH & Nl VFs
3-D Thickness Map
                       Thickness Map with
                        adjustable opacity

                       Can be rotated to
                        change perspective

                       Floor shows reflectance
                        image to help orient
                        user
    Support Literature
   Heidelberg Engineering website:
    www.heidelbergengineering.com
    –   Complete list of published articles on all products
    –   Abstracts of published articles
    –   Condensed summary of the supporting literature for main
        topics of interest
    –   Downloadable tutorials for all HE products
  RTA
Early
Complete
 & Reliable
      Diagnostics

                    John A. McGreal Jr., O.D.
    Optic Nerve Consult
 27 yowf with optic atrophy
 HPI OD / 3w / mild /MVA 7 yrs ago / head
  trauma, concussion, multiple fractures
 Meds: rhinocort, patanol, OCs
 OcROS: PAC, DSCLs
 BVA 20/20 OU        IOP: 18OU        Optic
  nerve pallor OD
    Assessment / Plan
   Optic atrophy OD
    –   Order RTA
    –   Order VF
    –   Order Fundus photo
     Assessment / Plan
   Optic atrophy OD with field defect
    –   Order MRI of brain and orbit, R/O mass lesion of chiasm or
        optic nerve, MS
Case of Black Out
  32 yobf Transient loss of vision / OU /
   painless / obese
  HA / constant / dull / AM worse /
   cholesterol elevated
  Meds:Glucatrol, Wellbutrin
  VA 20/20 OU IOP: 17 OU
  Fundus: elevated ON heads OU, Mild non-
   proliferative DR
   What is the diagnosis?
    Papilledema
 Drusen of optic nerve
 Bilateral optic neuritis
 Ischemic optic neuropathy
    Assessment / Plan
 Order VF
 Order Fundus photo
 Order RTA
 Order BP
        Assessment / Plan
 Probable pseudotumor cerebri
 Must rule out mass lesion
    –   MRI of brain and orbit
   Must confirm elevated CSF
    –   Lumbar puncture
   Anomalous discs are diagnosis of exclusion
    with burried drusen likely cause
Case of “Macular Hole”
    21yowm CC: “have holes in my eye”, denied LASIK
    HPI: OU / 1 mos duration / gradual loss / no pain
    Meds: Atenolol, ASA        NKDA
    BVA: 20/80 OD 20/100 OS         PERRL No APD
    EOM: Full       EXT: W&Q
    SLE: nl, IOP: 13 OU
    Fundus: as pictured
What is the diagnosis?
    1.   Epiretinal membrane
    2.   Cilioretinal artery occlusion
    3.   Macular drusen
    4.   Macular hole – full thickness
    5.   Macular hole – partial thickness
What eye test would you order now?
 1.   IVFA
 2.   Visual fields
 3.   RTA
 4.   ERG
What should you do now?
  1. Take a refresher course in ophthalmoscopy
  2. ERG
  3. Retina consult
  4. Buy stock in scanning laser companies
What is the diagnosis?
   1.   Epiretinal membrane
   2.   Cilioretinal artery occlusion
   3.   Macular degeneration – atrophic type
   4.   Cone dystrophy
   5.   Macular hole – partial thickness
    Benefits of RTA
   State of the art SCODI
   New paradigm in glaucoma diagnosis
   New paradigm in retina diagnosis
   Improves clinical decision making
   Improves quality of care
   Generates additional revenue
   Take advantage of unprecedented tax incentives
    for new equipment
Optical Coherence Tomography OCT
Optical: Light-based
Coherence: property of light waves in which the
 oscillations maintain a fixed relationship to
 each other
Tomography: Cross-sectional imagery
 How OCT works

 Similar to ultrasound but uses light instead of
  sound to image tissue
 Beam of light is directed into tissue and
  reflections coming from different layers of the
  tissue are received by a detector
    Stratus OCT Software

 Macula  Thickness
  Analysis
 RNFL Analysis
 ONH Analysis
    RNFL analysis

   Circular scanning around ONH
    at a radius of 1. 73mm
   Scan begins temporally
   Three scans are acquired and
    data is averaged
    Optic nerve head analysis


   Radial scanning across
    optic nerve head
   Six 4mm scans are taken
            Optic Nerve Head Parameters
   Volumetric Information
    –   Volume of Cup
   Dimensional
    Information
    –   Disk Area
    –   Cup Area
    –   Rim Area
   Cup Disk Ratios
    –   Horizontal
    –   Vertical
    –   Average
     Ophthalmic Genetics
   Researchers have identified genes for OAG
    –   TIGR/Myocilin = juvenile OAG
    –   OPTN (optineurin) = Primary OAG (NTG)
            Optineurin may provide neuroprotection to optic N
    –   CYP1B1 = Congenital glaucoma
   Genetic testing will allow clinicians to determine if Pt is
    predisposed to or affected with specific type of glaucoma, even
    before symptoms appear
   OcuGene (InSite Vision/Alimeda) – simple, in office test, 99%
    accurate detection of TIGR (trabecular meshwork inducible
    glucocorticoid response gene)
    –   Positives may be treated more aggressively, earlier
    Blood Flow Analysis
 Paradigm/Dicon
 TonoPlus Tonograph
    –   Pulsatile Ocular blood flow analysis
    –   Identifies ocular ischemic syndromes
    –   Reimbursable procedure
    –   Small laptop size
    Anti-Glaucoma Agents

   Non-Selective B-Adrenergic Antagonists
    –   Timolol (Timoptic 0.25%, 0.50%, XE, Istalol/Ista
        Pharmaceuticals)
    –   Levobunolol (Betagan 0.25%, 0.50%)
    –   Metipranolol (Optipranolol 0.3%)
   Selective B-Adrenergic Antagonists
    –   Betaxolol (Betoptic-S 0.25%, 0.50%)
    –   Levobetaxolol (Betaxon)
    –   Carteolol (Ocupress 1.0%)
    Anti-Glaucoma Therapy
   Adrenergic Agonists
    –   Dipivefrin (Propine 0.1%)
    –   Epinephrine (Epinal,Eppy-N, Epifrin, Glaucon)
    –   Apraclonidine (Iopidine 0.5%, 1.0%)
    –   Brimonidine (Alphagan 0.2%, Alphagan P-0.1%, 0.15%) /
        Timolol (Combigan)
            41% less ocular allergy with Alphagan P vs Alphagan over 12 months
            Only ophthalmic glaucoma drug without BAK
   Cholinergic
    –   Pilocarpine (Pilocar 0.50% - 8.0%, Pilogel 4%)
    –   Carbachol (Carbachol 0.75%, 1.5%, 2.25%, 3%)
    –   Echothiophate Iodide (0.03%, 0.06%, 0.125%, 0.25%)
    Antiglaucoma - CAI
   Topical
    –   Dorzolamide (Trusopt)
    –   Dorzolamide-Timolol (Cosopt)
    –   Brinzolamide (Azopt)
   Oral
    –   Acetazolamide (Diamox)
    –   Methazolamide (Neptazane, MZM)
    –   Dichlorphenamide (Darinide)
        Anti-Glaucoma Agents
   Prostaglandin Analogue
    –   Latanoprost (Xalatan 0.005%)
    –   Bimatoprost (Lumigan 0.03%)
    –   Travoprost (Travatan 0.004%/ Extravan with timolol 0.5%)
    –   Travaprost (Travatan Z 0.004%) – No BAK
    –   Unoprostone (Rescula 0.15%)
   Pipeline
    –   DE-085 (Santen) prostaglandin based; phase II
    Profile of a Desirable Alternative IOP
                Lowering Agent
 BAK-free formulation
 Unsurpassed IOP-lowering efficacy
 Enduring IOP-lowering efficacy
 Well-tolerated
 Multi-dose bottle
 Same cost as current agents
 Anti-microbial activity meeting or exceeding
  regulatory standards


                                                 G
                Summary & Conclusion
   Ocular Surface Disorder (OSD) has a significant presence in
    the glaucoma population
   OSD signs & symptoms are often under-appreciated by
    doctors
   Chronic, long term use of benzalkonium chloride (BAK)
    contributes to OSD
   Glaucoma patients are at an added risk of OSD
   A BAK-free IOP-lowering medication is needed
   Current BAK-free IOP-lowering alternatives have
    significant limitations
   TRAVATAN® Z Solution represents the first and only
    IOP- lowering PGA medication without BAK
                                                             G
     Low Tension Glaucoma
   Compromised ocular blood flow
   50% have a cause / find it / fix it
    –   Past hx transfusions, bleed, hypovolemic
    –   Medications: B-blockers, digoxin, digitalis
    –   MRI: orbits & brain
    –   R/O all cardiovascular causes of LTG
            CBC/anemias, CA doppler, TEE, sleep studies, coagulaopathies (PTT), overly
             fit (low BP)
   Treatment
    –   Decrease IOP, avoid B blockers, start with PG, bromonidine, CAIs
        last resort
    –   Ginko biloba 60mg/D: inc fluidity without affecting platelet
        aggregation
    Surgical Glaucoma Therapy
 Argon Laser Trabeculoplasty (ALT, LTP)
 Selective Laser Trabeculoplasty (SLT)
    –   Q switched Nd:YAG selectively targets pigmented
        trabecular cells (increasing activity?)
    –   Increases immune system by increasing monocytes &
        macrophages in TM
    –   Selective because it does not cause appreciable damage to
        TM
    –   50 confluent applications to 180 degrees @0.06mJ
          No   blanching or bubble phase needed
    –   Addresses greatest roadblock = compliance with medical
        therapy
     Surgical Glaucoma Therapy
 Trabeculectomy
 Trabeculectomy with surgical adjuncts
    –   5 FU (lower risk eyes)
    –   Mitomycin-C (MMC) – higher risk eyes
   Indications
    –   Maximum tolerated medical therapy
    –   Progression of disease
    –   Unable to instill medications
    –   Secondary glaucomas (Neovascular glaucoma)
   Consideration
    –   Age, HTN, DM, Anticoagulants, Preop IOP, previous vitrectomy
    –   Degree of visual impairment,
    –   Lens status
    –   Comorbidities
     Surgical Glaucoma Therapy
   Future directions
    –   Newer antifibrinolytics
          CAT-12,    a monoclonal antibody to TGF-B2
    –   Photodynamic therapy
    –   Novel drug delivery systems
                  implants, bioerodable polymers, liposomes &
          Collagen
          microspheres
    –   Glaucoma drainage implants instead of filtering surgery
          Shunts   aqueous from AC tube through an episcleral plate
    –   Ocular genetics
                  genes, gene therapy, primary prevention of glaucoma
          Discover
          may become a reality
            Glaucoma Pipeline
 Extracellular Matrix metalloproteinases
 Oral neuroprotectants - Memantine (Nameda)
 Sustained release formulations
 Anecortave acetate (Retaane/Alcon) – ARVO 2006
    –   Originally studied for ARMD
    –   Steroid that actually LOWERS IOP
    –   No cataract formation
    –   25% decrease in IOP at six months after 1 juxtascleral
        injection
                        Neurologic
   Multiple Sclerosis
    –   Glatiramer (Copaxone)
    –   Interferon B-1b (Betaseron)
    –   Interferon B-1a (Avonex)
    –   Interferon B (Rufab)
          Side effects – macular edema, CRVO, CRAO, CWS, optic
           neuritis, papilledema
          Flu-like symptoms are common for 2 weeks
          Medications are given by injection
          Annual costs range from $12,000-$33,000/year
                              Neurologic
   Optic Neuritis
    –   Controlled High-Risk Avonex Multiple Sclerosis Study
        (CHAMPS), Optic Neuritis Treatment Trial (ONTT)
          Initial   demylinating episode (like ON) treated with interferon
             –   Conclusively showed that treatment with interferon slowed rate of
                 development of MS
          Do  not use oral steroids to treat ON
          Brain MRI obtained in all patients with ON
          If MRI abnormal IV/oral steroid regimen should be used
             –   IV methylprednisolone 100mg q6h x 3d, followed by PO prednisone x 11
                 days
          Abnormal   MRI should be referred to neurologists for
           consideration of interferon treatment
                        Neurologic
   Optic Neuritis
    –   Optic Neuritis Treatment Trial (ONTT)
    –   Archives Ophthalmology 2003
    –   Reported 10 year risk of developing MS is significantly
        higher if there is a single brain lesion noted on MRI scan
        at the time diagnosis (56% vs. 22%)
    –   The overall 10 year risk is 38%
    –   Male gender, no lesions on MRI and presence of disc
        swelling places a patient at lower risk of developing MS
                   Neurologic / Psychiatric
   Alzheimer’s Dementia – chronic, progressive
    deterioration in global intellectual functioning. Familial
    tendencies, associated with B- amyloid and organic
    changes in the brain. 4.5 million Americans diagnosed
    –   Research at Boston University
          2,581 patients
          79% reduction in risk of developing AD
          Statins reduce cholesterol by blocking enzyme HMG Co-A reductase
          Also interfere with production of B-amyloid

    –   Current treatments target anticholinesterase, target amyloid
        production and gamma secretase
                  Neurologic / Psychiatric
   Alzheimer’s Dementia
    –   Donepezil (Aricept)
    –   Tacrine (Cognex)
    –   Rivastigmine (Exelon)
    –   Galantamine (Reminyl)
   Experimental drugs with promise include Gleevec/Novartis
    which targets proteins that regulate secretase, sage extract,
    raloxifene, huperzin A (cholinesterase inhibitor, Chinese herb)
   Combinations with Memantine (Namenda) are safe and effective
    in moderate to severe AD
   Regular exercise in midlife reduce risk of AD by 50% (Lancet
    Neurol 2005)
    –   20-30 minutes of exercise twice a week
                  Neurologic / Psychiatric
   Alzheimer’s Dementia – 50% develop psychiatric and
    behavioral symptoms
    –   Anxiety, aggression/violent outbursts, paranoid thoughts
    –   Treatment trials and “off-label” use of Depakote
                  tangles and plaques
          Inhibits
          May prevent psychiatric symptoms

    –   Rule out UTI, thirst, hunger, pain, medication side effects
               Neurologic / Psychiatric
   Acute Ischemic Stroke
    –   700,000/yr or one every 45 seconds
          500,000   new, 200,000 recurrent
    –   164,000 deaths/yr, 3rd leading cause of deatths
    –   Cost $56.8 billion in 2005
 Risk factors – HTN, smoking, DM, artery diseases,
  African-Americans twice prevalence
 Treatment
    –   Alteplase (Activase)
    –   Carotid artery stents – option in CA endarterctomy
    –   Brain stents – Boston Scientific’s Wingspan
     Theories on Aging and Eye Disease
   Age related macular degeneration and cataracts are
    associated with age
    –   Leading causes of blindness worldwide
    –   Elderly
    –   Family history, gender, cardiovascular disease
    –   Smoking – nicotine, benzopyrene, nickel, lead and arsenic
    –   Light colored irides and hair
    –   Exposure to UV radiation
    –   Diet – saturated fat intake increases risk for AMD
   Mechanisms – free radical damage, UV damage
    AMD Risk Factors
 Age > 60
 Race W>B
 Sex F>M
 HTN
 Smoking
 Nutrition
 Family History
 Fair complexion
 Cardiovascular disease
                        Neurologic
   Multiple Sclerosis
    –   Glatiramer (Copaxone)
    –   Interferon B-1b (Betaseron)
    –   Interferon B-1a (Avonex)
    –   Interferon B (Rufab)
          Side effects – macular edema, CRVO, CRAO, CWS, optic
           neuritis, papilledema
          Flu-like symptoms are common for 2 weeks
          Medications are given by injection
          Annual costs range from $12,000-$33,000/year
                              Neurologic
   Optic Neuritis
    –   Controlled High-Risk Avonex Multiple Sclerosis Study
        (CHAMPS), Optic Neuritis Treatment Trial (ONTT)
          Initial   demylinating episode (like ON) treated with interferon
             –   Conclusively showed that treatment with interferon slowed rate of
                 development of MS
          Do  not use oral steroids to treat ON
          Brain MRI obtained in all patients with ON
          If MRI abnormal IV/oral steroid regimen should be used
             –   IV methylprednisolone 100mg q6h x 3d, followed by PO prednisone x 11
                 days
          Abnormal   MRI should be referred to neurologists for
           consideration of interferon treatment
                        Neurologic
   Optic Neuritis
    –   Optic Neuritis Treatment Trial (ONTT)
    –   Archives Ophthalmology 2003
    –   Reported 10 year risk of developing MS is significantly
        higher if there is a single brain lesion noted on MRI scan
        at the time diagnosis (56% vs. 22%)
    –   The overall 10 year risk is 38%
    –   Male gender, no lesions on MRI and presence of disc
        swelling places a patient at lower risk of developing MS
                   Neurologic / Psychiatric
   Alzheimer’s Dementia – chronic, progressive
    deterioration in global intellectual functioning. Familial
    tendencies, associated with B- amyloid and organic
    changes in the brain. 4.5 million Americans diagnosed
    –   Research at Boston University
          2,581 patients
          79% reduction in risk of developing AD
          Statins reduce cholesterol by blocking enzyme HMG Co-A reductase
          Also interfere with production of B-amyloid

    –   Current treatments target anticholinesterase, target amyloid
        production and gamma secretase
                  Neurologic / Psychiatric
   Alzheimer’s Dementia
    –   Donepezil (Aricept)
    –   Tacrine (Cognex)
    –   Rivastigmine (Exelon)
    –   Galantamine (Reminyl)
   Experimental drugs with promise include Gleevec/Novartis
    which targets proteins that regulate secretase, sage extract,
    raloxifene, huperzin A (cholinesterase inhibitor, Chinese herb)
   Combinations with Memantine (Namenda) are safe and effective
    in moderate to severe AD
   Regular exercise in midlife reduce risk of AD by 50% (Lancet
    Neurol 2005)
    –   20-30 minutes of exercise twice a week
                  Neurologic / Psychiatric
   Alzheimer’s Dementia – 50% develop psychiatric and
    behavioral symptoms
    –   Anxiety, aggression/violent outbursts, paranoid thoughts
    –   Treatment trials and “off-label” use of Depakote
                  tangles and plaques
          Inhibits
          May prevent psychiatric symptoms

    –   Rule out UTI, thirst, hunger, pain, medication side effects
               Neurologic / Psychiatric
   Acute Ischemic Stroke
    –   700,000/yr or one every 45 seconds
          500,000   new, 200,000 recurrent
    –   164,000 deaths/yr, 3rd leading cause of deatths
    –   Cost $56.8 billion in 2005
 Risk factors – HTN, smoking, DM, artery diseases,
  African-Americans twice prevalence
 Treatment
    –   Alteplase (Activase)
    –   Carotid artery stents – option in CA endarterctomy
    –   Brain stents – Boston Scientific’s Wingspan
                       Lung Cancer
 Most caused by cigarette smoke (90%)
 25% of adult women smoke
 30% of high school women smoke
 13-22% of pregnant women smoke
 Cessation of smoking
    –   Quit by 35 = 6-8 years of life expectancy
    –   Quit by 44 = 6-7 years of life expectancy
    –   Quit by 55 = 3-6 years of life expectancy
    –   Quit by 65 = 1-4 years of life expectancy
    –   55% decrease in heart attack after quitting for one year!
                    Smoking Cessation
 1-7% chance of quitting without help
 Antidepressants
    –   Bupropion (Wellbutrin/Zyban)
   Nicotine replacement
    –   Nicodern CQ Patch (Transdermal Nicotine 21mg, 14mg,
        7mg steps over 10 weeks)
    –   Nicorette Gum (2mg if <25 cigarettes/D, 4mg if >25
        cigarettes/D)
    –   Nicotrol Inhaler
    –   Nicotrol Nasal Spray
    –   Nicotrol Patch
                       Smoking Cessation
   Best new option
    –   Varenicline (Chantix/Pfizer)
          43.9%  quit vs 29.8% quit on bupropion
          Treatment is for 12 weeks, if successful take it 12 more weeks to
           lessen chance of smoking again
          Blocks nicotine receptors in brain and stops “reward” associated
           with smoking again
          Side effects – nausea is mild and tolerable but occurs at 32%, 3%
           discontinued
     Photodynamic Therapy for CNV
   Intravenous infusion of photosensitiser
     – Verteporfin (Visudyne/Novartis)
    –   tin ethyl etiopurpurin (SnET2/Miravant)
   Photoactivation - low level non- thermal 689nm light
    within 15min after starting 10min IV infusion
    –   50j/cm2 of NV lesion @ 600mW over 83secs
Photodynamic Therapy for CNV
   Treatment spot =1000u larger than the Greatest
    Linear Dimension (GLD)
    –   allows a 500u border
    –   established by IVFA & color photography
    –   measure all classic & occult NV, blood +/- blocked
        fluorescence, serous detachment of RPE
          maximum   spot size = 6400u
          recheck every 3 months & retreat if any CNV
            –   Averages 3.4 treatments / year x 1 year
          avoid   exposure to bright light x 5 days
                       New for CNV
   Intravitreal injection- (Pegaptanib / Macugen)
    – Selective VEGF antagonist for classic, occult, and mixed
      forms on CNV
    – Intravitreal injection every six weeks
    – 70% lost <3 lines (27% treatment effect for loss of 3 lines
      or more). Less effect in second year
    – Complications include endophthalmitis, RD, cataract, IOP
      spikes
   Retrobulbar injection - Antecortave (Retaane /Alcon)
 Intravitreal implant – (Fluocinolone / Retisert)
 Intravitreal implant – (Dexamethasone / Posurdex)
         New FDA Approval for CNV
Vascular endothelial growth factor (VEGF/rhuFab V2,/
 Lucentis / Avastin, Genentech)
  –   Therapeutic antibody fragment that interferes/binds with
      VEGF-A, a protein that plays a critical role in angiogenesis
  –   Genentech renames rhuFab “Lucentis”
  –   FDA approval for CNV in AMD
  –   Proven efficacy in MARINA, ANCHOR, PIER & others
  –   Intravitreal injection 0.5mg as 10mg/ml solution
  –   Caution: Increased IOP, endophthalmitis, RD, cataract,
      HTN, HA, thromboembolic events
    New Ideas in AMD
 Sub-subspecialty emerging in Retina
 Devices to measure Macular Pigment Optical Density
    –   Macuscope
    –   QuantifEye (ZeaVision)
   Hyperacuity perimetry
    –   Forsee PHP (Notal/MSS)
 Zeaxanthin is considered important in supplementation
 Combination therapies more common in wet AMD
    AMD Research on Genetics
 Age related macular degeneration gene located
 Encodes for a protein called Compliment Factor H
    –   Increases inflammatory proteins
    –   Increases C-reactive protein
   We now know a genetic component of the disease
    exists!
Components of Ocular Supplements
   Vitamins
    –   Vitamin A as beta carotene
    –   Vitamin C
    –   Vitamin E
   Minerals
    –   Zinc
    –   Copper
    –   Selenium
   Macular pigments
    –   Lutein – macular carotinoid
    –   Zeaxanthin – foveal carotenoid
   Bioflavenoids
    –   Ginko biloba – for AMD and glaucoma (blood flow) and memory
    Treatment Modalities
   Dietary Supplements
    – TheraLife Eye & TheraLife Enhancer (TheraLife)
         Betacarotene, bilberry, chrysanthemum, copper, fructus lycii,
          Vitamin E & C, riboflavin (B2), selenium, semen cassiae, zinc
    –   Hydrate Essential (Cynacon/Ocusoft)
         Essentialfatty acids - Flaxseed oil and bilberry extract
          encapsulated in hydroxylated lecithin
    –   HydroEye (Science Based Health)
         Blend   of omega fatty acids and nutrients
    –   TheraTears Nutrition (Advanced Vision Research)
         EPA    enriched flaxseed oil & omega-3s
     Nutritionals and OTC Vitamins
   Ocuvite Lutein (B&L)
   Ocuvite extra (B&L)
   Ocuvite PreserVision (B&L)
    –   AREDS NIH Study
    –   2 tabs bid
   ICAPS Lutein & Zeaxanthin Formula (Alcon)
   ICAPS AREDS formula
   ICAPS MV
   I-Sense OcuShield (Akorn)
   Maximize
   EyePromise (ZeaVision)
    Nutritionals
 First degree relatives of ARM pts 2-4 times greater risk
  of ARM compared to controls
 Twin studies show high levels of concordance of the
  disease among monozygotic sibs
 Vitamin E may cause bleeding
 Vitamin D may be of benefit
 Diets high in omega-3 FAs are of benefit
 Control of weight, HTN & cholesterol is important
 Diet of green leafy vegetables increase lutein,
  zeaxanthin which increase optical density of macular
  pigment providing protective role
Measurement of Macular Pigment
   Objective Techniques
    –   Modified Fundus Cameras
    –   Fundus Reflectence
    –   Raman Spectroscopy
    –   Autofluorescence Spectroscopy
    –   Modified SLO
   Subjective Techniques
    –   HFP (Heterochromatic Flicker Photometry) (pschyophysical)
    –    (Ability to detect a blue flickering light)
 Is MPOD Related to AMD?
 Three donor eye studies published, all show 30-50%
  less pigment in AMD eyes vs controls
 Moran Eye Center (Bernstein) Raman method
 Manchester UK group HFP method found AMD patient
  eyes had 50% lower MPOD
 Germans found 50% lower MPOD in dry AMD patient
  eyes
 Dutch group did cross sectional prospective study using
  reflectance and found no difference on MPOD in early
  AMD
The AREDS I & II Formulations
    AREDS (Age-Related Eye Disease Study)
    Vitamin C: 500 mg*
    Vitamin E: 400 IU*
    Beta-carotene: 15 mg (May be listed on the label as “25,000 IU
     vitamin A as beta-carotene) (eliminate!)
    Zinc oxide: 80 mg (40 mg)
    Copper: 2 mg (needed to prevent copper deficiency caused by
     high dosage of zinc)
    Lutein & Zeaxanthin 10 mg & 2 mg
    Omega-3 fatty acids 1 gram
    Nutritionals
   EyePromise (ZeaVision)
    –   Zeaxanthin 6mg
          in   the same 1:1 ratio as found in healthy macula
    –   Lutein 6mg
    –   Beta carotene – none
    –   Vitamin C – 120mg
    –   Vitamin E – 60 IU
    –   Zinc – 15mg
    –   Copper – none
    –   Fish oil (omega-3) – 250mg
    –   Alpha Lipoic acid – 10mg
           Flaxseed Oil & Fish Oil
 Flaxseed Oil thins meibomian gland oils and thickens
  the oil layer, but does not suppress inflammation.
 Fish Oil suppresses inflammation, but does not thicken
  the oil layer.
 Flaxseed Oil and Fish Oil work together synergistically
  to stimulate tear and salivary gland secretion.
         Special Flaxseed Oil, Special Fish Oil,
         Special Vitamin E

   Flaxseed oil (short-chain Omega-3s)
    –   Organically grown, cold pressed, and ligand free.

   Fish oil (long-chain Omega-3s)
    –   Molecularly distilled/pharmaceutical grade.

   Vitamin E
    –   Includes just less than 200 IU of Vitamin E.
    –   Includes gamma-tocopherol. Acts synergistically with DHA to
        increase cellular resistance to apoptosis and suppress inflammation
           TheraTears Nutrition
        Vitamin E content
 Other Benefits of Vitamin E
  –   Vitamin E prevents oxidation, maintaining the
      integrity of the oils.
  –   Long-term supplementation with omega- 3s
      depletes serum levels of vitamin E.
  –   Addition of vitamin E to TheraTears Nutrition
      maintains serum levels of vitamin E.
  –   Lacrimal-gland disease-based dry eye has
      oxidative damage in the lacrimal gland and
      depleted levels of vitamin E.
                 How Omega-3s Treat Dry Eye
                 Conclusions
   Dietary deficiency of omega-3s
    or imbalance of omega-
    6:omega-3s can cause dry eye.
   Flaxseed/Fish oil supplement
    effective in treating dry eye and
    dry mouth through
    well-understood mechanisms of
    action.
                   Visual Field 9208x
 Bilateral
 Requires Interpretation
    –   separate report form
    –   narrative in body of medical record, on date of service
 Fee $44.77- (-81) / $46.18
 Fee $58.29- (-82) / $59.09
 Fee $66.96- (-83) / $68.17



                                                                  JAM
Why Is Early Diagnosis Important?

    Earlier Diagnosis    Lesion   size was a more
      Means Better
   Final Visual Acuity
                         significant factor affecting
                         treatment benefit than either:
                             1. Lesion composition
                             2. Baseline visual acuity
                         TAP   and VIP Report 1, AJO, Sept., 2003
Average CNV Presentation

                                          Average size:
                                           –   3300μ

                                          Location:
                                           –   80%     Subfoveal
                                           –   20%     Extrafoveal

                                          Initial Vision:
                                           –   20%     > 20/40
                                           –   40%     20/50 – 20/200
                                           –   40%     < 20/200
   Olsen, TW Ophthalmology Feb. 2004
Inherent Faults of the Amsler Grid
             Completion
              –   The Amsler Grid does not overcome
                  cortical completion
             Fixation
              –   The Amsler Grid does not force
                  fixation
             Crowding
              –   Inhibition by neighboring peripheral
                  lines reduces detection
Foresee PHP™ Technology
                   Vernier Acuity
                  The human ability to perceive
                   minute differences in the relative
                   spatial localization of two objects in
                   space
                  The brain is exceptionally sensitized
                   to the detection of small shifts in the
                   co-linear arrangement of
                   photoreceptors.
   2 sec arc
Hyperacuity
                 Snellen 20/15 Resolution
                   – 1minute of arc
                   – 0.017 degrees

                 Vernier Resolution
                  – Two seconds of arc
                  – 0.03 minutes of arc
                  – 0.00051 degrees
                  – The width of a pencil
                    viewed at 300 m !
The Future of AMD Monitoring
        Foresee PHP™

                 Easy operation
                 Comfortable for patient
                 Noninvasive Rapid threshold test ~
                  5 min/eye
                 Automated results analysis
                 Generates visual field map of
                  disturbance patterns consistent with
                  the progression of AMD
                    Botulinum Toxins
   Toxins type A to G
    –   Blocks neuromuscular transmission by inhibiting the release
        of presynaptic acetylcholine at peripheral neuromuscular
        junctions
    –   Local denervation produces paresis or paralysis with few
        side effects, good duration of action
   Approved for the treatment of focal muscle spastic
    disorders and excessive muscle contractions, such as
    dystonias, spasms, twitches, strabismus
                    Cosmetic Considerations
   Nonsurgical treatments
    –   Botox injections
    –   Laser hair removal
    –   Hyaluronic acid fillers
            Restylane (Medicis)
               –   Perlane (Thicker version waiting FDA approval)
            Hyalform (Allergan)
            Rejuvederm (Allergan)
            Radiesse (Bioform Medical) – lasts twice as long
   Surgical treatments – 12 million in 2005
    –   Liposuction
    –   Breast augmentation
    –   Eyelid surgery
     Thank you
McGreal Educational
Institute
  Missouri inEye Associates
     Excellence Optometric Education

				
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