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Cornea, Contact Lens, and Contemporary Vision Care Symposium

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Cornea, Contact Lens, and Contemporary Vision Care Symposium Powered By Docstoc
					                         27TH
    ANNUAL CORNEA, CONTACT LENS AND
       CONTEMPORARY VISION CARE
              SYMPOSIUM

      DECEMBER 4-5, 2010 HOUSTON, TX




                HANDOUTS


         OMNI HOUSTON HOTEL
             Four Riverway
           Houston, TX 77046




| Continuing Education
                                TURBO CHARGE YOUR PRACTICE
                                            The 27th Annual
                    Cornea, Contact Lens, and Contemporary Vision Care Symposium

                                                         Course Date:
                                                      December 4 – 5, 2010

                                                       Course Location:
                                                      Omni Houston Hotel
                                                         Four Riverway
                                                      Houston, Texas 77046

                                                       Course Agenda

                                                      December 4, 2010
                                                  Saturday Morning Session
7:00    - 8:00      REGISTRATION/CONTINENTAL BREAKFAST/VISIT EXHIBITS


                                                                                   William Miller, OD, PhD
8:00    - 8:40      Clinical Grander Rounds at U.E.I. - Part I
                                                                                   Jan Bergmanson, OD, PhD
8:40    -   9:10    Scleral Lens Easier Than Ever.                                 Edward Bennett, OD, MS




                                                                                                                 COPE ID # 29890-AS
9:10    -   9:30    Scleral Lens – A Viable UVR Filter                             Jan Bergmanson, OD, PhD
9:30    -   10:00   Another Approach to Contact Lens Bifocal Design: Translation   Thomas Baugh, OD
10:00   -   10:30   BREAK/VISIT EXHIBITS
10:30 - 11:10 Update on Diagnosis and Treatment for Dry Eye                        Steve Pflugfelder, MD
                    ‘Is the Limbal Stem Cell Deficiency a Contact Lens Entity?
                    Diagnosis and Management.’
11:10 - 11:40                                                                      William Townsend, OD
                    Does Punctal Occlusion Influence Tear Film Osmolarity
11:40 - 12:00 PANEL DISCUSSION
12:00   1:00 LUNCH/VISIT EXHIBITS

                                                 Saturday Afternoon Session
                                        Combo-Agents-When they are needed the most
1:00    - 1:30      The Latest and Old Work Horses                                 Norman Leach, OD, MS

1:30    - 2:00      Clinical Indications and Recommended Dosages                   Randall Reichle, OD

2:00    - 2:20      Treatment Pearls and Turbocharged Coding                       Clarke Newman, OD             COPE ID # 29891-AS

2:20    - 2:40      PANEL DISCUSSION
                                            Saturday Late-Afternoon Session
2:40    -   3:10    BREAK/VISIT EXHIBITS
3:10    -   3:40    In Pursuit of Happiness – Specs, CLs, or Lasers                Shehzad Naroo, BSc, MCOptom
3:40    -   4:10    Surgical Update                                                John Goosey, MD
4:10    -   4:40    Myopia – Getting Closer!                                       Earl Smith, III, OD, PhD
4:40    -   5:00    PANEL DISCUSSION
                                                     December 5, 2010
                                                  Sunday Morning Session
7:00    - 8:00      REGISTRATION/CONTINENTAL BREAKFAST/VISIT EXHIBITS
                                                                                William Miller, OD, PhD
8:00    - 8:50      Clinical Grander Rounds at U.E.I - Part II
                                                                                Jan Bergmanson, OD, PhD




                                                                                                          COPE ID # 29894-CL
8:50    -      Epidemiology and Clinical Trials – Lifting the Smoke Screen
            9:25                                                                David Berntsen, OD, PhD
9:25    -      The Promise of New Solutions
            10:05                                                               Marc Bloomenstein, OD
10:05   -      PANEL DISCUSSION
            10:30
10:30   -      BREAK/VISIT EXHIBITS
            11:00
                                    Sunday Morning Session Continued
              “UHCO Award for Distinguished Research on the Cornea and Contact Lenses”
11:00 - 11:10 Introduction                                                 Jan Bergmanson, OD, PhD
11:10 - 12:00 GP Lenses Past, Present and Turbo Charging into the Future.       Edward Bennett, OD, MS
12:00 - 1:00 LUNCH/VISIT EXHIBITS


                                                 Sunday Afternoon Session
1:00    - 1:25      Blepharitis – MGD Update                                    William Townsend, OD
1:25    - 1:50      Tarsal Gland Expression                                     William Miller, OD, PhD




                                                                                                          COPE ID # 29893-CL
1:50    - 2:10      TX Options & Coding                                         Clarke Newman, OD
2:10    - 2:25      PANEL DISCUSSION
                                     Sunday Late-Afternoon Session
2:25    - 2:55      BREAK/VISIT EXHIBITS
2:55    - 3:20      Conjunctival Epithelial Flaps – Do They Require Treatment   Norman Leach, OD, MS
3:20    - 3:45      Stay in Practice and out of Court                           Christine Tyler, OD, JD
3:45    - 4:00      PANEL DISCUSSION
4:00    - 5:00      Professional Responsibility Course                          Kevin Gee, OD
                                      Clinical Grand Rounds at UEI

                                        William L Miller, OD, PhD
                                       Jan Bergmanson, OD, PhD

This course is designed to review important concepts relating to diagnosis, treatment and management
of common corneal and anterior segment diseases. The course will expound on important cases seen at
the University Eye Institute concerning disease detection to provide the practitioner with a grand rounds
approach to patient management. Original cases will be introduced to provide a realistic perspective to
the participants. Each disease entity will be considered using a clinical case format. Diseases and
complications of the cornea to be covered include infectious keratitis, contact lens complications,
phlyctenular keratoconjunctivitis, chemical burns, blepharitis, neovascularization and corneal
dystrophies.


Learning Objectives:

    1. To highlight various cornea and anterior segment disease processes in a grand rounds format.
    2. To present the practitioner with diagnostic as well as treatment and management tools for
       handling each of the covered topics.
    3. To enhance the diagnostic capabilities of practitioners in determining the influence of contact
       lens wear on corneal and conjunctival health.
                                                                                                                       11/24/2010




                                                                      GP SCLERAL LENS CATEGORIES (SINDT, CLS Oct., 
                                                                                        2008)
                                                                      •   Corneo‐Scleral:  12.9 ‐ 13.5mm
                                                                      •   Semi‐Scleral:  13.6 ‐ 14.9mm
 SCLERAL LENS EASIER THEN EVER                                        •   Mini‐Scleral:  15.0 ‐ 18.0mm
                                                                      •   Full Scleral:  18.1 ‐ 24+ mm
         ED BENNETT OD, MSED, FAAO
       Assistant Dean for Student Services 
       and Alumni Relations, UM‐St. Louis




                      Indications                                                   Semi‐Scleral Lens  Fitting
• Irregular cornea                                                    •   Rest on sclera
  – Keratoconus / PMD
                                                                      •   Contour the cornea
  – PK
                                                                      •   Limbal clearance
• Severe DES                                                          •   Scleral alignment

• Scarred and/or severely pathological cornea

• Healthy cornea (very high astigmatism)




                Evaluating the Fit                                                            Evaluating the Fit
• Examine entire corneal chamber                                        Examine corneal fit
                                                                           Optic section with high illumination 
                                                                            and medium magnification (white 
                                                                            light)
  – Diffuse cobalt blue with high illumination
                                                                      • Outermost band is the lens 
                                                                        (dark black)
                                                                        (d k bl k)
  – Lens should completely vault the cornea while 
                                                                             Straddled by two hairline reflections 
    aligning to the bulbar conjunctiva                                        which arise from the front and back 
                                                                              surface of the lens

                                                                      • Middle band is the tear lens 
  – There should be no areas of                                         (green)
    corneal bearing
                                                                      • Inner band is the cornea




                                                                                                                               1
                                                                                                                  11/24/2010




                Evaluating the Fit                                             Evaluating the Fit
 Compare the lens                                                                          Examine peripheral 
  (black layer) to the tear 
  layer (green layer)                                                                        fit

 Example: if the trial 
        p                                                                                     Peripheral portion of
                                                                                               Peripheral portion of 
  lens is known to have a                                                                      lens should align with 
  thickness of 300 
  microns and the tear                                                                         the bulbar conjunctiva
  lens appears to be half 
  that thickness, then the                                                                    Look for blanching, 
  lens vaults the cornea 
  by approx 100‐150                                                                            excessive movement, 
  microns                                                                                      bubble formation




           Additional Information                                                  Basic Design
 • Mini‐scleral lenses are designed to fit on the sclera – or 
   more accurately  on the bulbar conjunctiva. 
 • After a lens is put on the eye, it will settle over the next 
                                                                   • Jupiter
   30‐40 minutes
      Initially may show no bearing, but bearing may appear 
    – I iti ll       h        b i b tb i
      after settling; A lens that touches the cornea may 
                                                                   • AVT
      disrupt the corneal epithelium
 • Over‐Topography                                                 • MSD
    – Perform after lens has settled
    – Reveals any lens flexure
    – More than 0.50D should be addressed by increasing            • Tru‐Scleral
      central thickness of the lens




            Blanchard msd design
• 15.8mm overall diameter
• Fit based on sag value
• Sag value varies from 3.7(most shallow) to 
    8(hi h       l)
  4.8(highest vault)
• 4.60 S recommended for advanced KCN; 4.20 
  S for moderate KCN, PMD; 3.80 S for post‐                                                                      msd tm

  surgical
                                                                      •Sagital depth value of the mini‐scleral 
                                                                    contact lens is adjusted to vault the highest 
                                                                                point on the cornea




                                                                                                                          2
                                                                                                                            11/24/2010




      msd 3.90 
      std




                                                                                                                  msd tm


                                                                    Each “Sagital Depth” in the fitting set has  3 Mid‐
                                                                  Peripheral/Limbal Clearance Values  ‐ Standard, Increased, 
                                                                  and Decreased ‐ to better align the lens in that area.




                                              msd tm                                                            msd tm

The  msd lens on a cornea with irregular astigmatism – note      The msd lens with decreased mid‐peripheral  clearance on the 
Excessive mid‐peripheral clearance with a large bubble at 1‐4 
              p p                             g                  same cornea note improve mid peripheral clearance
                                                                 same cornea – note improve mid‐peripheral clearance. 
o/c. 




                                                                                                                                    3
                                                                                                                               11/24/2010




                 Lens Insertion                                                      Lens Insertion
                          • Cover patient’s lap with paper 
                            towels (or patient can hold         • Completely fill lens with isotonic non‐
                            paper towels) and position            preserved tears (Refresh Optive 
                            patient’s face parallel to the        Sensitive)
                            ground
                                                                • Add fluorescein from a strip
                            Clean lens with conditioning 
                          • Cl    l      ith    diti i
                            solution (no abrasive cleaner)      • Have patient retract upper lid and look 
                                                                  straight down towards the ground
                          • Position lens on large DMV 
                            scleral cup (or equivalent);        • Doctor will retract lower lid and raise the 
                            suction is usually not necessary
                                                                  lens onto the eye  in one continuous 
                                                                  motion
                          • Can also form a tripod with the 
                            thumb, middle and index fingers
                                                                • Release lids before lowering plunger




                  Lens Removal                                                             Bubble?
• Always loosen the lens prior to removal                       • If a large bubble is observed after insertion
   – If needed, apply Refresh Optive Sensitive (preservative 
     free)                                                          – The lens was not inserted in one continuous 
                                                                      motion
     Gently push on inferior periphery of lens in a repeated 
   – Gently push on inferior periphery of lens in a repeated                     or
     motion for several seconds; have pt look in different 
     gaze positions                                                 – The lens well was not completely filled with 
                                                                      solution before insertion
• With the superior lid well controlled, the inferior 
  lid can be used to lift the lower portion of the 
  lens away from the eye                                        • Remove lens and reinsert




       Lens Removal with Suction                                                       Proper Care
 Medium DMV suction cup                                        • Cleaning and Disinfecting
  can be used                                                       – Optifree GP
                                                                • Filling Liquid
 Apply to inferior lens 
  periphery and pull “down and
  periphery and pull “down and                                        Unisol4 or Refresh Optive Sensitive                   
                                                                    – Unisol4 or Refresh Optive Sensitive
  out” (perpendicular to                                              (preservative free)
  surface rather than straight                                      – NEVER USE: contact lens saline, tap water, soft 
  along visual axis)                                                  contact lens solution, etc. to fill the lens
                                                                • Rewetting
 Use the other hand to apply 
  pressure to the top of the                                        – Refresh Optive Sensitive (preservative free)
  lens through the upper lid




                                                                                                                                       4
                                 Scleral Lens – a Viable UVR Filter


                     Jan P. G. Bergmanson, OD, PhD, PhD hc, DSc, FCOptom, FAAO
                               Texas Eye Research and Technology Center
                               University of Houston College of Optometry
                                     505 J Davis Armistead Building
                                       Houston, Texas 77204-2020


The contact lens has come back to where it started! Historically – late eighteen hundred - the first
contact lenses were of a scleral lens design. They fell out of favor because they were bulky and had an
unphysiological performance that limited wearing time. Today scleral lenses, utilizing the latest
material developments and complex curvatures, are the latest vogue in the field of contact lenses. For
many of our corneas within the domain of ocular pathologies, post-surgical, post-refractive surgical
and extremes of refractive errors the modern scleral lens is the optimal choice. Patient satisfaction is
very high and this profitable lens design also leads to great patient loyalty.

A large number of scleral lens fits are on compromised eyes vulnerable to the high intensities of
ultraviolet radiation (UVR) that is experienced in Texas. The current scleral contact lens designs cover
the entire cornea, including limbus and the part of the conjunctiva housing the palisades of Vogt.
Therefore, with an appropriate UVR blocker formulated into the plastic, these lenses may qualify as a
valid UVR protective device capable of protecting the ocular media, internal structures and vital ocular
surface stem cells.

Texas Eye Research and Technology Center assessed the light and UVR transmittance characteristics of
the Bausch & Lomb XO2 gaspermeable material with and without a UVR blocker. Lenses of -3.00D
power were measured centrally and peripherally to obtain a UVR absorbing profile for the scleral lens.
The UVR blocking material absorbed 99% of the UVB and over 87% of the UVA. This lens performance
makes the Bausch & Lomb XO2 gaspermeable material an excellent choice for UVR protection, while
the non-UVR absorbing material - transparent throughout the entire UVR spectrum – offers no
protection. All eyes stand to benefit from UVR protection and especially so the pathologically (eg
keratoconus) or iatrogenically (eg LASIK) thinned corneas, where the corneal UVR filter is
compromised.
   Another approach to soft contact
                                                              Relevant Financial Interests
      lens design: Translation                                     Texas Practicing Optometrist
                                                                 Self Employed Solo Practicioner
                                                                   Writer, Editor, Board Member
                        ●              g
                            Dr. Tom Baugh
                                                                                M    i
                                                                 GLOBAL CONTACT Magazine
     ●   Main Street Optical Denison, Texas USA
                                                                Media-Welt of Ratingen, Germany
                  ●   tkbaugh@hotmail.com
                                                           Inventor of two multifocal contact lens patents
                                                                  Pending patent in contact lenses
                                                               Contact Lens Prototyper with Gelflex




                                                                      A few definitions
                                                         Translation: Vertical movement of a contact
                                                         lens on the eye


                                                         Ideal Translation: enough movement up or
                                                         down of the contact lens to allow for a
                                                         bifocal or multifocal experience.


                                                         Degrees of freedom: The amount of
                                                                translation possible on the cornea, 1
                                                                to 2 mm would be optimum.




                                                           All (men) are born with Auto Focus Specialty
Corneal dimension: The cornea is non-circular, it
is actually a horizontal oval of low eccentricity
averaging 12mm V X 13.6 mm H

Visual Axis: the true 'line of sight' from the fovea
to the object of regard, through the lens and slightly
      (1      3mm)
nasal (.1 to .3mm) of the pupil center and also nasal
of the corneal center. (about.6mm)

Registration: correspondence with the visual axis.
Optics are at optimum in registration.

         It is all about the line of sight.




                                                                                                             1
            Just two more terms                          Flo? Nasal pupil in oval eye
Pupil center: The pupil is not centered under the
cornea but displaced nasal usually .4mm.


Pupil size variation: is a complex limiting factor
with varied lighting levels and diameter.




            Another young lady                         Visual Axis Relationship to CL




   center add cannot deliver a cornea
APlacing a centered add contact lens onpower if
                                                     Two ways to fix the center add fail.
                it's off-center
that 'centers well' means that the lens is not in
registration with the line of sight.                 1. Decenter the add nasally on a non-rotational
 Even worse, most soft lenses center on the                               lens.
temporally decentered cornea cap.


 The result is a ”bullseye” type lens that has a          2. Make a translating add soft lens.
center segment that usually does not fit in
registration with the visual axis. Fit success
is at best only 50%. They work or they FAIL.




                                                                                                       2
Acuvue Toric with decentered add




    TRANSLATION
      HISTORY




                                   The Gelflex Triton




                                                        3
Translating Lens History




                                How do we get these lenses?

                           Contact Gelflex at www.Gelflex.com


                            For decentered segment lenses or translating
                           segment lenses ask your
                           contact lensmaking companies.
                            They know about these lenses and are
                           reluctant to develop new lenses for corporate
                           reasons.




                                                                           4
      More Presbyopia Coming

   David Harmon, president of Market Scope,
  “The global presbyopia population in 2009 was
   b     1 8 billi i di id l           f h      ld
  about 1.8 billion individuals, 23% of the world
  population,” Harmon said. “This is expected to
   increase to 2.4 billion in 2020 to 27% of the
population. In countries in which people will have
 sufficient means to afford presbyopic correction,
      this represents growth of about 52.3%.”




             Thank You
                Tom Baugh, OD


                tkbaugh@hotmail




                                                     5
                                                                                                                      10/26/2010




     Update on Diagnosis and                                                     Disclosures
      Treatment of Dry Eye?
                                                                   • Allergan: research grant, speaker’s
                                                                     bureau, consultant
                                                                   • Alcon: speaker’s bureau, consultant
                                                                     I    i          h     t      k ’
                                                                   • Inspire: research grant, speaker’s
                                                                     bureau
                                                                   • GSK: research grant

              Stephen C. Pflugfelder, M.D.
          Professor, James and Margaret Elkins Chair
                Department of Ophthalmology
                  Baylor College of Medicine




        Definition of Dry Eye                                             Definition of Dry Eye
   International Dry Eye Workshop                                         Delphi Panel Definition
             (DEWS) 2007                                           “Specifically, all patients with this
 Dry eye is a multi factorial disease of the                         condition do not have reduced tear
  tears and ocular surface that results in
  symptoms of discomfort, visual                                     volume, rather they have abnormalities
  disturbance, and tear instability with                             of tear film composition that include
  potential damage to the ocular surface. It                         the presence of pro- inflammatory
  is accompanied by increased osmolarity                             cytokines”
  of the tears and inflammation of the
  ocular surface.
                                             Ocular Surface 2007                                   Behrens et al. Cornea 2006




          DTS Classification                                        Tear Dysfunction – A New Paradigm
                                                                   • Emphasizes tear composition not volume
                                                                   • More encompassing term
  With Lid          Altered Tear             Without Lid             – covers dry and “wet” eyes
Margin Disease      Distribution            Margin Disease
                                                                   • Might explain lack of association between 
                 Conjunctivochalasis
                                                                     conventional signs and symptoms in patients 
  Anterior                                         SS ATD            with dry eye disease (Nichols K et al. Cornea. 
                   Lagophthalmos
  Posterior                                      Non SS ATD
                 Salzman’s Nodules                                   2004)
                     Pterygium

                 4 Severity Levels
          Based on Symptoms and Signs




                                                                                                                                1
                                                                                                     10/26/2010




                                                   Tear Composition Changes  are a
               Is This Dry Eye?                        Proinflammatory Stress
                                                Increased tear osmolarity
                                                  • activates intrinsic stress pathways in surface 
                                                    epithelium stimulating production of:
                                                     – Matrix metalloproteinases
                                                        y
                                                     – Cytokines and Chemokines
                                                     – Adhesion molecules
                                                  • These factors recruit CD4+ cells to the 
                                                    conjunctiva/cornea that produce IL‐17 and 
                                                    IFN‐γ that:
                                                     – Alter epithelial barrier function, epithelial 
                                                       differentiation and induce apoptosis (DePaiva et 
                                                       al. Mucosal Immunol. 2009; Chotikavanich S et al. 
                                                       IOVS. 2009; Chauhan et al. J Immunol 2009)




                                                        Dysfunctional Tears




         Tear Dysfunction Syndrome
                                                      Tear Stability/Integrity
                                                • Invasive
                                                  – Fluorescein TBUT
                                                • Noninvasive
  Alt
  Altered
        d          Aqueous
                   A                 MGD          – Tearscope
Distribution       Deficiency     Evaporation     – Static topography (SRI)
                                                  – Kinetic topography
                                                     • Tear Stability Analysis System (TSAS;
        Abnormal Tear Composition                      Gumus K et al. Invest Ophthalmol Vis Sci
                                                       2010)

               Tear Instability




                                                                                                             2
                                                                                            10/26/2010




  MGD               ATD
                                        TearScope™ Evalulation
                                             of Lipid Layer




                                Specular reflection
                                  of white light         Open Meshwork   Colored
                                                             0.02µm    0.09 - 0.6µm




Surface Regularity Index                                  TSAS




 Normal      Sjögren Syndrome    Summed deviations of ring spacing in 256 radial semi meridians
                                       in sequential images captured ever second x 6




          TSAS                                            TSAS




                                                                                                    3
                                                                                                 10/26/2010




             Tear Parameters                                 Anterior Segment OCT
 • Tear Volume
   – Tear meniscus measurement
       • manual, meniscometer, OCT
   – Phenol red cotton thread
 • Tear Dynamics
   – Production
                                                              RTvue Spectral Domain OCT
       • Schirmer test
   – Turnover
       • Fluorescein clearance test
       • Fluorometric measurement of fluorescence decay




                                                          Conjunctivochalasis Interferes
         Anterior Segment OCT
                                                               with Tear Clearance




     Delayed Clearance                    SS ATD
 MGD and Conjunctivochalasis           Schirmer 3mm
      Schirmer 22mm




        Aqueous Volume/Production                              Tear Clearance




                                                                           Assessment of tear
                                                                            dynamics on the
                                                                             ocular surface


Cotton Thread              Schirmer ( ± anesthesia)                       Macri Arch Ophthalmol 2000




                                                                                                         4
                                                                                                                                            10/26/2010




       Tear Composition                                     Tear Osmolarity in Dry Eye
• Tear composition                                                                                    Tear Osmolarity

  – Osmolarity                                                                              500


                                                                                            450


    • Freezing point depression, vapor pressure,




                                                                                sm/liter)
                                                                                            400


      microchip
              p                                                                             350




                                                             Tear Osmolarity (mOs
                                                                                            300

  – Tear proteins/glycoproteins                                                             250


    • LG secreted proteins (lysozyme, lactoferrin,                                          200



      EGF)                                                                                  150


                                                                                            100

    • Goblet cell associated mucin MUC5AC                                                    50


    • Inflammatory Cytokines/chemokines/MMPs                                                  0



      (multiplex arrays)                                                                          Normal                  KCS

  – Meibomian gland lipids                                                                                      Gilbard et al. Arch Ophthalmol 1978




         Tear Osmolarity                                     Tear EGF Concentration




                                                                                                                   Rao et al. IOVS 2010




                                                            Tear Inflammatory Cytokines
    Too Much of a Good Thing!                                          in DTS
                         Rao K et al. IOVS 2010




          P < 0.03                                P<0.001                                                                       Lam et al. AJO 2008




                                                                                                                                                      5
                                                                                                                                              10/26/2010




   ↑ Metalloproteinase Ac vity                         ↑ Metalloproteinase Ac vity 




                                                                                                        16
                                                                                                        14




                                                                                     Corneal Staining
                                                                                                        12
                                                                                                        10
                                                                                                         8
                                                                                                         6
                                                                                                                                      y = 0.0217x + 1.2661
                                                                                                         4                                 r2 = 0.4232
                                                                                                         2
                                                                                                         0
                                                    Chotikavanich et al. IOVS 2009                           0   100    200 300 400 500 600           700
                          Afonso et al. IOVS 1999                                                                      Tear MMP-9 activity (ng/ml)




                                                    Base Treatment on Severity


      Treatment of DTS




      Neural Hyperesthesia
• Inflammatory cytokines (i.e. IL-1, IL-6,
  NGF) and prostaglandins increase
  nerve sensitivity (Rosenthal P et al.
  Corneal pain without stain: is it real?
                                                                               Level 1
  Ocul Surf. 2009)
• Free nerve endings in cornea become
  more sensitive to normal environmental
  stimuli (air drafts, temperature change)
• Keratoneuralgia (Rosenthal 2009)




                                                                                                                                                             6
                                                                                                                                     10/26/2010




       Options for Artificial Tears

  • Physiological electrolyte composition                                            Level 2
    and osmolarity
                                                                           Initiate Anti-inflammatory
  • Osmoprotectants (carnitine, erythritol)
  • Multidose with disappearing
                                                                                     Th
                                                                                     Therapy
    preservatives
  • Non-blurring gels
  • Oil emulsions (prevent evaporation?)
  • Guar, HA protective coating




CsA
                                                           Steroids        Anti-inflammatory Therapy
                                                            TCNs
TCNs
                                                          Omega-3 FA
Steroids                                                                                              CsA                   Steroids
                                                                         Epithelial Factors            -                         +
                                                                         Cytokines/MMPs

                                                                          BV Adhesion                  +                         +
                                                                           Molecules

                                                                         T Cell Activation            +++                        +
                                                CsA?
                                                                          ↓ Epithelial
                                                                           Apoptosis                   +                         -
                                  Stern ME et al. Mucosal Immunol 2010




                                                                                   Phase III Clinical Trial -
    Cyclosporin – What Does it Do?                                                  Goblet Cell Density
   • Decrease epithelial apoptosis (Gao et al.
     Cornea 1998; Brignole et al. IOVS 2001; Strong et al Cornea                  200         191%*    *P =   0.013 vs vehicle
     2005)

                     j              g
   • Increase conjunctival goblet cell                                            150

     density (Kunert et al. Arch Ophthalmol 2000)
                                                                                  100
   • Improve corneal barrier function
      (Sall et al. Ophthalmology 2000)                                             50
                                                                                                                   13%
   • Decrease conjunctival T cell infiltration
     (Kunert et al. Arch Ophthalmol 2000)                                           0
                                                                                         0.05% CsA               Vehicle
                                                                                              n=11                 n=12




                                                                                                                                             7
                                                                                                                                                                                                       10/26/2010




                                                                                                                                                      Temporal Bulbar Conjunctiva
                                                                                                                                             25


                                                                                                                                             20
                                      Effects of Tears and CsA on




                                                                                                                            Mean Gob Cells
                                                                                                                                             15                                                    *
                                       Goblet Cell Differentiation




                                                                                                                                   blet
                                                                                                                                             10


                                                                                                                                              5


                                                                                                                                              0
                                                                                                                                                  Baseline        Tears        CsA 6 wks      CsA 12 wks
                                                              Pflugfelder et al. Cornea 2008
                                                                                                                                                              * P < 0.001 vs Baseline, Tears and CsA 6 weeks




                                                                                                                                                      Tears                      CsA 12 weeks

                                                 Inferior Bulbar Conjunctiva
                                      25
                                                                                                        4 / IB
                                                                          *                 *
                                      20
                                                                                                       Subject / Location
                     Mean Gob Cells




                                      15
                            blet




                                                                                                             t




                                      10


                                       5
                                                                                                       1 / IB
                                       0
                                           Baseline       Tears      CsA 6 wks        CsA 12 wks

                                                                   * P < 0.001 vs Baseline and Tears




                                                                                                                                                                                                           48
                                                  Tears               CsA 12 weeks                     9.15.06 VA 20/50                                                   VA 20/40


3 / TB
Subject / Location




                                                                                                       6 22 09 VA 20/25
                                                                                                       6.22.09                                                            VA 20/20
      t




            2 / IB




                                                                                                                                                                                                                8
                                                                                                                                                                                                                                          10/26/2010




                                                               49
         9.06
                                                                                                                                     Corticosteroids
                                                                    • Improve signs and symptoms
                                                                    • Improve tear clearance
                                                                    • Normalize mucus production
          6.09                                                      • Often have sustained benefit after a 2
                                                                      week pulse
                                                                    • Soft steroids such as fluorometholone
                                                                      and loteprenol etabonate are effective
                                                                    • Synergistic with CsA




SS KCS
                                                                                                                      Percentage Change in Means Between BL and Two Weeks
                                                                                                                             Subjects with Corneal Staining Score ≥ 10 at Baseline

Pre-Steroid                                                                                                             40
                                                                                                                                                                                                       33.3
                                                                                    Percentage Change From Baseline




                                                                                                                        20
                                                                                                                                                                                                                  12.5


                                                                                                                                                                   0.0   0.0 0.0
                                                                                                                         0
                                                                                                                                                     2.8
                                                                                                                                                    -2 8
                                                                                                    e




                                                                                                                                             -9.7                                          -10.0
                                                                                                                                                                                                                                  -11.7
                                                                                                                                                                                   -15.8
                                                                                                                       -20
                                                                                                                                                                                                   -25.0
                                                                                                                                     -28.4
                                                                                                                                                           -30.6                                              -31.8

Post-Steroid                                                                                                           -40
                                                                                                                             -41.8
                                                                                                                                                                                                                          -47.3

                                                                                                                       -60
                                                                                                                              SUB             OBJ           CCS           LMI        ITH            IBH       NBH          RED


                                                                                                                                                           Lotemax                                 Placebo


                      Marsh & Pflugfelder Ophthalmology 1999                                                                                                                    Pflugfelder Am J AJO 2004
                                                                                                                                                                            Pflugfelder S et al. et al Ophthalmol 2004




 Steroids May Improve Corneal Surface Regularity
                                                                                                                             Surface Regularity Index
                                                                               2

                                                                              1.8                                                                                                                                        Pre-Tx
                                                                              1.6
                                                                                                                                                            P < 0.04                                                     Post-Tx
                                                                              1.4

                                                                              1.2
                                                                         RI
                                                                        SR




                                                                               1

                                                                              0.8

                                                                              0.6

                                                                              0.4

                                                                              0.2

                                                                               0


                                                                                                                                             LPE                                                    Vehicle
                                                                                                                                                                                Pflugfelder et al AJO 2004




                                                                                                                                                                                                                                                  9
                                                                                                                        10/26/2010




  Tetracyclines – Modulate MMP                                                   Ocular Rosacea
             Activity
• Tetracyclines
   – Inhibit production of MMP-1, -3, -9 and by
     the corneal epithelium (Dursun 2001, Li
     2001, 2004,        2004,
     2001 Li 2004 Kim 2004 de Paiva 2006)
                                   IL-1β (ng/ml)
                 Media




                         0.1   1    10        1+        10 +
       MW                                Ab   RA Doxy   Doxy



     106 kD →
      81 kD →                                                  MMP-9
                                                               MMP-2
     47.5 kD →




         Tetracycline Therapy                                           Oral Doxycycline ↓ Tear MMP-9
• Oral tetracyclines
   – Doxycycline at 20 – 50mg BID (Yoo et al.
     Korean J Ophthalmol 2005, Smith et al. BJO
     2008;92:856-9)
   – Minocycline 50-100 mg BID (Aronowitz JD et
     al. BJO 2006)
• Alternate therapy for tetracycline intolerance
      • Azithromycin 250mg 3x/wk for 5 – 19 wks or
        500mg 3d per week x 4 wks
      • Topical AZM 1% BID 2d, qd for 28 days (Luchs
        J. Adv Ther. 2008;25:858)                                                100mg/d x 2 weeks
                                                                                                     Smith VA et al. BJO 2009




                                                                               Nutritional Therapy

                                                                       • Omega-3 essential fatty acid
                                                                         supplements:
                                                                         – Fish oil – 650 mg of eicosapentaenoic acid
                                                                           (EPA) and docosahexaenoic acid (DHA)
                                                                           per day (Macsai MS. Trans AOS. 2008;106:336)
                                                                         – Flaxseed and Primrose oils
                                                                       • Topical omega 3 FA (ALA)
                                                                         – significantly ↓ K fluorescein staining and
                                                                          expression of IL-1 and TNF-α (Rashid et al.
     Pre-Doxycycline                               Post-Doxycycline
                                                                          Arch Ophthal 2008)




                                                                                                                                10
                                                                                                              10/26/2010




Omega-3 FAs Inhibit Inflammation
               α Linolenic Acid
                (Flaxseed oil)


                Steridonic Acid                                                   Level 3
             Elcosatraenoic Acid


                       EPA
                                   Blocks IL-1, TNF-a and COX-2
                 (Fish Oil)

          PGE3                            LTB5
   Anti-inflammatory               Anti-inflammatory




           Punctal Occlusion                                            Punctal Plug Designs
• ↓ irritation symptoms                                           • Dissolvable intracanalicular plugs
• ↓ ocular surface dye                                              – Short-term collagen (≤ 1 week)
  staining                                                          – Medium-term polymer (1- 6 months)

• ↓ use of artificial tears                                         N    di    l bl        t l d
                                                                  • Non-dissolvable punctal and
                                                                    intracanalicular plugs
                                                                    – Long-term occlusion (months to years)




                                                                            Secretogogues
                                                                   • Oral
                                                                     – Pilocarpine (Salagen)
                                                                     – Cevimeline (Evoxac)
                                                                     – Side effects: sweating, GI
                                                                       cramping




                                                                                                                     11
                                                                                                  10/26/2010




   Moisture Spectacles

                               Increase humidity
                                    to >80%




        Look Good and Feel Good




                                                                Contact Lenses
                                                   • Hydrate
                                                   • Smooth surface
                                                   • Minimize lid frictional forces
                  Level 4                          • Soft - consider silicone hydrogel or large
                                                                                y   g        g
                                                     diameter (Kontur)
                                                   • Boston Ocular Surface Prosthesis
                                                       – High Dk, fluid ventilated
                                                       – “Liquid bandage”




            BOSP Design                                 SJS with Severe Trichiasis
• 3 Zones
  – Central (optic) zone
  – Peripheral haptic
  – Transitional zone
    • joins optic and haptic
    • vaults the limbus




                                                                                                         12
                                                                             10/26/2010




SJS with Lipid Keratopathy             GVHD with Severe Filaments




                                               Pre BOSP            5d Wear




        HZO Neurotrophic Ulcer
                                     5.19.09
             Bradley




                                     6.01.09




RA 2° SS & Corneal Perforation                 Conjunctivochalasis
                                      • Common cause of irritation
                                        unresponsive to conventional dry eye
                                        therapy
                                      • Underdiagnosed
                                      • Often associated with delayed tear
                                        clearance and altered tear composition
                                      • Look for discontinuous inferior tear
                                        meniscus
     20/200 BCSV → 20/25 with BOSP




                                                                                    13
                                                                           10/26/2010




                                                        Chalasis Cautery




Cauterize Folds                                       Chalasis Excision




                                               Preop Thermocautery
  Excision



                                               2 mos Postop




        Yokoi et al. Cornea. 2005;24:S24-S31




                                                                                  14
                                                                                                   10/26/2010




            Summary                                  Ocular Surface Team
• Tear Dysfunction is a more
                                                                                Ocular Surface Center
  encompassing term for tear related                                            Rosa Corrales PhD
  ocular surface disorders                                                      Lucia Zhuo-Chen MD, PhD
                                                                                Cintia DePaiva MD
• Tear composition changes promote                                              William Farley MS
  ocular surface inflammation that                                              De-Quan Li MD, PhD
  sensitizes nerve endings and causes                                           Margaret Olfson
                                                                                Michael Stern, PhD
  epithelial disease                                                            Xiaofen Zheng MD, PhD
• Utilize the ever increasing               Supported by NEI Grants EY11915 and RO1EYE018090
  armamentarium to treat tear dysfunction   Allergan, Research to Prevent Blindness,
                                            Oshman Foundation, William Stamps Farish Fund
  and related inflammation                  Hamill Foundation




            Thank You !




         Alkek Eye Clinic




                                                                                                          15
William D. Townsend, OD, FAAO

Is Limbal Stem Cell Deficiency a Contact Lens-induced Entity?

Course Description

Stem cells have a long life span which may last as long as the natural life of the
organism. They are poorly differentiated, and appear primitive compared to
more differentiated cell, but are unique in their high capacity for self-renewal
and propensity for error-free proliferation and replication. Contact lens wear is
believed to be one of cause of stem cell deficiency. This lecture addresses
recent finding abouts, as well as diagnosis and management of corneal stem
cell loss deficiency.
William D. Townsend, OD, FAAO

Course Description

Does Punctal Occlusion Influence Tear Film Osmolarity?

In 1978 Gilbard et al demonstrated that tear film hyperosmolarity is related to
keratitis sicca. In the present study we enrolled subjects with diagnosis of dry eye
disease, and each subject filled out a SANDE questionnaire. Then we obtained
baseline tear film osmolarity reading using the TearLab instrument. performed
bilateral occlusion of the inferior punctal. In subsequent visits we obtained
osmolarity measurements and the subjects filled out post-treatment SANDE
questionnaires. We report our initial results and their relevance in this presentation
                                                                                                         Disclosures
Combination Pharmaceuticals:
                                                                                         • I have no financial interest in any of the products
  The Latest and Old Work                                                                  mentioned in this presentation.
          Horses
                                                                                                      received                following
                                                                                         • TERTC has recei ed grants from the follo ing
                                                                                           companies over the last 2 years:
    Norman E. Leach, O.D., M.S., F.A.A.O                                                    – Alcon
   University of Houston, College of Optometry                                              – Bausch & Lomb
                  Houston, Texas
                                                                                            – Cooper Vision




      Ophthalmic Combinations                                                            When do you Rx Combo Agents?
• Offer the convenience of having both an                                                • Ocular/adnexa inflammations that may
  anti-infective and anti-inflammatory in a                                                compromise ability to resist microbial
  single bottle                                                                            invasion
                                                                                            – Treat inflammation
• Steroids are generally used in combination
                                                                                            – Corneal epithelial edema or disruption
  with anti-infectives for quick relief of acute                                              present?
  episodes of conjunctivitis/blepharitis                                                    – Keep 2o infections out
• Treatment is generally limited to the extent                                           • Clinical Ex:Ocular rosacea;
  of the acute episode                                                                     superficial burn
  – Monitor IOP




     Ocular Damage Caused by                                                             When do you Rx Combo Agents?
     Uncontrolled Inflammation
  Corneal Scarring &
  Neovascularization                                                                     • Inflammation and
                                                                                           bacterial infection co-
                                                                                           existing
                                                                                           – Discharge?
                                                                                           – Infiltrates?
 Subepithelial Fibrosis                                                                  • Clinical Ex: blepharitis;
                                                                                           marginal corneal
                                                   Corneal Perforation                     infiltrates; meibomian
                                                                                           gland disfunction

                          Photos courtesy of University of Pittsburgh, Visual Services
Clinical Treatment of Inflammation
                                                                                 Antibiotics in Combo Agents
       with Risk of Infection
• Non-Otherwise-Specified (NOS)                                                    • Tobramycin
  Conjunctivitis                                                                   • Polymyxin B
• Non-Infectious Keratitis                                                         • Neomycin (high
• Blepharitis                                                                        incidence of sensitivity)
• Scleritis/Episcleritis                                                           • Sodium Sulfacetamide
• Uveitis                   Acute atopic conjunctivitis                            • Bacitracin
                            with itching, mucous, and
                                                          chemosis
                                                                                   • Gentamicin




                                                                                 Combo Suspensions and Solutions
         Steroids in Combo Agents                                              Generic Name / Concentration               Trade Name            Preparation
                                                                               Dexamethosone 0.1%                         Methadex-Major        Ophthalmic Suspension
                                                                               Neomycin 0.35%                             Maxitrol-Alcon        5ml
                                                                               Polymyxin B sulfate 10,000 units/ml        Poly-Dex-OcuSoft
                                                                                                                          Generics
     • Dexamethosone                                                           Dexamethosone 0.1%                         TobraDex-Alcon        Ophthalmic Suspension
                                                                               Tobramycin 0.3%                            Generics              2.5ml, 5ml

     • Fluorometholone                                                         Fluorometholone 0.1%                       FML-S-Allergan        Ophthalmic Suspension
                                                                               Sodium sulfacetamide 10%                                         5ml, 10ml
     • Prednisolone acetate                                                    Prednisolone acetate 1%
                                                                               Gentamicin sulfate 0.3%
                                                                                                                                      g
                                                                                                                          Pred-G-Allergan        p             p
                                                                                                                                                Ophthalmic Suspension
                                                                                                                                                2ml, 5ml, 10ml

     • Prednisolone sodium                                                     Hydrocortisone 1%
                                                                               Neomycin 0.35%
                                                                                                                          Generics              Ophthalmic Suspension
                                                                                                                                                7.5ml
                                                                               Polymyxin B sulfate 10,000 units
       phosphate                                                               Loteprednol etabonate 0.5%
                                                                               Tobramycin 0.3%
                                                                                                                          Zylet-B&L             Ophthalmic Suspension
                                                                                                                                                2.5ml, 5ml, 10ml

     • Hydrocortisone                                                          Prednisolone acetate 0.5%
                                                                               Neomycin 0.35%
                                                                                                                          Poly-Pred-Allergan    Ophthalmic Suspension
                                                                                                                                                5ml, 10ml
                                                                               Polymyxin B sulfate 10,000 units/ml

     • Loteprednol etabonate                                                   Prednisolone acetate 0.2%, 0.5%
                                                                               Sodium sulfacetamide 10%
                                                                                                                          Blephamide-Allergan
                                                                                                                          Metimyd-Schering
                                                                                                                                                Ophthalmic Suspension
                                                                                                                                                5ml, 10ml
                                                                               Prednisolone sodium phosphate 0.25%        Vasocidin-Novartis    Ophthalmic Solution
                                                                               Sodium sulfacetamide 10%                   Generics              5ml, 10ml




                             Combo Ointments
                                                                                                                     TobraDex®
 Generic Name / Concentration         Trade Name         Preparation
 Dexamethosone 0.1%                   AK-Trol-Akorn      Ophthalmic Ointment
 Neomycin 3.5 mg/g                    Maxitrol-Alcon     3.5g
 Polymyxin B sulfate 10,000 units/g   Poly-Dex-OcuSoft
                                      Generics
                                                                               • 16-year history with TobraDex, and the
 Dexamethosone 0.1%
 Tobramycin 0.3%
                                      TobraDex -Alcon    Ophthalmic Ointment
                                                         3.5g
                                                                                 agent shows an outstanding safety record,
 Prednisolone acetate 0.6%
 Gentamicin 0.3%
                                      Pred-G-Allergan    Ophthalmic Ointment
                                                         3.5g                    with a reported rate of adverse events at
 Hydrocortisone 1%
 Neomycin 3.5 mg/g
                                      AK Spore HC
                                      Generics
                                                         Ophthalmic Ointment
                                                         3.5g
                                                                                 less than 0.0001%
 Polymyxin B sulfate 10,000 units/g
 Bacitracin zinc 400 units/g                                                   • Generic available with suspension; not
                                                                                 ointment
           TobraDex® vs Zylet                                       TobraDex® vs Zylet
• Both have 0.3%                        • Endotoxin-induced
• Dexamethasone 0.1% vs Loteprednol       uveitis in rodents
  etabonate 0.5%                               – Neutrophil inhibition
                                                 at 24 hours
                                               – Dexamethasone
                                                      • 0.01% - 0.1%
                                               – Loteprednol
                                                      • 0.3% - 3.0%



                                      Phillips K, et al. Submitted for presentation at annual meeting of the Association for Research in Vision
                                      and Ophthalmology. Fort Lauderdale, FL; May 2005.




                TobraDex® ST




     TobraDex® ST
     (tobramycin/dexamethasone                                  for your attention!
     ophthalmic suspension)
     0.3%/0.05%
    Treatment Pearls and Turbocharged Coding
                                          Clarke D. Newman, OD, FAAO
                                               Plaza Vision Center
                                        600 North Pearl Street, Suite G-204
                                            Dallas, Texas 75201-7492
                                                  (214) 969-0467
                                            cdnewman@earthlink.net



Abstract
This course will review a few important facets of treating dry eye syndrome, and in using CPT modifiers to improve claim
filing and increase reimbursement.

Learning Objectives
    1. To understand the etiologies of dry eye syndrome
    2. To understand how to distinguish between the various etiologies of dry eye syndrome quickly
    3. To understand how to use the CPT modifier codes to increase claims efficiency and reimbursement

    1. Introduction
            a.   What is Dry Eye Syndrome (DES)?
            b.   How Prevalent Is Dry Eye Syndrome?
            c.   What is the Associated Morbidity of Dry Eye Syndrome?
            d.   What Are Relevant CPT Modifiers?
            e.   How Do We Use These Codes to Our Advantage?

    2. Dry Eye Syndrome
            a. Classification
                     i. The DEWS Schema: Appendix A
                    ii. The Mechanism of Dry Eye Syndrome: Appendix B
                   iii. The Modified ITF Grading Schema: Appendix C
            b. Diagnosis Pearls
                     i. The DEQ 5
                            1. How frequently do Your Eyes Water?
                            2. How often do Your Eyes feel Dry?
                            3. Is the Dryness Worse Late in the Day?
                            4. How often Do You Experience Ocular Discomfort?
                            5. Is the Discomfort Worse Late in the Day?
            c. Treatment Pearls
                     i. Control Lid Disease
                    ii. Treat Lid Wiper Epitheliopathies
                   iii. Look for Systemic Etiologies
                  iv. Follow the Treatment Schema

    3. Coding With Modifiers
            a.   Modifier -22 (Increased Services)
            b.   Modifier -24 (Unrelated Service during a Postoperative Period)
            c.   Modifier -25 (Unrelated Service on the Same Day as a Surgery)
            d.   Modifier -50 (Bilateral Procedure)


                                Treatment Pearls and Turbocharged Coding: Page 1 of 4
     e. Modifier -51 (Multiple Services)
     f. Modifier -52 (Reduced Services)
     g. Modifier -53 (Discontinued Procedure)

4. Conclusion
     a.   The Key to Successful Treatment Is Quick and Accurate Diagnosis
     b.   Use the Latest Tools
     c.   Keep Your Protocols Evidenced Based
     d.   Use Modifiers Often and Accurately




                         Treatment Pearls and Turbocharged Coding: Page 2 of 4
Appendix A




                       The Ocular Surface, April 2007, Vol. 5, No. 2



Appendix B




                      The Ocular Surface, April 2007, Vol. 5, No. 2
             Treatment Pearls and Turbocharged Coding: Page 3 of 4
Appendix C




                       The Ocular Surface, April 2007, Vol. 5, No.2


Appendix D




                       The Ocular Surface, April 2007, Vol. 5, No. 2




             Treatment Pearls and Turbocharged Coding: Page 4 of 4
                                                                                                                                                                                                                                                     25/10/2010




                                                                                              Declaration


                                                                                              Co-authors: Rakesh Kapoor, Sunil Shah,
In the pursuit of happiness                                                                   Gurpreet Bains, Navneet Gupta, Baldev Ubhi,
   p   ,
– Specs, CLs or Lasers                                                                        Asif Akhtar, Zabir Ali, Risha Kotecha, Sarah
                                                                                              Humphries, Selina Mansukhani and Stephanie
                                                                                              Mroczkowska
                 Dr Shehzad A. Naroo
     BSc(Hons), MSc, PhD, MCOptom, FIACLE, FAAO, FBCLA
                                                                                              No financial support received for these studies
     Senior Lecturer, School 0f Life and Health Sciences
      Global Vice-President, Int’l Association Of CL Educators
       Editor-in-Chief, Contact Lens and Anterior EyeJournal




Consultancy




                                                                 www.ees.elsevier.com/clae/

                                                                 s.a.naroo@aston.ac.uk




Factors that influence patient choice                                                                         Why have refractive surgery/CL? (1999)


                                                                                        120                                                                                                                                                    Ref Surg
 J Refract Surg. 1999;15(2):132-6                                                       100
                                                                                                                                                                                                                                               CL

 Naroo SA, Shah S and Kapoor R
                                                                 P e rc e nta ge (% )




                                                                                         80
                                                                              g




 Contact Lens and Anterior Eye Journal. 2006;                                            60


 29(1): 17-23                                                                            40


 Gupta, N and Naroo SA                                                                   20


                                                                                          0
                                                                                                                                                                                                                                                          M e d ica l
                                                                                                                                                                                                                                          S p o rt
                                                                                                                                                  A d ve rtisin g




                                                                                                                                                                                                          In co n ve n ie n ce



                                                                                                                                                                                                                                 W o rk
                                                                                                                C o st (P R K )



                                                                                                                                  C o st (C L )




                                                                                                                                                                                         a d vice fro m
                                                                                                                                                                    p ro fe ssio n a l
                                                                                               C o sm e tic




                                                                                                                                                                                            P o sitive

                                                                                                                                                                                            frie n d s
                                                                                                                                                                       P o sitive

                                                                                                                                                                        a d vice




                                                                                                                                                                                                                                                                        1
                                                                                                                                                         25/10/2010




    Who were the patients? (1999)                          Why have refractive surgery/CL? (2006)



     Equal numbers of males and females               80
                                                                                                      Refractive Surgery
         more females wearing CL (2:1)                70
                                                                                                      Contact Lenses
     Mean age 36                                      60
         Mean age 26 for CL patients                  50
     MSE of around 4D                                 40
         MSE of around 3D for CL patients
                                                      30
     Many former contact lens users (83%)
                                                      20

                                                      10

                                                      0




                                                                                                                                                           Inconvenience
                                                                                                                               R x/Professional
                                                                                                       A dvertising
                                                                              Advice From
                                                            C osmetics




                                                                                            S ports




                                                                                                                      C osts




                                                                                                                                                  Work
                                                                                Friends




                                                                                                                                    A dvice
Why give up CL? (2006)                                     Who are the patients now?

          35
         %30                                               More females than males (37%M, CL Px 32%M)
          25                                               Disposable income, professional
          20                                               Lower refractive errors than earlier study
          15                                                       Around 3.5D for ref surg and CL Px
          10
             5                                             Mean age 39 years for ref surg, 32 years for CL
             0                                                     Tan (1993) found age of ref surg Px to be 29 years
                              e
                              s




                                                           Many former contact lens users (71%)
                             al

                             ts
                              r




                            ce
                              n
                           ea




                           nc
                           ct

                          tio
                          on

                          os




                          vi
                         fe
                       rw




                        ie
                       ip

                      Ad
                       C
                       si




                                                                   Compared to 83% in former study
                      Ef




                     en
                    ve




                    cr
                    es




                 nd
                  n




                 nv
                 es
                  O

                 of




               tio




              ie
             Pr




            co
             Pr




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          In
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        L
      C




Comparison of old and new study                            Co-management in refractive surgery

      100
%     80
                                                                         Naroo SA and Ubhi BK
      60
                                                                         Optometry in Practice
      40
                                                                                ( )
                                                                         2004: 5(1): 5-14
      20
         0
                                                                         Questionnaire to investigate attitudes
                                                                         65 Optoms, 35 GPs, 40 Ophthalmols
                         g

                         f)




                         e
                        s)
                        is




                       ts




          nv ork

                     nc
                      in

                     ro
                    es

                    nd

                    or




                                            1999
                  tis




                  W
                  (p




                  ie
                Sp
                  m

                 ie




               en




                                            (n=255)
               er
              os




                e
              (fr




             ic
           dv
           C




                                            2006
         dv
           e




         A
        ic




       co




                                            (n=212)
      A
    dv




    In
     A




                                                                                                                                                                           2
                                                                                                                                                                    25/10/2010




How many px enquire about ref surg                                                                    Where have you learnt about ref surg



%                                                                                                         %




                                                                                                         Quality of life in refractive correction
    Procedures carried out by optometrists
                                                                                                         (QIRC)
                                                                                         96%
                                                        89%

                        77%                                                                                  QIRC is validated questionnaire designed to
       72%
                                                                                                             investigate Quality of Life (QoL) of pre-presbyopic
                                                                                                             patients with various types of refractive correction
                                                                         53%


                                                                                                             Changes in quality of life after laser in situ
                                                                                                             keratomileusis for myopia. J of Cat & Ref
                                        19%
                                                                                                             Surg, 31:8, 2005, pp 1537-1543. Estibaliz
                                                                                                             Garamendi, Konrad Pesudovs & David B. Elliott
       Initial       Preoperative   Procedures on    Postoperative   Prescribing of   Postoperative
    consultation     assessment     day of surgery       care            tear           follow-up
                                                                     supplements

                   Slide courtesy of William Harvey (Reed Business Information)




                                                                                                         Demographics

                                                                                                      Ref Surg                  CL                 Spex
         Rasch Analysis estimates joint maximum likelihood                                            n=94                      n=64               n=60
         estimation                                                                                   36.9±9.9 years            24.2±5.2 years     29.8±5.4 years
         The responses of people are expressed in log odd
                                                                                                      60F, 34M                  44F, 24M           40F, 20M
         units or logit positioned along a hierarchical scale
                                                                                                      3/12 post-op              F/T>50hours        DV only
         with logits of greater magnitude representing
                                                                                                                                P/T<50 hours
         increased vision related QOL
         Initially 647 questions (items), professional focus                                          100% completion           89% completion     100% completion
         group reduced to 115 items, further 25 items                                                 Pre-op -2.71±2.34 DS, -2.89±3.14 DS          -2.55±2.52 DS
         removed by further focus groups, remaining 90 items                                          Post-op -0.01±0.27 DS
         reduced to 20 with infit and outfit statistics




                                                                                                                                                                            3
                                                                                                                                                                                                                          25/10/2010




                    QIRC score versus type of surgery                                                                                          QIRC versus Rx (CL Px)

                                                                                                                                    42.1±5.4 versus 47.7±7.7 for CL>4D versus CL<4D                              70



               60
                                                       n=50                            n=40
                                n=4
                                                                                                                                                          y = 0.7349x + 47.807                                   60
               55                                                                                                                                              R² = 0.1113


               50




                                                                                                                       QIRC score
   QOL score




                                                                                                                                                                                                                 50

               45


               40                                                                                                                                                                                                40



               35

                                                                                                                                                                                                                 30
               30                                                                                                                         -14       -12         -10         -8        -6          -4   -2             0        2
                                PRK                    LASIK                        LASEK
                                                                                                                                                                             Mean Rx (dioptres)




                    QIRC versus age (CL Px)                                                                                                    QIRC versus age (Ref Surg)

                                                                                                                                     70


                70



                                                                              y = -0.2593x + 52.026
                                                                                                                                     60
                                                                                    R² = 0.0385
                60
                                                                                                           QOL score
                                                                                                                   e
QIRC score




                50                                                                                                                   50




                40
                                                                                                                                     40


                                                                                                                                                                                                                 y = 0.1378x + 47.173
                                                                                                                                                                                                                      R² = 0.0441
                30
                     15    17    19   21   23   25     27      29   31   33       35       37         39
                                                                                                                                     30
                                                                                                                                          20                     30                    40                   50                     60
                                                     Age (years)
                                                                                                                                                                                      Age




                    Results                                                                                                                    Results


                    No statistical difference in QIRC scores                                                                                    The mean QIRC scores were highest in
                    for Rx, age or gender for any group                                                                                         the refractive surgery group (52.1±6.5)
                    (p>0 05)
                    (p>0.05)                                                                                                                      This was significantly higher than in the CL
                                                                                                                                                  (45.8±6.9) or spectacle group (43.0±5.3)
                                                                                                                                                  There was no significant difference between
                    P/T or F/T CL wearers showed statistical
                                                                                                                                                  CL wearers and spectacle wearers (ANOVA,
                    difference (p<0.05)
                                                                                                                                                  p>0.05)
                          41.2±7.4 versus 45.2±6.4




                                                                                                                                                                                                                                        4
                                                                                                              25/10/2010




Conclusions                                               Conclusions


 Patients perceive a better QoL after ref surg             Many ref surg Px may have a psychological
 than those wearing CL or spectacles                       sentiment their QoL has improved since they
                                                                 g           p
                                                           no longer use an optical device
 However, many ref surg patients will be
 former CL users and all will be former                    As per earlier studies Px feel QoL to be lower
 spectacle wearers                                         when reliant on an optical device and this is
   83% in (Naroo, Kapoor & Shah JRS 1999)                  exasperated with higher levels of ametropia
   71% in (Gupta and Naroo CLAE 2006)




Personal opinions                                         Medical Ethics

                                 CL should be used as a   Autonomy - the patient has the right to refuse or
                                 first option             choose their treatment (Voluntas aegroti suprema lex)
                                 Refractive surgery       Beneficence - a practitioner should act in the best
                                 should be offered only   interest of the patient (Salus aegroti suprema lex)
                                 to carefully selected    Non-malice - "first, do no harm" (primum non nocere)
                                 patients                 Justice - concerns the distribution of scarce resources,
                                 Optometrists to offer    and who gets what treatment is decided fairly
                                 unbiased advice          Dignity - the patient has the right to dignity (and the
                                 Optometrists should be   person treating the patient)
                                 fully aware              Honesty – including the concept of informed consent




                                                                                                                      5
Myopia – Getting Closer
(30 minutes)

Earl L. Smith III, O.D., Ph.D.
Dean
Greeman-Petty Professor
College of Optometry, University of Houston, Houston, TX

Summary:
In order to develop effective optical treatment strategies for myopia, it is
important to understand how visual experience influences refractive
development. Beginning with the discovery of the phenomenon of form
deprivation myopia, research involving many animal species has demonstrated
that ocular growth and refractive development are regulated by visual feedback
associated with the eye’s refractive state. Because of the prominence of central
vision in primates, it has generally been assumed that signals from the fovea
dominate the effects of vision on refractive development. However, our
experiments in monkeys demonstrate that eye shape and emmetropization are
mediated by local retinal mechanisms and that foveal vision is not essential for
many of the vision-dependent aspects of refractive development. On the other
hand, the peripheral retina, in isolation, can effectively regulate emmetropization
and mediate many of the effects of vision on the eye’s refractive status.
Moreover, when there are conflicting visual signals between the fovea and the
periphery, refractive development is dominated by peripheral vision. The overall
pattern of results suggests that optical treatment strategies for myopia that are
directed at the periphery may be more successful than strategies that effectively
manipulate only central vision.

Description:
This presentation will review new evidence that demonstrates that refractive-error
development is regulated by visual feedback associated with the eyes’ refractive state
and the applicability of the results from laboratory animals to human refractive
development.

Learning Objectives.
By attending this presentation the participant should be able:
1) to describe the potential role of visual experience in early ocular growth and
the possible effects of spectacle lenses on emmetropization.
2) to identify factors associated with early visual experience that may alter ocular
growth in animals and humans.
3) to describe the variations in the normal pattern of peripheral refractive errors
and the relative role of peripheral vision in refractive development.
4) to make informed decisions concerning the use of traditional optical myopia
therapies.
 V


Outline
I. Epidemiologic aspects of myopia
       A. Ocular morbidity
       B. Increasing prevalence

II. Evidence that visual experience regulates ocular growth and refractive
development
        A. Emmetropization and the effects of dark rearing
        B. Form deprivation myopia
              1. Observations across species
              2. FDM in humans
        C. Recovery from induced refractive errors
              1. Age dependence
        D. Lens compensation experiments.
              1. Nature of Vision-Induced Refractive Error
              2. Clinical Implications

III. Operational properties of vision-dependent mechanisms
       A. Evidence for local retinal mechanisms
              1. Extraocular influences
              2. Hemi-retinal form deprivation and defocus
       B. Variations in visual signals with eccentricity
              1. Pattern of peripheral refractive
              2. Peripheral refractive errors as risk factors

IV. Relative role of central and peripheral vision in refractive development
       A. Effects of foveal ablation
              1. emmetropization
              2. form deprivation myopia
              3. recovery from induced refractive error
              4. compensation for hyperopic defocus
       B. Effects of conflicting central and peripheral visual signals
              1. peripheral form deprivation
              2. peripheral hyperopic defocus

V. Optical treatment strategies for myopia
       A. Peripheral defocus and curvature of field
       B. Effects of conventional correcting devices
       C. Implementation strategies
              1. Peripheral optical changes with CRT
              2. Results from initial spectacle lens trials


Bio.
Dr. Smith received his O.D. and Ph.D. from the University of Houston and joined
the faculty of the UH College of Optometry in 1978. Currently he holds the
Greeman-Petty Professorship and is the Dean of the College of Optometry. His
research is centered on the role of visual experience in refractive development.
Dr. Smith is the recipient of the Glenn Fry Award and the Charles Prentice Medal
from the American Academy of Optometry. He is past Chair of NIH’s Central
Visual Processing Study Section and a past member of NIH’s National Advisory
Eye Council. Dr. Smith is currently the President of the Association of Schools
and Colleges of Optometry.
                                                                                                                         11/24/2010




                                                                       Review of Epidemiology
            Epidemiology and                                      Epidemiology is…
             Clinical Trials –                                     – The study of health or illness in human or
                                                                     other populations
            Lift the Smoke Screen
                                                                  Why is this important?
                                                                   – We want to practice evidence-based medicine
            David A. Berntsen, OD PhD                                  Papers in the literature use various study designs
                   Assistant Professor                                  to test hypotheses
                   University of Houston                               A basic understanding is needed to identify
                   College of Optometry                                 strengths and weaknesses of these papers




       Evidence-based medicine
                                                                          Beyond the abstract
           and your patients
 Your patients hear or read the USA Today                        Why not just read the abstract?
  version and ask you questions                                    – Don’t judge a book by its cover…
 For better or for worse, your patients surf                      – Don’t take the abstract at face value
  the net
                                                                   – Dangers of just reading the abstract
                                                                     conclusions:
                                                                       Misinterpretation
                                                                       Misinformation




    Dangers of just reading the abstract                                             Overview
   All details are not in the abstract
    – Was the study design appropriate to answer the              Study Designs
      research question?                                           – Advantages and disadvantages
    – Who were the subjects? -- generalizability
                                                                  Sources of Bias
                       p
    – How were the exposure variable and event of interest
      defined and measured?                                                       k h      d
                                                                   Questions to ask when reading any paper
    – Did the authors control for other important variables?
    – What are the sources of bias?




                                                                                                                                 1
                                                                                                                                            11/24/2010




                     Study Designs                                                      Case-Control Study
   Observational                                                           Case-control
     – Case-control Study                                                    – Match cases with a disease of interest (such as
          Retrospective (outcome of interest already occurred)                microbial keratitis) with controls having similar
     – Cross-sectional Study                                                   characteristics (e.g., age, gender)
          Non-directional (snapshot at time of study)                         Used t id tif di           i kf t
                                                                             – U d to identify disease risk factors
     – Cohort Study
          Prospective (outcome occurs after start study)
          No randomization
   Experimental
     – Clinical Trial (gold standard)
          Prospective
          Randomization to an exposure




               Case-Control Study                                                       Case-
                                                                                        Case-Control Study
   Ex: Buehler PO, Schein OD, Stamler JF, Verdier DD, and Katz J.          Schein OD, Buehler PO, Stamler JF, Verdier DD, Katz J. (1994) The
    (1992) The increased risk of ulcerative keratitis among disposable       impact of overnight wear on the risk of contact lens-associated
    soft contact lens users. Arch Ophthalmol. 110:1555-1558                  ulcerative keratitis. Arch Ophthalmol. 112:186-90
     – “Disposable soft contact lens users had the highest                   – “Compared with users of daily-wear soft lenses, users
       risk of developing ulcerative keratitis, with an                        of disposable soft contact lenses had a 13.33-fold
       adjusted relative risk of 14.16 compared with daily-                    excess risk of ulcerative keratitis. However, after
       wear soft contact lens users and 7.66 compared with                     adjusting for overnight wear, the excess risk
       conventional extended-wear soft contact lens users”                     associated with disposable contact lenses is reduced to
                                                                               3.21. Overall, overnight wear of contact lenses
                                                                               conferred an 8.25-fold excess risk of ulcerative keratitis
                                                                               after controlling for lens type.”




             Cross-Sectional Study                                                             Cohort Study
   Cross-sectional                                                         Cohort study
     – Determine prevalence of disease in a population                       – Study natural progression of a disease over time
          No information on progression or incidence                             Identify risk factor profile of the disease
                                                                             – Investigator does not influence exposure
                                                                                  Subjects followed longitudinally for disease onset


             Incidence                                                            Collaborative Longitudinal Evaluation of Keratoconus (CLEK)
                                                                                  Collaborative Longitudinal Evaluation of Ethnicity and
                             Prevalence                                            Refractive Error (CLEERE)

                                           Fatality, recovery




                                                                                                                                                    2
                                                                                                                                                   11/24/2010




                        Clinical Trial                                                                     Clinical Trial
   Clinical Trial (most like an experiment)                                               In CLs: Compare lens A to B or solution A to B
    – Subjects enrolled following strict entry criteria
    – Subjects randomly assigned to treatment or control
        Unknown sources of bias are randomly distributed between                          Other Examples:
         the two groups
         th t                                                                                  Ocular H     t   i T t        t Study
                                                                                             – O l Hypertension Treatment St d (OHTS)
    – Followed looking for disease progression or                                            – Contact Lens and Myopia Progression (CLAMP) Study
      occurrence of a predefined endpoint                                                    – Correction of Myopia Evaluation Trial (COMET)
        Determine efficacy of a treatment
   Double-masked (double-blind)
    – Neither the examiner nor the subject know the
      treatment assignment




                   Sources of Bias                                                                       Selection Bias
 Selection Bias                                                                           Systematic error resulting from:
 Information Bias                                                                          – the way subjects were selected to participate
                                                                                                Ex: only the sickest subjects are referred to a
 Confounding
                                                                                                 study testing a new drug versus an old drug
                                                                                                      y      g           g                    g
                                                                                                Ex: Recruited sample—effect of incentive to
                                                                                                 participate

                                                                                            – selective losses of subjects during the study
                                                                                                Ex: a subset of subjects randomized to receive a
                                                                                                 new treatment are more likely to experience side
                                                                                                 effects and therefore drop out than the controls




                  Information Bias                                                                        Confounding
                                                                                      Two conditions are necessary for a variable to be a confounder:
   Systematic error arising because of incorrect
    information obtained on a variable                                                                 Exposure               Outcome
    – Misclassification Bias
        subjects are misclassified as having a disease of interest
         when they don’t because:                                                                               Confounding
           – they were misdiagnosed
           – a poorly worded survey designed to determine if subject has the Dz
                                                                                                                  variable
             (Ex: a dry eye survey)
                                                                                       1. Be associated with the exposure
        subjects incorrectly remember whether they were exposed to
         something of interest                                                               - without being the consequence of exposure
           – Subject incorrectly recalls the brand of contact lens or solution that    2. Be associated with the outcome
             they use
                                                                                             - must be independent of exposure (not an intermediary)




                                                                                                                                                           3
                                                                                                                                                                      11/24/2010




Confounding example                                                                                  Confounding example

                                                                                                                               Lung           No Lung
                   Alcohol                                   Lung Cancer                                                       Cancer         Cancer
                                                                                                             Drinker           50             50
                                                                                                             Non-drinker       50             150
                                                                                                                               100            200
                                          Smoking


        Smoking (the confounder) is correlated with the                                             50% of cases are drinkers 50 / 100 = 0.5 or 50%
        consumption of alcohol (the exposure) but not a                                             25% of controls are drinkers 50 / 200 = 0.25 or 25%
               consequence of drinking alcohol
                                                                                                    It seems that drinking is associated with lung cancer.
   Smoking is associated with lung cancer (the outcome)
       and is independent of alcohol consumption




  Confounding example                                                                                                      Confounding
                                                                 Among smokers:
Smoker                 Lung               No Lung
                       Cancer             Cancer                 45/75=60% of lung                              Alcohol                             Lung Cancer
Drinker                45                 15                     cancer cases drink
Non-drinker            30                 10                     15/25=60% of controls
                                                                    /
                       75                 25                     drink.                                                              Smoking

                                                                 Among non-smokers:                           Smoking is correlated with alcohol consumption and
Non-Smoker             Lung               No Lung                                                             a risk factor for lung cancer even for those subjects
                       Cancer             Cancer                 5/25=20% of lung                                            who do not drink alcohol
Drinker                5                  35                     cancer cases drink
Non-drinker            20                 140                    35/175=20% of
                       25                 175                    controls drink.




                                 Confounding

                  Disposable                                       Microbial
                   Soft CLs                                        Keratitis

                                                                                                               g           p
                                                                                                      Dissecting a Manuscript
                                     Extended Wear

             Extended wear is correlated with disposable soft CL wear
               and a risk factor for microbial keratitis even for those
                  subjects who do not wear disposable soft CLs


Schein OD, Buehler PO, Stamler JF, Verdier DD, Katz J. (1994) The impact of overnight wear on the
risk of contact lens-associated ulcerative keratitis. Arch Ophthalmol. 112:186-90




                                                                                                                                                                              4
                                                                                                        11/24/2010




    Identify the Central Question                          Selection of the study sample
   Distill the study to a single, central question,      Is it a…
    perhaps with ancillary questions                       – Clinical population—inherent bias toward
   What is the primary objective of the study?              more severe disease
   What is the statistical null hypothesis of the                      sample effect
                                                           – Recruited sample—effect of incentive to
    study?                                                   participate
   What is the target population?                         – Random population sample
                                                          The study sample selected determines the
                                                           generalizability of the results




    Selection of the study sample                       Selection of the study endpoint
 Look for lack of comparability between                Is the appropriate variable being
  subjects and controls on covariables (e.g.,            measured?
  age, sex, ethnicity, etc.)                            Is it being measured by the appropriate
                            (e g
 Classification of sample (e.g., presence of            method?
  dry eye)—reliable, consistent, unbiased?              Reliability and validity of measurement
 Loss to follow-up or rate of non-                      methods
  participation




               The Sample Size                             Results and Statistical Analysis
   Did the authors have the number of                    Tables and figures
    subjects needed to answer the primary                  – 1. Consistency: do subject numbers sum to
    question?                                                the total; are values reasonable?
    – Sample size calculation for measuring                  2.
                                                           – 2 Figures: mutually exclusive bins in
      different proportions of an event                      histograms; appropriate number of points on
    – Sample size calculation for measuring                  figures?
      different means of a variable                     Did the investigators use the right
                                                         statistical analysis?
                                                        Are the authors’ conclusions based upon
                                                         the reported results?




                                                                                                                5
                                                                                                                                                             11/24/2010




                                                                                Basic Statistical Concepts
                        Statistics
                                                                                         non-
                                                                                (for the non-statistician)
 Bergmanson describing the typical
                                                                         When applied appropriately, statistical
  clinician’s view of statistics:
                                                                          tests are valuable tools
  “There are three types of lies…small lies,                              – When used incorrectly, incorrect conclusion
  big lies, and statistics”
    g     ,                                                                                         in,
                                                                            can be drawn (garbage in garbage out)
 When used appropriately, statistics are a                               – The appropriate test to use is determined by
  valuable tool                                                             the type of data being analyzed
    – Tests have assumptions that must be met
    – False conclusions if used inappropriately
    – p < 0.05 does not mean it is clinically
      meaningful




                    Statistics
                                                                                        p-
                                                                          What does the p-value mean?
               What are we testing?
    – Null hypothesis (H0): no difference exists                         p < 0.05
    – Alternate hypothesis (H1): a difference exists
                                                                          – Chance that a “Type I error” will occur (i.e.,
    – Statistics used to test whether we can reject the null
                                                                            incorrectly reject the null hypothesis)
      hypothesis (H0)
                                                                                                                      true,
                                                                          – Interpretation: If the null hypothesis is true a
                             True State of the Null Hypothesis
Statistical Decision                                                        result as extreme as the one observed will
                             H0 true                   H0 false
                           Type I Error
                                                                            occur by chance less than 5% of the time (1
        Reject H0                                      Correct
                         (False Positive)                                   in 20 times)
                                                     Type II Error
     Do not reject H0        Correct
                                                   (False Negative)
                                                                          – Beware of statistical “trends”
                                                                                 May times, use of word “trend” by the author =
                                                                                  not significant, but I wish it were




Parametric vs.
                                                                                         Non-
                                                                          Parametric vs. Non-Parametric
Non-
Non-Parametric                                                             Non-parametric tests generally used when:
                                                                           •Analyzing ordinal data (i.e., categorical data, not continuous)
   Parametric tests have                                                  •The distribution is not normal
    more assumptions than                                                  •Outliers are present
                                                                           •The sample is small (n < approximately 20)
    their non-parametric
                                                                      Parametric Test        Non-parametric Cousin   Use
    counterparts:                                                     One-sample t-test      Sign test or Wilcoxon   Compare mean to a constant value
                                                                                             Signed-Rank Test
    – Assumes equal variance
      (variability) and that the                                      Paired t-test          Sign test or Wilcoxon   Compare change within a group (e.g., test
                                                                                             Signed-Rank Test        same subjects before and after)
      data are normally
      distributed (y normally                                         2-sample
                                                                      (Independent) t-test
                                                                                             Wilcoxon Rank Sum or
                                                                                             Mann-Whitney U
                                                                                                                     Compare means of two independent samples

      distributed at each x)                                          One-way ANOVA          Kruskal Wallis test     Compare means for three or more independent
    – Parametric tests are only                                                                                      samples
                                                                      Repeated-measures      Friedman Test           Compare three or more means from the same
      more powerful if the                                            ANOVA                                          sample (e.g., same subjects, 3 conditions)
      assumptions are met                                             Regression or          Spearman Correlation    Measure association of two continuous
                                                                      Pearson correlation                            variables




                                                                                                                                                                     6
                                                                                                       11/24/2010




                    T-test traps                           Linear regression transgressions
 Additional assumptions: independent                       Additional assumptions: linearity in the
  populations, independent observations in                   outcome, independence
  each sample                                               Regression of non-continuous data (two
             t tests
 Too many t-tests                                                            x values
                                                             groups without x-values in between)
    – Must adjust (i.e., raise your expectations) if        Correlation between one variable and
      multiple tests are performed                           another that it contains (e.g., axial length
        If do 20 t-tests without adjusting, one will be
                                                             and anterior chamber depth)
         significant by chance alone
    – Planned tests vs. fishing expeditions                 Outliers in small samples




                                                                                                               7
                                                                                                      11/24/2010




                                                                         AFFILIATIONS

     GP LENSES PAST, PRESENT, AND                          • Contact Lens Manufacturers Association
      TURBO CHARGING INTO THE                              • Bausch & Lomb (Thought Leaders)
               FUTURE
          Ed Bennett OD, MSEd, FAAO
      Assistant Dean, Student Services and 
                Alumni Relations
       UM‐St. Louis College of Optometry




RIGID GAS PERMEABLE/Gas Permeable 
                                                                  THANK YOU DR. BORISH
              or GP
   Modified PMMA Designs (1970’s)
   • Ultrathin, low wetting angle
• Cellulose Acetate Butyrate  1978 became the first 
  approved RGP; very low O2 permeability and 
        bl
  unstable
• Silicone/acrylate (Polycon I):  approved January, 
  1979; Gaylord patent of 1974; Seidner ‐ Syntex ‐ Sola‐
  Barnes‐Hind ‐ Sola ‐ WJ ‐ Ciba
• Fluoro‐Silicone/acrylate:  Boston Equalens (1986)




        THANK YOU BOB GROHE                                  RIGID GAS‐PERMEABLE LENSES




                                                                                                              1
                                                                                           11/24/2010




      Thank You Alan Tomlinson                         REFITTING PMMA WEARERS INTO GPS:  




                                                       IMMEDIATE REFITTING FROM PMMA 
                                                          TO GP LENSES:  AOA J  3/83
• PMMA wearers divided into 2 groups:  (1) 
  total cessation or cold turkey & then refit into 
  Polycon;  2) immediate refit into Polycon
  without loss of wearing time
  without loss of wearing time
• Immediate refitting slowed but did not inhibit 
  recuperative changes
• Vision was better and more stable with 
  immediate refit group




                                                         Negative Effects of “Cold Turkey”  
          REFITTING INTO GPS
                                                           Optometric Monthly  11/83
• Refitting Procedure
  – Immediate refit without loss in wearing time
  – If corneal warpage, reduce wear time to minimum 
    they can wear and refit one week later
    they can wear and refit one week later




                                                                                                   2
                                                                                                11/24/2010




  Silicone/Acrylate Lens Design  ICLC  
                                                  GP Materials: Fluoro‐Silicone/Acrylate
                 1/85
                                                  • Combined fluorine with other ingredients 
                                                    of S/A to enhance mucin interaction with 
                                                    lens surface = wettability & stability; 
                                                    increase Dk
                                                    increase Dk

                                                  • Materials can be divided by Dk:
                                                    – Low Dk = 25 ‐ 50
                                                    – High Dk = 51 ‐ 99
                                                    – Hyper Dk = ≥ 100




OXYGEN PERMEABILITY (DK) AND LENS                           GP LENS MATERIALS
           SELECTION
• Low Dk = 25 ‐ 50 (Boston ES & FP 30, Fluorex 
  300 & 500, FLOSI; SGP III)
• High Dk = 51 ‐ 99 DW (Boston EO; FP 60 & 92; 
  Paragon HDS; Optimum Comfort)
  Paragon HDS; Optimum Comfort)
• Hyper Dk = ≥ 100 (Boston XO/X02; Menicon Z, 
  Paragon HDS 100, Paragon HDS100; Optimum 
  Extra & Extreme) 




  Rigid EW:  Fluoroperm EW  Contact 
          Lens Journal  3/89




                                                                                                        3
                                                               11/24/2010




   Thank You Rex Ghormley          RIGID EW:  ICLC  8/87




                                MODIFICATION OF GP LENSES:  
MODIFICATION:  Rev Optom 1/98
                                 Contact Lens Forum:  7/90




                                UMSL MODIFICATION STUDY:  
   Thank You Bruce Morgan
                                      AOA J  3/92




                                                                       4
                                                                                   11/24/2010




    UMSL Modification Study Results                  GP QUALITY CONTROL  AOA J  3/95   
• Edge polishing, surface polishing and 
  repowering performed
• SLE, SEM & Subjective evaluation
           f       li h & d      li h did
• Front surface polish & edge polish did not 
  impact performance; repowering did not with 
  one of the methods
• Important to control polish, application & tool 
  pressure




               GP Quality Control
• 200 ODs polled
• Overall opinion was that quality varied 
  resulting in edge defects, poor initial surface 
              and other problems
  wettability and other problems
• Verification essential at that time
• Optical quality and lens parameter accuracy 
  considered much more important that 
  turnaround time & material cost




Professor Efron’s 10 Reasons for “Rigid                   NATHON EFRON???
      Contact Lenses Obituary” 
•   1.  Initial Discomfort
•   2.  Induced corneal/lid pathology
•   3.  Soft lens advertising
•   4.  Superior soft lens fitting logistics
•   5.  Lack of clinical training
    5 Lack of clinical training
•   6.  Problem‐Solver Function redundant
•   7.  Improved soft toric/multifocal lenses
•   8.  Limited uptake of ortholeratology
•   9.  Lack of investment in rigid lenses
•   10.  Aberration  control soft lenses  




                                                                                           5
                                                                                      11/24/2010




    MY EFRON RESPONSE Contact Lens 
                                                     MY RESPONSE
       Anterior Eye (online 10/10)
                                      •  Initial Comfort
                                      • Presbyopia
                                      • Training
                                      • Overnight Orthokeratology
                                      • Problem‐Solving
                                      • Safety




       COMFORT AND GPs:  Practical 
                                                   New OD  (recent)  
           Optometry  8/97




             GP LENS COMFORT                PRESENTATION METHODS
•   Presentation                      • Gauge patient’s reactions to ocular tests
•   Topical Anesthetic                • High reactors = gradual adaptation
•   Lens Design                       • Offer realistic expectations
•   Good Initial Vision               • Don’t be tentative in GP description
                                      • Don’t use negative phrases: discomfort, pain, 
                                        intolerance, failure; use “lens awareness,” “lid 
                                        sensation”
                                      • “GP” (not “RGP”)




                                                                                              6
                                                                                                                  11/24/2010




     Effect of Different Methods of 
                                                                      STUDY METHODS
       Presenting GPs  OVS  7/98
                                                        • 49 subjects, non‐CL Wearers, age and sex matched, 
                                                          randomly assigned to 3 groups
                                                          •  Fear‐arousing:  observed a video of Dr. talking to Pt 
                                                          about GP adaptation using fear‐arousing terms
                                                          •  Neutral Non‐Enthused:  Dr. talking to Pt using 
                                                          neutral terms but is non‐enthused
                                                          •  Neutral Enthused:  Same as previous but Dr. has 
                                                          positive attitude




              STUDY RESULTS                                      UNSUCCESSFUL SUBJECTS
• 6/19 dropped out (in one month) from fear‐
  arousing; 2/17 in neutral NE; 0/13 in neutral              6

  enthused                                                   5


  Fear‐arousing submitted only 50% of daily 
• Fear arousing submitted only 50% of daily                  4
                                                                                                               Negative
  questionaires; neutral NE = 55%; neutral                   3                                                 Neutral

  enthused = 87%
                                                                                                               Positive




                                                             2

                                                             1

                                                             0
                                                                                 Dropouts




        QUESTIONAIRE RETURN                                              CONCLUSIONS
30
                                                        • Method of presentation can affect success.  If 
25
                                                          presented negatively, there was greater risk of 
20
                                             Positive
                                                          discontinuation of lens wear.
15                                           Neutral
                                             Negative
                                                          Subjects provided with a positive approach 
                                                        • Subjects provided with a positive approach
10
                                                          toward GPs were most likely to be compliant 
 5                                                        with daily questionnaire submission.
 0
                 Compliance




                                                                                                                          7
                                                                                    11/24/2010




                                             TOPICAL ANESTHETIC USE: 
           GP LENS COMFORT
                                                 CONTROVERSIAL
• Presentation                       • Concerns:
• Topical Anesthetic Use               – Staining
                                       – Effect of Eye Rubbing
                                         Potentially Mislead Patient
                                       – Potentially Mislead Patient




        TOPICAL ANESTHETIC USE: 
            CONTROVERSIAL
• Potential Benefits:
  – Improved Initial Comfort
  – Less Reflex Tearing
    Less Initial Chair Time
  – Less Initial Chair Time
  – Greater Patient Satisfaction




TOPICAL ANESTHETIC USE  OVS: 11/98      ANESTHETIC STUDY METHODS
                                     • One Month Study
                                     • 80 subjects at four institutions (UMSL, SCO, 
                                       Pacific & OSU)
                                        ll      G
                                     • All new GP wearers
                                     • 40 given Ophthaine, 40 placebo at fitting visit




                                                                                            8
                                                                                                                                   11/24/2010




           OVERALL ADAPTATION                                                       OVERALL SATISFACTION

    9
    8
    7                                                                           9
                                                                                8
    6
                                                                                7
    5
                                                            Anesthetic          6
    4                                                                           5
                                                            Placebo
    3                                                                           4
    2                                                                           3

    1                                                                           2
                                                                                1
    0
                                                                                0
        Dispensing   1 Week   2 Weeks   3 Weeks   4 Weeks
                                                                                     Dispense   1 Week   2 Weeks   3 Weeks   4 Weeks




    ANESTHETIC STUDY RESULTS                                             GP PARAMETERS & INITIAL COMFORT
• 10 dropouts, 8 in the placebo group
• Bottom Line:  Topical Anesthetic 
  recommended for all new GP patients but 
  especially beneficial with children, 
  especially beneficial with children
  keratoconics, soft lens refits & any 
  apprehensive patients; remember, you have to 
  compete with soft (efficiency/comfort)




              EMPIRICAL FITTING                                                INCREASE IN GP LENS USE
Has benefits of:                                                         • Significance of first impression
 Good initial vision                                                     • If GP lenses are perceived more positively by 
 Improvements in manufacturing technology                                  patients initially, less negative comments and 
 (thin designs, standard periphery)                                        fewer dropouts should result
                                                                           fewer dropouts should result
 Psychological Benefit to patient:  improved                             • Likewise, a reduction in chair time should 
 initial comfort???                                                        result due to quicker adaptation




                                                                                                                                           9
                                                                          11/24/2010




                                        BASE CURVE RADIUS SELECTION 
                                               (Minus Lenses)
                                    Corneal CylinderFit
                                    PL ‐ 0.50D      0.50 ‐ 0.75D Flat
                                    0.75 ‐ 1.00D    0.25 ‐ 0.50D Flat
                                    1.25 ‐ 1.50D    “On K” ‐ 0.25D Flat
                                    1.75 ‐ 2.00D    0.25D Steep
                                    2.25 ‐ 2.50D    0.50D Steep
                                    2.50 ‐ 3.00D    0.50 ‐ 0.75D Steep




                                           CLINICAL & EXPERIMENTAL 
PERIPHERAL CURVE DESIGN (Bennett)
                                               OPTOMETRY  5/08
• Tetracurve (> 8.8mm OAD)
  – SCR = BCR + 0.8mm/0.3mm
  – ICR = SCR + 1.0mm/0.2mm
    PCR = ICR + 1.4mm/0.2mm
  – PCR ICR + 1 4mm/0 2mm
  EXAMPLE:  BCR = 8.01mm
  SCR/W = 8.80mm/0.3mm
  ICR/W = 9.80mm/0.2mm
  PCR/W = 11.20mm/0.2mm




                                                                                 10
                                                                                          11/24/2010




CONTACT LENSES 5th ed.  Phillips &          GP MULIFOCAL INNOVATIONS  
      Speedwell (2007)                        Clinical Optometry  2/10




                                                         METHODS
                                      • N = 32 (range 42 – 65)
                                      • 8 each for GP monovision, soft bifocal, aspheric GP 
                                        multifocal & PALs
                                      • Binocular low (18%) and high (95%) contrast acuities 
                                        (B il L i )
                                        (Bailey‐Lovie)
                                      • Binocular contrast sensitivity (15 – 18cpd) with 
                                        Vistech VCTS 6500
                                      • Monocular glare sensitivity @ 3 luminance settings 
                                        (400, 100 and 12 foot lamberts) using brightness 
                                        acuity tester (BAT) 




                                         Contrast Sensitivity & Presbyopia: 
                                          Journal of Modern Optics  6/07




                                                                                                 11
                                                                                                                  11/24/2010




                                                                     MONOVISION VERSUS CL 
                                                                       BI/MULTIFOCALS
                                                          • Rajagopalan A, et al:  CONCLUSIONS
                                                          • GP wearers exhibited highest contrast 
                                                            sensitivity at all frequencies, high and low 
                                                            contrast acuity and least disability glare; soft 
                                                            contrast acuity and least disability glare; soft
                                                            bifocals were second; monovision last in all 
                                                            categories




         MONOVISION VERSUS CL                                               Survey of Diplomates
                                                              Contact Lens and Cornea Section American Academy of 
           BI/MULTIFOCALS                                                           Optometry
• Johnson J, et al; Multivision Vs. Monovision: A         • Prescribing trends presbyopic patients wearing contact 
                                                            lenses? (28 responded)
  comparative study:  presented at CLAO, Feb, 2000
• 6 weeks GP multifocal; 6 weeks monovision (or vice      • GP Multifocals – 23.8%
  versa)
                                                              f    l if l          %
                                                          • Soft Multifocals – 35.7%
• 75% who completed study preferred multifocal
                                                          • Monovision (GP & Soft) – 24.9%

                                                          • Single Vision CLs w/Readers – 15.4%




                                                            EXCHANGE RATES:  THE RESULTS OF A LARGE 
  Comfort: MF vs. Spherical: CLS 2/05                                     PRACTICE
• GP Insights
Researching GP Multifocals
BY               • Practitioner DB:  710 GP multifocal lenses 
  EDWARD S. BENNETT, OD, MSED.  Recently, two               purchased over 3 years (10 patients/month)
  students from the University of Missouri‐St. Louis, 
  College of Optometry, Allyson Conn, OD, and Tyler       • Average return rate of 42% (close to national 
  Kramer OD performed a pilot study to evaluate the
  Kramer, OD, performed a pilot study to evaluate the       average)
  following questions:1. How does the initial comfort 
  of GP bifocal and multifocal lens designs compare to 
  a spherical GP design?
• GP MF & BF lenses more initially comfortalbe than 
  spherical lenses




                                                                                                                         12
                                                                  11/24/2010




                                  GP SUPPLEMENTS (DESIGN, FITTING & 
REVIEW OF CORNEA & CLS  1/02
                                         TROUBLESHOOTING)




CONTACT LENS SPECTRUM ANNUAL 
                                  GLOBAL SPECIALTY LENS SYMPOSIUM
           GP ISSUE




GLOBAL SPECIALTY LENS SYMPOSIUM        Thank you Milton Hom




                                                                         13
                                                                                               11/24/2010




       Thank You Barry Weissman                      Clinical Manual of Contact Lenses




              GP LENS INSTITUTE
• Educational 
  division of the 
  CLMA
• Responsible for 
       titi
  practitioner, 
  student and 
  resident educate 
  via new and 
  innovative 
  programs and 
  resources 




   Resources Available from the GP Lens Institute                      GP Case Grand Rounds 
                                                                       Troubleshooting Guide
                  (www.gpli.info)
      • Practitioner Fitting Aids                                 • This resource an online guide 
                                                                    that a practitioner can access 
                                                                    while in his examination room 
                                                                    to help troubleshoot any GP 
                                                                    case
                                                                  • To be updated in mid‐2009 with 
                                                                    new and unique cases from 
                                                                    GPLI Advisory Committee 
                                                                    members as well as contact lens 
                                                                    residents and faculty




                                                                                                       14
                                                                                         11/24/2010




                                           SMART:  Contact Lens Spectrum 
     FITTING YOUNG PEOPLE                             10/09)
                                       • MYOPIA CONTROL STUDY The SMART Study: 
                                         Background, Rationale, and Baseline Results: This 
                                         long‐term longitudinal study aims to answer the 
                                         question of whether ortho‐k can control myopia.By
                                         S. Barry Eiden, OD, FAAO; Robert L. Davis, OD, 
                                         S Barry Eiden OD FAAO; Robert L Davis OD
                                         FAAO; Edward S. Bennett, OD, MSEd, FAAO; and 
                                         Julie O. DeKinder, OD, FAAO
                                       • N = 162 (treatment subjects)
                                       • 80.5% first‐fit success
                                       • Absence of microbial keratitis in year one




                                               Can GP Wearers Undergo 
Myopia Control (Points de Vue 1/10) 
                                              Orthokeratology?  OVS  5/07




                                             GP EW Problem‐Solving  ICLC  
GP PROBLEM SOLVING  AOA J (7/86)
                                                   (May/June 90)




                                                                                                15
                                                                                       11/24/2010




   GP PROBLEM SOLVING: CORNEAL 
                                                            Thank You Vinita
           DESICCATION
• Diameter: larger reduces area; smaller 
  reduces mass
• Lens Position:  Inferior least desirable (Henry, 
  Bennett & Forrest, AJO, 1986)
                     ,     ,      )
• 3 & 9 o’clock staining‐to‐fit relationship
  – Position #Eyes 3 & 9     %
    Sup‐Centr 125   48        38
    Interpalp 193  111       57
    Inf‐Centr 46     34       73




                                                      High Minus Lens: No Lenticular




                                                                                              16
                                                                                  11/24/2010




High Minus Lens: With Lenticular           Plus Lens: No Lenticular




                                   EDGE LIFT & GPs:  Contact Lens Journal  
   Plus Lens: With Lenticular
                                                   4/86




                                            EDGE LIFT/CLEARANCE
                                   • Excessive edge lift/clearance acts in a funnel‐
                                     like manner ‐ drying out the surrounding tear 
                                     pool
                                       Lid Gap may further exaggerate process
                                   • “Lid Gap” may further exaggerate process
                                   • Edge lift/clearance is decreased via:
                                     – Steepening peripheral curve radii
                                     – Decreasing pc (bevel) width
                                     – Increase # of curves (width unchanged)




                                                                                         17
                                                                                         11/24/2010




                                                   Overnight Swelling/lens Performance c
                                                   S/A vs F‐S/A Lenses  CLAO J  Apr/Jun  88




  OXYGEN: HOW MUCH IS ENOUGH: ADAPTED 
               WEARERS                                  O2 RATINGS  Cornea (1990)
• Nelson, Bennett, Mirowitz, et al (1987):
   Approximately 7.5% swelling with 60 Dk lens 
   materials (S/A & F‐S/A) upon awakening
           lli    h               k i
•  No swelling 4 hours upon awakening
•  Lens stability and subjective preference for 
   surface wettability better with F‐S/A




Rigid Vs. Hydrogel (Bennett/Gordon, presented 
 at the Am Acad of Ophthalmology, Oct. 1993)               Bennett/Gordon (cont.)
• Via Tyler’s Quarterly, determined Dk/t for        • % Holden‐Mertz Requirement:
  three popular lens materials in each of the         – 40% +3.00D Disposable EW
  following categories:
                                                      – 58% +3.00D Disposable DW
  – GP DW
                                                        75% ‐3.00D Conventional EW
                                                      – 75% 3 00D Conventional EW
  – GP EW
                                                      – 90% ‐3.00D Disposable EW
  – Hydrogel DW
  – Conventional Hydrogel EW                          – 100% +3.00D GP EW
  – Disposable DW                                     – 125% ‐3.00D Disposable DW
  – Disposable EW                                     – 170% ‐3.00D GP DW




                                                                                                18
                                                                                              11/24/2010




GPs: No Acanthamoeba adherence: 
                                    TURBO CHARGING INTO THE FUTURE
           OVS:  1/96
                                   • Poll of the GP Lens Institute Advisory 
                                     Committee found the following GP 
                                     applications very promising (35 responses):
                                                               Correction (N = 22)
                                     – Multifocals/Presbyopic Correction (N = 22)
                                     – Scleral Lenses (N = 20)
                                     – Overnight Orthokeratology (16 responses)
                                     – Irregular Cornea (16 responses)




 BUT WHAT ABOUT HYBRIDS??                 SynergEyes Duette Lenses
                                   • FDA approval August, 2010
                                   • Silicone hydrogel skirt
                                   • Two separate lenses:  one for astigmatic 
                                             i            b i d i
                                     correction; one presbyopic design




      THE “PILLOW” LENS                     HIGH INDEX MATERIALS
                                   • OptimumHR (Contamac)
                                       Hirafocon A: DK = 50  SG = 1.04  IOR = 1.51
                                       Hirafocon B: DK = 50  SG = 1.04  IOR = 1.53

                                     Paragon HDS HI (Paragon)
                                       DK = 22  SG = 1.12  IOR = 1.54

                                     Other GP lens materials have Specific Gravity values between 
                                       1.10 ‐ 1.27 and IOR values between 1.42 ‐ 1.47

                                     Thinner, less mass & ideal for multifocal designs




                                                                                                     19
                           11/24/2010




Thank You Jean


                 SUMMARY




                                  20
William D. Townsend, OD, FAAO
2010: An Update on Blepharitis & Meibomian (Tarsal) Gland Dysfunction
Course Description

This lecture addresses the epidemiology, anatomy, and pathophysiology of the
eyelid disease with special emphasis on meibomian (tarsal) gland. In this bried
discussion we use actual cases from the speaker’s practice to discuss clinical
evaluation of lid conditions along with management strategies. We close with
new and future ”in the pipeline” therapies and procedures.
                                                               12/1/2010




                                 L. Miller, OD, PhD,
                        William L Miller OD PhD FAAO
                       Chair, Clinical Sciences Department
                                         Associate Professor
              University of Houston, College of Optometry




              TFOSS
Meibomian Gland Dysfunction Workshop
           Results: IOVS




 Dry   Eye
 Vision
 Contact     Lens discomfort
  ◦ deposits
  ◦ Dropouts
 Chalazia    precursor
 Aesthetics
 Overall   ocular surface health




                                                                      1
                                                      12/1/2010




                                      Result in an
                                      abnormal tear
                                      film & tear
                                      function
Bergmanson 2009




                         y J y         g ,   ,
                  Courtesy of Jerry Paugh, OD, PhD




                                                             2
                                     12/1/2010




         biomarkers
 Indirect
 Biomicroscopy
                               (a)


 ◦ Plugged orifice
 ◦ Orifice squamous metaplasia
            q             p
 ◦ Telengectasia
                              (b)
 ◦ Notched lid margins
 ◦ TBUT
 ◦ Lissamine green
    Lid wiper epitheliopathy




                                            3
                                                                   12/1/2010




              Meibography
                     ◦ Look for dropout
                                    p
                     ◦ Look for irregular acini




                                    …..but we can miss mild
                                    disease….
                                          Non-Obvious




                                                  MGD
                          Non-Obvious                   Obvious




                                                    Therefore…….
Photos courtesy of Dr. Justin Webb, Alcon 2010.




                                                                          4
                                                 12/1/2010




                    To uncover the non-obvious




 Simple
 Simple Plus
 Simple Enhanced
 ◦Mastrota paddle
  M t t ddl
 ◦Gutierrez MG Expressor
 Complex
 ◦Korb
 ◦Maskin




                                                        5
                                                          12/1/2010




   Multiple
    ◦ Mathers- 1991
      Grade 1 Free flowing liquid
      Grade 2 Slight increase in viscosity, still free
       flowing
      Grade 3 noticeably thickened
      Grade 4 toothpaste consistency




                                                                 6
                                                      12/1/2010




   Multiple
    ◦ Shimazaki-1995
      Grade 0- clear meibum easily expressed
      Grade 1- cloudy meibum expressed with mild
              1
       pressure
      Grade 2- cloudy meibum expressed with
       moderate pressure
      Grade 3-meibum cannot be expressed even with
       strong pressure




   Multiple
    ◦ Sotozono- 2007
      Grade 0- clear oily fluid expressed
      G d 1- yellowish-white oily fl d expressed
       Grade 1 ll        h h        l fluid     d
      Grade 2- thick cheesy material expressed
      Grade 3- inability to express any fluid




   Multiple
    ◦ Grade 0- clear fluid
    ◦ Grade 1- greasy slightly turbid fluid
    ◦ Grade 2- opaque
    ◦ Grade 3- semi-solid
    ◦ Grade 4- waxy substance if any




                                                             7
                             12/1/2010




 Conservative
 Topical tear supplements
 Topical antibiotic
 Systemic antibiotic
 Nutrition/Nutraceuticals




            wmiller@uh.edu




                                    8
                     Treatment Options and Coding
                                          Clarke D. Newman, OD, FAAO
                                               Plaza Vision Center
                                        600 North Pearl Street, Suite G-204
                                            Dallas, Texas 75201-7492
                                                  (214) 969-0467
                                            cdnewman@earthlink.net



Abstract
This course will review a few important facets of treating the watering eye and how to code properly to get reimbursement
for those services.

Learning Objectives
    1. To understand the etiologies of epiphora
    2. To understand how to distinguish between the various etiologies of epiphora
    3. To under stand ho w t o us e t he C PT codes and modifier c odes t o receive pr oper and f ull r eimbursement f or
       treating epiphora

    1. Introduction
            a.   What Are the Etiologies of Epiphora?
            b.   How Does One Differentiate Between the Etiologies?
            c.   How Does One Treat Epiphora?
            d.   How Does One Bill for These Services?

    2. Epiphora
            a. The Etiologies of Epiphora
                     i. Primary Acquired Nasolacrimal Duct Obstruction
                    ii. Secondary Lacrimal Drainage Obstruction
                   iii. Dry Eye Syndrome
                   iv. Conjunctivalchalasis
                    v. Lid Appositional Disorders
                   vi. Allergy
                  vii. Infection
                  viii. Foreign Body
                   ix. Trauma
            b. Diagnosis
                     i. History
                    ii. Slit Lamp Examination
            c. Treatment
                     i. Treating NLDO
                             1. Dilation and Irrigation
                    ii. Treating SLDO
                   iii. Treating Chalasis

    3. Coding
            a. 68761 Closure of Lacrimal Punctum, Each
            b. 68801 Dilation of the Lacrimal Punctum, With or Without Dilation
            c. 68840 Probing of Lacrimal Canaliculi, With or Without Dilation

                                      Treatment Options and Coding: Page 1 of 2
4. Conclusion
     a.   Managing Epiphora is a Key Component of Anterior Segment Care
     b.   The Differential Is Extensive
     c.   Effect the Proper Therapy for the Proper Etiology
     d.   Bill Properly or You Will Not Get Reimbursed Fully




                              Treatment Options and Coding: Page 2 of 2
                                                                                                                     Disclosures

    Conjunctival Epithelial Flaps:                                                    • I have no financial interest in any of the products
    Do They Require Treatment?                                                          mentioned in this presentation.

                                                                                                   received                following
                                                                                      • TERTC has recei ed grants from the follo ing
                                                                                        companies over the last 2 years:
           Norman E. Leach, O.D., M.S., F.A.A.O                                             – Alcon
          University of Houston, College of Optometry                                       – Bausch & Lomb
                         Houston, Texas
                                                                                            – Cooper Vision




                     Silicone Hydrogel CL                                                                 A Danish Discovery

                                                                                       Lofstrom T, Kruse A. A conjunctival response
                                                                                       to silicone hydrogel lens wear. Contact Lens
                                                                                              Spectrum 2005;September:42-44.




                            • 1999 – (DW & EW)
                                                                                                FLAP
                            • 2003 - (DW)
                            • 2008 – 1/3 of CL




  Conjunctival Epithelial Flap (CEF)                                                                                       Results

       Conjunctival epithelial flaps with silicone                                  Daily Wear (DW)                          # Eyes             # CEF           Occurrence
                                                                                    Lenses                                                                       Rate (%)
         hydrogel lenses worn for daily wear
                                                                                    Lotrafilcon B                               41                   5                 6% *
   Meng           Lin1,   Tan   Truong1,    Sri   Thota2,     Judith   Perrigin2,   Comfilcon A                                 117                  4                  2%
     1 - University of California Berkeley Clinical Research Center
     2 - University of Houston College of Optometry, TERTC
                                                                                    Galyfilcon A                                37                   1                  1%
                                                                                    Omafilcon A
                                                                                    (Control)                                   195                  0                  0%
                                                                                             * Correspondence analysis suggested that lotrafilcon B had a dissimilar frequency
                                                                                               pattern compared to the other 3 lens types; p = 0.045



Lin et al, 2005                                                                     Lin et al, 2005
                   Risk Factors:
                                                                                                           Clinical Findings
              Lens Modulus & Modality
                                                                                              • No discomfort reported
                                         Modulus                      CEF (%)
                                                                                              • SLE
  Omafilcon A                                 0.3                     0% (DW)
                                                                                                 – Acceptable fitting lenses
  Galyfilcon A                              0.4 *                     1% (DW)                    – Slight conjunctival injection
  Comfilcon A                                0.75                     2% (DW)
                                                                                              • CEF
  Lotrafilcon B                               1.1                     6% (DW)                    – Appear with CW/FW vs DW
  Balafilcon A                              1.2 **                  8% (CW)***                   – Difficult to detect with lens wear but are
  Lotrafilcon A                             1.4 **                 56% (CW)***                     easily identified with flourescein after lens
                                                                                                   removal
   * J&J product brochure; ** Ross, et al BCLA poster 2005; *** Lofstrom & Kruse, CLS Sept.
   2005

Lin et al, 2005




   Conjunctival Epithelial Flap (CEF)                                                         Conjunctival Epithelial Flap (CEF)
  • Incidence                                                                                 • Cause:
        – 3% (Meng et al. 2005)                                                                 – Tightly fitted CLs with sharp
        – 35% (Graham et al. 2009)                                                                edges
  • Characteristics                                                                                • 8.4/13.8 Air Optix Night
        – Asymptomatic                                                                               and Day Aqua
        – 64% bilateral                                                                         – CW
        – Superior
          conjunctiva (90%)
        – Inferior
          conjunctiva
                                                           Graham et al, 2009, OVS




                    Sri Thota, et al., 2006                                                                        Purpose
  •   Follow-up to our MCS
                                                                                                To describe the composition and cellular
  •   Conjunctival flap investigation                                                          health of conjunctival flaps (CEF) resulting
  •   2 subjects                                                                                from silicone hydrogel contact lens wear
  •   TERTC C
                  Methods                                        Subject 1 (OD)
• Two adapted silicone hydrogel lens wearers
  exhibited bilateral CEF after 1 week of
  continuous wear
  – Subject 1 (S1): lotrafilicon B lenses
  – Subject 2 (S2): lotrafilicon A lenses
• All flaps from each eye were sampled using
  impression cytology with cellulose acetate
  filters
• The specimens were subsequently stained
  with hematoxylin and analyzed
  microscopically




                   Results                                         Conclusion
• CEF location                                   • CEF appear strictly comprised of healthy and
  – inferiorly in S1 and superiorly in S2          vital epithelial cells
    approximately 1 mm away from the limbus
                                                 • The etiology may be mechanical in nature
    and peripheral to the lens edge
                                                   – Lens edge shape
• CEF cytology                                     – High modulus silicone hydrogel material
  – multi-layered tightly packed sheets of
    polygonal epithelial cells
  – Similar nucleus cell size and shape was
    noted in all cells within the CEF
  – No inflammatory cells were observed in any
    of the samples examined




           Revisit Cellular
                                                     Cellular Composition of CEF
         Composition of CEF
• Thota, et al. 2006 (n=2)                       • Data collection
• Purpose of study                                 – Impression
  − To investigate the cellular composition of       cytology
    CEF and compare with normal conjunctiva      • Staining
    in SiHi contact lens wearers and non-lens      – Stained with hematoxylin
    wearers.
                                                     and eosin
• Subjects
  – Nine subjects
                                                 • Morphometry
  – 8.4/13.8 Air Optix Night and Day Aqua          – Longest dimension of the
                                                     cell and nucleus measured
                                                     on 40 cells per sample
               Impression Cytology                                          CEF Morphometry
           Non CL            CL w/o Flap            CL w Flap
                                                                              Non-CL    CL-wearer     CL-wearer
                                                                              wearer     w/o flap       w flap
10X                                                               Cell size
                                                                             22 1 ± 4 9 27 3 ± 5 6*
                                                                             22.1 4.9 27.3 5.6        23.2 5.1
                                                                                                      23 2 ± 5 1
                                                                   (µm)
                                                                Nucleus size
                                                                              9.7 ± 1.5 10.5 ± 2.2    10.0 ± 2.0
                                                                   (µm)
20X                                                              C:N Ratio       1.3       1.7*          1.4

                                                                *P < 0.05




      Composition of CEF Confirmed                                             Be Aware….
  • Normal non-inflammatory                                     • New discoveries – new complications
    epithelial cells
  • Formed by dislocated healthy
    epithelial and goblet cells
  • A refit may be indicated
                                                                     FLAP




      Acknowledgements & Funding
  • Acknowledgements:




  • Funding:
      –   Core Grant # P30 EY007551
      –   William C. Ezell Fellowship 2009 & 2010
      –   TERTC
      –   Optikbranschen, Sverige
                                                                                                                                                     11/24/2010




                                                                            Criminal
                                                                             • guilty
                                                                             • innocent
                                                                             • convicted
                                                                                    i t d
                                                                            Civil
                                                    Christine A. Tyler,
                                                                             •   liable
                                                               OD, JD        •   lawsuit
                                                                             •   negligence
                                                                             •   malpractice




     Criminal Justice System
                                                                          Statutes (laws of your state, federal, e.g. HIPAA)
     • arrested, charged with, convicted of, investigated for a crime
     • state (DPS, state/local police, etc.), federal (FBI, DEA, etc.)    Regulatory, licensing and policing boards / agencies (TOB, DEA, DPS)

     Civil
     Ci il                                                                M di l P    l  / Vi i  Pl
                                                                          Medical Panels / Vision Plans
     • Lawsuits                                                           Malpractice Insurer
     • Carve‐outs: arbitration, mediation, agencies, other ADR
                                                                          Your actual boss / partner
     Regulatory
                                                                          Patients?
     • Licensing
     • Self regulating boards (TOB)




Being investigated for / charged with a crime                                                    • Criminal penalties (fines, jail)
• Drug use / abuse                                                                  Criminal     • Lawsuits can lead to mayhem if not properly insulated 
• DUI                                                                     convictions or even      (malpractice, workers comp insurance, proper business 
• Fraud
                                                                                     charges       entity structure)
Getting sued
                                                                                                 • Professional discipline, even if unrelated to your 
                                                                                                   professional duties
•   Malpractice                                                                 g
                                                                            Being named in a     • Credentialing / professional liability insurance 
•   Employment
•   Premises liability
                                                                                     lawsuit       procurement trouble in the future
•   Contract disputes                                                                            • Poor audit result: give the money back NOW
Complaints                                                                        Sticky audit   • Suspension / exclusion from panels, which also can lead 
                                                                                                   to problems in the future with procurement of 
• Patients (TOB, BBB, online chat)
• Employees (TWC / EEOC, as a prelude to lawsuit)
                                                                                                   professional liability insurance, credentialing
• Peers / other professionals                                              Complaints to the     • Shrinking stature in community / peer group
                                                                            TOB / BBB, even      • Reduction in future employment opportunities, 
Audits                                                                     online comments         shrinking patient base
• Insurance panels / vision plans
                                                                                                 • Reduced income




                                                                                                                                                              1
                                                                                                                                                                                            11/24/2010




Limited by legislation in every state for ODs
                                                                                     Common Law

                                                                                     • Appellate decisions from lawsuits against ALL EYE DOCTORS (not just ODs)
Varies by state                                                                      • Non‐negligent care: you and your staff / partners / employee doctors

                                                                                     What is common law negligence?
Struggle to remove inappropriate restrictions on scope of practice
                                                                                     • Failure to act with reasonable care, and that failure causes harm to someone
                                                                                     • Reasonable Person standard (failure to do what a reasonable eye doctor would do if presented with 
                                                                                       similar circumstance, e.g., failure to meet statutory / regulatory minimums, inadequate patient 
Ideally, scope would be limited by expertise and training ONLY                         education, medical mistake, wrong f/u schedule, etc.)
                                                                                     • Whatever a jury says it is
                                                                                     • Most jurors don’t like doctors
But then how would you control doctors’ behavior?  
                                                                                     Keeping a complete, clean record
• The same way we (and other medical professionals) already do!
• TOB, professional discipline                                                       •   This will go a long way to saving you from an unfavorable result
                                                                                     •   Enhances your chances of favorable outcome, makes you look like you know what you are doing
• Malpractice insurance, lawsuits
                                                                                     •   Should accurately, concisely reflect what actually happened in the patient encounter
• Stature in the community and among peers                                           •   Watch out for EMR templates….
• STANDARD OF CARE




Function of the record
                                                                                         Admissibility of Evidence: Relevance
•   Record patient’s needs, your findings, the conclusions and plan                      [Exhibits (documents), Testimony (depositions)]
•   Prove an eye exam occurred, prove the patient’s condition before and after
                                                                                             Strict rules regarding admissibility in courts – still, nearly everything on 
•   Prove to whom?  Insurance audit, lawsuit, patient dispute
                                                                                              paper in our world gets admitted, because almost always relevant
•   Your best defense in case of lawsuit
                                                                                                      y                                   y     y      gg
                                                                                              Virtually no rules in other forums – literally everything gets admitted,  ,
                                                                                              adjudicators determine relevance
Form of the record
                                                                                         Form of document irrelevant: medical records, emails, scraps of 
• EMR vs. paper                                                                           paper all may be evidence.
• EMR templates with stock language, populating data forward
• “Monitor condition at suggested intervals.”
                                                                                         Healthy business practice: prompt finalization, routine purge of 
                                                                                          unnecessary documents.
Altering or enhancing records                                                                Keep anything that would help you in a lawsuit
                                                                                             clean out unnecessary trash
• Addenda, later‐made notes, “finalization” of the record
                                                                                         Once a dispute arises, cannot destroy any papers or notes.  NONE.




                                                                                     Suffer and permit
 Protections from liability                                                          • Taking work home
                                                                                     • Unrecorded time at work

                                                                                     Salary vs. hourly (overtime)

 Tax structure                                                                       • Cannot escape overtime just by paying salary
                                                                                     • Must also give executive, professional or administrative status
                                                                                     • Key: discretion (significant freedom to exercise judgment at work)

                                                                                     Volunteerism

 Varies state by state                                                               • Your employees cannot volunteer for you or be compelled to volunteer for 
                                                                                       your favorite cause
                                                                                     • What about for the business that you own?




                                                                                                                                                                                                    2
                                                                                                                                                       11/24/2010




Independent Contractor vs. Employee:                                                  Classifying a doctor as an independent 
Many factors, including but not limited                                               contractor vs. employee:
to:
                                                                                      • Benefits
•   Bring own equipment or use yours?                                                 • Total number of employees is sometimes 
•   Exclusively work for you, or also for others?                                       important
•   Occasion for profit and loss (have own business)?                                 • Taxes (1/2 of FICA)
•   Autonomy in manner of performing tasks?                                           • What about liability?
•   Control of days worked?                                                           • Malpractice insurance?  Credentialing?




    Why have it?
                                                                                        Harassment: A form of discrimination
    • Limits liability for injuries sustained by employees while at work
    • Employer is shielded, insurance pays (or not), and there is NO LAWSUIT
    • Exception: employee may still be sued for gross negligence (very tough 
                                                                                        • Issue must be related to protected class
      standard)                                                                         • Title VII of Civil Rights Act of 1964 (race, sex, religion, 
    • Payouts are limited and defined                                                     national origin)
    • If you do not have it, you can be sued by the employee for simple negligence 
      AND you lose all common law defenses                                              • Age Discrimination in Employment Act (ADEA); over 40
    • Biggest one is contributory negligence; also assumption of risk                   • Americans with Disabilities Act (ADA); disabilities
                                                                                        • Texas Commission on Human Rights Act (TCHRA); 
    Premiums determined by certain factors, including:
                                                                                          creates state law cause of action for all of the above, to 
    • Claims history                                                                      avoid Federal Court
    • Type of business                                                                  • Only applies to businesses with 15+ employees
    • Number of employees




    Harassment                                                                          Hiring and Firing

    • Form of harassment: hostile environment (or quid                                  • Must be non‐discriminatory
      pro quo for sexual harassment)                                                    • Protected class (e.g., race, gender, age, disability, 
                                                                                          religion, military status; not sexual orientation)
      Exposure to the offending item  environment or 
    • Exposure to the offending item, environment or                                    • 15+ employees
      activity, not necessarily directed at the offended 
                                                                                        • Disparate impact of hiring / promotion / job position, 
      employee                                                                            even if not on its face a member of protected class
    • Isolated incidents may be actionable, depending                                   • e.g., commission positions all occupied by a certain race 
      on the incident and the authority of the actor                                      or gender
    • Harasser could be anyone (other employees, even                                   • e.g., seeking “recent college grads” for an open position
      clients or outside business contacts)




                                                                                                                                                               3
                                                                                                                 11/24/2010




Firing an employee                                Harassment: Play it safe
• “Employment at Will” – you may fire for any 
  reason (except an illegal reason) or for no     • Foster a professional environment
  reason at all
           t  ll                                  • P li i   i t           j k      il
                                                    Policies against porn, joke emails
• Documentation – it should not be a surprise     • Internet chat policies?
• Sooner rather than later
                                                  • Have a plan in place to deal with bad 
• Have someone else in the room
• Do not lie to them; tell them the reason and 
                                                    behavior
  then stick to it                                • Follow the plan




                                                  Return patient calls asap
Obviously: try to avoid it!
                                                  Phone triage protocol that is standardized and in writing

Outward professionalism                           • Staff must know what issues are urgent and what can wait
                                                  • Review this periodically at staff meetings
                                                  • Follow up on errors made by staff during the triage

Outward appearance of being organized             Maintain a 24‐hour emergency call service


                                                  Tell every “higher‐risk” patient about it
Waivers – do they protect you?                    • Increased risk of developing problems OR
                                                  • Increased risk of misinterpreting symptoms




Contemporaneous finalization of records           Calling in Rx over the phone?


DON’T CHANGE ANYTHING                             DFE as a matter of course: Waiver?


CL: EW?
                                                  Refer

CL: FDA approved replacement schedule
                                                  Make notes!

Off‐label Rx of drugs?                            • Warnings, instructions, refusal of DFE, discussion of the 
                                                    24‐hour emergency on call service, etc.




                                                                                                                         4
                                                                                                                                                   11/24/2010




                                                            Don’t change / replace anything

                                                             • Can I add things?


                                                            Don’t destroy / delete anything


                                                            Don’t make new documents


                                                            Alert your carrier immediately and hand it over to your attorney (reservation of rights)

                                                            Don’t talk to anyone about it until you have discussed with your attorney; never talk to 
                                                            opposition about anything

                                                            Don’t represent yourself




When deposed, stay calm and talk slowly; tell the 
truth
• Answer ONLY the question asked, without any additional 
      ,          OU
  info, EVEN IF YOU THINK IT HELPS YOUOU

It is nice if your record is complete, and even 
nicer if it contains no treats for the opposition

You don’t have to be perfect, you just have to be 
non‐negligent




                                           1@




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