Off the Cuff: Don’t Ignore Your Allergy Patients

Sitting in the den on a frigid Sunday evening, I read through a backlog of journals as my daughter watched her favorite TV shows. I couldn’t help noticing that one allergy commercial after another was running. First it was Zyrtec, then Allegra, then Clarinex. One of the ads even focused on red, itchy eyes. Now that got my attention. Hey, that’s my turf!

As I listened, I started to wonder what these marketers knew that I didn’t. Why spend millions on national TV advertising that runs in the dead of winter, when allergy season is still months away? Or is it? What the advertisers know that we clinicians usually don’t think about is that millions of allergy patients suffer year-round. While our minds may close to the plight of allergy patients after the first frost, perennial allergic conjunctivitis or rhinoconjunctivitis continues to torment them throughout the year.

With this in mind, I started asking my own patients about their allergy symptoms. To my surprise, many were suffering silently. More disturbing was that many were self-treating. A patient who self-treats with ineffective over-the-counter products not only has a fool for a doctor, but he or she also blocks the real doctor (you) from using more effective and safer products. OTC use teaches patients that they don’t need you as part of their treatment team--and this should be taken as a sign of problems in your practice. Thanks to those TV commercials, I wrote a lot of allergy scrips last week.

On a personal note: When one of our colleagues is appointed vice president of a major corporation like CIBA Vision, it is truly a great accomplishment--not just for him, but for all of us. Rick Weisbarth has been a good friend and a tireless supporter of optometry. His promotion to V.P. could not have come at a better time or to a more deserving individual. Please join me in congratulating Rick!

Arthur B. Epstein, OD Chief Medical Editor optometricphysician@jobson.com

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Case in Point: Laser vs. Mechanical Microkeratome for Corneal Flaps

In an "inside-out" process, the femtosecond laser defines a dissection plane by forming an interconnecting series of plasma bubbles (made of water and carbon dioxide). The all-laser procedure eliminates manual and mechanical manipulation of corneal tissue.

An advanced laser approach for creating corneal flaps in laser in situ keratomileusis (LASIK) may provide greater safety and reliability than the mechanical microkeratome, which is frequently seen as a source of blade-related complications in post-op patients.

The IntraLASE FS (femtosecond) Laser uses custom-programmed software to focally photodisrupt the cornea at the prescribed depth and position with great accuracy. As the suction ring holds the eye, the laser's 3-micron spot size forms plasma bubbles of water and carbon dioxide in a zigzag raster pattern, beginning at the hinge and continuing across the cornea. These bubbles coalesce to create a planer dissection that becomes the stromal bed and flap interface. The femtosecond laser approach preserves corneal curvature, refractive error and surrounding tissue. In addition, the flap has longer vertical edges than those made with the mechanical microkeratome; this helps prevent epithelial cells from migrating under the flap.

Laser-made flaps reduce the risk of corneal abrasion and other problems associated with the microkeratome, such as irregular, partial and uneven flap thickness; incorrect diameter; buttonholes; flap slippage; and wrinkling. The femtosecond laser's extremely thin flaps maintain optimal stromal bed thickness when treating higher refractive errors, thinner corneas, large pupils, moderate to high astigmatism and small corneal diameters.

A disadvantage of the femtosecond laser approach is the length of time the suction ring is on the eye, although it is at relatively low pressure; a few incidences of subconjunctival hemorrhage have resulted. One-day post-op visual acuities are sometimes decreased slightly, most likely from trace edema or stippling that can initially result at the flap interface from the bubbles. This often clears up within 15 to 20 minutes. In our experience with 600 eyes, and in the more than 5,000 procedures performed nationally to date, most patients see 20/20 in 1 to 7 days post-op after laser procedure. We have converted 95 percent of patients to IntraLASIK in our practice: Patients tend to have higher confidence in this type of procedure, and this extends the surgical option to many who are fearful of LASIK.

Thanks to Mark A. Lipton, O.D., of Virginia Beach, Va., for this week's Case in Point. Dr. Lipton can be reached at Beach Eye Care, Neatrour Eye Institute, Virginia Beach, Va., 757-425-5550; mlipton@beacheyecare.com. For details on IntraLASE technology, click here. -- AE

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Topography after Penetrating Keratoplasty

This report by the Dr. Rajendra Prasad Center for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi, India, examined corneal topographic patterns following three different types of single continuous suturing techniques in penetrating keratoplasty (PK).

One hundred forty-eight maps obtained from 40 patients who underwent PK with single continuous suturing were retrospectively analyzed at a tertiary eye care center. The videokeratograph maps were obtained on the Eye Sys System 2000 at 1, 3 and 6 months after surgery. Physicians performed suture adjustment for cases with astigmatism greater than 3 diopters, and obtained maps after suture adjustment. The maps were classified according to the corneal profile and the astigmatic pattern seen in the topographic maps.

Investigators saw combined prolate patterns most frequently, and their proportion was significantly higher at 1 month, 3 months and 6 months. The simulated keratometric astigmatism was significantly higher in the prolate group compared with the other groups at 1 month. However, all the topographic patterns showed comparable magnitude of astigmatism after suture adjustment and at 3 and 6 months. The antitorque suturing technique showed a higher proportion of prolate maps compared with the other suturing techniques.

Prolate patterns of the cornea are the most frequently seen patterns after single continuous suturing, which is the normal physiological pattern of the cornea. The initial astigmatism is higher in the prolate pattern, which can be successfully reduced with suture adjustment.

SOURCE: Sharma V, Sharma N, Vajpayee RB, et. al. Study of corneal topographic patterns with single continuous suturing techniques in penetrating keratoplasty. Cornea 2003;22(1):5-9.

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Zinc, Vitamin A and the Ocular Surface

The purpose of this animal study by the Department of Ophthalmology and Visual Sciences at Japan’s Nagasaki University was to assess morphologically the interaction between zinc and vitamin A in their effect on the ocular surface. Three-week-old Wistar Kyoto rats were divided into five groups: Group 1 was fed a diet containing both vitamin A and zinc; Group 2 was fed a vitamin A-deficient diet; Group 3 was given a vitamin A-deficient diet and deionized distilled water with zinc; Group 4 was fed a zinc-deficient diet, and Group 5 was fed a zinc-deficient diet and received an intraperitoneal injection of vitamin A.

Corneas and conjunctivas of each group were examined by electron microscopy, with the following results:

Group 2 demonstrated a decrease in the number of microvilli in the epithelium vs. Group 1; corneas showed keratinization

Group 3 had a decrease in microvilli in corneas and conjunctivas but had more microvilli than those of Group 2; corneas showed no keratinization

Group 4 showed sparse microvilli on the conjunctiva and cornea

Group 5 had a decrease in microvilli, but had more than Group 4; it also had more goblet cells with granules in the conjunctivas than those of Group 4.

These results suggest that a synergistic interaction exists between vitamin A and zinc for maintaining the corneal and conjunctival epithelium.

SOURCE: Kanazawa S, Kitaoka T, Ueda Y, et. al. Interaction of zinc and vitamin A on the ocular surface. Graefes Arch Clin Exp Ophthalmol 2002;240(12):1011-21.

Reinnervation in the Cornea After LASIK

A recent study by the Mayo Clinic’s Department of Ophthalmology (Rochester, Minn.) showed that the number of subbasal and stromal nerve fiber bundles in the corneal flap decreases by 90 percent immediately after laser in situ keratomileusis (LASIK). During the first year after LASIK, subbasal nerve fiber bundles gradually return, but by 1 year the number remains less than half of the number before LASIK.

Researchers evaluated the denervation and reinnervation of human central corneas using sequential, quantitative measurements of nerves viewed by confocal microscopy in vivo during the first year after LASIK. They studied 17 eyes of 11 patients who had undergone LASIK to correct myopia from -2.0 D to -11.0 D; eyes were treated with an excimer laser with a planned 180-microm flap. Clinicians scanned central corneas throughout their full thicknesses by confocal microscopy before and at 1 week and 1, 3, 6 and 12 months after LASIK. They determined the number of nerve fiber bundles per scan in two to eight scans per eye per visit in the subbasal region, the full-thickness stroma, the stromal flap (layer between the most anterior keratocyte and the flap interface) and the stromal bed (layer between the flap interface and the endothelium).

In the subbasal region, the number of nerve fiber bundles decreased by more than 90 percent 1 week after LASIK and was significantly lower at all times after surgery than before. It increased 6 and 12 months after LASIK, but remained less than half of the preoperative value. In the stromal flap, the number of nerves at all times after surgery was also significantly lower than before surgery and did not increase significantly by 1 year. In the stromal bed, researchers found no significant differences among any of the nerve measurements before and after LASIK.

SOURCE: Lee BH, McLaren JW, Erie JC, et. al. Reinnervation in the cornea after LASIK. Invest Ophthalmol Vis Sci 2002;43(12):3660-64.

NEWS & NOTES

	NEW VP FOR CIBA VISION. Rick Weisbarth, O.D., F.A.A.O., has been promoted to Vice President of Professional Services for CIBA Vision North America. Dr. Weisbarth will ensure that company programs and services are aligned with the North American eyecare community; he will also act as company liaison to eyecare practitioners and distributors on technical and professional matters. A 21-year veteran of CIBA Vision, Dr. Weisbarth has published and lectured internationally on an array of contact lens and lens care–related topics. He is a fellow of the American Academy of Optometry and a diplomate in its Cornea and Contact Lens Section. In 1996, he was elected to the Academy’s executive council and was recently elected secretary treasurer. Dr. Weisbarth received his O.D. degree from Ohio State University College of Optometry.
	PHASE III TESTING TO BEGIN FOR BACTERIAL CONJUNCTIVITIS TREATMENT. SInSite Vision, Inc. of Alameda, Calif., will begin Phase III testing for ISV-401, a treatment for bacterial conjunctivitis, during the second quarter of 2003. ISV-401 combines azithromycin, a broad-spectrum antibiotic not currently used in ophthalmology, with DuraSite, InSite’s patented drug-delivery vehicle for prolonged release of an active ingredient. The Phase III protocol is based on the same formulation and dosing regimen as that of the Phase II study. The earlier study showed positive safety and efficacy results (clinical resolution and bacterial eradication for both gram-positive and gram-negative strains of acute bacterial conjunctivitis) using six drops of ISV-401 administered over five consecutive days. These results were comparable to those usually seen with more than 35 drops administered over 7 days of currently marketed drugs, the company says. For more information on InSite Vision, click here.
	STAFF ASSESSMENT TOOLS FOR OPTOMETRISTS. KnowYourStaff, a new division of Hayes Consulting, has partnered with The Computer Psychologist to develop two online employee assessment tools. The tools allow optometrists to evaluate candidates or present employees based on traits of peak-performing eyecare employees in specific positions. A 45-minute "16-Point Profile" measures problem-solving ability and 16 "core human personality traits." A 20-minute "8-Point Profile" measures the eight personality traits deemed critical for top-performing eyecare employees. Results of both tests are compared to a Peak Performer Profile for a specific position, and graded with a numerical score between 0 and 100, the higher number being a closer match to peak performance. For more information, click here.
	ORTHOKERATOLOGY ACADEMY OF AMERICA LAUNCHED. Cary Herzberg, O.D. (Aurora, Ill.), has announced the formation of the Orthokeratology Academy of America (OAA), aimed at providing education and information on orthokeratology to interested eyecare practitioners. The OAA’s main goals are to encourage research and educational activities promoting orthokeratology, and to serve as a forum for developing and exchanging ideas regarding orthokeratology. The OAA has a cooperative arrangement with the International College of Orthokeratology to set membership and fellowship standards. Annual practitioner membership is $200 U.S. Click here for an application form, or call 630-851-9922.
	EYECARE PROFESSIONALS OPTIMISTIC ABOUT 2003. A recent CIBA Vision e-mail survey of 205 U.S. eyecare professionals shows that most are relatively optimistic about the growth of their practices in the year ahead. Seventy-two percent of those surveyed expect a slight or significant increase in the number of eye exams they will perform in their practices. Sixty-eight percent expect a slight or significant increase in contact lens fits (new and re-fits). In addition, more practitioners--52 percent of those surveyed vs. 43 percent in 2002--expect 30-day continuous-wear lenses to be the fastest-growing area of contact lens growth. Others predicted that their fastest-growth area in contact lens sales would be bifocals/multifocals (18 percent); daily disposables (16 percent); cosmetic tinted lenses (6 percent); toric lenses (4 percent); or two-week disposables (4 percent).

	It's only been up and running a few short weeks. Yet, it's already clear that the Check Yearly. See Clearly.(SM) marketing campaign is opening consumers' eyes to the benefits of regular eye exams. Call the Vision Council of America at 800-424-8422 today or visit checkyearly.com for your free promotional materials.