Off the Cuff: Clarifying Ortho-K

Last week I presented two reports that described microbial keratitis associated with overnight ortho-k. Although I believed I made my thoughts quite clear, after reading the issue, several colleagues expressed concern about the safety of overnight orthokeratology. Allow me to clarify: while everything in life has some risk, the probability of infection or other sight-threatening problem with modern U.S.-designed and manufactured corneal reshaping technology is minimal. In my estimation, overnight corneal refractive therapy (CRT) or orthokeratology using modern designs and high Dk lenses bears less risk of visual loss than common alternatives such as LASIK. Further, there is absolutely no evidence that CRT or overnight orthokeratology is more risky than conventional contact lens wear.

Both of the reports cited emanated from Asia, one from Taiwan and the other from Hong Kong. Lenses and standards of care are quite different there compared to that of the United States. It is important to understand that these were only case reports and numerous potential contributory factors were neither described nor investigated. FDA-tested and approved Paragon CRT, the only lens currently approved in the United States for overnight use, has proven safe and effective. Not a single case of microbial keratitis has ever been reported with CRT lenses. The inherent safety of overnight rigid lens wear is supported by extensive scientific research and large-scale U.S. FDA-sanctioned clinical trials. There is no reason to believe that they are not safe.

The reason I presented those two reports was more to alert you about a likely flood of negative publicity than to warn you about risk to your patients. While I would not question the integrity of published reports, clearly there is a political agenda at play. Be aware of the double standards that are sometimes applied to our profession and to the things that are important to our profession. Most of all, don’t always believe everything you read, especially without reading between the lines.

On a brighter note, ultimately excellence and achievement rise above politics and turf wars. Warm congratulations to Eli Peli, O.D., M.Sc., for being the first O.D. to become Professor of Ophthalmology, full time, at Harvard Medical School and for being named the first Moakley Scholar by the Schepens Eye Research Institute (see below). It is a step forward for us all....

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

First Moakley Scholar Named by Schepens: Eli Peli, O.D., M.Sc. Eli Peli, O.D., M.Sc., the 2002 recipient of the Fry Award, was appointed the first Moakley Scholar by the Schepens Eye Research Institute, Boston, Mass., on April 14. Dr. Peli is the first O.D. to become Professor of Ophthalmology, full time, at Harvard Medical School. The award was presented in a ceremony to honor the late congressman, Rep. Joe Moakley of Massachusetts, for whom the citation is named. Moakley became a supporter of national funding for eye research in the 1980s, and he was instrumental in obtaining federal funding for Schepens.

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Case in Point: A Novel Use for Glaucoma Medications

A 64 year-old Caucasian male with Chronic Obstructive Pulmonary Disease (COPD) presented to the clinic with sharp corneal pain due to a long standing case of bullous keratopathy secondary to Fuchs Dystrophy OD and OS. Repeated attempts to quell the problem with Muro 128 drops and ointment, and desiccated air from a hair dryer were unsuccessful. Entering corrected visual acuities were 20/50 OD and 20/30 OS. The slit lamp exam revealed a beaten metal appearance to the corneal endothelium with the presence of mild stromal edema and epithelial micro-bullae. Anterior chamber, iris and lens were all normal, OD and OS. Goldmann Applanation Tonometry was 19mm OD and OS.

Treatment was initiated with Xalatan (Pharmacia) QHS, OD and OS. The patient was released and scheduled to return for follow-up in one week.

The patient returned three days before the scheduled appointment, happy to report complete resolution of the pain. Corrected visual acuities were 20/25 OD and OS. Tonometry measured 13 mmHg OD and OS. The corneal findings revealed resolution of bullae OU.

Intraocular pressure, lowered by glaucoma medications, decreases the differential imbibing pressures between the cornea and anterior chamber. As such, the disruption of the corneal matrix and formation of bullae are less likely because less aqueous is forced into the cornea.

In the case, an aqueous outflow medication was used due to the repeated failure of hypertonic preparations and air desiccation. Xalatan, rather than a beta-blocker, was chosen due to the patient's history of COPD.

-- Case study courtesy of Deegan M. Lew, O.D., F.A.A.O., and Optometricpearls.com.

Keratoconus, Myopia and Personality

This study investigated the association between keratoconus and personality attributes including obsession traits. Researchers reviewed records of 289 keratoconus patients and 149 myopes and contacted the patients by mail to invite them to complete two standardized personality questionnaires (Maudsley Obsessive-Compulsive Inventory and the revised Eysenck Personality Questionnaire). On receipt of consent, questionnaires and an explanatory letter were sent to potential participants.

Completed replies from 118 keratoconic and 75 myopic controls were suitable for analysis after exclusion of patients who returned incomplete data or were deemed unreliable by scoring highly on the lie scale. This study indicated that there is little evidence to suggest that keratoconus patients differ significantly in personality from a group of moderate to high myopes who also depend on contact lens correction for distance vision. Although myopes showed marginally higher levels of psychosis than did keratoconus patients, analysis of the range of personality traits assessed indicates that the differences between the two groups is not significant. The authors could not substantiate the clinical notion of the keratoconic personality.

SOURCE: Cooke CA, Cooper C, Dowds E, et al. Keratoconus, myopia, and personality. Cornea 2003;22(3):239-42.

Selected Medications and Visual Function: The Beaver Dam Eye Study

A cross sectional population based study was carried out on participants in the 1993-1995 examination phase of the Beaver Dam Eye Study. All drugs in current use by study participants were recorded. Researchers obtained performance-based and self-assessed visual functions at the time of the study evaluation. Main outcome measure was the relation of levels of visual functions by use of specific drugs.

In at least two performance-based visual functions, many classes of drugs were associated with decreases. For example, high blood pressure drugs were significantly associated with poorer best corrected visual acuity, poorer near vision, and poorer contrast sensitivity. Patterns of association for self-assessed visual functions were not as strong. However, use of glaucoma drops and benzodiazepines were associated with poorer self-assessed visual functions in most circumstances cited.

The bottom line of this study: don’t underestimate the effect of medications on middle-aged and older patients. Many commonly used medications are inversely associated with visual function in this population. This may influence the patient’s ability to perform complex tasks and quality of life.

SOURCE: Klein BE, Klein R, Knudtson MD, Lee KE, et. al. Associations of selected medications and visual function: the Beaver Dam Eye Study. Br J Ophthalmol 2003;87(4):403-8.

Glaucoma Education Program A wealth of glaucoma education will be available at this year's American Optometric Association Meeting, San Diego, CA (June 18-22, 2003). Attendees may visit the Educational Theatre program, supported by an unrestricted educational grant from Heidelberg Engineering. Faculty and topics include: M. Fingeret, O.D. Introduction to Glaucoma: Clinical Trials in Glaucoma New Advances in Glaucoma J. Flanagan, Ph.D., MCOptom Imaging in Glaucoma Fields in Glaucoma D. Mann, O.D. The Optic Nerve in Glaucoma Glaucoma Grand Rounds   J. Thimons, O.D. Secondary Glaucoma Therapy of Glaucoma R. Wooldridge, O.D., FAAO Normal Tension Glaucoma -- What We Don’t Know May Hurt Us The Heidelberg HRT II in the Diagnosis and Management of Glaucoma

NEWS & NOTES

	INFINITI VISION SYSTEM DEBUTS. Alcon, Inc. introduced a tri-modal cataract removal surgical instrument, the Infiniti Vision System, during the American Society of Cataract and Refractive Surgery (ASCRS) Symposium this month. The instrument supplies surgeons with a choice of three methods for removing a cataract: advanced ultrasound phacoemulsification alone, a combination of ultrasound and oscillation provided by the NeoSoniX handpiece, or Alcon's AquaLase liquefaction device that generates pulses of surgical solution to safely break up and remove the natural lens material. The Infiniti Vision System was developed with input from surgeons for ease of use, improved ergonomics, and versatility.
	VISION SCREENING LAW FOR SCHOOL-AGE CHILDREN INSPIRES SIMILAR LEGISLATION. A Kentucky law requiring vision screening for all children entering school in the state has sparked interest in similar laws in other states. The law, put into effect in July 2000, requires every youngster enrolling in school to undergo a comprehensive vision exam. An estimated 10 million children aged 10 and younger have vision problems. Currently no strict or consistent standards are in effect in the United States; the Vision Council of America estimates that only 14 percent of children younger than 6 have received a comprehensive eye exam. Legislation similar to Kentucky’s has been introduced in New York and is also being considered in Arkansas, Georgia, Nebraska and New Hampshire. Federal legislation to help states fund eye-exam programs is expected to be introduced this year.
	ALLERGAN AND ACADIA COLLABORATE ON DRUG DEVELOPMENT. Allergan has collaborated with Acadia Pharmaceuticals, a California-based drug discovery and development company dedicated to discovering novel small-molecule drug candidates with a proprietary chemical-genomics platform. The collaboration focuses primarily on eyecare applications and is the third major arrangement of this kind between the two companies since 1997. Under the agreement, Allergan will have the exclusive right to license chemistry and related assets for up to three drug targets, while Acadia will receive an up-front payment, research funding and additional fees over three years. It is also eligible to receive license fees, milestone payments and royalties on future product sales worldwide.

	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.