Off the Cuff: Dear 1-800. . . .

After years of frustration watching you fill patient prescriptions that have long expired, asking me to verify prescriptions for patients that I've never seen and otherwise hiding your greed beneath a thin veneer of consumerism, turn-about is only fair play.

I just received a copy of your most recent prescription verification form. You know the one. It’s essentially the same one that you totally ignored in the past. This new one threatens to share my response with my patient. No problem. This patient hasn't been in my office in two years and his prescription has expired. Feel free to let him know that he needs an exam.

You should also know that I intend to call the patient in a few days to verify that you have not filled the expired prescription. If I find that you have filled it illegally, I will personally file a complaint with the FTC and follow through with that complaint until I have confirmed that you have been heavily fined. I will do this repeatedly and relentlessly every time you endanger a patient by filling an expired prescription.

It turns out that the Fairness to Contact Lens Consumers Act is a sharp blade, but it is one that cuts both ways. And nothing in it changes the fact that contact lenses are medical devices, and that dispensing them illegally endangers patients. The only difference is that now you will pay a price for doing that. Have a good day.

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

Case in Point: What’s Wrong With Your Eye?

A 28-year-old Caucasian female presented for evaluation, reporting an odd-shaped pupil that a coworker had pointed out to her. She had not noticed anything unusual herself and had no idea how long her pupil was shaped that way. Her medical history was unremarkable and she was using no medications.

Visual acuity was 20/20 in each eye. The right eye displayed corectopia in the form of a tadpole-shaped pupil pointing superior nasally. Thinning of the peripheral iris was evident. Intraocular pressure was 15 mmHg OU. Gonioscopically, there was a broad area of peripheral anterior synechiae in the superior nasal angle. Dilated fundus examination revealed healthy, symmetrical optic discs and normal retinal periphery OU.

The patient was diagnosed with essential iris atrophy. She was educated about the possible progression to glaucoma. We explained future medical and surgical options and prognosis. The patient is monitored for progression every four months.

The Iridocorneal Endothelial (ICE) syndromes represent a continuum of disease involving distinct entities: essential iris atrophy, Chandler syndrome and Cogan-Reese (iris nevus) syndrome. Essential iris atrophy is characterized by progressive iris atrophy and hole formation, corectopia and marked peripheral anterior synechia. The iris and pupil are pulled in the direction of the peripheral anterior synechia. It appears that the endothelial cells undergo a metaplastic transformation into "epithelial-like" cells, which migrate in membrane form over the angle to the iris. Contraction of this membrane pulls the iris towards the cornea with a chronic progressive synechial closure of the angle. This can result in secondary angle closure without pupil block. The cellular membrane may also cause aqueous outflow blockage in the absence of peripheral anterior synechia.

--Case study courtesy of Joseph Sowka, OD, FAAO, Professor, Nova Southeastern University College of Optometry, Fort Lauderdale, FL.

Conservative Treatment of Meibomian Gland Dysfunction

In this noncontrolled case-cohort study of selected patients with meibomian gland dysfunction (MGD), lid hygiene and preservative-free artificial tears significantly improved tear breakup time and relieved symptoms of the condition during a six-week period.

Suitable patients with MGD were educated about their disease and instructed to begin a regimen of lid hygiene, which included the application of a heated saline solution and the use of nonpreserved artificial tears. Baseline measurements obtained at the time of enrollment included basic tear secretion test, tear breakup time, a questionnaire grading MGD symptoms (burning, irritation, itching, sharp pains, foreign body sensation and hazy vision) and lid margin slitlamp photographs. All measurements except for basic tear secretion were repeated at the six-week follow-up visit. Photographs were unlabeled, and two cornea specialists graded them in a masked fashion for the presence of lid erythema, irregularity, thickness, meibomian gland capping and telangiectasis.

Thirty-seven patients with a clinical diagnosis of MGD were enrolled, and 26 patients (70 percent) completed the study. Initial measurement of basic tear secretion averaged 17 mm and was more than 10 mm in 81 percent of eyes. The tear breakup time was prolonged by an average of 3.4 seconds; in 30 percent of cases, it was normalized to 10 seconds or more. Symptoms improved in 88 percent of cases; among those, symptoms were graded mild or less in 83 percent, and none in 39 percent. Photographs before and after treatment were not significantly different.

SOURCE: Romero JM, Biser SA, Perry HD, et. al. Conservative treatment of meibomian gland dysfunction. Eye Contact Lens 2004;30(1):14-19.

Plastic Particles at the LASIK Interface

Numerous plastic particles are generated during microkeratome oscillation and are deposited at the interface during LASIK, according to a small case series and experimental animal study by Denmark’s Aarhus University Hospital. The particles persist unaltered for at least one year.

Four patients received LASIK using a Schwind Supratome (Schwind, Kleinostheim, Germany) and a MEL 70 G-Scan excimer laser (Asclepion, Jena, Germany) and were examined over the course of one year using slitlamp and in vivo confocal microscopy. Four rabbits received a monocular microkeratome incision and were examined immediately after surgery without lifting the flap. After monthly evaluation for four months using in vivo confocal microscopy, two corneas were processed for histologic analysis and were sectioned serially. To measure the iron content, atomic absorption spectrometry was performed on two operated and two unoperated rabbit corneas. The chemical composition of the metal and plastic parts of the microkeratome blade was identified using energy dispersive X-ray fluorescence (metal part) and Raman and infrared spectroscopy (plastic part). Before and after oscillation in air, the microkeratome blade and motor-head were examined using light and fluorescence microscopy. In serial sections, interface particles were identified by fluorescence microscopy and their chemical composition was determined using Coherent Antistokes Raman Scattering microscopy.

In LASIK patients, researchers observed thousands of brightly reflecting particles (up to 30 microns) throughout the interface. They detected the highest particle density where the microkeratome blade had first entered the cornea. Both in the center and at the flap edge, the morphologic features, distribution and density of these particles remained unaltered throughout the one-year observation period. In rabbit corneas, researchers observed interface particles immediately after the microkeratome incision, even though the flap had not been lifted. These particles were similar to those observed in humans and persisted unaltered throughout the study. The operated and unoperated rabbit corneas had comparable iron content, demonstrating that the particles were not fragments of the uncoated steel blade. Only a few particles were observed on the unused microkeratome motor head and blade, whereas numerous fluorescent particles were detected after oscillation in air, the amount of particles increasing with oscillation time. Interestingly, the only fluorescent part of the microkeratome was the plastic segment of the blade. This plastic (polyetherimide) emitted fluorescence identical to that of the observed particles, whereas all metal parts of the microkeratome blade and motor head were nonfluorescent. In serial sections, interface particles showed fluorescent properties equivalent to polyetherimide and exhibited molecular resonance at 1780 and 3100 cm(-1), in accordance with the Raman spectrum of polyetherimide.

SOURCE: Ivarsen A, Thogersen J, Keiding SR, et al. Plastic particles at the LASIK interface. Ophthalmol 2004;111(1):18-23.

Etanercept for Patients with Primary Sjögren’s Syndrome

A 12-week or prolonged treatment of etanercept 25 mg twice weekly does not appear to reduce sicca symptoms and signs in Sjögren’s Syndrome (SS), according to this Netherlands study. However, etanercept treatment may be beneficial in a small subgroup of SS patients with severe fatigue. Moreover, etanercept 25 mg twice weekly does not affect minor salivary gland biopsy results.

The pilot study evaluated the effect of anti-tumor necrosis factor-a antiinflammatory treatment with etanercept (Enbrel) on sicca, systemic and histological signs in patients with primary SS. Fifteen patients with well defined primary SS were treated with 25 mg etanercept subcutaneously twice per week during 12 weeks, with follow-up visits at Weeks 18 and 24. Evaluation measures included a Multidimensional Fatigue Inventory questionnaire, serological monitoring, salivary flow tests, Schirmer test, rose bengal cornea staining and tear film breakup time. A sublabial minor salivary gland biopsy was performed at baseline and at Week 12 and lymphocytic focus score and percentage IgA-containing plasma cells were assessed.

Results showed no increase of salivary or lachrymal gland function in any participant. Four patients showed a decrease of fatigue complaints, which was also reflected by decreased scores in the Multidimensional Fatigue Inventory questionnaire. Reduced erythrocyte sedimentation rate was observed in three of four patients with reduced fatigue. No significant change of lymphocyte focus score or percentage IgA-containing plasma cells was observed. A repeated treatment up to 26 weeks showed the same results.

SOURCE: Zandbelt MM, De Wilde P, Van Damme P, et al. Etanercept in the treatment of patients with primary Sjögren’s syndrome: a pilot study. J Rheumatol 2004;31(1):96-101.

Corneal Epitheliopathy of Dry Eye Induces Hyperesthesia to Mechanical Air Jet Stimulation

In this retrospective, clinic-based case-control study, researchers evaluated corneal sensation in different groups: normal subjects, dry eye patients, and patients with and without dry eye after LASIK using the modified Belmonte gas esthesiometer.

Clinicians evaluated 20 normal subjects, 20 dry eye patients, 20 post-LASIK patients without dry eye and six post-LASIK patients with dry eye. Corneal sensation was measured with the modified Belmonte gas esthesiometer, which employs two different stimuli to assess mechanical and polymodal receptors on the corneal surface. Mechanoreceptors were assessed by two-second pulsed air jets of variable intensity. Polymodal receptors were measured by stimulating the cornea with two-second pulsed air jets of varying concentrations of CO₂, a gas that is converted to carbonic acid on contact with the corneal surface. The main outcome measure was determining corneal sensation.

The mean +/- standard deviation (+/- SD) age was similar in all groups. The mean mechanical threshold was 61.50 +/- 20.07 ml/min in the normal group, 34.60 +/- 21.09 ml/min in the dry group, 99.50 +/- 47.40 ml/min in the post-LASIK group and 50.00 +/- 15.49 ml/min in the post-LASIK patients with keratitis sicca. The percentage of CO₂ to elicit discomfort was similar in all groups. No sex-related differences were noted. There was a significant inverse correlation between the threshold of mechanical stimulation and the severity of corneal fluorescein staining.

The Belmonte modified noncontact esthesiometer is a sophisticated instrument that can assess different types of corneal sensory receptors. Patients with dry eye were hypersensitive to the air jet stimulus of this instrument, and this appears to be the result of altered corneal epithelial barrier function. Profound hypoesthesia was observed after LASIK and similar to dry eye, post-LASIK patients with dry eye were sensitized. These findings provide new insight into the hypersensitivity to environmental stresses, particularly air drafts experienced by dry eye patients.

SOURCE: Sade De Paiva C, Pflugfelder SC. Corneal epitheliopathy of dry eye induces hyperesthesia to mechanical air jet stimulation. Am J Ophthalmol 2004;137(1):109-15.

NEWS & NOTES

VA BILL GAINS SUPPORT; OPTOMETRISTS’ INPUT NEEDED. According to Don E. Williamson, OD, Chairman of the AOA Federal Relations Committee, ophthalmology’s effort to gain passage of legislation to restrict clinical privileges for VA optometrists (H.R. 3473, the Veterans Eye Treatment Safety Act of 2003), is gaining support. H.R. 3473 has gained 43 cosponsors in the House, and recently, the campaign released an advertisement suggesting that it is somehow unpatriotic for VA optometrists to provide care to America's veterans at the highest level of their professional education, training and licensure. The AOA has responded aggressively to this challenge. Thousands of optometrists recently responded to an AOA appeal and sent more than 15,000 e-mail messages to Capitol Hill. If you have not done so already, Congress needs to hear from you. Click here to tell Congress what you think of the bill. If you have already sent a message, please click here to visit the legislative action center again and send a follow-up message. You can also visit the AOA members' web site at www.aoa.org to stay abreast of unfolding developments concerning this and other legislation, or call David Danielson or Jeff Mays in the Washington office at 703-739-9200.

LUMIGAN APPROVED IN EUROPE AS FIRST-LINE GLAUCOMA, OCULAR HYPERTENSION THERAPY. The European Commission has approved Lumigan (bimatoprost ophthalmic solution, 0.03%) as first-line therapy for the reduction of elevated intraocular pressure in chronic open-angle glaucoma and ocular hypertension. Lumigan was approved by the FDA in 2001 and by the European Commission in 2002 but was indicated only for patients who were insufficiently responsive, intolerant or contraindicated to first-line therapy. Under the new indication, European ophthalmologists can initiate Lumigan therapy immediately.

 

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