Off the Cuff: Standing on Our Own Two Feet

A few years ago, I stood transfixed as Irvin Boorish and Donald Korb discussed the importance of developing clinician scientists in optometry. Time has slightly faded my recollection of what was said, but their key point still remains clear. Both of these giants agreed that ultimately, our credibility rests largely upon our profession's ability to develop true clinician-scientists.

One sign we are succeeding can be found in the July issue of the journal of the American Academy of Optometry, Optometry and Vision Science. In the words of OVS editor, colleague and friend, Dr. Tony Adams (and borrowed with permission from his July editorial): "Guest Editors (John Flanagan, OD, PhD; Murray Fingeret, OD; Tom Lewis, OD, PhD; and Bill Swanson, PhD) have brought together an impressive collection of original research and discovery in the field. All four were founding members of the highly successful Optometric Glaucoma Society (OGS), which meets for scientific paper presentations immediately before each Annual Meeting of the American Academy of Optometry. In their Editorial, they leave little room for any skepticism about optometry contributions to glaucoma-related discoveries!"

"Their editorial precedes 17 original articles, case reports, and reviews that collectively illuminate challenges and an optimistic horizon for glaucoma research. These articles point to discovery in many areas, including morphology, topography, and tomography in glaucoma, to vision function, screening and analysis of vision function in glaucoma, and finally to pathophysiology, treatment, electrophysiology, and models of glaucoma mechanisms."

In my opinion, this represents a watershed moment in our profession’s history and reflects dramatic improvement in the content and quality of our profession’s journals. It is important to note that Optometry, the journal of the American Optometric Association, has likewise undergone a remarkable metamorphosis and is now filled with clinically relevant and scientifically important papers. The days when academically oriented optometrists sought to publish in ophthalmology journals are fading fast. Congratulations to John Flanagan, Murray Fingeret, Tom Lewis and Bill Swanson for their important contribution. To OD editors Tony Adams and Paul Freeman, my sincere thanks for all that you do for us.

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

 

The views expressed in this editorial are solely those of the author and do not necessarily represent the opinions of the editorial board, Jobson Publishing or any other entities or individuals.

 

A survey of ophthalmologists and general medical practitioners from nine countries in Eastern Europe and the Middle East was conducted to estimate the percentage of patients presenting with a red eye and to examine the differential diagnosis and treatment. Practitioners detailed information concerning signs and symptoms, differential diagnosis and treatment for all patients presenting with a red eye during 20 consecutive days between May and September, 2004.

Red eyes accounted for approximately 15 percent of consultations with ophthalmologists and almost six percent of consultations with general medical practitioners. Allergic conjunctivitis was the most common diagnosis (35 percent), followed by dry eye (25 percent) and bacterial conjunctivitis (24 percent). General medical practitioners were far more likely to prescribe a combination topical antibiotic and steroid preparation than ophthalmologists.

This survey illustrates that red eye remains a very important problem for both ophthalmologists and general medical practitioners. Identification of dry eye as a common cause of red eye symptoms and more appropriate treatment of dry eye, allergic conjunctivitis and viral conjunctivitis are key messages to emerge.

SOURCE: Petricek I, Prost M, Popova A. The differential diagnosis of red eye: a survey of medical practitioners from eastern europe and the middle East. Ophthalmologica 2006;220(4):229-37.

Sixty smokers and 34 healthy subjects were enrolled in this study evaluating the effects of smoking on the ocular surface. Patients with associated ophthalmic or systemic diseases and history of contact lens use and ocular surgery were excluded. The average duration of smoking was 13.1 years. The ocular surface was evaluated by measuring corneal and conjunctival sensitivity, surface staining with fluorescein, tear film breakup time, Schirmer 1 test and conjunctival impression cytology. Dry eye symptoms were scored by questionnaire. Kinetic analysis of sequential tear interference images obtained by a DR-1 tear lipid layer interferometry was used to investigate the pre-corneal lipid layer spread.

In the smoker group, the mean Schirmer 1 test value was 10.8 mm. The mean breakup time was 5.3 seconds, the average conjunctival sensitivity was 26.2 mm and the average central corneal sensitivity was 37.6 mm. There was no statistically significant difference in goblet cell densities or in Schirmer 1 test values between smokers and controls. Higher grades of lipid layer changes were observed in smokers by DR-1 interferometry kinetic analysis.

Smoking has deteriorating effects on the lipid layer of pre-corneal tear film.

SOURCE: Altinors DD, Akca S, Akova YA, et al. Smoking associated with damage to the lipid layer of the ocular surface. Am J Ophthalmol 2006;141(6):1016-21.e1.

Outcomes in Fellow Eyes After Angle Closure in the Contralateral Eye

Seventy-nine individuals were examined at two Singapore hospitals from four to 10 years after a unilateral episode of acute primary angle closure (APAC) glaucoma to determine the long-term outcome of the contralateral eye. All subjects underwent a complete eye examination. The optic discs were graded clinically and photographically for the presence of glaucomatous optic neuropathy, and automated visual field tests were performed to assess damage. All visual fields and optic nerve photographs underwent a second evaluation by a masked glaucoma specialist who assessed whether the changes were consistent with glaucoma.

Ninety of 138 eligible patients (65.2 percent) with APAC were examined, 79 with unilateral attacks. Subjects were predominantly Chinese (68 subjects; 86 percent). There were 54 females (68 percent) and mean age was 68.5 years at the time of APAC with a mean duration of 6.3 years from the time of the APAC episode to the study examination. The contralateral eyes of seven patients (8.9 percent) had definite or probable glaucoma, two of whom were felt to have glaucoma in that eye at the time of the attack. Three eyes had markedly cupped optic discs (cup-to-disc ratio 0.9 or greater). Thirteen eyes (16.9 percent) had best-corrected vision worse than 20/40; this was due to cataract in almost half the cases. Only one eye had less than 20/200 vision, the cause of which was corneal decompensation. One other patient had only a central island remaining with vision of 20/40. Mean intraocular pressure of the study participants was 15.7 +/- 4.7 mm Hg, with six subjects (7.6 percent) having undergone trabeculectomy.

Definite or probable glaucoma was present at the time of diagnosis in two (2.5 percent) fellow eyes and developed in an additional five (6.5 percent). More than 80 percent of this cohort retained good vision in the contralateral eye in contrast to the eye that had the APAC. Unoperated cataract accounted for most of the visual impairment in this group.

SOURCE: Friedman DS, Chew PT, Gazzard G, et al. Long-term outcomes in fellow eyes after acute primary angle closure in the contralateral eye. Ophthalmol 2006;113(7):1087-91.

Contact Lens Care Products’ Effect on Corneal Sensitivity and Patient Comfort

This study evaluated the possible effect of two soft contact lens care products on corneal sensitivity, relative comfort and superficial corneal staining in adapted disposable soft contact lens wearers. Eight disposable soft contact lens wearers equally divided between habitual users of Opti-Free Express Lasting Comfort No Rub formula (OFX, Alcon) and ReNu MultiPlus (ReNu, Bausch & Lomb) were enrolled in this crossover study. The habitual lens care product was designated the first crossover period. Patients completed a visual analog scale rating of mid-day and end-of-day comfort, underwent slit lamp examination for staining, and had corneal sensitivity measured by Cochet-Bonnet esthesiometry before and after being switched to the alternative lens care product. The lens care product used was masked from the investigator.

Patients habitually using OFX reported higher comfort ratings than did patients using ReNu. On crossover, patients who initially used ReNu experienced similar comfort when using OFX, whereas OFX users experienced a substantial decrease in comfort when switched to ReNu. Esthesiometry showed significant differences in average sensitivity in favor of OFX. Statistical trends supported observed increases in corneal sensitivity when switching to OFX and decreased corneal sensitivity when switching to ReNu. ReNu was also associated with more corneal staining.

ReNu, a biguanide-based contact lens care product, was associated with decreased comfort during mid-day and end-of-day periods. ReNu was also associated with significant reduction in relative corneal sensitivity compared to Polyquad-based OFX. Disturbance to normal corneal sensitivity may play a role in contact lens-related dry eye and discomfort. Further investigation is warranted.

SOURCE: Epstein AB. Contact lens care products effect on corneal sensitivity and patient comfort. Eye Contact Lens 2006;32(3):128-32.

Delayed Wound Healing after PKP for Corneal Lattice Dystrophy

Records of nine patients with lattice corneal dystrophy (LCD), 14 with keratoconus and 11 with corneal leukoma (controls) who underwent penetrating keratoplasty (PKP) were reviewed to investigate whether their corneal epithelial cells possess an intrinsic defect.

The time required for resurfacing of the corneal epithelium after PKP was significantly greater in LCD patients (8.56 +/- 4.95 days) than in patients with either keratoconus (1.71 +/- 0.91 days) or corneal leukoma (3.00 +/- 1.95 days).

Corneal epithelial wound healing was delayed in LCD patients after PKP, suggesting that the keratoepithelin gene mutations responsible for this condition affect corneal epithelial cells.

SOURCE: Kawamoto K, Morishige N, Yamada N, et al. Delayed corneal epithelial wound healing after penetrating keratoplasty in individuals with lattice corneal dystrophy. Am J Ophthalmol 2006;142(1):173-4.

NEWS & NOTES

	FDA APPROVES LUCENTIS FOR TREATMENT OF WET AMD. The FDA has approved Genentech’s Lucentis (ranibizumab injection 0.5 mg) for treating neovascular (wet) age-related macular degeneration (AMD). Lucentis was approved following a Priority Review; the drug is scheduled to ship immediately. In Phase III clinical trials, 95 percent of patients treated with Lucentis maintained their vision; vision improved by at least three lines (or 15 letters) on the study eye chart in up to 40 percent of these patients at one year. Lucentis is designed to inhibit the formation and leakage of new blood vessels in the back of the eye, the primary cause of central vision loss associated with AMD. It’s recommended for intravitreal injection once a month; if monthly injections are not feasible, treatments can be reduced to one injection every three months after the first four monthly injections, but this dosing may lead to an approximate five-letter (one-line) loss of visual acuity benefit, on average, over the following nine months. Patients should be evaluated regularly.
	TREATMENT FOR WET AMD BEGINS PHASE II CLINICAL TRIAL. Genaera Corporation has enrolled the first patient in its multicenter, open-label pharmacodynamic Phase II clinical trial aimed at determining the efficacy and safety of Evizon (squalamine lactate) at higher doses. The study is designed to evaluate up to 140 patients with wet age-related macular degeneration (AMD) treated with Evizon at four dose levels (40 mg, 80 mg, 120 mg and 160 mg) over 20 weeks. For information about participation in the clinical trials, eyecare professionals may call Genaera's toll-free clinical trial hotline at 1-800-299-9156.
	LUMIGAN APPROVED AS FIRST-LINE TREATMENT FOR ELEVATED IOP IN GLAUCOMA. The FDA has approved Allergan's once-daily prescription eye drop Lumigan (bimatoprost ophthalmic solution 0.03%) as a first-line treatment for elevated intraocular pressure (IOP) associated with open-angle glaucoma or ocular hypertension. The new Lumigan indication is in addition to the drug’s established use as a second-line treatment. Lumigan was originally approved in 2001 as an IOP-lowering medication for second-line use and has been prescribed by eyecare professionals to reduce elevated IOP in open-angle glaucoma and ocular hypertension patients who were intolerant of other IOP-lowering medications or who did not have a sufficient reduction in IOP in multiple measurements using another IOP-lowering medication.
	VISIOGEN GRANTED EUROPEAN CE MARK FOR DUAL-OPTIC ACCOMMODATING IOL. California-based Visiogen Inc. has received approval in Europe for its dual-optic accommodating intraocular lens (AIOL). The CE Mark designation for the Visiogen Synchrony AIOL signifies that the device conforms to the essential requirements of the Medical Devices Directive, which allows Visiogen to begin post-marketing research studies in Europe. The Synchrony AIOL is the first dual-optic accommodating lens developed for both cataract and refractive surgery. It is designed to enable accommodation in patients undergoing cataract surgery who may or may not have a presbyopic condition. The AIOL system includes a proprietary self-contained pre-loaded injector. The lens can be inserted through a 3.6- to 3.8-mm clear corneal incision and unfolds in the eye upon insertion. A spring system connects a 5.5-mm high-power anterior optic and a 6-mm negative power posterior optic; the spring action moves the front optic and changes the eye's focus from near to far. Optics powers are customized for individual patients. The AIOL has been implanted in more than 300 patients at multiple clinical sites in Europe; the FDA is presently conducting a clinical study for the Synchrony AIOL in the United States. For more information, e-mail info@visiogen.com.

	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.