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Off
the Cuff: Standing With Giants
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Like most ODs, I
was forced to purchase a copy of Borish's
Clinical Refraction when I was in optometry
school. Even back in the premultimedia 1970s,
the book seemed so dry that you needed to add
milk just to read it. A universal truth is that
you don't know what you don't know. I didn't
know.
Years later, knee-deep in patients, I realized
that Dr. Borish's text is filled with more knowledge
and wisdom than I will ever possess, even if
I live two lifetimes. Irv Borish was so far
ahead of his time that even now, most of us
fail to understand the stunning genius of the
man. Fewer yet understand that his life's work
and his steadfast devotion to optometry are
more of a reflection of his love of people and
of his profession than of any personal mission.
A few years ago at an AOA Congress, I had the
experience of a lifetime. I spent more than
an hour speaking with Dr. Borish and Dr. Don
Korb about the profession we love. I relish
those minutes more than words can convey, because
for a few moments I was able to see the view
while standing alongside true giants. Most don't
know how instrumental Dr. Borish was in expanding
our scope of practice into medical eyecare.
He helped set the stage for where we stand now,
and he pointed us in the right direction. Irv
Borish may have written the book on refraction,
but more than anything else, he remains one
of our greatest visionaries.
Case
in Point: Isolated Cotton-wool Spot Heralds
Undiagnosed Anemia
 A
32-year-old Caucasian female presented asymptomatically
for a comprehensive examination. She claimed
that she simply wanted to "check her glasses,"
since two years had passed since her last exam.
Her ocular and medical history were reportedly
unremarkable.
Corrected visual acuity was 20/20 OD and OS.
Pupils, visual fields, motilities, biomicroscopy
and tonometry were all normal. Blood pressure
was measured at 117/75. Dilated examination
revealed a single, isolated cotton-wool spot
in the left posterior pole. The remainder of
the fundus OU appeared normal.
Cotton-wool spots represent microinfarcts at
the level of the retinal nerve fiber layer,
indicative of localized hypoxia. These findings
do not constitute a diagnosis in and of themselves;
rather, cotton-wool spots can be associated
with a host of systemic and ocular conditions.
They are most notably observed in systemic vascular
disorders such as diabetes and hypertension,
but they are also seen in retinal infections
and systemic autoimmune disorders, or following
trauma to the eye, head or chest. However, one
of the most common causes of isolated, asymptomatic
cotton-wool spots in otherwise healthy young
females is anemia.
The management of cotton-wool spots involves
a targeted workup based upon the patient’s
known medical history, family history, symptoms
and attendant signs. Basic testing typically
includes at least a complete blood count (CBC)
and fasting plasma glucose. In this case, the
patient had diminished hemoglobin, hematocrit
and mean corpuscular volume levels consistent
with iron-deficiency anemia. Modification of
the patient’s diet combined with oral iron
supplements resulted in resolution of the cotton-wool
spot within six weeks, as well as normalization
of her hematologic studies.
--Case study courtesy of Alan G. Kabat, OD,
FAAO, Associate Professor, Nova Southeastern
University College of Optometry, Fort Lauderdale,
FL.
Patient-Reported
Symptoms and Clinical Signs of Dry Eye
This study investigated
symptom profiles and clinical signs in subjects
with dry eye and normal subjects in a cross-sectional
multicenter study. Researchers recruited subjects
aged 35 to 65 according to dry eye diagnostic
codes and telephone interviews. Subjects completed
the Dry Eye Questionnaire 2001 among others,
and they underwent dry eye clinical tests. The
122 subjects included 28 control subjects (C),
73 with non-Sjögren’s keratoconjunctivitis
sicca (non-SS KCS) and 21 with Sjögren’s
syndrome (SS). Subjects with SS or non-SS KCS
reported discomfort and dryness most frequently
and said that many of their symptoms worsened
and were quite bothersome as the day wore on.
Groups differed significantly in corneal fluorescein
staining, conjunctival lissamine green staining,
Schirmer 1 tear test and tear break-up times.
Results showed statistically significant but
moderate correlations between the frequency
and evening intensity of dryness and discomfort
and tear break-up times, Schirmer's tear test,
overall corneal fluorescein staining and temporal
lissamine green conjunctival staining. Symptoms
were moderately to highly correlated with the
clinician's global grading of severity and highly
correlated to patient's self-assessment of severity,
whereas signs showed lower correlations. The
global clinician grade of dry eye correlated
more highly with patient symptoms than did clinical
signs, suggesting that patient symptoms influence
dry eye diagnosis and grading of dry eye more
than clinical test results.
SOURCE: Begley CG, Chalmers
RL, Abetz L, et. al. The relationship between
habitual patient-reported symptoms and clinical
signs among patients with dry eye of varying
severity. Invest Ophthalmol Vis Sci 2003;44(11):4753-61.
Staging
of Functional Damage in Glaucoma Using Frequency
Doubling Technology
The intent of this
study of 104 patients with either ocular hypertension
or chronic glaucoma was to evaluate three new
approaches for staging severity of glaucomatous
visual field defects using frequency doubling
technology.
Patients were tested with standard automated
perimetry (SAP, 30-2 Humphrey threshold test)
and frequency doubling technology (N-30 threshold
test). Using the Glaucoma Staging System, researchers
classified standard automated perimetry results
into four groups: normal tests, early defects,
moderate defects and severe defects. They also
classified frequency doubling technology tests
into four groups using three approaches: frequency
doubling technology probability map analysis,
considering the number and location of disturbed
points; frequency doubling technology MD and
PSD indices, graphed on a two-axis diagram (FDT
Staging System); and an abnormality score, based
on both the statistical significance and the
spatial location of depressed points. They also
tested and classified a control group of 20
eyes from 20 normal subjects in the same way.
The Cohen Kappa was used to compare the level
of agreement among the three frequency doubling
technology methods of classification and the
glaucoma staging system.
All the studied approaches correctly staged
the glaucomatous functional damage, but the
frequency doubling technology staging system
was the easiest and quickest method. Moreover,
it is the only method that supplies information
on the characteristics of the defect without
requiring any other time-consuming procedures.
SOURCE: Brusini P, Tosoni
C. Staging of functional damage in glaucoma
using frequency doubling technology. J Glaucoma
2003;12(5):417-26.
Ocular
Surface Impression Cytology
Impression cytology,
either with cellulose acetate strips or using
the Biopore membrane device, is a simple, noninvasive
technique that aids in diagnosing several disorders
of the ocular surface. These disorders include
ocular surface squamous neoplasia, dry eye syndrome,
limbal stem-cell deficiency, specific viral
infections, vitamin A deficiency, allergic disorders,
conjunctival melanosis and malignant melanoma.
Another advantage of impression cytology is
the preservation of limbal stem cells, which
occur in the basal layer of the limbal epithelium
and are responsible for renewal of the corneal
epithelium. The Biopore membrane device is particularly
user-friendly; the clinician requires little
expertise and adequate specimens can be obtained
in a very high percentage of cases. Other applications
include the rapid specific diagnosis of ocular
surface infections with herpes simplex, adenoviruses
and Varicella-Zoster viruses. One may also use
impression cytology samples to obtain mRNA,
cells for phenotyping by flow cytometry and
proteins for Western blotting for research studies.
SOURCE: McKelvie P. Ocular
surface impression cytology. Adv Anat Pathol
2003;10(6):328-37.
NEWS
& NOTES
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BREAKING
NEWS. The Fairness to Contact
Lens Consumers Act (HR 3140) passed
the House of Representatives by
406 to 12 on Wednesday, November
19 and passed the Senate, unanimously
and without opposition, on Thursday,
November 20. The act will become
law 60 days after being signed by
President Bush.
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ALCON
LAUNCHES NEW TRIALS OF RETAANE.
Alcon, Inc. will initiate two new
Phase III studies of Retaane (anecortave
acetate for depot suspension) for
treatment of age-related macular
degeneration (AMD). The new trials
will evaluate the safety and efficacy
of treatment every six months with
the depot suspension of the investigational
drug versus placebo, in patients
with advanced dry AMD who are at
risk of progressing to wet AMD.
After the enrollment period, scheduled
to begin in January 2004, the four-year
studies will include approximately
2,500 patients at 100 sites worldwide.
The FDA has assigned "fast
track" status to Retaane, since
the drug represents a significant
unmet medical need for a serious
condition. Anecortave acetate is
a member of a class of compounds
known as angiostatic cortisenes;
it works by slowing or stopping
new blood vessel growth in AMD so
that less leakage and retinal damage
occurs. Retaane is currently in
clinical trials evaluating its safety
and efficacy in treating patients
with wet AMD; a recently completed
two-year study in such patients
showed that treatment with a Retaane
15-mg Depot every six months inhibited
all aspects of choroidal neovascularization
lesion growth.
Editor's note: With many AMD
patients in optometric offices,
promising new drugs like Retaane
will likely facilitate closer relationships
with retinal specialists. Retaane
is not only good for our patients
but may perhaps be good for our
profession as well.
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 NEW
PACKAGING CLAIM FOR CIBA MPS.
CIBA Vision has received clearance
by the FDA to add two claims to
the packaging of Clear Care hydrogen
peroxide contact lens cleaning and
disinfecting solution. The claims
of greater comfort are based on
results of a large-scale clinical
study of Clear Care vs. other multi-purpose
solutions, in which subjects showed
clinically significant improvements
in ocular surface symptoms, such
as frequency of dryness and end-of-day
comfort. After 30 days of using
the solution, about 64 percent of
the patients in the study said that
Clear Care was easier to use than
their current multi-purpose solution.
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WHO:
ELIMINATING TRACHOMA BY 2020 IS
POSSIBLE. The World Health Organization,
which in 1997 set a goal of eliminating
trachoma by 2020, says that the
goal now seems achievable. According
to the International Trachoma Initiative
(ITI), programs to eradicate the
disease are in progress in countries
such as Ethiopia, Ghana, Mali, Morocco,
Nepal, Niger, Sudan, Tanzania and
Vietnam. As a result of the initiative,
some of the countries in which trachoma
is endemic have experienced a reduction
rate of acute infection in children
by as much as 50 percent. Pfizer
and the Edna McConnell Clark Foundation
(which cofounded the ITI), in association
with several national governments
and nongovernmental organizations,
will donate 135 million treatments
of Zithromax (azithromycin tablets)
in addition to the 8 million donated
since 1998. According to the ITI,
more than 70,000 surgeries have
been performed in these countries
in an effort to halt corneal damage
and prevent blindness.
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 B&L
DONATES $1 MILLION TO INTERNATIONAL
BLINDNESS PREVENTION EFFORTS.
Bausch & Lomb will donate $1
million to VISION 2020: The Right
to Sight, in support of the organization's
goal to eliminate preventable and
treatable blindness worldwide by
the year 2020. B&L is the first
"Corporate Patron" of
VISION 2020, which works with the
World Health Organization, developing
nations and non-governmental organizations
to eradicate preventable blindness.
The donation comes as B&L celebrates
the 150-year anniversary of its
founding in Rochester, NY.
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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. |
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