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In the News
In the News Optometrists'
patients in Ohio give their doctors very high marks, says a statewide patient satisfaction survey by the Ohio Optometric Association (OOA). More than 99 percent of respondents rate their eye doctors' "thoroughness of exam" as
good or very good. Ohio O.D.s got similar excellent marks for "quality of time spent with doctor," "warmth and concern of staff," "comfort and cleanliness of office," and "convenience of scheduling." Topical NSAIDs May Be Associated with Corneal Complications One letter says that in response to an ASCRS survey, more than 100 doctors reported at least 200 cases of corneal
toxicity. The complications ranged from superficial punctate keratitis to full corneal melts. Although the majority of these cases have been associated with generic diclofenac sodium, a handful were associated with brand name
diclofenac (Voltaren) as well as ketorolac (Acular). Most of the problematic cases seemed to be reported just this year. In response, Alcon, maker of the generic diclofenac and another NSAID suprofen (Profenal), suspended
distribution these two drugs. "We are confident that our products, when used according to label directions, are safe and effective," Alcon's R&D Vice President Stella Robertson, Ph.D., says in a statement. "However, we have
taken this step because of the importance of these issues to our customers and their patients." Meanwhile CIBA Vision, maker of Voltaren, also maintains that its product is safe and efficacious after anterior segment surgery.
CIBA says it had not received any reports of corneal melting since the introduction of generic diclofenac, and that's in light of more than 3.2 million prescriptions filled. Corneal complications, on the whole, are rare: About
200 cases are reported a year out of about 1.5 million cataract surgeries. Alcon notes that the increase in reports correlates with both a general increase in topical NSAIDs and an increased use of diclofenac for ocular surgery.
Questions on dosage patterns in excess of the recommended usage and/or concomitant use of antibiotics have been raised by some surgeons. A more frequent and prolonged dosing regimen may increase the amount of corneal toxicity.
And the use of NSAIDs prior to the recommended 24-hour postoperative waiting period could delay cor-neal healing after surgery, contributing to the risk of the corneal complications. Treating patients according to the recommended
dosing regimen (TID or QID beginning 24 hours post-op and continuing for no more than two weeks) may indeed decrease the incidence of complications. To get to the bottom of it all, ASCRS is working on three fronts: to refer
further studies to professional public health and epidemiological investigators; to support laboratory investigation; and to urge eye doctors to be fully aware of which agents are dispensed by pharmacies. Treatment of Nitric Oxide Could Significantly Reduce Researchers at the Washington University of School of Medicine in St. Louis reason that if high levels
of the toxic chemical nitric oxide harmed certain body tissues, then it might also harm optic tissue. Examining glaucomatous human and rat eyes, the researchers found high levels of the enzyme nitric-oxide synthase (NOS-2), which
produces the destructive nitric oxide. The researchers then tested a treatment to reduce nitric oxide. Inducing glaucoma in rats' eyes, they gave the rodents a new drug called aminoguanidine, a specific NOS-2 inhibitor, and
compared them to a group of control rats. The researchers said the treated rats had no retinal damage. "At six-months, untreated animals had pallor and cupping of the optic disks in the eyes with elevated IOP. Eyes of
aminoguanidine-treated animals with similar elevations of IOP appeared normal," the researchers report. Eyes not treated with aminoguanidine lost 36 percent of retinal ganglion cells. However, eyes with similar IOP in the
treated group lost less than 10 percent of these cells. Thus, the destructive process in the treated group was largely avoided even in eyes with moderately elevated IOP. Neufeld AH, Sawada A, Becker B. Inhibition of nitric oxide synthase-2 by aminoguanidine provides neuroprotection of retinal ganglion cells in a rat model of chronic glaucoma. Proceedings of the National Academy of Sciences 1999;96(17)9944-9948.top
Open Enrollment for Charitable O.D.s "We need to make Vision USA bigger and better," says AOA President Harvey P. Hanlen, O.D. Some 7,400 AOA-member doctors have signed up for the
program. Here's how Vision USA works: Optometrists sign up by October 15 to donate services for up to eight Vision USA patients in 2000. The AOA adds the doctors to its national data base, then matches them with patients who
contact the association through the AOA web site or by mail. Patients may sign up for exams beginning in November. Doctors traditionally provide the free exams in March, but may give them at any time through the year.
Prescription eyewear typically comes from ophthalmic manufacturers, optical labs and civic groups such as Lions Clubs. Some 262,000 people have received free eye care in the 10 years of the program, and the numbers have grown each
year. This year, the AOA is focusing more on children, Dr. Hanlen says. The AOA will automatically re-enroll O.D.s who participated in Vision USA this year. First-time enrollees may contact Carol Glick, Vision USA National
Coordinator, at 1-800-365-2219, ext. 261. Ophthalmic manufacturers or labs also interested in participating may also contact Ms. Glick. Information is also available through the AOA's Web site, The Meds O.D.s Like to Prescribe Most What drugs do optometrists prescribe most? That was the question we put to our optometrists this month. Their answer: Alcon's Patanol (olopatadine)
anti-allergy
Here's a rundown of the major drug categories and what drugs O.D.s prescribe most: • Glaucoma medications. Because prescription privileges are most restrictive in this category, only 163 of the responding doctors answered this question. Of the 14 drugs listed, 91 percent of the answering panelists prefer Xalatan (latanoprost, Pharmacia & Upjohn) to any other drug. (Note: the list "Optometry's Top 10 TPAs" is based on total responses, not on percentages of O.D.s who responded in each question. Panelists were asked to list all meds they use in this category, so the total is more than 100 percent.) Rounding out the top five glaucoma drugs are Merck's Timoptic (timolol maleate), 82 percent; Allergan's Alphagan (brimonidine), and Merck's Timoptic-XE, each at 77 percent; and Alcon's Betoptic-S (betaxolol), 74 percent. Betagan was the next choice, garnering the vote of 60 percent of panelists. Cosopt and Azopt earned equal scores, with 44 percent of panelists choosing these medications. • Antibiotics. The generic tobramycin is the drug O.D.s most prescribe in this category. Some 41 percent say they use this most, followed by Ciloxan (ciprofloxacin, Alcon), 25 percent; Tobrex (tobramycin, Alcon), 20 percent; and Ocuflox (ofloxacin, Allergan) 14 percent. • Antibiotic combination agents. Polytrim (trimethoprim/polymyxin B, Allergan), is the choice of 70 percent of doctors in this category. Next are Polysporin (polymyxin B/bacitracin, Monarch), 14 percent; generic polymyxin B/bacitracin, 9 percent; and AK-POLY-BAC (Akorn's polymyxin B/bacitracin), 5 percent. • Steroidal agents. Among the 215 doctors who answered, 47 percent say Pred Forte (prednisolone acetate, Allergan) is their first choice, followed by FML (fluorometholone suspension, also by Allergan), 20 percent; Lotemax (loteprednol, Bausch & Lomb), 6.5 percent; and Flarex (Alcon's fluorometholone acetate), 5.6 percent. • Non-steroidal anti-inflammatory drugs. The most-prescribed drug in this category, Acular (ketorolac, Allergan), is the choice of 68 percent of the panelists who answered, Voltaren (diclofenac, CIBA) is a close second at 64 percent. • OTC ocular decongestants. Of course, Naphcon-A is the top choice here. Next is Vasocon-A (naphazoline, CIBA), 58 percent; and Vasoclear (naphazoline, CIBA), 9 percent. • Prescription antihistamines. The overall number one drug, Patanol, is the optometrists' choice here; 86 percent of respondents prefer it. Next are Livostin (levocabastine, CIBA), 38 percent; Opcon (naphazoline, B&L), 12 percent; and Vasocon (naphazoline, CIBA), 7 percent. • Antihistamine-decongestant combinations. The top three choices of panelists here are Naphcon-A (59 percent), Vasocon-A (53 percent) and Opcon-A (52 percent). • Mast-cell stabilizer. Patanol registers tops in this category, too, as the choice of 85 percent of respondents. Next are B&L's Crolom (cromolyn sodium), 43 percent, and Alcon's Alomide (lodoxamide), 37 percent. Pennsylvania Bill Would Allow O.D.s
The bill would allow doctors' unions to negotiate with insurers over non-fee related items, such as covered treatments. And, in markets where one insurer has a
dominant presence, health-care providers could collectively negotiate fees with insurers. Texas recently enacted a bill to allow physicians to jointly negotiate quality-of-care
issues and, in some instances, fees. The U.S. Congress also is considering legislation that would allow doctors to collectively bargain with insurers. However,
neither of these bills cites optometry in its definition of "health-care providers." That's one aspect of the proposed Pennsylvania legislation that appeals to both to
the Pennsylvania Optometric Association and the Pennsylvania Optometric Guild, the union formed by the Philadelphia County Optometric Society in 1997.
Even so, the POA is cautious about taking a position on the legislation. "Right now, we're not going to jump on the bandwagon before we feel its appropriate," says POA President Mike R. Mohn, O.D., of Shillington, Pa.
Philadelphia optometrist Aaron Chasan, president of the Pennsylvania Optometric Guild, praises the bill for including optometrists, but adds that the guild also is
studying it. "But it does attack the problem of the insurers going unbridled in terms of inequitable payments, which can jeopardize the health-care infrastructure," he says. Does the DMV Need a Checkup
A recent study concludes that visual acuity is less related to driving safety than are other vision-related areas of study, determined researchers at the University of Alabama at Birmingham School of Medicine.
States use visual acuity screening to judge the capability of drivers and, subsequently, to license them. This study suggests, however, that there is not enough evidence to prove a strong correlation between visual acuity and
on-the-road safety. These tests do not identify crash-prone drivers. Bottom line: So much emphasis is put on visual acuity to get a license that other visual factors are overlooked. Says Cynthia Owsley, Ph.D., UAB professor of
ophthalmology and one of the study coordinators: "Detail vision is not as crucial as peripheral vision, visual attention, contrast sensitivity, etc." Many times eye doctors do not have the necessary tools to determine whether a
driver, especially an older one, has the visual skills to drive a car safely. To be sure, doctors can now refer these patients to a Driving Assessment Clinic like the one
Dr. Owsley runs at UAB. The clinic was founded because of a great need in the area. "Clinics of this nature are popping up all over in health-care settings," Dr. Owsley says.
The clinics use two steps to assess a patient's visual ability to drive a car. Step one is a battery that includes visual screening, visual attention testing, contrast
sensitivity tests, a history of medications and the driver's individual needs. In step two, a certified driving rehab specialist accompanies the patient for a
45-minute on-the-road test in varying driving conditions and traffic situations. From these tests, the patient and/or family, and referring physician receive a written evaluation and risk assessment.
The state department of motor vehicles still determines who is licensed to drive. The clinics only make recommendations. More research needs to be done on the
connection between safety and visual conditions, but the DMV may soon need to give its driving test a checkup. Owsley C and McGwin G. Vision impairment and driving. Survey of Ophthalmology 1999; 43(6):535-48.top Study of Extended-Wear Risks: Something New or Déja Vu? Wearing soft contact lenses for more than 24 hours significantly increases a
patient's chances of developing microbial keratitis, report a group of Dutch researchers in the July 17 issue of The Lancet (354:181-85). Researchers used telephone surveys from 1994 to 1997 to see how many people
in the Netherlands wore both rigid and soft contact lenses, and for how long. They also asked all Dutch ophthalmologists how many cases of microbial keratitis they diagnosed from April to June 1996.
The researchers estimated the annual incidence of microbial keratitis to be 1.1 per 10,000 among daily-wear RGP wearers and 3.5 per 10,000 daily-wear soft lens
wearers. The incidence rises dramatically—to 20.0 per 10,000—among people who wear soft contact lenses for more than 24 hours at a time. While newer silicone-hydrogel materials improve oxygen transmissibility, many
researchers say that other factors may also contribute to the development of microbial keratitis. Commenting in the same issue, Dr. John Dart, of London, says
lifting restrictions on extended-wear lenses (now approved for 30 days in Europe) may be premature. These findings are similar to those of a decade earlier in the United States. In 1989
researchers reported that the incidence of ulcerative keratitis jumped from 4.1 per 10,000 daily-wear soft contact lens wearers to 20.9 per 10,000 extended-wear soft
contact lens wearers.1 Extended-wear lens manufacturers then voluntarily reduced wearing times from 30 days to seven days, and included information about the risks in the product labeling.
Contact lens manufacturers, the American Academy of Opto-metry and others point out that the Dutch study doesn't include newer extended-wear materials such as
those used in Bausch & Lomb's PureVision and CIBA Vision's Focus Night & Day.
CIBA Vision's Focus Night & Day lenses are available in 11 countries and are in U.S. clinical trials. The lotrafilcon-A lenses, CIBA says, have a high O2
transmissibility level—175 Dk/t—and patients can wear them for up to 30 nights of extended wear. Phoenix, Md., O.D. Barry Weiner, past chair of the AOA's Cornea and Contact
Lens Section, says the Dutch study also failed to ask about care regimens or compliance, materials, and whether patients wore daily wear materials on an
extended-wear basis. Also, researchers asked about cases of microbial keratitis that occurred when seasonal allergies may have been a contributing factor. An AAO statement says, "Although infection can be severe and be sight
threatening, such complications occur in only a small percentage of cases. Proper lens care and routine professional care probably decrease the risk of infection or
complication. In the event of infection, it has been shown that prompt and appropriate treatment is effective in decreasing the risk of long-term complications such as loss of visual acuity in the vast majority of cases."
St. Cloud, Minn., optometrist Burt Dubow agrees. None of his patients have asked about The Lancet study. "Those of us in serious contact lens practices who recommend and prescribe extended wear know that serious complications are
very rare when patients are properly selected, monitored and educated," he adds. "We are also prepared to treat any related eye disease before it becomes serious." 1. New England Journal of Medicine (321(12):779-83).top
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