Off the Cuff: Self-Image and PR

Many of us, especially in years past, accepted second place as status quo. This "We are not as good as they are" attitude infected our profession like a virus. Damaged by this insidious and pervasive insecurity, our professional self-image suffered. It wasn’t just our professional self-image either. Our public-image suffered as well. This was compounded by our rapid evolution as the primary eyecare profession.

Less than a year after the AOA initiated its public relations campaign, the profession has virtually redefined itself in the public eye. In the process, we have become more comfortable with ourselves and with each other. As we continue to evolve as an independent profession, I believe that we will ultimately discover that professional growth and expansion starts from within. However, a little push in the right direction never hurt.

As we celebrate this Memorial Day weekend, let us not forget those who put themselves in harm’s way to protect freedom and our way of life....GBA.

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

The aim of this study was to evaluate the accuracy and reliability of three single-use devices (Tonoshield, Tonosafe, Tonojet) as an alternative to standard Goldmann prisms in an emergency eye department.

All patients seen in the emergency department of the Manchester Royal Eye Hospital for a period of four months who required intraocular pressure (IOP) measurement were eligible for this prospective study. Exclusion criteria were: age below 18 years, corneal anomalies that might affect measurement and refusal to participate. After giving informed consent, the patients were examined by one practitioner who measured IOP three times. In the first part of the study, standard Goldmann prism vs. Tonoshield and Tonosafe prisms were compared. The second part of the study used standard Goldmann, Tonosafe and Tonojet prisms.

Tonosafe and Tonojet correlated well with standard Goldmann tonometry, while the measurements obtained with Tonoshield were higher, especially for raised IOP measurements. Tonojet and Tonosafe measurements were more reproducible than Tonoshield measurements. This study shows that Tonosafe and Tonojet are accurate and reliable alternatives to standard Goldmann tonometry.

SOURCE: Maino AP, Uddin HJ, Tullo AB. A comparison of clinical performance between disposable and Goldmann tonometers. Eye 2006;20(5):574-8.

This study assessed the agreement between slit lamp indirect ophthalmoscopy and Stratus optical coherence tomography (OCT) when assessing cup-to-disc ratios (CDRs).

Twenty-five ocular hypertensive subjects and 56 patients with primary open-angle glaucoma (POAG) were included. Estimation of vertical and horizontal cup-to-disc ratio (VCDR and HCDR, respectively) with slit lamp ophthalmoscopy was made by three glaucoma specialists, along with OCT scanning of optic nerve head.

The mean VCDR and HCDR were significantly higher with OCT than those estimated by the specialists, with the difference ranging from 0.08 to 0.11 and from 0.13 to 0.18, respectively. Difference was higher for cuppings below 0.3 and lost significance for larger VCDR cups (above 0.7). When data were plotted according to the Bland-Altman method, as the cupping increased, the agreement between OCT and glaucoma specialists also increased.

There is very good agreement among specialists when estimating CDRs by stereoscopic slit lamp biomicroscopy. OCT shows higher values than the specialists; the greatest differences occurred when assessing small CDRs, and the differences diminished as the cupping increased. These two methods of measurement are not interchangeable, and the difference must be considered, especially in discs with smaller CDRs.

SOURCE: Arnalich-Montiel F, Munoz-Negrete FJ, Rebolleda G, et al. Cup-to-disc ratio: agreement between slit-lamp indirect ophthalmoscopic estimation and stratus optical coherence tomography measurement. Eye 2006; May 5 [Epub ahead of print].

Ocular Motor Differences in Depression

Major depressive disorder may be a heterogeneous disorder, yet melancholic depression is the most consistently described subtype, regarded as qualitatively different to non-melancholic depression in terms of cognitive and motor impairments. This study employed a battery of saccadic eye movement tasks to explore reflexive saccades, as well as higher order cognitive aspects of saccades including inhibitory control and spatial working memory. Nineteen patients with major depressive disorder (nine melancholic; 10 non-melancholic) and 15 healthy controls participated.

Differences were revealed between melancholic and non-melancholic patients. Melancholia was associated with longer latencies, difficulty increasing peak velocities as target amplitudes increased and hypometric primary saccades during the predictable protocol. In contrast, the non-melancholic depression group performed similarly to controls on most tasks, but saccadic peak velocity was increased for reflexive saccades at larger amplitudes. Note that most patients were taking antidepressant medication.

The latency increases, reduced peak velocity and primary saccade hypometria with more severe melancholia may be explained by functional changes in the fronto-striatal-collicular networks relating to dopamine dysfunction. In contrast, the serotonergic system plays a greater role in non-melancholic symptoms, and this may underpin the observed increases in saccadic peak velocity. These findings provide neurophysiological support for functional differences between depression subgroups that are consistent with previous motor and cognitive findings.

SOURCE: Winograd-Gurvich C, Georgiou-Karistianis N, Fitzgerald PB, et al. Ocular motor differences between melancholic and non-melancholic depression. J Affect Disord 2006; May 5 [Epub ahead of print].

Fatal Pemphigoid with Bronchial Involvement in 17-Year-Old Girl

A 17-year-old girl presented with worsening dyspnea, skin rash and bilateral ocular injection, symblepharon and fornix foreshortening. Conjunctival, skin and bronchial biopsies were performed along with imaging and serological tests in an effort to establish a diagnosis for this unusual constellation of findings. The surprising occurrence of a cerebrovascular accident during her hospitalization prompted a search for a concurrent coagulation disorder.

Immunofluorescence studies of conjunctival, skin and bronchial tissue specimens revealed deposition of multiple antibody classes at the basement membrane zone. The patient also possessed circulating basement membrane zone antibodies in her serum and a significant titer of antiphospholipid antibodies. She underwent dilation and stent placement for subglottic tracheal and left bronchial stenosis and was treated with immunosuppressive agents. After a favorable initial response, the patient experienced progressive bronchial stenosis and respiratory compromise, culminating in her death from bronchospasm and cardiopulmonary arrest.

This is the first report of mucous membrane pemphigoid involving the lower airways that was confirmed by immunofluorescence analysis. It highlights the potentially lethal systemic nature of mucous membrane pemphigoid and underscores the need to question patients about symptoms of respiratory dysfunction.

SOURCE: Gamm DM, Harris A, Mehran RJ, et al. Mucous membrane pemphigoid with fatal bronchial involvement in a seventeen-year-old girl. Cornea 2006;25(4):474-8.

Corneal Pachymetry Mapping with OCT

Forty-two eyes of 21 normal subjects undergoing LASIK had high-speed (2000 axial scans/second) 1.3-micron-wavelength corneal and anterior segment optical coherence tomography (OCT) corneal scanning performed. The scan pattern consisted of 10-mm radial lines on eight meridians centered on the vertex reflection. The entire scan pattern of 1024 a-scans was acquired in 0.5 seconds. Corneal thickness was measured normal to the anterior surface and presented as color pachymetry maps and zonal statistics. The maps were then divided into a central zone (less than 2 mm) and three annular areas (pericentral, 2mm to 5 mm; transitional, 5mm to 7 mm; peripheral, 7 mm to 10 mm), which were further divided into quadrantal zones. The average, minimum and maximum corneal thicknesses were computed for zones within the 7-mm diameter. OCT and ultrasound pachymetry were measured three times at the preoperative and three-month postoperative visits.

Before LASIK, central corneal thicknesses (CCTs) were 546.9 +/- 29.4 microns for OCT and 553.3 +/- 33.0 microns for ultrasound. After LASIK, CCTs were 513.7 +/- 44.5 microns for OCT and 498 +/- 46.6 microns for ultrasound. OCT and ultrasound CCT were highly correlated. The differences were statistically significant, but no more than the CCT measurement differences between ultrasound pachymeters. The reproducibility of the OCT zonal pachymetry averages was roughly 2 microns.

High-speed OCT provided non-contact, rapid, reproducible pachymetric mapping over a wide area of the cornea. It is equivalent to ultrasound for CCT measurement before and after LASIK. This technology could be valuable for planning keratorefractive procedures and diagnosis of corneal diseases.

SOURCE: Li Y, Shekhar R, Huang D. Corneal pachymetry mapping with high-speed optical coherence tomography. Ophthalmol 2006;113(5):799.e1-2.

Higher-Order Aberrations Induced by Soft Contact Lenses in Normal Eyes

Higher-order aberrations (HOA) of 30 eyes of 15 myopic soft contact lens wearers who had no ocular diseases were assessed with a Nidek Marco three-dimensional Wave wavefront analyzer. Zernike's polynomial was used to describe the wavefront measurements. Root mean square (RMS) values of the total HOAs, coma, trefoil and spherical aberrations were obtained in the same eyes with and without soft contact lenses.

Mean RMS values for all higher order aberration components with and without soft contact lenses were: total HOA 0.364 +/- 0.129 microns without lenses and 0.456 +/- 0.175 with lenses, total coma 0.203 +/- 0.095 microns without lenses and 0.220 +/- 0.133 with lenses, total trefoil 0.193 +/-0.074 microns without lenses and 0.254 +/- 0.153 with lenses, total spherical aberration 0.126 +/- 0.121 microns without lenses and 0.148 +/- 0.095 with lenses.

Wavefront analysis showed soft contact lenses for myopia induced a significant increase in total HOA. Though total coma, trefoil and spherical aberrations were also higher with contact lenses, they were not statistically significant when individually evaluated and compared to values without contact lenses.

SOURCE: Roberts B, Athappilly G, Tinio B, et al. Higher order aberrations induced by soft contact lenses in normal eyes with myopia. Eye Cont Lens 2006;32(3):138-42.

NEWS & NOTES

ALLERGAN'S GANFORT RECEIVES PAN-EUROPEAN LICENSE FROM EUROPEAN COMMISSION. The European Commission has granted a license to Allergan to market Ganfort, the company's Lumigan/timolol combination product (bimatoprost/timolol ophthalmic solution) for the treatment of glaucoma, in the European Union. Ganfort is indicated for the reduction of intraocular pressure (IOP) in patients with open-angle glaucoma or ocular hypertension who are insufficiently responsive to topical beta-blockers or prostaglandin analogues. A fixed combination of bimatoprost 0.03% and timolol maleate 0.5%, the drug offers IOP-lowering efficacy comparable to the free combination of the two agents and greater efficacy than monotherapy with either agent used alone. It also provides clinically important IOP control in a once-daily dose. For more information, go to www.allergan.com.

LYMPHOMA DRUG MAY BE LINKED TO RISK FOR VISION LOSS. The FDA has approved safety labeling revisions for denileukin diftitox injection (Ontak, Ligand Pharmaceuticals) to warn of the risk for visual loss associated with its use. Denileukin diftitox is indicated for the treatment of patients with persistent or recurrent cutaneous T-cell lymphoma whose malignant cells express the CD25 component of the interleukin-2 receptor. Loss of visual acuity, usually with loss of color vision with or without retinal pigment mottling, has been reported after administration of the drug. Although some affected patients recovered, most reported persistent visual impairment. The FDA notes that because this adverse event was reported voluntarily from a population of uncertain size, the incidence rate for visual loss and its relationship to drug exposure remain unclear.

	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.