Off the Cuff: Allergy Opportunity

Results of the recently published CDC Third National Health and Nutrition Examination Survey found that more than half of all Americans test positive to at least one allergen. This was double the percentage of those who tested positive 30 years ago. Without a doubt, allergy is on the upswing.

It should come as no surprise then, that as I travel the country, I have found that colleagues who aggressively identify and treat ocular allergy have developed the most successful therapeutic practices. Two things make ocular allergy a tremendous practice builder. The first is that patients suffer greatly; the second is the ease with which their suffering can be alleviated by modern ophthalmic medications. It is the unique cause and effect of allergy treatment that reinforces the patient’s perception of the doctor’s knowledge and skill. It is also what builds therapeutic practices.

Keep in mind that allergy is so much a part of patients’ lives that many will neglect to mention it when asked about existing medical conditions. Thus, turning the allergy opportunity into a practice success is often as simple as asking patients about allergy and letting them know that you can treat it effectively.

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

Case in Point: Degenerative Retinoschisis

Right Eye		Left Eye

A 72-year-old white man presented with a chief complaint of blurred vision while reading. He also complained of intermittent red, burning eyes. The patient’s medical history was positive for Type II diabetes, hypertension, gout, hypercholesterolemia and a myocardial infarction. His medications included allopurinol, felodipine, lisinopril, lorazepam, methocarbamol, metoprolol, nitroglycerin and simvistatin.

Examination found corrected visual acuity of 20/30 OD and 20/25 OS at distance. Pupils, motilities and visual fields were within normal limits, as was intraocular pressure. Biomicroscopy revealed nuclear and cortical sclerosis OU. Posterior pole examination with 90D lens was normal. Peripheral fundus examination showed that the photographed regions were seen inferotemporally in both eyes.

Degenerative retinoschisis represents a splitting of the layers of the retina. Clinically, this condition consists of bilateral, often symmetrical bullous or thin elevated layers of tissue, usually within the inferotemporal quadrant, which may slowly progress. Retinal vessels are often sheathed terminally, and the surface may have fine white spots or "snowflakes." Holes may develop in either or both walls of a retinoschisis cavity, although outer layer holes are more common. Schisis-related retinal detachments are always associated with outer layer holes.

Retinoschisis is differentiated from retinal detachment in that in retinoschisis, the retinal surface remains smooth and does not fluctuate with eye movements. This is easily demonstrated with B-scan ultrasonography. Vitreous pigment and blood are characteristically absent. A relative (not absolute) scotoma may be found on visual field testing.

Although retinoschisis is typically asymptomatic and benign, 2.5 percent of cases result in retinal detachment. Treatment is not warranted unless the patient becomes symptomatic, the macular is threatened or retinal detachment occurs. Patient education is important, and it should consist of informing the patient about retinal detachment symptoms (e.g., flashes, floaters, veiling or loss of vision). Recommended follow-up is every six months.

--Case study courtesy of Samuel R. Sant, OD, Primary Eye Care Resident, Daytona Beach VA Outpatient Clinic, Daytona Beach, FL.

Intraocular Foreign Body Injuries During Operation Iraqi Freedom

This retrospective case series reviewed the number of intraocular foreign body (IOFB) injuries that occurred during Operation Iraqi Freedom and determined the cause of injury, the type of foreign body and the associated injuries to other body systems.

Fifty-five U.S. military personnel with an IOFB injury during Operation Iraqi Freedom were reviewed. Foreign bodies were caused by propelled explosive in twenty patients (36 percent) and a non-propelled explosive in 31 patients (56 percent). The cause of the foreign body was not known in four patients (7 percent). The size of the laceration of the cornea and/or sclera averaged 5.4 mm with an average of 1.7 foreign bodies in the injured eye. The size of those foreign bodies ranged from less than 1 mm to 12 x 14 mm. The most common type of foreign body was metal (68 percent), followed by glass (14 percent), stone/cement (14 percent), bone (5 percent), and cilia (3 percent). The time from injury to foreign body removal averaged 20.6 days. No cases of endophthalmitis were seen. The most common associated injury was to the upper extremity, face, lower extremity and neck.

Unlike trauma in the civilian sector, IOFB injuries in a military setting tend to be caused by explosive devices, which often result in multiple foreign bodies and simultaneous injuries to other body systems. Because of the lack of availability of specialty care in the combat theater, there is often a delay in removal of the foreign body.

SOURCE: Thach AB, Ward TP, Dick Ii JS, et al. Intraocular foreign body injuries during Operation Iraqi Freedom. Ophthalmol 2005; Aug 9 [Epub ahead of print].

Higher-Order Aberrations After Laser Refractive Surgery

Thirty-three symptomatic, postoperative LASIK and/or photorefractive keratectomy eyes with subjective visual complaints not corrected by spectacles more than six months after surgery were compared with 46 normal preoperative and 46 asymptomatic, postoperative, conventional LASIK eyes. Postoperative wave aberrations were measured for each patient using a Shack-Hartmann wavefront sensor over a 6-mm pupil. These measurements were averaged across patients with similar corneal topographic diagnoses (central islands, decentered ablations and a new group termed baby bowties).

The average higher-order root-mean-square (RMS) wavefront error values for symptomatic patients was 1.31 microns. This was an average of 3.46 times greater than the average magnitude of normal preoperative eyes (0.38 microns), and an average of 2.3 times greater than the average magnitude of asymptomatic, postoperative conventional LASIK eyes (0.58 microns). Higher-order RMS wavefront error increased with pupil size, roughly doubling for every millimeter of increasing pupil diameter. On average, eyes with central islands had the most vertical coma. Eyes with central islands and decentered ablations also had elevated amounts of spherical aberration compared with postoperative, LASIK eyes. Eyes with a topographic central baby bowtie demonstrated the most secondary astigmatism, despite the lowest average higher-order RMS among symptomatic topographic subgroups.

Symptomatic postoperative laser refractive surgery patients with irregular corneas have higher-order aberrations that are 2.3 to 3.5 times greater than asymptomatic postoperative LASIK and normal preoperative eyes, respectively. The higher-order aberrations seem to correlate with corneal topography.

SOURCE: McCormick GJ, Porter J, Cox IG, Macrae S. Higher-order aberrations in eyes with irregular corneas after laser refractive surgery. Ophthalmol 2005; Aug 9 [Epub ahead of print].

Relationship Between Eye Symptoms and Blepharospasm

Although patients with primary blepharospasm (BSP) commonly report experiencing ocular symptoms before the onset of orbicular spasms, the precise frequency and pathogenic role of this subjective ocular discomfort are poorly understood. This multi-center case-control study investigated symptoms related to disorders of the anterior segment. Investigators administered a questionnaire to 165 patients with BSP and 180 age- and gender-matched control patients with hemifacial spasm.

On a validation sample, the questionnaire yielded high accuracy in detecting eye diseases (predominantly, dry eye syndrome) using detailed ophthalmological examination as the criterion. Statistical analysis indicated a significant association between ocular symptoms at disease onset and BSP. Ocular symptoms starting in the year preceding disease onset showed a stronger association with BSP than ocular symptoms occurring earlier.

These findings support the view that ocular symptoms associated with BSP result from eye diseases and may be involved in the pathogenesis of BSP. The differential risk of developing BSP, based on age at onset of ocular symptoms, suggests that age and eye diseases may interact in the development of BSP.

SOURCE: Martino D, Defazio G, Alessio G, et al. Relationship between eye symptoms and blepharospasm: A multicenter case-control study. Mov Disord 2005; Aug 9 [Epub ahead of print].

Body Mass Index and Age-Related Cataract

This study investigated the association between body mass index (BMI) and cataract in a metropolitan Asian elderly population. Age-related cataract was defined as any type of lens opacity with a Lens Opacities Classification System III grade of more than 2 in one or both eyes. Weight and height were measured by intensively trained interviewers.

A total of 2,045 subjects 65 years and older in Shihpai, Taipei, were invited to participate with 1361 (66.6 percent) completing the survey. Eight hundred six participants were diagnosed as having age-related cataracts. With a BMI of less than 21.3 as a reference point, a U-shaped relationship between BMI and nuclear opacity was demonstrated. A reverse U-shaped relationship was shown for cortical opacity. In the final multiple logistic regression models, BMI was significantly related to nuclear and cortical opacity but not to posterior subcapsular opacity. BMI is an independent risk factor for nuclear and cortical opacities, yet the risk factors are inverse to each other.

SOURCE: Kuang TM, Tsai SY, Hsu WM, et al. Body mass index and age-related cataract: the Shihpai Eye Study. Arch Ophthalmol 2005;123(8):1109-14.

NEWS & NOTES

	FIRST OPHTHALMIC NON-STEROIDAL ANTI-INFLAMMATORY PRODRUG EARNS FDA APPROVAL. After a priority six-month review, the FDA has approved a new drug application for Alcon’s Nevanac (nepafenac ophthalmic suspension, 0.1%) for the treatment of pain and inflammation associated with cataract surgery. Nevanac contains a novel prodrug that rapidly penetrates ocular tissues and is target-specific; it is the first ophthalmic non-steroidal anti-inflammatory prodrug to receive FDA approval. The approval was based on results of two multi-center placebo-controlled studies, involving more than 680 patients, in which the drug was dosed three times per day, beginning one day before cataract surgery, continuing on the day of surgery and for 14 days postoperatively. Patients were evaluated at baseline and at one, three, seven and 14 days after surgery. Those treated with Nevanac had significantly less ocular pain and inflammation in the early postop period through the end of treatment. More than 80 percent of patients treated with Nevanac suspension were pain-free the day after surgery, compared to less than 50 percent in the placebo group. Following two weeks of treatment with Nevanac, about 95 percent of patients were pain-free, compared to 45 percent of patients in the placebo group, and 91 percent of patients treated with Nevanac had no clinically significant inflammation, compared to about 47 percent of patients in the placebo group. No unexpected adverse events were reported. Alcon expects Nevanac to be commercially available within the next several weeks.
	NEW ALPHAGAN FORMULATION APPROVED BY FDA. Allergan, Inc. has been approved to market Alphagan P (brimonidine tartrate ophthalmic solution 0.1%), indicated for lowering intraocular pressure (IOP) in patients with open-angle glaucoma or ocular hypertension. The new product is an optimized formulation of Alphagan (brimonidine tartrate ophthalmic solution 0.2%), and was developed to further minimize drug exposure while maintaining the drug's favorable efficacy profile. In a clinical trial, the new formulation was proven to have IOP-lowering efficacy equivalent to Alphagan 0.2%, effectively lowering IOP in patients with open-angle glaucoma or ocular hypertension by approximately 2 mmHg to 6 mmHg. Alphagan P 0.1% is contraindicated in patients taking MAO inhibitors; the most frequently reported adverse events included allergic conjunctivitis, conjunctival hyperemia and eye pruritus. For more information, go to www.allergan.com.
	OPTOS FORMS STRATEGIC ALLIANCE WITH EYEMAGINATIONS. Ophthalmic retinal imaging company Optos, Inc. has formed a strategic alliance with interactive design and multimedia firm Eyemaginations, Inc. The partnership aims to capitalize on the strengths of both companies to focus on eyecare patient education materials. The first project for Eyemaginations and Optos is an educational animated video explaining the Optomap Retinal Exam, which will be incorporated into Eyemaginations’ software, the 3D-Eye Office. The animation helps eyecare practitioners and their staff members clarify procedures and educate patients about key components of their ocular health. For more information, go to www.eyemaginations.com or www.optos.com.

 

	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.