Off the Cuff: Katrina: A Wakeup Call

In the clarity that comes after an overwhelming natural disaster, we are reminded of just how small we are as individuals and how interconnected our lives really are. As Hurricane Katrina destroyed the city of New Orleans and damaged much of the surrounding Gulf Coast, many of our colleagues who practice there lost homes, practices, patients--and for some, even more than that. Many may never completely recover.

Thanks to the sage wisdom of my good friend Dr. Brent Dulitz, who grew up in New Orleans, I was able to see beyond the immediate devastation to the consequences that will haunt many of these colleagues for years to come. With no place to practice or make a living, some of these ODs have no choice but to seek temporary work in other areas--including other states.

A frequent theme of this column has been the need for national standards allowing reciprocity of licensure throughout the United States. This crisis underscores just how important this is to our profession and to each and every one of us. I understand that several state boards have already enacted emergency endorsement for the affected ODs. I applaud their wisdom and kindness. I again call on all state boards that have not yet enacted reasonable means for practicing ODs to become licensed in their states to do so expeditiously. There but for the grace of God go all of us.

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

Rheopheresis for AMD

This literature review explored the pathophysiology of age-related macular degeneration (AMD) and the use of rheopheresis in its treatment. There appears to be a diffusion barrier caused by accumulation of cross-linked proteins known as advanced macular oxidation products (AMOPS) in AMD. Rheopheresis allows removal of uncross-linked proteins and facilitates antioxidant entry into Bruch’s membrane, preventing further accumulation of AMOPS.

The Multicenter Investigation of Rheopheresis for AMD (MIRA-1), an ongoing double masked randomized trial, should determine the efficacy of rheopheresis in preventing the progression of AMD. The interim results from an analysis of visual acuity data for 43 patients are encouraging, confirming the potential of rheopheresis as a therapeutic option for dry AMD.

Benefits were evident immediately after treatment and remained essentially stable throughout the 12-month follow-up period. Eyes with late-stage, high-risk, dry AMD appeared to be at significant risk for substantial vision loss over the 12 months if not treated. Subgroup analysis demonstrated that the timing of rheopheresis in the course of a patient’s disease may have a pronounced effect on outcome.

SOURCE: Pulido JS, Sanders D, Klingel R. Rheopheresis for age-related macular degeneration: clinical results and putative mechanism of action. Can J Ophthalmol 2005;40:332–40.

Editor’s Note: Rheopheresis has been tested in several clinical trials and is looking increasingly promising as a viable and effective treatment for AMD.

Erythropoietin and Proliferative Diabetic Retinopathy

Vascular endothelial growth factor (VEGF) is a primary mediator of retinal angiogenesis, yet VEGF inhibition alone has been insufficient to prevent retinal neovascularization. It has been postulated that there are other potent ischemia-induced angiogenic factors. Erythropoietin possesses angiogenic activity, but its role in ocular angiogenesis has not been established.

In this study, both erythropoietin and VEGF levels in the vitreous of 144 patients were measured using radioimmunoassay and enzyme-linked immunosorbent assay. Vitreous proliferative potential was measured according to the growth of retinal endothelial cells in vitro and with soluble erythropoietin receptor.

The median vitreous erythropoietin level in 73 patients with proliferative diabetic retinopathy was significantly higher than that of 71 patients without diabetes. The median VEGF level in patients with retinopathy was also significantly higher than that of patients without diabetes. Statistical analyses indicated that erythropoietin and VEGF were independently associated with proliferative diabetic retinopathy and that erythropoietin was more strongly associated with the presence of proliferative diabetic retinopathy than VEGF.

This study suggests that erythropoietin is a potent ischemia-induced angiogenic factor that acts independently of VEGF during retinal angiogenesis in proliferative diabetic retinopathy.

SOURCE: Watanabe D, Suzuma K, Matsui S, et al. Erythropoietin as a retinal angiogenic factor in proliferative diabetic retinopathy. New Engl J Med 2005;353(8):782-92.

Tono-Pen Accuracy for Measuring IOP in Children

This study compared intraocular pressure (IOP) measurements by Perkins tonometer and Tono-Pen in young children with primary congenital glaucoma (PCG). Clinical records of 28 eyes of 16 children with primary congenital glaucoma who underwent examinations at Soroka University Medical Center, Israel, between January 1999 and July 2002 were reviewed.

Children were examined under general anesthesia. The mean IOP was 18mmHg +/- 6 mmHg with the Perkins tonometer and 22 mmHg +/- 8 mmHg with the Tono-Pen. In 18 post-surgical eyes, IOP was less than 21 mmHg with the Perkins tonometer. The other 10 eyes with IOP greater than 21 mmHg with the Perkins tonometer underwent surgery. In eyes with IOP greater than 16 mmHg (Group A, 18 patients), a significant difference was found between the Perkins and Tono-Pen measurements, even although the values were strongly correlated. In contrast, eyes with IOP less than 16 mmHg (Group B, 10 patients) no statistically significant difference or good correlation were obtained.

A difference of 5.8 mmHg +/- 3.8 mmHg and 0.6 mmHg +/- 1.7 mmHg between Perkins and Tono-Pen readings, respectively, was found in Groups A and B. Tono-Pen readings disagree with Perkins tonometer measurements for measuring IOP in children with PCG who present with IOP greater than 16 mmHg tending to overestimate IOP. A further study with a similar population is necessary to confirm these results.

SOURCE: Levy J, Lifshitz T, Rosen S, et al. Is the tono-pen accurate for measuring intraocular pressure in young children with congenital glaucoma? J AAPOS 2005;9(4):321-5.

Long-Term Visual Prognosis of Infantile-Onset High Myopia

Fifty-seven children with infantile-onset high myopia (spherical equivalent above -5.00D prior to age five) were included in this study. All children received initial full-correction glasses at the mean age of 3.52 years. Cycloplegic refraction, axial length and best-corrected visual acuity were collected every six months. The mean follow-up time was 9.36 years.

Tendency toward progression or regression of myopia appeared to be related to the degree of refractive error. Lower grades of high myopia (-5.00D to -7.75D) showed a greater tendency to progress than those with the highest initial myopic refraction level (-11.00D or greater). The latter group exhibited a more substantial regression rate than those with lower initial refraction level. About 80 percent of infantile-onset high myopes demonstrated a final best-corrected vision of greater than 20/40, with 37 percent revealing best-corrected vision better than 20/25.

Clinical course of infantile high myopia is different than school myopia. Usually, higher degree of high myopia showed a stable state or even possible regression, whereas the lower grades of high myopia revealed a strong tendency to progress.

SOURCE: Shih YF, Ho TC, Hsiao CK, Lin LL. Long-term visual prognosis of infantile-onset high myopia. Eye 2005;Aug 12 [Epub ahead of print].

Corneal Thickness in Glaucoma Progression

This study determined whether central corneal thickness (CCT) is a significant predictor of visual field and optic disc progression in open angle glaucoma. A total of 101 eyes of 54 glaucoma patients were tested with static automated perimetry and confocal scanning laser tomography every six months. Progression was determined using a trend-based approach called evidence of change (EOC) analysis. Visual field progression was also determined using the event-based glaucoma change probability (GCP) analysis using both total and pattern deviation.

Lower CCT was associated with worse baseline visual fields and lower mean IOP in the follow-up. In the longitudinal analysis, CCT was not correlated with the EOC scores for visual field or optic disc change. In the GCP analyses, there was a tendency for groups classified as progressing to have lower CCT compared to non-progressing groups.

In this cohort of patients with established glaucoma, CCT was not a useful index in the risk assessment of visual field and optic disc progression.

SOURCE: Chauhan BC, Hutchison DM, Leblanc RP, et al. Central corneal thickness and progression of the visual field and optic disc in glaucoma. Br J Ophthalmol 2005;89(8):1008-12.

NEWS & NOTES

	PROGRAM DEVELOPED BY ODS TO HELP COLLEAGUES AFFECTED BY HURRICANE KATRINA. The American Optometric Institute (AOI), the Missouri non-profit corporation established by the AOA, has established an Optometric Disaster Relief Fund designed to provide immediate financial relief for all ODs who have experienced the loss of or severe damage to their practice and/or home as a result of Hurricane Katrina. It is estimated that more than 400 optometrists are in dire need of immediate financial assistance. They may not be able to rebuild for several months and thus have no means of generating income. The AOI will provide each optometrist who completes a brief grant application with a $2,000 grant for critical and urgent needs such as food, clothing and shelter. The AOA Board of Trustees is providing the initial capital for the AOI Optometric Disaster Relief Fund so the organization can begin providing financial help immediately. ODs who wish to contribute to the fund can fill out the contribution form at www.aoa.org. Gifts to the Optometric Disaster Relief Fund are tax deductible. For more information, contact Julie M. Mahoney at 800-365-2219, ext. 176 or at jmmahoney@aoa.org.
	NEW HYBRID CONTACT LENS RECEIVES FDA CLEARANCE. SynergEyes, Inc. has received FDA clearance to market its SynergEyes A hybrid contact lens for the correction of hyperopic, myopic and astigmatic refractive errors, including the correction of presbyopia. The lens features a high-Dk rigid gas permeable center with a hydrophilic, non-ionic soft skirt, it can correct ametropia from -20.00D to +20.00D with up to 6.00D of astigmatism. The company’s patent-pending HyperBond junction technology provides an interface between the soft and rigid portions of the lens for extended durability. SynergEyes plans to launch the new lens in select markets during the fall of 2005; over the next six months, it will expand its family of contact lenses to include hybrid lenses designed specifically to treat keratoconus, presbyopia and patients with post-surgical vision correction needs. For more information, call 877-733-2012 or go to www.synergeyes.com.
	FIRST NATIONAL AOA ADVOCACY CONFERENCE SCHEDULED FOR OCTOBER. The first national AOA Advocacy Group Conference for optometry will be held from October 6 to 9, 2005 in St. Louis, MO. The goal of the conference is to share information and provide potential solutions for addressing serious state and federal legislative issues, trends in the eyecare marketplace and health policy issues using all the entities within the Advocacy Group. These include the State Government Relations Center, the Federal Relations Committee, the Eye Care Benefits Center, the Healthy Eyes Healthy People Committee, the Professional Relations Committee and the Political Action Committee. For more information on the conference, go to www.aoa.org/x4121.xml.
	MEDICARE RX OUTREACH MATERIALS NOW AVAILABLE. The Centers for Medicare and Medicaid Services recently unveiled new outreach materials to help physicians and patients prepare for the implementation of the Medicare prescription drug program, which becomes effective January 1, 2006. AOA members and their patients can find information on the prescription drug program at www.cms.hhs.gov/partnerships/default.asp.

	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.