San Diego County Optometric Society
The San Diego View
Volume XVII, No. 8 – September 2016
Inside this Issue:
- President’s Message
- Retina Corner
- Tech Corner
- Eye See
- Digital Devices and Dryness: Selecting a Contact Lens to Meet the Challenge
- Keratoconus/Ectasia Prediction in Refractive Surgery: Science and Clinical Implications
- CE Corner
- Volunteer Corner
- SDCOS Announcements
- Upcoming Events
Thank You To Our Sponsors!
The San Diego County Optometric Society is one of the largest and most active societies in the state. Our activities include supporting the political interests of optometrists both locally and on a state level, providing monthly continuing education to our doctors, and giving back to our community with our Monarch School eye exams and the Lions Vision Optometric Clinic. We are able to successfully run all the programs we have available largely due to the support of our generous sponsors. We are one of the few local optometric societies to have a healthy network of sponsors which not only provide financial support, but also extend discounts to members for using their products and provide resources to help with building practices and optometric careers. Additionally, sponsorship helps fund our public awareness projects, advocacy efforts, our website, social media, and other SDCOS social events.
Every fall, the SDCOS Board hosts an annual Vendor Appreciation dinner to thank our fantastic sponsors. This year, the dinner is being held on Thursday, October 13th at the Braille Institute of San Diego. All of our sponsors are invited to join us for a fun night of drinks, dinner, and conversation devoted to continually improving our mutually beneficial relationship. As a member, I encourage you to show how much you appreciate the support of our sponsors by taking the time to sit down with them and allow them the opportunity to discuss ways in which they can personally assist you. It is important to support the sponsors who are so passionate about supporting our society and profession!
We are lucky to have an extensive variety of sponsors and I would like to take a moment to recognize them. Our highest level of sponsorship is the platinum level. The amazing companies who have committed to this level of sponsorship include Empire Optical/Essilor Labs, EyeCarePro, NVISION Eye Centers, VSP Optics Group, and Carl Zeiss Vision/Carl Zeiss Meditech. Our wonderful sustaining sponsors include ABB Optical Group, Alcon, Bausch & Lomb, Comfort Vision, Coopervision, Gordon Schanzlin New Vision Institute, Golden State Web Solutions, Inc, La Jolla LASIK Institute, Marchon, OcuSci, Optovue, PERC, Professional Optical Laboratories, Shamir, Synergeyes, The McGee Group, Vision West, Vistakon, VSP Global, Wells Fargo, and WestPac Wealth Partners. We also greatly appreciate an educational grant from Allergan Eye Care.
Again, I offer a warm thank you to all of our sponsors! I am committed to seeing the relationships our sponsors have with our society and our doctors continue to thrive and grow in the future. Thanks to the generous support of our sponsors, the San Diego County Optometric Society can continue to strive and achieve the goal of being the strongest optometric society in California!
Next Generation Treatment Options for Wet AMD
By Nikolas London, MD, FACS
Last month we discussed a fascinating potential treatment option for our patients with exudative macular degeneration – an eyedrop that may enhance the efficacy of our intravitreal anti-VEGF injections (Squalamine, Ohr Pharmaceuticals). If it proves to be beneficial this would be a welcome addition to patients, however the gold standard for the foreseeable future will certainly remain intravitreal injections. Less certain is which medications we will be injecting. Pharmaceutical companies have motivation to develop the next great AMD treatment option, and are investing billions of dollars in R&D. It is easy to understand why if you look at the number of injections performed annually in the United States, the vast majority of which are anti-VEGF agents. According to the Medicare claims database, fewer than 5000 injections were performed in 2005. This skyrocketed to 812,413 in 2007 (soon after Lucentis and Avastin became available) and then to 2.3 million injections in 2012. In 2016 it is projected to surpass 6 million injections. Given that the cost of some injections approaches $2000, the financial incentive for drug companies to develop the “go to” drug is obvious, and our patients can expect increasingly sophisticated drugs and increasingly better outcomes over the next decade. In this month’s article I would like to discuss a drug we are currently studying that may be a part of that next generation of injections, an agent that simultaneously inhibit both vascular endothelial growth factor (VEGF) as well as a new target, Angiopoietin-2 (Ang2).
Like VEGF, Ang2 is involved in angiogenesis, the growth of new blood vessels. This is an important process during human development and in wound healing, but becomes aberrant and destructive in diseases such as AMD. Increased Ang2 levels attract other pro-angiogenic inflammatory cells, and destabilize and sensitize vascular endothelium, making it more able to sprout vascular buds. As such, blocking both VEGF and Ang2 may be more effective than blocking VEGF alone. We currently have three separate clinical trials evaluating this theory – two for AMD and one for diabetic macular edema. One molecule being developed by Genentech is a very sophisticated agent – a monoclonal antibody with bi-specific activity against both VEGF and Ang2 (Figure). Further, the Fc region of the antibody, which is important in keeping antibodies in our blood stream, is disabled, resulting in faster systemic clearance, and therefore less likelihood of systemic side effects. Essentially this molecule is Lucentis+. It has the same amount of anti-VEGF activity as Lucentis with potential additional benefit from the anti-Ang2 activity. This makes it an easy choice for patients interested in clinical trials. I am hopeful that it will optimize the visual recovery for patients, minimize the number of patients who are poor-responders (about 5-10% of all patients), minimize the development of scar tissue under the macula, and minimize the number of injections patients need to receive in a year.
If you have any untreated wet AMD patients, please feel free to reach out to me. I’ve found that patients are interested in having access to cutting edge treatment options, and most really enjoy being involved in the discovery process. As with most clinical trials, insurance is not an issue, travel is paid for, patients are often compensated, and the study drug and all testing and exams will be covered by the company sponsor.
Thanks again for reading. Please don’t hesitate to contact me with any questions.
Best wishes, and until next time,
Nikolas London, MD
Retina Consultants San Diego, Poway, La Jolla, and Coronado
firstname.lastname@example.org (personal email)
email@example.com (RCSD email)
Got Tech questions? We’ve got Answers!
5 EMAILS YOU DON’T WANT TO CLICK ON! Provided by Dave Tuckman from Golden State Web Solutions, Inc. (www.GSWS.com) Whether for personal or for work use, we all rely on email in lives on a daily basis. It’s one of the easier way to communicate between individuals or within a group. We can share documents, ideas, and maintain ongoing dialogue at times when it is convenient for us. Unfortunately, people with bad intentions know this also, and will try to take advantage of natural instincts to trust and take things at their word. In this month’s article, we take a light hearted approach to highlight some of the more common email scams that initially look attractive, but really have a more nefarious intent behind them.
- THERE IS A NIGERIAN PRINCE, BUT HE’S NOT A RELATIVE AND DOESN’T WANT TO SEND YOU MONEY This scam is one of the first email scams that was unleashed on the Internet. These start by someone introducing themselves as a relative (or they received your contact information from a relative) and wants to discuss details of transferring a large amount of money from one account to another with your assistance. Obviously, there is a sizeable reward when completed for your assistance completing the transaction. It may sound obvious to steer far away from these, but it’s successful enough that it continues to circulate after all these years.
- YOU MOST LIKELY DIDN’T WIN AN OVERSEAS LOTTERY (ESPECIALLY IF YOU DIDN’T PLAY ONE) This Lottery scam evolved from the success of our Nigerian Prince’s efforts described above. It works in the same manner, but changes the narrative to appear it is from a more legitimate source (a lottery vs. a private bank account) and will appear to come from Europe (vs. Africa). Despite its efforts, stay away. Try your luck with the Powerball or Mega Millions – your odds are better playing those.
- THE 20 SOMETHING RUSSIAN HOTTIE THAT WANTS TO MEET YOU REALLY ISN’T 20 OR HOT, (BUT MIGHT BE RUSSIAN) Ever get an email from a young gal in Russia (perhaps the Ukraine) who is looking for someone older, more mature that she can spend the rest of her life with? One flavor of this email can be romantic in nature, and others get straight to the point – using more direct language. In any flavor – this isn’t where you are destined to find true love. If you are really looking for a relationship, check out a website like Match.com, or maybe just try going on a date with the person your mother has been trying to set you up with all these years. Statistically, that has a better chance of working out for you.
- YOUR BANK AND/OR PAYPAL DIDN’T JUST SEND YOU A LINK TO RESET YOUR PASSWORD Sometimes scammers aren’t as direct and will try to trick you into giving up access information to other website accounts you have. A common method is to send an email that might look like it’s from PayPal or your bank. The red flag is that they provide a link (within the email) for you to click on. Banks, financial institutions, PayPal and the like will never provide a link. They will send an email telling you to GO DIRECTLY TO THEIR WEBSITE and login there. That way you confirm you are at the correct website (not where the link sends you to).
Got questions, or a quality scam you’ve been exposed to? Give us a call (619-825-4797) or email (SDCOS@GSWS.com) to share your story. We’d love to hear it – and are happy to help best we can – no strings attached.
written by Dr. Byron Y. Newman
The Ministry of Medicine
“Doctors tend to view their roles and responsibilities too narrowly,” writes Dr. Margaret Mohrmann in her book “Medicine as Ministry.” Mohrmann, a professor of pediatrics at the University of Virginia, proposes a dramatically different perspective, which, if accepted, could drastically change the nature of medical training and treatment. Her book, discussed on radio by Michael Josephson on his program, “Character Counts,” pointed out that doctors are so focused on the scientific aspects of diagnosis and treatment of illness or injury that they ignore, and maybe even become annoyed by things like pain, fear, or anxiety. “In her view,” stated Josephson, “the most needed remedy for the kinds of suffering doctors face daily, is not more or better pain killing drugs, but more genuine caring. She says doctors should listen more even if it makes them weep. She believes that true compassion and empathy are healing agents for pain and anxiety. Genuine gestures of concern, from a comforting squeeze of the hand to a follow-up phone call or visit, can be as important as prescriptions and surgical procedures.” Mohrmann contends that the ultimate object of medicine is not just to diagnose and cure disease, but to alleviate suffering. “The practice of the ministry of medicine,” she adds, “is the practice of paying attention.” Being attentive means sensing, treating seriously, and responding appropriately to the myriad of feelings that inevitably accompany illness and injury. Josephson closed his remarks with, “I think she’s right. It takes a kind of moral courage for a doctor to keep an open heart. But, what a huge difference it would make.”
Digital Devices and Dryness: Selecting a Contact Lens to Meet the Challenge
Nearly one-third of millennials and Generation Xers spend 9+ hours per day using a digital device – that’s more than half their waking hours. However, digital device use has no age boundaries. Nearly one in four kids (23.6%) spends more than 3 hours per day using a digital device! And let’s not leave out the Baby Boomers. One in four boomers (26%) also spends at least nine hours per day using a digital device.
The result for many manifests in the form of digital eye strain – physical eye discomfort and dryness after two or more hours in front of a digital screen. As a result of prolonged use of digital devices, nearly 70% of American adults experience some form of digital eye strain. And it takes a toll creating discomfort and affecting productivity.
Dryness is commonly associated with overexposure to digital devices, but digital devices also have an impact on the contact lens wearing experience. In a study of current and former soft contact lens wearers, there was a relationship between digital device usage and contact lens drop-off – defined as discontinuation of wear or less frequent lens wear. In this study, drop-off was 2 times higher for heavy digital device users (10+ hours per day) than for light digital device users (1 to 4 hours per day). Although viewing a computer screen most of the day and dryness were the highest contributing factors to contact lens drop-off, those who dropped-off also were likely to report experiencing symptoms such as discomfort, suboptimal visual clarity, and sensitive eyes. It isn’t surprising to learn that the more symptoms a contact lens wearer experienced, the more likely they were to reduce their wearing time.
Use of digital devices for prolonged periods can contribute to blink rate and tear film integrity alterations resulting in symptoms of dryness. On average, patients may blink up to 66% less frequently when they are using a digital device, which may contribute to lens dehydration. Bausch + Lomb ULTRA® contact lenses with MoistureSeal® Technology have an extensive network of polyvinylpyrrolidone (PVP) which helps the lenses to maintain 95% of their moisture for 16 hours.
In a recent study, Bausch + Lomb ULTRA® contact lens wearers who spend at least 3 hours each workday using a computer or digital device and report having dry eyes showed great success with the lens. Most agree the lenses are comfortable, provide clear vision, help their eyes stay moist, and prevent their eyes from feeling tired or fatigued after focusing for long times at digital devices. Outcomes such as these demonstrate that Bausch + Lomb ULTRA® contact lenses with MoistureSeal® Technology can help practitioners provide a positive contact lens wearing experience for digital device users, even those who report symptoms of dryness.
Bausch + Lomb ULTRA and MoistureSeal are registered trademarks of Bausch & Lomb Incorporated or its affiliates.
© 2016 Bausch & Lomb Incorporated. ZUS.0210.USA.16
Keratoconus/Ectasia Prediction in Refractive Surgery: Science and Clinical Implications
Traditionally, keratoconus had been a feared diagnosis, as the cornea ultimately steepened to the point where hard contact lenses fell out and the only option was corneal transplant. Today with advanced contact lenses available and corneal cross-linking newly FDA-approved, we have more options, but at La Jolla LASIK Institute, we continue to screen patients carefully for pre-keratoconic conditions before choosing LASIK, PRK, or corneal cross-linking.
Clinicians, statisticians, and scientists have worked hard on studies to devise screening systems to help us predict keratoconus/corneal ectasia before it happens, and to predict how much thinning a given cornea can tolerate. At La Jolla LASIK Institute, we run four metrics:
- Ectasia Risk Score System (ERSS)
- Pentacam Refractive Indices
- Belin Ambrosio Display
- Percent Tissue Altered
Ectasia Risk Factor Score System (ERSS)
At La Jolla LASIK Institute, we have used the ERSS since it was published in 2008 by Randleman and colleagues at Emory University. It took refractive surgeons from guesswork and speculation and into science when it came to keratoconus/ectasia risk and prevention. It was revolutionary in several respects:
- First system to recognize age as a factor, resulting in more PRK for patients in their 20’s
- Raised the ideal Residual Stromal Bed to 300 from the prior guess of 250
- Allowed for LASIK treatments as high as -12.00 as long as other factors were ideal
Pentacam Refractive Indices
In addition, we always take a look at the Pentacam Refractive Indices, which conveniently color-code the keratoconus risk, white for no evidence of keratoconus, yellow for prior corneal surgery or possible form fruste keratoconus, and red for keratoconus, which it automatically grades from 1-4 in severity.
Belin/Ambrosio Enhanced Ectasia
The Belin/Ambrosio Enhanced Ectasia software is useful for detecting occult ectatic disease (i.e. subclinical keratoconus). Unlike in contact lens fitting, when we want to see the Best Fit Sphere as shown in a standard topographic image so that the contact lens vaults over any bulge or ectatic area, in refractive surgery we want the bulges and ectatic areas to stand out. Drs. Belin and Ambrosio devised a New Reference Shape that follows the main curvature of the cornea and highlights any ectatic bulges, causing them to really “pop out.”
Percent Tissue Altered
The cornea is not uniformly strong. There is increasing weakening in the deepest 60%, and the LASIK flap does not contribute significantly to the strength of the cornea, so the full thickness of the LASIK flap must be regarded as part of the treatment rather than part of the cornea contributing to its postoperative strength. Santhiago and colleagues concluded in their study that the combination of the flap thickness and the treatment (ablation) depth, or Percent Tissue Altered (PTA), is the single most important variable in assessing the likelihood of corneal ectasia/keratoconus postoperatively in corneas with normal symmetry.
The Santhiago paper concluded that for a perfectly symmetric cornea, defined as a corneal inferior-superior (I-S) difference of 0.50 or less, the highest percentage of the cornea that should be involved in the treatment is 40%.
In a second paper, Santhiago and colleagues showed that corneas with an I-S difference greater than 0.5 require keeping the Percent Tissue Altered even less than 40%. We use our stepwise nomogram based upon their data to set an even higher standard for these patients.
We choose the most conservative treatment option based on the results of the four tests. And if one of four metrics points to PRK as the safest option, PRK it is! So expect to see more PRK in our co-management relationships. This higher number of PRK patients has caused us to re-evaluate every single step of our postoperative care in PRK to provide:
- Greatest postoperative comfort
- Fastest healing
- Greatest corneal clarity
This year, we have made several changes to our postoperative protocol and have found substantial gains in all three measures. Between choosing between three lasers available to us, adjusting the treatment profile to reduce treatment depth, and a world-class PRK protocol, we really feel we have reduced risk and improved outcomes for our mutual patients. At La Jolla LASIK, we continuously strive to improve and perfect every step of the refractive surgery process for the safety and comfort of the patient and the peace of mind of the referring doctor. If you have patients who might benefit from our refractive screening method and treatment protocols and would like to discuss, feel free to contact me or our optometric representative, Matt Harnish.
Thank you for reading. Please feel free to contact me with questions and suggestions.
Sincere best regards,
Angela Nahl, MD
La Jolla LASIK Institute
Scripps Memorial Hospital Campus
H.M. Poole Building, Fourth Floor
9834 Genesee Ave, Suite 428
La Jolla, CA 92037
Director of Co-management Services
We are committed to helping you fulfill your CE requirements through our local meeting with the support of our sponsors!
Featured Annual Sponsors
September 11, 2016 5-hour CE
Speakers: Dawn De Castro-Marceau, MD – Srini Iyengar, MD – Bobby Korn, MD, PhD – Asa Morton, MD – David Samimi, MD
Topic: Updates in Oculoplastic
Continuing Education Seminars are at the Handlery Hotel 950 Hotel Circle North, San Diego, 92108.
Two-hour seminar, Thursday, 7:00 pm – 9:00 pm. Buffet meal included and served ½ hour prior to lecture.
- SDCOS Members free, COA/AOA Members $35.00, Non-Members $130.00.
Five-hour seminar, Sunday, 8:00 am – 1:30 pm. Buffet meal included and served ½ hour prior to lecture.
- SDCOS Members $90.00. COA/AOA Members, $90.00 Non-Members $325.00.
FirstSight Vision Services has both part time and full time positions available for Optometrists in San Diego. We are offering generous compensation for positions in the San Diego area including fill-in coverage. Please email me at Delaney.Bashaw@firstsightvision.net or call me at 909-920-5008 ext. 2062 as I would love to speak with you about these opportunities! (09/16)
New office opening in San Diego! We are looking for motivated full time Optometrist to join our Ophthalmology practice in Escondido! This office will be located in a busy strip mall next to nationally-recognized retailer Eyeglass World. Please email ODJobs@firstsightvision.net for more information about this exciting opportunity! (09/16)
For Sale In San Diego Excellent net profit makes this a great opportunity. In a free standing building with great parking. The business has been established since 2003. Opportunity to grow, for more information reply back at firstname.lastname@example.org (09/16)
OD wanted 1 day a week to start, Tuesdays Rancho Penasquitos area. Contact Dr Ring at: email@example.com (10/16)
A young, prepared, and energetic new graduate doctor is looking for a full-time/ part-time/ fill-in work in San Diego area. If you are in need of a vacation relief or looking to add a new doctor and grow your patient base, I would be delighted to talk to you. Please call/text (704)777-1986 or email DArdakani@yahoo.com Thank you in advance for your interest. (09/16)
Part time and/or Fill In Optometrist – private sublease practice looking for part time OD or an OD looking for fill in opportunities with a flexible schedule. Please email CV to firstname.lastname@example.org (09/16)
Seeking Optometrist for Full Time and/or Part Time Must have own liability insurance coverage. Office hours: Mon, Tues, Thurs, Friday: 10-6pm, last pt scheduled at 5pm; Weds: 11-7pm, last pt scheduled at 6pm. Patients are scheduled every 20-25 minutes and 1 hour lunch. Please attach resume if interested. email@example.com (09/16)
Dr. Jack Anthony, the Society Optometrist Relations Liaison, offers a unique service to the San Diego County optometric community. Several lists are kept on file for doctors seeking the following, or any combination thereof: • positions • fill-in work • part-time work • full-time work • to purchase a practice • to fill positions • to partner in a practice • to sell a practice There is no charge for this service. Please contact Dr. Jack Anthony at E-mail: firstname.lastname@example.org to put your name on the list.
Monarch School Screening
Next Screening: VSP Mobile Clinic will be October 3rd and 4th– We need one or two optometrists for each day– please contact Dr. Meisel if you are interested in helping!
Contact Dr. Bob Meisel for more information at email@example.com ; www.monarchschools.org
Lion’s Optometric Vision Clinic
Volunteer OD’s needed for flexible shifts throughout the year according to each doctor’s availability. OD’s unable to volunteer at the clinic can see patients at their office.
Call 619-298-5273, between 9-1:00 pm.,
Monday -Friday ~ 1805 Upas St, San Diego, CA 92103
Doctors interested in donating glasses to the Lions Optometric Vision Clinic (LOVC) please bring them to a CE meeting or contact Nancy-Jo at 619-663-8439 to make arrangements for delivery.
SDCOS keeps a list of all doctors willing to speak in front of groups about various topics, do home visits for patients, and assist in student mentoring. ODs interested in the Speakers Bureau, Home Visits, Student mentoring, and Low Vision OD’s, please contact Nancy-Jo at 619-663-8439
Please join us in participating in the annual Step Out Walk to Stop Diabetes. You can sign up to fundraise or walk, or you can make a donation. The best choice is to do all three! For any of you who are new to this SDCOS annual event, fundraising is easy and the walk is fun! This year it is on a Saturday morning (October 22 @ 8:00 AM). Team SDCOS has been the top fundraising team in our category for years we would love to keep our streak going!! Click HERE for more details and to register.
- September 11th: 5 Hour CE: Oculoplastics Sympsoium
- October 20th: 2 Hour CE: Glaucoma Update
- October 22nd: Annual Step Out Walk to Stop Diabetes 5K
Phone: 619 663 8439
Fax: 800 643 8301