The San Diego View

Inside this Issue:

• President’s Message
• Retina Corner
• Eye See
• CE Corner
• OCTA: Filling in New Pieces of the Glaucoma Puzzle
• Classifieds
• Volunteer Corner
• SDCOS Announcements

President’s Message May 2020

Dr. Wendy Gross

After weeks of shutdown, the nation is beginning to slowly and cautiously re-emerge.  Like the decisions to shut down and shelter in place, the plans to reopen have come state by state or region by region. California is now in Phase I of the White House’s “Opening Up America Again” plan, a three-phased approach based on the advice of public health experts.

The California Department of Public Health (CDPH) issued a statement on April 27, 2020 providing guidelines for resuming health care for non-emergent and non-COVID-19 health care. Their guidance is intended to set a plan for California, while understanding there may be circumstances that require different timelines for different locations or regions.

Based on these new guidelines, Doctors of Optometry in California are encouraged to gradually resume full scope of services when possible and safe to do so.  Businesses are advised to continue to encourage telework, whenever possible, to protect patients and healthcare workers.  The physical layout and flow of patient care may also change in order to maintain physical distancing in patient movement and waiting areas.

Optometric services fall under the CDPH’s “Outpatient Visit Guidelines.”  These guidelines prioritize scheduling for patients that cannot be treated by telehealth in the following order:

1. Patients with acute illnesses
2. Patients with chronic illness that have not been seen due to Stay-at-Home rules and need an in-person visit
3. Preventative services, including vaccinations
4. List of previously cancelled or postponed patients
5. Other patients needing in-person visit to monitor status or assess illness, etc

Although San Diego County has not officially released guidance or a timeline of when the current restrictions will be lifted, optometrists are advised to use their judgment to determine when it is appropriate to provide non-urgent care.  The use of telemedicine is still recommended, whenever possible.

The AOA and COA websites are great resources for updated information during this constantly evolving situation. There you will find helpful resources, guidelines, webinars, and checklists to help with practice reopening and activation as well as practice relief, information about personal protective equipment (PPE), and other safety and financial considerations.

I also want to thank everyone who virtually attended our informational Q&A webinar this week.  If you missed it, the presentation and Q&A have been posted on our website for your convenience.  Please check our website frequently for updates to the Continuing Education schedule as well.

The SDCOS board and I are doing our best to stay up to date on the latest developments of the coronavirus response in the Optometry community and provide useful information to our members as we face this pandemic together.  Please do not hesitate to reach out to our board with any questions or comments.  We are in this together and SDCOS is here to support you.

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Retina Corner Introduction to Clinical Research

By Nikolas J.S. London, MD FACS
Director of Clinical Research, Retina Consultants San Diego
Chief of Ophthalmology, Scripps Memorial Hospital La Jolla

Hopefully everyone is healthy and staying sane these days. What a world we now live in. It is impossible to overstate how tragic and challenging some of the events have been with COVID19. However, there must always be silver linings. My silver lining has been plenty of time to work on some of the other parts of my practice, in particular getting caught up with my passion for clinical research. It has been exciting for me to get things ultra-organized.

One of the things I have been working on over the past few weeks is a sort of handbook for my clinical research staff. As it has evolved, I wonder if it might be of interest to others, particularly anyone interested in becoming involved in clinical research. Below is an excerpt from the beginning of the handbook. If anyone is interested in seeing the rest, please feel free to reach out – there is quite a bit more, including basic staff needed at the research site, external staff employed by the study sponsor, the institutional review board and other safety measures, standard operating procedures, standard equipment needed, responsibilities of the study site’s Clinical Trial Coordinator, and, finally, a detailed timeline of events that happen during the trial. Interesting to me, but likely perfect bedtime reading for most others.

Basics of Clinical Research

Clinical studies are research using human volunteers with the intent of adding to medical knowledge. The two main types are clinical trials (also called interventional studies) and observational studies. Clinical trials follow pre-clinical studies, which typical evaluate the intervention in one or more animal models. Before a clinical trial may begin, the investigators must apply as an Investigational New Drug (IND) from the Food and Drug Administration (FDA).

For the most part, most medical practices participate in interventional studies evaluating new medications being developed for FDA approval. Participants are recruited from the clinical practice and receive specific interventions according to the research protocol created by the investigators. This protocol is developed by the investigator, and provides a highly detailed framework for the conduct of the study. The protocol summarizes what we already know about the drug, explains the rationale for its use in the context of the disease being studied, poses specific research questions or objectives for the clinical trial, and specifies the types of patients that will be eligible for the study according to strict inclusion and exclusion eligibility criteria. The protocol also describes how many participants will be included, what the control group will be (i.e. what the intervention will be compared to), how long the study will run, the dose(es) that will be studied, what assessments will be conducted during the study, as well as what data will be collected and how those data will be analyzed.

There are three main phases of clinical trials, aptly named phase I, phase II, and phase III. Phase I trials are small, first-in-human studies evaluating the intervention in a small number of participants with a focus on safety. These often involve medication doses of varying strength, termed dose-escalation, to find the maximally-tolerated dose, and typically last several months. Approximately 70% of phase I studies move on to the next phase. Once the intervention has been shown to be safe in a small population, phase II trials involve a larger number of patients to look at side effects in a larger population, as well as evaluate initial efficacy. Phase II studies often involve several hundred participants and may run several months to two years. Approximately 33% of phase II studies move on to phase III. Phase III trials are the final step before applying for FDA approval. These studies involve a large number of participants, often hundreds to thousands, may involve two identical studies run in parallel, and typically run over the course of several years. Approximately 25-30% of studies pass phase III.

The clinical trial journey is fascinating, extremely regimented, and demanding. It is one that I truly enjoy, and I am proud to be able to serve as principal investigator for many trials at our site. If anyone is interested in learning more about our trials, how clinical trials work, or would like to see the rest of my handbook, just shoot me an email or call my cell phone.

Thanks again for reading. Please don’t ever hesitate to contact me.
Best wishes, and until next time,
Nik

Nikolas London, MD, FACS
415-341-5456 (cell)
nik.london@gmail.com

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Eye See written by Dr. Byron Y. Newman SLEEP RELATED QUESTIONS

The questions we ask during our history taking seem to have less and less to do with optometry, and more to do with health conditions and other health matters. The problem with history seems to be its length. Maybe adding one more question that helps our patients wouldn’t matter.

Physicians say that as many as one third of patients seen by primary care physicians have occasional sleep difficulties, and as many as 10% have chronic sleep problems. The consequences include fatigue, mood changes, and impaired daytime functioning, leading to absenteeism, healthcare utilization, and social disability.

Check out Dr. Newman’s website, www.thehumorfactory.com!!!

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by Karanjit Kooner, MD, PhD OCTA: Filling in New Pieces of the Glaucoma Puzzle

OCT angiography (OCTA) has been inspiring groundbreaking questions and providing new answers about retinal vascular disease, and it’s doing the same in glaucoma.

In my referral practice at the University of Texas Southwestern Medical Center, I obtain OCTA scans on all patients the first day I see them. Alongside the OCT-generated measurements I had already been assessing – retinal nerve fiber layer (RNFL) thickness, ganglion cell complex thickness and focal loss volume percentage, optic nerve rim and disc area – I have added the OCTA-generated measurement of vessel density. OCTA provides vessel density values for the macula as well as the optic disc and the radial peripapillary capillaries. It has been established that optic disc and peripapillary vascular abnormalities detected by OCTA are seen in eyes with glaucoma.1 It has also been shown that macular and peripapillary areas of reduced vessel density in eyes with glaucoma correlate with the location of visual field damage.2 Furthermore, as expertly outlined in a recent editorial from researchers at the University of California – San Diego Hamilton Glaucoma Center, some evidence suggests that vascular changes may occur prior to RNFL thickness changes, OCTA may provide information about disease progression that is additive to RNFL thickness, and OCTA may be a more reliable way to measure change in advanced disease.3

While many questions about OCTA’s ultimate role in glaucoma care still need to be answered with certainty,taking OCTA measurements into account improves my confidence in determining whether a patient needs immediate treatment and where to place him or her in my treatment protocols. For example, a highly myopic patient referred to me recently had normal IOP but suspicious-looking optic discs. Her visual field test results were nonspecific. OCT and OCTA, however, showed normal RNFL values and normal vessel density. Given this palette of information, I’m comfortable observing her rather than recommending medication, and the associated burden and cost, at this time.

With a different set of information, for example, a mild visual field defect but OCTA vessel density values indicating moderate damage (Figure 1), I’m likely to be more aggressive in categorizing the patient’s status and need for treatment. My current follow-up strategy for most patients, after baseline OCTA and visual field testing, includes alternating between OCTA and a visual field test every 6 months. For patients unable to perform a visual field test, I replace it with OCTA.

From a research perspective, my colleagues and I have been collecting normative data and analyzing OCTA vessel density measurements and OCT structural measurements in controls, glaucoma suspects and patients with mild, moderate and severe glaucoma. We’ve found that both OCT structural properties and OCTA vessel densities have been effective in determining glaucoma stage based on visual field damage. One aspect we’ll watch as we continue to collect and

analyze our data is the lack of vessel density change compared to controls that we’ve seen in some glaucoma suspects who exhibit change in OCT structural properties.

Working with OCTA has been an exciting addition to my practice, and I look forward to its expanding foothold in glaucoma care as it nudges the field toward a broader and deeper understanding of the disease and hence improved care and less burdensome testing for patients.

References

1. Jia Y, Morrison JC, Tokayer J, et al. Quantitative OCT angiography of optic nerve head blood flow. Biomed
   Opt Express. 2012;3(12):3127-3137.
2. Yarmohammadi A, Zangwill LM, Diniz-Filho A, et al. Peripapillary and macular vessel density in glaucoma patients with single-hemifield visual field defect. Ophthalmology. 2017;124(5):709-719.
3. Moghimi S, Weinreb RN. Potential clinical applications of optical coherence tomography angiography in glaucoma. J Curr Ophthalmol. 2018;30(3):191-193.
4. Yang A, Deng T, Noorani S, et al. Power of OCT-A (Optical Coherence Tomography Angiography) in Glaucoma. Presentation PO055, American Glaucoma Society Annual Meeting, March 2, 2018, New York, NY.

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CE Corner We are committed to helping you fulfill your CE requirements through our local meeting with the support of our sponsors!

Featured Annual Sponsors

See 2020 CE schedule

All 2020 CE meetings are located at the Handlery Hotel, 950 Hotel Circle North, San Diego, 92108.

2 Hour CE

• SDCOS Members: Free if reserved 4 days in advance*
• COA/AOA Members: $35
• Non-members: $130
• Registration 6:00 pm, lecture at 7 pm. Dinner included.

5 Hour CE

• SDCOS Members: $90 if reserved 4 days in advance*
• COA/AOA Members: $90*
• Non-members: $325
• Registration 7:00 am, lecture at 8 am. Breakfast included.

*Late registration and no-shows will result in an additional fee of $35 to cover the cost of food.*

Members need to make sure they sign out at the end of all CE meetings. Even though they receive a letter of Validation and COA is notified, if audited, the sign in and out sheet is the document that will be considered.

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Classifieds

For Sale: Zeiss Humphrey Field Analyzer with Glaucoma Progression 745i with an internal printer, stand, chair and owner’s manual. Perfect condition. $5,000. Available now. Contact  jhkmd5@gmail.com (05/20)

Full-time position (Monday through Friday) available for an Associate Optometrist with a strong medical background. Large group practice includes 3 Optometrists, 3 Ophthalmologists, full-sized optical, and state-of-the-art equipment in a brand new clinic in Downtown Chula Vista. Job duties include medical co-management of ocular pathology patients along with routine eye care. Requirements include prior residency or minimum 1-year experience in a medical eye care setting, current CA Licensure, and Professional Liability Insurance. Basic Spanish language skills preferred. Competitive Salary. If interested please email a cover letter and CV to Olga Ramirez at castillejoseyeinstitute@hotmail.com (05/20)

Practice for sale: Longtime established practice for sale in La Mesa. The seller wishes to retire and has set a very low purchase price to facilitate an immediate sale. Don’t miss out on this great opportunity to own your own practice.  Contact Dr. Levy 619-743-1442 (06/20)

 

Dr. John Fitzpatrick, the Society Optometrist Relations Liaison, offers a unique service to the San Diego Optometric community. Several lists are kept on file for doctors seeking the following, or any combination: • full-time work • part-time work • fill-in work • purchase a practice • sell a practice • partner in a practice. There is no charge for this service. To put your name on the list, please contact Dr. John Fitzpatrick at jpfod@aol.com

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Volunteer Corner

Monarch School Screening

Contact Dr. Bob Meisel for more information at rmeisel47@gmail.com ; www.monarchschools.org

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Lion’s Optometric Vision Clinic

ALL DOCTORS WILL RECEIVE A FREE 5 HOUR CE FOR EVERY SHIFT FOR WHICH THEY VOLUNTEER

VOLUNTEER DOCTORS needed for flexible shifts throughout the year. 9-1:00 pm. Monday -Friday 1805 Upas St San Diego, CA 92103.  Can’t volunteer at the clinic? See patients in your office. Call 619-298-5273.

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DONATE GLASSES
Please bring to a CE meeting or contact the society office at 619-663-8439 for arrangements to pick up.

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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 the society office at 619-663-8439 or email sdcos@sdcos.org

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SDCOS Announcements

Gerald (Jerry) Easton died on Coronado on Feb. 2, 2020.

He was born April 26, 1931 in Long Beach, California, and was the only child of Aaron and Sarah Easton. He attended Polytechnic High School in Long Beach. He graduated from Long Beach City College in 1951 and Los Angeles College of Optometry (LACO) in 1954.

Jerry married Roselyn Marie (Rowland) Easton in 1956 and they settled in Coronado where he established his optometric practice.

He served in numerous positions in his professional field, including president of the San Diego Optometric Association (1960-1961), president of the California Optometric Association (1974-1975), and as president of the American Optometric Association in 1985.

As president of the California Optometric Public Vision League, he presented a visual perceptual program to the Coronado School District which was implemented and titled the “Coronado Project.” It was funded by the Department of Education and provided special therapy training to students identified as having vision defects, such as dyslexia.

His participation in various community organizations included: president of the Crown Club; president of the Coronado School Board (1968-69); president of Coronado Rotary (1978); Rotarian of the Year (1992); Coronado Hospital Board of Directors (1986-1987); chairman of the Hospital Board (1988-1990); and the Coronado Roundtable of which he was one of the founding members.

In 1972, Jerry and Dr. Joseph Drazek, a local dentist, created a partnership and build their professional office building located at 1010 Eighth Street where they both had their practices. After providing optometric service in Coronado for 47 years, he retired and sold his practice to Dr. Stephen Moffett.

Jerry enjoyed community service, reading, golf and travel.

He is preceded in death by his wife Roselyn. He is survived by his sons Jeffrey Easton and Christopher (Carla) Easton; his grandsons Alexander Easton and Casey Easton; and great-granddaughter Meadow Easton.

Dr. Richard Rex Memorial Fund

Any SDCOS member may apply for up to $100 towards material costs for uninsured patients who receive free exams from their optometrist. Tax-deductible donations are also accepted for this fund. If you have any questions about this fund or would like to request an application, please contact Nancy-Jo at 619-663-8439 or email Dr. Marcelline Ciuffreda at marcelline11@hotmail.com.

Upcoming Events

• Click here for most recent SDCOS Board Meeting Minutes
• Click here for the 2020 CE schedule!
• Click here for COA membership benefits!

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Welcome, new members!!

• • Tiffany Turner
  • Fabian Luna
  • Karen Love
  • Kelly Keane
  • Kristin Difuntorum

Please update your information on www.eyehelp.org