Advanced clinical skills workshops, disease grand rounds, leadership skills, new friends, new places… all of this, and more, was at the American Academy of Optometry in Boston, Massachusetts during October. When local Optometrist Nicole Carnt asked a couple of Aussie optoms why they fly 20 hours or so to attend this continuing education event, she gained an interesting perspective on its education program and associated activities.
Example of lipid deposition on a silicone hydrogel contact lens
I am primarily a researcher these days, but one of my goals is translational research, where findings can be incorporated into clinical practice. Many international conferences are targeted at research but the “Academy” is not a research meeting. It is an education meeting that covers every sphere of practice, and offers the opportunity to learn about the latest technologies and research findings as well as how these might inform and change future practice.
The session examined the effects of high-energy blasts in a young, otherwise fit group of Afghanistan and Iraq veterans
That’s why I love the Academy… but why does the handful of Aussie optoms I see there every year, dish out the cash and time to go along as well?
Optometrist William Trinth said he values the Academy for the clinical workshops, which are hands on and cover a wide range of topics – ranging from scleral indentation to clinical sampling techniques in practice.
He has attended the leadership courses over consecutive years – three half-day sessions facilitated by some of the top clinicians and educators across the U.S. The sessions cover change leadership, evolving your practice to the next phase and getting the best out of staff. Delegates work through real world situations and gain insight into how it’s done in other parts of the world.
This year I also attended and was impressed with the integration of child health services in the U.S. system. Optometry is a central figure, in contact with the school, paediatrician, occupational therapy and GP. That may sound like too much work, but not when the system is set up and the patient is set to get better care.
One facilitator recounted how when optometry’s scope of practice was threatened in her State, the student body rallied and visited cabinet to secure their futures. When a new graduate asked, “Why didn’t you call on the network of student bodies”, the first thing the cabinet member asked was, “Are you in my constituency?” Lessons for other U.S. States and maybe for us down the line.
Fellow Australian optometrist Margaret Knapman said she is motivated to attend the Academy by the chance to travel, see a new city, meet up with friends and hear the latest about products and practice. She remarked on the 12 streams of events that cover all aspects of vision care. Additionally, she said, the Academy provides a valuable chance to meet international, as well as U.S. optometrists and find out about different forms of practice, such as military service.
This year one of the Academy highlights was the Plenary Session: Today’s Research, Tomorrow’s Practice, Mild Traumatic Brain Injury (mTBI). The session examined the effects of high-energy blasts in a young, otherwise fit group of Afghanistan and Iraq veterans, and highlighted the need to understand the causes and impacts of this increasing impairment. Douglas H. Smith MD, Director, Center for Brain Injury and Repair, University of Pennsylvania, described how mTBI or “concussion” affected over 1.4 million Americans per year. Studies they have done, in vitro and in parallel with investigations in swine and humans, have shown that the torsional stress on axons results in damage and swelling that is related to a progressive degeneration of neurons.
The Plenary Session was followed by a lecture in which William Milberg and Regina McGlinchey from the Harvard Medical School detailed the overlap between psychological impairment and the cognitive damage of mTBI. They reported on how brain impairment impeded the resilience needed to recover from Post-Traumatic Stress Disorder. This is further complicated by personality, institutional, social, medical and genetic factors. They said that repeated trauma often shows different effects in the form of a Chronic Traumatic Encephalopathy.
How to Sessions
The many practical workshops offered each year are a major drawcard of this meeting. A two hour session gives you that burst of experience and time to trial different techniques and technologies. In the exhibition hall, you are then better able to make choices about the instrumentation you might like to introduce into your practice – and you’re not such a novice when you try them out on your own patients. The workshops cover diverse topics such as scleral indentation and gonioscopy, the latest imaging technologies, vision training and specialised contact lens fitting, including scleral lenses.
I was particularly interested in the in-office diagnostic procedure workshop this year and was amazed at the level of investigations that are conducted in the US. At Station One, the Erythrocyte Sedimentation Rate (ESR) was demonstrated with whole blood samples. The ESR is elevated in cases of acute inflammation and infection and is indicated when there are signs and symptoms of giant cell arteritis, recalcitrant inflammation of unknown etiology and autoimmune disorders. An alternative or supplementary test is the C-reactive protein which is more sensitive and rises more quickly in inflammation but returns to baseline quicker than the ESR.
Rapid Pathogen Screening (RPS) and conjunctival swabbing was another station. The RPS is an inexpensive and useful tool to diagnose adenovirus in suspected cases, particularly in non-verbal patients. The demonstrators remarked that in the future, such tools may be available to diagnose Chlamydia conjunctivitis, Herpes simplex keratitis (HSK, “the great masquerader”) and allergies. With anecdotal reports of increased prevalence of Chlamydia conjunctivitis, and with the possibility that Acanthamoeba keratitis in contact lens wearers appears as a neural keratitis which may mimic HSK (thought to be related to the corneal nerves providing the path of least resistance), these options would be certainly welcome.
Of course, traditional conjunctival swabbing is still possible, but media needs to be properly maintained and in the case of Chlamydia needs to be specialised for just that purpose.
Blood glucose and Glycosylated Haemoglobin (Hb A1c) is performed with the finger prick test and a variety of commercial instruments. The tests are useful for suspect diabetes, poorly controlled diabetes and diabetic crisis. Of course, ocular indications are retinal haemorrhages and refractive shifts.
Another test for suspected diabetes is Macroscopic urinalysis (or the dipstick test) as ketones are elevated in diabetes. As well as pregnancy testing, ocular signs such as refractive shifts and suspected toxic amblyopia can be investigated more thoroughly in optometric practice.
With increasing numbers of therapeutically endorsed optometrists, it will be interesting to see whether these tests become standard office procedures in the future.
The Academy is very good at rewarding outstanding service to the profession. Among several awards presented each year is the Charles F. Prentice Medal, which this year went to Dennis Levi, Dean of the School of Optometry, University of California, Berkeley. Dennis’ research is in the area of visual development associated with anisometropia and childhood strabismus. He presented a fascinating lecture on the plasticity of the visual system and perceptual learning. In his lecture, Dennis detailed how they started training adult amblyopes using vernier acuity, which is 10 times better than, but linked to, optotype acuity. Over 5,000 trials they found an improvement of 3.5 times in vernier acuity, which translated to 1.7 times better Snellen acuity. They found that some amblyopes learned to use the information more efficiently but the most important factor was that they decreased the high levels of internal noise associated with the condition. The problems however, included poor transference to other tasks and boredom.
Taking a buccal (Cheek) swab for DNA collection
Dennis and his colleagues then turned to video games, as those that play action games tend to be better at other tasks as well. They patched the good eye and used action games with aiming tasks, sometimes using low contrast. Acuity improved 30 per cent, and although one eye was patched, there was some improvement in stereoacuity. The next trials are commencing, this time without the patch, and using different contrast and targets. Maybe all those video games our kids are playing are not that bad after all!
UNSW Mark Willcox Awarded
The Max Shapero Memorial Award for significant contributions to the cornea and contact lens field went to Mark Willcox from the Brien Holden Vision Institute and School of Optometry and Vision Science, UNSW. Mark’s major contributions have been in the fields of microbiology, immunology, tear film biochemistry and novel antimicrobials. Having worked with Mark for over 10 years, this is a well-deserved honour – he is a supreme scientist who has bridged the gap between clinical and laboratory science and has developed research collaborations across the world.
Mark’s talk covered work on contact lens case contamination by some of his PhD student’s, Jaya Dantam and Yvonne Wu. Jaya has found that MicroBlock cases (CIBA Vision, Atlanta, GA) are effective in combating gram-negative organisms, while the i-clean case (Sauflon Pharmaceuticals Ltd., London, U.K) is effective against Staphylococcus aureus.1
This finding could be effectively applied to different patient profiles, for example, if a patient has lid contamination or a history of contact lens peripheral ulcer (CLPU), which is associated with Staphylococcal aureus, the i-clean case might be useful. If they suffer from Contact Lens Acute Red Eye (CLARE) or generalised infiltrative keratitis, that may be more likely associated with gram-negatives, the MicroBlock case maybe more effective. Yvonne showed that a case cleaning protocol of rub, rinse with solution, tissue wipe and air dry upside down, has proven to reduce microbial load and biofilm.
Mark also talked on his ground breaking work on antimicrobial agents, specifically furanone’s,2 the sea’s own natural algae defence and a novel antimicrobial peptide material, melinine,3 both of which show great promise.
Carol Lakkis, another eminent Australian researcher, now working with Vistakon in the US, showed good performance of silver salt-infused silicone hydrogel contact lenses.4 Silver is used as an antimicrobial agent in many devices. We expect it will not be long before we see antimicrobial lenses in addition to cases on the market.
A symposium was held on “OMICS” – the challenging field of what happens when DNA is converted into messengers in the body. Although all cells have the same DNA sequence, they can express a variety of proteins, sugars and lipids, at different times and in different quantities. It underpins the importance of validating genetic data in the disease or degenerated specific tissue.
It was at the American Academy last year in San Francisco, that I came across an advertising stand for genetic testing for age related macular degeneration. An optometrist or ophthalmologist can order a buccal (cheek) swab that a patient with early AMD can use to collect DNA. This DNA swab is sent off to a laboratory and delivers a report giving a risk score for early disease progressing to geographic atrophy and choroidal neovascular AMD, based on four genetic factors and smoking status. This service attracts a Medicare fee. This year two companies offered this service. The second company does not give a risk score, rather it gives a report to the practitioner to interpret and deliver the findings to the patient. It is estimated that between 46 – 71 per cent of the variation in severity of disease can be accounted for by genetic factors. The way we will practice over the next 10 years or so is set to be very different.
The Ocular Nutrition Society held their Annual Fall Education Symposium at the conference. The Keynote Speaker was Johanna Seddon, Director of the Ophthalmic Epidemiology and Genetics Service, New England Eye Centre, Tufts University. Information was presented on the historical evolution of information on diet and supplements and effect on age related macular degeneration (AMD). There is now good evidence that oral carotenoids, lutein and zeaxanthin reduce the risk of AMD progression. These lipid-based antioxidants are the primary components of macular pigment. It is this pigment that contributes to the protection from oxidative stress from second shortest visible wavelength, blue light. Furthermore, supplementation of these carotenoids decreases disability and discomfort due to glare, improves colour contrast and shortens the visual processing time and recovery.
As we are aware, omega three, a long chain polyunsaturated fatty acid found in oily fish and some nuts, is beneficial in cardiovascular5 and inflammatory joint disease6 as well as brain functioning7 and bipolar disorder.8 A higher ratio of dietary omega three to omega six lowers the risk of AMD but there is no definite link with glaucoma. The ideal ratio of omega three to six is around 1:4, although western diets typically have ratios of 1: 25. Dietary oily fish improves symptoms in dry eye disease, reported Isabelle Jalbert, Senior Lecturer at the School of Optometry and Vision Science, UNSW. Additional oral supplements such as fish and evening primrose oil may also be beneficial but are still under investigation.
Dry Eye Findings
The major cause of evaporative dry eye is now confirmed as meibomian gland dysfunction (MGD).9 Omega three decreases inflammation in dry eye and clears and thins meibum secretions, which may be a key mechanism in reducing discomfort. Heat and pressure to express glands are still a mainstay of MGD treatment. Meibomian gland drop out is a new technique for assessing meibomian function. Meibomian glands are viewed on lid eversion with transilluminator (meibography). Patent glands are seen as white lines extending the entire tarsal plate. Glands that do not reach the lid margin are termed as dropped out. The number of glands dropped out correlates with symptoms in MGD.10
High osmolarity of tears is a recent finding associated with dry eye symptoms.11 David Sullivan, president of the Tear Film and Ocular Surface Society and Senior Scientist at the Schepens Eye Institute, reported that lowering the osmolarity of tears correlates with decreased dry eye symptoms and is thought to be a new way to measure the effectiveness of dry eye therapy. Commercial non-invasive instruments are now available for use in clinical settings. High osmolarity is also associated with contact lens discomfort and may be a source of discomfort in chronic preservative use in glaucoma patients.
Soft and RGP Design Multifocal Lenses
Thomas Quinn, a private practitioner with a wealth of experience in fitting soft and RGP design multifocal lenses, gave an excellent overview of the options available and clinical pearls on how to approach fitting these lenses. He described the old paradigm of pushing the plus over the years and nudging up the non-dominant eye to monovision, as now surpassed with the new lens designs and adjusted expectations. In recent studies, over 70 per cent of wearers prefer multifocals to monovision.12 He recommends fitting early and following fitting guides. These fitting guides have been clinically tweaked to give the best outcomes for a range of prescriptions and to use this expertise in practice.
Thomas said emerging presbyopes tend to have more active lifestyles than in the past, and require a range of options, including spectacles and contact lenses aimed at particular lifestyle tasks. Additionally, he emphasised the importance of managing expectations – one device does not necessarily do all and light is a multifocal contact lens wearer’s best friend at near. Communication skills are key, said Thomas, who uses a marketing tool widely adapted across a range of products called the “sandwich approach”. With this method, “meat” in a sandwich is layered between two positive statements.
To assess performance, he sends patients out of the consulting room, into the real world, and encourages them to report back by posing open-ended questions and showing a considerate, non-confrontational approach. He encourages the wearer to remember the two eyes are working together, that they will experience a process of adaptation and not to forget that extra light for near.
Other CL Highlights
Alex Hui, from the University of Waterloo, Canada, presented a paper on molecular imprinting a contact lens material with different acetic acid – ciprofloxacin concentrations – to determine which slowed and controlled the release of the drug.13
He found that the lower concentrations could release therapeutic doses of ciprofloxacin for 14 days compared to a control lens that discharged the load in one day. This is a very exciting area of research that has wide-reaching applications across many disease platforms, especially in conditions such as glaucoma, where compliance is so poor.
Negar Omali Babaei, from the Brien Holden Vision Institute, presented interesting research on phospholipid attachment to contact lenses and the ability of the phospholipid to induce bacterial growth.14 She found that on two types of test lenses which were worn, (PureVision – Bausch & Lomb, Rochester, NY and Acuvue Oasys – Vistakon, Jacksonville, FL), many phospholipid species were ad/absorbed. However they did not facilitate the growth or lens adhesion of three different bacterial strains of Pseudomonas aerugenosa and Staphylococcus aureus, the most prevalent pathogens in contact lens related microbial keratitis.15-17 This indicates that phospholipid deposition on contact lenses is not a factor in microbially driven adverse events.
Paediatric Eye Disease
An interesting session on paediatric eye disease included a presentation and discussion on glaucoma, from an optometrist, Joseph Sowka, Professor of Optometry Nova Southeastern University College of Optometry, Chief of The Advanced Care Service and Director of the Glaucoma Service at the College’s Eye Institute.
Congenital glaucoma arises in utero and is due to malformation of the trabecular meshwork. Infantile glaucoma develops later but is due to a similar cause. The other group of glaucoma patients in children is juvenile open angle glaucoma, which develops from three years of age to early adulthood. It was stressed that for congenital glaucoma, surgical therapy was always the primary treatment. For juvenile Open Angle Glaucoma (OAG), medical and surgical treatment was on a case-by case basis. Prostaglandin analogues, the mainstay treatment in adult OAG, are safe in children but not effective at lowering intraocular pressure (IOP). Topical carbonic anhydrase inhibitors are the mainstay of medical therapy in children. Brimonodine, an alpha 2 agonist, lowers IOP effectively but is contraindicated as it potentially crosses the blood brain barrier and shows an unacceptable level of adverse events.
Next year, the American Academy of Optometry will be hosted in Phoenix, Arizona, 24 to 27 October. I hope to see a few more familiar faces there. Go to www.aaopt.org/meetings
Ms. Nicole Carnt is an optometrist and a PhD candidate at the Brien Holden Vision Institute and School of Optometry and Vision Science, University of New South Wales. She is keenly involved in contact lens and translational research.
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