Ocular Surface Wellness in My Practice with Dr. Jack Schaeffer

[AdminWolf]

In many non-eye care medical specialties wellness is a pillar of practice success -- think of dentists who see patients for checkups every 6 months.

For optometrists, helping patients maintain healthy eyes can be a source of satisfaction for the doctor and success for the practice.

Because maintaining a healthy ocular surface can help patients look, feel, and see their best, ocular surface wellness is a natural addition for practices that fit contact lenses or treat ocular surface conditions.

In this webinar, Jack Schaeffer, OD, president and CEO of Schaeffer Eye Center, a 15-doctor optometric practice with 13 locations in Alabama, discusses implementing ocular surface wellness in his practice.

If you've got any questions for Jack, please feel free to post them in the thread below.

Enjoy!
Adam

 

[AdminWolf]

Thanks again to Jack for taking the time -- it is sort of amazing that he's getting an operation as large as his to change their workflow around these concepts.

 

[Kandi S. Moller]

I am listening to this now, thanks Adam for posting it.
I have a question: at about 7:20 he states that kids with the proper rx have less of a chance of progressing than those that are undercorrected. Can someone find this study or something I can give to parents to show them I am not making this up?

 

[Greg Gemoules]

Kandi, this is THE only study I know of on the subject.

http://www.sciencedirect.com/science/article/pii/S0042698902002584

Abstract
The effect of myopic defocus on myopia progression was assessed in a two-year prospective study on 94 myopes aged 9{14 years, randomly allocated to an undercorrected group or a fully corrected control group. The 47 experimental subjects were blurred by approximately +0.75 D (blurring VA to 6/12), while the controls were fully corrected. Undercorrection produced more rapid myopia progression and axial elongation (ANOVA, F(1,374)=14.32, p<0.01). Contrary to animal studies, myopic defocus speeds up myopia development in already myopic humans. Myopia could be caused by a failure to detect the direction of defocus rather than by a mechanism exhibiting a zero-point error.

 

[Kandi S. Moller]

So a 6-year old with no complaints but is -050 does need to get glasses. Huh. Before I would have said don't worry about it.

 

[Tom Vaxmonsky OD]

Kandi, this is THE only study I know of on the subject.

http://www.sciencedirect.com/science/article/pii/S0042698902002584

Abstract
The effect of myopic defocus on myopia progression was assessed in a two-year prospective study on 94 myopes aged 9{14 years, randomly allocated to an undercorrected group or a fully corrected control group. The 47 experimental subjects were blurred by approximately +0.75 D (blurring VA to 6/12), while the controls were fully corrected. Undercorrection produced more rapid myopia progression and axial elongation (ANOVA, F(1,374)=14.32, p<0.01). Contrary to animal studies, myopic defocus speeds up myopia development in already myopic humans. Myopia could be caused by a failure to detect the direction of defocus rather than by a mechanism exhibiting a zero-point error.

Thanks for this, I never saw the article above, but have observed this clinically. Often over-minused patients who tolerate the Rx have progressed less or stabilized over the time between exams in my 20+ years of practice. It is an opinion I often offer when patients are "asking" for their nearsighted Rx to NOT be too strong.

Some here might see it as a reason to justify an Rx change that others might judge as insignificant...???

 

[Greg Gemoules]

But

Thanks for this, I never saw the article above, but have observed this clinically. Often over-minused patients who tolerate the Rx have progressed less or stabilized over the time between exams in my 20+ years of practice. It is an opinion I often offer when patients are "asking" for their nearsighted Rx to NOT be too strong.

Some here might see it as a reason to justify an Rx change that others might judge as insignificant...???

It would be nice if somebody would try to replicate this study.

 

[Charles A McBride]

But


It would be nice if somebody would try to replicate this study.

Maybe you could post the entire paper and we could pick through it here once and for all. It's been picked through before, exhaustively, and all who have done so (that I've read) have reached the conclusion that it was a poorly designed study and that there is no evidence that under correction increases the progression of myopia.

I know none of us has the time, but we really ought to have an ODwire section where we put an end to (or support!) these zombie ideas for future graduates. If that study is a crock, and it probably is, our colleagues have no business quoting it to the public, especially because it is potentially self-serving. -Charlie

 

[AdminWolf]

Maybe you could post the entire paper and we could pick through it here once and for all. It's been picked through before, exhaustively, and all who have done so (that I've read) have reached the conclusion that it was a poorly designed study and that there is no evidence that under correction increases the progression of myopia.

I know none of us has the time, but we really ought to have an ODwire section where we put an end to (or support!) these zombie ideas for future graduates. If that study is a crock, and it probably is, our colleagues have no business quoting it to the public, especially because it is potentially self-serving. -Charlie

I suggest a new forum (or sub-forum of the clinical section) -- "Fact or Fiction".

You posit a topic, and people can come up with supporting evidence (or evidence that the theory is -- as Tom Magliozzi would say -- BOH-gus!)

 

[Greg Gemoules]

Maybe you could post the entire paper and we could pick through it here once and for all. It's been picked through before, exhaustively, and all who have done so (that I've read) have reached the conclusion that it was a poorly designed study and that there is no evidence that under correction increases the progression of myopia.

I know none of us has the time, but we really ought to have an ODwire section where we put an end to (or support!) these zombie ideas for future graduates. If that study is a crock, and it probably is, our colleagues have no business quoting it to the public, especially because it is potentially self-serving. -Charlie

Somebody asked a question and I led them to the answer. Professionals don't need to be spoon fed. If somebody has an issue with the study (you), then go ahead and post the entire study. This is an old issue with me and I am so over it.

 

[Charles A McBride]

Somebody asked a question and I led them to the answer. Professionals don't need to be spoon fed. If somebody has an issue with the study (you), then go ahead and post the entire study. This is an old issue with me and I am so over it.

I missed the leading them to the answer part.

 

[Greg Gemoules]

Kandi Moller wanted to know the study behind Jack Schaeffer's remark. I knew about the study and so posted a link to it. I am neither endorsing or arguing against the findings. Every few years there arises another pet theory on myopia. What I am sure of is that it has a genetic basis, is influenced by environment. I am also sure that the retina responds to localized defocus with scleral collagen remodeling, and that broad spectrum anti-muscarinic agents can stop or slow down this process.

I think the quoted study is interesting, but I would like to see another study to support those findings. It does not inform or direct my prescribing habits.

 

[Charles A McBride]

Kandi Moller wanted to know the study behind Jack Schaeffer's remark. I knew about the study and so posted a link to it. I am neither endorsing or arguing against the findings. Every few years there arises another pet theory on myopia. What I am sure of is that it has a genetic basis, is influenced by environment. I am also sure that the retina responds to localized defocus with scleral collagen remodeling, and that broad spectrum anti-muscarinic agents can stop or slow down this process.

I think the quoted study is interesting, but I would like to see another study to support those findings. It does not inform or direct my prescribing habits.

Roger that.

 

[Kandi S. Moller]

So who would put that -050 6yo in glasses?

 

[Tom Vaxmonsky OD]

So who would put that -050 6yo in glasses?

For me depends on more info but most often see back in 6 months and Rx if is any progression....

or consider 0.01% atropine?

 

[Michael I. Davis]

For me depends on more info but most often see back in 6 months and Rx if is any progression....

or consider 0.01% atropine?

I would love to do that, but I don't think we can do that in Maryland. Am I wrong?

 

[Tom Vaxmonsky OD]

I would love to do that, but I don't think we can do that in Maryland. Am I wrong?

Maybe then diluted Homatropine or cyclopentolate?

 

[Dr Jack Schaeffer]

To ALL
As we all know there are studies that you can use to back up almost anything you desire.
As far as the Myopia Control and Evidence based medicine , there are three individuals who are leading most of the work.
Dr Earl Smith , Dr Brien Holden, and Dr Jeff waline
I trust each one of these professors which is very important when you are developing a preventive approach to Optometry. This whole prevention concept is new and if you wait for too much validation what is happening to your patients?

As far as the patient with -.50
DO SOMETHING!
6 month reevaluations
CRT
Distance centered Bifocal contact lenses
Atropine therapy

even a possible progressive RX depending on accommadtion and Phorias

I am fortunate to have a pediatirc OD in our practice so when we get into progressvie Glasses or atropine therapy, I refer to him for a comprehensive BV evaluation to determine feasibility of results

 

[Charles A McBride]

To ALL
As we all know there are studies that you can use to back up almost anything you desire.
As far as the Myopia Control and Evidence based medicine , there are three individuals who are leading most of the work.
Dr Earl Smith , Dr Brien Holden, and Dr Jeff waline
I trust each one of these professors which is very important when you are developing a preventive approach to Optometry. This whole prevention concept is new and if you wait for too much validation what is happening to your patients?

As far as the patient with -.50
DO SOMETHING!
6 month reevaluations
CRT
Distance centered Bifocal contact lenses
Atropine therapy

even a possible progressive RX depending on accommadtion and Phorias

I am fortunate to have a pediatirc OD in our practice so when we get into progressvie Glasses or atropine therapy, I refer to him for a comprehensive BV evaluation to determine feasibility of results

All those things... except encouraging an Rx because of the boloney that undercorrection will spur progression.

-Charlie

Charles McBride, OD
Beaverton, OR

 

[Greg Gemoules]

All those things... except encouraging an Rx because of the boloney that undercorrection will spur progression.

-Charlie

Charles McBride, OD
Beaverton, OR

Charlie, why do you call the study "boloney"?

 

[Rahul M. Gupta]

Maybe you could post the entire paper and we could pick through it here once and for all. It's been picked through before, exhaustively, and all who have done so (that I've read) have reached the conclusion that it was a poorly designed study and that there is no evidence that under correction increases the progression of myopia.

I know none of us has the time, but we really ought to have an ODwire section where we put an end to (or support!) these zombie ideas for future graduates. If that study is a crock, and it probably is, our colleagues have no business quoting it to the public, especially because it is potentially self-serving. -Charlie

I suggest a new forum (or sub-forum of the clinical section) -- "Fact or Fiction".

You posit a topic, and people can come up with supporting evidence (or evidence that the theory is -- as Tom Magliozzi would say -- BOH-gus!)

I think this actually is an excellent suggestion. I'm not sure exactly how it would work, but a "Journal Club" section in ODWire.org might be great.

 

[Charles A McBride]

Charlie, why do you call the study "boloney"?

It would have been more reasonable to have used the term suspect as opposed to "boloney." That said...

http://wildsoetlab.berkeley.edu/index.php?title=Controlling_Myopia_Progression_-_A_Confusing_Story

It is contrary to animal studies.

There are complicated variables that aren't accounted for. For example, the under corrected children may have chosen to spend less time outdoors because of blurry vision.

A 2006 six study looking at the same thing found no statistical difference. (Adler & Millodot)

The FUMET study is another designed to investigate under-correction vs. full correction, like the O'Leary study. Should be out in another year or two. -Charlie

 

[Charles A McBride]

I think this actually is an excellent suggestion. I'm not sure exactly how it would work, but a "Journal Club" section in ODWire.org might be great.

Great! Can we start by differentiating basal laminar drusen from reticular pseudo-drusen?

 

[Greg Gemoules]

It would have been more reasonable to have used the term suspect as opposed to "boloney." That said...

http://wildsoetlab.berkeley.edu/index.php?title=Controlling_Myopia_Progression_-_A_Confusing_Story

It is contrary to animal studies.

There are complicated variables that aren't accounted for. For example, the under corrected children may have chosen to spend less time outdoors because of blurry vision.

A 2006 six study looking at the same thing found no statistical difference. (Adler & Millodot)

The FUMET study is another designed to investigate under-correction vs. full correction, like the O'Leary study. Should be out in another year or two. -Charlie

I completely agree with Wildsoet's comments about the confusing world of myopia control. Is she still relevant? The COMET study shows no effect of bifocals. Only myopes with nearpoint esophoria benefit.

I agree that with so much controversy, another study is in order to see if Chung et. al.'s results can be duplicated, which is what I said earlier.

 

[Tom Vaxmonsky OD]

I would love to do that, but I don't think we can do that in Maryland. Am I wrong?

Or maybe you could if you had a convenient working situation with a physician. If you are really looking to do myopia control in total, I would think a Maryland OD should be offering that.

 

[Rahul M. Gupta]

Great! Can we start by differentiating basal laminar drusen from reticular pseudo-drusen?

To my recollection, basal laminar drusen are what we think of when we conceive traditional drusen of senile macular degeneration. They are lipoprotein and cellular-debris accumulations beneath the R.P.E., within the inner layers of Bruch's membrane. (Basal linear deposits are similar, but are more external within Bruch's, nearer to the choroid.)

Reticular pseudodrusen, on the other hand, are collections of debris in the sub-retinal space, internal to the R.P.E. Fundoscopically, I see the deposits in an interlacing, networked pattern — thus the adjective, "reticular."

 

[Charles A McBride]

To my recollection, basal laminar drusen are what we think of when we conceive traditional drusen of senile macular degeneration. They are lipoprotein and cellular-debris accumulations beneath the R.P.E., within the inner layers of Bruch's membrane. (Basal linear deposits are similar, but are more external within Bruch's, nearer to the choroid.)

Reticular pseudodrusen, on the other hand, are collections of debris in the sub-retinal space, internal to the R.P.E. Fundoscopically, I see the deposits in an interlacing, networked pattern — thus the adjective, "reticular."

What do you call pseudo drusen without the reticular pattern? Pseudo drusen? And what are the risks of vision loss with both reticular and non-reticular pseudo drusen compared to traditional drusen?

BTW, how'd you hook up your typewriter?

 

[Rahul M. Gupta]

What do you call pseudo drusen without the reticular pattern? Pseudo drusen? And what are the risks of vision loss with both reticular and non-reticular pseudo drusen compared to traditional drusen?

BTW, how'd you hook up your typewriter?

Yes, if I observe pseudodrusen without reticular pattern, I'll just name them pseudodrusen. That said, in this case, fundoscopically, I find these to look like typical (usually small) drusen, and will cite them as such in my note. It is on O.C.T. that I find they are in the sub-retinal space, thus I will describe them this way ("pseudodrusen") in my imaging interpretation.

From what I've read, the risk of progression to neovascular macular degeneration with the presence of reticular pseudodrusen actually is quite high (I do not recall a figure). An interesting question is whether patients with such findings ought to be placed on A.R.E.D.S.-2 supplementation, as, although pseudodrusen were part of the grading system in these studies, it seems all the discussions in the reports center on typical drusen (and don't even make much direct mention of R.P.E. abnormalities in isolation).

P.S.: My entire computer system consists of an elaborate contraption involving my manual typewriter, a Tesla coil, and a rubber-band from a stalk of broccoli.