How to Qualify For CE Credit | Frequently Asked CE Questions

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Presbyopia Drops, Pt 2 (3-Part Series)

👉 Episode Sponsor
Thank you to Oasis Pharmaceuticals — Olosis™ Presbyopia Drops. Olosis helps improve near vision (20/40 or better) by Day 15 without sacrificing distance vision, offering a convenient option for today’s presbyopic patients. Learn more & start prescribing: https://qlosiecp.com/resources#sign-up

Dr. Chris Lopez and Dr. Janelle Davison discuss real-world presbyopia management with miotic drops. They cover patient-friendly explanations, current options, side-effect profiles, retinal safety, ocular surface priorities, workflow, and case-based selection.

Learning Objectives

  • Explain how miotic presbyopia drops (pupil miosis → pinhole effect) improve near vision without restoring accommodation.

  • Compare currently discussed options on concentration, comfort/tolerability, and common adverse effects.

  • Identify who is and isn’t a good patient candidate.

  • Implement a clinic workflow (screening, counseling, retinal evaluation) that aligns with ocular surface stewardship and practice growth.

Framing Presbyopia for Patients

  • Prevalence: ~2B affected globally; 120M+ in the U.S.

  • Psychologic impact: “midlife rite of passage.” Keep explanations simple.

  • Patient analogy: Old-school camera zoom. The lens no longer “zooms” well with age.

Why Patients Want Options

  • Glasses: readers are convenient but cumbersome; progressives not everyone’s cosmetic favorite.

  • Contact lenses: monovision/multifocals can work, but compromise/comfort issues.

  • Younger presbyopes seek “non-aging” solutions; symptoms also include eye strain/fatigue and productivity loss.

Topical Therapeutics on the Market

  • Vuity (pilocarpine 1.25%): miosis → near boost for a few hours. Adverse events often include headache/brow ache and dim-lighting issues.

  • Qlosi (pilocarpine 0.4%): lower concentration. Preservative-free with dual lubricants. Once or twice daily flexibility.

  • Vizz (aceclidine 1.44%): more pupil-selective with less ciliary spasm than pilocarpine. May be better suitable for older presbyopes.

Class Mechanism & Safety

  • Mechanism: miosis → pinhole effect → ↑ depth of field (does not restore accommodation).

  • Class warnings: rare retinal tears/breaks/detachment risk with miotics.

    • Selection and screening: prefer healthy retinas; DFE for anyone considered.

    • Avoid high myopes; rely on DFE.

    • Counsel patients to return ASAP if noticing flashes/floaters.

Ocular Surface & Vehicle Priorities

  • For dry eye practices, prefer preservative-free and near-neutral pH vehicles. Dual lubricants support comfort/tolerability.

Dosing & Neuroadaptation

  • BID for the first week, 2 hours apart, to help neuroadaptation; then tailor to QD or PRN use.

Clinic Integration & Practice Management

  • Front-end screening: add a questionnaire (“interested in reducing readers?”), virtual forms, and door/back-of-room signage to prompt conversations.

  • Staff training: tee up interest. Consider offering an opt-in “anti-aging” package with presbyopia screening.

  • Visit model: boutique flow. Integrate into comprehensive exam.

  • Positioning: it’s an “and,” not an “or.” Prescribe glasses/CLs plus drops to expand flexibility—not to cannibalize optical sales.

Case Illustrations

  • Case 1 — 48M, low myope (−2.00 with 0.75 cyl), healthy exam

    • Goal: avoid progressives; wants daytime flexibility.

  • Case 2 — 51F, low hyperope (+0.25 / +0.75, +2.00 add), healthy exam

    • Plan: progressives for evenings/low light + presbyopia drop.

  • Case 3 — 60F, low hyperope, healthy exam

    • Plan: presbyopia drop; follow-up pending.

Take-Home

  • Select carefully, examine the retina, protect the ocular surface, set expectations, and integrate with optical (not against it).

 
 
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Presbyopia Drops, Pt 1 (3-Part Series)

👉 Episode Sponsor
Thank you to Oasis Pharmaceuticals — Olosis™ Presbyopia Drops. Olosis helps improve near vision (20/40 or better) by Day 15 without sacrificing distance vision, offering a convenient option for today’s presbyopic patients. Learn more & start prescribing: https://qlosiecp.com/resources#sign-up

Dr. Chris Lopez and Dr. Nathan Lighthizer explore the evolving presbyopia landscape with a focus on pilocarpine-based drops. This discussion breaks down how these drops work, which patients benefit most, and how to safely and effectively integrate them into everyday clinical practice. Topics include mechanism of action, concentration differences, side-effect considerations, ideal patient selection, contact lens compatibility, dosing strategies, ocular surface considerations, retinal safety, and practical implementation tips.

Learning Objectives

  • Explain how miotic presbyopia drops improve near vision through the pinhole effect and increased depth of field
  • Identify ideal candidates, dosing strategies, and contact lens considerations to optimize patient satisfaction
  • Integrate safety considerations and clinical workflows when prescribing presbyopia drops

Why the Renewed Interest in Presbyopia Drops?

  • Active patients want convenient options beyond readers and contact lenses
  • Growing emphasis on quality of life and flexible vision solutions
  • First meaningful pharmaceutical innovation in presbyopia management in decades

Core Mechanism: Pilocarpine & the Pinhole Effect

  • Primary action: miosis → smaller pupil → pinhole effect → increased depth of field
  • These drops do not restore accommodation; they enhance functional near vision rather than accommodative amplitude

Concentrations & Side-Effect Considerations

  • Traditional pilocarpine concentrations historically ranged from 1–4% for other indications
  • Presbyopia-specific formulations discussed include approximately 1.25% and 0.4%
  • Use the lowest effective concentration to balance efficacy and tolerability

Ideal Patient Selection

  • Best early candidates: ages 45–55, minimal dependence on readers or contact lenses, active lifestyle, motivated to avoid spectacles
  • Use caution with very advanced presbyopes and complex surgical histories
  • Clinical pearl: start with easier cases to build experience and confidence

Contact Lens Compatibility

  • Presbyopia drops are compatible with contact lens wear
  • Instill drop without lenses and reinsert lenses after approximately 10 minutes
  • Works well for both once-daily and twice-daily users

Dosing Strategy & Neuroadaptation

  • 0.4% pilocarpine approved for up to BID dosing; trials used 2–3 hour separation for the second dose
  • Week 1: two doses daily (2–3 hours apart); after week 1: second dose as needed
  • Patients often experience better vision by day ~8 compared to day ~2 due to neural adaptation

Post-Surgical Eyes (Off-Label Considerations)

  • Pivotal trials excluded prior LASIK and cataract surgery; use is off-label and clinician-dependent
  • Potential benefits include reduced dysphotopsias and improved functional near vision
  • Balance pinhole benefit against potential dimming or intolerance

Ocular Surface & Dry Eye Considerations

  • Dry eye is common in this population and additional drops may worsen symptoms if poorly selected
  • Prefer preservative-free, near-neutral pH formulations with dual lubricants (e.g., HPMC, hyaluronic acid)
  • Goal: improve near vision without compromising ocular surface health

The Vehicle Matters

  • Vehicle design affects stinging, redness, SPK risk, and adherence
  • Comfort drives compliance; poor tolerability leads to abandonment
  • Drop selection should be part of the overall treatment strategy

Retinal Safety & Patient Counseling

  • Miotics carry a rare class warning for retinal tears, breaks, and detachments
  • Risk appears low, especially at lower concentrations
  • Perform and document peripheral retinal evaluation (DFE and/or ultra-widefield imaging)
  • Counsel patients to seek immediate care for new flashes or floaters

Practice-Management Workflow Tips

  • Position drops as complementary—not competitive—with glasses or contact lenses
  • Consider a cash-pay counseling visit if no medical diagnosis supports insurance billing
  • Offering progressives, contact lenses, and presbyopia drops positions the practice as modern and patient-centered

Closing Pearls

  • Confidence comes from experience—treat more than just 1–2 cases
  • Start with strong candidates and refine your approach over time
  • Clear counseling and realistic expectations lead to happier patients
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Not All That Burns is Dry Eye: Masqueraders of Dry Eye Disease

👉 Episode Sponsor: Thanks to ODs on Finance, supporting optometrists with resources like Merchant Services (text MERCHANT to 55444) and the ODoF Brokerage (text BROKERAGE to 55444)—helping doctors save money, grow practices, and build long-term wealth.

In this episode, Drs. Melissa Bollinger and Chris Lopez tackle one of the most challenging areas in ocular surface disease management—when “dry eye” isn’t truly dry eye. Not All That Burns is Dry Eye: Masqueraders of Dry Eye Disease explores how to recognize, diagnose, and manage the numerous conditions that mimic dry eye symptoms and often lead to misdirected treatment. 

This lecture empowers optometrists to accurately differentiate true dry eye disease (DED) from conditions that mimic it. Through real-world examples and diagnostic pearls, attendees will learn to recognize, diagnose, and manage masquerading conditions to improve patient outcomes.

Learning Objectives

  • Define what constitutes a dry eye masquerader and its clinical relevance
  • Identify ocular and systemic conditions that mimic dry eye
  • Use targeted history and diagnostics to distinguish DED from mimickers
  • Apply treatment strategies based on underlying cause
  • Recognize referral and co-management scenarios

I. Introduction

  • Dry eye symptoms are among the most common ocular complaints
  • High rates of misdiagnosis lead to treatment failure
  • Dry Eye Masquerader: A condition presenting with dry eye–like symptoms (burning, tearing, grittiness, blurred vision) but due to a different pathology

II. Redefining Dry Eye & Its Mimics

  • Review of DEWS III definition and symptom–sign mismatch
  • When standard therapy fails → suspect a masquerader
  • Importance of comprehensive history and testing

III. Major Categories of Masqueraders

A. Ocular Surface Inflammatory Disorders

  • Allergic Conjunctivitis: Itching, papillae, seasonal pattern
  • Ocular Rosacea: Telangiectasia, chronic redness

B. Neuropathic Ocular Pain

  • Severe symptoms, minimal signs
  • Burning or photophobia without staining
  • May respond to neuromodulators or IPL

C. Exposure-Related Conditions

  • Lagophthalmos / CPAP / Floppy eyelid
  • Thyroid Eye Disease: Proptosis, poor lid closure

D. Toxicity or Drug-Induced Disease

  • From preserved glaucoma meds, antihistamines, vasoconstrictors
  • Look for inferior staining and worsening with drops

E. Structural Disorders

  • Conjunctivochalasis: Alters tear flow
  • Pinguecula / Pterygium: Local inflammation
  • Recurrent Corneal Erosions: Pain on awakening

F. Systemic & Neurologic Conditions

  • Fibromyalgia, Migraine, Anxiety: Neurologic pain amplification
  • Sjogren’s Syndrome: Autoimmune, early misdiagnosis common
  • Neurotrophic Keratitis: Corneal nerve damage, staged management

IV. Diagnostic Approach

  • Questionnaires: OSDI, SPEED
  • Tests: TBUT, staining, Schirmer’s
  • Adjuncts: Meibography, sensitivity testing, OCT
  • Watch for red flags suggesting alternate etiologies

V. Management by Etiology

  • Tailor treatment: anti-inflammatory, antihistamine, neuropathic meds
  • Refer when systemic or structural issues identified
  • Educate patients—set expectations for chronic conditions

VI. Key Clinical Takeaways

  • Correlate symptoms with signs—if they don’t align, suspect a masquerader
  • Screen for lagophthalmos and conjunctivochalasis
  • Ask about systemic symptoms (fatigue, joint pain, headaches)
  • Limit preserved drops in chronic cases
  • Keep neuropathic ocular pain in mind for refractory dryness
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A Primer on RGPs

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Drs. Marie Huegel and Chris Lopez deliver a concise, clinic-first guide to modern RGP lenses. We’ll cover core material science (Dk, thickness, surface treatments), key designs (spherical/aspheric/toric, reverse geometry, multifocal), and when to use them; from high corneal astigmatism and presbyopia to orthokeratology and irregular corneas. The audience will learn streamlined fitting, keratoconus techniques, empirical ordering with lab support, and practical troubleshooting paired with clear patient communication.

Objectives

  • Select the right RGP material/design for refractive & irregular-cornea cases.
  • Fit & evaluate using fluorescein patterns, lens movement, over-refraction, and cone-specific strategies.
  • Troubleshoot & counsel: manage astigmatism, flexure, decentration, discomfort, and guide transitions to hybrids/sclerals.

I. RGP Material & Design

Materials

  • Oxygen-permeable plastics (Dk 30–160+).
  • Thin lenses + high Dk = better oxygen transmission.
  • Hydra-PEG & plasma treatments → better wettability/comfort.

Designs

  • Spherical, aspheric, bitoric, toric (front/back), reverse geometry.
  • Multifocals (simultaneous/translating).
  • Key parameters: base curve, diameter, optic zone, edge lift.

II. Indications

Refractive

  • High corneal astigmatism, soft toric intolerance.
  • Presbyopia (better optics vs. soft MF).
  • Orthokeratology (myopia control).

Irregular Cornea

  • Keratoconus, PMD, post-LASIK ectasia, post-RK/PRK, keratoplasty.
  • RGP masks irregularities with tear lens.

Other

  • Mild dry eye.
  • Alternative to scleral lenses (cost/handling).

III. Fitting & Evaluation

  • Pre-workup: topo, Ks, HVID, pupil, lid position.
  • Base curve near flat K; adjust as needed.

Approaches

  • Apical clearance → cones/irregular.
  • Alignment fit → even fluorescein spread.
  • Lid-attachment vs. intrapalpebral.
    On-Eye
  • Fluorescein: central bearing, pooling, edge lift.
  • Ideal movement: 0.5–1.0 mm blink.
  • Over-refraction to refine power.

IV. Keratoconus Fitting

  • Challenges: irregular elevation, thin apex, poor centration.
  • Three-Point Touch: gentle apical touch + midperipheral alignment + peripheral clearance.
  • Use smaller optic zones or cone-specific designs (e.g., Rose K).

V. Empirical Fitting & Lab Support

  • Topography-based empirical orders = high accuracy.
  • Labs use algorithms, profilometry, past fits.
  • Resources: consults, design sims, refit warranties.
  • Boosts efficiency for general practices.
  • VI. Troubleshooting

Vision Issues

  • Residual cyl → front toric.
  • Flexure → increase CT or stiffer material.
  • Decentration → adjust BC/diameter/edge lift.
    Comfort
  • Edge discomfort → adjust peripheral curves.
  • Poor adaptation → gradual wear + counseling.
    Surface Complications
  • 3 & 9 o’clock staining → blink/edge fit.
  • GPC → peroxide cleaner, hygiene reinforcement.

VII. Patient Communication

  • Set expectations: initial discomfort is normal, vision gains are worth it.
  • Train on insertion/removal, cleaning systems.
  • Reinforce adaptation commitment.
  • If intolerant → hybrids, sclerals, or custom softs.

VIII. Key Takeaways

  • RGPs = powerful & cost-effective when fit correctly.
  • Three-point touch = cornerstone in keratoconus.
  • Empirical ordering = efficient & accurate.
  • Success = clinical skill + patient education + follow-up.
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Cataract Surgery IOL Technology

👉 Show Sponsor Special thanks to RxSight, makers of the revolutionary Light Adjustable Lens. Their cutting-edge technology gives patients true post-op customization, and gives doctors the control to deliver outstanding results. Learn more at ⁠⁠⁠RxSight.com⁠⁠⁠.

Dr. Jeff Banas and Dr. Nick Bruns discuss advanced cataract surgery, focusing on patient evaluation, lens selection, and post-operative care. They highlight the shift from basic to premium cataract surgery due to declining reimbursements and rising patient expectations. The importance of pre-operative counseling is emphasized, particularly regarding lens options like multifocal, light adjustable lenses (LAL), and toric lenses. The lecture also covers the challenges of managing higher-order aberrations.

Learning Objectives

  • Educate ODs on the cataract surgery post-operative process and patient expectations
  • Highlight the latest advancements in premium IOL technologies and their performance characteristics
  • Understand patient selection criteria and decision-making process for determining the most appropriate lens option

Outline

Introduction

  • Introduce the advanced cataract discussion
  • Highlight a focus on premium technology and advanced innovation in refractive and cataract surgery
  • Market research shows only a minority of patients elect for upgraded IOL options

Challenges and Market Trends

  • Decline in reimbursements for basic cataract surgery
  • Increasing patient expectations
  • Is there such a thing as a non-refractive cataract surgery?
  • Importance of setting realistic expectations for patients regarding post-surgery vision
  • Introduce the concept of accommodative IOL
  • Note limitations and potential financial benefits of accommodative IOL solutions

Patient Expectations and IOL Options

  • Emphasize the need for patients to understand limitations of current IOL technology
  • Discuss importance of setting realistic expectations
  • Collaborative team approach between ODs and OMDs
  • OD involvement in patient evaluation and lens selection
  • Importance of topography and biometry in IOL determination

Preoperative Counseling and Lens Selection

  • ODs review scans, biometry, and topography to fine-tune lens selection
  • Importance of ensuring regular, symmetrical topography
  • Counseling patients about realistic options and financial considerations
  • Types of IOLs: multifocal, light adjustable lenses

Light Adjustable Lenses (LAL)

  • Benefits of post-surgery adjustability
  • Unique characteristics: suitable for retinal complications, contrast sensitivity issues
  • Adjustment process and importance of proper dilation
  • Advantages in mitigating higher-order aberrations and improving visual fidelity

Multifocal and Extended Depth of Focus Lenses

  • Benefits and limitations compared
  • Challenges with higher-order aberrations in multifocals vs. advantages of LAL
  • Patient expectations: glare, halos, contrast sensitivity
  • Success rates across different IOL types

Conclusion and Future Discussions

  • Importance of proper patient education and realistic expectations
  • Emphasis on collaborative approach in advanced cataract surgery
  • Continuous advancements in IOL technology
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Contact Lens Technology Update

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The lecture emphasizes the benefits and advancements in contact lens technology, including improvement in refractive errors, cosmesis, and ocular diseases. Key points include the importance of patient education to dispel misconceptions, proper cleaning protocols, the role of new materials like silicone hydrogel in enhancing comfort and oxygen permeability, and the various contact lens modalities available. 

Learning Objectives 

  • Learn how to better educate patients on the importance of proper lens care and hygiene. 
  • Feel more comfortable recommending daily disposable lenses to patients, especially those with allergies or dry eye. 
  • Screen for and manage any ocular surface conditions before fitting contact lenses. 
  • Provide personalized education and ongoing guidance to support complex contact lens patients. 

Outline 

Contact Lenses: Benefits and Misconceptions 

Dr. Huegel discusses the various uses of contact lenses, including correcting refractive errors, astigmatism, corneal lactasia, ocular surface disease, and therapeutic uses. 

New technologies have improved patient comfort, wear time, and optics, reducing dropout rates due to discomfort, cost, handling, and convenience. 

Emphasize the importance of patient education and asking every patient about their interest in contact lenses to enhance practice revenue and improve their quality of life. 

Fitting presbyopic patients with multifocal contact lenses can restore their independence and confidence, leading to loyal, long-term patients. 

Patient Education and Lens Care 

  • Highlight the importance of patient education on contact lens care to minimize risks like microbial keratitis, inflammation, scarring, and vision loss. 
  • Review key practices for contact lens care include clean hands, replacing lenses as directed, avoiding water exposure, and not sleeping in lenses unless FDA approved.
  • Regular replacement of solution and lens cases, and flipping the case upside down to ensure drying, are crucial to prevent bacterial buildup. 
  • Proper lens care enhances comfort and visual performance, minimizing the risk of corneal infection and long-term complications. 

Types of Soft Contact Lenses 

  • Soft contact lenses were originally made from HEMA but are now primarily composed of hydrogel or silicone hydrogel materials. 
  • Silicone hydrogel lenses have higher DK values, offering better oxygen permeability and corneal health compared to traditional hydrogels. 
  • Different modalities of soft contact lenses include daily disposables, weekly, bi-weekly, and monthly disposables, with options for spherical, toric, multifocal, and toric multifocal designs. 
  • Advancements in toric lens designs, such as prism, ballast, and thin zone designs, improve stability and comfort for patients with astigmatism. 

Multifocal Contact Lenses and Complex Fits 

  • Multifocal contact lenses are designed with aspheric optical zones, offering various fit options and power gradients. 
  • Fitting presbyopic patients with multifocals can be challenging but rewarding, requiring multiple follow-ups and setting clear expectations. 
  • Proper lens care and realistic expectations are crucial for successful multifocal fits, with some patients needing two to three trials to fine-tune the fit. 
  • Removing numbers from the visual acuity chart helps patients focus on their vision experience rather than specific numbers. 

Advantages and Disadvantages of Soft Contact Lenses 

  • Soft contact lenses offer high initial comfort, ease of use, and accessibility for all ages, making them a popular choice. 
  • Potential drawbacks include an increased risk of eye infections, especially with water exposure, and the need for proper hygiene. 
  • Extended wear of soft contact lenses can lead to protein and lipid deposits, causing discomfort and reduced visual clarity. 
  • Daily disposables may help to minimize the risk of infection and improve comfort, especially for patients with allergies or dry eyes. 

Therapeutic and Cosmetic Uses of Contact Lenses 

  • Colored contact lenses offer a non-invasive option for changing eye color, but are only available in spherical designs in the U.S., limiting options for some patients.
  • Bandage contact lenses protect the cornea from mechanical friction and promote epithelial regeneration, used for corneal abrasions, recurrent erosions, and post-surgical healing. 
  • Central occluded lenses are used in amblyopia therapy, offering a more cosmetic and socially acceptable alternative to drops or patches. 
  • Myopia control lenses feature a central zone for distance correction and a treatment zone to slow down myopia progression, benefiting long-term visual health. 

Task-Specific Contact Lenses 

  • Sports-specific contact lenses, such as golf and billiards, offer customized vision correction for different distances and activities. 
  • Red-colored contact lenses can help with light sensitivity, improving visual comfort and efficiency. 
  • TBI patients and those susceptible to migraines can benefit from purple-tinted lenses (FL 41) to minimize glare and improve headaches. 
  • Shooting and hunting patients can use modified monovision lenses for different distances, enhancing their performance and safety. 

Ocular Health and Contact Lens Wear 

  • Proper contact lens wear includes avoiding sleeping in lenses, managing ocular surface conditions like meibomian gland dysfunction, Demodex, blepharitis, and dry eye syndrome. 
  • Demodex is found in 51% of contact lens wearers, significantly impacting contact lens intolerance and dropout. 
  • Regular eye examinations and patient education on ocular health factors are essential for optimizing lens performance, comfort, and reducing complications. 
  • Offering personalized education and ongoing guidance can significantly improve patients' quality of life, especially those managing complex visual conditions. 

Recap and Clinical Pearls 

  • Clear expectations, patient education, and screening for contraindications are crucial for successful contact lens fits. 
  • Providing patients with the right tools, resources, and educational guides empowers them to maintain their daily routines with confidence and independence. 
  • Specialty contact lens care, including multifocals, toric lenses, and therapeutic lenses, offers significant benefits for patients with complex visual conditions. 
  • Continuous patient support and personalized recommendations are essential for long-term contact lens success and patient satisfaction.
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Step Into the Vitreous - Dealing with Floaters

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Dr. Jeff Banas discusses the vitreous, a key component of the eye, and its related conditions such as posterior vitreous detachment and vitreous syneresis. He reviews the anatomy of the vitreous, explains how to evaluate floaters, and highlights current and emerging treatments including vitrectomy, vitreolysis, and the innovative one-step LVR procedure.

Learning Objectives

  1. Understand the anatomy and clinical significance of the vitreous, including its role in common ocular conditions such as floaters and posterior vitreous detachment.
  2. Learn how to evaluate and diagnose visually significant floaters using both subjective patient assessments and objective testing.
  3. Compare and contrast current and emerging treatment options for floaters, including observation, vitrectomy, YAG laser vitreolysis, and the one-step Limited Vitrectomy Removal (LVR) procedure.

Outline

Anatomy of the Vitreous

  • Primarily composed of water, collagen fibers, mucopolysaccharides, and hyaluronic acid.
  • Occupies about 80% of the eye’s volume and divided into core (central) and cortical (peripheral) vitreous.
  • The vitreous base is a 3D zone extending anterior and posterior to the ora serrata.
  • Firmly attached to the lens capsule, retinal vessels, optic nerve, and macula—key for understanding conditions and management.

Common Conditions of the Vitreous

  • Posterior vitreous detachment, diabetic retinopathy, vitreous hemorrhage, vitreomacular traction, and floaters.
  • Vitreous syneresis: microscopic collagen fibers that cast shadows on the retina, often seen as dark spots.
  • Recognition and management are important for improving quality of life.

Evaluating the Visual Significance of Floaters

  • Traditional methods: dilated fundus exams, fundus photography, and macular OCT.
  • Wavefront aberrometry: measures visual quality objectively and quantitatively.
  • Helps determine floater impact on vision and quality of life.

Subjective and Objective Evaluation

  • Subjective reports can be limited; objective measures provide quantifiable data.
  • Tools include corneal topography and Dysfunctional Lens Index (DLI).
  • DLI scale (0–10): higher values = more significant floaters.
  • Both methods are complementary for proper evaluation.

Treatment Options for Floaters

  • Observation & Neuroadaptation: First-line management for many patients.
  • Vitrectomy: Removal of vitreous replaced by saline, oil, or gas.
    • Used for floaters, blood, scar tissue, or foreign objects.
    • Innovative three-port vitrectomy uses valve cannulas, infusion line, and vitractor.

Vitreolysis (YAG Laser Treatment)

  • Non-invasive option for large, symptomatic floaters.
  • Uses YAG laser with gonio lens to fragment and vaporize floaters.
  • Typically requires dilation and sometimes multiple sessions.

One-Step LVR Procedure

  • Less invasive than traditional vitrectomy.
  • Uses a single-port 27-gauge needle with cutting capacity to remove ~60% of core vitreous.
  • Currently approved only for pseudophakic patients; under study for broader use.
  • Potential to become a standard approach in the future.

Conclusion

  • Multiple treatment options exist for visually significant floaters: observation, vitrectomy, vitreolysis, and one-step LVR.
  • Floaters should not be ignored when they impact patient quality of life.
  • Optometrists should remain informed on evolving techniques to provide the best patient outcomes.
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Lasers in Optometry

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Dr. Chris Lopez and Dr. Joseph Munsell discuss the integration of laser procedures in optometry, focusing on YAG capsulotomies and selective laser trabeculoplasty (SLT). The lecture highlights the benefits of lasers, including improved patient outcomes, reduced complications, and cost-effectiveness. It details the historical background, indications, and procedures for YAG caps and SLT, emphasizing the importance of proper training and documentation. The discussion also explores interprofessional collaboration and the future of laser technology in optometry. Additional topics include Laser Peripheral Iridotomy (LPI), relevant studies, and the evolving standard of care for glaucoma management. 

Key highlights:

  • Benefits of lasers: improved patient outcomes, reduced complications, cost-effectiveness
  • Historical background, indications, and procedures for YAG caps & SLT
  • Emphasis on proper training and documentation
  • Interprofessional collaboration and the future of laser technology in optometry
  • Additional topics: Laser Peripheral Iridotomy (LPI), relevant studies, evolving glaucoma care standards

Learning Objectives

  • Discuss YAG capsulotomies in detail, including physics, indications, contraindications, and procedure steps
  • Review LPI, including physics, indications, procedure, and considerations (prophylactic vs emergent)
  • Discuss SLT, including physics, indications, procedure, and key studies on efficacy and cost-effectiveness
  • Provide guidance for ODs interested in incorporating lasers into practice

Outline

I. Introduction: Purpose of the Lecture

  • Educate ODs on integration of laser procedures in clinical practice
  • Demystify steps, protocols, and safety behind YAG, SLT, and LPI
  • Share real-world experiences from ODs in expanded-scope states

II. Evolution & Importance of Laser Privileges in Optometry

  • Brief history of laser use in ophthalmology → transition into optometry
  • Current scope expansion: 12+ states allow SLT, YAG capsulotomy, and LPI by ODs
  • Importance in rural/underserved areas: reduces wait times, increases access to vision-saving care
  • Response to ophthalmologist shortage by 2035: OMDs stagnant, ODs increasing, aging U.S. population

III. YAG Capsulotomy: Physics, Indications & Procedure

  • Common post-cataract complication: posterior capsular opacification (PCO)
  • YAG laser: quick, effective, safe, minimally invasive
  • Physics: Nd:YAG (neodymium-doped yttrium aluminum garnet), photodisruption creates central opening
  • Indications: reduced VA, glare, monocular diplopia, impaired quality of life
  • Contraindications: CME, active inflammation, unstable IOL, certain macular conditions
  • Pre-op: informed consent, signatures, risks/benefits explained
  • Procedure: patient education, proper settings, “timeout,” staff presence, beam alignment, pulse delivery
  • Post-op: topical NSAIDs/steroids, IOP check, education on floaters/rare complications

IV. Selective Laser Trabeculoplasty (SLT): Modern Glaucoma Standard

  • Increasing use as first-line glaucoma treatment
  • Physics: 532 nm, frequency-doubled Q-switched Nd:YAG, selectively targets pigmented TM cells
  • Indications: POAG, NTG, OHT, pigment dispersion, pseudoexfoliation
  • Key Studies: LIGHT (SLT vs drops), SALT (steroid adjunct), Curry 2014 (delayed responders)
  • Procedure: gonioscopy, consent, anesthetic, goniolens, laser applications
  • Post-op: topical steroids/NSAIDs, IOP check, follow-ups at 1 & 6 weeks
  • Billing: CPT 65855, 10-day global

V. Laser Peripheral Iridotomy (LPI): Indications & Execution

  • Purpose: prophylactic/emergent tx of pupillary block in narrow-angle patients
  • Risk Factors: ethnicity, age, sex, hyperopia, medications
  • Physics: Nd:YAG 1064 nm for iridotomy creation
  • Decision-Making: gonioscopy, AS-OCT, cataract extraction as alternative in elderly
  • Key Studies: EAGLE (lens extraction vs LPI), ZAP (low conversion rate)
  • Procedure: Abraham lens, brimonidine pre-tx, laser placement (11 or 1 o’clock)
  • Post-op: brimonidine, prednisolone, IOP monitoring, patient education
  • Billing: CPT 66761, 10-day global

VI. Integration & Workflow Strategies

  • Dedicated surgical blocks
  • Pre-op/post-op flow charts, consent forms
  • Staff training for prep, education, documentation
  • Marketing: internal (existing patients) & external (physician/community)
  • Patient communication: frame as safe, effective, expectation-setting

VII. Future Directions

  • Non-contact SLT
  • Direct SLT with AI-assisted targeting
  • Expanded OD legislative scope

VIII. Final Thoughts & Recommendations

  • Importance of laser proficiency in OD toolkit
  • Emphasize safety, documentation, patient-centered care
  • Encourage peer collaboration/mentorship
  • Provide training resources
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Mastering MGD Management

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Dr. Bryce Heffington covers the identification, grading, and management of Meibomian Gland Dysfunction (MGD), a condition affecting many dry eye patients. MGD is categorized into three main types: obstructive, hypo-secretory, and hyper-secretory. Risk factors include age, hormonal changes, rosacea, and prolonged screen time. Common symptoms are burning, grittiness, and fluctuating vision. Treatment options range from warm compresses and lid hygiene to prescription medications and in-office procedures like thermal pulsation and IPL. Future therapies include Nova 03, Azr Dash, and stem cell treatments. A combined approach with home care, prescriptions, and office therapies is recommended for best outcomes.

Learning Objectives

  • Stay up-to-date on educational resources and emerging MGD treatments.
  • Educate patients about diet, lifestyle, and systemic health's impact on MGD.
  • Consider pausing oral antihistamines in MGD patients.

Outline

Introduction to Meibomian Gland Dysfunction (MGD)

  • MGD is a common, underdiagnosed dry eye condition.
  • Meibomian glands secrete meibum to prevent tear evaporation and maintain ocular surface stability.

Categories and Risk Factors of MGD

  • Types: Obstructive, hypo-secretory, hyper-secretory
  • Risk factors: Age, hormonal changes, rosacea, screen use, contact lens wear, medications, environmental exposure
  • Symptoms: Burning, grittiness, sandpaper sensation, fluctuating vision

Symptoms and Diagnostic Indicators

  • Burning, foreign body sensation, gritty feeling
  • Fluctuating vision, especially during screen use
  • Diagnostic clues: capped glands, telangiectasia, thickened lid margins, foamy tears

Meibomian Gland Expression

  • Expression is a key diagnostic and therapeutic tool.
  • Use tools like rollers, forceps, and paddles.
  • Video recordings enhance patient understanding and compliance.

Meibography and Additional Diagnostics

  • Imaging tools: LipiScan, Oculus, Keratograph
  • Infrared and AI-enhanced meibography reveal gland structure
  • Other tests: Tear Breakup Time (TBUT), osmolarity, MMP-9

Home and Prescription Treatments

  • Home: Warm compresses, lid hygiene, hypochlorous sprays, tea tree cleansers, Omega-3s
  • Prescription: Azithromycin, cyclosporine, lifitegrast, doxycycline, minocycline
  • Lifestyle: Blink exercises, screen breaks

In-Office Procedures

  • Thermal pulsation
  • Intense Pulse Light (IPL) for rosacea-associated MGD
  • Bulk heating IPL provides sustained thermal energy
  • Low-Level Light Therapy (LLLT) for reducing inflammation

Lifestyle and Dietary Modifications

  • Avoid high glycemic foods, processed diets
  • Stay hydrated, limit alcohol
  • Key nutrients: Vitamin A, D, Zinc
  • Stop smoking, avoid secondhand smoke

Systemic Health Factors

  • Hormonal imbalances, diabetes, metabolic syndrome linked to MGD
  • Poor sleep and screen time reduce blinking and alter meibum
  • Long-term contact lens wear and medications can worsen MGD

 

Emerging Treatments

  • Nova 03 (Miebo) – water-free drop that stabilizes tear film
  • Azr Dash (MD-001) – selenium sulfide-based, targets hyperkeratinization
  • TP-03 (Xdemvy) – FDA-approved for Demodex
  • Stem cells and exosomes under investigation for gland regeneration

Clinical Scenarios

  • 65-year-old female: Gland dropout, managed with thermal pulsation and doxycycline.
  • 55-year-old postmenopausal woman: Chronic dryness treated with compresses and oral doxycycline.
  • 28-year-old software engineer: Mild MGD with lifestyle modification.
  • 32-year-old office worker: Screen fatigue managed conservatively.

Conclusion

  • MGD is chronic and progressive. It requires consistent, layered management.
  • Use diagnostics like expression and meibography.
  • Educate patients and stay proactive with updated treatments.
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Cataract Surgery Post Op Care

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Dr. Jeff Banas and Dr. Nick Bruns discuss post-operative care for cataract surgery, emphasizing the importance of several aspects of care including monitoring intraocular pressure (IOP). They highlight that IOP should be less than 30 mmHg, with hypotensive agents used if necessary. The significance of the ocular surface is discussed, particularly dry eye, in post-operative outcomes. They also discuss the use of combination drops and the potential for complications like endophthalmitis and retinal detachment. There is a need for meticulous follow-up and patient education.

Learning Objectives 

  • Ensure proper post-operative follow-up and management of eye pressure, inflammation, and other potential complications. 
  • Aggressively address ocular surface issues pre-operatively to optimize biometry measurements and post-operative outcomes. 
  • Maintain proactive ocular surface therapy, especially for patients with premium intraocular lenses or light-adjustable lenses, to achieve desired refractive results. 

Outline 

Post-Operative Care for Cataract Surgery

  • The focus of this lecture will be on post-operative care for corneal refractive and cataract surgery. 
  • Explain the initial post-operative process, emphasizing the importance of eye pressure and vision variability. 
  • Discuss the use of hypotensive agents and the threshold for burping the wound to relieve pressure. 

Day One Post-Operative Visit 

  • Describe the day one visit, focusing on checking eye pressure and managing patient expectations.
  • Discuss the use of anti-hypertensive agents and the importance of not using PGAAs due to inflammation. 
  • Highlight the potential for high eye pressure and the need to burp the wound if necessary. 
  • Understand the importance of checking for lens mispositioning, inflammation, and other complications. 

Managing Low and High Eye Pressure 

  • Explain how low eye pressure and the potential for wound leaks are problematic. 
  • Explain approaches to managing low pressures, including looking for leaks and using bandage contact lenses. 
  • Discuss the use of topical antibiotics and the importance of daily follow-ups for wound leaks. 
  • Outline the typical follow-up schedule for routine cataract surgery, emphasizing the importance of patient improvement. 

Post-Operative Medication Regimen 

  • Describe the post-op medication regimen, including a combination of prednisolone, bromfenac, and intracameral ofloxacin. 
  • Explain the use of combination drops and the importance of patient compliance. 
  • Discuss the use of intracanalicular inserts for steroid coverage and the injection of antibiotics during surgery. 
  • Keep patients on the combination drops for four weeks and adjust as needed. 

Advanced Procedures and Ocular Surface Management 

  • Explain the importance of pre-operative measurements for advanced procedures like light adjustable lenses. 
  • Emphasize the need for aggressive ocular surface management to ensure successful outcomes. 
  • Appreciate the impact of dry eye on vision fluctuations and the importance of patient education. 
  • Highlight the increased risk of dry eye post-refractive surgery and the need for proactive management. 

Impact of Dry Eye on Patient Satisfaction 

  • Understand the impact of dry eye on patient satisfaction, especially with light adjustable lenses.
  • Emphasize the importance of maintaining ocular surface therapy for long-term success. 
  • Discuss the importance of managing dry eye pre-operatively to avoid perceived complications post-operatively. 
  • Highlight the need for a comprehensive approach to dry eye management, including the use of preservative-free artificial tears and other treatments. 

Conclusion and Final Thoughts 

  • Emphasize ODs’ role in post-operative care and the role of ocular surface management in patient satisfaction. 
  • Reiterate the need for proactive management of dry eye and the importance of patient compliance. 

 

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Pediatric Prescribing in Optometry

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This engaging lecture by Dr. Miki Lyn Zilnicki provides a comprehensive roadmap for optometrists to confidently examine and manage pediatric patients. Attendees will learn practical exam techniques, prescribing principles based on amblyogenic risk, and communication strategies that make eye care enjoyable for children and parents alike—all while unlocking the growth potential of an often-underserved patient population.

Lecture Objectives 

  • Review recommended timelines for pediatric eye exams and the impact of early detection on development.

  • Demonstrate efficient pediatric exam techniques including VA testing, retinoscopy, BV assessment, and ocular health screening.

  • Understand when and how to use cycloplegia based on refractive findings and presentation.

  • Apply evidence-based prescribing using amblyogenic risk factors.

  • Improve pediatric compliance through engaging communication and parent education.

Lecture Outline 

I. Introduction

  • Importance of pediatric care: underserved but high-growth potential

  • Goal: build clinician confidence in examining and prescribing for children

II. Eye Exam Timelines & Frequency

  • AOA recommends first exam at 6–12 months (InfantSEE/Optometry Cares)

  • Normal findings: repeat at age 3, before kindergarten, then annually

  • Frequency of dilation: based on findings, not fixed schedule

III. Pediatric Exam Strategies

  • Be flexible, engaging, and set expectations with parents

  • Prioritize key tests early (e.g., cover test, stereo)

  • Behavior management: confident, adaptable approach for all children

IV. Clinical Techniques

  • VA Testing: Lea symbols, matching games; document method

  • BV Testing: Cover test, Hirschberg, NPC, EOMs with engaging targets

  • Retinoscopy: Crucial for accuracy; build skills through practice

  • Ocular Health: Use BIO/ophthalmoscope; general screening

  • Stereo & Color Vision: Use age-appropriate, playful methods

V. Cycloplegia & Dilation Protocols

  • Indications: strabismus, high RE, noncompliance

  • Agents: Cyclopentolate vs. Tropicamide (March 2025 study cited)

  • Instillation: playful approach; parents can assist at home if needed

VI. Common Pediatric Presenting Concerns

  • Failed screenings, strabismus, head turns, clumsiness

  • Rule out: amblyopia, significant refractive error, ocular pathology

VII. Prescribing Guidelines

  • Amblyogenic Thresholds

    • Anisometropia: Hyperopia >+1.00, Myopia >2–3.00, Astig >1.50

    • Isometropia: Hyperopia >+3.00–5.00, Myopia >6.00, Astig >2.50

  • Condition Tips

    • Astigmatism: Full Rx if above threshold

    • Hyperopia: Start partial, adjust gradually; bifocals for esotropia

    • Myopia: Rare in young kids; rule out pathology if severe

VIII. Follow-Up & Compliance

  • First follow-up ~6 weeks post Rx (after 4 weeks of wear)

  • Gradual adaptation; recheck Rx if intolerance

  • Make glasses fun and part of the child’s routine

  • Long-term: monitor every 3–6 months depending on case

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Explore the Rising Prevalence of Ocular Surface Disease (OSD)

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Dr. Chris Lopez and Dr. Marie Huegel explore the rising prevalence of ocular surface disease (OSD), particularly focusing on Meibomian Gland Dysfunction (MGD) and Demodex blepharitis. They emphasize the importance of early detection, patient education, and a proactive treatment model. The discussion includes epidemiology, pathophysiology, diagnostic tools, and a broad range of treatment strategies—from home care to advanced in-office procedures like intense pulsed light (IPL) and blepharoexfoliation. The podcast draws parallels between ocular and dental hygiene, advocating for routine lid maintenance to prevent disease progression.

Learning Objectives

  • Educate patients on the connection between MGD, Demodex blepharitis, and ocular surface disease—and stress the importance of early intervention.
  • Offer in-office treatment procedures such as blepharoexfoliation, IPL, and intraductal probing for effective, proactive management.
  • Incorporate advanced diagnostics like meibography and tear film analysis into routine exams to support early diagnosis and disease monitoring.
  • Encourage proper lid hygiene and consider recommending omega-3 supplementation as part of patients’ ongoing home care routines.

I. Introduction 

  • Dr. Chris Lopez and Dr. Marie Hugel introduce the lecture which will focus on MGD and demodex blepharitis.

II. Trends in Ocular Surface Disease

  • Increasing prevalence of OSD linked to digital device use, aging, hormonal changes, and environmental factors.
  • Patients are becoming more proactive, demanding deeper explanations and better care from providers.

III. Understanding MGD and Demodex Blepharitis

  • Definitions:
    • MGD: Dysfunction of the meibomian glands leading to unstable tear film.
    • Demodex blepharitis: Infestation of Demodex mites causing inflammation and eyelid irritation.
  • Clarification between anterior blepharitis, posterior blepharitis, and Demodex-specific presentations.

IV. Epidemiology and Risk Factors

  • 100% of patients over age 70 show signs of Demodex blepharitis.
  • 70% of individuals over age 60 may have MGD.
  • MGD and Demodex are more common in males and contact lens wearers.
  • Demodex also found in 51% of contact lens users and 56% of cataract surgery patients.

V. Symptoms and Psychosocial Impact

  • Symptoms: Dryness, grittiness, fluctuating vision, eyelid itching, tearing.
  • Demodex-specific: Itching along the full lid margin (vs. inner canthus in allergies).
  • OSD negatively impacts quality of life, night driving, work efficiency, and mental health.
  • Patients with blepharitis show increased risk of anxiety and depression.
  • Importance of long-term care plans and managing expectations.

VI. Anatomy and Pathophysiology

MGD:

  • Meibomian glands produce lipids critical to tear film stability.
  • Obstructive MGD involves hyperkeratinization and ductal blockage.
  • Leads to stagnant secretions, gland atrophy, and evaporative dry eye.

Demodex Blepharitis:

  • D. folliculorum affects lash follicles; D. brevis invades sebaceous/meibomian glands.
  • Causes mechanical damage, triggers immune response, and contributes to bacterial biofilms.

VII. Diagnosis of MGD and Demodex

  • Importance of detailed history: screen time, medications, environmental exposures.
  • Slit lamp exam: Check gland expression, lid margin vascularity, telangiectasia.
  • Advanced tools:
    • Meibography for visualizing gland dropout.
    • TBUT, staining, tear osmolarity to evaluate tear film.
    • Use of lissamine green for enhanced detection of lid wiper epitheliopathy.

VIII. MGD Treatment Options

  • Home therapies: Warm compresses (6–10 mins), lid scrubs, omega-3s, artificial tears.
  • Pharmacologic: Topical anti-inflammatories (e.g., cyclosporine, corticosteroids).
  • In-office treatments:
    • Punctal plugs
    • Amniotic membranes
    • Intense pulsed light therapy (IPL
    • Intraductal probing

IX. Demodex Blepharitis Treatment

  • First-line: Warm compresses, lid hygiene, omega-3s.
  • Pharmacologic:
    • Lotilaner ophthalmic solution BID for 6 weeks (targets life cycle).
    • Topical antibiotics, immunomodulators.
  • Procedural:
    • Blepharoexfoliation
    • IPL, low-level light therapy (LLLT)
  • Analogy to dentistry: Routine "deep cleanings" to prevent disease—highlighting a missed opportunity in eye care.

X. Conclusion

  • Early detection and consistent management are crucial to preventing progression and improving quality of life.
  • Diagnostic imaging, patient education, and in-office procedures enhance outcomes and compliance.
  • The episode closes with encouragement to optometrists to stay engaged in the evolving ocular surface care landscape.
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Nutrition & Eye Health: A Comprehensive Guide for the Practicing Optometrist

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I. Introduction & Core Principles

  • Dr. Neufeld introduces ocular nutrition as a complement to standard eye care. The goal is to empower optometrists with evidence-based nutritional recommendations, focusing on how diet impacts ocular health and reduces disease risk.

II. Nutrient Interactions with Ocular Structures

Nutrition affects key eye structures and mechanisms:

  • Retina & Macula: Impacted by oxidative stress, light, and pigment density.
  • Lens: Influenced by protein crosslinking and cataract development.
  • Cornea & Tear Film: Affected by inflammation and hydration.
  • Optic Nerve: Relates to vascular health and neuroprotection.

Key mechanisms include oxidative stress, inflammation, mitochondrial dysfunction, glycation, and vascular compromise. Bioavailability is crucial for nutrient effectiveness.

III. Essential Nutrients for Eye Health

  • Carotenoids (Lutein & Zeaxanthin): Filter blue light, provide antioxidant support. Found in leafy greens, corn, egg yolk. Beta-carotene is a Vitamin A precursor, but poses lung cancer risk in smokers (AREDS1 vs. AREDS2).
  • Vitamin A: Essential for phototransduction and corneal health. Deficiency causes night blindness.
  • Vitamin C: Antioxidant for aqueous humor and lens; may prevent cataracts.
  • Vitamin E: Lipid-soluble antioxidant protecting photoreceptor membranes.
  • Zinc: Cofactor for antioxidant enzymes; caution with high doses (GI upset, copper depletion).
  • Omega-3 Fatty Acids (EPA/DHA): Support tear production, reduce inflammation; beneficial for dry eye.
  • Other Notables: Copper (prevents zinc-induced anemia), B-vitamins (optic nerve health), Resveratrol and polyphenols (vascular/retinal protection).

IV. Evidence-Based Supplementation: AREDS

  • AREDS1 (2001): Reduced progression to advanced AMD by 25% with beta-carotene, C, E, zinc, copper.
  • AREDS2 (2013): Improved formula by removing beta-carotene and adding lutein/zeaxanthin and omega-3s, maintaining benefit especially for those with low dietary lutein.
  • Important Caveat: Supplements are for moderate to advanced AMD only, not general prevention. Emphasize quality control (third-party testing).

V. Dietary Patterns and Eye Disease Risk

  • Mediterranean Diet: Rich in fruits, vegetables, whole grains, olive oil, fish; reduces risk of AMD, cataracts, glaucoma.
  • Plant-Based Diets: High in antioxidants, but may require B12, DHA/EPA, and iron supplementation.
  • Low Glycemic Index Diets: Reduce risk of cataracts and AMD by minimizing glucose-induced glycation.
  • Western Diet Risks: High in unhealthy fats, sugar, processed foods; increases risk of AMD and diabetic eye disease.

VI. Nutritional Strategies for Ocular Conditions

Targeted nutritional approaches for:

  • Dry Eye Syndrome: Omega-3s, hydration.
  • Cataracts: Antioxidants, low-glycemic diet.
  • AMD: AREDS2, high-antioxidant diet.
  • Glaucoma: Emerging evidence for magnesium, omega-3s.
  • Diabetic Retinopathy: Glycemic control, antioxidants.

VII. Clinical Application & Communication

Optometrists can recommend dietary patterns and evidence-based supplements (like AREDS2 for AMD). Emphasize whole foods over pills when possible. Stay within scope, referring complex cases to nutritionists, and be aware of drug-nutrient interactions.

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Artificial Intelligence in Eyecare: Current Applications and Future Directions

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In Artificial Intelligence in Eyecare: Current Applications and Future Directions, Dr. Aaron Neufeld provides a comprehensive overview of how AI technologies—such as machine learning and deep learning—are transforming clinical and operational aspects of optometry and ophthalmology. The lecture explores AI's current use in retinal disease detection, glaucoma management, corneal screening, and surgical planning, as well as emerging roles in systemic disease prediction and teleoptometry. Dr. Neufeld also examines AI’s potential in optimizing practice workflows and retail strategies while addressing critical ethical, regulatory, and professional considerations. This course encourages eye care professionals to embrace AI as a tool to enhance clinical care, efficiency, and patient outcomes

I. Welcome & Learning Objectives 

  • Dr. Neufeld discusses the relevance to AI in practice
  • Define Artificial Intelligence (AI), Machine Learning (ML), and Deep Learning (DL) in a medical context
  • Learning objectives:
    • Understand AI’s current role in optometry and ophthalmology
    • Learn clinical and operational applications
    • Explore ethical, regulatory, and communication implications
    • Identify future trends shaping the profession

II. Why Eyecare is a Prime Candidate for AI (5–10 min)

  • Prevalence of high-resolution imaging (OCT, fundus, topography)
  • Availability of large, labeled datasets for training AI models
  • Clear diagnostic endpoints ideal for automation (e.g., DR staging)
  • High patient volume in primary care optometry enhances scalability
  • Need for coverage in rural/underserved areas supports AI in telehealth

III. AI in Retinal Disease Detection (10–15 min)

  • Diabetic Retinopathy (DR):
    • FDA-approved tools like IDx-DR and EyeArt
    • Autonomous DR detection with in-office imaging
    • Benefits: early detection, higher screening rates, improved patient compliance
  • Age-related Macular Degeneration (AMD):
    • AI identifying drusen and pigmentary changes from OCT/fundus
    • Research models predicting progression to wet AMD

IV. Glaucoma Detection & Management (15–20 min)

  • Structural analysis: optic nerve, RNFL, ganglion cell complex via OCT
  • Functional analysis: visual field interpretation using pattern recognition
  • Trend analysis: AI forecasting progression and treatment need
  • Limitations: variability in disease presentation and lack of diagnostic gold standard

V. Cornea and Refractive Screening (20–25 min)

  • Keratoconus detection using Scheimpflug, topography, and machine learning
  • Enhancing pre-op screening for refractive surgery
  • Potential for AI-driven contact lens fitting algorithms
  • AI use in meibography for quantifying meibomian gland dropout
  • Future use of blink pattern analysis in dry eye diagnostics

VI. Systemic Disease Prediction via Ocular Biomarkers (25–30 min)

  • Retinal imaging used for cardiovascular risk, cognitive decline prediction
  • Google DeepMind study on predicting age, gender, BP, and smoking status
  • Early-stage Alzheimer’s prediction based on retinal vasculature
  • Supports a broader role for optometrists in interprofessional care

VII. Surgical Planning and Post-Operative Care (30–35 min)

  • Cataract surgery:
    • IOL calculation refinement via Hill-RBF, AI-enhanced formulas
    • Post-op refractive outcome prediction using biometric trends
  • Retina surgery:
    • Experimental AI-assisted microsurgical robotics
  • Post-op OCT monitoring:
    • AI detecting recurrence of fluid in anti-VEGF patients
    • Home monitoring potential using AI-enhanced devices

VIII. Teleoptometry & Remote Screening (35–40 min)

  • AI integrated into asynchronous telehealth platforms
  • Fundus image triage systems identifying urgent findings
  • Use in remote screenings, school programs, and mobile clinics
  • Barriers: variable image quality, legal restrictions, and patient trust

IX. Practice Workflow Optimization (40–45 min)

  • AI in patient triage and scheduling:
    • NLP bots for initial intake, symptom analysis
    • Automated prioritization of appointment types
  • AI in revenue cycle management:
    • Error detection in billing codes
    • Predictive analytics for insurance denials
  • Streamlining documentation and reducing admin time for doctors

X. Optical & Retail Applications (45–50 min)

  • Virtual try-on tools using facial recognition and AI styling
  • Personalized eyewear recommendations based on demographics, past purchases
  • Inventory management based on patient data and purchasing trends
  • Smart lens customization guided by user experience feedback

XI. What’s Next? (50–55 min)

  • Personalized medicine: predicting myopia progression, AMD treatment response
  • “Digital twin” modeling: simulating disease progression and outcomes
  • Multimodal AI: combining imaging, genetic, and behavioral data
  • AI-enhanced electronic health records with clinical decision support tools

XII. Ethical, Regulatory & Professional Considerations (55–60 min)

  • Bias and equity: datasets lacking diversity may limit AI accuracy
  • Liability: who is accountable for AI-guided decisions?
  • Data privacy: informed consent, HIPAA compliance, third-party vendors
  • The OD’s evolving role:
    • Embrace AI as a tool to enhance, not replace, clinical judgment
    • Focus on empathy, interpretation, and patient communication
  • Final message: stay informed, collaborate in innovation, and lead with integrity
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MIGS Complications

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Dr. Jessica Schiffbauer discusses the management of complications associated with minimally invasive glaucoma surgery (MiGs). MiGs, which include procedures like SLT, iStent, and the Zen gel stent, are minimally invasive, have a high safety profile, and require less follow-up compared to more invasive glaucoma surgeries. Complications such as inflammation, IOP fluctuations, and blood reflux are common, especially in patients with a history of uveitis or chronic inflammation. Management involves using antibiotics, NSAIDs, and steroids, and in some cases, pilocarpine or digital pressure. Effective communication with glaucoma specialists is crucial for successful outcomes.

Learning Objectives

  • Better understand MIGS procedures and the management of complications.
  • Highlight the importance of gonioscopy.
  • Discuss open communication with the surgeon performing MIGS procedures, including sending notes and receiving updates on the patient's status.
  • Illustrate postoperative care, especially for signs of inflammation, IOP fluctuations, and hyphema or reflux bleeding.
  • Understand the use of pilocarpine in patients at higher risk of peripheral anterior synechiae.
  • Learn how to better manage IOP fluctuations and hyphema/reflux bleeding.
  • Be aware of serious complications like wound leaks, hypotony, and bleb fibrosis.

Outline

Overview of MiGs and Its Importance

  • Jessica emphasizes the importance of managing complications associated with MiGs.
  • MiGs (minimally invasive or micro invasive glaucoma surgery) involves minimal trauma to the eye, has a modest effectiveness at lowering eye pressure, and a high safety profile.
  • MiGs procedures are typically done in ASCs or office-based surgical suites, requiring less operating room time and being gentler to the eye.
  • Different types of MiGs are classified by their site of drainage, device implanted, and whether they are standalone or combined with cataract surgery or corneal procedures.

Types of MiGs and Their Applications

  • Trabecular meshwork MiGs are reserved for mild to moderate open-angle glaucoma or ocular hypertension, targeting a modest IOP target.
  • Subconjunctival filtration MiGs are for more advanced or severe disease, targeting lower IOP targets and those intolerant to medications.
  • Implantable devices like the iStent, iStent Infinity, iStent inject, Hydrus, and Zen have been available since 2012, targeting different outflow pathways.

Candidate Selection and Patient Communication

  • Good candidates for MiGs include those with ocular hypertension, mild to moderate primary open-angle glaucoma, and those close to needing cataract surgery.
  • Patients with a history of non-compliance, uncontrolled IOP, multiple medication intolerances, or poor response to SLT are also suitable candidates.
  • Emphasize the importance of starting the conversation early with patients about potential glaucoma treatment options, including surgery.
  • Effective communication with glaucoma specialists or surgeons performing MiGs is crucial for managing complications and improving patient care.

Managing Complications Post-Surgery

  • Most MiGs patients are seen a week and a month after surgery, with follow-ups every 5 to 6 weeks to 3 months, typically on antibiotics, NSAIDs, and steroids.
  • Inflammation and IOP fluctuations are common post-surgery, and patients may need to be on drops for longer if inflammation persists.
  • Highlight the importance of identifying different things on gonioscopy, such as peripheral anterior synechiae (PAS) and blood reflux, to manage complications effectively.
  • The use of pilocarpine to manage PAS and the importance of patient education on post-operative care, including avoiding strenuous activities, are highlighted.

Specific Complications and Management Strategies

  • Hyphema and blood reflux are common complications, often seen early post-operatively, and can lead to decreased vision.
  • Educate patients on managing blood reflux, including avoiding strenuous activities and keeping their head elevated.
  • The importance of performing gonioscopy at follow-up visits to identify blood reflux and other complications is emphasized.
  • For severe cases, an anterior chamber washout may be necessary,

Subconjunctival MiGs and Their Complications

  • The Zen gel stent, a commonly used stent, creates a subconjunctival bleb and is effective in managing IOP in advanced glaucoma.
  • Complications of Zen procedures include conjunctival wound leak, scarring, scleral exposure, high hyphema, and choroidal effusions.
  • Discuss the importance of assessing for wound leaks and managing them with antibiotics, aqueous suppressants, and potentially vancomycin contact lenses.
  • Hypotony and choroidal detachments are also common complications, and patients should be monitored closely for these issues.

Fibrosis and Digital Pressure Techniques

  • Fibrosis of the blood in the subconjunctival space can be difficult to identify but can lead to increased IOP.
  • Digital pressure can be performed to promote aqueous outflow and decrease IOP, and patients can be taught to perform this technique.
  • If IOP remains uncontrolled, further management may include blood needling, revision, or anti-fibrolytic injections.

Conclusion and Recommendations

  • Emphasize the importance of developing strong relationships with MiGs surgeons and maintaining open communication to manage complications effectively.
  • The prevalence of glaucoma and the use of MiGs procedures are increasing, and it is essential to be prepared to handle both positive outcomes and complications.
  • Maintain continued vigilance in identifying and managing complications to ensure the best possible outcomes for patients.
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IPL and LLLT

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Dr. Sarah Terlesky, an optometrist in Virginia, discusses the implementation and benefits of intense pulse light (IPL) and low-level light therapy (LLLT) in optometry. IPL, which targets chromophores in the skin, has shown significant success for many patients. IPL is effective for dry eye relief, particularly for skin types 1-4, while LLLT, which uses specific wavelengths for photobiomodulation, is safe for all skin types. Photobiomodulation has shown promising results for dry eye, rosacea, and AMD, with personalized treatment plans and careful patient selection being crucial for success.

Learning Objectives

  • [ ] Educate patients on the benefits of IPL and LLLT for dry eye and other ocular conditions.
  • [ ] Implement IPL and LLLT treatments in the practice and follow the recommended treatment protocols.
  • [ ] Utilize before-and-after patient images to help with patient education and treatment conversions.
  • [ ] Discuss light therapy options with both symptomatic and asymptomatic dry eye patients to maximize opportunities.
  • [ ] Ensure that the practice has a designated staff member who is comfortable discussing the pricing and benefits of the light therapy treatments with patients.

Outline

Introduction to Light Therapies in Optometry

  • Sarah discusses the transition from basic dry eye treatments like artificial tears to implementing IPL and low-level light therapy in her practice.
  • The initial concern was getting patients to sign up for treatments, but the response was positive with 20 patients signing up in the first month.
  • Sarah explains the mechanism of action for IPL, targeting chromophores in the skin to reduce inflammation and improve dry eye symptoms.

Mechanism and Adjustments of IPL

  • IPL uses polychromatic, incoherent light pulses at high intensities, typically between 400 to 1200 nanometers.
  • The treatment works by targeting chromophores like hemoglobin and melanin, causing thrombosis and photocoagulation.
  • Adjustments can be made by the amount of pulses, intensity of light, and wavelength filter used, with a three-pulse mechanism and a 590-nanometer filter being common for dry eye treatment.
  • Pulse duration and delay are crucial for preventing epidermal burning, especially for darker skin types.

Patient Selection and Contraindications for IPL

  • Sarah describes the typical IPL patient as a female between 50 to 70 years old, typically Caucasian, with dry eye.
  • The Fitzpatrick scale is used for skin typing, with skin types 1 to 4 being safe for IPL and 5 and 6 (darker skin types) being contraindicated.
  • Contraindications include pregnancy, breastfeeding, recent sun exposure, cancer, medications causing photosensitivity, active infections, and skin types 5 and 6.
  • Sarah emphasizes the importance of asking patients about the use of creams or lotions that may alter skin pigmentation.

Post-Treatment Instructions and Treatment Protocols

  • Patients may experience redness, swelling, and hyperpigmentation after treatment, with hypopigmentation or blistering being rare.
  • Treatment protocol for dry eye involves IPL to the skin beneath the eyes, with optional treatment of the upper eyelids.
  • Sarah recommends overlapping treatment zones by 10 to 20% and applying appropriate pressure to ensure effective treatment.
  • Treatments should be repeated monthly for the first four months, with maintenance treatments varying from three to twelve months.

Introduction to Low-Level Light Therapy (LLLT)

  • LLLT is an emerging treatment option that requires no consumables and no doctor time, making it suitable for technicians to administer.
  • LLLT uses specific wavelengths for a constant period of time at lower intensity, with the irradiance playing a significant role in treatment time.
  • The mechanism of action is photobiomodulation, targeting cytochrome-c oxidase within the mitochondria to activate ATP production and reduce oxidative stress.
  • Wavelengths used include red, infrared, blue, yellow, and green, with red and infrared being particularly effective for healing and neuro regenerative impacts.

Patient Selection and Contraindications for LLLT

  • LLLT is inclusive and safe for all skin types, with fewer contraindications compared to IPL.
  • Contraindications include photosensitive medications, lupus, suspicious lesions or cancer, epilepsy, extreme photosensitivity, claustrophobia, and active infections.
  • Patient selection is similar to IPL, with LLLT being a suitable option for those with recent facial surgery, early to intermediate AMD, and pediatric patients.
  • Sarah shares a case study of a patient with blepharoplasty who used LLLT to speed up healing and improve scar appearance.

Treatment Protocols for LLLT

  • For MGD, patients are advised to come once weekly for four weeks, with a follow-up evaluation within one month of completion.
  • For gland atrophy, treatments are more aggressive, with patients advised to come as frequently as every other day until improvement is seen.
  • For chalazions, treatments are recommended every other day until resolution, with express after each session if necessary.
  • LLLT has been studied and approved for treatment of early to intermediate AMD, with promising results showing disease regression.

Combining IPL and LLLT

  • Sarah explains the differences between IPL and LLLT, describing IPL as the cleanup device and LLLT as the healer.
  • Both treatments serve their purpose, and combining them can lead to faster and longer-lasting results.
  • If cost and contraindications are not a concern, Sarah recommends both treatments for optimal results.
  • For patients with rosacea and MGD, starting with IPL can get them to a better baseline faster, while LLLT can be more suitable for pediatric patients or those with low pain tolerance.

Marketing and Selling Light Therapies

  • Sarah emphasizes the importance of educating patients about light therapies while they are in the exam chair.
  • Evaluating the patient's face for signs of dry eye, rosacea, and age spots can help motivate the conversation about treatment options.
  • Using before and after images of other patients can be a powerful tool to help sell treatments.
  • Sarah advises not to limit light therapies to just symptomatic patients and to use a dry eye rack card to explain treatment options clearly.

Final Tips and Advice

  • Sarah advises not to use light therapies as a last resort and to talk to as many patients as possible about them.
  • Being genuine and not pushy in recommending treatments is crucial for patient acceptance.
70% Passing Grade Copy

Light Adjustable Lenses, Pt. 1: Introduction

Dr. Jeff Banas and Dr. Nick Bruns discuss the Light Adjustable Lens (LAL) technology in a three-part series. The LAL, FDA-approved in 2017 and commercially available in 2019, offers precise refractive adjustments post-cataract surgery. It addresses issues like refractive surprise and dissatisfaction rates of up to 5% with premium IOLs. The LAL can correct up to +/- 2 diopters with 2 diopters of cylinder. Adjustments are typically done bilaterally sequentially, with an average of four visits over six to eight weeks. The technology allows for more customized vision outcomes, reducing patient dependence on glasses.

Learning Objectives

  • [ ] Discuss in-depth the preoperative and postoperative management of the LAL.
  • [ ] Discuss the nuances and art of managing the LAL to maximize its capabilities.

Outline

Introduction to the Light Adjustable Lens (LAL) Technology

  • Jeff introduces the three-part series on the LAL technology, focusing on preoperative, postoperative management, and patient awareness.
  • Jeff and Nick, both optometrists in southeastern Wisconsin, discuss their backgrounds and areas of expertise.
  • Nick shares his experience with the LAL, mentioning its impact on his practice since early 2020.
  • Jeff highlights Nick's extensive experience with the LAL, noting he has performed more treatments than anyone in the country.

History and Evolution of Adjustable Lens Technology

  • Nick explains the LAL's history, noting it was FDA approved in 2017 and commercially available in 2019.
  • The concept of adjustable lenses dates back to the mid-1990s, with early attempts like the fluid inflatable lens.
  • Nick and Jeff discuss the evolution of adjustable lens technology, including the pioneering work by Schwartz and Grubbs in 1996.
  • The first actual implant of a lens was in 1946, highlighting the relatively recent development of modern lens implants.

Challenges and Benefits of Traditional IOLs

  • Nick discusses the limitations of traditional monofocal and toric lenses, noting a success rate of 60-70% for hitting within a half diopter.
  • Jeff and Nick emphasize the dissatisfaction rate among patients with premium IOLs, often due to aberrations and poor visual quality.
  • The LAL addresses these issues by providing more precise and customized refractions, reducing patient dissatisfaction.
  • Nick mentions that unhappy patients with multifocal and toric IOLs are a common topic at major ophthalmology meetings.

Refractive Surprise and Effective Lens Position

  • Jeff and Nick discuss the concept of "refractive surprise," where post-operative outcomes differ from pre-operative expectations.
  • Nick explains the importance of effective lens position, noting even a small deviation can significantly affect the lens power.
  • The LAL allows for adjustments to compensate for these deviations, improving post-operative outcomes.
  • Jeff highlights the benefits of the LAL for post-LASIK and post-corneal refractive surgery patients, who often have irregular corneas.

Basics of the Light Adjustable Lens (LAL)

  • Jeff describes the LAL as a three-piece silicone lens with excellent optics and a large range of adjustability.
  • Nick explains the adjustment process, noting the LAL can correct up to two diopters of cylinder, eliminating the need for traditional toric lenses.
  • The LAL allows for bilateral sequential surgery, making the process more convenient and time-saving for patients.
  • Jeff and Nick discuss the financial implications of bilateral sequential surgery, noting it is more cost-effective for patients.

Adjustment Process and Patient Management

  • Nick outlines the adjustment process, typically involving four visits over six to eight weeks.
  • Jeff and Nick discuss the importance of patient feedback and test driving the LAL in different environments.
  • The LAL allows for multiple adjustments, ensuring patients achieve their desired visual outcomes.
  • Jeff emphasizes the importance of post-operative management, including addressing issues like posterior capsular opacification before adjustments.

Patient Experience and Outcomes

  • Jeff and Nick share their experiences with patients, noting the positive feedback and improved quality of life.
  • The LAL allows for more precise and customized refractions, reducing the need for glasses and improving overall vision.
  • Jeff and Nick discuss the importance of patient involvement in the adjustment process, ensuring they achieve their visual goals.
  • The LAL provides a more flexible and tailored approach to cataract surgery, improving patient satisfaction and outcomes.

Future Discussions and Conclusion

  • Jeff and Nick preview the next episode, focusing on the art of managing the LAL preoperatively and postoperatively.
  • They emphasize the importance of understanding the nuances of the LAL to maximize its capabilities.
  • Jeff thanks the audience for joining the discussion and looks forward to continuing the conversation in the next episode.
  • The session concludes with a commitment to providing valuable insights and practical advice for managing the LAL.
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Glaucoma and Retina Billing and Coding

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Dr. Chris Lopez discusses the complexities of billing and coding for glaucoma and retina conditions in optometry. He highlights that only 28% of optometrists bill for visual fields, 28% for OCT of the nerve, 27% for OCT of the retina, 33% for fundus photos, 6% for pachymetry, and less than 5% for gonioscopy. Ophthalmologists bill for these tests at higher rates. Lopez emphasizes the importance of medical necessity and provides detailed reimbursement rates for various tests. He also notes the growing demand for medical eye care due to an aging population and the need for optometrists to expand their roles.

Learning Objectives

  • [ ] Familiarize ODs with guidelines on testing frequency.
  • [ ] Consider increasing use of gonioscopy 
  • [ ] Must document medical necessity.
  • [ ] Be aware of reimbursement for CPT codes.

Outline

Glaucoma and Retina Billing and Coding Overview

  • Dr Chris Lopez introduces glaucoma and retina billing and coding, emphasizing its educational purpose and the use of professional resources.
  • The purpose of the lecture is to clarify confusion and discrepancies in billing and coding for glaucoma and retina, aiming to provide a solid foundation for optometrists.
  • The lecture will focus on glaucoma, retina, and proper billing and coding for posterior segment conditions, excluding ophthalmologic codes, EM codes, S-codes, modifiers, and insurance-related topics.

Billing and Coding Statistics for Optometrists

  • Dr Chris Lopez presents billing statistics for optometrists, highlighting that 28% of optometrists bill for visual fields, 28% for OCT of the nerve, 27% for OCT of the retina, 33% for fundus photos, 6% for pachymetry, and less than 5% for gonioscopy.
  • Ophthalmologists bill for these tests at a higher percentage, with 2/3 billing for visual fields, OCT of the retina, and OCT of the nerve, and 80% billing for OCT of the retina.
  • The increasing number of optometrists and the stagnant number of ophthalmologists indicate a growing demand for medical eye care, which optometrists will need to address.
  • The lecture covers ICD-10 codes, CPT codes, frequency of testing, reimbursement information, and preferred practice patterns for glaucoma and retina.

Glaucoma Codes and Classification

  • Glaucoma codes include open angle with borderline findings, categorized by low risk or high risk, and primary open angle glaucoma (POAG).
  • Low-risk glaucoma suspects have two or fewer risk factors, while high-risk suspects have three or more risk factors.
  • CPT codes for glaucoma include visual field (92083), OCT of the nerve (92133), pachymetry (76514), gonioscopy (92020), fundus photos (92250), and extended ophthalmoscopy (92202).
  • Reimbursement rates for these tests are briefly highlighted

Preferred Practice Patterns and Testing Frequency

  • Preferred practice patterns from organizations like the AAO provide guidelines for testing frequency based on disease stages.
  • The importance of medical necessity and justifying tests for diagnosis or treatment is emphasized, with criteria for Medicare coverage.
  • The lecture covers the importance of documenting medical necessity, patient cooperation, and reliability, and comparing test results to previous ones.
  • The need for optometrists to step up in medical eye care due to the stagnant number of ophthalmologists and the increasing demand for medical eye care is highlighted.

Detailed Discussion on Specific Codes and Reimbursement

  • Visual field (92083) is discussed, with over 2800 CPT codes that may be reimbursed, but the focus is on whether the test is reasonable and necessary.
  • OCT of the nerve (92133) is medically necessary for glaucoma, glaucoma suspects, or optic neuropathy, with no more than two tests per year recommended.
  • Pachymetry (76514) should be performed with handheld units, and the alternative code (92499) may be more appropriate for optical pachymetry.
  • Gonioscopy (92020) is easy to remember, and fundus photography (92250) is typically not covered for routine screening but for monitoring disease progression or guiding treatment.

Additional Codes and Reimbursement Details

  • Serial tonometry (92100) is not commonly used, with most carriers requiring three tests over a six-hour span.
  • Corneal hysteresis (92145) is not covered by Medicare due to the low quality of evidence, despite its potential as a risk assessment tool.
  • Extended color vision (92283) is gaining steam in glaucoma management, as many glaucoma patients have color vision defects.
  • Extended ophthalmoscopy (92202) is highly audited and requires a detailed drawing, with reimbursement rates being poor.

ERG and SLT Codes and Reimbursement

  • Electroretinography (ERG) is not covered for primary open angle glaucoma but may be covered for other diagnoses like retinal diseases.
  • Selective laser trabeculoplasty (SLT) is covered for various glaucoma types and conditions, and has a global period of 10 days.
  • The safety of optometric laser surgery is highlighted, with a complication rate of 0.001% based on a study.
  • The introduction of direct SLT, a non-contact, automated procedure, is expected to increase the number of SLT procedures performed by optometrists.

Retina Codes and Reimbursement

  • OCT of the retina (92134) should not be performed more than one test per couple of months for non-active treatment patients and no more than one test per year for hydroxychloroquine users.
  • Extended ophthalmoscopy of the retina (92201) requires a detailed drawing and is not medically necessary if the condition is unchanged.
  • The lecture concludes with a reminder of the importance of medical necessity and the need for optometrists to step up in medical eye care due to the increasing demand and the stagnant number of ophthalmologists.
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Plaquenil Overview

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Hosted by Dr. Chris Lopez and Dr. Sam Valley, this episode discusses hydroxychloroquine, its uses, side effects, and role in eye care. Introduced in 1955, hydroxychloroquine is used for malaria treatment, prophylaxis, and autoimmune diseases like lupus and rheumatoid arthritis. Key dosing guidelines are 400 mg weekly for malaria prophylaxis, 800 mg initially followed by 400 mg at intervals for malaria treatment, and 200-400 mg daily for autoimmune diseases. Monitoring for toxicity involves visual field testing, OCT retina, and other assessments. Risk factors include dose, duration, age, renal function, and genetics. Effective communication with rheumatologists is crucial for patient care.

Learning Objectives

  • Communicate with rheumatologists and other prescribers about hydroxychloroquine patients, including documenting therapy duration, dose, and risk factors.
  • Establish a good relationship with a local clinical pharmacist for guidance on hydroxychloroquine and other medications.
  • If signs of toxicity are detected, discuss them with the prescribing rheumatologist, as alternative medications may be available.

Outline

Introduction and Overview
The education focuses on hydroxychloroquine, its uses, side effects, and role in eye care. Dr. Valley highlights its importance in current practice and the need for communication with rheumatologists.

Historical Context and Uses of Hydroxychloroquine
Dr. Lopez provides a historical overview of hydroxychloroquine, its origins in malaria treatment, and development from quinacrine and chloroquine. The discussion covers its use in treating autoimmune conditions like lupus and rheumatoid arthritis. The evolution of hydroxychloroquine from a malaria treatment to a staple in rheumatology is highlighted. Its use during the COVID-19 pandemic and pharmacology, including its mechanism of action and classification as a DMARD, are briefly mentioned.

Pharmacology and Dosing of Hydroxychloroquine
Dr. Lopez explains the pharmacology of hydroxychloroquine, focusing on its mechanism of action in suppressing tumor necrosis factor alpha. The concept of a narrow therapeutic window is introduced, stressing the need for close monitoring. Dosing guidelines for malaria prophylaxis, treatment, and autoimmune diseases are detailed, including the importance of weight-based dosing. Clinical pearls on dosing discussions with patients and the significance of actual body weight are covered.

Potential Side Effects and Toxicity
Dr. Valley outlines common side effects of hydroxychloroquine, including gastrointestinal disturbances and skin reactions. Major toxicities, such as ocular toxicity (Plaquenil maculopathy) and cardiac toxicity (QT interval prolongation), are discussed. The concept of cumulative toxicity and the significance of reaching 1000 grams of hydroxychloroquine in seven years are explained. Risk factors, including dose, duration of use, age, renal function, and genetics, are detailed.

Monitoring and Testing for Hydroxychloroquine Toxicity
Dr. Lopez discusses the importance of monitoring Plaquenil patients and the role of visual field and OCT retina testing. CPT codes and reimbursement details for these tests are provided, along with typical visual field defects and OCT findings. Less common tests, such as multifocal ERG and fundus autofluorescence, are mentioned as potential tools for early detection. The importance of repeating tests before making medication adjustments and the role of microperimetry and adaptive optics in future testing is highlighted.

Guidelines and Best Practices for Managing Plaquenil Toxicity
Dr. Valley summarizes the AAO's guidelines for baseline and follow-up testing, emphasizing early detection. Higher-risk criteria for toxicity, such as high dosage, long-term use, and renal dysfunction, are discussed. The role of continued care with rheumatologists and the importance of intra-professional communication are stressed. The irreversibility of Plaquenil toxicity and the need for proper documentation and communication with prescribers are highlighted.

Case Study and Practical Insights
Dr. Valley shares a case study from a VA clinic, underscoring the importance of communication between prescribers and optometrists. Dr. Lopez discusses personal experiences with Plaquenil toxicity and the role of communication in managing these cases. The need to balance the risks and benefits of long-term hydroxychloroquine use is discussed, with a focus on early detection and communication with rheumatologists. The episode concludes with a summary of key points and a reminder of the importance of proper documentation and communication in patient care.

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Opening a VT Practice Cold

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Dr. Mikey Lynn Zilnicki, co-owner of Twin Forks Optometry, shared insights on cold starting a vision therapy practice. Key decisions include whether to focus solely on vision therapy or offer full-scope services, accepting insurance, and whether to include an optical. Miki emphasized the importance of aligning practice goals with personal values and cautioned against over-investing in advanced technology initially. She detailed the costs of starting a practice, which was around $250,000 for her, and highlighted the benefits of virtual vision therapy during COVID-19. She also discussed the importance of precise documentation for workers' compensation and no-fault cases.

Learning Objectives

  • [ ] Determine the long-term vision and goals for the practice.
  • [ ] Decide whether to accept insurance and which insurances to accept.
  • [ ] Evaluate the need for an optical department within the practice.
  • [ ] Assess the essential equipment required to start a basic vision therapy practice.
  • [ ] Explore virtual vision therapy options and platforms, such as HTS and Eye-Hero, to accommodate patients who cannot attend in-person sessions.

Outline

Starting a Vision Therapy Practice: Initial Considerations

  • Miki introduces herself as the co-owner of Twin Forks Optometry, a vision therapy and rehabilitation practice.
  • Emphasizes the importance of deciding the long-term vision for the practice and reverse engineering goals to create the desired space.
  • Highlights that no two vision therapy practices are alike and stresses the importance of personal goals and values in shaping the practice.
  • Stresses that the job should fuel life, not be life itself, and outlines the first step in starting a vision therapy practice: defining goals and values.

Deciding on the Practice Scope and Insurance

  • Miki discusses the decision of whether to focus solely on vision therapy or to offer full-scope services, including primary care.
  • Explains the insurance debate in the vision therapy community, noting that many insurances do not cover vision therapy or do so at low rates.
  • Describes the challenges of being on insurance panels, including the risk of being busy but not profitable.
  • Shares their decision to accept three major insurances (Medicare, Blue Cross Blue Shield, and Aetna) and the limitations of Aetna's coverage for convergence insufficiency.

Handling Workers Compensation and No Fault Cases

  • Discusses the additional paperwork and systems required for workers compensation and no fault cases.
  • Emphasizes the importance of precise documentation and the potential risk of being subpoenaed for records or testimony.
  • Shares their experience of handling these cases and the benefits of being on insurance panels.
  • Highlights the importance of having systems in place to manage these complex cases effectively.

Deciding on an Optical and Building Relationships with Local Opticians

  • Miki and her partner decided not to have an optical in their practice, focusing instead on building a specialty care vision therapy practice.
  • Explains the decision based on local competition and the abundance of optical options in their area.
  • Describes their approach to building relationships with local opticians to ensure proper prescription fulfillment.
  • Highlights the benefits of these relationships in creating lifelong patients and maintaining high standards of care.

Equipment and Cost Considerations for Starting a Vision Therapy Practice

  • Miki references an article she wrote detailing the costs of opening a cold start vision therapy practice, which was around $250,000.
  • Emphasizes the importance of distinguishing between what is needed versus what is wanted in terms of equipment.
  • Lists essential equipment for a vision therapy practice, including an exam lane, auto refractor, lensometer, and possibly a fundus camera.
  • Recommends using a manual phoropter over a digital phoropter for better binocular assessments and flexibility in vision therapy exercises.

Advanced Vision Therapy Equipment and Technological Advancements

  • Discusses advanced vision therapy equipment such as the VTS four, Synaptec, and Vision Integrator.
  • Highlights the benefits of these technologies in providing comprehensive vision therapy and sports vision training.
  • Shares their decision to invest in the VTS four and gradually add other equipment as the practice became more profitable.
  • Emphasizes that while advanced equipment is nice to have, it is not necessary to start a vision therapy practice.

Navigating Virtual Vision Therapy and COVID-19 Impact

  • Miki initially resisted virtual vision therapy but was forced to adopt it during COVID-19.
  • Describes their approach to conducting virtual sessions, including setting up home vision therapy studios for patients.
  • Highlights the limitations of virtual therapy but acknowledges its benefits for patients who cannot attend in-office sessions.
  • Mentions other virtual vision therapy programs like HTS and Eye Hero, which are effective for certain patients and conditions.

Final Advice and Encouragement for Starting a Vision Therapy Practice

  • Miki encourages aspiring vision therapists to go for it, emphasizing the high demand for vision therapy services.
  • Reviews key questions to consider when starting a practice, including the long-term vision, insurance acceptance, and equipment needs.
  • Advises against analysis paralysis and stresses the importance of taking action to open the practice.
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Hypertension & Cholesterol - An Ocular Look

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The discussion focused on the interplay between hypertension, cholesterol, and cardiology, emphasizing their implications for ocular health. Key points included the ASCVD risk calculator, which evaluates factors like blood pressure and cholesterol levels. Hypertension treatments were detailed, highlighting thiazide diuretics (e.g., hydrochlorothiazide) and their side effects like dry eye. ACE inhibitors (e.g., Lisinopril) and ARBs (e.g., Losartan) were also discussed, noting their effects on blood pressure and potential side effects like dry cough. Calcium channel blockers and beta blockers were mentioned for their roles in hypertension and arrhythmia management. The conversation also covered statins for hyperlipidemia, their benefits and rare side effects like myopathies. Finally, the discussion touched on medications for congestive heart failure, including loop diuretics and potassium-sparing diuretics, and their potential ocular side effects.

Learning Objectives

  • [ ] Review the ASCVD risk calculator and understand how it can provide insight into a patient's risk of cardiovascular events.
  • [ ] Be aware of the potential ocular side effects of thiazide diuretics, such as photosensitivity, angle closure glaucoma, and dry eye, and be prepared to communicate with prescribers about medication changes if the side effects are severe.
  • [ ] Recognize ACE inhibitors and ARBs on a patient's medication list and understand that they are being treated for hypertension.
  • [ ] Be aware of the potential increased risk of glaucoma associated with calcium channel blockers, although more research is needed to establish a causal relationship.
  • [ ] Monitor patients taking amiodarone closely for the development of corneal deposits and optic neuropathy, and communicate any findings to the patient's cardiologist.
  • [ ] Be aware of the potential ocular side effects of other antiarrhythmic medications, such as dry eye and vision changes, and communicate these to prescribers.
  • [ ] Communicate with primary care and cardiology providers about patients taking medications that may have ocular or visual implications, even if the patient is not experiencing any adverse effects, to build stronger interprofessional relationships.

Outline

Hypertension, Cholesterol, and Cardiology Overview

  • Speaker 1 introduces the meeting's focus on hypertension, cholesterol, and cardiology, emphasizing their importance to eye care providers and patients.
  • The discussion will cover medications for these conditions, their implications for ocular and visual health, and clinical pearls for interprofessional communication.
  • Speaker 1 highlights the overlap in medications used for these conditions and the importance of concomitant use.
  • The ASCVD risk calculator is introduced as a tool for evaluating patient risk factors for cardiovascular complications.

Hypertension: Factors and Treatments

  • Speaker 1 explains the factors that determine a hypertensive patient's risk for ocular events, including disease severity, duration, and treatment status.
  • First-line therapies for hypertension are discussed, including thiazide diuretics, ACE inhibitors, and ARBs.
  • Thiazide diuretics, particularly hydrochlorothiazide (HCTZ), are explained in detail, including their mechanism and common side effects like photosensitivity, angle-closure glaucoma, and dry eye.
  • Clinical pearls for managing HCTZ-induced dry eye are provided, emphasizing the importance of medication changes if symptoms are severe.

ACE Inhibitors and ARBs

  • Speaker 1 discusses ACE inhibitors, explaining their mechanism of blocking the enzyme that converts angiotensin I to angiotensin II.
  • Common ACE inhibitors are listed, along with their side effects, including photosensitivity and a dry, lingering cough.
  • A case study is presented to illustrate the importance of interprofessional communication in identifying and managing side effects of ACE inhibitors.
  • ARBs are introduced, with a focus on their mechanism of blocking the angiotensin receptor and their lack of ocular or visual side effects.

Calcium Channel Blockers and Beta Blockers

  • Calcium channel blockers are discussed, including their classification into dihydropyridine and non-dihydropyridine subclasses.
  • The potential ocular side effects of calcium channel blockers, such as glaucoma, are mentioned, along with the need for more data to confirm causation.
  • Beta blockers are briefly covered, noting their use for rate and rhythm control of the heart and their lack of significant ocular or visual side effects.
  • The importance of checking for beta blockers and other anti-arrhythmia drugs when prescribing topical glaucoma medications is emphasized.

Hyperlipidemia and Statins

  • Speaker 1 transitions to discussing hyperlipidemia, emphasizing the importance of cholesterol levels in estimating cardiac risk.
  • The role of statins in treating hyperlipidemia is explained, with a focus on their mechanism of reducing low-density lipoproteins.
  • Common statins are listed, along with their most common adverse effect, ocular surface disease, and the rare but serious side effects of myopathies and rhabdomyolysis.
  • The importance of interprofessional communication in managing statin therapy and identifying severe adverse events is highlighted.

Cardiology: Anti-Arrhythmic Medications

  • Speaker 1 introduces the topic of cardiology, focusing on medications used for different types of heart disease and arrhythmias.
  • Class I anti-arrhythmics, also known as sodium channel blockers, are discussed, along with their common side effects of dry eye and vision changes.
  • Class II anti-arrhythmics, or beta blockers, are briefly covered, noting their use for both hypertension and arrhythmias.
  • Class III anti-arrhythmics, or potassium channel blockers, are discussed, with a focus on amiodarone and its side effects of corneal deposits and optic neuropathy.

Non-Dihydropyridine Calcium Channel Blockers and Other Medications

  • Class IV anti-arrhythmic medications, or non-dihydropyridine calcium channel blockers, are discussed, with a reminder of their potential to cause open-angle glaucoma.
  • Other medications used to treat arrhythmias, including adenosine and digoxin, are briefly covered, with a focus on their ocular side effects.
  • The importance of monitoring patients on digoxin for visual changes and ensuring timely discontinuation if adverse events occur is emphasized.
  • The discussion transitions to congestive heart failure, with a focus on the use of diuretics and their potential side effects.

Congestive Heart Failure and Diuretics

  • Speaker 1 explains congestive heart failure as a chronic condition leading to the heart's inability to pump blood effectively, resulting in fluid buildup in the body.
  • The role of diuretics in managing congestive heart failure is discussed, with a focus on loop diuretics (furosemide and bumetanide) and potassium-sparing diuretics (Spironolactone).
  • The potential side effects of loop diuretics, including elevated blood glucose levels, are mentioned, along with the importance of monitoring for vision changes.
  • The importance of interprofessional communication in managing patients on diuretics and identifying side effects is emphasized.

Closing Remarks and Clinical Pearls

  • Speaker 1 emphasizes the role of eye care providers in the patient's care team, highlighting their ability to advocate for patients and communicate with other healthcare providers.
  • The importance of sending notes to primary care and cardiology to keep them informed about patients' status and potential side effects is reiterated.
  • Speaker 1 concludes the meeting by thanking the listeners and expressing hope that they gained valuable clinical insights.
  • The meeting ends with applause, indicating the end of the discussion.
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Diabetes Management

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Dr. Sam Valley, who holds both an OD and PharmD degree, discusses the role of eye care providers in diabetes management, emphasizing interprofessional communication and continuity of care. Key points included the common use of metformin for type 2 diabetes, its adverse effects like nausea, and strategies to improve patient adherence. Sulfonylureas, such as glipizide, glyburide, and glimepiride, were highlighted for their risk of hypoglycemia. GLP-1 agonists, like ozempic, were discussed for their effectiveness in controlling blood glucose and reducing cardiovascular risks, despite potential ocular side effects. The importance of monitoring patients on these medications was stressed, especially for those using them for weight loss.

Learning Objectives

  • [ ] Educate patients taking metformin to take it with food to reduce GI side effects.
  • [ ] Recommend glucose monitoring to providers prescribing GLP-1 agonists for weight loss due to risk of hypoglycemia.
  • [ ] Monitor patients closely if aggressively decreasing blood glucose leads to worsening of microvascular changes initially.

Outline

Diabetes Medications and Their Impact on Eye Health

  • Dr. Valley introduces the episode's focus on diabetes, including medications, their effects on the eyes, and the role of eye care providers.
  • Emphasis on interprofessional communication and the need for improved efficiency and continuity of care in the healthcare system.
  • Overview of the episode's structure: clinical overviews by disease state, with a focus on medications affecting the eyes.
  • Introduction to the first class of diabetic medications, biconids, specifically metformin, and its common use in type 2 diabetes.

Medication Reconciliation and Metformin Usage

  • Discussion on medication reconciliation, defined as reviewing the patient's medication list for accuracy and pairing each medication with a disease.
  • Common adverse effects of metformin, such as nausea, vomiting, and diarrhea, and strategies to improve patient adherence, including taking the medication with food.
  • Importance of documenting diabetes as a diagnosis if a patient is taking metformin, even if well-controlled.
  • Mention of off-label use of metformin for polycystic ovary syndrome (PCOS) and similar dosing recommendations.

Sulfonylureas and Their Clinical Pearls

  • Introduction to sulfonylureas, including glipizide, Glyburide, and glimepiride, and their use as second-line or combination therapies with metformin.
  • Clinical pearls: potential allergic reactions in patients with a sulfa allergy and the risk of hypoglycemia due to these medications.
  • Importance of recognizing sulfonylureas and their mechanism of action, which can lead to hypoglycemia.
  • Scenario of a diabetic patient presenting with sudden vision changes and the need to rule out hypoglycemia if using sulfonylureas.

DPP-4 and SGLT-2 Inhibitors

  • Overview of DPP-4 and SGLT-2 inhibitors, their use as third-line add-ons to diabetes therapy, and common medications in these classes.
  • Mention of specific medications like Januvia, Sitagliptin, and Invokana, and their lack of significant ocular implications.
  • Brief discussion on the importance of recognizing these medications and their relation to diabetes.
  • Transition to the next topic: injectable GLP-1 agonists, which are currently a hot topic in diabetes management.

GLP-1 Agonists and Their Clinical Significance

  • Introduction to GLP-1 agonists, including ozempic, trulicity, and semaglutide, and their effectiveness in controlling blood glucose for type 2 diabetic patients.
  • Discussion on the potential for worsening of microvascular diabetic complications, including diabetic retinopathy, due to aggressive blood glucose control.
  • Importance of staying the course with treatment and monitoring patients more frequently if worsening occurs.
  • Positive outcomes of GLP-1 agonists in reducing cardiovascular risks, as shown in recent studies.

Weight Loss and GLP-1 Agonists

  • Discussion on the use of GLP-1 agonists for weight loss and the need for close monitoring due to the lack of insurance coverage for glucose meters and continuous testing tools for non-diabetic patients.
  • Importance of interprofessional communication to educate providers about visual symptoms and recommend more regular glucose testing.
  • Studies showing the effectiveness of semaglutide in reducing body weight and returning patients to normal glycemia, with significant outcomes.
  • Emphasis on the importance of due diligence by prescribers and eye care providers in identifying and managing patients at risk for adverse events.

Insulins and Their Clinical Implications

  • Introduction to insulins, including mealtime and long-acting insulins, and the importance of documenting their use in diabetic patients.
  • Brief overview of different types of insulins, including rapid-acting, short-acting, intermediate-acting, long-acting, and ultra-long-acting insulins.
  • Importance of recognizing the use of insulin and documenting it in patient records.
  • Discussion on the risk of hypoglycemia and visual changes due to rapid decreases in blood glucose levels.

Monitoring and Managing Insulin-Dependent Patients

  • Importance of close monitoring by prescribers and interventions by eye care providers to ensure positive patient outcomes.
  • Recognition of insulin dependence in both type 1 and type 2 diabetic patients.
  • Brief list of common insulin names, including rapid-acting insulins like aspart and lispro, and long-acting insulins like insulin degludec and Glargine.
  • Emphasis on the need for interprofessional communication and collaboration in managing insulin-dependent patients.

Conclusion and Final Thoughts

  • Recap of the episode's focus on diabetes medications, their effects on the eyes, and the role of eye care providers.
  • Emphasis on the importance of interprofessional communication and continuous care in improving patient outcomes.
  • Final thoughts on the need for close monitoring and intervention by healthcare providers to ensure the best possible outcomes for diabetic patients.
  • Encouragement for continued education and collaboration among healthcare professionals to enhance patient care.
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Norms & Expectations in PreOp Prep

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Josh Davidson, an optometrist at Williamson Eye Center, discussed norms and expectations in preoperative prep for cataract surgery. He highlighted that 60-80% of cataract patients have ocular surface disease (OSD), which affects post-surgery satisfaction. Davidson emphasized the importance of treating OSD before surgery to prevent vision and safety issues. He noted that routine preoperative lab tests are unnecessary, citing studies that found no benefit. Davidson recommended tear osmolarity, MMP-9 tests, and staining for preoperative workups. He also stressed the need for optometrists to educate patients about surgical options and preoperative hygiene.

Learning Objectives

  • [ ] Test all cataract patients for dry eye and treat any issues found before referring for surgery.
  • [ ] Discuss dry eye risks and treatment strategies with patients. Recommend pre-surgical hygiene kits if needed.
  • [ ] Consider delaying surgery if dry eye is present to optimize ocular surface first.

Outline

Introduction and Purpose of the Meeting

  • He outlines the course's objectives, including highlighting research on preoperative prep guidelines and patient behaviors.
  • Josh mentions the high number of cataract surgeries performed annually in the U.S. and the issue of patients not utilizing recommended diagnostic tests and treatments for ocular surface disease (OSD) before surgery.
  • He explains the risks patients face if OSD is not managed before surgery, including vision, comfort, and safety issues.

Incidence and Impact of Ocular Surface Disease

  • Josh discusses the incidence of OSD in cataract patients, estimating it to be between 60% and 80%.
  • He cites an ASRS survey showing that even mild to moderate dry eyes affect patient satisfaction after cataract and refractive surgery.
  • Josh emphasizes the importance of optometrists handling preoperative care for cataract patients, given the high prevalence of OSD.
  • He highlights the effectiveness and safety of cataract surgery, which is the most commonly performed operation in the Medicare population.

Historical Context and Evolution of Preoperative Testing

  • Josh recounts the 1993 guidelines from the Agency for Healthcare Policy and Research, which recommended comprehensive medical exams and laboratory testing for cataract surgery.
  • He explains that a survey from that time showed that many surgeons ordered preoperative tests out of institutional requirements or medico-legal concerns rather than clinical necessity.
  • Josh discusses the 1994 study initiated by the Agency for Healthcare Policy and Research, which found that routine medical tests with lab work before cataract surgery were unnecessary.
  • He mentions that subsequent Cochrane reviews and updates in 2009 and 2012 confirmed the findings, leading to the discontinuation of routine lab testing before cataract surgery.

Role of Optometrists in Preoperative Care

  • Josh emphasizes the importance of optometrists referring cataract patients to ophthalmologists and ensuring that patients with OSD are treated before surgery.
  • He shares his experience of seeing many patients with substantial OSD who have never been told about it by their previous eye doctors.
  • Josh stresses the importance of treating OSD before surgery to improve patient outcomes and satisfaction.
  • He explains that if dry eye is discussed before surgery, it is considered the patient's problem, but if it is discovered after surgery, it becomes the surgery center's issue.

Preoperative Workup and Testing Recommendations

  • Josh recommends a dry eye workup for all cataract patients, including tear osmolarity readings, MMP-9 tests, and staining with lissamine green and fluorescein strips.
  • He suggests using non-invasive tear breakup time measurements and other advanced diagnostic tools to assess the ocular surface.
  • Josh explains the importance of objective data in patient education and the potential for referral centers to send tough dry eye patients to optometrists for preoperative treatment.
  • He advises optometrists to delay surgery if abnormal readings or symptoms indicate OSD and to educate patients about the importance of a healthy ocular surface.

Treatment of Dry Eye and Its Impact on Cataract Surgery

  • Josh discusses the importance of treating OSD before cataract surgery to improve patient outcomes and reduce infection risks.
  • He mentions studies showing that untreated OSD can lead to dissatisfaction with cataract surgery and postoperative dry eye symptoms.
  • Josh recommends preoperative prophylactic treatments, such as artificial tears, warm compresses, and hypochlorous acid solution, to improve biometry results and surgical planning.
  • He highlights the need for optometrists to be aware of the diagnostic tools and guidelines available to manage OSD before surgery.

Patient Expectations and Misconceptions About Cataract Surgery

  • Josh references a 2022 study by Miss Amy Helm, which found that only 6.1% of patients expect perfect vision after cataract surgery and that many are afraid of surgery.
  • He explains that patients often delay seeking care for cataracts, leading to a more desperate state when they finally seek treatment.
  • Josh discusses the importance of addressing patient fears and educating them about the benefits and risks of different cataract surgery options.
  • He emphasizes the need for optometrists to be proactive in discussing OSD risks and treatment options with patients.

Preoperative Prep Kits and Patient Compliance

  • Josh mentions a study by Miss Amy Helm, which found that 87% of patients would use a preoperative prep kit if provided, and 83% would buy one if recommended.
  • He discusses the availability of preoperative prep kits and the importance of patient compliance in managing OSD before surgery.
  • Josh highlights the role of optometrists in providing patients with the necessary tools and information to prepare for cataract surgery.
  • He emphasizes the importance of optometrists being knowledgeable about the surgical options and the preoperative needs of their patients.

Final Recommendations and Conclusion

  • Josh provides recommendations for preoperative care, including discontinuing certain medications and ensuring patients are well-informed about the day of surgery requirements.
  • He emphasizes the importance of treating OSD before surgery to improve patient outcomes and satisfaction.
  • Josh encourages optometrists to be proactive in discussing OSD risks and treatment options with patients and to be knowledgeable about the surgical options available.
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Identifying Bino Vision Disorders

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Dr. Miki Zilnicki, co-owner of Twin Forks Optometry, discusses handling complaints of double vision (diplopia). Key steps include determining onset, frequency, and direction of double vision, which can indicate serious conditions like space-occupying lesions. Imaging is recommended for new onset cases. Visual acuity, extraocular muscle testing, and cover tests are essential examinations. Prism and vision therapy are treatment options, with vision therapy being particularly effective for convergence insufficiency. Proper handling of double vision can enhance patient satisfaction and build practice reputation.

Learning Objectives

  • Address patient double vision complaints thoroughly through history and evaluation.
  • For new onset double vision, consider medical imaging to rule out underlying causes even if the exam suggests accommodative or vergence issue.
  • Consider combination treatment with prism and vision therapy if seeking immediate relief and long term treatment.

Outline

Handling the Chief Complaint of Double Vision

  • Emphasizes the importance of addressing double vision (diplopia) promptly to rule out serious conditions.
  • Stresses the need to understand the onset, frequency, and direction of double vision.
  • Shares a case where a patient with new onset double vision had a small growth in the cavernous sinus, highlighting the importance of imaging.

Key Initial Questions for Double Vision

  • Outlines the first three questions to ask about diplopia: (1) onset, (2) frequency, and (3) direction of double vision.
  • Onset is crucial to rule out serious conditions like space-occupying lesions or uncontrolled high blood pressure.
  • Frequency helps determine if it is intermittent or constant, and the time of day it occurs.
  • Direction can be horizontal, vertical, or diagonal, providing valuable information for the exam.

Detailed Examination and Case History

  • Miki discusses the importance of a thorough case history, including systemic diseases, medications, stress levels, and diet.
  • Visual acuity, extraocular muscle testing (EOM), and cover tests are essential parts of the examination.
  • Emphasizes the need to check for muscle restrictions and any increase in double vision in different gazes.
  • Non-competent cover tests indicate more serious conditions that may require further evaluation through MRI.

Cover Test and Its Importance

  • Miki explains the cover test, including unilateral and alternate cover tests.
  • The unilateral cover test looks for strabismus, while the alternate cover test assesses visual posture.
  • For intermittent double vision, a prolonged cover test is necessary to identify fatigue-related tropias.
  • Vertical deviations require careful observation, including head position and eyelash movement.

Von Graff Phoria and Binocular Ranges

  • Miki describes setting up the Von Graefe phoria test to quantify deviations.
  • Explains the importance of aligning the patient's eyes and understanding the setup for accurate results.
  • Binocular ranges help assess how well patients compensate for deviations, especially for new onset verticals.
  • The Park three-step method is mentioned for isolating muscle involvement in vertical deviations.

Treatment Options for Double Vision

  • Miki outlines treatment options: prism, vision therapy, or a combination of both.
  • Prism is effective for vertical and esophoric deviations, especially in distance vision.
  • Vision therapy is recommended for convergence insufficiency and intermittent exotropia, addressing the root cause of double vision.
  • Emphasizes the importance of presenting treatment options clearly to patients, explaining the benefits and limitations of each.

Final Advice and Practice Building

  • Miki advises optometrists not to ignore double vision complaints and to address them thoroughly.
  • Highlights the financial benefits of providing effective glasses and the potential for repeat business.
  • Encourages optometrists to refer patients for further medical evaluation when necessary.
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Enhancing Patient Care with Anterior Segment Technology

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Dr. Chris Lopez discusses the advancements in posterior segment technology, focusing on four key areas: ERG (Electroretinography), extended color vision, virtual visual field testing, and lasers in optometry. ERG, now a handheld device, assesses retinal function objectively, with protocols like DRA for diabetic retinopathy. Extended color vision tests, quick and subjective, aid in retinal and optic nerve function assessment. Virtual visual fields, performed via headsets, offer convenience and are comparable to traditional tests. Lasers, including YAG capsulotomy, LPI, and SLT, are increasingly used by optometrists, especially in rural areas, despite low ROI, emphasizing comprehensive patient care. 

Learning Objectives

  • [ ] Consider implementing ERG testing into the practice to objectively assess retinal and optic nerve function for conditions like diabetic retinopathy.
  • [ ] Evaluate extended color vision testing for tracking progress in patients with retinal conditions like macular degeneration and diabetic retinopathy. 
  • [ ] Assess virtual visual field devices for testing patients with limited mobility, like those in wheelchairs. They are convenient and less physically demanding than traditional devices. 
  • [ ] Obtain proper training before implementing laser procedures like YAG capsulotomy, LPI, and SLT. Have standard protocols and patient materials ready

Outline 

Enhancing Patient Care with Posterior Segment Technology 

  • Chris introduces the podcast episode titled "Enhancing Patient Care with Posterior Segment Technology," focusing on four topics: ERG, extended color vision, virtual visual field testing, and lasers in optometry. 
  • ERG (Electroretinography) is described as a modern, handheld device that assesses retinal and optic nerve function, providing quick, objective results with a small footprint. 
  • The benefits of modern ERG include its quickness, objectivity, ease of use, and detailed reports, which are crucial for managing retinal diseases like diabetic retinopathy. 
  • ERG protocols include the DRA (Diabetic Retinopathy Assessment), PHNR (Photopic Negative Response), and Flicker 16, each measuring different aspects of retinal function. 

Extended Color Vision Testing 

  • Extended color vision testing is introduced as a method to assess cone receptors, which are responsible for color vision, and can indicate cone damage associated with retinal disorders or optic neuropathies. 
  • The test is quick, subjective, and functional, providing easy-to-interpret reports similar to OCTs, with red, yellow, green indicators for severity. 
  • Applications for extended color vision testing include retinopathy, posterior segment disease, and glaucoma, where color deficiencies are common. 

Virtual Visual Field Testing 

  • Virtual visual field testing is highlighted as a rapidly advancing technology, with headset devices performing visual fields and other tests, such as extended color vision. 
  • The benefits of virtual visual fields include convenience for patients, especially those with physical limitations, and the ability to perform tests in various settings, including wheelchairs. 
  • The technology is also useful for hydroxychloroquine testing, ptosis, and driver's license testing, with applications expanding to include binocular vision tests. 
  • Virtual visual fields are quick, easy to use, and provide comparable results to traditional visual field tests, with a smaller footprint and patient appeal. 

Lasers in Optometry

  • Chris discusses the increasing role of lasers in optometry due to the aging population and the need for more surgeons, with optometrists taking on more laser procedures. 
  • The three main laser procedures are YAG capsulotomy, LPI (Laser Peripheral Iridotomy), and SLT (Selective Laser Trabeculoplasty), each with different settings and energy levels. 
  • Implementing lasers in a practice requires comfort in performing procedures, standard operating protocols, patient education, and trained staff. 
  • The footprint of laser devices is similar to a slit lamp
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Enhancing Patient Care with Anterior Segment Technology

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Dr. Chris Lopez discusses the integration of anterior segment technology in optometry to enhance patient care. Key technologies include low-level light therapy (LLLT), which has anti-inflammatory properties and improves dry eye symptoms, and intense pulse light (IPL), which reduces inflammatory mediators and improves meibomian gland function. Zest, a product by Zocular, uses okra polysaccharide technology to remove Demodex mites, providing immediate clinical improvement. Anterior segment cameras aid in disease management by improving patient compliance and buy-in for advanced treatments. These technologies offer significant ROI and are often used as cash-pay services. 

Action Items 

  • [ ] Consider implementing low level light therapy in your practice. 
  • [ ] Consider implementing IPL in your practice. 
  • [ ] Consider implementing zest in your practice to treat Demodex and blepharitis. ● [ ] Consider obtaining an anterior segment camera to improve patient buy-in and compliance.

Outline 

Introduction to Anterior Segment Technology in Eye Care 

  • Dr. Chris Lopez introduces the lecture on enhancing patient care with anterior segment technology. 
  • The lecture aims to explore technological advancements in eye care, focusing on anterior segment diseases. 
  • Objectives include understanding the benefits and challenges of incorporating technology into optometric practice. 
  • The focus is on anterior segment, particularly ocular surface disease. NPR Strategy for Technology Integration 
  • Dr. Lopez introduces the NPR strategy: N for nerd (clinical information), P for practical (implementation), and R for revenue (financial impact). 
  • Low Level Light Therapy (LLLT) is introduced as the first technology to be discussed. ● LLLT has been used in dermatology for anti-inflammatory and aesthetic purposes and is now used in eye care. 
  • The mechanism of action involves activating mitochondria to increase ATP, leading to anti-inflammatory effects. 

Benefits and Applications of Low Level Light Therapy 

  • LLLT has shown impressive results in dry eye disease management. 
  • It is non-invasive, painless, and safe, with a spa-like experience for patients. ● LLLT is repeatable, with sessions separated by a few days. 
  • The financial impact varies, but most offices use it as a cash pay offering with a good ROI. 

Intense Pulse Light (IPL) Technology 

  • IPL is the second technology discussed, commonly used in eye care and other medical fields. 
  • IPL works by absorbing light to destroy blood vessels, reducing inflammatory mediators. ● It has anti-inflammatory properties and may have antibacterial effects, reducing Demodex load. 
  • IPL is safe, repeatable, and effective for dry eye disease, blepharitis, and rosacea. Implementation and Financial Impact of IPL
  • IPL is usually performed by doctors but can be delegated to staff or technicians. ● The procedure involves pre and post-procedure steps, with treatments separated by three to four weeks. 
  • IPL devices are moderately sized and require some office space. 
  • Most offices use IPL as a cash pay offering, with a good ROI despite the high cost of devices. 

Demodex Management with Zest Technology 

  • Demodex is an underdiagnosed condition, now receiving more attention due to its impact on dry eye disease. 
  • Zest, a product by Zocular, uses patented okra polysaccharide technology to remove Demodex load. 
  • Zest provides immediate clinical improvement and is safe, repeatable, and non-invasive. ● It is effective for blepharitis, Demodex, dry eye disease, and acne. 

Implementation and Financial Aspects of Zest 

  • Zest is usually performed by doctors but can be delegated to staff. 
  • The procedure takes five to ten minutes and involves a pre-procedure prep. ● Zest kits are affordable and easy to use, with a minimal footprint. 
  • Most offices charge patients out of pocket, avoiding insurance claims and ensuring a good ROI. 

Anterior Segment Camera Technology 

  • Anterior segment cameras are basic but underutilized, with various offerings available. ● The cameras help in disease management by providing visual evidence to patients. ● They improve buy-in for advanced treatment options and enhance patient compliance. ● Anterior segment cameras are easy to use, with a minimal footprint and a CPT code for reimbursement. 

Conclusion and Final Thoughts 

● Dr. Lopez emphasizes the rapid advancement of technology in optometry. ● The lecture aims to highlight financially feasible technologies to improve patient care.