COOKIE Issue 10: The DED & Glaucoma Issue

A paradigm shift in

dry eye disease and glaucoma management

Glaucoma underwent a technological and treatment revolution two decades ago with the introduction of optical coherence tomography (OCT), pachymetry, and the use of once-a-day prostaglandin analogs (PGAs). Dry eye disease (DED), on the other hand, is undergoing a similar paradigm shift with the introduction of diagnostic testing like meibography, non-invasive tear break-up time, and osmolarity. DED treatments are also taking a quantum leap — from intense pulsed light (IPL) to radio frequency and low-level light therapy, among many others.

Time will tell which technologies are most popular and practical. Just as some early competing technologies like GDx in glaucoma became obsolete, so too will several of the emerging DED solutions.

One does not need to be practicing in a very optometryfriendly jurisdiction or spend hundreds of thousands in equipment purchases to diagnose and manage this disease. The great news about treating dry eye is that there are extremely effective low-tech options, such as expression, debridement and microblepharoexfoliation.

What is most important is a doctor’s understanding of dry eye disease and their ability to listen to the patient. Case history, like in any other condition, is still king. The emergence of scores of different DED technologies has not lessened the importance of clinical decision-making, but raised it. Doctors need to know which tool to employ at every stage of the disease and in what sequence. One does not become an expert by merely purchasing a specific instrument but by taking a holistic and individualized approach to care.

Multiple studies have established a strong link between glaucoma medication use and dry eye/blepharitis/ meibomian gland dysfunction (MGD). While glaucoma is asymptomatic but potentially blinding, blepharitis can be extremely bothersome but does not commonly cause vision loss. However, the negative impact MGD/

blepharitis has on all patients (and glaucoma sufferers in particular) is greatly underestimated.

Preventing damage to the meibomian glands is essential, and early intervention in glaucoma suspects with DED could decrease their complications with medication. This would likely lead to less ocular surface disease and better adherence to pressure-reducing drops.

What we need to realize is that dry eye is not just a nuisance for patients in general or glaucoma sufferers in particular. Patients often discontinue treatment for glaucoma because they are medicating a condition they don’t feel or see. Yet they get the negative reinforcement of stinging, burning red and dry eyes when using their pressure-lowering drops. Getting the dry eye under control would greatly improve glaucoma medication adherence and therefore may help prevent blindness. Choosing non-preserved medications and formulations that cause less damage to the meibomian glands is also essential.

At-home and in-office dry eye treatments should be employed in concert. I compare it to dental hygiene: just like teeth need daily maintenance and regular in-office cleaning, so do eyes. DED is an inflammatory and multifactorial disease, not just a lack of moisture. Simply suggesting artificial tears to patients while not getting to the root of their problem is unacceptable.

It’s time to stop thinking about dry eye as a minor issue and realize it not only decreases quality of life but can be a major reason for vision loss in glaucoma patients.

We hope you enjoy our ‘Glaucoma and DED’ issue!

Dr. Mark Eltis OD, FAAO, Dipl. ABO

Abesamis Eye Care & Contact Lens Center

Manila, Philippines

carmen.dichoso@gmail.com

Doctor Eye Health

Minnesota, USA

hello@doctoreyehealth.com

Matt Young

CEO & Publisher

Hannah Nguyen COO & CFO

Gloria D. Gamat Chief Editor Mapet Poso Editor

Maricel Salvador

Graphic Designer Writers

Andrew Sweeney

Chow Ee-Tan

Hazlin Hassan

Joanna Lee

Matt Herman

Customer Care

Ruchi Ranga

International Business Development

Brandon Winkeler

Perez and Associates and Phan-Tastic Eye Care

Florida, USA

kristie817@gmail.com

View Eye Care

Toronto, Canada

drmarkeltis@vieweyecare.com

Robert Anderson

Adam Angrisanio

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Dr. Monica Chaudhry

Learn Beyond Vision

New Delhi, India

monica.rchaudhry@gmail.com

NearSight

California, USA

elisebrisco@hollywoodeyes.net

Society Friend

He Eye Specialist Hospital

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Dr. Carmen Abesamis-Dichoso

Dr. Kristie Nguyen

Dr. Joseph J. Allen

Dr. Mark Eltis

Dr. Elise Brisco

Novaliq Announces FDA Acceptance of the NDA for CyclASol® for DED

Novaliq recently announced that the US Food and Drug Administration (FDA) has accepted the New Drug Application (NDA) for CyclASol® (cyclosporine ophthalmic solution), a firstof-its-kind anti-inflammatory product for the treatment for the signs and symptoms of dry eye disease (DED).

The Agency completed the filing review of the CyclASol NDA and determined that the application is sufficiently complete to permit a substantive review. No potential review issues have been identified at this time. The Prescription Drug User Fee Act (PDUFA) target action date set by the FDA for announcing its decision on Novaliq’s NDA after reviewing the application is June 8, 2023.

“This is an exciting time for ophthalmologists and optometrists and their patients as we are one step closer to address[ing] important needs and

INDUSTRY UPDATE

to better treat a serious ocular surface condition affecting millions of Americans,” said Christian Roesky, CEO of Novaliq.

“If approved, CyclASol would be a highly potent but comfortable anti-inflammatory therapy for patients with dry eye disease. It shows impressive and rapid therapeutic effects objectively measured on the ocular surface in the majority of patients, with clinical benefits on the signs and symptoms of the disease.”

CyclASol has demonstrated in two pivotal studies fast onset of therapeutic effect in afflicted patients in this indication, clinical meaningful improvement of ocular surface damage, and excellent tolerability. Results from a 12-month long-term study confirmed that the effects are maintained, and even improved, for most sign and symptom endpoints.

“This important milestone marks the second NDA acceptance of water-free dry

eye therapies in less than three months. The two distinct modalities of action of the EyeSol-based dry eye therapies open new and complimentary clinical prospects on how to treat DED in the future,” said Sonja Krösser, VP for Preclinical & Clinical Development at Novaliq. “We are committed to work[ing] closely with the FDA to bring this novel cyclosporine drug product to patients suffering from DED as quickly as possible.”

Dry eye is one of the most common ocular surface disorders, with approximately 18 million Americans diagnosed with DED. Inflammation and immunologic processes play a key role in the pathology of the disease.

Novaliq further plans to submit a marketing authorization application to the European Medicines Agency and further authorities this year.

Bausch + Lomb and GRF Launch New Glaucoma Awareness Campaign in Recognition of Glaucoma Awareness Month

Bausch + Lomb Corporation and Glaucoma Research Foundation (GRF), a national non-profit organization with the vision of curing glaucoma, recently announced the US launch of ‘Screen, Protect, Cure’ — a campaign designed to provide educational resources and raise awareness of glaucoma, a leading cause of irreversible blindness — during Glaucoma Awareness Month.

“We are proud to collaborate with Glaucoma Research Foundation to provide critical information about this serious eye disease and underline the negative toll it can have if left untreated,” said Christina Ackermann, president, Ophthalmic Pharmaceuticals, Bausch + Lomb. “Glaucoma can affect individuals of all

ages and only half of those affected are aware they have it, so it’s important that we share risk factors, how to get tested, and what treatment options are available. Through ‘Screen, Protect, Cure,’ we hope to help support patients in every step of their treatment journey.”

During the month of January, Glaucoma Awareness Month, Bausch + Lomb and GRF shared educational resources to educate individuals who may be at risk for glaucoma and empower them to take an informed and active role in their eye health. The campaign also features a fundraising challenge that will match every dollar raised up to $20,000 in support of GRF research for a potential cure for glaucoma.

“Glaucoma Awareness Month provides a

great opportunity to share information about this sight-threatening disease and remind people there are steps they can take to help preserve their vision,” said Thomas M. Brunner, president and CEO of GRF. “Visiting an eye care provider on an annual basis and paying attention to visual function are the best things someone can do to avoid the irreversible damage from glaucoma. Although there is currently no cure, our fight to prevent visual disability is ongoing, and we are grateful for the collaboration of organizations, such as Bausch + Lomb, who share this commitment with us.” For more information, visit glaucoma.org/ screen-protect-cure.

The Dry Eye Report

… and it is not just a pain in the eye

by Hazlin Hassan

While dry eye disease (DED) may seem like a minor inconvenience, the condition is becoming more and more common — and it is not just a pain in the eye.

A Global Dry Eye Treatment Devices Market Report 20221 released in November 2022 revealed that the market size is expected to reach US $348.8 million by 2028. This is an increase in the market growth of 7.4% compound annual growth rate (CAGR) during the forecast period.

The rise underlines the demand for cutting-edge treatments and the need for treatments to be customized to each patient by focusing on the distinct mechanisms linked to their condition, depending on the various presentations and pathophysiology.

Prevalence and pain

Dry eye is an extremely prevalent and underdiagnosed ocular condition. It is a growing health problem worldwide with a global prevalence of 11.59%.2 In the US alone, DED has been diagnosed in about 16.4 million adults, and 6 million more experience DED symptoms without a formal diagnosis.3 It is also more prevalent in older individuals and women.

Patients who have dry eyes experience uncomfortable

symptoms, including burning, stinging, grittiness, soft tissue sensation, tearing, ocular fatigue, and dryness — because their tear film is unstable and unable to maintain the protective qualities required for its structure and function.

According to the report, DED is considered untreatable and needs constant care to restore and keep the ocular surface system's equilibrium.

Treatments, signs, and symptoms

Treatments for DED currently include broadband light (BBL), intense pulsed light (IPL),

meibomian gland expression (MGX), and combination (MGX+IPL).

The report shared that the IPL segment garnered a significant revenue share in the dry eye treatment devices market in 2021.

Slit-lamp examinations with and without various stains, such as fluorescein, are used in diagnosing a patient. Further tests include the Schirmer test, tear break-up time, tear function index, and functional visual acuity.

People with dry eyes can experience itchiness, watery eyes, a sensation of foreign bodies, redness, and eye pain. Uncontrolled screen time using smartphones, laptops or tablets can lead to an increase in dry eye symptoms.

Other symptoms of DED include hyperemia, low tear lakes, a quick tear break-up period, and meibomian gland disease. DED symptoms are usually exacerbated by diseases such as blepharitis, diabetes, thyroid problems, rheumatoid arthritis,

systemic lupus, and Sjogren's syndrome.

Who are at risk?

At the Hava Optique eyewear company in Cyberjaya, Malaysia, fluorescein tests conducted on patients with complaints of DED symptoms found that 70% were women with low tear break-up time. It also found a higher prevalence in older patients, with all patients aged 40 years and above recording low tear break-up time.

While DED is common among both contact lenses wearers and nonwearers, the symptoms can be more severe for the previous. “In Malaysia, an online survey of Contact Lens Dry Eye Questionnaire (CLDEQ-8) was distributed through social media. A total of 140 contact lens wearers completed the online survey, and 98.6% of them were soft contact lens wearers,” shared Ms. Nur Marsya Sabrina Mohamad Sahrizal, an optometrist at Hava Optique.

Some 93.6% of contact lens wearers complained of dry eye symptoms, she noted. Environmental factors include low humidity, wind, air conditioning, prolonged near-work — including reading, screen time, driving, and exposure to second-hand smoke.

Medications also play a role in the increased risk of DED. Some of the medications that can cause dry eyes include diuretic agents, betablockers, antihypertensive agents, antihistamines, decongestants, antidepressants, oral contraceptives, herbal supplements, and isotretinoin.

The OSDI questionnaire…

The Ocular Surface Disease Index (OSDI) questionnaire is often used for patients experiencing ocular surface discomfort, with questions regarding visual functions, social activity, and environmental influences.

One of the signs observed in dry eye patients is their tear break-up time. “At Hava Optique, we determine dry eye disease when tear break-up time is less than five seconds. Using the Schirmer test, patients with less than 5 mm in five minutes are also considered to have dry eye disease,” said Ms. Nur Marsya Sabrina.

The Schirmer's test determines whether the eye produces enough tears to keep it moist. It works by placing a strip of filter paper in the lower eyelid pouch. A normal test result would see more than 10 mm of moisture on the filter paper in five minutes.

The Meibomian glands are also checked for any blockages. Lastly, the tear meniscus height measurement is taken. "If it is less than or equal to 0.3 mm, it is classified as abnormal using the variable beam height on the slit lamp,” Ms. Nur Marsya Sabrina noted.

…versus the SPEED questionnaire

Another questionnaire, known as the Standard Patient Evaluation of Eye Dryness (SPEED), has been shown to be a repeatable and valid metric with the needed psychometric properties for the identification of a patient’s dry eye symptoms using a clinic-based sample.

The two questionnaires differ, but they both aim to accurately capture a patient’s dry eye symptoms and also monitor the efficacy of various dry eye treatments.

The SPEED questionnaire is both a frequency- and severity-based questionnaire designed to track diurnal and long-term symptom changes over a period of three months.

The composite score of the SPEED questionnaire is obtained by summing the scores from the

frequency and severity parts of the questionnaire.

The symptoms include dryness or grittiness or scratchiness, soreness or irritation, burning or watering, as well as eye fatigue reported and scored as sometimes, often, and constant — and whether these symptoms posed no problems, were tolerable, uncomfortable, bothersome, or intolerable.

Ms. Nur Marsya Sabrina said she finds the OSDI questionnaire easier for her to use in patients compared to the SPEED, as patients can better understand it — both in the English and Malay versions — and the symptoms are more relatable to her patients.

References

1. Global Dry Eye Treatment Devices Market Report 2022: High Incidence & Prevalence of Dry Eye Diseases Boosting Sector. Available at: https://www.globenewswire.com/en/newsrelease/2022/11/08/2550646/28124/en/ Global-Dry-Eye-Treatment-Devices-MarketReport-2022-High-Incidence-Prevalenceof-Dry-Eye-Diseases-Boosting-Sector.html. Accessed on December 28, 2022.

2. Papas EB. The global prevalence of dry eye disease: A Bayesian view. Ophthalmic Physiol Opt. 2021;41(6):1254-1266.

3. Aggarwal S, Galor A. What's new in dry eye disease diagnosis? Current advances and challenges. Review. 2018;7:F1000 Faculty Rev-1952.

Contributing Doctor

Ms. Nur Marsya Sabrina Mohamad Sahrizal is currently an optometrist at the Hava Optique eyewear company in Cyberjaya, Malaysia. She graduated in optometry from the National University of Malaysia (UKM). She has conducted research studies on dry eye diseases, and her passion lies in issues concerning contact lenses. She has conducted several community services for eye health screening offline as well as online. During her leisure time, she enjoys dancing on her own and watching horror movies.

marsyaams@gmail.com

Optometry and the Glaucoma Sweet Spot

Glaucoma, especially open-angle glaucoma (OAG), is an insidious disease and one of the world’s most common causes of sight loss. It is also notoriously difficult to detect, diagnose, and deter the onslaught of danger that increased intraocular pressure (IOP) presents. And though glaucoma’s high profile has inspired a promising wave of innovations, there remain key challenges in both diagnosing and managing the disease.

The main problem is the gargantuan pile of appointments and tests it takes to root out and manage the progression of glaucoma. Detection is difficult — especially in the early going. Oftentimes, a diagnosis then requires a battery of follow-up tests for confirmation. Management is time consuming. As the disease progresses, IOP must be monitored, efficacy of drugs measured, and regimens adjusted.

Glaucoma is manageable, yes — but it does not go gentle into that good night.

Screen to win

Enter optometrists, whose roles worldwide are progressively expanding into that of primary eye care provider. This expansion puts optometrists directly in the sweet spot of glaucoma management, and Dr. Monica Chaudhry,

an optometrist on the front lines of bridging the glaucoma gap, knows why.

“The whole concept of optometry, when it evolved from opticianry, was a clinical person who has to be the primary eye care screener,” she explained. The first step in managing a disease is detecting it, and glaucoma screening is a complex beast.

One of the unique features of glaucoma is the challenges of early detection. Around 50%1 of people that have glaucoma do not know they have it. Damage to the optic nerve is slow, and the signs non-existent or subtle. Optic nerve damage is also irreversible, and by the time noticeable vision loss is observed, glaucoma has already done most of its work.

“It is this time [in the early stages] when the patient should be screened, and that’s how we can keep the vision safe and preserved,” Dr. Chaudhry noted. “The patient is picked up well in advance and protected from [optic nerve damage],” she added.

That’s the spot!

Screening is thus a massive void in the glaucoma management puzzle.

Dr. Chaudhry believes that there are many reasons why optometrists, as

primary eye care providers, are the best candidates to fill this and the many other holes.

The first is time. Ophthalmologists are not known to have many empty slots in their appointment books, and this is a harbinger of a looming shortage of MDs.

The density of ophthalmologists in the United States decreased from 6.3 per 100,000 in 1995 to 5.68 by 2017.2 And with an aging population, this hunger for expertise will only increase — the Health Resources and Services Administration believes that by 2025, there will be a shortfall of around 6,000 ophthalmologists in the United States.

Quarts of (digital) ink have been spilled elsewhere debating the ‘whys’ of this shortfall. But one of the clear answers is the sheer amount of time it takes to train an ophthalmologist. With 10 (or more) years of education to complete a full course of study, it's not surprising that the population is far outpacing the supply of fresh MDs.

This time crunch has knock-on effects well outside of crowded appointment books. Dr. Chaudhry pointed out that this leaves ophthalmologists geographically scattered, and in her native India, more concentrated in urban areas.

Glaucoma is a unique disease, but optometrists are also in a unique position to help

by Matt Herman

“Patients need at least an hour or two for the total process of [tests]. If you restrict them to a few places, people will find it difficult to travel and they’ll skip off these tests,” she said.

This is especially important in rural areas, and it is not only screening that is at stake. “For monitoring, if someone living in a rural area has to travel 500 kilometers and spend money out of their earnings, it’s not possible,” Dr. Chaudhry added.

The glaucoma management sweet spot thus takes shape. The need clearly exists for a practitioner that can be trained (relatively) quickly at enough depth to pick up on the subtleties of glaucoma detection — all with the ability to set up shop away from major hospitals.

These mystery practitioners, of course, are optometrists. And there are even more boxes that they check that go beyond even the capabilities of ophthalmologists.

Dr. Chaudhry believes there are subtle things that are invaluable in detecting glaucoma early. “Any patient who comes to me for vision correction, even if I have not done the investigation, there are certain signs. Does the patient have any family history or parents with glaucoma or unexplained headaches? Does the near number keep changing? Are there contrast problems?”

All things that an ophthalmologist, who sees a patient only a few times in their life might miss. Things that an optometrist who sees the same patient regularly would pick up on.

Put me in, coach

There is a mountain of evidence pointing to optometrists playing a bigger role in glaucoma detection and management. But obstacles remain, both in Dr. Chaudhry’s native India and around the world, to ODs shouldering a burden for which they are seemingly custom-designed to bearing.

Dr. Chaudhry believes that the first step is education for prospective patients. “A lot more awareness campaigns for patients to please visit and have a

routine eye screening need to be done,” she argued. In this way, patients who might have 6/6 vision but are exhibiting other early warning signs can go get checked properly.

This goes hand in hand with optometrist education. “The professionals of course have to be very well trained. Supposing we built up patient awareness, the cycle has to be completed and the optometrist has to be well trained in handling this equipment and conducting screenings,” she continued. “We need more skilled optometrists, and we need public awareness at the same time.”

Equipment is the next big step. From tonometers to slit lamps and gonioscopes, the kit needed to be confident in a diagnosis is numerous and expensive. “Glaucoma screening and the equipment cost money, and the patient has to also pay for these things. It’s a vicious cycle,” Dr. Chaudhry noted. “Optometry needs investments.”

One of the best ways to drive investment, especially from government, is through demand. “Many of these devices which industry makes — if the sales increased, the costs would also come down,” she observed. And of course, demand is driven by more practicing optometrists, who in turn can do their job more effectively with equipment subsidized by governments, the industry itself, or even NGOs.

In the end, there are many ways to get over the obstacles to getting more optometrists activated in the fight against glaucoma. Equipment cooperatives where multiple optometrists take turns using subsidized advanced detection and monitoring equipment is one that helps keep costs for patients low.

Organizations like Dr. Chaudhry’s Learn Beyond Vision, an online optometry upskilling education platform, also aim to keep existing optometrists abreast of the latest developments and research. “We are qualified enough to handle this. You have existing professionals, you just need to upskill them. Training and education is the key,” she concluded.

And while much needs to be done, the bottom line is clear — optometrists can and should play a bigger role in glaucoma management, and the avenues for getting them involved are as many as they are promising.

References

1. Don't let glaucoma steal your sight! Centers for Disease Control and Prevention. Available at: https://www.cdc.gov/visionhealth/resources/ features/glaucoma-awareness.html/. Accessed on January 2, 2023.

2. Supply and demand: Navigating the future of ophthalmology. Healio. Available at: https://www. healio.com/news/ophthalmology/20210707/ supply-and-demand-navigating-the-future-ofophthalmology. Accessed on January 2, 2023.

Contributing Doctor

Dr. Monica Chaudhry is a consultant optometrist and educator who has more than three decades of experience as an academic and clinician. With her extraordinary skills in optometry education, she has recently ventured to be a freelancer educator, strategy advisor, and practitioner. She is the founder of an online optometry upskilling education platform, Learn Beyond Vision. Also, she has instituted some centers of excellence and vision centers, which aim to be a unique referral, academic and research units. She is well-known contact lens and low vision specialist and has a far and wide patient referral in India. Dr. Chaudhry has served at the All India Institute of Medical Sciences (AIIMS) in New Delhi, had academic experience with various universities, including the Indira Gandhi National Open University (IGNOU) and Amity University (India), and has recently retired as director of School of Health Sciences at Ansal University (Gurgaon, India). In recognition of her contribution to the field of academic medical service, she has been awarded the Shreshtshree Award by the Delhi Citizen Forum, the Australian Leadership Fellowship award in 2012 and the IACLE Contact Lens Educator of the Year (Asia Pacific) award in 2015. Dr. Chaudhry was chairman of the Optometry Council of India. She has been actively involved in organizing conferences, seminars, national and international workshops, faculty development programs and many corporate training programs. monica.rchaudhry@gmail.com

A Crackly Issue

Which is better for DED, eyeglasses or contact lenses?

by Joanna Lee

You hear this from your patients too often these days: They’re driving along a highway and they’re suddenly hit with a sensation of their eyes drying up with a sharp stab that feels like their eye balls are going to crack. They pull over to the side of the busy road, desperately trying to pat their eyes to induce tears or use eye drops to soothe the painful episode before attempting to drive home safely.

The cracking sensation can be attributed to how dry eyes affect the cornea’s natural ability to heal itself, as a recent discovery at the Washington University School of Medicine in St. Louis explained.1 This finding adds impetus towards finding ways to treat dry eye disease (DED), which is usually associated with meibomian gland dysfunction (MGD).

What’s more, this condition which was previously prevalent among the aging population or those experiencing hormonal changes is now spreading to different age groups.

“We are noticing DED among younger people, even in their mid-30s and younger kids. The pandemic has resulted in longer use of monitor screens and mobile phones, and working and studying from home — all contributing to the prevalence of dry eyes,” shared Mr. Ryan Ho, an optometrist from Malaya Optical in Malaysia.

On a daily, practical level, how can those who need to wear prescription lenses deal with the discomforts of dreadful dry eyes? Would glasses or contact lenses impact wearers for the better?

A few optometrists who have also experienced dry eye symptoms themselves share their thoughts.

Go for glasses?

Those who are already sensitive to the painful sensations and effects of dry eyes would eschew wearing contact lenses and choose to wear prescription glasses instead.

“Generally speaking, glasses are better for dry eyes as contact lenses absorb more of your natural tears and can increase the signs and awareness of dry eye symptoms,” shared Dr. Jason Teh, In2Eyes’s owner, as well as founder and director of the Dry Eye Group in Melbourne, Australia — comprising three practices that focus on dry eyes.

“One of the main reasons contact lens wearers drop out of wearing contact lenses is due to dry eyes,” he continued.

Ms. Nur Marsya Sabrina Mohamad Sahrizal, a junior optometrist at Hava Optique in Cyberjaya, Malaysia, also concurs. “As we all know, contact lenses cover the front part of the cornea. So, this prevents the cornea from getting direct oxygen and worsens the dry condition,” said Ms. Nur Marsya Sabrina.

Ms. Nur Marsya Sabrina's deep interest in dry eyes began when she suffered

from the condition herself during her optometry undergraduate days. And today, in her practice, she often comes across dry eye sufferers.

“For our patients with 0.25 or zero power, we would still suggest that they wear glasses as they help reduce the rate of moisture evaporation from the eyes and help protect the eyes,” she added.

Moisture chamber glasses

Dr. Teh said moisture chamber glasses could be prescribed for dry eyes. Currently available in certain markets, these dry eye glasses — like the ones produced by Ziena — have silicone gaskets or cups surrounding the eye area, which create a sealed pocket of protection from dust particles, wind,

and other environmental factors that could lead to dry eyes.

These moisture chamber glasses have given patients relief from dry eye symptoms and reduced reliance on eye drops. They also help protect the eyes from pollutants and reduce risks of infections that may induce dry eye episodes.

An interesting debate comes with the use of blue light filter glasses in association with dry eyes. While the American Academy of Ophthalmology (AAO) says blue light does not contribute to digital eye strain2 (rendering blue light filtering glasses unnecessary), some emerging studies are showing concerns about blue light having an impact on dry eyes.3,4

According to Mr. Ho, “There are certain studies which show that blue light filters can help dry eyes. It enables the patient to slightly prolong their wear time.”

Choose contact lenses?

For those who prefer to wear contact lenses, it is still a viable choice for eyesight correction despite the setbacks of dry eyes while wearing them. The key is in understanding the choices.

“As we know, contact lenses are directly touching our eyes, so they offer us a clearer vision when we wear them,” Ms. Nur Marsya Sabrina explained. However, she recommends that dry eye patients wear daily disposable contact lenses.

There is, however, something to take note of, contrary to popular belief. “Conventional soft contact lenses with higher equilibrium water content (EWC) may not be that comfortable for dry eyes because the water content from the lens tends to evaporate. And to compensate, they absorb moisture from the eyes’ natural tear film, increasing the discomfort for dry eyes,” continued Ms. Nur Marsya Sabrina.

Silicon hydrogel contact lenses

Here is where silicone hydrogel contact lenses could be a good alternative. These types of contact lenses carry from five up to seven times more water content than hydrogel contact lenses and are more oxygen permeable — enabling more oxygen to be carried to the eye via the water content in the lens. Thus, patients with dry eyes might prefer wearing these types of lenses.

Scleral lenses

Alternatively, dry eye sufferers with refractory issues could consider the use of scleral lenses.5 Conventionally reserved for therapeutic use, these lenses which have a larger area of coverage over the cornea have been showing efficacy ever since Kok and Visser's pivotal 1992 study6 first highlighted dry eye patients who reported longer wear time with the lens with substantial improvement in their visual acuity.

In another study7 by Alipour et. al in 2012, mini scleral lenses were used on patients with moderate to severe dry eyes due to a variety of causes.

Four out of seven patients reported relief from dry eye symptoms, decreased artificial tear usage, and improved visual acuity over their 18-month follow-up period.

“Under extreme dry eye conditions, a bandage contact lens can also be used to help heal the cornea so that normal vision and comfort can be achieved,” Dr. Teh shared.

For him, educating patients is key to mitigating this crackly issue. “Dry eye is such a silent problem initially. We can see the early signs of dry eyes, but most of the patients won’t feel it until it’s progressed to a point where they get the symptoms,” he said. “By then, the dysfunction is a lot worse. So, we’re trying to tap into that early treatment and prevention, along with education instead of waiting for a patient to be really in pain first.”

Contributing Doctors

Mr. Ryan Ho first undertook a Bachelor of Science in Microbiological Sciences at the University of Kansas, USA, in 1996 before studying Optometry at the International University College of Technology Twintech, Malaysia, in 2008. He is a skilled optometrist with over 15 years of experience. He obtained his first degree in B.Sc. at the University of Kansas, USA, and continued to pursue his passion for his Bachelor of Optometry (Hons) in Malaysia. His opinions on the treatment of Ortho-k, monovision, progressive lens fitting, and myopia in children have been well sought after on national television stations, such as RTM, TV3, and national newswires, as well as publications such as Bernama, The Star, and more. He has helped build Malaya Optical from a family-owned business of three generations to become a twotime award winner of the prestigious Brand Laureate Award. While he is busy running his retail practices, online store, and building an eyewear brand, Mr. Ho makes sure to spend

Finding the most suitable options for your patients

Dr. Teh’s practice focuses on thorough eye examinations, and at In2Eyes, they utilize the Lipiflow and the relatively novel IPL (intense pulse light) treatments. Meanwhile, at Malaya Optical, Mr. Ho runs the Oculus K5 to examine the meibomian glands and test tear break-up times.

With a choice of the most suitable lens

References

— be it glasses or contact lenses, while getting proper diagnoses and treatment, dry eye sufferers can continue battling the excruciating symptoms that often disrupt their daily routines.

“While the use of these digital lenses is very much important, patients should still be reminded of the 20-20-20 factor in managing their daily routines,” Mr. Ho concluded. “Don’t stare at the computer for over 20 minutes. Every 20 minutes, look away 20 feet for 20 seconds.”

1. Dry eye disease alters how the eye’s cornea heals itself after injury. Available at: https://medicine.wustl. edu/news/dry-eye-disease-alters-how-the-eyes-cornea-heals-itself-after-injury/. Accessed on January 8, 2023.

2. Are Blue Light-Blocking Glasses Worth It? Available at: https://www.aao.org/eye-health/tips-prevention/ are-computer-glasses-worth-it. Accessed on January 8, 2023.

3. Zhao ZC, Zhou Y, Tan G, Li J. Research progress about the effect and prevention of blue light on eyes. Int J Ophthalmol. 2018;11(12):1999-2003.

4. Niwano Y, Iwasawa A, Tsubota K, Ayaki M, Negishi K. Protective effects of blue light-blocking shades on phototoxicity in human ocular surface cells. BMJ Open Ophthalmol. 2019;4(1):e000217.

5. Bavinger JC, DeLoss K, Mian SI. Scleral lens use in dry eye syndrome. Curr Opin Ophthalmol. 2015;26(4):319-324.

6. Kok JH, Visser R. Treatment of ocular surface disorders and dry eyes with high gas-permeable scleral lenses. Cornea. 1992;11(6):518-522.

7. Alipour F, Kheirkhah A, Behrouz MJ. Use of mini scleral contact lenses in moderate to severe dry eye. Cont Lens Anterior Eye. 2012;35(6):272-276.

quality time with his family as they are the inspiration behind this brand. During his leisure time, Mr. Ho enjoys riding his road bike on numerous road adventures.

ryan@malayaoptical.com

Dr. Jason Teh is a dedicated practicing optometrist. He is the founder and director of the Dry Eye Group in Melbourne, Australia, a comprehensive diagnostic eye clinic with a vision and commitment towards a variety of advanced treatment options in dry eye disease (DED). A long-standing member of the Optometry Australia Association, Dr. Teh was also a graduate of the University of Melbourne with a B.S. in Pharmacology (Hons) in 1998 and a Bachelor of Optometry in 2001. Having lived with DED himself for more than 25 years, Dr. Teh specializes in its management. Passionate about improving lives through better vision and eye health, he is also committed to educating his patients on the causes of their dry eyes and helping

them manage their symptoms through preventative and modifying lifestyle measures. He is proud and most fulfilled by his contribution to the growth of the optometry industry by running dry eye workshops, lecturing on DED at various conferences, performing clinical research trials of new dry eye products, and assisting his colleagues to establish their own dry eye clinics.

jason@dryeyegroup.com.au

Ms. Nur Marsya Sabrina Mohamad Sahrizal is currently an optometrist at the Hava Optique eyewear company in Cyberjaya, Malaysia. She graduated in optometry from the National University of Malaysia (UKM). She has conducted research studies on dry eye diseases, and her passion lies in issues concerning contact lenses. She has conducted several community services for eye health screening offline as well as online. During her leisure time, she enjoys dancing on her own and watching horror movies.

marsyaams@gmail.com

Round the Clock

Smart lenses for 24-hour IOP monitoring, a revolution in glaucoma management?

by Andrew Sweeney

lenses,” called smart soft contact lenses (SSCL). They hope that this new design will offer all the key functions, such as lens power, biocompatibility, softness, transparency, wettability, and oxygen transmissibility — without sacrificing efficacy. The lenses are also designed to match nearly any cornea shape and with low-cost production, SSCLs can be disposed of after multiple uses.

The ability to consistently monitor a patient’s intraocular pressure (IOP) could lead to significantly improved patient outcomes — and it is something of a Holy Grail in glaucoma management.

Glaucoma is associated with IOP that gradually increases over time, and by the time the patient presents with more serious symptoms (like intense eye pain, headaches, and blurred vision), the damage has been done.

It’s no small wonder that glaucoma is often described as the “silent thief of sight.” However, it is not a condition that strikes without warning… we just often fail to notice.

As such, monitoring increases in IOP is crucially important — and so too is finding a method that can consistently monitor changes in IOP.

The gold standard in IOP monitoring

Currently, Goldmann applanation tonometry (GAT) is regarded as the gold standard for in-clinic IOP measurements, but it's not without drawbacks. The requirement for routine clinic visits remains a significant burden, especially in areas with limited facilities, and for the elderly and infirm. Handheld devices have also been developed like I-Care Home, but these have their limitations, too, such as requiring the patient to remain awake.

This is an important point — as the ideal way to understand a patient’s IOP is to measure it constantly over

24 hours — so naturally, a handheld device is limited as it can only work while the patient is awake. As such, finding a way to measure IOP during sleep is a major area of research at the moment, and one possible method uses highly adapted contact lenses. And yes, this does tend to contradict the conventional wisdom about the nocturnal wearing of contact lenses, but it’s permissible in this case.

Good news from Hoosier Country

According to a group of researchers based primarily at Purdue University (Indiana, USA), the lenses used to monitor IOP at night are much softer than usual and use ophthalmic silicone hydrogels. Such lenses can seamlessly fit a variety of corneal shapes and sizes without significant safety concerns for those even with glaucoma, other ocular diseases, or post-incisional surgeries.

The challenge in making them effective at monitoring IOP is that they need to include a wireless tonometer due to the high temperatures and corrosive chemicals required for microfabrication production. That’s to say nothing of the discomfort a patient might experience while wearing such a device in their eye during sleep, regardless of how soft the lenses are.

In a study called Smart Soft Contact Lenses for Continuous 24-hour Monitoring of Intraocular Pressure in Glaucoma Care,* researchers look into this issue and offer a potential solution, a “soft, thin and stretchable ocular tonometer [that] is built upon various commercial brands of soft contact

Can smart lenses bear the GAT?

To understand the efficacy of SSCLs, the researchers carried out a set of in vivo evaluations in rabbit, dog, and human eyes (from normal to hypertension) to confirm superior measurement accuracy, within-subject repeatability, and user comfort. They compared the results with those taken from more conventional lens-based tonometers. The results taken from the trials involving humans were the most interesting.

The IOP of the participants under postural changes was monitored in real-time with the SSCL as compared to control measurements with both the iCare Home and the Triggerfish lens at time-matched points. The researchers found that the results of the SSCL were closer to those of the GAT over the iCare Home, and that the SSCL had a high level of measurement accuracy. In an interesting sub-conclusion, unlike the Triggerfish lens, the SSCL did not produce any residual heat.

So it might not be long until we have an easy-to-use and effective tool to measure IOP in glaucoma patients. The researchers behind the study go even further: They believe that the SSCL could also be tailored for other chronic ocular diseases, such as cataract and age-related macular degeneration.

Time will tell if it will enjoy similar levels of efficacy… and that’s a development we look forward to reporting on.

Reference

* Zhang J, Kim K, Kim HJ, et al. Smart Soft Contact lenses for Continuous 24-hour Monitoring of Intraocular Pressure in Glaucoma Care. Nat Commun. 2022;13:5518.

In the Blink of an AI

Cracking the code for dry eye and glaucoma with artificial intelligence

by Matt Herman

Artificial intelligence is growing more sophisticated by the day, and researchers in dry eye disease and glaucoma are just starting to harness its power.

In the half-century plus since the advent of the first powerful computers, few technologies have garnered such breathless excitement as artificial intelligence (AI). Even before the advent of the transistor and modern silicon wafer semiconductors, human beings have had a remarkably prescient sense that one day our machines would become intelligent.

After years of promise, AI’s nascent potential is beginning to bloom. And healthcare is proving to be fertile ground for the seeds of AI to take root.

Though the most cynical among us may note that the most high-powered AIs are reserved for the military and the markets, medicine is not far behind.

In eye care, great strides have already been made with AI algorithms. Optometrists, as primary eye care providers whose duties encompass screening, monitoring, and management of disorders of the eye, stand to gain greatly. Even today, algorithms for image processing for diseases like

diabetic retinopathy, macular edema, and age-related macular degeneration are changing the field forever.

As two of the most critical ailments affecting the eye, glaucoma and dry eye disease (DED) would seem to follow. Depending on diagnostic criteria, the prevalence of dry eye in the population has been listed at between 5% and an eye-watering 50%. Glaucoma is also

consistently one of the leading causes of moderate to severe vision impairment worldwide, especially in adults aged 50 and over, where it is the second leading cause of blindness behind cataract.1

Unleashing the AI beast on glaucoma and DED would thus alter countless lives around the world. But there’s a problem.

To err is human, to diagnose is divine

Glaucoma and DED are two of the most stubborn holdouts resisting the inevitability of the AI revolution. The roots of the difficulty adapting the problems of these two diseases for powerful machines, though, ultimately lie with humans.

The issue with dry eye and glaucoma is that diagnoses can both vary from clinician to clinician. Practicing optometrists know that DED symptoms can be present without any clear signals in medical imaging.

“You can have a very clean clinical picture and still have a very symptomatic patient [with dry eye]”, said Dr. Mark Eltis, a prominent Canadian optometrist, lecturer, and prolific author in both glaucoma and DED for optometry.

Early stage, and especially normaltension glaucoma (NTG), can evade even the most scrupulous and experienced observers. And this is when the diagnosis is most critical. “Glaucoma is a disease that doesn't have any signs or symptoms for the most part,” explained Dr. Eltis. “If glaucoma is easy to diagnose, then the doctor may have been missing it for a long time or the patient has not come in regularly enough. It shouldn’t be easy.”

The difficulties for optometrists in glaucoma and DED only get murkier from there. Diagnosis of both diseases can vary greatly from practitioner to practitioner. And in the case of DED, management is subjective and highly tailored to the individual patient.

“We have so many treatments for dry eye, [as well as] diagnostics,” Dr. Eltis said. “The bad news is that buying

a piece of equipment does not make you an expert. Like with any other condition, there's no replacement for experience and training.” Though shiny tools and fancy imaging machines may be mainstays of the modern optometrist, detection and management are still down to individual practitioners and the weight of their experiences. And they can still be wrong.

Data errata

This poses massive problems for many of the most common iterations of AI being used in medicine. Whether man or machine, the strength of any decision-maker lies in the data set used to train their judgment. Human cognition is in many ways the sum of all of the experiences we have — our data set. And if there are issues with the data set, errors occur. An American who has only visited Europe (and not Malta), for example, would think that everyone in the world drives on the right until told otherwise.

Machine learning (ML), including many kinds of so-called ‘neural networks’, computer systems built to mimic the processing style of the human brain, is similarly restricted by the data set.

Mr. Daniel Eckert, a member of the computer vision and machine learning research group at Huawei, Switzerland, and developer of a smartphone-based corneal topographer, provided some insight into the problems that AI excels in. “One thing [machine learning methods] are really good at is if you optimize them to a specific problem or question. Then you have a data set with the correct answers and it learns to replicate those answers,” he explained.

“I think it's really powerful when it comes to these kinds of classification tasks where you need a yes or no response based on a well-defined problem,” Mr. Eckert continued.

The trouble, of course, is that DED and glaucoma are a classification task that is not so great with correct answers. As mentioned above, DED can have a negative clinical picture but be symptomatic. The nebulous nature of diagnosing early-stage glaucoma makes it difficult to discern what is glaucomatous and what is not.

DED to rights

At first glance, the prospects for the use of AI for DED and glaucoma in optometry may seem dismal. Depending on regional regulations, most optometrists need tools that will aid them in screening, managing, and monitoring DED and glaucoma.

But glaucoma and DED remain fundamentally classification problems, and new research into applications in the field are promising. In dry eye disease, machine learning algorithms, and especially DL algorithms and deep neural networks (DNN), are causing the biggest stir.

Tear break-up time (TBUT) is a common way of screening for DED. Thus far, four studies have been done with varying ML methods, and machines are able to get fairly close to human performance, including a 91% accuracy in detecting dry areas compared to optometrists.2

Artificial intelligence algorithms are also being fed images from interferometers and slit lamps to see if they can be of assistance. The tear film lipid layer is a font of information, and this direction of investigation is promising. Of particular interest to optometrists are studies being done to directly aid in the somewhat subjective diagnosis process, including a 100% accurate system for predicting ocular redness from slit lamp images.2

Artificial intelligence has also been used in the hunt for less conventional

biomarkers to aid in DED diagnosis. Research has shown promising results using convolutional neural networks (CNN) on various features of corneal nerves,2 which were gold for detecting meibomian gland dysfunction (MGD), a key contributor to DED. Tear osmolarity has been looked at, but the more promising avenue for optometrists is the use of tear proteins. One model combining DNN and discriminant analysis had an astonishing 89.3% accuracy when distinguishing aqueousdeficient DED, MGD, and a healthy eye using the tear proteome.2

OCT is another interesting avenue for optometry in detecting DED, though it is still in its infancy.

Corneal epithelium thickness has often been associated with DED, and a model using a CNN showed impressive accuracy in predicting severe DED,2 making this method a must for future research into image analysis.

Artificial intelligence doesn’t need to knock it out of the park with diagnosing dry eye to be useful. Time savings are also critical, especially in underserved areas, and AI showed great promise in time savings. For example, most, but not all, clinicians have little problem with meibography for looking at the meibomian glands. But a DL algorithm was found to outpace experienced clinicians in quantifying meibomian glands, and a higher degree of accuracy in determining meibomian gland atrophy.2

Glaucoma automata?

Just as with DED, uncertainty in diagnosis is the name of the game for glaucoma. And just like DED, modern machine learning algorithms are opening up doors in screening and monitoring unimaginable before AI and DL algorithms came to town.

The success of these algorithms, however, is more muted. This is because variability in screening for and diagnosing glaucoma, and especially challenging early-stage and normal tension cases, takes on a decidedly different flavor than dry eye. In DED, symptoms can be present without signals in imaging and biomarkers. In glaucoma, the disease can be asymptomatic and be nearly undetectable from imaging and biomarkers.

Dr. Eltis thinks part of this has to do with human error and a kind of imaging

indicates glaucoma. This also means that some are not always right. And even the most advanced artificial intelligence algorithms don’t jive with that.

According to a study3 assessing the issues facing AI in glaucoma, it’s all about the definition of what glaucoma actually is. The AI arrow needs a target to fly true, but this target is currently ill-defined. Once researchers can decide what glaucoma is, then it becomes manageable for AI.

“It's [still] a classification problem,” explained Mr. Eckert. “Whether you define two categories or if you define 50 categories, it's still the same class of problem.”

examination burnout. “There is a lot of manual looking and seeing [with glaucoma]. The truth is, regardless of how intelligent or perceptive or detailoriented you are, you’re gonna miss stuff because that’s just the nature of being bombarded with too much information,” he said.

Sign AI up for the job? Not so fast. It’s true that artificial intelligence algorithms don’t succumb to human quirks like getting bored, distracted, or burned out. And with image processing and classification, AI does not really miss even minute variations in things like fundus imaging or OCT. But only when it is presented with a robust and concrete data set to train on.

This is exactly where the trouble begins for glaucoma. ODs and MDs do not always agree on when an imaging set

This is a simplesounding, yet enormous task. There is wild variability in the three tests that show the most promise for AI analysis in screening — fundus imaging, OCT, and visual field testing. OCT is still wildly expensive and not widely available. There is no accepted global, and in some cases even regional, standard for any of the tests. This is particularly pressing in fundus imaging, which shows promise for low-resource environments, but is performed on anything from smartphones to clinical-standard equipment. Even some of the most promising research is being done on ethnically homogenous populations, which opens up another can of worms in data selection bias.

The list goes on. But standardization efforts are underway in the form of projects like the Crowd-Sourced Glaucoma Study at Dalhousie University in Canada, which aims to shore up OCT and visual field tests with specialist assessments of glaucoma likelihood, which would provide standardized inputs for AI to learn from and grow into valuable tools for optometrists screening for glaucoma.

A future beyond screening

Though AI glaucoma and DED have been slow out of the gate, they are well on their way to becoming prized ponies in the optometric toolbox. AI has demonstrated great ability in opening up new avenues for screening, but there is also untapped potential elsewhere.

Management is one key area that optometrists can hope to get a boost from with the helping hand of a machine, and this comes from predicting the course of both diseases. “For [prediction], machine learning is an amazing tool,” said Mr. Eckert. “The hope, of course, is that the algorithm can detect patterns that humans are not familiar with or that maybe a doctor doesn't even know yet, and then maybe gain deeper insight into the mechanisms behind it.”

standardization puzzle is unlocked. The possibilities, from scanning patient records using AI-derived tools like natural language processing, to flagging patients at high risk for more frequent checkups, would further streamline and simplify the process of catching and stopping glaucoma in its tracks.

Whatever the result is, AI can be a powerful tool. But whatever the prevailing sentiment on artificial intelligence in medicine, one thing

References

is clear to Dr. Eltis: Nothing will ever replace a human doctor.

“Ultimately, the executive decision is still left to the captain of the ship, and that's the doctor. That's why, on a ship, you have experts in terms of navigation and everything else, which translate the data or transmit the data to the captain. But ultimately, it's up to the captain to see the big picture and make an executive decision,” Dr. Eltis concluded.

1. GBD 2019 Blindness and Vision Impairment Collaborators, & Vision Loss Expert Group of the Global Burden of Disease Study. Causes of blindness and vision impairment in 2020 and trends over 30 years, and prevalence of avoidable blindness in relation to VISION 2020: the Right to Sight: an analysis for the Global Burden of Disease Study. Lancet Glob Health. 2021;9(2):e144-e160.

Contributing Doctors

Another comprehensive study4 on DED illuminated how the predictive power of AI assessment of dry eye can optimize custom treatment protocols for the management of dry eye using not only AI analysis of imaging test results, but also from medical records and population-based studies.

Similar, wide-ranging work can be done on glaucoma for predicting the progression of the disease once the

With almost 20 years of experience, Dr. Mark Eltis has practiced Optometry in New York, California, and Toronto. He is a graduate of the University of Waterloo School of Optometry and has taught there for over a decade. Dr. Eltis is a fellow of the American Academy of Optometry and a diplomate of the American Board of Optometry. He is also a faculty member of the Academy of Ophthalmic Education and has completed his California Glaucoma Certification at UC Berkeley. He has served as an examiner for national licensing assessment in both Canada and the United States. He has presented and published internationally and has been sought-after as an expert on optometric issues for national television and print. In 2013, Dr. Eltis was honored as a member of the Optometric Glaucoma Society (OGS), having “demonstrated excellence in the care of patients with glaucoma through professional education and scientific investigation.” Dr. Eltis has been reviewer for over a dozen publications, including Journal of Glaucoma and Canadian Journal of Optometry. In 2017, he was recognized for his “outstanding contribution in reviewing” by the editors of Journal of Optometry and Elsevier. He is also on the editorial

board of scholarly publications and is a US optometric residency program evaluator. Dr. Eltis has been a consultant for academic institutions overseas, contact lens/ pharmaceutical companies, law firms, and a subject matter expert for competency evaluations. He serves on the board of directors of the Council for Healthy Eyes Canada and was elected to council at the College of Optometrists of Ontario. Dr. Eltis is currently focusing his practice on dry eye patients employing the latest diagnostic and therapeutic options. He loves connecting with optometry students and the public by sharing his eye care tips on social media.

drmarkeltis@vieweyecare.com

Mr. Daniel Eckert is a computer vision and robotics expert. His interest in ophthalmology comes from being a keratoconus patient himself, and realizing the potential that interdisciplinary collaboration can bring in this space. Between 2020 and 2022, he developed a smartphone-based corneal topographer for keratoconus screening at the University of Zurich in Switzerland. He has worked for several years in the autonomous driving industry, and is currently part of the computer vision and machine learning research group at Huawei Switzerland.

deckert277@gmail.com

2. Storås AM, Strümke I, Riegler MA, Grauslund J, Hammer HL, Yazidi A, Halvorsen P, Gundersen KG, Utheim TP, Jackson CJ. Artificial intelligence in dry eye disease. Ocul Surf. 2022;23:74-86.

3. Lee EB, Wang SY, Chang RT. Interpreting Deep Learning Studies in Glaucoma: Unresolved Challenges. Asia Pac J Ophthalmol (Phila). 2021;10(3):261-267.

4. Yang HK, Che SA, Hyon JY, Han SB. Integration of Artificial Intelligence into the Approach for Diagnosis and Monitoring of Dry Eye Disease. Diagnostics (Basel), 2022;12(12):3167.

“Ultimately, the executive decision is still left to the captain of the ship, and that's the doctor. That's why, on a ship, you have experts in terms of navigation and everything else, which translate the data or transmit the data to the captain. But ultimately, it's up to the captain to see the big picture and make an executive decision.”

— Dr. Mark Eltis

Tune In To Eye Health

Dr. Elise Kramer on eye care and music

by Chow Ee-Tan

For someone who has only been in the industry for over a decade, Dr. Elise Kramer — optometrist, contact lens specialist, and musician — has a very impressive resume. If you search her name online, you’ll find that her expertise and versatility go beyond her practice.

After obtaining her doctorate in optometry, Dr. Kramer opened her own practice specializing in contact lens design and fitting, as well as ocular surface diseases, such as dry eye syndrome.

“I had never thought of working in someone else’s practice,” Dr. Kramer shared. “Even when I was still in university, I pictured myself having my own practice and doing it my way. There is nothing more fulfilling than being able to do what you love most, on your own terms. With my own practice, I can decide the type of work and time I spend on my patients, and determine my own schedule.”

Of course, starting her own business was not easy. Dr. Kramer had to do

everything from scratch. “I had never taken any business courses, so I had to learn the trade as I went along,” she said. “Yes, it is a lot of hard work if you’re both the doctor and the business owner, but it was a rewarding journey.”

It’s all in the family

“My father is a pediatrician and I have uncles and aunts who are cardiologists, radiologists, and other medical practitioners,” shared Dr. Kramer. “I always knew I wanted to be a physician, but I decided to specialize in the eye when my mother suddenly developed a benign tumor behind one of her eyes in 2007.”

Her mother had double vision and sought every alternative treatment possible to have the tumor removed for fear that she would lose her vision. “Finally, an oncologist suggested to do a series of radiotherapy treatments to shrink rather than remove the tumor,” Dr. Kramer continued.

“From this experience, I became very

interested in the eye and decided to take up optometry in university,” she shared.

A passion for eye health

Dr. Kramer graduated in optometry from the University of Montreal in Canada and proceeded to do her doctorate in optometry. She received a grant from the Scholarship Program of the Québec Ministry of Education for short-term university studies outside of Québec. In the summer of her second year, she participated in a humanitarian mission in Laayoune, Morocco, where she helped hundreds of impoverished people by giving them free eye examinations and glasses.

Her residency at the Miami VA Medical Center included training at the Bascom Palmer Eye Institute, the nation’s top eye hospital. After which, Dr. Kramer became a fellow of the Scleral Lens Education Society (SLS), where she now serves as secretary.

“I was privileged to work with a cornea specialist and helped fix contact lenses on patients. I didn’t take up contact lenses for residency because I already had very good training in contact lenses from my university years. Instead, I decided to take up ocular diseases,” Dr. Kramer shared.

She now specializes in ocular surface diseases and contact lenses, in particular designing lenses for a variety of specific conditions. “Montreal had very advanced contact lens programs. I felt quite comfortable fitting and designing contact lenses and wanted to continue to work in that specialty,” she added.

“Most of my patients who have suffered from vision loss are now wearing custom-made contact lenses I have designed using advanced technology,” she said.

Not surprisingly, Dr. Kramer devotes her practice to helping patients, many of whom have keratoconus, refractive surgical complications (such as LASIK), corneal transplant surgery, eye trauma, chronic dry eyes, corneal dystrophies, degenerations, and many others.

At the forefront in the fight against DED

Dr. Kramer is constantly at the forefront of the latest developments and findings for treatments of dry eye syndrome.

Dry eye disease (DED) affects approximately 1.5 billion people worldwide and is the most common disorder of the ocular surface. A common cause of DED is meibomian gland dysfunction (MGD), which is typically treated with lid margin hygiene, or the removal of the meibomian gland obstruction.

“Redness, burning, and gritty sensations are all common among patients with DED, as well as sensitivity to light, blurred vision, and the accumulation of water and/or mucus in the eye,” explained Dr. Kramer. She added that these symptoms are often most severe among people who wear contact lenses, and can cause persistent irritation, pain, and decreased quality of life.

She noted that DED doesn’t have to be debilitating for patients who wear contact lenses. However, she added that the condition remains somewhat underdiagnosed, and symptoms range essentially limitless due to patients believing the symptoms they experience are normal and therefore do not need to be discussed with their eye care practitioner.

One of Dr. Kramer’s specializations is designing scleral lenses — largediameter gas-permeable lenses that vault over the cornea and rest over the sclera. Scleral contact lenses provide a smooth optical surface that works to correct vision problems caused by keratoconus and other irregular cornea problem.

Dr. Kramer also specializes in diagnosing DED and prescribing different treatments for dry eyes. Her focus is on finding ways for anyone to tolerate their contact lenses if they have allergies, dry eyes, or ocular surface conditions.

She aims to identify the underlying cause of her patients' dry eye and treat it based on specific equipment

and customized treatment. “DED is chronic,” she said. “It is not a condition that can be cured but needs to be managed properly. Therefore, patient education is one of the most important aspects of my practice,” she enthused.

Mastering the art of comanagement and education

Dr. Kramer works closely with ophthalmologists. She has patients who have had surgeries or are scheduled for surgeries. Cases that involve retinal detachment vitreous issues and cataract surgery are more complex, thus she has many patients that she comanages with ophthalmologists.

What is truly rewarding for Dr. Kramer is patient care. She strives to assist each patient with quality and advanced eye care whether they require a basic eye exam or specialized vision care.

Besides improving her patients’ quality of life, Dr. Kramer’s other passion is education. She enjoys being at the forefront of education and technology to make a difference among other practitioners — to teach them and to raise awareness about different treatment options and available technology.

Her advice to young aspiring optometrists is to specialize in an area of their interest.

“There is so much more to optometry than refraction. And there are many more things we optometrists can do. We can specialize in fields that demand more specialties, and thus help more people,” she added.

This year, Dr. Kramer will be focusing more on her practice at home. At the same time, she is involved in many virtual optometry-related conferences and activities.

Her practice — Miami Contact Lens Institute — was launched in 2013. Five years later she expanded by opening a center in a second location, in Weston, about half an hour’s drive from Miami. These days, she divides her time between the two locations.

Life beyond optometry

One may be surprised to know that this single mother to a seven-year-old boy has so much energy, not just in her career but also in living life to the fullest.

Dr. Kramer can speak several languages, including English, French, Spanish, Italian, Hebrew, and Portuguese.

She is also an avid singer and musician who has released a few singles online under the name Elise Gabrielle (Gabrielle is her middle name). Dr. Kramer has been singing and playing the piano since she was four years old. Playing mostly classical music, Dr. Kramer has participated in various concerts and regional competitions.

“I guess you can say I have lots of passions and energy to spread,” she smiled.

Contributing Doctor

Dr. Elise Kramer is a residencytrained optometrist in Miami, Florida, who specializes in ocular surface disease and specialty contact lens design and fitting. She has a doctorate degree in optometry from the Université de Montréal in 2012. During her fourth year, she completed her internship in ocular disease at the Eye Centers of South Florida and went on to complete her residency at the Miami VA Medical Center. Her time there included training at the Bascom Palmer Eye Institute, the nation’s top eye hospital. After her residency, Dr. Kramer became a fellow of the Scleral Lens Education Society (SLS) and now serves as its treasurer. Dr. Kramer is a member of the American Optometric Association and the International Association of Contact Lens Educators, as well as a Fellow of the American Academy of Optometry and the British Contact Lens Association. She is also the Delegate of International Relations for the Italian Association of Scleral Lenses. Dr. Kramer has published several important articles and reviews and participates in clinical research trials. She enjoys giving lectures all around the world in several different languages about ocular surface diseases and specialty lenses.

elise@miamicontactlens.com

That’s a Relief!

Communication, compliance, and embracing innovation are key to better DED treatment

by Andrew Sweeney

Beyond joyous celebrations, the holiday season is a time often associated with niggling health complaints — ranging from winter chills and coughs to heartburn and hangovers caused by excessive consumption at parties. Tis’ the season for all sorts of optometric considerations, too, with one of the most important being the enfant terrible, dry eye disease (DED).

DED is one of the most commonly encountered conditions of late, and its sheer prevalence is only likely to grow. Unfortunately for most people, it is a chronic condition — one that they have to learn to manage.

Around 16.4 million Americans (6.8% of the adult U.S. population) have been diagnosed with DED, and an additional 6 million (2.5% of adults) may experience dry eye symptoms but have not been diagnosed with DED. That means up to 10% of the total adult population in the United States is likely to be affected by the condition, and that ratio is projected to grow in the coming years.*

So what can optometrists do to meet the rising demand for treatment for a condition that is widely prevalent and

yet remains poorly understood by much of the lay community? DED, after all, is not a condition that most people would be able to readily identify despite understanding the symptoms well enough. Itchy, sore, red, and tired eyes are complaints they’ll be aware of, but it can prove challenging that DED is what it is — a disease. It is not a minor complaint that will just go away.

To understand how optometrists can better meet this rising demand for DED treatment, we spoke with Dr. Elise Kramer, a specialist in DED and ocular surface diseases based at the Miami Contact Lens Institute in Florida, USA. Dr. Kramer has experienced a record number of referrals from other clinics experiencing high patient volumes.

Communicate with other clinicians

For Dr. Kramer, the key to successfully tackling the emerging crisis in DED is to work closely with all stakeholders in patient treatment, both with ophthalmologists and optometrists.

“There's both patient education and then there's practitioner education,”

explained Dr. Kramer. “Obviously, DED is something that we're all taught about in optometry school. But this education is not necessarily focused on the way it should be. There’s so much more to learn, especially about how to communicate with patients,” she said.

“A lot of practitioners may not have the time to fully educate their patients about DED because they have a busy practice. That happens, so if they don't have the time or resources, then they should be co-managing those cases with practitioners who do. After all, it’s hard to sit down with patients and really talk to them if there’s 60 in the waiting room,” she continued.

Simplify treatment

Dr. Kramer is optimistic about the developments that we can expect from optometry in 2023. And in her opinion, another key to achieving the best patient outcomes is to simplify treatment.

DED treatment requires a high level of compliance to work, so treatment needs to fit in with a patient’s daily routine. So for Dr. Kramer, finding

treatments that are easy to take and can be monitored by the patient’s primary care team, even if they go to multiple clinics, is the best way forward.

“I’m hoping eventually we can simplify treatment for dry eye to something more realistic for patients because there are so many parts of treatment and sometimes that can be overwhelming for them. There are a lot of different pharmacological products that are in the pipeline. So I'm looking forward to other things that are going to be released,” enthused Dr. Kramer.

Embrace innovation and technology

DED treatment is predicated on more than education, of course, and there are exciting developments in this field as more research time is given to improving treatment.

LipiFlow Thermal Pulsation System

There are a number of intriguing developments that can be observed in diagnostics, treatment, as well as in palliative care. One of the best examples is the LipiFlow by Johnson & Johnson (Jacksonville, Florida), a device that controls the application of sterile, single-use activators under and over one’s eyelids, which do not actually touch the eye ball to dissolve the gland obstructions caused by meibomian gland dysfunction (MGD) — one of the primary causes of DED.

Dr. Kramer uses LipiFlow at her clinic and she points to its simple design and ease of use as being a considerable asset for her patients. Treatment for DED needs to be easy to access and undergo for patients, she said, and shouldn’t focus solely on addressing the root cause of DED either. Treatments that can alleviate the symptoms of the disease should be considered even if they come in novel forms.

“LipiFlow is an FDA-approved treatment for meibomian gland evacuation, and having that stamp of approval means patients are a little bit keener on it. There's a lot of solid evidence that it's beneficial for patients who have MGD or posterior blepharitis. It’s a great

treatment,” confirmed Dr. Kramer.

Eximore Integrated Pack & Release Drug Delivery System

Another device that may be able to alleviate the issue of packed waiting rooms is the Eximore (Rosh Haayin, Israel) Integrated Pack & Release Drug Delivery System, also known as EXPTC. It’s a non-invasive punctal plug that is designed to optimize patient compliance via consistent dosing. It uses the eye’s dissolved natural tears to diffuse active drugs through the plug’s composite nano-channel, then the tears distribute and deliver the active drug to the eye.

This preserves the eye’s natural tears and the device can offer mono or combo therapy via the same delivery port. Crucially for overstretched clinicians, it is a non-invasive procedure, meaning the 1 mm plug can be fitted in a doctor’s office. Eximore reports that EXP-TC is undergoing trials involving 20 patients at the Hospital de la Ceguera in Mexico City.

Tyrvaya Nasal Spray

“There’s also a new nasal spray that helps with the quality and volume of dry tears, it's called Tyrvaya,” shared Dr. Kramer. “It is particularly interesting because it can be used while wearing contact lenses, whereas a lot of dry eye treatments cannot. Besides preservative-free artificial tears, a lot of the immunomodulators need to have the contact lenses removed. So it's definitely an improvement,” she added.

NOV03

While nasal sprays are a pretty cool and innovative development in DED, it’s eye drops that are going to feature more commonly — and one of these is NOV03. Developed by Novaliq (Heidelburg, Germany) under license in the US and Canada by Bausch + Lomb (Laval, Canada), NOV03 is an investigational, proprietary, water-free, single-component preservative-free eye drop. Designed to prevent excessive tear evaporation, it can restore tear film balance, stabilize the lipid layer, and penetrate the meibomian glands.

NOV03 has successfully undergone phase 3 trials with few subjects experiencing ocular adverse events (9.6% NOV03 group, 7.5% control group), and change from baseline in tCFS was statistically significantly greater in the NOV03 arm compared to the control saline group. The US Food and Drug Administration (FDA) has now assigned NOV03 a Prescription Drug User Fee Act (PDUFA) action date of June 28, 2023.

With exciting developments on the horizon, Dr. Kramer is optimistic about the good things we can expect in DED treatment in 2023. NOV03, LipiFlow, EXP-TC, among others, are all likely to help improve compliance — a key issue in DED treatment.

Reference

* O’Neil EC, Henderson M, MassaroGiordano M, Bunya VY. Advances in Dry Eye Disease Treatment. Curr Opin Ophthalmol. 2019;30(3):166-178.

Contributing Doctor

Dr. Elise Kramer is a residencytrained optometrist in Miami, Florida, who specializes in ocular surface disease and specialty contact lens design and fitting. She has a doctorate degree in optometry from the Université de Montréal in 2012. During her fourth year, she completed her internship in ocular disease at the Eye Centers of South Florida and went on to complete her residency at the Miami VA Medical Center. Her time there included training at the Bascom Palmer Eye Institute, the nation’s top eye hospital. After her residency, Dr. Kramer became a fellow of the Scleral Lens Education Society (SLS) and now serves as its treasurer. Dr. Kramer is a member of the American Optometric Association and the International Association of Contact Lens Educators, as well as a Fellow of the American Academy of Optometry and the British Contact Lens Association. She is also the Delegate of International Relations for the Italian Association of Scleral Lenses. Dr. Kramer has published several important articles and reviews and participates in clinical research trials. She enjoys giving lectures all around the world in several different languages about ocular surface diseases and specialty lenses.

elise@miamicontactlens.com

Grit Begone

How to optimize your clinic’s DED practices

by Andrew Sweeney

Every optometrist has their own techniques that they use in their practice, taking from years of education, training, and practical experience to develop the fundamental skills they first learned. That’s how improvements are discovered, after all — novel techniques and technological innovations, among others, that can advance the treatment of a wide variety of diseases.

When it comes to dry eye disease (DED), the search is always on to optimize treatment. And we recently discovered one idea best summed up by a patient named Roy Orbison…

“Crying, crying, crying, it's hard to understand, that the touch of your hand, can start me crying...”

Now, unless we’ve completely

misunderstood Mr. Orbison’s point here, he’s describing how his optometrist was able to alleviate his terrible DED by merely touching him with his hand. This remarkable new technique could be of significant value to optometrists if they can replicate what we’d like to call the Orbison technique. We are entirely certain that we have not confused this song with anything else.

But just in case we have… it’s worth considering how some of optometry’s leading minds are adapting their clinics to better meet the growing demand for DED.

Worldwide, symptomatic cases of the disease are estimated to reach 9.12% of the total population, and it is particularly prevalent in Africa, with other regions expected to experience growth in tandem with

aging populations. Onset usually begins after the fifth decade of life and is roughly as common in women as in men.1

This year, if you’re planning to start optimizing your clinic’s DED practices, here are a few pointers that might help.

Start with a basic DED checklist for your patients

The British National Health Service (NHS) has built up a considerable amount of experience in treating DED. One of its local clinical commissioning groups in West Sussex, located just south of London, created a DED treatment guide that can help clinicians prepare and optimize their clinic for this disease.

The group’s DED checklist starts with the basics, such as limiting the use of contact lenses if these cause irritation, taking regular breaks for using electronic devices with screens, and stopping medication that exacerbates dry eyes (including antihistamines, tricyclic antidepressants, diuretics, and beta blockers).

Work closely with ophthalmologists

The guide also recommends a number of practices related to more advanced DED cases and lays out how an optometrist can reorganize their clinic practices accordingly.

For example, the document recommends trialing a product for four to eight weeks to determine its effectiveness before trying out another when severe cases are suspected. When red flag symptoms and pre-existing conditions appear, such as one eye being affected much more than the other, additional dry mouth, and other mucosal tissue,

Establish effective communication with patients

Dr. Mark Schaeffer, an American optometrist who works as the clinical field manager at MyEyeDr in Birmingham, Alabama, has dedicated a considerable portion of his career to DED and has published a number of articles and research papers on finding the correct protocols for treating patients with the condition.

One of the key factors Dr. Schaeffer emphasizes repeatedly in his writings is the importance of establishing good communication with patients.

In one article, How to Present Dry Eye Therapies to Patients, Dr. Schaeffer recommends using pre-prepared scripts when communicating with patients, as this helps to balance the impact of high patient volume. He also recommends role-playing sessions where staff alternates playing patients and clinicians as it’s a good way to understand the patient’s perspective.

Other planning points Dr. Schaeffer emphasizes include detailed treatment planning, sharing experience and patient progress reports, and crucially for the American audience, explaining out-of-pocket expenses in detail.3

Consider financing options for patients

This advice works particularly well in countries that, like the United Kingdom, have a comprehensive state-funded medical system. This covers most countries in Europe as well as many in Asia.

However, how can optometrists best meet patient demand for DED treatment in countries with an entirely private healthcare system, such as the United States? In this country, many individuals go without health insurance entirely, and those who do have a policy often find that it doesn’t extend to ocular conditions like DED.

The issue of payment for treatment is a difficult one for many patients in countries with privatized healthcare like the US, and Dr. Schaeffer recommends giving the patient time and resources to decide on these services.

However, a point that needs to be emphasized during this process is that clinicians should avoid saying DED is ‘cured or healed,’ and should make it clear that the disease is a continuum from no signs or symptoms to a severe disease state.

The goal of treatment is to move closer and closer to the “normal” side, which takes time and financial input. So consider offering a number of financing options for your patients that will last the full duration of the treatment.3

References

Papas EB. The Global Prevalence of Dry Eye Disease: A Bayesian View. Ophthalmic Physiol Opt. 2021;41(6):1254-1266.

West Sussex Clinical Commissioning Group. Dry Eye Treatment Guideline. Available at https://westessexccg.nhs.uk/your-health/ medicines-optimisation-and-pharmacy/ clinical-guidelines-and-prescribingformularies. Accessed on December 29, 2022.

How to Present Dry Eye Therapies to Patients. Building Your Dry Eye Center of Excellence. Available at: https:// www.reviewob.com/how-to-present-dryeye-therapies-to-patients/. Accessed on December 29, 2022.