EYE DIGEST BCDO’S QUARTERLY OPTOMETRIC MAGAZINE
APRIL 2019
the
FINANCIAL issue
Tax Tips
for Optometrists
Dr. Talisa Dennis Shares her journey to become an optometrist
Gardening Tips Enjoy the gifts of sunshine!
info@optometrists.bc.ca 604.737.9907
BC Doctors of Optometry 121 –10551 Shellbridge Way, Richmond B.C, V6X 2W8
CONTENTS
Finances Funding a Shareholder’s and Buy-Sell Agreement 101 .................................................................................... 4 Tax Tips and Deductions for Optometrists........................... 6 Private Company Tax Changes.................................................. 10 Bank Rate & Prime Rate ............................................................... 14
Industry Nikon Presents: SeeMax Ultimate............................................. 16 2019 New Member Benefits .............................................................. 18
Programs Eyesafe ................................................................................................. 20
Spotlight on a Member Dr. Talisa Dennis ............................................................................... 22 2019 Annual Conference & OPTOFAIR Re-Cap...................... 24
Research Establishing AMD Center of Excellence ............................... 28 The Importance of Testing for Osmolarity in Dry Eye Patients ............................................................................. 30 Corneal Hysteresis for the Diagnosis and Management of Glaucoma ......................................................... 32 Concussion in the Twenty-First Century: an Optometric Perspective......................................................... 36
Leisure Springtime in the Province: What to Do Outside ..................................................................... 40 Gardening Tips ................................................................................ 44
FUNDING A SHAREHOLDER’S AND BUY-SELL AGREEMENT 101 Alphil Guilaran, CPA, CA, CFP, CLU, TEP Financial Literacy Counsel Inc., Co-founder and Financial Coach
Getting your practice off the ground can be a time-consuming process and sustaining it may require a continuity and succession plan. This might include bringing in a business partner or multiple partners. ODs have expressed that during their training, core courses focused on clinical competency. Unfortunately, they were somewhat unprepared when it came to the business side of being an OD and co-owning clinics with other ODs. This includes learning the importance of having a written shareholder agreement to define the relationship between you and your business partners. As a follow-up to the Financial Literacy Counsel’s Continuity and Succession Planning session during the 2019 BCDO Conference, we want to build on the theme of sustainable OD practices by highlighting shareholder agreements as a must-have document to govern a multi-owner practice. Creating a written shareholder’s agreement is one of the most effective ways to clearly outline duties and responsibilities for how you and your business partner(s) will run the OD practice. It outlines how revenues, expenses, salaries and future financing commitments will be handled. This agreement also clearly outlines how to trigger an exit from the partnership through buy-sell provisions and shot4 | Eye Digest Magazine
gun clauses inside the shareholders agreement. Some OD practices have a standalone buy-sell agreement to compliment the shareholder’s agreement to deal with buying out shares in the event of death, disability or critical illness of one of your partners. It is important to seek legal advice to make sure that you have one drafted and that it is reviewed and updated on a yearly basis. For ODs who do have shareholder agreements and buy-sell agreements to govern business partnerships, one important consideration needs to be whether or not there is adequate money to fund the provisions found in the agreements especially in the event of incapacity, sickness and premature death of a business partner. Without proper funding, all the best intentions found in the shareholder and buy-sell agreement will fall apart. In closing, the time is now to review any gaps in your shareholder and buy sell agreement or to setup these documents. This should also provide the opportunity to review
FINANCES
There are a few ways ODs fund their agreements: 1. After tax savings in the professional corporation a. Taxable investment income that the owners put away in an investment account. 2. Borrowing money from the bank when needed a. With the loss of a business partner, the ability to borrow will be affected and the amount borrowed must be repaid over time. 3. Business overhead, life, disability, critical illness insurance a. The most cost-efficient way to fund shareholder and buy-sell agreements is through the use of business overhead, life, disability and critical illness insurance. These policies provide guarantees when they are setup ahead of time and can be used for funding a buyout of a partner whether it is because of retirement, disability or a critical illness diagnosis for one of the business partners.
your insurance coverages to ensure you have adequate business overhead, disability, critical illness and life insurance to reflect your current financial situation. As a BCDO member, if you have any questions or concerns about OD money matters includ-
ing funding shareholder agreements or financial planning don’t hesitate to reach out and take advantage of the financial coaching benefits provided in collaboration with Financial Literacy Counsel. Contact FLC directly at 604.872.4972 or by email at consultation@flci.ca Eye Digest Magazine | 5
Tax Tips and Deductions for Optometrists Richard Wong, CPA, CA of Baker Tilly WM LLP (formerly Wolrige Mahon LLP) Richard has extensive experience in providing accounting and tax services to health professionals. For more information, Richard can be reached at rwong@bakertilly.ca or at 604.691.6886.
It’s that time of the year again‌it is almost time to file your 2018 tax returns! Now is a good time to go over the various deductions and tax credits so that you are not missing out. Here is an overview of some of the most relevant ones for optometrists. If one has an incorporated practice, the business expenses would simply be claimed through their corporation.
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Home Office Expenses If you use your home as your principal place of business (e.g. an associate practicing at various clinics but without an office there) or to regularly see patients then you can deduct the business portion of expenses including rent, mortgage interest, home insurance, property tax, utilities, and repairs and maintenance. The business portion is based on the square footage of the home office (must be a room and not just a designated space in the living room) relative to the total square footage of the home.
s Automobile Expenses
Wages to Family Members
You can claim the business portion of automobile expenses although commuting costs are excluded. Deductible costs include lease payments (max $800 per month), interest expense (max $3,600 per year), depreciation (through capital cost allowance or CCA), fuel, insurance, registration fees, and repairs and maintenance. Since the deduction is pro-rated for the business-use portion, it is important to keep a logbook detailing the distance and purpose of each trip to substantiate your claim. Business-related costs like parking and tolls are fully deductible.
You can deduct wages paid to a spouse or children to perform work for your business although the amount must be similar to what would be paid to an unrelated employee. This is beneficial if your spouse or children are in a lower tax bracket than you.
Meals and Entertainment You can deduct 50% of meals and entertainment costs including meals incurred when travelling to conventions or on business.
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Office Supplies and Equipment Office supplies such as stationary as well as medical supplies are deductible. Equipment including computer and medical equipment is not deductible in full but can be depreciated through capital cost allowance or CCA with the rate dependent on the type.
Utilities The business portion of utilities such as your mobile phone and internet service is deductible.
Professional Fees Legal, accounting, tax preparation, and consulting fees are deductible.
Professional Dues and Insurance Dues required to maintain membership in a professional body (e.g. College of Optometrists of BC) as well as dues to professional associations (e.g. BC Doctors of Optometry) are deductible. Liability insurance is deductible although life insurance is not unless required as a collateral for a loan.
Home Buyer’s Amount (First Time Buyers) You and/or your spouse or common-law partner can claim $5,000 (credit amount is $750) for the purchase of your first home provided that you did not live in a home that was owned by either of you in the current or preceding four years. The amount can be split between spouses or common-law partners but the total cannot exceed $5,000.
Parents Parents are entitled to various tax credits and deductions for their children: 8 | Eye Digest Magazine
• Canada Child Benefit: Introduced in July 2016, this replaced the myriad of existing credits. This is a monthly non-taxable amount that is based on the number of children, their ages, whether any have a disability, and on family income. You will need to apply for this benefit. • Childcare Expenses: These can be deducted from income for the lower-income spouse up to a maximum of $8,000 for each child under the age of 7 and $5,000 for each child between the age of 7 and 16. If the child has a disability, a larger amount can be claimed. • Registered Educational Savings Plan (RESP): While not only a tax-time item, parents should set this up for their children in order to receive the Canada Education Savings Grant (CESG) that adds 20 cents for every dollar contributed up to a maximum grant of $500 per year (for a contribution of $2,500). The grant is paid annually up to the year in which the child turns 17 and there is a lifetime limit of $7,200. Unused grant amounts in a year are carried forward to future years although due to catch-up limits it could take more than a year to claim unused amounts.
US Citizens The US requires its citizens and green card holders to file income tax returns even if they are not resident in the US. This means that persons who were born in the US and left as a child are still required to file annual income tax returns. US legislation requires foreign banks to disclose certain information about US citizens which increases the chance of detection of non-filers. While the credit for Canadian taxes payable will often result in no US taxes payable on the US income tax return, a return must still be filed and penalties for non-compliance can be significant. Programs to assist in getting filings up to date are available for US citizens who are behind on their filings.
Eye Digest Magazine | 9
Private Company Tax C Income Sprinkling and Richard Wong, CPA, CA of Baker Tilly WM LLP (formerly Wolrige Mahon LLP) Richard has extensive experience in providing accounting and tax services to health professionals. For more information, Richard can be reached at rwong@bakertilly.ca or at 604.691.6886.
In the past year, the federal government has rolled out significant changes regarding the taxation of private companies. Since many optometrists have either incorporated their practices or are planning to do so in the future, this is of particular relevance to them.
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Changes: d Passive Income Introduction to Incorporation Incorporation, the creation of a separate legal entity, is done by many optometrists mostly for the tax benefits:
(e.g. children aged 18 or over). This benefit was removed on January 1, 2018 since dividends paid to family members must now be reasonable on the basis of labour and capital contribution as well as risk assumption. Dividends in excess of this amount are now subjected to an additional tax on split income (TOSI). There are certain circumstances that exempt family members from the reasonability test, such as the spouse of an owner who is aged 65 or over, and family members aged 18 or over who work at least 20 hours a week in the year or a total of five years in prior years. Although not eligible for professional corporations or companies who earn more than 90% of their income from services, family members aged 25 or over who own at least 10% (by vote and value) of such a business are also exempt
• T ax Deferral: Effective January 1, 2019 in BC, income in a corporation is taxed at the small business low rate which is 11% on the first $500,000 of business or professional income. This contrasts with personal tax rates which are much higher, topping out at 49.8% on income above $205,843 in 2018. The low corporate tax rate leaves more funds for a corporation to invest which is financially beneficial. While corporate tax rates are lower, additional taxes apply to funds withdrawn from corporation so this is a tax deferral as opposed to a tax savings strategy. • Income Sprinkling: A corporation enables Changes to the Taxation a high income earner to sprinkle income of Passive Income Earned to family members at lower tax brackets in a Corporation which realizes tax savings. This can be done through salaries and dividends; aside Passive income includes investment income, from a few exceptions, these now need to rental income, and capital gains (although for be “reasonable” meaning that it must be this purpose capital gains from the sale of active similar to the amount paid to an unrelated business assets are not included). For tax years beginning after 2018, if total individual for the same work. investment income in the prior year exceeds $50,000 (assuming a 5% return it would require Changes to Income Sprinkling investments of $1 million) the $500,000 limit of Prior to 2018, dividends could be paid to related active business income eligible for the low tax shareholders without regard for reasonability. rate would be reduced such that it would be This resulted in significant tax savings when nil once investment income reaches $150,000. paid to family members at lower tax brackets In other words, for every $1 that the $50,000 Eye Digest Magazine | 11
passive income threshold is exceeded the small business deduction limit is reduced by $5. While active income within the small business limit is taxed at 11%, such income above the limit would be taxed at 27% which in essence is an additional tax on investment income. However, it is important to note that this higher tax enables the payment of eligible dividends to shareholders which result in a lower personal tax so that the overall tax (combined corporate & personal) is only marginally higher. The additional tax on passive income essentially decreases the benefits of tax deferral by reducing the differential between corporate and personal tax rates. Various strategies can be employed to minimize the impact of the additional tax including: • Withdrawing more funds from the corporation and investing in RRSPs. • Employing permanent life insurance (whole or universal life) products since those earnings are not included in the passive income calculation. These also enable wealth transfer to future generations through payouts as tax-free capital dividends to beneficiaries. • Selling investments and realizing capital gains over several years to stay under $50,000 per year. • Ensure that passive income is minimized through deducting related expenses such as interest on loans used in investments and investment management fees.
Tax Changes Regarding Unbilled Work or Work-In-Progress (WIP)
these amounts (at the lower of underlying costs and expected revenue at the hourly rate). In the past, only amounts that were billed by year-end needed to be included in revenue. Fortunately, this is usually not applicable to most optometrists since most services are billed when rendered. An example of when this would be applicable is when a patient comes for a multi-visit treatment but is only billed at the end and the year-end falls before that; this unbilled work would now need to be included in revenue at year-end.
BC Province Employer Health Tax (EHT) In conjunction with the end of MSP premiums beginning on Jan 1, 2020, the BC government introduced a new Employer Health Tax (EHT) which came into effect on January 1, 2019. This tax applies to employers whose BC remuneration exceeds $500,000 in a calendar year. The EHT is taxed at 2.925% of BC remuneration between $500,000 and $1.5 million with amounts above this taxed at 1.95%. Note that this only applies to salary paid out (including to shareholders) but does not include dividends or gross revenues. As such, most optometrists will be below the $500,000 threshold but this could affect larger clinics whose payroll exceeds $500,000.
Conclusion
As a result of these new changes, optometrists are encouraged to consult their accountants to ensure that they are in compliance and in the best position to optimize their tax situation. For tax years starting after March 21, 2017, Nonetheless, there are still significant tax beneprofessionals with rendered but not billed fits to be potentially realized through professervices or WIP will need to include in revenue sional corporations.
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Eye Digest Magazine | 13
Bank Rate & Prime Rate Katie Van Nguyen, Finance Manager, BC Doctors of Optometry
Why do we look at a bank rate forecast? Because it can help you make personal and business decisions. Here is a little insight on bank rate, the rate at which financial institutions can borrow from the Bank of Canada. As expected, the current bank rate of 1.75% (also called the overnight rate) remained unchanged on Wednesday, March 6, 2019. None of the major banks had expected the Bank of Canada to raise rates. Recent economic data shows the Canadian economy had been shrinking for the last three months of 2018. It appears the housing slowdown has been a drag on economic growth. The next rate will be announced on April 24, 2019.
Currently, Canada-wide prime rate is at 3.95%. The prime rate, also known as the prime lending rate, is the interest rate that financial institutions set for variable loans and lines of credit, including variable-rate mortgages.
Overall, there’s an upward trend in rates for the next six months; most economists anticipate a quarter point increase in the bank rate in mid-2019. By the end of 2020, the majority
The prime rate increases when the bank rate goes up, so variable and adjustable mortgage rates might rise from 0.5% to 0.75% by the end of 2020.
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of economists expect at least three more rate increases up to 2.25%. The bank rate was 4% in 2007, so the forecast rates stay within the longterm range. The bank rate influences other interest rates, such as those for consumer loans and mortgages, which makes it important for real estate as well as banking transactions.
Prime Rate
Please note that this is a forecast of competitive rates for an average mortgage. Available mortgage rates vary depending on the purpose of the mortgage (e.g., purchase, renewal/transfer, refinance, rental property) as well as other factors (e.g., mortgage default insurance, amortization, loan-to-value). Based on this forecast, you can see that locking in today’s 3.6% 5-year mortgage rate will start benefiting you in 2020 if variable rates go up to 4.2%. The average forecaster predicts that
variable rates will rise another 0.5% over the next 2 years. Some predict further rate increases in 2021, while others predict a recession that might lead to a decrease in rate. Given the uncertainties, there is no right or wrong answer when choosing between locking in or taking a variable rate mortgage. If you
choose to lock in, you will be in good company because, according to Mortgage Professionals of Canada, 68% of homeowners in 2018 held a fixed-rate mortgage. However, if you think of selling your home or moving in the next few years, then locking in a rate may not be an ideal option, as it can result in a large penalty fee if you cancel the mortgage before the full term is completed. The fee can be quite high, so keep this in mind when deciding to lock in an interest rate.
References: https://www.bankofcanada.ca/ https://business.financialpost.com/ https://www.canadianmortgagetrends.com/
Eye Digest Magazine | 15
Nikon Optical Canada Inc. is Launching a Revolutionary Progressive Lens:
SeeMax Ultimate Nikon has developed a broad expertise in customization over the past 15 years. In fact, it has been the central thrust of the company’s R&D efforts in optics over the years and has recently evolved even further. Nikon continues to distinguish itself as an innovator. It is with great pride that we introduce the beginning of a new era, where the uniqueness and sensitivity of each individual’s vision are fully taken
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into consideration. It is an unparalleled experience made possible by a new high-end progressive lens: the SeeMax Ultimate. Nikon’s new patented Insights technology takes into account your preferences, needs and habits. With 428,793740 possible combinations, each SeeMax Ultimate lens gives its owner a unique visual “fingerprint” while adapting to his or her visual habits. Your vision will seem limitless!
Eye Digest Magazine | 17
say
2019
YES to Savings!
New Member Benefits MemberPerks Enhanced Healthcare for Members With your BCDO membership you have access to Venngo, BCDO’s new discount program partnership, which provides members with access to discounts at a variety of stores, restaurants, and service providers. There is no additional cost to register, as access to Venngo is included with your BCDO membership. If you have suggestions for businesses to add to the Venngo program, you can use the “Suggest a Perk” feature on the Venngo website. 18 | Eye Digest Magazine
BC Doctors of Optometry has partnered with Great West Life and Financial Literacy Counsel Inc. to provide members and their families with access to individual health insurance. Members can choose from three plans with various levels of coverage depending on the member’s needs. Contact Bobby Ning at Financial Literacy Counsel Inc. for more information: bobby.ning@flci.ca or 604-603-0201.
Coming Soon: Online COPE-Approved Continuing Education Partnership with SECO University
SECO and BC Doctors of Optometry are working together to help members succeed. When you enrol in SECO University, not only will you have access to their growing library of online courses, but you will also support the Association. When you subscribe at the $299 USD annual rate, a full 50% ($149.50) goes to BCDO to support its yearly activities. With enough support from our member optometrists, this can represent a significant secondary income stream for our Association. No matter how you look at it, it’s a win-win situation both for you and BCDO, while helping SECO continue to provide the finest education in the profession. The annual SECO University subscription gives optometrists access to: •
100 hours of COPE-approved online CE, with an additional 50+ hours by the end of the year
•
108 courses not for credit
•
11 years of SECO Audio Course Recordings (1,200+ hours)
•
5 years of multi-media posters (a total of 450) from the Advanced Media Learning Center.
Stay tuned for more information! Eye Digest Magazine | 19
PROGRAMS The past few years have held a lot of change for the BCDO prescription safety eyewear program. Back in 2016, the OVP Committee and the Association staff completed the Strategic Plan and generated a list of priorities and goals for the program. This included rebranding of the current Prescription Safety Eyewear program and introducing a more intuitive online ordering and accounting system. As of January 2019, we have been proudly operating our new Eyesafe program. We have also introduced an updated Frame Core Kit, which includes new suppliers, and continued to work with the national and provincial safety standards for prescription eyewear. The BCDO optometrists initiated the Safety Eyewear program almost 40 years ago. Their vision was simple: to address the safety concerns of the BC workers by providing an inexpensive and complete safety eyewear package that complied to national and provincial standards and was backed up with the support and knowledge of the optometry profession. Thanks to them, 40 years later, we have over 350 companies registered through our program, tending to the needs of over 300,000 employees. We would like to improve upon these successes and expand the program to help more BC workers. Every day, 700 Canadian workers sustain eye injuries on the job. These injuries range from simple eyestrain to severe trauma that can cause permanent damage, vision loss, and blindness. A surprising 70% of all eye injuries result from flying objects the size of a pinhead or smaller striking the eye, and 90% of all these injuries can be prevented by wearing the correctly fitting eyewear. The BCDO Prescription Safety Eyewear program message needs to reach a greater number of BC employers or employees. Three 20 | Eye Digest Magazine
out of every five workers injured were not wearing protective eyewear at the time of the accident. The main obstacles to wearing safety eyewear are the following: thinking glasses are too expensive, company policy doesn’t enforce wearing safety eyewear, and the eyewear doesn’t fit properly or is uncomfortable. Eyesafe gives you, the optometrist, the confidence and control to help clients to adhere to or exceed the Canadian Standards Association and the American National Standards Institute safety standards while being simple to manage for company employees and for optometrists’ patients. Due to lack of awareness of prescription safety eyewear programs, it is our goal to be the number one source for doctors who want to prescribe protective glasses. Eyesafe will continue to promote and educate eye safety both in the workplace, doctors’ offices, and at home. In 2019, we plan to expand the program to doctors’ offices for non-company safety orders to allow employees whose employer is not part of a safety eyewear program, as well as self-employed, contract workers, and other individuals, to purchase protective glasses through an optometrist’s office. This will enable you to protect your patients’ eyes, their expensive dress eyewear glasses, and increase the profitability of your office through second-pair sales. If you require further information regarding the Eyesafe program or wish to request a meeting with our team, please contact us and we will be more than happy to assist you.
Spotlight on a Member Dr. Talisa Dennis Career Path What inspired you choosing optometry as your profession? I gravitated toward health care because I wanted to merge my interest in science with my passion for taking care of others. The push to go into optometry versus other health care options happened when I went on a Volunteer Optometric Services to Humanity trip with my dad in my second year of science undergrad. It was on that trip that I decided to apply for optometry, as I was able to witness the fundamental value of what optometry does for us all. I realized how optometry helps us to see our best and how this enhances and allows us to enjoy life. It is touching to see someone put on What are some successes and challenges a pair of glasses for the first time and see their you have as a young OD? face light up, as if they are seeing a new world. I find young ODs are successful because we tend to be the most up to date about what is Is there anything you would change about current in our field. We are comfortable with your career if you could? technology, and we have lots of opportunity I would like to see a medically geared shift in ahead of us. how others see our profession. I would like the A challenge can be translating book knowlpublic and other health care providers to see edge to live practice; however, success is when, optometrists as the primary healthcare prac- over time, you see how you can do this on your titioners for eye care. For example, a patient own. The customer service and sales aspect of with red eye would come directly to us, rather the job and interpersonal part can be challengthan seeing another health provider first and ing, as people can be unpredictable. As we are then requesting a second opinion from an OD. I partially private pay, I do feel like we need to would like the public to understand the impor- excel in customer service more than a physician tance of a routine eye exam, even if they do would for example. Also, as one of the unique not need to wear glasses. Additionally, I would jobs where medicine and fashion are combined also like to see optometrists paid as well for our into a sale, I feel it can be trickier to know how medical services and expertise as we are for to best set out your recommendations. For me glasses sales. I do think there is a shift towards personally, as an introvert, this has been chalthis, as more practitioners undertake speciali- lenging. However, it has also been rewarding ties within optometry. as I work on improving these skills, the positive 22 | Eye Digest Magazine
benefits translate to other areas of my life as well.
As a practicing Optometrist in BC, how does the BCDO help you? The BCDO has helped me get involved and keeps me updated about what is going on within optometry in BC outside of my own practice. They have provided me with mentorship from other ODs and support from the BCDO staff, as well as the chance to give back to others by being a mentor myself and working on different committees and the board. Working with them has given me the opportunity to grow and expand my leadership skills. The BCDO also helps with providing many member benefits, continuing education opportunities, and discounts, and the Association assists in government relations by negotiating more opportunities for us as ODs to help serve our patients better. The BCDO also helps with advertising and educating the public on what we can offer such as the ESEL program for Kindergarten children.
The Profession of Optometry
with their glasses; that is success to me. I also like the aspect of technology that is involved, and I hope that our profession will continue to evolve along with technology to best serve our patients.
Advice for New Grads Tell us about your education in the field of optometry. What were the biggest challenges? Optometry school provides us with a significant amount of knowledge relating to eyes and eye care. Our final year of optometry school is the most relevant as it is hands on, applying what we have learned in class in a practical setting. We are evaluated and have mentors during the process of being at different work sites in our final year. A challenge is getting the most out of all the stages at school and applying it to the real world. Tying these aspects together comes with time and experience, but it certainly helps to have good mentors along the way.
How well did university prepare you for life as an optometrist?
What kind of person do you need to be to succeed as an optometrist?
I do think university programs give us what we need to know about optometry skills, but I found I think you need to be someone who genuinely learning about the avenues for the career paths we can take with that education required a lot of cares about others, who is focused on helping self-exploration. This can be intimidating because patients as well as staff. I always take it to heart there is no set framework around what to do after what is best for the patient sitting in my chair. In school. Although it is touched upon briefly, we are terms of everything else, I believe many differnot taught a lot about the business side, nor do ent personality types and mindsets can be we learn much about interpersonal communicasuccessful. There are several different modes of tion in school. These are challenges that we have practice and paths you can take in optometry. to set our own goals for and resolve on our own. I Having the determination to go for it and make find I am still working on these components, as I your career what you want it to be is important. am in the process of deciding what my long-term goals are for my career. What do you enjoy / value most about I find BCDO helpful in this process. I like being an optometrist? volunteering with the BCDO because it opens I like how we get to meet all different kinds of up my network with other ODs and helps me to people daily and help them out. I love when see what types of practice others are in, which people are satisfied with a medical treatment or is fun to see. Eye Digest Magazine | 23
2019 Annual Conference & OPTOFAIR Re-Cap
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The 2019 Annual Conference & OPTOFAIR, held at the Hyatt Regency Vancouver from February 22-25, 2019, was once again a successful event. A total of 420 optometrists and 110 optometric staff attended, and 64 different vendors exhibited in our OPTOFAIR. Renowned speakers such as Drs. Justin Bazan, Jay Haynie, Joseph Sowka, Yin Tea, Clark Chang, and Michael Kling held OD sessions. Three courses were offered on the subjects of finance, wellness, and legal issues. A hands-on 2-hour workshop, “Contemporary Orthokeratology for Myopia Control in Children,� was offered for practising optometrists. The program also included an interactive Peer Circle by the College of Optometrists allowing colleagues to identify and resolve quality problems related to clinical care. Optometric assistants (OAs) also had knowledgeable speakers, including Drs. Errin Bligh, Sandy Johal, Mahnia Madan,
Petar Prpic, Surjinder Sahota, and Sherman Tung. In addition, our corporate partners, Johnson & Johnson Vision, Carl Zeiss, Nikon Optical Canada, and Visual Eyes, had the opportunity to present non-credited product-only sessions to attendees. Over 460 delegates attended the OPTOFAIR to visit 65 different vendors while participating in a variety of prize draws and enjoying specialty themed cocktails. This year, entertainment was literally on fire with the fire show performances and a 9-foot interactive LED robot. A total of 17 different prizes were raffled, including Apple watches, gift cards, a BCDO membership fee waiver, and beautiful art from our BC First Nations. The Chocolate Passport tradeshow game was a sweet addition to the OPTOFAIR. Delegates visited participating booths to collect gourmet chocolates until completing their bonbon box.
To network and mingle, delegates attended the Seeing is Believing cocktail reception at the Waterfront Rogue Kitchen & Wetbar. DJ Kyboom provided the music for the evening, and guests enjoyed food and entertainment. The star of the night was our ice sculpture— cocktails travelled through the ice before reaching guests’ glasses. Our President Dr. Johnathan Lam hosted the Awards Luncheon where delegates received updates from the Alberta Association of Optometrists, the Saskatchewan Association of Optometrists, the Manitoba Association of Optometrists, and the University of Waterloo. At the luncheon, Dr. Lam presented the OD of the Year Award to Dr. Sherman Tung, the Young OD of the Year Award to Dr. Brad Genereux, and the Industry Representative of the Year Award to Ms. Lindsey Wightman from Bausch + Lomb. These winners set high standards in innovation, patient care, and professionalism. At the Annual General Meeting, delegates
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met with Dr. Lam and the BCDO stakeholders, the BCDO Board of Directors, the CAO representatives, as well as non-members. They discussed the strategic priorities, the treasury rep o r t , m em b er en g a g e me nt proj e ct s, p u b l i c awa ren ess i n i t i at ive s , a nd ou r n ext step s i n negotiations with the government officials. Dr. Lam shared our new advances in 2019, including a partnership with the Ministry of Health to advance children’s eye health and vision development in BC; the launching of our Eyesafe program with a new core frame kit; and the partnership with Venngo, North America’s largest discount program that is available now to all the BCDO members and staff. We are especially grateful to our corporate partners, exhibitors, speakers, and the BCDO team for delivering this incredible Conference & OPTOFAIR. It was a truly team effort. Our event has become a landmark in North America’s eye care, and it gets bigger and better every year! We look forward to seeing you in 2020!
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3 RESEARCH
Effective Strategies for Building Your
AMD
Center of Excellence
Dr. Lowe is a graduate of Loyola University with a Doctor of Optometry Degree from the Illinois College of Optometry, where she was awarded Alumnus of the Year in 2002. She has published several articles regarding eye health and speaks at many optometric conferences across the country. She serves on the Contact Lens and Cornea Section, is a spokesperson for the American Optometric Association, Director of Vision Source Chicagoland, and is active in several other wellrespected optometric organizations. Dr. Lowe is also the owner of Professional Eye Care Center in Niles, Illinois. Pamela Lowe, OD, FAAO
There are certain tasks we optometrists perform every day to ensure our practices run smoothly. From inventory management to team-bonding sessions, we all have a certain rhythm that we’ve become accustomed to, yet I find sometimes it helps to shake things up a bit. I found I had to step out of my comfort zone to pursue my goal of establishing our practice as an AMD Center of Excellence. What prompted this paradigm shift? A while back I started asking my patients over the age of 50 if they were having problems seeing at 28 | Eye Digest Magazine
night. To my surprise, many reported difficulties adjusting from bright light to darkness – much more than I expected! Knowing dark adaptation impairment is the first symptom of subclinical AMD, I realized I needed to act to help this undertreated demographic. It takes effort to strive for the formidable objective of turning your practice into an AMD Center of Excellence, but it is attainable. With the right mindset and planning, practices committed to their AMD patients can successfully implement dark adaptometry into their retinal exam routine.
1. Identify Patients at Risk for AMD 2. Invest in Dark Adaptation Technology 3. Educate and Inspire
Identifying At-Risk Patients It’s vital to identify patients who are at risk for developing AMD to ensure proper measures are taken to help preserve their vision. The most common risk factors are pre-determined: • Age (1 in 8 over age 60; 1 in 3 over age 75) • Gender (females are twice as likely to develop the condition) • Concurrent diabetes • Concurrent cardiovascular disease • Family history • Race (specifically Caucasian) • Light-colored eyes In contrast, there are other risk factors that can be modified and should be addressed: • Smoking • High cholesterol • Obesity • Chronic sunlight exposure Following a healthy diet, exercising regularly and maintaining overall health are sound goals for all patients. These lifestyle choices may act synergistically to prevent or delay onset or progression of AMD. As a clinician, it is best practice to examine your patient for risk factors and devise a plan of action to prolong their quality of vision.
Invest in Dark Adaptation Technology Is your patient 50 or older? Are they having difficulty seeing or driving at night? Is it hard for them to read in dim light? Is this dark adaptation impairment a normal part of aging or something worth investigating further? Pay close attention as these could be red flags. Dark adaptation impairment is the first
symptom of AMD and occurs very early in the disease, at least three years before drusen can be seen during a clinical evaluation. In fact, dark adaptation is a highly accurate measure of retinal function and is useful in the detection of AMD. Thus, measuring the time it takes for your patient’s eyes to adjust from bright light to dark – the Rod Intercept (RI) – offers an opportunity to intervene early in the disease, well before visual loss occurs. The AdaptDx dark adaptometer is revolutionizing the way AMD is detected and monitored and, as such, has become an essential part of our AMD armamentarium. It is easy to fit into our workflow, has a minimal learning curve, and the patients seem to find it valuable. That one objective measure, the Rod Intercept, helps me to confidently diagnose and treat my patients. It also helps me to identify when the disease progresses, so I can take proper measures. What can I say? Investing in the AdaptDx is one of the best business decisions I have made as a clinician.
Educate and Inspire Intervening early in the disease is critical. That’s why, as doctors, education starts with us and it is our job to stay informed of the latest studies, technologies, and treatments on the market. AMD is the leading cause of blindness for adults in developed countries and knowing when and how to detect AMD is one of optometry’s biggest opportunities to impact patients’ lives positively; as well as build stronger, more profitable practices. Identifying risk factors, educating patients on lifestyle modification and prescribing nutritional supplements, plus assessing retinal function using the latest dark adaptation technology is a winning combination in our fight against AMD. Develop an AMD Center of Excellence and your practice will not only better serve your patients, but it will also inspire other optometrists. Together, we can greatly impact the standard of care of our AMD patients. Eye Digest Magazine | 29
THE IMPORTANCE OF TESTING FOR OSMOLARITY IN DRY EYE PATIENTS Diana Ferraez, MBA Marketing Director, I-MED Pharma, Inc.
Early detection of dry eye disease (DED) is key to stopping its progression but the lack of clinical signs in the early stages, combined with the fact that there is no single test that is 100% reliable to distinguish dry eye patients from normal, often makes it challenging to establish a diagnosis. Because of the increasing prevalence of this condition and its known complications in the later stages such as permanent ocular surface damage, neuropathic eye pain and visual impairment, screening for DED is becoming the standard of care.
Who suffers from dry eyes? It is estimated that 30% of Canadians suffer from dry eye disease, and this number is expected to rise in the years to come. It is a condition that can affect anyone, young or old, and is one of the leading reasons for in-office consultations with eye care practitioners. It can be caused by a variety of factors, such as side effects from medication, environmental factors (air conditioning, heating, sun, wind), refractive surgery, wearing contact lenses and diet. Tear film quality can also be affected as the ageing process occurs, as symptoms of dry eye are more likely to present themselves after the age of 55. It’s estimated that 50% of patients walking into an optometrist’s or ophthalmologist’s office have dry eyes. 30 | Eye Digest Magazine
What is the relationship between the quality of the tear film and dry eyes? The tear film is what keeps the eyes sufficiently hydrated and lubricated. When it works properly, it protects the eyes and guards them against infection. When the tear film evaporates or breaks up too quickly, dry eyes are the result. The quality of the basal tears can be compromised by an inadequacy of any of the 3 layers (lipid, water, mucin) of the tear film. Osmolarity (the concentration of dissolved salts in a solution), along with tear instability, is part of the core mechanisms behind DED. High levels of osmolarity, or hyperosmolarity, result in a loss of water in the epithelial cells.
Why is tear osmolarity so important? While the lack of correlation between signs and symptoms of dry eye disease makes it difficult to diagnose, tear osmolarity has the capacity to predict the severity of DED with high accuracy. I-MED Pharma’s I-PENŽ, a hand-held diagnostic device, is designed for in-practice screening both for patients presenting with dry eye symptoms and for all pre- and post-surgical patients. Used with a patient questionnaire, it’s an invaluable tool for two main reasons. First, the measure of osmolarity allows to recommend the appropriate treatment for patients based on the severity of the condition. Second, it can be used to monitor the progress of dry eye treatment therapies. The results can then be shared with patients, showing them exactly where
they fall on the severity dry eye scale, which helps them understand their condition better, even when there may be a disconnect between their signs and their symptoms. This empowers patients and often helps them to continue with their therapy, thus improving clinical outcomes. DED is a public health issue with a significant cost both financially and to the quality of life of those affected. Osmolarity testing represents a significant opportunity for eye care professionals to grow their practice by identifying which of their patients have DED and getting them onboard with a treatment plan that they can understand and comply with. Eye Digest Magazine | 31
Corneal Hysteresis for the Diagnosis and Management of Glaucoma: The Time is NOW Dr. Felipe Medeiros Dr. Medeiros joined Duke Ophthalmology as Professor in August 2017. His research has been published in over 300 peer-reviewed publications, 40 book chapters, and five books on the evaluation of the optic nerve, visual field, intraocular pressure, diagnosis and progression of glaucoma. His work has received over 11,000 citations with an h-index of 60, one of the highest in the field of Ophthalmology. As a result of his research productivity, Dr. Medeiros was named recently as one of the Top 5 Glaucoma Researchers in the World. Dr. Medeiros had the honor of recently being selected to be the first scientist to have a profile featured by in Ophthalmology, the Journal of the American Academy of Ophthalmology. In 2018 He received the prestigious ARVO Cogan Award, given annually to researcher age 45 or younger. Glaucoma is a leading cause of irreversible IOP.4 Other studies since have confirmed this blindness worldwide. The number of affected and established CCT as a glaucoma vital.5–6 people is on the rise and is expected to increase It should be noted that these studies did not to 112 million by 2040.1 Despite advancements in find that CCT-based IOP correction adds value diagnosis and treatment, glaucoma is frequently to glaucoma decision making, but that the undetected or diagnosed too late. Many treated CORNEA ITSELF is associated with glaucoma.7 patients continue to lose vision, despite appar- Glaucoma diagnosis and treatment requires ent disease control.2 Traditional risk factors proper risk stratification so that resources can include: Age, race, elevated IOP, family history, be allocated to the proper patients. Since glauand optic nerve characcoma is progressive in When compared to other risk teristics (fundus photos, nature, identification of OCT, etc).3 The land- factors CH was 2x more related to its onset is essentially mark Ocular Hyperten- glaucoma progression than IOP impossible. As such, sion Treatment Study patients with risk factors and 3X more than CCT (OHTS), published are monitored over time, in 2001, precipitated a paradigm-shift in our sometimes for years, until reaching a definitive understanding of glaucoma risk with the finding diagnosis.8-9 Unfortunately, despite advancethat Central Corneal Thickness (CCT) was more ments in our understanding of glaucoma risk, associated with development of glaucoma than all the factors noted have poor sensitivity 32 | Eye Digest Magazine
and specificity.10 Once diagnosed, accurately predicting which patients are likely to progress more rapidly remains difficult. The good news is that a newer parameter, corneal hysteresis, can help us to more accurately identify risk of developing glaucoma AND risk of more rapid visual field loss from the disease. Hysteresis, a term meaning “delay�, is a physical property of materials or systems that have a viscous component. Corneal Hysteresis (CH), measured by the Ocular Response Analyzer (ORA), is a biomechanical parameter indicative of the cornea’s ability to absorb and dissipate energy. In addition to providing CH, the ORA also provides IOPcc: An IOP measurement that is less effected by corneal properties than other tonometers, including Goldmann Applanation (GAT). Since the operation of the ORA was first described by Luce in 200511 there have been nearly 700 publications establishing evidence for these parameters. A substantial number of these publications focus on glaucoma risk and progression. Several early publications found that CH is associated with visual field loss. Eyes with worse VF damage tend to have lower corneal hysteresis than normal eyes, or glaucomatous eyes with higher CH. This association is independent from CCT and IOP and is evident even in cases of asymmetric glaucoma progression when IOP and CCT are statistically identical in both eyes of the same patient.12-15 Numerous studies have provided us with a better understanding of WHY CH is related to glaucoma, showing that corneal biomechanics are related to deformability of the optic nerve and structural changes consistent with the development and progression of glaucoma.16-18 The aforementioned studies were retrospective and found evidence of an association between CH and glaucoma. To determine if the CH measurement is predictive of glaucoma progression, a series of prospective longitudinal studies were conducted. In the first study a group of 68 glaucoma patients were followed over a 4-year period. Researchers demon-
strated that the baseline CH measurements were significantly predictive of the rate of future glaucoma progression. When compared to other risk factors CH had two times greater associate with glaucoma progression than IOP and
Every 1 mmHg lower CH was associated with a 21% increase in the risk of developing glaucoma over three times greater than CCT. Importantly, investigators showed that CH explained the impact of IOP on rates of progression. Patients with a high IOP and low CH were particularly at risk for rapid progression. Patients with high IOP and high CH did not progress rapidly.19 This revelation should fundamentally change the way we stratify risk, and determine efficacy of treatment, in glaucoma patients. These same investigators sought to determine if these findings were also relevant to glaucoma suspects. 199 patients suspected of having glaucoma were followed over a 4-year Eye Digest Magazine | 33
period. In this study, the baseline CH was predictive of development of visual field loss. Even after adjusting for age, intraocular pressure, central corneal thickness, PSD, and treatment, CH was still the parameter that was most predictive of glaucoma development. Every 1 mmHg lower CH was associated with a 21% increase in the risk of developing glaucoma. These finding support the role of corneal hysteresis as an important factor to be considered in the assessment of glaucoma risk.20 Beyond CH, numerous studies have demonstrated the usefulness of the ORA “IOPcc” measurement, These studies have shown that the IOPcc measurement agrees with GAT on average, but is not affected by CCT, corneal curvature, and corneal biomechanical parameters like Goldmann and other tonometers are.21 This would seem to indicate that IOPcc is closer to the true IOP. To validate this theory, a
prospective observational study compared IOP measurements from three tonometers (GAT, iCare, and IOPcc) in glaucoma patients followed over time. The results showed that the IOPcc measurement was significantly more associated with glaucoma progression than estimates of IOP provided by GAT and iCare.22 In conclusion, the corneal hysteresis measurement is no longer novel. A wealth of evidence confirms the usefulness of this parameter in the diagnosis and management of glaucoma. In every instance where CH has been compared to other risk factors the Corneal Hysteresis measurement is significantly more associated with glaucoma risk. In addition, the IOPcc measurement appears to be a clinically useful tool for the accurate assessment of IOP. The time is now to incorporate this valuable information into routine clinical practice.
References 1. CY. Global prevalence of glaucoma and projections of glaucoma burden through 2040: a systematic review and meta-analysis. Ophthalmology. 2014 Nov;121(11):2081-90. 2. Deol M, Taylor DA, Radcliffe NM. Corneal hysteresis and its relevance to glaucoma. Curr Opin Ophthalmol. 2015 Mar;26(2):96-102. 3. Who Is at Risk for Glaucoma? https://www.aao.org/eye-health/diseases/glaucoma-risk 4. Gordon M, Beiser JA, Brandt JD, Heuer DK, Higginbotham EJ, Johnson CA, Keltner JL, Miller JP, Parrish RK 2nd, Wilson MR, Kass MA. The Ocular Hypertension Treatment Study: baseline factors that predict the onset of primary open-angle glaucoma. Arch Ophthalmol. 2002 Jun;120(6):714-20; discussion 829-30. 5. Leske MC, Heijl A, Hyman L, Bengtsson B, Dong L, Yang Z; EMGT Group. Predictors of long-term progression in the early manifest glaucoma trial. Ophthalmology. 2007 Nov;114(11):1965-72. 6. Medeiros FA, Sample PA, Zangwill LM, Bowd C, Aihara M,Weinreb RN. Corneal thickness as a risk factor for visual field loss in patients with preperimetric glaucomatous optic neuropathy. Am J Ophthalmol 2003;136:805–813. 34 | Eye Digest Magazine
7. James D. Brandt, MD, Mae O. Gordon, PhD, Feng Gao, PhD, Julia A. Beiser, MS, J. Phillip Miller, AB, and Michael A. Kass, MD for the Ocular Hypertension Treatment Study Group Adjusting Intraocular Pressure for Central Corneal Thickness Does Not Improve Prediction Models for Primary Open-Angle Glaucoma Ophthalmology. 2012 March ; 119(3): 437–442. 8. Chan, Michelle P Y et al. Glaucoma and Intraocular Pressure in EPIC-Norfolk Eye Study: Cross Sectional Study. The BMJ 358 (2017): j3889. PMC. Web. 21 Nov. 2017. 9. Gordon MO, Kass MA: The ocular hypertension treatment study: design and baseline description of the participants. Arch Ophthalmol 1999, 117:573–583. 10. Tielsch JM, Katz J, Singh K, Quigley HA, Gottsch JD, Javitt J, Sommer A A population-based evaluation of glaucoma screening: the Baltimore Eye Survey. Am J Epidemiol. 1991 Nov 15; 134(10):1102-10. 11. Luce DA. Determining in vivo biomechanical properties of the cornea with an ocular response analyzer. J Cataract Refract Surg 2005; 31:156–162. 12. Congdon NG, Broman AT, Bandeen-Roche K, et al. Central corneal thickness and corneal hysteresis associated with glaucoma damage. Am J Ophthalmol. 2006;141:868–875. 13. De Moraes CV, Hill V, Tello C, Liebmann JM, Ritch R. Lower corneal hysteresis is associated with more rapid glaucomatous visual field progression. J Glaucoma. 2012 Apr-May;21(4):209-13 14. Sullivan-Mee M, Billingsley SC, Patel AD, et al. Ocular response analyzer in subjects with and without glaucoma. Optom Vis Sci 2008; 85:463–470. 15. Anand A, De Moraes CG, Teng CC, et al. Corneal hysteresis and visual field asymmetry in open angle glaucoma. Invest Ophthalmol Vis Sci 2010; 51:6514–6518 16. Wells AP et al. Invest Ophthalmol Vis Sci. 2008;49:3262-3268. 17. Lanzagorta-Aresti A, Perez-Lopez M, Palacios-Pozo E, Davo-Cabrera J. Relationship between corneal hysteresis and lamina cribrosa displacement after medical reduction of intraocular pressure. Br J Ophthalmol. 2017 Mar;101(3):290-294. 18. Zhang C, Tatham AJ, Abe RY, Diniz-Filho A, Zangwill LM, Weinreb RN, Medeiros FA. Corneal Hysteresis and Progressive Retinal Nerve Fiber Layer Loss in Glaucoma. Am J Ophthalmol. 2016 Jun;166:29-36. 19. Medeiros FA, Meira-Freitas D, Lisboa R, Kuang TM, Zangwill LM, Weinreb RN. Corneal hysteresis as a risk factor for glaucoma progression: a prospective longitudinal study. Ophthalmology. 2013 Aug;120(8):1533-40. 20. Susanna CN, Diniz-Filho A, Daga FB, Susanna BN, Zhu F, Ogata NG, Medeiros FA. A Prospective Longitudinal Study to Investigate Corneal Hysteresis as a Risk Factor for Predicting Development of Glaucoma. Am J Ophthalmol. 2018 Mar;187:148-152. 21. Medeiros FA, Weinreb RN. Evaluation of the influence of corneal biomechanical properties on intraocular pressure measurements using the ocular response analyzer. J Glaucoma. 2006 Oct;15(5):364-70. 22. Bianca Susanna, Carolina Susanna, Fabio Daga, Alberto DinizFilho, Robert Weinreb, Linda Zangwill, Felipe Medeiros. Association between Rates of Visual Field Progression and Intraocular Pressure Measurements Obtained by Different Tonometers. Ophthalmology (accepted for publication July 2018) Eye Digest Magazine | 35
Concussion in the Twenty-First Century: an Optometric Perspective Kenneth J. Ciuffreda, OD, PhD, FCOVD-A Diana P. Ludlam, BS, COVT Barry Tannen, OD, FCOVD Kenneth J. Ciureda, OD, PhD, FCOVD-A New York City, NY OD 1973, Massachusetts College of Optometry PhD, Physiological Optics University of California at Berkeley School of Optometry Distinguished Teaching Professor SUNY, State College of Optometry Research Diplomate in Binocular Vision American Academy of Optometry Diana P. Ludlam, BS COVT New York City, NY BS, 1962 Doane College, (English/Music) COVT—the first therapist certified by COVD
Barry Tannen, OD, FCOVD, FAAO Hamilton Square, NJ 1978, Colgate University, Biology 1982, Pennsylvania College of Optometry Private Practice, Hamilton Square, NJ Associate Clinical Professor, SUNY College of Optometry Program Supervisor, Vision Therapy and Neuro-Optometric Rehabilitation Residency (Southern College of Optometry) 36 | Eye Digest Magazine
The phenomenon of concussion is not a new medical problem. It dates back to ancient Greece, in the Hippocratic Corpus, as “commotio cerebri”.1 It is derived from the Latin word ‘concutere” meaning “to shake violently,”2 which is a great, intuitive description for the typical ‘coup-contrecoup’ injury found in this population. The word concussion has been used over the past century in a variety of contexts, but mainly in sports, with the phrases “death harvest” in football (1905)3 and “punch drunk” in boxing (1928).4 This important issue of concussion continues today, with even greater intensity and interest. This has come about as a result of the recent wars in Afghanistan and Iraq, where mTBI/concussion was the “signature injury”5 and really the “invisible” injury in many cases. This then led to the present area of sports concussion,6 in particular those involving considerable physical contact, once again focusing on football and boxing. Thus, the area has come the full circle over the past 100 or so years. This recent attention has had a positive aspect. It has alerted the medical establishment, and the optometric community, to the general
problem, and more specifically to the constellation of visual problems so prevalent in this population. This includes general refractive, binocular/ oculomotor, and ocular health issues, with their unique problems is each of these areas.7,8 More specifically, they include a range of oculomotor and non-oculomotor deficits. In the former case, there are dysfunctions of the versional (e.g., saccadic dysmetria, reading eye movements), vergence (e.g., convergence insufficiency), and accommodative (e.g., accom modative insufficiency) systems, and thus there are a range of motor dysfunctions. Under non-oculomotor deficits, this includes abnormal egocentric spatial localization, photosensitivity, motion sensitivity, vestibular problems, visual field defects, and visual information processing and perceptual dysfunctions — and thus there is a range of sensory and perceptual dysfunctions. Lastly, there is a range of non-vision-based problems (e.g., attentional issues, cognitive deficits) that, in general, we as optometrists cannot address directly except by referral. Eye Digest Magazine | 37
However, these nonvision-based problems are important to recognize and address, as their presence will likely adversely impact on the patient’s prognosis and progress in vision rehabilitation. Over the past decade, our profession of Optometry has “stepped up” to fill this gap and the visual needs in a multitude of ways in this population, for both the civilian and military population. First, we have attended and participated in professional meetings of the military and veteran’s associations dealing with this important topic. Second, we have organized symposia dealing with the topic at all of the national optometric organizations, including COVD and the American Academy of Optometry, and furthermore have published these proceedings as ‘special’ issues of the various journals (e.g., JOVP, VDR). Third, we have organized specific courses in the area at COVD and NORA, and other organizations. Fourth, we have been politically active at the national governmental level to lobby support for these ideas and related congressional bills. Fifth, we have been given hospital privileges to assess and treat the mTBI/ TBI patient in the hospital setting. Sixth, we have been aggressive in our clinical
and basic research in the area, for example developing objective approaches in the diagnosis and treatment of concussion/mTBI, including attempting to find the related, diagnostic “visual biomarker” for its presence. 9 Seventh, we have developed a residency programs in this area (e.g. NeuroOptometric Rehabilitation at SUNY College of Optometry), with others likely to follow in the near future, as well as fourth year externships in this area of optometry. Lastly, COVD has started a new journal, most appropriately named, “Vision Development and Rehabilitation,” with the goal of providing the latest optometric and interdisciplinary clinical research in this exciting area. In doing the above, and more, we in Optometry have increased our clinical abilities and acumen in the area to help diagnose and remediate the range of sensory, motor, and perceptual dysfunctions frequently found in patients with concussion, with yet further advances to develop the most efficacious treatments for these visual problems in additional randomized clinical trials. 10 Given the above, the future bodes well for the optometric care of vision problems in the “concussion/ mTBI” patient.
Correspondence regarding this perspective should be emailed to Barry Tannen, OD, at btannenod@aol.com. All statements are the authors’ personal opinion and may not reflect the opinions of the College of Optometrists in Vision Development, Vision Development & Rehabilitation or any institution or organization to which the author may be affiliated. Permission to use reprints of this article must be obtained from the editor. Copyright 2015 College of Optometrists in Vision Development. VDR is indexed in the Directory of Open Access Journals. Online access is available at http://www.covd.org.
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References 1. Masferrer R, Masferrer M, Prendergast V, Harrington TR. Grading scale for cerebral concussions. BNI Qrtly 2000:16;ISSN 0894-5799. 2. Pearce JM. Observations on concussion. Europ Neurol 2007;59:113-119. 3. Maroon JC, Mathyssek C, Bost J. Cerebral concussion: a historical perspective. Prog Neurol Surg 2014;28:1-13. 4. Martland HS. Punch drunk. JAMA 1928 ;91:1103-1107. 5. Warden D. Military TBI during the Iraq and Afghanistan wars. J Head Trauma Rehabil 2006:21;398-402. 6. Pieroth EM, Hanks C. Management of concussion in the professional football player. Prog Neurol Surg 2014; 28:171-183. 7. Ciuffreda KJ, Ludlam DP. Conceptual model of optometric vision care in mild traumatic brain injury. J Beh Optom 2011;22:10-12. 8. Ciuffreda KJ, Ludlam DP, Yadav NK. Conceptual model pyramid of optometric care in mild traumatic brain injury (mTBI): a perspective. Vis Dev Rehabil 2015;2:105-108. 9. Ciuffreda KJ, Ludlam DP, Thiagarajan, P, Yadav NK, CapoAponte, JE. Proposed objective visual system biomarkers for mild traumatic brain injury. Mil Med 2014;179:12121217. 10. Thiagarajan P, Ciuffreda KJ, Capo-Aponte JE, Ludlam DP, Kapoor N. Oculomotor neurorehabilitation for reading in mild traumatic brain injury (mTBI): an integrative approach. NeuroRehabil 2014;34:129-146.
Canadian Optometrists in Vision Therapy & Rehabilitation
traumatic brain injuries and vestibular problems Practical knowledge to implement right away!
PINNACLE: CLIMBING TOGETHER Aug. 23-25, 2019 Vancouver marriott pinnacle
Canadian Optometrists in Vision Therapy & Rehabilitation (COVT&R), would like to help you get your start into Vision Therapy or Expand your knowledge in Vision Therapy.
Join us for our 2019 AGM.
CE with theoretical knowledge, practical workshops, tradeshow event, wine and cheese, and a gala night.
Let's learn and party together. Bring your teams!
VISIT OUR WEBSITE TO REGISTER: WWW.VISIONTHERAPYCANADA.COM Eye Digest Magazine | 39
Springtime in the What to Do Outside After a long period of deep freeze, the nature of British Columbia is finally waking up. When the snow melts and the trees look like massive marshmallows , it’s hard to resist spending some time outside. Our province has a plethora of things to offer when it comes to spring and early summer activities. From the sandy ocean shores to the majes-
tic mountain peaks, there are dozens of places worth visiting, whether you’re travelling alone or off on a family vacation. We have compiled a list of outdoor events and activities, from the Italian Day on the Drive to the Kamloops Wine Festival, that span from spring to early summer, so you can get outside and enjoy the beautiful spring season!
Greater Vancouver & Fraser Valley Sakura Days Japan Fair Dates: April 13 to April 14 Address: VanDusen Botanical Garden, 5251 Oak Street at 37th, Vancouver, BC Phone: 604.257.8335 Website: www.vcbf.ca/community-event/sakura-days-japan-fair
Sakura Night Dates: May 5 Address: Stanley Park Pavilion, 610 Pipeline Road, Vancouver, BC V6G 1Z4 Phone: 604.257.8120 Website: www.eventbrite.ca/e/2019-sakura-night-tickets-53313392793
Vancouver’s Richmond Night Market Dates: May 10 to October 14 Address: Concord Pacific Place, 811 Carrall Street, Vancouver, BC Phone: 604.244.8448 Website: www.richmondnightmarket.com
Italian Day on the Drive Dates: June 9 Address: 1726 Commercial Dr, Vancouver, BC Phone: 778.783.0655 Website: www.italianday.ca 40 | Eye Digest Magazine
Province: Langley Greater Vancouver Food Truck Festival Dates: June 15 Address: Douglas Park 206 St, Langley, BC Contact: info@fvfoodtruckfestival.com Website: www.fvfoodtruckfestival.com/events
Lafarge Lake Annual Free Fishing Day Dates: June 16 Address: 1299 Pinetree Way, Coquitlam, BC Phone: 604.980.9311 Website: http://festivalcoquitlam.ca/events/ lafarge-lake-annual-free-fishing-day
6th Annual Strawberry Festival Dates: June 22 Address: 23823–72nd Avenue, Langley BC Phone: 604.888.1665 Website: www.driedigerfarms.com
Vancouver Coast & Mountains First Nations Feast & Performance Dates: April 18 Address: 4584 Blackcomb Way, Whistler, BC Contact: 1.800.944.7853 Website: www.whistler.com/arts/squamish-lilwat-cultural-cen tre/#two
Whistler Farmers’ Market Dates: May 26 Address: 4545 Blackcomb Way, Whistler, BC Website: www.whistler.com/events/whistler-farmers-market/
Lower & Upper Vancouver Island Tofino Public Market Dates: May 18 to October 12 Address: 3rd Street @ Campbell Street, Tofino, BC Phone: 250.788.1943 Website: www.tofinomarket.com
BC Seafood Fesitval Dates: June 8 to June 16 Address: All around Comox, Vancouver Island, BC Phone: 250.400.2882 Website: www.bcseafoodfestival.com
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Northern & Interior Kitamaat Open Basketball Tournament Date: April 12 to April 14 Address: Kitamaat Village Recreation Centre and Mount Elizabeth Secondary School 396 City Centre, Kitimat, BC Website: www.kitimatbasketball.com
Chetwynd International Chainsaw Carving Championship Dates: June 6 to June 9 Address: 97 Hwy Little Prairie, BC Contact: chetwyndchainsawcarvings@gmail.com
Central Okanagan & Kootenay BC Wildlife Park Date: ongoing until April 30 Address: 9077 Dallas Drive, Kamloops, BC V2C 2A9 Website: www.bcwildlife.org
Kamloops Wine Festival
Date: June 1 Address: 101–465 Victoria Street, BC, Kamloops, BC Website: www.tourismkamloops.com/listing/kamloops-wine-festival/975/ Eye Digest Magazine | 43
Gardening Enjoy the gifts of sunshine!
Imagine this: It’s a warm summer afternoon and you bring to the dining table a fresh salad prepared only with vegetables and fruits grown in your garden. Your guests are amazed! They love your garden and they love your food! The truth is, there is nothing more rewarding than sharing your own fresh vegetables
or fruits with your family and friends. April is an ideal month to start gardening, and the benefits to your well-being are tremendous: stress reduction and enhanced mental clarity, all while soaking in vitamin D and exercising. Here are four tips to start growing your garden and having a refreshing summer.
Plan Your Season To avoid stunted seedlings, determine when to begin planting your starts by following the chart below.
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Tips April
Arugula, broad beans, beets, broccoli, cabbage, carrots, kale, leeks, lettuce, onions, peas, potatoes, radish, spinach, swiss chard, turnips.
May
Arugula or rocket, bush beans, beets, broccoli, cabbage, carrots, kale, leeks, lettuce, onions, peas, spinach, swiss chard, turnips.
June
Arugula, beets, bush beans, broccoli, cabbage, carrots, corn, cucumbers, kale, lettuce, soy beans, spinach, squash, swiss chard, turnips.
July
Arugula, bush beans, beets, broccoli, cabbage, cucumbers, kale, lettuce, peas, spinach, swiss chard, squash, turnips.
August
Arugula, carrots, lettuce, peas, spinach, swiss chard, turnips.
Eye Digest Magazine | 45
Seeding First, test the soil to make sure it has the right density and the right amount of water. You do this by squeezing some of the soil tightly in your fist. The soil is wet enough if a single drop of water trickles out between your fingers. Seeds should be sowed to a depth that is equal to their length. Knowing this, make the appropriate indents into the soil seeding 2 or 3 seeds per cell, pressing down a little on the seed, and then cover with soil. Sewing more than one seed will ensure a high germination rate.
Love Your Seeds
Seedlings like warm, humid, bright places, with enough nutrients to get them to maturity. In other words, they need light, heat, water, and nutrients. Like everything in life, the secret lies in finding a good balance Make sure your plants have 8 to 12 hours of direct sunlight per day and mist your plants two times a day instead of watering them, which will help to avoid root rot because of poor soil drainage. Also, the right combination between soil, nutrients, and perlite or vermiculite is needed for the roots to properly develop. Here are two recipes for healthy potting mix: 6 parts of mature compost, 3 parts of vermiculite, and 3 parts of perlite; or 3 parts of peat moss, 2 parts of perlite, 2 parts of compost, and 1 part of garden soil.
Watch It Grow
Your seed packet will give you estimated times of germination. Depending on the seed, germination can take just three days or up to two or more weeks. All seeds need to be checked daily to ensure the soil is moist, but not wet. On cold days or at night cover your plants with clear polyethylene but on warm days or during sunlight uncover the plants so they don’t overheat. We hope these tips help get you into your garden and enjoying the fruits of your labour. Happy spring season! Eye Digest Magazine | 47
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