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Alongside Rachelle Lin, OD, MS, FAAO; Nguyễn, MD, MSc, detailed what treatments are currently available for retinal vascular diseases, including neovascular age-related macular degeneration and diabetic retinopathy.

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Myopia- Management

Artificial intelligence (AI) may hold the answers to some of the biggest challenges in optometry, according to Nahida Akter, PhD; Jack Phu, OD, PhD, FAAO; and Christopher Clark, OD, PhD, at the 2019 American Academy of Optometry meeting in Orlando.


	AI shows promise in ophthalmic applications of disease screening, image interpretation, and data synthesis. Research is exploring how modified convolutional neural networks (CNNs) can analyze patterns and data to classify glaucoma based on raw optical coherence tomography (OCT) images.

This process assessed 410 raw OCT images of temporal-superior-nasal-inferior-temporal (TSNIT) retina layers across both glaucoma and non-glaucoma patients.

“I think all of the layers have some benefits,” Dr. Akter says.

Each layer contributes to the transfer-learning based CNN, creating a more detailed profile of retinal layers that could aid ODs in clinical imaging.

Related: new research highlights how data is processed to detect glaucomatous optic neuropathy


	As ODs know, angle-closure glaucoma is a significant public health problem. Gonioscopy is the gold standard for assessing angle-closure spectrum disease, but the tool has its limitations.

“It is highly skill-intensive and highly subjective among doctors,” Dr. Phu says.

And while angle-closure glaucoma is the one form of glaucoma that can be prevented, success is contingent on an early diagnosis through gonioscopy grading.

But what if ODs could rely on anterior segment (AS) OCT imaging instead of gonioscopy?

Dr. Phu detailed the research questions his team studied. He honed in on whether quantitative parameters obtained using OCT imaging could describe the spectrum of gonioscopic angle closures that ODs typically use in the clinic.

This involved reviews of gonioscopy and AS-OCT clinical data, including evaluations of nasal and temporal angles, gonioscopic grades, and the posterior trabecular meshwork.

Results showed that while AS-OCT evaluations were somewhat reliable for identifying the continuum of change in open angles to closure, there were significant errors when no prior gonioscopic information was available.

Although there is potential for further integration of artificial intelligence models for distinguishing between open and closed angles, gonioscopy is still an essential skill for ODs. It remains the gold standard for grading angle-closure disease.

“The features that we see on AS-OCT, or any imaging device, should supplement what we already see in our gonioscopic view,” Dr. Phu says.

Retinal monitoring in diabetics without retinopathy


	Computing power has advanced to the point where ODs can explore more advanced ways to diagnose and monitor diabetes through machine learning. In particular, there are applications for measuring subclinical changes to retinal architecture, based on HA1c levels, that may indicate disease.

“We can monitor changes in the retina before people have retinopathy,” Dr. Clark says.

To do so, researchers applied several training models based on 8,760 spectral domain (SD) OCT images, all taken from people with diabetes. Data sets were analyzed and applied to each model in conjunction with data on each patient's HA1c.

Results showed that the chosen model, KNN, was effective at measuring the discrepancies in data, examining topics such as capillary distance and spacing to detect retinopathy. The model was able to predict disease incidence even with relatively low HA1c levels, indicating that there may be potential for further clinical application.

“I think eyecare professionals are going to need some sort of AI, computerized detection system to diagnosis and monitoring for the average clinician,” he says.

American Academy of Optometry

AI may be the answer for early disease detection

Halting glaucoma progression can be challenging, but as it turns out, medication is not the only tool in an OD’s toolbox. Many factors influence glaucoma progression in patients, some of which may be unrelated to the disease itself.

ODs must be aware of the hidden links among glaucoma symptoms, medication, and contact lenses with respect to how ocular surface disease (OSD) affects patient outcomes.

Karen Lee, OD, FSLS, FAAO, and Jane Kuo, OD, FAAO, rose awareness to these links at the American Academy of Optometry 2019 meeting in Orlando.


	It is known that there is a higher prevalence of OSD in glaucoma patients, primarily related to decreased tear production and break up time. These symptoms may not be related to glaucoma proper, but instead, the medical drops patients use to manage symptoms.

In particular, the benzalkonium chloride (BAK) preservative is a common culprit, present in 70 percent of ophthalmic glaucoma drops. These drops may sometimes produce side effects in patients that may reduce treatment compliance.

“When you have patients with dry eye, it really decreases the quality of life. Anti-glaucoma eye drops containing BAK compromises patient compliance,” Dr. Kuo says.

This molecule disrupts the corneal epithelium by damaging DNA and increasing inflammation. Such a disruption can create particularly challenging concerns when the patient is a contact lens wearer.

Certain contact lenses, particularly hydrogel lenses with high water content, absorb BAK molecules and release them slowly into the corneal epithelium over time. Prolonged exposure to BAK is known to increase symptoms.

Fortunately, ODs can mitigate these corneal/drug interactions through patient education.

“The big idea here is that corneal exposure time to BAK tends to be relatively short-lived,” Dr. Lee says.

The U.S. Food & Drug Administration (FDA) recommends that patients using both glaucoma drops and contact lenses wait at least 15 minutes after instilling drops before applying their lenses. ODs should share this information with their patients to ensure they understand the possible interaction between their contact lenses and their medication.

Additionally, ODs who fit glaucoma patients in contact lenses can work these considerations into their lens selection.

“I might be reaching for a low water content hydrogel soft lens if I know the patient will abuse his drops with contact lens wear,” Dr. Lee says.

Related: Keep an eye on link between glaucoma and blood pressure


	It is common for ODs to encounter patients interested in wearing contact lenses during or after surgical treatments. While there are no contraindications to contact lens wear after procedures like minimally invasive glaucoma surgery (MIGS), ODs need to assess the corneal health of each patient to determine the best approach.

“If the cornea or the sclera is not affected, then patients can potentially keep wearing what they are currently wearing,” Dr. Lee says.

However, if the cornea is affected, ODs will need to consider using gas permeable (GP)s contact lenses that produce a new refractive surface. In these cases, soft contact lenses may not be enough.

“Think about other options. Maybe using scleral topography or some customized lens designs,” Dr. Lee says.


	Glaucoma can cause corneal challenges, but what about corneal procedures that make glaucoma worse?

“As the techniques are getting more and more advanced, we are starting to see more partial thickness procedures,” Dr. Lee says.

While the link between corneal refractive surgery and intraocular spikes in pressure are not well understood, it is clear that such procedures can change the biomechanics of the cornea. For some patients with high refractive errors, this can produce a predisposition for glaucoma.

But new procedures are on the horizon, such as corneal cross-linking that can slow down or even halt progression of keratoconus without undoing corneal changes.

“We are really recommending our keratoconus patients go out and get this done,” Dr. Lee says.

However, changes to the physiology of the cornea may be unavoidable in some procedures, and ODs must be aware of these concerns before recommending a procedure.

“If your patient had glaucoma before a transplant, there is a 12-15 percent risk of glaucoma worsening afterward,” Dr. Lee says.

ODs must monitor and continue treating patients after invasive procedures, particularly helping patients manage their intraocular pressure (IOP) by testing via temporal sclera, Tono-Pen (Reichert), or globe palpation. This preventative care is a necessary part of managing patient symptoms and delivering a high standard of care.

“Try to get patients the best vision that you can in a healthy way,” Dr. Lee says.
	 

More from Greg Hill and Marek Biernacinski

Know the hidden links among glaucoma, contact lenses, and the cornea

Optometry doesn’t play a great enough role in the long-term management of chronic disease globally. Eyecare practitioners must do more to bring eye health into public health strategic plans and deconstruct the silo that so often surrounds eye care.

This was the message from the American Academy of Optometry 2019’s plenary session in Orlando. Guest speakers from the World Health Organization (WHO) presented major points from the recently released 2019 World Report on Vision. The report’s findings and its implications for optometry were explored by Alarcos Cieza, PhD, from the WHO Kovin Naidoo, OD, PhD, FAAO, and Sandra Block, OD, MPH, FAAO.


	Dr. Cieza says that the WHO recently released its 2019 World Report on Vision, a collection of research meant to share insights and strategies on the current state of optical health globally.

The report estimates that there are at least 2.2 billion people globally with a vision impairment. While optometrists are well-acquainted with the prevalence of common ocular diseases, these concerns take on a new context when viewed from a national perspective.

The WHO reports that 196 million people have age-related macular degeneration (AMD) across the world-more than half of the entire U.S. population.

“The significance of these numbers is that they proclaim the huge need for eye care around the world,” Dr. Cieza says.

An increased demand for eyecare services will force practitioners to confront current challenges related to care access, like physician shortages. These concerns are compounded by the fact that populations in lower-income areas are at higher risk for vision impairment-related problems.

To manage this, optometrists should reflect on their interventions and consider how new strategies could be applied. In particular, better service coordination will be key.

“What we see is that there is a huge amount of services provided by the private sector without any kind of coordination,” she says. “Knowledge is not shared.”
	Better coordination means, in part, examining which services need to be provided and reviewing the costs of those services. This is a crucial part of providing quality eye care to patients without the burden of undue financial hardship.

There is an urgency for action because we have a window of opportunity,” she says.”

The WHO has established specific targets for achieving improved health outcomes by 2030. To accomplish these targets, the report recommends that eyecare providers take specific actions towards progress:
	• Make eye care a part of universal health coverage
	• Implement integrated people-centered eye care in health systems
	• Promote high-quality research that tells the full story of eye care
	• Monitor trends and evaluate progress

“We hope that the eyecare sector feels the same urgency for action that we at the WHO feel,” Dr. Cieza says.

Related: ODs talk healthcare rankings in their state

Public Health eyecare in developing nations


	Optometry has a growing role to play in global health, and optometrists need to shift perspectives of the global environment for optometry.

“It is not about, ‘Who are the people who need services?’ It is about who should be prioritized when resources are limited,” Dr. Naidoo says.

Proper prioritization is vital in delivering eye care to underserved populations. Across many of the world’s public healthcare systems, there is a lack of optometry relevance which makes optical care even more difficult to provide.

Some developed countries, such as the United States, are exceptions to this, but eye care is marginalized across the world.

“We are falling far behind the population growth across the world,” he says.

And while the eyecare industry has had great successes in promoting care, these accomplishments underscore how much work there is yet to do.

Globally, there is a need for a new system that can help eyecare professionals deliver the same standard of care in developing nations as they do in countries like the United States. The expertise available in the United States has the potential to provide huge public health benefits to the rest of the world-provided that eyecare professionals can export those skills in relevant and valid ways to developing nations.

“You are the central, primary eye care for individuals in your healthcare system. In our countries, it’s not the same,” Dr. Naidoo says. “Optometrists are not the first point of contact.”

This deficit of talent will be a key obstacle to overcome, but it is not the only public health challenge worth mentioning. Access to care is an ongoing goal, as well as increased collaboration among governmental entities, schools, and other institutions.

Collaboration will be instrumental in overcoming public health eyecare challenges, both today, and in the future.

Related: Best practices for comanaging crosslinking patients


	Eye care is becoming a focal point for public health around the globe, but industry leaders, practitioners in North America have an important role to play in making care more accessible.

“The reality is, we do need to think about where we fit in the big picture,” Dr. Block says.

The World Report on Vision details strategies for better integrating eye care into public health systems, but there are challenges to overcome. One challenge is that the North American population is aging fast and experiencing more eye concerns than previously seen.

It is important to compare the U.S. to other countries. For example, Canada’s healthcare delivery model.

“The fact is, we in the United States have a significant increase in the cost of healthcare systems, and we need to do a better job,” she says.

In 2008, the United States spent 15 percent of its total gross domestic product (GDP) on health care. In 2017, it increased to 17 percent.

And while part of these costs are due to the advanced level of care offered in the U.S., the rest of it (like access to care and social determinants) can should be reviewed and reduced.

Addressing obstacles like these means considering new frameworks for healthcare delivery. Universal health care is a growing area of interest across the U.S., but improvements to systems don’t need to be drastic. ODs can improve healthcare by prioritizing vulnerable populations such as children and the elderly, for example.

“Aging combined with visual impairment, certainly, is one of our biggest challenges to address,” Dr. Block says.

Along with that, expanding services to better meet the needs of those without access to care, including those in rural communities, gains importance.  These concepts will be instrumental in addressing care access gaps moving forward and providing continuous care to all patients.

“The impact of visual impairment is far greater than we had ever thought about,” Dr. Block says. “We need to do a better job in getting surveillance all the way through the United States and ensuring both optometry and ophthalmology are contributing to the data that is out there.”

WHO vision report: How optometry can make an impact

-Breaking bad news is one of an optometrist’s toughest tasks, yet medical instruction typically grazes the surface of formal preparation for it. Without adequate educational groundwork, the distress of delivering bad news may lead to emotional detachment between optometrists and their patients.

Jay Lytle, OD, FAAO of Columbus, OH, discussed physician burnout at the American Academy of Optometry 2019 annual meeting. Armed with optometry-focused best practices and evidence-based clinical methods, Dr. Lytle equipped fellow optometrists with tools to improve patient satisfaction and prevent the negative effects of physician burnout as a result of delivering bad news.


	According to Dr. Lytle, bad news is “any news that negatively alters a patient’s view of his or her future.” In optometry, this may refer to a glaucoma or vision loss diagnosis. It may also denote the news that a patient’s favorite eyeglasses frame is discontinued or that he is not a candidate for an elective surgery he needs.

While bad news is typically associated with a terminal diagnosis, it may also refer to a finding that impedes on a patient’s lifestyle in any negative way.

Most physicians report that they deliver bad news one to two times a week, but Dr. Lytle says that number is probably higher.

“The person who determines whether news is bad or not is the patient,” Dr. Lytle says.

Why is it so difficult to break bad news?


	ODs face many difficulties associated with breaking bad news. Until recently, it was common practice to conceal a terminal diagnosis from the patient. That practice has changed and today, doctors have a legal obligation to deliver bad news.

“It’s our responsibility,” Dr. Lytle says.

One of the most common concerns is that, upon hearing bad news, patients deteriorate emotionally or physically.

In addition to that, breaking bad news is unpleasant. Many physicians don’t want to remove hope from their patients, and there may be uncertainty around how to effectively communicate bad news.

“Physicians may feel guilty-as if they have failed a patient,” Dr. Lytle says. “They could also be worried about staying on schedule with the rest of their patients.”

Research shows that physicians tend to withhold emotions or become overly optimistic when delivering bad news. But with proper education in evidence-based clinical methods like ABCDE and SPIKES, physicians can avoid stress and burnout.

Related: How pain gates affect dry eye and chronic pain


	ABCDE and SPIKES are step-by-step protocols for physicians to follow in order to communicate bad news effectively.

ABCDE stands for:
	• Advance preparation
	• Build therapeutic environment
	• Communicate well
	• Deal with patient reaction
	• Encourage emotions

SPIKES stands for:
	• Setting up interview
	• Patient’s perception
	• Invitation from patient
	• Knowledge and information
	• Emotions and empathy
	• Strategy and summary

Dr. Lytle combined the most important ideas from each method to deliver a guide for ODs. 

The first step in delivering bad news is to thoroughly review patient records and arrange for a private, comfortable setting. Optometrists should negate interruptions and allow patients to have support members present when receiving bad news.

“It is important to introduce yourself to every person present, even babies,” Dr. Lytle says. “Doing so will reinforce the family unit, and you will appear more likeable to the patient.”

The next step is to sit in a neutral body position with your feet flat on the floor and palms face down in your lap.

“Research shows that when we can see someone’s hands, we trust him more because we know he is not hiding anything,” Dr. Lytle says.

From there, ODs should ask the patient to tell them what she knows of her medical situation and wait for an invite to hear more by asking an open-ended question such as, “Is this a good time?”

“Asking such a question allows the patient to take responsibility of the news,” Dr. Lytle says.


	The most challenging part of delivering bad news is sharing it with empathy.

“Don’t be afraid to be silent,” Dr. Lytle says. “Offer tissues. One of the best ways to handle someone who is crying is to allow silence and space for her to let it out.”

Best practices advise ODs identify and explore the patient’s emotion, then make a connecting statement to validate it, such as “you are correct to think that way.”

“We often don’t do this part; the clinic gets busy, and we forget. But it’s so important,” Dr. Lytle says.

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