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The State of the Art and the State of the Science in Ocular Therapeutics

By: JEFFREY R. VARANELLI, OD, AND NICHOLAS COLATRELLA, OD

Supplement Credits: 2

This COPE Accredited activity captures content from interviews with key opinion leaders in the field of optometry.

Participants should read the CE activity in its entirety. After reviewing the material, please complete the self-assessment test, which consists of a series of multiple-choice questions. To answer these questions online and receive real-time results, please visit www.evolvemeded.com and click “Online Courses.” Upon completing the activity, and achieving a passing score of
higher than 70% on the self-assessment test, you may print out a CE credit letter awarding. The estimated time to complete this activity is 1 hour.

Expiration Date: Thursday, February 28, 2019
Release Date: December 2015

Learning Objectives

Upon completion of this activity, participants should be able to:

• properly diagnose external infectious and inflammatory eye disease

• discuss lid disease therapies and perioperative treatment strategies

• assess chronic conditions such as ocular surface disease and ocular allergies

• discuss current and emerging ocular allergy treatment options

• describe effective perioperative management of ocular surface disease

• interpret glaucoma diagnostic techniques

• incorporate current glaucoma therapeutics and address patient compliance

• explain effective combined surgical and medical glaucoma management

• describe key aspects of corneal and cataract surgery comanagement

• recognize new agents in the pipeline and off label indications for emerging agents.

Statement of Need

Identification of Educational Gap

Optometrists face increasing pressure to remain current in their clinical knowledge, diagnostic skills, and selection of therapeutic options due to a number of important factors. Shifts in population demographics, access to care, and the increasing number of aging patients will continue to have significant implications for the delivery of modern eye care for years to come. As population changes lead to shifts in ocular disease prevalence, ophthalmic development in pharmaceuticals and new medical device technology continues to change the treatment strategies available to optometrists. As an example, Tsontcho Ianchulev, MD, noted during the March 2010 Innovative Glaucoma Surgery Symposium that he had identified 548 ongoing clinical research studies, including 24 device studies and 198 studies in the active recruitment phase for glaucoma treatment.1 The coordinated management of dry eye disease therapy, including preoperative and post-surgical attention to the ocular surface, can be a significant factor in patient satisfaction. Knowledge of the ocular surface impact of pharmaceuticals and surgical techniques is a continual process as new options are studied. Bielory and O’Brien also noted the importance of ocular allergy diagnosis and treatment in candidates for laser corneal refractive surgery.2

Investigators have also found that ocular allergy is frequently underdiagnosed prior to elective eye surgery and perhaps underreported as the cause for poor outcomes in patients that suffer from dry eye following refractive surgery.3 Key aspects in improving the effective delivery of ocular disease treatments include expanding the diagnostic skills of clinicians, as well as the awareness of patient symptoms and available treatment options. Additionally, in a review of past Dulaney Foundation medical education activity feedback, fewer than 40% of glaucoma experts responding were aware of the prevalence of ocular surface disease among glaucoma patients being treated with topical IOP-lowering medications. Clearly, the ocular surface plays a key role in all areas of patient satisfaction when implementing other disease therapies or managing preoperative and postoperative surgical care.

Patient compliance with prescribed therapies remains a significant barrier to effective treatment in many areas of ocular disease, especially in glaucoma management, where failure can lead to the permanent loss of vision. In fact, new research in the journal Ophthalmology involving glaucoma medical therapy adherence and visual field defects demonstrated that patients “who were less than 80% adherent, according to the MEMS devices, were significantly more likely to have worse defect severity.”4

The issue of patient adherence to medical therapy is a key aspect of improving patient outcomes in all areas of ocular disease management. Addressing these gaps in education relative to the burden of ocular disease is an important part of improving the delivery of effective care and improving the ocular health of the population.

Assessment of Educational Need

Due to the increased attention given to the medical needs of our aging population, the efforts to contain increasing medical costs, and the need to improve the efficient delivery of care, we continue to learn more about the current and future burden of ocular disease. According to several key papers5,6 published in 2004 by the Eye Diseases Prevalence Research Group, the number of people in the United States with cataract is projected to rise to more than 30 million by the year 2020, and the number of open angle glaucoma cases will increase by 50%. Glaucoma is the leading cause of preventable blindness and at least 3 million Americans have the disease, according to the American Glaucoma Society.7 Given the rapid increase in the aging population, as well as increases in groups at high risk for glaucoma, the burden of disease related to this condition becomes more significant each year.8

The Centers for Medicare & Medicaid Services (CMS) recognizes the following as high risk groups for glaucoma:9

• individuals with diabetes mellitus

• individuals with a family history of glaucoma

• African Americans aged 50 and older

• Hispanic Americans aged 65 and older

A report by Rosario and Bielory10 determined that while the prevalence of allergic conjunctivitis in older population studies was 15% to 20%, current estimates may be as high as 40%. They also noted the high comorbidity of ocular allergy, rhinitis, and asthma. Similarly, ocular surface disease continues to be an increasing issue for many patients, especially in older patients that may have additional needs for ocular surgery for cataracts or retinal degenerative disease.11,12 In August 2011, a poll by Review of Ophthalmology discussed how improved familiarity with clinical trials reporting and critical analysis of outcomes should improve the implementation of new techniques into clinical practice.13 Understanding the near to market ocular therapeutics in the pipeline is a key element of coordinating the needs of a patient with the available clinical strategies. Possession of this knowledge can have a direct impact on optometrists’ ability to more effectively communicate with patients and address their expectations. A thorough education program consisting of expert opinions and recent clinical evidence can serve as a valuable means of education for the target audience.

The use of current practice pattern reviews, ophthalmic therapeutic discussions, and clinical case examples that demonstrate treatment decision-making plans can effectively deliver key program learning points and take home messages designed to immediately impact patient care.

1. Ianchulev S. Clinical trial design. Paper presented at: The Innovative Glaucoma Surgery Symposium; March 3, 2010; Naples, FL.

2. Bielory BP, O’Brien TP. Allergic complications with laser-assisted in-situ keratomileusis. Curr Opin Allergy Clin Immunol. 2011;11(5):483-491.

3. Li XM, Hu L, Hu J, Wang W. Investigation of dry eye disease and analysis of the pathogenic factors in patients after cataract surgery. Cornea. 2007;26(9 suppl 1):S16-S20.

4. Sleath B, Blalock S, Covert D, et al. The relationship between glaucoma medication adherence, eye drop technique, and visual field defect severity. Ophthalmology. 2011;118(12):2398-2402.

5. Congdon N, Vingerling JR, Klein BE, et al; Eye Diseases Prevalence Research Group. Prevalence of cataract and pseudophakia/ aphakia among adults in the United States. Arch Ophthalmol. 2004;122(4):487-494.

6. Friedman DS, Wolfs RC, O’Colmain BJ, et al; Eye Diseases Prevalence Research Group. Prevalence of open-angle glaucoma among adults in the United States. Arch Ophthalmol. 2004;122(4):532-538.

8. American Glaucoma Society. Frequently asked questions. Available at: http://www.americanglaucomasociety. net/patients/faqs. Accessed October 3, 2013.

9. Fiscella RG, Lee J, Davis EJ, et al. Cost of illness of glaucoma: a critical and systematic review. Pharmacoeconomics. 2009;27(3):189-198.

10. Centers for Medicare & Medicaid Servies (CMS). Available at: http://www.cms.gov/MLNProducts/downloads/ jan_glaucoma.pdf. Accessed October 3, 2013.

11. Rosario N, Bielory L. Epidemiology of allergic conjunctivitis. Curr Opin Allergy Clin Immunol. 2011;11(5):471- 476.

12. Galor A, Feuer W, Lee DJ, et al. Prevalence and risk factors of dry eye syndrome in a United States veterans affairs population. Am J Ophthalmol. 2011;152(3):377-384.e2.

13. Poll about clinical trials. Review of Ophthalmology. Available at: http://www.revophth.com/e-newsletters/rponlinenl/c/29982/. Accessed October 3, 2013.

Faculty and Disclosures

Derek Cunningham, OD, Lead Faculty
Director of Optometry and Research
Dell Laser Consultants
Austin, Texas

Nicholas Colatarella, OD
Owner and Medical Director, PineCone Vision Center
Sartell, Minnesota

Mark Dunbar, OD
Bascom Palmer Eye Institute
University of Miami, Miller School of Medicine”
Miami, Florida

Whitney Hauser, OD
Founder, Signal Ophthalmic Consulting
Assistant professor ,Southern College of Optometry
Memphis, Tennessee

Milton Hom, OD
Private practice
Azusa, California

Michael McFarland, OD
Vold Vision
Fayetteville, Arkansas

Justin Schweitzer, OD
Vance Thompson Vision
Sioux Falls, South Dakota

Jeffrey Varanelli, OD
Simone Eye Center
Warren, Michigan

FACULTY/STAFF DISCLOSURES

Nicholas Colatarella, OD, has had a financial agreement or affiliation during the past year with Allergan; Bio-Tissue; BioD LLC; and Katena/IOP Ophthalmics.

Derek Cunningham had a financial agreement or affiliation during the past year with the following: Abbott Medical Optics; Advanced Tear Diagnostics; Alcon Nutrition; Allergan; Artic Dx; Bausch + Lomb; Bio-Tissue; Glasses Off; Lumenis; Marco; Optovue; and Tearlab.

Mark Dunbar, OD, has had a financial agreement or affiliation during the past year with

Whitney Hauser, OD, has not disclosed any financial agreements or affiliations during the past year.

Milton Hom, OD, has had no relevant financial agreements or affiliations during the past year.

Michael McFarland, OD, has had no relevant financial agreements or affiliations during the past year.

Justin Schweitzer, OD, has had a financial agreement or affiliation during the past year with Allergan and Glaukos Corporation.

Jeffrey Varanelli, OD, has had a financial agreement or affiliation during the past year with Allergan; Bio-Tissue; BioD LLC; Johnson & Johnson Vision Care; and Katena IOP Ophthalmics.

All of those involved in the planning, editing, and peer review of this educational activity report no relevant financial relationships.

In accordance with the disclosure policies of the Evolve Medical Education LLC and Advanced Ocular Care, anyone in a position to affect the content of a CE activity is required to disclose to the activity participants (1) the existence of any financial interest or other relationships with the manufacturers of any commercial products/devices or providers of commercial services, and (2) identification of a commercial product/device that is unlabeled for use or an investigational use of a product/device not yet approved.

Disclaimer

The views and opinions expressed in this educational activity are those of the faculty and do not necessarily represent the views of Allergan, Evolve Medical Education LLC, and Advanced Ocular Care.

Pretest

THE STATE OF THE ART

JEFFREY R. VARANELLI, OD, AND NICHOLAS COLATRELLA, OD

Test

Instructions

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