Sorry for being late this week. This year's Vision Expo West was superb and kept me so busy that I wasn't able to get my editorial done in time. It was great seeing so many old friends and a real thrill to see the packed audiences for my courses.

On the flight out, I read AOA President Joe Ellis's President's Column, “Get Ready, 'cause here it comes,” in the current AOA News. The editorial expressed the critical challenge we face in assuring access as the healthcare landscape changes unpredictably before our eyes. This President's Column was one of the most important editorials I've ever read and I strongly recommend that you read it.

The message was clear. The battle for our profession's survival is shifting from the federal level to state legislatures and insurance commissioners' offices. What happens in the next few years is so key to our survival as a profession that more than 30 years of scope battles pale by comparison. Scope expansion was about growth and future potential, the fight for access is essentially life and death.

Although access battles will be fought state by state, we need to work together, support and learn from each other's successes and failures. We have no time to waste.

The AOA is hosting a State Legislative and Third Party National Conference in Denver October 21–24. This critically important meeting will bring together advocacy and reimbursement leaders from around the U.S. It is geared to sharing information, tactics and knowledge necessary to insure broad access for optometry. It is vitally important that all state advocacy leadership attend this meeting˜even in states that already have broad and secure access.

For more information or to register for the conference, contact Brian Reuwer at 800-365-2219 ext. 1343 or [email protected] or Maureen West at 703-837-1010 or [email protected].

Arthur B. Epstein, OD, FAAO Chief Medical Editor [email protected]

 

 

Two patients with confirmed Acanthamoeba keratitis (AK) and one patient with presumptive AK, which were all refractive to multi-drug conventional therapy to present the first three cases of AK that were successfully treated with a novel adjunctive therapy using ultraviolet light A (UVA) and riboflavin (B2). Two treatment sessions involving topical application of 0.1% B2 solution to the ocular surface combined with 30 minutes of UVA irradiation focused on the corneal ulcer. Clinical examination by slit lamp, confocal microscopy and histopathology, when available, was performed.

All patients in these series showed a rapid reduction in their symptoms and decreased ulcer size after the first treatment session. The progress of the clinical improvement began to slow after 1 to 3 weeks of the first application and was then renewed after the second application. All ancillary signs of inflammation mostly resolved after the second treatment session. The ulcers in all patients continued to decrease and were closed within 3 to 7 weeks of the first application. Two patients developed dense central corneal scars, and penetrating keratoplasty was performed for visual rehabilitation. Histopathologic examination of the excised tissue revealed no Acanthamoeba organisms. The remaining patient had no symptoms or signs of infection, both clinically and by confocal microscopy, and was left with a semitransparent eccentric scar that did not affect visual acuity.

The adjunctive use of UVA and B2 therapy seems to be a possible alternative for selected cases of medication-resistant.

Histopathologic studies have reported retinal nerve fiber layer (RNFL) thinning in various neurodegenerative diseases. Attempts to quantify this loss in vivo have relied on time-domain optical coherence tomography (TDOCT), which has low resolution and requires substantial interpolation of data for volume measurements. This study assessed whether the significantly higher resolution of spectral-domain optical coherence tomography (SDOCT) would better detect RNFL changes in patients with multiple sclerosis, and that RNFL thickness differences between eyes with and without optic neuritis might be identified more accurately.

In this retrospective case series, patients with multiple sclerosis were recruited from the Judith Jaffe Multiple Sclerosis Center at Weill Cornell Medical College in New York. Patients with a recent clinical diagnosis of optic neuritis (less than three months) were excluded. Eyes with a history of glaucoma, optic neuropathy (other than multiple sclerosis-related optic neuritis), age-related macular degeneration or other relevant retinal and/or optic nerve disease were excluded. Both eyes of each patient were imaged with the Heidelberg Spectralis HRA + OCT. RNFL and macular thickness were measured for each eye using the Heidelberg OCT software. These measurements were compared with validated published normal values, and were modeled as linear functions of duration of disease. The odds of an optic neuritis diagnosis as a function of RNFL and macular thickness were calculated.

A total of 94 eyes were prospectively evaluated using OCT. Ages of patients ranged from 26 to 69 years, with an average age of 39 years. Peripapillary RNFL thinning was demonstrated in multiple sclerosis patients; mean RNFL thickness was 88.5 µm for individuals with multiple sclerosis compared with a reported normal value of 97 µm. Eyes with a history of optic neuritis had more thinning compared with those without optic neuritis (83.0 µm versus 90.5 µm, respectively). No significant differences were observed in macular thickness measurements between eyes with and without optic neuritis, nor were macular thickness measurements significantly different from normal values. As a function of multiple sclerosis duration and controlling for age, RNFL thickness was decreased in patients with a duration of multiple sclerosis greater than five years compared with those with a duration less than or equal to one year.

Patients with a history of multiple sclerosis had RNFL thinning that was detectable on SDOCT. Decreasing RNFL thickness in eyes with optic neuritis was found, and the odds of having optic neuritis were increased significantly with decreasing RNFL thickness. Average RNFL thinning with increasing duration of disease was an excellent predictor of a reported history of optic neuritis. SDOCT retinal imaging may represent a high-resolution, objective, noninvasive and easily quantifiable in vivo biomarker of the presence of optic neuritis and severity of multiple sclerosis.

Seventy-three subjects with glaucoma and 146 age-matched normal subjects were evaluated to determine the ability of optic nerve head (ONH) parameters measured with spectral domain Cirrus HD-OCT (Carl Zeiss Meditec, Inc.) to discriminate between normal and glaucomatous eyes and to compare them with the discriminating ability of peripapillary retinal nerve fiber layer (RNFL) thickness measurements performed with Cirrus HD-OCT. Peripapillary ONH parameters and RNFL thickness were measured in one randomly selected eye of each participant within a 200×200 pixel A-scan acquired with Cirrus HD-OCT centered on the ONH. Optic nerve head topographic parameters, peripapillary RNFL thickness and area under receiver operating characteristic curves (AUCs).

To distinguish normal from glaucomatous eyes, regardless of disease stage, the 6 best parameters (expressed as AUC) were vertical rim thickness (VRT, 0.963), rim area (0.962), RNFL thickness at clock-hour 7 (0.957), RNFL thickness of the inferior quadrant (0.953), vertical cup-to-disc ratio (VCDR, 0.951) and average RNFL thickness (0.950). The AUC for distinguishing between normal eyes and eyes with mild glaucoma was greatest for RNFL thickness of clock-hour 7 (0.918), VRT (0.914), rim area (0.912), RNFL thickness of inferior quadrant (0.895), average RNFL thickness (0.893) and VCDR (0.890). There were no statistically significant differences between AUCs for the best ONH parameters and RNFL thickness measurements.

Cirrus HD-OCT ONH parameters are able to discriminate between normal eyes and eyes with glaucoma or even mild glaucoma. There is no difference in the ability of ONH parameters and RNFL thickness measurement, as measured with Cirrus OCT, to distinguish between normal and glaucomatous eyes.