EYE ON PACIFIC

INSIDE

-Understanding scleral topography: p.5 -A handy guide to ophthalmic medications: p. 6 -When is neuroimaging necessary: p. 8

pacificu.edu

As vision subspecial�es con�nue to grow, we can ensure that pa�ents con�n-

ue to get the care they deserve.

Spring | 2016

Pacific University College of Optometry

When It’s Not Obvious:

Finding Ocular Surface Disease

TRACY DOLL, OD, FAAO | DRY EYE SOLUTIONS CLINIC COORDINATOR

Characteristicsoffrankmeibomianglanddysfunction

(MGD)areveryeasytospot:thickenedeyelidmargins

withtelangiectasia,cappedglandopenings,and

toothpaste-likesecretionsonexpression.Athorough

medicalhistorymayshowunderlyingacnerosaceaor

sebaceousglanddisorder.Commonsymptomsinclude

burning,stinging,visionfluctuation,reflextearing,and

fatigue.However,thereisadistinctsubsetofpatients

whosufferfromMGDthatdonotdisplaytheabove

characteristics.Thedysfunctionishappeningdeeper

insidetheglandandisnotdisplayedonthesurface.In

fact,theeyelidmarginscanbelargelyunremarkable.

Inthesecases,themeibomianglandsareeithernot

producinglipidortheoilistrappeddeepintheglands.

YoucanstillidentifythissubtleMGDifyouarelooking

forthesigns.Properscreeningtoolscanleadtoa

clinicalexplanationofMGDsymptomsdespitethelack

ofclassicsigns.

Ocular Surface Disease (continued)

Figure 1: The Korb Meibomian Gland Evaluator™

Figure2:A.Dullappearanceofadecreasedlipid

layer(38nm).B.Normallipidlayer(greaterthan

100nm)producesabrightre#lection.

Figure 3: LipiView® II printout showing a greater

rate of par#al blinks in the le% eye (86%)

compared to the right eye (47%).

TheKorbMeibomianGlandEvaluator™

(Figure1)isahandhelddevicethatcanbe

usedtogentlyexpresstheglandswiththe

samepressureasanaverageblink.The

practitionercanapplythisgentlepressureto

theeyelidsandscreenforlowsecretionofthe

glandsinunderaminute.

Amoreadvanceddiagnosticdeviceavailable

atournewPaci.icDryEyeSolutionsclinicis

theLipiViewII®(Figure2).Thisinstrument

con.irmssubtleMGDbymeasuringthe

thicknessofthelipidlayerusingnoninvasive,

whitelightinterferometry.Alipidlayer

thinnerthan60nmcorrelateswellwith

symptomaticMGD.

Acompleteblinkisnecessarytostimulate

thereleaseofthemeibumandspreadthe

oilytearlayerevenlyacrosstheeye.Greater

thana40%partialblinkrateisindicativeof

daytimeexposureandstagnationofthe

lipidsontheeyelidmargin.TheLipiView®II

canquantifyincompleteorpartialblinkrates

(Figure3).

Anincompleteblinkcanoccurasasideeffect

ofcertainmedicationsorasaresultof

occupationaldemands.Theoverallblinkrate

candropupto75%whenlookingata

computerizeddevice.Patientswithalow

blinkrateandhighnumberofincomplete

blinkscanbene.itfromblinktraining.Paci.ic

DryEyeSolutionsprovidesblinktraining

regimenstopatientswithpoorblinkratesvia

theuseofcommerciallyavailablecomputer

andsmartphoneapps.

A

B

Figure 4: Images from Dynamic Meibomian Imaging.

A. Healthy glands extending the en#re length of the eyelid

(blue arrow). B. Dila#on of the meibomian ducts (yellow

arrow). C. Impac#on of the meibomian glands (orange

arrows), best imaged with transillumina#on meibography.

D. Dropout of the meibomian glands (red arrow).

Ocular Surface Disease (continued)

Figure 5: Setup of the LipiFlow®

Imagingofthemeibomianglandsthemselves

canshowunderlyingblockage,aswellas

damageandlossoftheglands.AtPaci.icDry

EyeSolutionsweofferDynamicMeibomian

Imaging™(DMI™)utilizinginfrared

photographycombinedwithtransillumination

(Figure4).Meibomianglandsshouldappearas

twolinesofadjacentclusters.Obstruction

causesthebasesoftheglandstoseparateand

widen.Thisisknownasductdilation.Chronic

obstructionandin.lammationleadtogland

dropout.Becauseglanddropoutisirreversible,

earlydiagnosisandmanagementiscrucialto

avoidpermanentmeibomianglanddamage.

NewtreatmentoptionsareavailableforMGD.

Paci.icDryEyeSolutionsofferstreatmentwith

theLipiFlow®.Thistreatmentmethodusesa

disposableactivatortodelivervectored

thermalpulsetherapy.Theactivatorisplaced

betweentheglobeandtheeyelid(Figure5),

whilethecorneaisprotectedbyashellthatis

similarindiametertoascleralcontactlens.

Theactivatorappliesconstantheatand

pulsatilepressuretotheeyelids.Itisimportant

tonotethattheactivatorheatsthroughthe

backsideoftheeyelid,closertowherethe

meibomianglandsarelocated.The12-minute

treatmentispainlessduetothecombinationof

heat,pressure,andcornealprotection.Fully

expressingstagnantglandcontentallows

restorationofthenormalmeibomiangland

function,improvingtearqualityandreducing

thein.lammatorycascade.

Excellentnewsforpatients:thecostofthe

LipiFlow®activatorsdroppedsigni.icantlyat

theendof2015,resultinginsavingsbeing

passedontopatients.LipiFlow®issuperiorto

classicmeibomianglandexpression(useof

paddlesandforceps)inthatitiscompleteand

painless.

ItisimportanttonotethatMGDcanaffectany

portionofthepopulation,whichiswhyhaving

thenecessarydiagnosticequipmentiscrucial.

Thefollowingcasesdemonstratethatpoint.

IllustrativeCases:

Case1:Figure6showsglanddropoutanda

verylowlipidlayermeasuredona56-year-old

malewithacnerosacea.Afterinitialdiagnosis

andcon.irmationofsevereglandloss,hewas

placedonahometherapyregimenthat

includedhotcompresses,lidscrubs,and

vegetarian-basedomega-3fattyacid

A B

C D

supplementationinordertolowerin.lammation

andachieveacleanocularsurface.Onthis

therapy,thepatientachieveddecreased

symptomsandclearingofhislidsofscurfdebris.

Hisglandlossremainedstable,asdidthelipid

layerthicknessandincompleteblinkrate

demonstratedwiththeLipiView®II.MGE

scoreshadincreasedbytwoglandsineacheye,

andLipiFlowtreatmentwasperformedto

furtherimprovethemeibomianglandfunction.

Case2:Figure7showsasimilarlypoorlipid

layerandglanddropoutina24-year-old

professionalstudent.Thehighincompleteblink

ratewasalargeareaofconcern.Hertreatment

regimenvaried,inthatblinktrainingwith

computerappswereprescribed.Shealsowas

abletoundergoLipiFlowtreatmentwith

dramaticimprovementinsymptoms.

Ocular Surface Disease (continued) Figure 7: Case 2

Figure 8: Case 3

Figure 6: Case 1

ScleralshapedisplaygeneratedbythesMap3Dscleraltopographysystem.

Advances in Contact Lenses SHEILA MORRISON, OD, MS | CORNEA AND CONTACT LENS RESIDENT

Innovationsincontactlenslathing

technologyandcontemporarycon-

tactlensmaterialshavegreatlyim-

provedtheperformanceofmodern

sclerallenses.Sclerallensesare

indicatedwhencornealdiseaseor

irregularityprohibittheuseoftra-

ditionalcornealgaspermeable

lenses.Asclerallenscanvaultthe

irregularcornealsurface,allowing

thefullweightofthelenstoreston

thesclera.

Understandingthescleralshapeis

imperativetosuccessful.ittingof

thesespecialtycontactlenses.This

ispossibleusingtheanteriorseg-

mentOCT(Zeiss),Scheimp.lugim-

aging(Pentacam),andpro.ilometry

(sMap3D&Eaglet).

Withtheincreasinguseofscleral

lenses,practitionersandresearch-

ersarebeginningtounderstand

theimportanceoffurtherresearch

elucidatingtheoptimal.ittingrela-

tionshipbetweencontactlenses

andthecorneo-scleraljunction.

OurstudiesatPaci.icUniversity

indicatethatthescleraisasymmetricinmostpatients.The

asymmetryincreasesasyoumoveperipherallyfromthelim-

bus.

Becauseofthisasymmetry,scleraldesignsof14.5mmorless,

whichlandclosetothelimbus,maybene.itfromtraditional,

rotationallysymmetricsclerallandingzones,whereaslens

designslargerthan14.5mmmaybene.itfromatorichaptic

and/oraquadrantspeci.icdesigninanattempttomatchthe

moreasymmetricperipheralsclera.

Modi.icationsavailableinmodernsclerallensdesignsinclude

theabilitytocreateatoricperiphery.Thesecustomizable

sclerallandingzonesallowforbetter.ittinglensesandoffer

greatercomfortforpatients.

Ocular Surface Disease (continued) Case3:Figure8demonstratesa12-year-

oldpatientwithsymptomsoffatiguewith

nearworkthatcouldnotbeexplainedbya

binocularorrefractivedisorder.Hewas

referredtoPaci.icDryEyeSolutionswith

suspecteddryness.Hislipidlayerthickness

was27nmODand32nmOS,lessthan1/3of

normal.Meibographyshowedmoderateto

advancedglandlossofthelowereyelids.He

hasbeenscheduledforLipiFlowtreatment

andreferredforVitaminAde.iciencytesting.

Themodernpractitionerhasnewtoolstoboth

discoverandmanagetheunderlyingcauseof

oculardrynessassociatedwithmeibomiangland

dysfunction.Newmethodsofscreeningcanhelp

to.indevensubtlecasesandallowfortreatment

priortopermanentdamagetotheglands.

Paci.icDryEyeSolutionsoffersadvancedin-

of.icediagnosticandtreatmentoptions.Ifwe

canbeofservicetoyouoryourpatientsdon’t

hesitatetocallusat503-352-1699.

Advances in Medical Eye Care LORNE YUDCOVITCH, OD, MS, FAAO | MEDICAL EYE CARE SERVICE CHIEF

Ophthalmicmedicationsareanintegralpartof

optometricpractice,andeachyeardrugupdates

occur.Recenthighlightsfrom2015includethe

introductionofPazeo(olopatadine0.7%),as

wellastheintroductionofgenericalternatives

forLumigan(bimatoprost0.03%),Travatan

(travoprost0.004%),Vigamox(moxi.loxacin

0.5%),andPataday(olopatadine0.2%).Cur-

rently,topicalophthalmichomatropineandsco-

polamineareunavailable;hopefullytheywillbe

re-introduced.

Foraneasy-to-usesourceforthemainophthal-

micmedications,pleasefeelfreetoaccessthe

OphthalmicDrugs2016chart(Figure).This

chartshowcasesthemostcommonophthalmic

drugs,updatedasofthebeginningof2016.Both

topicalophthalmicandoralmedicationsarein-

cluded,withFoodandDrugAdministration/

AmericanAcademyofOphthalmologycapcolor

representationwhenindicated.Commonbottle

sizes,concentrations,anddosagesareincluded.

Medicationswithgenericversionsarenotedwith

anasterisk(*).Pleasedownloadthechartforyour

personalusefromPaci.icUniversity’sCom-

monKnowledge.Gotohttp://

commons.paci.icu.edu/coofac/38andselect

“download.”

Wearehappytoconsultwithyouregardingoph-

thalmicmedications.Pleasefeelfreetocontactthe

MedicalEyeCareServiceatanyofourEyeClinics.

Inthisissuewewouldlikeyoutomeettwoof

themostimportantpeopleinourVision

TherapyServices.MeganandIrene,ourvision

therapypatientandschedulecoordinators,

serveasourpublicrepresentatives.Without

thesetwowonderfullycapablepeople,our

VisionTherapyServiceswouldnotfunction

well.WeaskedIreneandMegantowriteabrief

introduction.

MynameisIreneArroyo,andIamtheVision

TherapyCoordinatorforourForestGroveClinic.

IstartedwithPaci.icUniversityin2002asthe

MedicalRecordsCoordinatorandmovedtothe

VTCoordinatorpositionfouryearsago.

Myfavoritepartofthevisiontherapyjobis

workingcloselywiththedoctorsandinterns,as

wellasgettingtoknowthepatientsona

personallevel.Ilovetoseehowinvolvedthe

parentsareintheirchildren’ssuccess.Ihaveto

behonestandsaythattheotherbestpartofmy

jobisthelittletreatsIgetfromthekidsand

internsattheendofthesemester.Ihave

receivedhomemadebookmarks,cards,cookies,

candy,andanendlessamountoflove!Themost

challengingpartofmyjobishavingtowear

manyhatsonanygivenday.Igofrombeingthe

visiontherapycoordinatortothecredentialing

specialist,totranslatingorbeingthebackupfor

thefrontdeskstaff.AttimesI’meventhecleaning

lady!But,Iwouldn’thaveitanyotherway.

WhenIamnotatwork,Ilovetospendtimewith

myfamily,whichincludesmyhusband,mytwo

daughtersandtheirspouses,andmythree

granddaughters.Ienjoybeinginvolvedinmy

church,playingsoftballandkickball,longwalks,

thebeach,andhappyhourwithfriends.

Youcanalwaysreachmeviae-mail@

iarroyo@paci.icu.eduorbyphone@503-352-

2174.Pleasefeelfreetocontactmeifyouever

haveanyquestionsaboutourservices!

MynameisMeganChapman-Rexford,andIamthe

VisionTherapyCoordinatorforourPortland

Clinic.IstartedatPaci.icEyeTrendsin2010asa

.loatingopticiananddidthisthroughoutmy

undergraduateyears.Iacceptedthispositionin

Septemberof2015.Mygoalistobecomean

optometrystudentnextautumn.

Ihavebeendeeplymovedbyhowhardour

wonderfulattendingdoctorsandinternsworkto

rehabilitateourpatients.Iwouldhavetosaythat

myfavoriteaspectofthispositionisthedetective

workIwitnessfromeveryoneinvolvedinthecare

IreneArroyo,ForestGroveVTCoordinator

Advances in Binocular Vision HANNU LAUKKANEN, OD, MEd, FAAO | VISION THERAPY/PEDIATRICS SERVICE

MeganChapman-Rexford,PortlandVTCoordinator

DENISE GOODWIN, OD, FAAO| NEURO-OPHTHALMIC DISEASE CLINIC

Advances in Neuro-Ophthalmic Disease

ToImageorNottoImage

Whetherornottoperformneuroimagingona

patientwithanisolatedextraocularmotor

nervepalsyiscontroversial.Anisolatedcranial

nerve(CN)palsyinanolderpatientisoften

vasculopathicinnature.However,some

patientshaveamoreseriousunderlying

condition.Weoftenfacethedilemmaof

exposingthepatienttothecostsof

neuroimagingorriskmissingaseriousand

potentiallytreatablecondition.

Arecentprospective,multicenterstudy

suggestedthatupto5%ofpatientsthoughtto

haveavasculopathicCN4orCN6palsyended

uphavinganon-vasculopathiccause,including

aneurysm,tumor,orstroke.Thisincreasedto

16%ifCN3palsieswereincluded.Inaddition,

vasculopathicriskfactorswerepresentin61%

ofpatientsfoundtohaveanon-vasculopathic

causeforthepalsy.Thistellsusthatjust

becauseapatienthasvasculopathicriskfactors

doesnotmeanthatthepalsyisalways

vasculopathic.

Advantagesofimagingearlyincludeimproved

clinicaloutcomeandpsychologicalbene.its.

Treatmentofdemyelination,tumors,stroke,

andotherneurologicdiseasehasimproved

greatlyinrecentyears.Thismakesearly

diagnosismorecriticalinthesepatients.A

normalMRIcanalsoallayfearsassociatedwith

neurologicdiseasewhich,inturn,canimpact

socialandpsychologicalhealth.

BothcompleteandpartialCN3palsiesshouldbe

imagedduetotheriskofaneurysm.Whetherto

imagethosewithaCN4orCN6palsyismore

debated.Althoughweliveinatimewherecost

constraintsareparamount,wemustask

ourselvesifwearewillingtotaketheriskof

missingapotentiallyseriouscausethatmaybe

treatable.Ultimatelythedecisiontoobtain

neuroimagingmustbemadeonanindividual

basis.Performingathoroughhistoryand

recognizingsubtlesignsorsymptomsarecritical

indetermineifneuroimagingwouldbe

advantageoustothepatient.

Feelfreetocontactusat503-352-7300ifyou

haveaquestionregardingwhetherornotto

orderneuroimagingforyourpatient.

ofourpatients.Conversely,themost

challengingaspectisthefactthatIhaveto

eventuallywatchourpatientsandinternsleave.

Wegettoknowthem-theirsuccessesand

challenges-andwatchthemgrow.Itistruly

dif.icultsayinggoodbye.

WhenI’mnotatwork,Icareformyelderly

parents,binge-watchTVshows,andcrochet

somemeanafghans!Ienjoyspendingtimewith

mynewfamily,whichincludesmyhusbandand

mynine-yearoldstepdaughter.

Ikeepmydooropentoeveryone,notjusttheVT

crew,andIprovidetastycandywhenIcan.Itis

prettyeasytocontactmeviaemailat

chap9064@paci.icu.edu.Callingmeat503-352-

2504isalittlemoredif.icultasIamalways

runningaround.Pleasefeelfreetocontactmeif

youeverhaveaquestionaboutourservices!

OurnewestadditiontothePaci.icUniversity

EyeClinicteamisCindiRapp,RDH,Directorof

ClinicalOperations.Cindibringsenergyanda

newperspectivetoourclinicalsystem,having

spentherearliercareeratKaiserPermanentein

theDentalCareProgram.Thereshehad

opportunitiestobeinclinicalpractice,workas

consultantandtrainer,andserveasareamanager

forKaiser’smanydentalof.ices.Althoughnewto

theCollegeofOptometry,Cindibecameinvolved

withPaci.icUniversityduringtheinitial

developmentphaseofitsdentalhygienedegree

program,havingbeenaskedtoserveonits

advisoryboard.Cindirecalls,“Itwasexcitingto

seetheworkoftheadvisory/curriculum

committeecometofruitionwhentheDental

HygieneStudiesProgramopenedwiththe.irst

class,in2007.”Shewassubsequentlyrecruited

asanadjunctclinicfacultymemberand

thoroughlyenjoyedheryearsworkingwiththe

students.

HernewroleinclinicaloperationsfortheCollege

ofOptometryenableshertocontinuetointeract

withstudents,whilereturningtoherpassionof

healthcareadministration.InCindi’sownwords,

“Itisaprivilegetocontinueworkingwith

students,staffandfacultyandtooverseethe

operationsofoureyeclinics.Iamdelightedtobe

partoftheCollegeofOptometry!Havingspent

manyyearsindentistry,bothinmanagementand

asaregistereddentalhygienist,Iamexcitedto

learnabouttheworldofvision.Icanalreadyfeel

thepositiveenergyandseeacommitted,cohesive

teamwhichissoimportant,aswecanallachieve

somuchmoretogetherthanwhatwecan

accomplishalone.Ilookforwardtobeinga

contributingmemberoftheoptometryteam!”

Whennotatwork,Cindienjoysspendingtime

withherfamily—husband,Greg,of25years;her

daughter,Meg(ajunioratGonzagaUniversity);

andherson,Chris(ajunioratValleyCatholicHS).

Shelikestogarden,cook,enjoytheoutdoors,and

watchherkidsplaysports.

Ourclinicalfacultyandstaffareheretohelpyou

withpatientconsultationsandreferrals.Pleaselet

usknowhowwecanbestserveyourneeds!

CindiRapp,DirectorofClinicOperations

Pacific EyeClinics Updates CAROLE TIMPONE, OD, FAAO, FNAP | ASSOCIATE DEAN OF CLINICAL PROGRAMS

April 2016:

-Coeur d’Alene CE; Coeur d’Alene Golf and Spa Resort, Coeur d’Alene, ID; Apr. 15-16. -Teplick Vision’s 22nd Annual Blockbuster 5 hour CE Event; NVision Eye Center, Portland, OR; April 30, 7:30-2:30. Click here to register.

May 2016:

-Oregon’s Meeting; Sunriver Resort; Sunriver, OR; May 19-22.

June 2016:

-Northwest Residents Conference; Jefferson Hall, Forest Grove, OR; June 10-11.

July 2016:

-Victoria Conference; Delta Victoria Ocean Pointe Resort, Victoria, Canada; July 21-24.

CE Opportunities

Referral Service Contact Numbers Pacific EyeClinic Forest Grove 2043CollegeWay,ForestGrove,OR97116

Phone:503-352-2020

Fax:503-352-2261

VisionTherapy:ScottCooper,OD;GrahamErickson,OD;HannuLaukkanen,OD;JPLowery,OD

Pediatrics:ScottCooper,OD;GrahamErickson,OD;HannuLaukkanen,OD;JPLowery,OD

MedicalEyeCare:RyanBulson,OD;TracyDoll,OD;LorneYudcovitch,OD

LowVision:KarlCitek,OD;JPLowery,OD

ContactLens:MarkAndre;TadBuckingham,OD;PatrickCaroline;AmieeHo,OD;BethKinoshita,OD;

HannahShinoda,OD

Pacific EyeClinic Cornelius 1151N.Adair,Suite104Cornelius,OR97113

Phone:503-352-8543

Fax:503-352-8535

Pediatrics:JPLowery,OD

MedicalEyeCare:TadBuckingham,OD;SarahMartin,OD;CarolineOoley,OD;LorneYudcovitch,OD

Pacific EyeClinic Hillsboro 222SE8thAvenue,Hillsboro,OR97123

Phone:503-352-7300

Fax:503-352-7220

Pediatrics:RyanBulson,OD

MedicalEyeCare:TracyDoll,OD;DinaErickson,OD;MichelaKenning,OD;CarolineOoley,OD

Neuro-ophthalmicDisease:DeniseGoodwin,OD

Pacific EyeClinic Beaverton 12600SWCrescentSt,Suite130,Beaverton,OR97005

Phone:503-352-1699

Fax:503-352-1690

3DVision:JamesKundart,OD

Pediatrics:AlanLove,OD

MedicalEyeCare:SusanLittle.ield,OD

ContactLens:MattLampa,OD

DryEyeSolutions:TracyDoll,OD

Pacific EyeClinic Portland 511SW10thAve.,Suite500,Portland,OR97205

Phone:503-352-2500

Fax:503-352-2523

VisionTherapy:BradleyCoffey,OD;BenConway,OD;ScottCooper,OD;JamesKundart,OD

Pediatrics:BradleyCoffey,OD;BenConway,OD;ScottCooper,OD;JamesKundart,OD

MedicalEyeCare:RyanBulson,OD;CandaceHamel,OD;ScottOverton,OD;CaroleTimpone,OD

ContactLens:MarkAndre;CandaceHamel,OD;MattLampa,OD;ScottOverton,OD;SarahPajot,OD

Neuro-ophthalmicDisease/Strabismus:RickLondon,OD

LowVision:ScottOverton,OD

Whenschedulinganappointmentforyourpatient,pleasehavethepatient’sname,address,phonenumber,

dateofbirth,andinsuranceprovider,aswellasthetypeofserviceyouwouldlikePaci.icUniversityeye

clinicstoprovide.