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March 2012

News in Review
A Look at Today's Ideas and Trends
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Caring for Eyes Brings Pain for Some

A decade after surveys uncovered the first hints that ophthalmologists’ work was hurting them, a case-control study has confirmed that work-related musculoskeletal pain is more prevalent among ophthalmologists than it is in a comparable group of nonophthalmic physicians.1

The authors of the paper compared electronic surveys completed by two carefully matched groups of practitioners at the University of Iowa Hospitals and Clinics, Iowa City, and the Mayo Clinic, Rochester, Minn. The groups consisted of 94 eye care providers (ophthalmologists and optometrists) and 92 family medicine physicians from both institutions.

“There’s just a handful of literature about this problem, and there were no case-control studies at all. All the other studies we could find were survey studies of ophthalmologists,” said Anna S. Kitzmann, MD, lead author and assistant professor of ophthalmology at the University of Iowa. “We felt it was important to have a control group.”

Comparing the two groups, the researchers detected statistically significant differences in the proportions of respondents who reported experiencing pain in three areas of the body:

  • Neck (46 percent for eye care providers vs. 21 percent for family practice doctors; p < 0.01)
  • Hand/wrist (17 percent vs. 7 percent; p = 0.03)
  • Lower back (26 percent vs. 9 percent; p < 0.01)

The study identified these contributing factors: repetitive tasks; prolonged muscle contractions from holding arms, wrists, neck, or torso in prolonged or awkward/cramped positions; and bending/twisting motions or postures.

The study’s numbers are comparable to results of a 2001 survey in which 51.8 percent of the responding ophthalmologists (n = 697) reported neck, back or upper extremity symptoms.2

More visibility for MSD issue. In the 11 years since those survey results were presented at the Academy’s Annual Meeting, musculoskeletal disorders (MSDs) in ophthalmology have steadily gained visibility. Other surveys echoed its findings, and anecdotes have been accumulating about colleagues with career-ending MSDs. At last fall’s Annual Meeting in Orlando, a symposium on ergonomics drew a standing-room-only crowd.

“It’s scary when you talk to a lot of more senior colleagues who have been affected by this and they tell you their stories,” said Dr. Kitzmann, who is in her fourth year of practice. “Off the top of my head, I can name more than five ophthalmologists I know who have job-related musculoskeletal disorders.”

Dr. Kitzmann is a member of the Academy Task Force on Ergonomics, established by the Board of Trustees in June 2010 to educate members about how to avoid MSDs at work. The group’s chairman, Jeffrey L. Marx, MD, conducted the 2001 survey that laid the foundation for today’s push to prevent MSDs. Dr. Marx is a retina subspecialist at Lahey Clinic Medical Center in Burlington, Mass. In an editorial3 that ran simultaneously with the current study, Dr. Marx wrote that it confirmed what he and other advocates of better eye care ergonomics already believed.

Small fixes. Changes in the design of instruments—or even the redesign of the ophthalmic lane and operating rooms—ultimately might be required to keep MSDs from occurring, Dr. Marx wrote in his editorial, adding, “However, one should not discount even the smallest changes as they can have a profound effect.” In fact, the task force’s slide show presented at the Academy’s Annual Meeting emphasizes that upon entering a new room or starting a procedure, the ophthalmologist should take a few extra seconds—every time—to adjust the equipment and to reposition the patient optimally for the doctor. Because MSDs are cumulative injuries, one awkward motion, twisted posture or forwardly flexed neck is one too many.

—Linda Roach   


1 Kitzmann AS et al. Ophthalmology. 2012;119(2):213-220.
2 Dhimitri KC et al. Am J Ophthalmol. 2005;139(1):179-181.
3 Marx JL. Ophthalmology. 2012;119(2):211-212.

Drs. Kitzmann and Marx report no related financial interests.


Trends in Practice 

About Preop Tests for Premium IOL Surgery

Douglas D. Koch, MD, professor of ophthalmology at Baylor College of Medicine in Houston, said, “I’ve implanted many multifocal IOLs. I have also removed a good number of them—although, fortunately, only one of my own implants.” The main reasons for explantation? Irregular corneal astigmatism and macular pathology. “Both problems could have been detected preoperatively had corneal topography and macular OCT been done,” he said.

But nearly a quarter of comprehensive ophthalmologists surveyed by the Academy routinely perform neither test in patients being considered for premium IOL implantation. Another one-quarter of respondents performed corneal topography alone, and less than 10 percent performed macular OCT alone.

About half of those surveyed performed both tests, mirroring Dr. Koch’s practice. “If I’m going to take the big step of putting in a multifocal lens,” he said, “I want to establish that the optical and anatomic integrity of the eye is essentially perfect—that there’s no irregular astigmatism or corneal pathology and that the macula is pristine, without evidence of an epiretinal membrane or any hint of macular changes that could progress to significant macular degeneration.”

Given the widespread availability of these two tests, what might account for the lack of their consistent use by so many clinicians? Dr. Koch said that it could be because the testing was not fully mandated or endorsed when the lenses were first rolled out. “We only began to realize the value of these tests after these implants became more widely used.”

The good news is that about three-quarters of those surveyed are performing corneal topography, said Dr. Koch. Also, most macular pathology should be picked up when looking carefully at the macula. But in the absence of macular OCT, what might slip through the proverbial cracks, he said, are things like subtle epiretinal membranes and vitreoretinal traction, which are much more difficult to detect with a fundus exam.

—Annie Stuart   


Dr. Koch is a consultant for Alcon and AMO.

CLINICAL PREFERENCES. To better understand current practices on a number of topics, the Academy surveyed comprehensive ophthalmologists last year about how they would handle various clinical situations. Each month, EyeNet will feature one question—this month about preop evaluation for premium IOLs—and ask an expert to provide perspective on the responses.


Stabilizing the Cornea 

CXL Gains Orphan Status

Despite having been adopted internationally, corneal collagen cross-linking (CXL) has only just become an orphan in the United States.

In late 2011, the FDA granted orphan designation to Avedro’s 0.1 percent riboflavin solution (VibeX) for use with UV-A radiation to treat both keratoconus and ectasia after refractive surgery. The company’s next step: to get FDA approval to bring the drug to market.

To be eligible for orphan status, a medical product must be intended as therapy for a disease that affects too few people to otherwise offset the cost of gaining FDA approval. Avedro estimates that, for each of the two indications, fewer than 200,000 Americans a year would be candidates for cross-linking, which uses riboflavin plus UV-A light to add structural cross-links to the stroma.

For this orphan, though, the economic stakes in the U.S. market are substantial. A single application of VibeX costs about $200, and Avedro’s UV-A system (KXL) sells for $45,000 overseas, where CXL has been in use for several years.

“It’s a race. There can be only one company that gets orphan [and marketing] approval,” said Avedro CEO David Muller, PhD. “The first company to get their application in to the FDA and approved wins the race. It will receive seven years of exclusive rights to the orphan drug or procedure in the United States.”

Avedro submitted its phase 3 clinical trial results and marketing application to the FDA in January, and it hopes for final FDA approval in 2012, he said.

Meanwhile, Avedro’s orphan-drug strategy appears to have stalled other clinical trials of CXL in the United States. For instance, a coalition of surgeons led by ophthalmologist James J. Reidy, MD, ended a self-funded FDA trial of CXL after another device maker promised the group financial support, took over the doctors’ FDA trial authorization— and then put everything on hold.

“It’s a mess,” said Dr. Reidy, associate professor of ophthalmology at the State University of New York, Buffalo. “We got about two-thirds of the patients we wanted to. Now we’re just going to analyze the data and go ahead and publish it.” He’s sending potential CXL candidates to Canada, and his UV-A machine is sitting idle. “Right now I can’t use it because I don’t have access to the riboflavin and because nothing’s approved by the FDA,” Dr. Reidy said. “It’s a shame, because it’s already taken way too long to get this procedure to the United States.”

—Linda Roach   


Dr. Muller is an employee of Avedro. Dr. Reidy reports no related financial interests


Pediatric Update 

Maternal Smoking Linked to Esotropia, Exotropia

A consistently higher risk for esotropia and exotropia is associated with babies born to mothers who smoked during pregnancy, according to the largest population-based study to date on children younger than 6 years of age.1

The study was part of the federally funded Multi-Ethnic Pediatric Eye Disease Study and the Baltimore Pediatric Eye Disease Study, which, combined, involved examining nearly 10,000 preschool children of various ethnicities (African- American, Hispanic and non-Hispanic white), who ranged in age from 6 months to 72 months.

To ensure consistency of the eye exams, all medical personnel who provided them were asked to adhere to a strict protocol. “There were specific steps to assure uniformity across all examiners,” said Rohit Varma, MD, MPH, one of the lead investigators and professor of ophthalmology and director of glaucoma service, ocular epidemiology center and the clinical trials unit at the University of Southern California in Los Angeles.

In addition to maternal smoking during pregnancy, preterm birth, hyperopia and astigmatism were significantly associated with a child’s higher risk of having esotropia or exotropia.

Dr. Varma noted, “These risk relationships should inform development of guidelines for screening, examining and treating preschool children.”

—Anne Scheck   


1 Cotter SA et al. Ophthalmology. 2011;118(11):2251-2226.

Dr. Varma reports no related financial interests.


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