03/19/2018. H53.72 Impaired Contrast Sensitivity THE POWER OF CONTRAST SENSITIVITY IN PRIMARY EYE CARE OUR PRACTICE PHILOSOPHY

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1 FINANCIAL DISCLOSURES THE POWER OF CONTRAST SENSITIVITY IN PRIMARY EYE CARE The Speaker is a Consultant for MacuHealth, LLC. The Speaker is a Consultant for M&S Technoies. --WHY EVERY ECP SHOULD BE TESTING CONTRAST SENSITIVITY-- Mark W Roark, OD, FAAO Allisonville Eye Care Center Fishers, IN Allisonville Eye Care Center Fishers, Indiana OUR PRACTICE PHILOSOPHY We combine our passion for patient care with the latest scientific research to enhance the quality of your life through HEALTHY EYES and BETTER VISION 1) We must know how our patients REALLY SEE 2) Visual Acuity testing is important but NOT ENOUGH to thoroughly assess VISUAL PERFORMANCE 3) Contrast Sensitivity testing gives additional ESSENTIAL INFORMATION and can easily be incorporated into practice 4) Nutritional or other intervention and can lead to BETTER PATIENT CARE YOU NEED THE BEST TOOLS TO MAKE THE BEST DECISIONS! CONTRAST SENSITIVITY TESTING IN PRIMARY EYE CARE DO YOU WANT TO ADD SOMETHING TO YOUR PRACTICE THAT REQUIRES ABOUT ONE MINUTE PER EYE BUT HAS A BIG IMPACT? H53.72 Impaired Contrast Sensitivity 1

2 VA CHART USING SLOAN LETTERS CONTRAST SENSITIVITY- IMPORTANT MEASURE OF VISUAL PERFORMANCE DEFINITIONS Stroke width= 1/5 th of the letter height Sloan designed a uniform series of 10 letter optotypes Letters are C, D, H, K, N, O, R, S, V and Z (no serifs) ETDRS chart chosen for research uses Sloan letters. Contrast Sensitivity Threshold () is the minimum difference between the luminance of the target and the background required to recognize the target Contrast Sensitivity (CS) is the reciprocal of this. - Photopic Contrast Sensitivity: background luminance 85 cd/m2 - Mesopic Contrast Sensitivity: background luminance 3 cd/m2 We are measuring the border between the visible and the invisible. Contrast Sensitivity gives insight into the patient s VISUAL QUALITY! LOW CONTRAST SITUATIONS- COMMON IN THE REAL WORLD LOW CONTRAST IMAGES--COMMON IN THE REAL WORLD Contrast is dramatically improved by white edge strips! CONTRAST SENSITIVITY FUNCTION USING SINE WAVE GRATINGS CONTRAST SENSITIVITY TESTING - WHAT TARGET SIZE SHOULD BE MEASURED? -. Overall, 6 cpd is the best spatial frequency for predicting the ability to identify and recognize faces, signs, and objects. VISUAL ACUITY STUDY: Owsley and Sloane: Contrast Sensitivity, acuity, and the perception of real-world targets (BJO 1987) 2

3 UNDERSTANDING SPATIAL FREQUENCY NOTATION CONTRAST SENSITIVITY TESTING IN PRIMARY EYE CARE 20/20 = 30 cpd 20/100 = 6 cpd Just check Visual Acuities and Photopic Contrast Sensitivity at 6 cpd. 20/20 Letter 20 Foot Testing Distance You will gain valuable information quickly about your patient s true visual performance to guide your treatment recommendations. CONTRAST SENSITIVITY: USING ELECTRONIC LCD CHARTS-- HARRIS CONTRAST TEST PELLI-ROBSON CHART VS HARRIS CONTRAST TEST ON LCD SCREENS 2013 Comparison Study published in the Journal of Ophthalmoy showed similar results for both normal and diseased eyes. (262 eyes) Conclusion: LCD testing using the Harris Contrast Test with individual Sloan letters is an alternative to the Pelli-Robson gold-standard for measuring Contrast Sensitivity Old School New School and Cool! HOW TO MEASURE PHOTOPIC LETTER CONTRAST SENSITIVITY 1) Measure CS monocularly with best distance prescription and with non-dilated pupils 2) Turn the room lights OFF 3) Isolate a 20/100 (6 cpd) Sloan letter on a properly calibrated electronic chart 4) Project a contrast letter for demonstration 5) Next, project a 5% contrast letter and ask the patient to identify it 6) Decrease (or increase) the contrast level by one step as needed 7) Proceed slowly, allowing time for the letters to come into view 8) Record the lowest where the patient can correctly identify 2 of 3 random letters 9) Document OD or OS: (Example - OD@6cpd ) Table 1 UNDERSTANDING THE VISUAL IMPACT OF CHANGES IN CONTRAST SENSITIVITY COMPARISON OF VISUAL ACUITY TO CONTRAST SENSITIVITY GOOD VA WITH POOR CONTRAST SENSITIVITY IS STILL POOR QUALITY VISION! Roark Model for Assessing Visual Impact of Letter Contrast Sensitivity Threshold 6cpd Compared to Visual Acuity Changes Constant CPD With Decreasing Contrast Sensitivity Poor Visual Performance CPD LogCS Steps 20/ /16 20/20 20/25 20/32 20/40 20/50 20/63 100% Contrast LogMAR Steps Constant Contrast With Decreasing Letter Resolution Poor Visual Performance *Assuming Limiting Letter of 1% and Peak BVA of 20/12 3

4 USING CONTRAST SENSITIVITY TESTING IN PATIENTS WITHOUT OCULAR DISEASE DETERMINE BCVA NORMAL EYE HEALTH CONFIRMED CHECK LETTER CONTRAST 6CPD PATIENTS AGE GOOD AVERAGE - POOR PATIENTS > AGE GOOD 2.5- AVERAGE - POOR WHEN CONTRAST SENSITIVITY TESTING APPEARS ABNORMAL IN A NORMAL PATIENT - NOW WHAT? Thanks to CREST Normal- we now have a plan based on Science! June 2016 Investigative Ophthalmoy and Visual Science (IOVS) AVERAGE BASELINE % CONTRAST SENSITIVITY IN OCULAR DISEASE- BASIC CONCEPTS CONTRAST SENSITIVITY IN OCULAR DISEASE-- AMD STUDIES Contrast Sensitivity: Reduced in numerous disease states Reduced with amblyopia Non-specific Indicates level of visual impact Corneal edema associated with amantadine use MESO-ZEAXANTHIN OCULAR SUPPLEMENTATION TRIAL(MOST) -AMD (2015) Supplements with Meso-Zeaxanthin were more effective than competing formulas in improving macular pigment volume and contrast sensitivity in patients with early AMD After 36 months@ 6cpd: Baseline approx 36 Month approx Results: Letter Contrast Sensitivity at 36 Months MPOD Retinal Eccentricity Log CS Spatial Frequency CONTRAST SENSITIVITY IN OCULAR DISEASE COMPARISON OF IMPROVEMENTS IN CONTRAST SENSITIVITY CREST AMD CREST AMD 75% OF VISUAL PERFORMANCE PARAMETERS IMPROVED SIGNIFICANTLY IN BOTH GROUPS BUT A HIGHER PERCENTAGE OF PATIENTS IN THE GROUP WITH MZ SHOWED SIGNIFICANT IMPROVEMENT IN CS OCT 2017 Investigative Ophthalmoy and Visual Science (IOVS) CLINICAL IMPROVEMENT DEFINED AS ONE OR MORE LINES ON A LETTER CS CHART Level Month Study in patients with Non-Advanced AMD A GAME CHANGER! Courtesy of John Nolan, PhD Group 1, 10mg/day meso-zeaxanthin [MZ], 10mg/day lutein, 2mg/day zeaxanthin plus 500mg/day vitamin C, 400 international units [IU]/day of vitamin E, 25mg/day zinc and 2mg/day copper Group 2, 10mg/day lutein, 2mg/day zeaxanthin plus 500mg/day vitamin C, 400 international units /day of vitamin E, 25mg/day zinc and 2mg/day copper; 4

5 CONTRAST SENSITIVITY IN OCULAR DISEASE- REFERENCE VALUES Contrast Sensitivity Threshold () References (Pelli-Robson-NCBI) How is visual impairment defined in regard to CS? OR WORSE is likely to have significant impact on visual performance OR WORSE is likely to cause severe visual impairment CONTRAST SENSITIVITY IN OCULAR DISEASE- REFERENCE VALUES FOR OLDER ADULTS WITH CATARACTS: A of OR WORSE is associated with an increased risk of driving accidents! Crash-involved drivers were 6 times more likely to have this level of impairment in both eyes (or 3 times more likely if only one eye impaired) compared to crash-free drivers (1) For older drivers, a possible but weak association between visual acuity and crash involvement may exist (2) 1) Owsley, Cynthia. Visual Risk Factors for Crash Involvement in Older Drivers With Cataract. Archives of Ophthalmoy, vol. 119, no. 6, Jan. 2001, p ) Owsley, Cynthia, and Gerald Mcgwin. Vision Impairment and Driving. Survey of Ophthalmoy, vol. 43, no. 6, 1999, pp USING CONTRAST SENSITIVITY TESTING IN MANAGING OCULAR DISEASE SUGGESTED GUIDELINES FOR CATARACT MANAGEMENT DETERMINE BCVA CATARACT CONFIRMED CHECK LETTER CONTRAST 6 cpd OR BETTER ACCEPTABLE BORDERLINE INTERVENTION NEEDED Cataract surgery significantly reduces falls in elderly Palagyi A, et al. J Cataract Refract Surg. 2017;doi:1016/j.jcrs December 15, 2017 First-eye cataract surgery was found to be associated with a 33% reduction of falls in older adults, suggesting that efficient services for early cataract management might minimize the burden of falls in this population. Number of patients CONTRAST SENSITIVITY THRESHOLDS OF 50 CONSECUTIVE FULL EXAM PATIENTS 0.6% AGE RANGE % CASE STUDIES 1) Normal Visual Acuity and Healthy Eyes 2) Cataracts- Cortical, NS, PSC 3) Secondary Cataract 4) Macular Disease 5) Post-Op Complications 6) Medication Toxicity 7) Corneal Disease 5

6 CASE STUDIES 1 Normal Visual Acuity No History of Laser Vision Correction No Signs of Ocular Disease CLINICAL OBSERVATIONS WITH CONTRAST SENSITIVITY TESTING IN NORMAL PATIENTS: 47 YEAR-OLD MYOPIC FEMALE WITH REDUCED CS@ 6 CPD OU 47 Year-Old Science Teacher DW Single use SCL wearer 20/20 VA and healthy eyes Notes vision not sharp with daily activities Also c/o poor vision at night Takes Prozac, Zyrtec Systemic diagnosis of Sarcoidosis Good ocular health Refraction: OD x 005 / 20 OS x 012 / 20 What else should we do? CLINICAL OBSERVATIONS WITH CONTRAST SENSITIVITY TESTING IN NORMAL PATIENTS: 47 YEAR-OLD MYOPIC FEMALE WITH REDUCED CS@ 6 CPD OU 47 Year-Old Science Teacher Refraction: OD x 005 / 20 OS x 012 / 6 cpd 6 cpd 4% MPOD 0.31 CLINICAL OBSERVATIONS WITH CONTRAST SENSITIVITY TESTING IN NORMAL PATIENTS 47 YEAR-OLD MYOPIC FEMALE WITH REDUCED CS@ 6 CPD OU No signs of corneal or other abnormality Large pupils but minimal Higher Order Aberrations Contrast Sensitivity expected to be at least 2 lines better Potential improvement with enhanced Macular Pigment RMS 2D RMS 0.09D RMS 6D RMS 0.23D Patient started on triple carotenoid formula; rec medical recheck in 6 months H53.72 Impaired Contrast Sensitivity CLINICAL OBSERVATIONS WITH CONTRAST SENSITIVITY TESTING IN NORMAL PATIENTS 23 YEAR-OLD MYOPIC FEMALE WITH REDUCED CS@ 6 CPD OU Patient with longstanding night glare and poor vision in fog OU Paternal GF blind from AMD, Paternal Aunt with AMD Takes Fioricet for migraines OD: x 085 / 20+ OS: x 077 / 20+ What else should we do? 6

7 CLINICAL OBSERVATIONS WITH CONTRAST SENSITIVITY TESTING IN NORMAL PATIENTS 23 YEAR-OLD MYOPIC FEMALE WITH REDUCED 6 CPD OU OD: x 085 / 6cpdc RMS 8D RMS 7D History of poor diet Low MPOD of 0.28 OS: x 077 / 6cpd RMS 0.24D RMS 0.39D CLINICAL OBSERVATIONS WITH CONTRAST SENSITIVITY TESTING IN NORMAL PATIENTS 23 YEAR-OLD MYOPIC FEMALE WITH REDUCED CS@ 6 CPD OU Patient motivated to start nutritional intervention with 10MZ-10L-2Z Being followed with MPOD and But.what if is average and patient is symptomatic? Use the same treatment based on the CREST Normal Trial! CLINICAL OBSERVATIONS WITH CONTRAST SENSITIVITY TESTING USE OF THE MACULAR DENSITOMETER: Useful, but an imperfect method of determining the true amount of macular pigment volume as noted in slide below Central Macular Pigment Macular Pigment Volume Central Macular Pigment Macular Pigment Volume Limitations of Testing Macular Pigment: Similar central pigment peaks with large differences in Macular Pigment Volume can occur. *Graphs courtesy of John Nolan, PhD CLINICAL OBSERVATIONS WITH CS TESTING IN PATIENTS WITH NORMAL VISUAL ACUITY 43 YEAR-OLD WITH POOR CS AND VISUAL COMPLAINTS 43-year-old notes increased night glare Complains of mild night glare MPOD 0.58, macular pigment volume unknown Wears CW SCL x 3-4 days ( Night and Day), changes lenses monthly Takes Lialda and 6-MP for Crohn s disease and on Zyrtec for allergies No sign of corneal edema or nafl staining OU Hint of subtle pigmentary migration at the macula OU OD: x 043/ cpd OS: x 140/ cpd QUESTIONS: Why is the patient s CS low average OD and poor OS? Could there be an effect on the cornea from overnight CL wear? CLINICAL OBSERVATIONS WITH CS TESTING IN PATIENTS WITH NORMAL VISUAL ACUITY 43 YEAR-OLD WITH POOR CS AND VISUAL COMPLAINTS CLINICAL OBSERVATIONS WITH CS TESTING IN PATIENTS WITH NORMAL VISUAL ACUITY 43 YEAR-OLD WITH POOR CS AND VISUAL COMPLAINTS Changed to DW for several days and returned for repeat CS testing OD: x 043/ cpd (vs ) (2 lines of improvement) OS: x 140/ cpd (vs 4% (1 line of improvement) PLAN improved by 2 lines OD and 1 line OS on repeat testing AFTER DW ONLY Still with poorer OS Rec DW for patient with occasional CW only Pt also on a triple carotenoid supplement and will be monitored 7

8 CLINICAL OBSERVATIONS WITH CS TESTING IN PATIENTS WITH NORMAL VISUAL ACUITY TESTING CONTRAST SENSITIVITY EVEN IN PATIENTS WITH NORMAL VISUAL ACUITY AND HEALTHY EYES OFTEN UNCOVERS UNADDRESSED VISUAL PROBLEMS AND BRINGS THE IMPORTANT TOPIC OF OCULAR NUTRITION INTO THE EXAM LANE CASE STUDIES 2 Cataract Studies Normal or Moderately Reduced VA OCULAR DISEASE AND USE OF CONTRAST SENSITIVITY TO ASSESS VISUAL IMPACT CORTICAL CATARACTS IN A 50 YEAR- OLD MALE- MAY 2017 OCULAR DISEASE AND USE OF CONTRAST SENSITIVITY TO ASSESS VISUAL IMPACT CORTICAL CATARACTS IN A 50 YEAR- OLD MALE Does this patient need cataract surgery? Does this patient need cataract surgery? OD OS x 005 / x 180 /20 Complains of glare with difficulty seeing in bright sunlight Notes starbursts around lights at night Had PRK in 2005 OU with good result Has noted worsening vision gradually over the last 2-3 years Exam shows significant central cortical cataract, mainly anterior OU. No other ocular disease What do we need to do? OD (dilated) OS (dilated) OCULAR DISEASE AND USE OF CONTRAST SENSITIVITY TO ASSESS VISUAL IMPACT CORTICAL CATARACTS IN A 50 YEAR- OLD MALE Does this patient need cataract surgery? OD: x /25+ OS: x cpd: 6 cpd: OD (dilated) OS (dilated) OCULAR DISEASE AND USE OF CONTRAST SENSITIVITY TO ASSESS VISUAL IMPACT CORTICAL CATARACTS IN A 50 YEAR- OLD MALE Does this patient need cataract surgery? YES! 8

9 OCULAR DISEASE AND USE OF CONTRAST SENSITIVITY TO ASSESS VISUAL IMPACT CORTICAL CATARACTS IN A 50 YEAR- OLD MALE- OCTOBER 2017 Successful Cataract Surgery- A Happy Patient! OD OS x / x cpd 6 line improvement in CS! 4 line improvement in CS! Pt also taking triple carotenoid and building his MP: 02/17 MPOD 0.35; 10/17 MPOD YEAR-OLD FEMALE WITH BILATERAL NUCLEAR SCLEROSIS BCVA OD: 20/40 BCVA OS: 20/40+ The patient notes some improvement with demo of an updated prescription. She is willing just to change her glasses if recommended. Is it acceptable to delay Cataract Extraction? 70 YEAR-OLD FEMALE WITH BILATERAL NUCLEAR SCLEROSIS BCVA OD: 6cpd BCVA OS: 6cpd WAIT FOR CATARACT SURGERY? NO! 70 YEAR-OLD FEMALE WITH BILATERAL NUCLEAR SCLEROSIS Patient returned for post-op visit thrilled with improved vision! BCVA OD: 6cpd BCVA OS: 6cpd 3 lines of improvement in VA in each eye. 7 lines of improvement in CS in each eye! 70 YEAR-OLD FEMALE WITH BILATERAL NUCLEAR SCLEROSIS 78 YEAR-OLD MALE WITH CORTICAL CATARACT OU The patient complains of mild distance blur in the left eye. On triple carotenoid for three years with min macular mottling. BCVA 2O/20- BVA 20/25- Patient is taking triple carotenoid supplement daily to enhance macular pigment due to increase in blue light exposure and oxidative stress on the macula following cataract removal Drivers involved in automobile accidents are six times more likely to have severe CS impairment in each eye! This patient is now safer on the road. Does the patient need cataract extraction? 9

10 78 YEAR-OLD MALE WITH CORTICAL CATARACT OU Does the patient need cataract extraction OS? NO. BUT- Why is there a 3 line difference in CS? BCVA 6cpd BCVA 6cpd 78 YEAR-OLD MALE WITH CORTICAL CATARACT OU Does the patient need cataract extraction OS? NO. BUT- Why is there a 3 line difference in CS? BCVA 6cpd More central cortical vacuoles OS! BCVA 6cpd 78 YEAR-OLD MALE WITH CORTICAL CATARACT OU 78 YEAR-OLD MALE WITH PSC CATARACT R>L Patient complains of worsening vision mainly in the Right Eye. OD: X 165 /30- OS: X 170 /25- Careful monitoring of CS and patient symptoms will enable confident referral at the appropriate time. Patient needs CE OD. Does he need it OS as well? 78 YEAR-OLD MALE WITH PSC CATARACT R>L OD: X cpd OS: X cpd Yes, the Left Eye vision is also visually impaired. 78 YEAR-OLD MALE AFTER PSC CATARACT SURGERY Post-Op Visit #1 Pt notes good improvement in vision Still using Durezol bid OU BCVA OD: 6 cpd!! BCVA OS: 6 cpd!! 10

11 78 YEAR-OLD MALE AFTER PSC CATARACT SURGERY OD CORNEAL EDEMA WITH DEEP FOLDS OU OS BCVA OD: 6cpd 25%! 78 YEAR-OLD MALE AFTER PSC CATARACT SURGERY 4 WEEKS LATER: Worse- patient non-compliant Start Durazol qid OU Referred back to surgeon INCREASING CORNEAL EDEMA WITH DEEP FOLDS OU OS BCVA OS: 6cpd 8% CCT 607um CCT 609um CCT 683um CCT 636um 71 YEAR-OLD FEMALE WITH BILATERAL PSEUDOPHAKIA CASE STUDIES 3 Secondary Cataract Patient notes mild blur OD with some glare at night IOLs implanted in 2011 OU and had YAG LASER OS in 2014 On carotenoid formula for several years No signs of macular disease in either eye BCVA OD 20/20 BCVA OS 20/20 How much is the PCO OD affecting vision? Does she need YAG OD? 71 YEAR-OLD FEMALE WITH BILATERAL PSEUDOPHAKIA BCVA OD 6cpd BCVA OS 6cpd How much is the PCO OD affecting vision? Does she need YAG OD? YES! Comments: 71 YEAR-OLD FEMALE WITH PCO OD Visual performance OD impaired with significant asymmetry YAG LASER indicated OD and patient referred Good visual performance OS after supplementation triple carotenoid formula restarted -preferred over the AREDS2 here BCVA OD 6cpd BCVA OS 6cpd 11

12 71 YEAR-OLD FEMALE POST YAG LASER FOR PCO HAPPY PATIENT AT ONE MONTH S/P YAG LASER OD Notes significantly better vision in daily activities! Contrast Sensitivity improved, symmetrical OU BCVA OD 6cpd BCVA OS 6cpd CASE STUDIES 4 Macular Disease DRY AMD OD AND WET AMD OS IN A 67 YEAR-OLD FEMALE -Patient on triple carotenoid formula for several years -Also has POAG and mild cataract OU OD: VA 20/25+ OS: VA 20/40- How well is this patient really seeing? DRY AMD OD AND WET AMD OS IN A 67 YEAR-OLD FEMALE OD shows good CS despite Dry AMD and Glaucoma OS has impaired CS as expected with active Wet AMD and Glaucoma OD: VA 6cpd: 2% OS: VA 6cpd 57 YEAR-OLD FEMALE WITH FAMILY HX OF WET AMD The patient notes blur OD, mild distortion with Amsler Grid OD only Takes 10L-10MZ-2L formula- but not every day OD 6cpd Why a 4-line difference in CS? OS 6cpd 57 YEAR-OLD FEMALE WITH FAMILY HX OF WET AMD OCT IMAGES EXPLAIN REASON FOR CS DISPARITY WITH CHANGES OD>OS 12

13 CASE STUDIES 5 POST-OP COMPLICATIONS 88 YEAR-OLD FEMALE WITH CME OD Patient seen 05/2017 complaining of reduced vision due to significant cataracts OU BCVA 20/30 OD 6cpd ; BCVA 20/40- OS 6cpd Also diagnosed with DED, possible Sjogren s and treated prior to cataract surgery Returned for post-op after successful surgery with monofocal IOLs OU OD: post-op 7 weeks OS: post-op 5 weeks Pt pleased with vision in each eye Post-Op Refraction: OD x /20-2 OS x cpd Why is CS reduced by 3 lines OD? 88 YEAR-OLD FEMALE WITH CME OD The IOLs look 6cpd 88 YEAR-OLD FEMALE WITH CME OD Subtle abnormality noted at the central macula OD on R/G and FAF photos. 88 YEAR-OLD FEMALE WITH CME OD OCT makes the diagnosis easy! OD OS 88 YEAR-OLD FEMALE WITH CME OD Pseudophakic CME (Irvine-Gass Syndrome) Angiographic studies indicate an incidence of 20-30% following ECCE/Phaco Symptomatic in about 1-5% of patients following ECCE/Phaco Usually presents within 4-12 weeks of surgery Spontaneous resolution occurs up to 80% of the time The longer it persists, the less likely to spontaneously clear If chronic (>6 months), can lead to permanent reduction in vision A decrease in contrast sensitivity occurs across a wide spectrum of spatial frequencies at 8 weeks and may cause persistent visual difficulties despite good Snellen visual acuity. (Ibanez et al 1993) *Update on pseudophakiccystoid macular edema treatment options; Levin, Darrin S et al.ophthalmoy Clinics, Volume 15, Issue 4, *.Cystoid macular edema following extracapsular cataract extraction and posterior chamber intraocular lens implantation. Bradford JD, Wilkinson CP Bradford RH Retina 1988;8:

14 88 YEAR-OLD FEMALE WITH BILATERAL CME VISIT 2: 3-WEEK FOLLOW-UP OD (Using Durezol bid & Ilevro bid) OD: VA: 20/25- (1 line 6cpd: (1 line better) Good initial response to treatment 7 Weeks Post-Op OD 10 Weeks Post-Op OD 88 YEAR-OLD FEMALE WITH BILATERAL CME VISIT 2: 3-WEEK FOLLOW-UP OS OS: VA: 20/30- ( 2 lines 6cpd: (1 line worse) OCT shows new fluid! Treatment started OS 5 Weeks Post-Op OS 8 Weeks Post-Op OS 88 YEAR-OLD FEMALE WITH BILATERAL CME VISIT 2: 3-WEEK FOLLOW-UP Subtle signs of CME OU 10 weeks post-op 8 weeks post-op 88 YEAR-OLD FEMALE WITH BILATERAL CME VISIT 3: 3 WEEKS LATER OD (Using Durezol bid & Ilevro bid) OD: VA: 6cpd Good response to treatment OD 7 Weeks Post-Op 10 Weeks Post-Op 13 Weeks Post-Op 88 YEAR-OLD FEMALE WITH BILATERAL CME VISIT 3: 3-WEEKS LATER OS (Using Durezol bid & Ilevro bid) OS OS: VA: 20/20 5 Weeks Post-Op 6cpd 8 Weeks Post-Op 11 Weeks Post-Op VISIT 3: 88 YEAR-OLD FEMALE WITH BILATERAL CME Pt notes significant improvement in vision in each eye from last visit This correlates with reduced fluid and improved 13 weeks post-op 11 weeks post-op 14

15 CHANGES OVER TREATMENT PERIOD OD 88 YEAR-OLD FEMALE WITH BILATERAL CME VISIT 4: 4 WEEKS LATER 7.00% 6.00% 5.00% 4.00% 3.00% 2.00% 1.00% 0.00% CS Threshold Post-Op Week Change (Microns) Central Subfield Fluid Post-Op Week Thickness weeks post-op 11 weeks post-op 30 Visual Acuity 17 weeks post-op 15 weeks post-op Patient reported improvement in vision as improved even though little change occurred in VA. 5 0 Post-Op Week YEAR-OLD FEMALE WITH BILATERAL CME VISIT 4: 4 WEEKS LATER 13 weeks post-op 11 weeks post-op 17 weeks post-op 15 weeks post-op 88 YEAR-OLD FEMALE WITH BILATERAL CME VISIT 4: 4 WEEKS LATER 17 weeks post-op LOOKS GREAT!! 15 weeks post-op Currently using Ilevro 3x/week to OD: BCVA 20/20 reduce likelihood ofrecurrence. OS: 54 YEAR-OLD FEMALE WITH NS OD/ PSEUDOPHAKIA OS Right Eye: The patient c/o poor vision OD with advancing NS cataract. Jan 2017: DS 20/20 Aug 2017: DS 20/ CPD Significant Nuclear Sclerosis OD Min Cortical Cataract Left Eye: Good visual acuity and no complaints S/P CE with PC IOL DS 20/20 CPD: COMMENTS: 54 YEAR-OLD FEMALE WITH NS OD/PSEUDOPHAKIA OS Increasing refractive asymmetry and complaints of poor vision warrant consideration of cataract surgery OD now even though VA still good- about one line difference Harris Contrast Test shows FOUR line difference in between the eyes CS testing corresponds to patient s symptoms, though NS mild OD triple carotenoid formula recommended to provide maximum protection from oxidative stress from additional blue light exposure after cataract removal and promote optimal visual performance 15

16 54 YEAR-OLD FEMALE NOW WITH PSEUDOPHAKIA OU 2-week Post-Op Visit OD Excellent improvement in vision Still on 1% pred acetate qid Macula clear on 90D view OD: pl / 6 cpd OS: S/P CE with PC IOL 2012 OS: DS CPD: 54 YEAR-OLD FEMALE NOW WITH PSEUDOPHAKIA OU 5-week Post-Op Visit OD Slight blur noted OD after questioning Stopped steroid after 3 weeks OD: -0.25/ 6cpd OS: Good visual acuity and no complaints S/P CE with PC IOL 2012 OS: DS 20/20 6cpd: Why is the OD higher by 2 lines compared to last visit? OCT of the Macula indicated. 54 YEAR-OLD FEMALE NOW WITH SEUDOPHAKIA OU 5-week Post-Op Visit OD OD: -0.25/ 6cpd OS: DS 6cpd: 54 YEAR-OLD FEMALE NOW WITH PSEUDOPHAKIA OU 5-week Post-Op Visit OD Significant ERM OD Significant ERM OD Minimal ERM OS Minimal ERM OS 54 YEAR-OLD FEMALE NOW WITH PSEUDOPHAKIA OU 5-week Post-Op Visit OD Significant ERM OD CASE STUDIES 6 Medication Toxicity Patient restarted on predacetate 1% bid and Prolensadaily OD 16

17 48 YEAR-OLD FEMALE ON PLAQUENIL SINCE 2006 FOR LUPUS BCVA OD 20/20 BCVA OS 20/20 The FAF looks normal. What other information might be helpful? 48 YEAR-OLD FEMALE ON PLAQUENIL SINCE 2006 FOR LUPUS BCVA OD 6cpd 4% MPOD 8! BCVA OS 6cpd 4% OCULAR DISEASE AND USE OF CONTRAST SENSITIVITY TO ASSESS VISUAL IMPACT 82 YEAR-OLD WITH AMIODARONE TOXICITY CASE HISTORY 82 year-old white female with heart problem started on 800mg of Amiodarone in July, 2015 Tapered to 400mg, then 200mg over a few months Vision changes occurred with optic disc edema noted Dec 2015 MRI negative and neuro-ophthalmoist stopped amiodarone Jan 2016 Improvement but optic disc pallor noted March 2016 Vision problems persisted and significant cataracts noted R>L BCVA 20/125 OD prior to surgery Successful CE with PC IOL for OD performed March, 2017 Persistent c/o poor vision with subtle positive scotoma OD The patient was released for new glasses following post-op visit late April, OCULAR DISEASE AND USE OF CONTRAST SENSITIVITY TO ASSESS VISUAL IMPACT 82 YEAR-OLD FEMALE S/P AMIODARONE TOXICITY 6-Week Post- Op Exam ( May 03, 2017) CC: Vision OD still blurry, area of central dimness noted OD Minimal improvement overall since CE; mild blur OS as well OD OS RX: X 099 / X 130 / 6 6 CPD: 5% Well-placed PC IOL, clear capsule Mod disc pallor, no edema Amsler: Dim area just below fixation 3+ NS, 1+ cortical spokes Mod disc pallor, no edema Normal OCULAR DISEASE AND USE OF CONTRAST SENSITIVITY TO ASSESS VISUAL IMPACT 82 YEAR-OLD FEMALE S/P AMIODARONE TOXICITY 82 YEAR-OLD FEMALE: RNFL THINNING IN AMIODARONE TOXICITY July Normal RNFL on OCT Averages: 93um OD / 92um OS May RNFL Averages: 59um OD / 57um OS Optic Neuropathy not illustrated Incidence from % 17

18 OPTIC DISC APPEARANCE WITH AMIODARONE TOXICITY Moderate disc pallor noted OU (Window defect inferior OD is longstanding) View OS slightly cloudy due to cataract 82 YEAR-OLD FEMALE WITH VISUAL FIELD LOSS S/P AMIODARONE TOXICITY OD:VFI 53%, dense central defect OS: VFI 90% OD OS 82 YEAR-OLD FEMALE WITH MACULAR CHANGE IN AMIODARONE TOXICITY Macular Thickness Scan; Thinning central/sup OD GCC very thin, esp OD May 2017 May YEAR-OLD FEMALE: AMIODARONE TOXICITY AND CONTRAST SENSITIVITY SUMMARY AMIODARONE TOXICITY Optic disc involvement occurs but with incidence of less than 2% Typically occurs when patients on 200mg for 2 months or more Optic disc edema may persist for several months after med is stopped Permanent damage to the optic nerve can occur CONTRAST SENSITIVITY TESTING IN THIS CASE Much better in predicting visual function than VAs Better than OCT of the nerve in identifying the eye more impacted Correlates well with Macular GCC findings, and VF results Explains reason for better vision in the non-surgical eye Valuable information obtained very quickly to guide recommendations regarding potential improvement when cataract surgery considered OS CASE STUDIES 7 Corneal Disease CLINICAL OBSERVATIONS WITH CS TESTING IN PATIENTS WITH NORMAL VA 61 -YEAR-OLD WITH CORNEAL GUTTATA L>R AND ASYMMETRIC CS BCVA 6cpd BCVA 6cpd 18

19 Why Measure Contrast Sensitivity in Your Practice? S O A P EXAM FLOW ASK QUESTIONS ABOUT VISION AND EYE HEALTH- DOCUMENT CC, HPI, ROS, HISTORY VA, NCT, VF, PUPILS, IOP, SLIT LAMP, PHOTOS, FUNDUS EXAM, ETC ADD ONE EXTRA MINUTE PER EYE TO 6CPD BETTER ASSESSEMENT OF HOW THE PATIENT IS SEEING IN THE REAL WORLD AND WHAT TO DO ABOUT IT BETTER PLAN = BETTER DECISION-MAKING, MORE EFFICIENCY BETTER OUTCOMES, HAPPIER PATIENTS TIME SAVINGS INCREASED REVENUE OFFER SUPPLEMENTS IN YOUR OFFICE THANK YOU Please direct questions to markroark.od@gmail.com 19