Article Date: 6/1/2006

Practice pulse

Eye Fungus Attributed to Solution Formulation and Non-Compliance

If You Suspect Fusarium

1. Report the event o the FDA at 1-800-FDA-1088 (phone), 1-800-FDA-0178 (fax) or at
2. Scrape tissue for laboratory analysis — in initial presentation, clinicians cannot differentiate between bacterial disease and most fungal keratitis.
3. Do not initiate steroid treatment until fungal infection is ruled out. Fungal disease "feeds" on the immuno-suppression produced by steroids.


• The American Optometric Association:
• The American Academy of Ophthalmology:
• The Centers for Disease Control and Prevention:

In response to the incidence of Fusarium keratitis among soft contact lens wearers, eyecare professionals re-evaluated the management of contact lens patients, while Bausch & Lomb announced it would permanently remove its MoistureLoc solution from world markets.

B&L announced the voluntary recall on May 15, citing customer safety as a top priority. An investigation by the U.S. Centers for Disease Control and Prevention (CDC) reported that in cases of Fusarium infection among contact lens wearers who could identify their solutions (118 persons), 64% reported using MoistureLoc alone and another 12% reported using MoistureLoc with another product.

The CDC concluded that MoistureLoc was the only product with a statistically significant association with reports of Fusarium. As testing by the manufacturer and health authorities revealed "no evidence of product contamination, tampering counterfeiting or sterility failure," B&L concluded some aspect of the formulation was responsible.

Further tests by B&L found a disinfecting agent in MoistureLoc, alexidine, was safe and effective when the solution was used properly. However, evaporation of the solution can lead to a higher concentration of polymers that may make the solution more likely to be contaminated with Fusarium.

Brian Levy, O.D., M.Sc., chief medical officer, B&L, noted that the "extensive R&D effort" found that polymers in the MoistureLoc formulation could create films under certain conditions of use, in particular evaporative conditions. "This could occur in a number of instances — for example, when solution is 'topped off' in lens cases instead of changing solution daily, when bottles are left open between uses and polymer forms around the tip or in the cap, or when cases are not cleaned properly or changed regularly. The polymer film, which may form on the bottle tip or in the case, reduced efficacy of the disinfectant and provided an environment protective of Fusarium with the MoistureLoc formulation," said Dr. Levy. "Under similar test conditions, efficacy remained high for ReNu MultiPlus, which does not contain the polymer content of MoistureLoc."

As of May 18, the CDC reported 130 confirmed cases of Fusarium keratitis and of these 125 reported wearing contact lenses. "We advise patients that infections are extremely rare, but they should report any incidents of red or painful eyes to us immediately," says Sheldon Kreda, O.D.

Andrew S. Gurwood, O.D., provides strict instructions for lens care including: clean contact lenses twice a day, keep lenses in a clean case, discard lenses at the prescribed time, do not sleep in lenses, do not change solutions "randomly" and remove lenses and call the practice ASAP in the case of discomfort or red eyes.

Paul Karpecki, O.D., says he was "shocked" at how few patients were honestly compliant when he brought up hygiene issues. "About 90% had taken numerous shortcuts in contact lens care," he notes.

Dr. Karpecki says the incidence of poor contact lens compliance "is up substantially from where it was before the 'no-rub' marketing."

"In my practice, I have taken steps to review patient compliance, to dismantle the entire idea of no-rub, and to inform patients of the risks associated with poor hygiene related to contact lens wear," says Dr. Karpecki.

What to Do at Optometry's Meeting

If the reasons you chose to attend the this year's American Optometric Association meeting in Las Vegas (June 21-24) go beyond the purely educational, local optom-etrists can give you tips for getting the most out of your down time. While you probably already know about the casinos, you may need some suggestions when it comes to dining and sightseeing. James A. Beckwith, O.D., of Vision Source, and Jeffrey Austin, O.D., F.A.A.O., president of the Nevada Optometric Association, offer their homegrown insights into the city's finest.

Dining on The Strip


WHAT: the 109th annual American Optometric Association Congress and the 36th annual American
Optometric Student Association
WHEN: June 21-26
WHERE: Mandalay Bay Resort and Casino (

Andre's. Simply "the best French food in town," according to Dr. Austin. Price range: $35+. 3770 S. Las Vegas Blvd.; (702) 730-7955.
Cannaletto. Located in the Venetian Hotel, this northern Italian-style restaurant offers outside dining on the piazza ("Which in Las Vegas is really inside, but it seems like outside," says Dr. Beckwith) or more formal dining indoors. "The risotto is fabulous," says Dr. Beckwith. Price range: $15-$25. 3355 S. Las Vegas Blvd; (702) 733-0070.
Capital Grille. Specializing in steak and seafood, this restaurant offers plenty of Las Vegas ambiance, with enormous paintings of quintessential "Vegas people" such as Sinatra and Liberace, and a view of the Strip. It's located in the Fashion Show Mall. Price range: $35+. 3200 S. Las Vegas Blvd.; (702) 932-6631.
Del Frisco's Double Edge Steakhouse. This fine-dining restaurant "has the best steaks" in town, according to Dr. Austin. Price range: $35+. 3925 Paradise Rd.; (702) 796-0663.
Mon Ami Gabi. Located in the Paris Las Vegas Hotel, this spot offers dining both indoors and outside on the Strip. "Ask for a view of the Bellagio Fountains," Dr. Beckwith recommends. "Very reasonable prices for outstanding food and view." Price range: $25-$35. 3655 S. Las Vegas Blvd.; (702) 944-4224.

Must-see attractions

You'll find plenty of entertain- ment right there on the Strip:

The Venetian Hotel and Casino houses the Grand Canal Shoppes, which offer a real canal and gondola rides in addition to shopping, a branch of Madame Tussaud's wax works museum and the Guggenheim Hermitage. 3355 S. Las Vegas Blvd.

The fountain show at the Bellagio Hotel and Casino runs every half hour from 3p.m. till 8p.m., and every 15 minutes from 8p.m. until midnight. 3600 S. Las Vegas Blvd. (at the intersection of Flamingo Rd. and the Strip).

Dr. Austin recommends the avant-garde Blue Man Group Theater, which will appear at the Venetian from 6/15-6/25.

If you want to venture outside the city, Dr. Austin recommends a visit to the Hoover Dam. A National Historic Landmark, it's the highest concrete dam in the Western Hemi- sphere and only 35 miles south of Las Vegas. For information on tours, go to

Oklahoma Passes Vision Screening Law

Oklahoma recently enacted the Children's Vision for Excellence Act, which requires vision screenings and follow-up eye exams for students who fail. The law goes into effect in 2007 and will result in screenings for 140,000 students and an estimated 10,000 follow-up exams each year.

The law requires children entering kindergarten, first and third grades receive a screening. Students who fail will be required to receive a comprehensive eye exam.

Follow-up care for students who fail the screenings is a critical issue. Vision Council of America noted of the 31 states that required vision screening last year, 28 did not require a follow-up exams for those who failed.

When it comes to referrals, the right specialist may be closer than you think

When it comes to referring your patient to a specialist, M.D.s are not your only option. Many optom-etrists are qualified to handle complicated ocular conditions, from challenging contact lens cases to eye disease. Whether you need to find an appropriate practitioner to refer to, or get referrals yourself, here are the issues you'll need to consider.

Why go to another O.D.?

When optometrists think of making referrals to colleagues, they typically think of M.D.s. (A complete list of conditions that are appropriate to refer to M.D.s is included in the feature "A Complete Guide to Referrals," which begins on page 76.) When the patient needs surgery or treatment for eye disease, this makes sense. However, there are also many situations in which sending a patient to another O.D. not only benefits that patient, but your practice as well.

Just like an M.D., another optometrist may have specialized knowledge that you don't. Kenneth A. Lebow, O.D., F.A.A.O., of Virginia Beach, Va., points out that visual training or developmental vision are specialties he will refer for. Neuro-retinal cases, such as retinitis and optic neuropathy, and systemic issues also qualify. "An excellent example of when to refer to another O.D. is when the practitioner has limited experience with keratoconus or post-refractive surgery contact lens fittings," Dr. Lebow says. Referrals for these situations should occur more frequently than they do, he claims.

Another important reason to find other optometrists to whom you can refer your patients is to get coverage for an emergency when you are out of town or otherwise unavailable. This is critical, Dr. Lebow says. "It then becomes a reciprocal relationship."

William L. Jones, O.D., of Albuquerque, on the other hand, covers many of the problems M.D.s typically do. Nearly 12 patients are referred to his office on a weekly basis. His referral-only practice treats patients with glaucoma and performs retinal evaluations, such as age-related macular degeneration, diabetic retinopathy and retinal breaks. He gets referrals for such cases because he has made himself an expert. "I've been involved in cases such as these since my residency in 1977," Dr. Jones says. "I decided to open a practice specializing in them to help fellow O.D.s with eye-disease patients."

Building your network

How can you find qualified O.D.s like Dr. Jones to whom to refer your patients? It's a more sociable experience than you might think. "It's as easy as getting to know the practitioners in your area," says Dr. Lebow. Find out who handles what, he advises, and be sure to ask what the practitioner feels most comfortable doing.

Dr. Jones incorporated a more formal approach as well. He says that shortly after opening his practice, he hosted an open house to answer questions.

Play fair

Getting your patient back after you've referred him or her to a specialist has always been a major concern for practitioners. Dr. Jones says that sending the patient back to the referring optometrist is always his policy. He provides a detailed report back to his colleagues in the form of a written report and a PowerPoint presentation with all of the tests he performed on the patient. He says he sends these reports as soon as possible so the referring O.D. knows that the cases were treated promptly and taken seriously. Dr. Jones also often calls the referring O.D. with an update the same day he's seen the patient.

Rather than take that level of conscientiousness for granted, Dr. Lebow recommends discussing the matter with the specialist prior to the referral. Making it clear that you expect the patient back once the treatment is completed is critical, he says.

As a contact lens specialist, Dr. Lebow explains, "When a practitioner refers me a contact lens fit due to its complexity, I typically return the patient to the referring doctor to get glasses that can be interchanged with their contact lenses. The original O.D. does the eye health exam and I evaluate the contact lenses." He warns, though, that every once in a while, a patient does choose not to return to his or her original doctor.

Get started

If you're ready to begin your referral network, there's no need for lengthy preparation. Dr. Lebow advises simply picking up the phone and calling the O.D. you're considering to handle your patient's care. Remember to have that discussion about returning the patient to you once the treatment is completed. Find an optometrist who makes you feel comfortable with the relationship.

If you want to receive referrals, then you do need to do some preparation. Not only does this require extensive knowledge of a given specialty, but, "Then you have to build a reputation upon your knowledge," Dr. Jones says. He recommends publishing or lecturing on your area of specialization to boost your image in the community.

For your referral network to succeed, be sure to keep it a two-way proposition. "Too often it is a one-way street," says Dr. Lebow. "When this happens, referrals fail and feelings get hurt." — René Luthe, Senior Associate Editor


The Senate rejected Bill S.1955, the Health Insurance Modernization and Affordability Act, designed to establish small business health plans that would be exempt from many state coverage requirements. The legislation would have allowed health plans to discriminate against O.D.s, according to the American Optometric Association.

The Journal of the American Medical Association has published a National Institutes of Health (NIH) study, which finds that 14 million Americans are visually impaired. Of these, more than 11 million, many economically disadvantaged, would benefit from eyeglasses or contact lenses.

President and CEO James V. Mazzo has been named Advanced Medical Optics' (AMO) chairman of the board, following the retirement of William R. Grant, who will remain a member of the company's board of directors.

The Allergan Foundation, the philanthropic arm of Allergan, presented the University of California Irvine Department of Ophthalmology with $2 million, the largest donation ever for ophthalmology.

VSP (Vision Service Plan) recently launched a video series to provide tools for young baseball players. The Get Focused Sports Vision Video series ( helps children sharpen their skills while learning about the overall importance of eyecare. The drills require only inexpensive household products or sporting goods.

Carl Zeiss Vision International, and SOLA International have completed the merger of the North American ZEISS and SOLA ophthalmic lens businesses into a single, entity: Carl Zeiss Vision.

Correction. On page 60 of "The GP Industry Update" (OM, April 2006) the photos are transposed. The photo on the right depicts a contact lens treated with a plasma coat.

Optometrist Runs for South Dakota State Senate

Dr. Phil Sietstra has always been interested in politics. That's part of what drove him to throw his hat into the ring for the state senate seat in South Dakota's tenth district. No one has challenged the Republican senators in his district for six years. "It just seemed like the right time," says Dr. Sietstra. In fact, timing is everything. Dr. Sietstra's youngest son is just off to college, allowing him more free time. And his group practice just hired two new associates, which provides enough staff to cover his patient load without causing patients a problem. "That's very important to me," he says.

Dr. Sietstra's career in optometry was part of his political inspiration. "If you think about it, being an optometrist is a bit political," says Dr. Sietstra. He was in optometry school when West Virginia passed the first diagnostic laws. "In order to get there, and to sustain our profession, we are constrained to stay active in politics. Otherwise, someone else will tell us what our profession is and that won't be good," he says.

Dr. Sietstra believes in community and responsibility. He'd like ade-quate funding for public education and a raise in the state's minimum wage. "A living wage is a family value," he says, "It's very difficult to take care of a family if you're working three jobs." He'd also like to address healthcare costs, which he says are a burden for small businesses.

"It's imperative that we be active in politics at the local level. We can make a huge difference in protecting our profession from all sorts of untoward influences," says Dr. Sietstra.

Aging Americans Need AMD Education

According to Prevent Blindness America, a new survey shows that only 55% of those over age 65 are aware of wet AMD. In addition, only 10% of the same age group knew that vision can deteriorate rapidly with wet AMD.

In response, Prevent Blindness America and the Macular Degeneration Partnership have sponsored "My Eye Health: In the Wink of an Eye," a national campaign to educate Americans about AMD. The campaign, which received funding from OSI Eyetech and Pfizer Ophthalmics, features actress Betty White, who discusses the importance of early detection and treatment.
About 15 million Americans — almost one in four over the age of 50 — have AMD. More than half of adults aged 65 and older did not know that there are treatment options available for wet AMD.
The My Eye Health campaign will educate the public about signs and symptoms of wet AMD. In addition, patients can receive free copies of the Amsler grid along with instructions on how to use it through or by calling (866) 702-EYES (866-702-3937).

The study results and the campaign are both signs that optometrists have a tremendous opportunity to educate patients in the area of AMD.

Optometric Management, Issue: June 2006