Epinephrine 1mg/10ml (0.1mg/ml) from Lifeshield is much cheaper: this one is harder to use & you need your own 22G or 30G needle and you should only inject 1/3 of vial at a time, but it is less expensive than the alternatives. I
Tuesday, March 6, 2018
Epinephrine Auto-Injector
Still some doctors do not know that they can write "Epinephrine Auto-Injector" instead of EpiPen for a cheaper equally effective alternative for patients. EpiPen is still very expensive and there are cheaper alternatives.
Epinephrine 1mg/10ml (0.1mg/ml) from Lifeshield is much cheaper: this one is harder to use & you need your own 22G or 30G needle and you should only inject 1/3 of vial at a time, but it is less expensive than the alternatives. I
Epinephrine 1mg/10ml (0.1mg/ml) from Lifeshield is much cheaper: this one is harder to use & you need your own 22G or 30G needle and you should only inject 1/3 of vial at a time, but it is less expensive than the alternatives. I
Stem Cell Use for Dry Eye
Today I saw another patient in her 20's who has had to quit her job because she cannot stand to look at screens. She was a computer programmer working 10hr days in front of some form of electronic screen. This is the 15th patient under the age of 30 who has quit a job because of chronic eye pain. This is unheard of in the eye surgical world. Quitting your job because of eye pain has not been published as far as a I know.
My concern is all the young children under the age of 15 with severe dry eye and meibomian gland atrophy in part due to excessive screen time. What will become of them? Why are the schools not banning screens? How can we quickly get this news spread to all schools globally?
Our Stem Cell protocol for the use to restore the meibomian glands, lacrimal gland, and mucin gland has begun thanks to a very generous donor who has contributed to our research.
We will be following patients to see if we can prove or disprove with the relatively objective test of Meibography to see if autologous stem cells work or not.
The message for everyone, is "Do not ignore your eye symptoms. Get a meibography and eyeMD check if you have any redness, tearing, burning, irritation, foreign body sensation, pain."
My concern is all the young children under the age of 15 with severe dry eye and meibomian gland atrophy in part due to excessive screen time. What will become of them? Why are the schools not banning screens? How can we quickly get this news spread to all schools globally?
Our Stem Cell protocol for the use to restore the meibomian glands, lacrimal gland, and mucin gland has begun thanks to a very generous donor who has contributed to our research.
We will be following patients to see if we can prove or disprove with the relatively objective test of Meibography to see if autologous stem cells work or not.
The message for everyone, is "Do not ignore your eye symptoms. Get a meibography and eyeMD check if you have any redness, tearing, burning, irritation, foreign body sensation, pain."
Friday, March 2, 2018
Risk of Vision Loss with Cymbalta and Irenka
Yes, there is a risk of bilateral acute angle closure glaucoma with Cymbalta and Irenka.
The risk is rare and usually occurs in patients who have narrow angles and are older.
Still, be sure you do not have narrow angles (simple Pentacam can check this at your eyeMD's office), before starting Cymbalta and Irenka.
SLC
To report a patient who had an attack of bilateral acute angle-closure glaucoma (ACG) probably associated with the use of duloxetine.
The case reported here involves an 81-year-old Caucasian woman whose past ocular history was unremarkable except for high hyperopia and cataract. The patient developed ocular symptoms 2 days after starting duloxetine, a serotonin norepinephrine reuptake inhibitor (SNRI) and was diagnosed with acute ACG. The elevated intraocular pressure (IOP) was successfully lowered with medical treatment, and the patient was advised to discontinue duloxetine. She subsequently underwent laser iridotomy in both eyes, and her IOP remained adequately controlled. A score of 6 was obtained using the Naranjo adverse drug reaction probability scale, suggesting duloxetine as the probable cause of the attack of ACG in this patient.
There are a few previous reports of acute ACG associated with venlafaxine, another member of the class of SNRIs. In addition, there are several reports of ACG associated with members of the related class of selective serotonin reuptake inhibitors (SSRIs)-namely, fluoxetine, paroxetine, fluvoxamine, sertraline, citalopram, and escitalopram. The mechanism responsible for the precipitation of ACG by members of these 2 classes of drugs is likely a result of mydriasis caused by their adrenergic effects, weak anticholinergic activities, or the increased levels of serotonin.
Because the SNRIs, including duloxetine, and SSRIs are commonly used in the management of depression or chronic pain, caution is warranted with the use of these drugs in patients with risk factors for ACG.
The risk is rare and usually occurs in patients who have narrow angles and are older.
Still, be sure you do not have narrow angles (simple Pentacam can check this at your eyeMD's office), before starting Cymbalta and Irenka.
SLC
Ann Pharmacother. 2014 Jul;48(7):936-939. Epub 2014 Apr 14.
Probable Association of an Attack of Bilateral Acute Angle-Closure Glaucoma With Duloxetine.
Abstract
OBJECTIVE:
CASE SUMMARY:
DISCUSSION:
CONCLUSION:
Thursday, June 8, 2017
Autologous Serum (AS) Versus Platelet-rich plasma (PRP)
Platelet-rich plasma (PRP)
Platelet-rich plasma (PRP) contains a higher concentrated of growth factors which stimulate epithelial cells faster than Autologous Serum or whole blood and lead to faster healing. PRP is obtained via centrifugation from whole blood mixed with anticoagulant. Platelets are critically important in the wound-healing process. They translocate rapidly to the wound site and adhere to the damaged tissue, initiating a healing reaction which includes the release of a variety of cytokines and growth factors. Hartwig et al. reported a superior effect on cell growth in platelet releasates in PRP than in Autologous Serum owing to its high content of growth factors
Platlets contain α-granules which liberate a very high concentration of:
-platelet-derived growth factors,
-platelet factor IV,
-transforming growth factor (TGF)-β
-circulating stem cells
Thus, PRP is known to harbor higher concentrations of growth factors and can promote effective wound healing and may be better than Autologous Serum in certain patients.
PRP eye drops can be used to treat ocular surface diseases, such as:
-pain after LASIK (laser-assisted in situ keratomileusis)
-ocular surface diseases
-corneal ulcers
-severe dry eye
-ocular graft-versus-host disease,
-persistent epithelial defects,
-neurotropic keratopathy,
- recurrent epithelial erosions: it reduces the risk of recurrent erosions
-infectious keratitis
-persistent epithelial defects
Kim, et al. reported improved outcomes with PRP eye drops than Autologous Serum eye drops in patients with persistent epithelial defect after infectious keratitis, for instance (Reference 1).
Autologous Serum (AS)
Autologous Serum (AS) acts as a lubricant on the ocular surface and also supplies several essential substances for the recovery of damaged epithelium.
It contains:
- vitamin A
- epidermal growth factor (EGF)
-fibronectin and a variety of cytokines
-circulating stem cells
These factors help with the proliferation, migration, and differentiation of the ocular surface epithelium cells which helps restore the eye surface to prevent pain or heal a patient from pain.
Autologous Serum eye drops have been used for years for the treatment of:
-ocular surface diseases,
-corneal ulcers
-severe dry eye,
-ocular graft-versus-host disease,
-persistent epithelial defects,
-neurotropic keratopathy,
- recurrent epithelial erosions: it reduces the risk of recurrent erosions (Reference 2)
References:
1. Kim KM, Shin YT, Kim HK. Effect of autologous platelet-rich plasma on persistent corneal epithelial defect after infectious keratitis. Jpn J Ophthalmol. 2012;56:544–550.
2. Del Castillo JM, de la Casa JM, Sardina RC, et al. Treatment of recurrent corneal erosions using autologous serum. Cornea. 2002;21:781–783
3. Alio JL, Pastor S, Ruiz-Colecha J, et al. Treatment of ocular surface syndrome after LASIK with autologous platelet-rich plasma. J Refract Surg. 2007
4. Hartwig D, Harloff S, Liu L, et al. Epitheliotrophic capacity of a growth factor preparation produced from platelet concentrates on corneal epithelial cells: a potential agent for the treatment of ocular surface defects? Transfusion. 2004;44:1724–1731
5. Korean J Ophthalmol. 2016 Apr; 30(2): 101–107.
Autologous Platelet-rich Plasma Eye Drops in the Treatment of Recurrent Corneal Erosions
Jun Hun Lee,1 Myung Jun Kim,1 Sang Won Ha,2 and Hong Kyun Kim
1
1Autologous Serum and Platelet-Rich Plasma for Corneal Ulcers, Recurrent Erosions, and Dry Eyes
We are beginning to offer Platelet-Rich Plasma for our patients with Corneal Ulcers and dry eyes.
Platelet-Rich Plasma (PRP) has been used for years in many different specialties. PRP is now being used to help heal patients with Corneal Ulcers, Recurrent Erosions, and Dry Eye as a way to stop the process of scar tissue formation and improve wound healing of damaged cells. Though PRP has not been shown to restore meibomian glands yet, it has not been studied. I wonder if injecting PRP into the meibomian glands may help restore the glands. It may. Stem Cells though is likely better for injection into the Meibomian Glands.
Platelet-Rich Plasma (PRP) is full of platelets which are good reservoirs of growth factors that improve wound healing and restore damaged ocular surfaces.
We create PRP in a similar way we create autologous serum for a patient's own blood. We have been using Autologous Serum in hundreds of adults and children at Visionary Ophthalmology for about 25 years with very good results. I used Autologous Serum for adults at Harvard Medical School's Massachusetts Eye and Ear Infirmary rarely for many years when I was there on staff.
For PRP, the blood is spun in a centrifuged to remove white and red blood cells to leave the platelets and growth factors. The plasma is placed into sterile eye droppers for topical administration. It is kept in the freezer until one plans to use it and then put in the refrigerator. They can be used for 1 week after defrosted.
The biggest risk of using a blood product on a patient is a corneal infection. This is very rare but has been reported in patients who failed to keep the drops frozen or cold. I have not seen one yet from AS or PRP made in our office (nor at Harvard). Still any type of worsening while someone is using AS or PRP requires immediate attention and evaluation by an EyeMD.
In future studies, a group of patients would have injection of Stem Cells in one eyelid and the other eyelid would be used as a control. Another set of patients would have PRP injected into the lower eyelid and the their other non-treated eye would serve as a control.
Studies have shown Platelet rich plasma improved light sensitivity/photophobia, pain and inflammation. It helped reepithelialization of corneal epithelium, promoted corneal wound healing. It improved clinical conditions and resulted in improved vision in the majority of the patients
Sandra Lora Cremers, MD, FACS
Ophthalmology. 2007 Jul;114(7):1286-1293.e1. Epub 2007 Feb 26.
Use of autologous platelet-rich plasma in the treatment of dormant corneal ulcers.
Abstract
PURPOSE:
To investigate the potential role of autologous platelet-rich plasma in promoting healing in dormant corneal ulcers.
DESIGN:
Prospective, consecutive, interventional, noncomparative, nonrandomized, observational study.
PARTICIPANTS:
Forty eyes of 38 patients with dormant corneal ulcers.
METHODS:
Autologous platelet-rich plasma was used in a total of 40 eyes with dormant corneal ulcers divided into 2 groups: group I, 26 eyes treated with topical eyedrops of autologous platelet-rich plasma (12 neurotrophic, 9 herpetic, and 5 immunological ulcers), and group II, 14 eyes treated surgically with a solid clot of autologous platelet-rich plasma combined with amniotic membrane transplantation in perforated corneas or with impending perforation. The treatment was used in patients with chronic nonhealing ulcers (mean, 2 years of evolution) that had been unresponsive to conventional topical therapy. Autologous blood from each patient was obtained by venipuncture, and platelet-rich plasma was prepared from each blood sample without additives.
MAIN OUTCOME MEASURES:
Ulcer size, inflammation, healing, visual acuity, and patient's subjective symptoms.
RESULTS:
Autologous platelet-rich plasma promoted healing of ulcers. In group I, 13 eyes healed, 11 eyes improved significantly, and 2 eyes showed no change. In group II, 10 eyes healed and 4 eyes improved significantly. Inflammation and subjective symptoms, particularly pain, improved in all patients. Vision remained stable or improved in all cases.
CONCLUSION:
Autologous platelet-rich plasma promoted healing of dormant corneal ulcers even in eyes threatened by corneal perforation and was accompanied by a reduction in pain and inflammation.
- Alio JL, Abad M, Artola A, et al. Use of autologous platelet-rich plasma in the treatment of dormant corneal ulcers. Ophthalmology. 2007.114:1286-1293.
- Kojima T, Ishida R, Dogru M, et al. The effect of autologous serum eye drops in the treatment of severe eye disease: a prospective randomized case-controlled study. Am J Ophthalmol. 2005;139:242-246.
- Tsifetaki N, Kitsos G, Paschides CA, et al. Oral pilocarpine for the treatment of ocular symptoms in patients with Sjögren’s syndrome: A randomised 12-week controlled study. Ann Rheum Dis. 2003;62:1204-1207.
Plast Reconstr Surg. 2012 Jan;129(1):46e-54e. doi: 10.1097/PRS.0b013e3182362010.
Nonactivated versus thrombin-activated platelets on wound healing and fibroblast-to-myofibroblast differentiation in vivo and in vitro.
Abstract
BACKGROUND:
METHODS:
RESULTS:
CONCLUSIONS:
BioMed Research International
Volume 2014 (2014), Article ID 692913, 10 pages
http://dx.doi.org/10.1155/2014/692913
Research Article
Does Platelet-Rich Plasma Freeze-Thawing Influence Growth Factor Release and Their Effects on Chondrocytes and Synoviocytes?
1Nano-Biotechnology Laboratory, Rizzoli Orthopaedic Institute, Via di Barbiano 1, 40136 Bologna, Italy
2II Clinic-Biomechanics Laboratory and Nano-Biotechnology Laboratory, Rizzoli Orthopaedic Institute, Via di Barbiano 1/10, 40136 Bologna, Italy
3Laboratory of Immunorheumatology and Tissue Regeneration/RAMSES, Rizzoli Orthopaedic Institute, Via di Barbiano 1/10, 40136 Bologna, Italy
4Laboratory RAMSES, Rizzoli Orthopaedic Institute, Via di Barbiano 1/10, 40136 Bologna, Italy
5Immunohematology and Transfusion Medicine and Cell and Musculoskeletal Tissue Bank, Rizzoli Orthopaedic Institute, Via di Barbiano 1/10, 40136 Bologna, Italy
6Laboratory of Immunorheumatology and Tissue Regeneration Rizzoli Orthopaedic Institute, Via di Barbiano 1/10, 40136 Bologna, Italy
7Department of Medical and Surgical Science, University of Bologna, Via Giuseppe Massarenti 9, 40138 Bologna, Italy
8Clinical Pathology Unit, Rizzoli Orthopaedic Institute, Via di Barbiano 1/10, 40136 Bologna, Italy
2II Clinic-Biomechanics Laboratory and Nano-Biotechnology Laboratory, Rizzoli Orthopaedic Institute, Via di Barbiano 1/10, 40136 Bologna, Italy
3Laboratory of Immunorheumatology and Tissue Regeneration/RAMSES, Rizzoli Orthopaedic Institute, Via di Barbiano 1/10, 40136 Bologna, Italy
4Laboratory RAMSES, Rizzoli Orthopaedic Institute, Via di Barbiano 1/10, 40136 Bologna, Italy
5Immunohematology and Transfusion Medicine and Cell and Musculoskeletal Tissue Bank, Rizzoli Orthopaedic Institute, Via di Barbiano 1/10, 40136 Bologna, Italy
6Laboratory of Immunorheumatology and Tissue Regeneration Rizzoli Orthopaedic Institute, Via di Barbiano 1/10, 40136 Bologna, Italy
7Department of Medical and Surgical Science, University of Bologna, Via Giuseppe Massarenti 9, 40138 Bologna, Italy
8Clinical Pathology Unit, Rizzoli Orthopaedic Institute, Via di Barbiano 1/10, 40136 Bologna, Italy
Received 27 February 2014; Accepted 23 June 2014; Published 17 July 2014
Wednesday, June 7, 2017
Proof Meibomian Gland Probing Works
Many patients have been feeling significant relief of eye pain and discomfort with Meibomian Gland Probing with Meibomian Gland Expression.
Here are more studies showing the benefit of Meibomian Gland Probing.
Here are more studies showing the benefit of Meibomian Gland Probing.
In my opinion, just doing Meibomian Gland expression may not be enough to keep Meibomian Glands working for many patients. Performing a probing will break orifice scar tissue that is preventing the gland from expressing as much oil as it can.
So far 95% of my patients have had relief with one MGP procedure. I do have about 5 patients with Sjögren's syndrome that return for probing about once every 1-3 months for probing given the relief it provides. I suspect their underlying inflammation re-scars the orifice of the gland. They feel relief for a few weeks, but then the pain returns. They are praying the Stem Cell Injection into the Meibomian Gland protocol we are launching will revive Meibomian Glands and prevent the need for repeated probings.
Sandra Lora Cremers, MD, FACS
This paper below is by a fellow colleague from Harvard who has no financial interest that I know of in probing.
Ophthal Plast Reconstr Surg. 2017 Feb 17. doi: 10.1097/IOP.0000000000000876. [Epub ahead of print]
Dynamic Intraductal Meibomian Probing: A Modified Approach to the Treatment of Obstructive Meibomian Gland Dysfunction.
Author information
- 1
- Department of Ophthalmology, Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, Massachusetts, U.S.A.
Abstract
PURPOSE:
METHODS:
RESULTS:
CONCLUSIONS:
Cornea. 2016 Jun;35(6):721-4. doi: 10.1097/ICO.0000000000000820.
Effectiveness of Intraductal Meibomian Gland Probing for Obstructive Meibomian Gland Dysfunction.
Abstract
PURPOSE:
METHODS:
RESULTS:
CONCLUSIONS:
Cornea. 2016 Jun;35(6):725-30. doi: 10.1097/ICO.0000000000000777.
Efficacy of Intraductal Meibomian Gland Probing on Tear Function in Patients With Obstructive Meibomian Gland Dysfunction.
Author information
- 1
- Department of Ophthalmology, Beijing Shijitan Hospital, Capital Medical University, Beijing, China.
Abstract
PURPOSE:
METHODS:
RESULTS:
CONCLUSIONS:
Cornea. 2015 Oct;34(10):1206-8. doi: 10.1097/ICO.0000000000000558.
Analysis of Meibum Before and After Intraductal Meibomian Gland Probing in Eyes With Obstructive Meibomian Gland Dysfunction.
Abstract
PURPOSE:
METHODS:
RESULTS:
CONCLUSIONS:
Thursday, December 1, 2016
How to Do Outcomes Research? How to Do Outcomes Research in Ophthalmology?
How to Do Outcomes Research?
How to Do Outcomes Research in Ophthalmology?
The focus of my research has always been deeply connected with my desire to teach
and improve our understanding of how to improve the surgical outcomes of residents and surgeons. Mostly I focused on outcomes research to improve how we teach surgical residents. Thus starting in 2000, my teaching and research contributions at Harvard Medical School focused on the establishment of a database of resident
cataract surgery called OASIS (Objective Assessment of Skills in
Intraocular Surgery) as part of the Harvard Medical School Residents
in Ophthalmology Cataract Surgery outcomes study (HMS ROCS) at
the Massachusetts Eye and Ear Infirmary. I started this study in order to
improve our surgical outcomes and to identify factors increasing
patients’ surgical risk in resident cases. In contrast to other surgical
specialties, ophthalmology is severely lacking in published studies on
medical education as well as risk analysis in resident cases. Knowledge
about how a resident surgeon learns to become competent in their
surgical skills and rely less on the surgical preceptor will improve
surgical training programs. By mapping out when a surgical preceptor
intervenes and when this intervention is no longer needed, we can begin
to better understand the learning curve with surgical procedures. This can also apply to seasoned surgeons, if other surgeons are obtaining better results, we need to study why, and see if everyone can get such results. Benchmarks are important to help us all achieve better results for our patients. If I ever need a surgery, I would love to know if my surgeon is above the Benchmark. Currently, the way surgeons do this is by asking the scrub nurses in the OR: "how is he as a surgeon?""does he have a lot of complications." But this option is not available to everyone, so benchmarks, if done correctly, can protect everyone in the medical and surgical arena.
At Harvard, we created a well organized database, that allowed us to identify some basic factors
involved with preoperative surgical evaluation, surgical events, and
surgical care that increase a patient’s surgical risk. This database was the
first of its kind in any residency program in the United States and since then Harvard Medical School's Department of Ophthalmology has taken off in doing outcomes research in all aspects of surgery.
Now the rest of the country is starting to see (or be forced) into doing outcomes research.
“Comparative Effectiveness Research” and “Patient Centered Outcomes Research” (PCOR) are the relatively new interchangeable terms that came from legislation leading to the:
Medicare Prescription Drug, Improvement and Modernization
Act of 2003, which established the Effective Health
Care Program at the Agency for Health Research and Quality
(AHRQ); the American Recovery and Reinvestment Act
of 2009 (ARRA) which allocated $1.1 billion for PCOR;
and the Affordable Care Act of 2010 which created the
Patient-Centered Outcomes Research Institute (PCORI).
What is PCOR?
PCOR is “The generation and synthesis of evidence that compares
the benefits and harms of alternative methods to prevent,
diagnose, treat, and monitor a clinical condition or to
improve the delivery of care. The purpose of comparative
effectiveness research is to assist consumers, clinicians,
purchasers, and policy makers to make informed decisions
that will improve health."
[defined by the Institute of Medicine]
Basically this is 360 degrees of evaluation and outcomes research that could be open to insurance, the public and everyone to see.
So it is in every surgeon's best interest to get moving with their own outcomes research asap before you and your practice are booted from an insurance plan because you fall below the benchmark.
Here is a short cut to doing outcomes research for your busy practice. I have used this to set up outcomes protocols at Harvard and now in private practice at Visionary Eye Doctors, where the owner, Dr. Alberto Martinez, saw immediately the importance of this in 2012 and signed on to hire a full time research assistant.
Here are the steps to launch an effective Outcomes Research Team and Outcomes Research Program
Short Version:
1. Find someone on your staff, an MD, OD, RN, or administrator who is passionate about helping patients get the best care in the world at your office. Put this person in charge of the Outcomes Research Program.
You should name the program.
At Harvard, I named our HMS ROCS: Harvard Medical School Residents
in Ophthalmology Cataract Surgery outcomes study (HMS ROCS)
At Visionary Eye Doctors, a good title might be: Visionary Eye Doctors Patient-Centered Outcomes Research Institute (VEDPCORI).
or Visionary Eye Doctors Outcomes Research Program (VEDORP)
2. Find a research fellow. At Harvard, my first research fellow made almost no money initially until I got a grant. He helped make the database in to a large source of information that allowed us to publish multiple studies. He is not an Assistant Professor at Harvard.
There are many students out there that would love to have a chance to publish or even do some research. When my fellow and I started, we did not know exactly how we should do things, but all it took was an interest in helping patients and finding the truth in outcomes research.
3. Set up a database: There are many ways to do this. At Harvard we started with a simple Excel file and years later moved to SPSS. An example of our initial excel database is below in the Expanded Section.
a. Decide what is important to you and your patients
b. Collect the data
c. Analyze the data
4. Find a statistician who can help you. At Harvard, our now world famous statistician initially wanted to be paid by the hour or to be listed on the paper. Towards the end of my time there, she wanted both: that was painful. But she was great.
Currently, our fellow is excellent at statistics but is able to access help from the Statistics Department at Georgetown.
5. Write it up. Don't be scared if you have never written a paper in your life. Just write down your results, analyze your results and write them down, write the conclusion, and write the introduction and title at the end. Add references. Have a couple of respected colleagues read it over. Submit it.
After a few times writing up your outcomes work, it becomes a process like putting a puzzle together, which can actually be enjoyable. Likely the reason it is most enjoyable is because you are revealing truths about yourself and your practice and striving to be the best for your patients who you love and adore.
Expanded Version:
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