001 rccl0110 atonhalf - review of optometry · 2010-02-18 · review of cornea & contact lenses...

JAN/FEB 2010

Supplement to

January 2010

INSIDE:• Surface and Polymer Chemistry:

Th e Quest for Comfort• Solution Confusion

• Beyond the Basics: Treating Severe Dry Eye• Standards of Care in the Age of Advanced

Technology

FC_rccl0110.indd 1 1/5/10 4:54 PM

News Review

2 REVIEW OF CORNEA & CONTACT LENSES | JAN/FEB 2010

In The News

• YourLens.com from ABB Concise now offers enhanced retail pricing functionality that can increase revenue by maximiz-ing tiered pricing and other discounts. The company also has introduced newly designed menus and grids to provide the best pos-sible experience for navigation. Patients can now select the “auto ship” feature, allowing them to choose their preferred shipping method and intervals.

• CooperVision has expanded the sphere powers of Proclear 1 Day disposable contact lenses. These lenses are now available in a broader sphere power range from +8.00D to -12.00D. Proclear 1 Day lenses are manufactured with patented PC Technology and are made with omafilcon A material. The lenses feature aspheric front surface optics, which correct for lens and theoretical cor-neal aberrations. Proclear 1 Day lenses have a center thickness of 0.09mm at -3.00D, a Dk/t of 36.6, a water content of 60%, an 8.7mm base curve and a 14.2mm diameter.

• Art Optical Contact Lens, Inc. has received the prestigious Seal of Manufacturing Excellence Award for the 16th straight year. According to the program test results, Art Optical products ranked in the top tier of the qual-ity category. The Seal of Excellence is only awarded to CLMA member labo-ratories that pass an independent evaluation of GP lens quality. In the voluntary program, GP lenses are ordered anonymously by practitioners and tested for eight different criteria by an indepen-dent panel of experts in a double-blind study.

VOL. 147, NO. 1

A Lens for AthletesiZon SL Polarized Lenses, from Ophthonix, provide wearers with

high- defi nition vision in sunlight glare, even when refl ected off water, land, ice and snow. This lens is designed for patients who are involved in sports and other outdoor daytime activities.

The new wavefront-guided iZon SL Polarized Lens is customized to the patient’s optical fi ngerprint, or iPrint, that contains all second- to sixth-order aberrations of the eye measured by the Z-View Aberrom-eter. The index of the lens is 1.6, and its surface is scratch-resistant, anti-refl ective and super-hydrophobic. The iZon SL Polarized Lens is available in gray and brown tints and provides 100% UVA and UVB blocking.

For more information, go to www.izonlens.com, or call 760-842-5740.

Pink Eye Treatment Does Not Cause Resistance

Members of the health care community are ex-tremely concerned about

the potential for systemic antibiot-ics to increase bacterial resistance, which may result in additional infections that do not respond to current antibiotics. There is also much discourse over the potential of topical antibiotic treatment of eye infections leading to bacterial resistance outside of the eye as a result of overfl ow or drainage.

In a clinical study by Alcon Laboratories, Inc., investigative sites enrolled children between the ages of eight months and 12 years who were diagnosed with bacterial conjunctivitis, as well as unaffected children who served as control subjects. The subjects had microbi-ological swab specimens collected at day one, day eight and day 42, and seven swabs were collected at each visit from the tested sites.

Microbiologists processed swab

specimens from the eye onto non-selective aerobic and anaerobic media to recover bacteria. They processed swab specimens from the cheeks, nostrils and throat onto non-selective and selective media.

The selective media recov-ery was to detect changes in the fluoroquinolone-susceptibility of bacteria found in subjects with eye infections compared to changes occurring in healthy children. The microbiologists isolated 2,985 bac-teria and tested them for resistance against 20 different antibiotics.

The results of this study show that treating conjunctivitis with Vigamox (moxifloxacin, Alcon) does not appear to lead to fluoro-quinolone resistance for three bac-teria (S. pneumoniae, S. aureus and H. influenzae) in the eye or other areas of the body.1

1. Marshall B, Cupp G, Foster K, et al. Moxifloxacin treatment of conjunctivitis: microbial effects beyond the eye. ICAAC 2009. Poster C2-103.

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REVIEW OF CORNEA & CONTACT LENSES | JAN/FEB 2010 3

JOBSON MEDICAL INFORMATION LLC11 Campus Blvd., Suite 100Newtown Square, PA 19073Telephone (610) 492-1000Fax (610) 492-1049

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EXECUTIVE EDITORArthur B. Epstein, O.D., [email protected]

ASSOCIATE CLINICAL EDITORErnie Bowling, O.D., F.A.A.O. [email protected]

ASSOCIATE CLINICAL EDITORAlan G. Kabat, O.D., F.A.A.O. [email protected]

ASSOCIATE CLINICAL EDITORChristine W. Sindt, O.D., F.A.A.O. [email protected]

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EDITORIAL BOARDMark B. Abelson, M.D.James V. Aquavella, M.D.Edward S. Bennett, O.D.Brian Chou, O.D.S. Barry Eiden, O.D.Gary Gerber, O.D.Susan Gromacki, O.D.Brien Holden, Ph.D.Bruce Koffler, M.D.Jeffrey Charles Krohn, O.D.Kenneth A. Lebow, O.D.Kelly Nichols, O.D.Robert Ryan, O.D.Jack Schaeffer, O.D.Kirk Smick, O.D.Barry Weissman, O.D.

REVIEW BOARDKenneth Daniels, O.D.Michael DePaolis, O.D.Desmond Fonn, Dip. Optom. M. Optom.Robert M. Grohe, O.D.Patricia Keech, O.D.Jerry Legerton , O.D.Charles B. Slonim, M.D.Mary Jo Stiegemeier, O.D.Loretta B. Szczotka, O.D.Michael A. Ward, F.C.L.S.A.Barry M. Weiner, O.D.

Advertiser Index

Aton Pharma, Inc .........................................................Cover 2, Page 1 Bausch & Lomb. ...................................................................... Cover 4CIBA Vision ...................................................................... Pages 20-21

A High Performing LensA study conducted by Adam Coffee, O.D., and associates, and

sponsored by Vistakon sought to determine the fi tting success of Acuvue Oasys for Presbyopia, using “real world” endpoints of doctor and patient criteria at the one-week follow-up visit.

A total of 206 soft contact lens wearers were fi t with Acuvue Oasys for Presbyopia and followed for two weeks. Questionnaires were given to subjects at all visits and to practitioners at the start and end of the study. Clinical data regarding wearing times, lens fi t, deposits and conjunctival and corneal staining were collected at baseline, one week and two weeks

According to the study, overall handling with the lens was rated as “excellent” or “very good” (Ex/VG) by 71% of subjects at one week and 80% of subjects at the two-week follow-up. Overall comfort with was rated as Ex/VG by 76% of subjects at one week and by 86% of subjects at two-weeks follow-up. Overall vision quality was rated as Ex/VG by 45% of subjects at one week and by 68% of subjects at two-week follow-up.

Overall lens centration and movement was rated as optimal in the vast majority of subjects. There was a statistically signifi -cant reduction in the levels of both limbal and bulbar hyperemia (>grade 1 P<0.0001) after one week of wearing Acuvue Oasys for Presbyopia vs. habitual lenses.

New Tonometry MethodThe Reichert 7CR Auto Tonometer

+ Corneal Response Technology from Reichert, Inc., features Corneal Compen-sated IOP (IOPcc), a pressure measurement that is less affected by the cornea than other methods of tonometry, the company says. The 7CR incorporates the patented bi-directional applanation technology, fi rst used in the Reichert Ocular Response Analyzer (ORA), to quantify the biomechanical properties of the cornea, permitting the determination of IOPcc. IOPcc provides clinicians with a better understanding of patient tonometry values, enhancing their ability to make critical diagnosis and treatment decisions.

For more information, call 1-888-849-8955, or go to www.reichert.com.

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contentsON THE COVER

Departments


Review of Cornea & Contact Lenses January/February 2010

26 Beyond the Basics: Treating Severe Dry Eye What can practitioners do when fi rst line therapy fails?

William F. Townsend, O.D.,F.A.A.O.

22 Solution ConfusionThough we advocate the use of par-ticular care systems, even the most compliant patients can go astray as they encounter myriad “look-alike” products on the store shelf.

Susan J. Gromacki, O.D., M.S., F.A.A.O.

15 Surface and Polymer Chemistry: The Quest for ComfortIn order to provide lens wearers with a well-performing, comfortable lens, eye care practitioners must be mindful of such issues as surface wetting and solu-tion interactions during wear.

Art Epstein, O.D., F.A.A.O., and Ralph Stone, Ph.D.

2 News Review

5 EditorialTo Treat or Not to TreatJoseph P. Shovlin, O.D., F.A.A.O

6 Gas-Permeable StrategiesThe PMMA DilemmaJohn M. Rinehart, O.D., F.A.A.O.

7 Out of the BoxWho’s the Boss?Gary Gerber, O.D.

8 Down on the PharmAvoid Medication BlundersErnie Bowling, O.D., M.S., F.A.A.O., Dipl., and Gregg Russell, O.D., F.A.A.O.

10 Derail DropoutsStrategies for Better ComplianceMile Brujic, O.D., and Jason Miller, O.D., M.B.A.

12 Lens CareBeat the BugChristine W. Sindt, O.D., F.A.A.O.

14 Naked EyeBetter Diagnostics in a Blink of an EyeMark B. Abelson, M.D., C.M., F.R.C.S.C., Daniel Dewey-Mattia and Keith Lane

Solutions and Rewetting Drops

31 Standards of Care in the Age of Advanced TechnologyHow important is it to have high-tech machines in your eye care practice?

Katherine M. Mastrota, M.S., O.D., F.A.A.O.

004_rccl0110_toc.indd 4 1/6/10 9:55 AM

Editorial By Joseph P. Shovlin, O.D., F.A.A.O.


To Treat or Not to TreatDoes topical antibiotic therapy confer a signifi cant benefi t in the treatment of acute bacterial conjunctivitis?

The dogma has been to prescribe a topical an-tibiotic agent for acute bacterial conjunctivitis regardless of the exact causative bacteria or

age of the patient.1,2 Historically, antibacterial topical therapy has been the preferred method of treatment because it will usually shorten the course of the disease slightly and allow the early re-admittance of children to school and adults to the workplace.1

Exceptions to this practice occur when it’s important to avoid specifi c drugs (including oral medications), especially when they are contraindicated because of age or the potential for allergic reaction.

Without hesitation, H. infl uenza conjunctivitis, Gonococcal conjunctivitis and any other severe forms of conjunctivitis with scleral extension need to be treated systemically due to their extraocular involve-ment and potential for devastating consequences.1,2

The Case for Not Prescribing Fortunately, most infective (viral and bacterial)

conjunctivitis resolves spontaneously without treat-ment. So, should topical antibiotics routinely be used? One study concluded that infective conjunctivitis should be managed conservatively with antibiotics prescribed either after a delayed period, if symptoms do not improve within three days of onset (generally when we see them), or not at all.3 More physicians have recently been successful in promoting conserva-tive treatment for upper respiratory infections (initially avoiding antibiotic treatment) and changing manage-ment expectations of parents and patients. Likewise, some authorities feel that it might be time to take a close look at our prescribing patterns for acute infec-tive conjunctivitis, where the patient has relatively few signs and symptoms, except for the redness and minor irritation. Most cases of acute infectious conjunctivitis are viral in etiology. But, viral and bacterial etiolo-gies are sometimes diffi cult to distinguish in clinical measures alone. So, the real uncertainty rests in the decision on whether to prescribe when there is high probability that the infection is bacterial.

The Opposing ViewAcute bacterial conjunctivitis is generally a self-

limiting condition, but the use of topical antibiotics is

associated with a signifi cantly improved rate of early (days two to fi ve) clinical remission and early and late microbiological remission in bacterial disease.1-3 Any additional benefi t is marginal for later remission (days six to 10).4 Although unanswered questions about serious risk or adverse events that may occur in those who do not receive treatment for bacterial conjuncti-vitis linger, on balance, topical antibiotics offer at least marginal benefi t in improving clinical outcomes.1,3

Make it PersonalWhether or not to treat acute bacterial conjunctivitis

will remain a highly personal decision. The optimal way to handle these cases from a socioeconomic and medical perspective needs to be thoughtfully evaluated on a case-by-case basis by every clinician who encoun-ters acute infectious conjunctivitis. Keep in mind that the effects of a non-prescribing attitude on transmission rates of various bacterial pathogens in the community remain uncertain.1

For now, I will continue to prescribe antibiotics with confi dence when conditions warrant, such as in early presentations of suspected bacterial conjunctivitis and when severe infections present where a bacterial etiol-ogy is confi rmed. I would like to again acknowledge the value of the Cochrane Library.5 The Library is an invaluable collection of databases in medicine and other health care-related topics by the Cochrane Collabora-tion. The core of the Library is the Cochrane Reviews, a database for systematic reviews and meta-analyses that summarize and interpret the results of quality medical research. It serves as a key source of evidence-based medicine, an invaluable tool to evaluate and attempt to answer diffi cult questions in health care. RCCL

1. Ehlers JP, Shah CP. Acute Conjunctivitis. In: Ehlers JP and Shah CP, eds. The Wills Eye Manual: Office and Emergency Room Diagnosis and Treatment of Eye Disease. Philadelphia, PA. Wolters/Kluwer/JB Lippincott. 2008:104-07.2. Hovding G. Acute bacterial conjunctivitis. Acta Ophthalmol. 2008 Feb;86(1):5-17.3. Visscher KL, Hutnik CM, Thomas M. Evidence based treatment of acute infective conjunctivitis: Breaking the cycle of antibiotic prescribing. Can Fam Physician. 2009 Nov;55(11):1071-5.4. Sheikh A, Hurwitz B. Topical antibiotics for acute bacterial conjunctivitis: Cochrane systematic review and meta-analysis update. Br J Gen Pract. 2005 Dec;55(521):962-4.5. The Cochrane Collaboration. Available at: www.cochrane.org/reviews. (Accessed Dec 2009).

Joseph P. Shovlin, O.D., F.A.A.O., Clinical Editor

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By John M. Rinehart, O.D., F.A.A.O.


There are still many people who are wearing PMMA lenses. Some patients wear

them without problems, while others only think they’re hav-ing no problems. I was curious about practitioners’ opinions on whether or not to refi t these patients into state-of-the-art gas-permeable (GP) materials. So, I decided to survey my colleagues and received input from Chris-tine Sindt, O.D., F.A.A.O., of the University of Iowa, and Arizona private practitioners Robert May-nard, O.D., Charles Edmonds, O.D., and Ken Johnson, O.D.

Ideal CandidatesThe four doctors agreed that the

treatment choice would depend on answers to the following questions:

• How long has the patient been out of lenses (if at all)?

• Is the correction stable?• How long are the lenses worn

each day?• Has the patient been under a

certain doctor’s care for several years, or is he or she new to the practice?

• Has the patient had problems in the past, whether or not the patient was aware of them?

The interviewees also agreed that if the patient’s refraction is stable, topography shows no abnormali-ties and the cornea appears healthy, refi tting the patient with a new PMMA lens is a good option. When these criteria are met, this shift is expected to cause the fewest problems for the patient. But, these patients should be advised that the time may come when there is com-

promise to the health or optics of the cornea, and once that happens, it will be necessary to discontinue PMMA lens wear. To ensure that the eye is kept out of jeopardy, these patients must be seen on a semi-annual basis.

Dr. Edmonds evaluates the en-dothelial cell layer for polymege-thism and pleomorphism. If there are problems with a compromised endothelium and topography shows corneal warpage, he fi rst refi ts the patient temporarily with a silicone hydrogel lens until the cornea stabilizes, at which point he refi ts with a higher-Dk GP lens.

Another option is for the patient to be kept out of all contact lenses until the cornea stabilizes. But, this likely creates signifi cant hardship for the patient. Long-time PMMA wearers seldom have a pair of spec-tacles that will allow them to see well enough to work, and if a new correction is provided, it will most likely change within a few days. For this reason, it is best to refi t the pa-tient either as Dr. Edmonds suggests with a silicone hydrogel then a GP lens, or directly into a GP lens.

From PMMA to GP When refi tting into GP lenses,

the recommendation is to dupli-cate the fi t of the PMMA lens as closely as possible, using a low- to medium-Dk material. The patient should be advised that the cornea will change and to expect that additional lenses may be needed in order to fully rehabilitate the cornea. As the patient adapts to the new mate-rial, the fi t can be fi ne-tuned in

order to achieve a more ideal lens-to-cornea relationship.

The Comfort IssueLong-term PMMA wearers

frequently have problems with the comfort of GP lenses, as well as dryness. Also, GP lenses may not be as durable as PMMA lenses. The increased oxygen supply to the cornea will enhance corneal sensitivity that may have been lost due to a lack of oxygen availabil-ity through the PMMA material. Patients may consider this change a negative response to the new lenses, so they need to be counseled ahead of time about this potential occur-rence and the fact that it’s in their best interest. A good way to deal with this is to explain that corneal sensitivity is necessary to protect the eye from foreign bodies and early signs of corneal distress, whether from injury or disease.

Patients with polymegethism and pleomorphism should be refi t into GP lenses. An altered endothelium is a tell-tale sign that there is a problem or soon will be. With that said, there are still people who successfully wear PMMA lenses, and there may be no need to change them to the newer GP materials.

When there are problems with distorted optics or compromise to any layer of the cornea, it will be necessary to refi t the patient with a GP lens. This should be done with caution, but without fear. Careful counseling and instruction to the patient will make this tran-sition easier for both the patient and the practitioner. RCCL

Gas-Permeable Strategies

Should you refi t patients who wear PMMA lenses into GP materials?

The PMMA Dilemma

006_rccl0110_gps.indd 6 1/5/10 4:55 PM

By Gary Gerber, O.D.


There are many different ways to practice eye care. You can be in a private

group setting with multiple partners, collaborate with an optician, practice in a hospital or the military, work in a corporate practice or be a solo home-town doc—the choice is yours. Yet, the ownership of all of these types of practices is the same. That is, they are all owned by the patients who visit them.

Who is in Charge?You may have heard the saying,

“Your patients are the ones who sign your paycheck.” While this is not the case in the literal sense, your patients’ needs and opinions should be the driving forces in your practice, regardless of the setting. After all, where would you be without them? As owners, shouldn’t they have a say in how your practice runs, how it looks, when it’s open and what products you offer?

What Your Patients Are Telling You

On some level, you already lis-ten to what your patients want. For example, you’re probably not open between 1:00a.m. and 6:00a.m. because patients have “told” you that they won’t come during those hours.

Your patients have probably also “told” you that they won’t tolerate a rude or uncaring staff. (The word “told” is in quotes because most patients won’t verbalize their lack of desire for insomniac offi ce hours, and rude

staff members are simply dealt with by patients never returning to the practice.)

Likewise, have your patient-owners “told” you what lenses they’d like you to offer? It’s implied that patients don’t expect an offering of a bologna and cheese sandwich, nor do they expect you to carry greeting cards. Yet, they probably have not specifi cally told you what they do expect. In the retail fi eld, this concept is referred to as managing your mix—selling cer-tain products to attract or retain certain customers.

For instance, Ralph Lauren attracts a different customer base than Hollister. Are you managing your product mix to attract the patients you want and to keep your owners happy? Your pa-tients probably don’t expect you to be offering older technology lenses like PMMA or CAB—in fact, most of us don’t. But, few of us actually specify why we offer the lenses we do, and even fewer make it a point to offer specifi cally what our patient-owners want.

Do the ResearchWhat do our patients want?

That’s probably the easiest market research exercise of all to undertake. There are two great sources that can help answer that question. The best source is your current patient base; you’ll fi nd out exactly what you need to know by simply asking them.

Here’s how you can go about this task: First, survey patients

and ask them questions about their proclivity for things such as continuous wear, daily dis-posable lenses, orthokeratology, and the like, and you might fi nd that their desires aren’t in sync with your offerings. They are the owners of your practice; care-fully examine their responses and adjust your product mix accordingly.

The second sources for re-search are sales reps. Yes, a rep will promote their own products, but if you look beyond that promotion for data that sup-ports categories of products and not just the products themselves, you’ll fi nd a wealth of pertinent information.

The Macro PhilosophyThis perception of manag-

ing your mix for your practice owners is a macro view. It’s like looking at a country’s culture, not the individuals who make it up. Therefore, if you fi nd from this macro view that patients would prefer the convenience of daily disposable lenses, it doesn’t mean you need to fi t every patient with them. But, it does mean that every patient should know that you do indeed offer them to all clinically appropriate candidates.

Give the people what they want. It’s a basic tenet of mar-keting. And in your case, it only makes sense to ensure that your ophthalmic products and services align with the interests of your patients—the owners of your practice. RCCL

Out of the Box

Who’s the Boss?How to make sure that your patients’ needs are being met in your practice.

007_rccl0110_otb.indd 7 1/5/10 4:56 PM


Down on the Pharm By Ernie Bowling, O.D., M.S., F.A.A.O., Dipl., and Gregg E. Russell, O.D., F.A.A.O

Eye care practitioners write prescriptions every day. These little slips of paper

with doctor scribble on them impart important medical advice to opti-cal dispensaries, pharmacies and hospitals and provide important instructions for care to our patients. In good times, the prescription is a confirmation of our wisdom as a practitioner and health care professional. In bad times, it is a validation of our ignorance and a sobering reminder of why due dili-gence is so important.

Years ago, before therapeutic prescriptive authority was earned by our profession, the magnitude of our incidental “goofs” was lim-ited to errors writing the spectacle prescription, especially with trans-posing errors. These mistakes were quickly corrected by remaking the lenses and apologizing profusely to the patient. Now, however, we provide medical care with accom-panying therapeutic prescriptions, so the risk of injury to the patient goes up dramatically. As doctors, we need to be on guard against any error regarding a prescription medication.

Ensure Conscientious Prescribing

Almost everyone in the modern world takes medication at one time or another. According to one estimate, in any given week four out of every fi ve U.S. adults will use prescription medicines, over-the-counter drugs or dietary supplements of some sort, and nearly one-third of adults will take fi ve or more different medications.1

Older people may be at greatest risk for medication errors because they often take multiple prescrip-tion medications. Most of the time, these drugs are benefi cial, or at least they cause no harm. But on occasion, they do injure the person taking them. This is precisely what none of us want.

A study conducted in a Brit-ish intensive care unit sought to determine the incidence and varia-tions in prescription writing errors. All prescriptions were tracked for 24 units in a four-week period. Over the course of time, 21, 589 prescriptions were produced, and of those, 85% were deemed safe. But a little over 3,141 had errors.2

While most of the errors were not considered signifi cant, 618 (19.7% of all the errors) were considered life threatening. In other words, almost one in every fi ve errors that occurred could have resulted in the death of the patient.2 Keep in mind this was in an intensive care unit!

With all 50 states enjoying thera-peutic prescriptive authority won in hard-fought legislative battles, optometrists are able to provide medical care to the patients they serve. But, we also have to be diligent with our responsibility. Medication errors are among the most common and preventable mistake, harming at least 1.5 mil-lion people every year according to Preventing Medication Errors, a report from the Institute of Medi-cine of the National Academies.1

Drug errors encompass all mistakes involving prescription drugs, over-the-counter products, vitamins, minerals or herbal supplements.

Errors are common at every stage, from prescribing and administering a drug to monitoring the patient’s response. Not all errors lead to injury or death, but the number of preventable injuries that do occur is disturbing. Roughly one third of the errors—530,000—occur annu-ally just among Medicare recipi-ents in outpatient clinics, similar to the places where most practitioners practice. And, these numbers are likely underestimates.1

The cost of these medication errors is staggering. A study of outpatient clinics found that medication-related injuries resulted in roughly $887 million in extra medical costs in 2000, and the study looked only at injuries expe-rienced by Medicare recipients, a subset of clinic visitors.2 Note that none of these fi gures take into ac-count lost wages and productivity or other costs.

Eliminate Errors TodayOne of the most effective ways

to reduce medication errors is by forming a partnership between patients and their health care providers.1 Patients should under-stand more about their medications and take more responsibility for monitoring them, while provid-ers should take steps to educate, consult with and listen to their patients. Patients should maintain an up-to-date list of all medications they use—including over-the-coun-ter products and dietary supple-ments—and share it with all of their health care providers. Doctors must communicate with patients at every step of their care and

Avoid Medication BlundersHow do you ensure that drug errors do not occur in your practice?

008_rccl0110_dotp.indd 8 1/5/10 5:17 PM

Optometric Physician delivers UP-TO-DATE news and researchto your inbox every Monday morning,

allowing you to view all of the latestclinical information on a convenientand consistent basis.

Subscribing to Optometric Physician is an efficient and easy way to stay current with all of the information andevents going on in the field. To orderyour free subscription, e-mail: [email protected].

make that communication a two-way street: listening to the patients as well as talking to them fully about the risks, contraindications and possible side effects of the medications they are taking and what to do if they experience any side effects. While we are all very busy in our practices, and time is at a premium, it is impor-tant to remember that our patients may not completely understand what we are saying. Many will simply nod in agreement without really understanding what has been said. We must make use of written sheets that outline the medications, their dosage and frequency, in order to bolster what has been said.

A New FrontierNew computerized systems for prescribing drugs

and other applications of information technology show great promise for reducing the number of drug-related mistakes. Paper-based prescribing is associated with high error rates because they are often illegible or the instructions for the medications not properly fi lled out. Even for the most seasoned practitioner, this is stunning. Electronic prescribing should be safer because it eliminates problems with handwriting legibility (my personal demon), and when combined with decision-support tools, automatically alerts prescribers to possible interactions, allergies and other potential problems. But, it is not foolproof.

It wont be long before most providers will be us-ing e-prescribing systems, and all pharmacies will be able to receive prescriptions electronically. Theoreti-cally, it is benefi cial to interface data electronically on prescriptions in case there are interactions to which the patient might be prone. This way, we can be aware of it ahead of time. Wouldn’t it be nice to know that your recently presenting glaucoma patient can’t tolerate a certain IOP-lowering drug because of a previously developed sensitivity, especially after the patient failed to disclose this to you? Any improve-ment in patient care adds to improvement of the accuracy and outcome of that care. Isn’t that what we are all trying to do? RCCL

1. Institute of Medicine, National Academies. Preventing Medication Errors: Quality Chasm Series. National Academies Press. Jul 20. 2006. 2. Ridley SA, Booth SA, Thompson CM. Intensive care society’s working group on adverse incidents. Prescription errors in UK critical care units. Anaesthesia. 2004 Dec;59(12):1193-200.

008_rccl0110_dotp.indd 9 1/5/10 5:17 PM

Optometric Physician delivers UP-TO-DATE news and researchto your inbox every Monday morning,

allowing you to view all of the latestclinical information on a convenientand consistent basis.

Subscribing to Optometric Physician is an efficient and easy way to stay current with all of the information andevents going on in the field. To orderyour free subscription, e-mail: [email protected].

make that communication a two-way street: listening to the patients as well as talking to them fully about the risks, contraindications and possible side effects of the medications they are taking and what to do if they experience any side effects. While we are all very busy in our practices, and time is at a premium, it is impor-tant to remember that our patients may not completely understand what we are saying. Many will simply nod in agreement without really understanding what has been said. We must make use of written sheets that outline the medications, their dosage and frequency, in order to bolster what has been said.

A New FrontierNew computerized systems for prescribing drugs

and other applications of information technology show great promise for reducing the number of drug-related mistakes. Paper-based prescribing is associated with high error rates because they are often illegible or the instructions for the medications not properly fi lled out. Even for the most seasoned practitioner, this is stunning. Electronic prescribing should be safer because it eliminates problems with handwriting legibility (my personal demon), and when combined with decision-support tools, automatically alerts prescribers to possible interactions, allergies and other potential problems. But, it is not foolproof.

It wont be long before most providers will be us-ing e-prescribing systems, and all pharmacies will be able to receive prescriptions electronically. Theoreti-cally, it is benefi cial to interface data electronically on prescriptions in case there are interactions to which the patient might be prone. This way, we can be aware of it ahead of time. Wouldn’t it be nice to know that your recently presenting glaucoma patient can’t tolerate a certain IOP-lowering drug because of a previously developed sensitivity, especially after the patient failed to disclose this to you? Any improve-ment in patient care adds to improvement of the accuracy and outcome of that care. Isn’t that what we are all trying to do? RCCL

1. Institute of Medicine, National Academies. Preventing Medication Errors: Quality Chasm Series. National Academies Press. Jul 20. 2006. 2. Ridley SA, Booth SA, Thompson CM. Intensive care society’s working group on adverse incidents. Prescription errors in UK critical care units. Anaesthesia. 2004 Dec;59(12):1193-200.

008_rccl0110_dotp.indd 9 1/5/10 5:18 PM

By Mile Brujic, O.D., and Jason Miller, O.D., M.B.A.


Derail Dropouts

Strategies for Better ComplianceBy reinforcing the importance of compliance with lens care regimens, you can help your patients enjoy safe and comfortable lens wear.

All eye care practitioners want their lens-wearing patients to feel as comfortable as

possible in their contact lenses. We continue to offer the newest innova-tions in contact lens materials, and because contact lenses are a pre-scribed product, we are confi dent in the lenses we choose for each patient. But, how certain are we about the care system patients are using and the way they are caring for their lenses?

Prescribe Care SystemsResearch has demonstrated

the impact that contact lens care systems can have on the comfort of lens wear.1,2 As we learn more about silicone hydrogel contact lenses, the way they interact with the ocular surface and the solu-tions that are used, it has become increasingly important to fully understand the care systems that our patients are utilizing.

So, what care system are our patients using, and are they adher-ing to our recommendations? Many practitioners state that their patients seem to be taking this decision

into their own hands. In a recent survey of eye care practitioners, none admitted to recommending store brand or generic contact lens solutions to their patients. Yet when market share of current units sold were analyzed, over 30% of the solutions sold were store brand solutions.3 There is a large discon-nect between what eye care practi-tioners are recommending and what patients are actually purchasing.

There could be multiple reasons for this discrepancy. Patients who stray from doctor recommenda-tions may not have received proper education from their eye care provider. Starter kits given at the end of an examination may provide an implied recommendation, but unless that message is reinforced, our patients will not understand the importance of using any particular contact lens care solution or place any value on it. Sometimes writ-ing the name of a contact lens care system on a prescription pad will resonate signifi cantly more with the patient. You can also use coupons as a way of reinforcement of the care system that your have selected.

Without properly educating our patients, they will often make a decision based on price. Unfortu-nately, after all the time and exper-tise that was used to create a proper contact lens fi t that maximizes com-fort and vision, this patient decision may lead to a poor experience with their contact lens wear.

Confirm Proper CleaningAs many as 35% of patients

don’t even wash their hands be-fore handling their contact lenses.4

Also, contact lenses become up to eight times cleaner when they are rubbed.5 In addition to sticking with the specifi c contact lens care system, adhering to the proper lens care regimen is also a very important factor.

Signifi cant research has been done in the area of understanding the care habits of contact lens wearers. Up to 90% of contact lens wear-ers are non-compliant with their lens wear and care, and only 16% of contact lens wearers perform the rub, rinse and soak steps of lens disinfection.4 Additionally, the Contact Lens Council found that 44% of contact lens wearers always or occasionally top off (re-use) their contact lens solution.5

Unfortunately, there is a signifi -cant amount of apathy that exists with patients when it comes to proper contact lens wearing habits. It is our professional responsibility to deliver a consistent message to them on the importance of proper lens wear and care.

Boost ComplianceWhen questioned, many patients

will often tell eye care practitioners what they think the right answers are supposed to be. For example, “I replace my contact lenses when I am supposed to, use the solutions that you recommended, and rub and rinse my contact lenses every night before storing them in fresh solution.” These are the obvious “right” answers, but in many cases, they aren’t representative of what the patient actually does.

While promoting compliance is not an easy feat, it is not

In this patient, who failed to replace her contact lens solution for one week, we see a clear line made in the contact lens case demarcating where the contact lens solution was present in the well.

010_rccl0110_Derail.indd 10 1/5/10 5:19 PM

Derail Dropouts


impossible. Here are some strate-gies that we have found helpful when trying to re-emphasize the importance of contact lens care:

• Ask your patients to bring in their contact lens case, solution and any other products they use to care for their lenses. This request can be made when they initially schedule their appointment and again when their appointment is confi rmed. This will give you greater insights into patients’ actual contact lens care habits.

• When taking a thorough his-tory, use pointed questions to deter-mine if patients are washing their hands, rubbing their lenses, replac-ing their solution daily and cleaning their case regularly.

• When discussing the reasons for using certain solutions and follow-ing certain steps when cleaning and disinfecting lenses, try to make the message simple, but leave a lasting impression. This is how we describe contact lens care to a typical lens wearer: “I never want comfort to limit your ability to wear contact lenses successfully, which is why I want you to use this particular contact lens care system. When you take your contact lenses out, I want you to rub your contact lenses in the palm of your hand and then rinse all of the debris off of the contact lens with the solution.

Then, store the contacts in fresh solution that you have just put in the case. By utilizing the solution that I recommended and following these steps, we will minimize the chance of discomfort that may limit your ability to wear contact lenses comfortably.”

A Case In Point“Emily,” a 49-year-old female

is a pseudophake O.U. She had worn contact lenses in the past but had depended on reading glasses to correct her near vision since her cataract surgery. In the past few years, this has become cumbersome for her, so she wants to know if she has contact lens options that will help her see better at near. She was fi t in a multifocal contact lens, but because of her prior history of suc-cessful contact lens wear, I neglected to re-educate her on proper care habits with her contact lenses.

I saw Emily one week after wear-ing the lenses, and she complained

of uncomfortable contact lens wear. She brought in her contact lens solution and case. Figure 1 shows the inside of one of the wells of the contact lens case. There is a clear demarcated line consistent with the height of the contact lens solution. When asked how she cared for her contact lenses, she said that she took them out and put them in her contact lens case. She denied rubbing or rinsing the contact lenses, and when asked how often she replaced the con-tact lens solution in her case, she looked at me with a surprised look and responded, “I was supposed to replace the solution?”

Emily was re-educated on proper contact lens care, provided with a new pair of diagnostic lenses and was seen back the following week. Not surprisingly, her comfort had improved signifi cantly. This case shows that even the smallest changes in care habits can make signifi cant improvements in the

performance of con-tact lenses, helping to derail dropouts! RCCL

1. Potter B, Stiegemeier M, Movic W, et al. A clinical evaluation of solutions. RCCL. 2005 Nov:2-5.2. Corbin G, Bennett L, Espejo L, et al. Comfort associated with a marketed contact lens care solution. Poster presented at AOA. June 2009. Washington, DC.3. Alcon, data on file.4. Stone R. The importance of compliance: Focusing on the key steps. Poster presented at BCLA. May 2007. Manchester, UK.5. Cho P, Cheng SY, Chan WY, Yip WK. Soft contact lens cleaning: rub or no rub? Ophthal Physiol Opt. 2009 Jan; 29(1):49-57.6. Contact Lens Council. New survey finds more education on contact lenses and lens care will help consumers see 20/20. PR Newswire. Aug 15, 2007.

Role of Patient Compliance4

Do not wash hands before

lends handling

Wash hands and leave wet with tap water

Handle lensesduring the day

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Perc

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35%

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This graph shows patient compliance with hand washing prior to lens handling.

010_rccl0110_Derail.indd 11 1/5/10 5:20 PM

Lens Care Update By Christine W. Sindt, O.D., F.A.A.O.


Beat the BugHere are some easy-to-follow steps you can take to prevent the spread of pathogens in your practice.

According to the Centers for Disease Control and Prevention (CDC), the

main symptoms of the fl u include fever, coughing, sore throat, runny or stuffy nose, headaches, body aches, chills and fatigue.1 In addition to these, H1N1 fl u infec-tion may also include vomiting and diarrhea, and in rare cases, conjunctivitis.1 The CDC states that fl u activity is widespread in the United States and that hospi-talizations and deaths have risen above expectations. On June 11, 2009, the World Health Orga-nization (WHO) declared that a global pandemic of H1N1 fl u is underway.2

PreventionBoth the CDC and the Food

and Drug Administration (FDA) are stressing that the best way to prevent the spread of H1N1 and other fl u subtypes is to vaccinate, cover the mouth while coughing, practice proper hand hygiene and avoid touching the eyes, nose and mouth.1,2

For health care workers, hand washing is the single most im-portant intervention to prevent the spread of disease. Numer-ous epidemics have been traced back to the contaminated hands of healthcare workers, including reports of epidemic keratocon-junctivitis.3

Practitioner ComplianceDespite these concerns, compli-

ance with hand-washing guide-lines remains a problem in most healthcare settings and does not

usually exceed 40%, even under controlled-study conditions.4

The factors associated with low rates of compliance are a lack of availability of sinks, skin irrita-tion with repeated exposure, high work volume and low perceived risk. Compliance also depends on the time required to perform adequate hand washing relative to the time available.4

Washing hands for 15 seconds achieves a microbial kill of 100.6-

1.1; this rate increases to 101.8-2.8

when hands are washed for 30 seconds. However, hand-washing of less than 10 seconds is com-mon in many clinical settings.5

The Alternative to Hand Washing

Studies have shown that solutions containing 60% to 70% alcohol are effective on gram-positive, gram-negative and spore-forming bacte-ria, as well as fungi and viruses.6

These preparations are 100 times more effective than antimicrobial soaps. And, the time necessary for hand disinfection with alcohol-based antiseptics is only 25% of regular hand-washing.6

These products are a great alter-native for those who are not within proximity of a sink and others who simply do not have the time to wash their hands. Standard hand wash-ing can irritate the skin, and many available gels contain moisturizing emollients. Sanitizing gels are as-sociated with signifi cantly less irrita-tion/dryness by both objective and subjective measures.7 In addition, alcohols are non-toxic and lack al-lergenic potential.

Alcohol products should contact all surfaces of the hands and fi ngers, and artifi cial nails are discouraged because preparation may not come into contact with the interface between the nails. Remember—al-cohols evaporate quickly from the skin, which is why they do not have sustained activity and require repeated application.

Most dispensers produce about 1mL of product, so larger hands may require more than one pump.8

Soap and water should be used after approximately 10 to 12 applica-tions of alcohol gel, as the hands may feel slightly sticky.

Stay HealthyIn a contact lens practice, soap

and water must be used prior to handling a contact lens to reduce lens residue and ocular irritation. It only takes a few seconds to ensure that you and your prac-tice stays healthy during this and every fl u season.

For more information on H1N1 in your practice and at home, visit www.fl u.gov. RCCL

1. 2009 H1N1 Flu. Situation Update. Available at: www.cdc.gov/H1N1FLU. (Accessed November 2009).2. Pandemic (H1N1) 2009. Available at: www.who.int/csr/disease/swineflu/en/index.html. (Accessed November 2009).3. Larson EL, Bryan JL, Adler LM, Blane C. A multifaceted ap-proach to changing handwashing behavior. Am J Infect Control. 1997 Feb;25(1):3-10.4. Gould D, Drey N. Preventing the spread of acute respiratory viral infections. Nurs Stand. 2009 Oct 7-13;24(5):44-9.5. Rofter M. Hand washing and hand disinfection. In: Mayhall CG. Hospital Epidemiology and Infection Control. 1st ed. Baltimore. Williams and Wilkins. 1996: 1052-68.6. Mitka M. Hand washing, a key anti-flu strategy, often neglected by health care workers. JAMA. 2009 Nov 4;302(17):1850-1.7. Boyce JM, Kelliher S, Vallande N. Skin irritation and dryness associated with two hand-hygiene regimens: soap-and-water washing versus hand antisepsis with an alcoholic hand gel. Infect Control Hosp Epidemiol. 2000 Jul;21(7):442-8.8. Larson EL, Eke PI, Wilder MP, Laughon BE. Quantity of soap as a variable in handwashing. Infect Control. 1987 Sep;8(9):371-5.

012_rccl0110_lenscare.indd 12 1/5/10 4:55 PM

Sponsored b y Sponsored b y

If the adage “If it ain’t broke don’t fi x it!” enters into your clinical jargon, you may be

missing the boat. With today’s improved contact lens materials and designs, we have the abil-ity to offer patients improved comfort, clearer vision and whiter eyes. Upgrading currently happy patients to the newest contact lens technology serves to enhance their contact lens wear-ing experience, thereby reducing dropouts and reinforcing the value of our professional care and recommendations.

We must be equally committed to selecting the most appropriate lens care regimen. In fact, the choice of lens care solution, while often merely a secondary consideration, frequently proves to be an even more important modifi able fac-tor in patient comfort and ocular health response. By understanding the differences in multi-purpose solution formulations, we have an additional opportunity to improve the contact lens wearing success of even our currently satisfi ed patients.

A multi-site open label comparison of OPTI-FREE® Replen-iSH® Multi-Purpose Disinfecting Solu-tion (MPS A) to both ReNU MultiPlus* Multi-Purpose Solu-tion (MPS B) and Complete EasyRub* Multi-Purpose (MPS C) Solution was con-ducted with normal soft (traditional and silicone hydrogel)

contact lens wearers. Some 109 patients who had previously used either MPS B or MPS C for at least 30 days prior to the baseline visit were enrolled and assigned MPS A for 30 days of use. Sub-jective comfort was assessed at Baseline and at Day 30. Patients ranked OPTI-FREE® RepleniSH® higher in instillation comfort, end of day comfort and clearer vision, and reported better satisfaction with their overall lens wear-ing experience vs. their previous multipurpose solution. In fact, 80 percent of patients reported that they would continue to use OPTI-FREE® RepleniSH® Multi-Purpose Disinfecting Solution.1

Because patients may not real-ize that a lens care solution can contribute to the comfort of their contact lenses, it is incumbent upon us to reinforce the features and benefi ts of our prescribed solu-tion at every routine visit. With an estimated two to three million established lens wearers dropping out of contact lens wear each year, the continued satisfaction of our

currently non-complaining patients hangs in the balance. Dryness and discomfort, the most commonly cited reasons for patient dropout, may present as a subtle reduc-tion in wearing time at fi rst.2,3

Patients often silently accept this as a normal and expected compo-nent of contact wear. Thus, when it comes to our seemingly happy contact lens patients, silence may not be golden. It is critical to probe for changes in the comfort of their lenses, appearance of their eyes and wearing time. Doing so will help to uncover non-compliance with our prescribed lens care regimen, thereby limiting the erroneous association of symptoms with the actual contact lenses themselves.

Lens care solutions are complex and sophisticated products that are formulated to achieve synergy in three key areas: enhanced lens wettability, effi cacious lens clean-ing and biocompatible disinfec-tion. By proactively upgrading patients to the latest solution technology as in OPTI-FREE® RepleniSH®, patients can experi-

ence enhanced com-fort with a product that was specifi cally designed for today’s advanced silicone hydrogel lenses.

1. Corbin C, Bennett L, Espejo L, et al. Comfort associated with a marketed contact lens solution. Poster presented at AOA. June 2009. Washington, D.C.2. Schlanger JL. A study of contact lens failures. J Am Optom Assoc. 1993 Mar;64(3):220-4.3. Pritchard N, Fonn D. Dehydration, lens movement and dryness rating of hydrogel contact lenses. Ophthalmic Physiol Opt. 1995;15:281-6.

A Stitch in Time

What’s the Solution By Susan A. Resnick, O.D., F.A.A.O., Dipl.

*Trademarks are the property of their respective owners.

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ReNu Multi-Plus* or Complete Easy Rub*End-of-Day Comfort at Day 0

OPTI-FREE® RepleniSH® MPDSEnd-of-Day Comfort at Day 30

N = 30p<0.0001 + 29%

013_rccl0110_alcon.indd 13 1/5/10 4:55 PM

Naked Eye


By Mark B Abelson, M.D., C.M., F.R.C.S.C., Daniel Dewey-Mattia and Keith Lane

Go beyond TFBUT in dry eye diagnostics.

Better Diagnostics in a Blink of an Eye

Epidemiological estimates sug-gest that between 11% and 22% of the U.S. population

suffers from some form of dry eye.1

But, despite its prevalence, investi-gators have yet to fully elucidate all the clinical features of the disease. In order to understand the nature of dry eye and improve treatment, researchers must add new param-eters to the diagnostic and assess-ment criteria. One such variable that may prove invaluable is the eye blink.

The eye blink is vital to the maintenance of normal tear fi lm physiology, ocular surface integ-rity and visual acuity.2 Lasting only about a quarter of a second, each blink facilitates the drainage of tears, excretion of lipids from meibomian glands, elimination of debris in the tear fi lm and spread-ing of lipids across the tear fi lm. The cornea requires this constant nourishment, as extended periods of non-blinking lead to a progres-sively thinner tear fi lm. This can cause dry spots over the cornea, causing surface damage that is manifested as keratitis.3

Since tear fi lm break-up time (TFBUT) was fi rst described as a clinical entity at Schepens Eye Re-search Institute in the late 1960s, it has been the primary diagnostic tool in dry eye disease. Tradition-ally, reference values of TFBUT in normal (≥10 seconds) and dry eye (<10 seconds) subjects were determined using large volumes of fl uorescein dye (20µL to 40µL), but a more physiologically accurate threshold of fi ve sec-onds (similar to the average time

between blinks) has been estab-lished for dry eye subjects, using smaller more controlled quanti-ties of 5µL of fl uorescein.

Despite improvements in both the specifi city and sensitivity of TFBUT, its use as a primary clini-cal endpoint is fl awed for a few key reasons. First, the calculation of TFBUT assumes a static and invariable blink rate, an unreason-able expectation even in the most controlled clinical environment. Secondly, tear fi lm break-up is re-corded upon the fi rst observation of a single dry spot on the cornea without consideration of the area or magnitude of the drying. Fi-nally, TFBUT does not account for the fi ve patterns of tear fi lm break-up, which have been identifi ed by our group.

In an effort to more adequately measure the symptomatology of dry eye, researchers have developed a parameter known as symptom-atic break-up time (SBUT). It is a measure of the time it takes patients to fi rst report a sensation of ocular awareness after they blink twice then stare straight ahead. The out-come shows variable reproducibility when compared with TFBUT, with 72% of patients experiencing ocular discomfort within one second after their recorded TFBUT. However, SBUT may help augment the as-sessment of mild cases of dry eye, in which an irritated symptomatol-ogy is often present without clinical signs (i.e., decreased TFBUT).4

Recently, investigators have found direct correlation between shorter inter-blink interval (IBI) and shorter TFBUT. An analysis by the group

ORA, Inc., found that dry eye patients have a higher blink rate than non-dry eye controls.5-7 In ac-cordance with these fi ndings, drugs that are currently being evaluated for dry eye, such as ecabet sodium, have shown a positive effect on blink rate.

Other researchers, however, have failed to fi nd a statistically signifi -cant correlation between IBI and TFBUT.8 This may be explained by the fact that as the disease intensifi es, dry eye patients begin to experience progressive corneal desensitization. Conversely, those dry eye patients who still experi-ence corneal sensation may exhibit a rapid blink rate in response to continual irritation.

In the future, blinking may serve as a measure in the diagnosis and treatment of dry eye. Because dry eye patients may have a lower IBI in order to compensate for a decreased TFBUT, maintain VA and alleviate irritation, blink rate may serve as a valuable clinical endpoint in the future of dry eye management. RCCL

1. Brewitt H, Sistani F. Dry eye disease: the scale of the problem. Surv Ophthalmol. 2001;45 Suppl 2:S199-202.2. Carney LG, Hill RM. The nature of normal blinking patterns. Acta Ophthalmol (Copenh). 1982 Jun;60(3):427-33.3. Nakamori K, Odawara M, Nakajima T, et al. Blinking is con-trolled primarily by ocular surface conditions. Am J Ophthalmol. 1997 Jul;124(1):24-30.4. Abelson MB, Ousler GW, III, Welch D, Nentwig B. Symp-tomatic break-up time (SBUT) in dry eye patients with normal vs. low corneal sensitivity. Invest Ophthalmol Vis Sci. 2009 May;50(5):4675.5. Tsubota K, Hata S, Okusawa Y, et al. Quantitative videographic analysis of blinking in normal subjects and patients with dry eye. Arch Ophthalmol. 1996 Jun;114(6):715-20.6. Yap M. Tear break-up time is related to blink frequency. Acta Ophthalmol (Copenh). 1991 Feb;69(1):92-4.7. Walker PM, Ousler GW, III, Lane K, et al. A comparative inves-tigation of spontaneous blink rates across a series of tasks in dry eye and control patients; IOVS. 2008. ARVO E-Abstract 5317.8. Schlote T, Kadner G, Freudenthaler N. Marked reduction and distinct patterns of eye blinking in patients with moderately dry eyes during video display terminal use. Graefes Arch Clin Exp Ophthalmol. 2004 Apr;242(4):306-12.

014_rccl0110_NakedEye.indd 14 1/5/10 4:56 PM


Surface and Polymer Chemistry: The

Quest for ComfortIn order to provide patients with a well-performing, comfortable lens, we must be mindful of issues such as surface wetting and solution interactions during wear.By Arthur B. Epstein, O.D., F.A.A.O., and Ralph Stone, Ph.D.

Despite being trivialized by today’s commodity market, contact lenses are increas-

ingly complex medical devices. Even with the tremendous advances in design and materials, the same problems that frustrated both con-tact lens fitters and wearers in the 1950s still persist today. Safety and comfort issues are still the primary determinants of contact lens success or failure.

The search for improved comfort drives innovation and development of improved contact lens modali-ties—glass lenses gave way to plastic materials, and corneal lenses replaced older, molded scleral designs. But, it is clear that safe and successful contact lens wear requires more than just permeability. Practitioners now recognize that a lifetime of successful contact lens wear requires clean lens surfaces with sustained wettability and biocompatibility.

Physiology, Safety and ComfortThe first soft lenses, introduced

by Bausch & Lomb in 1971, were far more comfortable than the

PMMA hard lenses that were avail-able then. Still, even with the advent of soft lenses, comfort continued to be a problem until the early 1980s, when advances in lens materials and designs provided moderate improve-ment in patient comfort. Despite the advances, additional comfort and safety issues loomed on the not-too-distant horizon.

The 1980s was the decade of extended-wear contact lenses—the modality was convenient, and thanks to material advances, comfortable. However, complications, including microbial keratitis (MK), became increasingly common and eventually caught the attention of the public media. A decisive moment in the modern history of contact lenses occurred when studies comparing the incidence of MK in daily and extend-ed-wear lenses were published in the New England Journal of Medicine in 1989. Overnight extended wear was found to have a five-times greater risk of MK vs. conventional daily wear.1

The resultant scientific push to find both a cause and a solution for these relatively high rates of MK implicated

Dr. Epstein is a founding partner of North

Shore Contact Lens & Vision Consultants, P.C., a referral-based contact lens specialty and primary care prac-tice in Roslyn Heights, N.Y. He is also a con-sultant for Alcon.

Dr. Stone retired from Alcon

Laboratories as Vice President for Consum-er Products Research and Development in 2006 after 25 years in the eye care industry working for Bausch & Lomb and Wesley-Jes-sen Corp, in addition to Alcon. He developed many of the care sys-tems used in the field.

015_rccl0110_polymer.indd 15 1/5/10 4:47 PM


insufficient corneal oxygen levels as a primary cause of MK.2

In 1999, after extensive and prolonged research, the oxygen permeability levels needed to meet the projected minimal oxygen requirements were finally achieved by Bausch & Lomb with the intro-duction of their Purevision silicone hydrogel.3 Highly permeable mate-rials reduced levels of edema that occurred from overnight wear and appeared to minimize longer-term corneal changes (e.g., epithelial and endothelial changes), limbal redness and neovascular response.4

Increasing available oxygen to the cornea was believed to be the key solution to the high rates of MK reported in the 1989 study, and subsequently by another group of researchers in 1999.5 Both groups found MK rates of approxi-mately 20 per 10,000 annually in overnight extended wear—about five-times the rate observed with soft lens daily wear.1,5 With the advent of silicone hydrogel materi-als featuring oxygen permeability of over 100Dk, many believed that the risk of MK associated with overnight wear would dimin-ish. Contrary to this prediction, a reduction in infection rates was not observed in U.S. Food and Drug Administration-mandated post-approval surveillance studies.6 More recent studies found that the rate of infection in extended wear was essentially unchanged from the ear-lier reports—slightly more than 20 per 10,000 in extended wear and 4 per 10,000 in daily wear annually.7,8

Despite the absence of a signifi-cant reduction in risk as well as evi-dence of increases in rates of other complications, such as infiltrative keratitis, the improved corneal phys-iology of silicone hydrogel materials has helped drive their rapid adop-tion. However, the complex chem-istry of these materials has made

it much more difficult to maintain clean and wet contact lens surfaces. This, in addition to the higher modulus of some of these materials, has refocused attention on patient comfort issues.

Polymer ChemistrySilicone hydrogel materials derive

from the marriage of polymers tra-ditionally used for soft hydrophilic materials (currently termed conven-tional hydrogels) and hydrophobic polymers that previously served as the base for gas-permeable contact lens materials. These materials were initially classified with the tradition-al hydrophilic groups developed in the 1980s as groups 1 and 3 contact lens materials. It quickly became apparent, however, that these novel materials behave quite differently from earlier hydrogels. As a result, they are now recognized as a new class—group 58. When comparing silicone hydrogels and conventional hydrogels, research has shown that they differ in their interaction with the environment, that they absorb more lipids from the tears and that they absorb lower levels of the tear proteins.9,10 Silicone hydrogels also have different affinities for certain care system preservatives.11-14

Advances in lens care product formulations have also added to the complexity and potential for inter-action between materials and lens care components. This has been observed in increased corneal stain-ing and related comfort issues asso-ciated with combinations of lens care products and lenses.15,16 The complexity of modern lenses and lens care products has made it criti-cal that practitioners who prescribe these products consider the effects of their combined use.

Lens Surfaces and Comfort Combining plastic and water

to create a hydrogel material was

a remarkable scientific break-through, accomplished by Czech scientists Otto Wichterle and Drahoslav Lim in the late 1950s. Beyond his genius as a chemist, Dr. Wichterle envisioned the prac-tical use of hydrogel materials to make contact lenses and actually created prototype lenses. Because hydrophilic lenses contain water and are constantly in a wet envi-ronment, it was generally assumed that the water content of the lens remained stable after equilibrat-ing when taken from the storage medium and placed within the ocular environment.17 However, even with high water-content lens-es, and in some cases even more so, comfort remained an issue for many patients.

The ocular environment is complex and can easily become destabilized. A lens within the ocular environment can have a profound effect on the stability of the environment and comfort of the patient. The impact of contact lens wear on the ocular surface includes more rapid fluorescein break-up time, increased corneal staining, and frank damage to the wiper surfaces of the lid. This has been described as lid wiper epi-theliopathy and is associated with diminished lens comfort.18

Contact lens drop-out is a prob-lem for both practitioners and industry alike. Industry data show that every year, approximately the same number of patients discontinue contact lens wear as those who become new wearers.19 Clinical experience has shown that discomfort, particularly end-of-day discomfort and dryness, are primary causes of discontinu-ation of lens wear. It is incumbent on us as eye care practitioners to understand the causes and develop effective approaches to minimizing contact lens drop-out

015_rccl0110_polymer.indd 16015_rccl0110_polymer.indd 16 1/5/10 4:48 PM1/5/10 4:48 PM


rates. Understanding contact lens-related discomfort requires a thor-ough knowledge of contact lens materials and their interaction with the eye.

To gain insight into what occurs during contact lens wear, it is important to first understand how a normal ocular surface maintains a comfortable envi-ronment. This knowledge has been facilitated by a significant amount of research regarding dry eye and tear dysfunction. Much of this data is summarized in the 2007 Report of the Dry Eye WorkShop.20

There is an increased incidence of dryness when the inter-blink interval is greater than the fluo-rescein break-up time.21 This func-tion has been termed the Ocular Protection Index (OPI). Although somewhat variable, a normal patient shows tear film break-up times (TFBUT) in excess of 10 to 12 seconds. Normal blink inter-vals are generally around seven seconds, so normal patients do not experience tear break-up on the ocular surface and generally remain comfortable. Contact lens wearers experience more rapid TFBUT: typically less than four seconds. As a result, the front sur-face of the lens dries during each of the nearly 7,000 blinks a day.

During each blink, the lids, especially the superior lid, sweep across the cornea. This process is necessary to wipe and resurface the cornea. A study of dry eye patients found that damage to the

specialized stratified squamous epithelial wiping surfaces of the lids can be observed after staining with fluorescein and rose bengal.18 Findings demonstrate that 76% of patients exhibiting dry eye symptoms showed staining of the lid wiper vs. 12% of patients who did not report dry eye symptoms. And, the degree of staining in the symptomatic patients correlates to severity of symptoms.18,22 The cor-relation between reported contact lens dryness and the observation of lid wiper epitheliopathy was strong (see “Incidence of Lid Wiper Staining in Contact Lens Wearers,” above).22

Contact Lens vs. EyeIs the contact lens surface dif-

ferent from the ocular surface? A critical question: How can the surface of the contact lens and its interaction with the lid be modi-fied to make lenses more comfort-able throughout the wearing day? Beyond the physical effects of the rigidity of the lens and edges result-ing from material properties and design, changes in the lens surface are critical if we hope to improve the all-day comfort of lenses.

In soft lens wearers, tear break-up on the front surface of the lens has been observed to occur much more quickly than it would occur on the cornea itself.23 Exposing the unwet-ted lens surface to the environment is believed to cause the lens to dry. But, lens materials are homogenous, and with conventional hydrogel materials containing as much as

70% water, drying seemed improb-able, especially with the eye refresh-ing the tear film at every blink.

Careful examination of the struc-ture of the lens polymers reveals that all lens materials, even conven-tional high water-content hydro-gels, have sites in the polymer that are hydrophilic (“water loving”) and sections that are hydrophobic (“water hating”). In the base state, bathed in water, both the hydro-philic site at the surface and in the bulk are oriented to attract water and make the overall structure and surface hydrophilic (figure 1). When the lens is removed from an aqueous environment and is in air, there is a shift in the overall arrangement of the hydrophilic and hydrophobic groups in the poly-mer—air is hydrophobic. As the surface dries, the hydrophilic group looks for an environment satisfying its need for water, and the polymer structure rotates so that the hydro-philic group finds a water loving environment in the inside or bulk of the polymer. The opposite occurs at the surface (figure 2).

In practice, we see this phenom-enon as a contact lens is worn in the eye. The lens surface dries over time, and this can be readily observed as a change in surface wettability. Surface wettability is a function of the contact angle formed between the surface and a liquid droplet. The contact angle is defined as the angle formed by the solid surface and the tangent line to the upper (droplet) surface at the end point. It can be measured in a variety of ways.23-27

A study examining the surface wettability of lenses under systems designed to model this change in polymer orientation found that conventional lenses equilibrated in saline over time showed advanc-ing surface contact angles that demonstrate the full hydration and

Incidence of Lid Wiper Staining in Contact Lens Wearers 22

No Staining Grade 1 Grade 2 Grade 3Asymptomatic

84% 11% 3% 3%Wearers (n=75)

Symptomatic 27% 37% 20% 17%Wearers (n=30)



a hydrated surface.23 By exposing the lenses to cycles involving 1.5 minutes of drying followed by five minutes in saline, the contact angles varied from 25° in etafilcon lenses coming directly from the package to nearly 100° in 10 simulated cycles, thus showing the effect of the dry-ing process. What is more interest-ing is that once it occured, this process was not easily reversible.23

When this technique is applied to lenses over a normal wear cycle, the findings demonstrate the same effect. In measurement of ex vivo lenses after eight hours of wear, the contact angle was measured at 105° to 118°. Com-pare this to the 100° measurement obtained in the in vitro model after 10 simulated cycles.23,24 At the start of the measurement with a lens taken directly from its packaging solution, the advancing contact angle was 25°.28

When these same studies are applied to silicone hydrogel lens materials, the baseline wetting as

measured by advancing contact angles reveals the effectiveness of different approaches to making the surface wettable. The plasma-bonded chemical treatment in the Night and Day lens (CIBA Vision) shows superior surface wetting vs. attempts to modify the surface using an internal wet-ting agent (see “Effects of Surface Treatment of Silicone Hydrogel Lenses,” pg 19).25

The second set of measure-ments relates to the estimate of the effect of lubrication achieved during each blink. Measuring the coefficient of friction provides an estimate of the drag upon the lid during each blink. The coefficient of friction describes resistance of two surfaces moving across each other. It is independent on both the force pushing the two sur-faces together and the direction of the movement, whether hori-zontal or vertical.

A study that analyzed the effect of interactions between tissues in an

attempt to understand the effect on the lid in dry eye used tissue from human umbilical vein segments in a reciprocating pin-on-disc fric-tion test device.29 The coefficient of friction was affected by the wet-ness of the surfaces, and various demulcent formulations reduced the coefficient of friction. An in vitro procedure for evaluation of lens-on-tissue friction proposed by the lead researcher of this study now uses tissue from bovine pericardium, a reproducible material made under controlled conditions.30

These experiments demonstrate the importance of filling the inter-face with the “right” material and achieving appropriate properties to minimize the coefficient of friction. Using microscopy to evaluate these initial experiments with tissue-on-tissue friction shows the role of even small changes in friction and damage to the tissue surface.

Measurements of wettability of the lens surface and of surface lubrication are two approaches that provide in vitro and ex vivo measurements of key material and solution properties that affect contact lens comfort. Correlation of data from these measurements, as well as clinical effects upon lid wiper surfaces provide us with the tools to understand the surfaces of contact lenses and how to pro-vide more comfortable lens wear throughout the day.

Newer contact lens designs and lens care products incorporate components that increase surface wettability and decrease friction to improve and sustain comfort. Examples of lenses optimized for more wettable surfaces include Dailies AquaComfort PLUS (CIBA Vision) and 1-Day Acuvue Moist (Vistakon). Currently available lens care products incorporating enhanced wetting agents include OPTI-Free RepleniSH (Alcon) and

1. Orientation of hydrophilic sites in a lens in an aqueous environment.

Hydrophobic

HydrophilicWet Hydrated Bulk

Aqueous Layer

LensHydrophobic

HydrophilicWet Hydrated Bulk Polymer

Hydrophobic Air Layer

2. Orientation of hydrophilic sites in a dry environment.



AQuify MultiPurpose Solution (CIBA Vision). Additional prod-ucts containing innovative wetting agents will be introduced in 2010.

Performance and ComfortContact lenses have advanced

dramatically from their genesis as uncomfortable refractive devices, offering only limited wearing time. But, keeping pace with patient expectations and demands has been challenging. Today’s patients are far more interested in immedi-ate and sustained comfort than they are intrigued by the novelty of contact lens wear. Patients expect good comfort and stable vision for at least 12 to 14 hours a day, and with a greater variety of avail-able refractive options than ever, they are likely to seek alternatives if their contact lenses fail to meet their expectations. New technolo-gies for lenses and lens care require continuing evaluation of the paradigms for in vitro and in vivo testing to meet the comfort expec-tations of patients.

Awareness of patient expecta-tions and new technologies will help ensure that contact lenses remain a viable choice for many years to come. And, understand-ing the complex technical issues is becoming a requisite for maximiz-ing the patient experience.

Researchers have the primary tools for the development of new approaches to improved contact

lens surfaces. Meeting our patients’ comfort expectations comes directly from continued advances in sur-face chemistry—either chemically modifying the surface, adsorbing or bonding long-lasting wetting components to the surface during storage or care, or providing an internal wetting system that releases or migrates to the surface during wear. The future of contact lenses will undoubtedly lead to new prod-ucts that combine excellent visual performance and long-lasting, sus-tained comfort. RCCL

1. Poggio EC, Glynn RJ, Schein OD, et al. The incidence of ulcerative keratitis among users of daily-wear and extended soft contact lens wearers. N Engl J Med. 1989 Sep 21;321(12):779-83.2. Weissman BA, Mondino BJ. Risk factors for contact lens associated microbial keratitis. Cont Lens Anterior Eye. 2002 Mar;25(1):3-93. Holden BA, Merz GW. Critical oxygen levels to avoid corneal edema for daily and extended wear contact lenses. Invest Oph-thalmol Vis Sci. 1984 Oct;25(10):1161-7.4. Bergenske P, Long B, Dillehay S, et al. Long-term clinical results: 3 years of up to 30-night continuous wear of lotrafilcon A silicone hydrogel and daily wear of low-Dk/t hydrogel lenses. Eye Contact Lens. 2007 Mar;33(2):74-80.5. Cheng KH, Leung SL, Hoekman HW, et al. Incidence of con-tact lens associated microbial keratitis and its related morbidity. Lancet. 1999 Jul 17;354(9174):181-5.6. Schein OD, McNally JJ, Katz J, et. al. The incidence of microbial keratitis among wearers of a 30-day silicone hydrogel extended-wear contact lens. Ophthalmology. 2005 Dec;112(12):2172-9.7. Stapleton F, Keay L, Edwards K, et al. The incidence of con-tact lens-related microbial keratitis in Australia. Ophthalmology. 2008 Oct;115(10):1655-62.. 8. Dart JK, Radford CF, Minassian D. et al. Risk factors for microbial keratitis with contemporary contact lenses: a case-control study. Ophthalmology. 2008 Oct;115(10):1647-54.9. Jones L, Senchyna M, Glasier MA, et al. Lysozyme and lipid deposition on silicone hydrogel contact lens materials. Eye Con-tact Lens. 2003 Jan;29(1 Suppl):S75-9.10. Senchyna M, Jones L, Louie D, et al. Quantitative and conformational characterization of Lysozyme depositied on Balafilcon and Etafilcon contact lens materials. Curr Eye Res. 2004 Jan;28(1):25-36.11. Rosenthal RA, McDonald MM, Schlitzer RL, et al. Loss of bacterial activity from contact lens storage solutions. CLAO J.

1997 Jan;23(1):57-62.12. Dannelly HK, Waworuntu RV. Effectiveness of contact lens disinfectants after lens storage. Eye Contact Lens. 2004 Jul;30(3):163-5.13. Rosenthal RA, Dassanayake NL, Schlitzer RL, et al. Biocide uptake in contact lenses and loss of fungal activity during storage of contact lenses. Eye Contact Lens. 2006 Dec;32(6):262-6.14. Warburton K, Noble-Wang JA, Henry BM, et al. Absorption of alexidine by contact lenses and lens cases and its effect on disinfection activity against Fusarium solani. Poster Q-426 pre-sented at American Society of Microbiology. Toronto. 2007. 15. Jones L, MacDougall N, Sorbara GL. Asymptomatic corneal staining associated with the use of balafilcon silicone-hydrogel contact lenses disinfected with a polyaminopropyl biguanide-preserved care regimen. Optom Vis Sci. 2002 Dec;79(12):753-61.16. Andrasko G, Ryen K. Corneal staining and comfort observed with traditional and silicone hydrogel lenses and multipurpose solution combinations. Optometry. 2008 Aug;79(8):444-54.17. Efron N, Brennan NA, Bruce AS, et al. Dehydration of hydro-gel lenses under normal wearing Conditions. CLAO J. 1987 May-Jun;13(3):152-6.18. Korb DR, Herman JV, Finnemore HE, et al. Lid wiper epi-theliopathy and associated dry eye symptoms. IOVS 2004; 45 E-Abstract 100.19. Bart JT. 2004 Contact Lens Spectrum Annual Report. Cont Lens Spectrum. 2005 Jan;20(1).20. Research in dry eye: report of the Research Subcommittee of the International Dry Eye WorkShop (2007). Ocul Surf. 2007 Apr;5(2):179-93.21. Ousler III GW, Hagberg KW, Schindelair M, et al. The Ocular Protection Index. Cornea. 2008 Jun;27(5):509-13.22. Korb DR, Greiner JV, Herman JP, et al. Lid-wiper epitheli-opathy and dry eye symptoms in contact lens wearers. CLAO J. 2002 Oct;28(4):211-6.23. Ketelson HA, Meadows D. Wettability of soft contact lenses new thoughts about an old problem. Rev Cornea & Cont Lens. 2004 Oct;141(7):34-8.24. Ketelson HA, Meadows DM, McQueen N, Stone RP. Enhancing wettability with multi-purpose solutions. Rev Cornea & Cont Lens. 2005 Jan/Feb;142(1);44-7.25. Ketelson HA, McQueen N, Meadows D, Stone RP. Wettabil-ity of silicone hydrogel lenses in the presence of tear compo-nents. Rev Cornea & Cont Lens. 2005 Apr;142(3):24-8. 26. Tonge S, Jones L, Goodall S, Tighe B. Ex vivo wettability of soft contact lenses. Curr Eye Res. 2001 Jul;23(1):51-9.27. Moldanado-Codina C, Efron N. Dynamic wettability of pHEMA-based hydrogel contact lenses. Ophthalmic Physiol Opt. 2006 Jul;26(4):408-18.28. Alonso-Caneiro D, Iskander DR, Collins MJ. Tear film surface quality with soft contact lenses using dynamic-area high-speed videokeratoscopy. Eye Contact Lens. 2009 Sep;35(5):227-31. 29. Meyer AE, Baier RE, Chen H, et al. Differential tissue-on-tissue lubrication by ophthalmic formulations. J Biomed Mater Res B Appl Biomater. 2007 Jul;82(1):74-88.30. Meyer AE. An in-vitro procedure for evaluation of lens-on-tissue friction. Available at: www.lsu-eye.lsuhsc.edu/docs/Meyer%20Talk%2011-08.pdf.

Effect of Surface Treatment of Silicone Hydrogel Lenses

Brand Material Advancing Contact Angle Advancing Contact Angle after Eight Directly from Package Simulated Blink Cycles (Five Minutes in Saline and 1.5 minutes in air)

02Optix Lotrafilcon B 30º 60ºFocus Night and Day Lotrafilcon A 50º 50ºAcuvue Advance Galyfilcon A 100º 100ºAcuvue 2 (Traditional Etafilcon A 70º 110ºHydrogel)



Solution ConfusionThough we advocate the use of particular care systems, even the most compliant patients can go astray as they encounter myriad “look-alike” products on the store shelf.By Susan J. Gromacki, O.D., M.S., F.A.A.O.

Consider this scenario: You are having the following conversation with a patient

who is new to your contact lens practice. During the case history, you ask him, “Which solution do you use to clean and disinfect your lenses?”

He replies, “I don’t know the name.”

You ask, “Do you use one bottle or two?”

“One,” he replies. “With a flat contact lens case

like this or a tall case with a disk in it?”

“A flat case.” “What color is the bottle?” “Blue, I think.” “Is it ReNu?” you ask.“I don’t think so.” “Does it have a yellow sun-like

design on it?” “No.” “Is the bottle white or aqua in

color?” “I don’t know the type of saline

I use,” he says again. “Does the bottle say ‘saline’ on

it?” “I don’t think so, actually.” “Good,” you say. “Because saline

is salt water. It can’t disinfect your lenses anyway.” Sound familiar?

Of course you’ve experienced this conversation before. This scene is repeated over and over again every day in eye care offices all over the world. Thank goodness for estab-lished patients. We know which care system we dispensed, and we know that we provided the proper training and education regarding compliance with that system.

Still, patients can go astray. They encounter myriad products on the store shelves and can experience “solution confusion” (figure 1). The appeal of these lookalike prod-ucts? Many are less expensive than our prescribed care system. Others may contain the words “no rub,” indicating a more expedient regi-men than the one we reviewed. Still others may boast a simpler system and/or case than we recommended, with no “red capped” solution and no platinum disc.

At the Meijer department store, for example, one box states, “If you like Opti-Free, try me.” Like Opti-Free (Alcon), it has a green label, and it is placed strategically next to the Opti-Free on the store shelf. (If you haven’t visited the contact lens care displays in your local stores lately, it’s worth the trip.) But, it isn’t Opti-Free at all.

Dr. Gro-macki is a diplomate in the Cornea,

Contact Lens and Refractive Tech-nologies Section of the American Academy of Optometry. She is Chief Research Optometrist at Keller Army Community Hospital, West Point, New York.

022_rccl0110_solution.indd 22 1/5/10 4:47 PM


In fact, the preservative/active ingredient is completely different than polyquad and may not be as compatible with silicone hydro-gel lenses as Opti-Free. In addi-tion, this formulation does not include the wetting agent present in Opti-Free RepleniSH. For dry eye patients, this swap could very easily interfere with successful contact lens wear. Does your patient know this? Of course not! Is this labeling legal? Unfortu-nately, according to the United States Federal Trade Commis-sion, yes. So, what are the con-sequences of patients utilizing lens care regimens other than the one prescribed for them? And, what can practitioners do to maximize adherence to our prescribed lens care regimen?

Do Your Background Research

We must educate ourselves on the existing products before we can educate our patients. Before seeing patients, there is a baseline knowledge that all contact lens practitioners must have: exactly what’s in the bottle they are recommending. If anything good came out of the recent Fusarium and Acan-thamoeba keratitis outbreaks, it taught our patients that not all solutions are identical. But, we as practitioners need to know not only that they are different, but how they are different.

Contact lens disinfecting solu-tions are complex combinations of chemicals designed to remove surface deposition, disinfect microorganisms and improve sur-face wettability. We must know each solution’s active ingredient or preservative, its benefits and possible shortcomings and with which lens materials it is most compatible. Which care system

would you select for a borderline dry eye patient? Which would you prescribe for a patient with extreme allergies or hypersensi-tivities? Which is best for heavy depositors? This knowledge can be obtained by referencing the contact lens care chapters of sev-eral excellent contemporary text-books (e.g., Manual of Contact Lens Prescribing and Fitting and Clinical Contact Lens Practice), by reading journal articles on solutions and by attending contact lens care lectures at continuing education conferences.1,2

Keep up-to-date on new lens and-solution technology. In addition to the sources described above, indus-try sales representatives can be a tremendously informative resource. Just remember that they are paid to promote only one line of prod-ucts—theirs. If you want to hear the complete story, then you should meet with several reps.

By offering the latest technol-ogy to your patients, you are setting your practice apart from the others. By understanding

this technology, you can avoid the learning curve that is usu-ally present when utilizing a new product. And, by educating patients about your new offer-ings, you demonstrate that you care about their eyes by provid-ing them with the best technol-ogy. You also reinforce the fact that each product is unique. This little bit of patient knowledge goes a long way in preventing a patient from deviating from your recommended care regimen.

Understand the Impact of Private Label Solutions

When a patient strays from your prescribed name-brand solution, it is most often to a private label or “generic,” prod-uct. Generics currently make up 25.3% of the United States solutions market (see “Solution Use in 2009” pg 24).3 Cur-rently, Bausch & Lomb, Abbott Medical Optics, CIBA Vision and Sauflon are among the com-panies supplying product for private label. (Alcon recently left the private market when it dis-continued production of the for-mulation that was once labeled as Opti-One.)

Every six to12 months, a retailer such as Walmart enter-tains bids for which company will produce and package its

private-label solution.4 Since the store may pay the manufacturer only $1.00 per bottle (vs. the consumer’s $6.50 or more than a company’s premium product), these solutions are most often older formulations of a compa-ny’s premium brand.5

Here is where things get more convoluted. When a contract expires, the formulation con-tained in a generic brand may change. And, because expira-tion dates are typically 18 to

1. “Solution confusion” is created when generics are packaged to look like brand name solutions.



36 months after production, there could be two dif-ferent combina-tions of chemicals residing in two of the very same bot-tles that sit next to each other on the supermarket shelf. Adding to the confusion, some retailers sell the exact same solu-tion labeled in different bottles.4

Companies do make a conscious effort to distinguish their premium products by changing the appear-ance of their labels (figure 2). However, the packaging compa-nies that serve the generic market quickly follow suit.

So, why is this a problem? The consequences of substituting a generic for a name brand product are numerous. For starters, the patient does not reap the benefits of the latest technological advances in lens care, such as better cleaning and disinfection, less toxicity and increased comfort and wettability.4

The newest multipurpose solu-tions are specifically formulated for silicone hydrogel lenses. For instance, Opti-Free RepleniSH

(Alcon) includes TearGlide (Tet-ronic 1304 and C9-ED3A) as a wetting agent. This additive gives the solution FDA-approved label-ing claims for retaining moisture and reconditioning lenses for enhanced comfort.6 AQuify’s (CIBA Vision) HydroLock is a combination of dexpanthenol (ProVitamin B5), a moisturizer and sorbitol, a humectant. The latter draws moisture to the lens, and the former creates a barrier effect that that prevents evapora-tion and helps to maintain wetta-bility.7 It is well-documented that dry eye is the primary etiology of contact lens dropout.8

Most of the generic products were invented long before the utilization of silicone hydrogel materials. They continue to be

quite adequate for cleaning and dis-infecting the older generation HEMA-based lenses, but their use with silicone hydrogel materials may lead to parameter changes, decreased biocompatibility, increased sensitiv-

ity reactions or even toxicity.6

Until we gain a complete under-standing of how these materials perform, we need be on alert for anything out of the ordinary. For example, the now-discontinued SOLO-care Plus (CIBA Vision) was found to alter the diameter and power of Acuvue Advance (Vistakon) lenses.6 Also, a com-prehensive study of material-solu-tion combinations has found that generic solutions, when used with silicone hydrogel lenses, cause the greatest amount of superficial punctate staining (figure 3).9

In addition, patients are at higher risk for contact lens-induced ocular complications when they switch solutions or fail to comply with their cleaning and disinfection regimens. A recent study found a statistically higher rate of such ocular complications with patients who use private label, rather than name brand solutions.10

Communicate With Your Patient

Review your choice of contact solution in your examination room. One result of the Fusariumand Acanthamoeba keratitis outbreaks has been the shifted responsibility of care system selec-tion from ancillary staff member to doctor. Practitioners are now carefully prescribing solutions based on their patient’s lens mate-rial, wearing and replacement

2. Brand name solutions routinely change their packaging.

Solution Use in 2009*

Private Label 25.3% Opti-Free RepleniSH 26.4% Opti-Free Express 11.2% ReNu MultiPlus 13.9% ReNu 1.5% AQuify 2.0% Clear Care 11.6% AOSept 1.7% Complete Easy Rub 6.2% All others 0.2%

*through 10/3/09; retail sales through food, drug and mass merchandiser stores, excluding WalMart. Renu Multiplus has been renamed to ReNu Fresh Lens Comfort, and ReNu has been renamed to ReNu Sensitive Eyes.



schedule and ocular health. I delegate insertion, removal and care training to my technician, but only after I have specifically selected the solution myself and reviewed it with my patients. This includes reading the package insert with them and asking that they review it at home as well.6

Explain that the care system you have chosen is unique and that not all solutions are alike. I instruct my patients not to deviate from my chosen brand because I selected it specifically to work in combination with their lens mate-rial, wearing and replacement schedules and ocular health. I let them know that if they go astray, complications may ensue. Some practitioners even show patients pictures of contact lens-related complications to drive the mes-sage home.11

Provide patients with a sample of the solution you are prescrib-ing; in my experience, this step increases compliance. Ask them to bring their bottle to the store to make sure they purchase the correct one. Additionally physi-cally demonstrate how to clean, disinfect and store the lenses with the actual solutions and case. Remember: the United States Food and Drug Administration now recommends a digital rub-bing step for all contact lenses, which is something many of us have always done and recom-mended to our patients.12

In addition, always provide handouts with good graphics because many patients learn bet-ter visually and via written mate-rial. For others, these materials will reinforce what they heard in your office. Make sure to always include the solution name.

Don’t overdo it. Although you do not want to forget any impor-tant information, be careful not

to inundate the patient with too much written information, or it will go unread.

Present patients a copy of their solution “prescription” on an Rx pad. This reinforces the fact that contact lenses are medical devic-es, not commodities, and that lens care is serious business.

Follow UpMake every follow-up appoint-

ment count. Try your best to convey to patients, both before and after the visit, that follow-up appointments are an important utilization of their time. Do not charge a separate fee for this visit, but rather, bundle this fee with the fitting/diagnostic charg-es. Otherwise, patients may “no show” in an effort to save money.

Follow-ups are, of course, a valuable use of our time as well. If I notice discomfort or exces-sive deposition, I can change lens solution, material or modality. Perhaps the most important rea-son for the contact lens follow-up, however, is to confirm proper lens care. I ask the patient, “Tell me how you clean your lenses from the time you start until the time you’re finished.” I utilize every patient visit as an opportu-nity to review lens care.

Educate Your StaffStart by dedicating a quiet,

pleasant and well-lit area for contact lens training. Select a specific staff member or two to provide this education. Choose someone who will show patience and devote ample time to each patient. Furthermore, make sure that you and your staff members are on the same page. Your tech-nicians must share your philoso-phy on proper contact lens care and follow-up, so that patients will receive a consistent message

no matter whom they interact with in the practice.13

Choose Your ApproachSome practitioners utilize some

of the methods discussed here, and others use all of them. But, no matter the method you choose, good communication, consistent education and regular follow-up care are key to reinforcing compli-ance with your prescribed solu-tion. Your patients’ ocular health depends on it! RCCL

1. Hom MM, Bruce AS, eds. Manual of Contact Lens Pre-scribing and Fitting. Butterworth Heinemann Elsevier. St. Louis. Missouri. 2006.2. Bennett E, Weissman B, eds. Clinical Contact Lens Practice. Lippincott, Williams & Wilkins. New York. New York. 2005.3. AC Nielsen. Solution Use in 2009 Year to Date. Percent-age by Brand. May 29, 2009. 4. Gromacki SJ. The truth about generics. Cont Lens Spect. 2005 Dec;20(12):24.5. Smythe J. What’s in a solution name? Cont Lens Spect. 2003 May;18(5):27.6. Gromacki SJ. Hydrogel and silicone hydrogel lens care. Cont Lens Spect. 2008 Feb;22(2):26-32.7. Gromacki SJ. Prescribe the best solution for silicone hydrogel lenses. Opt Man. 2007 Apr;42(4):61-5.8. Richdale K, Sinnott LT, Skadahl E, Nichols JJ. Frequency of and factors associated with contact lens dissatisfaction and discontinuation. Cornea. 2007 Feb;26(2):168-74.9. Andrasko G, Ryen K. Corneal staining and comfort observed with traditional and silicone hydrogel lenses with multipurpose solution combinations. Optometry. 2008 Aug;79(8):444-54.10. Forister JY, Forister EF, Yeung KK, et al. Prevalence of contact lens-related complications: UCLA contact lens study. Eye Contact Lens. 2009 Jul;35(4):176-80.11. Szczotka-Flynn L, Yeung K, Brujic M. An expert perspec-tive on lens care. Rev Optom. 2009 Sept:146(9):73-9.13. Gromacki SJ. A good tech means good care. Cont Lens Spect. 2004 Oct;19(10):25.12. FDA. Ensuring safe use of contact lens solution. Avail-able at: www.fda.gov/ForConsumers/ConsumerUpdates/ucm164197.htm#rub (Accessed October 2009).

3. This patient demonstrated corneal staining after utilizing Target Multi-purpose Solution and Pure Vision lenses.

Courtesy: Gary Andrasko, O.D., (www.StainGrid.com.)



Beyond the Basics: Treating Severe Dry Eye

What can practitioners do when first line therapy fails?By William F. Townsend O.D., F.A.A.O.

In every practice, there are hun-dreds—perhaps even thousands—of patients who suffer from

some form of ocular dryness. Many monikers have been assigned to this condition (ocular surface disease, ker-atoconjunctivitis sicca, dysfunctional tear syndrome, etc.), but regardless of the terminology, individuals who struggle with these maladies represent a tremendous opportunity for us to provide symptomatic relief and ongo-ing care. They are also a potential source of practice growth. Many of these individuals can be successfully treated with one or more of the con-ventional treatment modalities that are in common use today.

But unfortunately, a small subset of these patients suffers from severe, potentially sight-threatening dryness. They may report minimal or no relief from artificial tears, punctal plugs and other commonly prescribed therapies.

In this article, we will review the current thinking on the various pathogeneses of dry eye and meth-ods to manage and treat the more severe forms.

What the Experts SayDuring the past two decades, sev-

eral panels of experts in the field of dry eye and ocular surface disease have pooled their collective expertise to reach some consensus on the causes of dry eye and devise paradigms for treating these conditions. The National Eye Institute/Industry Work-shop on Clinical Trials in Dry Eyes, the Dry Eye WorkShop (DEWS) and the Delphi Panel helped us to better understand the underlying patho-physiologies of dry eye and established logical paradigms for treatment.1-4

One important concept that came out of these panels is that dry eye can be caused by inadequate lacrimal layer

Dr. Townsend is in private practice

in Canyon, Tex., and is an adjunct profes-sor at the University of Houston College of Optometry. He is a member of the executive board of the Ocular Surface Society of Optometry (OSSO) a non-profit organiza-tion whose mission is to increase aware-ness and advance the understanding and management of dry eye and ocular surface disease. Information for joining OSSO can be found at [email protected].

026_rccl0110_Therapy.indd 26 1/5/10 4:45 PM


production (aqueous tear deficiency) or excessive evaporation of the tear film (evaporative dry eye), which is often associated with meibomian gland dysfunction.

The Delphi Panel expanded on the initial classification of aqueous tear deficiency vs. evaporative dry eye, because in many cases, dry eye sufferers may have both entities, and because earlier classification schemes did not emphasize the contribution of inflammation to the pathogenesis of dry eye.4 You may think that arriving at a definition for “severe dry eye” is simple, but when you consider the numerous studies and conferences on dry eye, there is cur-rently no common consensus on a universal description of the more severe form of this condition.

What is Severe Dry Eye?The DEWS report assimilated

information from the NEI work-shop and the Delphi panel to formulate criteria for higher levels of severity. These include severe and frequent discomfort; chronic, constant or disabling visual symp-toms; some degree of conjunctival injection; marked central corneal staining with possible erosions; filamentary keratitis with mucin clumping and increased tear debris; advanced meibomian gland chang-es that may include trichiasis and keratinization; and a Schirmer test score of 2mm to 5mm.2

Severe dry eye may result from extreme dysfunction of the lacrimal glands, the meibomian glands or both. In 1930, Henrik Sjögren first published a descrip-tion of five patients with marked dryness of the eyes and mouth. In his doctoral dissertation, he referred to the condition as “kera-titis sicca.”5 Histological evalu-ation subsequently revealed that Sjögren’s syndrome (SS) results from chronic autoimmune disease involving proliferation of T lym-phocytes and B lymphocytes in exocrine glandular cells. Sjögren’s syndrome may occur independent-ly (primary Sjögren’s) or in con-junction with other autoimmune disease (secondary Sjögren’s). The expression of cytokines, including tumor necrosis factor- (TNF- ), causes destruction of the acini of secretory cells.6 We now know that both forms of SS may cause severe dry eye.

One study evaluated the effec-tiveness of punctal occlusion for treating severe SS. Researchers used one eye as a control and performed punctual occlusion in the other eye. They found that occlusion improved comfort and rose bengal scores in the treated eye, but had no effect on Schirmer scores and mucus debris scores.7

The lack of effect on the Schirm-er test in SS has been reported previously and may be due to the deficiency of reflex tearing found in this patient group.8

Inflammation has become a well-recognized factor in the pathogenesis of non-SS ocular dryness; Restasis (Cyclosporin A 0.05%, Allergan) is a widely pre-scribed therapeutic agent approved for instillation every 12 hours. The original Phase II and III trials did not demonstrate a statistically significant difference between the currently approved protocol and

higher dosing frequency or con-centration.9,10 One study evaluated the effect of more frequent dosing in individuals whose severe dry eye was refractory to twice-daily dosing of Cyclosporin A 0.05% after a period of at least four months. All these subjects’ severe dry eye was secondary to graft-versus-host disease or SS. Findings demonstrated that increasing dos-ing to t.i.d. or q.i.d. resulted in sig-nificant improvement in both the subjective complaints and the rose bengal score, but did not improve Schirmer values and the tear mucus scores.11 This study suggests that increasing the dosing or con-centration of cyclosporine might benefit our patients with advanced dry eye.

Trachoma is another form of severe dry eye and is also a common

This 87-year-old female with Sjögren’s syndrome shows significant cornealstaining with fluorescein. Her presenting complaints were ocular pain andblurred vision.

This patient has corneal neovasculariza-tion and extreme ocular drynesssecondary to Stevens-Johnson syndrome.

This contact lens wearer has severe dry eye that is evidenced by marked lissa-mine green staining of the conjunctiva.



cause of vision loss and blindness worldwide.12 Conjunctival cicatri-zation destroys the basic secretory system and obliterates the excretory ductules of the lacrimal gland, often resulting in severe ocular surface dis-ease. Tissue biopsies that were taken from patients with active trachoma revealed infiltrative lymphoid fol-licles in the underlying conjunctival stroma. Specimens obtained from eyes with inactive disease showed subepithelial fibrous membranes,

squamous metaplasia and loss of goblet cells. Acini and ducts of acces-sory lacrimal glands were damaged by subepithelial infiltration and scarring.12 Cyclosporine has been evaluated for treatment of severe tra-chomatous dry eye. After six months of therapy, researchers found sta-tistically significant improvement in symptom scores and Ocular Surface Disease Index (OSDI) scores, rose bengal and fluorescein staining scores, tear film break-up time (TFBUT) values and Schirmer test values. Impression cytology also showed improvement of goblet cell density in 23 patients (71.88%).13

Severe dry eye may also occur as a result of chemical trauma, radiation or immunologic diseases that target mucous membranes.18-20

Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are severe acute adverse drug reac-tions that primarily affect the skin, but they may also involve ocular, oral and genital mucous mem-branes. Although similar in most respects, SJS typically affects less that 10% of body surfaces, whereas TEN affects greater than 30% of body surface.20 These conditions, as well as ocular cicatricial pemphi-goid (OCP), may severely damage the ocular surface—particularly the mucous membranes. The most commonly reported complication of these conditions is severe dry eye.18-20

Treatment OpportunitiesIn the past decade, several excel-

lent artificial tear products have been introduced. But, despite these advances, currently available artifi-cial tear preparations do not include endogenous tear components such as epidermal growth factor, hepa-tocyte growth factor, fibronectin, neurotrophic growth factor, cyto-kines, mucins and vitamin A. These molecules play an important role in the maintenance of a healthy ocular

surface.14 Several studies have com-pared use of autologous serum (AS) modified for use as artificial tears to conventional or non-preserved artificial tears.14,15 For example, after two weeks, patients assigned to AS eye drops (vs. subjects assigned to preservative-free artificial tears) showed improvement in mean TFBUT as well as fluorescein and rose bengal staining scores.15 Subjec-tive symptom scores also showed significant improvement after two weeks of treatment.15

The process for preparing AS to artificial tears requires several steps. The blood is permitted to clot at 4º Celsius for 10 to 12 hours, and it is then centrifuged at 4,500rpm for 15 minutes to eliminate erythrocytes and leukocytes.16 The serum is sepa-rated in a laminar flow hood and diluted with sterile saline (0.9%) to a 20% concentration. Dilution is necessary to reduce levels of transforming growth factor (TGF-beta), which has been identified as an inhibitor of proliferation.16,17

Because AS is unpreserved, there is always the risk for contamination. Of 134 samples of AS prescribed for individuals after ocular surface sur-gery that were cultured in one study, only 13 were positive for contami-nants. Nine of these were Staphy-lococcus epidermidis, and one was Staphylococcus aureus. But, none of the subjects had clinical or labora-tory evidence of infection.17

In a study of severe conditions, such as SJS or TEN, causative agents included antibiotics (27.4%), anti-epileptic drugs (26.5%), allopurinol (17%) and phenytoin (10%). Ten (8.5%) of these subjects died dur-ing the acute phase of disease, 69% had ocular involvement, and severe dry eyes and trichiasis were the two most common late complications.21 During the acute phase of the sys-temic disease, 32 subjects (82%) underwent aggressive treatment with

Through this subcutaneous catheter the pump delivers fluid from the abdomen to the upper conjunctival fornix.

The pump is implanted in the abdominal subcutaneous pocket.

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systemic steroids equivalent to oral prednisolone 1mg/kg body weight per day.21

Topical ophthalmic steroids, antibiotics and lubricants were also prescribed for these patients, but in many cases, the outcome was severe dry eyes present in 46% of those with long-term follow-up care. Use of topical antibiotics during the acute phase of the disease was asso-ciated with late ocular complica-tions, especially severe dry eyes. The authors recommended withholding use of antibiotics unless there is clear evidence of active infection.21

In very severe dry eye, surgical management may be necessary to prevent vision loss. In 1986, the Spanish ophthalmologist Juan Murube del Castillo, M.D., Ph.D., first reported transplantation of autologous submandibular gland (SMG). The gland is positioned in the temporal fossa, the vascular sup-ply was anastomosed to the super-ficial temporal artery and vein, and the excretory duct was implanted into the upper conjunctival fornix.22

This was later performed in 15 eyes with cicatrizing conjunctivitis.23

Researchers reported significant improvement in subjective find-ings, such as reduced instillation of lubricants and objective parameters, including reduced signs of ocular surface damage. Unfortunately, the quality of secretions is salivary, and the osmolarity is lower than that of lacrimal secretions. In six of the 14 patients, this resulted in corneal edema and vision reduction secondary to chronic hypoosmolar condtions.23 Less than half of these subjects expressed a desire to have the procedure performed in the fel-low. The authors recommended that autologous SMG transplantation be limited to individuals with Schirmer values less than 1mm.23

Individuals with xeropthalmia (possessing virtually no tear film),

are among the most symptomatic and difficult to treat sufferers of extreme dry eye. Drs. Murube and Geerling described the use of an implantable pump reservoir in 21 patients with severe dry eye, whose Schirmer values were less

than 2mm in five minutes.24 These subjects reported that they instilled artificial tears to the ocular surface every five to 10 minutes.24

Here’s how it’s done. The procedure is performed under general anesthesia. The skin

Improve Quality of Life Through Severe Dry Eye Management

“Margaret,” an 84-year-old female presented for evaluation complaining of severe pain that was worse in the left eye. She had seen numerous eye care providers for this condition, but none had successfully ameliorated her symptoms. Margaret’s ocu-lar health history was positive for cataract surgery and laser treatment for exudative macular degeneration. She had self-treated the long-standing discomfort with a BAK-preserved over-the-counter artificial tear product. She could count fingers at 3.00 feet O.S., and her best-corrected visual acuity was 20/160 O.S. Biomicroscopy revealed severe tear film reduction, grade 3+ corneal staining with fluorescein O.U. and fila-mentary keratitis O.S.

Our initial diagnosis was severe dry eye with secondary filamentary keratitis, which was possibly exacerbated by the BAK-preserved product. Our treatment plan included the following:

• Debridement of the filaments with a sterile Kimura spatula.• Bandage soft contact lens.• Non-preserved artificial tears O.U., every two hours.• Return to clinic in two days.

Two days later, Margaret described her pain and discomfort as “100% better, and the non-preserved drops did not burn.” But, she reported irritation in the right eye. After removal of the lens, instillation of fluorescein showed staining. We recommended continuation of the bandage contact lens O.S., and performed temporary occlusion of the upper and lower puncta O.D. One week later, she continued to have no ocular dis-comfort and reported that the temporary occlusion had enhanced comfort in the right eye. We inserted a medium Parasol punctal occluder (Odyssey Medical) in the lower puncta O.D. and continued use of the bandage lens O.S.

Although Margaret continued to have vision problems for the remainder of her life, our management of her severe dry eye enhanced her quality of life. Her case demonstrates the importance of taking the time to investigate complaints suggestive of dry eye, and if it is found to be causative for the symptoms, managing dry eye appropriately.

Two large mucin-coated filaments in this patient with severe dry eye.

On initial presentation, Margaret’s left eye showed diffuse central cornealstaining with sodium fluorescein.



is incised 2mm to 4mm below the ribcage, and the wound is deepened through the subcutane-ous tissue.24 A pocket is formed over the underlying external oblique and straight up along the abdominal muscles. The pump/reservoir (Medtronic model IP 20.1, Anschütz & Co. GmbH) is implanted in the space. Two sequential subepithelial catheters connect the reservoir to the lateral aspect of the orbit and thereby the superior fornix. The device deliv-ers a continuous flow of isotonic electrolyte solution 1ul/min with a total of approximately 1.5ml delivered to the surface of the eye each day. The reservoir must be refilled approximately every 40 days; this procedure is performed in the operating room under ster-ile conditions. Initial results of this procedure have been encour-aging, and complications have been rare and not severe.24

Scleral lenses have been used to treat individuals with corneal scar-ring and ocular surface irregularities for decades, but edema secondary to hypoxia presented a challenge to practitioners using polymethyl methacrylate material. In 1990, there were 15 cases in which gas-permeable materials were success-fully used to fabricate scleral lenses for individuals with a variety of con-ditions that caused reduced vision. Several of these subjects experienced significant improvement in vision and function.25

Perry Rosenthal, M.D., andDeborah S. Jacobs, M.D., reported fitting 33 consecutive patients with severe dry eye who were unrespon-sive to conventional therapy with the Boston Scleral Lens Prosthetic Device (BSLPD). All subjects’ disease was caused by chronic graft-versus-host disease secondary to allogeneic bone marrow or hematopoietic stem cell transplantation. The BSLPD is

a custom-designed, gas-permeable contact lens that vaults the cornea and limbus and rests solely on the sclera. The tear layer trapped between the posterior surface of the lens and the cornea maintains a wet, oxygenated surface and protects the cornea from shear forces gener-ated by blinking. The vast majority (97%) reported reduction in eye pain in the worse eye, and 73% of subjects reported a great improve-ment in quality of life. Sixty-one percent reported an outstanding improvement in reading. Prop-erly fitted scleral lenses are another potential means of improving the vision and quality of life in individu-als with severe dry eye.26,27

Know Your OptionsSevere dry eye is a rare but

bothersome condition that nega-tively affects both visual and general quality of life.28,29 It is encouraging to see the emergence of new treatments and technology that effectively reduce the untow-ard effects of severe dry eye on individuals who suffer from this debilitating condition. Given the potential for improving quality of life through these measures, it is incumbent upon eye care practi-tioners to provide or arrange for treatment of this disease. In order to do this, we must stay abreast of the many novel and effective new therapies and devices for the management of various forms of dry eye that may be introduced in the future. RCCL

1. Lemp MA. The Report of the National Eye Institute/Indus-try workshop on Clinical Trials in Dry Eyes. CLAO J. 1995 Oct;21(4):221-32.2. The definition and classification of dry eye disease: report of the Definition and Classification Subcommittee of the International Dry Eye WorkShop (2007). Ocul Surf. 2007 Apr;5(2):75-92. 3. The epidemiology of dry eye disease: report of the Epide-miology Subcommittee of the International Dry Eye WorkShop (2007). Ocul Surf. 2007 Apr;5(2):93-107.4. Behrens A, Doyle JJ, Stern L, et al. Dysfunctional tear syndrome: a Delphi approach to treatment recommendations. Cornea. 2006 Sep;25(8):900-7.5. Rehman HU. Sjögren’s Syndrome. Yonsei Med J. 2003

Dec;44(6):947-954.6. Meijer JM, Pijpe J, Bootsma H, et al. The future of biologic agents in the treatment of Sjögren’s syndrome. Clin Rev Allergy Immunol. 2007 Jun;32(3):292-7.7. Mansour K, Leonhardt CJ, Kalk WW, et al. Lacrimal punctum occlusion in the treatment of severe keratoconjunctivitis Sicca caused by Sjögren syndrome: a uniocular evaluation. Cornea. 2007 Feb;26(2):147-50. 8. Tuberville AW, Frederick WR, Wood TO. Punctal occlu-sion in tear deficiency syndromes. Ophthalmology. 1982 Oct;89(10):1170-2.9. Stevenson D, Tauber J, Reis BL. Efficacy and safety of Cyclosporin A ophthalmic emulsion in the treatment of moderate-to-severe dry eye disease: a dose-ranging, randomized trial. The Cyclosporin A Phase 2 Study Group. Ophthalmology. 2000 May;107(5):967-74.10. Sall K, Stevenson OD, Mundorf TK, et al. Two multicenter, randomized studies of the efficacy and safety of cyclosporine ophthalmic emulsion in moderate to severe dry eye disease. CsA Phase 3 Study Group. Ophthalmology. 2000 Apr;107(4):631-9.11. Dastjerdi MH, Hamrah P, Dana R. High-frequency topical cyclosporine 0.05% in the treatment of severe dry eye refractory to twice-daily regimen. Cornea 2009 Oct 5. [Epub ahead of print].12. Guzey M, Ozardali I, Basar E, et al. A survey of trachoma: the histopathology and the mechanism of progressive cicatrization of eyelid tissues. Ophthalmologica 2000;214(4): 277-84. 13. Guzey M, Karaman SK, Satici A, et al. Efficacy of topical cyclosporine A in the treatment of severe trachomatous dry eye. Clin Experiment Ophthalmol. 2009 Aug;37(6):541-9.14. Schornack MM, Baratz KH. Ocular cicatricial pemphigoid: The Role of Scleral Lenses in Disease Management. Cornea. 2009 Oct 5. [Epub ahead of print]15. Ghasemi H, Ghazanfari T, Ghassemi-Broumand M, et al. Long-term ocular consequences of sulfur mustard in seriously eye-injured war veterans. Cutan Ocul Toxicol. 2009;28(2):71-7.16. Gueudry J, Roujeau JC, Binaghi M, et al. Risk Factors for the development of ocular complications of Stevens-Johnson Syndrome and toxic epidermal necrolysis. Arch Dermatol. 2009 Feb;145(2):157-62.17. Kojima T, Higuchi A, Goto E, et al. Autologous serum eye drops for the treatment of dry eye diseases. Cornea 2008 Sep;27 Suppl 1:S25-30.18. Kojima T, Ishida R, Dogru M, et al. The effect of autologous serum eye drops in the treatment of severe dry eye disease: a prospective randomized case-control study. Am J Ophthalmol. 2005 Sep;140(3):565.19. Quinto GG, Campos M, Behrens A. Autologous serum for ocular surface diseases. Arq Bras Oftalmol. 2008 Nov-Dec;71(6 Suppl):47-54.20. Lagnado R, King AJ, Donald F, Dua HS. A protocol for low contamination risk of autologous serum drops in the manage-ment of ocular surface disorders. Br J Ophthalmol 2004 Apr;88(4):464-5.21. Yip LW, Thong BY, Lim J, et al. Ocular manifestations and complications of Stevens-Johnson syndrome and toxic epidermal necrolysis: an Asian series. Allergy. 2007 May;62(5):527-31.22. Murube del Castillo J. Transplantation of salivary gland to the lacrimal basin. Scand J Rheumatol Suppl. 1986;61:264–267.23. Geerling G, Collin JR, Dart JK. Ophthalmic experience with submandibular gland transplantation for severe dry eyes. Laryn-goscope. 2009 Jul;119(7):1445-6. 24. Murube J, Geerling G. Mechanical Pump Dacryoreservoirs. Dev Ophthalmol. Dev Ophthalmol. 2008;41:269-82. 25. Schein OD, Rosenthal P, Ducharme C. A gas-permeable scleral contact lens for visual rehabilitation. Am J Ophthalmol. 1990 Mar 15;109(3):318-22.26. Jacobs DS, Rosenthal P. Boston scleral lens prosthetic device for treatment of severe dry eye in chronic graft-versus-host dis-ease. Cornea. 2007 Dec;26(10):1195-9. 27. Segal O, Barkana Y, Hourovitz D, et al. Scleral contact lenses may help where other modalities fail. Cornea. 2003 May;22(4):308-10. 28. Miljanović B, Dana R, Sullivan DA, Schaumberg DA. Impact of dry eye syndrome on vision-related quality of life. Am J Ophthal-mol. 2007 Mar;143(3):409-15.29. Mertzanis P, Abetz L, Rajagopalan K, et al. The relative bur-den of dry eye in patients’ lives: comparisons to a U.S. normative sample. Invest Ophthalmol Vis Sci. 2005 Jan;46(1):46-50.

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Standards of Carein the Age of Advanced

TechnologyHow important is it to have high-tech machines in your eye care practice? By Katherine M. Mastrota, M.S., O.D., F.A.A.O.

As Center Director of a busy eye care referral center, Omni Eye Surgery in New York, I

have the luxury of access to most of the state-of-the-art diagnostic equip-ment available. Certainly, the ability to use these instruments to aid or con-firm diagnoses, follow treatment or purely for academic/teaching purposes enhances the doctor and patient expe-rience and, in some cases, lends confi-dence to clinical decision making.

But, how important is it to have these “high-tech” machines, and what do you do when you have an active practice without them? Are you meet-ing the standard of care in eye care?

While gathering information for this article, I tapped into the opinions of a number of colleagues for their thoughts on the topic of standard of care, and what their practice pattern is if the office does not house the tech-nologies in question.

What is Your Standard of Care?

Craig Steinberg, O.D., J.D., Oak Park, Calif., says, “The legal stan-dard of care does not come from

case law. It is determined by the jury.” He continues on to advise that when negligence is at the heart of the issue, “the legal standard of care is what a prudent optometrist would do under similar circum-stances.”

Complicating this broad notion is the fact that practitioners are often compared to colleagues in their communities, which makes the standard of care different from case to case and region to region, further blurring the lines of what is “standard.” Taking this a step further, eye care practitioners, such as Christopher Press, O.D., Bakers-field, Calif., note that we can “push the limit of what constitutes primary eye care in 2009.” He says that we can achieve this by using diag-nostic technology akin to that of a retinal sub-specialist, for instance. Although diagnostics such as this may not be in the office of the “average” practitioner, this may dif-ferentiate the regular eye care office with the “latest and greatest” care.

Opinions differ as to whether such advanced technologies as

Dr. Mas-trota is Center Director at the New

York Office of Omni Eye Services. Addi-tionally she serves as secretary of the Ocu-lar Surface Society of Optometry (OSSO).

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scanning and confocal laser devices are necessary for standard practice. Richard Hom, O.D., San Francisco, Calif., considers that advanced technologies are not essential to an advanced practice. He goes on to say that a clinician with “experience and excellent functional analysis instrumenta-tion (e.g., a visual field unit) can still care for 80% to 90% of eye disease cases.”

There are times, however, when the “prudent practitioner” does determine that a technologically advanced diagnostic instrument is in order and that the informa-tion it provides is necessary—as opposed to merely useful. What recourse is there for this practitio-ner without the required technol-ogy in his or her practice?

Janet Carter, O.D., Las Vegas, says that, if she feels the informa-tion gleaned from a high-technol-ogy diagnostic tool is warranted for her patient, she will inform the patient of the required test-ing and outsource that patient to receive the evaluation. Dr. Carter sometimes refers to a colleague and other times to an ophthal-mologist’s office. She goes on to say that if her informed patient chooses not to have the recom-mended testing, she continues to treat the patient based on her clinical examination, the instru-mentation she has available and her expertise.

On the flip side, doctors who own advanced technologies, such as Christine Cook, O.D., Virgina Beach, Va., examine referred patients from nearby offices, bill-ing the “technical component” for the service rendered and send the results to the referring doc-tor for him/her to interpret. In these cases, it is necessary for the referring doctor to understand the information provided, even

though the instrument that gen-erated it is not available in their own practice.

The Alternative to Owning High Tech

Leasing or renting equipment is another option open to consid-eration for offices in need of spe-cialty equipment. Several leasing services with short or long term contracts are currently available around the country.

Alternately, mobile diagnostic units, such as a GDx (Carl Zeiss Meditec), HRT, (Heidelberg Retinal Tomograph, Heidelberg Engineering), optical coher-ence tomography (OCT) and/or various corneal topographers can be rented on a daily basis with or without a technician to administer testing. The primary advantage to equipment rental is the lack of initial capital outlay. An added benefit of rental is that staffing and/or staff training for the new procedure is mitigated by the rental process. Additionally, no dedicated space is required for the equipment, which may be an issue for practices with limited office space.

The Role of IOLs in Your Practice

The discussion of high technol-ogy in eye care goes beyond diag-nostic instrumentation. Advanced technology intraocular lenses (IOLs) are an expanding frontier in cataract surgery, allowing sur-gery patients to achieve spectacle independence for most activities. These so-called “lifestyle lenses” have been embraced by leading cataract surgeons.

The practitioner whose practice includes cataract surgery coman-agement would best serve patients by knowing that the referred sur-geon offers these lenses to patients

and is facile in the surgical tech-nique necessary to implant them.

Similarly, the referring surgeon should have up-to-date instrumen-tation for biometry and topog-raphy for accurate IOL power calculations. Multifocal, accom-modating and toric IOL technolo-gies should be available to those patients in your practice who have been appropriately identified to benefit from them. As the referring provider, you must be prepared to discuss this technology with your patients and to manage postopera-tive concerns or difficulties in more challenging cases.

When Things Go WrongThe concern for medical mal-

practice looms over every health-care practitioner. New diagnostic tools can give us false comfort and make us believe that they can pro-tect us if we’re sued. Remember: Advanced technologies are not the legal standard of care. Culpability in a malpractice case will be deter-mined by the jury that evaluates the testimony of one expert against the other on the circumstances of a particular case.

Standards of care are evolving and remain ill-defined. Christo-pher Quinn, O.D., Iselin, N.J., President of Omni Eye Services, stresses: “Advanced instrumen-tation is not a substitute for professional clinical judgment. Instruments can augment and refine clinical decision-making, but rarely should advanced instruments be considered a sub-stitute for standard examination techniques.”

Bottom line: Providing your best care is paramount. That, dear colleague, is your charge! RCCL

Dr. Mastrota thanks the doctors on the OptCom list who contrib-uted to this article.

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