also inside this issue - review of cornea & contact lenses€¦ · severe bacterial keratitis...

JUNE 2012

Supplement to

June 2012

ALSO INSIDE THIS ISSUE:• Keeping Up with Technology:

Old vs. New• Four Reasons to Stop

Polishing Rigid Lenses• The Mystery of MGD• Are Phospholipids the Critical

Ingredient? • Contact Lens Prescribing:

USA vs. the World

001_rcl0612.indd 1 5/24/12 4:12 PM

I AM THEIN MY PATIENT’S EYES,

© 2012 Novartis 4/12 POW12041JAD

MORE POWERFOR GREATER SUCCESS

Some eye care professionals may believe that 2-week replacement lens wearers are more compliant* than monthly replacement lens wearers, but the opposite is actually true.1

Studies have shown that daily disposable and monthly replacement lens wearers are the most compliant* patients.1,2,3

Alcon proudly off ers the lens modalities that promote patient compliance* and satisfaction with our DAILIES® brand daily disposable and AIR OPTIX® brand monthly replacement contact lenses.

Visit myalcon.com/power-of-one or speak to your Alcon representative to learn more.

*Compliance with Manufacturer-Recommended Replacement Frequency (MRRF).

References: 1. Dumbleton K, Woods C, Jones L, et al. Patient and practitioner compliance with silicone hydrogel and daily disposable lens replacement in the United States. Eye Contact Lens. 2009;35(4):164-171. 2. Yeung K, Forister J, Forister E, et al. Compliance with soft contact lens replacement schedules and associated contact lens-related ocular complications: The UCLA Contact Lens Study. Optometry. 2010; 81: 598-607. 3. Jones L, Dumbleton K, Fonn D, et al. Comfort and compliance with frequent replacement soft contact lenses. Optom Vis Sci. 2002;79:259.

See product instructions for complete wear, care, and safety information.

The Power of OneTM Program from AlconDon’t let your patients sacrifi ce comfort and vision

RCCL0612_Alcon POW.indd 1 5/22/12 3:10 PM

http://www.myalcon.com/power-of-one

contents

27 Keeping Up with Technology: Old vs. NewPractitioners will fi nd that new does not always mean better when it comes to technology.Douglas P. Benoit, O.D.

Review of Cornea & Contact Lenses | June 2012

Departments 4 Editorial

Redux: Corticosteroids and Bacterial KeratitisJoseph P. Shovlin, O.D.

6 News Review

7 Lens Care UpdateGet Charged Up: A New Lubricating DropChristine Sindt, O.D.

8 Naked EyePre-Surgical Steps for Your PatientMark B. Abelson, M.D., C.M., and Caroline Tobey

10 Down on the PharmAre Four Weeks Better Than Two?Elyse L. Chaglasian, O.D., and Jill Autry, R.Ph., O.D.

12 Gas-Permeable StrategiesDealing with DegenerationsJason Jedlicka, O.D.

14 Derail DropoutsRepurposing the Offi ce TopographerMile Brujic, O.D., and Jason Miller, O.D., M.B.A.

16 Out of the BoxThe Case for EyeglassesGary Gerber, O.D.

Replacement and Wearing Schedules

18 CE: Today’s Scleral LensScleral lenses are now universal—used not only for irregular cornea patients, but also to treat high refractive errors and presbyopia.Greg W. DeNaeyer, O.D.

34 The Mystery of MGDIn two years, we have already gained a more refi ned understanding of meibomian gland dysfunction and dry eye.Andrea Knouff, O.D.

38 Are Phospholipids the Critical Ingredient?Anionic phospholipids can enhance lipid layer thickness and help patients fi nd relief from dry eye.Donald Korb, O.D., and Ralph Stone, Ph.D.

ON THE COVER

REVIEW OF CORNEA & CONTACT LENSES | JUNE 2012 3

31 Four Reasons to Stop Polishing Rigid LensesPolishing can harm optics, wettability, effi ciency and profi tability.Brian Chou, O.D.

Photo: Greg W. DeNaeyer, O.D.

43 Contact Lens Prescribing: USA vs. the WorldA look at how contact lens prescribing in the United States compares with other world markets.Philip Morgan, B.Sc., Ph.D., MCOptom, Nathan Efron, Ph.D., D.Sc., and Craig Woods, Ph.D., DipCLP

003_rcl0612_toc.indd 3 5/24/12 4:13 PM

Editorial

4 REVIEW OF CORNEA & CONTACT LENSES | JUNE 2012

Bacterial keratitis is the fourth leading cause of blindness worldwide and poses signifi cant consequences due to corneal morbidity and

economic hardship.1-6 Ultimately, corneal opacifi ca-tion and scarring caused by both bacterial infection and the host infl ammatory response are the major consequences of bacterial corneal ulcers.2,3

So, it’s not surprising that many treating practitioners choose to use topical steroids in an attempt to minimize morbidity. Several predisposing factors can affect the course of the disease and its outcome, including prior health, infecting organism(s), infl ammatory conse-quences and therapeutic choices––just to name a few.1

The DebateThe pros and cons of using topical corticosteroids

for bacterial keratitis have been debated heartily for decades. The main concern is localized immu-nosuppression, which allows for increased bacterial survival and proliferation.1-4 Some clinicians believe that the “anti-infl ammatory” effects of antibiotics are frequently suffi cient in the treatment of bacte-rial ulcers.3 However, many practitioners––without strong scientifi c rationale––may rely heavily on topical steroids after adequate antibiotic coverage in order to minimize corneal scarring.

The ResearchA Cochrane systematic review identifi ed just a few

studies addressing the appropriateness and timing of topical steroid use for bacterial keratitis; most have limited sample size and applicability.7,8

A 50-year meta-analysis by Kirk Wilhelmus, M.D., did not demonstrate a clear-cut benefi cial effect of topical corticosteroid use on the course of bacterial corneal ulcers.1,3 He found three impor-tant results: First, steroid use before the diagnosis of bacterial keratitis signifi cantly predisposed eyes with pre-exiting disease to ulcerative keratitis (odds ratio: 2.63). Second, once microbial keratitis oc-curred, prior steroid use signifi cantly increased the odds of antibiotic treatment failure or other infec-tious complications (odds ratio: 3.75). And third, the effect of topical steroid use with antibiotics after the onset of bacterial keratitis was unclear.

New InformationThe long-awaited Steroids for Corneal Ulcers

Trial (SCUT) study also has recently provided valu-able population-based results to answer the long-standing question on whether to use topical steroids for the treatment of bacterial keratitis. The major advantage that this well-designed study had over previous studies is its sample size.4,6

The SCUT study––a multicenter, double-masked, randomized clinical trial––compared the use of 1% topical prednisolone phosphate to a placebo during the treatment of culture-proven bacterial corneal ulcers. The primary outcome was best-corrected visual acuity at three months. Secondary outcomes were scar size, re-epithelialization rate and signifi -cant adverse events, such as perforation.4,5

The authors of the SCUT trial were careful to point out limitations that are commonly seen in prospective trials. The antibiotic (broad spectrum fl uoroquinolone) chosen for treating the ulcers in this trial may not have been best agent for all cor-neal ulcers encountered in this trial.6 For example, an antibiotic with a lower minimum inhibitory concentration (MIC) to the particular organism may yield a better outcome.

Also, the fi xed dose of topical steroid may have limited the results in this study, and increasing the dose or frequency of steroid application might have provided different results.

Another critical factor is the timing of steroid initiation.6 The start time was set and determined by enrollment criteria, with a gap of 48 hours before a patient could begin treatment with topical steroid.4,6

The core concepts gained from the SCUT trial are: 1. Steroids used topically offer no signifi cant

benefi t or major risk in the treatment of bacterial keratitis at three months.

2. Adjunctive steroid therapy may improve visual outcome in severe bacterial keratitis, such as in those caused by Pseudomonas.

3. Steroids should not be used in bacterial infec-tions caused by Nocardia.

4. MIC correlates with clinical results in bacterial corneal ulcers (i.e., a lower MIC to a particular or-ganism is associated with a better visual outcome).5,6

New research suggests that the role of topical corticosteroids in the presence of bacterial keratitis is still partially undetermined.

Redux: Corticosteroids and Bacterial Keratitis

Editorial By Joseph P. Shovlin, O.D.

004_rccl0612_ed.indd 4 5/24/12 4:13 PM

Editorial

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


Strict GuidelinesThe principles for use when choosing adjunctive

therapy (i.e., Pseudomonas ulcers): • Scrapings for stain and culture are crucial.• Use adequately dosed bactericidal antibiotics. • Delay initiation of steroids until a clearly ben-

efi cial effect has been determined. • Continue concurrent use of antibiotic with

steroids.• Delay use of steroids if causative organism is

not identifi ed. Use steroids two to fi ve days after appropriate antibiotic therapy.2,3,6

Avoid steroid use if fungal, herpetic, atypical Mycobacterium or Nocardia infection is suspected, or if there is severe thinning, enlarging epithelial defect, poor wound healing (diabetes) or immuno-suppression.2,3,6 The use of topical corticosteroids in Acanthamoeba keratitis remains controversial regarding its appropriateness and timing. One study showed a prolonged course of therapy in treating Acanthamoeba keratitis when initiated, but was not associated with medical treatment failure.9

Future trials likely will deal with frequency, intensity and timing of steroid initiation. In the meantime, the valuable SCUT study can lead us to

conclude that steroids are not as effective as some have suggested, nor are they as dangerous as oth-ers would lead you to believe.5,6 Topical steroids certainly appear to have a role in select cases of severe bacterial keratitis (Pseudomonas), but not in others (Nocardia). RCCL

1. Wilhelmus K. Indecisions about corticosteroids for bacterial keratitis an evidence-based update. Ophthalmol. 2002 May;109(5):835-42.2. Hindman HB, Sheel B, Patel MD, Jun AS. Rationale for adjunctive topical corticosteroids in bacterial keratitis. Arch Ophthalmol. 2009 Jan;127(1):97-102.3. Cohen EJ. The case against the use of steroids in the treatment of bacterial keratitis. Arch Ophthalmol. 2009 Jan;127(1):103-4.4. Srinivasan M, Mascarenhas J, Rajaraman R, et al. SCUT: Study design and baseline charac-teristics. Arch Ophthalmol, 2011;129 [Epub ahead of print].5. Srinivasan M, Mascarenhas J, Rajaraman R, et al. Corticosteroids for bacterial keratitis: The Steroids for Corneal Ulcers Trial (SCUT). Arch Ophthalmol. 2012 Feb;130(2):143-50.6. Lietman TM. Topical steroids for bacterial corneal ulcers: What have we learned from the SCUT? Topics in Ocular Anti-infectives. 2012 Feb;27.7. Chen A, Prajna L, Srinivasan M, et al. Does in vitro susceptibility testing predict clinical outcomes in bacterial keratitis? Results from the steroids for corneal ulcers trial. IOVS. 2007;48:ARVO e-abstract 4277.8. Acharya N, Srinivasan M, Mahalakshmi R, et al. Steroids for corneal ulcers treatment. SCUT pilot study results. IOVS. 2006;47:ARVO e-abstract 4752.9. Hammersmith KM. Diagnosis and management of Acanthamoeba keratitis. Curr Opin Ophthalmol. 2006 Aug;17(4):327-31.

Acanthamoeba keratitis.

Phot

o: K

irk L

. Sm

ick, O

.D.

Pseudomnas bacterial ulcer.

Photo: Ernie Bowling, O.D.

004_rccl0612_ed.indd 5 5/24/12 4:14 PM

News Review


VOL. 149, No. 5

In The News

• OcuSoft, Inc. announces the avail-ability of Retaine MGD ophthalmic emulsion, a new therapy for individuals suffering from dry eye syndrome and meibomian gland dysfunction. Retaine is packaged in 30 single-dose vials. For more information, visit www.ocusoft.com/retainemgd.

• CooperVision Inc. announces the launch of Proclear 1 Day Multifocal Daily Disposable contact lenses, which will provide presbyopic patients with improved vision at all distances and address age-related dryness. These lenses feature sphere powers from +6.00D to -10.00D (0.50D steps after -6.00D), a base curve of 8.7mm and a diameter of 14.2mm. The lens is de-signed with a single power profi le that can accommodate patients up to +2.50 ADD power. For more information, visit www.coopervision.com/multifocal.

• ABB Concise’s Primary Eyecare Network (PEN) announces a new monthly webinar series, “The Road to Optometric Internet Marketing,” as a lead-in to their annual Preserving Independent Optometry (PIO) confer-ence in August. The webinar is free and all participants will be provided with vouchers for a variety of products. For more information, visit www.primary-eye.net/education.

• WebMD launches Eye TV, which features on-demand video program-ming featuring real people successfully managing their eye health and vision. For more information, visit www.webmd.com/eye-health/default.htm.

• Prevent Blindness America (PBA) announces that the 2012 “Most Beauti-ful Eyes” contest will accept entries from June 25 through July 31 via their Facebook page, www.facebook.com/preventblindness. Parents of children up to 17 are encouraged to submit a photo. For more information, visit www.preventblindness.org.

Hydogen Peroxide Solutions Kill Fungi

Project Glass To Initiate Public TestingProject Glass, Google’s fi rst foray into wearable computing, is testing

new augmented-reality glasses. The working prototype includes a loca-tion-based component. Team members, including Babak Parviz, Steve Lee and Sebastian Thurn, announced the initiative to collect input from the general public.

The prototype version looks like a pair of wrap-around glasses with a clear display that sits above the eye. The glasses can stream information to the lenses and allow the wearer to send and receive messages through voice command. There is also a built-in camera to record video and take pictures. The Project Glass team is currently experimenting with designs that can be extended to different frames, including prescription glasses.

Team members began testing the prototype in April 2012. The New York Times reports that the glasses will be available to the public, at a cost of $250 to $600, by the end of 2012.

News Review

When treating fungal eye infections, a recent study found that hydrogen per-

oxide-based contact lens care systems were significantly more effective than most multi-purpose contact lens solu-tions at killing fungi.

Researchers examined the effec-tiveness of two hydrogen peroxide lens care systems and fi ve popular multipurpose solutions against bio-

fi lms of two strains of fungi: Fusari-um solani and Fusarium oxysporum. Both fungal strains were susceptible to the hydrogen peroxide care solu-tions. Only two of the fi ve multipur-pose solutions were effective against F. solani and only one of the fi ve was effective against F. oxysporum.

A complete summary of the study is available in the April 2012 issue of Optometry and Vision Science.

Digitalizing Patient FormsAnoto and NextGen Healthcare Information Systems, introduce a new digi-

tal pen and paper technology to collect patient registration information. The new software will require minimal training for staff and virtually no

change in the current process being used by patients to fi ll out registration forms. The solution interprets the handwriting with high accuracy and pro-vides the added benefi t of verifying health history information quickly.

The paper forms are imprinted with the Anoto dot pattern, transforming them into a temporary intuitive data entry device. The information is stored in the digital pen, until it is uploaded to the patient’s record in the NextGen Ambulatory electronic health records (EHR) via a USB docking station or Bluetooth transmission. For more information, visit www.anoto.com and www.nextgen.com.

006_rcl0612_news.indd 6 5/24/12 4:15 PM

Lens Care UpdateBy Christine Sindt, O.D.


There are signifi cant chal-lenges with developing new formulations for topically

applied eye drops. Perhaps the biggest obstacle is fi nding a way to increase substantivity (dwell time on the eye) for better drug absorp-tion. Conventional water-based lubricating drops are limited: They use water-soluble molecules in the solution and approximately 80% of the drop is eliminated via the nasolacrimal duct two minutes after instillation.1

Excipients with either increased viscosity or bioadhesive properties are commonly used to increase this dwell time. These excipients include carbopol gels, cellulose derivatives, detran, gelatin glycerin, polyethyl-ene glycol, poloxamer 407, polysor-bate 80, propylene glycol, polyvinyl alcohol and polyvinyl pyrrolidone. These agents, however, have the potential disadvantage of blurred vision, diffi culty dispensing from the bottle tip and limiting pharmaceuti-cal mixtures to water-soluble drugs.

Oil-in-water emulsions have been investigated as a vehicle to improve bioavailability of lipophilic drugs to the ocular surface. Nanoemul-sions provide a high encapsulation rate, enhance stability of lipophilic drugs and increase ocular penetra-tion. In 2002, Restasis (cyclospo-rine ophthalmic, Allergan), an anionic emulsion of cyclosporine A, was the fi rst marketed ophthal-mic emulsion product.2

The Cationic AlternativeCationic nanoemulsions will

interact with the negatively charged corneal cells and can be used to

bring lipids to stabilize the tear fi lm, interact electrostatically with mu-cins and improve ocular absorption. Compared to anionic surfactants, cationic surfactants may be toxic to the ocular surface.

Quaternary ammoniums, such as benzalkonium chloride (BAK), have surfactant properties and can give a cationic charge to solutions. These agents work as a solution preserva-tive by electrostatically binding to the negatively charged cell surface, and disrupting the cell membrane.3 While BAK works well as a preser-vative, it has been repeatedly shown to cause corneal epithelial toxicity. One study comparing latanoprost with BAK to a preservative-free cat-ionic emulsion containing latano-prost, showed signifi cantly reduced epithelial toxicity with the cationic emulsion in a rabbit model.4

Cationic emulsions have better spreading coeffi cients across the cornea and conjunctiva vs. conven-tional eye drops and anionic emul-sions.5 Improved spreading coef-fi cient leads to better ocular surface wettability, and electrostatic attraction reduces tear washout. In oil emulsions, the electro-attractive

interactions between the positively charged oil droplets of the cat-ionic emulsion and the negatively charged ocular surface effectively lowers the contact angle by 50%, compared to anionic emulsions. A low contact angle, better spreading coeffi cient and increased dwell time of the cationic emulsion will con-tribute to better drug absorption of lipophilic drugs.6

On the Market TodayCationorm (Novagali Pharma)—

marketed in the United States as Retaine MGD (Ocusoft)—is the fi rst cationic emulsion technology introduced to the market specifi -cally for treatment of dry eye. Re-taine MGD is a preservative-free, hypotonic, oil-in-water emulsion based on the positively charged emulsion and the negatively charged epithelial surface. Clinical studies have shown this product to improve spreading on the ocular surface, improve retention time, and reduce the number of drops needed throughout the day (which increases compliance), in both meibomian gland dysfunction and dry eye sufferers. Retaine MGD is packaged in 30 single-dose vials.

The introduction of the fi rst cationic emulsion is a key tool for practitioners to help patients better absorb drug treatments and manage conditions like dry eye. RCCL

1. Shell JW. Ophthalmic drug delivery systems. Surv Ophthalmol. 1984 Sep-Oct;29(2):117-28.2. Allergan insert.3. Lallemand F, Daull B, Benita S, et al. Successfully improving ocular drug delivery using the cationic nano-emulsion, novasorb. J Drug Deliv. 2012;2012:604204. Epub 2012 Feb 27.Additional references at www.reviewofcontactlenses.com.

Retaine MGD is the fi rst cationic emulsion technology on the market today.

Get Charged Up: A New Lubricating Drop

The advantages of cationic emulsion technology include:3

1) Solubilization of lipophilic drugs.2) Better penetration through mem-

branes, resulting in enhanced bioavail-ability.

3) Better spreading on the ocular surface.4) Potential for controlled drug release.5) Stable and can be sterilized.6) Inexpensive to manufacture.

007_rcl0612_lenscare.indd 7 5/24/12 4:44 PM

Naked EyeBy Mark B. Abelson, M.D., C.M., and Caroline Tobey


Pre-Surgical Steps for Your PatientBy addressing ocular surface disease in pre-operative patients, you can pave the way for a smooth surgery.

It is inevitable that, at some point, one of your patients may need to undergo surgery.

Although you, the practitioner, may not necessarily be the one performing the surgery, it is still your responsibility to appropriately optimize the health of the patient’s ocular surface ahead of time to achieve the best surgical outcomes. This should start with addressing any lingering ocular surface issues.

In this article, we will discuss the technologies that should be em-ployed to accurately and effi ciently assess your patients’ ocular surface criterion preoperatively, how to treat their condition(s) accordingly, and how to create a helpful dis-course with an ophthalmologist in the case of a referral. Such prepara-tion will no doubt improve your patient’s quality of life pre- and post-surgery, and will help to pro-vide a more comprehensive service to your patients. Lastly, these types of preemptive groundwork will help keep your patients coming back to you as their primary eye care practitioner.

Preoperative CareOcular surface disease can

encompass a multitude of issues including dry eye, meibomian gland dysfunction (MGD), allergy, blepharitis, infection and infl am-mation. Each corneal surface prob-lem should be addressed individu-ally in order to accurately treat the entirety of your patient’s problem. Why is it important to acknowl-edge and treat the ocular surface preoperatively? Approximately 20% of cases presented to eye care

practitioners are cases involving ocular surface disease.1

A recent study by George M. Sal-ib, M.D., and colleagues found that, in 21 dry eye patients, preoperative cyclosporine treatments provided a greater refractive predictability three and six months post-operatively.2

All patients over the age of 55 who plan to undergo cataract surgery should be routinely tested for dry eyes, whether or not they report symptoms.3 Additionally, dry eye can affect corneal topography and ocular biometry readings, which may negatively affect surgical outcomes. Ultimately, the patient is more prepared for surgery and has a better outcome if you optimize the corneal surface ahead of time.

Diagnosing the ConditionHow do you know what to look

for? How can you properly diag-nose what you may not see? In the dry eye arena, there are a number of diagnostic tests that can be employed to accurately assess the quality of your patient’s tear fi lm.

The fi rst and primary diagnosis tool typically has been the use of

fl uorescein or lissamine green dyes in standardized corneal and con-junctival staining. These dyes are an effi cient and noninvasive method to identify damage in the ocular sur-face at a cellular level.

Certain methods of analysis coupled with a standard slit lamp examination can help to accurately assess your patient’s signs of disease including redness, swelling, and discharge. For dry eye analysis, Michael A. Lemp, M.D., and John R. Hamill, M.D., initially reported that the TFBUT cut-off for dry eye diagnosis was less than 10 seconds.4

By reducing the quantity of fl uo-rescein used, we now have a more accurate threshold of fi ve seconds. In addition, the Ocular Protec-tion Index (OPI) was developed to quantify the interaction between blinking and the tear fi lm, providing a framework to assess the effects of tear fi lm instability associated with dry eye.5

Conducting a Verbal DiscourseIn addition to using the afore-

mentioned diagnostic technologies, the preoperative assessment of your patient’s ocular surface also needs to include a verbal dynamic between you and your patient. Asking the right questions and understanding your patient’s history are extraor-dinarily important for an accurate diagnosis. Beyond a comprehensive patient history, this includes learn-ing what your patient’s occupa-tional needs and hazards are, as environmental elements can play a determining role in their ocu-lar health. Working in front of a computer all day, or gardening, can

Look for signs and symptoms of OSD before your patient undergoes surgery.

008_rcl0612_NakedEye.indd 8 5/24/12 4:16 PM

Naked Eye

make your patient susceptible to dry eye or allergy. If it is diffi cult to read or work in front of a com-puter for an extended period of time without experiencing a burn-ing sensation in your eyes, that is a defi nitive sign of dry eye, even if the pain is just minor discomfort.

Most likely, you will be refer-ring your patient to a specialist for cataract or refractive surgery. It is crucial to start a dialogue with all involved practitioners to appropri-ately comanage the patient. This includes providing information on your past treatments, and the past and current conditions of the ocu-lar surface disease (OSD). Open and honest communication will help facilitate a better post-oper-ative treatment plan, as dry eye or other pre-existing issues may worsen or new complications may arise. Comanagement will help to create an increased level of trust with your patient as well, while re-enforcing your position as the primary eye care practitioner.

Once your patient has been identifi ed as having OSD, many treatments can come into play. For dry eye, an increased regi-men of artifi cial tears will help treat the condition and should be continued postoperatively. Get-ting your patients on an artifi cial tear routine early on will not

only prepare their ocular surface, but also will help postoperatively as their tear fi lm will be compro-mised. In addition, discontinuing oral antihistamines pre-opera-tively and adjusting anti-allergy therapies may be necessary; postoperatively, a combination of an antibiotic and steroid may be helpful for an allergy patient. Be-yond artifi cial tears, treating pre-operatively can include lubricat-ing tears, topical drugs, systemic medications, anti-infl ammatories, antibiotics, nutritional supple-ments and/or punctal plugs.

Overall, understanding your patient and having an accurate un-derstanding of diagnostic technol-ogies will be your most valuable tools concerning pre-surgical con-siderations. Preemptively assessing and treating your patient for OSD will prepare your patient and un-doubtedly reassure confi dence in their eye care practitioner. RCCL

1. Lemp M, Marquardt R. The dry eye. A comprehensive guide. Berlin: Springer-Verlag; 1992. 2. Salib GM, McDonald MB, Smolek M. Safety and efficacy of cyclosporine 0.05% drops versus unpreserved artificial tears in dry-eye patients having laser in situ keratomileusis. J Cataract Refract Surg. 2006 May;32(5):772-8.3. Trattler W. The Impact of dry eye on cataract and refrac-tive surgical outcomes. Advanced Ocular Care. 2011 Jul/Aug(Suppl).4. Lemp MA, Hamill JR Jr. Factors affecting tear film breakup in normal eyes. Arch Ophthalmol. 1973 Feb;89(2):103-5.5. Ousler GW, 3rd, Hagberg KW, Schindelar M, Welch D, Abelson MB. The Ocular Protection Index. Cornea. 2008 Jun;27(5):509-513.

Advertiser Index

Alcon Laboratories ..........................Cover 2, Page 30, Cover 3, Cover 4Bausch + Lomb ...................................................................... Page 37Vistakon .......................................................................... Pages 23-26

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

Editorial inquiries (610) 492-1003Advertising inquiries (610) 492-1011E-mail [email protected]

EDITORIAL STAFFEDITOR-IN-CHIEFAmy Hellem [email protected]

SENIOR EDITORPooja Shah [email protected]

CLINICAL EDITORJoseph P. Shovlin, O.D., [email protected]

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

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

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

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

CONSULTING EDITORMilton M. Hom, O.D., [email protected]

CONSULTING EDITORStephen M. Cohen, O.D., [email protected]

SENIOR ART/PRODUCTION DIRECTORJoe Morris [email protected]

GRAPHIC DESIGNERAlicia Cairns [email protected]

AD PRODUCTION MANAGERScott Tobin [email protected]

BUSINESS STAFFPRESIDENT/PUBLISHERRichard D. Bay [email protected]

SALES MANAGER, NORTHEAST, MID ATLANTIC, OHIOJames Henne [email protected]

SALES MANAGER, SOUTHEAST, WEST Michele Barrett [email protected]

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.

008_rcl0612_NakedEye.indd 9 5/24/12 4:16 PM


Down on the PharmBy Elyse Chaglasian, O.D., and Jill Autry, R.Ph., O.D.

Which is better: the one-month or two-week replacement contact

lens modality? The answer to that question is not as simple as it may seem. Logically, it would make sense that if a contact lens was replaced more frequently that it would be healthier for the eye, leading us to believe that the daily disposable option likely would be the best of all. And, perhaps that is true in a perfect world. But, reality must account for several other factors, includ-ing patient non-compliance in lenses, solutions, cases and follow-up exams.

In our own academic clinical practice, we instruct the students to ask two questions: how often does the patient replace his lens-es and how old is the patient’s current pair. The students are amazed that, while the answer to the former may be two weeks, the answer to the latter is often anywhere from two weeks to six months––and, on occasion, even two years!

So, if we can agree that no pa-tient or modality is perfect, and work under the premise that not everyone is able and/or willing to use a new lens each day, let’s examine some evidence to help us decide which is better…the one-month or the two-week.

The Argument for One-Month Lenses

Perhaps it is telling that the availability of a two-week disposable lens is waning, while the one-month lens market is

expanding with the introduction of newer materials and increased availability in torics and mul-tifocals. But, let’s look at the literature.

Kathy Dumbleton, O.D., M.S., and colleagues at the University of Waterloo surveyed more than 500 silicone hydrogel soft lens wearers from seven optometric practices.1 They found that 49% wore the two-week replacements and 51% wore the one-month alternative. Sixty-seven percent of all participants wore their lenses longer than the manufac-turer’s recommendations; two-week wearers had a non-compli-ance rate of 82%, with a mean replacement frequency 2.6 times over the manufacturer’s recom-mended replacement frequency (MRRF), while the one-month wearers were at a 53% non-com-pliance rate, with a replacement frequency that was 1.5 times over the MRFF.1

Non-compliance was more signifi cantly associated with self-reported contact lens-related problems, such as abrasions, conjunctivitis, discharge, discom-fort, eyelid problems, infection or keratitis, photophobia, red-ness and sudden pain. However, there was no statistically signifi -cant difference between those in the compliant vs. non-compliant groups.1 This might help explain why patients continue in their bad habits despite our best ef-forts to educate them about the dangers.

Karen Yeung, O.D., and col-leagues at UCLA found that non-

compliance was highest in the two-week group, as well as in teenagers and patients fi t in non-silicone hydrogel materials.2 Ad-ditionally, those who wore their lenses more than three times over the MRFF had a somewhat signifi cantly higher number of complications.

Addressing ComplianceIn an earlier study on compli-

ance, Dr. Dumbleton found that the two most common reasons given by patients for overusing their lenses were forgetting the day (51%) and trying to save money (26%).3

To address the fi rst concern, 53% of patients said that a reminder system would be use-ful; most selected an electronic reminder system. Fifty-two percent of compliant patients (compared to 28% of non-compliant patients) reported using a calendar or other system to help them remember when to change lenses. The study also reported that patients believed in the importance of having their doctor offer a detailed explana-tion of the replacement schedule; this fi nding was signifi cantly higher in the compliant group.3

There are also a number of new, more hi-tech methods to remind patients to change their lenses at the appropriate time interval in-cluding downloadable apps, such as Lenstoss (Eyes) and Contact Lens Reminder (Ofi jo), and free text- or email-based reminder services, such as Acuminder (Vistakon).

Are Four Weeks Better Than Two?Here is a review of the literature and compliance studies regarding the two replacement modalities.

010_rcl0612_dotp.indd 10 5/24/12 5:01 PM

Optometric Physician delivers

UP-TO-DATE news and researchto your inbox every Monday morning, allowing you to view all of the latest clinical information on a convenient and consistent basis.

Subscribing to Optometric Physician is an effi cient and easy way to stay current with all of the information and events going on in the fi eld. To order your free subscription, e-mail: [email protected] today.

In terms of fi nancial constraints, we certainly can be more cognizant of a patient’s situation prior to their fi tting. There usually is some cost savings with lenses that have longer replacement intervals and, often times, there are manufacturer rebates available. Keep in mind that there are other factors at play, such as the patient’s attitude, face-to-face patient education and whether this is an initial fi t or a subsequent follow-up exam.

As long as the two-week and one-month replace-ment options remain the most popular with our patients, we need to continue to review appropriate replacement intervals and potential ocular repercus-sions at each visit. Encourage your patients to be innovative, but consistent, in whatever method they use to stick to their schedule.

In the end, the literature suggests that compliance is better in the one-month replacement modality.1-3

While there does not appear to be a great disparity in reported contact lens-related complications due to non-compliance between the two groups, there may be more mild, and thus non-reported, prob-lems that the patient self manages. RCCL

1. Dumbleton K, Woods C, Jones L, Fonn D. The relationship between compliance with lens replacement and contact lens-related problems in silicone hydrogel wearers. Cont Lens Anterior Eye. 2011 Oct;34(5):216-22. 2. Yeung KK, Forister JF, Forister EF, et al. Compliance with soft contact lens replacement schedules and associated contact lens-related ocular complications: the UCLA Contact Lens Study. Optometry. 2010 Nov;81(11):598-607.3. Dumbleton K, Woods C, Jones L, et al. Patient and practitioner compliance with silicone hydrogel and daily disposable lens replacement in the United States. Eye Contact Lens. 2009 Jul;35(4):164-71.

Contact lens non-compliance can result in red eye.

Phot

o: C

hrist

ine S

indt

, O.D

.

010_rcl0612_dotp.indd 11 5/24/12 4:17 PM

Gas-Permeable Strategies By Jason Jedlicka, O.D.


Dealing with DegenerationsThere are innovative and novel ways to use GP lenses when treating nodular corneal degeneration.

Nodular corneal degener-ations can lead to both decreased vision and

ocular discomfort, and the range of findings can vary greatly.1 It is more commonly bilateral, but a significant percentage of patients have unilateral findings.1 Nodu-lar changes occur predominantly in middle-aged women and may be associated with chronic ocu-lar surface inflammation and/or irritation.1 Patients with nodu-lar corneal degenerations most often seek surgical treatment for visual symptoms more so than irritation.1

Given that the vision issues that lead patients to seek surgical intervention are caused mainly by irregular astigmatism, it would seem that gas-permeable (GP) lenses would be an option for treating nodular degenera-tions. However, one of the prob-lems with using GPs for correct-ing irregular astigmatism in these patients is the contact between the rigid lens and the corneal nodules. In most cases, patients with nodular corneal degenera-tions will not tolerate standard GP lenses. In these cases, opting for methods of correcting their vision with non-standard ap-proaches can be very effective.

In this column, I will discuss the fi rst of two such patients and the two different approaches that led them both to successful lens wear.

A Case StudyJF, a 33-year-old white female,

visited my offi ce in September

2005 at the request of her cor-neal specialist for replacement of a bandage soft contact lens in her left eye. She had a long-standing history of Salzmann’s nodular corneal degeneration (SNCD) in both eyes, and had a corneal transplant in the right eye a few years prior.

The transplant procedure in the right eye had not gone as expected and the vision in that eye was very poor at 20/400. The vision in her left eye was not much better (best-corrected visual acuity was 20/200), but due to the poor outcome of the right eye, she was not interested in a corneal graft O.S.

She continuously used bandage soft lenses in both eyes to allevi-ate symptoms of chronic irrita-tion; the bandage lenses were removed and replaced every two months in an off-label manner. The bandage lenses were well-tolerated, and JF presented with no new complaints. As this was my fi rst visit with her, I had no knowledge of her history beyond what her chart indicated. I evalu-ated her corneas and her vision and asked her how she was functioning.

She reported that, in the last fi ve years, her vision had dete-riorated to the point where she was unable to drive or hold a job, which was why she had the transplant on the right eye. Unfortunately, the corneal trans-plant had not been effective to date with episodes of rejection, infection and dehiscence with repair.

At the time of her presenta-tion, her right eye had signifi cant scarring of the cornea due to prior infection, as well as a tube shunt for complicated glaucoma. There was little to do for this eye at the moment.

Upon examination of her left eye, there were numerous nod-ules covering the entire corneal surface, creating haze and irregu-larity (fi gure 1). Refraction over the top of the bandage contact lens provided no improvement. I asked JF if anyone had ever sug-gested using a GP lens in her left eye to try to improve her vision. She said that she had not, but was willing to try.

After consulting with her corneal specialist and getting approval from him, I placed an average base curve lens on her left eye over the soft bandage lens. Her initial impression of the comfort was as positive as could be expected, but the visual acuity was overwhelming. With the trial lens on, her vision was 20/50. With a small over-refraction her vision improved to 20/25-1. The lens was essentially a lid control fi t over the soft bandage lens.

Fluorescein pattern evaluation was done using high molecular weight fl uorescein, which clearly demonstrated the signifi cant cor-neal irregularity caused by the SCND (fi gure 2).

The fi nal lens was ordered with the following parameters in a thin design: 7.85 O.S./-3.50D/9.5mm. Because the irregularities do not occur across a common axis, a

012_rcl0612_gps.indd 12 5/24/12 4:35 PM

Gas-Permeable Strategies


thin lens design was very effective at covering the irregularities and maintaining good comfort. Be-cause the soft lens was used under the GP, the corneal surface did not suffer breakdown or irritation from contact with the GP lens.

The patient continued to use the same soft lenses as she had previously worn, and vision con-tinued to be stable in the 20/25 to 20/30 range. She applied and removed the GP lens daily, but left the soft lens in for two months as she had always done. JF continues to use this modality of correction more than six years later, and vision and comfort are maintained as the same levels as at the initial fi t.

Further DiscussionNodular corneal degenera-

tions can be diffi cult to manage. Surgical intervention often can be helpful, but carry signifi cant risks in eyes with chronic infl am-mation, and nodules are shown

to recur in eyes after surgical therapy.2-4

Penetrating keratoplasty can be an option in severe cases, though it carries all the standard risks, in addition to likeliness of recurrence. Instead, photothera-peutic keratectomy (PTK) is the procedure of choice in recent years—it carries less risk than keratoplasty while achieving comparable results.5

Keep in mind that recurrence is still a risk when performing PTK for nodular corneal degenera-tions.6 Practitioners can apply 0.02% mitomycin C to the post-keratectomy corneal surface with a cellulose sponge for 30 seconds to 120 seconds to reduce both the risk of nodular recurrence and haze.6,7

When effective at correcting vision and well tolerated, GP lenses can be considered as a treatment for patients with ir-regular astigmatism from SCND.

Because of potential problems with GP lens and corneal inter-action, piggybacking or scleral lenses are some options that can minimize or avoid contact and should be considered as fi rst choices. In the next column, we’ll discuss a similar case man-aged with scleral lenses. RCCL

1. Farjo AA, Halperin GI, Syed N, Sutphin JE, Wagoner MD. Salzmann’s nodular corneal degeneration clinical characteristics and surgical outcomes. Cornea. 2006 Jan;25(1):11-5.2. Sinha R, Chhabra MS, Vajpayee RB, et al. Recurrent Salzmann’s nodular degeneration: report of two case and review of literature. Indian J Ophthalmol. 2006 Sep;54(3):201-2.3. Severin M, Kirchof B. Recurrent Salzmann’s cor-neal degeneration. Graefes Arch Clin Exp Ophthalmol. 1990;228(2):101-4.4. Yoon KC, Park YG. Recurrent Salzmann’s nodular de-generation. Jpn J Ophthalmol. 2003 Jul-Aug;47(4):401-4.5. Sharma N, Prackash G, Titlyal JS, Vajpayee RB. Comparison of automated lamellar keratoplasty and phototherapeutic keratectomy for Salzmann nodular degeneration. Eye Contact Lens. 2012 Mar;38(2):109-11.6. Marcon AS, Rapuano CJ. Excimer laser photothera-peutic keratectomy retreatment of anterior base-ment membrane dystrophy and Salzmann’s nodular degeneration with topical mitomycin C. Cornea. 2002 Nov;21(8):828-30.7. Khaireddin R, Katz T, Baile RB, et al. Superficial kera-tectomy, PTK, and mitomycin C as a combined treatment option for Salzmann’s nodular degeneration: a follow-up of eight eyes. Graefes Arch Clin Exp Ophthalmol. 2011 Aug;249(8):1211-5.

1. Salzmann’s nodular corneal degeneration O.S. with piggyback lenses in place.

2. Fluorescein pattern of left eye with Salzmann’s nodular corneal degeneration and piggyback contact lenses in place.

012_rcl0612_gps.indd 13 5/24/12 4:36 PM

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


Repurposing the Offi ce TopographerBy being creative with our existing technology, practitioners have more ways to improve lens wear and decrease dropouts.

To keep our patients in their contact lenses, we need to leverage every

tool that we have in our practice. Sometimes this means thinking of outside-the-box uses for tradi-tional equipment.

In this month’s column, we ex-plore alternative uses for corneal topographers, and discuss how the results of these tests may give us an enhanced understanding of contact lens dynamics to maxi-mize successful lens wear and minimize dropouts.

Understanding the Line of Sight

Fitting soft multifocal contact lenses present unique challenges. There are times when two pa-tients with very similar ocular characteristics may have very different outcomes with multifo-cal lenses. Some patients’ vi-sual complaints may be fi xed by following the multifocal fi tting guide, while this does very little to improve the visual outcome for others. There are times where we dismiss these failures or sim-ply attribute them to a patient being too “picky” or unable to adapt to a multifocal lens. While this may occasionally be true, there are likely other physical measurements that are contribut-ing to the success or failure of lens wear.

Matthew Lampa, O.D., and colleagues recently presented a poster that looked at the dif-ference between the anatomical center of the pupil and a pa-tient’s line of sight.1 They used

a topographer to measure the difference between the center of the pupil and the central ring of the videokeratoscopic image as it is centered over the patient’s line of sight (fi gure 1). They also measured topographies over the surfaces of multifocal con-tact lenses. All of the contact lenses that they examined on the patients’ eyes were well centered when viewed with a slit lamp, but some patients did show a poor centration of the multifo-cal lens optics over their line of sight.

Anecdotally, we have been paying particular attention to videokeratoscope images and comparing the difference be-tween the line of sight and pupil center. We’ve also been perform-ing topographies over the surface of aspheric multifocal lenses, and have seen a high rate of success with patients whose lens optics appear to line up well over the patient’s line of sight.

For those patients whose mul-tifocal lens optics are not lined up over their line of sight (even though at the slit lamp it may be well centered), we’ve found it diffi cult to meet the patient’s vi-sual demands even when trouble-shooting with the fi tting guides. This is particularly true in higher add powers.

Although additional research to clarify the role of the optics of the lens centering over the patient’s line of sight and its effects on patient outcomes is still needed, this is certainly an important variable that deserves attention and may help better explain successes and failures with simultaneous vision soft multifocal contact lenses.

Topography of GP SurfacesJust as topographies can be tak-

en over the surface of soft contact lenses, they can also be utilized over the surface of gas-permeable (GP) contacts to better understand the patient’s visual experience.

One such example is a patient wearing a Bi-expert (Baush + Lomb) contact lens, which is a segmented multifocal lens. This lens is unique in that it does not have a visible line on the lens. When the lens is sent to your offi ce, it comes with a small dot that is located on the nasal and temporal aspect of the lens that corresponds to where the line that separates the near and the distance optics are located. This marking usually wipes away within a few weeks through nor-mal care for the contact lens.

1. The videokeratoscopic image of the right eye shows a prominently displaced nasally located line of sight with respect to the center of the pupil.

014_rcl0612_Derail.indd 14 5/24/12 4:36 PM

Derail Dropouts


When working with a segment-ed bifocal, also consider these requirements:

• First, make sure that it trans-lates effectively and allows the patient to see through the near optics of the lens when looking down.

• Second, make sure that the segment is high enough to al-low easy transition between the distance and near optics, and low enough so that it doesn’t interfere with distance vision. Keep in mind that, while we can get a sense of whether the segment is too high or too low based on changes in vision that the patient describes while tilting their head either for-ward or backwards, this cannot be visualized at the slit lamp.

Topography over the surface of the lens can easily allow visual-ization of changes on the contact lens surface (fi gures 2a and 2b). This lets you easily determine the transition zone between the distance and the near optics, and also allows you to observe

where the pupil is with respect to the transition zone and whether the segment is low enough in primary gaze. This is valuable for any segmented multifocal GP that does not have a visible line dividing the distance and near optics in the lens.

Infrared CapabilitiesSome topographers offer the

unique ability to view the mei-bomian glands through infrared imaging. These capturing systems can image the meibomian glands

of everted upper and lower eyelids. It was recently shown that meibomian gland dropout is positively correlated with the ocular surface disease index score.2 Meibomian gland dropout and tortuosity of the glands, both considered signs of meibomian gland dysfunction, can easily be imaged.

This is an interesting and critical fi nding especially when working with those who suffer from dry eye symptoms, particu-larly presbyopes. By viewing the meibomian glands in this way, the practitioner has one more factor to consider when fi tting and treating patients for contact lens-related dryness (fi gure 3).

For example, a patient who complains of comfort issues and has relatively normal ocular health fi ndings, other than visible meibomian gland dropout with infrared imaging, may be best served by optimizing the function of the meibomian glands.

With new technologies come new ways to view contact lenses and the tissues that support comfortable, optimized lens wear. Corneal topographers may provide a unique opportunity to view contact lenses and meibo-mian glands, which can help to improve patient outcomes and minimize dropouts. RCCL

1. Lampa M, et al. Assessing multifocal soft contact lens centration with the aid of corneal topography. Poster presented at the annual Global Specialty Lens Symposium meeting, January 26-29, 2012; Las Vegas.2. Srinivasan S, Menzies K, Sorbara L, Jones L. Infrared imaging of meibomian gland structure using a novel kerato-graph. Optom Vis Sci. 2012 May;89(5):788-94.

3. A picture of the tarsal plate showing the meibomian glands in a healthy individual.

2a. Topography over a segmented bifocal. Note the change in topography profile corresponding to the segmented portion of the RGP and the pupillary margin with respect to the segment line (left). 2b. A segmented RGP bifocal lens. The dots at 2:30 and 8:30 represent the edges of the segment of the lens. The dot at 7:30 is to identify the lens as the right lens (right).

014_rcl0612_Derail.indd 15 5/24/12 4:36 PM

Out of the Box By Gary Gerber, O.D.


An eye care practitioner asks his patient how the prescrip-tion for his back-up glasses

is working out. The patient says that, for the frequency and length of wear time, the glasses are fi ne. With some prodding, the patient says he only wears the glasses when going from the bedroom to the bathroom in the middle of the night, so they work fi ne as is. The doctor just nods his head.

With that typical doctor-patient dialogue, is it any wonder why so many -5.00D O.U. patients are walking around with 10-year-old -3.00D O.U. eyeglasses? Let’s ex-amine why this happens and how you can better address it with your next patient.

The Root of the ProblemJust as many psychological prob-

lems are connected to one’s child-hood, the source of many eye care complications stem from when the patient was fi rst fi t in contact lenses. Undoubtedly, contact lenses were presented to the patient as a sub-stitute for eyeglasses. The patient chose to wear contact lenses instead of eyeglasses. However, the contact lenses should have been initially introduced as a vision correction modality in addition to eyeglasses.

When fi tting a patient with con-tact lenses, a practitioner should say: “You should do great with contact lenses. So, in addition to getting your eyeglasses updated for when you won’t be wearing your contact lenses, we’ll fi t you today with daily disposables.”

The patient may naturally ques-tion the need for glasses, assuming

he will be wearing his lenses all the time. At this point, you can explain that contact lens wear will be the primary modality that will be worn most of the time. How-ever, there may be times when this is not the case, and that is why it is important to remember that contacts are not merely a substi-tute for eyeglasses.

At this point, you can discuss specifi c scenarios when this may happen. For example, patients should wear eyeglasses instead of contact lenses when on a plane, if they get sick, when swimming or when working with heavy machin-ery or doing woodwork.

Fixing Past MistakesThe aforementioned narrative

works great with new contact lens patients, but how do you correct past mistakes and address your cur-rent lens wearers?

I suggest looking through your notes to pinpoint the original reason you are seeing the patient—which often is the patient’s quest for great vision. As their eye care practitioner, you have an obligation to prescribe what you defi ne as the best treat-ment modalities. In this case, who could argue that a -3.00D O.U. prescription is clinically appropriate for a -5.00D O.U. patient? If you believe a -2.00D defi cit warrants discussion, you are professionally obligated to address it.

Try this explanation: “I under-stand that you currently wear your glasses at night, after you take out your contact lenses. When you have your eyeglasses on, I’m sure you can tell that your vision is

not the same. If you had to drive to work with those glasses, or do anything outside your house, you wouldn’t be able to do it. It’s for that reason, that I recommend you get new glasses with today’s updated prescription.”

Obvious? Of course! Yet, so few of us do it for fear of being perceived as selling eyeglasses to someone who doesn’t need them. Consider the ramifi cations if this same patient runs out of lenses or has a red eye and can’t wear lenses for a few days; that same patient will now be complaining that they didn’t have the updated prescription and now have to wait for the new glasses.

The point here is that you have a professional obligation and duty to alert your patients about current state of their vision correction. And if there are gaps in their correc-tion, you have to talk about it and explain why. That’s not selling a product, it is doing the right thing to take care of your patients!

Let’s drop the words “back up” from our vocabulary, as they imply that eyeglasses are less important than contact lenses. Which, as you just read, they are not—or at least shouldn’t be!

Note: When presented as above, package pricing (e.g., get a dis-count on your glasses when you get a year supply of contact lenses) isn’t necessary. The reason more contact lens patients don’t have accurate glasses has nothing to do with price and everything to do with their eye care practitioners not talking about them. RCCL

The Case for EyeglassesYou know your contact lens-wearing patients need up-to-date eyeglass prescriptions. Do they?

016_rcl0612_otb.indd 16 5/24/12 4:38 PM

What’s the SolutionBy Susan Resnick, O.D.

Sponsored b y

Achieving compliance with safe contact lens wear and care practices is an ever-

present challenge. We recognize that achieving compliance is a goal, which, if not met, has the potential for signifi cant implica-tions with respect to our contact lens wearing patients’ health and comfort.1 While the approach an individual practitioner takes may vary, each of us must strive to convey a meaningful and strong message, demonstrate and elicit appropriate contact lens wear and care behaviors, and continually reinforce the positive rewards of compliance.

So how effective are we? A recent study compared two clinical populations: 281 from the general optometric popula-tion in the Dallas/Fort Worth area vs. 152 examined at the University of Texas Southwestern Medical Center. The results indi-cated that 58% of patients in the general community could identify by name a complication associ-ated with lens wear. In addition, 85% of all patients perceived themselves as compliant with their lens wear and care prac-tices, but only 2% of patients demonstrated good compliance and even fewer (a mere 0.4%) of patients were fully compliant with contact lens wear and care practices.2 Even more compel-

ling, perhaps, is that overall, the entire study population thought they were maintaining good compliant practices, despite their overwhelming low actual compli-ance scores.2

Where can we improve? This study revealed three areas where education is needed: topping off solutions, tap water exposure and hygiene. Ninety percent of patients indicated they under-stood the signifi cance of using

fresh solution daily, but failed to recognize the importance of removing pre-existing solution before adding new.2

How can we improve? To suc-cessfully foster compliance, we must ensure that patients concep-tually “buy in” to our message and have a vested interest in the benefi ts and rewards of adher-ing to our recommendations. To achieve this, I have adopted a three-pronged approach. First, I inform patients that I am recom-mending OPTI-FREE® PureMoist®

MDPS as their personal lens care system because it is specifi cally

formulated to clean, disinfect and recondition today’s advanced contact lens materials. I always mention that while there are many solutions on the shelf, they are not all the same and substitu-tions should not be made with-out consulting me fi rst.

Second, my staff instructs the patients on all phases and proce-dures related to proper hand hy-giene, lens handling and replace-ment, case care and replacement,

and wear schedules and cycles. Patients are ad-vised to rub their lenses with OPTI-FREE®

PureMoist® MPDS and to avoid topping off.

Finally, and most importantly, I inspiremy patients’ ongoing compliance by explain-ing that OPTI-FREE®

PureMoist® MPDS is designed to optimize

the comfort of their contact lenses by helping to keep the lens surface moist throughout the day.

Given that discomfort is one of the most common self-reported complications, recommending OPTI-FREE® PureMoist® MPDS is an invaluable tool to optimize the lens wearing experience and, in turn, to reinforce the benefi ts of excellence in lens care.

1. Dumbleton KA, Woods CA, Jones LW, Fonn D. The relationship between compliance with lens replacement and contact lens-related problems in silicone hydrogel wearers. Cont Lens Anterior Eye. 2011;34:216–22.2. Robertson D, Cavanagh D. Non-Compliance with contact lens wear and care practices: a comparative analysis. Optom Vis Sci. 2011 Dec;88(12):1402-8.

Achieve Compliance: Inform, Instruct, Inspire

017_rcl0612_alcon.indd 17 5/24/12 4:22 PM


CONTINUING EDUCATION

Scleral lenses are now universal––used not only for irregular cornea patients, but also to treat high refractive errors and presbyopia.By Gregory W. DeNaeyer, O.D.

Today’s Scleral Lens

The recent resurgence of scleral contact lenses has significantly improved our

success in managing patients with corneal irregularity and ocular surface disease (OSD).1-4 Patient and practitioner demand for scleral contact lenses has pushed manu-facturers to improve existing prod-ucts and to develop new designs. New materials and solutions also have helped to improve the success of scleral contact lenses.

This article will review the lat-est updates in materials, solutions, designs and fitting techniques that will continue to advance the suc-cess of scleral lenses.

ClassificationThe fitting characteristics and

functionality of gas-permeable (GP) lenses are directly related to their diameter. Therefore, it’s critical that a universal classifica-tion system be employed so that practitioners can use designs that have predictive characteristics. The Scleral Lens Education Soci-ety (SLS) has recently designed a classification system that defines

GP lenses on both size and fitting characteristics (see “Terminology,” page 20):5,6

• Corneal lenses (8mm to 12.5mm) are supported com-pletely by the cornea. Corneal contact lenses do not hold a tear reservoir.

• Corneal-scleral lenses (12.5mm to 15mm) extend beyond the limbus, and are supported by both corneal and scleral tissue. Corneal-scleral lenses hold a limited tear reservoir.

• Scleral lenses (15mm to 25mm) place all lens bearing on the sclera. Scleral lenses are further subdivided as: mini-scleral lenses (15mm to 18mm) which have a somewhat lim-ited tear reservoir capacity, and full scleral lenses (18mm to 25mm) which have an almost unlimited tear reservoir capacity.

This classification system allows manufacturers to design and mar-ket scleral lenses for specific types of patients. Practitioners can then utilize these products with predic-tive results.

MaterialsThe advent of hyper-Dk materials

has significantly reduced hypoxic-related complications associated with scleral lens use. Using materi-als with Dk values of 100 or more is important with scleral lenses, because they semi-seal to the eye, making tear exchange relatively slow as compared to corneal GP designs. To prevent lens flexure, scleral lenses often are manufac-tured with thicknesses four times greater than that of corneal GPs. Using hyper-Dk lenses to maximize oxygen helps to compensate for permeability decreases secondary to increased lens thickness.

Occasionally scleral lenses will exhibit poor on-eye wettability (figure 1). If this occurs soon after the lens is dispensed, then it is most likely due to lab-related over-polishing or residual lab debris. Patients who have OSD may also have difficulty wetting a scleral lens secondary to their tear quality. In either case, the wettability can almost always be restored by plas-ma treating the lens. Instruct the lab to plasma treat each lens ordered

Dr. DeNaeyer is the clinical direc-tor for Arena Eye Surgeons in Colum-bus, Ohio, and a

consultant to Visionary Optics, Bausch + Lomb and Aciont. You can contact him at [email protected].

Release Date: June 2012Expiration Date: June 1, 2015Goal Statement: This article will present an update on today’s scleral lenses and outline their ability to treat patients with irregular cor-nea, high refractive errors and presbyopia.Faculty/Editorial Board: Greg W. DeNaeyer, O.D.Credit Statement: COPE approval for 1 hour

of CE credit is pending for this course. Check with your local state licensing board to see if this counts toward your CE requirements for relicensure.Joint-Sponsorship Statement: This con-tinuing education course is joint-sponsored by the Pennsylvania College of Optometry.Disclosure Statement: The author has no financial relationships to disclose.


018_rcl0612CEscleral.indd 18 5/24/12 4:38 PM


and have lenses treated as needed if wettability decreases during the life of the lens.

SolutionsAs with any other type of con-

tact lens, solutions play an impor-tant role in the success of scleral contact lens wear. Scleral lenses can be cared for using approved GP lens cleaning and disinfecting products or off-label use of multi-purpose soft lens solutions. Using preserved solutions with scleral lenses puts the patient at a greater risk for toxic reactions because residual solution can become trapped underneath the lens, which increases exposure time to the anterior ocular surface. Prescribing a hydrogen peroxide-based care system eliminates exposure to any potential toxins or antigens.

Scleral contact lenses have to be filled with saline before application to prevent trapped air bubbles that compromise both fit and vision. Unfortunately bottled saline solu-tions contain preservatives that could induce a toxic reaction.

Bottled, non-preserved solu-tions are available but pose two potential risks. First, there is the possibility of contamination if the bottle is used over several days. Secondly, although non-preserved, most of these solutions still contain a buffering agent that can be toxic to the patient.7,8

Alternatively you can prescribe off-label use of 0.9% sodium chloride solution that comes in 3ml single-use vials (figure 2). The sodium chloride vials do not con-tain any buffers and eliminate the risk of contamination because they are single use.

DesignsThere has been a dramatic

increase in available scleral lens designs in the last five years (see “Scleral Lens Designs,” above). All of these designs require a diagnostic set for successful lens fitting. Fitting sets generally have diagnostic lenses that have increasing amounts of sag-ittal depth with standard peripheral curves or haptic section.

Determining which lens design to use can be a challenging first step to scleral lens fitting. Visiting with the various manufacturers that are rep-resented as exhibitors at contact lens meetings can be a great way to learn which designs will be most beneficial for your practice.

One of the major differences between available scleral lenses is the amount of customization that can be done on a specific design. Some scleral lenses offer only a

Scleral Lens Designs

Company Lens Front surface Back surface Quadrant Multifocals toric haptic toric specificAcculens Maxim* Yes No No Yes

Acculens Comfort** Yes No No Yes

Art Optical SoClear No No No Yes

Advanced Vision Technologies AVT Yes Yes Yes Yes

Blanchard MSD No Yes No No

Blanchard One Fit No No No Yes

Dakota Science SoClear No No No Yes

Essilor Jupiter No Yes No No

Essilor Perimeter No No No No

Essilor ICD No No No No

Lens Dynamics Dyna Semi-Scleral Yes Yes Yes Yes

Truform DigiForm Yes Yes Yes Yes

Truform Tru-Scleral Yes Yes Yes Yes

Valley Contax ICD No No No No

Valley Contax Valley 15, 16, 18 Yes Yes No Yes

Visionary Optics Jupiter Yes Yes No No

* Indicated for the irregular cornea. ** Indicated for the regular cornea and can be fit empirically.



CONTINUING EDUCATION

limited amount of change that can be made to the standard param-eters represented by the diagnostic lens. For the novice scleral lens fit-ter, this can be somewhat helpful because it can simplify the fitting process. However, some patients may require more creative changes to achieve a successful fit; for these cases, using a lens design that has unlimited customization will be beneficial.

• Toric and quadrant-specific design. Most standard manufactured scleral lens designs have spherical front and back surface optic zones. Normally, this design setup fits the patient adequately because the lenses are vaulted completely off the cornea surface; therefore, corneal toricity or irregularity is often not a factor.

Scleral lenses effectively mask both regular and irregular astigma-tism by means of liquid reservoir. Residual astigmatic error from a scleral lens correction is often the result of lens flexure that can be eliminated by increasing the center thickness of the lens or improving the lens fit. Occasionally, residual astigmatism can manifest from the crystalline lens and thus is not inher-ently corrected for by the scleral lens. If the amount of residual astig-matism is significant, the patient can wear glasses over their scleral lenses

to correct the astigmatic error. Alter-natively, the scleral lens can be man-ufactured with front surface toricity. In this case, the lens will need to be ballasted to orient and stabilize the lens position.

Typically, scleral lens designs come with a standard spherical back surface haptic. It is now known that the scleral is not spherical, but non-rotationally symmetrical.2 Scleral asymmetry worsens with increasing distance from the corneal limbus. Minor differences between the spherical lens haptic and the sclera may be offset due to the spongy scleral conjunctiva.

Some patients have asymmetric scleral anatomy that results in a poor fitting relationship when fit with a scleral lens that has a spherical haptic surface. These poorly fitting lenses often exhibit a with-the-rule appearance. The lens will have 3 o’clock and 9 o’clock compressions, as well as excessive lift at the 6 o’clock and 12 o’clock positions. In these instances, some manufactur-ers offer toric back surface haptic (peripheral curves), which can dra-matically improve the scleral lenses fitting relationship.

Some practitioners report routine-ly using back surface haptic designs for their scleral lens fits. Esther-Simone Visser, M.Sc., and colleagues

reported significant increases in com-fort, visual quality and overall satis-faction when patients were switched from back surface spherical designs to back surface toric designs.9 Anec-dotally, patients with toric back sur-face haptics report less accumulation of reservoir debris trapped between the lens and the eye during wear.

A few labs are able to manufac-ture scleral lenses with quadrant-specific curves for either the back surface optical zone or the haptic portion when troubleshooting an extremely complex scleral lens fit. For these cases, optical coherence tomography (OCT) of a diagnostic lens is helpful in determining quad-rant-specific changes.

• Multifocals. Scleral lenses pri-mary have been used to improve distance vision for patients who have corneal irregularity. Recently, how-ever, there has been some interest in using multifocal scleral lenses to cor-rect presbyopia. Theoretically, multi-focal scleral lenses could be used for patients who have either regular or irregular corneas. Scleral lenses don’t translate on the eye, so the available multifocal scleral lens designs incor-porate simultaneous designs with center near optics. Unfortunately, multifocal optics may not work well for the irregular corneal patient if they have significant corneal scar tissue or significant residual higher-order aberrations.

Notching LensesScleral GP lenses fit onto the

sclera. Scleral GP lenses can fit over mild pinqueculas, but their firm nature prevents them from draping scleral obstacles that have significant elevation. In these cases, a notch can be beveled into the scleral lens so that the lens bypasses the obstacle. Scleral notches can improve the fit for patients who have moderate to severe pinqueculas or conjunctival blebs resulting from trabeculectomy.

Terminology Alternative Diameter Bearing Tear Names ReservoirCorneal 8.0 to 12.5mm All lens bearing No tear on the cornea reservoirCorneo-scleral Corneal-limbal 12.5 to 15.0mm Lenses share Limited tear Semi-scleral bearing on reservoir Limbal the cornea and capacity the sclera 15.0 to 25.0mm Somewhat Mini-scleral limited tear 15.0 to 18.0mm reservoirFull scleral Haptic capacity Large-scleral Almost 18.0 to 25.0mm unlimited tear reservoir capacity

All lens

bearing



A diagnostic lens that is notched can be kept in the office for fitting purposes. Photos of the diagnos-tic lens can be sent to the lab for evaluation and modification of the notch that will be beveled into the prescribed scleral lens. Notches have to be kept shallow because they will induce bubbles if they are cut too deep. For this reason, it’s best to use a corneal-scleral lens or mini-scleral lens because a relatively smaller lens will require a shallower notch.

When the lens is dispensed, we instruct the patient to insert it like a puzzle piece so that the notched area is aligned with the scleral obstacle. At the follow-up visit, monitor the patient to make sure that the lens is still adequately clearing the obstacle and not creating any tissue disrup-tion, which is especially important in the case of conjunctival blebs.

Piggybacking LensesFor the irregular cornea patient,

scleral lenses are considered the lens of choice when all other design modalities have failed. Most of the time, as long as the diameter is large enough, a scleral lens can completely vault up over almost any cornea. There are rare cases where the practitioner will have a difficult time with complete corneal clearance resulting in some areas of lens touch.

If the patient is asymptomatic and their cornea is without any disruption, then lens changes aren’t always necessary and the patient can be monitored. However, if the patient is symptomatic––especially if

the cornea shows epithelial disrup-tion that is associated with the lens touch––then the practitioner needs to address the fitting relationship immediately.

It is best if the lens vault or design can be changed to improve the fit. If, however, the practitioner is unable to improve the fitting relationship, then a soft lens placed under the scleral lens can be used as a piggy-back system. The soft lens effectively cushions the cornea against any scleral lens-related bearing.

If a standard molded design fits on the cornea reasonably well, then start with a daily disposable silicone hydrogel (SiHy) lens that the patient wears underneath the best-fit scleral contact. A daily disposable elimi-nates the need for multiple solutions and prevents lens-related solution interactions. A SiHy lens will help to maximize oxygen to prevent hypox-ic-related complications.

If a standard molded soft lens design does not adequately fit, then a custom fit lathe cut design can be used. Diameters larger than 14.5mm may interfere with the lens haptic to sclera relationship and disrupt the scleral lens fit.

Lens ApplicationScleral lens application is chal-

lenging because of the relatively increased overall lens diameter. Patients who are disabled and/or elderly may especially have trouble effectively applying scleral lenses. Dalsey Adaptives, LLC has devel-oped the See-Green device that can

be used to help patients successfully apply their scleral contact lenses.10

The See-Green system comes with a stand that holds a lighted plunger (figure 3). Using this system, the patient no longer has to hold the lens, but rather lowers their eye onto it, which leaves both hands free for improved lid control. The light at the center of the plunger is used as a tar-get to allow for central positioning.

Scleral lens use has increased exponentially over the last five years. Utilization of scleral lenses has expanded beyond the irregular cornea, as practitioners are now using scleral lenses for patients with high refractive errors and presby-opia. Solution, material and design updates will continue to improve scleral lens fitting success. RCCL

1. Schornack MM, Patel SV. Scleral lenses in the management of keratoconus. Eye Contact Lens. 2010 Jan;36(1):39-44.2. Pecego M, Barnett M, Mannis MJ, Dublin-Johnson B. Jupiter scleral lenses: the UC Davis Eye Center experience. Eye Contact Lens. 2012 May;38(3):179-82.3. Schornack MM, Baratz KH, Patel SV, Maguire LJ. Jupiter scleral lenses in the management of chronic graft versus host disease. Eye Contact Lens. 2008 Nov;34(6):302-5.4. Jacobs DS, Rosenthal P. Boston scleral lens prosthetic device for treatment of severe dry eye in chronic graft-versus-host disease. Cornea. 2007 Dec;26(10):1195-9.5. DeNaeyer G. A New Way To Classify Scleral Contact Lenses. CL Spectrum. 2011 Oct.6. van der Worp E. A Guide to Scleral Lens Fitting [monograph online]. Scleral Lens Education Society; 2010. Available at: http://commons.pacificu.edu/mono/4/ (accessed May 2012).7. Imavasu M, Hori Y, Cavanagh HD. Effects of multipurpose contact lens care solutions and their ingredients on membrane-associated mucins of human corneal epithelial cells. Eye Con-tact Lens. 2010 Nov;36(3):361-6.8. Gorbet MB, Tanti NC, Jones L, Sheardown H. Corneal epi-thelial cell biocompatibility to silicone hydrogel and conventional hydrogel contact lens packing solutions. Mol Vis. 2010 Feb 19;16:272-82.9. Visser ES, Visser R, van Lier HJ, Otten HM. Modern scleral lenses part II: patient satisfaction. Eye Cont Lens. 2007;33(1):21-5.10. The See-Green Lens Inserter. Dalsey Adaptives. Available at: www.dalseyadaptives.com (accessed May 2012).

1. A non-wetting scleral lens. 2. Single-dose sodium chloride vials. 3. The See-Green system.



Examination Answer Sheet Valid for credit through June 1, 2015

This exam can be taken online at www.reviewofcontactlenses.com. Upon passing the exam, you can view your results immediately. You can also view your test history at any time from the website.

Today’s Scleral Lenses

Directions: Select one answer for each question in the exam and completely darken the appropriate circle. A minimum score of 70% is required to earn credit.

Mail to: Jobson - Optometric CE, PO Box 488, Canal Street Station, New York, NY 10013

Payment: Remit $20 with this exam. Make check payable to Jobson Medical Information LLC.

COPE approval for 1 hour of CE credit is pending for this course.

This course is joint-sponsored by the Pennsylvania College of Optometry

There is an eight-to-ten week processing time for this exam.

1. A B C D 1 = Excellent 2 = Very Good 3 = Good 4 = Fair 5 = Poor

2. A B C D Rate the effectiveness of how well the activity: 3. A B C D

4. A B C D 21. Met the goal statement: 1 2 3 4 5

5. A B C D 22. Related to your practice needs: 1 2 3 4 5

6. A B C D 23. Will help you improve patient care: 1 2 3 4 5

7. A B C D 24. Avoided commercial bias/influence: 1 2 3 4 5

8. A B C D 25. How would you rate the overall 9. A B C D quality of the material presented? 1 2 3 4 5

10. A B C D 26. Your knowledge of the subject was increased: Greatly Somewhat Little 27. The difficulty of the course was: Complex Appropriate Basic How long did it take to complete this course? Comments on this course:

Suggested topics for future CE articles:

Please retain a copy for your records. Please print clearly.

You must choose and complete one of the following three identifier types:

1 SS # - -

Last 4 digits of your SS # and date of birth State Code and License #: (Example: NY12345678)

2 - 3

First Name

Last Name

E-Mail

The following is your: Home Address Business Address

Business Name

Address

City State

ZIP

Telephone # - -

Fax # - -

By submitting this answer sheet, I certify that I have read the lesson in its entirety and completed the self-assessment exam personally based on the material presented. I have not obtained the answers to this exam by any fraudulent or improper means.

Signature Date

Lesson 108308 RO-RCCL-0612

1. Scleral lenses can be beneficial for patients who have:a. Presbyopia.b. Regular astigmatism.c. Irregular astigmatism.d. All of the above.

2. Which characteristic does not apply to corneal-scleral lenses (12.5mm to 15mm)?

a. Lens shares bearing between cornea and scleral tissue.b. Lens will exhibit near corneal alignment and some movement

upon blinking. c. Lens extends beyond the limbus.d. Lens holds a limited fluid reservoir.

3. Which lens exhibits almost unlimited tear reservoir capacity?a. Full-scleral lenses. b. Mini-scleral lenses.c. Corneal lenses.d. Corneal-scleral lenses.

4. Why is it important to use hyper-Dk materials for scleral contact lenses?

a. Hyper-Dk materials reduce hypoxic-related complications.b. Scleral lenses create a semi-seal to the eye, making tear

exchange relatively slow.c. Hyper-Dk materials can maximize oxygen to help compensate

for permeability decreases secondary to increased thickness. d. All of the above.

5. What is the risk of using bottled, non-preserved solutions with scleral lenses?

a. The lens likely will accumulate more reservoir debris.b. The possibility of contamination if the bottle is used over

several days.c. The lens will more likely become deposited with proteins.d. The lens will more likely become deposited with lipids.

6. Scleral lenses hold a fluid reservoir and are able to mask:a. With-the-rule astigmatism.b. Against-the rule astigmatism.c. Irregular astigmatism.d. All of the above.

7. Residual astigmatism with a scleral contact lens can result from:

a. Lenticular astigmatism.b. Lens flexure.c. An optic zone larger than 8mm.d. Both A and B.

8. When did Esther-Simone Visser, M.Sc., and colleagues report increased overall patient satisfaction?

a. When patients switched from back surface spherical designs to back surface toric designs.b. When patients used 0.9% NaCl saline to fill their scleral lenses

with before application.c. When patients switched from back surface toric designs to

back surface spherical designs.d. With decreased scleral lens time—from 16 hours to 12 hours.

9. Notching scleral lenses helps to:a. Improve comfort.b. Improve centration.c. Bypass scleral obstacles. d. All of the above.

10. Piggybacking a scleral lens should only be considered if:a. The patient is asymptomatic and their cornea is without any

disruption.b. The cornea shows epithelial disruption when the best-fit

scleral lens exhibits corneal touch.c. The scleral lens exhibits significant movement upon blinking.d. None of the above.

CE TEST FOR TODAY’S SCLERAL LENSES


June 2012 1

What makes patients happy? You? Your staff ? The care you

provide? Or a combination of them all? Fact is, making patients happy is a catalyst that can set in motion the kind of positive momentum that can impact your practice for years to come.

Why? Well, because happy patients talk—they talk to their families, friends, and anyone else who will listen. They can trans-form from patients to evangelists who spread the word about the care you provide.

That type of fervor can have a positive eff ect on your practice. But how much? Consider the results from a recent survey of 605 doctors conducted by John-son & Johnson Vision Care. Inc.

How Happy Patients Aff ect Your Referrals

and Your Success by Jordin Alford

Research Manager – U.S. Business Insights

VISTAKON, Division of Johnson & Johnson Vision Care, Inc.

When asked what type of patients are more likely to refer others to their eye doctor, 3x more doctors said “happy” or “enthusiastic” than

“satisfied”.

SUPPORTED BY

The Happiness Factor™:

000_vistakon_fin.indd 1 5/23/12 2:25 PM

2 June 2012

When asked what type of patients are more likely to refer others to their eye doctor, 3x more doctors said “happy” or “enthusiastic” than “satisfi ed”.

But what makes patients happy? What are the key factors? Optometrists re-vealed that the most important driver to patient happiness, for contact lens wear-ers and non-wearers alike, is their vision correction product experience.

MAXIMIZING THE VISION CARE PRODUCT EXPERIENCEThe Patient Happiness Survey support-ed the premise that patients’ product experience was most important to Optometrists. In fact, 92% of eye care practitioners answered “Extremely”

or “Very” when asked how important product experience is to their contact lens patients’ happiness with them asa doctor. What factors impact a pa-tient’s experience with vision correc-tion products?

For contact lens patients, comfort and vision were pinpointed most often as important to product experience happi-ness. In fact, optometrists ranked com-fort (84%) and vision (63%) as being more important by far to the happiness of contact lens patients. By comparison, only 29% of optometrists thought cost impacted happiness.

So, if comfort is the #1 benefi t of contact lenses that creates patient happiness, you

%

0 10 20 30 40 50 60 70 80 90% of respondents

Comfort

Vision

Cost

84%

63%

29%

What vision product factors infl uence the happiness of your contact lens patients?

n = 605


3June 2012

may be asking yourself how does happi-ness translate into practice growth?

HAPPY PATIENTS’ REFERRALS GROW YOUR PRACTICEIt’s a tried and true practice that word-of-mouth referrals are the way to grow your practice. And while focusing on the margin of box price may bring a small short-term gain, focusing on gar-nering new patients brings success in both the short and, more importantly the long-term. Much like investing, rely-ing on proven strategies is the best way to help ensure future growth.

Did you know that the most successful practices conduct 3x as many eye ex-ams as the average practice, and have twice as many patients wearing con-tact lenses as the average practice?1

It’s not surprising that nearly all (99%) Optometrists believe that keeping pa-tients happy leads to practice growth through referrals. And, since doctors also believe that product experience is linked to patients’ opinion of them as doctors, they need to be mindful

of prescribing lenses that will provide patients with the best possible wearing experience.

Most doctors believe that a comfortable patient is a happy one. With that as a starting point, it is critical to recom-mend lenses based on providing the utmost in comfort.

HOW TO BUILD A PRACTICE THAT LASTSFocusing your practice on increasing patients per day rather than dollars per patient is indeed a more pragmatic—and eff ective business approach. Increased patient traffi c and improved exam productivity have major impacts on practice revenue. In fact, the MBA study found that, on average, 52% of a prac-tice’s gross revenues and two-thirds of a practice’s profi ts come from exam fees alone.1 And when patients do start com-ing in, utilizing these simple tactics can pay big dividends for your practice.

I. Communicate the value of services.Communicating the value of the vari-ous eye exams with their patients during an eye exam was deemed important by 96% of those surveyed. Making the ef-fort to explain the value of your services to patients will lead them to value you and your practice even more. They’ll be more likely to take your recommenda-tions and not seek a second opinion, and

Making patientshappy increases patient

referrals, leading tomore patients, which

leads to practicegrowth.


they’ll also want to tell their families and friends about your attentiveness and about the care they received from you and your staff .

II. Keep in touch with patients. Build-ing stronger relationships through follow-up communications and re-minder cards with their current patient

base garnered agreement from 92% of Optometrists. Loyal patients are the backbone of a practice. Staying in touch with them—to fi nd out how a treatment or vision correction option is working or any other reason—makes them feel important and valued.

WHERE DOES MARKETING FIT IN?Social media starts face-to-faceThinking your practice should have a Facebook page? Wondering if you’re missing an opportunity by not Tweet-ing your optometric wisdom? A major-ity of Optometrists agreed that it is important to advertise their practices

using social media tools.

But if you agree that referrals are the way to practice growth, you know that the best spokesperson for your practice is sitting in your chair. Subscribing to that can lead to organic and sustainable practice growth.

CONCLUSIONGiving patients the best vision correc-tion product experience is the mostimportant factor in growing your prac-tice. Recommending the most comfort-able contact lenses is the most impor-tant part in ensuring your contact lens patients leave your practice happy—because every visit is an opportunity to grow your practice.

Remember: happy patients lead to more referrals and practice success and growth. ■

1. Management & Business Academy: Practice Profi le Report, 2009. Page 23, Table 1: Complete Exams.

June 20124

The best spokesperson for your practice is sitting in your chair.

Successful practices conduct 3x as many eye exams as the average practice.1



In this era of rapid technologic advances, it can be difficult to keep up with the latest equipment and

procedures within the field of eye care. Even when we do stay abreast of these changes, do we need or want to buy the latest instruments? Some practi-tioners feel that the old standby is just fine, while others are eager to have the newest tools immediately. The path to follow is likely somewhere in between. In this article I look at some of the instrumentation and lenses of the past and present, and discuss the pros and cons of each in relation to contact lens practice.

Visual AcuityLet’s start with measuring visual

acuity. Traditionally, this was done with a Snellen wall chart set 20 feet from the patient. The patient was asked to cover one eye and read the letters, then repeat with the other eye. Of course, there are some pitfalls to keep in mind. First, the lighting must be proper; and second, we have to be conscious that the patient is not already familiar with the letter sequence.

The next step up is the standard projected chart, which ensures good lighting of the letters and good con-trast, but we still find that the patient’s memory can be a factor here.

The latest instrument for acuity measurement is a computer-based system like the Smart System II 2020 Wireless Remote (M&S Technolo-gies). With this arrangement, the letter selection and sequence is infinitely varied, thus memorizing the chart is not a concern. Because contrast and lighting can be controlled and varied, contract sensitivity and vision can both be assessed. Personally, having worked with such a system for several years, it is difficult to switch back when doing a vision screening or working in a satellite office without this equipment. Score one for new technology!

RefractionMost of us are taught to use a

phoropter to perform refractive evalu-ations. We get good at retinoscopy to find a starting point for new patients. In fact, the retinoscope and phoropter have been mainstays for refractive determinations for over 100 years.

Practitioners will find that new does not always mean better when it comes to technology. By Douglas P. Benoit, O.D.

Keeping Up with Technology:

Old vs. New

Dr. Benoit is senior optom-etrist with The Eye

Center of Concord, a multi-subspecialty ophthalmology group located in Concord, N.H. He is a diplo-mate and chair of the American Academy of Optometry’s Section on Cornea, Contact Lenses and Refractive Technology.

027_rcl0612Tech.indd 27 5/24/12 4:40 PM


But, before the phoropter, there was the trial frame and loose lenses. While the phoropter has the advan-tage of allowing the measurement of phorias, ductions and AC/A ratios, a trial frame refraction can be just as fast—and sometimes more accu-rate—than a phoropter refraction. Think about the young, fidgety patient who will not sit properly behind a phoropter, or the older, infirm patient who cannot be aligned behind a phoropter. In these instanc-es, a trial frame refraction is a far better option. Other examples of the superiority of the trial frame include cases when patients present with large ametropias (particularly astig-matism) and when you need to do an over-refraction on bifocal/multi-focal contact lens patients. I would give this point to old technology.

When it comes to determining the initial refractive values on a new patient, many practitioners have embraced the autorefractor and moved away from retinoscopy. This allows technicians to determine the objective refraction, and frees up the doctor for other tasks such as subjective refraction. A subjective refraction is still needed after the objective determination to refine the prescription.

Back in the 1970s, Humphrey Instruments introduced the Hum-phrey Vision Analyzer, which is a fully subjective refracting system.1 It used what was termed a “remote refraction,” involving a system that manipulated lenses before the projector rather than before the patient’s eyes.2 The results were accurate and repeatable—but a cost of $31,500 to $39,000 per unit made it an expensive option for the average practitioner.3

A new refracting system, the PSF Refractor (VMax Vision), uses a point-spread function by measuring a patient’s subjec-tive visual response to a point

source.4 This enables correction of higher-order aberrations by giving precise refractive results. Coupling that instrument with VMax’s Encepsion lenses brings the cost of the unit from $25,000 to $45,000, depending on the selected package. Time will tell whether or not the cost proves to be a stumbling block.

CorneaExamining the cornea requires

use of a slit lamp biomicroscope. The basic design has not changed much over the years; there are cur-rently two instrument configurations dominating the market. There is the Zeiss design with a low-profile illumination system and a large magnification range, and there is the Haag-Streit design with a tall illu-mination tower and a choice of two magnifications (at least in the basic model). Practitioners may debate the merits of one design over the other for clear images, but both work very well, so it really is a matter of per-sonal preference.

In recent years, specular micro-scopes have been developed to provide a fantastic view of corneal structures. They also offer some advantages in diagnosing infections and other problems with the cornea. While they may be very helpful for evaluating the endothelial guttata before cataract surgery, they are not going to replace the slit lamp for routine evaluations. Also, keep in mind that the cost of the unit can reach $35,000 or more.

We also need to evaluate the corneal curvature, especially before contact lens fittings. The tradi-tional instrument for this task is the keratometer. These units have not changed much since electricity replaced candles and mirrors for the illumination system. Keratometers measure the curvature of the central 3.5mm of the cornea, which gives us

information about that area but not what is going on beyond that.

Corneal topographers, developed in the 1980s, allow for a wider measurement area and give more information than just the curvature of the cornea. They provide a two-dimensional view of the elevation and variation of the cornea to about 12mm. Topographers are great for following keratoconus patients because they allow you to detect subtle changes over time.

A newer instrument for access-ing the cornea and other anterior segment structures is the corneal tomographer. The more advanced technology employed in these devic-es allows a three-dimensional view of both the anterior and posterior cornea, the anterior iris and crystal-line lens.5 We also must mention anterior segment optical coherence tomography (OCT), which is even more sophisticated that the previous devices and covers a larger area of the cornea and sclera.6 Its sensitivity allows the practitioner to easily dis-cern the level of the cornea involved in dystrophies, degenerations and infections.7 This is very valuable for the anterior segment/corneal surgeon, as well as fitters of large-diameter gas-permeable lenses.

Contact LensesIn contact lens practice, there

has been tremendous change due to technological advances. Back in 1888, contact lenses were literally glass shells. They had zero oxygen flux and were very involved from a fitting standpoint. They were large lenses that did not move much and caused a lot of corneal edema and conjunctival injection.

The development of polymethyl-methacrylate plastic allowed for smaller lenses to be made, and a more precise lens-to-cornea fitting relationship was achieved. While the material did not allow oxygen

027_rcl0612Tech.indd 28 5/24/12 4:40 PM


to pass through, the smaller size and the ability to move on the cornea did reduce the instances of corneal edema to a more acceptable level. Adding silicone and other components to the polymer mix did increase oxygen permeability and transmis-sibility. These advances have allowed gas-permeable lenses to be used for extended wear, up to 30 nights, with very few problems. The new mate-rial advances also have made it possible to manufacture larger lenses, with diameters above 24mm, enabling better comfort and offering relief from painful ocular conditions. Chalk that up to another point for new technology, and we won’t even talk about the advances in lathing technology that make these new lenses possible. (That would be an article of its’ own.)

Soft Contact LensesSoft contact lenses currently make

up about 90% of the lenses being used worldwide.8 From their humble beginnings in the kitchen of Profes-sor Otto Wichterle in 1961 to the silicone hydrogel lenses of today, polymer technology for soft lens materials has been steadily changing. The earliest materials, such as poly-macon, had very low dK values and did cause corneal edema in some patients. Polymers with increased water content gave some relief from corneal swelling, thus the idea of extended wear was born.

Following an outbreak of cor-neal infection and ulcers in the mid-1980s, Oliver Schein, M.D., and colleagues conducted the first major study of extended wear com-plications.9 Clearly embracing new technology can have its own perils. However, the setback spurred new development in polymer technology and eventually resulted in silicone-

based polymers that were wearable and had dK values up to 175. These changes allowed for safer extended wear, or continuous wear up to 30 days, but they were not with-out risks.10 Even daily wear of the silicone-hydrogel materials did not eliminate problems like keratitis, superior epithelial arcuate lesions (SEALs), contact lens-induced acute red eye (CLARE) and infiltrates.11

The changes in technology for manufacturing soft lenses have allowed us to move away from the need to save our lenses for a year to a much more convenient dispos-able schedule. Early lenses were prone to deposits of denatured proteins on the surface, so the thought was that replacing them more frequently would eliminate that problem and the inflammation issues related to conventional soft lenses. Whether the replacement schedule is every one month, two weeks or daily, complications such as keratitis still exist.12

Lens CareThe evolution of lens care technol-

ogy has also been tremendous. We went from having to make our own cleaner and saline to selecting from a multitude of laboratory-made products and from heat disinfecting to chemical and peroxide-based sys-tems, all new technologies designed

to increase comfort and ease. Yet, we still find issues with irritation and eye redness in some patients—stemming in part from interactions between the polymers and solution components, and in part from patient non-compliance.13

Patient education, and re-education, about the impor-tance of following the proper wear, care and replacement schedules is very important.

All things being equal, when it comes to lens materials, using the most oxygen-permeable polymer available makes the most sense. The shortest possible replacement fre-quency is advisable to decrease the likelihood of complications due to surface changes over time.

The skills and expertise we attain from optometry school to our prac-tice lives and continuing education are enhanced by all the new technol-ogy and the studies that support them. We put all of this information to use during our interactions with each patient. Ultimately, we formu-late the best plan for the individual in our chair, regardless of whether it involves old or new technology. RCCL

1. Efron N. Instrument review: The Humphrey Vision Analyser. Aust J Optom. 1982 Apr; 64(4):149-53.2. Alvarez LW. Development of variable focus lenses and a new refractor. J Am Optom Assoc. 1978 Jan;49(1):24-9.3. Kratz LD, Flom MC. The Humphrey Vision Analyser: reliability and validity of refractive-error measurements. Am J Optom Physiol Optics. 1978 Oct; 54(10):653-9.4. Rosenweig T. Instrument Focus: Provide night sight—refractive device enhances night vision. Optom Management. 2011 Nov;46(11):62-3.5. Yeung KK, Chang S. New equipment sees the cornea better. Rev Cornea Contact Lens. 2011 Oct;147(7):16-9.6. Sobara L, Maram J, Fonn D, et al. Metrics of the normal cornea: anterior segment imaging with the Visante OCT. Clin Exp Optom. 2010 May;93(3):150-6.7. Vajzovic L, Karp C, Haft P, et al. Ultra high-resolution ante-rior segment optical coherence tomography in the evaluation of anterior corneal dystrophies and degenerations. Ophthalmol-ogy. 2011 Jul;118(7):1291-6.8. Bennett ES. GP Annual Report 2011. Contact Lens Spec-trum. 2011 Oct;26(10):28-33,48.9. Schein OD, Glynn RJ, Poggio EC, et al. The relative risk of ulcerative keratitis among users of daily-wear and extended-wear soft contact lenses. N Eng J Med. 1989 Sep;321(12):773-8.Additional references at www.reviewofcontactlenses.com.

Konan Specular Microscope.

027_rcl0612Tech.indd 29 5/24/12 4:40 PM

Give your patients an upgrade with AIR OPTIX® AQUA contact lenses

*AIR OPTIX® AQUA (lotrafi lcon B) contact lenses: Dk/t = 138 @ -3.00D. **Prior to evaluation, 100% fi t AIR OPTIX® AQUA contact lenses and 85% indicated AIR OPTIX® AQUA contact lenses were their preferred SiHy lens for new fi ts. †Successful conversion defi ned as the patient received a prescription for or purchased AIR OPTIX® AQUA contact lenses. ††Compared to ACUVUE^ OASYS^, ACUVUE^ ADVANCE^, PureVision^, Biofi nity^, and Avaira^ contact lenses. ‡Compliance with manufacturer-recommended replacement frequency. ^Trademarks are the property of their respective owners.

Important information for AIR OPTIX® AQUA (lotrafi lcon B) contact lenses: For daily wear or extended wear up to 6 nights for near/far-sightedness. Risk of serious eye problems (i.e. corneal ulcer) is greater for extended wear. In rare cases, loss of vision may result. Side eff ects like discomfort, mild burning or stinging may occur.

References: 1. Based on a post-launch evaluation in which 88 eye care practitioners refi t over 400 patients in AIR OPTIX® AQUA contact lenses. Alcon data on fi le, 2011. 2. Nash W, Gabriel M, Mowrey-Mckee M. A comparison of various silicone hydrogel lenses; lipid and protein deposition as a result of daily wear. Optom Vis Sci. 2010;87:E-abstract 105110. 3. Compared to HEMA contact lenses; based on the ratio of lens oxygen transmissibilities; Alcon data on fi le, 2010. 4. Dumbleton K, Richter D, Woods C, et al. Compliance with contact lens replacement in Canada and the United States. Optom Vis Sci. 2010;87(2):131-139. 5. Compared to 2-week replacement lenses; based on self-reported lens replacement time and third-party industry pricing information; Alcon data on fi le, 2012.


© 2012 Novartis 2/12 AOA12002JAD

In a post-launch evaluation with ECPs experienced in fi tting AIR OPTIX® AQUA contact lenses,** 91% of HEMA lens patients were successfully converted to AIR OPTIX® AQUA contact lenses1†

Unique TriComfort™ Lens Technology provides moisture retention, superior deposit resistance,2†† and breathability3*

Monthly replacement schedule promotes patient compliance4‡ and may increase practice profi tability5

Visit myalcon.com to learn more.

The 90s called. They want their HEMA lenses back.

RCCL0612_Alcon Aqua.indd 1 5/22/12 3:26 PM

http://www.myalcon.com


Rigid contact lens polishing units are still commonly found in contact lens practices (figure

1). Yet, they are headed toward obso-lescence. It is not because the rigid lens modality is dying. Prescribing rigid lenses is still important, especially in a practice like mine with many kera-toconus and other irregular cornea patients. Instead, changes in our indus-try are making the disadvantages of rigid lens polishing apparent.

In-office polishing is rooted in the good intentions of reducing accumu-lated surface deposits to extend the life of the rigid lens, sort of like refinishing wood flooring to give it life anew. This deep cleaning is designed to remove deposits more effectively than digitally rubbing with an abrasive cleaner. But lens polishing has a dark side.

Concern for the OpticsFirst, with the newer “no-polish”

computer numerical controlled (CNC) lathes, like the Optoform 80 (Ametek, Inc.), rigid lenses are generated with such high accuracy and precision that polishing can harm their optics. For example, interferometry shows how polishing a rigid lens can induce aber-rations (figure 2). I even once observed a center-add rigid bifocal lens have the add segment accidentally polished off, causing the patient loss of near vision.

Even though it may seem like pol-ishing is helping the patient by remov-ing deposits, it may actually work

against your goal of offering the best quality of vision. While a new lens is often the best treatment, an alter-native to polishing is using Progent (Menicon), a protein remover that uses sodium hypochlorite and potassium bromide to chemically clean the lenses.

Watch for Plasma TreatmentSecond, more rigid lenses today

have plasma treatment. Plasma treat-ment is intended to reduce deposits from accumulating, reduce bacterial adhesion and increase lens wetting. Abrasive cleaners such as Boston Original and Boston Advance (Bausch + Lomb) can remove the plasma treat-ment. Instead, use non-abrasive clean-ers such as Boston Simplus (Bausch + Lomb), Opti-Free GP (Alcon) or Opti-mum (Lobob).

Lens polishing can also remove plasma treatment. To illustrate this

Polishing can harm optics, wettability, efficiency and profitability.By Brian Chou, O.D.

Four Reasons to Stop Polishing Rigid Lenses

Dr. Chou is in private practice at EyeLux

Optometry in San Diego and is the co-developer of EyeDock.com, an online clinical reference guide for con-tact lens practitioners.

1. Rigid lens polishing unit.

031_rcl0612Rigid.indd 31 5/24/12 4:40 PM


effect, I had five identically lathed rigid lenses (HDS 100 material, Paragon Vision Sciences) with the contact angle measured before and after plasma treatment. After having the lenses plasma treated at Syner-gEyes, Inc., the contact angle was measured. Then after polishing, the contact angle was measured again (see “Contact angle before plasma treatment, after plasma treatment and after polishing,” below).

I found that plasma treatment dramatically improved lens wet-ting; subsequent polishing returned the lenses to their wettability state prior to plasma treatment. Indis-criminate lens polishing on plasma-treated rigid lenses negates the benefits of plasma treatment.

Perils of Lens PolishingThird, lens polishing is inef-

ficient. Many ancillary personnel

confide that they are uncomfort-able polishing lenses, even those supposedly trained to do it. There is the fear of breaking the lens, having the lens spin off or losing the lens down the drain.

All too often, the doctor ends up polishing the lenses. But, the doc-tor is not always available when the patient comes in asking to have their lenses polished. This can dis-rupt the schedule and cause delays, especially if the patient has no back-up contact lenses or eyewear.

Also, keep in mind that most practices do not charge enough to cover the doctor’s time for lens polishing. In most cases, the doctor operates more productively and effi-ciently examining patients. Pulling the doctor away from direct patient care toward lens polishing is not and should not be the doctor’s core competency. Therefore, a patient

coming in to have their lenses pol-ished creates an unnecessary opera-tion, which is often unpredictable in timing and can throw a wrench into busy practice operations.

Replacement SchedulesFinally, polishing lenses can

decrease the frequency of purchas-ing new lenses if patients mistaken-ly believe that polishing makes the lenses perform like new. Reduced practice profitability limits your ability to reinvest in new technolo-gy, and sustain or even grow prac-tice operations, and can threaten your ability to give employees cost-of-living adjustments to their compensation.

In this fragile economy, where there is still widespread consumer appeal to save money, take the time to educate your patients that insist on lens polishing. Explain to them that that polishing today’s advanced rigid lenses can compromise optical quality, lens wettability and their overall wearing experience. RCCL

Dr. Chou graciously acknowl-edges William Meyers, Ph.D., vice president of Science & Technology at Paragon Vision Sciences, for pro-viding the test lenses, and Ramazan Benrashid, Ph.D., vice president of R&D of SynergEyes, for providing plasma treatment, measuring wet-ting angle, and interferometry of the lenses for this article.All lenses were made with the following parameters: 7.80 BC, -3.00 D, 9.2 Diam, 0.120 CT.

2. Interferometry of a rigid lens before polishing (left) andafter polishing (right). Note the polish-induced aberrations.

3. Wettability of rigid lens with plasma treatment before polishing (left) and after polishing (right).

Contact angle before plasma treatment, after plasma treatment and after polishing.

Lens Contact angle Contact angle after Contact angle No. no plasma coat SynergEyes with plasma coat plasma coat after polish1 100.16 31.56 109.1

2 112.59 25.34 102.86

3 113.94 33.58 90.66

4 113.99 33.28 104.78

5 99.67 30.18 105.53

031_rcl0612Rigid.indd 32 5/24/12 4:40 PM

2011_RCCL_website ad.indd 1 3/21/12 1:28 PM

http://www.reviewofcontactlenses.com


Traditionally, discoveries in medicine take years, even decades, to conclude. How-

ever, in just two years, the Inter-national Workshop on Meibomian Gland Dysfunction was able to develop a better understanding of the meibomian glands as they relate to dry eye. The study involved the clinical research of 50 international experts that began in November 2008, and continued with a review of outlines and the drafting of reports following the Association for Research in Vision and Oph-thalmology (ARVO) meeting in May 2009. After reviewing the lit-erature and combining the findings with evidence-based research, the final draft of the MGD workshop was completed in April 2010.1

DefinitionMeibomian gland dysfunction,

or MGD, is the leading cause of dry eye syndrome (DES). The term “meibomian gland dysfunction” evolved in the mid-1980s. Since then, other terms such as posterior blepharitis, meibomian gland dis-ease, meibomianitis, meibomitis and meibomian keratoconjunctivi-tis have been termed by clinicians to describe MGD and lid disease.

Although literature has referred to posterior blepharitis and MGD inter-changeably, the two are not synony-mous. MGD is strictly a term used to describe an obstruction within the glands themselves and changes in the secretion of meibum from the gland. By altering the tear’s compo-sition, the patient may experience

In only two years, we have already gained a more refined understanding of meibomian gland dysfunction and dry eye.By Andrea Knouff, O.D.

The Mystery of MGD

Dr. Knouff, is board certified by the Ameri-can Board

of Optometry, and is residency trained in ocular disease. She has no financial dis-closures. She currently practices at Omni Eye Services in Atlanta.

034_rcl0612LidDisease.indd 34 5/24/12 4:28 PM


symptoms of dry eye, irritation and discomfort.1 Posterior blepharitis is defined by inflammation of the posterior lid margin. Early gland dysfunction may not show signs of blepharitis as the inflammation is not always present.1

EtiologyMGD has been a clinical condi-

tion for more than 100 years. The Report of the International Work-shop of MGD points out significant evidence as to the causes of gland dysfunction, but systemic and ocu-lar contributions remain unknown.1 We know that MGD contributes to a subset of DES called evaporative dry eye. MGD is extremely preva-lent, but the exact rate of occur-rence varies widely because it often goes undiagnosed. MGD has been found to be higher in Asian popula-tions—as high as 60% suffer from dry eye.1 In comparison, predomi-nance of dry eye in whites varies from 3.5% to 19.9%.1

Systemic factors contributing to MGD include hormonal deficien-cy, menopause, aging, Sjögren’s, psoriasis, rosacea, hypertension and benign prostatic hyperplasia (BPH). Medications interfering with meibomian gland produc-tion include anti-androgens, BPH medications, post-menopausal therapy, antihistamines, antide-pressants and retinoids.1

Anatomy, Physiology and Pathology of MGD

Meibomian glands are large sebaceous glands located in the upper and lower tarsal plates. The majority reside in the upper lids. Once the lipids and proteins are made from these glands, they are secreted into the tear film, thus preventing evaporation.

Unlike most sebaceous glands, meibomian glands do not have contact with the hair follicle.

These glands are densely inner-vated and controlled by andro-gens, estrogens, progestins, retinoic acid, growth factors and possibly neurotransmitters. The process by which they produce polar and non-polar lipids is not completely understood. What we do understand is that the mecha-nism of action is a holocrine process. A muscular contraction occurs during lid movement, which delivers the meibum to the ocular surface.3

MGD is primarily caused by a chronic duct obstruction with thickening meibum. The epithe-lium of the duct then begins to hyperkeratinize, which leads to dysfunction. The blockage of the gland is altered by several endogenous and exogenous fac-tors, such as age, sex, hormonal changes and topical medications. The gland interference may lead to telangiectasia, gland drop out, meibocyte atrophy and low mei-bum secretion.1

Diagnosis of MGDDiagnostic and treatment

modalities for DES are becoming more sophisticated. Many times clinicians can make a diagnosis based on the patient’s symp-toms alone. This can be difficult because often the symptoms do not match the clinical appearance.

The patient complains of burn-ing, irritated eyes that seem worse in the morning, at the end of the day or after long hours of computer use. He or she may also complain of fluctuating vision upon blinking.

MGD is separated into two categories based on meibum secretion: low-delivery and high-delivery states. Low-delivery states are further divided into hyposecre-tory and obstructive subcatego-ries. Hyposecretory occurs when the glands produce less amounts of meibum, but are not fully obstructed. Obstructive MGD refers to terminal duct obstruction, where no meibum is produced. High-delivery or hypersecretory MGD is characterized by large amounts of lipid release which can be visible on gland expression upon examination.

Multiple tests can be per-formed to assess the patient’s dry eye and the presence of MGD:

• Lid exam. First, lid exami-nation may show significant blepharitis with inspissation in meibomian glands, and neovas-cularization of the lid margin may be present depending on the severity of the condition.

• Corneal staining. A second important observation in the evalu-ation of DES is the presence of cor-neal staining. Corneal staining with

Clogged meibomian glands in a contact lens patient complaining of intolerance.

Fluorescein staining due to dry eyes prior to a contact lens fit.

Photo: Mile Brujic, O.D., and Jason M

iller, O.D., M.B.A.

Photo: Keshia S. Elder, O.D., M.S.



instillation of fluorescein indicates tissue damage to the cornea and dryness. According to Eric Don-nenfeld, M.D., the use of these dyes can be quite beneficial to the practice. The dyes are effective because they stain dam-aged epithelial cells where there is a loss of mucin in the tear film.9

• Tear evaluation. Lastly, we can evaluate the amount of tears via the tear film break-up time, Schirmer’s test and corneal topography. For these cases, we can now use the TearLab osmometer (TearLab Corporation) to evaluate tear osmolarity. A recent study by Dr. Donnenfeld and colleagues reiter-ated the importance of using tear osmolarity testing on contact lens and refractive surgery patients. This is especially important because DES can affect surgical outcomes or pose a problem for contact lens wear.5 Topography is also useful in determining the severity of dryness by evaluating the regularity of the axial maps, as well as the placido rings, espe-cially in pre- and post-refractive surgery cases.9

TreatmentTreatment plans are formulated

depending on the quality and quantity of tears, symptoms and the presentation of the cornea. Most clinicians delegate treat-ment according to the severity of the case. Treatment for mild to moderate blepharitis and MGD consists of better lid hygiene and digital massaging of the lids. In severe cases, oral antibiot-ics should be considered and it’s important to treat the underlying pathology. Topical medications,

such as antibiotic and/or combi-nation steroid ointments, qd to b.i.d. for up to two weeks, and oral doxycycline (20mg to 50mg/day) can help improve tear film quality.9

In-office expression of the mei-bomian glands also provides relief for the patient. Topical antisthetic is applied to the lid margin and the eye care provider manipulates the lid with two cotton-tipped applica-tors—one on either side of the lid. Alternatively, a Mastrota paddle (Ocusoft) can be used. The paddle is a smooth-edged titanium paddle designed to gently express the mei-bum from the glands. The paddle is placed behind the tarsal plate and digital pressure is applied. This is a less expensive and less irritat-ing option for the patient.10

The FDA approved the second edition LipiFlow (TearScience) pulsation treatment in March 2012. With this system, the prac-titioner applies a sterile single-use combined lid warmer and eye cup to the patient’s lids. The machine generates heat and pulsation to the area. The procedure lasts for approximately 12 minutes.

Insurance currently does not cover the procedure. The machine itself can cost more than $90,000.

Some centers charge around $1,500 for the treatment. Studies show that patients do well with one treat-ment a year and report a significant increase in patient comfort and less symptoms, particu-larly in comparison to the alternative of mei-bomian gland probing.

Information on prev-alence, risk factors and how MGD affects the ocular surface is only

just beginning to emerge. More than a decade ago the mecha-nism and etiology of this dry eye syndrome was unknown. Today there is a plethora of information regarding dry eye, easily acces-sible to the general public. Keep in mind that in addition to the millions of Americans who suffer from dry eye disease, an estimated 39 million have not yet been diag-nosed.3 It is only a matter of time now before we solve the remain-ing mysteries of MGD. RCCL

1. Nichols KK. The international workshop on meibomian gland dysfunction: introduction. Invest Opthalmology Vis Sci. 2011 Mar 30;52(4):1917-21.2. Knop E, Knop N, Millar T, et al. The international workshop on meibomian gland dysfunction: report of the subcommittee on anatomy, physiology, and pathophysiology of the meibomian gland. Invest Ophthalmol Vis Sci. 2011 Mar 30;52(4);1938-78.3. McDonald MO. The importance of improving the ocular surface on surgical outcomes. Novel Therapeutic Regimens in Treating Ocular Surface Disease and Blepharitis. EyeWorld. 2008 Sep;(Suppl):6-7. 4. Narayanan S. Osmolarity: a diagnostic test for dry eye. Rev Optom. 2011 Jan;148(1):69-73.5. Donnenfeld E. Goundbreaking osmolarity prevalence study. Presented at the annual meeting of the American Society of Cataract and Refractive Surgery, April 23, 2012; Chicago.6. Kaiser P, et al. Blepharitis. In: The Will’s Eye Manual, 2nd ed. Philadelphia: Lippincott, Williams & Wilkins; 2004:58-9.7. McCulley JP, Shine WE. Changing concepts in the diagnosis and management of blepharitis. Cornea. 2000 Sep;19(5):650-8.8. Shimazaki J, Sakata M, Tsubota K. Ocular surface changes and discomfort in patients with meibomian gland dysfunction. Arch Ophthalmol. 1995 Oct;113(10):1266-70.9. Caceres V. Dry eye step-by-step: how to diagnose and treat dry eye. Eye World News. 2006 Sep. Available at: www.eye-world.org/article.php?sid=3381 (accessed May 2012).10. McCulley JP. A combination therapy for blepharitis and mei-bomianitis. Ophthalmol Manage. 2006 Sep. Available at: www.ophmanagement.com (accessed May 2012).

Diagram of the LipiFlow thermal pulsation system.


They need consistently

crisp, clear vision.

1 Results from a 21-investigator, multi-site study of PureVision2 HD contact lenses. After 14 days of daily wear, subjects completed an online survey regarding lens performance. A total of 225 new-to-contact lens subjects completed the survey. Consumers rated the extent to which they agreed or

disagreed with performance attributes on a 6 point scale (1 = strongly disagree and 6 = strongly agree).2 Results from a 20-investigator, multi-site cross-over study of PureVision2 For Astigmatism and PureVision Toric lenses. A total of 292 subjects completed the study. After 7 days of wear for each lens, subjects completed an online survey regarding lens performance. Consumers rated performance

attributes using a 6-point scale (1 = strongly disagree and 6 = strongly agree) and using a 5-point scale (excellent, very good, good, fair, poor). At the fi nal visit, investigators rated the extent to which they agreed or disagreed with performance attributes also using a 6-point scale.3 Results from a study of eye care professionals who had prescribed PureVision2 HD lenses. 201 eye care professionals completed an online survey regarding lens performance and rated the extent to which they agreed or disagreed with performance attributes on a 6-point scale (1 = strongly

disagree and 6 = strongly agree).

© 2012 Bausch & Lomb Incorporated. ®/™ are trademarks of Bausch & Lomb Incorporated or its affi liates. PNS06112 HL5676

NOW AVAILABLE

FOR ASTIGMATISM

NEW!

What do all these patientshave in common?

Bausch + Lomb PureVision®2 HD and PureVision2 HD For Astigmatism contact lenses are designed to give your patients consistently crisp, clear vision.

Both feature High Defi nition™ Optics for crisp, clear vision, and signifi cant design advancements for comfort and breathability. Plus, new PureVision2 HD

For Astigmatism lenses include our unique Auto Align Design™ for consistent on-eye stability and fewer visual fl uctuations.

Add it all up, and you’ve got a family of lenses that give your patients more of what they are looking for.

What wearers are saying about PureVision2 lenses:

83% of fi rst-time lens wearers say PureVision2 HD lenses are the ideal lens for them1

87% of astigmatic wearers rate their vision with PureVision2 HD For Astigmatism

as good to excellent2

84% of eye care professionals say PureVision2 HD provides crisp, clear vision3

Scan to learn how HD Optics help

deliver crisp, clear vision.

RCCL0512_BL Pure.indd 1 4/26/12 9:52 AM


The tear film is a unique fluid in the body, with multiple functions that include pro-

tecting the cornea and ocular sur-faces from infection, providing key nutrients and oxygen to the avas-cular cornea, carrying away debris and cellular waste and maintaining a clear fluid to wet and lubricate the ocular surfaces.1-4 We are just beginning to appreciate the mag-nitude of the role of the lipid layer and the tear film in providing a planar film of nanometer specifica-tions for clarity of vision.

The tears and lipid layer are dynamic, not uniform, and change in thickness with and between each blink. Eugene Wolff, M.D., the renowned English ophthalmologist and author of “The Anatomy of the Eye and Orbit,” was the first to propose a three-layered fluid comprising a lipid layer over an aqueous layer, with a mucin layer anchored to the corneal surface.5,6 It is this dynamic, metastable mixture of ingredients that makes the tear unique, reforming after each blink.

We have since further developed our understanding of the tear film, evolving from the three-layer sys-tem of Dr. Wolff to a more com-plex understanding of as many as six layers, and a mix of additional ingredients.7

The Lipid Layer and Dry EyeWe went from an aqueous and

mucin model of dry eye to under-standing the critical impact of the lipid layer. As recently as 2007, the Dry Eye Workshop Report empha-sized the causative mechanisms and roles of tear hyperosmolality and inflammation, minimizing the role of the meibomian glands and the lipid layer.8 Treatments revolved around the use of demulcents, emulsifiers and viscosity agents in over-the-counter products, with emollients comprised of lanolin, mineral oil, petrolatum and waxes used in oint-ments.9 Restasis (cyclosporine, Aller-gan) is the only prescription drug reported to increase the production of the aqueous portion of the tears.10

The obstruction of the meibomian

Anionic phospholipids can enhance lipid layer thickness and help patients find relief from dry eye.By Donald Korb, O.D., and Ralph Stone, Ph.D.

Are Phospholipids the Critical Ingredient?

Dr. Korb has divided his time between the prac-

tice of optometry and research. His accom-plishments include over 95 refereed publica-tions, 35 U.S. patents, founding five research companies and naming MGD, GPC and lid wiper epitheliopathy.

Dr. Stone retired from Alcon Labora-tories in

2006, after nearly 30 years in research and development of prod-ucts for contact lens care and the treatment of dry eye and other ophthalmic products. He currently continues to consult in the area of ophthalmology.

038_rcl0612phospholipids.indd 38 5/24/12 4:33 PM


gland ducts leads to disturbances in the production of lipids for the tear film’s lipid layer, a process first described and named meibo-mian gland dysfunction (MGD) in 1980 by Dr. Korb and Antonio Henriquez, M.D., Ph.D.11

In 2011, The International Workshop on Meibomian Gland Dysfunction reported that “it is believed that meibomian gland dysfunction may well be the leading cause of dry eye disease throughout the world.”12 A 2012 report further confirmed this paradigm shift by indicating that 86% of all dry eye disease patients demonstrated signs of MGD.13 It is therefore apparent that understanding the contribu-tion of the lipid layer, as well as the function and dysfunction of the meibomian glands, is impor-tant in the diagnosis and treat-ment of dry eye.

It has been reported that the thinning or loss of the nanometer thick lipid coating at the surface of the tears leads to increased evaporation of the aqueous por-tion of the tears resulting in dry areas.14 Majd A. Isreb, M.D., and colleagues noted that lipid layer thicknesses (LLT) of 60nm or less correlated with fluorescein break-up time and Schirmer’s test scores indicative of dry eye; LLT of greater than 120nm have low to no likelihood of having dry eye.15

The Tear StructureGiven that the lipid layer has

an important influence on the tear, understanding the structure of this portion of the tear struc-ture is critical. This thin layer of lipid, usually 50nm to 100nm, is not a single homogeneous layer. It is believed that there is a layer of polar lipids overlying the aqueous layer of the tears, and a second layer of non-polar, hydro-

phobic lipids facing the air.16,17

The precise composition of these tear film lipids continues to be debated. While the non-polar fraction is reported to contain cho-lesterol esters and mono, di- and tri-glycerides, the polar fractions forming the interface between hydrophobic and hydrophilic domains are more interesting. It is in this layer that phospholipids play an important role.

Igor Butovich, Ph.D., and

Thomas James Millar, Ph.D., reported that the levels of phos-pholipids in the tears were dependent on the animal species—rabbits and koala bears, for exam-ple, and other animals with long inter-blink intervals show much higher levels of phospholipids.18

What are Phospholipids?Phospholipids are a class of

molecules that are important in the body. Members of this class make

Examples of Phospholipids Associated with the Eye20-23

Phospholipid Structure of R3 From Figure 1 or Full StructurePhosphatidylcholine

Phosphatidylserine

Sphingomyelin

(full structure)

Phosphatidylethanolamine

Phosphatidylglycerol

Dihydrosphingomyelin

(full structure)

Ethanolamineplasmalogen

Lysophosphatidylcholene

Phosphatidylinositol



up the important structures form-ing the bi-layer of the cell wall.19

These molecules help form the structure of the tears (figure 1).

Research into identifying and understanding the role of phos-pholipids present in tears has seen mixed results. “Examples of Phospholipids Associated with the Eye” shows some of the phospholipids identified in tears. Phospholipids have basi-cally two types: zwitterionic and anionic. All the compounds contain a negative charge on the oxygen attached to the phospho-rous group. If the polar group at R3 contains a positive charge, such as phosphatidylcholine, then the overall net charge of the system is neutral. These are called zwitterionic phospholipids. Phospholipids that have polar groups at R3 that contain a polar group containing no charge such as phosphatidylglycerol, or have a net negative charge such as phosphatidylserine, are defined as anionic phospholipids.

We now understand that not all phospholipid structures are equally important in providing a thicker, more stable lipid layer in the tear.

Phospholipids and TearsThere are two phospholipids

predominant in tears—phospha-tidylcholine and phosphatidyl-ethanolamine—which account

for 60% of the phospholipid profile of the meibomian secre-tions.20 Oliver Shine, Ph.D., and James McCulley, M.D., reported that low levels of phosphatidyl-ethanolamine and sphingomyelin were associated with evaporative dry eye rather than tear insuf-ficiency.23 They determined that chronic blepharitis patients had significantly lower amounts of anionic phosphatidylethanol-amine and sphingomyelin but not the zwitterionic neutral phospho-lipid phosphatidylcholine.23

Dr. Korb and colleagues inves-tigated the effect of the polar anionic phospholipid, dimyriste-roylphosphatidylglycerol and the zwitterionic phosphatidylcholine alone and combined with white mineral oil.24 We found that an anionic formulation with white mineral oil increased the lipid layer thickness from 63nm to 115nm at 60 minutes.24 In com-parison, an identical formula-tion, but with the zwitterionic

phospholipid phosphatidylcho-line substituted for the anionic dimyristeroylphosphatidylg-lycerol resulted in a marginal increase from 63nm to 67.5nm at 60 minutes.24

Using formulations with no added mineral oil provided much lower, but similar results. The zwitterionic phosphatidylcholine showed no increase in LLT at 60 minutes compared to baseline.

Phospholipids and Dry EyeDr. Isreb and colleagues found

that LLT was correlated with measurement of tear film break-up time (TFBUT) and Schirmer test with anesthesia (STA).15 The results demonstrated the impor-tance of the LLT (see “Classifica-tion of Probable Dry Eye,” page 41).

Only recently have emulsions been designed and marketed to target the lipid layer for the treatment of the signs and symp-toms of dry eye. However, these approaches can only replace the lipids produced in the mei-bomian glands, not change the actual production of meibum. The Soothe (Bausch + Lomb) emulsion formula used non-phospholipid ingredients to rebuild the interface with the non-polar lipid facing the hydrophobic air and the hydro-philic aqueous portion of the tears. Results of these studies indi-cated that the lipid layer could be

2. Good right overlay. 3. Average left overlay. 4. Bad right overlay.

1. The general structure of phospholip-ids, where R1 and R2 are saturated or unsaturated fatty acids, and R3 is numer-ous polyols, aminoalcohols and complex O and N groups.



enhanced at one, five and 15 min-utes from 59.6nm to 121.5nm.25

Soothe XP (Bausch + Lomb), a non-phospholipid emulsion, was compared to Systane Balance (Alcon), an anionic phospholipid emulsion, in a study by Dr. Korb and colleagues.26 Systane Balance increased LLT from baseline of 60nm to 90nm at two hours, a 50% improvement over base-line. Soothe, on the other hand, increased LLT from baseline of 60nm to 73nm at two hours, only 13nm above baseline. This differ-ence was significant (p=0.0002), providing further support for the efficacy of anionic phospholipids in increasing LLT.

Confirming the improvement in LLT with the anionic phospho-lipid-based formulation, a clini-cal study by Gary Foulks, M.D., and colleagues reported that use of this anionic phospholipid-based formulation (Systane Bal-ance) for one month compared to their habitual dry eye therapy showed significant improvement in TFBUT (p=0.032) and corneal staining reduction (p=<0.001).27

There were improvements in the patient’s ability to perform activities (p=0.006), a reduction of daily activity and work limita-tions (p=0.001, <0.001), as well as a reduction of symptom bother (<0.001), based on the Impact of Dry Eye Everyday Living (IDEEL) questionnaire.

Current evidence indicates that MGD and the resultant decrease in lipid secretions may be the primary cause of dry eye. It is now established that the lipid layer must be adequate to mini-mize evaporation and stabilize the tear film—to avoid dry eye or treat it when already present. Nature’s secret to the stability of the overall tear film appears

to be the anionic phospholipids that provide a stable interface between non-polar lipids at the surface and the hydrophilic aque-ous layer. These molecules work to enhance the lipid layer thick-ness resulting in reductions of key signs and symptoms of dry eye.

We now have ways to repair the lipid layer. An emulsion based on anionic phospholipids enhances the lipid layer thickness, resulting in improved overall tear stability. While not a cure for dry eye, these anionic phospholipid formulations can provide relief for many patients. RCCL

1. Craig JR. Structure and function of the preocular tear film. In: Korb DR, Craig J, Doughty M, et al. (Eds): The Tear Film: Structure Function and Clinical Examination. London: Butterworth-Heinemann;2002:18-50.2. Lemp MA. Basic principles and classification of dry eye disorders. In: Lemp MA, Marquardt R (eds). The Dry Eye. New York: Springer-Verlag;1992:101-31.3. Pfugfelder SC, Tseng SC, Sanabria O, et al. Evaluation of subjective assessments and objective diagnostic tests for diagnosing tear-film disorders known to cause ocular irritation. Cornea. 1998 Jan;17(1):38-56.4. Stahl U, Wilcox M, Stapleton F. Osmolality and tear film dynamics. Clin Exp Optom. 2012 Jan;95(1):3-11.5. Wolff E. The muco-cutaneous junction of the lid margin and distribution of the tear fluid. Trans Ophthalmol Soc UK. 1946;66:291-308.6. Wolff E. The Anatomy of the Eye and Orbit, 4th ed. London: H.K. Lewis and Co.;1954:49.7. Holly FJ. Formation and stability of the tear film. Int Ophthalmol Clin. 1973 Spring;13(1):73-96.8. 2007 Report of the International Dry Eye Workshop. Ocul Surf. 2007;5(2):65-206.9. Ophthalmic drug products for over-the-counter use; final monograph. Fed Regist. 1988; 53(43):7076-93.10. Restasis [package insert]. Irvine, CA: Allergan, Inc; 2010 Feb.11. Korb DR, Henriquez AS. Meibomian gland dysfunction and contact lens intolerance. J Am Optom Assoc. 1980 Mar;51(3):243-51.

12. Nichols KK, Foulks GN, Bron AJ, et al. The Report of the TFOS Workshop on Meibomian Gland Dysfunction. Invest Ophthalmol Vis Sci. 2011;52(4):1917-2085.13. Lemp MA, Crews LA, Bron AJ, et al. Distribution of aqueous-deficient and evaporative dry eye in a clinic-based patient cohort: a retrospective study. Cornea. 2012 May;31(5);472-8.14. Mishima S, Maurice DM. The oily layer of the tear film and evaporation from the corneal surface. Exp Eye Res. 1961 Sep;1:39-45.15. Isreb MA, Greiner JV, Korb DR, et al. Correlation of lipid layer thickness measurements with Fluorescein tear film break-up time and Schirmer’s test. Eye. 2003 Jan;17(1):79-83.16. Yamada M, Mochizuki H, Kawai M, et al. Decreased tear lipocalin concentration in patients with meibomium gland dysfunction. Br J Ophthalmol. 2005 Jul;89(7):803-5.17. Millar TJ, Mudgil P, Butovich IA, Palaniappan CK. Adsorption of lipocalin to human meibomian lipid films. Invest Ophthalmol Vis Sci. 2009 Jan;50(1):140-51.18. Butovich IA, Millar TJ. In search of a better animal model of human tear film: comparative lipiomic analysis of human and animal meibum. Invest Ophthalmol Vis Sci. 2009;50: e-abstract 2545.19. Alberts B, Johnson A, Lewis J, et al. Molecular Biol-ogy of the Cell, 4th Edition. New York: Garland Science; 2002.20. Greiner JV, Glonek T, Korb DR, et al. Phospholipids in gland secretion. Ophthalmic Res. 1996;28(1):44-9.21. Dean AW, Glascow BJ. Mass spectrophoyometric identification of phospholipids in human tears and tear lipocalin. Invest Ophthalmol Vis Sci. 2012 Apr 2;53(4):1773-82.22. Ham BM, Cole RB, Jacob JT. Identification and com-parison of the polar phospholipids in normal and dry eye rabbit tears by MALDI-TOF mass spectrometry. Invest Ophthalmol Vis Sci. 2006;47(8):3330-8.23. Shine W, McCulley JP. Keratoconjunctivitis sicca associated with meibomian secretion polar lipid abnormal-ity. Arch Ophthalmol. 1998 Jul;116(7):849-52.24. Korb DR, Greiner JV, Glonek T. The effects of anionic and zwitterionic phospholipids on the tear film lipid layer. Adv Exp Med Biol. 2002;506(Pt A):495-9.25. Scaffidi RC, Korb DR. Comparison of two lipid emul-sion eye drops in increasing tear film lipid layer. Eye Contact Lens. 2007 Jan;33(1):38-44.26. Christensen MT, Blackie CA, Korb DR, et al. An evalu-ation of the performance of a novel lubricant eye drop. Invest Ophthalmol Vis Sci. 2010;51:e-abstract 4141.27. Foulks G, Sindt C, Griffin J. Efficacy evaluation of a novel emulsion based, anionic phospholipid-containing artificial tear in meibomian gland dysfuntion subjects. Poster presented at the 6th Conference of the Tear Film and Ocular Surface Society, Florence, Italy; September 2010.

Classification of Probable Dry Eye

Category TFBUT STA LLT High probability of 0-5 seconds 0-5 mm < 60 nmsignificant dry eyesigns and symptoms

Intermediate probability 6 to <10 seconds 6 to <10 mm > 75-105 nmof significant dryeye signs and symptoms

Low or no probability > 10 seconds > 10 mm > 120 nmof significant dry eye signs and symptoms


RO0512_House Seco Vancouver.indd 1 4/19/12 3:29 PM

http://www.seco2012.com/Vancouver


Along with other facets of commericialization, the con-tact lens market has become

globalized during the past 30 years. The major international companies have worldwide distribution net-works and supply lenses of the same product names and replacement frequencies to all nations, with a few minor adjustments for marketing and regulatory reasons. Small and medi-um-sized companies, often produc-ing more specialized lenses, are also active in markets across the world.

As a result of this contact lens globalization trend, one might expect there to be little difference between the way contact lenses are prescribed in the United States and other nations. One way of address-ing whether this is true is to directly compare contact lens prescribing trends around the world. In the past 15 years, we have built up a consor-tium of about 40 countries in which we conduct annual surveys of con-tact lens prescribing techniques.

In 2011, we gathered information on 22,362 lens fits in 29 countries. Through coordinators in each coun-try, we distributed up to 1,000 paper or electronic survey forms to contact lens practitioners who, in turn, col-lected information about their next

10 lens fits. Data were processed and checked in the survey administrative offices at the University of Manches-ter, United Kingdom, and the Univer-sity of Waterloo, Canada.

In this article, we analyze our 2011 data set to determine the extent to which the U.S. market aligns with—or differs from—other nations with respect to a selection of some key aspects of contact lens prescribing.

The DemographicsIn the U.S., 66% of contact lens

wearers are women, which is com-parable to the world average of 67% (ranging from 58% in Hungary to 77% in Taiwan). The mean age for all patients fitted was 32.4 years in the U.S. vs. 31.2 years worldwide; the lowest average age was 23.3 years in Nepal and the highest was 36.5 years in New Zealand and Swe-den. In general, more mature contact lens markets report older patients, principally driven by a larger, more experienced pool of existing wearers returning for refitting.

The Rigid Lenses WearersFigure 1 shows the proportion

of rigid lenses fitted in different nations, stratified according to new

A look at how contact lens prescribing in the United States compares with other world markets.By Philip Morgan, B.Sc., Ph.D., MCOptom, Nathan Efron, Ph.D., D.Sc., and Craig Woods, Ph.D., DipCLP

Contact Lens Prescribing: USA vs. the World

Dr. Mor-gan is the director of Eurolens Research

and program director of optometry at the Uni-versity of Manchester in the United Kingdom.

Dr. Efron is research professor in the School of Optom-

etry and Vision Science and the Institute of Health and Biomedi-cal Innovation at the Queensland University of Technology.

Dr. Woods is the director of Optometric Clinical

Studies, teaches at Dea-kin University and the University of Waterloo and serves as secretary of the International Society for Contact Lens Research.

043_rcl0612Trends.indd 43 5/24/12 4:42 PM


fits and refits. Of the 29 countries surveyed, we can see a varying spread—ranging from 28% of con-tact lens wearers fit in rigid lens in Slovenia to no rigid fits in Iceland and Lithuania.

Worldwide, 10% of all con-tact lens fits were rigid lenses and orthokeratology was reported in 2% of the fits. Comparatively, the United States sits towards the lower end of this spectrum with only 4% of new lens fits and 2% of refits in rigid lenses.

The high percentage of rigid lens fitting in New Zealand and the Nether-lands is likely credited to the fact that practitioners in those nations, along with the local lens manu-facturing industry, have a long tradition of fitting these lenses. In New Zea-land, the popularity of orthokeratology is likely responsible for the report-ed 39% of new rigid lens fits and 11% of rigid lens refits.

In Japan and France, the tradition of rigid lens fittings is likely bol-stered by the fact that a significant proportion

of contact lens fittings in both these countries are performed by ophthalmologists who tend to fol-low a more traditional approach. The emphasis on rigid lens fittings by a predominantly ophthalmo-logical profession may relate to the belief—substantiated to some extent by epidemiological studies of contact lens-associated infec-tious keratitis—that this lens type affords greater benefits in terms of ocular health.1

In nations with 35 or more recorded rigid lens fits, high Dk lenses (>90 units) are the lens of choice—accounting for 65% of all of these lens fits. About half of all rigid lenses (51%) are prescribed on a planned replacement modal-ity, usually annually.

Silicone Hydrogel LensesAs was the case with rigid lenses,

there is a wide spectrum in the popularity of silicone hydrogel lens

fittings across the world. In Slovenia, 99% of new soft lens fits are with this silicone hydrogel, compared to only 1% of fits in Taiwan. Figure 3 shows the proportion of all daily wear soft lens new fits that are silicone hydrogel (SiHy) lenses.

The United States, with 56% of new soft lens fits, sits close to the world average. Keep in mind that this graph needs to be interpreted with caution because it fails to take into account the popularity of daily disposable lenses in many markets. At the time of the 2011 survey,

1. The proportion of rigid lenses prescribed, shown as new fits and refits.

3. The proportion of all new daily wear soft lens new fits which are silicone hydrogel lenses.

2. Overall breakdown of the United States market (outer ring) compared with the rest of the world.



only two of the many brands of daily dispos-able lenses on the world market were available in SiHy materials.

Daily Disposable Lenses

Since their introduc-tion to the market in the mid-90s, daily disposable lenses have considerably changed the contact lens industry. A 2011 snap-shot of the worldwide lenses shows that there were at least 12 brands of spherical, five brands of toric, one brand of multifocal and one brand of cosmetic colored hydrogel lenses, as well as two brands of spherical SiHy lenses, available in the daily disposable modality.

Daily dis-posables now represent 26% of soft daily wear fits across all nations surveyed. The United States reported a 19% soft daily wear percentage, ranking 16 of the 29 nations surveyed. Note: Monthly replacement lenses now constitute the majority (53%) of soft lenses prescribed in the United States, with two-week replacement

lenses following with 27% of fits. Only 1% of U.S. fits, compared to 10% worldwide, are prescribed for

less frequent replacement schedules.

Daily disposable pre-scribing varies from a high of 55% in Norway to a low of 2% in Bul-garia (figures 4 and 5). Perhaps a significant driver of daily disposable prescribing is the gener-ally higher retail cost of this modality.

We have found that, for part-time wearers, the cost of daily dispos-able contact lens wear is not significantly different

compared to other replacement modalities when the cost per wear is calculated. However, there are

greater costs encountered with daily dis-posables for full-time wearers.2

The metric we developed fac-tors in all related lens wear costs, including contact lens solutions and professional fees, and cre-ates an equitable basis for compar-ing the true costs of contact lens wear.

Toric Soft Lenses

Perhaps the key advance in soft lens design over the past 10 years is the improvement of toric lenses—including better stabilization designs, greater lens-to-lens

4. The proportion of all soft lens fits prescribed for daily disposability.

Country Codes and Coordinators for the 2011 Annual Survey

Code Country CoordinatorAU Australia Nathan EfronBG Bulgaria Christina N. GrupchevaCA Canada Craig A. Woods, Deborah JonesCN China Kah-Ooi TanCZ Czech Republic Alice PesinovaDK Denmark Ole RavnES Spain Jacinto SantodomingoFR France Florence MaletHK Hong Kong Kah-Ooi TanHR Croatia Ioannis TranoudisIL Israel Nir ErdinestIS Iceland Hreinn Ingi HreinssonJP Japan Motozumi ItoiKR South Korea Byoung Sun ChuLT Lithuania Jolanta BendorieneNL Netherlands Eef van der WorpNO Norway Magne HellandNP Nepal Suresh AwasthiNZ New Zealand Geraint PhillipsPT Portugal José Manuel González-MéijomeRO Romania Simona RaduRU Russia Vadim BelousovSE Sweden Jorgen GustafssonSI Slovenia Mirna Stabuc SilihTW Taiwan John C.J. HsiaoUK United Kingdom Philip B. MorganUS United States Jason Nichols



reproducibility and easier fitting protocols. In general, this has led to greater use of soft toric lenses.

Figure 6 shows the proportion of soft torics among the total number of spherical and toric lenses (i.e., excluding multifocals, monovision and cosmetically tinted lenses). The United States, with 30% of fits, falls in the middle of the range of world-wide markets—from the high end of 50% in India and Sweden to a low of 4% in China.

It is important to consider the “ideal” rate of toric lens prescribing: If all astigmatism of 0.75D or greater was corrected, it would be 45%. Since that threshold is not reached in most markets, here are some potential reasons:

• The perception that greater chair time might be required to appropriately fit a soft toric lens with 0.75D power compared to the small visual benefit.

• The erroneous percep-tion that spherical soft lenses will “mask” signifi-cant amounts of corneal astigmatism.

• The limited range of toric lens corrections in some lens types, such as daily disposables.

• The tendency by some practi-tioners to opt for the simplicity of a bilateral spherical correction in the case of a patient with a low refrac-tive cylinder in one eye (i.e., 0.50D) and a higher refractive cylinder in the other (i.e., 1.00D), thereby low-ering the overall proportion of toric lenses prescribed.

In the past decade there has been a clear trend towards

globalization in the contact lens market, yet a clear differ-ence between the United States and other contact lens markets around the world still exists. This is likely due to the differences within the professional groups fitting lenses, as well as various regulatory constraints imposed by governments, issues of costs and profit margins, the effectiveness of local marketing initiatives and, perhaps most importantly, the knowledge and attitudes of lens fitters. Although it is likely to be

a considerable amount of time before this list of factors is harmo-nized on a global level, we should expect to see continued differences between contact lens markets and prescribing habits for many years to come. RCCL

1. Morgan P, Efron N, Hill E, et al. Incidence of keratitis of varying severity among contact lens wearers. Br J Oph-thalmol. 2005;89:430–6.2. Efron SE, Efron N, Morgan PB, et al. A theoretical model for comparing UK costs of contact lens replacement modalities. Cont Lens Anterior Eye. 2012 Feb;35(1):28–34.

6. The proportion of soft lenses (excluding bifocal and tinted tenses) that are fitted in toric form.

5. Color-coded map showing proportion of daily disposable lens fits. The key shows a range of prescribing from 0% to 60%.


THE OCULAR SURFACE IS ONE.

© 2012 Novartis 2/12 SYS11179JAD

References1. Christensen MT, Blackie CA, Korb DR, et al. An evaluation of the performance of a novel lubricant eye drop. Poster D692 presented at: The Association for Research in Vision and Ophthalmology Annual Meeting; May 2-6, 2010; Fort Lauderdale, FL. 2. Lane S, Paugh JR, Webb JR, Christensen MT. An evaluation of the in vivo retention time of a novel artifi cial tear as compared to a placebo control. Poster D923 presented at: The Association for Research in Vision and Ophthalmology Annual Meeting; May 3-7, 2009; Fort Lauderdale, FL. 3. Davitt WF, Bloomenstein M, Christensen M, et al. Effi cacy in patients with dry eye after treatment with a new lubricant eye drop formulation. J Ocul Pharmacol Ther. 2010;26(4):347-353. 4. Alejandro A. Effi cacy of a Novel Lubricant Eye Drops in Reducing Squamous Metaplasia in Dry Eye Subjects. Presented at the 29th Pan-American Congress of Ophthalmology in Buenos Aires, Argentina, July 7-9, 2011. 5. Wojtowica JC., et al. Pilot, Prospective, Randomized, Double-masked, Placebo-controlled Clinical Trial of an Omega-3 Supplement for Dry Eye. Cornea 2011:30(3) 308-314. 6. Geerling G., et al. The International Workshop on Meibomian Gland Dysfunction: Report of the Subcommittee on Management and Treatment of Meibomian Gland Dysfunction. IOVS 2011:52(4).

RCCL0612_Alcon Systane.indd 1 5/24/12 2:08 PM

FDA approved for up to 30 nights of continuous wear**

#1 ECP-recommended brand for patients who sleep overnight in their contact lenses2

Delivers the highest oxygen transmissibility* of any available soft contact lens3

Monthly replacement schedule promotes patient compliance4† and may increase practice profi tability5

Visit myalcon.com to learn more.

More people are sleeping in their contact lenses

than you think.

Nearly 1 in 5.1

Important information for AIR OPTIX® NIGHT & DAY® AQUA (lotrafi lcon A) contact lenses: AIR OPTIX® NIGHT & DAY® AQUA contact lenses are indicated for vision correction for daily wear (worn only while awake) or extended wear (worn while awake and asleep) for up to 30 nights. Relevant Warnings: A corneal ulcer may develop rapidly and cause eye pain, redness or blurry vision as it progresses. If left untreated, a scar, and in rare cases loss of vision, may result. The risk of serious problems is greater for extended wear vs daily wear and smoking increases this risk. A 1-year post-market study found 0.18% (18 out of 10000) of wearers developed a severe corneal infection, with 0.04% (4 out of 10000) of wearers experiencing a permanent reduction in vision by two or more rows of letters on an eye chart. Relevant Precautions: Not everyone can wear for 30 nights. Approximately 80% of wearers can wear the lenses for extended wear. About two-thirds of wearers achieve the full 30 nights continuous wear. Side Eff ects: In clinical trials, approximately 3-5% of wearers experience at least one episode of infi ltrative keratitis, a localized infl ammation of the cornea which may be accompanied by mild to severe pain and may require the use of antibiotic eye drops for up to 1 week. Other less serious side eff ects were conjunctivitis, lid irritation or lens discomfort including dryness, mild burning or stinging. Contraindications: Contact lenses should not be worn if you have: eye infection or infl ammation (redness and/or swelling); eye disease, injury or dryness that interferes with contact lens wear; systemic disease that may be aff ected by or impact lens wear; certain allergic conditions or using certain medications (ex. some eye medications). Additional Information: Lenses should be replaced every month. If removed before then, lenses should be cleaned and disinfected before wearing again. Always follow the eye care professional’s recommended lens wear, care and replacement schedule. Consult package insert for complete information, available without charge from Alcon at (800) 241-5999 or myalcon.com.

References: 1. Alcon date on fi le, 2009. 2. In a survey of 203 optometrists in the U.S.; Alcon data on fi le, 2011. 3. Based on the ratio of lens oxygen transmissibilities; Alcon data on fi le, 2009, 2010. 4. Dumbleton K, Richter D, Woods C, et al. Compliance with contact lens replacement in Canada and the United States. Optom Vis Sci. 2010;87(2):131-139. 5. Compared to 2-week replacement lenses; based on self-reported lens replacement times and third-party industry pricing information; Alcon data on fi le, 2012.


*AIR OPTIX® NIGHT & DAY® AQUA (lotrafi lcon A) contact lenses: Dk/t = 175 @ -3.00D. Other factors may impact eye health. **Extended wear for up to 30 continuous nights as prescribed by an eye care practitioner. †Compliance with manufacturer-recommended replacement frequency.

For those people, choose the next best thing to not sleeping in lenses—AIR OPTIX® NIGHT & DAY® AQUA contact lenses

© 2012 Novartis 2/12 AND12017JAD

RCCL0612_Alcon ND.indd 1 5/22/12 3:23 PM

http://www.myalcon.com

also inside this issue - review of cornea & contact lenses€¦ · severe bacterial keratitis...

Documents