expert advice on diagnosing, treating preventing · pdf fileexpert advice on diagnosing,...

APRIL 2015RCCLRCCLREVIEW OF CORNEA & CONTACT LENSES

Supplement to

SPECIAL ISSUE

• Bringing Clarity to CLARE

• Is That Corneal Infi ltrate Sterile or Infectious? EARN 1 CE CREDIT

• Special Care Keeps Specialty Lens Wearers Safe

• Five Steps to Increase Contact Lens Adherence

• Anti-VEGF for Corneal Neovascularization

• Troubleshooting GP Lens Complications

ALSO• Dry Eye: See It Through Their Eyes

!SAFETY

STRATEGIES

COMPLICATIONSExpert advice on diagnosing, treating and—most of all—preventing problems.

CONTACT LENS

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contentsReview of Cornea & Contact Lenses | April 2015

/ReviewofCorneaAndContactLenses #rcclmag

departments

12Dry Eye: See It Through Their EyesPatient questionnaires quantify the subjective experience of the disease. Though vital for research, are they worth using in your practice?By Aliza Martin, Associate Editor

16Bringing Clarity to CLAREUnderstanding and knowing how to treat this common contact lens complication can benefi t both your patients and your practice.By Lindsay A. Sicks, OD

20Special Care Keeps Specialty Lens Wearers SafeContact lens care is a vital step to the continued safety and health of the contact lens patient. So how does lens care diff er in the case of sclerals and other specialty lenses?By Susan J. Gromacki, OD, MS

24CE — Is that Corneal Infi ltrate Sterile or Infectious?Diff erentiating between the two requires close observation and analysis. Here’s a results-oriented approach.By Jeff rey Sonsino, OD, and Shachar Tauber, MD

News Review4Sclerals May Aff ect Corneal Nerves;

Age and Astigmatic VA: No Link

My Perspective 6Getting Serious About OSD

By Joseph P. Shovlin, OD

Lens Care Insights7 The Great Silicone Cover-Up

By Christine W. Sindt, OD

Five Steps to Increase Contact Lens Adherence

By Mile Brujic, OD, and Jason R. Miller, OD, MBA

Pharma Science & Practice10

Derail Dropouts 8

Anti-VEGF in the Anterior Segment

By Elyse L. Chaglasian, OD, and Tammy P. Than, OD, MS

features

Troubleshooting GP Complications

By Stephanie L. Woo, OD

Managing Acute Corneal Hydrops

in Keratoconus

By James Thimons, OD

Are You a Mentalist?

By Gary Gerber, OD

GP Expert30

Corneal Consult32

Out of the Box34

Cover design by Matt Egger©iStock.com/Jobsonhealthcare

REVIEW OF CORNEA & CONTACT LENSES | APRIL 2015 3

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News Review

4 REVIEW OF CORNEA & CONTACT LENSES | APRIL 2015

IN BRIEF• Corneal crosslinking may acceler-ate epithelialization and reduce length

and severity of necessary treatment in

moderate bacterial keratitis, according to a study in the April 2015 Cornea.1

Researchers separated 32 bacterial keratitis patients into two groups. The control group was treated using stan-dard medical therapy (i.e., lubrication, fortifi ed cefazolin (50mg/mL) every hour, and systemic doxycycline every 12 hours following loading doses of forti-fi ed cefazolin and gentamicin) and the case group was treated with CXL and standard medical therapy. No statisti-cally signifi cant diff erence was noted between the two groups one day fol-lowing treatment, but researchers noted the epithelial defects and the area of

infi ltrates were both smaller in the CXL group compared to the control group by day seven following the beginning of treatment.1. Bamdad S, Makelhosseini H, Khosravi A. Ultravio-let A/Ribofl avin Collagen Crosslinking for Treat-ment of Moderate Bacterial Corneal Ulcers. Cornea. 2015 Apr;34(4):402-6.

• Tobramycin can help prevent second-

ary corneal infections in patients wear-ing therapeutic soft contact lenses, says new research published in the March 2015 Eye & Contact Lens.1

Researchers cultured 40 therapeutic soft lenses of patients being treated for recurrent corneal erosion following a two-week wearing period. During wear time, patients were treated four times per day with topical tobramycin 3% and topical sodium hyaluronate 0.1%. Upon culturing, however, nine of the 40 lenses yielded positive cultures, with Staphy-lococcus epidermidis identifi ed as the predominant organism. Methicillin-sen-sitive coagulase-negative staphylococci, methicillin-resistant coagulase-negative staphylococci, Enterobacter gergoviae and Citrobacter freundii were also isolated. No clinical signs of infectious

keratitis were found.

1. Park YM, Kwon HJ, Lee JS. Microbiological Study of Therapeutic Soft Contact Lenses Used in the Treatment of Recurrent Corneal Erosion Syn-drome. Eye Contact Lens. 2015 Mar;41(2):84-6.

Extended wear of fl uid-fi lled scleral contact lenses may change corneal nerve func-

tion in patients with certain diseas-es, according to research published in the April 2015 Cornea.1

Researchers measured tear pro-duction, central corneal sensation, sub-basal nerve density and tortu-osity, and stromal nerve thickness of 20 patients from the Prosthetic Replacement of the Ocular Surface Ecosystem (PROSE) treatment program. Patients were divided into two groups—distorted cor-neas (DC) or ocular surface disease (OSD)—and evaluated before and after 60 days of wear for a mini-mum of eight hours per day.

Researchers found basal tear production signifi cantly decreased and corneal sensation increased in patients with DC following long-term wear of the PROSE prosthetic device. In contrast, tear

production and corneal sensation did not change in patients with OSD. This difference, the research-ers say, may be because patients with DC have a healthier ocular surface; thus, the intact lacrimal functional unit (LFU) “responds to the constant saline exposure by reducing the basal tear production and increasing corneal sensa-tion, which are possible signs of improvement in corneal disease.” In contrast, “patients with OSD did not have similar alterations in LFU function possibly because of ongoing infl ammatory processes disrupting the LFU.”

No signifi cant change in sub-basal nerve density and tortuosity or stromal nerve thickness was observed in either patient group.

1. Wang Y, Kornberg DL, St. Clair RM, et al. Cor-neal nerve structure and function after long-term wear of fl uid-fi lled scleral lens. Cornea. 2015 April;34(4):427-32.

Sclerals May Aff ect Corneal Nerves

Advertiser Index

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CooperVision ......Cover 2, Cover 3

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Age has no signifi cant infl u-ence on visual acuity in the presence of defocus and

astigmatic blur, reports a study published in the March 2015 Op-tometry and Vision Science.1

Researchers dilated the right eyes of 22 participants—12 young adults and 10 older adults—using cyclopentolate 1.0%, then pro-vided each with artifi cial pupils mounted on the back of a trial lens. To evaluate visual acuity, researchers simulated 13 blur conditions using fi ve spherical lens conditions and two cross-spherical lenses at four negative cylinder axes. In each instance, partici-pants were asked to read lines of decreasing size of high-contrast letters based on the Bailey-Lovie

chart through the center of the artifi cial pupil. Following visual acuity measurements, aberrations were also measured.

Researchers found no signifi cant differences in visual acuity be-tween the two age groups, dis-proving their hypothesis regarding the older group experiencing less decrease in visual acuity with blur; accordingly, they reported no need to test their second hypothesis that variations between the two age groups is explained by differences in higher-order aberrations. How-ever, they suggested further study with more participants may yield a different outcome. 1. Mathur A, Suheimat M, Atchison DA. Pilot Study: Eff ect of Age on Visual Acuity with Defocus and Astigmatism. Optom Vis Sci. 2015 Mar;92(3):267-71.

Age and Astigmatic VA: No Link

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Advertorial

1

S P O N S O R E D B Y

For many of my patients there’s a kind of “Ah hah” moment on lens insertion; they find that with Bausch + Lomb ULTRA® contact lenses they truly don’t feel the lens on their eye. When it comes to lens selection, I encourage patients not to decide too quickly but instead to take a couple of days in making up their minds. What I’m finding is that even patients who have been refit in the last year or so and are very happy with their current lens typically voice a desire to go with the Bausch + Lomb ULTRA® contact lenses once they’ve tried them.

I take time to explain to patients what’s behind the exceptional comfort and performance that Bausch + Lomb ULTRA® contact lenses offer, starting with oxygen transmissibility. I explain to patients that the cornea needs oxygen to stay healthy, particularly for the long wearing cycles and sustained visual demands of today’s digital device users. With a Dk/t of 163, the Bausch + Lomb ULTRA® contact lens has the highest oxygen transmissibility among the leading monthly replacement lenses.1 Surprisingly, the lens also has a low modulus, running counter to the long-held presumption that an increase in Dk/t also meant an increase in modulus. In fact, the Bausch + Lomb ULTRA® contact lens also has the lowest modulus among the leading monthly replacement lenses.1 As a third important component, the Bausch + Lomb ULTRA® lens also has high water content (46%), so it’s also an extremely wettable lens.1 These physical properties are summarized in the table. Lastly, the addition of aspheric optics combine to offer a lens with best in class performance that my patients deserve.

Over the years, I have developed a reputation for offering my patients the very best in cutting edge lens technology. I tell patients to come back at no charge if the contact lenses they are wearing

are not the absolute best they have ever worn. It’s been over seven years since we have really had anything new to offer our patients in monthly replacement contact lenses, so I find it very exciting to be able to recommend an innovative, best in class lens that represents a great value.

An important note: the level of innovation Bausch + Lomb ULTRA® contact lenses bring to the monthly replacement category does not come with an inherently expensive price tag: they are very affordable to the patient. Beyond that, a $60 rebate is offered to patients who order a 4-box annual supply of lenses; in effect, they get the last box for free, effectively reducing the price per box—pretty exciting for such a lens.

Comparison chart showing physical properties among leading replacement lenses. High Dk/t, low modulus, high water content and aspheric optics combine to give excellent overall performance.1

Bausch + Lomb ULTRA® Contact Lenses with MoistureSeal® TechnologyA real no-brainer for my patients and my practiceby Dean NolanOD Private PracticeLawton, Oklahoma

I n my own practice my goal is to provide contact lens patients with the lens that is best for them. These days, that means finding a lens that not only offers the best comfort and performance, but also offers excellent value. In a relatively short time, the recently launched Bausch + Lomb ULTRA® contact lens has become my “go to” lens in the monthly replacement category.

BRAND Dk/t MODULUS WATER ASPHERIC CONTENT OPTICS

Bausch + Lomb ULTRA®

contact lenses

ACUVUE OASYS 147 73 38%

AIR OPTIX AQUA 138 102 33%

Biofinity 160 82 46%*

163 70 46%

about the author: Dean Nolan, OD has practiced in his hometown of Lawton, Oklahoma since being among one of the first graduates from Northeastern Oklahoma College of Optometry in Tahlequah, and is a proud member of the Oklahoma Optometry Association.

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Have you noticed the new catch phrase, “wellness of the ocular surface”? It heralds a change in

thinking that emphasizes routine screening and maintenance in all patients. Indeed, the most impor-tant part of an initial diagnostic exam for lens wearers is an accurate assessment of the ocular surface, as many contact lens-related problems can be blamed on an unstable tear fi lm, lid disease or overall poor ocular surface health.

Fortunately, we’re now armed with ways to assess and treat ocular wellness. When I started in practice three decades ago, artifi cial tears were the mainstay of ocular surface treatment, and sometimes the only option for combating an issue. Our inability to accurately diagnose the problem was also a major impedi-ment—for example, until recently dry eye was mostly attributed solely to aqueous defi ciency. Now, how-ever, we know that’s not the case.

Dry eye is a complex disease with many interactions and cascades. In the last four decades, research-ers like James McCulley, MD, and others have refi ned a classifi cation scheme based on research data. For example, his work on lid disease has led to the reclassifi cation of pos-terior blepharitis into three broad categories: hypersecretory MGD(also called meibomian seborrhea), hyposecretory MGD (either pri-mary or obstructive) and turbid hy-persecretory MGD. Other research has revealed as many as 50% of all patients with blepharitis co-present with dry eye, likely because the detergent effect on the lipid layer

alters epithelial cell membranes, leading to cell death and infl amma-tion—a possible contribution to an aqueous-defi cient dry eye.

POINT OF CARE OPTIONS

New in-offi ce testing options have also changed how we handle this broad disease category by reducing diagnosis time, improving patient education and acting as a metric to assess treatment effectiveness. In addition to TearLab’s osmolarity test, newer procedures include the following:

• Infl ammaDry (RPS) provides an assay of the proteolytic enzyme matrix metalloproteinase 9 (MMP-9). A marker for infl ammation, MMP-9 is a measure of epithelial cell stress and is complementary to measuring tear osmolarity; its real value, however, is in identifying risk and treatable problems that respond to steroid and immunomodulator therapy. We know that if the test is negative for MMP-9, the patient’s issue is not dry eye-related. The opposite, however, is not true: a positive response (i.e., >40ng/mL) doesn’t serve as confi rmation of dry eye disease since there are many dif-ferent conditions with an elevated MMP-9 value.

• The TearScan MicroAssay of-fers two diagnostic tests: one detects tear fi lm lactoferrin content to assess lacrimal gland function and the other quantifi es IgE to gauge the allergic component of ocular in-fl ammation. It has a relatively good sensitivity in detecting an aqueous-defi cient dry eye.

• One in 10 dry eye patients have Sjögren’s syndrome. Unfortunately, detection of conventional or tra-

ditional biomarkers for SS-A (Ro) and SS-B (La) is only about 70% sensitive in confi rming a diagnosis. Early diagnosis of Sjögren’s is criti-cal, as its morbidity is troubling and its link to lymphoma—including non-Hodgkins lymphoma—is well established. Now, other novel bio-markers such as salivary protein-1, carbonic anhydrase-6, and parotid secretory protein, instead offer ex-tremely sensitive measures of early Sjögren’s. They can be identifi ed using the Sjö test from Nicox.

Ongoing R&D involving secreta-gogues, IL-1 blocking anti-infl am-matories, LFA-1 antagonists, selec-tive glucocorticoid receptor agonists and even androgen modulation promise more treatment break-throughs coming down the pike.

In the face of all these new devel-opments, however, let us not forget that decades ago our knowledge and techniques, while crude, still helped our patients achieve some symptomatic relief. Assessing the tear fi lm, looking for debris and meniscus height, staining the cornea and conjunctiva and looking for lid pathology helped shape our diag-nostic decisions and treatment plans then, and still have relevance today.

In closing, thank you to our pioneers for paving the way and asking the right questions that led to the products we have today. I’m certain anyone looking back de-cades from now will be as equally amazed at the progress made combating ocular surface disease, particularly dry eye disease. We look forward to the future work that helps assess the “vital signs” of ocular wellness that’s sure to come. Stay tuned! RCCL

Getting Serious About OSDWe have made huge strides in understanding dry eye disease, with more on the way.


My Perspective By Joseph P. Shovlin, OD

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It can be argued that the most frustrating aspect of contact lens practice isn’t determin-ing the fi t or the power, but rather dealing with a non-

wetting lens—it decreases clarity and comfort and affects a patient’s overall lens wearing experience. Silicone-based materials are inher-ently hydrophobic, so any exposed silicone in a lens has the potential to be non-wetting. Additionally, in some patients, excessive lipids in the tear fi lm may deposit onto the lens to create a foggy, hydrophobic surface. This issue can be reduced by dispensing low-silicone-content contact lenses; however, such lenses also impede oxygen transmission, increasing the chance for corneal complications. Other solutions in-clude switching lid hygiene regimens and the most common method, treating the lens with plasma.

A NEWCOMER

Hydra-PEG (Ocu-lar Dynamics) is a polyethylene glycol (PEG)-based poly-mer mixture that is covalently (perma-nently) bonded to the surface of the contact lens, ef-fectively creating a wetting surface on the underlying lens material and separating it from the ocular surface and tear fi lm. PEG has been used in ocular lubricants for decades and is known to improve lens surface wettability, which improves tear breakup time, increases lubricity and reduces protein and lipid depo-sition. Hydra-PEG can be applied to hydrogel, silicone hydrogel or GP lenses.

During application, the fi rst step of lens surface preparation is either the addition of a functional activa-tor to the monomer mix or a short plasma surface treatment. Once active, the lenses are then soaked in the Hydra-PEG polymers during the extraction/hydration step, or the Hydra-PEG polymers are added to the blister pack during the autoclave process.2 In either case, once the active lens is placed in the PEG poly-mers, the Hydra-PEG permanently bonds to the lens surface.

In ex-vivo tests, Hydra-PEG was shown to improve wettability, surface water retention, lubricity and deposit resistance.3-6 These lens surface properties have been corre-lated with contact lens comfort in a number of studies.7 When applied to the Acuvue Oasys lens in a random-ized controlled trial, Hydra-PEG surfaced lenses demonstrated good

comfort in patients suffering from contact lens-induced dry eye.8

Note: although it is a permanent coating, Hydra-PEG has only been tested out to three months of simu-lated rubbing/cleaning cycles. Ocu-lar Dynamics currently recommends hydrogen peroxide-based cleaners, but reports it is also in the process of testing multipurpose solutions for compatibility.

Thus far, my clinic experience with this product has been positive: I have found it creates a wettable, clear and comfortable surface, even in the most challenging of condi-tions, such as lagophthalmos and signifi cant ocular surface disease. I anticipate Hydra-PEG will provide another useful option in most con-tact lens practices. RCCL

1. William Hoff man. Personal communication. 2008. 2. Ocular Dynamics. Hydra-PEG Manufac-turing. Available at: www.oculardynamics.com/#!manufacturing/c11sc. Accessed March 25, 2015.3. Measured via Captive Bubble Contact Angle. Ocular Dynamics data on fi le, 20144. Measured via Water Breakup Time. Ocular Dynamics data on fi le, 20145. Measured via Digital Friction Evaluation. Ocular Dynamics data on fi le, 20146. Measured via Radiolabeled Lysozyme Deposi-tion Assay. Ocular Dynamics data on fi le, 20147. Jones, L. et al. “The TFOS International Workshop on Contact Lens Discomfort: Report of the Contact Lens Materials, Design, and Care Subcommittee”. IOVS, October 2013, Vol. 548. Caroline, P. “Hydra-PEG: A Solution to Contact Lens Discomfort?” Poster presented at Global Specialty Lens Symposium 2015.

The Great Silicone Cover UpA new lens surfacing option improves wettability and lubricity. How does it work?

By Christine W. Sindt, OD

Lens Care Insights


THE 4th STATE OF MATTER

Plasma—ionized gas with an approxi-

mately equal number of positively

and negatively charged particles—is

neither completely a gas nor a liquid

but has properties similar to both.

It’s created by forming a vacuum in a

reaction chamber, then refi lling with a

low-pressure gas such as oxygen.1

During contact lens treatment,

high-energy oxygen plasma bombards

the lens surface, transferring energy

from the plasma to it. This also cleans

and oxidizes the surface by creating

reactive species (i.e., free radicals, ions,

electrons, short-wavelength photons

and unstable oxygen species) that

react with water, altering the lens

surface to a hydrophilic state. This

eff ect occurs to depths of several hun-

dred angstroms to 10µm without any

change to the bulk properties of the

lens material. Note that while plasma

treatment is superior to other options,

the hydrophilic result may last for only

a few minutes to several months.1

Before (left) and after (right) Hydra-PEG treatment.

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Recent advances in contact lens technol-ogy have given us a host of new lens op-tions in the realms of

presbyopic, toric and single vision designs. Positive improvements in contact lens care systems also continue to provide additional benefi ts to those who use them. Together, these developments have increased our arsenal of options to re-engage with those contact lens wearers who may have dropped out in the past.

However, other reasons for contact lens drop out still remain. When a lens wearer abuses their modality or care system, compli-cations—although rare—can arise as a result of non-adherence to practitioner recommendations, a common problem across all health conditions, especially contact lens care regimens.1 This month, we share fi ve highly effective ways to better emphasize the importance of adherence to your contact lens patients. By increasing and tailor-ing our efforts, we improve our patient’s chances of successfully wearing contact lenses, which will ultimately help keep them in lenses long-term.

1.Be aware of how your patients are caring for their

lenses. How often do contact lens wearers walk into our practices without any idea of which solu-tion or rewetting drops—if any—they are using? What about the

condition of the patient’s contact lens case? Certainly, migrating pa-tients to a daily disposable contact lens will help eliminate these po-tential issues, as they obviate the need for care solutions and lens cases. However, the patient may still be using drops that you are unaware of to alleviate comfort issues.

So, how do you fi nd out what exactly your patients are doing to care for their lenses? The answer is fairly simple: ask them to bring in their contact lens case, solu-tion and any other care products, as well as any drops they may be using. Seeing them fi rsthand gives us the opportunity to educate patients on proper lens care if needed and gives us the opportu-nity to intervene with appropri-ate clinical solutions if necessary, including refi tting them into a daily disposable lens or suggesting an alternate product.

2.Educate patients on how to appropriately care for

their lenses. While proper lens care is common knowledge for the eye care practitioner, many patients are not as educated regarding its importance and infl u-ence. Surprisingly, even the most seasoned contact lens wearers may not know how to appropriately care for their lenses. Try ask-ing your contact lens patients to explain their process for applying and removing their contact lenses.

How do you educate these

patients? Devise a consistent conversation to have with all contact lens patients and modify it according to each patient’s individual needs. Explaining the importance of adherence and correcting patient-specifi c errors means they are more likely to adhere to your guidelines. As an example, you can say, “I want you to be able to consistently wear your contact lenses comfortably and in a healthy way. This can best be achieved by following our recommendations on cleaning and caring for your contact lenses.” Next, follow this with the actual steps necessary to care for the lenses, and consider a discussion of a daily disposable lens use.

3.If the patient has issues or complications, show them.

Sometimes, patients will present with symptoms caused by contact lens abuse, such as GPC on the su-perior tarsal plate from lens over-wear when deposits occur on the lens surface and interact with the lid while blinking.2 This response leads to the clinically evident giant papillae and, often, excessive mu-cus production. In these instances, contact lens wearers typically seek symptomatic relief—and deliver-ing it will likely create a more compliant lens wearer.3

But what about changes that are less symptomatic, but still impor-tant to teach patients about? In these cases, we often use slit lamp imaging systems as an educational

Five Steps to Increase Contact Lens AdherenceGetting patients to comply with lens wear and care guidelines is a well-known battle. Here are some points to make it a little easier.

By Mile Brujic, OD, and Jason Miller, OD, MBA

Derail Dropouts


008_RCCL0415_DD.indd 8008_RCCL0415_DD.indd 8 3/27/15 3:42 PM3/27/15 3:42 PM

tool. For example, the patient who is sleeping in hydrogel lenses, but who is asymptomatic, may have signifi cant corneal neovascular-ization that can be imaged and demonstrated. Or, someone who is keeping their lenses in for longer than prescribed who presents with signifi cant deposits on the lens surface might benefi t from seeing those deposits up close. In either case, imaging of these scenarios helps the patient understand their condition and hopefully, the need for more compliant wear.

4.Give them the tools they need. As practitioners, we

have heard almost every single ex-cuse in the book for why our pa-tients are noncompliant with their replacement schedules. We have made it a point to make it as easy as possible for patients to remem-ber to replace their contact lenses. So, regardless of the modality, be sure to give them the best tools possible to help them remember their replacement schedule.

Obviously, daily disposable lenses are the easiest modality to replace. It’s one of the main reasons these lenses are associ-ated with such a high level of adherence.4 For patients wearing two-week or monthly disposable lenses, however, we need to guide them to select a day or two days, depending on the modality, as their designated replacement day.

Depending on your practice, you may also have the means to provide patients with contact lens cases, solution and other accoutre-ment to help with adherence.

5. Don’t assume non-adher-ence is the reason. A pa-

tient wearing contact lenses who comes in with a corneal infi ltrative response is often immediately assumed to be someone who has abused their contact lenses. While this is often the case, take caution to consider other clinical entities that may present similarly.

For example, a point-of-care test such as AdenoPlus can be used to rule out adenoviral keratocon-junctivitis in a contact lens wearer presenting with an acute red eye and corneal infi ltrates.5 Clinically, we will often pigeon-hole these patients as contact lens abusers when in fact they are contact lens wearers who simply have another etiology responsible for the cause of their red eye.

It is well understood that adher-ence in health care is a constant challenge. But by incorporating these strategies, we can help infl u-ence contact lens adherence in a positive way, reduce complications and ultimately help those patients who may discontinue lens wear continue wearing their lenses suc-cessfully. RCCL

1. Claydon BE, Efron N. Non-compliance in con-tact lens wear. Ophthalmic Physiol Opt. 1994 Oct:14(4):356-64.2. Elhers WH, Donshik PC. Giant papillary conjunctivitis. Curr Opin Allergy Clin Immunol. 2008 Oct;8(5):445-9. 3. Chigbu D. The management of allergic eye diseases in primary eye care. Cont Lens Ante-rior Eye. 2009 Dec;32(6):260-72. 4. Dumbleton K, Woods C, Jones L, et al. Pa-tient and practitioner compliance with silicone hydrogel and daily disposable lens replacement in the United States. Eye Contact Lens. 2009 Jul;35(4):164-71.5. Sambursky R, Trattler W, Tauber S, et al. Sensitivity and specifi city of the AdenoPlus test for diagnosing adenoviral conjunctivitis. JAMA Ophthalmol. 2013 Jan;131(1):17-22.

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EDITOR-IN-CHIEFJack Persico [email protected]

ASSOCIATE EDITORAliza Martin [email protected]

CLINICAL EDITORJoseph P. Shovlin, OD, [email protected]

EXECUTIVE EDITORArthur B. Epstein, OD, [email protected]

ASSOCIATE CLINICAL EDITORChristine W. Sindt, OD, [email protected]

CONSULTING EDITORMilton M. Hom, OD, [email protected]

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EDITORIAL BOARD

Mark B. Abelson, MD

James V. Aquavella, MD

Edward S. Bennett, OD

Aaron Bronner, OD

Brian Chou, OD

S. Barry Eiden, OD

Gary Gerber, OD

Susan Gromacki, OD

Brien Holden, PhD

Bruce Koffler, MD

Pete Kollbaum, OD, PhD

Jeffrey Charles Krohn, OD

Kenneth A. Lebow, OD

Kelly Nichols, OD

Robert Ryan, OD

Jack Schaeffer, OD

Kirk Smick, ODBarry Weissman, OD

REVIEW BOARD

Kenneth Daniels, OD

Desmond Fonn, Dip Optom M Optom

Robert M. Grohe, OD

Patricia Keech, OD

Jerry Legerton , OD

Charles B. Slonim, MD

Mary Jo Stiegemeier, OD

Loretta B. Szczotka, OD

Michael A. Ward, FCLSA

Barry M. Weiner, OD

RCCLRCCLREVIEW OF CORNEA & CONTACT LENSES

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One of the hallmarks of the cornea is its avascular, transpar-ent nature, which is a result of the pre-

cise composition and arrangement of its constituent parts. A variety of affronts—including infection, infl ammation, ischemia, degen-eration and loss of the stem cell barrier—can lead to the loss of this avascularity in the form of corneal neovascularization.1,2,

Over 1.4 million patients develop corneal neovascularization each year, with up to 12% of cases as-sociated with subsequent decreased acuity as immature and abnormal vessels invade from the limbal vascular plexus, causing scarring, edema and infl ammation.1,3 This invasion occurs when the habitually precise balance between pro- and anti-angiogenic factors is disturbed by an excess of pro-angiogenic fac-tors.4

While a number of constituents promote new vessel proliferation, vascular endothelial growth factor (VEGF) is one of the key regulators of this process and, as such, has be-come an important target for medi-cal therapy.5 Anti-VEGF treatments, a mainstay of therapy for retinal conditions, also hold promise for corneal applications and may play a particularly auspicious role in graft survival after penetrating kerato-plasty.2

A BETTER WAY?

Conventional therapy for corneal neovascularization includes steroids, thought to suppress activation and

migration of macrophages, mast cells, cytokines and other infl am-matory cells promoting angio-genesis.2,6,7 Steroids are also often used in combination with oral matrix metalloproteinase (MMP) inhibitors such as doxycycline in an effort to regress abnormal corneal vasculature. These techniques are limited in effi cacy, however, and lead to well-known side effects of topical steroids including cataracts and glaucoma. Nonsteroidal anti-infl ammatory medications, photo-dynamic therapy, laser photocoagu-lation, fi ne needle diathermy and conjunctival, limbal and amniotic membrane transplantation have also been used with varying suc-cess.2,6

Topical anti-VEGF therapy for corneal neovascularization has been investigated off-label using both bevacizumab and ranibizumab, which are monoclonal antibodies against VEGF and traditionally used for retinal indications.2,8,9

Both target VEGF-A, leading to

inhibition of abnormal blood vessel formation and decreased vascular permeability. Bevacizumab has been used more often in off-label indica-tions and in studies as a result of its increased affordability. Bevaci-zumab was originally approved for metastatic colorectal cancer, but has long been used in ophthalmology for off-label therapy of wet AMD, proliferative diabetic retinopathy and iris rubeosis.2,10

Therapy with anti-VEGF medi-cations has been studied both in subconjunctival and topical use and has shown promise in the treatment of herpetic keratitis, recurrent pte-rygium, corneal transplant rejection and Stevens-Johnson syndrome.11

Multiple studies confi rm the effec-tiveness of topical bevacizumab in reducing corneal neovascularization in experimental animal models, and human use has shown signifi cant reductions in abnormal vascula-ture, even in patients recalcitrant to traditional anti-infl ammatory therapies.2,6 Early treatment appears

Pharma Science & PracticeBy Elyse L. Chaglasian, OD, and Tammy Than, MS, OD

Anti-VEGF in the Anterior Segment


Corneal neovascularization from contact lens overwear and other hypoxic events may respond to this posterior segment therapy.

Vessel encroachment into the cornea in a case of neovascularization due to

hypoxic stress. Might this be a patient who would benefi t from anti-VEGF?

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more effi cacious in both animal and human models, with both topical and subconjunctival therapy.6,12,13

Chronic vascular conditions tend not to respond as well to therapy as active or acute angiogenesis.6,12

Clinically, corneal neovasculariza-tion can be seen after infectious, in-fl ammatory and traumatic events.1,2

Infl ammatory stress tips the balance of growth and inhibitory factors in favor of angiogenesis and leads to the growth of new, abnormal vasculature.4 The same can be seen under hypoxic conditions, such as contact lens overwear.2 The result-ing neovascularization may be deep, stromal or may present as super-fi cial vascular pannus, depending on the ocular insult.2,14 Deep and stromal neovascularization may be associated with interstitial and disciform changes seen in herpetic keratitis, while superfi cial changes are typically associated with ocular surface disease.2

Other bacterial, viral, protozoan and fungal antigens may also induce a keratitis that can lead to subse-quent neovascularization. Trauma (including chemical burns), ischemia (i.e., limbal stem cell defi ciency), and infl ammatory conditions may also promote the abnormal vascu-lature.2,11,15 Autoimmune diseases (e.g., Stevens-Johnson syndrome, graft rejection and cicatricial pemphigoid) and corneal degenera-tions (e.g., pterygium and Terrien’s marginal degeneration) have further been implicated in corneal neovas-cularization.2,11,15 Perhaps the most widespread application, however, lies in corneal transplantation, where recipient neovascularization before transplantation doubles the

risk of graft rejection, and where increases in graft survival after anti-VEGF therapy have been demon-strated in animal models.2

GROWTH OPPORTUNITY

Clearly, there is a role for anti-VEGF therapy in corneal neovascu-larization, and its potential anterior segment indications are plentiful. Areas for further research include determining the ideal administra-tion, route, dosage and formulation, and whether a targeted combina-tion therapy for multiple growth factors is necessary to completely regress vasculature in these patients. While large, randomized studies are required to fi rmly establish the safety and breadth of corneal indications, it seems clear that anti-VEGF therapy will have an increas-ingly signifi cant role in the manage-ment of corneal neovascularization patients moving forward, and that corneal specialists will have a more effi cacious tool at their disposal

when treating this potentially blind-ing condition. RCCL

The authors would like to ac-knowledge Stephanie Fromstein, OD, for her invaluable contribu-tions to this article.

1. Chang JH, Gabison EE, Kato T et al. Corneal neovascularization. Curr Opin Ophthamol. 2001; 12: 242-249.2. Chang JH, Garg NG, Lunde E et al. Corneal neo-vascularization: an anti-VEGF therapy review. Surv Opthalmol. 2012 ; 57(5): 415-429.3. Lee P, Wang CC, Adamis AP. Ocular neovascu-larization: an epidemiologic review. Surv Ophthal-mol. 1998; 43: 245-269.4. Kvanta A. Ocular angiogenesis: the role of growth factors. Acta Opthalmol Scand. 2006.; 84: 282-288.5. Gan L, Fagerholm P, Palmblad J. Vascular endothelial growth factor (VEGF) and its receptor VEGFR-2 I the regulation of corneal neovascu-larization and wound healing. Acta Ophthalmol Scand. 2004; 82: 557-563.6. Papathanassiou M, Theodoropoulou S, Analitis A et al. Vascular endothelial growth factor inhibitors for the treatment of corneal neovascularization: a meta-analysis. Cornea. 2013; 32(4): 435-444.7. Phillips K, Arff a R, Cintron C et al. Eff ects of prednisolone and medroxyprogesterone on cor-neal wound healing, ulceration and neovasculariza-tion. Arch Opthalmol. 1983; 101: 640-643.8. Avila MP, Farah ME, Santos A et al. Three-year safety and visual acuity results of epimacular 90strontium/90yttrium brachytherapy with beva-cizumab for the treatment of subfoveal choroidal neovascularization secondary to age-related macular degeneration. Retina. 2011; 32(1): 10-18.9. Krebs I, Lie S, Stolba U et al. Effi cacy of intravit-real bevacizumab (Avastin) therapy for early and advanced neovascular age-related macular degen-eration. Acta Opthalmol. 2009; 87: 611-617.10. Cheng SF, Dastjerdi MH, Okanobo A et al. Short-term topical bevacizumab in the treatment of stable corneal neovascularization. Am J Oph-thalmol. 2012; 154: 940-948.11. Ambati B. Corneal applications for anti-VEGF agents. Adv Oc Car. 2011: 24-25.12. Papathanassiou M, Theodossiadis PG, Liarakos VS et al. Inhibition of corneal neovascularization by subconjunctival bevacizumab in an animal model. Am J Opthalmol. 2008; 145: 424-431.13. Stephenson M. Anti-VEGF for CNV: questions remain. Rev Ophthalmol. 2011. Published online14. Ellenberg D, Azar DT, Hallak JA et al. Novel as-pects of corneal angiogenic and lymphangiogenic privilege. Prog Retin Eye Res. 2010; 29: 208-248.15. Bock F, Konig Y, Kruse F et al. Bevacizumab (Avastin) eye drops inhibit corneal neovasculariza-tion. Graefes Arch Clin Exp Ophthalmol. 2008; 246: 281-284.


FROM VEGF TO VESSELS

While there are a number of itera-tions of VEGF found throughout the human body, VEGF-A is one of the key regulators of hemangiogenesis in ocular tissues.2 It is secreted by corneal epithelial and endothelial cells, vas-cular endothelial cells and fi broblasts and microphages found in scar tissue; importantly, this process is exacer-bated in infl amed and vascularized corneas.6 Once released, it promotes vascular endothelial cell proliferation, migration and tube formation, and may also play a secondary role in infl am-mation.1,6 Circulating VEGF exerts its infl uence by binding to tyrosine kinase receptors, which leads to a signaling cascade promoting cell division and proliferation of vessels.2

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Dry eye is easily one of the most common diseases worldwide, encompassing a wide range of ocular

surface alterations with different etiologies and pathophysiologies.1,2

In recent years, eye care practi-tioners have made great advances in objectively measuring dry eye with precision, using high-tech tools to quantify tear osmolar-ity, infl ammatory cytokines and Sjögren’s biomarkers in addition to familiar clinical evaluation tools like the Schirmer’s test and tear fi lm breakup time. Methods to assign an objective number or severity score to dry eye have fl ourished.

But despite this success, the sub-jective component of the disease—how it feels for patients—remains for the most part poorly document-ed. Thus, it’s no surprise a number of patient evaluation questionnaires exist as part of an ongoing move-ment to quantify patient symptom-atology. Dry eye questionnaires are commonly used in clinical research to screen participants, grade disease severity and assess the effects of treatments. They vary in length, focus and extent of validation, and often involve a number of rating scales that are combined to produce a total raw score (see “Comparing Notes,” p. 14).13 So, how does one determine which to use in a busy

clinical practice, especially given that such questionnaires typicallymeasure patients against a pre-estab-lished clinical diagnosis of dry eye?

This article discusses some of the more popular questionnaires avail-able and examines their relevance in the context of evaluating patients in a clinical practice setting.

EXPERT TESTIMONY

In 2007, the International Dry Eye WorkShop published a report on the epidemiology of dry eye, which evaluated the practicality of a number of dry eye questionnaires.17

Requirements for consideration included that the questionnaire had been used in randomized clini-cal trials (RCTs) or epidemiologic studies, had passed psychometric testing and been deemed suitable for evaluating general, non-disease specifi c dry eye populations.17 Four-teen questionnaires met the criteria, including fi ve discussed here.

The committee identifi ed charac-teristics that designate a question-naire as suitable for use in epide-miologic studies and RCTs. First, it must be able to detect and measure changes in symptoms with effec-tive treatment or disease progres-sion.17 The recall period must also be specifi ed and the ability to set a threshold of disease severity as an inclusion criterion should be present.17 Additionally, because of

the possibility of dry eye symptoms worsening over the course of the day, there must be a single, set time for administering dry eye examina-tions and the questionnaire.17

The subcommittee recommended adding a better defi nition of clini-cally meaningful changes in scores as well as a better concept of the “worst” symptom and a question on visual function with respect to dry eye.17 Also, more research on the relationship between frequency and severity of dry eye symptoms as a means to better identify a clinical-ly meaningful change in symptoms is warranted.17

WHAT DO YOU USE?

Granted, dry eye questionnaires are commonly used in clinical research as a means to grade disease sever-ity and assess treatment effects, all within a controlled environment with a pre-selected population seg-ment. But are they useful in clini-cal practice, where many different patients present who have not been pre-sorted and who may fall within a range of disease severity and treat-ment types and stages?

A validated questionnaire, says Arthur B. Epstein, OD, provides a good starting point to evaluate the patient’s unique experience and gather information about the specifi cs of the disease. Dr. Epstein is director of clinical research at

DRY EYE:

By Aliza Martin, Associate Editor

Patient questionnaires

quantify the subjective

experience of the disease.

Though vital for research,

are they worth using

in your practice?

See It Through Their Eyes

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Phoenix Eye Care and runs a dry eye clinic at the practice. He uses dry eye questionnaires to evaluate every patient who walks in.

“I use questionnaires for docu-mentation and especially for prog-ress evaluations,” he says. “While both are important, my personal bias is to measure outcomes by a re-duction in patients’ symptoms even more than a reduction in physical signs. Questionnaires provide a standardized way of assessing how well the patient is doing and if they are responding to therapy.”

Dr. Epstein uses both the OSDI and SPEED questionnaires, and says each has its own benefi ts. “SPEED is quicker, but OSDI provides a bit more information. As odd as it sounds, I haven’t totally settled on ei-ther, but I make sure we use the same one we used previously to monitor change” in a specifi c patient.

Overall, he adds, the usefulness of the different dry eye questionnaires varies depending on the patient. “For example, the CLDEQ is optimized for lens wearers, and the DEQS focuses more on quality-of-life issues. Some are research tools and less useful in clinical practice.”

Al Kabat, OD, and Whitney Hauser, OD, of Southern College

of Optometry’s TearWell Advanced Dry Eye Treatment Center in Mem-phis, also use the OSDI and SPEED questionnaires for similar purposes. Because both are validated and used in the practice together, they act as a good system of checks and balances. “We use the question-naires to fi rst quantify the patient’s symptoms as a fi nite entity, and then track the patient’s progress as we perform or initiate specifi c treat-ment regimens,” Dr. Kabat says.

“Occasionally, patients are in-fl uenced by how they feel on a particular day, and the surveys provide a more global view,” adds Dr. Hauser. “Dry eye care, unlike many other eye diseases, is driven by symptom relief, and the surveys give a measureable indication of improvement.”

The responses from the dry eye questionnaires do have a big infl uence on treatment decisions, Dr. Kabat says. “For a severely symptomatic patient, we are more apt to initiate aggressive therapy even in lieu of signifi cant fi ndings. Likewise, for a patient with less symptomology, we might be more conservative in our treatment algorithm.”

Eric Don-nenfeld, MD, a Long Island oph-thalmologist who special-izes in cata-ract and refrac-tive surgery, uses OSDI and SPEED to guide diagnostic testing. “All patients who have positive fi ndings on the questionnaire undergo osmolarity and

MMP-9 testing,” he says. “We can also assess treatment response by following the patient’s symptomatic improvement on the questionnaire.”

DIY EFFORTS

Some practitioners choose to create their own dry eye questionnaire. In addition to using the SPEED questionnaire, Paul M. Karpecki, OD, of Koffl er Vision Group in Kentucky, also uses a custom one of his own making (shown below).

“The second is a much more extensive questionnaire about dry eye disease that is administered on a clipboard when the patient is placed in the exam lane waiting on the doctor,” he says. Contrary to the SPEED questionnaire, which is used on every patient, the custom form is only used for new patients referred specifi cally for dry eye disease eval-uations. “The SPEED questionnaire initiates a potential dry eye patient workup,” says Dr. Karpecki. “The extensive custom questionnaire actually predicts potential diseases ranging from anterior blepharitis to


Dry eye questionnaires can also

be custom-made, such as this one from

Paul M. Karpecki, OD. To download a copy

of it suitable for use in your practice, look for

this article at www.reviewofcontactlenses.com.

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Does reliance on dry eye signs, like the

corneal staining above, overshadow

the role of the patient's symptomatic

experiences and quality-of-life issues?


DRY EYE: SEE IT THROUGH THEIR EYES


Comparing Notes: Selected Dry Eye Evaluation FormsThe options for documenting the patient’s experience of dry eye range from simple one-page sheets with three key components to a complete soup-to-nuts account of their case history. Here’s a quick overview of several popular ones. To fi nd links to these forms, snap a picture of the QR code on the right with your smartphone or visit www.reviewofcontactlenses.com.

• McMonnies Questionnaire. Arguably the fi rst modern dry eye questionnaire, the McMonnies is comprised of 14 items that focus on established risk factors for dry eye including age, sex, contact lens wear, medication use and certain systemic and ocular factors.5 The questionnaire was intended to both determine the presence of dry eye and identify individuals at risk for developing the disease.

Several studies validating the McMonnies questionnaire as a means to screen patients for dry eye disease exist.6,7 A separate study evaluating the psychometric properties—reliability, validity and accuracy—of it re-ported poor internal consistency, moderate test-retest reliability and fair concurrent validity and accuracy.8

The McMonnies questionnaire appears on p. 15. • Dry Eye Questionnaire (DEQ) and Contact Lens Dry Eye Questionnaire (CLDEQ). Both versions of

the DEQ include categorical scales to measure prevalence, frequency, diurnal severity and intrusiveness of common ocular surface symptoms in a typical date of a one-week recall period. Participants are asked to indicate “never, infrequent, frequent or constant” with regard to frequency and intensity of comfort, dry-ness, visual changes, soreness and irritation, grittiness and scratchiness, burning and stinging, foreign body sensation, light sensitivity and itching.9

The two questionnaires also include questions on the perceived time of day that symptoms worsen, how much the symptoms aff ect daily activities, computer use, use of systemic and ocular medications, and presence of allergies.9 The DEQ has been successfully evaluated for its use in measuring the frequency and intensity of symptoms of ocular irritation in patients with aqueous tear defi cient dry eye.10

• Ocular Surface Disease Index (OSDI). Developed by the Outcomes Research Group at Allergan, the OSDI questionnaire is a self-administered 12-question scale designed to assess a range of ocular surface symptoms, their severity and impact on visual function in a one-week recall period.11 Currently, the OSDI is one of only two validated dry eye questionnaires to include quality-of-life measures for clinical use.12

• Subjective Evaluation of Symptom of Dryness (SESoD). The SESoD is a three-item questionnaire created by Allergan to evaluate a patient’s perception of ocular discomfort related to dryness. Together with the DEQ, McMonnies and OSDI, the SESoD has been shown to exhibit unidimensionality—that is, it is comprised of questions that measure specifi c metrics simply and linearly to yield straightforward values.13 For example, income is a unidimensional variable; socioeconomic status, which includes income, occupa-tion and education, is a multidimensional variable.

• Impact of Dry Eye on Everyday Life (IDEEL). The 57-question IDEEL survey from Alcon assesses the eff ect of dry eye with respect to three primary modules: dry eye symptom bother, impact on daily life (comprising impact on daily activities, emotional state and work) and treatment satisfaction (comprising patient attitude towards treatment eff ectiveness and treatment-related bother/inconvenience).14 Together with the OSDI questionnaire, the IDEEL survey comprises a small category of dry eye questionnaires that include quality-of-life measures for clinical use.12

A psychometric analysis performed as part of a validation study involving 210 subjects—130 with non-Sjögren's keratoconjunctivitis sicca, 32 with Sjögren's syndrome and 48 controls—found IDEEL to exhibit good consistency and reliability.14 Strong correlation between IDEEL and the Dry Eye Questionnaire was also noted.14

• Standard Patient Evaluation of Eye Dryness (SPEED). The SPEED questionnaire is a four-question sur-vey developed by TearScience to assess frequency and severity of patient dry eye symptoms. In particu-lar, it monitors diurnal and longer-term symptom changes over the course of three months.15 The SPEED questionnaire has been shown to exhibit good validity, unidimensionality, objectivity and consistency when compared with the DEQ, McMonnies questionnaire, OSDI and SESoD.15

• Dry Eye-Related Quality-of-Life Score Questionnaire (DEQS). The DEQS is a 15-item questionnaire created to assess the presence of dry eye symptoms and their severity, and the eff ects of these symptoms on aspects of patients’ everyday lives, including psychological and social aspects.16 A psychometric analysis found the study had good internal consistency, test-retest reliability, discriminant validity and responsive-ness to change; thus, the test is valid and reliable for evaluating the multifaceted eff ect of dry eye disease on a patient’s daily life.16


dry eye to allergic conjunctivitis. It also triggers various treatment op-tions.” Also, its short length allows patients to feel like they are making the best use of their time.

Dr. Karpecki created a custom questionnaire because he felt he “needed more information and didn’t want to have to rely on my memory to ask the right questions of the patient.” It’s a culmination of his 20 years’ experience running a dry eye clinic plus information from research papers and dry eye studies.

Another option is to adapt an existing questionnaire or two. John D. Sheppard, MD, president of Vir-ginia Eye Consultants, uses both the OSDI and SPEED questionnaires, but says “both ask a little less than we’d like to differentiate the differ-ent types of ocular surface disease. We all think about dry eye, which is ubiquitous, but also extremely common are MGD and blepharitis as well as ocular allergy.”

Patients who present at Dr. Sheppard’s practice take a modifi ed version of the SPEED questionnaire. “A good supplemental question to ask on the SPEED is, ‘Do your eyes itch?’ Answer choices include: In-frequently; frequently; all the time; it’s driving me crazy. Itching is an important symptom that overlaps between the three most common ocular surface conditions but focuses most on ocular allergy,” Dr. Sheppard says. “Another question that seems to help with blepharitis is, ‘Are your eyelids red?’ with the same frequency qualifi ers. Also, ‘Are your eyes burning?’ Burning seems to be something that helps with identifying blepharitis. You can also ask patients about crusting and matting on their lids as well.”

THE IDEAL

What might the ideal dry eye questionnaire look like? Dr. Epstein says SPEED comes closest. “It’s

free, it’s quick, it’s repeatable and it should be used consistently with all dry eye patients. It is also an excel-lent tool for uncovering dry eye among patients who are ‘silent suf-ferers’ and don’t realize they have a problem that can be effectively—or more effectively—managed.”

Dr. Kabat agrees about the basic principles of an ideal questionnaire and that the SPEED is one such example, but also offers a more general set of characteristics. “If the questionnaire takes more than three minutes for the patient to complete, then it is impractical. If it takes more than one minute to score, then it is impractical. If it cannot be administered and scored by a technician or assistant, then it is impractical,” he says. “For the physician, there should be no more of a time commitment than glanc-ing at the number and assessing its value relative to the scale.”


(Continued on p. 19)

Female / Male

Age: less than 25 years(0) / 25-45 years(M1/F3) / more than 45 years(M2/F6)

Currently wearing: no contact lenses / hard contact lenses / soft contact lenses

1. Have you ever had drops prescribed or other treatment

for dry eyes?

Yes(6) / No(0) / Uncertain(0)

2. Do you ever experience any of the following eye

symptoms?

1. Soreness 2. Scratchiness 3. Dryness 4. Grittiness 5. Burning

3. How often do your eyes have these symptoms?

Never(0) / Sometimes(1) / Often(4) / Constantly(8)

4. Are your eyes unusually sensitive to cigarette smoke,

smog, air conditioning, or central heating? Yes(4) / No(0) / Sometimes(2)

5. Do your eyes become very red and irritated when

swimming?

Not applicable(0) / Yes(2) / No(0) / Sometimes(1)

6. Are your eyes dry and irritated the day after drinking

alcohol?

Not applicable(0) / Yes(4) / No(0) / Sometimes(2)

7. Do you take: antihistamine tablets(2) or use antihistamine eye drops(2), diuretics (fl uid tablets)(2), sleeping tablets(1), tranquillizers(1), oral contraceptives(1), medication for duodenal ulcer(1), digestive problems(1), high blood pressure(1), antidepressants(1) or ___________________? (Write in any medication you are taking that is not listed.)

8. Do you suff er from arthritis?


9. Do you experience dryness of the nose, mouth, throat,

chest or vagina?

Never(0)/ Sometimes(1) / Often(2) / Constantly(4)

10. Do you suff er from thyroid abnormality?


11. Are you known to sleep with your eyes partly open?

Yes(2) / No(0) / Sometimes(1)

12. Do you have eye irritation as you wake from sleep?

Yes(2) / No(0) / Sometimes(1)

McMonnies Dry Eye Questionnaire

Please answer the following by underlining the responses most appropriate to you:

Scores: Normal (< 10) Marginal dry eye (10 - 20) Pathological dry eye (>20)

From: McMonnies C, Ho A: Patient history in screening for dry eye conditions. J Am Optom Assoc 1987, 58(4):296–301.



The clinical entity known as contact lens-induced acute red eye, or CLARE, is an infl ammatory reaction

of the cornea and conjunctiva associated with overnight contact lens wear. It is also commonly referred to as acute red eye or tight lens syndrome. Often, the patient will present to your practice wearing dark sunglasses or clutching a box of tissues in an effort to cope with their symptoms. While treatment is relatively straightforward, episodes of this condition can recur; thus, our job as clinicians is not only to treat the condition in its acute stage, but also to educate the patient and give them the tools to return to lens wear in the healthiest possible manner.

SIGNS AND SYMPTOMS

CLARE is typically character-ized by sudden onset of unilateral eye pain, photophobia, epiphora and ocular irritation. Accom-panying slit lamp signs include diffuse conjunctival and limbal hyperemia, as well as the pres-ence of multiple corneal epithelial and subepithelial infi ltrates. The infi ltrative reaction is generally located in the corneal periphery and mid-periphery; when sodium fl uorescein stain is instilled in the

eye, the infi ltrative areas do not typically exhibit overlying punc-tate staining, indicating minimal epithelial involvement.3,4 In more severe cases of CLARE, corneal edema or anterior uveitis may also be present, although these signs are not common.1,2 Visual acuity is usually unaffected.

It is prudent to ask patients presenting with CLARE symptoms about any recent illnesses, includ-ing symptoms of the common cold such as headache, fatigue and runny nose. Often, upper respira-tory tract infections are associated with gram-negative organisms like Haemophilus infl uenza.1,2 One study found that patients who were colonized with H. infl uen-zae were more than 100 times as likely to have had a CLARE or infi ltrative response than those subjects who were not colonized with this bacterium.5

CASE HISTORY

AND EVALUATION

Typically, the most reliable way to accurately diagnose CLARE is with a complete case history and assessment of the symptoms mentioned above. By defi ni-tion, CLARE is associated with sleeping while wearing contact lenses.2,3 This can be anything from a short afternoon nap to a full night of extended wear—the

fact that the eye is closed for an extended period of time is key to our diagnosis. So, consider asking all your contact lens patients how many times per week they sleep or nap in their lenses as part of your routine history sequence.

Knowledge of the patient’s habitual lens type and wearing schedule may also have some value in our diagnostic consider-ations. Conventionally, CLARE is associated with tight fi t or poor movement of extended-wear, low oxygen permeability, high water content hydrogel lenses. However, note that CLARE can also be caused by extended wear of sili-cone hydrogel lenses, which have signifi cantly risen in market share in the United States in the last de-cade.1,6 CLARE has been reported to occur in 34% of continuous wear hydrogel lens patients and less than 1% of silicone hydrogel extended wear patients.7-9 Re-ports have also linked CLARE to

By Lindsay A. Sicks, OD

Understanding and knowing how to treat this common contact lens

complication can benefi t both your patients and your practice.

Dr. Sicks is an assistant professor at Illinois College of Optometry in Chicago. She is involved in the contact lens didactic

curriculum and also serves as a clinical attending

physician in the Illinois Eye Institute’s Cornea Center for Clinical Excellence.

ABOUT THE AUTHOR

Bringing Clarity

TO CLARE


extended wear gas permeable (GP) lenses, high oxygen permeabil-ity silicone elastomer lenses and overwear of daily disposable soft contact lenses.10

In the absence of a lens fi t evalu-ation, history questions regarding hours per day of lens wear and diffi culty with lens removal at the end of the day may assist in diag-nosis. If you are able to assess the lens on-eye, pay special attention to lens movement and push-up test results. Note, however, that there are reported cases of CLARE occurring with well-fi t contact lenses showing adequate move-ment.10,11

ETIOLOGY

While the etiology of CLARE is not completely understood, it is generally classifi ed as an infl amma-tory event of the cornea and conjunctiva. General risk factors include wear of high water content lenses, wear of tight fi tting lenses and history of a recent upper respiratory tract infection.2

One commonly cited cause of CLARE is coloni-zation of the lens sur-face with gram-negative bacteria, specifi cally H. infl uenzae, Pseudomonas aeruginosa and Serratia marcescens.12 An infl ammatory response is triggered by endotox-ins released by the breakdown of bacterial cell walls. The con-dition is worsened in the tight lens environment because of lens dehydration, minimal lens move-ment, decreased tear exchange and hypoxia.1,7,10,12,13

In the infl ammatory process, limbal vasodilation occurs, fol-lowed by release of white blood

cells, and then infi ltration of the injured tissue by polymorpho-nuclear leukocytes and other cells. This collection of infl ammatory cells within the cornea forms what we call an infi ltrate. The result is CLARE and its associated signs of conjunctival hyperemia and corneal epithelial and subepithelial infi ltrates.7

DIFFERENTIAL DIAGNOSIS

In a case that may be CLARE or another corneal infi ltrative event (CIE), the most important element to consider is whether the pre-senting condition is infectious or non-infectious.

Due to its sight-threatening po-tential if left untreated, microbial keratitis (MK) should be high on the list of differentials in any con-tact lens wearer presenting with a red eye. To differentiate MK from other CIEs, look for a discrete area of fl uorescein staining, typi-cally greater than 1mm diameter and often located in the central cornea. There may also be lid edema, a reactive ptosis, and more

moderate to severe pain symptoms that worsen with lens removal. Anterior chamber cells and fl are and mucopurulent discharge are more common in MK than CLARE and CLPU.3 A positive bacterial culture or the presence of tear fi lm exudate can also help make an MK diagnosis.

CLARE can also appear similar to conditions like contact lens-induced peripheral ulcer (CLPU) and infi ltrative keratitis (IK).3 However, while CLARE typically presents with multiple small focal and diffuse infi ltrates that do not stain with fl uorescein, CLPUs are characterized as single circular

focal infi ltrates up to 2mm in diameter that pick up fl uores-cein stain. IK is associated with Staphylococcal hypersensitivity and may occur in one or both eyes showing multiple small infi ltrates with or without corneal staining. A careful history and slit lamp examination can help guide your diagnosis.

The remaining CIEs are cat-egorized as asymptomatic and


Acute contact lens-associated red eye presentation in a 28-year-old Indian male.

He noted associated blurry vision, foreign body sensation and photophobia.

After a 10-day course of tobramycin/dexamethasone suspension QID and

preservative-free artifi cial tears every hour for relief, he reported a signifi cant

improvement in symptoms. (Case and photo courtesy of Kelli Theisen, OD.)


clinically insignifi cant.3 Asymp-tomatic infi ltrative keratitis (AIK) and asymptomatic infi ltrates (AI) are simply differentiated from CLARE in that they are seen on physical exam but carry no enter-ing complaints. Other differentials to consider include: chlamydial conjunctivitis, trachoma, adeno-viral infection, epidemic kera-toconjunctivitis, Staphylococcal marginal keratitis, Thygeson's superfi cial punctate keratitis and herpes simplex keratitis.14

TREATMENT AND

MANAGEMENT

Management of CLARE always begins with discontinuation of contact lens wear. Beyond that, the condition is often self-limiting and may not require therapeutic intervention—in many cases, palliative treatment with artifi cial tears will suffi ce. However, we often prescribe additional thera-peutic options to promote healing and improve patient comfort. De-pending on severity, the infi ltrates can take days to weeks following cessation of lens wear to heal.

Since many of the signs and symptoms of CLARE mimic those of microbial keratitis, it is prudent to instill sodium fl uorescein and assess the corneal integrity for any epithelial disruption. Typically, there is minimal to no epithelial disruption with CLARE; however, if there is corneal staining present in association with an infi ltrate, the diagnosis no longer clear-cut and the lesion becomes suspicious for MK. In such cases, conserva-tive management warrants using a topical antibiotic for at least the fi rst 48 hours of treatment. Some practitioners may prefer to ad-dress both the infl ammation and risk of infection as quickly as pos-sible by prescribing a combination

topical antibiotic/steroid from the start. Recommended follow-up is daily until signs of improvement are shown.

In cases where the photophobia is particularly symptomatic, or where there is an accompanying anterior uveitis component, ap-plication of a topical cycloplegic agent is warranted for at least the fi rst 24 hours. Topical and oral NSAIDs are also effective adjunct treatment options to quell the discomfort. If cells and fl are per-sist, consider addition of a topical steroid to the regimen.

After complete healing, patients can resume lens wear using a fresh lens right out of the vial or blister pack. Consider changing lens fi t, material, modality and/or replacement schedule prior to resuming lens wear to reduce potential for reoccurrence. For example, if the habitual lens was a tight fi t, try selecting different base curve or diameter to im-prove movement and centration. If the patient has a history of lens abuse or overwear, switch them to a daily disposable lens design instead. Also, consider refi tting patients into GP lenses—patients with a history of soft lens com-plications often adapt well to GP lenses and appreciate the benefi ts they provide.

It is important to note that recurrence of infl ammatory complications can happen in 50% to 70% of wearers who resume hydrogel extended wear after resolution of their initial episode of CLARE.15 Additionally, patients who have had a CLARE episode retain higher levels of lim-bal injection, bulbar injection and conjunctival staining afterwards compared with controls.9 Care-ful slit lamp examinations and shorter intervals between contact

lens appointments following a CLARE episode may be the best practice to follow based on your clinical judgment.

Above all, patient educa-tion plays an important role in preventing corneal infi ltrative events such as CLARE. Stressing the importance of appropriate lens replacement, wear and care schedules to all of your contact lens patients can promote better patient adherence to our recom-mendations.

Patients should be advised to stop wearing their lenses while ill and when lens wear is uncomfort-able or painful, particularly while their eyes are closed. For patients who have had a CLARE episode, emphasizing the risk of recurrence as well as a review of symptoms to look out for may also be helpful. Be sure to also provide an easy way for patients to contact your offi ce in case of an emergent issue so that they end up in the best hands possible should another complication occur. RCCL

BRINGING CLARITY TO CLARE


Coding for CLARE

Currently, there is no exact match in ICD-9 nomenclature for CLARE, and it does not appear that ICD-10 will have any additional entries that are more appropriate. As such, one should continue to re-port CLARE using a symptom code appropriate to the chief complaint, such as those for eye pain, redness of the eyes or epiphora. If there is an ac-companying corneal infi ltrate, additional codes for central and peripheral corneal opac-ity would also be appropri-ate. Other applicable options may include anterior uveitis, viral conjunctivitis or corneal edema codes, depending on the case.



1. Dumbleton K, Jones L. Extended and Continu-ous Wear. in Clinical Manual of Contact Lenses. E. Bennett and V. Henry, Eds. Williams and Wilkins. 2008:410-443.2. Stapleton F, Keay L, Jalbert I and Cole N. The epidemiology of contact lens related infiltrates. Optom Vis Sci. 2007;84(4):257-272.3. Sweeney DF, Jalbert I, Covey M, et al. Clinical characterization of corneal infiltrative events observed with soft contact lens wear. Cornea. 2003;22(5):435-442.4. Sankaridurg PM, Holden BA, Jalbert I. Adverse events and infections: which ones and how many? In e. Sweeney D, Silicone Hydrogels: Continuous Wear Contact Lenses (pp. 217-274). Oxford: Butterworth-Heinemann.5. Sankaridurg PR, Willcox MD, et al. Haemophilus influenzae adherent to contact lenses associated with production of acute ocular inflammation. J

Clin Microbiol. 1996;34(10):2426-2431.6. Nichols JJ. Annual Report: Contact Lenses 2013. Contact Lens Spectrum;29(January 2014):22-28.7. Zantos SG, Holden BA. Ocular Changes Associated with Continuous Wear of Contact Lenses. The Australian Journal of Optometry. 1978;61(12):418-26.8. Nilsson, S. Seven-day extended wear and 30-day continuous wear of high oxygen transmis-sibility soft silicone hydrogel contact lenses: a randomized 1-year study of 504 patients. CLAO J. 2001;27(3):125-36.9. Stapleton F, Keay L, Jalbert I, Cole N. Altered Conjunctival Response After Contact Lens–Related Corneal Inflammation. Cornea. 2003;22(5):443-7.10. Sankaridurg PM, Vuppala N, Sreedharan A, et al. Gram negative bacteria and contact lens

induced acute red eye. Indian J Ophthalmol, 1996;44(1):29-32.11. Crook, T. Corneal infiltrates with red eye re-lated to duration of extended wear. J Am Optom Assoc. 1985;56(9):698-700.12. Holden BA, La Hood D, Grant T, et al. Gram-negative bacteria can induce contact lens related acute red eye (CLARE) responses. CLAO J. 1996;22(1):47-52.13. Binder PS. The physiologic effects of ex-tended wear soft contact lenses. Ophthalmology. 1980;87(8):745-9.14. Robboy MW, Comstock TL, Kalsow CM. Con-tact Lens-Associated Corneal Infiltrates. CLAO J 2003;29(3):146-54.15. Sweeney DF, Grant T, Chong MS, et al. Recur-rence of acute inflammatory conditions with hydrogel extended wear. Invest Opthalmol Vis Sc 34:S1008.

DRY EYE: SEE IT THROUGH THEIR EYES

Additionally, Dr. Kabat says, it should assess symptom impact on lifestyle and provide a metric for quantifying symptom severity, and should have the ability to be used “as a screening tool for all patients in a practice with interest in dry eye management, or as part of the data/history collection in a specialty dry eye practice.”

The ideal dry eye questionnaire should also cover certain symptoms. “Key symptoms must be included such as blurred or transient blurred vision, dryness/grittiness, irritation, burning and watering,” Dr. Kar-pecki says, and also include severity, frequency and which eye drops are currently being used.

Dr. Donnenfeld adds, “We want to know the patient’s ability to function at normal tasks.”

Dr. Sheppard envisions the devel-opment of something more techno-logically advanced. “I would have a questionnaire that the patient could fi ll out at home in a reproducible format that we could then plug in digitally when they walk into the offi ce with essentially no effort on the part of the technician,” he says. “The information would then ap-pear as a global score on the chart,

with maybe a bar graph read-out that tells us this is aqueous defi -ciency, this is lipid defi ciency, this is blepharitis, this is allergy.” Histori-cal data could then portray the pro-gression or resolution of important complaints in one readout, he says.

Ultimately, the choice of which—if any—dry eye questionnaire depends on practitioner preference. But no matter what, “providing surveys to patients about their symptoms demonstrates a sense of empathy for their condition that many practitioners fail to do,” Dr. Hauser says. “Often, dry eye patients feel as if they are relegated to an afterthought by their doctors. The patients recognize that their ac-tivities of daily living have been in-hibited, if not devastated, by ocular surface disease, and they appreciate the attention to their plight.” RCCL

1. Gayton JL. Etiology, prevalence and treat-ment of dry eye disease. Clin Opthalmol. 2009; 3:405-12. www.ncbi.nlm.nih.gov/pmc/articles/PMC2720680/2. Savini G, Prabhawasat P, Kojima T, et al. The challenge of dry eye diagnosis. Clin Ophthalmol. 2008 Mar;2(1):31-55. 3. Bjerrum KB. Test and symptoms in kerato-conjunctivitis sicca and their correlation. Acta Ophthalmol Scand 1996;74:436–41.4. Hay EM, Pal TB, et al. Weak association between subjective symptoms of and objective testing for dry eyes and dry mouth: results from a population based study. Ann Reum Dis 1998;57:20–4.

5. McMonnies CW. Key questions in a dry eye his-tory. J Am Otpom Assoc. 1986 Jul;57(7):512-7.6. McMonnies CW, Ho A. Patient history in screen-ing for dry eye conditions. J Am Optom Assoc. 1987;58:296-301.7. McMonnies CW, Ho A. Responses to a dry eye questionnaire from a normal population. J Am Optom Assoc. 1987:58:588-591.8. Nichols KK, Nichols JJ, Mitchell GL. The reli-ability and validity of McMonnies Dry Eye Index. Cornea. 2004 May;23(4):365-71.9. Begley C, Chalmers RL, Mitchell GL et al. Char-acterization of Ocular Surface Symptoms from Optometric Practices in North America. Cornea 2001;20(6):610-18.10. Begley CG, Caffery B, Chalmers RL, et al. Use of the Dry Eye Questionnaire to Measure Symptoms of Ocular Irritation in Patients with Aqueous Tear Deficient Dry Eye. Cornea 2002;21(7):664-70.11. Walt JG, Rowe MM, Stern KL. Evaluating the functional impact of dry eye: the Ocular Surface Disease Index [abstract]. Drug Inf J. 1997;31:1436.12. Grubbs JR Jr, Tolleson-Rinehart S, Huynh K, Da-vis RM. A review of quality of life measures in dry eye questionnaires. Cornea. 2014 Feb;33(2):215-8.13. Simpson TL, Situ P, Jones LW, et al.. Dry eye symptoms assessed by four questionnaires. Op-tom Vis Sci. 2008;85:692–699.14. Espindle D, Simpson T, Nelson J, et al. Develop-ment and validation of the impact of dry eye on everyday life (IDEEL) questionnaire, a patient-reported outcomes (PRO) measure for the assess-ment of the burden of dry eye on patients. Health Qual Life Outcomes. 2011 Dec 8;9:111.15. Ngo W, Situ P, Keir N, et al. Psychometric properties and validation of the Standard Patient Evaluation of Eye Dryness questionnaire. Cornea. 2013;32(9):1204-10.16. Sakane Y, Yamaguchi M, Yokoi N, et al. Devel-opment and validation of the Dry Eye-Related Quality-of-Life Score questionnaire. JAMA Oph-thalmol 2013 Oct:131(10):1331-8.17. The Epidemiology of Dry Eye Disease: Report of the Epidemiology Subcommittee of the Inter-national Dry Eye WorkShop (2007). The Ocular Surface. April 2007;5(2):93-107.

(Continued from p. 15)



We and our patients are fortunate to live in an age where

we have a variety of contact lens options designed to improve vision and comfort, and promote ocular surface health. These specialty lenses are truly different and, as such, require special care.

SCLERAL CONTACT LENSES

Currently, scleral gas permeable (GP) contact lenses represent the fastest growing segment of the specialty contact lens industry.1

Already invaluable for treating patients with keratoconus and other corneal irregularities, scleral lenses are now also being worn by healthy patients who require simple refractive correction.

Inherently larger than corneal GP lenses, sclerals are designed to vault the cornea and rest on the sclera. As such, they must be fi lled with solution prior to application to prevent air bubbles from form-ing underneath the lens (Figure 1), which can compromise comfort, vision and corneal health (i.e., compression of the epithelium

and differential oxygen levels). In order to prevent this solution from spilling during application, patients should be instructed to keep their head down, parallel to the ground. In this position, the patient should open both eyelids wide (scleral lenses average about 16.0mm in diameter), gently place the lens on the conjunctiva and then close the eyelids.2

Dr. Gromacki is a Fellow of the American Academy of Optometry and a Diplomate in the Cornea, Contact Lens, and Refractive Technologies

section. She has written extensively and lectured

internationally on the topics of cornea and contact lenses and serves as the Director of the Contact Lens Service at a subspecialty group practice in Maryland.

ABOUT THE AUTHOR

SPECIAL CARE

Safe

Keeps SpecialtyLens Wearers

By Susan J. Gromacki, OD, MS

Fig. 1. Scleral contact lens with insertion bubble.

Pho

to: G

reg D

eNaeyer, O

D

Contact lens care is a vital step to the continued safety and health of the contact lens patient. So how does lens care diff er in the case of sclerals and other specialty lenses?

020_RCCL0415_F3.indd 20020_RCCL0415_F3.indd 20 3/27/15 3:44 PM3/27/15 3:44 PM

Note a scleral lens’s thickness (approximately 0.3mm), diameter and depth can affect its center of gravity, making it more diffi cult to balance the lens on one fi nger com-pared with a soft or corneal GP lens. As such, a number of methods may be utilized to assist in holding the lens for proper insertion:

• The “tripod method.” After forming a tripod with the thumb, index fi nger and middle fi nger, rest the lens in the center of the three digits for application.

• A large DMV or suction cup. As a recommendation, cut a small slice off the bottom or order the suction cup fenestrated so that it will be easier to remove from the lens following placement on the ocular surface.

• A #8 O-ring. Available from GP lens manufacturers or at many hardware stores. Before applica-tion, place the ring on the tip of the index fi nger and place the lens on top of the ring.3

• Ezi Scleral Lens Applicator (Q-Case). A ring-like device equipped with a bowl on which to balance the scleral lens during application.

• See Green Lens Inserter (Dalsey Adaptives). A device equipped with a permanent stand-ing suction cup and green light to

help focus the patient’s gaze during application (Figure 2). According to the manufacturer, the device is particularly suited for patients who struggle with manual dexterity, are monocular and cannot see the lens, or need to hold their eyelids.4

FILLING THE LENS

Scleral lenses provide minimal tear exchange, meaning the solution placed in the bowl of the lens prior to application remains in direct contact with the cornea during most of the lens-wearing day; thus, it is critical to use a nonpreserved solution to prevent preservatives from inducing allergic or hypersen-sitivity reactions.5,6

Scleral lenses are commonly fi lled with unit-dose sodium chlo-ride 0.9% inhalation/irrigation solution, which can be obtained in 3mm or 5mm vials from a phar-macy or online. Note that although it is a non-prescription item, some pharmacies may still require a pre-scription. I provide a preprinted, signed medical prescription to all of my scleral lens patients. This has two benefi ts: it tells the pharma-cist that the solution is for scleral contact lenses (thus saving us both a phone call) and it increases the likelihood that the patient’s medi-

cal insurance will cover the expense.5,6

Scleral patients suf-fering from dry eye and those whose lenses exhibit areas of touch or minimal clearance may benefi t from fi ll-ing their lenses with unit-dose artifi cial tears instead, which provide extra lubrication and corneal protection. Keep in mind, how-ever, that only the clear brands, not the milky

or viscous ones, will work without compromising visual clarity. Also, try to avoid formulations with HP-GUAR; while a fantastic wetting agent, it has the potential to gel underneath the lens.7

Manufacturers are also increas-ingly recommending against use of larger (e.g., 4 oz.) bottles of non-preserved saline because they often contain buffers, which can con-tribute to debris or mucin buildup underneath the lens.8,9 Patients are also less likely to comply with discarding a larger bottle should it become contaminated.

Note that all of the options cur-rently available for fi lling scleral lenses are considered off-label by the US Food and Drug Administra-tion. That being said, research may one day produce a solution that is more biocompatible and similar to the tear fi lm, but for now, unit-dose nonpreserved saline is the best option we have at this time.5,6

CLEANING SCLERAL LENSES

Scleral contact lenses are simply large GP lenses, so any solutions approved to clean and disinfect corneal GP lenses can be used for scleral lenses. However, because there is less tear fl ow under the edge of a scleral lens compared with a corneal GP lens, additional care should be taken to ensure that the lens surface is both clean and free of pathogens. I recommend a separate daily cleaner for all scleral lenses, regardless of whether they’re plasma-treated or not.


Enzymatic Cleaners

Patients wearing GP, soft or hybrid lenses who are prone to heavy protein deposition can use an enzymatic cleaner once per week or more.

Fig. 2. The See Green Lens Inserter with stand

(Dalsey Adaptives).


Examples of daily cleaners suit-able for GP lenses include: Boston Cleaner (Bausch + Lomb), Boston Advance Cleaner (Bausch + Lomb), Optifree Daily Cleaner (Alcon), or Optimum by Lobob ‘Extra Strength Cleaner’ (Lobob). The lat-ter, or an isopropyl alcohol-based cleaner approved for GP lenses, may be preferable for cleaning high Dk materials, which may scratch more easily with more abrasive cleaners. I also follow the FDA’s

recommendation to rinse with saline, rather than tap water, to re-move all cleaner from the lens, due to the fact that all water contains some levels of bacteria, fungi and amoebae.11

Lens disinfection should be performed with a GP condition-ing/disinfection solution such as Boston Advance Comfort Formula Conditioning Solution (Bausch + Lomb) or Boston Conditioning Solution (Bausch + Lomb) or with

a GP multipurpose solution such as Boston Simplus Multi-Action Solu-tion (Bausch + Lomb), Menicon Unique pH (Menicon), Optifree GP (Alcon), or Optimum C/D/S (Lobob). In addition, the Menicon Deluxe Care System (with Progent) is now approved for home use.

Many scleral lens fi tters advise sensitive patients to rinse the lens with nonpreserved saline prior to application. While this removes any residual solution—including its preservatives—left over from the disinfection process, it can also diminish wettability. Hydrogen peroxide solutions like PeroxiClear (Bausch + Lomb) or Clear Care (Alcon) are good preservative-free alternatives; however, these solutions are FDA-approved for GP lenses only if they are digitally rubbed prior to disinfection. If necessary, larger cases that accom-modate diameters up to 30mm can be obtained from online stores like the Dry Eye Shop. The catalytic neutralization disc is not included with purchase, however, so one needs to be transferred from the smaller case prior to use.12

HYBRID LENSES

Hybrid contact lenses are com-prised of a GP center surrounded by a hydrophilic skirt. Examples include the Duette and Ultra-Health (SynergEyes). Manufacturer guidelines advise patients who wear these lenses to digitally rub the lens, front and back, with a daily cleaner approved for silicone hydrogel soft lenses, then rinse off the cleaner with nonpreserved sa-line. For disinfection, manufacturer guidelines recommend Clear Care (Alcon), BioTrue (Bausch + Lomb), Renu fresh (Bausch + Lomb) or Complete Easy Rub (Abbott Medi-cal Optics). It should be noted that UltraHealth, due to its vaulted

SPECIAL CARE KEEPS SPECIALTY LENS WEARERS SAFE


Generic Solutions, Specifi c Problems

According to a recent study, the main determinant (38%) of which type of contact lenses were fi tted and purchased was price.14 If lens price has such an eff ect on the fi nal selection when the doctor is the primary decision-maker, imagine its considerable impact when patients are making purchasing decisions on their own, such as when selecting a solution.

Every year or so, a retailer entertains bids on which company will produce and package its private-label solution. When the contract expires, the formulation may likely change. Because a retailer generally accepts the lowest bidder, companies typically do not place their premium solutions in generic bottles. So, because expiration dates are typically 18 to 36 months into the future, there could be two diff erent chemical formulations residing in two of the same bottles sitting side-by-side on the store shelf. Likewise, a retailer can label two bottles of the same formulation diff erently—each to mimic popular brands.15,16

The bottom line: older formulations were the state-of-the art 10 or 15 years ago, and most work well for most patients. But since then, we have learned more about material/solution interaction; the private label solution may not be what’s most compatible for the patient.17,18 Research has also demonstrated a statistically higher rate of such ocular complications with patients who use private label compared with name-brand solutions.19

Additionally, FDA recommended in 2010 that all multipurpose solutions carry “rub and rinse” instructions, and the care systems launched since then have complied. However, some mass retail-ers’ packages still contain the words “no rub.” It has been common knowledge for several years that a cleaner lens is a healthier lens, and research has proven that digitally rubbing a lens is more eff ec-tive than not at removing the deposits that can lead to infl amma-tion or infection.20

We have made great advances in solutions over the past few years—including improved cleaning and disinfection, less toxicity, and increased comfort and wettability—and the patient who buys generic isn't benefi ting from that technology.16


design, needs to be fi lled with non-preserved saline or artifi cial tears prior to insertion, then inserted with the head kept down similar to inserting a scleral lens.

For keratoconus patients who wear the KC and ClearKone (SynergEyes) hybrid lenses, preser-vative-based care systems should be avoided. Hybrid lens manufac-turer guidelines recommend Clear Care or Oxysept Ultracare (Abbott Medical Optics).

For all hybrid lenses, a digital rubbing step is required, as they have a six-month replacement schedule. Since they contain a soft skirt, gas permeable solutions are contraindicated.

SOFT LENSES FOR

KERATOCONUS

There are now excellent soft con-tact lens designs used specifi cally to treat keratoconus. Because these lenses are custom-produced and last up to three months, a digital rubbing step is typically recom-mended. (Of specifi c note, Bausch + Lomb recommends rubbing its KeraSoft IC lens in between the fi ngers, rather than in the palm of the hand.13)

Because soft lenses for kera-toconus tend to be thicker than disposable soft contact lenses, most manufacturers recommend using nonpreserved disinfectants because of the potential for absorption into the lens matrix. Alden Optical recommends hydrogen peroxide systems for its NovaKone lens (Figure 3), while Bausch + Lomb recommends use of either multi-purpose or hydrogen peroxide with its KeraSoft IC. However, if multipurpose solution is used, B+L suggests rinsing it off with sterile rinsing solution prior to applica-tion.13

CONCLUSION

The fi tting of scleral and other specialty contact lenses requires great diligence and attention to de-tail on the part of the practitioner. However, even the best scleral lens fi t can be compromised by poor lens care on the part of the patient. This part of the equation is just as critical to contact lens success.

For further information on con-tact lens care, please consult each lens and/or material manufacturer for its specifi c care recommenda-tions. RCCL

1. Nichols, J. 2014 annual report: Contact lenses 2014. Contact Lens Spectrum. 2015;30(1):22-27.2. Gromacki SJ. Handling and care of scleral GP contact lenses, Part 1. Contact Lens Spec-trum. 2011;27(10):27.3. Gromacki SJ. Scleral GP contact lens inser-tion, removal, and care. [Webinar.] Gas Perme-able Lens Institute, March 2014. Available at: www.gpli.info/videos/webinar-2014-03.htm.4. Dalsey Adaptives. The See-Green Lens In-serter. Available at: www.dalseyadaptives.com. Accessed February 2015.5. Gromacki SJ. Handling and care of scleral GP contact lenses, Part 2. Contact Lens Spec-trum. 2012;27(1):19.6. Gromacki SJ. Scleral GP lens preparation: The latest standard of care. Contact Lens Spectrum. 2013;28(11):25.7. Smythe M. Personal communication, April 10, 2014.8. Imavasu M, Hori Y, Cavanagh HD. Eff ects of multipurpose contact lens care solutions and their ingredients on membrane-associated mucins of human corneal epithelial cells. Eye Contact Lens. 2010 Nov;36(3):361-6.9. Gorbet MB, Tanti NC, Jones L, Sheardown H. Corneal epithelial cell biocompatibility to silicone hydrogel and conventional hydrogel contact lens packing solutions. Mol Vis 2010 Feb 19;16:272-82.10. US Food and Drug Administration. Medical Devices. Available at: www.fda.gov/Medi-calDevices/ProductsandMedicalProcedures/HomeHealthandConsumer/ConsumerProducts/ContactLenses/. Accessed February 2015.11. Ward M. General Session #9: Contact Lens Care. Lecture at The Global Specialty Lens Symposium, January 24, 2015; Las Vegas, Nevada.12. The Dry Eye Shop. Lens Cases. Available at: www.dryeyeshop.com/lens-cases-c95.aspx. Accessed February 2015.13. A&R Optical. Patient Instruction/Wearer’s Guide for Intelliwave3/KeraSoft IC. Available at: www.artoptical.com/fi les/documents/resources/Intelliwave_Patient_Instruction_-_Efrofi lcon_A_1.pdf. Accessed February 2015.14. Ichijima H, Shimamoto S, Ariwaka Y, et al. Compliance study of contact lens wearing in Japan, part 1: Internet survey of actual circum-stances of lens use. Eye & CL 2014;40(3):169-174. 15. Ferris State University. Private Label Lens Care Guide. Available at: www.ferris.edu/HTMLS/colleges/michopt/vision-research-institute/PDFs/contact-lens-solutions.pdf. Accessed February 2015. 16. Gromacki SJ. The truth about generics. Contact Lens Spectrum. 2005;20(12):24.17. Green JA, Phillips KS, Hitchins VM, et al. Material Properties That Predict Preservative Uptake for Silicone Hydrogel Contact Lenses. Eye Contact Lens. 2012 Nov;38(6):350-357.18. Andrasko G, Ryen K. Corneal staining and comfort observed with traditional and silicone hydrogel lenses with multipurpose solution combinations. Optom. 2008; 79: 444-454.19. Forister JY, Forister EF, Yeung KK, et al. Prevalence of contact lens-related complica-tions: UCLA contact lens study. Eye Contact Lens. 2009;35(4):174-80.20. Schnider C: Clinical performance and eff ect of care regimen on surface deposition of galy-fi lcon A contact lenses. [Electronic abstract 055102.] Optom Vis Sci. 2005; 82.


Fig. 3. Acceptable NovaKone (Alden Optical) fi t on a keratoconic eye,

enhanced with high molecular weight fl uorescein.


Does this sound famil-iar? “Doctor, I don’t understand what’s wrong. I have been wearing my contact

lenses overnight for years and this has never happened before.” Upon close examination, you note the presence of small, grayish aggre-gates in the corneal epithelium. The diagnosis? Corneal infi ltrates. But how do you tell if they are sterile or infectious—harmless, or a potential serious problem?

As practitioners, we have seen any number of contact lens-related complications walk through our doors. Corneal infi ltrates and ulcers are two such examples that have long been an unfortunate reality of patient care. In the 19th century, treatment of corneal ulcers included chemical cauterization with silver nitrate. While we’ve come a long way since those days in the care we provide, when such adverse events occur, differentiating infectious and sterile infi ltrates is still no easy task.

BREAKING IT DOWN

Corneal infi ltrates result from the penetration of white blood cells into the corneal tissue as part of the body’s infl ammatory response

to the presence of bacterial tox-ins, enzymes and byproducts.1-4 A corneal ulcer, by comparison, is an epithelial defect with underlying infl ammation (which typically leads to necrosis of corneal tissue).

Infi ltrates and ulcers are similar in that they both involve disruption of the corneal epithelium; indeed, a staining infi ltrate may be the begin-ning of a corneal ulcer. The differ-ence, however, is that while corneal infi ltrates are not sight-threatening, corneal ulcers involve active tissue damage caused either by infectious or non-infectious etiologies. Infec-tious ulcers are caused by fungus, virus, or parasites like Acantham-oeba) or, most commonly, bacteria.5

Alternately, noninfectious ulcers result from autoimmunity, neuro-trophic keratitis, allergy (e.g., shield ulcers), infl ammation from blepha-ritis or chemical burns, or idiopath-ic conditions (e.g., Mooren’s ulcer).

In the case of microbial insult, the damage typically results in an excavation of the corneal stroma, which triggers an anterior chamber response of fl are with or without cells (Figures 1, 2 and 3). For this reason, the terms microbial keratitisand bacterial ulcer are sometimes used interchangeably.

Four subtypes of contact lens-related corneal infi ltrates exist: microbial keratitis, contact lens-induced peripheral ulcer (CLPU), contact lens-induced acute red eye(CLARE) and infi ltrative keratitis. While the etiology of these subtypes is multifactorial, research shows signifi cant overlap between their clinical presentations, suggesting it is not possible to clinically differ-entiate between them; rather, they should be considered as stages of a single disease spectrum.6

Diff erentiating between the two requires close observation and analysis.

Here’s a results-oriented approach.

By Jeff rey Sonsino, OD, and Shachar Tauber, MD

1 CE Credit

(COPE Approval Pending)

Dr. Sonsino is a partner in a

specialty contact lens and

anterior segment practice

in Nashville, Tenn. He is a

diplomate in the cornea,

contact lens, and refrac-

tive therapies section of

the AAO, a council member

of the cornea and contact lens section

of the AOA, a fellow of the Scleral Lens

Education Society and an advisory board

member of the GPLI. Dr. Sonsino is board-

certifi ed by the ABO.

Dr. Tauber is an ophthal-

mologist at Mercy Clinic Eye

Specialists and Surgery

Center. He is a fellow of

the American Academy

of Ophthalmology and a

member of the American

Society of Cataract and Re-

fractive Surgery and International Ocular

Surface Society.

ABOUT THE AUTHORS


IS THAT CORNEAL INFILTRATE STERILE

OR INFECTIOUS?

024_RCCL0415_F4_CE.indd 24024_RCCL0415_F4_CE.indd 24 3/27/15 4:02 PM3/27/15 4:02 PM

THE “TWO CORNEAS”

When determining whether the cor-neal infi ltrate is infectious or sterile, one helpful method is to divide the cornea into two distinct regions. Consider that the central cornea encompasses the 6mm of the cornea apex whereas the peripheral cornea is a 2mm to 4mm dough-nut, with the limbus as its posterior border.

Based upon the close approxima-tion of the peripheral cornea to the limbus (with its preponderance of stem cells and vascularity), investi-gators believe the immune response to be more active in this region of the cornea. Quantifi cation of the nerve fi bers shows a densely innervated cornea and a fi ve to six times lower innervated peripheral cornea.7 Higher mitotic activity has also been demonstrated in the peripheral cornea.8

These observations indicate the two distinct regions of the cornea have key anatomic, physiologic and pathologic differences, allowing for the generalization that infi ltrates in the periphery of the cornea are non-infectious while infi ltrates in the central 6mm of the cornea may have an infectious etiology.9

ALWAYS TAKE NOTES

As with any medical concern that presents to the clinic, careful his-tory taking can lead the eye care practitioner to identify the proper diagnosis and resultant treatment that gives the patient the best pos-sible outcome with the least risk.

• Contact lenses. Contact lens use is one identifi ed risk factor for the development of corneal infi l-trates, as evidence shows continu-ous wear of contact lenses increases the risk of ocular complications. However, it is not the primary cause of corneal infi ltrates; rather, it is simply one of several contribu-tors. Other risk factors for corneal infi ltrate development in con-tinuous wear contact lens patients include age (i.e., between 18 and

29 years) and a history of smoking, corneal scarring, contact lens acute red eye or corneal infi ltrates.10

Of the different corneal infi ltrate types, microbial keratitis is the most severe complication of contact lens wear. In the 1980s and 1990s, risk of microbial keratitis was found to be four cases per 10,000 lens wearers per year for daily wear and 20 cases per 10,000 wearers per year for extended wear.11,12 Pseudo-monas aeruginosa has been identi-fi ed as the most common bacterial source of microbial keratitis in contact lens wearers.13

• Corneal trauma. Risk of micro-bial keratitis also increases any time there is a history of corneal trauma or foreign body presence due to the possibility of incomplete removal. This is especially true when the foreign body is vegetative matter, which is more likely to be con-taminated by pathogens. Corneal trauma may also include iatrogenic etiologies, such as retained or bro-ken sutures in penetrating kerato-plasty patients.

• History of surgery. Because anterior segment surgery compro-mises epithelial barrier function, any corneal surgery carries a risk of resultant infi ltrative keratitis and infectious ulcer. In particular, infi l-trative keratitis is associated with astigmatic keratectomy, penetrating keratoplasty, DSAEK, pterygium removal, trabeculectomy, LASIK

Release Date: April 2015Expiration Date: April 1, 2018Goal Statement: This course reviews the eti-ology, contributing factors and clinical pre-sentations of sterile and infectious corneal infiltrates. Key points in ocular examination and treatment will also be discussed.Faculty/Editorial Board: Jeffrey Sonsino, OD, and Shachar Tauber, MD Credit Statement: COPE approval for 1 hour of continuing education credit is pending for this course. Check with your state licens-ing board to see if this counts toward your

CE requirements for relicensure.Joint-Sponsorship Statement: This contin-uing education course is joint-sponsored by the Pennsylvania College of Optometry.Disclosure Statement: Dr. Sonsino con-sults for SynergEyes, Bausch + Lomb, Alcon, Visionary Optics and Optovue, has received grant support from Visioneering, and owns stock in LVR Technology. Dr. Tauber consults for AMO and Allergan, has received grant support from the Department of Defense, and owns stock in Calhoun Vision and Ocugenics.


Fig. 1. Slit beam evaluation of a corneal ulcer. Deviation of the beam shows

corneal excavation.


and cataract surgery.14-17 It is not clear if the relative risk is greater with regards to a particular corneal surgery.

• Ocular surface disease. Sterile peripheral (i.e., marginal) corneal infi ltrates may result from a com-promised ocular surface. Staphlo-coccal blooms in the lids spill bacte-rial byproducts onto the cornea, which triggers a hypersensitivity reaction that is theorized to lead to infi ltrates.18,19 Often small and multiple in nature, these infi ltrates are typically positioned roughly 1mm from the limbus. Marginal infi ltrates may be asymptomatic, or may be accompanied by conjuncti-val injection. Pathogenesis includes bacterial, allergic or autoimmune etiologies.

In the case of severe blepharitis and meibomian gland dysfunction (MGD), the bacterial blooms within the meibomian glands can produce a hypersensitivity reaction, leading to peripheral, non-staining subepi-thelial infi ltrates (SEIs). The body responds to the to antigen presented by this presence of Staphlococcalbacteria in the lids by recruiting white blood cells to the area as part of an antibody response. For this reason, the SEIs associated with

Staphlococcal marginal keratitis are typically in the 2 o’clock and 10 o’clock regions and the 4 o’clock and 8 o’clock regions, contiguous with the upper and lower lids.

Similarly, ocular rosacea can lead to MGD. However, with severe rosacea, potential outcomes include marginal infi ltrates, chronic conjunctivitis, sterile ulceration, corneal neovascularization and corneal scarring (Figures 4 and 5). It is also critical to rule out herpes simplex keratitis (HSK), which may resemble the infi ltrates seen in Staphlococcal marginal keratitis. HSK lesions, however, are typically harder to treat and appear with deeper stromal infl ammation.20

• Allergic conjunctivitis. All eye care practitioners are familiar with the signs and symptoms of

seasonal allergic conjunctivitis, atopic conjunctivitis and papillary conjunctivitis. Perhaps less com-monly encountered, however, is a variant of allergic conjunctivitis found most often in young boys. Vernal conjunctivitis is a severe bilateral condition characterized by photophobia, chemosis, sticky discharge, eosinophils at the limbus (i.e., Horner-Trantas dots) and shield ulcers.21 Secondary bacterial keratitis typically results from 10% of shield ulcers.22

• Medications. Contamination of ocular medications has been implicated in numerous case studies of corneal ulceration; the pathogen may originate in topical medication dropper tips or within the medica-tions themselves.23,24

LOOK FOR THE SIGNS

The next step after collecting a complete patient history is to con-duct an ocular examination, which can help determine whether an infi ltrate is sterile or infectious. The following are all key elements of a physical examination that can help with proper diagnosis:

• Does the patient report symp-toms of pain, photophobia or loss of vision? What about corneal sen-sation? Pain out of proportion with the signs points to Acanthamoeba, while loss of corneal sensation (i.e., lack of pain upon history or with the corneal wisp test) signals HSK.

• Do you observe blepharitis, nasolacrimal duct obstruction, poor or incomplete blink or lag-ophthalmos, entropion/ectropion or conjunctival injection? Is the conjunctival injection localized or diffuse? How about circumlimbal? Be sure to grade the injection (i.e., 1-4+). What about corneal foreign bodies?

• Is there discharge and, if so, what are its characteristics?

IS THAT CORNEAL INFILTRATE STERILE OR INFECTIOUS?


Fig. 2. Sodium fl uorescein evaluation of a corneal ulcer. The hyperfl uorescence

is attributed to staining of the mucous plug.

Fig. 3. Contact lens-related microbial

keratitis. Ulcer fi lled with mucous

plug.


• What is the location, depth and size of the infi ltrate(s)? Do you ob-serve stromal loss?

• Is there visible loss of corneal endothelium? What about plaque or pigment on the endothelium?

• What is the status of the patient’s corneal graft, if they have one?

• Do you observe any stromal haze and edema?

• Do you observe anterior cham-ber reaction, cells/fl are or hypopyon?

• Are there vitreous cells present? Note, a corneal ulcer will rarely lead to endophthalmitis with vitre-ous cells present.

THE CULTURAL REVOLUTION

In the last 20 years, a major shift in thought regarding the need to obtain corneal material to identify offending organisms and deter-mine sensitivity to antibiotics has occurred. Today, broad-spectrum fl uoroquinolones are readily avail-able as the primary treatment for a corneal infi ltrate believed to be infectious. Thus, the majority of community-acquired cases of bacte-rial keratitis are typically resolved with empiric therapy and managed without smears or cultures.

However, such tests are indicated in certain cases, including those that involve a corneal infi ltrate that is central, large and extends to the mid to deep stroma, particularly with signifi cant thinning of the cornea or scleral extension; those chronic in nature or unresponsive to broad-spectrum antibiotics; and those that present with atypical clinical fea-tures suggestive of fungal, amoebic or mycobacterial keratitis.25 Smears and cultures may also be helpful in cases with an unusual history, such as trauma caused by vegetable matter or if the patient wore contact lenses while in a hot tub.25

Additional specialized studies can help identify atypical organisms, for example in sight-threatening or se-vere keratitis of suspected microbial origin.25 However, the American Academy of Ophthalmology—not-ing that the hypopyon that occurs in eyes with bacterial keratitis is usually sterile—recommends aque-ous or vitreous taps should not be performed unless there is a high suspicion of microbial endophthal-mitis, such as following an intra-ocular surgery, perforating trauma or sepsis.25

When obtaining corneal mate-rial, proper technique is critical to identify the causative organism and select the proper antibiotic, antiviral, antifungal or antiproto-zoal medications. The process of obtaining corneal material should fi rst involve the instillation of a topical anesthetic agent (note that tetracaine should be avoided due to its antimicrobial effect) followed by the use of a heat-sterilized platinum spatula, blade, jeweler’s forceps or other similar sterile instrument to obtain scrapings of material from the advancing borders of the infected area of the cornea. Culture yield may be improved by avoiding anesthetics with preservatives.

A thiol or thioglycollate broth-moistened dacron/calcium alginate or sterile cotton swab can also be used to obtain material.25 However, solid as well as liquid plating media is always recommended.26 If treat-ment is refractory and cultures do not yield results, it is advisable to halt antibiotics in order to isolate the exact pathogen for further treatment. It is also important to consider culturing contact lenses, contact lens cases and contact lens solutions if appropriate and avail-able.

TREATMENT OPTIONS

Topical antibiotics are the fi rst-line therapy for suspected or culture-proven bacterial keratitis; however, the selection depends on severity. A peripheral infi ltrate associated with lid margin disease may be appro-priately managed with inexpensive early fl uoroquinolones such as ofl oxacin, ciprofl oxacin, azithro-mycin or a polymixin-bacitracin ointment, while central or more aggressive infi ltrates warrant use of fourth-generation fl uoroquinolones such as gatifl oxacin, moxifl oxacin or levofl oxacin.


Fig. 4. Severe ocular rosacea. Visible on the lid is tyalosis, scalloped lid

margin and telangiectasia, which signals severe infl ammation within the

meibomian glands.


REVIEW OF CORNEA & CONTACT LENSES | JANUARY 2015 28

For more serious keratitis, the use of besifl oxacin has recently been advocated. This new fl uoroquino-lone has high MIC values for many common ophthalmic pathogens and a unique compound containing polycarbophil, edetate disodium dihydrate and sodium chloride, which allows for greater ocular surface contact time. Additionally, its position as the only ophthalmic fl uoroquinolone not used systemi-cally makes it unique by reducing the risk of antibiotic resistance.

In severe situations with risk for perforation, failure to respond to monotherapy or central aggressive ulcers with the potential for vision loss, the use of combination forti-fi ed-antibiotic therapy should be considered. This should be formu-lated by a compounding pharmacy that is a member of the Pharmacy Compounding Accreditation Board. Note that methicillin-resistant Staphylococcus aureus (MRSA) has been isolated with increasing frequency from patients with bacte-rial keratitis. Fluoroquinolones are generally poorly effective against MRSA ocular isolates; however, vancomycin has demonstrated some success.27 In cases of severe ulcer, consider more complete coverage with combination therapy.28

Systemic antibiotics are rarely needed, but may be considered in severe cases where the infectious process has moved to adjacent tis-sues (e.g., the sclera) or when there

is impending or frank perforation of the cornea. Research shows oral tetracycline controls the anti-collagenase activity commonly seen in necrotizing infections such as Pseudomonas.29 Systemic therapy is necessary in gonococcal keratitis because of the extremely aggressive nature of this organism (corneal penetration in 24 hours with inad-equate treatment). For this reason, the CDC recommends immediate hospitalization with IV antibiotics for adult gonococcal infection.

Treating viral, fungal and amoe-bic keratitis may be challenging and is beyond the scope of this article. Regardless, the eye care provider who has clinical suspicion or labo-ratory data supporting any of these infectious processes should be fl uent in their current treatment options or have available the appropriate consultants to offer prompt referral.

Determining whether an infi ltrate is sterile or infectious is not an easy task for even the best clinicians. However, with careful history tak-ing, physical examination, differen-tial diagnosis and proper treatment, patients have the best chance of making the best of a bad situation. RCCL

1. Josephson JE, Caff ery BE. Infi ltrative keratitis in hydrogel lens wearers. Int Contact Lens Clin. 1979;6:223–41.2. Szczotka-Flynn L, Lass JH, Sethi A, et al. Risk factors for corneal infi ltrative events during con-tinuous wear of silicone hydrogel contact lenses. Invest Ophthalmol Vis Sci. 2010 Nov;51(11):5421-30.3. Pearlman E, Johnson A, Adhikary G, et al. Toll-like receptors at the ocular surface. Ocul Surf. 2008;6:108–16. 4. Sweeney DF, Naduvilath TJ. Are infl ammatory events a marker for an increased risk of microbial keratitis? Eye Contact Lens. 2007 Nov;33(6 Pt 2):383-7; discussion 399-400. 5. Online Merck Manual. Corneal Ulcer. Available at: www.merckmanuals.com/professional/eye_disorders/corneal_disorders/corneal_ulcer.html. Accessed March 10, 2015.6. Efron N, Morgan PB. Can subtypes of contact lens-associated corneal infi ltrative events be clini-cally diff erentiated? Cornea. 2006 Jun;25(5):540-4.7. Müller, Vrensen, Pels, et al. Architecture of Hu-man Corneal Nerves. Invest Ophthalmol Vis Sci. April 1997;38(5):985-94.8. Lemp MA, Mathers WD. Corneal Epithelial Cell Movement in Humans. Eye. 1989;3:438-45.

9. Mah FS. Corneal infi ltrates merit care: Diff er-entiating sterile and infectious conditions key to diagnosis, treatment. Ophthalmology Times. 2010 Oct;35(19):42.10. McNally JJ, Chalmers RL, McKenney CD, Robirds S. Risk factors for corneal infi ltrative events with 30-night continuous wear of silicone hydrogel lenses. Eye Contact Lens. 2003 Jan;29(1 Suppl):S153-6; discussion S166, S192-4.11. Poggio EC, Glynn RJ, Schein OD, et al. The incidence of ulcerative keratitis among users of daily-wear and extended-wear soft contact lenses. N Engl J Med. 1989;321:779–83.12. Cheng KH, Leung SL, et al. Incidence of contact-lens-associated microbial keratitis and its related morbidity. Lancet. 1999;354:181–5.13. Mondino BJ, Weissman BA, Farb MD, et al. Corneal ulcers associated with daily-wear and extended-wear contact lenses. Am J Ophthalmol. 1986;102:58–65.14. Adrean SD, Cochrane R, Reilly CD, Mannis MJ. Infectious keratitis after astigmatic keratotomy in penetrating keratoplasty: review of three cases. Cornea. 2005 Jul;24(5):626-8.15. Moon SW, Kim YH, Lee SC, Lee MA, Jin KH. Bi-lateral peripheral infi ltrative keratitis after LASIK. Korean J Ophthalmol. 2007 Sep;21(3):172-4.16. Villarrubia A, Cano-Ortiz A. Candida keratitis after Descemet stripping with automated en-dothelial keratoplasty. Eur J Ophthalmol. 2014 Nov-Dec;24(6):964-7.17. Akpek EK, Demetriades AM, Gottsch JD. Peripheral ulcerative keratitis after clear corneal cataract extraction(1). J Cataract Refract Surg. 2000 Sep;26(9):1424-7.18. Mondino BJ. Infl ammatory diseases of the peripheral cornea. Ophthalmol 1998;95:463-12.19. Mondino BJ, Lahedi AK, Adamu SA. Ocular immunity to Staphylococcus aureus. Invest Oph-thalmol Vis Sci 1987;28:560.20. One Network. Herpes Simplex Virus. Available at: one.aao.org/focalpointssnip-petdetail.aspx?id=356f0d13-8853-410f-ac6b-7ff 5e0257800. Accessed March 25, 2015.21. Bonini S, Coassin M, Aronni S, Lambiase A. Vernal keratoconjunctivitis. Eye. 2004;18:345–51.22. Reddy JC, Basu S, Saboo US, et al. Manage-ment, clinical outcomes, and complications of shield ulcers in vernal keratoconjunctivitis. Am J Ophthalmol. 2013 Mar;155(3):550-9.23. Donzis PB. Corneal ulcer associated with contamination of aerosol saline spray tip. Am J Ophthalmol. 1997 Sep;124(3):394-5.24. Schein OD, Wasson PJ, et al. Microbial keratitis associated with contaminated ocular medica-tions. Am J Ophthalmol. 1988 Apr 15;105(4):361-5.25. American Academy of Ophthalmology Cornea/External Disease Panel. Bacterial keratitis. Limited revision. San Francisco (CA): American Academy of Ophthalmology (AAO); 2011.26. Bhadange Y, Sharma S, Das S, Sahu SK. Role of liquid culture media in the laboratory diagnosis of microbial keratitis. Am J Ophthalmol. 2013 Oct;156(4):745-5127. Eiferman RA, O'Neill KP, Morrison NA. Meth-icillin-resistant Staphylococcus aureus corneal ulcers. Ann Ophthalmol. 1991 Nov;23(11):414-5.)28. Asbell PA, Colby KA, Deng S, et al. Ocular TRUST: nationwide antimicrobial susceptibility patterns in ocular isolates. Am J Ophthalmol 2008;145:951-8.29. Ralph RA. Tetracyclines and the treatment of corneal stromal ulceration: a review. Cornea. 2000 May;19(3):274-7.


IS THAT CORNEAL INFILTRATE STERILE OR INFECTIOUS?

Fig. 5. Corneal scarring with severe

ocular rosacea.


1. All of the following are likely symptoms or signs of corneal infection EXCEPT:

a. Pain and photophobia. b. Discharge and foreign body sensation. c. Anterior chamber reaction that includes cell and flare. d. Lack of debris at the tear menuscus.

2. There are many reasons to culture corneal ulcers. Which of the following

is NOT one of them?

a. Culturing would be a helpful medico-legal component of your record in case the ulcer doesn’t respond to empiric treatment.

b. Culturing reveals sensitivities of the organism(s). c. Because no single agent is generally effective for all infections. d. Because ineffectively treated organisms are difficult to isolate.

3. Currently, the most effective/complete treatment plan for resistant

bacterial infection is:

a. Vancomycin and ceftazidime. b. Tobramycin. c. Gentamycin and Ocuflox. d. Ocuflox and erythromycin.

4. Which of the following statements is true regarding corneal infiltrates?

a. Sterile infiltrates are often single in number and are found closer to the visual axis.

b. Corneal infiltrates at least histologically present in all infections. c. Large, central infiltrates with overlying stains are probably sterile. d. Corneal infiltrates associated with microbial keratitis generally produce little

to no pain and photophobia.

5. The most common cause of perennial allergic conjunctivitis is:

a. Ragweed or tree pollen. b. Summer grasses. c. Home allergens, such as dust mites and animal dander. d. Multipurpose disinfecting solutions used in contact lens care.

6. Which of the following is not true regarding the use of systemic

antibiotics?

a. They often provide a more effective dose to the cornea than topicals alone. b. They have a lower chance of producing an allergic response. c. They are often ineffective when the infection has scleral extension. d. Tetracycline may aid in patients with an impending corneal melt.

7. Risk for infiltrative keratitis is increased with all of the following EXCEPT:

a. Poor compliance/hygiene. b. Smoking. c. History of corneal scarring and CLARE. d. Age 39 to 40.

8. The incidence rate for microbial keratitis has been estimated to range from

what to what per 10,000 extended-wear lens patients per year:

a. 18 to 20. b. 4 to 5. c. 34 to 38. d. 1 to 2.

9. Which of the following is NOT a risk for microbial keratitis?

a. Wearing contact lenses overnight. b. History of corneal trauma or foreign body. c. Prior corneal surgery. d. Daily use of aspirin. 10. Which of the following is true regarding monotherapy use in presumed

microbial keratitis?

a. A fourth-generation fluoroquinolone is probably the best overall option and can be used alone for deep central ulcers.

b. Besivance is likely the best option for MRSA infections. c. Monotherapy should be reserved for use in central infiltrates only. d. Erythromycin is generally the best treatment option pending culture results.

CE TEST ~ APRIL 2015 EXAMINATION ANSWER SHEET

Is That Corneal Infiltrate Sterile or Infectious?

Valid for credit through April 1, 2018

Online: This exam can also 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.

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, Canal Street Station, PO Box 488 New York, NY 10013

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

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

Sponsorship: Joint-sponsored by the Pennsylvania College of Optometry

Processing: There is an eight-to-10 week processing time for this exam.

Answers to CE exam:

1. A B C D 6. A B C D

2. A B C D 7. A B C D

3. A B C D 8. A B C D

4. A B C D 9. A B C D

5. A B C D 10. A B C D

Evaluation questions (1 = Excellent, 2 = Very Good, 3 = Good, 4 = Fair, 5 = Poor)Rate the effectiveness of how well the activity: 11. Met the goal statement: 1 2 3 4 5

12. Related to your practice needs: 1 2 3 4 5

13. Will help improve patient care: 1 2 3 4 5 14. Avoided commercial bias/influence: 1 2 3 4 5

15. How do you rate the overall quality of the material? 1 2 3 4 5

16. Your knowledge of the subject increased: Greatly Somewhat Little 17. The difficulty of the course was: Complex Appropriate Basic

18. How long did it take to complete this course? _________________________

19. Comments on this course: _________________________________________

___________________________________________________________________

20. Suggested topics for future CE articles: ______________________________

___________________________________________________________________

Identifying information (please print clearly):

First Name

Last Name

Email

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 present-ed. I have not obtained the answers to this exam by fraudulent or improper means.

Signature: ________________________________________ Date: _____________

Please retain a copy for your records. LESSON 111206, RO-RCCL-0415



Contact lenses, whether rigid or soft, are a foreign object on the ocular surface. They interact with the tear

fi lm, cornea, bulbar conjunctiva and palpebral conjunctiva; not sur-prisingly, complications may arise on any of these ocular structures as a result of contact. Addition-ally, the tear fi lm is separated into a pre- and post- contact lens fi lm with different thicknesses, which can initiate a variety of issues.1

3 AND 9 O’CLOCK STAINING

A common complication with corneal GP lenses is 3 and 9 o’clock staining, which is a result of epithelial punctate staining of the peripheral cornea near the edge of the GP lens.2 These so-called 3 and 9 o’clock areas may not be adequately resurfaced with tears after a blink, thus resulting in small desiccated regions. At fi rst the staining is mild, but over time the epithelial defects may become larger and denser. In severe cases, those portions of the cornea may become vascularized and even form an opacity.

When treating, be sure to check the edge of the contact lens fi rst. If you have a modifi cation unit within the offi ce, you can alter the edge of the lens to be rounded or a “plus” shape to help with edge-cornea interaction.3 If your patient has a particularly high plus or high minus lens, be sure to use lenticular lens designs to improve the edge of the lens.4

Inferiorly centered GP lenses are another major cause of 3 and 9

o’clock staining, so improving the centration of the GP lens is key.3

Additionally, selecting a GP lens material with good wettability may help to decrease peripheral erosion by reducing friction be-tween the lens and ocular surface. Artifi cial tears and gels can also help increase lubrication, but will need to be used consistently to prevent further complications.

If all other modifi cations fail, try altering the diameter of the lens. Smaller diameters may decrease

3 and 9 o’clock staining, though going larger is also an option. A scleral lens will resolve the issue completely because of the fl uid layer between the cornea and the contact lens, which will act as a lubricating cushion between the lens and ocular surface. Switching the patient to a hydrogel material may also be an answer.

FOREIGN BODIES

Foreign body tracking—when

dirt, dust or another small object adheres to the ocular surface and ends up underneath the lens—can be an extremely frustrating issue for both soft and GP lens wears alike.

Even the smallest foreign body can result in ocular surface dam-age, as with every blink, the trapped object scratches the delicate epithelium. This can lead to track marks, which are both very uncomfortable and potentially painful for the patient (Figure 1).

Lens edge design plays a major role regarding foreign body entrapment; for exam-ple, if the edge is poorly fi n-ished or has unpolished sec-ondary curves, this can lead to more occurrences.5 Thus, rolling the edge and polish-ing the secondary curves can help reduce foreign body entrapment. Be sure to also check the edges for chipping, as it can also increase risk of foreign body entrapment.5 If the problem persists, consider switching to a larger diameter lens, such as a scleral lens, to reduce or eliminate this issue.

SPECTACLE BLUR

Every once in a while, a patient comes in who complains that when they remove their contacts and put on their glasses, their vision is blurred. One reason this so-called spectacle blur may oc-cur is from the accumulation of fl uid within the epithelial cells. When contact lenses are removed, the swelling of these cells slowly decreases, and the spectacle blur

Troubleshooting GP ComplicationsMany GP lens problems are easily resolved once identifi ed.

By Stephanie L. Woo, OD

The GP Expert


Fig. 1. Foreign body entrapment under

GP lens shows track marks on the corneal

epithelium.

030_RCCL0415_gpe.indd 30030_RCCL0415_gpe.indd 30 3/27/15 3:45 PM3/27/15 3:45 PM

usually resolves after an hour.6

Spectacle blur can also result from changes in corneal curvature that is not related to edema. This is due to mechanical molding of the cornea (resulting from lens fi t) or prolonged metabolic stress.

This issue is particularly common in patients who wear fl at-fi tting or hybrid lenses.

In the case of corneal mold-ing, when the fi t of the contact lens is poor, the lens reshapes the cornea, thus resulting in spectacle blur (Figure 2). Spectacle blur is usually not a large issue, unless the primary cause is because the contact lens fi t is inappropriate. For example, in more extreme cases, deep stromal striae or opacifi cation of the cornea can be seen, which is indicative of further potential issues. In most cases, however, the cornea will eventually remold to a stable shape if the lens is removed (Figure 3).6 Regardless, education on spectacle blur and

what to expect usu-ally eases patients so they do not get upset or anxious.

LENS

ADHESION

Lens adhesion is the most common complication of extended wear GP lenses.7,8 Upon ex-amination, the lens will be immobile with mucous/lipid deposits present underneath. When fl uorescein is in-

stilled, none will be seen under the lens, indicating no tear exchange or lens movement. When the lens is removed, an arcuate ring pat-

tern is visible around the edge of the lens.7 Patients usually do not have any complaints with lens binding; in fact, they may report better comfort (except late in the day) because of the decreased lid interaction and movement.

If an extended wear patient ex-hibits lens adhesion, changing their wearing schedule to daily wear

will likely resolve the issue. During sleep, the pressure from the eyelids squeezes out the tear layer under the GP lens, which results in lens binding.7 If lens binding occurs with a daily wear patient, however, the fi t of the lens will need to be altered. When the lens decenters, the secondary and peripheral curve junctions contact the fl atter areas of the cornea.7,8 This, combined with pressure from the eyelids, leads to lens adherence. Try alter-ing the centration and curvature of the lens to achieve a more centered fi t and check to make sure the curves are well blended. If normal modifi cations do not work, con-sider switching to an aspheric back surface design.

Note that another potential cause of lens adherence is dry eye, specifi cally aqueous defi cient dry eye, so it is important to check your patient for any type of dry eye during their exam. RCCL

1. Nichols J, King-Smith PE. Thickness of the pre- and post-contact lens tear fi lm measured in vivo by interferometry. Invest Ophthalmol Vis Sci. 2003 Jan;44(1):68-77.2. Van der worp E, de Brabander J, Swarbrick HA, Hendrikse F. Evaluation of signs and symp-toms in 3 and 9 o’clock staining. Optom Vis Sci. 2009 Mar;86(3):260-5.3. Holden T, Bahr K, Koers D, et al. The ef-fect of secondary curve liftoff on peripheral corneal desiccation. Am J Optom Physiol Opt 1987;64:113.4. Henry VA, Bennett ES, Forrest JM. Clinical investigation of the Paraperm EW rigid gas permeable contact lens. Am J Optom & Physiol Opt 1987;64:313-320.5. Bennett, E. et al. Clinical Contact Lens Prac-tice. Lippincott, Williams, and Wilkins. Philadel-phia, PA. 2005. Pp 351. 6. Bailey SC. Contact lens complications. Op-tometry Today. June 4 1999. 7. Bennett, E. et al. Clinical Contact Lens Prac-tice. Lippincott, Williams, and Wilkins. Philadel-phia, PA. 2005. Pp 346-8. 8. Swarbrick HA, Holden BA. Rigid gas perme-able lens binding: signifi cance and lens factors. Am J Optom Physiol Opt. 1987;64(11)815-823.


Fig. 2. Topography of a poorly fi tting tangent streak

GP lens caused corneal steepening.

Fig. 3. Corneal topography after

discontinuing GP lens wear for

several months.

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Corneal hydrops, an uncommon complica-tion seen in patients with corneal ectatic disorders, is charac-

terized by the leakage of aqueous through a tear in Descemet’s mem-brane, which leads to a rolling of the edge and subsequent gaping of the posterior surface of the cornea. This allows the aqueous fl uid to intrude into the cornea, produc-ing an acute edematous response, relative changes in corneal archi-tecture and clinical symptomatol-ogy. Patients typically present with a rapid decrease in visual acuity, photophobia and pain. There is also notable localized edema and, in some instances, visible ectasia in the areas most compromised.

Corneal hydrops is estimated to occur in 2% to 3% of patients with keratoconus, with the major-ity presenting between ages 20 and 40. While some literature supports an increased rate of occurrence in males, there is no notable preva-lence by race. In most cases, the location of the hydrops is inferior to the apex of the cone. When ques-tioned, patients frequently admit to signifi cant eye rubbing. In some instances, severe coughing and/or heavy lifting have also been associ-ated with onset of disease. Down’s syndrome may be a risk as well.

Most cases heal naturally over a period of several months when treated using conservative methods, which include topical cycloplegic agents, corticosteroids to reduce

infl ammation and IOP-lowering drugs. Some patients, however, may require surgery if corneal edema persists or resultant corneal scarring affects visual clarity.

Conservative medical intervention is usually suffi cient to stave off the more concerning consequences of perforation, but overall has little im-pact on visual outcome or duration of disease. Thus, doctors are turning to other, more advanced methods of disease management. Recently, there has been renewed interest in the use of intracameral SF6 and C3F8 gases, which have been shown to lead to

faster improvement compared to more conservative treatments.1,2

Intrastromal venting incisions, used to delimit the large vacuoles that occur in some patients, have also demonstrated some success but are

still relatively experimental. Over-all, more research is needed on the effi cacy of these and other emerging treatments.

CASE STUDY

A recent case of corneal hydrops that presented to my offi ce is em-blematic of the conventional charac-teristics of the disease, and serves as a good example of conservative vs. more aggressive surgical treatment.

TW, a 42-year-old black female, was initially seen for a complaint of progressive change in visual function relative to longstanding keratoconus, and a recent history of possible progression noted by her current clinician. The consultation identifi ed signifi cant apical scarring in her right eye, and notably less scarring in the left. The best-correct-ed visual acuity with spectacles was 20/300 OD, which did not improve on pinhole, and approximately 20/80 OS with minimal pinhole improvement. Her previous history was positive for contact lens wear, although discomfort as well as poor acuity had decreased the patient’s wearing activity to a minimal level over the last six to 12 months.

The remainder of her examina-tion elements (i.e., intraocular pressure, lenticular assessment and posterior pole) were relatively normal. The patient was advised that several options were available: she could forgo intervention at this time, be fi t with a complex hybrid-type or scleral contact lens with the hope of achieving better results than

Corneal Consult By James Thimons, OD

Managing Acute Corneal Hydrops in KeratoconusUsing a structured approach to determine which factors impede healing will lead to success with these often challenging scenarios.


Fig. 1. Placement of intracameral

C3F

8 (non-expansile concentration)

in a diff erent patient than the one

described here. Note: the patient

was instructed to lie fl at with their

eyes looking up towards the ceiling,

so that the gas can occlude the

break in the posterior cornea.

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to: E

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ard B

oshnick, O

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010_RCCL0415_CC.indd 32010_RCCL0415_CC.indd 32 3/27/15 3:42 PM3/27/15 3:42 PM

her current standard hard lens, or undergo a corneal transplant.

The patient elected to consider the options and was scheduled for another appointment in three months, with plans to return sooner if a decision was made. Approxi-mately six weeks after her initial evaluation, the patient contacted the on-call service on a weekend and indicated that she had developed a notable decrease in vision, along with severe pain and photophobia.

I saw her on the same day, and it was evident she had a signifi cant corneal hydrops and a visible Des-cemet’s membrane tear. This was accompanied by notable apical ecta-sia in the zone of the hydrops. The presentation of the cornea was 3+/4 edema, focally located over the zone of the hydrops, which consisted of epithelial microcystic edema and in-trastromal cysts and vacuoles. The diameter of the area was approxi-mately 4.5mm to 5.0mm. Visual acuity was hand motion at two feet with no pinhole improvement.

I discussed treatment options with the patient, who elected to

proceed with conservative therapy, which included a topical antibiotic (ciprofl oxacin) QID to prevent infection, one drop of a cycloplegic (atropine) BID, the use of a hyper-tonic saline ointment (Muro 128) QID and an ocular antihyperten-sive agent to lower pressure and decrease the posterior forces on the cornea contributing to architectural change. The patient was also placed on topical Durezol QID, and a bandage lens was inserted—primar-ily for comfort, but also to prevent perforation.

The patient was observed over several weeks and, as is typical with hydrops, the intrastromal edema that was present at the initial episode began to resolve, as did the photophobia. At the initial three-day follow-up, the pain had less-ened signifi cantly with the atropine and Durezol, and the infl ammatory response present in the cornea showed a mild decrease. Addition-ally, the pressure had been reduced from 16mm Hg to 10mm Hg. The patient’s bandage lens was removed in order to view the corneal surface; upon removal, a decrease in the microcystic edema was observed and the stromal vacuoles and clefts appeared stable. I ordered current medication levels be maintained, but decreased the atropine to QD.

At the two-week follow-up, I reduced the steroids to BID and stopped the atropine. I continued the antibiotics but reduced the dose to BID. The bandage lens was also removed at two weeks and the cornea was competent with a negative Seidel. The patient called two days after the bandage lens was

discontinued and indicated that she had developed a foreign body sensa-tion, so I reinstituted lens wear. I maintained her on the antihyper-tensive agents for approximately four weeks. Additionally, she used the hypertonic saline ointment four times daily throughout the treat-ment period.

By the fourth week, the patient’s vision had returned to 20/200 best-corrected in the affected eye. Additionally, the microcystic edema had reduced dramatically, and the stromal edema had begun to dem-onstrate a coalescence of the vacu-oles, which were notably present at the initial clinical assessment.

It should be noted in cases like this one that therapeutic options like hybrid or scleral lenses are less viable because of the scar forma-tion, which is almost universal in patients of this type following a severe hydrops. I discussed the po-tential for a therapeutic penetrating keratoplasty as the option of choice, and TW is actively considering the possibility once the eye stabilizes. I anticipate that, given her current, relatively poor visual rehabilitative potential and the fact that the other eye also shows notable keratoconus, a penetrating keratoplasty would be a reasonable option to rehabilitate visual function and give her overall better visual potential in the years to come. RCCL

1. Panda A, Aggarwal A, Madhavi P, et al. Manage-ment of acute corneal hydrops secondary to keratoconus with intracameral injection of sulfur hexachloride (SF6). Cornea. 2007;26(9):1067-9.2. Basu S, Vaddavalli PK, Ramappa M, et al. Intracameral perfl uoropropane gas in the treat-ment of acute corneal hydrops. Am J Ophthalmol 2011:118(5):934-9.


Fig. 2. Hydrops resolved.

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ard B

oshnick, O

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010_RCCL0415_CC.indd 33010_RCCL0415_CC.indd 33 3/27/15 3:42 PM3/27/15 3:42 PM

If you’ve attended one of my lectures at a meeting or trade show, chances are you’ve probably also seen me do magic—specifi cally, a

type known as mentalism. Instead of pulling a rabbit out of a hat, mentalists use whatever is in the imagination of their audiences to complete their illusions. Mental-ism is essentially magic of the mind and frequently deals with predic-tions about the future. So, here’s a prediction I’ll make for everyone reading this article and, since you’re reading it for the fi rst time and I’m not standing in front of you, there is no possible way I could have set this up in advance!

My prediction is that the practice-building challenge you encounter most frequently is—wait for it—staff management. How’d I do? (Email me, I’d love to know!) And, the number one reason why so many doctors struggle with staff management is because they aren’t mentalists. In other words, they haven’t fi gured out how to predict the future! But what’s the connec-tion between understanding the future and staff management?

While it’s likely most of us do not know what our personal futures hold, chances are many of us have a good idea regarding the future of our practice. And, we have an obligation as practice leaders and CEOs to communi-cate this future to our staff. Great staff management and leadership involves understanding the long view and communicating that view to your staff—something that isn’t always easy.

AVOID MYOPIC LEADERSHIP

Due to the stresses and day-to-day pressures of running a practice, many of us succumb to “leader-ship myopia” and are only able to focus on what is directly in front of us at a given moment. As with all behaviors, staff members see your acute laser focus on the “here and now” and assume that if it’s important to you, it should be important to them too. The problem with this thought process is that big-picture goals, practice values and your very reason for be-ing a practice can get lost in this short-term view. People are people, and pa-tients are patients. You’ll always have acute patient management issues to deal with. Unless you rou-tinely set aside uninterrupted time to discuss with your staff why you are doing what you do with each patient on a day-to-day basis, they will never adopt your long-term view (i.e., your mentalist’s predic-tion, if you will) of the future.

Here’s an example: Mr. Late runs into the offi ce out of breath and says, “I ran out of contact lenses and I’m on my way to work. Can I have one more pair to hold me over?” As instructed at your last staff meeting, your staff cor-rectly checks his record and sees that his last examination was 16 months ago. Your clinical recom-mendation is once per year. So, the staff member says, “I’m sorry, you’re overdue for your exami-

nation, so we can’t give you any more lenses.”

Volumes have already been written about what may or may not happen next, and putting 10 of us in a room to discuss the best course of action would make for a nice fi reside chat—or perhaps a barroom brawl. However, what is rarely discussed is how to put your own view of how this situation should be handled into the minds of your staff.

What is your long-term, futur-istic macro goal for your practice and the micro short-term goal for this particular patient? The policy to deal with this individual patient is already known to every practice (i.e., either give the patient lenses or don’t, with any necessary expla-nations or caveats) but the reason for doing so, in the context of your big picture practice vision, is rarely articulated to staff. In other words, “Give or don’t give the lenses because our practice philosophy and long-term goals are…” is not usually discussed. This way, your staff members are able to better adhere to these long-term goals in the face of such situations.

So, hone your mentalist skills and start communicating your goals and aspirations to your staff. Your day-to-day operations will run much smoother. RCCL

Are You a Mentalist?Probably not. And neither are your staff members. Clear communication with your team is key to the success of your practice.


Out of the Box By Gary Gerber, OD

“BIG PICTURE GOALS AND PRACTICE VALUES CAN GET LOST.”

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