review & contact lenses of cornea sclerals · surgery; seven of these eyes had a history of...

JANUARY 2015

RCCLRCCLREVIEW OF CORNEA & CONTACT LENSES

Special Issue:

MAKING SCLERALS FIT

How the CDc helps in combating keratitis

earn 1 ce credit — glaucoma and dry eye: principles and parallels

Supplement to

• Who’s a Good Candidate?, page 10

• Simple Secrets to Success, page 14

• How to Incorporate Sclerals, page 18

Before you can fit these lenses

for patients, they have to fit your practice. Here’s help with both.

001_0115_rccl_cover.indd 1001_0115_rccl_cover.indd 1 12/29/14 9:10 AM12/29/14 9:10 AM

Now approved

info.meniconamerica.com

Menicon PROGENT removes protein and disinfects lenses without the mechanical rubbing or abrasive cleaners that can damage plasma treated lenses or complex surface geometries.

PROGENT every two weeks with daily use of Menicon Unique pH® multipurpose solution helpsmaintain deposit-free lenses for healthy andcomfortable lens wear.

Deep Cleaning today’s GP contact lenses.

PROGENT

Before After

Before and after photos courtesy of Stephen P. Byrnes, OD, Londonderry, NH. 16.5mm diameter FSA lens with a Dk of 141. US-WS102

Sign up for the WebStore today.

The Menicon GP lens care system is available for in-offi ce sales or on the Menicon WebStore. For a sample, contact us at 1.800.MENICON or [email protected]

Now Available!Large DiameterPROGENT Case

for Scleral Lenses

RCCL0115_Menicon.indd 1RCCL0115_Menicon.indd 1 12/22/14 9:49 AM12/22/14 9:49 AM

contentsReview of Cornea & Contact Lenses | January 2015

/ReviewofCorneaAndContactLenses #rcclmag

departments

10Who’s a Candidate

for Scleral Lenses?These specialty lenses are no longer just for the irregular cornea. By Greg DeNaeyer, OD

147 Simple Secrets to Scleral SuccessAre you intimidated by this resurgent modality? You don’t have to be. When fi tting sclerals, keep these handy tips in mind. By Muriel Schornack, OD

18How to Incorporate Scleral Lenses Into Your PracticeTurning your interest in scleral lenses into a successful practice-builder requires more than just knowing how to fi t them.By Stephanie L. Woo, OD

27CE — Glaucoma and Dry Eye: Principles and ParallelsCan one progressive eye disease teach us how to best treat another? By Leslie O’Dell, OD

News Review4Corneal Scars are Forever—Or Are

They?; DMEK Restores Visual Acuity

in Vitrectomized Eyes

My Perspective 6Antibiotic Resistance: Applauding

the President’s Council Report

By Joseph P. Shovlin, OD

Lens Care Insights7 Sticky Situation

By Christine W. Sindt, OD

Pharma Science & Practice

Bug Eyes

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

Derail Dropouts32

8

Obvious Problem, Elusive Cause

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

features

Out of the Box

Don’t Play the Percentages

By Gary Gerber, OD

34 24The Quest for ComplianceThe CDC recently completed its fi rst national contact lens health campaign. Can lessons learned during the eff ort help practicing clinicians?By Maya M. Rao, MPH

Cover design by Matt Egger

©iStock.com/blackred©iStock.com/karandaev

REVIEW OF CORNEA & CONTACT LENSES | JANUARY 2015 3

003_rccl0115_TOC.indd 3003_rccl0115_TOC.indd 3 12/29/14 9:11 AM12/29/14 9:11 AM

Anew treatment for cor-neal scarring using stem cells grown from the patient’s healthy stroma

could one day reduce the need for grafts, according to research published in the December 2014 Science Translational Medicine.1

“The body usually responds to corneal injuries by making scar tissue. We found that delivery of stem cells initiates regeneration of healthy corneal tissue rather than scar, leaving a clear, smooth surface,” says senior investigator James L. Funderburgh, PhD, as-sociate director of the Louis J. Fox Center for Vision Restoration of the University of Pittsburgh.

The purpose of the study was (1) to determine if mesenchymal stem cells present in limbal biopsy-derived stromal cells (LBSCs) dif-ferentiate into corneal keratocytes in vitro and (2) to evaluate whether LBSCs can prevent corneal scarring.

The researchers fi rst obtained and cultured LBSCs from tissue harvested from the limbus region of human donor corneas. The cells proliferated quickly, and were then tested to determine that they had

indeed become keratocytes. In the second half of the study, researchers used fi brin glue to engraft the cells onto the debrided corneas of mice. A separate control population was similarly debrided, but without the addition of LBSCs.

OCT performed at two and four weeks after debridement showed a marked increase in light scatter in the untreated scars; conversely, light scatter in the LBSC-treated scars was similar to levels in the preoper-ative normal corneas. Transmission electron micrography also revealed that collagen organization in the stroma appeared similar to that of native tissue in the LBSC-treated corneas. Reduced corneal vascu-larization in response to the LBSC treatment was also observed.

“Even at the microscopic level, we couldn’t tell the difference be-tween the tissues that were treated with stem cells and undamaged cor-nea,” Dr. Funderburgh says. “We were also excited to see that the stem cells appeared to induce heal-ing beyond the immediate vicinity of where they were placed. That suggests the cells are producing fac-tors that promote regeneration, not just replacing lost tissue.”

The study suggests LBSCs could eventually be used to treat corneal scarring in humans. Indeed, a small pilot study based on this research— in which a handful of patients will receive their own corneal stem cells as treatment—is underway in India.

1. Basu S, Hertsenberg AJ, Funderburgh ML, et al. Human limbal biopsy-derived stromal stem cells prevent corneal scarring. Sci Transl Med. 2014 Dec 10;6(266):172.

News Review

Corneal Scars Are Forever —Or Are They?

4 REVIEW OF CORNEA & CONTACT LENSES | JANUARY 2015

IN BRIEF

• Hepatitis C virus (HCV) RNA, com-monly found in the tear fl uid of patients with chronic HCV, may also be preva-lent in the tears of dry eye patients who exhibit no clinical evidence of HCV, according to a study published in the January 2015 Cornea.1 Researchers used real-time polymerase chain reaction testing to detect HCV RNA in tear fl uid collected from 36 dry eye patients and 20 healthy controls. Twenty-one of the 36 (i.e., 58.3%) dry eye tear samples tested HCV RNA-positive, while none of the control samples tested positive. These fi ndings, say the researchers, may indicate a possible etiological role of HCV in causing dry eye.

The researchers also evaluated 15 serum samples collected from dry eye patients. Enzyme-linked immunosor-bent assay for anti-HCV was nega-tive in all 15—a result they say further confi rms the presence of HCV RNA

without active viral infection. Normal levels of alanine aminotransferase were also observed in all 15, but alkaline phosphatase was abnormal in 12 of the 15 samples. This indicates the patients

likely do not have subclinical hepatitis, but it cannot be completely ruled out.

1. Rajalakshmy AR, et al. Patients with dry eye without hepatitis C virus infection possess the viral RNA in their tears. Cornea. 2015 Jan;34(1):28-31.

• A new hydrophilic daily disposable

soft multifocal lens for presbyopic cor-rection, called NaturalVue, has received FDA 510(k) clearance. Similar to a spherical contact lens, the NaturalVue 1-day multifocal is designed to be easy

to fi t, with one base curve, one diam-eter and one “universal” add power, which accommodates up to 3.00D of equivalent near power, says manufac-turer Visionering Technologies.

• SynergEyes has released eight video

tutorials designed to assist doctors with fi tting the Duette Progressive

lens for astigmatic presbyopes who no longer attain acceptable near vision from soft multifocal contact lenses. The step-by-step tutorials cover lens design, fi tting and dispensing, as well as how to achieve good near vision, distance vision and patient compliance.

Stem cells may be able to regenerate

tissue in corneal scarring patients.

Phot

o: C

hris

Sin

dt, O

D

004_rccl0115_news.indd 4004_rccl0115_news.indd 4 12/29/14 10:40 AM12/29/14 10:40 AM

Descemet’s membrane endothelial keratoplas-ty (DMEK) is success-ful in restoring visual

acuity in vitrectomized eyes, says a new study published in the Janu-ary 2015 Cornea.1 However, graft failure and the overall complica-tion rate are both higher than in standard DMEK procedures.

Researchers at Eberhard-Karls University, in Tubingen, Germany, reviewed 20 cases of DMEK surgery; seven of these eyes had a history of anterior vitrectomy and 13 eyes had a history of complete removal of the vitreous body. Sub-jects ranging in age from 37 to 78 years were evaluated the day be-fore surgery, on the day of surgery and during the fi rst, second and fourth week after the procedure. Additional three-month follow-up exams occurred after the initial fi rst month.

Following surgery, researchers reported an improvement in best-corrected visual acuity from 1.4 (± 0.5) logMAR (20/500) preop-eratively to 1.0 (± 0.5) logMAR (20/200) at four weeks. Subse-quent improvement to 0.8 (± 0.6) logMAR (20/125) at six months, and to 0.6 (± 0.3) logMAR (20/80) at 12 months, were also observed, despite the presence of comorbidi-ties, including age-related retinal

disease, glaucoma, corneal scarring and total retinal detachment.

Even with surgical success, how-ever, complications occurred in 13 of the 20 eyes. Graft dislocation occurred in 11 cases, requiring sur-gical intervention consisting of one or more additional air injections. In the immediate postoperative period, two eyes experienced iatro-genic primary graft failure, while four eyes had late graft failure.

Other complications included exacerbation of pre-existing glau-coma and intraocular pressure el-evation of up to 40mm Hg during follow-up in two eyes. “With more experience, probably better results could be achieved in vitrectomized eyes,” the authors concluded. RCCL

1. Yoeruek E, Rubino G, Bayyoud T, Bartz-Schmidt KU. Descemet membrane endothelial keratoplasty in vitrectomized eyes: clinical results. Cornea. 2015 Jan;34(1):1-5.


DMEK in Vitrectomized Eyes: Successes, Setbacks

11 Campus Blvd., Suite 100

Newtown Square, PA 19073

Telephone (610) 492-1000

Fax (610) 492-1049

Editorial inquiries (610) 492-1003

Advertising inquiries (610) 492-1011

E-mail [email protected]

EDITORIAL STAFF

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]

SENIOR ART/PRODUCTION DIRECTORJoe Morris [email protected]

GRAPHIC DESIGNERMatt Egger [email protected]

AD PRODUCTION MANAGERScott Tobin [email protected]

BUSINESS STAFF

PUBLISHERJames Henne [email protected]

REGIONAL SALES MANAGER Michele Barrett [email protected]

REGIONAL SALES MANAGER Michael Hoster [email protected]

VICE PRESIDENT OPERATIONSCasey Foster [email protected]

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

Advertiser Index

Alcon Laboratories ......................................................Cover 4

CooperVision ................................................Page 23, Cover 3

Menicon ......................................................................... Cover 2

RCCLRCCLREVIEW OF CORNEA & CONTACT LENSES

DMEK can improve visual acuity

even in vitrectomized eyes.

Phot

o: A

aron

Bro

nner

, OD

004_rccl0115_news.indd 5004_rccl0115_news.indd 5 12/29/14 10:41 AM12/29/14 10:41 AM

The President’s Council of Advisors on Science and Technology (PCAST) recently convened to discuss the ongoing

problem of “superbugs”—bacte-ria that have become resistant to antibiotics. The Council’s panel of scientists, researchers and engineers released a seven-part proposal on bacterial resistance to antimicrobial therapies in September that lays out the stakes for medical professionals and offers many practical recom-mendations.1-3

Historically, complications from disease were common and often serious. Roughly 30% of children died before their fi rst birthday.1 A scrape or insect bite could be a fatal malady, and consequences of sore throats often included rheumatic fever and heart failure. 1,2

Life changed with the advent of antibiotics in the 20th century, which have since saved millions of lives and increased life expec-tancy.1,3 Within the last decade, however, bacterial resistance has become a crisis—one that is outpacing the development of new countermeasures for treating infec-tions in humans.1-3

KEEP AN EYE ON IT

A major part of combating an-tibiotic resistance is providing adequate surveillance and rapid re-sponse capacity.1-3 Surveillance—the systematic collection and analysis of samples to ascertain the presence and characteristics of antibiotic-resistant bacteria—is absolutely

essential for detecting resistant pathogens, tracing their spread and determining their origin.1,2

Real-time tracking can help with early detection and identifi cation of outbreaks or epidemics and rapid response to prevent the spread.2

Topical ophthalmic drugs gener-ally achieve signifi cantly higher concentrations than their systemic counterparts achieve in serum levels.4 Nevertheless, the ophthal-mic community should still heed the warnings regarding bacterial adaptation.

COUNTING THE COST

The CDC estimates that antibiotic-resistant infections cost the United States $20 to $50 billion or more annually in direct health care, and up to $35 billion in lost productiv-ity.1,2 A staggering 23,000 deaths annually are reported as a result of antibiotic-resistant infections.1

Thus, aggressive action is necessary to contain this public health and fi nancial crisis.

PCAST gives a number of recom-mendations in its report:1-3

(1) Appoint a White House Director for National Antibiotic Resistance Policy, who should de-velop a National Action Plan for Antibiotic Resistance.

(2) Establish a national labora-tory network for pathogen surveil-lance based on genome analysis.

(3) Allocate $150 million per year over seven years to support investigation of non-traditional ap-proaches to overcoming antibiotic resistance.

(4) Initiate clinical trials with new antibiotics. Establish an infrastruc-ture and common protocols, and develop new regulatory pathways to evaluate urgently needed antibi-otics.

(5) Expand economic incentives for developing antibiotics. PCAST estimates an investment of $800 million will yield one new FDA-approved antibiotic each year.

(6) Revise stewardship of existing antibiotics in health care by creat-ing Medicare and Medicaid reim-bursement incentives that encour-age appropriate antibiotic use and establishing federal regulations for hospitals, long-term care facilities and outpatient settings.

(7) Limit the use of antibiotics in animal agriculture.

Overall, there is still much to be learned regarding resistance. Staying ahead will require novel approaches including anti-sense therapies, new narrow-spectrum drugs, agents to enhance immune response and drugs to attack viru-lence factors.1-3 RCCL

1. Report to the President on Combating Anti-biotic Resistance, Executive Offi ce of the Presi-dent/President’s Council of Advisors on Science and Technology, September 2014.2. Medscape. The President’s Report on Antibi-otic Resistance: What Does it Mean to Clinicians? Available at: www.medscape.com/viewarti-cle/834525. Accessed December 15, 2014.3. The White House. Executive Order—Combating Antibiotic-Resistant Bacteria. Available at: www.whitehouse.gov/the-press-offi ce/2014/09/18/executive-order-com-bating-antibiotic-resistant-bacteria4. Haas W, Pillar CM, Torres M, et al. Monitoring antibiotic resistance in ocular microorganisms: results from the Antibiotic Resistance Monitoring in Ocular Microorganisms (ARMOR) 2009 sur-veillance study. Am J Ophthalmol 2011:152:567-74.

Antibiotic Resistance: Applauding the President’s Council ReportOcular concerns diff er somewhat from systemic ones, but in many respects the risks and consequences are comparable.


My Perspective By Joseph P. Shovlin, OD

006_rccl0115_mp JP.indd 6006_rccl0115_mp JP.indd 6 12/29/14 9:13 AM12/29/14 9:13 AM

The benefi ts of using scler-al lenses to treat ocular surface disease are well known and have been supported by studies

in recent years, as well as decades of anecdotal reports of success. In short—sclerals vault the cornea and rest on the sclera, protecting the compromised ocular surface while providing space for a “liquid ban-dage.” There are problems specifi c to this combination of the distressed eye and specialty lens, however—namely, mucin and debris buildup under the lens.

Mucin forms deposits on the lens over time, decreasing comfort and affecting visual clarity. This is espe-cially problematic in patients with severe ocular surface disease, as the greater the irritation, the more mucus is produced. To limit this complication, I recommend weekly or bi-weekly prophylactic cleaning with Progent (Menicon America) to remove deposits and improve lens wear for all my scleral patients.

THE CASE FOR

PROGENT IS COGENT

Progent effectively disinfects and removes protein buildup from the surface of GP lenses. Primarily used as a cleaner to eliminate excess protein, Progent also has strong disinfection capabilities and has been shown to be effective against bacteria, molds, yeasts and viruses, as well as Acanthamoeba tropho-zoites and cysts, even after just a fi ve-minute soak.1 It also has been shown to deactivate the follow-ing virus strains: poliovirus type 1 equivalence for HIV, orthopoxvirus, bovine rotavirus, herpes simplex

virus type 1 and adenovirus type 5.2

Previously only available in-offi ce, Progent was FDA-approved for home use in 2010. Due to the toxic nature of the compounds, this product cannot be sold without a doctor’s approval, so doctors may either dispense it from their practic-es or patients can get it online using their doctor’s access code.

SOLUTION SPECIFICS

The Menicon Progent kit comes with two 5ml vials of fl uid. Ampule A contains sodium hypochlorite, sodium carbonate, sodium hy-droxide and purifi ed water, while ampule B contains potassium bromide, sodium carbonate and purifi ed water. An accompanying large scleral lens-holding container allows both lenses to be cleaned at the same time; if using the smaller container, scleral lenses can be ac-commodated by turning the holders 90 degrees. Once the fl uids mix, the lenses should soak for no more than 30 minutes to prevent lens discol-oration. After removal, the lenses should be rubbed with a GP lens cleaner and soaking solution.

The fi rst solution in ampule A (comprised principally of sodium hypochlorite) is a clear, pale yellow liquid commonly known as bleach. Because it can form explosive com-pounds with common substances like ammonia, amines, charcoal and organic sulfi des, it should be used only as directed to prevent spillage.

Be sure to handle the solution carefully, as dermal contact with hypochlorite can lead to skin ir-ritation, pain, infl ammation and blisters. Ocular exposure to gases will cause burning and lacrimation.

Furthermore, because hypochlorite solutions are basic (i.e., pH =11 to 13.5), ocular exposure to liquid hypochlorite can result in a chemi-cal burn. Burn severity is related to a number of factors, including pH, concentration and length of exposure time; thus, in the case of contact, it is imperative the eyes be irrigated immediately.

The solution in ampule B, con-taining potassium bromide, is color-less and odorless. Though it has a neutral pH, contact with the eye can cause irritation and redness. When the potassium bromide is combined with the sodium hypochlorite—a strong oxidant—the resulting oxidation-reduction reaction trig-gers protein degradation.

In closing, regular prophylactic use of Progent has solved comfort and vision issues for many of my scleral patients. I would recommend you consider it as an option to keep your patients healthy and happy. RCCL

Dr. Sindt has no fi nancial inter-est any products mentioned in this article.

1. Menicon. Contact Lenses & Care: Progent. Avail-able at: www.menicon.com/pro/gas-permeable/gp-lens-care/progent. Accessed Dec. 3, 2014.

2. Progent [data on fi le]. Waltham, MA: Menicon; 2003.

Sticky SituationDo your patients get mucus buildup on their scleral lenses? Here’s one way to remove it.

By Christine W. Sindt, OD

Lens Care Insights


Mucin deposits on a scleral lens in a

patient with lagophthalmos.

007_rccl0115_lenscare JP.indd 7007_rccl0115_lenscare JP.indd 7 12/29/14 9:13 AM12/29/14 9:13 AM

Ocular surface dis-ease. Meibomian gland dysfunction. Blepharitis. Every eye care meeting is

teeming with lectures on these top-ics, and rightly so. Although practi-tioners have always seen a multi-tude of patients with complaints of dryness, irritation and redness, it is only recently that diagnostic tools and treatments have improved enough to better pinpoint the exact problem and treat each individual patient appropriately and more effectively than ever before.

But there’s one more word that needs to be incorporated into our daily lexicon: Demodex. While we may not wish to embrace the no-tion that infestation of this intra-dermal parasitic mite is the cause of a host of eyelid problems, we cannot ignore the facts.

Consider this: in a study by Hyun Koo, MD and colleagues, Demodex were found in 84% of patients with ocular discomfort (i.e., dryness, pruritus, ocular pain, or visual disturbance).1 Prevalence was also found to increase with age: Demodex was identifi ed in 84% of the population at age 60 and 100% of the population over the age of 70.2

These are staggering statistics for a condition that is routinely over-looked. Many of us have patients in our practice who we are dog-gedly treating for blepharitis, with little to marginal improvement. In cases like this, we need to consider that Demodex could be the cause when the problem is refractory to the standard therapies of artifi -cial tears, warm compresses or

prescription topical or oral antibi-otic or steroid formulations. First, however, we need to know how to identify a Demodex-laden lid and then how to eradicate the problem.

A MITE-Y CHALLENGE

A classic presentation of Demodexblepharitis appears as cylindrical, waxy collarettes at the base of the eyelashes, thought to be an accu-mulation of Demodex folliculorumexcreta, epithelial hyperplasia and reactive hyperkeratinization.3-4

The mites consume epithelial cells at the hair follicle, causing lash distention.

Infestation is caused primarily by Demodex brevis, which reside deep in the meibomian glands, leading to blockage and lipid tear fi lm insuffi ciency, and sometimes recurrent and refractory chala-zia.5,6 Dying mites themselves may trigger a cascade of infl ammatory responses involving the lid margin,

conjunctiva and cornea that can be visually devastating.4

Often, the mites are not easily visible at the slit lamp. Traditional examination involves the epilation of four non-adjacent eyelashes that are evaluated under a micro-scope. However, a newer method has recently been described in which, with gentle tension, the eyelash is rotated manually with forceps scraping around the inner perimeter of the eyelash follicle to dislodge nonvisible mites that may reside deeper within the lash follicle.7,8 This rotational maneuver may help isolate Demodex mites in follicles whose lashes may not display the characteristic tubular base cuffi ng. However, additional research is needed to determine the effi cacy of this technique.

Tea tree oil has been previously shown to be effective in treating Demodex, though early treatments with the full-strength formulation

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

Bug Eyes


Are you fully considering Demodex in your work-ups and treatment decisions?

Fig. 1. Demodex, pervasive on lids and lashes, can clog the meibomian glands.

©PS M

icrographs

008_rccl0115_PSP JP.indd 8008_rccl0115_PSP JP.indd 8 12/29/14 11:14 AM12/29/14 11:14 AM

proved irritating to some patients and required cumbersome in-offi ce dilution. Ying-Ying Gao, MD and Jingo Liu, MD, among others, have demonstrated lid scrub with 50% strength tea tree oil and/or lid massage with 5% tea tree ointment and the use of tea tree oil shampoo to be effective in eradicating ocular Demodex. The treatments worked either by directly killing the mites or interrupting their life cycle by preventing mating, with marked subjective and objective improve-ment noted in the lid margin, conjunctiva and cornea.9,10

Cliradex (Bio-Tissue) is a pre-moistened lid, lash and facial towelette that contains the specifi c ingredient in tea tree oil, 4-terpin-eol, that has been shown to be the most effi cacious in killing Demo-dex in vivo.11 The wipes are recom-mended for once daily use for six to eight weeks for mild to moder-ate symptoms, or twice daily use

for six to eight weeks for moderate to severe symptoms.12 The new Cliradex Complete Advanced Lid Hygiene Kit also contains a stron-ger concentration of 4-terpineol for in-offi ce application by a doctor or trained technician for more severe cases of Demodex, in addition to the wipes for at home use.

The FDA recently approved Advanced i-Lid Cleanser (Nova-Bay Pharmaceuticals), a liquid lid and lash cleanser formulated with 0.001% hypochlorous acid (called Neutrox), a broad-spectrum antimicrobial.13 While the product is indicated for use against organ-isms such as Staph. aureus and epidermidis, as well as methicillin-resistant Staph. aureus (MRSA), NovaBay says its independent stud-ies suggest that cleansing may also help reduce Demodex-associated bacteria and minimize the infl am-matory cascade caused by the bacterial exotoxins.14

Additional Demodex-fi ghting options include the BlephEx in-offi ce exfoliation procedure from Rysurg, Ocusoft’s Lid Scrub Plus, over-the-counter cleansers from Ovanté, and other interventions.

As we increasingly encounter an aging population, we need to be fully cognizant of the possibility that many of these patients may have Demodex as a contributing factor in their eyelid and ocular surface dysfunction. Fortunately, we have simple and effective in-offi ce and at home treatments to eradicate the problem. RCCL

1. Koo H, Kim TH, Kim TW et al. Ocular Surface Discomfort and Demodex: Effect of Tea Tree Oil Eyelid Scrub in Demodex Blepharitis. J Korean Med Sci 2012; 27: 1574-1579.2. Post CF, Juhlin E. Demodex folliculorum and blepharitis. Arch Dermatol. 1963;88:298–302.3. Gao YY, Di Pascuale MA, Li W, et al. High prevalence of Demodex in eyelashes with cylindrical dandruff. Invest Ophthalmol Vis Sci 2005;46:3089-94.4. Bevins CL, Liu FT. Rosacea: skin innate immu-nity gone awry? Nat Med 2007;13:904–906.5. Gao YY, Di Pascuale MA, Elizondo A, Tseng SC. Clinical treatment of ocular demodecosis by lid scrub with tea tree oil. Cornea 2007;26:136–143.6. Koksal M, Kargi S, Taysi BN, Ugurbas SH. A rare agent of chalazion: demodectic mites. Can J Ophthalmol 2003;38:605–606.7. Mastrota KM. Method to identify Demodex in the eyelash follicle without epilation. Optom Vis Sci. 2013 Jun;90(6):e172-4.8. Por YM. Demodex blepharitis – Is it for real? www.youtube.com/watch?v=sgav_kZ_Hi49. Gao YY, Di Pascuale MA, Li W, Baradaran-Rafii A, et al. In vitro and in vivo killing of ocular Demodex by tea tree oil. Br J Ophthalmol 2005; 89: 1468-73.10. Liu, J, Sheha H, Tseng S. Pathogenic role of Demodex mites in blepharitis. Curr Opin Allergy Clin Immunol. 2010 October ; 10(5): 505–510.11. Tighe S, Gao YY, Tseng SCG. Terpinen-4-ol is the most active ingredient of tea tree oil to kill demodex mites. Transl Vis Sci Technol. 2013 Nov;2(7):2.12. www.biotissue.com/products/about-cliradex13. Wang L, Bassiri M, Najafi R, et al. Hypochlo-rous acid as a potential wound care agent: part I. Stabilized hypochlorous acid: a component of the inorganic armamentarium of innate immu-nity. J Burns Wounds. 2007 Apr 11;6:e5.14. http://novabay.com


Fig. 2. Collarettes around the base of lashes is a predictable sign of Demodex.

008_rccl0115_PSP JP.indd 9008_rccl0115_PSP JP.indd 9 12/29/14 9:14 AM12/29/14 9:14 AM

SPECIAL ISSUE: Making SCLERALS Fit


In the last few years, the use of scleral contact lenses has expanded beyond specialty contact lens centers into mainstream practices.

Practitioners have numerous scleral lens options to choose from, as most GP lens manufacturers now offer at least one design. With this growth, the indications for scleral lens wear have begun to more clearly divide into two groups of scleral lens patient candidates: those for whom the lenses are medically necessary and others whose needs are purely refractive. This article will review the relevant indications for use of scleral contact lenses with respect to both groups.

MEDICALLY NECESSARY

From the early use of a “contact shell” to treat keratoconus in 1888, scleral contact lenses have come to occupy a distinctive yet compre-hensive position in eye care, suited to treat a variety of eye conditions in patients whose corneal surfaces range from clinically normal all the way to extremely unique.1

• The irregular cornea. Scleral lenses are most commonly pre-scribed in the case of corneal irregularity, which induces higher-order aberrations; it can result from keratoconus, corneal surgery or trauma, or complications of otherwise routine surgery.

Such patients are often managed with corneal GP lenses; this modal-

ity’s ability to mask front surface corneal irregularity leads to dra-matically improved vision. How-ever, contact lens practitioners have struggled for decades to fi t corneal GP lenses on patients with moder-ate to severe irregularity because of one inherent problem: the lenses’ small relative size forces them to distribute their weight directly onto the uneven corneal surface, which can lead to destabilization of the fi t (Figure 1). Scleral contact lenses, on the other hand, vault over the cornea and rest on the sclera. As a result, centration and stability will remain unaffected.

Patients who have moderate to severe corneal irregularity, espe-cially those who have previously failed in corneal GP lenses, make excellent candidates for scleral lenses. Be sure to explain to these patients why scleral lenses may be a better option than other contact lens modalities, and keep in mind that patients with small apertures or poor dexterity may have dif-fi culty applying lenses. Patients may also be apprehensive about converting to a larger lens design. Demonstrating scleral lens comfort and stability in the offi ce with a diagnostic lens will often result not only in patient acceptance but excitement.

• Ocular surface disease. An-other common reason for prescrib-ing scleral lenses is to manage ocular surface disease. Patients with systemic conditions such as

Sjögren’s syndrome, Graft-versus-host disease and Stevens-Johnson syndrome often present with co-morbid ocular surface disease that can further decrease their quality of life and inhibit daily activities (Figure 2). For these patients, the rigid, curved shape of a scleral lens creates a liquid “cushion” that not only masks irregularity but also acts as liquid bandage that contin-uously bathes the anterior ocular surface. Scleral lenses also provide a barrier that protects the compro-mised anterior ocular surface from exposure.

Additionally, many patients with OSD may also present with cor-neal irregularity. With scleral lens use, patients with OSD typically experience quick, dramatic im-provement in comfort and vision, allowing them to return to their normal routines and activities.

Be sure to work in tandem with any other eye care specialists who are managing the patient’s care; patients are often able to reduce their palliative and therapeutic ophthalmic drop regimen if they are successful with scleral lenses. Make sure to avoid any bearing of

Who’s a Candidate These specialty lenses are no longer just for the irregular cornea.

Dr. DeNaeyer is the clinical director for Arena Eye Surgeons in Columbus, Ohio, and a consultant to Visionary Optics, Bausch + Lomb and

Aciont. You can contact him at gdenaeyer@arenaeyesurgeons.

com.

ABOUT THE AUTHOR

010_0115RCCL_F1 JP.indd 10010_0115RCCL_F1 JP.indd 10 12/29/14 9:16 AM12/29/14 9:16 AM

the lens on the cornea that could result in epithelial compromise.

REFRACTIVE ERROR

Though modern scleral lenses have been used successfully to manage medically related eye conditions for over 20 years, there has been rela-tively little research on the effects—especially long-term—of scleral lens use. Making the jump from us-ing scleral lenses for patients who require them for medical reasons to patients with refractive error or dry eye is signifi cant; thus, each practitioner needs to take into ac-count the possible unknown risk of scleral lens use for patients where scleral lenses are merely an option rather than a necessity.

• GP burnout. Patients gener-ally appreciate the sharp vision that corneal GP lenses provide, but some experience lens-related prob-lems that limit wear time or lead to dropout. Patients with corneal GP lenses may complain of intermit-tent lens decentration or expulsion that interrupts wear time. This is especially problematic if the patient is active in sports. Corneal GP patients may also complain that occasional foreign bodies like dust or debris get trapped underneath the lens, leading to irritation that can force the patient to remove the lens for relief. Soft lenses can offer improved comfort or stability, but at the cost of sharp vision.

For such patients, scleral lenses

can eliminate these symptoms while still providing the sharp vi-sion that GP contact lenses offer. First and foremost, sclerals are in-herently more comfortable to wear because they rest on the sclera, which is far less sensitive than the cornea. Scleral lenses also semi-seal to the eye and when fi t correctly, will not reposition with eye move-ment or blinking. This fi tting characteristic not only improves comfort, but stability as well. Ad-ditionally, the semi-sealed fi t keeps environmental foreign bodies from getting underneath the lens.

Consider scleral contact lenses for patients who develop diffi -culties wearing their corneal GP lenses. Keep in mind that while you may have empirically ordered corneal lenses, scleral lenses will re-quire a diagnostic lens fi tting. Also, remember it’s possible that if you refi t patients just out of their GP lenses, a power shift could occur over the fi rst month during which their corneal curvature rebounds because they no longer have a lens that is supported by the cornea.

• Astigmatism. Patients with moderate to severe astigmatism may have a history of poor visual performance with traditional soft and corneal GP lenses. Soft lenses can be unstable for some patients, causing visual fl uctuation that is frustrating for patient and practi-tioner alike.

Corneal GP lenses can effectively mask corneal astigmatism and are


By Greg DeNaeyer, OD

Fig. 1. A decentered corneal GP lens secondary to corneal irregularity. Such a

patient may experience a better fi t with a scleral lens.

for Scleral Lenses?


a great option for some of these unhappy soft lens patients; how-ever, corneal GP lenses are also notoriously unstable for patients who have against-the-rule astig-matism, in which the horizontal meridian is steepest (Figure 3). In these patients, corneal GP lenses will often slide horizontally, caus-ing lens instability.

Additionally, corneal GP lenses are not a great option for patients with lenticular astigmatism—they are unable to mask crystalline lens toricity with their tear lens, as they do for corneal toricity. Conse-quently, corneal GPs have to be manufactured with front surface toricity to correct the patient’s full refractive error. Just like soft lenses, front surface toric GP lenses can be unstable, leading to intermittent visual disturbances.

In contrast, the liquid reservoir that gets trapped underneath a scleral GP is able to mask corneal astigmatism, and the fi t is stable regardless of astigmatic orientation

because the lens fi ts the sclera, not the cornea. Front surface toricity can also be added to scleral lenses for cases of lenticular astigmatism. Unlike corneal GP lenses, ballasted scleral lenses are stable due to their large diameter and semi-sealed fi t.

Patients with moderate to severe astigmatism, especially those who have failed in other traditional lens modalities, are good candidates for scleral lenses. Be sure to do a sphe-rocylindrical over-refraction during the fi tting and follow up. If the over-refraction yields astigmatism, check over-topography to make sure the lens isn’t fl exing, which

can induce astigmatism. Increasing center thickness can eliminate fl ex-ure. If the lens isn’t fl exing, correct the residual astigmatism by adding front surface toricity. Spherocylin-drical over-refraction at follow-up can allow you to fi ne tune the power for any induced cylinder secondary to lens rotation. This is more accurate than trying to apply LARS (left add, right subtract).

• Dry eye. Patients suffering from dry eye who require refrac-tive correction may be candidates for scleral lenses, though this use is considered off-label. Scleral lenses have several advantages over traditional lenses for these patients: fi rst, unlike soft contact lenses, GP material doesn’t dehydrate, which can lead to discomfort after several hours’ wear. Scleral lenses also hold a liquid reservoir, as mentioned earlier, which provides a continu-ously lubricating tear layer against the compromised ocular surface. Even patients who are successfully medically managing their dry eye condition may still have diffi culty wearing other contact lenses and so could benefi t from scleral lenses.

When fi tting a dry eye patient, start with scleral lenses designed for the regular or normal cornea because you likely won’t need the size or geometry that scleral lens designs offer for fi tting irregularity. Sonsino and Mathe reported that the amount of central vault does not seem to affect success.2 Make


WHO'S A CANDIDATE FOR SCLERAL LENSES?

Fig. 2. Patients suff ering from severe ocular surface disease often can benefi t

from scleral lens wear.

"BALLASTED SCLERALS ARE STABLE DUE TO THEIR LARGE DIAMETER AND SEMI-SEALED FIT."


sure, however, that you completely vault the cornea to avoid bear-ing on a cornea surface that can be mildly comprised secondary to dryness.

Scleral lenses are a viable option for many patients who have struggled or been unsuccessful with soft, corneal GP or hybrid contact lenses. As such, with the growing popular-ity of these lenses it is recommended that you have a few diagnostic fi tting sets in your practice that allow you to fi t a broad spectrum of eyes—in par-ticular, at least one

diagnostic set designed for manag-ing corneal irregularity or OSD and a second set that can be used for patients with regular corneas who have failed in traditional lens

designs secondary to poor fi t, ir-ritation, uncorrected astigmatism or dryness.

Diameters for designs for corneal irregularity typically range from 16mm to 18mm, while diameters for refractive error and dry eye typically fall between 14.5mm and 16mm. Additionally, some designs are available with multifocal optics that can be added to the front surface for both for presbyopic patients with mild irregularity or those with regular corneas.

Overall, investigating scleral lenses to fi t a broad spectrum of patients will improve your fi tting success. RCCL

1. Pearson, RM. Kalt. Keratoconus and the Contact Lens. Optometry and Vision Science. 1989;66(9):565-648.2. Sonsino J, Mathe, DS. Central Vault in Dry Eye Patients Successfully Wearing Scleral Lens. Optom Vis Sci 2013. 90(9):e248-251.

Fig. 3. Against-the-rule astigmatism is another likely

clinical scenario where scleral lenses are worth

considering.

IN VISION CARE

2015

N T

& T

N T

& TNew

Tec

hn

ologies and Treatments

REVIEW OF OPTOMETRYEDUCATIONAL MEETINGS OF CLINICAL EXCELLENCE

SAVE THE DATE

For More Information: WWW.REVOPTOM.COM/SANDIEGO2015

SAN DIEGO, CA • APRIL 10-12 Up to 17 CE Credits

(COPE approval pending)

Chair: Paul Karpecki, OD Speakers: Derek Cunningham, OD; Ben Gaddie, OD

SAN DIEGO, CA • APRIL 10-12

*Approval Pending

Administered by

Review of Optometry


SPECIAL ISSUE: Making SCLERALS Fit


Once only available in specialized tertiary care centers, scleral lenses have become

increasingly popular in general optometric practice during the past several years. Recent proliferation of scleral lens designs, the ready availability of diagnostic fi tting sets and growth of educational programs and workshops designed to teach those interested in this lens modality how to fi t them properly have vastly increased awareness and availability of these lenses among eye care providers.

Indications for scleral lens pre-scriptions are expanding as well. Originally, the lenses were reserved for eyes with severe irregularity or surface disease and were used only when all other therapeutic options had been exhausted. Now, not only

are scleral lenses being prescribed for less severe disease, they are also being marketed as an option for correction of uncomplicated refractive error. Despite this overall progress, however, many optom-etrists remain wary of incorporat-ing scleral lenses into their practice due to concerns regarding excessive cost, time or potential complica-tions.

THE KEYS TO THE KINGDOM

Fortunately, there are a number of considerations you can make to simplify the process of fi tting scleral lenses. Don’t be afraid to pick and choose, or come up with your own ideas!

1You don’t need to spend a fortune to fi t scleral lenses. Depending on what images

you have seen presented during

scleral lens courses or lectures, you may have the impression that fi tting these lenses requires a considerable capital investment. Not to worry—fi tting sclerals is a surprisingly low-tech affair for most patients.

It’s true that anterior segment OCT can precisely defi ne the fi t-ting relationship between the lens and anterior ocular structures and confocal microscopy can provide much information on how scleral lens wear may affect corneal struc-ture and function. However, this

Simple Secrets

to Scleral Lens Success

Are you intimidated by this

resurgent modality? You

don’t have to be. When

fitting scleral lenses,

keep these handy

tips in mind.

Dr. Schornack is a consultant in the department of ophthal-mology at the Mayo Clinic in Rochester, MN. She is also a founding member of the Scleral Lens Education Soci-

ety, and currently serves as the organization’s vice president.

ABOUT THE AUTHOR

7By Muriel Schornack, OD


equipment is by no means neces-sary to fi t scleral lenses. Addition-ally, more commonly available imaging technology such as corneal topography—while extremely useful in fi tting corneal rigid gas permeable lenses—may be of only limited value in fi tting scleral lenses because precise alignment between the anterior corneal and posterior lens surfaces is unneces-sary in scleral lens fi tting.1 Slit lamp photography can also be used to document lens fi t as well as ante-rior segment structures, which may be helpful in following the condi-tion of the eye over time, but is not essential in scleral lens fi tting.

Realistically, an eye care provider who is interested in developing a scleral lens practice needs only the most basic equipment to get started. A diagnostic scleral lens fi t-ting set, a slit lamp and a trial lens set or phoropter are all that is nec-essary. These rudimentary items, along with careful observation and evaluation, can provide all of the information necessary to success-fully fi t scleral lenses. Diagnostic lenses will allow you to assess the fi t of the lenses, and over-refraction with either handheld trial lenses or a phoropter will provide the refrac-tive information that you need to order the initial lens.

2Learn how to use one or two lens designs well. There are dozens of scleral lens

designs available today. While there are certainly differences between them, the fi tting goals for all designs share some common characteristics. First, scleral lenses are designed to land on the conjunctival tissue overlying the sclera without causing excessive compression of tissue or blanching of conjunctival vasculature. Second, the lenses should com-pletely and measurably vault the cornea and limbus. Finally, the lenses should exhibit minimal vertical or lateral movement on the blink.

Most major laboratories now offer scleral lens designs, so consult with your lab to get recommen-dations on their most successful designs. While it is not necessary to become familiar with all scleral designs, it may be helpful to pro-cure fi tting sets for one larger (ap-proximately 17.0mm to 18.0mm) and one smaller (approximately 15.0mm to 16.0mm) design. This will allow for successful scleral lens fi tting for a variety of indications.

Laboratory consultants are also typically well versed in scleral lens fi tting, and can provide invalu-able assistance to novice scleral lens fi tters. Additionally, educa-tional resources are available both at formal professional meetings and online through organizations such as the Scleral Lens Education Society and Gas Permeable Lens Institute.

3Make the most effective use of your time. Selecting an initial diagnostic lens can

be challenging for the fi rst-time scleral lens fi tter. So, make use of all the tools at your disposal. Manufacturers’ guidelines can be


"THE FITTING GOALS FOR ALL SCLERAL DESIGNS SHARE SOME COMMON

CHARACTERISTICS."

Fig. 1. Fitting scleral lenses isn't a high-tech endeavor; all you need is a

diagnostic lens fi tting set, slit lamp and phoropter.

Phot

o: C

hris

tine

Sind

t, O

D


useful, as can simple observation of the contour of the cornea and sclera as viewed from the patient’s side (Figure 2). Once you become familiar with your lens design, it’s likely you will be able to better predict which diagnostic lens will provide an appropriate fi tting relationship on the basis of observation alone.

If you are uncertain of which lens to select, err on the side of greater sagittal depth. It is much easier to estimate the amount of excessive clearance in a lens that is too steep than it is to estimate the amount of additional sagittal depth required to clear the cornea in a lens that fi ts with considerable corneal touch.

Although we know that scleral lenses tend to settle with time, evaluating lens fi t immediately after application will allow you to identify a lens that obviously provides too much or too little clearance.2 Bracket the fi t in large intervals until you fi nd a lens that demonstrates approximately 100µm to 150µm more clearance than would be considered ideal. Once you’ve identifi ed an appro-priate lens, allow the lens to settle for 20 to 30 minutes before fi nal evaluation of fi t.

It should be noted the “ideal” amount of clearance in scleral lens fi tting has yet to be defi ned. Although recent studies have suggested that decreased oxygen transmissibility through an exces-

sively deep fl uid reservoir may be undesirable, successful scleral lens wear has been achieved with lenses providing between 100µm and 600µm of clearance.3,4

4Get creative with initial lens application. Patients may be apprehensive during

initial lens application, even if they have had previous experience with contact lenses. Distracting them from the application process, either by giving them something to do (such as holding their lower lid down while you apply the lens) or by encouraging them to look at something (such as a bottle cap or other object held on their lap) may make initial lens application easier.

While opening the lids widely enough to apply the lens directly to the ocular surface is ideal, it is not always possible. Sometimes, you may need to apply the lens by placing one edge beneath either the upper or lower lid and then “folding” or “tipping” the lens into place. If you fi nd that you need to manipulate the angle of the lens during application, it may be helpful to use Celluvisc or another relatively viscous non-preserved product to prevent excessive fl uid loss during application. Patients may also fi nd it easier to avoid entrapped air bubbles if they use a more viscous product during initial lens application training. Using these products as “training wheels” can give patients confi dence in

their ability to successfully handle and wear lenses.

If you wish to use fl uorescein to defi ne the fl uid reservoir during the fi tting process, the dye can either be placed in the bowl of the lens prior to application or applied to the ocular surface directly. While the concentration of dye in the post-lens fl uid reservoir may be somewhat diminished if fl uorescein is applied to the ocular surface prior to lens application, the con-centration will still be suffi cient to allow for easy visualization of the fl uid reservoir. Applying fl uorescein to the ocular surface rather than placing the dye in the bowl of the lens also reduces the risk of stain-ing clothing or fi ngers during lens application.

5Perform a careful spherocylindrical over-refraction. The tear fi lm

beneath a corneal rigid gas permeable lens is of negligible thickness, and allows for reasonably accurate calculation of power for a lens of a given base curve on a given eye. Not only are most scleral lenses considerably thicker than corneal lenses, but the post-lens fl uid reservoir is of considerably greater depth than the tear layer behind a corneal lens. Increased lens and fl uid reservoir thickness could potentially alter effective lens power, so careful refraction over a diagnostic scleral lens is recommended to avoid power calculation errors.

Consider using handheld trial lenses to refi ne the prescription. Trials lenses can frequently be held very close to the anterior surface of the scleral lens, and can even touch the surface of the lens, if desired. This minimizes the need to calculate power adjusted for vertex distance.


7 SIMPLE SECRETS TO SCLERAL LENS SUCCESS

"THE IDEAL AMOUNT OF CLEARANCE HAS YET TO

BE DEFINED."


Unlike spherical corneal GP lenses, scleral lenses tend to be very stable on the ocular surface. This rotational stability allows for incorporation of front surface toricity onto scleral lenses to cor-rect residual astigmatic refractive error. Numerous lens designs now offer this option. Patients with as little as 0.75D to 1.00D of residual astigmatism with a spherical scleral lens may appreciate improved clar-ity with a toric lens. If your patient demonstrates improved visual acu-ity with a spherocylindrical over-refraction compared to a spherical over-refraction, consider ordering a front surface toric lens.

6Follow your patients closely.Sclerals are still relatively new additions to the

market. Although they are made of materials that have long been used, these lenses exhibit considerably different fi tting characteristics than any other lens modality. We should not simply assume complications associated with scleral lens wear are identical to those we see with

other lens modalities, nor should we assume risk factors for those complications are exactly the same as those that have been identifi ed for other lenses. Though there have been case reports of microbial keratitis, we do not know for certain if risk factors are the same with sclerals as with corneal lenses; ideally, a national or international complications registry is needed. It should be noted, however, that application error might be a scleral-related complication—patients can give themselves corneal abrasions if the lens scrapes the cornea during insertion.

When scleral lenses are used in the treatment of severe ocular surface disease or corneal ectasia, the risk of complications that could be caused by scleral lens wear are outweighed by potential benefi ts, including the avoidance of more aggressive surgical intervention and maintenance of ocular surface integrity. However, as indications for scleral lenses have expanded to include correction of simple refractive error, we would do well

to carefully evaluate relative risks and benefi ts of scleral lens wear compared to other options for refractive correction.

Ongoing management of ocular disease necessitates frequent follow-up for patients who use scleral lenses as therapeutic devices. Although patients who choose to wear scleral lenses for correction of uncomplicated refractive error may not have medical conditions that require frequent evaluation, regular examination of anterior ocular structures is prudent even in these patients. Frequent follow-up would allow for early identifi cation of potential tissue changes, and would enable adjustments in lens design to minimize the potential for irreversible tissue damage.

7Defi ne your success. Characteristics of the “ideal” scleral lens fi t have

been described, but there may be more than one lens design that could provide an acceptable fi t for a given patient. A scleral fi t can be considered successful if the lens is stable on the eye, the patient achieves the best possible vision with the lens, there are no changes in ocular surface structures or tissue as a result of lens placement and long-term wear is comfortable. If the lens meets these criteria, you may declare success! RCCL

1. Schornack MM, Patel SV. Relationship between corneal topographic indices and scleral lens base curve. Eye & contact lens 2010;36:330-333.2. Kauffman MJ, Gilmartin CA, Bennett ES, Bassi CJ. A Comparison of the Short-Term Settling of Three Scleral Lens Designs. Optometry and vision science : official publication of the Ameri-can Academy of Optometry 2014.3. Michaud L, van der Worp E, Brazeau D, et al. Predicting estimates of oxygen transmissibility for scleral lenses. Contact lens & anterior eye : the journal of the British Contact Lens Associa-tion 2012.4. Sonsino J, Mathe DS. Central Vault in Dry Eye Patients Successfully Wearing Scleral Lens. Op-tometry and vision science : official publication of the American Academy of Optometry 2013.


Fig. 2. Observation of the contour of the cornea and sclera from the side can

help you choose an initial diagnostic lens.


SPECIAL ISSUE: MAKING SCLERALs fit

With scleral lenses increasing in popularity, more

practitioners than ever are considering how to incorporate them into their practice. So you’ve attended the workshops, seen the lectures, browsed through articles and maybe invested in a scleral lens diagnostic set. But, how do you bring this new modality into your practice so that it enhances rather than disrupts your offi ce? Here are some points to consider in developing the best method that works for your patients and your practice.

INFORM YOUR STAFF

Staff members play a critical role in enhancing patient experience, from the receptionist who answers the phone to the technician who works the patient up and the optician who fi ts the patient with glasses or contacts. Educating your team on the new service you are now

offering will better enable them to recommend scleral lens op-tions to patients and answer some patient questions before the patient even sits in your chair. Having knowledgeable staff members also enhances patients’ opinions of your practice.

When you make the decision to start fi tting scleral lenses, organize a staff meeting to let them know of this new service. Educate them on what these contact lenses are, how they differ from other types of lenses and which patients are good candidates (i.e., those with kerato-conus, corneal transplant, a history of LASIK, extreme dry eye, corneal scarring.). This way, staff members will be prepared when patients inquire about scleral lenses, and possibly even confi dent enough to recommend that certain patients look into this design for the best possible vision. It will also ensure patients get a consistent message no matter who in the practice they happen to be talking to.

Not too long ago, one of our

newest staff members came to my offi ce and said, “There is a pa-tient on the phone and they were wondering if we treat keratoco-nus?” Imagine the incredulous look I must have given the poor girl! But then I realized this lack of knowledge is my fault; I did not properly train her regarding the services we offered or which patients we could help. Since then, I’ve added an introduction to the practice and an explanation of what makes us different to my new employee orientation. During this meeting, I always mention that our practice has the ability to fi t dif-fi cult corneal problems and I give

How to Incorporate

Scleral Lenses Into Your Practice

Turning your interest in scleral lenses into a successful practice-builder requires more than just knowing how to fi t them.

ABOUT THE AUTHOR

Dr. Woo graduated from the Southern California College of Optometry and completed a cornea/con-tact Lens residency at the University of Missouri–St.

Louis. She is a Fellow of the American Academy of

Optometry and a Fellow of the Scleral Lens Education Society. She currently practices at Havasu Eye Center in Lake Havasu, AZ.


By Stephanie L. Woo, OD

018_0115RCCL_F3.indd 18018_0115RCCL_F3.indd 18 12/29/14 9:18 AM12/29/14 9:18 AM


examples of various typical cases. I also changed the system of how newly hired employees are trained—now all staff members are well informed of the services that we provide.

GET THE WORD OUT

It’s important to let people know you’re now offering this new ser-vice. Place an ad in the local paper announcing that you can now assist more diffi cult-to-fi t patients, including those with keratoconus or other corneal irregularities, such as irrgeular astigmatism follow-ing a transplant or other corneal surgery.

If you distribute an electronic or paper newsletter, highlight scleral lenses and the kinds of patients you can help in it. And make it personal: tell the story of a suc-cessful patient. Avoid overuse of

technical terms about the lenses and medical jargon.

Be sure to also update your web-site, social media pages and any online business listings. You will be surprised at how many people call your offi ce to inquire about the new product and ask if they can try these special lenses.

OFFER FREE

CONSULTATIONS

A great way to capture a potential patient’s interest is to offer a free contact lens consultation at your offi ce. When the patient calls to inquire about specialty lenses, have your staff explain the benefi ts of a free consultation. You can also advertise this service on your social media page or in your newsletter.

The services included in the consultation depend on what you deem appropriate, so feel free to

develop your own. In my practice, we check the patient’s vision, verify their glasses, perform topography and evaluate their eyes briefl y with the slit lamp. After this, I spend fi ve to 10 minutes reviewing the fi ndings with them and discussing contact lens options. I also review pricing and go over what to expect during the fi tting process so there will be no surprises.

Typically, when patients are aware of their condition and understand why they cannot wear standard contacts or glasses, they are more receptive to the treatment options that you, as the doctor, rec-ommend. Overall, these consulta-tions have been extremely success-ful in my practice, and I hope they are in yours too!

INFORM LOCAL DOCTORS

You may think, ‘Why would an-other eye care provider refer a pa-tient to me? Can’t they just fi t the patient themselves?’ The answer is: not everyone wants to fi t specialty contacts—many don’t even want to touch scleral lenses! I fi nd this especially true of optometrists who have been practicing for more than 10 years. Many learned to fi t corneal GP lenses, and that is what they are comfortable with—which is great for you! As you know, scleral lenses can work for a vari-ety of patients, and, in some cases, are the only viable option.

If you let other optometrists in the area know that you can fi t scleral lenses, many will be happy to send patients your way, especial-ly if you make it clear that you are simply trying to help their patient, not steal them. Many of these ODs have likely already tried other designs that have failed, so they may welcome the assistance. To maintain this relationship, I always make a point to send the patient


back to their referring doctor for everything that is unrelated to the contact lens services I’m providing, whether it’s a request for glasses or ocular health issues I observe that may need treatment. This serves as a good form of mutual adver-tisement—they will circulate your name to patients, and, if you’re so inclined, you can do the same for them.

Sclerals can also be a great way to establish or strengthen collab-orative relationships with local ophthalmologists, especially those who do a lot of corneal and refrac-tive surgery. Some of their patients will need specialty contact lenses after a procedure, and scleral lenses are not always part of the services offered at an ophthalmology prac-

tice. It’s to their benefi t, and yours, if you know each other’s capabili-ties.

OVERDO THE EDUCATION

You can never give a scleral lens patient too much information

about their new modality. Most patients have diffi culties with their lenses, and many who drop out do so because of simple problems like lens insertion. Providing patients with adequate information—be-fore, during and after the fi t—will greatly decrease their chances of dropping out.

After the lenses are dispensed, the patient should be given articu-late instructions about insertion, removal, lens care and frequently asked questions. Increase their chances of success by demonstrat-ing a variety of methods for lens insertion and removal (Figure 1). This way, if they get home and one method doesn’t work, they don’t have a panic attack. Also, make sure to provide written step-by-step


Of all the technological advances made in the last few decades, social media has been one of the

most disruptive forces that’s reshaping how com-panies—from huge multinationals to small medical offi ces—conduct business, promote their brand and engage customers in the 21st century. Of course, many companies that adopt these methods sell products with wide appeal, which makes the mass audience of social media an ideal way to commu-nicate. So, how can eye care providers use these techniques to engage scleral lens wearers, who make up only a portion of contact lens patients?

• More reach, less eff ort. Traditionally, companies often spent big bucks developing blanket-advertis-ing campaigns in an eff ort to reach as many custom-ers in as many diff erent ways as possible—choosing, in eff ect, quantity over quality of interaction. Typi-cally, the amount of money spent was proportional to how far the message was spread; thus, smaller companies were often at a disadvantage. Social me-dia, however, levels the playing fi eld for companies of diff erent sizes while simultaneously aggregating a wide variety of users in a single medium and col-lecting data on what makes each unique. Users can be targeted on Facebook, for example, based on location, demographics, interests or behavior, so try using this tool to target contact lens wearers in your area who may have previously searched for specialty lenses online.1

• Make conversation. The next step after fi nding the potential customer is to engage them. Social media has given users more control over choosing what they do or do not want to see while browsing. Thus, building a good one-on-one relationship with the customer is key: someone who feels respected, listened to and valued is more likely to maintain brand loyalty and share their positive experience with others, instead of simply ignoring a post or even clicking “unfollow.” So, engage your scleral patients online. Invite them to “like” your page and post a review, and be sure to respond to their com-ments. Post contests and other interactive content on your page to encourage conversation. Continually adding new information to your page will help keep patients involved and aware.

“Today, you need to think social media at all times,” says Jack Schaeff er, OD, head of Schaeff er Eye Center in Alabama. Have videos on your website that discuss the advantages of each product catego-ry you off er, including sclerals, so that patients can view, comment and share, he suggests. Dr. Schaeff er encourages his scleral patients to “go on Facebook and talk to other people, so it will be a word of mouth-type marketing campaign that would come basically from the patient, not from the practice.”

• Pick the right medium. Social media and the Internet in general have had a signifi cant impact on the average attention span, as we are constantly

HOW TO INCORPORATE SCLERAL LENSES INTO YOUR PRACTICE

USING SOCIAL MEDIA TO MARKET SCLERAL LENSES BY ALIZA MARTIN, ASSOCIATE EDITOR

Fig. 1. Give your patient multiple ways

to insert and remove the lens.


instructions for the patient to take home—just like a good portion of patients in general, many new scleral lens wearers forget instruc-tions as soon as they leave the offi ce (Figure 2).

Providing a list of online resourc-es where patients can fi nd informa-tion and videos on lens insertion, removal and care is another way to decrease dropout. I recommend www.gpli.info and www.scleral-lens.org as good sources for both practitioners and patients. Your staff can also create this content in-house. (See “Using Social Media to Market Scleral Lenses,” below.)

APPOINT A STAFF MEMBER

AS YOUR BILLING GURU

You do not need an experienced

biller to be successful with scleral lens reimbursement; instead, pick a team member who is committed to fi nding out the correct answers and willing to to do the research needed. Some practices call the insurance company before the patient is even seen for a consult or their comprehensive exam; others wait until the patient has been seen to report the proper diagnosis and procedure codes. Some insurance companies do not require a preau-thorization letter, while others do. If you designate a staff member at your practice to help you with specialty contact lens research, bill-ing and coding, they can help you determine the best approach for your practice, thus making your life easier.


Fig. 2. Provide your patient with a

variety of scleral lens resources, such

as an informative DVD and written

instructions to take home.

bombarded with information. The latest statistics place the average attention span at eight seconds in 2013, down from 12 seconds in 2000.2 In line with this trend, short Facebook posts, tweets and six-second video clips have largely supplemented and in some cases replaced newspaper, radio and televi-sion ads, as well as older forms of online advertising like website banners. These small campaigns can be quickly and easily shared and “reshared” between hundreds of thousands of social media users, creat-ing a ripple eff ect.

Try getting your staff involved in creating and dis-tributing videos or tweets for your practice to raise patient awareness. Many marketing research fi rms and social media giants like Twitter have published studies on, for example, how to best construct posts and when to send them.3

• Tweak your website. In this day and age, your website is just as important as the receptionist sit-ting at your front desk. Many prospective patients may visit your site well before calling to schedule a consultation. As this is their fi rst impression of your practice, make sure your website is clean, easy to navigate and as informative as possible.

“Our website is a big tool for us,” says Jason Jedlicka, OD, at the Cornea and Contact Lens Insti-tute of Minnesota. “We make sure to have a page devoted to scleral lens information.” He points out that he and his colleagues named their practice expressly to focus on their contact lens expertise. “We are not a routine eye care practice that happens to have a scleral lens fi tting set—we are fi rst and

foremost there for the patients that need specialty contact lenses. Patients will see our name and know what we are about.”

The rise of “content marketing” has also impacted the way businesses reach customers and so should be taken into account when designing a website. Content marketing, or the distribution of media and written content with the intent of infl uencing consumer behavior, is a good way to educate scleral lens candidates while also making them aware of your practice in particular. Posting a small article on the benefi ts of wearing scleral lenses or useful tips to keep in mind on your practice’s website may also help boost patient confi dence and trust. Addition-ally, writing or contributing to articles published elsewhere can also enhance patient referrals.

“We have written many articles on scleral lenses and it is amazing how many patients fi nd us by searching the web for information,” Dr. Jedlicka says. Patients “stumble across an article we wrote about how we fi tted someone like them in sclerals and helped them, and they call wanting to know if we can do the same for them.”

Employing search engine optimization (SEO)—the process of improving a website’s natural search engine ranking using a combination of certain keywords, images and other components—can also make the content on your site appear higher in search results, helping to drive web traffi c to your website and increase awareness of your practice. Google off ers a guide for getting started with SEO.4

(Continued on page 22)


Many vision insurance compa-nies like Eyemed, VSP, Spectera, Davis and Avesis also have good staff to assist you in determining medically necessary contact lens benefi ts. Remember that most vi-sion plans make scleral lens fi tting very easy to bill.

DON’T OVERLOOK YOUR

"REGULAR" PATIENTS!

Many patients who come in for their routine exam expect to simply receive their annual check-up and an updated glasses and/or contact lens prescription. If you feel, how-ever, that a patient might benefi t from a scleral contact lens evalu-ation, mention it to them! I can’t tell you how many post-refractive surgery patients show up for their routine exam unaware there are contact lens options for them. This

is especially true of the early adopt-er group who underwent refractive surgery using previous techniques that are no longer state of the art, such as radial keratotomy (RK)—it’s likely that they’ve been walking around with unaddressed vision problems for years.

Even if your patient reports see-ing relatively well, ask them about dry eye or fl uctuating vision. Then, inquire if they would be interested in contact lenses. Many patients will be shocked at the possibility because they are under the impres-sion they could never wear contact lenses again. I challenge you to ask your next RK patient who comes in for their comprehensive exam if they would be interested in contact lenses. You’ll likely be excited by their answer and even more excited to fi t them with scleral lenses!

JUST DO IT

That old Nike slogan applies here: just do it. Scleral lenses are the biggest growing category in gas permeable lenses, and it’s clear to see why. They are comfortable, stable, provide excellent vision and are easy to fi t! Scleral lenses have made fi tting both the irregu-lar cornea and the normal cornea simple and straightforward. They can be a good source of revenue for your practice, as well as a good move in establishing your clinic as a specialty contact lens resource.

The patients that you help by of-fering this service can be extremely rewarding. My favorite part of the day is when I see a scleral lens consult, fi tting or dispense on my schedule. Scleral lenses change lives—for both patients and practi-tioners alike! RCCL

HOW TO INCORPORATE SCLERAL LENSES INTO YOUR PRACTICE


• Combine social media with other platforms. Although social media has in many ways revolu-tionized marketing, more traditional methods like television and radio still hold signifi cant cultural weight. In fact, cross-platform advertising may be the most eff ective way to market your practice. Research by Nielson and Google found nearly 75% of consumers remember an ad when viewed across all media platforms, compared to just 50% when viewed only on TV.5 A separate Nielson study in 2013 found many marketers still view television as the most eff ective way to reach customers, but also noted that Internet advertising jumped by more than 32% in a year’s time.6

“In our practice, we try to do public relations-type stories on patients who are in keratoconic lenses,” for instance, says. Dr. Schaeff er. Local news media in his area have featured representatives of the practice discussing new treatments for kerato-conus and other corneal diseases. “And of course that’s where we talk about the advantages of scleral lenses.” Consider taking out an ad on a local television channel or in the newspaper.

• Don’t forget the original social network: word of mouth. “I market specifi cally to corneal surgeons,” says Shelley Cutler, OD, founder of Scleral Lens As-sociates in Pennsylvania. “I started out with a letter. I went through the phone book and online to fi nd

SOCIAL MEDIA MARKETING(Continued from page 21)

as many corneal-trained doctors in the Philadelphia area, and Delaware and New Jersey, and I sent them out a letter and some business cards, then I followed up with a postcard maybe four to six months later.”

Derek Louie, OD, of Casey Eye Institute in Oregon, uses similar methods. “I speak to other practitioners in the community and let them know we are us-ing these types of lenses frequently and have [the] familiarity to help their patients. Internal marketing to our existing patients also works if someone is struggling or looking for something diff erent than their current contact lenses.”

1. Facebook. How to target Facebook Ads. Available at: www.facebook.com/business/a/online-sales/ad-targeting-details. Accessed on Decem-ber 3, 2014.

2. Statistic Brain. Attention Span Statistics. Available at: www.statistic-brain.com/attention-span-statistics. Accessed on December 3, 2014.

3. Twitter. Tweet tips: Most eff ective calls to action on Twitter. Available at: https://blog.twitter.com/2013/tweet-tips-most-eff ective-calls-to-action-on-twitter. Accessed on December 4, 2014.

4. Google. Search Engine Optimization Starter Guide. Available at: http://static.googleusercontent.com/media/www.google.com/en/us/webmasters/docs/search-engine-optimization-starter-guide.pdf. Ac-cessed on December 11, 2014.

5. Nielsen. Nearly 75% of Consumers Remember an Ad When Viewed Across All Media Platforms. Available at: www.nielsen.com/us/en/insights/news/2011/nearly-75-of-consumers-remember-an-ad-when-viewed-across-media-platforms.html. Accessed on December 11, 2014.

6. Nielsen. TV Remains the Reigning Champ, But Display Internet Ads are the MVPs of 3Q. Available at: www.nielsen.com/us/en/insights/news/2014/tv-remains-the-reigning-champ-but-display-internet-ads-are-the-mvps-of-3q.html. Accessed on December 11, 2014.


©2014 CooperVision, Inc. 1315 12/14

Download your Biofinity multifocal 3-step fitting guide at coopervision.com/fitting-guide

Biofinity & Biofinity XR Biofinity toric Biofinity multifocal

Distance visionSpherical central zone

Intermediate visionProgressive zone

Near visionSpherical zone

Lens edge

Near visionSpherical central zone

Intermediate visionProgressive zone

Distance visionSpherical zone

Lens edge

Dominant eye lens Non-Dominant eye lens

Balanced Progressive™ Technology enhances vision near, far and intermediate.It also allows for an individualized fi tting for each wearer and each eye.

An

easy fit

Biofinity®

multifocal

CooperVision Biofinity® multifocal lenses combine a high-performing 3rd generation material with a streamlined fitting process. Now even your most challenging presbyopic patients can enjoy the freedom of all-distance clarity and lasting comfort.

for you and your presbyopic patients.

BIOFINITY MULTIFOCAL LENSESAVAILABLE UP TO -10.00D

RO0115_Cooper Biofinity.indd 1RO0115_Cooper Biofinity.indd 1 12/22/14 11:43 AM12/22/14 11:43 AM


Contact lens wear has been a safe and successful modality for millions of patients over

the last several decades. It’s an accomplishment and a source of pride for everyone involved. But clinicians, manufacturers and regulatory agencies all have a stake in continually striving to reduce adverse events. Do your efforts to encourage compliance and mitigate risk refl ect the latest consensus guidelines? Perhaps some new initiatives from the Centers for Disease Control and Prevention (CDC) can help.

Recently, the CDC closely col-laborated with the FDA, eye care providers, manufacturers and academic institutions to create the Healthy Contact Lenses Program, an initiative to reduce the burden of contact lens-associated eye infec-tions in the United States. Since July 2013, the CDC and partners have worked to increase aware-ness of behaviors and risk factors that can affect the eye health of contact lens wearers by developing and disseminating recommenda-tions about the proper wear, care and maintenance of contact lenses. These recommendations address

key risk factors for corneal infec-tions among contact lens wearers.

CORNEAL INFECTIONS IN

CONTACT LENS WEARERS

Improper wear and care of contact lenses can signifi cantly increase the risk of corneal infections, including microbial keratitis.1,2 With rates of noncompliance with contact lens wear and care recommendations ranging anywhere from 40% to 91%, many contact lens users are at risk for these painful, sometimes blinding eye infections as a result of inadequate lens hygiene.3.4

Poor contact lens sanitation habits have been implicated in multi-state outbreaks of microbial keratitis. Outbreak investigations of Fusarium and Acanthamoebakeratitis in 2006 and 2007 identi-fi ed specifi c multipurpose solu-tions with inadequate disinfection capabilities that were consequently recalled from the market.5-7 How-ever, further investigation also pointed to noncompliant contact lens wear and care practices as additional contributing factors to these outbreaks.

Behavioral risk factors for con-tact lens-related corneal infections are well known to many eye care providers; these include sleeping in contact lenses, poor storage case hygiene, “topping off” of solution in the storage case and exposing contact lenses to water, among others.5,7-16 Eye care providers play an important role in educating

patients on proper wear and care practices that can reduce the risk of serious eye infections; however, the CDC and its partners identi-fi ed several factors that suggested the need for a coordinated effort to promote healthy wear and care: persistence of contact lens-related eye infections, continued high rates of non-compliant behaviors and lack of consistent messag-ing around proper wear and care practices.18-20 Factors driving non-compliant behavior remain for the most part poorly understood, but economics, time requirements and regimen complexity are all thought to play a part.17

ENCOURAGING

LENS HEALTH

The CDC's Healthy Contact Lenses Program was implemented in July 2013 using fi nancial sup port from the nonprofi t Contact Lens Institute* with the mission of developing clear and consistent contact lens wear and care recommendations. The program team at CDC, within the Waterborne Disease Prevention Branch, convened a workgroup

Ms. Rao is a health communications spe-cialist and the coordinator of

the Healthy Contact Lenses Program at the Centers for Disease Control and Preven-tion. She received her Master of Public Health degree from

Emory University in Atlanta.

ABOUT THE AUTHOR

*The Contact Lens Institute’s member

companies include Alcon, Bausch + Lomb,

Cooper Vision and Johnson & Johnson Vision

Care. The Department of Health and Human

Services/Centers for Disease Control and

Prevention does not endorse any particular

company, product, activity or enterprise.

The Quest Photo: Christine Sindt, OD


of experts in eye health, contact lenses and epidemiology to advise program activities. With assistance from this advisory group, the CDC continues to work on creating data-driven recommendations and health promotion materials that are available on the CDC Healthy Contact Lens Wear and Care website (www.cdc.gov/contactlenses).

The website provides a range of information on the care of contact lenses, including decorative lenses, and the peer reviewed, microbiologic, epidemiologic and clinical studies that provide scientifi c evidence for these recommendations. Data on germs, infections and eye complications related to contact lens wear and promotional materials geared towards certain target audiences, including parents of children who are either current or potential contact lens wearers, are also available. Eye care providers can also use the health promotion materials to assist with patient education in their practice.

In addition to the website, the CDC expanded its contact lens health promotion efforts by imple-menting the fi rst annual Contact Lens Health Week campaign, which took place the week of Nov. 17-21, 2014. The goal of this campaign was to actively promote healthy contact lens wear and care among older teens and young adults, a group predisposed to an

increased risk of corneal infl amma-tory events related to contact lens wear.21 Healthy contact lens wear and care messages were dissemi-nated through social media chan-nels popular among older teens and young adults, such as Twitter, Facebook, Instagram and Pinter-est. These messages conveyed the risks of improper contact lens use as well as tips for avoiding infection, such as keeping water away from contact lenses, cleaning and replacing storage cases and visiting an eye care provider on an annual basis.

The CDC also collaborated with university campus groups, eye health organizations and the contact lens industry to distribute campaign materials and mes-sages to young adult contact lens wearers and their eye care provid-ers. Materials developed for the campaign include a toolkit for professional eye care organiza-tions, college campuses, members of the contact lens industry, public health organizations and non-profi t organizations; a video collabora-tion with Medscape and podcasts on keratitis and contact lens use; promotional material distributed through Twitter, Google+, Pinterest and other CDC social media chan-

nels; a feature article on healthy contact lens wear and care on the CDC’s website; and the Morbid-ity and Mortality Weekly Report(MMWR), which covered the estimated burden of keratitis in the US. The authors of the MMWR article analyzed insurance claims

data from 2010 and found that Americans made nearly one million doctor and emergency department visits per year for keratitis and con-tact lens-related diagnostic codes, resulting in $174.9 million in direct healthcare costs and the use of over 250,000 hours of clinician time. The authors also referenced poor contact lens hygiene as an important risk factor for keratitis and provided tips for contact lens wear and care to reduce the risk of keratitis.

Thanks to support from partner organizations and media cover-age from the MMWR, the CDC successfully achieved the following outcomes:

• 20 partners from clinical, regulatory, public health, academic, industry and non-profi t sectors helped promote the Contact Lens Health Week campaign


The CDC recently completed its fi rst national contact lens health campaign. Can lessons learned during the eff ort help practicing clinicians?

By Maya M. Rao, MPH

"RATES OF NON-

COMPLIANCE RANGE FROM 40% TO 91%."

for Compliance


• 13 reporters called in to CDC’s media briefi ng on the MMWR keratitis article, including the Asso-ciated Press, National Public Radio and The Washington Post.

• 463 news articles on contact lens health were published by top news sources, including The Examiner, The Washington Post and Reuters

• 2,493 tweets about contact lens health were sent from CDC and external groups

• 727 Facebook posts about con-tact lens health were generated

• One Twitter chat on contact lens health occurred with Good Morning America’s Rich Besser

This campaign was the fi rst coordinated effort to distribute CDC’s newly developed contact lens health recommendations and materials to the public and resulted in an estimated reach of 48.6 mil-lion individuals—including eye care providers and the general pub-lic—through traditional and social media. Campaign efforts also contributed to a 427% increase in traffi c to the CDC contact lenses website, indicating a signifi cant increase in the program’s visibility. While resources were not available to collect information on behavior, attitudes and awareness with re-gards to contact lens hygiene prior to the campaign, the CDC aims

to collaborate with other partner organizations in the future to fi eld an online survey of contact lens wearers that will establish a base-line for these outcome measures. A follow-up survey after subsequent contact lens health campaigns could then provide information on changes in behavior, attitudes and awareness as a result of the health promotion efforts.

Since the conclusion of the Con-tact Lens Health Week campaign, CDC has continued to work on promoting healthy habits among contact lens wearers. Plans are in place to make this campaign an an-

nual event and to promote contact lens health and patient educa-tion throughout the year. Please join CDC in this effort by visit-ing www.cdc.gov/contactlenses, downloading contact lens health promotion materials and teaching your patients how to properly wear and care for their contact lenses. Together, we can help prevent eye infections linked to poor contact lens hygiene. RCCL

1. Keay, L, Stapleton F, and Schein O. Epide-miology of contact lens-related inflammation and microbial keratitis: a 20-year perspective. Eye Contact Lens, 2007. 33(6 Pt 2): p. 346-53, discussion 362-3.2. Stapleton, F. Contact lens-related microbial keratitis: what can epidemiologic studies tell us? Eye Contact Lens, 2003. 29(1 Suppl): p. S85-9; discussion S115-8, S192-4.

3. Sokol, JL, Mier MG, Bloom S and Asbell, PA. A study of patient compliance in a contact lens-wearing population. CLAO J, 1990. 16(3): p. 209-13.4. Claydon, BE and Efron N. Non-compliance in contact lens wear. Ophthalmic Physiol Opt, 1994. 14(4): p. 356-64.5. Chang, DC et al. Multistate outbreak of Fu-sarium keratitis associated with use of a contact lens solution. JAMA, 2006. 296(8): p. 953-63.6. Ross, J et al. Clinical characteristics of acan-thamoeba keratitis infections in 28 States, 2008 to 2011. Cornea, 2014. 33(2): p. 161-8.7. Verani, JR et al. National outbreak of Acan-thamoeba keratitis associated with use of a contact lens solution, United States. Emerg Infect Dis, 2009. 15(8): p. 1236-42.8. Stapleton, F et al. The incidence of contact lens-related microbial keratitis in Australia. Oph-thalmology, 2008. 115(10): p. 1655-62.9. Dart, JK et al. Risk factors for microbial kera-titis with contemporary contact lenses: a case-control study. Ophthalmology, 2008. 115(10): p. 1647-54, 1654 e1-3.10. Poggio, EC et al. The incidence of ulcerative keratitis among users of daily-wear and extend-ed-wear soft contact lenses. N Engl J Med, 1989. 321(12): p. 779-83.11. Schein, OD et al. The relative risk of ulcerative keratitis among users of daily-wear and extend-ed-wear soft contact lenses. A case-control study. Microbial Keratitis Study Group. N Engl J Med, 1989. 321(12): p. 773-8.12. Stapleton, F et al. Risk factors for moder-ate and severe microbial keratitis in daily wear contact lens users. Ophthalmology, 2012. 119(8): p. 1516-21.13. Visvesvara, GS, Moura H, and Schuster, FL. Pathogenic and opportunistic free-living amoebae: Acanthamoeba spp., Balamuthia mandrillaris, Naegleria fowleri, and Sappinia diploidea. FEMS Immunol Med Microbiol, 2007. 50(1): p. 1-26.14. Hammersmith, KM. Diagnosis and manage-ment of Acanthamoeba keratitis. Curr Opin Ophthalmol, 2006. 17(4): p. 327-31.15. Joslin, CE et al. The association of contact lens solution use and Acanthamoeba keratitis. Am J Ophthalmol, 2007. 144(2): p. 169-180.16. Mena, KD and CP Gerba, Risk assessment of Pseudomonas aeruginosa in water. Rev Environ Contam Toxicol, 2009. 201: p. 71-115.17. Bui, TH, Cavanagh, HD and Robertson DM. Patient Compliance During Contact Lens Wear: Perceptions, Awareness and Behavior. Eye Con-tact Lens. Nov 2010; 36(6): 334–339.18. Yoder, J.S. et al. Acanthamoeba keratitis: the persistence of cases following a multistate outbreak. Ophthalmic Epidemiol, 2012. 19(4): p. 221-5.19. Dumbleton, K., D. Richter, P. Bergenske, and L.W. Jones, Compliance with lens replacement and the interval between eye examinations. Optom Vis Sci, 2013. 90(4): p. 351-8.20. Bui, T.H., H.D. Cavanagh, and D.M. Robert-son, Patient compliance during contact lens wear: perceptions, awareness, and behavior. Eye Contact Lens, 2010. 36(6): p. 334-9.21. Chalmers et al. Age and other risk factors for corneal infiltrative and inflammatory events in young soft contact lens wearers from the Con-tact Lens Assessment in Youth (CLAY) study. Invest Ophthalmol Vis Sci, 2011. 52(9):p.6690-6.


THE QUEST FOR COMPLIANCE

"ECONOMICS, TIME AND REGIMEN COMPLEXITY ARE ALL THOUGHT TO PLAY A PART IN NON-

COMPLIANCE."


Dr. O’Dell is an optometrist at the May Eye Care Center &

Associates in Pennsylvania, and a member of the Pennsylvania Optometric Association and the American Optometric

Association.

Dry eye disease (DED) and glaucoma: though fundamental-ly different in many ways, their similari-

ties are more numerous than you might expect. Both are chronic, progressive diseases with an age-related increase in prevalence. Both require diligent medication compli-ance from patients. Both can be confounded by a mismatch be-tween the subjective and objective fi ndings. And neither is likely to ever be “cured,” instead subjecting patients to a lifelong management regimen and some diminution of quality of life.

While advanced diagnosis and treatment of ocular surface disease is still in its infancy, a lot can be learned from earlier developments made in the fi eld of glaucoma—from obtaining a defi nitive diagno-sis and driving progressive research to developing effective treatment options and raising public aware-ness.

Early in my career in private practice, I realized ocular sur-face disease was the driving force behind many patient complaints and emergency visits. Patients with red, itchy, irritated eyes were

a common occurrence, so much so that I dreaded these patients at fi rst. However, as I learned the nuances of how to make the right diagnosis and subsequently devel-oped best-practice treatments, my confi dence and patient outcomes both improved. Today, my patient base is strong—both from colleague referrals for glaucoma evaluation and patient self-referrals for dry eye consultations.

DEFINING THE PROBLEM

Glaucoma took more than a cen-tury and a half to be truly under-stood. In the early 1970s, Drance developed the modern defi nition of glaucoma as a disease of optic neu-ropathy, not that of elevated IOP.1

Although the meibomian glands were initially defi ned by Heinrich Meibom in the 1600s, it wasn’t un-til 1980 that Korb and Henriquez defi ned meibomian gland dysfunc-tion (MGD). Since then, we have gained a much better understand-ing of their role in ocular surface disease.2 In the last three decades, a paradigm shift has occurred with respect to DED, and meibomian gland dysfunction is now recog-nized as the main cause of patient symptoms as well as a dry eye

cascade resulting in infl ammation of the ocular surface.3,4 With the help of the Tear Film and Ocular Surface Society, the DEWS and MGD workshops have introduced defi nitions of DED and MGD, respectively:

• Dry eye disease is defi ned as a multifactorial disease of the tears and ocular surface that results in symptoms of discomfort, visual disturbance and tear fi lm instabil-ity, with potential damage to the ocular surface. It is accompanied by increased osmolarity of the tear fi lm and infl ammation of the ocular surface.4

• Meibomian gland dysfunc-tion is defi ned as a chronic, diffuse abnormality of the meibomian glands, commonly characterized by terminal duct obstruction and/or qualitative and quantitative changes in the glandular secretion. It may result in alteration of the

ABOUT THE AUTHOR

Can one progressive eye disease teach us how to best treat another?

By Leslie O’Dell, OD

1 CE Credit

(COPE Approval Pending) GLAUCOMA

AND DRY EYE: PRINCIPLESPRINCIPLES and

Parallels


027_0115RCCL_F5 CE JP.indd 27027_0115RCCL_F5 CE JP.indd 27 12/29/14 9:25 AM12/29/14 9:25 AM

tear fi lm, eye irritation, clinically apparent infl ammation and ocular surface disease.5

These defi nitions are the fi rst step in directing future research in this area. To properly treat patients with both glaucoma and ocular surface disease, their condition must fi rst be defi ned. In glaucoma management, defi ning the disease’s primary and secondary forms helps when establishing a treatment plan. For a dry eye patient, dif-ferentiating aqueous defi cient from evaporative or a combination lays the foundation to build an effective treatment plan.

STRUCTURE VS. FUNCTION

Both glaucoma and ocular surface disease are chronic, progressive ocular pathologies with an endstage that results in vision loss. In glau-coma, patient vision loss is due to

progressive optic neuropathy, while in dry eye, corneal melts can cause loss of vision. Both groups of pa-tients face increased depression as a result of their respective diseases.6

Both conditions pose the ques-tion: when should treatment be initiated with respect to structure vs. function?

Glaucoma specialists have been arguing for years over the clinical signifi cance of structural changes of the optic nerve head (ONH) and retinal nerve fi ber layer (RNFL) associated with visual fi eld changes or functional vision loss, and it remains an important topic for research.7 In MGD, structural changes of the meibomian glands are associated with a change in the function or secretion of the gland, leading to alterations in the tear fi lm and infl ammation to the ocular surface.

In both cases, a change in struc-ture affects function. So, should we as dry eye specialists adopt the thought process already used by our colleagues treating glaucoma—namely, to treat before symptoms emerge in hopes of delaying onset or at least dampening their impact?

Preventative exams are recom-mended twice a year in the dental profession to help reduce the risk of tooth decay, often well before symptoms like tooth sensitivity and pain appear. Similarly, dermatolo-gists suggest applying sunscreen well before sun exposure to prevent skin damage. Clearly, preventa-tive care works in other contexts. It stands to reason that an ocular wellness evaluation could be a ben-efi cial part of every exam as well, as it may help identify nascent or subclinical pathology.

Much as the optic nerve and NFL can be evaluated using high-powered lenses and red-free settings without expensive OCT testing, evaluating the structure of the meibomian gland can be done simply with transillumination of the eyelid at the slit lamp. Addition-ally, manual gland expression can be performed to properly assess function. Using a tool such as the meibomian gland evaluator (MGE), we can determine the number of glands producing clear, healthy oil under normal physiological blink-ing.8 This procedure is important to use, as dry eye can easily be missed by only looking at the lid margin without expressing the glands—a condition known as “non-obvious” MGD, which can become serious if not identifi ed quick enough.9 Thus, evaluating and caring for mei-bomian glands early, before they atrophy, is likely the best course of action; however, further, large-scale research needs to support this concept.

Release Date: January 2015

Expiration Date: January 1, 2018

Goal Statement: This course reviews simi-larities in the pathophysiology and clinical work-up of glaucoma and dry eye disease. Both conditions involve the reconciliation of subjective vs. objective data and require long-term, ongoing care. Pearls on clinical care of dry eye are provided in this context.

Faculty/Editorial Board: Leslie O'Dell, OD

Credit Statement: COPE approval for 1 hour of CE credit is pending for this course. Check with your state licensing 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. O'Dell has no financial disclosures relevant to the con-tent of this course.

GLAUCOMA AND DRY EYE: PRINCIPLES AND PARALLELS


Fig. 1. Disease progression in glaucoma (left) and dry eye (right).

Phot

o C

redi

t: Te

arSc

ienc

e


RESEARCH IS KEY

Modern glaucoma management is based on several multicenter, ran-domized clinical studies.10-12 These fi ndings have served as a seminal guide on how to slow disease progression and what the goal of treatment should be. The main risk factor for glaucoma progression and severity is intraocular pressure; treatment has primarily focused on this because it is the only modifi -able risk factor. For glaucoma, the gold standard for progression has been optic nerve photographs and changes over time from baseline.

In the case of evaporative dry eye, the patient’s blink pattern and/or lipid layer thickness are the main modifi able risk factors. One limitation with current treatments and research, however, is that much of it is geared toward relieving symptoms, which can vary signifi -cantly with different contributing factors. Recent studies have also shown treatment can be challenging for some dry eye patients with low pain thresholds.13

When managing dry eye, the focus should be on rehabilitating

the ocular surface. Patients should be informed that this process can be diffi cult, and may require many treatments and ongoing care. Stud-ies are still somewhat lacking in the management of the ocular sur-face, but a few have offered some compelling insights. For example, Korb found debridement of the meibomian glands increased their function.14 Much like the dentistry model, scheduling routine exams to track overall ocular surface and meibomian gland health is a good fi rst step; it can make a big differ-ence in tackling symptoms.

When considering treatment methods, be sure to look at the data and research—not the cost of treatment. LipiFlow has been demonstrated to provide repeatable results and 79% to 88% symptom improvement for patients.15 These same studies also showed im-proved function of the meibomian glands.16-17 Additionally, new tech-nologies like the MiBoFlo Thermo-fl o, which helps improve meibo-mian gland function, and at-home treatments like warm compresses or masks, are also emerging.

FOCUSING ON THE

CORRECT DIAGNOSTICS Much as with glaucoma, new diag-nostic tools can provide the dry eye specialist with more key informa-tion we need to develop an inte-grated, clinical approach to making the best diagnosis. These tests will help improve diagnosis and progression analysis and hopefully continue to drive research forward towards better treatment methods.

For example, we now have questionnaires and history intake forms that provide information on modifi able factors, including environment, hormone changes, al-lergy and other medications, while TBUT has proven to be a valuable tool for evaluating tear stability. Tear volume can be evaluated with Schirmer testing, tear fi lm meniscus and anterior segment OCT, while meibomian gland function, lid seal and blink are also important ele-ments to consider. Finally, emerging blood tests like Sjö are demonstrat-ing that Sjögren’s syndrome is far more common than once thought and can be associated with both aqueous and evaporative dry eye.


GLAUCOMA OCULAR SURFACE DISEASE/MGD

Natural Course of Disease • Chronic

• Progressive

• Chronic

• Progressive

Loss of Function • Optic nerve ganglion cell atrophy • Meibomian gland atrophy

• Lacrimal gland atrophy

Symptoms • Asymptomatic to start • Symptoms vary greatly for patients

• Early disease asymptomatic

Modifi able Risk Factor(s) • IOP • Blink

Structure/Function • Structure: OCT (ganglion cells, RNFL)

• Function: Visual fi eld exam (optic nerve)

• Structure: Meibography (MG imaging and atrophy)

• Function: Meibomian gland expression

End-stage Disease • Vision loss resulting from total loss of ganglion

cells

• Vision loss resulting from corneal scarring

• Sterile corneal melt

• Mucous membrane pemphigoid

Barriers to Treatments • Adherence

• Cost

• Education

• Adherence

• Cost

• Education

Table 1. Similarities Between Glaucoma and Ocular Surface Disease


PERSONALIZE YOUR

APPROACH TO CARE

All glaucoma patients receive an individualized treatment plan based on their unique risk factors, symptomatology and likelihood of progression. These personalized treatment plans are under constant scrutiny during follow-up exams to determine if the risk of progression has been completely halted or only signifi cantly slowed, to prevent vision loss.

Treatments for these patients do not typically follow an all-or-none philosophy—some patients need multiple medications, while others require surgical intervention. In making these decisions for our patients, we develop our best treatment plans when we rely on pre-existing knowledge and ongoing research to guide us. The medications we prescribe all have pros and cons and do not always work for each patient, and even surgical interventions can fail.

Dry eye patients also need to be managed just like other chronic progressive disease patients. Planned follow-ups to continually reassess the ocular surface health and wellness of the eye are vital.

Schedule a follow-up exam whenever any treatment is initi-ated, even if it is only an artifi cial tear. Reassess the ocular surface and symptoms to determine if that treatment is effective and if not, reconsider what factors might still be contributing to the condition. Evaluating each patient’s disease and risk factors helps guide treat-ment plans to improve ocular health and patient comfort. Con-sider a patient with tear fi lm in-stability to be a “dry eye suspect” (akin to a “glaucoma suspect” in similarly vulnerable patients) and follow patients with risk factors accordingly.

Follow-up exams after treat-ment is initiated also allow better assessment of adherence to therapy. Adherence is a fairly common problem when managing glaucoma, even with the threat of blindness.18 The same barriers to adherence are present for dry eye patients—cost, increased age and comorbidities such as dementia or arthritis that make it hard to use eye drops. Changing the concept of DED begins with the prescrib-ing doctor’s attitude, so make it an important part of the general eye exam.

In any case, optometrists need to recognize one another as special-ists and refer more within our profession. The eye is undoubedly very complex; to master every aspect is a challenge. According to Malcom Gladwell, it takes 10,000 hours of practice to master a fi eld, making it an intimidating and unlikely goal to attempt to know everything there is to know about many subjects.18 Many fi elds often separate into subcategories—for example, there are at least nine specialties within ophthalmology, ranging from general ophthal-mology to neuro-ophthalmology. Thus, it is important to know what subspecialties the other eye care professionals in your referring network might have so you can refer a patient before their condi-tion progresses too far.

Work together with the ap-propriate specialist to initiate a treatment plan and achieve the goal of a healthy ocular surface. And as always, be sure to keep track of new dry eye research—change takes time, but the growing amount of interest in the area of ocular surface disease will likely continue to improve the under-standing of the condition and the available treatments. RCCL

1. Morgan RW, Drance SM. Chronic open-angle glaucoma and ocular hypertension. Br J Oph-thalmol. 1975;59(4):211-215.2. Korb DR, Henriquez AS. J Am Optom Assoc. 1980;51:243-251.3. Lemp MA, Crews LA, Bron AJ, Foulks GN, Sullivan BD. Distribution of aqueous-defi cient and evaporative dry eye in a clinic-based patient cohort: a retrospective study. Cornea. 2012;31(5):472-478.4. Nichols KK, et al. The international work-shop on meibomian gland dysfunction: executive summary. Invest Ophthalmol Vis Sci. 2011;30;52(4):1922-1909.5. The defi nition and classifi cation of dry eye disease: report of the Defi nition and Classifi ca-tion Subcommittee of the International Dry Eye Workshop (2007). Ocul Surf. 2007;5(2):75-92.6. Kim KW1, Han SB, et al. Association between depression and dry eye disease in an elderly population. Invest Ophthalmol Vis Sci. 2011 Oct 10;52(11):7954-8. 7. European Glaucoma Society. Terminology and guidelines for glaucoma. 3. Vol. 2008. Savona: Italy Editrice Dogma; 2008.8. Korb DR, Blackie CA. Meibomian gland diag-nostic expressibility: correlation with dry eye symptoms and gland location. Cornea. 2008 Dec;27(10):1142-7.9. Blackie CA, Korb DR, et al. Nonobvious ob-structive meibomian gland dysfunction. Cornea. 2010 Dec;29(12):1333-45. 10. Leske MC, Heijl A, et al. Early Manifest Glaucoma Trial: design and baseline data. Oph-thalmology. 1999 Nov;106(11):2144-53.11. Musch DC, Lichter PR, et al. The Collabora-tive Initial Glaucoma Treatment Study: study design, methods, and baseline characteristics of enrolled patients. Ophthalmology. 1999 Apr;106(4):653-62.12. Kass MA, Heuer DK, et al. The Ocular Hypertension Treatment Study: a randomized trial determines that topical ocular hypotensive medication delays or prevents the onset of pri-mary open-angle glaucoma. Arch Ophthalmol. 2002 Jun;120(6):701-13.13. Rosenthal P, Borsook D. The corneal pain system. Part I: the missing piece of the dry eye puzzle. Ocul Surf. 2012 Jan;10(1):2-14. 14. Korb DR, Blackie CA. Debridement-scaling: a new procedure that increases Meibomian gland function and reduces dry eye symptoms. Cornea. 2013 Dec;32(12):1554-7. 15. Lane SS1, DuBiner HB, et al. A new system, the LipiFlow, for the treatment of meibomian gland dysfunction. Cornea. 2012 Apr;31(4):396-404.16. Greiner JV. A single LipiFlow Thermal Pulsation System treatment improves mei-bomian gland function and reduces dry eye symptoms for 9 months. Curr Eye Res. 2012 Apr;37(4):272-8.17. Greiner JV. Long-term (12-month) improve-ment in meibomian gland function and reduced dry eye symptoms with a single thermal pulsa-tion treatment. Clin Experiment Ophthalmol. 2013 Aug;41(6):524-30.18. Cate H, Bhattacharya D, et al. Improving ad-herence to glaucoma medication: a randomised controlled trial of a patient-centred intervention (The Norwich Adherence Glaucoma Study). BMC Ophthalmol. 2014 Mar 24;14:32.

GLAUCOMA AND DRY EYE: PRINCIPLES AND PARALLELS



1. What recent paradigm shift has been identified for ocular surface disease?

a. Aqueous deficiency is the most common type. b. Allergy does not co-exist for dry eye patients. c. Evaporative dry eye is the most common form, contributing to a dry eye

cascade resulting in inflammation. d. None of the above.

2. Which of the follow is NOT true about the natural history of glaucoma?

a. It was first identified as a disease of elevated IOP. b. Only in 1973 was glaucoma thought of as a disease of optic neuropathy. c. IOP is considered the main modifiable risk factor for glaucoma. d. Co-morbidites are the main risk factors for a glaucoma patient.

3. When paralleling MGD to glaucoma, what structural component that can be

monitored is analogous to the nerve fiber layer in a glaucoma patient?

a. Meibomain glands. b. Schirmer test. c. Corneal health. d. Conjunctival staining patterns.

4. Applying the dental model to the treatment of dry eye means:

a. Recommending routine follow-up to evaluate a patients overall ocular surface wellness.

b. Debridement of the meibomian gland orifice to improve the glands overall function.

c. Increasing public awareness about ocular surface wellness. d. All of the above.

5. Which is NOT an effective method to view the meibomian glands for atro-

phy and/or dropout?

a. Transillumination of the lid. b. Meibography. c. Osmolarity. d. Anterior segment OCT.

6. Advanced ocular surface dryness can have grave visual consequences.

Which of the following can cause vision loss for these patients?

a. Sterile corneal melt. b. Superficial keratitis. c. Meibomian gland atrophy. d. None of the above; dryness will not result in vision loss.

7. Patients living with chronic diseases such as ocular surface disease and glau-

coma often suffer from which of the following other chronic illnesses?

a. Hypertension. b. Diabetes. c. Depression. d. Hypercholesterolemia.

8. Adapting a clinical approach similar to that used when caring for a glau-

coma patient or glaucoma suspect can improve management for dry eye

patients. This may include:

a. Performing a series of diagnostic tests for a patient to determine the overall health of the tear film.

b. Repeating diagnostic testing to determine the effectiveness of treatments. c. Scheduling recalls to re-evaluate any treatment initiated, even something as

“simple” as starting a tear supplement. d. All of the above.

9. What might be one of the most modifiable risk factors for patients with

MGD, similar to IOP in a glaucoma patient?

a. Schirmer score. b. Blink. c. Osmolarity. d. Tear meniscus.

10. Similar to glaucoma management, treatments available for dry eye patients

do not follow a one-size-fits-all approach. New diagnostic testing will prove

both helpful and challenging to interpret. What is the best strategy for man-

aging these patients, and any patient with a chronic condition?

a. Refer to a specialized provider when conventional treatments fail. b. Base treatments solely on symptom relief. c. Base treatments solely on personal success, not clinical research. d. Wait for symptoms to start before recommending treatment or educating

patient of their disease.

CE TEST ~ JANUARY 2015 EXAMINATION ANSWER SHEET

Glaucoma and Dry Eye: Principles and Parallels

Valid for credit through January 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 110881, RO-RCCL-0115



A 47-year-old female presents complain-ing of mild discom-fort while wearing her contact lenses.

A comprehensive ocular examina-tion reveals no physiological basis for the discomfort, as the ocular surface appears normal.

In this case, many of us may try to alleviate the discomfort us-ing a new lens material, solution or even a daily disposable lens. These technologies may make the patient comfortable for now, but will she return in a year and report more discomfort? And if she does, should she be re-fi t again, or is there an underlying cause that needs to be treated fi rst?

THE GREAT

POPULATION SHIFT

The rapid decline in the number of contact lens wearers is no coinci-dence—our population is aging, and the prevalence of dry eye increases proportionally with age. Studies have found the prevalence of dry eye to be 3.5% to 33%, depending on the criteria used for inclusion and the age of the popu-lation studied.1-5

With any number of endogenous factors contributing to alterations in the ocular surface, simply chang-ing the contact lenses, solutions and designs won’t necessarily address the underlying factor(s) responsibile for the decreasing comfort of the lenses.

In other words, the examination of the patient above revealed no ocular abnormalities—but does that necessarily mean the ocular surface is functioning normally?

THE MEIBOMIAN GLANDS

The meibomian glands produce the lipid layer of the tear fi lm that acts to prevent evaporation of the underlying aqueous layer. A robust lipid layer is critical for a healthy tear fi lm, so the meibomian glands need to be functioning properly. In a healthy individual, the meibum has a melting point between 660°F and 890°F, meaning it exists in a fl uid state at normal body tempera-ture (98.60°F).6

Traditional thinking on meibo-mian gland dysfunction (MGD) suggests that a defi ciency in the glands is accompanied by infl am-mation of the eyelid margins, visible capping of the gland orifi ces and generalized conjunctival injec-tion. There are two types of mei-bomian gland dysfunction: obvious MGD and non-obvious MGD. The obvious form is the scenario just described. Non-obvious MGD, on the other hand, is not characterized by visible infl ammation. Rather, the glands look normal, but the meibum is of abnormal consistency when expressed.7 The meibum may be completely stagnant—applica-tion of pressure yields no visible meibum—or abnormally thick-ened, instead of fl uid as expected.

The clinical challenge here is that non-obvious MGD, as the name implies, is elusive. Often, the lid margin appears normal. Only upon attempted expression would the clinician notice any abnormalities in gland function; unfortunately, if gland expression is not attempted, there will be no obvious reason to consider MGD treatment.

In light of this, think about at tempting gland expression at

every visit, regardless of whether the patient is exhibiting dry eye symptoms. This is the only way to determine for sure whether the meibum is in fact being expressed properly from the gland.

Most examiners can easily perform this by applying gentle pressure along the eyelid margin and visualizing the meibum that is expressed. Certain specialized tools can also assist with this procedure, such as the meibomian gland expressor (MGE), a device that applies pressure to the lid margin similar to the amount placed by the eyelids during a normal blink. This allows for an assessment of the meibum released from the glands under the pressure of a normal blink. Additionally, meibography allows the examiner to view the meibomian glands to determine abnormalities in structure that may exist in symptomatic patients.

NON-OBVIOUS MGD

DIAGNOSIS—NOW WHAT?

Once the diagnosis has been made, it is important to educate the pa-tient on the cause of the decreased comfort and your plan: to increase functionality of the glands by pro-ducing meibum that is more fl uid in nature. Often, this will require sustained heat to the eyes. A num-ber of eyelid heating systems are available, such as the Tranquileyes goggles from Ocusoft and moist heat compresses from Bruder.8,9

Recommended application time varies; many practitioners suggest 10 minutes at a time, twice a day.

Ocular nutrition has also become important in helping normalize the tear fi lm in those with MGD.10,11

Obvious Problem, Elusive CauseDiagnosing contact lens-related discomfort is not always as simple as you may think.

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

Derail Dropouts


032_rccl0115_DD JP.indd 32032_rccl0115_DD JP.indd 32 12/29/14 9:27 AM12/29/14 9:27 AM

Omega-3 fatty acids in particu-lar have been shown to decrease ocular surface infl ammation.12-14

Evening primrose oil, green tea extract and vitamin A have also been demonstrated to improve and maintain ocular surface health.15-17

Other contemporary treatments include Lipifl ow, a technology that distributes heat to the meibomian glands via the tarsal surface while providing pressure to the anterior surface of the eyelids to help renor-malize the meibum secreted from the glands.18 A similar device is the MiBoFlo Thermofl o.

All of these strategies, while varied in application, are geared towards renormalizing the patient’s tear fi lm to improve the environ-ment the lens is placed into. By

following this process, we will have the best chance of preserving the wearing ex-perience in individuals who are fi nding their lenses to be increasingly uncomfortable.

BACK TO THE

PATIENT AT HAND

So, how do we handle the patient in question? First, we need to deter-mine whether the patient’s meibomian glands are in fact producing quality meibum. As said before, this requires gentle pressure to determine the quality of the meibum. In this patient, it was evident that there was very little meibum expressed from the glands—in fact, signifi cant pressure was needed to express any meibum at all.

The patient was started on a regular regimen of heat applied to the eyelids in the morning and evening for 10 minutes per session, as well as an ocular nutraceutical that contained multiple ingredients to help with dry eye. She was also given a lipid-based artifi cial tear to use before inserting her contact lenses and then as needed through-out the day.

Of course, it’s important to remember treating non-obvious MGD is only one way to improve lens wear. Always be sure to try a multi-faceted approach—the use of daily disposable lenses, a change in solutions and experimentation with different new materials can also enhance a patient’s wearing experience. RCCL

1. Moss SE, Klein R, Klein BE. Prevalence of and risk factors for dry eye syndrome. Arch Ophthal-mol. 2000;118:1264-8.2. McCarty CA, Bansal AK, Livingston PM, et al. The epidemiology of dry eye in Melbourne, Australia. Ophthalmology. 1998;105:1114-9. 3. Schein OD, Munoz B, Tielsch JM, et al. Prevalence of dry eye among the elderly. Am J Ophthalmol. 1997;124:723-8. 4. Schaumberg DA, Sullivan DA, Buring JE, Dana MR. Prevalence of dry eye syndrome among US women. Am J Ophthalmol. 2003 Aug; 136(2): 318-26.5. Gayton JL. Etiology, prevalence, and treat-ment of dry eye disease. Clin Ophthalmol. 2009;3:405-12.6. Abelson MB, Oberoi S. Treating Dysfunctional Meibomian Glands. Review of Ophthalmology, Vol. No: 13:08. 20067. Blackie CA, Korb DR, Knop E, et al. Nonobvi-ous obstructive meibomian gland dysfunction. Cornea. 2010 Dec;29(12):1333-45.8. www.ocusoft.com/SearchResults.aspx?q=tranquileyes9. http://www.bruder.com/eye/products/10. Roncone M, Bartlett H, Eperjesi F. Essential fatty acids for dry eye: A review. Cont Lens Anterior Eye. 2010 Apr;33(2):49-54.11. Rosenberg ES, Asbell PA. Essential fatty acids in the treatment of dry eye. Ocul Surf. 2010 Jan;8(1):18-28.12. Miljanović B, Trivedi KA, Dana MR, et al. Relation between dietary n-3 and n-6 fatty acids and clinically diagnosed dry eye syndrome in women. Am J Clin Nutr. 2005 Oct;82(4):887-93.13. Pinazo-Durán MD, Galbis-Estrada C, Pons-Vázquez S, et al. Effects of a nutraceutical formulation based on the combination of anti-oxidants and omega-3 essential fatty acids in the expression of inflammation and immune re-sponse mediators in tears from patients with dry eye disorders. Clin Interv Aging. 2013;8:139-48.14. Brignole-Baudouin F, Baudouin C, Aragona P, et al. A multicentre, double-masked, random-ized, controlled trial assessing the effect of oral supplementation of omega-3 and omega-6 fatty acids on a conjunctival inflammatory marker in dry eye patients. Acta Ophthalmol. 2011 Nov;89(7):591-7.15. Sheppard JD Jr, Singh R, McClellan AJ, et al. Long-term Supplementation With n-6 and n-3 PUFAs Improves Moderate-to-Severe Kerato-conjunctivitis Sicca: A Randomized Double-Blind Clinical Trial. Cornea. 2013 Jul 23.16. Cavet ME, Harrington KL, Vollmer TR, et al. Anti-inflammatory and anti-oxidative effects of the green tea polyphenol epigallocatechin gallate in human corneal epithelial cells. Mol Vis. 2011 Feb 18;17:533-42.17. Kheir AE1, Dirar TO, Elhassan HO, et al. Xerophthalmia in a traditional Quran boarding school in Sudan. Middle East Afr J Ophthalmol. 2012 Apr-Jun;19(2):190-3.18. Lane SS, DuBiner HB, Epstein RJ, et al. A new system, the LipiFlow, for the treatment of meibomian gland dysfunction. Cornea. 2012 Apr;31(4):396-404.


Fig. 1. Lower eyelid of a patient with obvious

meibomian gland dysfunction.

Fig 2. Lower eyelid of a patient wearing

makeup with non-obvious meibomian gland

dysfunction.

032_rccl0115_DD JP.indd 33032_rccl0115_DD JP.indd 33 12/29/14 9:27 AM12/29/14 9:27 AM

It’s often stated by many practitioners, “A larger percentage of my practice is dedicated to medical eye care vs. contact lenses because

it’s more profi table.” Unsurpris-ingly, in many practices, contact lens patients comprise only about 15% of the total patient base. The key question remains, however: Is this number too low, too high or just right? What is the best percent-age breakdown of medical care, eyeglasses and contact lenses?

ROBBING PETER

TO PAY PAUL

From a purely profi t perspective, you might think that if a practice with 10% of its total services—we’ll use the term “points”—de-voted to medical eye care doubles that amount to 20%, that practice’s profi t margin would also increase.

Unfortunately, it’s not quite that simple: there are only 100 percent-age points or “slices” in the pie, so to speak, and those extra 10 points have to come from somewhere. Putting clinical considerations aside for the moment, you want to make sure the points “stolen” by the in-crease in medical services are more profi table there than in the division they were initially allocated to.

Consider this example: patient A hands you a check for $100 for something medically related, while patient B hands you a check for $100 for something non-medically related. Which is more profi table? Without more specifi cs, you can’t answer this question. Similarly, those who believe non-contact lens related care is more profi table than contact lenses without considering

the details are not always correct. It really depends on the particular services you’re talking about: for example, $100 vision care plan eye-glass dollars are probably less prof-itable than $100 corneal reshaping dollars (given the much lower cost of goods sold for services) or, for that matter, a higher margin pair of glasses (for self-evident reasons).

When looking at net income, not gross, in our experience the practice with the highest net incomes are still the ones with larger propor-tions of contact lens-related sales. Yes, there is no cost of goods sold associated with an OCT exam (after the capital equipment cost is covered), but you shouldn’t just take a snapshot of a single visit. In a well-run offi ce, with a great recall system, a patient who buys a pair of glasses will return and do the same many times over their lifetime. Ideally, they get a pair of glasses and an OCT scan. Or in the case of contact lenses, a patient who purchases lenses from the practice now will eventually get back-up glasses, and may require medically-related services as well.

NO RIGHT ANSWER

So, what is the best combination? Thus far, we’ve only discussed it from the perspective of profi tability. When doctors make comments like, “My contact lens practice is X% of

my total practice,” they are usually thinking the same way. The big problem with this thinking, which is unfortunately pervasive in our in-dustry, is that it is just plain wrong.

Simply put, there is no single “best” combination; rather, it’s a function of how you best care for your patients. If a patient will benefi t from multifocal GP lenses,

fi t them with such; if an OCT and fundus photos are medically indicated, perform those tests—in short, do what the situation re-quires. Approached this way, your ideal mix of percentages will form based on the belief that the pur-suit of clinical excellence and best patient care supersedes any other metrics. If something is appropri-ate for a patient, let the percentage points fall where they may.

While most practitioners do what’s best for patients, sometimes they unnecessarily fret when they look back at their percentages of services and revenues if those metrics don’t match so-called industry norms. Following advice from the podium, colleagues or articles that espouse, “Your contact lens practice should be X% of your total practice” is irresponsible and backwards. Don’t worry about it! Rather, consider what your prac-tice could be. Decide for yourself what you want to focus on, and the profi t will come accordingly. RCCL

Don’t Play the Percentages“Industry norms” are at best a distraction, at worst an irresponsible way to set goals.


Out of the Box By Gary Gerber, OD

"THE BIG PROBLEM WITH THIS THINKING IS THAT IT’S JUST PLAIN WRONG."

034_rccl0115_otb JP.indd 34034_rccl0115_otb JP.indd 34 12/29/14 10:45 AM12/29/14 10:45 AM

All eyes deserve clariti.

High Oxygen Transmissibility

clariti 1 day—now available for practices everywhere. The world’s fi rst and only family of silicone hydrogel daily disposable contact lenses designed for every patient type—sphere, toric and multifocal.

Now you can prescribe all of your patients with healthy, comfortable, aff ordable silicone hydrogel 1 day lenses—which will make all eyes very happy indeed.

To learn more, contact your CooperVision representative today or visit CooperVision.com/practitioner.

High Water Content

Low Modulus

UV Protection

Aff ordableUpgrade

RO0115_Cooper Clariti.indd 1RO0115_Cooper Clariti.indd 1 12/22/14 11:42 AM12/22/14 11:42 AM

Recommend CLEAR CARE® Solution and learn more at MYALCON.COM

The scientifically proven formula of CLEAR CARE® Solution deeply cleans, then neutralizes, to create a gentle saline similar to natural tears. The result is pure comfort and is why CLEAR CARE® has the most loyal patients of any lens care brand.2

^Trademarks are the property of their respective owners.

References: 1. A market research study conducted amongst 107 US contact lens wearers representative of CLEAR CARE® purchasers in the United States, 2007. 2. Based on third party industry report 52 weeks ending 12/29/12; Alcon data on fi le. 3. Alcon data on fi le, 2009. 4. SOFTWEAR™ Saline package insert. 5. Paugh, Jerry R, et al. Ocular response to hydrogen peroxide. American Journal of Optometry & Physiological Optics: 1988; 65:2,91–98.

© 2014 Novartis 02/14 CCS14004ADi

THIS IS WHY 4 out of 5 patients agree their lenses feel like new.1

SOFTWEARTM Saline2

CLEAR CARE® Solution1

RESIDUAL H2O2 IN PARTS PER MILLION (PPM)

OCULAR AWARENESS THRESHOLD3

2050 40 60 80 100

Range of Residual H2O2 on Lens:

The Science Behind a Pristine, Clean Lens:

PERFORMANCE DRIVEN BY SCIENCE™

Triple-Action Cleaning• Patented formula deeply cleans• Carries away dirt & debris• Pluronic^ 17R4 lifts away protein

Pristine, Clean Lens• Less residual H2O2

3-5

• Irritant-free comfort• No added preservatives

Pluronic 17R4

RCCL0914_Alcon Clear Care.indd 1 8/13/14 1:55 PM

review & contact lenses of cornea sclerals · surgery; seven of these eyes had a history of...

Documents