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SPECIAL ISSUE:Research andClinical Practice

New Ideas from ARVO 2016 P. 10

Post-Refractive Rigid Lens Use P. 16

Fitting Orthokeratology Lenses P. 22

CXL and Semi-ScleralsP. 28

ReinventingBrimonidine P. 40

Recycling Cyclosporine • Improving Patient Relations • Understanding Insurance Coverage

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JUNE 2016

RCCLRCCLREVIEW OF CORNEA & CONTACT LENSES

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Review of Cornea & Contact Lenses | June 2016

departments features

contents

22Unusual Clinical Cases in OrthokeratologyFor the right patient, these lenses may be life-changing. Two challenging cases provide insights into the fi tting process.By Daddi Fadel, DOptom

News Review4Considering New Treatments for

Neovascularization; Study on SPK

Lesion Size May Lead to Better

Equipment

My Perspective 6Corneal Crosslinking:

Its Time Has Come

By Joseph P. Shovlin, OD

Pharma Science & Practice8Recycling Cyclosporine

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

Brimonidine Breakup

By Mile Brujic, OD, andJason R. Miller, OD, MBA

Practice Progress40

28Contact Lens Use Following Corneal CrosslinkingAn irregular cornea patient presents needing better vision following a corneal stabilization procedure. What do you do?By Boris Severinsky, OD

10Building a Foundation for a Better Future: ARVO 2016 Abstract Review An expert weighs in on new ideas in the fi eld of cornea and contact lens care.By Joseph P. Shovlin, OD

16Fitting Rigid Lenses After Refractive SurgeryCorneal and scleral GP lenses cover the ‘last mile’ for patients who need correction after LASIK and PRK.By Melanie Frogozo, OD

34Case Report: Look Before You JudgeThe most unique cases sometimes present as the most mundane.By Mohammad Tallouzi, OD

36Medically Necessary Contact Lenses: Medical Plan or Vision Plan Responsibility?Do you know how to work with the insurance company to achieve the biggest bang for your buck?By Robert L. Davis, OD

Making the Best of It

By Gary Gerber, OD

Out of the Box42

ON THE COVEROptometry student photoshoot image courtesy of Cardiff University in Cardiff , Wales, United Kingdom.

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4 REVIEW OF CORNEA & CONTACT LENSES | JUNE 2016

News Review

Considering New Treatments

for Neovascularization

IN BRIEF

■ Certain characteristics including in-creased vascularity may be a risk factor for recurrence of pterygium following surgery, reports research published online in the journal Cornea.1 Researchers in Korea collected data on clinical and demographic variables of 149 subjects including length, width, area and vascularity of pterygium and age and sex of patients. Anterior seg-ment photos were taken prior to the proce-dure, and patients were followed up with at one year postoperatively. Recurrence rate was measured at 18.8% of the patients, with univariate analysis demonstrating that rela-tive length and width of the pterygium and degree of vascularity were all correlated with the trend. Multivariate analysis, how-ever, demonstrated only higher vascularity was correlated with recurrence. As such, automated image analysis of anterior seg-ment photos could assist with determining which patients might develop pterygium again, the researchers concluded. 1. Han SB, Jeon HS, Kim M, et al. Risk factors for recurrence after pterygium surgery: an image anal-ysis study. Cornea. 2016. [Epub ahead of print.]

■ Soft contact lens wearers with dry eye symptoms may also exhibit reduced tear menisci, reports a study in the May 2016 issue of Eye and Contact Lens.1 A reduction in tear volume is one of the common factors associated with ocular surface disease; in-deed, previous research has indicated there are more abnormal corneal nerve morpho-logic changes in patients with the aqueous tear defi ciency form of dry eye. However, to date no research has examined whether symptomatic contact lens wearers have had a similar reduction in corneal nerve density due to reduced tear volume. In this study, scientists in China found that upper and lower tear menisci height and area were signifi cantly lower in patients who wore soft contact lenses, compared with those who did not. Interestingly, this eff ect occurred specifi cally in the midperipheral area of the cornea. 1. Hu L, Chen J, Zhang L, et al. Eff ects of long-term soft contact lenses on tear menisci and corneal nerve density. Eye Contact Lens. 2016 May;42(3):196-201.

■ A study investigating corneal densitom-etry and higher-order aberrations (HOAs) one year post-transplantation of Bowman’s layer found that corneal HOAs decreased for both anterior and posterior corneal surfaces following surgery, while corneal backscattering increased. Neither trend correlated with alterations in corrected distance visual acuity, however. These re-sults, published online in the journal Cornea, suggest further research involving larger populations with patient-subjective visual outcomes and contrast sensitivity analysis is needed to help further explain the eff ect of corneal backscattering on optical quality.1

1. Luceri S, Parker J, Dapena I, et al. Corneal densitometry and higher order aberrations after bowman layer transplantation: 1-year results. Cor-nea. 2016. [Epub ahead of print.]

Afl ibercept may be a better alternative than bevacizumab in regulat-ing the advancement of

corneal neovascularization, reports research published online in the journal Cornea.1 Previous studies have investigated whether target-ing vascular endothelial growth factor—a key cytokine in the de-velopment of blood vessels in both normal and abnormal patients (i.e., in the case of a tumor or in tissues undergoing abnormal angiogene-sis)—is a good way to possibly treat this condition.

Researchers from Tel Aviv University in Israel investigated the effects of afl ibercept or bevacizum-ab administered to Sprague-Dawley rats with induced chemical burns. Thirty-one animals were random-ized to receive either subconjuncti-val injections of 0.08mL afl ibercept (25mg/mL), 0.05mL bevacizumab (25mg/mL) or 0.05mL physiologic saline using a 30-G needle applied 1mm distal to the limbus at the 6 o’clock and 12 o’clock positions. Afl ibercept is a VEGF-trap mole-cule that is both known to act as a receptor decoy for all isoforms of VEGF-A and also bind VEGF-B and placental growth factors 1 and 2 to enhance the antiangio-genic response, while bevacizumab has previously been confi rmed to inhibit chemically-induced neovas-cularization via its own action on VEGF-A.2,3

Degree of corneal neovascular-ization was evaluated on post-in-jury days one, three, seven, nine and 13 via corneal photography, with burn area measuring 2mm in

diameter and comprising approx-imately 15% of the total corneal area. Corneal samples were collect-ed on day 21 for histological and fl at-mount immunofl uorescence analyses. Results in all three groups indicated that neovascular sprout-ing began at the limbal area on day three following injury and reached maximum intensity around days seven through nine; however, those subjects treated with afl ibercept exhibited a signifi cantly smaller relative area of neovasculariza-tion than either the control or the bevacizumab groups. Additionally, a difference in the rate of change of the neovascularized area over time between the afl ibercept group and both the control and bevacizumab groups was observed, but not be-tween the control and bevacizumab groups, suggesting the latter is not as effective in this application.

“In conclusion, this suggests that afl ibercept may hold promise as an effective modality for use in patients with corneal neovascularization,” the researchers conclude. As such, “further investigation is warranted to determine the effi cacy of sub-conjunctival afl ibercept in inducing regression of preformed versus mature corneal vessels, its minimum effective dose and safety profi le and other possible modes of application in animals and humans.” RCCL

1. Gal-Or O, Livny E, Sella R, et al. Effi cacy of subconjunctival afl ibercept versus bevacizumab for preventional of corneal neovascularization in a rat model. 2. Sener E, Yuksel N, Yildiz DK, et al. The impact of subconjunctivally injected EGF and VEGF inhibitors on experimental corneal neovascularization in rat model. Curr Eye Res. 2011;36:1005-1013.3. Oner V, Kucukerdonmez C, Akova YA, et al. Topical and subconjunctival bevacizumab for corne-al neovascularization in an experimental rat model. Ophthalmic Res. 2012;48:118-123.

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EDITORIAL REVIEW BOARD

Mark B. Abelson, MD

James V. Aquavella, MD

Edward S. Bennett, OD

Aaron Bronner, OD

Brian Chou, OD

Kenneth Daniels, OD

S. Barry Eiden, OD

Desmond Fonn, Dip Optom M Optom

Gary Gerber, OD

Robert M. Grohe, OD

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Patricia Keech, OD

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Kirk Smick, OD

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Loretta B. Szczotka, OD

Michael A. Ward, FCLSA

Barry M. Weiner, OD

Barry Weissman, OD


Data from a study on epithelial lesion size in su-perfi cial punctate keratitis (SPK) could help with the

development of automated algo-rithms to obtain more objective and reliable classifi cations for corneal staining, report researchers from France in the journal Cornea.1

The isolated lesions that so often characterize SPK are small fl uores-cent dots of differing size and incan-descent intensity that are scattered across the corneal surface. In some cases, they can become confl uent, creating fl uorescent areas in which the individual lesions are no longer distinguishable. Because the number and specifi c locations of these dots is an important clinical criterion directly connected to the level of surface integrity, differentiating between them is critical—especially during clinical trials. The new algo-rithms could help ease this issue.

In this study, the team from Jean Monnet University, the University Hospital of Saint-Etienne and the

Institut Universitaire de France instilled fl uorescein into 10 pa-tients with dry eye graded using the Oxford Scheme. Pictures were tak-en using a standard slit lamp with cobalt blue light and no barrier fi lter to simulate the most common conditions of image acquisition. Two magnifi cation settings (i.e., x10 and x16) were used to focus on the corneal objects in question that measured 14.40µm and 7.81µm under each setting, respectively. SPK size did not differ between the fi ve Oxford Scheme grades of dry eye, but did appear to be slightly smaller than typical superfi cial epithelial cells, which measure approximately 25x50µm.

“Our data on the size of SPK staining lesions in this study is not directly relevant to clinicians,” the researchers acknowledged. “However, it will prove useful for researchers developing new devic-es and image analysis algorithms to improve SPK severity grad-ing. Indeed, if the size of isolated epithelial lesions characterizing SPK is known, it will be possible to optimize device resolution to detect individual lesions using the appropriate fi lters or thresholds and ultimately to precisely quantify corneal staining.” RCCL

1. Courrier E, Lepine T, Hor G, et al. Size of the lesions of superfi cial punctate keratitis in dry eye syndrome observed with a slit lamp. Cornea. 2016. [Epub ahead of print.]

Study on SPK Lesion Size May

Lead to Better Equipment

Surgical TrendsA national study from Switzerland suggests the number of keratoconus-related corneal transplants has decreased in the last 10 years, while lamellar techniques are being increasingly performed. Furthermore, among anterior lamellar keratoplasty techniques, maximal depth DALK is the most prevalent keratoplasty. Frequency of penetrating keratoplasty (PKP) is expected to remain stable.1

1. Godefrooij DA, Gans R, Imhof SM, Wisse RPL. Trends in penetrating and anterior lamellar corneal grafting techniques for keratoconus: a national registry study. Acta Ophthalmologica. 2016 Apr 7. [Epub ahead of print.]

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By Joseph P. Shovlin, OD

My Perspective


Corneal Crosslinking: Its Time Has ComeThough the main treatment for ectasia remains contact lens use, a new procedure could ease the fi tting ordeal.

The Food and Drug Administration’s recent approval of the corneal collagen crosslinking procedure in the United

States means that we have gained another valuable tool for treating eye disease. Photrexa Viscous (ribofl avin 5’-phosphate in 20% dextran ophthalmic solution) 0.146%, Photrexa (ribofl avin 5’-phosphate ophthalmic solution) 0.146%, and the KXL system (Avedro) will be promoted as the only current FDA-approved ther-apeutic treatment for progressive ectatic disorders like keratoconus.

The approval process for this technology included three separate studies over a period of several years that were ultimately com-bined for meta-analysis to provide reasonable assurance of both safe-ty and effi cacy. The NDA submis-sion studies were randomized (i.e., treatment eye vs. sham treatment), parallel group, open label pla-cebo-controlled 12-month trials conducted in the United States. Resulting data found that the col-lagen crosslinked eyes demonstrat-ed increased improvement in their steepest keratometric readings from month three to month 12.1

Yet while the system has been approved for use, many eye care practitioners may still have questions regarding the proce-dure itself—namely, what does it involve and what are the goals to focus on when recommending cor-neal crosslinking to a patient? In general, the procedure is simple to perform. It involves use of a pho-tosensitizer/enhancer (i.e., ribofl a-

vin) that helps “cure” the cornea with application of UVA light at 365nm to 370nm for approxi-mately 30 minutes provided at well-defi ned intervals and strength levels. The goal of the procedure is to halt further progression of corneal disease and reduce corneal surface and posterior irregularity in patients with corneal ectasia.2

Total offi ce visit time for both eyes is roughly 90 minutes.

IN THE CHAIR

The procedure works on the principle that when collagen fi brils are crosslinked, they form strong chemical bonds with one another.2

As we age, the cornea naturally forms stronger bonds due to an oxidative process that occurs during end-stage changes to the collagen. This may help explain the fast progression of corneal weakening that happens earlier in life in patients who develop keratoconus.2,3 The Europeans were the fi rst to employ corneal crosslinking at the University of Dresden in 1998 when animal model corneas exposed to ribofl a-vin and treated with UV light were found to be “stiffer” and resistant to enzymatic change over time.2

Potential candidates for the procedure include anyone with progressive ectasia, though most often the procedure is performed on those with keratoconus. Note, however, there are a few contra-indications like advanced ocular surface or autoimmune disease, signifi cant corneal scarring or opacity, infection or prior herpetic disease. These are listed as such

because irradiation is part of the procedure.

Interestingly, adjunct studies to evaluate corneal crosslinking’s effi cacy in treating corneal infec-tions are still being conducted; however, results to date remain mixed. Additionally, though this is less of a concern in cases when the epithelium remains in place during the procedure, corneal thickness cannot be exceedingly thin or there is risk of toxicity to the endothelium.

Investigators continue to look for alternatives for crosslinking

beyond use of ribofl avin and UVA, such as use of rose Bengal as a marker and green light for treat-ment. In the meantime, however, Avedro should be congratulated for sponsoring several well-de-signed clinical trials that went beyond simply including the observational evidence that was originally submitted for review. Considering the limited num-ber of potential patients and the uncertainty regarding whether insurance carriers will provide coverage, Avedro remained com-mitted throughout the approval process. They may eventually be able to expand indications for this procedure to include treatment of infectious keratitis, pain relief in bullous keratopathy and other novel indications. RCCL

1. Avedro. Avedro Receives FDA Approval for Pho-trexa Viscous, Photrexa and the KXL System for Corneal Cross-Linking. Available at: avedro.com/press-releases/avedro-receives-fda-approval/. Accessed May 10, 2016.2. EyeWiki. Corneal Collagen Cross-Linking. Available at: eyewiki.aao.org/Corneal_Collagen_Cross-Linking. Accessed May 10, 2016.

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

Pharma Science & Practice

These days, it seems that there is such a heavy em-phasis on drug delivery systems that many of our current ophthalmic

pharmaceuticals are simply being reformulated as “novel” thera-pies, rather than replaced entirely.1 Because the shortcomings of topical drops are well-known, these deliv-ery systems are aimed at eliminating variability in drug concentration with each dose to decrease dose frequency and increase absorption.2

FIRST OUT

One such drug is CyclASol (Novaliq), which incorporates EyeSol, an ophthalmic drug delivery technology based on semi-fl uori-nated alkanes (SFAs).3 SFAs have been used for over a decade in the management of retinal detachments and overall have been well-tolerated by patients. They are physically, chemically and physiologically inert and stable as well as water insolu-ble.4-7 Research shows the EyeSol preparation does not require pre-servatives, so a multidose bottle can be prepared without concern for contamination. Droplet size of SFAs is only 15µl compared with the 40µl or 50µl size of aqueous drops. SFAs also exhibit low viscosity and low surface tension, making them less likely to cause blurry vision and allowing for better wettability.3

Viscous vehicles like polyethylene glycol and hyaluronic acid currently used for ophthalmic solutions can effectively solubilize hydrophilic drugs. However, drugs that are lipophilic (i.e., hydrophobic) like cyclosporin A are more challenging; as such, SFAs are effective solvents

for these medications.5,6 CyclASol contains cyclosporin A in combina-tion with perfl uorobutylpentane, a unique formulation with an SFA.

Earlier this year, 207 patients were enrolled in a Phase II clinical trial of CyclASol’s safety, tolerabili-ty and effi cacy in treating moderate to severe dry eye disease. Patients were randomized into one of four treatment groups, including two CyclAsol groups (each containing a different concentration of cyclospo-rin A), a vehicle control group and an open-label cyclosporin A 0.05% ophthalmic emulsion (Restasis) group. Patients were directed to use the study medication twice a day for four months; researchers will then evaluate the primary outcome measure of corneal fl uorescein staining. Results are expected by the end of 2016.8

Other research has already demonstrated the drug’s absorp-tion profi le. In a pharmacokinetic study involving rabbits, CyclASol penetrated the lacrimal gland sig-nifi cantly better (14-fold increase) than an oil-in-water emulsion.5 Additionally, results from a Phase I trial of healthy volunteers who received CyclASol eye drops or a placebo and then switched to the alternate option in the second phase of the study found the drug offered excellent tolerability and safety.2

SECOND ONE

IN THE RUNNING

Another drug under consideration is Seciera (Auven Therapeutics), a nanomicellar formulation of cyclosporine previously known as OTX-101. Nanomicelles are tiny particles comprised of a hydropho-

bic core surrounded by a hydro-philic shell that measure 10nm to 100nm large. They are used to solubilize hydrophobic drugs and are believed to increase ocular bioavailability, minimize degrada-tion and improve penetration of the drug—all of which make them an excellent drug delivery method. Use of nanomicelles allows for cyclo-sporine to be formulated in a clear, preservative-free, isotonic aqueous solution.9,10

In a Phase IIB/III clinical trial, 455 patients in a randomized, double-masked study at 28 sites received either 0.05% cyclosporine, 0.09% cyclosporine or the vehicle as the control. All drops were ad-ministered twice a day for 84 days. Co-primary outcome measures consisted of changes in both con-junctival staining and global symp-tom scores from baseline. Results indicated both concentrations of Seciera were statistically superior to the placebo on both co-primary endpoints. Additionally, the 0.09% concentration also demonstrated an improvement in tear production and corneal staining.

Ultimately, however, the 0.09% concentration was superior to the 0.05% and so will be used in an additional Phase III trial to recon-fi rm some of the earlier fi ndings.8,11 This study will enroll 700 patients at 50 sites who will be random-ized to receive either cyclosporine 0.09% or the vehicle (control) for 12 weeks. Researchers will look for the number of subjects with a clinically signifi cant increase in Schirmer’s score as compared with baseline. Secondary measures include lissamine green conjunctival

Recycling CyclosporineNew formulations of an old drug may mean better treatments for dry eye.

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staining, fl uorescein corneal staining and changes in symptom score. Enrollment for this study began in February 2016. It is expected to conclude by the end of the year.8 Reports suggest a long-term safety study is also planned for 2016 that, if successful, may yield a new drug application for Seciera in 2017.11

KICKING KERATITIS

TO THE CURB

Ikervis (Santen Pharmaceutical) was approved last year as the fi rst ophthalmic drug to treat severe keratitis in adults with dry eye in Europe. Ikervis contains 1mg/mL of cyclosporin A and is formulated as a cationic oil-in-water emulsion. Drug retention time was improved using a cationic nanoemulsion plat-form technology (i.e., Novasorb). The drug is formulated as a series of nano-sized droplets, which increase the surface area-to-volume ratio and improve ocular surface expo-sure to the drug, allowing Ikervis to be given to the patient just once a day.12,13

Also, Santen recently completed a Phase III study, Vektis, evaluating a 1mg/mL formulation of cyclosporin

A for the treatment of severe active vernal keratoconjunctivitis (VKC) in Europe. The drug—tentatively named Vekacia—met its primary and key secondary endpoints in a multicenter, randomized, pla-cebo-controlled study of patients ranging in age from four to 18 years old.

CYCLOSPORINE REBORN

Allergan announced last fall it had submitted a supplemental document to the FDA for approval of a multi-dose preservative-free bottle of cyclosporin A 0.05%.14 The bottle will contain the equivalent amount of 60 single-unit vials and is a fi rst-of-its-kind product with a unidirec-tional valve and air fi lter technology designed to prevent the need for a preservative to be included. The FDA did request more chemistry, manufacturing and control (CMC) information regarding the bottle.

Monitoring clinical trial out-comes of these drugs will

surely be an interesting process. Restasis may soon have to share the limelight with more cyclospo-rine-based cousins. RCCL

1. Novack GD. Eyes on new product development. J Ocul Pharmacol Ther. 2016 Mar;32(2):65-6.2. Drug Development & Delivery. EyeSol: a novel topical ocular drug delivery system for poorly soluble drugs. Available at: www.specialtyphar-ma.com/Main/Back-Issues/EyeSol-a-Novel-Top-ical-Ocular-Drug-Delivery-System-137.aspx. Accessed Mar 1, 2016.3. ONdrugDelivery. An integrated pipeline of ophthalmic products based on eyeSol delivery technology. Available at: www.ondrugdelivery.com/publications/54/Novaliq.pdf. Accessed Mar 1, 2016.4. Meinert H, Roy T. Seminfl uorinated alkanes – a new class of compounds with outstanding prop-erties for use in ophthalmology. Eur J Ophthal-mol. 2000 Jul-Sep,10(3):189-97.5. Steven P, Scherer D, Krosser S, et al. Semifl uo-rinated alkane eye drops for treatment of dry eye disease – a prospective, multicenter noninter-ventional study J Ocul Pharmacol Ther. 2015 Oct;31(8):498-503.6. Dutescu R, Panfi l C, Merkel O, Schrage N. Semifl uorinated alkanes as a liquid drug carrier system for topical ocular drug delivery. Eur J Pharm Biopharm. 2014 Sep;88(1):123-8.7. Broniatowski M, Dynarowicz-Latka P. Semi-fl uorinated alkanes – primitive surfactants of fascinating properties. Adv Colloid Interface Sci. 2008 May 19;138(2):62-83.8. Novaliq. Novaliq announces last patient en-rolled in phase 2 clinical trial of cyclasol for the treatment of moderate to severe dry eye disease. Available at: www.novaliq.de/en/news/press-re-leases/. Accessed May 15, 2016.9. Vadlapudi AD, Mitra AK. Nanomicelles: an emerging platform for drug delivery to the eye. Ther Deliv. 2013 Jan;4(1):1-310. Guo C, Zhang Y, Yang Z, et al. Nanomicelle formulation for topical delivery of cyclosporine A into the cornea: in vitro mechanism and in vivo permeation evaluation. Nature. 2015;Aug:1-14. 11. Auven Therapeutics. Auven Therapeutics an-nounces positive results from pivotal clinical trial of seciera (OTX-101) in dry eye disease. Available at: www.auventherapeutics.com/pr/Seciera%20P3%20Results%20Release.pdf. Accessed: Mar 1, 2016.12. Santen. Santen announces approval of Ikervis for EU marketing authorization. Available at: www.santen.com/en/news/20150325.pdf. Ac-cessed: May 15,2016.13. The Ophthalmologist. Introducing Ikervis. Available at: theophthalmologist.com/is-sues/0615/introducing-ikervis/. Accessed: May 15, 2016. 14. EyeWireToday. In complete response letter, FDA requests more information from Aller-gan for multi-dose preservative-free restasis. Available at: eyewiretoday.com/2016/03/11/allergan-receives-complete-response-letter-from-fda-for-prior-approval-supplement-for-restasis-cyclosporine-ophthalmic-emulsion-005-multi-dose-preserv. Accessed: May 15, 2016.15. David Moore’s World of Fungi. Origin of drugs in current use: the cyclosporine story. Available at: www.davidmoore.org.uk/Sec04_01.htm. Accessed May 26, 2016.

What’s In a Name?

Cyclosporine was initially developed to suppress the immune response and prevent organ rejection in transplant patients. It was later brought to market in 1983 for oral and parenteral administra-tions; however, the drug exhibited poor solubility and had widely variable bioavailability, so it was then formulated as a microemul-sion in 1995 to address some of the malabsorption concerns. The drug is referred to by at least three nonproprietary names: cyclo-sporine by the United States Adopted Names Council, cyclosporin by the British Pharmacopoeia and ciclosporin as the drug’s inter-national non-proproprietary name designed by the World Health Organization.15 It is also commonly referred to as cyclosporin A, as an alternative to cyclosporine, in some applications.

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Widespread change is happening at a break-neck pace in

the ophthalmic fi eld, though new research and concepts for future studies remain cornerstones for all advancements. This year’s Association for Research in Vision and Ophthalmology’s (ARVO) meeting in Seattle, Wa. offered practitioners a peek at some of the newest discoveries and advances designed to aid in clinical practice. Areas of study included dry eye and associated comfort issues, keratoco-nus and its treatments and bacterial infections related to contact lens wear.

INFECTION AND

INFLAMMATION

Data collected on antibiotic resis-tant-bacteria highlights changing trends, report researchers who evaluated the frequency of meth-icillin-resistant Staphylococcus(MRS) keratitis as it appeared in a referral ophthalmology center in Mexico City, Mexico from February 2014 to February 2015.1

The bacteria identifi ed via diagnosis of infectious keratitis and positive culture predominantly included Staphylococcus, with those organ-isms that were drug resistant noted as being non-responsive to oxacillin and/or cefoxitin disk diffusion.

These results are concerning be-cause resistance to multiple antibi-otics means treatment options are limited.

Antibiotic resistance trends should be kept in mind when selecting therapy preoperative-ly, researchers from New York suggest.2 Use of topical antibiotics is key to help with minimizing intraocular infections prior to and following surgery, as bacterial re-sistance continues to be a prevalent issue and can inhibit an otherwise positive therapeutic effect. In this study, the investigators examined the resistance profi les of common bacterial pathogens to the anti-biotics that are routinely used by ophthalmologists. One hundred and seventy-two aqueous and vitreous humor isolates of note were collected from the ARMOR surveillance study, including 11 with Haemophilus infl uenzae, 10 with Pseudomonas aeruginosa, 21 with Streptococcus pneumoniae, 30 with Staphylococcus aureus, and 100 with coagulase-negative staphylococci (CoNS). Minimum inhibitory concentrations (MICs) were determined by broth micro-dilution and the isolates were cate-gorized as susceptible, intermediate or resistant according to systemic breakpoints. Results from the study indicated antibiotic resistance was most prevalent among staphylo-cocci, particularly CoNS, with

higher rates of opposition observed to azithromycin, ciprofl oxacin and oxacillin/methicillin. At least 70% of the methicillin-resistant staphylococci samples collected demonstrated multidrug resistance; furthermore, among S. pneumoniaeisolates, resistance was highest to azithromycin, chloramphenicol and oral penicillin.

Another study evaluated po-vidone iodine (PI) as a potential disinfecting solution for contact lenses, focusing on its antimicrobial effi cacy against ocular bacterial strains in planktonic form and following biofi lm formation in the contact lens case.3 Researchers in New South Wales, Australia found that the PI solution performed ex-ceptionally well against the plank-tonic forms of all bacteria strains tested; in fact, no viable organisms were recovered following the minimum recommended disin-fection time. The PI solution was also effective to varying degrees at removing the bacterial biofi lm; air-drying or wiping the lens case

Dr. Shovlin is the senior optom-

etrist at Northeastern Eye

Institute and a member of the

adjunct faculty at the Penn-

sylvania College of Optom-

etry. He is also the clinical

editor for Review of Cornea

& Contact Lenses, associate

clinical editor for Review of

Optometry and president-elect for

the American Academy of Optometry.

ABOUT THE AUTHOR

ARVO 2016ABSTRACT REVIEW

BUILDING A FOUNDATION FOR A BETTER FUTURE:

An expert weighs in on new ideas in the fi eld of cornea and contact lens care.By Joseph P. Shovlin, OD

010_RCCL0616_F1_ARVO.indd 10010_RCCL0616_F1_ARVO.indd 10 5/31/16 4:39 PM5/31/16 4:39 PM


with a tissue and then air-drying was deemed most effective (71% of the biofi lm was removed), while recapping the lens case wet was less so (55% removed). As such, results demonstrate not only that ocular strains of bacteria are susceptible to povidone iodine in planktonic and biofi lm form, but also reiterates the importance of air-drying in main-taining lens case hygiene.

Directed energy at certain wave-lengths may be capable of eliminat-ing the presence of Acanthamoebafrom contact lenses and lens cases, report researchers in Pennsylvania, who hypothesized that certain levels of ultraviolet energy admin-istered with and without ribofl a-vin will eradicate Acanthamoebawhile maintaining the clarity of the contact lens.4 To test this theory, the team administered multiple modes of energy in microjoules/cm² x 100 in a dose-dependent manner. Three groups were pre-pared: Acanthamoeba castellanii(106 cysts in saline) exposed to just UVE; Acanthamoeba castel-lanii (106 cysts in saline) plus soft contact lens exposed to just UVE; and Acanthamoeba castellanii (106

cysts) plus soft contact lens exposed to UVE in a saline solution or 0.01% ribofl avin. The soft contact lenses were evaluated for clarity following exposure via spectropho-tometry. Results indicated a total UVE amount of 89,991 micro-

joules/cm² x 100 for a time length of 180 minutes is required to elimi-nate the presence of Acanthamoeba castellanii in all three groups.

Though the rate of complications associated with scleral lens wear remains low, certain issues con-tinue to be prevalent and should be further monitored, according to researchers from Minnesota, Illinois, Ohio and Massachusetts, who collected data from a 19-ques-tion survey regarding scleral lens wear and management practices administered to eye care practi-tioners between January 12, 2015 and March 31, 2015 by the Mayo Clinic Survey Research Center.5

Nine hundred and eighty nine individuals responded to the survey, 723 of whom reported fi tting fi ve or more patients with scleral lenses for a total of 84,735 scleral lens pa-tients represented. Reported issues included edema, neovasculariza-tion, infi ltrates, toxic keratopathy, bullae and microbial keratitis as well as limbal stem cell compro-mise, elevated intraocular pressure, uveitis and retinal detachment. Handling error was reported as the primary cause of these problems in 448 patients.

DRY EYE

Keratoconjunctivitis sicca (KCS) pathology may be improved via topical antioxidant therapy, report researchers from the United States,

Finland and Lithuania.6 In this study, six-week-old mice were exposed to a desiccating envi-ronmental chamber with airfl ow and humidity levels set at 15 L/min and 5%, respectively, for 10 days. Each mouse received transdermal scopolamine in their left eyes twice daily with super-oxide dismutase (SOD) mimetic Manganese (III)-5,10,15,20-tetrakis (N-methylpyridinium-2-yl) porphy-rin Pentachloride (MnTM-2-PyP, EMD Millipore) diluted in physio-logical saline at 0.05%. Their right eyes served as controls and were treated with saline. Study results indicated the topical administration of the MnTM-2-PyP signifi cantly improved lacrimal gland pathology compared with the effects of the saline control, suggesting topical antioxidant therapy may be feasible as a treatment for KCS.

A study from investigators at Cornell Medical College, University of Illinois College of Medicine and Indiana University of Medicine suggested exposure of the corne-al surface to hyperosmotic tears may cause considerable damage to corneal subbasal nerve fi bers.7 The researchers studied the relationship between tear hyperosmolarity and corneal nerve abnormalities for the recorded fi rst time ever in an effort to explain the common signs and symptoms associated with dry eye disease. Results indicated the

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From left to right: Moraxella nonliquefaciens ulcer, Pseudomonas ulcer and HZO neurotrophic cornea with bacterial

superinfection. Research from this year’s ARVO conference could lend insight into treating these issues.



ARVO 2016 ABSTRACT REVIEW

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responses of the corneal neurons to the drying of the cornea were depressed or completely abolished by hyperosmolar tears in a time-ly and dose-dependent manner. The researchers observed that the disappearance of action potentials occurred as quickly as two min-utes, but generally within three hours following application of the tear solutions and suggested these fi ndings are consistent with the abnormal activities of trigeminal ganglion neurons demonstrated by electrophysiological recordings and may account for the signs (i.e., morphological abnormalities) and symptoms (i.e., abnormal sensa-tions) reported in dry eye patients.

Dry eye disease may also play a role in inhibition of corneal graft survival, says a team of scien-tists from Schepens Eye Research Institute, Harvard Medical School and the Juntendo University School of Medicine in Japan.8 These researchers evaluated the effect of the condition on allosensitization and graft rejection by transplanting healthy corneas with dry eye dis-

ease from donor mice onto recipi-ent mice. Graft survival rates and opacity scores were evaluated with slit lamp biomicroscopy. Corneas and draining lymph nodes were harvested at day 14 post-transplant and fi ndings demonstrated that the transplant recipients with the DED donor corneas demonstrated signifi -cantly reduced graft survival (i.e., 10%) as compared with control mice (50% survival).

Other research from Germany on omega-3 fatty acids (O3F) indicates they could be used as potential topical adjunct therapy for dry eye.9 Oral and topical treatments that use omega-3 fatty acids have previously demonstrated positive effects on the severity of dry eye. In the current study, experimental dry eye (EDE) was induced in mice and topical therapy was administered. Therapeutic treatment of mice with omega-3-fatty acids using a semi-fl uorinated alkane (F6H8) as a preservative-free lipophilic carrier demonstrated a signifi cantly earlier decrease of epithelial dam-age following EDE as compared

with untreated controls or another treatment. The amount of tear fl uid also increased following 03F/F6H8 treatment as compared with levels of the same in untreated controls or those treated with F6H8 alone or with artifi cial tears, as did the number of goblet cells.

Additionally, anterior segment optical coherence tomography (AS-OCT) may be appropriate for clinicians to use in assessing the level of ocular dryness in patients with conjunctivochalasis, report researchers from the University of Jukui in Japan, who compared tear meniscus area and height in patients with the disease and those with normal eyes.10 Potential rela-tionships between TMA or TMH and fl uorescein fi lm tear-breakup time, fl uorescein staining score and the extent of conjunctivochalasis were also evaluated in the con-junctivochalasis group. Results indicated that conjunctivochalasis eyes exhibited a reduced TMA and increased TMH as compared with the normal eyes. Note, a more severe dry eye condition in conjunc-tivochalasis is commonly associated with a reduction in TMA, despite a high level of TMH due to the conjunctival fold. As such, AS-OCT technology may be appropriate for use in this type of patient scenario.

Japanese researchers in the fi eld also suggest that address-ing the presence of patient sleep disorders may help alleviate cases of dry eye.11 A cross-sectional case control study involving 715 outpatients diagnosed with DED, chronic conjunctivitis or allergic conjunctivitis incorporated the Pittsburgh Sleep Quality Index (PSQI) and Hospital Anxiety and Depression Scale (HADS) as a means to evaluate their well-being. Regression analysis of patients with DED revealed correlations between higher PSQI and HADS and the

Anterior segment OCT measurements could help practitioners assess ocular

surface dryness in patients with conjunctovochalasis.



presence of DED, rather than other forms of ocular surface disease. There was also a connection to the condition’s level of severity, further raising quality-of-life concerns and supporting the theory that pro-viding psychiatric help to address a patient’s sleep issue may have a direct effect on the improvement of their ocular health.

Patients who use digital devices throughout the day, regardless of their age, may experience adverse impacts on their work perfor-mance, productivity and quality of vision, suggests a team of research-ers from Illinois, Pennsylvania, California and Tennessee.12 Overall, eye care practitioners have noted an increase in dry eye symptoms as the use of digital devices—includ-ing handheld tablets, smartphones, laptops and computers—increases. Data collected from questionnaires related to digital device use as well as additional answers regarding vision fl uctuation concerns and contact lens wear were used to generate results for the study. Six hundred and eighty-six subjects were evaluated, with the average number of hours spent on devices per day noted at 6.35 hours for the <40 age group and 4.83 hours for the >40 age group. Average ocular comfort was recorded on a scale of one to 10 as one at the beginning of the day and seven at the end of the day following gratuitous digital device use, further demonstrating a positive correlation.

A second study organized by re-searchers in Indiana and California in cooperation with CooperVision found that frequent and severe eye fatigue is prevalent among soft contact lens wearers who use digital devices.13 Previous reports have found that eyestrain or eye fatigue occurs in roughly 60% of student and working populations that use digital devices and typical-

ly results in a notable decrease in quality of life. This study attempted to quantify the symptoms most fre-quently associated with eye fatigue while using digital devices in soft contact lens wearers, who were asked to complete a survey with questions pertaining to the condi-tion. Eighty-eight percent reported experiencing eye fatigue once per month, while 74% reported experi-encing eye fatigue at least once per week. Reported symptoms included dryness, eye irritation, eyestrain and tired eyes. Strain, soreness, tiredness and headache comprised primary sensation factors, while burning, irritation and dryness comprised the secondary sensation factors in the study. Additionally, blurring, doubling and moving/fl oating were noted as visual sensa-tion factors. The researchers con-cluded that frequent and severe eye fatigue is highly prevalent among the population of soft contact lens wearers that use digital devices, and that the recorded symptoms can be used to better identify members of this population.

According to German investiga-tors in Cologne who examined the onset of DED pain symptoms like burning, stabbing or photophobia that presented without accom-panying clinical signs including normal visual acuity, intraocular pressure, Schirmer test and corneal fl uorescein staining in combination with pathological Ocular Surface

Disease Index score, there is a correlation between patients with a discrepancy of signs and symp-toms in dry eye that are resistant to therapy and the presence of psychosomatic diseases and/or previous eye surgery.14 Typically, in these cases of symptoms without signs, corneal neuralgia is postulat-ed; however, the results from this study that indicate the co-morbid-ities of psychosomatic disease or prior eye surgery suggest there may be different sensitization pathways for the proposed development of corneal neuralgia than previously believed. Furthermore, incomplete analgesia following topical corneal anesthesia supports the assumption of a central sensitization that would explain the resistance to topical therapy, the researchers concluded.

A cross-sectional study open to all participants of the American Academy of Optometry’s 2015 annual meeting suggested that the

Pseudophakia and severe dry eye

from graft-versus-host disease.

Researchers presenting at this year’s

ARVO conference found that dry eye

may inhibit survival of corneal grafts.

Meibomography images demonstrating the eff ects of electronic device use

on ocular dryness.

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hristine W. S

indt, O

DP

hoto

s: Jennifer Harthan, O

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Standard Patient Evaluation of Eye Dryness (SPEED) questionnaire may not be as successful at detect-ing dry eye in contact lens wearers as it is in those who do not wear lenses.15 One-hundred and fi fty contact lens wearers and 134 non-lens wearers elected to participate in the study by answering the ques-tions listed as part of the SPEED questionnaire and undergoing tear meniscus height photographic assessment and tear volume testing. Unfortunately, while the question-naire was accurately able to predict the dry eye status in non-contact lens wearers, it was unable to predict the same in those wearing lenses. The researchers concluded additional work should be con-ducted to further assess the study’s usefulness in contact lens wearers.

Furthermore, artifi cial tears may be less benefi cial than initially believed for patients with ocular surface disease, according to inves-tigators from Virginia who incor-porated a modifi ed version of the Schirmer test into their research.16

Study participants were divided into three groups: a control group not treated with artifi cial tears, a

group with ocular surface symp-toms that responded to artifi cial tear treatment, and a group with similar ocular surface symptoms that did not respond to the tears. No signifi cant difference in stan-dard Schirmer test scores, modifi ed Schirmer test scores, punctate epi-thelial erosion presentation (PEE), meibomian gland dysfunction (MGD), blepharitis tear break-up time (TBUT) or Ocular Surface Disease Index (OSDI) scores was noted in any group. The researchers concluded that current clinical tests are not able to adequately identify the subset of patients who might most benefi t from artifi cial tear use. Given the low cost and morbidity of artifi cial tear treatment, they suggest a trial treatment of the prescribed drops be performed in patients with chronic ocular surface symptoms and add that future studies should take into account the type of artifi cial tears used as well as frequency of use.

KERATOCONUS AND ITS

POTENTIAL REMEDIES

In Australia, investigators exam-ined changes in corneal sensitivity

and their association with other clinical parameters in keratoconus patients.17 Ocular symptoms using validated questionnaires, corneal topography, tear osmolarity, tear meniscus height measurement, tear volume, ocular surface stain-ing with fl uorescein and lissamine green dye, corneal sensitivity using Cochet-Bonnet aesthesiometer and corneal nerve mapping using HRT II confocal microscopy were recorded, and correlations were made using either Spearman’s or Pearson’s coeffi cient. Subjects were graded as having either mild or severe keratoconus, and partial cor-relation was performed to control the effect of confounding factors. Only data from each patient’s most severe eye was included in the study. Results found central corneal sensitivity to be lower in the severe keratoconus group, while in bivar-iate correlations, decreased corneal sensitivity in keratoconus was associated with condition severity, lower central nerve fi ber density, contact lens wear, contact lens tolerance, patient age and duration of disease. Researchers further ob-served a distinctive trend in which age and duration of keratoconus was also associated with decreased corneal sensitivity, and that contact lens wear-intolerants exhibited higher corneal sensitivity com-pared with tolerant wearers. They concluded that decreased corneal sensitivity was associated with age and duration of disease, and that reduced tolerance of keratoconic patients to contact lens wear was associated with increased corneal sensitivity.

Hair cortisol concentration as a biochemical correlate of chronic psychological stress may be an observable risk factor for kerato-conus, report German scientists who analyzed strands of hair taken from both healthy and keratoconic

ARVO 2016 ABSTRACT REVIEW

A slit lamp view of a keratoconic patient with hydrops. Research is

increasingly looking at the implications of this irregular corneal condition

and potential methods for its management.

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patients.18 As hair segments of 3cm in length represent the prior three-month stress profi le of an individ-ual, the researchers used sections of hair this length located most proximal to the scalp. Cortisol lev-els were determined using the hair by the Institute of Biopsychology of the TU Dresden; a standardized questionnaire for chronic stress was also administered to all subjects. Results indicated hair cortisol was higher in patients with progres-sive keratoconus compared with those with a stabilized form of the disease or those who were healthy. Furthermore, the study suggested increased hair cortisol concentra-tion could be a risk factor for the progression of keratoconus.

Other research from Germany supports the concept that axis alignment could be used in an algorithm to support the diagno-sis and staging of keratoconus.19

Scientists compared the power and axis orientation of anterior and posterior astigmatism in 861 eyes with keratoconus and 500 healthy eyes as part of a retrospective study, fi nding posterior axis alignment of corneal astigmatism is in line with the alignment of the anterior surface in the majority of cases of keratoconus. In contrast, the majority of the healthy eye group demonstrated a vertical posterior axis alignment independent of the anterior surface. These results indicate that with progression of the disease and a decrease in pachymetry, corneal resistance to vertical forces—most likely the eye-lids—decreases and axis orientation becomes increasingly vertical.

Corneal crosslinking may effectively relieve the intensity and frequency of pain associated with bullous keratopathy for at least one year following treat-ment, report researchers in Tokyo, Japan, who conducted a retrospec-

tive observational case study to monitor post-operational results of 11 patients who had under-gone surgery for the condition.20

Patient best-corrected visual acuity (BCVA), intraocular pressure and corneal thickness were examined prior to treatment, as well as at one-week, and three-, six- and 12-month intervals following treat-ment. Intensity and frequency of pain were scaled from zero to 10, while after 12 months of treat-ment, corneal stromal depths of 100µm and 200µm were observed using confocal microscopy. Density of the patients’ keratocytes and nerve fi bers was also calculated. Results indicated that BCVA did not signifi cantly improve following treatment, but pain—which was initially scored at an average of 6.27—decreased. Furthermore, the mean pain frequency score of 5.45 also decreased following treatment to 1.27 at 12 months post-opera-tion, while keratocytes and nerve fi bers were rarely observed at 12 months following the procedure. Persistence of pain relief was ulti-mately attributed to the inadequate regeneration of nerve fi bers in the corneal stroma.

Other abstracts from ARVO 2016 highlight alternative

treatment options, surgical tech-niques and potential concerns on the horizon to be aware of. As al-ways, practitioners are encouraged to review the full list of available abstracts, not just those chosen for this report. So, go take a look! RCCL

1. Avila-Lule I, Teran-Tejada T, Betancourt NR, et al. Methicillin-resistant staphylococcus keratitis in a referral ophthalmology center. Program 2354. Association for Research in Vision and Ophthalmol-ogy Meeting 2016.2. Asbell PA, DeCory H, Sahm D, Sanfi lippo CM. In vitro antibiotic susceptibility of ocular pathogens collected from the aqueous and vitreous humor during the ARMOR surveillance study. Program 2348. Association for Research in Vision and Oph-thalmology Meeting 2016.3. Vijay AK, Liu L, Nguyen TC, et al. Effi cacy a novel povidone iodine based contact lens disinfection

system against bacterial biofi lm. Program 1454. Association for Research in Vision and Ophthalmol-ogy Meeting 2016.4. Ross AGG, Kowalski RP, Dhaliwal D, KArenchak LM. The threshold of light energy to eliminate acan-thamoeba. Program 1456. Association for Research in Vision and Ophthalmology Meeting 2016.5. Schornack M, Harthan J, Barr et al. Complica-tions of scleral lens wear. Program 1467. Associ-ation for Research in Vision and Ophthalmology Meeting 2016.6. Kaja S, Kourlen P, Puranen J, Symantas R. A topically delivered synthetic metalloporphyrin SOD mimetic improves hallmarks of dry eye disease pathology. Program 396. Association for Research in Vision and Ophthalmology Meeting 20167. Mizerska KK, Hirata H, Dallacasagrande V, et al. Short exposure to hyperosmolar tears produces profound anatomical and physiological changes in rodent corneal nerves: implications for dry eye disease. Program 403. Association for Research in Vision and Ophthalmology Meeting 2016.8. Inomata T, Hua J, Shiang T, et al. Is dry eye disease in donors a risk factor for corneal graft rejection? Program 1438. Association for Research in Vision and Ophthalmology Meeting 2016.9. Gehlsen U, Braun T, Steven P. Omega-3 fatty acids using a F6H8-carrier as topical therapy in experimental dry eye disease. Program 417. Asso-ciation for Research in Vision and Ophthalmology Meeting 2016.10. Kimura K, Takamura Y, Gozawa M, et al. Diff er-ence in tear meniscus between conjunctivochalasis eyes and normal eyes using anterior segment optical coherence tomography. Program 2836. Association for Research in Vision and Ophthalmol-ogy Meeting 2016.11. Ayaki A, Kawashima M, Negishi K, et al. Sleep disorders in dry eye disease and allied irritating ocular diseases. Program 2840. Association for Re-search in Vision and Ophthalmology Meeting 2016.12. Harthan J, O’Dell L, Kwan JT, et al. Dry eye symptoms and visual function with digital device use. Program 2843. Association for Research in Vision and Ophthalmology Meeting 2016.13. Kollbaum PS, Meyer D, Huenick S, et al. Digital Device user survey of eye fatigue. Program 1492. Association for Research in Vision and Ophthalmol-ogy Meeting 2016.14. Steven P, Schneider T, Ramesh I, et al. Pain in dry-eye patients without corresponding clinical signs – a retrospective analysis. Program 2848. Association for Research in Vision and Ophthalmol-ogy Meeting 2016.15. Pucker AD, Jones-Jordan L, Kwan JT, et al. A comparison of SPEED scores in contact lens and non-contact lens wearers. Program 2855. Associ-ation for Research in Vision and Ophthalmology Meeting 2016.16. Young M, Zhong H, Peterson E, et al. Clinical evaluation of Schirmer test variations on the pre-dictability of benefi t from artifi cial tears. Program 2882. Association for Research in Vision and Ophthalmology Meeting 2016.17. Mandathara PS, Stapleton F, Kokkinakis J, Willcox MD. A pilot study of corneal sensitivity and its associations in keratoconus. Program 2896. Association for Research in Vision and Ophthalmol-ogy Meeting 2016.18. Lenk J, Spoerl E, Pillunat LE, Raiskup F. Hair cor-tisol analysis in progressive and stable keratoconus patients. Program 2906. Association for Research in Vision and Ophthalmology Meeting 2016.19. Schmack I, Shajari G, PourSadeghian M, et al. Characteristics of corneal astigmatism of anterior and posterior surface in healthy individuals and keratoconus patients. Program 2913. Association for Research in Vision and Ophthalmology Meeting 2016.20. Ono T, Terada Y, Mori Y, et al. The persistence of pain relief after corneal crosslinking in mild bullous keratopathy eyes. Program 2919. Association for Research in Vision and Ophthalmology Meeting 2016.



Despite the advances in PRK and LASIK in the past two decades, there are still patients who have complica-

tions from these procedures that keep them from experiencing the vision they expected. In these circumstances, contact lenses can help restore vision. However, many individuals who have elected to undergo surgery are often unhappy about the idea of wearing correc-tion again. Therefore, it is import-ant to be both skilled and effi cient at fi tting contact lenses for this population.

Gas permeable (GP) lenses are a

good choice for fi tting patients af-ter refractive surgery. These lenses have excellent optics and can mask several diopters of regular and ir-regular astigmatism. Additionally, the practitioner has complete con-trol over the lens parameters and the lenses can be made in high Dk materials. This article will review GP lens fi tting after refractive sur-gery using a series of case studies.

CORNEAL SHAPE

CONSIDERATIONS

Fitting patients who have under-gone refractive surgery is challeng-ing due to their altered corneal shape. A typical cornea has a

prolate shape, i.e., steeper centrally with fl attening towards the periph-ery. The rate of fl attening towards the periphery can be described by its eccentricity value. Normal corneas typically have eccentricity values of 0.5 to 0.7.

Hyperopic LASIK/PRK is accom-plished by ablating the peripheral cornea in order to steepen the central cornea. These patients have a corneal profi le similar to kerato-conus and an eccentricity value of greater than 1.0. And so, kerato-conic design lenses can be helpful in fi tting those who have had a hyperopic procedure done.

Myopic surgery is accomplished by ablating the central cornea in order to make it fl atter, which causes the peripheral cornea to steepen. This reverse corneal con-fi guration is oblate in shape and has a negative eccentricity value. A reverse geometry design contact lens can be used to align better with the corneal profi le of a patient who has had myopic refractive surgery.

The initial contact lens design after refractive surgery can be de-termined by looking at the eccen-tricity value. Values greater than

Dr. Frogozo, a fellow of the

AAO, is the owner and

director of Alamo Eye

Care and the Contact Lens

Institute of San Antonio

in San Antonio, Texas. She

specializes in diffi cult-to-fi t

contact lenses for both adult

and pediatric patients.

ABOUT THE AUTHOR

Fig. 1. Right eye axial power corneal topography post-hyperopic LASIK.

Fitting Rigid LensesAfter Refractive Surgery

Corneal and scleral GP lenses cover the ‘last mile’ for patients who need correction after LASIK and PRK.

By Melanie Frogozo, OD

016_RCCL0616_F2_GP-PostRefractive.indd 16016_RCCL0616_F2_GP-PostRefractive.indd 16 5/31/16 4:35 PM5/31/16 4:35 PM


1.0 could be fi t into a keratoconic lens. If the eccentricity value is negative, consider fi tting a reverse geometry design.3

Corneal topography can also help practitioners choose contact lens parameters after refractive surgery. The initial base curve of a corneal GP lens can be determined after refractive surgery by taking an average dioptric curvature 4.0mm away from the center on axial curvature maps and 2.0mm on tangential curvature maps.4

Additionally, a height map shows linear distances between positions on the cornea and a reference sphere. This reference sphere over the cornea gives an idea of what the GP fl uorescein pattern may look like.5 And so, a base curve calculated from a tangential or axial map could be applied as a curvature reference sphere on a height map to see how a corneal GP lens may fi t on the eye.

CORNEAL GP LENSES

The notable differences in shape present between ablated and non-ablated corneal areas after refractive surgery can make GP lenses challenging to fi t. Often, corneal GPs do not exhibit a clas-sic alignment pattern on a surgi-cally altered cornea. Instead, there will be pooling in fl atter ablated areas and bearing over the steep-er untreated areas. Nonetheless, this may be acceptable as long as there is adequate lens movement and room for a healthy tear pump behind the lens, and if the lens does not cause any harsh areas of punctate erosion.

Hyperopic procedures leave the cornea highly prolate. Patients who have had hyperopic refractive surgery can be fi t into keratoconic lens designs.1,3 In contrast, myopic refractive surgery will cause the cornea to become oblate in shape;

a reverse geometry design in which the base curve is fl atter than the adjacent peripheral curve will align better in oblate corneas.1,3

Iatrogenic corneal ectasia follow-ing myopic corneal refractive sur-gery results in anterior bulging of the ablated cornea to cause a kera-toconus-like situation. This poses a unique challenge in fi tting corneal GP lenses because the topography will have a combination of steeper areas at the apex of the cone and in the untreated periphery, and will be fl atter in the non-ectatic ablated areas. If the apex of the cone is central, a prolate kerato-conus design lens can be fi tted. In contrast, oblate reverse geometry designs will work better if the apex is decentered. In cases of iatrogenic corneal ectasia, consider a large diameter lens (i.e., greater than 10mm), as the increased size typ-ically centers better over broader areas of irregularity.1

1 Refractive Error After

Hyperopic LASIK. A 58-year-old female presented

with complaints of blurry vision while reading at near. She had undergone monovision hyperopic LASIK four years prior, during which her right eye was corrected for near reading and her left eye for distance. Although she present-ed with 20/20 distance vision OU, she could only read J5 at near. Her

manifest refraction corrected her to 20/20 and J1 (-0.50-0.75x035 OD and plano OS with a +2.25 add).

Prior to the LASIK procedure, she had been a long-time mono-vision corneal GP wearer and desired to have her vision correct-ed with this same modality. Since she was fully corrected for distance in the left eye, we only fi tted the

Fig. 2. A regular geometry tricurve

corneal GP lens design on a post-

hyperopic LASIK eye.

Fig. 3. LASIK fl ap interface with

fold irregularity OS. Note the arrow,

which points towards the defect.

Fig. 4. Tangential power corneal

topography showing oblate-shaped

OS cornea after LASIK in a patient

with fl ap fold irregularity.

Fig. 5. Reverse geometry corneal

GP for correction of irregular

astigmatism from fl ap fold after

myopic LASIK.



right eye. Her topography showed a normal eccentricity value and a topographic keratometry read-ing of 47.00@40/47.67@130 OD (Figure 1). Because her eccentricity values were normal (steep E value of 0.64 and fl at E value of 0.59), she was fi t into a regular geometry tricurve corneal GP lens. This lens was fi t half a diopter fl atter than K. Her fi nal lens parameters were: 46.50/+2.00/9.60 OD, and the lens demonstrated a close-to-alignment fl uorescein pattern (Figure 2). She reported successful wear of this lens about three times a week when she wanted to be free of spectacles.

2 Flap Fold Irregularities

Corrected with Corneal

GP. A 65-year-old female with a history of myopic LASIK presented with complaints of light sensitivity and glare OS while driving at night. These symptoms were caused by irregular astig-matism from a fl ap fold (Figure 3). Her vision was 20/40 with a spectacle correction of -0.25-0.75x085 and her corneal topog-raphy showed an oblate corneal shape with keratometry values of 39.09@164/39.56@074 (Figure 4).

Since her eccentricity value was negative, a 4D reverse geometry corneal GP with the following parameters was trialed: 40.00/plano/10.8. However, the lens

ultimately appeared to be about 0.75D too steep with minimal edge lift. A new lens with a fl atter base curve and periphery was created with an over-refraction of +0.25D. The fi nal lens parameters were 39.25/+1.00/10.8, and she was able to see 20/20. This lens showed mild apical touch and moderate bearing in the horizontal mid-pe-riphery (Figure 5). Nonetheless, the lens had great movement and good tear exchange, and the patient’s corneal health looked great at

subsequent follow-up visits. The patient was happy with her

improved visual acuity and night-time vision and was able to wear her lens for the entire day.

SCLERAL LENSES

In contrast to fi tting corneal GP lenses—a process in which cor-neal topography is crucial to lens design—a scleral lens has the advantage of being able to vault the cornea and rest on the anato-my of the scleral-conjunctival area. This makes scleral lenses ideal for fi tting over highly irregular corneas after refractive surgery, such as in the case of uneven ablation zones or iatrogenic corneal ectasia. These large lenses center well and offer stable vision and good comfort; additionally, their fl uid-fi lled reser-voir offers therapeutic applications in the case of LASIK-induced dry eye.6 Scleral lenses are available in both regular and reverse geometry designs.

INDICATIONS

Patient complications following refractive surgery include the overcorrection or undercorrection of refractive error, anisometropia, a decentered or uneven ablation zone, fl ap irregularities and the development of iatrogenic corneal ectasia. Any of these may lead to symptoms of reduced spectacle-corrected acuity and contrast sensitivity, or ghost images.1 LASIK-induced dry eye is another common complication. While its pathophysiology is unknown, it is believed to result from neurotrophic epitheliopathy due to damage of the sub-basal nerve plexus from the creation of the LASIK fl ap.2 GP lenses are capable of addressing all of these concerns.

Fig. 6. Multiple stromal folds within a LASIK fl ap OD (left) and OS (right).

Fig. 7. Tangential power corneal topography showing myopic ablation profi le

OU.

FITTING RIGID LENSES AFTER REFRACTIVE SURGERY



3 Flap Fold Irregularities

Corrected with Scleral

Lens. A 31-year-old male presented to the clinic with complaints of seeing glare around lights and decreased vision OU for the past year. The patient has a history of myopic LASIK OU and, within a week of undergoing the procedure, reported being aware of his symptoms. Anterior biomi-croscopy revealed multiple LASIK fl ap folds OD>OS (Figure 6).

His manifest refraction was plano-1.00x065 OD and pla-no OS, which corrected him to 20/50 and 20/25, respectively. Corneal topography indicat-ed a myopic ablation profi le with keratometry readings of 38.26@012/38.71@102 OD and 39.40@126/39.00@036 OS (Figure 7). A 16mm 4.00D reverse geometry scleral lens with a 42.00D base curve and plano power was trialed in both the right and the left eyes. The lens demonstrated excessive vault of 500µm upon insertion over the

central corneal surface, and the lens decentered inferiorly OU. Overrefraction values of -9.50D and -7.50D were found in the right and left eye, respectively, which led to the 20/30 OD and 20/20 OS visual acuity. As such, the following fl atter lenses with compensated powers were or-dered: 40.00/-8.50/16.0 OD and 40.00/-6.75/16.0 OS with a 2.00 D peripheral haptic OU (Figure 8).

Following dispensing, the lenses centered well and had approxi-mately 250µm of vault centrally after 40 minutes of allowance for settling OU. The lenses were dispensed to the patient and he re-ported less glare and better quality of vision in both eyes at the three-week follow-up appointment. The patient also had healthy corneas and noted being able to wear the lenses comfortably for 12 hours.

4 Intacs and LASIK-

Induced Dry Eye

Syndrome. A 54-year-old male with a history of myopic

LASIK OS presented to the clinic having formed subsequent iatro-genic corneal ectasia and dry eye four months after the procedure. Additionally, he had undergone intracorneal ring segment im-plantation in his right eye. The patient admitted to using preser-vative-free artifi cial tears once every hour to treat his dry eyes. His keratometry values were 47.25@032/43.12@125. Though he was corrected to 20/25 with a spectacle prescription of -4.25-2.50x140, he desired to be free of glasses.

Due to his dry eye syndrome, he wanted to try a scleral lens to gain some symptomatic relief. A 45.00/-1.50/18.0 lens was trialed and with a -1.00 over-refraction, the patient could see 20/20. This lens also demonstrated adequate vault over the limbus and aligned in the periphery (Figure 9). A fi nal lens was ordered with the param-eters of 45.00/-2.50/18.0. The pa-tient reported improved nighttime vision and was able to decrease his drops to application once every four hours.

5 Lagophthalmos

Complicates LASIK-

Induced Dry Eye

Syndrome. A 73-year-old female with a history of myopic LASIK

Fig. 9. An scleral lens fi t on a patient

with iatrogenic corneal ectasia and

dry eye syndrome after myopic

LASIK OS. This patient also has

intra-corneal ring segments in place.

Fig. 8. A 16mm diameter scleral lens with a toric peripheral haptic over

patient with multiple folds of LASIK fl ap.



OU 14 years prior was referred in for scleral lens fi tting to treat her severe dry eye symptoms. The patient stated that her eyes had remained relatively dry since her LASIK procedure, but that the severity of dryness had increased three years ago with the advance-ment of her Parkinson’s disease. The patient reported self-admin-istering autologous serum drops hourly, topical steroids BID, pre-servative-free artifi cial tears every 15 to 30 minutes, doxycycline

hyclate 50mg tablets PO daily and 1,000mg of omega-3 PO daily. Additionally, she had installed humidifi ers in all the rooms of her house to help with her dry eye symptoms.

Despite all of these efforts, however, none of the treat-ments gave her signifi cant relief. Additionally, she stated that her eyes constantly felt like they were “on fi re.” A slit lamp examination demonstrated inferior punctate staining and a decreased blink rate of once every 30 seconds. The patient was correctable to 20/20 at distance and J1 at near with a mild hyperopic and astig-matic correction of +0.50-0.75x 040 OD and +0.50-0.75x180 OD with a +3.00 add. Her topography showed a myopic ablation profi le OU and keratometry readings of 43.87@062/43.12@152 OD and 43.75@128/41.12@038 OS (Figure 10). The following 4D reverse geometry diagnostic scleral lenses were placed on her eyes: 46.00/-2.00/18.0 OD and

45.00/-1.50/18.0 OS. Following 45 minutes of wear in the offi ce, the patient stated 60% relief of her symptoms. A -3.00D OD and 2.00D OS overrefraction was added to the front surface of the fi nal scleral lens order. The lenses showed good vault over the corneal surface and aligned well with the scleral shape of both eyes (Figure 11). Following one month of wear, the patient stated that her symptoms were completely resolved and that she had discon-tinued all of her topical drops.

Though most patients who undergo refractive surgery ex-

hibit good visual outcomes, there are still some who need to wear contact lenses afterwards to reha-bilitate their vision and/or health of their eyes. Fitting contact lenses after these procedures can be challenging due to altered corneal shape and unenthusiastic patient attitudes about wearing lenses again. Knowledge of the various contact lens designs and the ability to interpret corneal shape after LASIK and PRK is key to helping this population succeed in contact lens wear. In most cases, GP lenses are a great choice and offer relief for surgically altered corneas. RCCL

1. Steele C and Davidson J. Contact Lens fi tting post-laser-in situ keratomileusis (LASIK). Contact Lens and Anterior Eye. 2007 May;30(2):84-93.2. Garcia-Zakisbak D, Nash D, Yeu D. Ocular Surface diseases and corneal refractive surgery. Current Opinions in Ophthalmology. 2014 Jul;25(4):264-269.3. Gruenauer-Kloevenkorn C et al. Varieties of contact lens fi ttings after complicated hyperopic and myopic laser in situ keratomileusis. Eye and Contact Lens .2006 Sep;32(5):233-39.4. Szczotka-Flynn L, Jani BR. Comparison of axial and tangential topographic algorithms for contact lens fi tting after LASIK. Eye Contact Lens. 2005;31:257–62.5. Rabinowitz YS. “Corneal Topography: Corneal Curvature and Optics, Clinical Applications, and Wavefront Analysis ” Clinical Contact Lens Practice. ES Bennett, BA Weissman. Philadelphia, Lippincott Williams & Wilkins: 215-32.6. Parminder A, Jacobs DS. Advances in scleral lenses for refractive surgery complications. Current Opinions in Ophthalmology 2015 Jul;26(4):243-248.

Fig 10. Tangential corneal topography OU of a patient with dry eye syndrome

after myopic LASIK procedure. The patient’s dry eye symptoms were

exacerbated by lagophthalmos caused by her systemic Parkinson’s disease.

Fig. 11. An 18mm diameter scleral

lens with 4D reverse geometry

used to treat the LASIK- and

lagophthalmos-induced dry eye

symptoms of the patient from Figure

8. OD lens shown here.

FITTING RIGID LENSES AFTER REFRACTIVE SURGERY


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The use of custom rigid lenses to reshape the cornea is increasingly prevalent throughout the world, albeit more

so in Asia than in Europe and the United States.1-3 Therapeutic orthokeratology lenses are typically fi t in Europe to eliminate the need for glasses or contact lenses, while in Asia they are primarily used to control the progression of myopia.1

Europe’s orthokeratology fi tting process employs corneal topogra-phy with a software-based ap-proach that is supplemented with trial lenses. This is achieved via the manufacturing of contact lenses by a third party, so the practitioner’s knowledge of back surface pa-rameters remains limited. In Asia, however, the fi tting process for or-thokeratology incorporates topog-raphy, trial lenses and fl uorescein pattern evaluation, meaning prac-titioners typically achieve a greater amount of confi dence and success with the fi tting process, though this is not always the case. This article will discuss the orthokeratology lens fi tting process in the context of calculating back lens parameters individually for unusual cases.

1 TEENAGE PATIENT

Presentation. A 17-year-old patient underwent an ortho-

keratology fi tting to control her myopic progression, as her mother

had myopia in both eyes corrected with eyeglasses (sph -18D). She presented with moderate myopia (-5.50D), a steep and small cornea and a medium-to-low eccentricity value. Her refractive and corneal data were as follows: Rx sph -5.50 cyl -0.50x175° BCVA 20/20, Ks 7.26/7.09mm, average corneal eccentricity E = 0.24, horizontal visible iris diameter 10.60mm and pupil size 3.60mm in the right eye; and Rx sph -5.00 cyl -0.50x10° BCVA 20/20, K 7.24/7.03mm, av-erage corneal eccentricity E = 0.30, horizontal visible iris diameter 10.70mm and pupil size 3.70mm in the left eye.

For this patient, the prescribed lens back surface exhibited a tetra-curve design with a back optic zone (BOZ); a fi rst peripheral zone or reverse curve steeper than the BOZ (BPZ1); a second peripheral zone or landing zone fl atter than the previous one (BPZ2); and a third peripheral zone steeper than the second one (BPZ3). This approach uses one of several different mod-ern reverse orthokeratology lens designs available on the market. In theory, more curves could occur to smooth the junction’s angle between one curve and another to produce conformal periphery and to increase the lens centration.

Methods. When choosing the back optical zone radius (BOZR) for the fi rst trial lens, it’s possi-

ble to use different formulas.4-7 Additionally, instead of selecting the BOZR, it’s possible to use sag fi tting methods.7,8 The indications to calculate these orthokeratology lens parameters (using the Jessen Factor formula) are demonstrated in Table 1, while the parameters of the fi rst pair of lenses fi t on the patient in question are shown in Table 2. For the purpose of this dis-cussion, however, it is not relevant which formula is used to calculate the fi rst lens back surface param-eters, because the fi nal parameters were revised after evaluating the lens fi t on the eye as well as its position, its movement and its fl uo-rescein pattern.

In comparing these parameters with those indicated in the litera-ture, note that the chosen BOZR is 0.36mm shorter; from this, a residual refractive error of 1.75D in the right eye (OD) and 1.25D in the left eye (OS) was then expect-ed. Additionally, the BPR1 was longer with a lower inversion than

Dr. Fadel specializes in fi tting

contact lenses for the

irregular cornea as well

as in scleral lens fi ttings

and orthokeratology. She

has a contact lens private

practice in Italy where she

designs special customized

contact lenses. She lectures and

publishes especially on the

aforementioned subjects. She can be reached

at [email protected].

ABOUT THE AUTHOR

Unusual Clinical Casesin OrthokeratologyFor the right patient, these lenses may be life-changing. Two challenging

cases provide insights into the fi tting process. By Daddi Fadel, DOptom

022_RCCL0616_F3_Orthokeratology.indd 22022_RCCL0616_F3_Orthokeratology.indd 22 5/31/16 4:34 PM5/31/16 4:34 PM


normal, while the BPR2 was longer than 0.40mm; this could mean a possible lifting of the optical zone with modest result in the treatment. Additionally, note that the lens is fi t steeply with central corneal stain-ing most visible after lens removal (Figures 1 and 2). Corneal topog-raphy demonstrated the typical central islands that can be induced from a steep lens.

Following this evaluation, new lenses were calculated based on the parameter analysis of the fi rst trial lenses and the fl uorescein pattern. The BOZ was fl attened according to calculations made previously, which automatically increased the reverse curve, leaving the same BPR1 (Table 3). The BPZ2 was also fl attened to allow a lifting of the optical zone to prevent corneal abrasions and allow for a better distribution of epithelial tissue.

Results. Five days after the pa-

tient was fi t with an orthokeratol-ogy lens, her UDVA was 20/25+2 OD with residual refractive errors present in the spectacle plane sph -1.00D and 20/20 OS with resid-ual refractive errors sph -0.50D. Twenty days after the fi tting, the patient’s UNVA was 20/16-1 OD with residual refractive errors: sph -0.25D; 20/16 OS with no resid-ual refractive errors; and 20/12.5 in both eyes (OU). The patient reported having good vision with the lenses for up to 15 hours per day, but complained that she some-times observed visual halos around lights. At her three-and-a-half month follow-up appointment, the UDVA was 20/16 OD with resid-ual refractive errors sph -0.25D and 20/16 OS with no residual refractive errors. The low contrast UNVA was 20/25 OD, 20/25 OS and 20/12.5 OU.

Discussion. Previous research

has suggested that low corneal eccentricity is predictive of a lower refractive error change. As such, these results are in agreement with other studies demonstrating that low eccentricity may not be an absolute contraindication to orthokeratology, despite the fact that the patient’s cornea was small and steep with a medium-to-high degree of myopia.8-12 In these cases, the corneal shape becomes oblate due to the negative eccentricity (i.e., E = -1.62 OD and E = -1.50 OS). In the case of this patient, her issue was resolved using a four-curve reverse lens with a mean back optic zone diameter and relatively small total diameter.

2 CONTACT LENS

DROPOUT

Presentation. A 48-year-old patient presented to the clinic wish-ing to try wearing orthokeratology

Tetracurve RGL for Myopia < -4.25D

(Jessen Factor (JF) 0.50 - 1.00D

BOZR = Kp + m. target + J.F.BOZR = 7.25 + 1.15 + 0.15BOZR = 8.56mm

BOZD = 5.80 - 6.40BPR1 = 6.00mm

BOZD = BOZR-2x/2.6x(m.t.+J.F.)BPR1 = 8.56 - 2 x (1.15 + 0.15)BPR1 = 5.96mm

W1 = 0.4 - 0.6 mmW1 = 0.6mm

BPR2 alignment with peripheral cornea • 0 < e < 0.30 • 0.31 < e < 0.55 • 0.56 < e < 0.70BPR2 = 7.20mm

W2 = 1.0 -1.3mmW2 = 1.2mm

BPR3 = 10.5 - 12.5mmBPR3 = 10.5mm

W3 = 0.4mm

TD = 10.0 - 11.50mmTD = 10.4mm

BPR2 = KBPR2 = K + 0.05mmBPR2 = K + 0.10mm

Table 1. Tetracurve Lens Parameter Calculations for Myopia up to 4.25D14

*The spherical equivalent was considered as the myopic target (-5.75D) and Jessen factor value of 0.75D.

Fig. 1. Fluorescein patterns of the fi rst pair of lenses, three nights after

initiation of treatment. Note, the steep pattern of the lenses is clear.

Fig. 2. Note the corneal staining in

the central area.



lenses to eliminate the need for eye-glasses. She had previously worn soft contact lenses, but had stopped due to resulting dry eye symptoms. Her refractive and corneal data at the time of presentation was Rx sph -0.75 cyl -2.50x170° BCVA 20/16 Add 1.50D, K 7.81/7.49mm, E = 0.10, horizontal visible iris diameter 11.60mm and pupil size 3.40mm OD; and Rx sph -1.50 cyl

-1.50x20° BCVA 20/16 add 1.50D, K 7.51/7.29mm E = 0.20, horizon-tal visible iris diameter 11mm and pupil size 3.50mm OS.

It was noted the patient’s cylin-drical component was three times larger than the spherical one in the right eye, while in the left eye they were equal. Also, there was refrac-tive astigmatism (cyl -2.50 OD and cyl -1.50 OS higher than corneal

astigmatism (i.e., -1.82D OD and -1.39D OS) and low eccentricity present. Additionally, though the patient’s marginal dry eye was not an absolute contraindication to orthokeratology lens wear, it could challenge the practitioner’s ability to create a reliable topography map, since corneal topographers are typically more effective at gen-erating a clear image when evaluat-ing a wetter corneal surface.12

Few published studies currently exist on the subject of toric ortho-keratology for astigmatism, though conference abstracts and case reports on the subject are numer-ous.13-21 One study was conducted on patients who have astigmatism greater than 1.25D at any orien-tation.13 The lenses used in this project contained fi ve toric zones with double reverse curves, with the second and the fourth zones be-ing the reverse ones. This design is known as a full toric double reser-voir. The researchers suggested that to achieve an adequate effect with a toric orthokeratology lens, me-chanical and hydrodynamic forces must occur in different ways in each corneal meridian, with greater fl attening in the meridian where the myopia is greater.20 Results demon-strated an 85% change in initial astigmatism.

Another study on patients ranging from six to 12 years old with myopia of 0.50D to 5.00D and with-the-rule astigmatism of 1.25D to 3.50D incorporated a lens characterized by an alignment

UNUSUAL CLINICAL CASES IN ORTHOKERATOLOGY

A better understanding of lens parameters and fi tting techniques may allow practitioners to beat some of these typical orthokeratology contraindications:1. Myopia correction up to -6.00D, due to a lack of predictability of the treatment.8,12

2. Correction of with-the-rule corneal astigmatism higher than 1.50D.22-25 The most common problem in patients with high corneal astigmatism is spherical lens decentration, which can lead to further induced astigmatism and poor vision.24,26

3. Correction of against-the-rule and oblique corneal astigmatism higher than 0.75D.18,19,25,26 This is due to lens decentration, which can induce more astigmatism.24,26

4. Correction of corneal astigmatism. Residual astigmatism can aff ect refractive outcomes post-treatment.27

5. The need for spectacle lens cylinder to always be less than the spherical power (i.e., less than one-third of the sphere).8 6. Astigmatism spanning limbus-to-limbus because of lens decentration.8

7. Irregular corneal astigmatism, given the diffi culty to stabilize the lens on the cornea.8

8. Pupil size of about 5mm to 6mm or larger under dim light conditions.12 Orthokeratology can induce higher-order aberrations, especially spherical aberrations. In patients who have a pupil size greater than 5mm, the amount of high order aberrations increases dramatically.9. Low corneal eccentricity, in that the correlation between eccentricity and the predictability of the treatment is not well defi ned, so orthokeratology is only considered safe for correction of myopia less than -4.00D.8,12

Potential Orthokeratology Contraindications

K f K s

OD 7.26 7.09

OS 7.24 7.03 Inv. 1.8

BOZR BOZD BPR1 W1 BPR2 W2 BPR3 W3

OD 8.20 6.00 6.40 0.60 7.60 1.15 10.0 0.50

OS 8.20 6.00 6.40 0.60 7.60 1.15 10.0 0.50

TD 10.50mm; BVP +0.50D.

Table 2. Parameters of the First Pair of Lenses Fit in Case 1



toric zone with spherical back op-tics and a reverse zone design.14,15

According to the authors of this study, the advantage of placing a spherical optic zone on a toric cor-nea is that the fl attest lens meridian creates a normal orthokeratology effect, while the steepest meridian results in a greater orthokeratology effect, leading to the correction of the corneal astigmatism. The study results demonstrated a fi t success rate of 95% with a sig-nifi cant reduction in myopia and astigmatism.

Some of the case reports in exis-tence in which authors fi t different toric orthokeratology lens designs include:

• A case of a 22-year-old patient, sph -4.25 cyl -3.75x8° OD. The corneal astigmatism (CA) was

-3.10x7°, and the lens used had two toric zones: the reverse and the landing zone.19 The reduction of a high CA can be achieved if the re-verse zone design allows for a close tangential or alignment in each me-ridian to properly modulate the hy-drodynamic forces, which enables for the fl attening of each meridian to establish the orthokeratology effect. In the presented case, at two months post-treatment the CA was largely reduced, and the subjective correction was cyl -0.50Dx8° with UNVA 20/20.

• A case of a 44-year-old patient with a mixed astigmatism in which the cylindrical component was greater than spherical one. The patient presented with sph + 1.00 cyl -2.00x180° OD and sph +1.25 cyl -2.25x180° OS.20 The lens fi t

on this patient was a hexacurve (i.e., six back curves) design with two back toric zones, dual toric zones and optical and landing zones. Also, the vertical meridian was steeper than the horizontal meridian in the landing zone and vice versa in the optical zone. Three months post-orthokeratology fi t-ting, the subjective correction was sph + 0.50 cyl -0.50x10° (UNVA 20/16) OD and sph+0.25 cyl -1.00x5° (UNVA 20/16) OS.

Methods. Because there do not appear to be any set guidelines for toric orthokeratology lens param-eter calculation in the literature, indications for spherical ortho-keratology lenses were followed instead. The fi rst pair of lenses used demonstrated a tetracurve design with two toric zones—one in the optical zone to correct the astig-matism and another in the landing zone to help achieve a centered lens. Parameters are listed in Table 4.

Fluorescein patterns for this lens fi t demonstrated the presence of an upward decentration in the right eye, while in the left eye the pattern was suitable as the BPZ2 was aligned over the corneal peripheral meridians. The spectacle correc-

Fig. 3. Fluorescein patterns of the second pair of lenses, 20 days

post-orthokeratology. Both lenses are decentered, compromising the

refractive outcome.

K f K s

OD 7.26 7.09

OS 7.24 7.03


OD 8.20 6.00 6.40 0.60 7.60 1.15 10.0 0.50

OS 8.20 6.00 6.40 0.60 7.60 1.15 10.0 0.50

TD 10.50mm; BVP +0.50 D

K f K s

OD 7.26 7.09

OS 7.24 7.03 Inv. 2.2/2


OD 8.60 6.00 6.40 0.60 8.00 1.15 10.0 0.50

OS 8.40 6.00 6.40 0.60 8.20 1.15 10.0 0.50

TD 10.50mm; BVP 0.00D.

BPR2 = BOZR - 2x/2.6x (m. t. + J.F.)BPR1 = 8.20 - 2 x (1.15 + 0.15)BPR1 = 6.00mm (inv. 2.6 mm)

Table 3. Comparison of the First and Second Pair of Lenses in Case 1



tion was OD sph +1.00 cyl -1.25 x 145°(UNVA 20/32) and OS cyl 1.00 x 40° (UNVA 20/25). Once the treatment effect was underway in the left eye, the design was main-tained via fl attening of the BOZ by 0.2mm in the horizontal meridian.

The second pair of lenses was calculated and a tetracurve lens with three toric areas—the opti-cal zone, the reverse zone and the landing zone—was selected based on the residual refraction with the fi rst lenses (Table 5). Fluorescein patterns and corneal maps post-fi t demonstrated lens decentration in both eyes, leading to poor refrac-tive results and visual acuity (Figure 3). Parameters were sph +1.00 cyl -1.25x145°(UNVA 20/32) OD and cyl -1.00x40° (UNVA 20/25) OS.

Next, a third pair of lenses was ordered; the parameters are shown in Table 6. It should be noted that the majority of new lens parame-ters do not necessarily respect the indication reported in literature for spherical orthokeratology lenses.

For example, the width of the reverse zone (W1) was larger than the landing one (W2) to achieve a greater hydrodynamic force action, allowing a higher closing lens in each meridian to increase the effect of orthokeratology. For the lens stability, it was decided that the BPZ2 should be fl atter than K. In this case, the BPZ3 was steeper than most literature indications to allow for a tear exchange, and the width of the third peripheral zone (W3) was the same as W2 to help balance corneal touch around all meridians.

Results. Twenty days post-treat-ment, the fl uorescein patterns looked good, with regular and constant (real or apparent) touch in all the corneal meridians (Figure 4). The corneal profi le post-ortho-keratology is shown in the corneal maps (Figure 5). The subjective cor-rection was cyl -0.75x150° (UNVA 20/16) OD, cyl -0.50x30° (UNVA 20/16-1) OS and UNOU 20/16. The patient demonstrated good

UNVA for more than 13 hours a day. Additionally, topoaberrometry showed that corneal higher-or-der aberrations were not relevant except the spherical ones, which allowed the patient to have a good VA at different distances and hence setting up close.

The slit lamp examination showed instability of the tear fi lm in both eyes but the patient reported no presence of symptoms throughout the day.

Discussion. As seen before, in the published studies, conference abstracts and case reports, there are a number of designs of toric contact lenses to treat astigmatism that work equally well.13-21 This second case was solved using a four-toric zone reverse lens, even if it was an apparently contraindicat-ed scenario for this type of lens. In fact, the cylindrical component in the OD was three times larger than the spherical one, while in the OS they were equal. Also there was a refractive astigmatism (OD -2.50D, OS -1.50D) higher than CA (OD -1.82D and OS -1.39D) and a low eccentricity. The parameters of the back curve were then calculated manually.

Though FDA approval criteria states that orthokeratology

is appropriate for myopia correc-tion up to -6.00D, there is enough evidence to suggest that orthokera-tology also has function for higher myopia and astigmatism. As such, the orthokeratology fi tting process

UNUSUAL CLINICAL CASES IN ORTHOKERATOLOGY

Table 4. Parameters of the First Pair of Lenses Fit in Case 2

K f K s

OD 7.81 7.49

OS 7.51 7.29 Inv. 1.8


OD 8.25/8.10 6.20 7.40 0.70 8.15/8.00 1.10 11.10 0.50

OS 7.90/7.75 6.20 7.15 0.70 7.85/7.65 1.10 10.50 0.50

TD 10.80mm; BVP +0.50D. BOZ and BPZ2 are toric.

Fig. 4. Fluorescein patterns of the third pair of lenses, 20 days post-

orthokeratology. In this instance, the lenses were centered.



in these instances could be made easier with the knowledge of all the lens’ back surface parameters. It enables the contact lens prac-titioner to become more familiar with the functionality of each parameter so that it can easily be changed to further improve the lens fi t. These cases also suggest that a “simple” tetracurve lens could be considered as an option to resolve complex cases as well. RCCL

1. Chetty E, Jackson S, Mitton C, Phillips TK. A look at important issues regarding safe ortho-keratology. The South African Optometrist, December 2007.2. Morgan PB, Woods CA, Tranoudis IG, Helland M. International contact lens prescribing in 2014. Contact Lens Spectrum 2015 January; 30: 28-33.3. Morgan PB, Woods CA, Jones D, et al. Interna-

tional contact lens prescribing in 2012. Contact Lens Spectrum 2013 January; 28: 31-44.4. Luk BMW, Bennett ES, Barr JT. Fitting ortho-keratology contact lenses. Contact lens Spectrum 2001 October, 16(10):22-32.5. Jessen GN. Orthofocus techniques. Contacto 1962; 6(7):200-204.6. Chan B, Cho P, Mountford J. The validity of the jessen formula in overnight orthokeratology: a retrospective study. Ophtalmic Physiol Opt 2008 May;28(3):265-268.7. Swarbrick HA. Orthokeratology review and update. Clin Exp Optom 2006; 89; 124-143.8. Mountford J, Ruston D, Dave T. Orthokeratol-ogy. Principles and Practice. London, Butter-worth-Heinemann, 2004.9. Mountford J. Orthokeratology. In Phillips AJ & Speedwell L. Contact lenses. Edinburgh, Butter-worth-Heinemann. 2007:423-450.10. Joe JJ, Marsden HJ, Edrington TB. The relationship between corneal eccentricity and improvement in visual acuity with orthokeratolo-gy. J Am Optom Assoc 1996; 67:87-97.11. Lui WO, Edwards MH. Orthokeratology in low myopia. Part I: effi cacy and predictability. Contact Lens Anterior Eye 2000;23:90-99.

12. Van der Worp E, Ruston D. Orthokeratology: an update. Optom in Practice 2006;7:47-60.13. Paunè J, Gardona G, Quevedo L. Toric double reservoir contact Lens in orthokeratology for astigmatism. Eye Contact Lens 2012;38:245-251.14. Chen C, Cheung SW, Cho P. Myopia control using toric orthokeratology. Invest Ophthalmol Vis Sci 2013; 54: 6510-6517.15. Chen C, Cho P. Toric orthokeratology for high myopic and astigmatic subjects for myopic con-trol. Clin Exp Optom 2012;95:103–108.16. Beerten R, Christie C, Sprater N, Ludwig F. Im-proving orthokeratology results in astigmatism. Poster presented at the Global Orthokeratology Symposium, Chicago, IL, July 29–31, 2005.17. Baertschi M. Short and long term success with correction of high astigmatism in OK. Poster presented at the Global Orthokeratology Sympo-sium, Chicago, IL, July 29–31, 2005.18. Chan B, Cho P, de Vecht A. Toric orthokeratol-ogy: a case report. Clin Exp Optom 2009;92:387–391.19. Baertschi M, Wyss M. Correction of high amounts of astigmatism through orthokeratolo-gy. A case report. J Optom 2010;3:182-184.20. Calossi A. Mixed astigmatism treated with a Dual-Toric ortho-k design. Contact Lens Spec-trum 2013, February;28:49.21. Jackson JM. Advanced corneal reshaping for astigmatism. Contact Lens Spectrum 2013, February;28:42.22. Ruston D, Van Der Worp E. Is ortho-K ok? Optometry Today 2004; Dec 17:25-32.23. Chen CC, Cheung SW, Cho P. Toric orthokera-tology for highly astigmatic children. Optom Vis Sci 2012; 89:849-855.24. Mountford J, Pesudovs K. An analysis of the astigmatic changes induced by acceler-ated orthokeratology. Clin Exp Optom 2002; 85:284–293.25. Cheung SW, Cho P, Chan B. Astigmatic changes in orthokeratology. Optom Vis Sci 2009;86:1352–1358.26. Chan B, Cho P, Cheung SW. Orthokeratology practice in children in a university clinic in Hong Kong. Clin Exp Optom 2008;91:453–460.27. Van der Worp E. Correcting astigmatism with orthokeratology. Contact Lens Spectrum 2006 July, 21(7):21.

Table 5. Parameters of the Second Pair of Lenses Fit in Case 2

K f K s

OD 7.81 7.49

OS 7.51 7.29 Inv. 1.8


OD 8.35/8.00 6.50 7.50/7.20 0.50 7.90/7.60 1.25 11.00 0.75

OS 8.10/7.80 6.50 7.35/7.15 0.50 8.10/7.90 1.25 11.00 0.75

TD 11.50mm; BVP 0.00D.

K f K s

OD 7.81 7.49

OS 7.51 7.29 Inv. 1.8


OD 8.00/7.70 6.30 7.60/7.30 0.80 7.90/7.60 0.70 9.00 0.70

OS 8.00/7.90 6.50 7.50/7.30 0.70 8.10/7.90 0.60 9.00 0.60

TD OD 10.70; OS 10.30mm; BVP 0.00D.

Table 6. Parameters of the Third Pair of Lenses Fit in Case 2

Fig. 5. Corneal topographies after removing the third pair of lenses.



CORNEALorneal collagen cross-linking (CXL) avail-able internationally for over a decade and now newly approved

in the United States, is the only surgical procedure capable of slow-ing down or stopping the progres-sion of keratoconus and secondary keratectasia after laser in-situ ker-atomileusis (LASIK) and photore-fractive keratectomy (PRK).1,2 CXL is also considered by many to be a vision-saving procedure, especially when performed on younger pa-tients with the goal of preventing the need for future keratoplasty. Research suggests CXL may have benefi cial visual and optical effects, as evidenced by the reduction in corneal steepness and improve-ment in uncorrected visual acuity and best corrected visual acuity (BCVA).3,4 Despite these impressive outcomes, however, in many cases corrective lenses are still necessary to achieve the best possible vision following CXL.

Specialty soft contact lenses in particular continue to gain popu-larity among eye care practitioners due to advancements in lens mate-rials and lathing technology.5 One such example is the silicone hy-drogel mini-scleral (SHmS): a large 17mm diameter lens that vaults the limbus and central cornea with minimal bearing on the corneal apex to rest on the patient’s sclera.

The lens’ central thickness varies from 0.5mm to 0.6mm and is responsible for the neutralization of corneal irregularity and the creation of a regular front refrac-tive surface. Scleral support also results in the formation of a true aqueous tear lake underneath the lens, which enhances the ability to correct irregular astigmatism, similar to gas permeable (GP) scleral lenses (Figure 1). One major indication for this type of lens is vi-sual rehabilitation following CXL, with the goal of the fi tting being to provide a stable, distortion-free refractive surface and minimize interference between the recover-ing ocular surface—especially the epithelium—and the contact lens.6

Examples of custom soft contact lenses for keratoconus include the NovaKone (Alden Optical), Flexlens Tricurve (X-Cel Specialty Contacts), and Eni-Eye Soft-K lens (Acculens).

Semi-scleral soft lenses can also be used as therapeutic ban-dage lenses following refractive or ocular surface reconstructive surgery, especially in eyes with high corneal toricity or steeper than average curvature, since a higher sagittal depth helps stabilize lens fi t and reduce excessive lens movement. Examples include the Kontur (Kontur Kontact Lens) or T74/85 (David Thomas Contact Lenses); however, the application

of these designs is limited entirely to therapeutic purposes due to their inability to correct irregular astigmatism.

So, with the CXL era fi nally about to begin in the US, let us consider whether the approach to contact lens fi tting shortly after CXL should be different from what we consider a standard of care for the irregular cornea patient through a series of case reports.

1 STANDARD PROCEDURE

A 29-year-old woman with a diagnosis of surgically-in-

duced keratectasia was referred in for a specialty contact lens fi tting due to decreased vision in her left eye for the last nine months. She reported that she had undergone LASIK for moderate myopia 12 years prior. The patient’s unaided visual acuities were 20/80 OD and 20/200 OS, and her refraction was +1.25/-3.75x140 OD and -5.00/-

Dr. Severinsky recently

completed a two-year doctor

of optometry program for

international graduates at

the New England College of

Optometry. Since 2001 he

has specialized in specialty

contact lens fi tting and

especially scleral lenses. Today

his primary area of interest is designing and

fi tting contact lens for keratoconus and after

corneal collagen cross-linking. He is a Fellow

of the American Academy of Optometry,

British Contact Lens Association and Scleral

Lens Education Society.

ABOUT THE AUTHOR

An irregular cornea patient presents needing better vision following a corneal stabilization

procedure. What do you do?

By Boris Severinksky, ODBy Boris Severinksky OD

CROSSLINKINGCROSSLINKINGoliafn

in the UnitedCC

C O N T A C T L E N S U S E A F T E R

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5.00x170 OS with best-corrected visual acuity (BCVA) of 20/30 and 20/80, respectively. Corneal topography revealed advanced keratectasia predominantly in the left eye (as compared with her right) with maximum keratometry (Kmax) values of 55.4D OD and 59.7D OS (Figure 2). The patient was subsequently evaluated by a cornea specialist and scheduled to undergo an epithelium-off corneal collagen crosslinking procedure to halt further progression. She was also given temporary spectacles with partial astigmatic correction in the right lens and plano correc-tion in the left to wear following the surgery. Two weeks after, the patient underwent CXL in her left eye.

Five weeks later, following complete epithelial healing and the discontinuation of all steroid medications, the patient’s left cor-nea exhibited no signs of epithelial hypertrophy or superfi cial punctate staining. As such, she was sched-uled for a contact lens fi tting and given a front toric, prism-ballasted version of the SHmS lens with a base curve of 7.3mm and the power of -3.75/-2.25x180. The lens was manufactured in a Filcon V3 silicone hydrogel material (Defi nitive 74, Contamac). At the dispensing visit, the patient’s BCVA was 20/30 OS, with a minor com-plaint of ghost images. She was instructed to increase lens wearing

time gradually, and was scheduled for a follow-up appointment in the next 10 days.

During the follow-up appoint-ment, a slight reduction in visual acuity (i.e., 20/50) was noted, but the patient reported noticeable improvement in vision clarity and her ability to perform daily tasks, as well as good lens tolerance and average lens wear of nine hours a day. An examination revealed the presence of a well-centered lens with about 1mm of on-blink movement (Figure 3). An over-refraction of plano/-1.50x175 was able to improve her vision to 20/25 OS and signifi cantly reduce the amount of ghost images seen. A new lens with an updated power was ordered; three weeks later, the patient was able to wear the revised lens up to 10 hours a day with stable contact lens-corrected vision. As a result of successful restoration of vision in the treat-ed eye, the patient underwent an uneventful CXL procedure eight weeks later for her other eye.

2 PROGRESSION

PROTECTION

A 29-year-old male con-struction worker was diagnosed with bilateral keratoconus (OS>OD) 12 years prior to pre-senting to the clinic. He reported he had undergone penetrating keratoplasty in his left eye in 2011; however, shortly after the proce-dure, the corneal transplant had begun to show signs of endothelial rejection, which eventually led to scarring and reduced vision. Numerous GP lens fi ts had been attempted but the patient had continued to demonstrate a severe intolerance to rigid lenses, especial-ly while outdoors. In the last three years, he had successfully managed using a soft lens made for kerato-conus (Soft-K, Sofl ex) with param-

eters BC 7.00, diameter 14.20 an power -8.00. Additionally, he had been able to achieve a visual acuity of 20/40-. Unaided vision in his left eye was 20/400.

However, in early 2014 his right eye had begun to exhibit signs of keratoconus progression along with a consecutive decrease in BCVA. A new attempt to fi t a GP lens also failed. The patient was referred to a cornea clinic for the possible necessity of CXL, who di-rected him to delay the procedure due to borderline corneal thickness of 408µm. He was scheduled for a follow up in six months but later the same year, the patient’s best-corrected vision dropped to 20/60, with marked steepening noted on corneal topography. To halt further deterioration of vision, an epithelium-on CXL procedure was performed. The postoperative recovery was uneventful, and four weeks later the patient had been scheduled for contact lens fi tting.

An examination at the time of the contact lens fi tting revealed the following fi ndings: manifest

Fig. 1. Optimal fl uorescein pattern

of silicone hydrogel mini-scleral

contact lens.

Fig. 2. Corneal topography of the left

eye reveals advanced keratoectasia.



refraction of -5.00/-6.50x125 VA 20/150 OD and -4.50/-7.50 x 110 VA 20/70 OS. Central keratome-try readings of the right eye were 56.0/57.4D with a Kmax value of 62.5D (Figure 4). A slit lamp ex-amination revealed a faint anterior stromal haze with an intact corneal epithelium (Figure 5). Fit assess-ment using the old right contact lens demonstrated an excessive rocking movement of the lens with fl uting edges upon blink. Attempts to refi t the patient’s right eye with a steeper Soft-K lens did not pro-vide suffi cient visual improvement (BCVA of 20/60). Instead, the pa-tient was selected for a trial fi tting

with a SHmS lens made from Defi nitive 65 (Filcon V4) rather than the practice’s default materi-al (Filcon V3, Contamac).

Filcon V4 is a polymer with a high-er silicone content than its predecessor, Filcon V3. Other than the high oxygen

permeability (Dk = 62) previously mentioned, the Filcon V4 material also possesses the highest mod-ulus of elasticity in the family of lathable silicone hydrogels (MPa = 1.0). Typically, lenses with a higher modulus are stiffer and will correct the underlying corneal irregularly more effectively, while those lenses with a lower modulus will simply drape over the cornea. Fitting of contact lenses with a higher modu-lus may be advantageous in terms of vision correction success, since lenses made of these materials help mask the entirety of corneal astig-matism and eliminate the need for a toric design. On the other hand, wear of stiffer lenses can lead to edge fl uting, tarsal irritation and mechanically-induced allergy. In these cases, additional adjustment of the peripheral curves is often required for successful lens wear.

This patient was fi t into a spher-ical version of the SHmS lens with a base curve of 6.5mm, “steep” peripheral curve, diameter of 17mm and central lens thickness of 0.6mm (Figure 5). The lens power was -12.5D. Four fenestration holes were added at the lens limbal zone to increase oxygen delivery and tear mixing.

Vision upon dispensing was 20/50. At the one-month follow-up appointment, the patient reported good lens tolerance with 12 to 14 hours a day of lens wearing. Visual acuity had decreased to 20/60, but improved back to 20/40- with overrefraction of +2.50/-1.50x050. The patient’s central cornea exhib-ited trace central superfi cial punc-tate keratopathy, which appeared to relate to corneal apex bearing. A new lens with base curve of 6.4mm, similar peripheral geom-etry and a power of -10.5D was dispensed. Overrefraction demon-strated similar residual astigmatism fi ndings of +0.50/-1.50x55. The patient was advised to wear poly-carbonate spectacles for correction of residual astigmatism and ocular protection. Final visual acuity of the right eye improved to 20/30-. No signifi cant corneal staining or corneal neovascularization were present at three-month follow-up. Current daily lens wearing time stands at 12 hours a day with the occasional use of lubrication agents for comfort.

3 HYDROPS HIJINKS

Successful use of full-size scleral lenses after corneal

crosslinking has also been previ-ously reported in the literature.7

Regular sclerals offer the advan-tage of minimal mechanical inter-action with the treated zone and help promote ocular surface heal-ing and provide optical benefi ts.

In this third case report, a 19-year-old male with advanced keratoconus OS and documented progression underwent an epi-thelium-off corneal crosslinking procedure in May 2013. Prior to the surgery, his maximum corne-al steepness was 64.5D with an unaided vision measurement of 20/800 (Figure 6a). Unfortunately, no pre-treatment refractive data

Fig. 4. Corneal topography of the

right eye demonstrating a classic

keratoconic nipple cone appearance.

Fig. 3. Well fi tted SHms lens. Proper allocation of the

fenestration holes (at 3 and 9 o’clock) indicates absence of

lens rotation.

CONTACT LENS USE AFTER CORNEAL CROSSLINKING



was available for this patient but postoperative recovery was positive for hypertrophic epi-thelium formation and delayed healing, which was treated using antibiotics and a bandage contact lens during the course of four weeks. At week fi ve, the patient presented back to the clinic with complaints of signifi cant pain and cloudy vision OS. His vision was reduced to CF at three feet and severe stromal edema with ruptures in Descemet’s membrane was observed (Figure 7).

The patient was treated for corneal hydrops with a fi ve-week course of topical steroids, in com-bination with antibiotic coverage during the fi rst seven days and hyperosmotic eye drops. After the patient’s cornea cleared up and the edema diminished, the patient was referred for a contact lens fi tting.

A slit lamp examination re-vealed a stromal scar of moderate density at the inferior pupillary margin, trace punctate keratop-athy of the inferior cornea, signs of meibomian gland dysfunction and fl oppy lid syndrome. Tear break-up time (TBUT) values were also low at seven to eight seconds. Corneal topography demonstrated a highly irregular corneal surface with signifi cant fl attening of the center and (Kmax value of ~50D) as compared to pre-treatment fi nd-ings (Figure 6b). Considering the

patient’s complex corneal geometry and decompensated ocular sur-face, we decided to manage this patient with a 18.5mm GP scleral lens. Incorporating the advances of reverse geometry technology, we were able to design a lens with a fl at enough base curve to more precisely follow an oblate central cornea (Figure 8). The patient’s lens-corrected visual acuity was 20/40, and, after a short adapta-tion period, he was able to achieve day-long uncomplicated lens wear. At his one-month follow-up, his BCVA was unchanged, the corne-al epithelium was intact and his TBUT values had improved to 15 seconds.

KEEP IN MIND

Though CXL is considered a po-tentially vision-saving procedure in many cases, it is not free of compli-cations. The most common side ef-fects are delayed epithelial healing, longstanding SPK, noninfectious infi ltrates and stromal edema with scarring (i.e., corneal hydrops) as well as minimal reduction in endothelial cell count secondary to UV irradiation damage.8 Despite the ocular surface complications attributed to crosslinking, however, the risks associated with corneal transplantation surgery still signifi -cantly outweigh those of CXL.

Currently, there are no clear recommendations regarding when

it’s safe to begin or resume contact lens wear after corneal collagen crosslinking. Post-CXL corneal recovery can fl uctuate over time. Crosslinking research with data on long-term follow-up has demon-strated that corneal thickness, as well as central keratometry, follows a dynamic curve in the fi rst six months.9,10 While patients following an epithelium-on proce-dure may be fi tted in a time frame of one to two weeks, patients who undergo the epithelium-off treatment may need a signifi cantly longer recovery time and may also experience a higher rate of corneal healing-related complications.

Though the epithelial defect typically closes four to seven days after the procedure, continuous epithelial remodeling followed by the modifi cation in the arrange-ment of stromal collagen fi bers and corneal nerve proliferation may be seen over several months.

Fig. 5. This image represents 6.50mm

lens with an excessive central

touch and minimal mid-peripheral

clearance. Note the presence of

the anterior corneal haze. The lens

thickness is 600µm.

Fig. 6. (A) pre-treatment corneal topography of the right eye; and (b)

topography of the same eye after the resolution of corneal hydrops. Note 14D

fl attening of Kmax.



Consequently, it is imperative that healing is achieved prior to lens fi tting to avoid mechanical disrup-tion. These changes are also re-fl ected in the further fl attening and regularization of the central cornea, and may often lead to improved spectacle-corrected visual acuity and more success with contact lenses. For epithelium-off patients, we recommend resuming contact lens wear fi ve to six weeks after the procedure, similar to post-PRK contact lens fi tting indications.11

In the fi rst months following CXL, the cornea may exhibit a thinner epithelial profi le with decreased quality of adherence between the epithelial layers. These changes may cause a higher corneal vulnerability to contact lens-induced mechanical trauma. As such, fi tting of traditional GP lens designs may prove problematic shortly after CXL; one of the most frustrating cases I have encountered recently is that of a 17-year-old male with advanced keratoconus (Kmax of 63D), who resumed wear-ing his old GP lenses three weeks after an epithelium-off procedure. One week later, he was admitted to the clinic with a complaint of signifi cant eye pain, light sensitivity and blurred vision in the treated eye. Exam revealed dense infi ltra-tive ulcerative keratitis at the center

of the left cornea. After being on fortifi ed cefazolin and gentamicin for almost two weeks, the ulcer-ation resolved but left him with a dense corneal scar and best-correct-ed vision of 20/50 (Figure 9).

One study reports that patients fi t with GP lenses three months after the procedure demonstrated evidence of epithelial cell stress with an increase in superfi cial epithelial cell size and a decrease in basal epithelial cell density.13 These fi ndings are also accompanied by a decrease in corneal sub-basal nerve plexus density. The other area of concern regarding GP lens wear after CXL is that contact lens-in-duced mechanical irritation may lead to infl ammation and consecu-tive keratocyte loss in the anterior stroma, in addition to apoptosis infl icted by UV irradiation.14

In summary, scleral and silicone hydrogel mini-scleral lenses in

particular continue to possess clin-ical importance in today’s specialty contact lens practice. The use of these new lens designs may become a preferred alternative shortly after CXL. In addition to providing successful visual rehabilitation, they minimize contact lens infl u-ence on epithelial remodeling and allow uncomplicated ocular surface recovery after the procedure. RCCL

1. Wollensak G, Spoerl E, Seiler T. Ribofl avin/ultraviolet-A–induced collagen crosslinking for the treatment of keratoconus. Am J Ophthalmol. 2003;135:620-7.2. Hafezi F, Kanellopoulos J, Wiltfang R, Seiler T. Corneal collagen crosslinking with ribofl avin and ultraviolet A to treat induced keratectasia after la-ser in situ keratomileusis. J Cataract Refract Surg. 2007; 33:2035–40.3. Caporossi A, Mazzotta C, Baiocchi S, Caporossi T. Long-term results of ribofl avin ultraviolet A corneal collagen cross-linking for keratoconus in Italy: the Siena Eye Cross Study. Am J Ophthalmol. 2010; 149:585–93. 4. Greenstein SA, Fry KL, Hersh PS. Corneal topog-raphy indices after corneal collagen crosslinking for keratoconus and corneal ectasia: One-year results. J Cataract Refract Surg. 2011; 37:1282–12905. Fernandez-Velazquez FJ. Kerasoft IC compared to Rose-K in the management of corneal ectasias. Cont Lens Anterior Eye. 2012;35(4):175-9.6. Severinsky B, Wajnsztajn D, Frucht-Pery J. Silicone hydrogel mini-scleral contact lenses in early stage after corneal collagen cross-linking for keratoconus: a retrospective case series. Clin Exp Optom. 2013;96(6):542-6.7. Visser ES, Soeters N, Tahzib NG. Scleral lens tol-erance after corneal cross-linking for keratoconus. Optom Vis Sci. 2015;92:318-23.8. Wajnsztajn D, Strassman E, David Landau D, Frucht-Pery J. Ocular surface-related complica-tions after corneal crosslinking for keratoconus. 19th Congress of ESCRS, Vienna, Austria, 2011.9. Greenstein SA, Shah VP, Fry KL, Hersh PS. Corneal thickness changes after corneal collagen crosslinking for keratoconus and corneal ectasia: One-year results. J Cataract Refract Surg. 2011; 37:691–700.10. Greenstein SA, Fry KL, Bhatt J, Hersh PS. Natural history of corneal haze after collagen crosslinking for keratoconus and corneal ectasia: Scheimpfl ug and biomicroscopic analysis. J Cata-ract Refract Surg. 2010; 36:2105–14.11. Woodward MA, Randleman JB, Russell B, et al. Visual rehabilitation and outcomes for ectasia after corneal refractive surgery. J Cataract Refract Surg. 2008;34:383–8.12. Rocha KM, Perez-Straziota CE, Stulting RD, Randleman JB. Epithelial and stromal remodeling after corneal collagen cross-linking evaluated by spectral-domain OCT. J Refract Surg. 2014;3:122-7.13. Sehra SV, Titiyal JS, Sharma N, Tandon R, Sinha R. Change in corneal microstructure with rigid gas permeable contact lens use following collagen cross-linking: an in vivo confocal microscopy study. Br J Ophthalmol. 2014;98:442-7.14. Kallinikos P, Efron N. On the etiology of keratocyte loss during contact lens wear. Invest Ophthalmol Vis Sci. 2004;45:3011–20.

Fig. 7. Corneal hydrops four weeks

after performance of the CXL

procedure in the eye with delayed

ocular surface healing.

Fig. 8. A properly fi tted 18.50mm

scleral lens on the eye with resolved

post-CXL corneal hydrops. Note

the scar-induced central corneal

fl attening.

Fig. 9. Dense central corneal scar

after an episode of microbial keratitis.

We assume that the infection was

propagated by the unauthorized

resumption of GP lens wear three

weeks after uneventful CXL.

CONTACT LENS USE AFTER CORNEAL CROSSLINKING


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Contact lenses are some of the smallest and least visible devices for correction of refrac-tive error. Considered

medical devices, they can be worn for therapeutic reasons; however, other reasons for wearing contact lenses exist, such as for cosmetic purposes.1 Contact lenses are an important part of the ophthalmol-ogist practice, with the demand for them increasing day-by-day; indeed, millions worldwide currently wear them.2 Therefore, it is also import-ant to take precautions and educate people when prescribing and fi tting these lenses.3

HISTORY

A 47-year-old female patient pre-sented to the clinic with a red left eye that had been present for the past seven days. This was accom-panied by a foreign body sensation and watering, but no discharge. She noted the presence of localized swelling on her left upper eyelid with a nodular-looking lesion. She was treated for lid cyst with chlor-amphenicol ointment by the general practitioner. Since then, however, the condition had not improved and so she decided to consult an eye spe-cialist. The right eye appeared to be without complaint or redness. The patient was a gas permeable contact lens wearer with her last wear time occurring eight days ago.

The patient exhibited no other ocular history, and her family ocular history was negative for ocular problems. She wasn’t taking any

systemic medications at the time of admittance and her best-corrected visual acuities were 20/30 OD and 20/25 OS. Pupils were round and reactive to light, with no relative afferent pupillary defect in either eye. Extraocular movements were full OU. A slit lamp examination demonstrated that the left eyelid was normal. Additionally, the left conjunctiva was white and quiet; the cornea, iris and lens were clear; and the anterior chamber was deep and quiet. Regarding the right eye, a 1.0mm by 0.7mm fi rm nodule on the center of the upper left eyelid was visible, with no periorbital erythema or edema or skin breaks (Figure 1). The right conjunctiva displayed hyperemic traits and the cornea was characterized by a few punctate epithelial erosions. The an-terior chamber was deep and quiet, the iris was round and regular and the lens was clear.

Upon inversion of the left upper eyelid, a circular foreign body was made visible, surrounded by the tar-sal conjunctiva (Figure 2). Attempts to shift it with a cotton bud were unsuccessful and subsequently, oxy-buprocaine eye drops were instilled. The object—a contact lens—was removed using typing forceps. A yellow pus discharge on the con-tact lens was observed immediately (Figure 3). Both the lens and the discharge was sent for culture and sensitivity. The patient reported in-creased comfort, and was sent home with topical ofl oxacin eye drops and the expectation that she would return in three days.

Culture results indicated the presence of Staphylococcus aureus, which proved sensitive to the ofl ox-acin. The patient reported no issue on follow-up, and was asked to continue the drop regimen for an-other week. A two-week follow-up appointment revealed everything had healed well.

DISCUSSION

Gas permeable contact lenses (GPs) are made of a complex polymer that includes silicone, PMMA and others. These lenses permit excel-lent perfusion of oxygen and are used to improve vision by correct-ing refractive errors.4 They work by focusing light so that it enters the eye with the proper power for clear vision.5 GP lenses have the main advantage of being durable with longer lifespans as compared with soft contact lenses. Modern GP lenses require a relatively short adaptation time as compared with older hard lenses, but patients still need some time to get used to them. Additionally, the size of the lenses is benefi cial as it provides for easy insertion and the fl exibility to allow them to move freely on the eye with each blink; however, their small size

ABOUT THE AUTHOR

Dr. Tallouzi is a surgical practitioner working

at Birmingham and Midland eye

Hospital. He specializes in

treatment of ocular surface

and infl ammatory eye

diseases and was awarded

the NIHR Clinical Research

Training Fellowship in 2015.

He is currently working on

his PhD at the University of

Birmingham.

By Mohammad Tallouzi, ODCASE REPORT:Look Before You Judge

The most unique cases sometimes present as the most mundane.

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can be disadvantageous as the lens may move from its position during daily activities or sports and be lost. This also increases risk for debris to become trapped underneath the lens.

This patient in particular dis-lodged her contact lens from its original position to where it sat on the palpebral or tarsal conjunctiva. The conjunctiva then began to fold over the lens. The patient report-ed she was aware of the time she placed the contact lens on the eye, but that she was not aware if and when she had lost the lens.2

Contact lens complications can vary from mild irritation to

sight-threatening issues, with result-ing problems leading to disturbanc-es of the eyelids and ocular surfaces that can result in long-term changes and a reduction in contact lens tolerance. In this case, the extended wear of a GP lens led to complica-tions that likely began as a result of abnormal blinking of the eyelid, ptosis due to a reduction of the palpebral slit and meibomian gland dysfunction.6

Other complications that might present may relate to the tear fi lm and result in dry eye due to the lack of lipids. This can lead to papillary conjunctivitis, which is intensifi ed by the mechanical irritation of the conjunctiva. Additionally, the presence of hypoxia below the lid, accompanied with an immuno-

logical reaction may also induce corneal changes like microcysts and striae such that GPs may not allow enough transmission of oxygen for successful long-term extended wear. Wear of the lens may also result in disruption of the corneal epitheli-um, corneal erosion and keratitis if not treated promptly. Corneal edema and corneal ulcers are two sight-threatening complications that can occur with contact lens wear.2,7,8

Regardless of the brand of contact lenses, however, their use requires accompanying care to prevent damage and avoid sight-threatening complications. The majority of con-tact lens complications are caused by careless handling and overwear of lenses. As such, patient education is key, as is early identifi cation of

the above mentioned conditions so that necessary medical help can be sought. RCCL

1. Farandos M, Yetisen K, Monteiro J, et al. Contact lens sensors in ocular diagnostics. Advanced Healthcare Materials. 2015 Apr 22;4(6):792-810.2. Lemp M and Bielory L. Contact lenses and asso-ciated anterior segment disorders: dry eye disease, blepharitis and allergy. Immunol Allergy Clin North Am. 2008 Feb;28(1):105-17. vi-vii.3. Dart JK, Saw VP, Kilvington S. Acanthamoeba keratitis: diagnosis and treatment update 2009. Am J Ophthalmol. 2008 Oct:148(4):487-499.e2.4. Denniston A and Murray P. Oxford Handbook of Ophthalmology. 2nd edition. Oxford: Oxford Univer-sity Press; 2009.5. Benjamin L. Training in Ophthalmology: The Essential Curriculum. Oxford: Oxford University Press; 2009.6. Beljan J, Beljan K and Beljan Z. Complications caused by contact lens wearing. Coli Antropol. 2013 Apr;37 Suppl 1:179-87.7. Compan V, Andrio A, Lopez-Alemany A, et al. Oxygen permeability of hydrogel contact lenses with organosilicon moieties. Biomaterials. 2002 Jul;23(13)2767-72.8. Ehler J, Shah C, Fenton G, Hoskins E. The Wills Eye Manual: Offi ce and Emergency Room Diagnosis and Treatment of Eye Disease. 4th edition. Philadel-phia: Lippincott Williams & Wilkins.

Fig. 2. Everting the patient’s left eyelid revealed the presence of a GP contact

lens.

Fig. 1. The patient presented with a

fi rm nodule near the center of the

eyelid of unknown origin.

Fig. 3. Lens removal led to the discovery of discharge.

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For those patients with certain medical con-ditions, contact lens-es provide a distinct opportunity to improve

patient quality of life in cases in which corneal shape is distorted or if a spectacle correction fails to provide adequate vision. Visual phenomena like glare, double vision and sensitivity to light can make processing images more diffi cult for patients; as such, in many cases non-elective procedures are the only solution to recapture a normal lifestyle. However, even when faced with the same procedures and diag-nostic codes, each vision insurance company has its own guidelines to determine what constitutes a “medically necessary” contact lens. As such, the imbalance in coverage between vision insurance compa-nies, coupled with rising health care costs, often means a policy night-mare for the eye care practitioner.

Today, most medical plans are coupled with vision care plans, though many limit medical cover-age for specialty services to just the diagnosis of the condition and cov-erage of the treatment. This creates a problem for patients seeking reso-lution for an ocular issue: they have covered access to the diagnostic services used to identify the condi-tion and the actual medical devices (i.e., corrective lenses) necessary to treat the issue, but not the medi-

cal procedures (i.e., surgery and medical treatment) they may have to undergo to enable the treatment to work. Ultimately, for patients to benefi t, the medical portion must be covered under both the vision care and medical care sides of an insurance plan.

INDICATIONS AND OPTIONS

As specialty lenses are indicated primarily for patients with irreg-ular corneas (e.g., in the case of keratoconus, pellucid marginal degeneration, scarring, post-surgical corneal abnormalities), gas perme-able materials fi gure prominently in the approach to care. GPs provide a rigid surface that neutralizes the corneal irregularity, in effect replac-ing it with the controlled regular surface of the lens. Some conditions are better served by sclerals rather than corneal GP lenses due to their design with an elevated dome and haptic zone that vaults the cornea to land on the sclera, respectively. Hybrids that combine a GP center with a soft lens periphery may be also be possible to improve comfort while custom soft lenses may suffi ce for some patients.

Beyond irregular cornea indica-tions, specialized custom contact lenses are typically also appropri-ate for most medically necessary criteria like:

• Binocular vision issues caused by the presence of nystagmus, an-

seikonia and anisometropia, as well as glare and light sensitivity result-ing from aniridia and anisocoria.

• High myopic or hyperopic pre-scriptions if visual improvement (as defi ned using Snellen acuity) with contact lenses surpasses that which is possible with spectacle wear.

• Lens use following refractive surgery and other traumatic cases, in which improved visual acuity can be demonstrated with lens wear.

However, some disputes remain regarding insurance coverage. Though patients and/or health care providers may defi ne a condition as medically necessary, guidelines for a specifi c health care plan may not agree.

Consider, for example, the role of scleral lenses. The lens design includes a fl uid compartment underneath the lens’s surface to keep the cornea hydrated; as such,

Dr. Davis practices in Oak Lawn,

Ill., where he is the director

of the contact lens clinic at

Davis EyeCare. He is also

a co-founder of EyeVis

Eye and Vision Research

Institute, where he works

developing contact lens

designs and furthering research

on anterior segment pathophys-

iology. Dr. Davis has been recognized as a

diplomate in the corneal, contact lens and

refractive technology section of the American

Academy of Optometry and is an inductee in

the National Academy Practice in Optometry

as well as an advisor to the Gas Permeable

Lens Institute and a recipient of the Gas

Permeable Practitioner of the Year Award. He

has also been honored as one of the 50 most

infl uential optometrists in 2015.

BY ROBERT L. DAVIS, ODDo you know how to work with insurance companies to

achieve the biggest bang for your buck?

Medical Plan or Vision Plan Responsibility?Medically Necessary Contact Lenses:

ABOUT THE AUTHOR

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Condition EyeMed Davis VSP Superior Humana Spectera

Anisometropia 3D in any meridian. ≥4D BVA ≥ 20/40 Intact epithelium. 3D

4D and VA improves ≥20/60

>3.5D with diplopia or With specs. aestheno-pia.

>3.5D.

HighAmetropia ±-10D ±-8D ±-10D ±-10D

KeratoconusNot correctable to 20/25 Two lines better than 20/25.

K readings or topog-raphy BVA ≤20/40 Two lines improve-ment. Absence of hydrops. Intact epi-thelium.

K readings, OCT or topog-raphy.

Topogra-phy or K readings and notes.

Two lines improve-ment. With documen-tation.

CornealEctasia

Achieve comfort and/or vision cor-rection not possible with mid- to mod-erate keratoconus. Suitable for contact lens applications.

VisionImprovement

Two lines better than specs.

Acuity <20/70 in spectacles and better than 20/70 in contact lenses.

Aphakia

BVA ≥20/100 Aphakia without implant. No corneal or vitreous opacity. Intact macu-la. Intact epithelium.

Included.

Glasses provided together with con-tact lenses.

Doctor must certify that contact lenses are medically necessary.

Aniseikonia

Unequal image size between the two eyes. Intermittent or constant diplo-pia. Less than 100 degrees stereopsis. Intact epithelium.

Aniridia Surgical or traumatic.

IrregularAstigmatism

≥2D principle merid-ians are separated < 90 degrees. Two lines of improvement. BVA <20/70.

Included.

Nystagmus Included.

CornealTransplant Included.

CornealDystrophy Included.

ColoredContact Lenses

For achroma-topsia, albi-nism, aniridia, anisocoria, or polycoria pupil abnormality.

Table 1. A Comparison of Medically Necessary Contact Lens Vision Care Plans



Test New Wearer Existing Wearer

Contact Lens-Related History Required Required

Keratometry and/or Corneal Topography Required Required

Anterior Segment Analysis with Dyes As Indicated As Indicated

Biomicroscopy of Eye and Adnexa Required Required

Biomicrscopy with Lens: Fluorescein Pattern (Rigid Lenses) or Orb Movement and/or Centration (Soft Lenses) Required As Indicated

Overrefraction As Indicated As Indicated

Visual Acuity with Diagnostic Lenses Required As Indicated

Determination of Contact Lens Specifi cations Determined to Obtain the Final Prescription As Indicated As Indicated

Member Instructions and Consultations Required Required

Proper Documentation with Assessment and Plan Required Required

Table 2. EyeMed Insurance Coverage for Contact Lens Wearers

MEDICALLY NECESSARY CONTACT LENSES

these lenses are well-suited for the treatment of severe ocular surface diseases like corneal stem cell defi -ciency, Stevens-Johnson syndrome, chemical and thermal injuries to the eye, ocular pemphigoid, neuro-trophic corneas, severe dry eye from Sjögren’s syndrome, chronic graft-versus-host disease, ocular radia-tion, corneal exposure and corneal disorders associated with systemic autoimmune diseases such as rheu-matoid arthritis. The question is, however, whether these are medical conditions, or whether they covered under primary vision care. It often varies among providers.

TAKING RESPONSIBILITY

Most health care plans determine the criteria for their respective covered population. For example, contact lenses for masking irreg-ular astigmatism associated with keratoconus and other corneal disorders requires certain documen-tation from the initial exam and follow-up visits to cover requests for coverage.1 Additionally, the patient’s fi rst visit to the clinic must include a comprehensive eye exam, performance of advanced corneal topographic modeling or keratom-etry and documentation of the lens

fi tting process.1 Failure on the part of the practitioner to adhere to these criteria may lead to disqualifi -cation from reimbursement.

Table 1 correlates the different covered conditions with corre-sponding vision care plans. Note that each offers different coverage for different conditions; uniformity is rare and should not be expected. As such, it is the responsibility of the practitioner to inform the in-surance carrier of the needs of their patient population.

Because we live in an era where most doctors are held accountable for their actions—including and especially billing policies—proper documentation is the best way to guarantee passing an audit and receiving payment for the work provided. As such, the contact lens fi tting, dispensing and follow-up visit must each be separately doc-umented in the practice’s medical records, with a thorough record made of all services provided. This includes patient pick-up of a reordered contact lens prescription or other ancillary events that may occur later on.

Typically, records should include the prescription, number and mate-rial type of contact lenses dispensed;

patient lens wear and replacement schedule; recommended care and cleaning instructions; any data from the fi tting appointment; visual acuity measurements taken both through the lenses and overrefrac-tion; and the date the fi nal lenses were dispensed. Additionally, practitioners should ensure they have a documented contact lens history on fi le. This should include information on the use and care of the patient’s lenses in their work environment; hobbies and daily routines; previous lens experience and any type of lens accoutrement used.

The patient’s lens fi t and evalu-ation appointment should include keratometry or topography, with proper diagnosis made if a corneal anomaly like corneal distortion or an ectatic disease is initially suspect-ed. Recorded observations from a slit lamp should document both views with a diagnostic contact lens for the purpose of assessing fi t and the patient’s eye sans-lens to assess the ocular health of the cornea, conjunctiva, sclera, tear fi lm and eyelids. Overrefraction with the contact lenses should be recorded monocularly, with visual acuities noted for each trial lens tested,



as well as the fi nal contact lens prescription. A short narrative as-sessment of the patient’s subjective response and/or the doctor’s ob-jective response regarding the state of the contact lens ordered should also be written; this should include comments on the clinical fi ndings, impressions and diagnosis.

Additionally, practitioners should add notes on their planned treat-ment plan to the patient’s fi le, with information like the contact lens materials and parameters included. Dispensing visit documentation should contain instructions pre-scribed to the patient for their lens care regime, handling and wear schedule. Finally, a description on the patient’s ability to apply and remove the contact lenses, as well as fi nancial records relating to the or-dering of the fi nal lens prescription and a comment regarding whether the contact lenses were dispensed from stock for record-keeping purposes may also be prudent to include.

Records taken at follow-up ap-pointments of the patient’s progress should document their positive and negative comments related to wear-ing the lens, as well as the patient’s report of their level of compliance with practitioner instructions. Notes on the patient’s advances in their lens wear should include mon-ocular acuities and overrefraction as well as slit lamp observations docu-menting the lens on the cornea and the health of the corneal surface and surrounding tissues. Finally, any new clinical fi ndings or changes in lens care, wearing or replacement recommendations should be written down for the purposes of updating treatment plan records. When docu-menting medical necessity, it may be useful to include pachymetry, specu-lar microscopy, tear fi lm assessment including osmolarity, Infl ammaDry scores, staining assessment with

both NaFl and lissamine green, meniscus height, tear break-up time and the status of the meibomian glands.

Table 2 lists an example of one company’s (EyeMed) test require-ments for provision of coverage to new and existing contact lens wearers. In comparison, other companies require itemized fi nan-cial records for medically necessary contact lenses to include: patient name; date of service; contact lens brand, type, quantity and date dis-pensed; customary costs for services and materials; amount billed to the insurance, amount paid by the patient and method of payment.

RETURN TO BASE

Going back to the question at hand—whether medical care plans and vision care plans should make a greater effort to overlap coverage for the patient—a related point is this: even with dual coverage, many of the medically necessary treatments fall through the cracks because vision care plan providers and medical care plan providers believe the procedure in question is not in their sphere of coverage. As such, both practitioners and their patients are the ones to take the hit. However, we may have the ability to make a difference.

First and foremost, we as prac-titioners must educate the medical plan coordinator as to the differ-ence between a vision care expense and the need for coverage for a medical condition. If this need is not successfully communicated, the patient is left with the confusing scenario of not understanding why their medical condition is not cov-ered by the vision care plan. Vision care plans should strive to provide a better environment for our patients, streamline the approval process and create improved billing effi ca-cy for eye care providers to em-

ploy. Customizing the coverage of medically necessary contact lenses may also help insurance companies develop a competitive advantage for their products in the marketplace. Creating clear guidelines may also help develop a more uniform cate-gorization system for practitioners to divide patients into, leading to improved effi ciency of submission for reimbursement and a reduction in the costs associated with billing for services.

Many industry watchers believe that separating the refraction tests from the medical eye health exam is coming in the future. The era of bundling services is a concept of the past. Each procedure will have its own billing code with corre-sponding payment. ICD-10 is the fi rst attempt to breakout diagnostic codes, and procedure codes will be the next project CMS will attempt to streamline. With the consolida-tion of medical insurance compa-nies in our immediate future, the trickle-down effect will soon reach the vision care plan providers with medical guidelines fi ltering into our vision insurance plans. Educating administrators with regards to the complete needs of our patients—both on the vision care side as well as the medical care side—will also allow patients that may not be aware of current options to receive the services they require.

Health care insurance is an ever-evolving entity, and con-

tact lens practitioners must remain informed of changes that impact the care we provide. We must remem-ber that some medical conditions require contact lenses as a serious form of treatment. For some peo-ple, they are not simply a cosmetic option. RCCL

1. Aetna. Contact Lenses and Eyeglasses. Available at: www.aetna.com/cpb/medical/data/100_199/0126.html. Accessed February 3, 2016.



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

Practice Progress

Brimonidine is an interesting molecule to consider. As an alpha-2 adrenergic agonist, many prac-

titioners may most often think of this medicine for its use in treating glaucoma. The majority of brimonidine’s activity resides in its ability to decrease aqueous production from the ciliary body, though it also helps to facilitate some extra aqueous drainage through the trabecular mesh-work. Currently, brimonidine is available in three commercial concentrations: 0.1%, 0.15% and 0.2%.1

So the question is, why would we bring this drug up in a contact lens column? Because brimonidine has an interesting side effect profi le that may prove useful to some lens wearers. Due to its activity on the alpha-2 receptor, it also acts to prevent pupil dilation under mesopic and scotopic conditions. This is done via the inhibition of the release of norepinephrine from the pre-synaptic nerve terminal in the cleft of the dilator muscle,

which allows the tonus of the sphincter muscle to take over and ultimately reduces the pupil’s size (Figure 1).2 Here, we will discuss three common uses for brimonidine in the contact lens wearer.

Orthokeratology. Some pa-tients are able to wear ortho-keratology lenses overnight to facilitate gentle progressive remodeling of the cornea’s shape to remove the need for spectacle or contact lens wear during the day. The most common type of refractive error corrected using orthokeratology lenses is my-opia, though advanced designs now also allow for higher levels of astigmatism to be corrected as well via fl attening of the central topography of the cornea to cre-ate a midperipheral steep curve. This results in a corneal appear-ance topographically similar to that of a postoperative LASIK cornea (Figure 2).

But, just as physiological pupil dilation can affect a postoper-ative LASIK patient’s vision in the evening, so too can it affect a patient who has undergone

orthokeratology treatment, as the pupil has the opportunity to dilate out to the edge of the treatment zone in certain condi-tions, potentially affecting vision. Increasing the size of the treat-ment zone with modifi cations to the lens size or decreasing the sagittal depth of the lens can assist with increasing the size of the treatment zone. In this case, one alternative is to have a patient use a drop of brimo-nidine in mesopic and scotopic conditions where vision may be sub-par.

Multifocal Gas Permeable Lenses. Some of these rigid lenses may at times have their optical zones located on their front surface, while other options will contain some of the multifocal optics on both the anterior and posterior surfaces of the lens. Multifocal GP lenses are typi-cally designed with the distance optics located in the middle of the lens and slowly progressing to the near optics towards the midperipheral and peripheral portions of the lens. Success with multifocal GPs requires appropriate centration both horizontally and vertically. Any signifi cant displacement from the location of the pupil in either of these meridians will affect visual clarity for the patient.

When appropriately aligned, multifocal GPs provide excellent distance vision and the opportu-nity for translation into the near optics of the lens. Of course, there are environments that may make the vision somewhat more challenging for these individuals.

Consider these alternative uses for this common glaucoma treatment.

Brimonidine Breakup

Fig. 1. (a) infrared pupil readings prior to the instillation of brimonidine; (b)

fi ve minutes after the instillation of 0.1% brimonidine.

040_RCCL0616_PP.indd 40040_RCCL0616_PP.indd 40 5/31/16 4:31 PM5/31/16 4:31 PM


One example is levels of low light, such as when driving near sunset. Depending on the amount of pupil dilation that occurs in these individuals, their pupils may widen into the region of the lens in which the distance optics begin to transition into the near optics. Fortunately, most GP lens designs can be altered to increase the distance center portion of the lens to allow for pupil dilation with less interference of the near optics.

It is in this case that topical brimonidine may be benefi cial as an alternative to moving the zones of the lens to compensate for mesopic and scotopic condi-tions. This would provide poten-tial visual benefi ts to the patient without the need to change the properties of the lens itself. Additionally, since the GP lens material won’t absorb the med-ication, the drug can be applied without removing the lens.

Small Diameter Lenses for Corneal Ectasia. At times, the GP lenses that practitioners fi t their irregular corneal patients with are slightly smaller than typical to compensate for how steep the curves on the back of the lenses are. Interestingly, this can create challenges for patients wearing these lenses in the eve-ning, as their pupils may dilate outside of the optical zones of the lenses (Figure 3). In these instances, we can create larger lenses with aspheric back surfac-es to compensate. Additionally, semiscleral, scleral and hybrid lenses are often times options for these individuals as well.

However, controlling pupil size with brimonidine may also be an option if the patient wishes for the lens characteristics to remain the same.

PRESCRIBING HABITS

Take note that while the above information constitutes sugges-tions for brimonidine use, min-imizing pupil dilation with this drug is not an FDA-approved indication for the product. As such, before proceeding with a prescription for patients in the instances discussed, we feel it necessary to mention this fact to them to ensure they are com-fortable using the medication in such a manner. As with any off-label indication, the benefi ts of treatment must outweigh the risk of adverse events that may result from it. Note, brimonidine use can in some cases lead to dry mouth or a tired feeling.

We typically prefer to pre-scribe brimonidine in its lowest commercially available concen-tration, which is 0.1% available as Alphagan P 0.1% (Allergan). We also send instructions with the prescription as follows: Sig:

1 gt OU prn for critical viewing tasks. This statement provides appropriate guidance to the pharmacist that the drug is not to be used on a chronic basis.

Keeping this solution in mind to enhance the vision for

those who may be having some diffi culties will help enhance their visual outcomes as nothing else can. So, look into it. RCCL

1. Allergan. Alphagan P Prescribing Information. Available at: www.allergan.com/assets/pdf/al-phaganp_pi.pdf. Accessed May 8, 2016.2. Shemesh G, Moisseiev E, Lazar M, Kesler A. Eff ect of brimonidine tartrate 0.10% ophthalmic solution on pupil diameter. J Cataract Refract Surg. 2011 Mar;37(3):486-9.

Fig. 2. Orthokeratology lens on the eye (left) and the topography of the

cornea when the lens is removed (right).

Fig. 3. Small diameter lens off -

center in which the lens edge is

approaching the pupil margin nasally.

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By Gary Gerber, OD

Out of the Box


Making the Best of ItSometimes the situation does not go the best way it can. Here’s how the right attitude can make the diff erence for your patients.

The airline recently lost my bag. Nothing is notable about this fact in and of itself—actual-ly, it’s happened before.

And indeed, the initial drill this time was the same as every other time: wait in a line and fi ll out a form describing what the bag looked like, give the agent your the baggage stub and pray. Sometimes you get lucky and they fi nd the bag with enough time to put it on the next fl ight; other times, you may receive it a few days later having survived with just your carry-on. I knew that chances were I’d get it back eventually, I just didn’t know when.

This particular time took a dif-ferent turn, however, once I arrived at the front of the line to speak to the agent there. Admittedly, she had a pretty thankless job since by defi nition, everyone she deals with is unhappy, so I wasn’t expecting much. Of note, however, was the way in which she dealt with me specifi cally—it made me think about the way many of us and our staff members deal with the pa-tients who come into our practices.

Now, there isn’t much she could have done in terms of recovery short of snapping her fi ngers and producing the lost luggage then and there. What she did do, however, was display a funny and empathetic personality that helped ease the otherwise negative ordeal.

Thinking about every other employee I’ve ever encountered or seen at the airport, she stood out as different to me in a profoundly positive way. My impression of her

willingness to help, and the clear acknowledgment that I was truly inconvenienced by the lost luggage was even further helped when she said, at least what you’re wearing now will work great for everything from a corporate business meeting to a rock concert to a trip to the beach. But, I understand—you’d prefer the gold tuxedo in your suitcase. I’ll try and get it to you as quickly as I can.

KEEP ONE HAND

ON THE WHEEL

There are many things that occur in the eye care offi ce that to a large extent, we cannot control. Take for example, a patient with an insurance benefi ts package that only covers the cost of a single examination every two years. When you recommend to them that they come in each year, they may become frustrated. How do you soothe this situation? The knee-jerk response for many practitioners is to simply tell the patient, we’re sorry, that’s how your insurance works. It’s not our fault and send the patient on their way. However, though this is factually accurate, it’s not the best way to deliver this information. What if the luggage hunter (her self-given name) I encountered at the airport said, yeah, I agree—it’s too bad the airline lost your luggage. Nothing I can do about it, though!

Many of us understand the benefi ts of turning a bad custom-er service situation into a good one by going above and beyond using a service recovery strategy.

Yet, few people recognize that even in day-to-day interactions with patients—whether things go smoothly from the get-go or not—an unexpectedly pleasant doctor and staff demeanor can be just as memorable. This behavior should be an integral part of your practice culture, as there are invariably many more times that things will go right instead of wrong as a result, and many more patients—essentially all of them—that will be impacted in a better way. As an exercise for your staff mem-bers, work out some hypothetical patient encounters that happen frequently and challenge your staff to consider the following: how can a routine, mundane patient-facing task be changed in such a way that patients immediately see it as a positive encounter instead of a negative or even neutral one? And, how can our personal execution and involvement in this task be modifi ed so patients see us as a more memorable and positive advocate for their care?

Though the answer to these questions likely depends on the dynamics of the practice and its staff members, one factor to note: don’t think in terms of “big heroic actions” like getting a certain pair of back-ordered lenses in faster. Instead, focus on the key “daily grind” items like booking appoint-ments, escorting patients, com-pleting clinical tests and all of the other small tasks that, when done correctly and in a timely manner, gel together to form your patient’s good experience with your prac-tice. RCCL

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