technology your practice - review of cornea & contact lensestechnology • ce course on new...

Technology

• CE Course on New Corneal Diagnostic Devices

• New Technologies to Improve Dry Eye Clinical Evaluation

• Do Mobile Apps “Click” With Contact Lens Wearers?

• Consumer Web Search Trends on Contact Lens Safety

• Iontophoresis For Drug Delivery — Pressing Forward

• Derail Dropouts with Better Pupil Measurement and Control

Supplement to

OCTOBER 2013

&Your Practice:

“SWITCH ON” FOR GREATER SUCCESS!

OCTOBER 2013

001_rcl1013_cover.indd 1 10/8/13 5:32 PM

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contents

22 New Technologies That Won’t Leave You Out to Dry

Recent advances in dry eye technology are improving the accuracy of test results, while at the same time simplifying and expediting the diagnosis of the disease.Frank Auletto, Associate Editor

Review of Cornea & Contact Lenses | October 2013

Departments 4 News Review

Do smartphones belong in the exam room?; Using infrared contact lenses to cheat casinos; Long-term supplement use improves dry eye

6 EditorialLiving With the Microbial WorldJoseph P. Shovlin, OD

7 Lens Care UpdateContact Lens Solutions 101 Christine W. Sindt, OD

9 Derail DropoutsShedding Light on Pupil Size Dynamics Jason R. Miller, OD, MBA, and Mile Brujic, OD

12 Down on the PharmOcular Drug Delivery — Pressing ForwardTammy P. Than, OD, MS, and Elyse L. Chaglasian, OD

14 Gas-Permeable StrategiesHybrids for Irregular Scleral ShapesJason Jedlicka, OD

34 Out of the BoxHear Ye, Hear YeGary Gerber, OD

Technology & Your Practice

16 CE — Taking a Closer Look at the Cornea

Advances in corneal diagnostic technologies are improving measurement and reading accuracy, while simplifying corneal examination. David I. Geffen, OD

26 Do Mobile Apps “Click” With Contact Lens Wearers?

Global smartphone uptake is rapidly growing, and consumers are turning to apps to improve daily life. But is there any place in this market for contact lens apps?Brian Chou, OD, and Ron Walker

REVIEW OF CORNEA & CONTACT LENSES | OCTOBER 2013 3

30 What Do Consumers Want to Know About Contact Lens Safety?Patients increasingly rely on the internet for answers about contact lens safety. But are they getting the right answers?Thomas G. Quinn, OD, MS

/ReviewofCorneaAndContactLenses #rcclmag

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News Review

VOL. 150, No. 7

Do Smartphones Belong in the Exam Room?

Infrared Contact Lenses Used to Cheat Casino

A recent study evaluated the capability of smartphones to capture images of the fundus

in both human and rabbit eyes. The study, published in Journal

of Ophthalmology, was conducted by a team of researchers from the Massachusetts Eye and Ear teach-ing hospital at Harvard University using the “Filmic pro” app for the Apple iPhone and a 20D lens, with or without a Koeppe lens. The system was tested on children under anesthesia, adults who were awake during the procedure and rabbits.

The researchers extracted high-resolution still photographs from the footage after recording the exam, thanks to the advanced ca-pabilities of the app, coupled with the 20D lens. Using a Koeppe lens further improved the results.

Previously, researchers concluded

that the iPhone’s native video cap-ture capabilities were not adequate for retinal examination, but the “Filmic pro” app offers users ad-vanced control over the video cap-ture process, such as direct control of focus, exposure and lighting.

The rapid advances in smartphone technology are leading to limitless potential for their use in the fi eld of health care. Using smartphones in the exam room offers practitioners a far more affordable option for clinical photography than highly expensive professional cameras. The technol-ogy also gives eye care professionals a powerful, portable tool for conduct-ing ocular examinations outside of the exam room. More technological advances in smartphone technology will only further increase the capabili-ties of these devices in and out of the exam room.

Law enforcement called the bluff of two separate poker play-ers who allegedly used infra-

red contact lenses to cheat casinos. According to news reports, Italian national Stefano Ampollini and New Jersey native Bruce Koloshi used invis-ible ink, marked cards and infrared lenses to tilt the odds in their favor. Police in the US and Europe said it’s the first time they’ve heard of cheaters using infrared lenses to bilk casinos. A French court sentenced Ampol-

lini to two years in jail. Koloshi was arraigned in Connecticut last month.

Ampollini, who said he ordered his lenses from China, won more than $120,000 from a casino in Cannes before being caught. He piqued the interest of casino security after winning more than $95,000 and folding two good hands. He admitted that his special contact lenses “were designed to see things that you normally wouldn’t be able to see.”

4 REVIEW OF CORNEA & CONTACT LENSES | OCTOBER 2013

In The News

• Bausch + Lomb will soon have a new edition to its frequent replace-ment lens line. The company has received marketing clearance from the FDA for a new monthly dispos-able silicone hydrogel lens. The new lenses, which will only be available with a prescription, are formulated to address the growing demand for comfort and improved vision through-out the day.

• Scientists with the National Institute of Health Research and UCL Institute of Ophthalmology have iden-tifi ed a new rare gene variant that predisposes people to age-related macular degeneration. More than 50 researchers from 30 countries sequenced DNA from 10 regions of the genome that had been previously linked to AMD and identifi ed two rare variants that are associated with increased AMD risk.

According to researchers, the results demonstrate the importance of ab-normal immune function and should lead to new treatments.

• A PhD student at the Brien Holden Vision Institute and the School of Optometry and Vision Science at the University of New South Wales believes he has come up with a solu-tion for infl ammation and infection in contact lens wearers. Debarun Dutta has been working on a novel antimi-crobial coating for contact lenses that uses melamine, a cationic peptide that is strongly active against a num-ber of ocular pathogens, including bacteria, fungi and Acanthamoeba.

The coating is heat stable, wet-table and does not have any effect on the physical dimensions of the contact lenses. This discovery could potentially lead to a reduction in microbial contamination and infection in contact lens wearers.

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Advertiser IndexAlcon Laboratories .......................................................Page 8, Cover 4

Bausch + Lomb ...................................................................... Page 33

CooperVision ........................................................................... Cover 3

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

JOBSON PROFESSIONAL PUBLICATIONS GROUP11 Campus Blvd., Suite 100Newtown Square, PA 19073Telephone (610) 492-1000Fax (610) 492-1049

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

EDITORIAL STAFFEDITOR-IN-CHIEFJack Persico [email protected]

ASSOCIATE EDITORFrank Auletto [email protected]

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

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

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

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

CONSULTING EDITORStephen M. Cohen, OD, [email protected]

SENIOR ART/PRODUCTION DIRECTORJoe Morris [email protected]

GRAPHIC DESIGNERMatt Egger [email protected]

AD PRODUCTION MANAGERScott Tobin [email protected]

BUSINESS STAFFVICE PRESIDENT OPERATIONSCasey Foster [email protected]

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EDITORIAL BOARDMark B. Abelson, MDJames V. Aquavella, MDEdward S. Bennett, ODBrian Chou, ODS. Barry Eiden, ODGary Gerber, ODSusan Gromacki, ODBrien Holden, PhDBruce Koffler, MDJeffrey Charles Krohn, ODKenneth A. Lebow, ODKelly Nichols, ODRobert Ryan, ODJack Schaeffer, ODKirk Smick, ODBarry Weissman, OD

REVIEW BOARDKenneth Daniels, ODMichael DePaolis, ODDesmond Fonn, Dip Optom M OptomRobert M. Grohe, ODPatricia Keech, ODJerry Legerton , ODCharles B. Slonim, MDMary Jo Stiegemeier, ODLoretta B. Szczotka, ODMichael A. Ward, FCLSABarry M. Weiner, OD

Long-term Fatty Acid Use Improves Dry Eye

Six months of supplemental use of gamma-linolenic acid (GLA) and omega-3 (n-3) polyunsatu-

rated fatty acids (PUFAs) improves ocular irritation symptoms, main-tains corneal surface smoothness and inhibits conjunctival dendritic cell maturation in postmenopausal patients with keratoconjunctivitis sicca, a recent study reports.

Notably, the study also suggests that long-term supplementation reduces the infl ammation and pain associated with dry eye.

Conducted by John D. Sheppard, MD, et al., the study examined the effect long-term supplementation with GLA and n-3 PUFAs had on the production of infl ammatory media-tors implicated in the pathogenesis of chronic dry eye. The six-month, mul-ticenter, double-masked clinical trial, published in the October 2013 edition of Cornea, randomly supplemented 38 postmenopausal tear dysfunction pa-tients with either GLA and n-3 PUFAs or a placebo.

Subjects had a number of disease parameters assessed at baseline, and then again at four, 12 and 24 weeks. The parameters assessed included Ocular Surface Disease Index (OSDI), Schirmer test, tear breakup time, conjunctival fl uorescein and lissamine green staining, and topographic cor-neal smoothness indexes. Conjunctival

impression cytologies were also used to measure dendritic cell CD11c integ-rin intensity and HLA-DR expression in subjects.

After 24 weeks, the OSDI score showed signifi cant improvement following supplementation (21 ± 4) when compared to placebo (34 ± 5). Surface asymmetry index also showed improvement at the 24-week mark in the supplemented patients (0.37 ± 0.03) vs. placebo (0.51 ± 0.03). Neither treatment was found to have any effect on tear production, tear breakup time, or corneal or conjuncti-val staining.

Also, placebo treatment showed a signifi cant increase in both HLA-DR intensity (36% ± 9%) and CD11c intensity (34% ± 7%) after 24 weeks. The stability in HLA-DR expression observed in the supplement-treated subjects may suggest a gradual mitiga-tion of infl ammation, but further studies must be conducted before this is confi rmed.

The researchers did not evaluate pain associated with KCS, but the OSDI includes criteria for pain assess-ment. These scores associated with pain showed signifi cant improvement in KCS patients following supplemen-tation. Sheppard JD Jr, Singh R, McClellan AJ, et al. Long-term supple-mentation with n-6 and n-3 PUFAs improves moderate-to-severe keratoconjunctivitis sicca: A randomized double-blind clinical trial. Cornea. 2013 Oct; 32(10):1297-1304.

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This month, I have decided to jump on the Demodex infestation bandwagon.

The topic is germane due to the myriad ocular signs and symp-toms that can result from mite infestation, ranging from seem-ingly harmless lash collarettes to corneal manifestations such as vascularization and opacity. Let’s consider the likely connec-tion between mite infestation and rosacea, and Demodex’s potential to serve as a bacterial vector.

For over a century, mites have been seen in a variety of habitats and, for at least a few decades, linked to a form of blephari-tis.1 Unfortunately, it was easy to dismiss Demodex, as it was thought to be only commensal, and not recognized as a poten-tial human pathogen, in part because of its ubiquity, as well as the diffi culty and rarity of visualizing the mites.1 (Most organisms living in or on the body represent commensals, but the designation might require some attention to microbial competition or antagonism.2)

Recently, there has been a resurgence of attention toward identifying Demodex mite infes-tation as a reason for signifi cant ocular morbidity.1,3-5 But the mite’s ability to impart havoc depends on the host’s innate immunity and response (current state and HLA typing), and the surrounding fl ora in which the mites thrive.1-3

In humans, only two species of Demodex (folliculorum and brevis)4 have been identifi ed and believed to play a role in three

facial conditions: pityriasis fol-liculorum, rosacea-like democi-dosis and democidosis gravis.5

There is statistical association between Demodex mite density and rosacea, facial itching and blepharitis.4 Papulovesicular rosacea-like lesions and spiny blepharitis often respond to treatments that reduce the number of Demodex mites.3,4

Controversy exists in whether the mites play the main role in the pathophysiology or a more minor role as the player aggravating rosacea in some patients.2,4

The Missing Link?It now appears that a link

exists between the bacteria Bacillus oleronius, carried by Demodex, and rosacea. The strong correlation between ocular Demodex infestation and serum reactivity to Bacillusproteins provides a better understanding of comorbid-ity between Demodex mites and symbiotic Bacillus in facial rosacea and blepharitis.4 The bacterium isolated from the mites may enable follicular-based infl ammatory changes in papulopustular rosacea; it also has the potential to involve deep sebaceous gland, and even sub-cutaneous, tissue.1,4,5

A timely diagnosis that includes simple lash epilation and viewing mites under light microscopy or rotation (twirling the lash to expose the cylindri-cal mites) is important.1

Treatment options, dis-cussed in detail elsewhere,1,5

include ether, turpentine, sulfur

preparations, Camphor oil, oil of oregano and tea tree oil. Unfortunately, all the above can be quite irritating to the ocular surface and skin. Compounded 1% ivermectin can be applied to the lash area in the evening for at least three to four weeks.1

Using a facial cleaner appears to be equally important to treating the lid area.

Immunocompromised patients or those on immuno-suppression therapy have an increased number of mites on the skin and lid area.4 Demodex folliculorum were more fre-quently detected in patients who had previously been treat-ed with topical corticosteroids.4

And, unfortunately, topical cor-ticosteroid agents are often the mainstay of therapy in blepha-ritis patients.

It’s easy to dismiss Demodex as innocuous, since many patients will not be symp-tomatic with mite infestation. We must constantly be on the lookout for conditions like mite infestation—the often unseen pests that can either cause or contribute to ocular complica-tions. Fortunately, attention has rebounded recently, bringing added awareness to this condi-tion. RCCL

1.http://www.youtube.com/watch?v=sgav_kZ_Hi42.http://www.mansfield-ohio-state.edu/~sabedon/black14.htm 3.Forton F, Germaux MA, Brassuer T, et al: Demodicosis and rosacea: epidemiology and significance in daily dermatologic practice. J Am Acad Dermatol. 2005 Jan;52(1):74-87.4.Li J, O’Reilly N, Sheha H, et al: Correlation between ocular Demodex infestation and serum immunoreactivity to Bacillus proteins in patients with facial rosacea. Ophthalmol. 2010 May;117(5):870-877.5.Clyti E, Sayavong K, and Chanthavisouk K: Demodicosis in a patient with HIV: successful treatment with Ivermectin. Ann Dermatol Venereol. 2005 May;132(5):459-461.

Living With the Microbial World

Editorial By Joseph P. Shovlin, OD

Our commensal creatures can overwhelm the eye’s defenses if left unattended.

006_rccl1013_ed.indd 6 10/8/13 6:54 PM

Lens Care UpdateBy Christine W. Sindt, OD


I am an educator, so I have a tendency to think about the minute devilish details,

how those details fi t into the big picture and—most importantly—how I’m going to teach them. Recently, as I was reviewing con-tact lens solutions with my wide-eyed, mortifi ed looking residents, I realized I had lost sight of the big picture. I had drifted so far away from the basics that I had lost the message altogether.

The basics of contact lens solutions that I’ve slowly moved away from are actually some of the most important aspects of lens care to understand: how they clean, disinfect and wet the lens surface to provide comfort-able and safe contact lens wear.

So, let’s take some time to step back and review some of the basics of contact lens solutions. These products contain two major ingredients: surfactants and disinfectants. This month’s column will focus on the role each of these ingredients play in the fi nished product.

SurfactantsA surfactant, or surface-active

agent, is used to both clean and wet the contact lens. Surfactants are composed of both hydrophil-ic and hydrophobic ends in the molecule structure.

In the case of surfactant clean-ing products, the hydrophobic ends cluster around debris to form micelles. The free hydro-philic ends are then able to react with water, and the micelle can then be whisked off the lens sur-

face. This creates a process that is very similar to what happens when we wash our hands with soap.

In the case of a surfactant wet-ting agent, the hydrophobic end interacts with the dry hydropho-bic lens surface, allowing the lens surface to regain hydrophilicity, as well as lubricity. The size of the surfactant molecule affects how tightly it will bind to the lens surface, and subsequently how long it will stay on the lens surface.

Newer generation contact lens solution surfactants are custom designed specifi cally to interact with hydrophobic silicone to cre-ate a more comfortable and long lasting wettable silicone hydrogel experience.

DisinfectantsThere are three major chemi-

cal disinfectants currently on the market: biguanides (primarily poly-hexyl-methyl-biguanide, aka PHMB), polyquaterium-1 (Poly-quad) and peroxide.

PHMB is a cationic disinfectant that has effi cacy against both gram-negative and gram-positive bacteria. PHMB also has some effect against Acanthamoeba. Its effi cacy is attributable to the elec-trostatic interaction of cationic sites of PHMB with anionic sites of the bacterial cell membrane. These interactions result in the disturbance of the membrane structure and the leakage of intracellular components.

Polyquad is a cationic surfac-tant that is larger in size than

PHMB. Polyquad also affects the phospholipid membrane but, be-cause of its size, it has a reduced uptake and release pattern in contact lenses and cases.

PHMB and Polyquad can be used together or with other anti-microbial agents to broaden anti amoeba/antifungal disinfection.

Hydrogen peroxide is a potent disinfectant because it is lipid soluble. It produces hydroxyl free radicals, which attack and penetrate lipid-containing cell membranes, and subsequently destroy DNA, mitochondria and other cell components. Perox-ide is active against amoebae, protozoa, viruses, bacteria and fungi, but its effi cacy depends on contact time and concentration. It’s worth noting that perfect disinfection occurs at four hours of straight 3% peroxide, but no commercially available products are capable of achieving this.

These “basics” may seem simple enough, but things can be-come complicated rather quickly. Adding chelating agents, other wetting agents (such as hyaluro-nate or methylcellulose), buffer-ing agents, compliance issues, the vast chemistry of lens materials, real-world bugs with varying virulence, contact lens cases and, of course, the human eye, can make keeping the patient “com-fortable and safe” seem nearly insurmountable.

Of course, no task is truly insurmountable if proper atten-tion to detail is paid—and as I’ve often heard, “the devil’s in the details.” RCCL

It’s important to sometimes step back and revisit the basics to better understand how solutions work, so that we can identify the appropriate options for each patient.

Contact Lens Solutions 101

007_rcl1013_lenscare.indd 7 10/8/13 6:55 PM

*AIR OPTIX® AQUA (lotrafi lcon B) and AIR OPTIX® AQUA Multifocal (lotrafi lcon B) contact lenses: Dk/t = 138 @ -3.00D. AIR OPTIX® NIGHT & DAY® AQUA (lotrafi lcon A) contact lenses: Dk/t = 175 @ -3.00D. AIR OPTIX® for Astigmatism (lotrafi lcon B) contact lenses: Dk/t = 108 @ -3.00D -1.25 x 180. **Compared to ACUVUE^ OASYS,̂ ACUVUE^ ADVANCE,̂ PureVision,̂ Biofi nity^ and Avaira^ contact lenses. †Superior lipid deposit resistance compared to ACUVUE^ OASYS,̂ ACUVUE^ ADVANCE,̂ PureVision,̂ Biofi nity^ and Avaira^ contact lenses. ††Image is for illustrative purposes and not an exact representation. T̂rademarks are the property of their respective ownersImportant information for AIR OPTIX® AQUA (lotrafi lcon B), AIR OPTIX® AQUA Multifocal (lotrafi lcon B) and AIR OPTIX® for Astigmatism (lotrafi lcon B) contact lenses: For daily wear or extended wear up to 6 nights for near/far-sightedness, presbyopia and/or astigmatism. Risk of serious eye problems (i.e., corneal ulcer) is greater for extended wear. In rare cases, loss of vision may result. Side effects like discomfort, mild burning or stinging may occur.Important information for AIR OPTIX® NIGHT & DAY® AQUA (lotrafi lcon A) contact lenses: Indicated for vision correction for daily wear (worn only while awake) or extended wear (worn while awake and asleep) for up to 30 nights. Relevant Warnings: A corneal ulcer may develop rapidly and cause eye pain, redness or blurry vision as it progresses. If left untreated, a scar, and in rare cases loss of vision, may result. The risk of serious problems is greater for extended wear vs. daily wear and smoking increases this risk. A one-year post-market study found 0.18% (18 out of 10,000) of wearers developed a severe corneal infection, with 0.04% (4 out of 10,000) of wearers experiencing a permanent reduction in vision by two or more rows of letters on an eye chart. Relevant Precautions: Not everyone can wear for 30 nights. Approximately 80% of wearers can wear the lenses for extended wear. About two-thirds of wearers achieve the full 30 nights continuous wear. Side Effects: In clinical trials, approximately 3-5% of wearers experience at least one episode of infi ltrative keratitis, a localized infl ammation of the cornea which may be accompanied by mild to severe pain and may require the use of antibiotic eye drops for up to one week. Other less serious side effects were conjunctivitis, lid irritation or lens discomfort including dryness, mild burning or stinging. Contraindications: Contact lenses should not be worn if you have: eye infection or infl ammation (redness and/or swelling); eye disease, injury or dryness that interferes with contact lens wear; systemic disease that may be affected by or impact lens wear; certain allergic conditions or using certain medications (ex. some eye medications). Additional Information: Lenses should be replaced every month. If removed before then, lenses should be cleaned and disinfected before wearing again. Always follow the eye care professional’s recommended lens wear, care and replacement schedule. Consult package insert for complete information, available without charge by calling (800) 241-5999 or go to myalcon.com.References: 1. In vitro measurement of contact angles on unworn lenses; signifi cance demonstrated at the 0.05 level; Alcon data on fi le, 2009. 2. Nash W, Gabriel M, Mowrey-McKee M. A comparison of various silicone hydrogel lenses; lipid and protein deposition as a result of daily wear. Optom Vis Sci. 2010;87: E-abstract 105110. 3. Ex vivo measurement of lipid deposits (total cholesterol) on lenses worn daily wear through manufacturer recommended replacement period; CLEAR CARE® Cleaning & Disinfecting Solution used for cleaning an disinfection; signifi cance demonstrated at the 0.05 level; Alcon data on fi le, 2008.See product instructions for complete wear, care, and safety information.© 2013 Novartis 8/13 AOA13002JAD-B

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Shedding Light on Pupil Size DynamicsPharmacologic pupil control can reduce visual fl uctuation due to varying light levels, helping to keep affected patients wearing contact lenses.

Contact lens wearers come to us with the hope of achieving improved vision

without the need for glasses, and we are quite capable of satisfying this desire even in the most challenging contact lens fits. Oftentimes, how-ever, some of our fitting strategies will give patients great vision under normal light condition, but can pose challenges in low-light levels, such as in the evening or in dark rooms.

In instances when we have reached the limits of what our contact lens options can achieve to ensure excellent acuity in all visual settings, we feel that it is important to discuss the role of pharmaceu-ticals that might be capable of helping patients further. Using every tool at our disposal may help to decrease the number of patients dropping out of lenses by eliminat-ing decreased vision in low-light levels as a motivating factor.

Normal PhysiologyIn a normal individual, the pupils

respond directly and consensually to increased light levels by decreas-ing in size. As such, when exposed to low light levels, a patient’s pupils will equally dilate as a result. As a pupil dilates, refractive aberrations of the eye that are not exposed under normal light levels become exposed. This is most evident in our post-refractive surgery patients.

Patients who have undergone ra-dial keratotomy (RK), photorefrac-tive keratectomy (PRK) and laser in-situ keratomileusis (LASIK) are particularly susceptible to the effects of variation in light levels on their vision. These patients may refract to

20/20 but report a significant sub-jective disruption to their vision un-der low-light levels. Under regular illumination, the pupils are smaller than the treatment zone. As such, the irregularity in the cornea created by the outer edge of the treatment zone, or by the visible incisions for those patients who have had RK, is not interfering with the vision.

For these patients, under situ-ations of lower light levels, the pupils dilate, allowing higher-order aberrations (HOAs) created by the edge of the treatment zones to now interfere with the vision (Figure 1). Objectively, we have instrumenta-tion that has the ability to measure these higher-order aberrations. Sub-jectively, we now even have access to refractive systems that can also correct for these HOAs.

Pupil Control EffortsAlthough these systems can

help reduce some of these chal-lenges, they often will not com-pletely eliminate the visual issues experienced by these patients. A strategy that works well clinically is to control the pupil size.

Pupil control can be accom-plished with a number of phar-maceutical agents. For example, pilocarpine is capable of pupil control, but this pharmacological agent will also induce a myopic shift due to a contraction of the ciliary muscle. Dapiprazole, an alpha-adrenergic antagonist, can control pupil dilation, but its side effect profile, which includes burn-ing and conjunctival hyperemia, often does not make it a practical solution.1 Brimonidine is a unique molecule that inhibits pupil dilation

through a unique mechanism and has a low side effect profile relative to the other two agents discussed.

How Does Brimonidine Work?

Brimonidine is an alpha-2 adren-ergic agonist.2 We understand its critical role in glaucoma man-agement. Alpha-2 receptors are located on the presynaptic nerve endings of the dilator muscle. Bri-monidine binds to those receptors and, by doing so, inhibits further release of neurotransmitter into the synaptic cleft. Thus, when brimo-nidine is introduced to the eye, the dilator muscle will experience reduced activity, causing less pupil dilation and resulting in a more miotic pupil (Figure 2).

Where is it Found?Brimonidine is commercially

available as Alphagan. Three concentrations of brimonidine are available: 0.1%, 0.15% and 0.2%.2

A recent study showed identical results with pupil size control under low-light levels with 0.1% and

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

1.Topography of a patient who has had LASIK. The black line represents the shape of the pupil under bright light lev-els. The red line represents the shape of the pupil under dim light levels.

009_rcl1013_Derail.indd 9 10/8/13 6:58 PM


0.2% brimonidine. It is approved by the FDA to be used in a regi-men of 1gt TID for IOP reduction in glaucoma patients.2 The discus-sion in this article is a non-FDA approved use of brimonidine, and should be discussed with patients before being considered.

For patients who would benefit from this medication, we usually recommend instilling drops in both eyes 30-60 minutes before critical viewing tasks in dim illumination.

How to Identify Candidates for Treatment

A very simple test in the exam room can be used to determine who may be a good candidate for treatment using brimonidine drops. If you suspect significant differences in visual quality under normal and dim light levels, darken the exam room and have the patient look at the distance visual acuity chart. Make sure to reduce as much light in the exam room as possible, including the monitor of any com-puter screens.

Next, occlude one of the patient’s eyes by holding the occluder on an angle over the non-viewing eye, so that it is unable to view the distance target but it is still possible for you to place a penlight behind the oc-cluder. Then, simply shine a light source (such as a transilluminator or penlight) at the patient’s non-viewing, occluded eye, and have the patient report whether the vision has improved with the introduction of light to the non-viewing eye.

If the patient reports an improve-ment in vision, he or she may prove to be an appropriate candidate for treatment with brimonidine drops.

Contact Lens ApplicationsAs discussed earlier, controlling

the pupil dilation response under dim illumination conditions for post-refractive surgery patients provides better visual outcomes for those experiencing decreased vision under those circumstances. But there are a number of potential ap-plications for contact lens wearers as well.

• Orthokeratology. These pa-tients often do very well in regular light levels. However, if the pupil dilates larger than the treatment zone, patients may experience decreased visual outcomes under low-light levels. Additionally, you may rule out some patients from pursuing orthokeratology because of the limitations of larger pupils. Either of these patient profiles may benefit from brimonidine treat-ment.

• Gas permeable (GP) lens wear-ers. GPs are typically smaller than the diameter of the cornea. Most designs are significantly larger than the pupil under low-light levels and do not cause any visual issues.

If a GP wearer does present with complaints of decreased vision in dim light, the first consideration should be an attempt to increase the diameter of the lens. For regu-lar corneas, that is a relatively easy task. But for patients with corneal irregularities, that may prove to be a challenge.

It can sometimes be difficult to increase the size of the lens and also maintain an acceptable fit for patients with ectatic corneas, such as those seen in our keratoconus patients. This may leave patients dependent upon small-diameter lenses. If the lens is decentered be-cause of centration over the cone, this can create a challenge for pa-tients in low-light levels (Figure 3). These patients would likely benefit from brimonidine treatment.

Additionally, aspheric multifocal GP lens wearers under certain cir-cumstances may also benefit from pupil control with brimonidine. Regardless of whether you work with multifocal GPs that have an aspheric front surface, back surface or a combination of the two, these

2a (left). Pupil image taken using infrared imaging before treatment with brimonidine.

2b (right). The same patient’s pupil taken under the same conditions 30 minutes after instillation of 0.1% brimonidine.


lenses are designed with their distance optics in the center of the lens and the near optics progress-ing towards the periphery. As such, it is conceivable to understand a situation in which a patient with a well-centered lens would see well in the distance in regular illumina-tion, but experience some visual disturbance under low light levels if the near aspheric zones interfere with the pupil.

Fortunately, we can manipulate the distance zone of the lens and increase its diameter, creating a larger distance zone through which the patient can view. However, this strategy comes with its own challenge. The size of the near zone of the lens decreases, potentially making it more difficult for the pa-tient to access the near zone when needed. In this case, brimonidine for low-light levels, in particular driving

in the evening, may serve these patients well.

Through a Lens, Darkly

Using brimoni-dine to keep your patients in their contact lenses is a novel concept; how-ever, there are some potential downsides associated with its use. For example, some patients using brimonidine may experience side effects such as dry mouth and fatigue. It is also impor-

tant to be mindful of toxicity over time when using higher concentrations of the agent. It also cannot be used with MAO inhibitors, and there are some concerns about its use in patients with elevated blood pressure.

In our quest to achieve the best possible visual outcomes and wearing experience for our contact lens patients, we need to keep non-traditional solutions in mind to meet their visual needs. Consider pupil control with brimonidine for those contact lens patients complaining of significant visual changes in dim illumination settings. RCCL

1. Canovetti A, Nardi M, Figus M, Fogagnolo P, Benelli U. Aceclidine, brimonidine tartrate, and dapiprazole: comparison of miotic effect and tolerability under different lighting condi-tions. J Cataract Refract Surg. 2009 Jan;35(1):42-6.2. Shemesh G, Moisseiev E, Lazar M, Kesler A. Effect of brimonidine tartrate 0.10% ophthalmic solution on pupil diameter. J Cataract Refract Surg. 2011 Mar;37(3):486-9.

3. The right eye of a patient with keratoconus wearing a GP lens that is 9.0mm in diameter. At the slit lamp, the pupil is constricted because of the light being shone at the eye during the examination. The pupil is coming close to the edge of the lens on the superior nasal aspect of the lens.

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Down on the PharmBy Tammy P. Than, OD, MS, and Elyse L. Chaglasian, OD

Ocular Drug Delivery — Pressing ForwardIontophoresis offers a new, non-invasive way to administer medication in a safer, more effi cient manner for chronic dry eye and anterior uveitis patients.

As primary eye care provid-ers, we often face the chal-lenge of patients presenting

with chronic dry eye or anterior uveitis whose condition appears to initially improve, only to then in-explicably regress. Despite our best efforts and the virtues of available medical therapy, we are unable to prevent this setback. Poor patient compliance due to cost issues and drug-related irritation could be a contributing factor to the variabil-ity of these conditions.

What if we could deliver an in-offi ce, cost-effective and painless dose of concentrated medication, without the worry of potential negative side effects, such as increased intraocular pressure, keratitis or cataract formation? What if patients weren’t burdened by the need for frequent admin-istration of eye drops and visits to the doctor because the medica-tion that they needed could be delivered comfortably, quickly and effi caciously? This scenario would be a clear win-win situation for both patients and providers alike. Well, iontophoresis may be the answer, and it could be a reality very soon.

How it WorksThe concept of iontophoresis

dates as far back as the early 1900s, but only recently have controlled clinical studies been un-dertaken to test the effi cacy of the concept.1 Iontophoresis is a nonin-vasive process that allows a greater bioavailability of a given drug to reach the anterior and posterior segments than is normally possible

with topical applica-tion. The process is a safer option than systemic dosing, which exposes the patient to the risk of system-wide adverse effects, or invasive intravitreal injec-tion, which increases infection risk.

Ocular drug delivery via ion-tophoresis works on the principle that like charges repel and opposite charges attract, to allow more effective penetration through ocular tissues.2

In rabbit eyes, ionotophore-sis demonstrated the ability to deliver greater than a 100-fold increase of drug concentration in the aqueous humor than was achieved with topical or intrave-nous administration.3 Safety of ocular iontophoresis in humans was demonstrated in a 2003 study conducted by Theodore Parkinson and colleagues.4

The EyeGate II delivery system (EGDS, Eyegate Pharmaceuticals) is an iontophoresis method of drug delivery in which an electri-cal fi eld, generated by a low-level electrical current, promotes the movement of a charged drug across biological membranes. This process enables the deliv-ery of negatively or positively charged therapeutics through tissues to targeted areas. The amount of the drug that enters the eye can be controlled in two

ways: the size of the current, and the specifi c length of time neces-sary for the treatment to deliver therapeutic levels of the drug into the eye while minimizing systemic absorption.

The device is equipped with an applicator containing a foam res-ervoir that houses the drug, which is placed just outside the limbus. The applicator is connected to a programmable generator, which is connected to an electrode that is placed on the forehead. The gener-ator creates an electric fi eld inside the applicator, and an opposite charge on the electrode, resulting in the propulsion of the drug into the eye.

EGP-437 is a novel 40-mg/mL dexamethasone phosphate specifi -cally developed for use in ionto-phoresis for the treatment of dry eye and anterior uveitis.5 Topical steroids are typically used off-label to alleviate the signs and symptoms of dry eye,6 and are the standard of care for anterior uveitis.

The EyeGate II generates a low-level electrical current that promotes the movement of a charged drug across biological membranes.

Down on the Pharm

012_rcl1013_dotp.indd 12 10/8/13 3:45 PM

Down on the Pharm


Clinical TrialsEyeGate Pharma has recently

completed two Phase III studies using the EGDS—one for dry eye and one for anterior uveitis:

• Dry eye: 198 patients were enrolled in a single center, nine-week, randomized, double-masked, placebo-controlled study, to evaluate the safety and effi cacy of EGP-437. The researchers used the EGDS at two different dose levels: EGP-437 4.0 mA-min at 1.5 mA and EGP-437 6.5 mA-min at 2.5 mA, compared to iontophoresis with placebo (sodium citrate buffer solution). The primary outcome measures were differences in corneal fl uorescein staining at visit six compared to placebo and ocular discomfort at visit fi ve, as compared to placebo. The improvement in inferior and

total corneal staining were sta-tistically signifi cant at P=0.0084 and P=0.0196, respectively. EGP-437 also signifi cantly improved symptoms (P=0.0058) at 24 hours post-treatment. The treat-ment was reported as both safe and well tolerated.7

• Anterior uveitis: In Phase II of this study, 40 randomized patients received an iontophoresis treatment in one qualifying eye. Patients were randomly placed into one of four iontophoresis dose groups (1.6, 4.8, 10.0 or 14.0 mA-min), treated with EGP-437 via the EGDS, and followed until day 28 of treatment. Two-thirds of the 40 patients enrolled achieved an anterior chamber cell score of zero within 28 days, after receiving only one iontophoresis treatment. Intraocular pressure remained within normal limits and there were no changes in visual acuity, nor were there any signs of cataract formation.8

Phase III, which was recently completed, was a random-ized, double-masked, positive-controlled inferiority study that enrolled 193 patients at 45 clinical sites to assess the effectiveness of EGP-437 compared to topically applied prednisolone acetate 1% eye drops. Patients were random-ized into either treatment with iontophoresis with EGP-437 on days 0 and 7, or 14 days of daily treatment with prednisolone ac-etate 1% eye drops, followed by two weeks of standard taper. The primary effi cacy endpoint is the number of patients with anterior chamber cell count of zero on

Day 14. Results were equivalent between the two groups; only two iontophoretic treatments resulted in 32/96 (33.3%) response and 32/97 (32.9%) of the prednisolone acetate eyedrop patients with no adverse events reported.9 -10

The Path ForwardConventional treatment of

chronic dry eye, as well as anterior uveitis, requires multiple doses of eye drops over an extended period of time, sometimes taking weeks to months. In some cases, treatment can take years. This ap-proach to treatment can be costly, inconvenient and could also carry potential side effects. Iontopho-resis appears to be capable of at least matching the effectiveness of topical steroids for anterior uveitis with a just a couple of treatments, and may provide the opportunity to use steroids more regularly and effi ciently for a number of our recalcitrant dry eye patients. RCCL

1.Myles ME, Neumann DM, Hill JM. Recent progress in ocular drug delivery for posterior segment disease: emphasis on transscleral iontophoresis. Adv Drug Deliv Rev. 2005 Dec 13;57(14):2063-79.2.Eljarrat-Binstock E, Domb AJ. Iontophoresis: a non-invasive ocular drug delivery. J Control Release. 2006 Feb 21;110(3):479-89.3.Gungor S, Delgardo-Charo MB, Ruiz-Perez B et al. Trans-scleral iontophoretic delivery of low molecular weight therapeu-tics. J Controlled Release 2010;147:225-231.4.Parkinson TM, Ferguson E, Febbraro S, Bakhtyari A, King M, Mundasad M. Tolerance of ocular iontophoresis in healthy vol-unteers. J Ocul Pharmacol Ther. 2003 Apr;19(2):145-51.5.www.eyegatepharma.com.6.Huang AJW. Immunosuppressive therapy for ocular surface disorders. In: Dry Eye and Ocular Surface Disorders. Pflugfelder SC, Beuerman RW,Stern ME; editors, New York, NY. Marcel Dekker, Inc. 2004.7.http://www.clinicaltrials.gov/ct2/show/NCT0069135.8.AE, Assang C, Patane MA, From S, Korenfeld M. Evaluation of dexamethasone phosphate delivered by ocular iontophoresis for treating noninfectious anterior uveitis. Ophthalmology. 2011;119(1):66-73.9.http://www.clinicaltrials.gov/ct2/show/NCT01505088. 10.http://www.eyegatepharma.com/pdf/news2013/EyegatePR_Uveitis_TopLineData_08apr_Final.pdf.

An applicator with a reservoir that houses the drug is placed just outside the limbus. The generator creates an electric field inside the applicator and an opposite charge on the forehead-based electrode, resulting in the propulsion of the drug into the eye.

012_rcl1013_dotp.indd 13 10/8/13 3:45 PM

Gas-Permeable Strategies By Jason Jedlicka, OD


Using Soft Lenses to Help Our GP PatientsLens wear modalities need not be an either/or proposition. A mix-and-match approach may be best in some cases.

For our irregular cornea pa-tients fi tted with GP lenses, the vast majority of their

days spent wearing GP lenses are characterized by good vision and acceptable comfort. However, many of those same patients will have a day every now and then when their eyes are particu-larly intolerant of their lenses. Whether due to dryness, epithe-lial erosion or other causes, the sensitivity and irritation they will occasionally feel is bad enough to make them have to take a brief respite from GP lens wear, at least in one eye.

Switching to glasses for the day is, unfortunately, not a good option, in that many of these individuals cannot easily wear spectacle lenses due to their unique refractive correction or lack reasonable best-corrected vi-sion with those lenses. This leaves them with compromised vision.

The advent of a number of new and improved soft lenses for irregular corneas has allowed many individuals who could not succeed with GPs to move into soft lenses, thus improving their ocular comfort and ability to wear contact lenses more of their waking hours. While these lenses do not always provide the same quality of visual correction as a GP lens, they often do come rea-sonably close; for many patients, it is an acceptable trade-off.

Case ReportJR, a 39-year-old male with a

history of keratoconus in both eyes, fi rst presented to my offi ce

three years ago after moving to the area. Two years prior to his fi rst visit to my offi ce, he had Intacs corneal implants and corneal collagen crosslinking performed, with no complica-tions. He was wearing piggy-back soft disposable lenses with intralimbal corneal GP lenses in each eye during work hours, and had a pair of soft keratoconic-designed lenses that he switched to in the evenings and at times on the weekends for entire days. His chief complaint was a desire to upgrade his soft lenses. He stated that his piggyback lenses were working well.

A complete exam was per-formed as well as assessment of both his piggyback lenses and soft lenses. All results were unre-markable other than the expected fi ndings related to keratoconus and Intacs. His piggyback lens fi t was excellent and his vision was good with no substantial over-refraction. His soft lenses were evaluated and did fi t well, but his vision was reduced to 20/60 and 20/40 with them. These lenses were over one year old, and he was interested in what newer technology was available. I told him there were new lens designs that used more oxygen permeable materials; he was interested in trying them.

A refi tting into Kerasoft IC lenses was performed. The fi nal lens parameters were:

OD: BC – 8.6 / -2.50 -2.25 x 60 / 14.5 / Steep 2 / 20/20-2

OS: BC – 8.6 / -5.75 / 14.5 / Steep 2 / 20/25

JR was happy with the com-fort and the noticeably improved acuity. He continued to use these lenses as a part-time mode over the next year, and has used the same basic lens fi t and parameters now for nearly three years.

Hard Problems, Soft Solutions

This case was one that opened my eyes to a new way of of ad-dressing my GP lens patients. Prior to this patient encounter, the concept of prescribing soft specialty contact lenses as a back-up to GP lenses had never really occurred to me, nor had I ever seen it successfully done. Since this encounter, I have discussed the option with most of my keratoconus patients who feel they cannot rely on glasses as an acceptable back-up to contact lens wear. Nearly half of those in-dividuals have been receptive and opt for a pair of soft lenses as an alternative means of correction to their GPs.

The benefi ts of this strategy are many. First, the wearer has the option of giving the eyes a planned hiatus from GPs to maintain the best comfort the other days of the week. Second, it gives them the ability to choose these lenses for wear during times of high physical activity, as they may be more stable than GPs in such scenarios. Third, on days when the GPs seem to bother an eye more than usual, a soft lens may be better tolerated, allowing the individual to have their vision corrected that day rather than

014_rcl1013_gps.indd 14 10/8/13 3:47 PM

foregoing a lens altogether and experiencing poor vision.

Surely the evolution of scleral lenses may, to some, make this option seem less useful. I would only relate that I have some scleral lens wearers who enjoy their soft lens option from time to time just as corneal GP wearers do. Others might feel that the cost is prohibitive to have multiple pair of lenses but, compared to the cost of glasses—particularly with the prescriptions needed for many of these patients—it really should not be.

As this column focuses on GP-related strategies, it may seem counterintuitive to contemplate specialty soft lens fi tting op-tions. However, this approach allows us to help our GP patients enjoy and get more mileage out of their GP lenses, not simply promote soft lenses. For GP lens wearers with irregular corneas and complaints of intermittent lens intolerance, consider a soft lens alternative. RCCL

Flexlens Tricurve soft lens on a patient who uses corneal GP lenses during work hours. Vision is 20/25 vision and comfort 10/10.

/ReviewofCorneaAndContactLenses #rcclmag

014_rcl1013_gps.indd 15 10/8/13 3:48 PM

CONTINUING EDUCATION

16 REVIEW OF CORNEA & CONTACT LENSES | JUNE 2013

The cornea is an amazing bio-logical tissue. It is unique in that it is one of the few avas-

cular tissues in the human body. It’s the main part of the eye we manipu-late to change light refraction. The cornea’s vital role in providing clear vision accounts for its many defense mechanisms––from extreme sensitivity to touch to rapid infil-tration by white blood cells when combating exogenous threats to its robust healing response. Advances that help clinicians to better observe and understand the cornea directly benefit the health of the eye and, by extension, the life of the individual.

The process of examining the

cornea has come a long way from using handheld placido discs and just a slit lamp. Today, a multitude of exciting technologies allow us to look in depth at this amazing struc-ture. As innovative new devices are constantly emerging, it would be impractical to elaborate on each in the ensuring discussion. Instead, this feature will emphasize a few that have become industry standards, while also calling attention to a few emerging newer concepts.

PentacamThis technology employs a

Scheimpflug imaging system, which in direct contrast to the more com-

mon placido-based systems, offers a wider range of measurement modal-ities.1 For example, a placido-based system can only measure the cen-tral cornea and extrapolates more peripheral data; the Pentacam can image both anterior and posterior corneal elevations. It also measures across most of the cornea, generally mapping about 8mm. The ability to measure the posterior corneal surface may help in determining the earliest signs of form fruste kerato-conus.

The Pentacam emits a slit of light that is transmitted through the ocular surface, anterior cham-ber and lens. Because cells are not completely transparent, there will be light scatter created by each level.

Advances in corneal diagnostic technologies are improving measurement and reading

accuracy, while simplifying corneal examination. By David I. Geffen, OD

Release Date: October 2013Expiration Date: October 1, 2016Goal Statement: This course describes several key diagnostic instruments and technologies for improved visualization and measurement of the cornea. By learning about these newer technolo-gies, clinicians can directly improve the patient’s eye health.Faculty/Editorial Board: David I. Geffen, ODCredit Statement: COPE approval for

1 hour of CE credit is pending for this course. Check with your state licensing board to see if this counts toward your CE requirements for relicensure.Joint-Sponsorship Statement: This continuing education course is joint-sponsored by the Pennsylvania College of Optometry.Disclosure statement: Dr. Geffen is a consultant and speaker for Abbott Medical Optics, Alcon, Allergan, Annidis, Bausch+Lomb, TearLab and Vmax.

David Geffen, OD, is director of optometric and refractive ser-vices at the Gordon & Weiss Vision Institute

in San Diego, Calif. He has lectured and written extensively on contact lenses, refractive sur-gery procedures and intraocular lenses.

Taking a Closer Look at the

Cornea


016_rcl1013 F1_CE_CornealExams.indd 16 10/8/13 3:49 PM


A camera is used to pick up this scatter and, by using computer software, it is able to create a 3D replica of the cornea, showing anterior as well as posterior views.

The Pentacam also has the ability to measure corneal thickness over a wide area. Pachymetry is an excellent measure of corneal health. By mea-suring the thinnest point on the cornea, it can help detect early ectatic disease.2 This is achieved by using software that will plot out the corneal thickness and then graph it compared to normal measurements, better known as “BAD,” or the Belin-Ambrósio Enhanced Ectasia Display.3 This helps us to differen-tiate a normal, thin cornea from one that is possibly ectatic, because corneas with ectatic disease show a more rapid progression of thicken-ing from the thinnest point to the periphery. Identifying the thinnest point of the cornea in relationship to the center is also a sensitive way to detect early abnormalities such as ectasia and keratoconus. The Pen-tacam also plays an important role in determining IOL calculations—it is critical in calculating residual astigmatism and will help in deter-mining the power of a toric IOL.

Ocular Response AnalyzerCorneal biomechanics are increas-

ingly becoming an integral part of the way clinicians assess general cor-neal health. The eye is dynamic and alive, and its variable nature should be accounted for in our measure-ments of intraocular pressure.

The Reichert Ocular Response Analyzer (ORA) uses a dynamic bi-directional applanation process

to measure the biomechanical properties of the cornea.4 Corneal hysteresis is a property of corneal tissue directly related to the struc-tural integrity of the cornea. If the structural integrity of the cornea is weakened, the possibility of distor-tion due to keratoconus is increased. Knowing this resistance factor can also help us to obtain a true IOP measurement.

By measuring the dampening effect of the corneal tissue, we can better identify those surgical candi-dates who may be at risk for ectasia. The ORA measures the dynamic resistance due to rapid movement generated by the viscous nature of the tissue. This is similar to com-pressing a spring, and creates a dampening affect. We also can mea-sure an IOP reading that accounts for the cornea’s biomechanical prop-erties. This gives the clinician a more accurate IOP measurement that can be used to better detect and follow glaucoma patients.

By measuring this factor, we are able to obtain a “corneal resistance

factor” unique to each individual. Corneal hys-teresis is a pressure mea-surement, represented in mm Hg, that allows the documentation of two factors: the corneal-compensated IOP and the corneal resistance factor. The latter, CRF,

is a measurement of the resistance of the cornea taking into account the corneal thickness. Corneal hysteresis is a measure of the viscous damping of the cornea. So, a cornea, which may be soft, will be more prone to ectasia; it will also give an incor-rect IOP reading without knowing this factor.5

Keratoconic eyes have been noted to have abnormal biomechanical properties. These corneas are typically thinner and deformed. The resistance is lower in keratoconic corneas, and this is what the ORA measures. The corneal resistance factor mentioned above can be measured by the ORA and used to predict this disorder in patients. Knowing that an individual may have a predisposition for this disorder can possibly help prevent future damage. Crosslinking the cornea may be indicated at an earlier time. We also may be able to better predict success in certain contact lens modalities when accounting for corneal hysteresis. One clinical application of this is in deciding when to use a custom soft lens vs. a gas permeable lens—if the cornea is compromised, there may be more visual fluctuation with a soft lens rather than a gas perm.4

AS-OCTOptical coherence tomography

has changed the way we view the eye. Today, retina specialists would

Pentacam can detect early abnormalities, such as ectasia and keratoconus.

Scott Havswirth, OD




be severely disadvantaged with-out this device to monitor their patients. Recently this technology has evolved, and now possesses the capability to view the anterior segment. But will this application become as commonplace as retina evaluation?

Anterior segment (AS) OCT has huge potential. Imaging the contact lens patient for proper lens fit may become a vital part of our practices. As the popularity of scleral gas per-meable lenses increases, evaluating the lens on eye with an OCT may prove to be the best way to evaluate lens fit. OCT allows for viewing of the contact lens, corneal epithelium, basement membrane, stroma, endo-thelium and the tear reservoir.

Measurement of the tear/lens interactions is important in large-diameter RGPs; if fit too flat they will cause corneal complications. Flat-fitting lenses will often cause central corneal staining and may lead to abrasions, scarring and dis-comfort. Sagittal depth is now being used to calculate the correct relation-ship these large lenses have on the corneal surface, and AS-OCT allows for better imaging and measurement of this parameter.6

One major advantage of AS-OCT is the higher resolution images pro-duced by the technology. It also is capable of providing pachymetric maps of the cornea. Topographic analyses, as well as anterior and posterior elevation maps, are now also possible with this technology. Observation of the anterior cham-ber is much more accurate and easier than gonioscopy. The results are less technique dependent than in gonioscopy and the resulting images allow for a better depiction of nar-row angles. AS-OCT will help you image the position of aphakic IOL, which is critical in determining the separation between the IOL and natural lens.

Observation of the cornea via AS-OCT can also help to monitor dis-orders of the epithelium, stroma and endothelium. This is a great benefit in monitoring patients who have had DSAEK. For instance, AS-OCT allows you to follow and document the healing of the new endothelium and monitor the progress of host/graft adaptation.

Specular MicroscopesSpecular microscopy allows you

to view the corneal endothelium with much greater precision than a slit lamp. It is essentially a photo-graphic technique used to visualize this vital layer. Various instruments have software that assist in analyz-ing the data obtained from these photographs. As we know, the pri-mary function of the corneal endo-thelium is to maintain the health and transparency of the corneal stroma by maintaining proper fluid balance across the corneal depth. When the endothelium breaks down

both edema and clouding of the stroma can be observed. Newer specular microscopes will automati-cally provide cell counts and can quantify the extent of polymegeth-ism and pleomorphism. There are many causes of polymegethism, including long-term contact lens wear, cataract surgery, phakic IOLs, keratoconus, glaucoma, diabetes and genetic defects.7

The value of this technology can-not be overstated. With this device you can simply check cell count before recommending a phakic IOL, with the confidence you will not cause corneal edema if there is dis-ruption of the endothelium. Specu-lar microscopy may prove beneficial to our contact lens practice, too.

Monitoring the endothelium can be a valuable resource in our effort to determine issues concerning con-tact lens intolerance. A patient in a hydrogel lens may have minor cor-neal edema due to some endothelial cell loss and may do well by switch-ing to a silicone hydrogel lens for better oxygen transmission.

Because it presents accurate endothelial cell counts, a specu-lar microscope will also help in monitoring corneal dystrophies. Examining endothelial cell counts most appropriately monitors Fuchs’ dystrophy, making this device an invaluable tool in diagnosing the condition.

Confocal MicroscopyConfocal microscopy is a non-

invasive technique for imaging the living cornea. It is useful in manag-ing and detecting infectious and pathologic conditions as well as cor-neal dystrophies and degenerations. Because this technique is capable of observation at the cellular level, it’s sometimes useful in determining the causative organism in infec-tious keratitis. Knowledge of the organism responsible often dictates

Specular microscopy is invalu-able for examining endothelial cell counts in Fuchs’ dystrophy.

Michael Cym

bor, OD



Important Notice: Processing Answer Sheets and CE Certificates

Review of Cornea & Contact Lenses is strengthen-ing our commitment to the environment and “going green.”

Effective immediately, we will send the results of any CE post-course test that is manually submitted (via mail or fax) to the email address provided on your answer sheet.

If you do not provide an email address OR if you prefer to receive a hard copy of your certificate of completion via mail, you will be charged a $2.50 processing fee per certificate (via credit card or check payable to Jobson Medical Information LLC).

We cannot process your post-course test if neither an email address nor $2.50 processing fee is provided. Any answer sheet will automatically be returned to you.

We appreciate your support of this new process. Please contact us via email at [email protected] with any questions. Thank you!

treatment decisions, such as antimi-crobial selection and dosing. Confo-cal microscopy has also proven itself useful in the detection of the Acan-thamoeba organism. The observer is able to see the hyperreflective nature of the Acanthamoeba cysts.

Another benefit of confocal microscopy is its ability to observe changes induced in corneal structure both pre- and post-surgically. You can see the difference in the corneal stroma in a post-LASIK eye as well as careful examination of the endo-thelium after DSEK. As such, you will be able to monitor any changes in endothelial structure very early in the post-op examinations.

The technique can also show the differing structures in corneal dystro-phies in detail to help determine the specific type. We can follow wound healing in post surgical cases like LASIK. We can follow nerve healing over years with this technique.8

Corneal TopographyWhile the technology isn’t

extremely new, corneal topography remains a valuable tool in monitor-ing corneal disease progression and has several new additions worth learning about and understanding. One of its most useful attributes is its ability to help with contact lens fitting, as well as follow-up. As noted above, the Pentacam is a very useful device for this function, tak-ing full advantage of Scheimpflug imaging technology.

A new technology that will soon hit the US market comes courtesy of i-Optics, based in the Netherlands. Its device, called the Cassini, uses color LED topography that mea-sures corneal curvature relative to adjacent points and triangulates the result, which is advantageous over placido disc topography. Placido disc topographers often have trouble imaging dry and irregular corneas. The nomograms often fill areas

that are not clearly imaged with estimated topography results. Point-source LED topography has the advantage of being able to detect smaller irregularities on the corneal surface—even in dry eyes. The LEDs provide a one-to-one correspon-dence between source and image points, providing practitioners with greater accuracy.

In data from a 2010 ARVO poster, the accuracy of this device is 0.8µm for corneal height and 0.2µm for aberrations. This compares with 1.7µm for the corneal height mea-surement of the Pentacam.9 This will assist the surgeon in determining toricity for IOL calculations and the optometrist for contact lens fits, particularly for highly astigmatic patients. The device is also capable of measuring higher-order aberra-tions of the cornea. The numerous benefits provided by point-source LED topography will prove to be a most valuable device for the general optometric practice.

These are just a few of the new devices being used in corneal evalu-ation today. The field is rapidly changing and better software is being developed at a torrid pace. For the general practice, it is not reasonable to purchase every one of these devices. As time goes by, the costs of the aforementioned technologies will drop, and we will discover how to best use most of these diagnostic aids in our practices soon. For the time being, it is impor-tant that you determine what type

of practice you have and pick those technologies that you feel will best complement your specific practice, and benefit your patient base. ■

1. Belin MW, Khackikian SS. An introduction to understanding elevation-based topography: how elevation data are displayed—a review. Clinical and Experimental Ophthalmology. 2009: 37; 14-29.2. Ambrosio R. Enhanced Ectasia Screening. Cataract & Refractive Surgery Today. 2009: November/December; 1-3.3. Ambrosio R. Enhanced Screening for Ectasia and its Susceptibil-ity: The Role of Corneal Tomography and Biomechanical Character-ization. ASCRS 2011: 1-19.4. Luce D, Taylor D. Reichert Ocular Response Analyzer measures corneal biomechanical properties and IOP: provides new indica-tors for corneal specialties and glaucoma management. Ocular Response Analyzer White Paper. Available at: www.ocularresponse-analyzer.com/downloads.html. 5. Medeiros FA, Meira-Freitas D, Lisboa R, et al. Corneal hysteresis as a risk factor for glaucoma progression: a prospective longitudinal study. Ophthalmology. 2013 Aug;120(8):1533-40.6. Baldwin B, Moyer S. AS-OCT and the Specialty Contact Lens. Review of Cornea and Contact Lenses. April 2012.7. Thomas C. Use Specular Microscopy to Diagnose Corneal Dis-ease. Review of Cornea and Contact Lenses. June 2009.8. Tavakoli M, Hossain P, Malik R. Clinical application of corneal confocal microscopy. Clin Ophthalmol. 2008 Jun;2(2):435-45.9. Sicam VA, Simpson PND, Mensink M, Zaal M. Accuracy and Precision of a Color Coded Multiple Point Source Specular Reflec-tion Corneal Topographer. ARVO 2010 E-abstract 5691.

AS-OCT showing a penetration scar of the endothelium.

Aaron Bronner, OD



Examination Answer Sheet Valid for credit through October 1, 2016

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

Taking a Closer Look at the Cornea

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

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

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

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

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

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

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

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

4. A B C D 11. Met the goal statement: 1 2 3 4 5

5. A B C D 12. Related to your practice needs: 1 2 3 4 5

6. A B C D 13. Will help you improve patient care: 1 2 3 4 5

7. A B C D 14. Avoided commercial bias/influence: 1 2 3 4 5

8. A B C D 15. How would you rate the overall 9. A B C D quality of the material presented? 1 2 3 4 5

10. A B C D 16. Your knowledge of the subject was increased: Greatly Somewhat Little 17. The difficulty of the course was: Complex Appropriate Basic How long did it take to complete this course? Comments on this course:

Suggested topics for future CE articles:

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Lesson 109471 RO-RCCL-1013

1. The Pentacam can map approximately how much of the cornea?a. 6mm.b. 8mm.c. 10mm.d. 12mm.

2. Which technology is used to most accurately measure the thinnest point of the cornea to detect early ectatic disease?a. AS-OCT.b. Ocular Response Analyzer.c. Pentacam.d. Confocal microscopy.

3. Corneal resistance factor can be determined by using:a. Corneal topography.b. Ocular Response Analyzer.c. Pentacam.d. AS-OCT.

4. AS-OCT is capable of providing:a. Pachymetric maps of the cornea.b. Topographic analyses.c. Anterior and posterior elevation maps.d. All of the above.

5. Which technology is best suited to measure sagittal depth for correctly fitting RGPs?a. Specular microscopes.b. Pentacam.c. AS-OCT.d. Confocal microscopy

6. Specular microscopes are useful in:a. Monitoring posterior corneal dystrophies.b. Measuring the tear reservoir. c. Determining the causative organism in infectious keratitis. d. Measuring the viscous damping of the cornea.

7. Which of the following diagnostic technologies can be best used to examine differences in the corneal stroma in post-LASIK eyes?a. Specular microscopy.b. AS-OCT.c. Confocal microscopy.d. Corneal topography.

8. Specular microscopy is described as:a. A photographic technique used to visualize the corneal endo-thelium.b. A process to measure the biomechanical properties of the cornea.c. Imaging the contact lens patient for proper lens fit.d. Only measuring the central cornea.

9. Confocal microscopy can do all of the following, EXCEPT:a. Follow wound healing in post-surgical cases.b. Show differing structures in corneal dystrophies.c. Monitor changes in endothelial structure.d. Determine toricity for IOL calculations.

10. The Cassini, a new corneal topography device, uses:a. Scheimpflug imaging system.b. Point-source LED topography to detect small irregularities on the corneal surface.c. Dynamic bi-directional applanation process to measure the biomechanical properties of the cornea.d. Placido discs and a slit lamp.

CE TEST



What’s the Solution

Sponsored b y

© 2012 Novartis 12/12 OPM12218AE

What’s The SolutionBy Joanna E. Slusky, OD

© 2013 Novartis 10/13 OPM13037AE

Sponsored b y

Whether you believe a hap-py patient is a returning patient or that the drive

to your practice is governed by price, insurance, or convenience, you may be correct. One answer to this debate may be driven from the clinical rationale in the contact lens solution that you recommend.

Economic principles suggest that the consumer will be driven to your business based on the afore-mentioned “Likes,” yet the overall experience of the encounter should defi ne who you are as a practitio-ner, and a business entity. For me, being remembered as a provider of a high level of care and service with attention to detail has pushed my practice forward; focusing on price and insurance comes second.

For my frequent replacement contact lens wearers, I have used the recommending of contact lens solution as both a marketing tool to ensure contact lens wearing suc-cess and to promote my skills and practice. With continued advances in contact lens material proper-ties, our patients are wearing their contact lenses longer each day, and their lifestyles are getting busier. Considering that our direct patient encounter is typically less than one hour of one day, of one year, we need to consider what truly hap-pens with our patient’s contact lens wearing experience the rest of the time. To thoroughly understand the patient’s goals and current ocular health status as it relates to their contact lenses, we have developed an open-ended question to form

the foundation for our exam: “Is there anything about the contact lenses you have been wearing that you wish was better?” Combined with a detailed slit-lamp evaluation of the anterior segment, we can use the answers to this question to make a clinical rationale and develop the appropriate language to communicate with our patients in achieving their goals.

The most common “wish” that I hear from my new patients is a desire to wear their contact lenses longer throughout their day with-out feeling dryness and discomfort. Once I have addressed all anterior segment conditions, and selected the best contact lens for my patient, it is time to begin the conversation of how to care for the contact lens. I believe that many of my patients would prefer to be informed on why I recommend a contact lens solution. This is the reason I prefer Alcon’s OPTI-FREE® PureMoist®

MPDS for my frequent replace-ment contact lens wearers.

I take time at the conclusion of the exam to inform my patient how to optimize healthy contact lens wear, and reduce their symp-toms of discomfort. I share with them why I have selected the lens material, and how OPTI-FREE®

PureMoist® MPDS was designed to work specifi cally with silicone hydrogel lenses to provide comfort and moisture throughout the day.

Details are effective when you make it conversational. “I real-ize that there are many different brands of solutions out there, and

the companies offering generic products have been tactical to package their solutions to resemble OPTI-FREE® PureMoist® MPDS. The challenge: if you switch to a generic, it may not be the latest technology developed that you are prescribed. That is why I recom-mend OPTI-FREE® PureMoist®

MPDS for you, to work in con-junction with the lens material you are wearing. We see this in the automotive industry with the different grades of octane, and the factory’s recommendation to use the highest octane possible. Now, that doesn’t mean that if you used the cheaper fuel your car will not get from point A to point B. It just means that the engine may not reach its full potential for the per-formance you bought the car for. In your case, this is one of the reasons why your contacts become less comfortable as the day goes on.”

In this brief moment, I have done something that the previous practitioner may not have ever taken the time to do, and made it a personal experience. This is my marketing time—and all I did was simply do my job. For my frequent replacement contact lens wearers, recommending Alcon OPTI-FREE®

PureMoist® MPDS has improved their quality of wearing contact lenses. As a practitioner, I feel very strongly about that; as a business owner, I have been able to market myself and shift the focus away from price and insurance, by giving my patients both a clinical and personal reason to return.

OPTI-FREE® PureMoist® MPDS: The Solution for Patient Retention

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Dry eye is a complex dis-ease that affects millions of people around the

globe. In 2011, the American Academy of Ophthalmology estimated that over five million Americans aged 50 or older suf-fered from the condition.1 But of course the condition impacts other demographics as well, particularly otherwise healthy contact lens wearers at any age. Its propensity to affect such a wide swath of patients in varying ways makes dry eye both mundane and also uniquely challenging—rarely does such a commonplace condition retain the ability to confound.

This conundrum has given rise to a number of new technologies, developed to help clinicians diag-nose and treat dry eye with greater precision. A plethora of diagnostic

tools designed specifically for dry eye disease now exist, but which truly might offer advantages over the humble Schirmer test and slit-lamp exam in your practice? This article will discuss the value of some emerg-ing technologies in dry eye care to help you expand and streamline your management of the disease.

The technologies detailed below are but a few options currently available for clinicians in an effort to simplify and improve dry eye diagnosis techniques. Each of these products employs a unique manner of diagnosing and treating the condition.

Tear Interferometry A new and noteworthy applica-

tion of an already existing tech-nology in dry eye diagnosis and treatment is the TearScience tear

interferometry system. The process of tear interferometry examines changes that occur over time on the tear film. TearScience’s offer-ing is comprised of two separate devices—the LipiView and the LipiFlow—to help clinicians in the diagnosis and treatment of dry eye.

• LipiView. The TearScience LipiView is notable in that it uses interferometry to quantify the average lipid layer thickness of a designated area of tear film, and capture the blink profile of an eye during a designated time interval. This helps to quantify the num-ber of partial blinks vs. complete blinks. This is clinically useful, as partial blinking that is left unno-ticed is a significant contributor to the chronic nature of dry eye, according to Caroline Blackie, OD, PhD, Senior Clinical Scientist at

Recent advances in dry eye technology are improving the accuracy of test results, while at the same simplifying and expediting the diagnosis of the disease.By Frank Auletto, Associate Editor

New Technologies that Won’t Leave You Out to Dry

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TearScience, who practices in Bur-lington, Mass. The LipiView also offers clinicians the ability to show their patients exactly what is seen during the examination. This meth-od of educating patients can help make treating dry eye easier for eye care professionals. “The LipiView provides the patient with a power-ful educational tool to help them better understand what the lipid layer is and why blinking exercises and other in-office and at-home treatment may be critical to their recovery,” says Dr. Blackie.

• LipiFlow. TearScience’s LipiFlow system applies heat and force directly and simultane-ously over the meibomian glands, relieving them of obstruction. According to Phoenix’s Arthur B. Epstein, OD, 86% of dry eye is caused by meibomian gland dysfunction (MGD) and lipid deficiency. The LipiFlow system is unique in its ability to treat MGD. “It applies therapeutic levels of heat directly over the glands as opposed to the conventional and highly inefficient application of heat to the outside of the eyelid,” says Dr. Blackie.

LipiFlow uses heat as a means to treat MGD because it helps to liquefy any solidified secretions that may cause obstruction in the gland duct. When pressure is simultaneously added, the lique-fied material is painlessly evacu-ated from the glands, Dr. Blackie says, significantly increasing the likelihood of normal gland func-tion post treatment.

Dr. Epstein is planning to incor-porate the system in his new prac-tice within the next few months, and says he couldn’t imagine not having access to this technology in a practice focused on dry eye. “When we planned our practice, we intentionally created a dry eye center specifically to incorporate

this technology,” Dr. Epstein says. “I've seen how LipiFlow provides a life-changing experi-ence for many dry eye sufferers who have spent amazing amounts of money on therapies that are palliative at best and often don't really help much at all.” Dr. Epstein considers this system the center-piece of a dedicated dry eye center and a potential new standard of care for managing MGD and evaporative dry eye.

MeibographyOne of the newest innovations

in the diagnosis of dry eye, the Keratograph 5M, comes from the German company Oculus. A key feature of the device is its abil-ity to conduct IR meibography, a non-contact method that uses a camera and an infrared light source to examine the meibomian glands in extensive detail, which Dr. Epstein says is “vastly superi-or to transillumination.” Because MGD is one of the leading causes of dry eye around the world, the device’s ability to examine the meibomian glands is an essential feature for clinicians treating the condition, he says.

The Keratograph 5M also offers clinicians non-invasive automated tear break-up time measurements. Examining tear break-up time measurements non-invasively is advantageous because it has the ability to produce accurate results more quickly and comfortably for patients. “They are reproducible and provide unique insight into tear stability,” says Dr. Epstein, who has used the 5M in his prac-tice for the past three months. “The 5M also offers tear meniscus height measurement, which is help-

ful in estimating tear volume and reserve rather than grossly estimat-ing it.”

Much like the LipiView, the unit also offers the advantage of being able to show patients exactly what you’re seeing via its display. “The graphical display is also very helpful in educat-ing patients as well as observing change from treatment or over time,” Dr. Epstein adds.

The device has become a staple in Dr. Epstein’s practice. “The 5M replaces a conventional topogra-pher, which I consider an essential instrument in its own right.“

Non-invasive Evaluation of the Tear Film

All clinicians are familiar with the clinical value of OCT for reti-nal disease management, but ante-rior segment OCT (AS-OCT) is emerging as a way to improve the diagnosis of dry eye in patients.

For diagnosing dry eye, David Huang, MD, PhD, one of the pioneering physicians and scien-tists who invented OCT technol-ogy in the early 1990s, suggests examining the tear meniscus with a typical OCT. “Specifically, the central-lower tear meniscus cross sectional area,” he says. “That measures tear volume like the Schirmer’s test, but it’s more

Dryness from incomplete blinks

Paul M

. Karp

ecki, OD

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repeatable than Schirmer’s, and doesn’t require putting in an anes-thetic or a stain.”

“It is important to perform the meniscus scan at the same point in the blink cycle,” Dr. Huang cau-tions. “In a published study, we performed scans at two seconds after a blink.”

“The tear film itself can be very thin in dry eye patients, and is beyond the resolution of standard clinical OCT systems,” notes Dr. Huang.

Ultra-high resolution (1-2µm) OCT devices can measure the thickness of the tear film to con-firm the presence of dry eye in patients. But for the time being, they may be too specialized to be worth the investment for clinicians. “The problem with ultra-high resolution is that the field of view

becomes very shallow,” adds Dr. Huang. “This makes scan acquisi-tion very difficult for more com-mon purposes, such as corneal mapping or angle imaging.”

Dr. Huang believes most clini-cians would already find their standard-resolution OCT useful for dry eye diagnosis. “I think that by detecting low tear meniscus and redundant conjunctival folds (con-junctivochalasis) with OCT, clini-cians can already identify the cause of irritation in most patients with complaints of dry eye symptoms.”

Another promising use for OCT is in the mapping of epithelial thickness. “The epithelial thick-ness becomes more irregular in dry eye,” says Dr. Huang. “This could be useful in dry eye evaluation. But further software development and clinical validation is needed,”

according to Dr. Huang.If we reach a point at which

higher resolution AS-OCTs become the norm, the technology will provide a non-invasive option to evaluate the tear film, which simplifies and speeds up the pro-cess of examining the tear film while keeping it free of interfer-ence by the clinician, for greater accuracy. But this application of ultra-high resolution OCTs for diagnosing dry eye may not cur-rently be ideal for clinicians.

Technology on the Horizon The following technologies

are not yet available in the US, but are expected to debut soon. Continuing the trend of unique diagnostic methods, the follow-ing emerging technologies will complement your current tech-

niques, resulting in a simplified and more complete overall diag-nosis of dry eye.

• RPS InflammaDry DetectorThe clinical signs of dry eye

often do not correlate with patient complaints. This can make the diagnosis of dry eye difficult for clinicians. Research has shown the enzyme matrix metalloprotein-ase-9 (MMP-9), an inflammatory marker, is consistently elevated in the tears of dry eye patient.5 The InflammaDry Detector tests for elevated levels MMP-9 to aid in the objective diagnosis of dry eye.

The test is easy for clinicians to conduct and produces results quickly. “This test is easy to administer using a small tear sample taken from the inside lin-ing of the lower eyelid, the palpe-bral conjunctiva,” says Dr. Robert Sambursky, MD, co-founder and CEO of RPS. “It takes only sec-onds to collect the sample and run the test. Results are available in just 10 minutes, allowing a diag-

Yan Li, P

hD and

David

Huang

, MD

, PhD

, Casey E

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rtland O

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Measuring the tear meniscus with a standard resolution OCT.

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nosis and treatment plan to be established with the patient before they leave the office.”

The InflammaDry test has shown promise in its ability to accurately diagnose dry eye. “In a prospective, sequential, masked, multicenter clinical trial of 206 patients, the InflammaDry test showed sensitivity of 85% and a specificity of 94%, compared to a clinical assessment of dry eye using the Ocular Surface Disease Index, Schirmer tear test, tear break-up time and keratoconjunctival stain-ing6,” says Dr. Sambursky.

The InflammaDry test is approved for use in Canada and

Europe, but is not yet available in the United State. It is still under review by the FDA.

• Nicox Dry Eye Panel Another technology that may soon make a splash in the diagnosis of dry eye is the Nicox Dry Eye Panel. The product will specifically help to simplify and improve the testing of Sjogren’s syndrome, a cause for severe dry eye symptoms. “The Nicox panel will help make diag-nosis more specific and allow us to better target severe dry eye patients well before they become severe,” says Dr. Epstein.

The Nicox Dry Eye Panel is a proprietary “lab on a chip” that

gives clinicians access to testing that would normally need to be con-ducted in a labora-tory. The diagnostic test combines three novel biomarkers (SP-1, CA-6 and PSP) with tradi-tional biomarkers (ANA, Ro, La and RF) to diagnose Sjo-gren’s syndrome at an early stage.

There is of course no “one-size-fits-all” option for diagnos-ing or treating dry eye—different tools will work better for different clinicians, so it’s all about what works best for you and your practice. Generally speaking, you will be employing mul-tiple technologies at any given time to achieve the best results, and each of the aforementioned

products and techniques could improve your ability to accurately diagnosis dry eye and tailor the therapy appropriately to each pre-sentation. RCCL

1.http://www.aao.org/newsroom/upload/Eye-Health-Statis-tics-April-2011.pdf2.http://www.tearlab.com/pdfs/TearLab%20Clinical%20Utility%20Guide.pdf 3.http://www.revophth.com/content/d/technology_update/c/25857/ 4.http://www.refractiveeyecare.com/2012/07/intraductal-meibomian-gland-probes/5.Kaufman, HE. The practical detection of mmp-9 diagnoses ocular surface disease and may help prevent its complica-tions. Cornea. 2013 Feb;32(2):211-6.6.Sambursky, Davitt, Latkany, et al. Sensitivity and Specific-ity of a Point-of-Care Matrix Metalloproteinase 9 Immunoas-say for Diagnosing Inflammation Related to Dry Eye. JAMA Ophthalmol. 2013;131(1):24-28.


Other Notable Dry Eye Technologies

TearLab Osmolarity SystemThe TearLab Osmolarity System mea-sures the osmolarity of human tears to aid in the diagnosis of dry eye. Abnormal tear osmolarity is a common feature found in patients with dry eye disease. As the osmolarity level increases in the tears, the severity of dry eye increases.2

Intense Pulsed Light for MGDFor patients with moderate to severe dry eye, intense pulsed light (IPL) can be used as a treatment option. Rolando Toyos, MD, founder of the Toyos Clinic in Memphis, helped refine this technology for patients with dry eye. IPL uses power-ful bursts of light to unclog meibomian glands and correct MGD, and is especially good for patients with rosacea.3

Maskin Meibomian Gland Intraductal ProbeThe Maskin Meibomian Gland Intraductal probe can be used to unclog meibomian orifices. After a bandage contact lens is placed on the eye and a topical anesthetic is administered, the probe is inserted into the blocked glandular orifice and distal duct. The procedure generally takes about 15 minutes in most cases. 4

A standard resolution OCT can be used to detect con-junctivochalasis in relation to dry eye symptoms.

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The consumer trend toward mobile technology contin-ues unabated. According

to a June 5, 2013 report, 56% of American adults are now smart-phone owners. To the practicing optometrist, it is unknown what implications the rapid consumer adoption of mobile technology portends.

Here is what we currently know about the smartphone market: The leading operating system (by market share) for all smartphones is Android, ahead of Apple’s iOS. During the second quarter of 2013, worldwide smartphone shipments were 79.3% Android and 13.2% iOS. Here in the Unit-ed States, Android has approxi-mately a 50% market share, with iOS around 40%. The recent release of new iPhone models just

last month may help iOS gain on Android.

Despite its smaller share, the iOS platform remains the first-tier prior-ity for most app developers because Apple’s smaller, more standard-ized product line makes it easier to release new software without hav-ing to create multiple iterations of the same app. The Android device family is far more diverse—and, thus, harder to support.

It’s no secret that smartphone apps have attained immense popu-larity in recent years. Everything from gaming to balancing finances can be done on your smartphone via an ever-growing library of apps. But what about contact lens care? In this article, we review the use and implications of smart-phone apps in optometry, and give our best projections for the future

Dr. Chou co-invented a patented smartphone app for self-

administered vision screen-ing. He practices at EyeLux Optometry in San Diego.

Ron Walker is the publisher of AllAbout-Vision.com and a found-

ing partner of Access Media Group LLC, in San Diego, Calif.

Global smartphone uptake is rapidly growing, and consumers are turning to apps to improve daily life. But is there any place in this market for contact lens apps?By Brian Chou, OD, and Ron Walker

Do Mobile Apps “Click” With Contact Lens

Wearers?

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of apps for contact lens wearers.

Appetite for AppsAccording to a March 2012

comScore report, approximately 80% of mobile media time is spent using apps, with the remain-der of time spent using a web browser. The caveat in interpret-ing this statistic is that the internet lives within most apps. That’s to say, many users spend significant time using interactive gaming and social networking apps, each of which access the internet to pro-vide their core functions.

While the majority of time on mobile devices is spent using such apps, it is still worth examining

and understanding the available contact lens apps geared toward consumers for the Android and iOS platforms.

A survey of the available Android apps for contact lenses shows that several options for users exist, but none been able to achieve an install volume above 10,000 to 50,000 users thus far. These numbers are not encourag-ing, and represent very low mar-ket penetration. The figures are curious, considering the increasing number of smartphone users, and the fact that there are 125 million contact lens wearers worldwide. The iOS apps for contact lenses show a similar pattern. Most of

these apps have relatively few user ratings—a statistic that suggests a low number of total installations.

After reviewing a majority of the contact lens apps, two major functional categories are consis-tent: a contact lens replacement counter and the ability to shop for new and replacement lenses. Below, we review apps that repre-sent these functions. The majority are free to download, with some that require purchase.

Contact Lens Replacement Counters

Several apps share a feature that counts down the days until the contact lenses are to be replaced.

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Some of these apps include the following options for the Android operating system: “Contact Lenses” (Figure 1), “forEyes,” “Contact Lens Timer Free” and “Contact Lens Counter.” A com-parable app for iOS is “Contact Lens Tracker” (Figure 2). The majority of these apps are simple in design, offering intuitive, user-friendly interfaces. Some allow skipping days, price comparison, storing the prescription and pre-scribing doctor information. Sure-ly, there are many users who find these features helpful. If these fea-tures are so useful, why have there been so few installations of these apps, especially when the majority are free to download?

Several factors contribute to the relatively low demand for apps that provide contact lens replace-ment counters. On one hand, the number of patients wearing single-use contact lenses is on the rise, estimated at 17% of contact lens prescriptions in 2012 in the United States. Due to the nature of the modality, it is unlikely that single-use contact lens wearers need a daily reminder to replace their contact lenses.

Second, for other lens replace-ment frequencies it is widely known that patient adherence to the recommended replacement

schedule is poor. Relatively few users seek an app that reminds them to replace their contact lenses due to a very low intrin-sic value to replace lenses as scheduled.

Finally, it is possible that a

smartphone user who really wants a reminder app will more likely install a more generic app which provides reminders for a broad range of categories, such as paying bills, birthdays of friends and fam-ily, taking medicine and so on. As most smartphones come with some sort of “reminder” app built in, the need to download one solely for contact lens replacement diminishes greatly.

By itself, contact lens replace-ment is a low-impact decision for most consumers. Because of this, it does not compel most wearers to download a specific app designed solely for that pur-pose. While these apps aren’t very popular, gen-eral reminder apps are downloaded far more often. For example, over 500,000 smartphone users have down-loaded “Life Reminder,” a general reminder app that alerts

users to perform a multitude of tasks. In comparison, none of the contact lens reminder apps for Android has exceeded more than 50,000 downloads.

Although reminder apps designed specifically for contact lens replacement haven’t experi-enced much consumer popularity, Vistakon has had some success in getting contact lens wearers to sign up for free e-mail alerts or text message reminders to replace contact lenses. The company recently has promoted corre-sponding apps in Canada for the iPad, iPhone and Android devices.

Overall, it seems that contact lens users don’t seek electronic reminders for lens replacement in great numbers out of some combi-nation of lack of awareness, lack of need or duplication of function in other apps.

Contact Lens ShoppingSeveral contact lens apps also

include a feature that allows users to shop for lenses directly through the phone. For example, the Android app “Contact Lens Counter” takes the user to a price

A screenshot of the “Contact Lenses” app for Android.

The 1-800-Contacts app on iOS, also available for Android.

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comparison page on the web-site, www.contactlenspric-es.com. The app for 1-800-CONTACTS, avail-able for both Android and iOS, comes equipped with a barcode scanning ability that can be used to determine the contact lens directly from the barcode on the box, allow-ing the user to easily order the same lenses directly from 1-800-CONTACTS.

In the case of Contact Lens Counter, the pricing for Acuvue Oasys lenses are shown from a number of sites, includ-ing, Vision Direct, AC Lens and Discount Contact Lenses. The 1-800-CONTACTS app only provides their pricing. The 1-800-CONTACTS app also includes a counter for lens replacement, a doctor search with-in their endorsed network and order tracking.

While the 1-800-CONTACTS app for Android has between 10,000 and 50,000 installations, the Google Goggles app has over 10 million downloads. When a box of contact lenses is scanned with Google Goggles, a full Google search is performed for the detected text, which yields a much larger number of online contact lens vendors selling the product. The discrepancy is due to the Google Goggles having potential use for just about any product, whereas the 1-800-CONTACTS scanner is only relevant for con-tact lenses barcode scanning.

Company Branding and Education

Aside from Vistakon and its Acuminder mobile apps, there have been only sparse attempts by other manufacturers with app-based efforts directed at the con-sumer.

But options outside of Vista-kon do exist. For example, Alcon offers patients its “Lens Facts from Opti-Free Brand” app, avail-able on iOS. This app provides a contact lens replacement tracker, a log for contact lens comfort and information about contact lens wear and care. More informa-tion can be found at www.ideo.com/work/lens-facts-iphone-app/. There is a FAQ section with answers to common questions, such as whether or not is it OK to use cheaper store-brand solution, to wear a friend’s contact lenses, and so on. The information avail-able in the app is displayed in a variety of ways, including videos.

For the Hong Kong market, Johnson & Johnson has an app specific for promoting Acuvue Moist. Aside from Johnson & Johnson’s offering, there seems to be a general absence of promo-tional apps for specific brands of contact lenses.

Summary ImpressionsWhen matched against popular

apps such as Google Maps, Face-book and Angry Birds, those that specifically target contact lens users are relatively unpopular when looking at their total num-ber of installations. But this fact really shouldn’t come as much of

a surprise to us. We generally believe that a contact lens wearer using a smartphone is more likely to use a common app, such as LifeReminder or Google Goggles, and adapt it for contact lens use. This sug-gests that apps that are more broad-based have a higher likelihood for use by contact lens users.

Based on the experience and statistics thus far, it

does not seem likely that mobile apps are the answer

to improving patient adherence to scheduled lens replacement sched-ules. While the application of smartphone apps for compliance may not be viable, online contact lens companies may employ apps as a means to offer a way to facili-tate lens purchase. There may be some potential for apps in patient education and product promotion, but this employment of apps has remained unexplored. RCCL

1. http://pewinternet.org/Reports/2013/Smartphone-Owner-ship-2013/Findings.aspx2. http://techland.time.com/2013/04/16/ios-vs-android/3. http://www.smartinsights.com/mobile-marketing/app-marketing/82-of-mobile-media-time-is-via-apps/4. http://www.ncbi.nlm.nih.gov/pubmed/179754175. https://play.google.com/store/apps/details?id=com.blogspot.kurinapps.lenses&hl=en6. https://play.google.com/store/apps/details?id=com.blogspot.kurinapps.lenses&hl=en7. https://play.google.com/store/apps/details?id=com.conod.apphealth.ContactTimer&hl=en8. https://play.google.com/store/apps/details?id=com.data.contactlenscounter9. https://itunes.apple.com/us/app/contact-lens-tracker/id363853333?mt=810. http://www.clspectrum.com/articleviewer.aspx?articleID=10785311. http://www.clspectrum.com/articleviewer.aspx?articleid=1318712. https://play.google.com/store/apps/details?id=com.payneser-vices.LifeReminders&hl=en13. http://www.prnewswire.com/news-releases/acuminder-tool-helping-to-change-contact-lens-wearing-behavior-survey-shows-115090899.html14. http://www.acuvue.ca/sites/default/files/content/ca/pdf/ACU%20Acuminder_App_PDF_EN.pdf15. https://play.google.com/store/apps/details?id=com.google.android.apps.unveil&hl=en16. https://itunes.apple.com/us/app/lensfacts-from-opti-free-brand/id450251400?mt=817. https://itunes.apple.com/us/app/acuvue-moist/id432834723?mt=8 http://en.wikipedia.org/wiki/List_of_most_downloaded_Android_applications


The “Acuvue Moist” app for the Hong Kong market, available for iOS.

026_rcl1013 F3.indd 29 10/8/13 3:56 PM


What is the “healthiest” contact lens type? Is it OK if I simply replace

my lenses when they start to bother me, rather than when my doctor said I should? What should I do if I drop my contact lens on the floor?

These are but a few of the com-mon questions on the minds of your contact lens patients. Although we would hope that patients would turn to us, their eye care providers, for answers, the reality is that their first source tends to be the internet more often than not.

Unfortunately, many of the health care websites that consum-ers frequently visit for answers are simply places where other consum-ers chime in with highly opinioned responses, unsupported by any scientific evidence or references. Their “expertise” is usually derived

only from their own experiences as a contact lens wearer. This reliance on non-professional opinions degrades the public’s knowledge of safe lens wear and care practices, and can lead to further complications in con-tact lens safety.

If you find this troubling, here’s good news. An authoritative online resource for consumers, media and even eye care professionals, has been developed by the American Optometric Association’s Contact Lens and Cornea Section, in coop-eration with the American Academy of Optometry’s Section on Cornea, Contact Lenses and Refractive Tech-nologies. As one of its developers, I’d like to share with you some details on how it works.

Safety’s Missing PieceIt is the mission of every contact

Dr. Quinn is in group practice in Athens, Ohio and a

clinical assistant profes-sor at Ohio University College of Medicine. He serves on the American Optometric Association’s Contact Lens and Cor-nea Section Council, is a Diplomate of the Cor-nea, Contact Lens and Refractive Technologies Section of the American Academy of Optometry, and is an advisor to the GP Lens Institute.

Patients increasingly rely on the internet for answers about contact lens safety. But are they getting the right answers?By Thomas G. Quinn, OD, MS

What Do Consumers Want to

Know About Contact Lens Safety?

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lens fitter to provide patients with crisp vision, good comfort and a safe wearing experience. We have made great strides in improving lens safety by developing ever-improving materials, modalities and care systems. But all this progress quickly falls apart if the patient does not properly wear or care for their lenses.

ContactLensSafety.org was developed to provide patients with a high-quality resource for contact lens-related information outside of the clinician’s office. The hope is that this resource will translate into improved habits and safer contact lens wear. Every answer on the website is properly refer-enced, so eye care practitioners can refer patients, and the public, to the site with confidence.

ContactLensSafety.org is rap-idly becoming a definitive online source for information on a number of subjects, ranging from proper contact lens care and lens case care to the dangers posed by illegal cosmetic lenses.

During just the first quarter of 2013, more than 4,000 unique visitors turned to ContactLens-Safety.org for reliable, referenced information on contact lenses.

Site LayoutThe site offers several ready

answers, in easy-to-understand layman’s terms, to what are thought to be 50 of the most com-monly asked contact lens-related questions.

The questions are categorized under one of the following topic headings:

• Lens Types/Replacement and Wearing Schedules/Safety

• Contact Lens Care • Care for Lens Cases • Contact Lens Wear in Various

Environments • Purchasing Contact Lenses

Figure 1 shows how these head-ings are organized and displayed on the ContactLens-Safety.org home page. The box in the center features a revolving series of images that represent each of these five main topic headings. One accesses the questions under each heading by simply clicking on the heading title.

Once the section of the chosen topic area is entered, a list of the most commonly asked questions relating to the area chosen will be displayed. Clicking on the text of the question reveals the answer to any given question. When the cursor is properly placed, the text will become underlined and change color (see Figure 2).

In contrast to many of the resourc-es online offering contact lens wear-ers information on safety, all of the answers on the site are supported by referenced sources. The details of each reference can be viewed by sim-ply placing the cursor over the refer-ence number. To return to the home page, users can click on “Contact Lens Safety” in the upper left corner of the page.

The top of each page provides visi-tors with the ability to search for an optometrist, connect to AOA’s social media accounts—such as Facebook and Twitter—and introduces the experts instrumental in developing the site: Christine Sindt, OD, Loretta Szczotka-Flynn, OD, PhD, Edward S. Bennett, OD, MSEd, and Thomas G. Quinn, OD, MS.

Consumer Interest Thus far, the most commonly

clicked-on question has been,

“How should I clean my contact lens case?” (see sidebar, “Public Inquiry #1” for the answer pro-vided on the site). In fact, of the top 10 questions clicked on by visitors to the site, six fall under the topic area of “Care for Lens Cases.”

Surprised? This can perhaps be explained by understanding that, of the top 10 Google searches that resulted in clicks to ContactLens-Safety.org, four were related to case care or lens storage. Most of the others had “safe” or “safety” in the search query.

Clearly, eye care providers may want to consider devoting more time to the topic of proper lens case care. Improved patient com-pliance begins with being edu-cated on proper wear and safety, and it is our duty to impart this knowledge on our patients. It is made clear through the most pop-ular topics on the website that we need to do a better job explaining proper lens case care.

The second most commonly explored area by site visitors concerns the topic of wearing contact lenses in various environ-ments, such as while flying in an airplane, taking a shower or nap-ping. While on the site, go to the “Contact Lens Wear in Various Environments” tab for answers to these questions.

1. The ContactLensSafety.org homepage.

030_rcl1013 F4.indd 31 10/8/13 3:58 PM


“Ask a Question” FeatureIf a visitor to the website does

not find their question listed, they have the option of submitting it for review by clicking on “Ask a Question,” displayed at the top-center of every page. Those who do so receive an email response based on referenced sources.

To date, the majority of submit-ted questions relate to general safety issues. Are contact lenses

safe? Are they safe in my prescrip-tion? At what age is it safe to begin wear? In many cases, such as with this last question, the submitter can simply be directed to a certain area of the website for the answer (go to Contact Lens Wear in Vari-ous Environments, Question 7).

Some questions that are repeated-ly asked via the “Ask a Question” system have been, or will be, added to the website. An excellent exam-ple is the question inquiring about the safety of wearing contact lenses in an industrial environment.

Questions on Lens CareA number of user-submitted ques-

tions relate to contact lens care. A common one has been, “Is it OK to use expired solution?” The simple answer to this question is no. For a more complete, referenced response, which includes an informative discus-sion of the concept of discard dates, please click on question 3 under the Contact Lens Care heading.

Handling IssuesMany consumers have asked for

advice on how to determine whether or not a soft contact lens is being worn inside out. Make sure this is an area you or your staff covers at any new dispensing visit. Asking your patients to demonstrate the employ-ment of these techniques is an excel-lent way of ensuring your patients are exercising proper compliance.

It is possible that some site visi-tors may be posing this question because they have purchased illegal cosmetic lenses from an unauthor-ized source, and have therefore received no training in proper lens care or handling. Recognizing this, each response to this question has encouraged patients to consult with a local eye care provider for proper instructions, and explains the importance of having contact lens fitting and follow-up services pro-vided by a qualified professional.

How You Can Use ContactLensSafety.org?

When you talk to your patients about the importance of proper lens wear, care and handling for a safe contact lens wearing experi-ence, provide them with a flier directing them to ContactLens-Safety.org. Fliers can be printed by visiting www.aoa.org/Docu-ments/optometrists/clcs-contact-lens-safety-flyer.pdf. Some offices routinely provide the flier to all

patients at their contact lens care and handling training visit. It’s a good habit to get into as a means of opening a dialogue with patients about proper lens care.

In addition to assisting your patients, ContactLensSafety.org can also be a great resource for you! Go to the site yourself to get ideas on how to answer what can sometimes be tricky questions, knowing your responses will be backed by sci-ence. Not only will the site help you answer these difficult questions, but it can also be useful in understanding what aspects of contact lens wear patients need the most guidance. This will allow you to be better pre-pared to educate your patients on these topics during visits.

Visiting the site periodically will prove to benefit both you and your practice. ContactLensSafety.org is a living resource, with unlisted ques-tions being added, and ignored ques-tions deleted. The site depends on what consumers, and you, want to know about contact lenses and how to wear them safely. RCCL

The author wishes to thank Capucine Chatman-Willams and Jon Schwab for their assistance in gathering statistics for this article.

1. Wu YT, Zhu H, Willcox M, Stapleton F. Removal of biofilm from contact lens storage cases. Invest Ophthalmol Vis Sci. 2010 Dec;51(12):6329-33. Epub 2010 Aug 18.2. Mutoh T, Ishikawa I, Matsumoto Y, Chikuda M. A retro-spective study of nine cases of Acanthamoeba keratitis. Clin. Ophthalmol. 2010;21(4):11890-92.

Public Inquiry #1The most popular question on ContactLensSafety.org, based on number of clicks from users, is “How should I clean my contact lens case?” Below is the answer provided on the site:To reduce the chances of infection or inflammation, immediately after lenses are removed, discard the old solution from the wells of the case. Then rub the case with clean fingers for at least five seconds, rinse with contact lens disinfection solution, then wipe dry with a clean cloth.1 Avoid washing the case with tap water as this has been linked with increasing the risk of developing Acanthamoeba keratitis, a severe corneal infection, resistant to treat-ment and cure, that can lead to permanent vision loss.2

2. Question display in a given topic area with one highlighted by the cursor.

030_rcl1013 F4.indd 32 10/8/13 3:59 PM

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Clarity of Vision and More Predictable Fitting in Contact Lens Patients with PresbyopiaImproving your chances of success

REFERENCES:1. Kadence International. PureVision2 for Presbyopia Multifocal Quntitative Testing. July 2012. 2. Ipsos OTX and Ipsos Gobal @dvisor. Socialogue: If You’re Awake, Chances Are You Are Well-Connected. http://www.ipsos-na.com/news-polls/pressrelease.asp id 2 . . ovinga KR udington P. Consistency of power pro les in multifocal contact lenses. Paper presented at: 2013 Global Specialty Lens Symposium; 24–27 January 2013; Las Vegas, Nevada, USA. .

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My experience with the PureVision®2 For Presbyopia multifocal lenses centers around a group of patients in my practice who were, with one exception, already wearing multifocal contact lenses but were not completely satisfi ed with their vision. Almost from the start patients reacted very positively to the new lenses, typically commenting “I love these lenses” or that they “were the best when I used my computer.” Remarkably, nearly all indicated that they preferred the new lenses over their previous lenses – extremely encouraging results both in the offi ce and in the real world.

Th e optics of the PureVision®2 For Presbyopia lens enhanced the patients’ experiences for near, intermediate (e.g., computer) and distance vision compared to the lenses they had been wearing. Additionally, compared to several patients’ previous lenses, PureVision®2 For Presbyopia lenses have an increased add power across the center portion of the lens for near vision and a wider intermediate zone where add power gradually transitions to an optimized distance power.3 Th is optimized design results in excellent distance – as well as near and intermediate – vision for patients. Overall, a more predictable add across the power range makes for clear vision and a more predictable fi t.

Diff erences in design that are remarkable for increased overall comfort on the eye include a thin lens design, and a rounded edge – making for a smooth transition between the conjunc-tival tissue and the lens surface – and reduced lens thickness, which gives the lens increased fl exibility. Having said that, I found that lens handling was not a problem – these lenses perform really well in the patient’s hands.

One last observation that attests to the improvement this lens brings is that the majority of my patients had successful fi tting in one visit using the very simple fi tting guide. Th at’s a huge diff erence from other multifocal contact lenses and a highly attractive feature for me as a practitioner – you don’t have to spend loads of chair time fi tting and refi tting and then refi tting again.

Many of us are seeing an increasing number of patients in their 40s and older who would benefi t from simultaneous vision correction for near, intermediate and distance vision. For a wide range of patient vision needs – from those who want to stay in contact lenses despite presbyopia to those who spend many hours a day on the computer or other digital devices – we now have an option that is likely to result in a predictable and successful outcome for patients and is easier to fi t than other multifocal lenses.

itting multifocal lenses for patients with presbyopia is challenging for both patients and eye care professionals alike. Data from a recent study document

an average of 2.6 attempts before a successful fi t is achieved and that nearly a third of presbyopes are never successfully fi tted with contact lenses.1 On the patient side, two thirds or more report dissatisfaction with near and intermediate vision,1 which is not surprising given that many patients spend more than 10 hours per day using electronic devices.2 I’d like to share with you my personal experience in fi tting patients with the PureVision®2 For Presbyopia multifocal lenses, which I think represents a signifi cant improvement both in terms of meeting patient vision needs and predictability of fi t.

F

By Kevin Tyber, BSc, OD

HL6280 SL-7257

RCCL1013_BL Medical.indd 1 10/3/13 2:26 PM

Out of the Box By Gary Gerber, OD


Epictetus, the ancient Greek philosopher, would have been a great optometrist.

He’s quoted as saying, “We have two ears and one mouth so that we can listen twice as much as we speak.”

It’s been said before that a great case history is the most important aspect of treating a patient. But, to complete a good history, master-ing two integral skills is necessary. For starters, you have to know what questions to ask the pa-tient. Secondly, and perhaps most importantly, you have to listen to the answers. Unfortunately, much of our training focuses on the fi rst task, while completely ignoring the second.

Active listening, or disciplined listening—call it what you like—is not something we instinctively do. It’s just not generally a part of most non-clinical conversations. For that reason, it’s important to step back and consciously focus on it and train yourself to become an active listening expert.

Take a typical patient conver-sation that starts with you ask-ing, “What brings you in to see us today?” Whether the patient responds with, “I’m here because you sent me a postcard,” or, “My contact lenses feel dry at the end of the day,” you have more than likely already mentally jumped to a diagnosis. Without listening any further, you’ve already devised a treatment plan and have the requi-site insurance codes in your head. While you are mentally processing all of that, the patient may follow up with some potentially sig-nifi cant information that you will totally miss. This is compounded

by having to then worry about re-cording the patient history, which is another good reason to consider using a scribe.

When I perform mentalism for entertainment, acutely focused listening coupled with the obser-vation of body language is a large part of what I do. Based on my own personal experience, I’ve dis-covered that it’s a trainable skill. In order to improve your listening skills, two simple yet extremely useful things must be practiced.

1. Let the patient talk.Getting to the heart of the

matter, or the chief complaint in our case, is something we want patients to do expeditiously and succinctly. After all, if we have a perfect understanding of exactly what the patient is describing, how long it’s been bothering them, etc., we feel we are better equipped to effi ciently treat the ailment. While there is certainly some diagnostic signifi cance to “I don’t remember when the pain started” vs. “It started last Tuesday at 2:15 PM while I was at work on my computer,” it is critical that we are careful not to rush patients towards where they are going—or where we think they should go.

The preambles to their stories may often contain pearls of clini-cal value. But when a patient be-gins, “My brother-in-law told me a story about this guy he worked with, who he met on a cruise to Cozumel, who wears contact lenses…” we immediately roll our eyes without a thought, and want to tell the patient, “That’s great, but why are you here today?”

However, it’s often stories like these that, with just a bit of active listening and observation of body language, add important color commentary to a patient’s chief complaint: “That guy had some-thing go really wrong with those lenses, and he can’t wear them anymore. So, if I get lenses, I don’t want the same kind he got at the gas station.”

And that is something that can lead to a potential lifelong effect on your patients’ contact lens wearing well-being, as it presents you the opportunity to respond with, “Of course, getting contact lenses from us is different than getting them from a gas station or fl ea market. Let me explain why this is a better approach. Also, if you follow our directions, you won’t have the same problems he had.”

2. Take your time. Yes, easy for me to say while

I’m writing this and I’m not three patients behind schedule, and constrained by decreasing reimbursements from vision care plans. But the reality is, slow-ing down by just a few seconds to intently listen to what your patient is saying, and not picking up your pen or mouse, can have a profoundly positive effect on your listening skills.

A great way to achieve this is to simply do nothing—don’t talk, write, click or do anything else—for one full second after a patient responds to you. I know, it will feel like an eternity at fi rst, but it will force you to refl ect, process and then appropriately respond to what you just heard. RCCL

Hear Ye, Hear YeListen closely to your patients’ complaints for a more accurate diagnosis.

034_rcl1013_otb.indd 34 10/8/13 3:59 PM

©2013 CooperVision, Inc. 0843 08/13

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REFERENCES: 1. Data on fi le, Alcon Research Ltd. 2. Lally J, Ketelson H, Borazjani R, et al. A new lens care solution provides moisture and comfort with today’s CLs. Optician 4/1/2011, Vol 241 Issue 6296, 42 -46. 3. Campbell R, Kame G, Leach N, et al. Clinical benefi ts of a new multi-purpose disinfecting solution in silicone hydrogel and soft contact lens users. Eye & Contact Lens 2012:38(2);93-101. 4. Davis J, Ketelson HA, Shows A, Meadows DL. A lens care solution designed for wetting silicone hydrogel materials. Poster presented at: ARVO; May 2010; Fort Lauderdale, FL.

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