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RCCL
REVIEW OF CORNEA
& CONTACT LENSES
NOVEMBER 2015
SURGERY ISSUE
ASTIGMATISM CORRECTION
DURING CATARACT SURGERY
Earn 1 CE Credit, p. 30
CASE REPORT: A TRICKY POSTSURGICAL CONTACT LENS FIT P. 26
THE CATARACT PATIENT IS
A DRY EYE PATIENT P. 18
SURGICAL PROBLEMS
= CL Opportunities P. 38
MANAGING INFECTION
AFTER LASIK P. 36
PREPPING THE SURGICAL EYE P. 14
Supplement to
CAN SMILE TOP LASIK? P. 22
ALSO INSIDE: Boost Your Contact Lens Profits • Lifitegrast in Limbo • Advice From GP Labs
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contents
Review of Cornea & Contact Lenses | November 2015
departments
4
News Review
Topical Presbyopia Correction
Takes a Step; Contact Lenses
Further Dilute Topical Drops
6
My Perspective
Generic Drugs:
More Than Meets the Eye?
By Joseph P. Shovlin, OD
7
Lens Care Insights
The Never-ending Story
By Christine W. Sindt, OD
8
Pharma Science & Practice
Lifitegrast in Limbo
By Elyse L. Chaglasian, OD,
and Tammy Tham, MS, OD
35
Out of the Box
Reach Out
By Gary Gerber, OD
36
Corneal Consult
When the Going Gets Tough
By James Thimons, OD
38
Practice Progress
New Kid on the Block
By Mile Brujic, OD,
and Jason R. Miller, OD, MBA
42
The GP Expert
Playing the Field:
How Manufacturers Can Help You
By Stephanie L. Woo, OD
features
10
14
18
22
26
30
Supercharge Your Contact Lens
Practice Profitability
Specialty lenses and properly priced
professional expertise can boost the revenue
in your contact lens business.
By Jane Cole, Contributing Editor
Prepping the Surgical Eye
In many anterior ocular surgeries, good ocular
surface integrity is vital to postoperative
success.
By Marc Bloomenstein, OD
The Cataract Patient
is a Dry Eye Patient
Both conditions require attention
and intervention.
By Josh Johnston, OD, FAAO
Something to SMILE About?
How does the newest refractive procedure
measure up against LASIK?
By John F. Doane, MD,
and Jace J. Rickstrew, BS
Staying in Shape: Post-Surgical
Keratoconic Lens Placement
Can additional surgery be avoided in a
keratoconus patient who requires better
functional vision?
By Paul Super, OD, FAAO
fea-
CE — Corneal Astigmatism Correction
During Cataract Surgery
Surgeons have more options—and decisions—than ever before.
Cover design by Ashley Schmouder
©iStock.com/Jobsonhealthcare
/ReviewofCorneaAndContactLenses
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#rcclmag
By Harmohina Bagga, MD, and Kerry K. Assil, MD
REVIEW OF CORNEA & CONTACT LENSES | NOVEMBER 2015
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News Review
IN BRIEF
• Bausch + Lomb has announced
the five-year results from its
Antibiotic Resistance Monitoring
in Ocular Microorganisms
(ARMOR) surveillance study.
The study pinpointed significant
methicillin resistance among
staphylococcal isolates from
ocular infections, with many
strains demonstrating multidrug
resistance. While overall resistance did not increase during the
study period, the authors stress
continued monitoring of ocular
isolates is needed.
• The Brien Holden Vision
Institute has released a set of
grading scales that can be used
as an in-office reference tool for
determining the severity and
progression of complications
such as bulbar redness, limbal
redness and corneal staining.
It also includes descriptions
and photographs of adverse
effects associated with contact
lens wear. You can download
the scale for free at academy.
brienholdenvision.org.
• Hyperopic patients can now try
the Dailies Total1 contact lens
from Alcon, as the company has
announced new plus power versions. The daily disposable lenses, manufactured with Alcon’s
water gradient technology
designed to mimic the environment of the cornea, are available
with a power range of -0.50D to
-6.00D in 0.25 steps and -6.50D
to -10.00D in 0.50 steps. The
latest release adds +0.50D to
+6.00D in 0.25D steps.
• Bausch + Lomb acquired
Doctor’s Allergy Formula, LLC.
The company’s diagnostic
system can be used to pinpoint
the cause of a patient’s ocular
surface disease from a panel of
60 potential allergens.
4
Topical Presbyopia Correction
Takes Another Step
Eye drops may one day compete with lenses.
C
hemically-induced pupil
contraction may soon
emerge as an alternative
treatment for patients with presbyopia, reports a new study in the
September 2015 Eye & Contact
Lens.1 The research accompanies
other recent attempts to manage
the age-related condition using
topical drops.2
External methods like pinhole
spectacles and multifocal contact
lenses are current treatments for
presbyopia; however, these must
be removed regularly. Patients can
also opt for surgical options like
intraocular lens implantation and
refractive lens replacement, but
face complex recovery processes
with the potential for procedure
failure or infection.
In this study, researchers in
Egypt investigated the use of
a parasympathomimetic drug
(carbachol) and an alpha agonist
(brimonidine) in a double-masked,
randomized placebo-controlled
clinical trial involving 48 naturally emmetropic and presbyopic
subjects. A treatment group (n=30
eyes) received a single dose of carbachol 2.25% plus brimonidine
0.2% eye drops, and a control
group (n=18) received placebo
drops. Pupil size at both near and
distance visual acuities was evaluated before and after treatment
at one-, two-, four-, eight- and
10-hour increments.
Mean near visual acuity in
patients older than 50 improved
from J-7.68±1.62 pre-treatment
to J-3±1.6 at one hour, J-3.4±1.4
at two hours, J-4±1.26 at four
hours, J-4.75±1.09 at eight
hours and J-5.6±1.3 at 10 hours.
Mean pupil size decreased significantly from 4.77±0.47mm
pre-treatment to 2.5±0.51mm
at one hour, 2.8±0.7mm at two
hours, 3.13±0.6mm at four hours,
3.48±0.36mm at eight hours and
3.881±0.35mm at 10 hours.
No statistically significant difference was found in mean near visual acuity and pupil size between
initial application and one month
and three months later, as well as
between patients older than 50
and those younger than 50. There
were no serious adverse ocular effects reported from carbachol plus
brimonidine application; however,
one patient did experience a mild
burning sensation, and another reported temporary visual difficulty
in low light.
The protocol “permits acceptable reading vision for many presbyopes, even in older subjects,”
the researchers conclude. “Because
of increased depth of focus from
the smaller pupil, it does not blur
distance vision or immediate vision as does typical monovision
therapy, and the perception of
normal brightness in the untreated
eye eliminates symptoms of dimming from the smaller pupil of the
treated eye.”
RCCL
1. Abdelkader A. Improved presbyopic vision with
miotics. Eye & Contact Lens. Sept 2015;41(5):323-327.
2. Is a topical treatment for presbyopia on the
horizon? Review of Cornea & Contact Lenses. Jun.
2014;5.
REVIEW OF CORNEA & CONTACT LENSES | NOVEMBER 2015
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RCCL
REVIEW OF CORNEA
& CONTACT LENSES
11 Campus Blvd., Suite 100
Newtown Square, PA 19073
Telephone (610) 492-1000
Fax (610) 492-1049
Editorial inquiries: (610) 492-1003
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Email: [email protected]
EDITORIAL STAFF
EDITOR-IN-CHIEF
Jack Persico [email protected]
SENIOR ASSOCIATE EDITOR
Aliza Becker [email protected]
CLINICAL EDITOR
Joseph P. Shovlin, OD, [email protected]
EXECUTIVE EDITOR
Arthur B. Epstein, OD, [email protected]
ASSOCIATE CLINICAL EDITOR
Christine W. Sindt, OD, [email protected]
CONSULTING EDITOR
Milton M. Hom, OD, [email protected]
SENIOR GRAPHIC DESIGNER
Matt Egger [email protected]
GRAPHIC DESIGNER
Ashley Schmouder [email protected]
AD PRODUCTION MANAGER
Scott Tobin [email protected]
BUSINESS STAFF
PUBLISHER
James Henne [email protected]
REGIONAL SALES MANAGER
Michele Barrett [email protected]
REGIONAL SALES MANAGER
Michael Hoster [email protected]
VICE PRESIDENT OPERATIONS
Casey Foster [email protected]
EDITORIAL BOARD
Mark B. Abelson, MD
James V. Aquavella, MD
Edward S. Bennett, OD
Aaron Bronner, OD
Brian Chou, OD
S. Barry Eiden, OD
Gary Gerber, OD
Susan Gromacki, OD
Bruce Koffler, MD
Pete Kollbaum, OD, PhD
Jeffrey Charles Krohn, OD
Kenneth A. Lebow, OD
Kelly Nichols, OD
Robert Ryan, OD
Jack Schaeffer, OD
Kirk Smick, OD
Barry Weissman, OD
REVIEW BOARD
Kenneth Daniels, OD
Desmond Fonn, Dip Optom M Optom
Robert M. Grohe, OD
Patricia Keech, OD
Jerry Legerton, OD
Charles B. Slonim, MD
Mary Jo Stiegemeier, OD
Loretta B. Szczotka, OD
Michael A. Ward, FCLSA
Barry M. Weiner, OD
Contact Lenses Further
Dilute Topical Drops
S
ilicone hydrogel contact
lenses may significantly
limit absorption of certain
anti-infective agents used to treat
ocular surface diseases such as
infectious keratitis, reports a new
study in the September 2015 Eye
& Contact Lens.1 Interactions
between contact lenses and topical drugs have become a muchexamined topic in recent years,
as lenses are known to stimulate
biochemical changes that alter the
composition of the ocular surface
and tear film.2,3 This can lead to
issues with drug effectiveness. Additionally, when used in conjunction with topical drops, therapeutic soft contact lenses may also
act as a physical barrier to topical
drug absorption and contribute
to formula dilution by trapping
debris underneath.
Researchers from the University
of Pittsburgh School of Medicine
performed a biological assay to
determine the activity of diffused
moxifloxacin, polyhexamethylene
biguanide (PHMB) and amphotericin B (AmB) against Staphylococcus epidermidis and Saccharomyces cerevisiae. Results indicated
sufficient diffusion of moxifloxacin and PHMB at 30 minutes, but
not AmB. Ultimately, however,
only moxifloxacin demonstrated
efficacy at the 60-minute mark,
and at 10 times the amount of the
most common commercial formulation; thus, the researchers say,
further study is needed.
RCCL
1. Zambelli AM, Brothers KM, Hunt KM, et al. Diffusion
of antimicrobials across silicone hydrogel contact
lenses. Eye & Contact Lens. Sept. 2015;41(5):277-280.
2. Mann A, Tighe B. Contact lens interactions with the
tear film. Exp Eye Res 2013;117:88-98.
3. Craig JP, Willcox MD, Argueso P, et al. The TFOS
International Workshop on Contact Lens Discomfort: Report of the contact lens interactions with the
tear film subcommittee. Invest Opthalmol Vis Sci.
2013:54:TFOS123-TFOS156.
Focus on HOAs May Increase Surgery Success
Managing quality of vision after lamellar keratoplasty was the subject of
a recent literature review published in the November 2015 Cornea.1 With
respect to the studies evaluated, researchers found no significant difference
in postoperative visual acuity between DALK and PKP; however, outcomes
after DSAEK were significantly better than after PKP. The researchers also
considered the concept of parallelism of anterior and posterior surfaces
following surgery as a means to reduce higher-order aberrations (HOAs),
which have been linked to poor visual acuity outcomes; ultimately, they suggest, “in clinical settings, increased attention to HOAs will avoid irregularity
of the DSAEK grafts or uneven residual stromal tissues in DALK and amend
the postoperative visual outcome.”
1. Yamaguchi T, Satake Y, Dogru M, et al. Visual function and higher-order aberrations in eyes after corneal
transplantation: how to improve postoperative quality of vision. Cornea. 2015 Nov;43(11):S128-S135.
Advertiser Index
CooperVision ................................................ Cover 2, Cover 3
Menicon ......................................................................... Cover 4
REVIEW OF CORNEA & CONTACT LENSES | NOVEMBER 2015
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My Perspective
By Joseph P. Shovlin, OD
Generic Drugs:
More Than Meets the Eye?
Not all drugs are created equal. Be aware of these potential differences.
C
urrent concerns over
prescription costs put
generic drugs at the
forefront of prescribing. Most patients
think they have hit the jackpot if a
medicine they need is available in
generic form. But, have they really
found a pot of gold—or are they
meddling with an impostor likely to
do harm?
BRAND NAMES
DON’T LAST FOREVER
As we know, patents are awarded
for approximately 20 years, depending on the country in which
they are issued.1-3 While this time
span may seem excessive, it takes
time for the drug to go through the
approval and manufacturing process. Consequently, the drug’s actual marketing or “money-making”
time is reduced to an average of
seven to 10 years.2 Manufacturers
can extend the patent by making a
“significant” formulation change,
but additional trials are often necessary to re-verify the patent, bogging
the process down further.
GENERIC REGULATIONS
When the patent is no longer in
force, the generic drug steps up to
the plate. Currently, generic drugs
account for nearly 80% of all prescriptions written.2 But, what scrutiny does the generic drug undergo to
deem it a suitable replacement for
the branded drug?
Policies and regulations for
generic drugs have changed
significantly over the years. Additionally, the FDA also allows
for a 10% variance in active and
6
inactive ingredients in branded
drugs; the same variance is acceptable in generic versions.4 Prior to
regulatory changes made in 1992,
the FDA permitted generic drug
manufacturers to use different inactive ingredients from the innovator
drug, as long as the active ingredients were the same. This poses
a problem for some medications
we use today, as generics approved
before 1992 were labeled the
same as medications we currently
use, but are not truly equivalent.
Changes in tonicity and demulcents
can affect retention time and alter
absorption.4 A simple pH difference
between generics and a brand name
may affect compliance and result
in detrimental long-term effects to
the eye.2
Wiley Chalmers of the FDA’s
ophthalmology division notes that
ointments and other non-solution
dosage forms present different
considerations.”4 These ophthalmic
drugs can be significantly affected
by different manufacturing processes, even when the active and
inactive ingredients are qualitatively
and quantitatively the same. Since
1992, comparative clinical trials
to dispel these concerns have been
implemented by FDA.1,3,4
An additional problem is the lack
of bioequivalency trials required of
generic drugs. Variances can occur
due to differences in bottle size,
shape and material; additionally,
cap colors don’t have to match.3
Drop size (based on the diameter of
the bottle opening) may be different
among generics, and the appearance of the bottle may change from
month to month. Oddly, generic
manufacturers are not required to
alert physicians or patients of any
problems on the package insert,
since the label can’t be altered from
the branded innovator product.3
STRANGER IN
A STRANGE LAND
Patients who shop online for generics expose themselves to even more
risks. Many times, these medications are produced outside of the
US. Generic drug manufacturing
practices in other countries are
sometimes not closely monitored.
As such, a number of potential
problems exist: products can have
impurities, imperfect ingredient matches and even fraudulent
formulations.2,3 This can lead to
ineffective treatment regimens, with
morbidity and vision loss.
W
ith the increasing frequency
in which insurance providers require generic substitution for
a brand name, it’s imperative that
we watch for any new signs or
symptoms related to generic drug
use. Although generics are generally safe, effective and can provide
substantial savings, I have concerns
when this savings comes at the
expense of drug standardization
and safety. Even with revised FDA
requirements that on the surface
appear to be adequate, the safety
and efficacy of some generic drugs
remains in dispute.
RCCL
1. Mandal A: Drug patents and generic pharmaceutical drugs. News Medical, Aug., 2015.
2. Zore M, Harris A, Tobe LA, et al: Generic medications in ophthalmology. Medscape, Aug., 2015.
3. Kahook MY: Branded vs. generic: Proceed with
caution. Review of Ophthalmology, April, 2015.
4. Chalmers WA: Ophthalmic generics-Are they
really the same? Ophthalmology, 119:6, 2012.
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Lens Care Insights
By Christine W. Sindt, OD
The Never-ending Story
When we already struggle with patient compliance, how are we going to get
patients to add even more steps?
C
ompliance with
contact lens care and
cleaning has always
been viewed as a key
factor in reducing
complications; however, it has
gained greater scrutiny since the
microbial keratitis outbreaks nearly a decade ago. There have been
a number of improvements in
contact lens materials, an increase
in recommended lens replacement
frequency and new lens solution
compositions.
The FDA recently removed the
“no-rub” indication from contact
lens solution bottles, citing the
need for mechanical disruption of
the microorganisms and deposits
on the lens surface. There is also
a strong indication that lens cases
should be wiped down daily to
remove biofilm formation, which
harbors microorganisms.1 Despite
these changes, research indicates
rates of infection are still significant.
In an effort to better understand
the noncompliance issue and prevent future problems, the Centers
for Disease Control (CDC) published a study in its Morbidity and
Mortality Weekly Report on the
demographics and risk behaviors
in contact lens-related eye infections.2
The CDC analyzed an online
survey of 4,269 adults over 18
years old from the United States,
approximately 1,000 of whom
were contact lens wearers. The
survey was statistically weighted
to make the panel representative
of the US population. Participants
were asked demographic questions,
if and what type of lenses they
wore and contact lens hygienerelated risk behaviors. The survey
estimated there are nearly 40.9
million adult contact lens wearers in the US—and nearly 99% of
them exhibit at least one contact
lens hygiene risk behavior.2
About half of all wearers report
overnight wear, with 87% stating they nap in lenses. Fifty-five
percent top off solutions, while
50% replace lenses less frequently
than recommended. Most shocking, but least surprising, was the
rampant exposure of contact lenses
to water-borne sources of infection: 84.9% reported showering
in lenses, 61% swim with lenses in
and 35.5% of all contact wearers
rinse lenses in water (91% of GP
wearers).2
A PRACTITIONER’S
PERSPECTIVE
I found the risk behaviors of daily
disposable wearers particularly
interesting. Daily disposable lenses
are supposed to reduce complications by eliminating the lens care
compliance problems associated
with storing lenses overnight.
Perhaps, however, in our effort to
eliminate lens care products and
increase compliance, we have unwittingly increased daily disposable
wearer noncompliance risk. Are
we putting our daily disposable
patients at risk by not talking to
them about lens care hygiene and
lens cases?
According to the CDC report on
soft lens wearers, daily lens wearers have the highest level of storing
lenses in tap water (28% of daily
wearers, compared with 12.4% of
planned replacement wearers) and
rinsing lenses in tap water (40.3%
of daily wearers compared with
27.2% of planned replacement
wearers). Sixty percent of daily
wearers use a contact lens case,
and most of those report topping
off solution (72% of daily wearers
compared with 51.3% of planned
replacement wearers).
T
he lens care compliance “talk”
remains difficult, tedious
and never-ending. I’m sure many
practices were happy to shorten
the lens care discussion when daily
disposables arrived on the scene.
However, daily disposable wearers
also have significant noncompliance habits, and in the absence of
proper instruction on lens care,
they increase their risk with water
exposure.
So, perhaps the conversation
should go something like this: “Replacing your lenses daily decreases
your risk of infection and red eyes.
Always carry a replacement pair
of lenses with you, so you never
have to reuse a lens. And if you
find yourself in a situation where
you do have to reuse a lens, there
are some safer practices that can
be used, such as rubbing, rinsing
and storing the lens in a disinfecting solution and never using tap
water on the lens.” These kinds
of reminders will help us increase
patient compliance one step at a
time.
RCCL
1. Wu YT, Willcox M, Zhu H, Stapleton F.
Contact lens hygiene compliance and lens
case contamination: A review. Cont Lens
Anterior Eye. 2015 Oct;38(5):307-16.
2. Cope JR, Collier SA, Rao MM, et al.
Contact lens wearer demographics and
risk behaviors for contact lens-related eye
infections. Morbidity and Mortality Weekly
Report. 2015;64(32):865-70.
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Pharma Science & Practice
By Elyse L. Chaglasian, OD, and Tammy Than, MS, OD
Lifitegrast in Limbo
The FDA recently requested more data on this investigational dry eye drug. What’s
known—and what’s next?
I
n April of this year, the FDA
granted priority review to the
lifitegrast new drug application (NDA) for the treatment
of dry eye disease. Priority
review is granted to drugs believed
to have the potential to improve the
treatment, diagnosis or prevention
of serious diseases. Priority review
accelerates the review process, reducing it from 12 to eight months.1
Lifitegrast’s developer, Shire
Pharmaceuticals, obtained it in
2013 when it acquired SARcode
Bioscience. FDA approval would
make it the first prescription dry eye
drug available to treat both signs
and symptoms of the disease.3 The
first Phase III study demonstrated
improvement in signs but not
symptoms, while the second met
the co-primary endpoint of relieving
dry eye symptoms, but missed the
second endpoint: improvement in
corneal staining.3,5,6
The FDA was expected to release
a decision on October 25, 2015
regarding lifitegrast; however, eight
days prior, the agency declined approval of the drug at this time, citing the need for additional clinical
tests and further information about
product quality.2 This column will
provide some background.
BENEATH THE SURFACE
Lifitegrast is a first-in-class, smallmolecule antagonist of the lymphocyte function-associated antigen-1
(LFA-1) integrin, inhibiting interaction with its cognate ligand, called
intercellular adhesion molecule-1
(ICAM-1).7,8 Whew! That’s a
sentence-full. So, what does this
mean clinically?
8
Integrins are heterodimeric (i.e.,
a protein composed of two different polypeptide chains) cell surface
receptors found in nearly all cell
types that act as bridges for cell-tocell and cell-to-extracellular matrix
interactions. They are comprised of
α and β subunits, which determine
the ligand specificity for a particular
integrin. The ligand is described
as cognate, meaning that a specific
ligand normally interacts with a
given integrin. The ligand is usually
the signal-triggering molecule that,
upon binding to the integrin, results
in a wide range of integrin-mediated
interactions, including pathological processes such as inflammation,
wound healing, angiogenesis and
tumor metastasis.8-10 The ligand
ICAM-1 is a protein normally
present in low levels on the surface of lymphocytes, macrophages
and vascular endothelium, but is
overexpressed in the presence of
inflammation.
The binding of LFA-1, a cell
surface adhesion molecule found
on all leukocytes, with ICAM-1, is
essential for the migration and proliferation of T-cells at inflammatory
sites as well as subsequent cytokine
release. This T-cell-mediated inflammation is a mechanism known to be
present in dry eye disease.6 Blocking the interaction of integrins with
their ligands is a major target for
new pharmaceutical agents, with
recent drugs approved or in trials
for conditions such as multiple sclerosis, Crohn’s disease, osteoporosis,
cancer, AMD and now dry eye.9,10
Lifitegrast acts as an ICAM-1 decoy, preventing LFA-1 from binding
to ICAM-1, which presents abun-
dantly on inflamed cells. This inhibition of LFA-1 binding to ICAM-1
is believed to break the inflammatory cycle, thereby reducing a dry
eye patient’s signs and symptoms.8
MAGNUM OPUS
The original lifitegrast NDA included one Phase II study, two Phase III
efficacy and safety studies (OPUS-1
and OPUS-2) and one long-term
Phase III safety study (SONATA).
More than 1,800 patients were
enrolled in these four randomized
clinical trials.4
A Phase II study of lifitegrast
conducted from 2009 to 2010
recruited 230 dry eye patients at five
sites. Typically in Phase II studies,
the drug concentration and dosing frequency are established; in
this study, lifitegrast was evaluated
at 0.1%, 1% and 5% concentrations. Subjects used the drops for
12 weeks and were evaluated at
several screening and on-treatment
visits. Using the controlled adverse
environmental (CAE) procedure to
reduce variables, signs and symptoms were assessed before and after
ocular surface drying. The CAE is
a chamber that regulates environmental factors including humidity (<10%), temperature (76±6º),
airflow and lighting. In this study,
there was an improvement in signs
and symptoms of dry eye in the
lifitegrast group as compared to
placebo with a dose response for
staining.11 A clinically meaningful
response, as defined by the FDA,
requires statistically significant
improvement in one sign and one
symptom that must be replicated in
Phase III studies.7,12
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Entering Phase III studies,
lifitegrast at a concentration of 5%
dosed twice a day was selected.
OPUS-1 was conducted from 2011
to 2012 involving 13 sites enrolling 588 dry eye patients. Patients
were randomized at a ratio of 2:1
(lifitegrast:placebo) and used the eye
drops twice a day for 12 weeks. The
primary objective outcome measure
was inferior corneal fluorescein
staining and the primary subjective
outcome measure was visual-related
function subscale of the Ocular
Surface Disease Index (VR-OSDI).
The visual-related function involved
questions six to nine on the OSDI.
Unlike the Phase II study, the CAE
was used during the screening
process, but not once patients were
on treatment. Objective findings
including corneal fluorescein staining and conjunctival lissamine green
staining were significantly reduced
in the lifitegrast group as compared
to placebo. There was symptomatic
improvement in ocular discomfort
and dryness in the treatment group.
However, the co-primary endpoint
of VS-OSDI was not met.5,12
OPUS-2 was then conducted
from 2012 to 2013 at 30 sites
involving 718 dry eye patients.
Participants were randomized to
use either lifitegrast 5% or placebo
twice a day for 12 weeks. The subjective primary outcome measure
was altered from VR-OSDI to Eye
Dryness Score (EDS), which assesses
seven subject-reported symptoms
using a visual analog scale for each
item with zero representing no
discomfort and 100 indicative of
maximum discomfort. The subjective primary outcome measure was
a single score that combined the
EDS from both eyes. In contrast to
OPUS-1, OPUS-2 demonstrated significant improvement in the subjective endpoint (i.e., eye dryness), but
failed to show significant improvement in the objective measure of
corneal fluorescein staining.6,12
SONATA was a multicenter (23
sites) Phase III safety study enrolling 331 dry eye patients conducted
from 2012 to 2014. Patients were
randomized; 220 received lifitegrast
and 111 received placebo. Patients
used the eye drops twice a day for
one year. No serious ocular adverse
events occurred in either group;
however, those receiving lifitegrast
had more ocular and nonocular adverse events than the placebo group.
Approximately half the study subjects reported adverse events, with
the most common being dysgeusia
and irritation upon instillation.
Secondary safety measures showed
no significant changes, including
plasma concentration.12,13
OPUS-3 concluded in October.
This Phase III study involved 41
sites enrolling 711 patients. Like
prior OPUS studies, dry eye patients
either received lifitegrast or placebo
twice a day for 12 weeks; however,
the main difference in this study
compared with the others is the inclusion of just a single primary outcome measure—the subjective eye
dryness score.12 Preliminary results
from this study released on October 27 indicated that the primary
endpoint was met with significant
improvement in patient-reported
symptoms in the group receiving
lifitegrast. Other key secondary
endpoints evaluating symptoms at
days 14 and 42 were also met. Shire
reportedly plans to resubmit the
lifitegrast NDA to the FDA in the
first quarter of 2016.
F
or now, the waiting continues.
These positive results from
OPUS-3 will hopefully address the
FDA’s concerns and ultimately give
us a new first-in-class medication
to offer relief of both the signs and
symptoms of dry eye.
RCCL
1. FDA Grants Priority Review to Lifitegrast NDA for
Treatment of Dry Eye Disease in Adults. Available
at https://www.shire.com/newsroom/2015/april/
fda-grants-priority-review-to-lifitegrast-nda-fortreatment-of-dry-eye-disease-in-adults. Accessed
Oct 5, 2015.
2. FDA Declines Approval of Shire’s Eye Drug
Lifitegrast. Available at http://www.techtimes.com/
articles/96514/20151017/fda-declines-approval-ofshires-eye-drug-lifitegrast.htm. Accessed Oct 19,
2015.
3. Lifitegrast Heads Up Promising Dry Eye Pipeline.
Available at: http://ois.net/lifitegrast-heads-uppromising-dry-eye-pipeline/. Accessed Oct 5, 2015.
4. Press Release: Shire Provides Update on Next
Steps for Lifitegrast in Light of FDA Complete Response Letter. Available at: https://www.shire.com/
newsroom/2015/october/shire-provides-update-onnext-steps-for-lifitegrast-in-light-of-fda-completeresponse-letter. Accessed Oct 19, 2015.
5. Sheppard JD, Torkildsen GL, Lonsdale JD,
D’Ambrosio FA, et al. Lifitegrast ophthalmic solution
5.0% for treatment of dry eye disease: results of
the OPUS-1 phase 3 study. Ophthalmology. 2014
Feb;121(2):475-83.
6. Tauber J, Karpecki P, Latkany R, Luchs J, et al.
Lifitegrast ophthalmic solution 5.0% versus placebo
for treatment of dry eye disease. Results of the randomized phase III OPUS-2 study. Ophthalmology.
2015 Sep 10. pii: S0161-6420(15)00777-0.
7. Semba CP, Swearingen D, Smith VL, et al. Safety
and pharmacokinetics of a novel lymphocyte
function-associated antigen-1 antagonist ophthalmic solution (SAR 1118) in healthy adults. J Ocul
Pharmacol Ther. 2011 Feb;27(1):99-104.
8. Zhong M, Gadek Tr, Bui M, et al. Discovery and
Development of Potent LFA-1/ICAM-1 Antagonist
SAR 1118 as an Ophthalmic Solution for Treating Dry
Eye. ACS Med Chem Lett. 2012 Jan;31;3(3):203-6.
9. Millard M, Odde S, Neamati N. Integrin Targeted
Therapeutics. Theranostics. 2011;1:154-188.
10. Takada Y, Ye X, Simon S. The integrins. Genome
Biology. 2007; 8(5):215.
11. Ousler GW, Gomes PJ, Welch D, Abelson MB.
Methodologies for the Study of Ocular Surface Disease. The Ocular Surface. 2005 July;3(3):143–154.
12. ClinicalTrials.gov. Accessed: Oct 19, 2015.
13. SONATA: 50% Adverse Event Rate Reported for
Lifitegrast. Available at http://www.medscape.com/
viewarticle/8443968_print. Accessed: Oct 5, 2015.
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Supercharge
Your Contact Lens Practice
Profitability
O
ptometrists dominate the contact
lens market, writing
nearly an estimated
90% of contact lens
prescriptions annually.1 However,
many practitioners are still not
taking full advantage of the revenue
potential from the contact lens arm
of their practices, instead relying
on it as a supplemental source of
income.1 Cutthroat pricing by the
big box retailers and online suppliers makes contact lenses a losing
proposition, many still believe.
Some optometrists say it’s time
to rethink that tired mindset. “Embrace contact lenses as a practice
builder and not a loss leader in your
practice,” says Glenda Secor, OD,
of Huntington Beach, CA. “Increasing your enthusiasm for new products, introducing opportunities for
new wearers and offering to address
problems will reduce dropouts, create loyalty and increase revenue.”
DON’T SHY AWAY FROM
SPECIALTY LENSES
Optometrist Ken Krivacic of Irving,
TX, believes the most profitable
contact lenses are specialty
lenses like sclerals, hybrids and
multifocals. “They generally cost
more, but you can also charge
more, and profit margins are much
10
larger than standard disposables
or gas permeables. If you can
train yourself in those areas and
then market to your existing and
potential patients, this will allow
you to charge more and increase
your net,” Dr. Krivacic says.
Equally important: specialty lenses
provide your patients with better
vision correction than conventional
lenses do, and that elevated level
of care bonds the patient to your
practice.
Offering specialty lenses in
your practice helps to distinguish
you from your peers, adds Jason
Jedlicka, OD, of Edina, MN. A
common mistake is underpricing
your professional services. “I’m not
talking about disposable bifocal
lenses; those are a commodity and
anyone can fit them. I’m talking
about GP multifocal, ortho-k and
sclerals,” Dr. Jedlicka says.
Additionally, patients usually
don’t shop around for specialty
services and lenses, says Justin
Bazan, OD, of Brooklyn, NY. “If
patients are referred to you or they
are coming to you because they did
their own research, they probably
aren’t overly concerned with saving
a few bucks,” he explains, adding
that specialty lenses are often
unavailable for the consumer to
purchase directly, which guarantees
the optometrist additional revenue
from dispensing in-office.
Patients who are fit with specialty
lenses are also likely to refer other
patients to your practice. “I saw a
new patient this week who came to
me for sclerals because he knows
someone who I fit in sclerals postRK. He didn’t even need contacts,
but was persuaded to see me for
sclerals because of word of mouth,”
Dr. Jedlicka says.
Specialty lenses are more
mainstream than ever, with new
modalities that are easier to fit and
are also affordable for patients.
One caveat with specialty lenses,
however, is that over time, they
may not be so unique, Dr. Bazan
says. “As technology advances
and doctors look for other revenue
streams, you will see more and
more providers doing specialty
‘whatever.’ As history shows, it
will probably lead to a form of
commoditization, and we will see a
dip in profitability.”
DON’T LOWBALL
YOUR SERVICES
To build a thriving contact
lens practice, be careful not to
undervalue your expertise. Most
doctors lowball their fees and try
to garner most of their contact
lens revenue from the material
REVIEW OF CORNEA & CONTACT LENSES | NOVEMBER 2015
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Specialty lenses
©iStock
k.com/Jobs
b onHe
nHealth
althca
care
are
and properly priced
professional expertise
can boost the revenue
in your contact lens
business.
By Jane Cole, Contributing Editor
side, Dr. Krivacic explains. In fact,
the revenue from the professional
fees can be substantial if you price
yourself correctly, and no direct cost
is involved, he adds.
Optometrists should provide a
higher level of service—and then
charge accordingly, Dr. Jedlicka
says. This includes performing
topography on all new contact
lens fits and refits; staining the
patient’s eyes and everting their
lids to look for any issues; using
photography when possible to back
up your recommendations; and
individualizing product offerings for
different patients.
When patients perceive a higher
level of service, they are either
willing to pay more for it—these
are the patients you want—or
not willing to pay for it. “Focus
on taking exceptional care of the
patients that appreciate the higher
level of care and are willing to pay
for it,” Dr. Jedlicka says.
By setting higher fees, many
patients will consider you to be
better at what you do since you are
more expensive, Dr. Jedlicka points
out. In turn, patients will often
consider you the expert.
“I know a doctor whose ortho-k
practice was languishing. In an effort
to grow it, he considered lowering
his fees. Instead, he was persuaded
to raise his fees considerably. Doing
so caused his ortho-k practice
to grow significantly as patients
perceived that—based on his higher
fees—he was the best, and they
wanted the best,” Dr. Jedlicka says.
For years, doctors have made
the mistake of giving away their
contact lens services with “free
contact lens evaluations,” says Dr.
Bazan. “Doctors would simply not
charge if there was no change in the
contact lens brand.” However, he
suggests, it is important for patients
to recognize that your services are
worth paying for. This can be done
by offering a higher level of service
and charging accordingly.
“Do you just simply flick a slit
lamp light on and off, or do you
explain what you’re doing as you’re
doing it? Do you simply ask how a
patient is doing with their contacts,
hoping to hear ‘fine’ so you can
just move on, or do you get better
answers because you ask better
questions? Do you find out how
the patient is wearing and caring
for their lenses, or is re-education
needed? Do you let them know
about new options and why you
are going to let them try them?”
Dr. Bazan asks. The bottom line,
he says, is that most patients are
used to getting a subpar contact lens
exam “and they feel like it’s worth
not much more than free. It’s time
for us to change that.”
You should, of course, monitor
what the competition is charging,
advises practice management
consultant Bryan Rogoff, OD, of
Baltimore, MD. If your practice is
not established, you can’t charge
$150 if the going rate is $100,
or you’ll price yourself out of the
market. “If you build up your brand
and your reputation, you can charge
higher prices,” Dr. Rogoff says.
STAFF TAKES THE BATON
Staff is a tremendous resource when
promoting a contact lens practice.
At Dr. Krivacic’s office, he relies on
his staff to make all the contact lens
sales. “They work with the patient
after the exam and go over fees and
material costs and are instructed to
promote yearly supplies. If staff are
properly trained and incentivized,
they can improve your bottom line,”
he says.
Dr. Jedlicka’s staff members are
fitted for and wear the contacts that
are offered at his practice, making
them the ideal ambassadors to
discuss the highlights and positive
experiences of their lens wear.
“Staff needs to hear the success
stories you have, so they can get
in your camp and become excited
about what you do as a practice.
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SUPERCHARGE YOUR CONTACT LENS PRACTICE PROFITABILITY
Photo: Christine W. Sindt, OD
Specialty contact lenses like this scleral lens could give your practice an edge over others.
Staff will often end up talking fees
with the patients, so they need
to believe in what you do and in
the level of care you provide, so
they are completely comfortable
explaining fees and why the fees
you charge are worth it,” Dr.
Jedlicka says.
When assessing your staff’s
role in contact lens sales, consider
whether you look at your staff as
“order takers or sales makers,” Dr.
Bazan suggests. Educate staff why
the annual supply is best for the
patient and the practice, he says.
Then train your staff on a script
that makes it easy for them to sell
the annual supplies to the patient.
“The annual supply sale should be
the norm, not the exception,” Dr.
Bazan says.
LOOK TO YOUR
SPECTACLE LENS PATIENTS
If a spectacle patient is a good
candidate for contact lenses, Dr.
12
Krivacic will ask if the patient
has considered them. He will also
mention the availability of one-day
options, which are often easier to
wear and easier to take care of,
and would therefore be able to be
worn easily on a part-time basis.
He also explains that contacts are a
good option for someone who only
wants them for sporting activities,
or for those with allergy issues.
In Dr. Jedlicka’s practice, he
concludes every exam with a
discussion of all available options
for refractive correction: glasses,
contact lenses and surgical
procedures. If a patient is a natural
candidate for contact lenses, he
offers them a chance to try lenses.
“Dailies are the perfect way [to
ease] into this, since they are low
maintenance and commitment,” Dr.
Jedlicka says.
A good opportunity to market
contact lenses to your spectacle
wearers is to offer a patient the
chance to try the lenses on while
they are waiting for their glasses in
the optical department, Dr. Rogoff
suggests. Also, don’t discount
contact lenses for special occasions,
such as weddings or other special
events where your patients might
want to opt out of wearing their
glasses, Dr. Secor says.
PRICING 'UPPS' AND DOWNS
Although contact lenses are medical
devices, they’re also a consumer
product, subject to all the same
incentives and disincentives to
purchase as any other. Pricing
matters, and patients want to
be treated fairly, the experts say.
Disposable lenses are the same no
matter where they are purchased,
so charging a premium for them,
Dr. Jedlicka feels, is “sticking it to
patients for their loyalty to your
practice.” He believes optometrists
should be competitive with product
pricing and place the premium on
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services—making sure, of course,
that the services offered are topnotch.
With the advent of the unilateral
pricing policy (UPP) from many
manufacturers, which dictates the
minimum price that can be charged
for certain brands of contact lenses,
some doctors feel UPP has benefited
private practice by leveling the
pricing playing field. They do say
UPP has posed some disadvantages
as well, however. News reports
on UPP, especially in states with
legislative efforts against it, tend to
misrepresent the policy as one of
price fixing or artificial inflation at
the consumer’s expense. Explaining
UPP to the patient can help keep the
sale in the practice instead of having
them search online or seek out a
cheaper retailer.
“UPP is helping, though most
patients are unaware of this until
we explain it to them,” Dr. Jedlicka
says. “When they find out, many
patients do elect to purchase their
lenses from us instead of going
elsewhere, as we point out the other
benefits to buying lenses from us
such as exchanges, trials, rebates
and free shipping.”
As doctors consider which brands
to keep in stock, they may want to
opt for lenses that can’t be ordered
for a cheaper price elsewhere.
“Why would any business sell a
product that can easily be found
for less online? I just don’t get it,”
Dr. Bazan says. “When there are
so many contact lens options that
are clinically equivalent, why not
go with the lenses that ensure your
doors will remain open for you to
see patients?”
Dr. Bazan says he is seeing some
slippage in UPP policies, so he
believes it is important to research
the brands you use to check on
current pricing. It’s also important
to remember the listed price is
010_RCCL1115_F1-1.indd 13
probably not the final price. He
suggests setting up an account
with the vendors your patients
use—or, hopefully, formerly used—
and actually go through with the
purchase until the site asks for a
credit card. You want to know
the bottom line price for the same
supply after all the extras like
shipping and handling are added in,
he says.
For Dr. Krivacic, he believes UPP
pricing has been both good and bad
for the industry. The good is that it
has helped level the playing field. If
a lens is distributed using UPP, the
prices at his practice are the same as
the big retailers. The price incentive
is then eliminated and most patients
would rather buy directly from the
doctor. “In our practice, this has
helped,” Dr. Krivacic says.
However, the downside is that
since all prices are now the same,
there is less incentive for the patient
to purchase a larger quantity unless
a rebate is involved, Dr. Krivacic
adds. Also, if the price is the same,
patients may opt for convenience
and purchase a lens online or at a
retailer.
O
ne final tip—you must have
enough volume to generate
good profits from the contact lens
side of your practice, Dr. Krivacic
says. This goes back to the basics of
practice management and keeping
your appointment book full.
“The contact lens patient is still
our most loyal patient, and they
appreciate and value the care you
provide,” Dr. Secor says. “They are
best at referring their friends and
family, and they share word of your
expertise with potential new patients
more effectively than you can ever
imagine.”
RCCL
1. The State of the Optometric Profession: 2013.
American Optometric Association, Jobson Medical
Information. 5-6.
Benchmarks
for Product
Profitability
How much money can you
expect to generate from
contact lens sales?
The unilateral pricing policy
has set a profitability bar
for optometrists in sales of
specific lenses made by the
manufacturers, says Dr. Krivacic.
“The average net seems to be
about $100 per annual supply
sold for most basic spherical
lenses. It’s slightly higher for
torics and multifocals. Specialty
lenses can generate much larger
profits,” he says. “Personally, I
concentrate more on the ability
to profit from professional fees,
and the fact that most contact
lens patients return to the
practice for their exams almost
twice as often as a spectacle
wearer does.”
For Dr. Bazan, his practice
earns a net profit of $188 on all
his best selling annual supplies
of spherical monthly sales and
$220 on his best-selling annual
supplies of spherical daily
disposables.
“The mix of product costs
should be below 30% of gross
sales,” suggests optometrist
Clarke Newman of Dallas. In
a large contact lens practice,
roughly a third of the total cost
of goods should be allocated to
contact lens costs, he suggests.
How you set your fees and
retail costs determines the
profitability of your overall
contact lens enterprise, Dr.
Newman adds.
10/29/15 2:23 PM
PREPPING
the Surgical Eye
T
he ocular surface is
the thin yet complex
layer of defense
against potentially
devastating adverse
effects on the refractive ability of
the eye. Its tear film is comprised
of nutrients, proteins and antiinflammatory components within
a rich mucin-laden adhesive that
is kept intact by an even thinner
layer of meibum. The successful
production of this muco-adhesive
layer is dependent on an intact
sensory-autonomic reflex,
comprised of a healthy corneal
sensation and lacrimal gland
function. This delicate homeostatic
balancing act has no safety net to
catch a failing ocular surface, with
one exception: us.
Optometrists know firsthand
how essential this layer is
to maintaining the optical
qualities that our patients
demand. As innovation created
new opportunities to care for
patients, modern technology
has provided patients with
ways to correct their ametropia
without the need for spectacles
and contact lens materials and
solutions have flourished. Such
technological advancement has
also been witnessed in the area
of refractive surgery, which has
14
evolved from its rather primitive
origins into a highly precise and
predictable protocol for refractive
error correction. However, the
quality of these results still rests
on the continued sustainability
of that minuscule layer coating
the epithelium. Any imbalance in
the delicate system—comprised
of a healthy and functioning
tear film plus a normal blink
reflex with well-positioned eyelid
apposition—will ultimately lead to
an unhealthy ocular surface.
The definition of refractive
surgery has changed significantly
in the two decades since LASIK
was approved, blurring the
line between refractive and
cataract surgeries. The use of
smaller corneal incisions during
cataract surgery and the ability to
incorporate laser into our surgical
suite, as well as the increase in lens
options (both multifocal and toric)
has repositioned the pseudophake
under the refractive umbrella.
Cataract surgery in particular
has been made better with the
introduction of the femtosecond
laser; however, laser surgery also
comes with some complications.
Virtually all laser eye surgery
patients experience some degree of
dry eye in the first six months after
surgery, with symptoms persisting
beyond that in nearly 20% of
patients.1 Subclinical preexisting
dry eye demonstrates the highest
risk of long-term postoperative
dry eye symptoms, possibly for
up to 16 months postoperatively.1
Peak dryness in cataract surgery
patients in particular occurs
around one month after surgery,
and may last longer than three.2
Some practitioners believe that
the damage to the corneal nerve
plexus during both cataract
and refractive procedures
leads to neurotrophic dry eye.
The incisions used to enter
the epithelium, deep stromal
nerve changes during ablation,
application of suction rings to
the mucin-secreting goblets cells
and microvilli all play a role
in perpetuating inflammatory
dry eye.3 The increase in this
dryness may also be exacerbated
by the necessary use of topical
medications, whereby their
sequelae is toxic to the epithelium.
ABOUT THE AUTHOR
Dr. Bloomenstein is the director
of optometric services at the
Schwartz Laser Eye Center
in Scottsdale, Arizona. He is
a founding member of the
OCRT and a past-president
of the Arizona Optometric
Association.
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In many anterior ocular surgeries, good ocular
surface integrity is vital to postoperative success.
By Marc Bloomenstein, OD
PREPARATION
As partners in our patients’ desire
to obtain the best quality of vision,
we need to be able to recognize
and treat any irregularities in the
patient’s ocular surface. Thus, we
need to identify these patients by
any means necessary to prevent
complications. Historically, we
have relied on patient complaints
or corneal staining to identify
these abnormalities; however, these
methods can be misleading since the
predictive diagnostic value is not
consistently high.
The first step toward achieving
a successful surgical outcome is
to record a thorough medical
history. Common preoperative and
intraoperative risk factors for dry
eye with refractive surgery include
the depth of the laser incision,
degree of preoperative myopia,
female gender, contact lens use,
diabetes and eyelid disorders; thus,
the evaluation should include an
examination of lid anatomy and
function, blink rate and tear film
composition (including osmolarity).
Clinicians should also inquire
about patients’ concurrent use of
systemic medications that may
increase dryness, the frequency
with which they use artificial
tears and the humidity of their
living environment, as these can
inhibit recovery
following
surgery. Note,
patients with
systemic
inflammatory
diseases, such
as Sjögren’s
syndrome and
rheumatoid
arthritis, are
often poor
TearLab can be used to quantify a patient's dry eye.
surgical
candidates based
be used to indicate an abnormal
on their pro-inflammatory status.
ocular environment. InflammaDry
IDENTIFICATION
(RPS) is one method of objectively
Several procedures can help detect
determining the levels of MMP-9,
preoperative dry eye in cataract
which has been associated with
patients. Tear hyperosmolarity,
inflammatory dry eye disease.5
defined as a tear concentration with
Tear analysis can also be used to
a greater than average mOsm/L,
assess dry eye conditions in preis a highly accurate marker of
operative patients by exposing the
dry eye and can also adversely
tear film and meibomian glands
affect cataract outcomes: one
to a light source to highlight any
study found 21% of patients with
abnormalities. Equally important
hyperosmolarity had a measurement is an assessment of the number
between 0.5D and 1.0D, and 16%
and functional level of lipidhad more than 1D of change in
secreting meibomian glands, as
keratometry readings.4 The TearLab well as an evaluation of meibum
osmolarity test can be used both
consistency. This can be done
to identify dry eye and quantify its
using meibography. In addition
severity.
to evaluating meibum quality,
The presence of certain levels of
gland integrity should also be
matrix metalloproteinase (MMP)
considered. Using a transilluminator
inflammatory mediators can also
to evert the lid and viewing the
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PREPPING THE SURGICAL EYE
retroillumination at the slit lamp
can be a way to see these glands
without a meibography.
POSTOPERATIVE
EVALUATION
Because postoperative dry eye
can compromise visual acuity
and adversely affect an otherwise
near-perfect visual outcome, it is
important to evaluate the patient’s
refractive ability postoperatively
to ensure the results are adequate.
Whereas in the past we could
anticipate patients being within a
diopter or two of the intended goal,
we now measure success in quarterdiopter steps.
Dry eye can lead to different
postoperative complications
depending on the procedure. In the
case of the KAMRA corneal inlay
(AcuFocus), for example, which
allows only central light rays to
reach the retina through a 1.6mm
diameter hole, the presence of
dryness on the central aspect of the
cornea can distort the final image.
Cyclosporine is a useful treatment
for reducing postoperative dry
eye in patients with marked
preoperative hyperosmolarity or
tear film abnormality. Starting your
patient on a twice-daily dose of
Restasis (Allergan), combined with
an artificial tear that is reflective of
their lid and osmolarity readings,
can foster a more hospitable
environment. Typically, the patient
should stay on this regimen for
a minimum of four to six weeks
before measurements are retaken.
Macrolide drops or lid scrubs
such as HypoChlor (OcuSoft)
can be used to reduce bacterial
colonization on the lid margin
to prevent infection, while warm
compresses can help to soften
meibomian gland issues. Punctal
plugs are also extremely useful in
the treatment of dry eye and can
be placed before any surgery is
performed; however, inflammation
should be reduced prior to
insertion.
Lastly, nutritional therapy may
also play an important role in
preoperative treatment of dry eye.
Fish oil containing eicosapentaenoic
and docosapentaenoic
polyunsaturated fatty acids
have been shown to reduce
inflammation, while omega-3
fatty acids decrease inflammation,
increase tear production and may
potentiate the regeneration of
nerves.6 Directing patients to take
high-dose capsules containing
omega-3 and omega-6 fatty acids
on a daily basis beginning one
month before surgery can help
maintain the tear film.
Postoperative dry eye treatment
should follow the same steps
of detection and therapy as in
the preoperative period. Note,
however, since patients are now
dealing with severed nerves and
the potential adverse response to
their medication, they should stay
Oculus meibography.
16
on any therapy instituted prior to
surgery. Restasis drops and artificial
tears should be used for a minimum
of 90 days postoperatively, with
further testing to determine the
long-term use. Lid disease should
be treated on the same level.
Additionally, check for variations
in best-corrected visual acuity on
every follow-up visit.
P
atient expectations are
increasing to match advances
in ocular surgery; thus, clinical
management of the ocular surface
before and after arguably becomes
as critical to cataract and refractive
surgeries as the actual surgical
process. Evaluation of patients with
diligence toward improving quality
of vision and minimizing dry eye
symptoms is a responsibility we
all share. This is a process that
should start from the moment the
patient wants to improve their
vision through any intervention—
be it glasses, contacts or surgery.
Yet, one can always stop wearing
contacts or change the lenses in
glasses; refractive surgical outcomes
are not as pliable. So, remember:
surgical success starts with a good
consultation, diagnosis and unique
ocular surface treatments.
RCCL
1. Bailey, MD, Zadnik K. Outcomes of LASIK
for myopia with FDA-approved lasers. Cornea.
2007;26(3):246-254.
2. Li XM, Hu L, Hu J, Wang W. Investigation of dry
eye disease and analysis of the pathogen factors
n patients after cataract surgery. Cornea. 007
Oct;26(9 Suppl 1):S16-20.
3. Oh T, Jung Y, Chand D, et al. Changes in the tear
film and ocular surface after cataract surgery. Jpn J
Ophthalmol. 2012 Mar;56(2):113-8.
4. Epitropoulos AT, Matossian C, Berdy GJ, et al.
Effect of tear osmolarity on repeatability of keratometry for cararact surgery planning. J Cataract
Refract Surg. 2015 Aug;41(8):1672-7.
5. Kaufman HE. The practical detection of MMP9 diagnoses ocular surface disease and may
help prevent its complications. Cornea. 2013
Feb;32(2):211-6.
6. Root M, Collier SR, Zwetsloot KA, et al. A
randomized trial of fish oil omega-3 fatty acids
on arterial health, inflammation and metabolic
syndrome in a young healthy population. Nutrition
Journal 2013 Apr 8;8:40.
REVIEW OF CORNEA & CONTACT LENSES | NOVEMBER 2015
014_RCCL1115_F2.indd 16
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The Cataract
a Dry
Both conditions require attention and intervention.
A
63-year-old female
presented in the
clinic for an eye
exam for the first
time in five years
with a best-corrected visual acuity
of 20/40 OD and 20/30 OS, with
glare disability of 20/80 OU.
She reported decreased vision in
both eyes and noted she often has
difficulty driving at night along
with a dry feeling and occasional
burning. The patient admitted she
uses an unknown brand of eye
drops to lubricate her eyes, which
provides her with some temporary
relief; however, she also stated
concern that her symptoms were
getting worse.
Following an examination,
the patient was educated about
chronic dry eye from decreased
tear production and increased
tear evaporation from meibomian
gland dysfunction—the cause
of her burning and dryness
symptoms. The patient was also
informed of the different surgical
options and intraocular lens
choices available for cataract
treatment. The two, it turns out,
go hand in hand. Cataract patients
need a full dry eye workup to
achieve the best possible outcome.
EXAMINING THE CATARACT
Considered the most common
18
cause of vision loss in patients
over 40, cataract formation has
been linked to a number of factors
including exposure to ultraviolet
radiation from sunlight and other
sources, diabetes, hypertension,
obesity, smoking and the use of
certain medications.1-5 Cataracts
can be subdivided into three types
based on location: nuclear—the
most common type—affects the
middle of the lens, while cortical
is located in the center of the lens
and subcapsular affects the back.
Subcapsular cataracts typically
progress more quickly than the
other two. Each type has different
risk factors that contribute to its
development, and each must be
handled differently.6
Regardless of cataract
type, however, many patients
develop similar postoperative
complications due to untreated
ocular surface disease and residual
refractive error, even as small as
0.50D.7,8 Uncontrolled ocular
disease may lead to residual
refractive errors of as much as
1.0D to 2.0D due to its effect
on preoperative calculations,
which can lead to incorrect toric
IOL power or axis placement.9
Research has shown ocular surface
disease can also limit the accuracy
of preoperative testing like
topography and biometry.10-12
So, why do so many patients
end up with postoperative residual
refractive error? Are the available
technology options in fact limited
for treating refractive error in our
cataract patients? This article will
review several corneal and ocular
surface considerations to help
practitioners successfully manage
cataract surgery patients.
LIDS AND LASHES
The first step to take when a
patient presents for a cataract
consultation is to perform a full
ocular exam from the front to the
back of the eye to identify any
possible conditions that may limit
visual outcome. Begin by looking
at the external ocular adnexa.
Look for any redness of the face
or periorbital area, rhinophyma
or other classic signs of rosacea.
Finding signs of rosacea can alert
you to more advanced meibomian
gland dysfunction. Perform a gross
examination of the periorbital
ABOUT THE AUTHOR
Dr. Johnston practices at
Georgia Eye Partners in
Atlanta, GA, where he
serves as the clinical
director and residency
director. He focuses on
ocular surface disease and
has experience in comanaging
cataract and refractive surgery patients.
REVIEW OF CORNEA & CONTACT LENSES | NOVEMBER 2015
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Patient is
Eye Patient
By Josh Johnston, OD, FAAO
surgery present with
this disease.13 Classified
as either anterior or
posterior and chronic
or acute, the disease
can lead to an array of
complications. In the
case of cataract patients,
anterior blepharitis
in particular must be
treated prior to surgery
by having the patient
clean the eyelid margin Pseudophakia and severe dry eye from Graftversus-host disease.
with prescribed lid
hygiene scrubs, foams or
cleansers. This decreases the load
improve prior to cataract surgery.
of bacteria around the lids and
Presentations of more severe or
reduces the chance of postoperative chronic staphylococcal blepharitis
endophthalmitis. Signs and
are typically characterized by some
symptoms of staphylococcal
eyelid inflammation. Treatment
blepharitis—the most common
for these cases involves use of
type of anterior blepharitis seen
topical antibiotics like topical
in practice—include lid irritation,
azithromycin, and/or topical
scurf, erythema, loss of lashes,
antibiotic/steroid combinations,
crusting and matting with lid debris or both, in addition to lid hygiene
and red irritated eyelids. Patients
regimens. Infectious staphylococcus
with chronic staphylococcal
should be treated with an antibiotic
blepharitis are also at increased risk ophthalmic ointment or drop to
for hordeolum and staphylococcal
prevent continued issues. The
blepharoconjunctivitis.
inclusion of a steroid—as in the
As with any lid disease, good lid
case of combination drugs—can
hygiene is critical to successfully
also help decrease inflammation
managing staphylococcal
resulting from the infection.
blepharitis; I typically prescribe
Oral medications such as
lid cleansing products that contain
doxycycline dosed at 50mg BID PO
hypochlorous acid BID for two
or a dose pack of oral azithromycin
weeks, then QD as symptoms
tapered over five days can be used
Photo: Christine W. Sindt, OD
anatomy to identify any lid
dermatochalasis that might cause
functional limitations on vision.
If the patient has droopy eyelids
or dermatachalasis, vision can
be limited from these functional
problems that can decrease the
visual field.
After examining the ocular
adnexa, focus on the lids. Demodex
is an often ignored and untreated
problem that can cause ocular
surface issues and other chronic
symptoms of itching, irritation and
discomfort. This can compound
dry eye symptoms that can be made
worse after surgery, as patients are
often using three to four preserved
topical eye drops. If a diagnosis of
Demodex is confirmed by plucking
a few eyelashes and viewing
them under magnification with a
microscope, there are a variety of
treatment options available today,
including commercially prepared
kits for in-office administration.
Many prescription and OTC
treatment options offer a wide
range of efficacy against severe
and mild cases of Demodex. Lid
scrubs and other cleaners contain
various combinations of tea tree
oil preparations and other active
therapeutic ingredients.
Blepharitis is another common
complication—up to 59% of
patients undergoing cataract
REVIEW OF CORNEA & CONTACT LENSES | NOVEMBER 2015
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THE CATARACT PATIENT IS A DRY EYE PATIENT
The Prospective Health
Assessment of Cataract
Patients’ Ocular Surface
(PHACO) conducted by
William Trattler, MD, sheds
light on just how disproportionately cataract patients
are affected by ocular surface disease. The purpose
of the study was to determine the prevalence of dry
eye in patients undergoing
cataract surgery. The results
were very compelling:16
• 171 eyes (62.9%) had a
tear break-up time of less
than five seconds.
• 209 eyes (76.8%) showed
positive corneal staining.
• 136 eyes (50%) showed
central corneal staining.
• Shirmer scores: 132 eyes
(48.5%) had a score of
10 or less, and 58 eyes
(21.3%) scored less than
five.
Not only does this segment
of patients have a higher
percentage of clinically significant dryness and meibomian gland dysfunction, but
these two chronic diseases
are often ignored and not
properly diagnosed and
treated.
20
Photo: Christine W. Sindt, OD
Dry Eye in Cataract
Patients: Prevalent
and Pervasive
Subconjunctival hemorrhage after cataract surgery.
to treat chronic staphylococcal
blepharitis. A comparison of the
safety and efficacy of these two
in the treatment of patients with
meibomian gland dysfunction
who had failed to respond to prior
conservative management found
both drugs improved signs and
symptoms significantly, with one
caveat: ocular surface staining
and bulbar conjunctival redness
were significantly better in the
azithromycin group, suggesting it
may lead to a better overall clinical
response with shorter treatment
duration.14
OCULAR SURFACE
Both aqueous-deficient dry eye
and evaporative dry eye caused
by meibomian gland dysfunction
must be treated prior to surgery
to prevent complications from
ocular surface disease. Typically, I
feel most dry eye patients present
with both types, and so are treated
concurrently. A study looked at the
prevalence of these two forms of
dry eye and found 49% of patients
had evaporative dry eye disease,
14% had aqueous deficient and
35% had both forms.15
Common management
approaches begin with a baseline
palliative treatment using artificial
tears. If meibomian gland
dysfunction and evaporative dry
eye are the primary issues, lipidbased artificial tears can be used to
supplement the lipid layer, which
is often depleted or even missing
entirely. For aqueous-deficient dry
eye, artificial tears can provide
relief. These can be used four times
a day; however, if application is
needed more frequently due to
continued patient symptoms, more
viscous tears or nonpreserved
artificial tears can also be used.
More viscous tears have a longer
residence time, offering longer
periods of symptomatic relief.
Patients with lagophthalmus and
incomplete nocturnal lid closure
can also be prescribed nighttime
ointments, sleep goggles and
REVIEW OF CORNEA & CONTACT LENSES | NOVEMBER 2015
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humidifiers to help with dryness.
For clinically significant dry
eye, immunosuppressive topical
drops like cyclosporine 0.05%
BID and ester-based steroids
used short-term can be used to
relieve inflammation. Studies
have suggested nutritional
supplements such as EPA, DHA,
GLA, omega-3 and omega-6 may
also reduce inflammation, increase
tear production and improve
meibomian gland secretions. Use
of lid scrubs and lid massage
after application of heat with eye
masks may also improve secretion
from the meibomian glands.
Meibomian gland expression
and meibomian gland probing
are other therapeutic options for
more advanced gland obstruction.
Topical antibiotics, steroids and
combination topical drops and
ointments can be efficacious
in treating meibomian gland
dysfunction.
NEW IOLS
The newest generation of
multifocal IOLs approved for use
in the United States aim to achieve
good distance, intermediate and
near vision while decreasing glare
and halos. This is done by altering
the lens design, including the
optics, of earlier multifocal IOLs.
Reducing the number of diffractive
rings decreases the add power. This
reduces the diffractive or refractive
surface area, allowing less light
scatter to decrease glare and halos.
Aspheric IOLs also allow for better
mesopic contrast sensitivity for
better vision at night and improved
distance vision. Even though the
add powers are decreased, the
lower add multifocal IOLs are
said to actually deliver better near
and intermediate vision than the
higher add IOLs while decreasing
symptomatic glare and halos.
C
ataract surgery has evolved
to now be a refractive
procedure, giving our patients
more options than ever before.
The current treatment options are
safe, accurate and can treat all
types of refractive errors. Staying
abreast of the latest advancements
is essential to being a part of the
co-management process.
RCCL
1. Roberts JE. Ultraviolet radiation as a risk factor for cataract and macular degeneration. Eye
Contact Lens. 2011 Jul;37(4):246-9.
2. Obrosova IG, Chung SS, Kador PF. Diabetic
cataracts: mechanisms and management. Diabetes Metab Res Rev. 2010 Mar;26(3):172-80.
3. Glynn RJ, Christen W, Manson JE, et al.
Body mass index. An independent predictor of
cataract. Arch Ophthalmol. 1995;113:1131-7.
4. Ye J, He J, Wang C, et al. Smoking and risk
of age-related cataract: a meta-analysis. Invest
Ophthalmol Vis Sci. 2012 Jun 22:53(7):388595.
5. Urban RC Jr, Cotlier E. Corticosteroidinduced cataracts. Surv Opthalmol. 1986 SepOct;31(2):102-10.
6. Foster PJ, Wong TY, Machin D, et al. Risk
factors for nuclear, cortical and posterior subcapsular cataracts in the Chinese population
of Singapore: the Tanjong Pagar Survey. Br J
Opthalmol. 2003;87:1112-20.
7. Roberts CW, Elie ER. Dry eye symptoms
following cataract surgery. Insight. 2007 JanMar;32(1):14-21.
8. Alio JL, Abdelghany AA, Fernandez-Buenaga R. Management of residual refractive error
after cataract surgery. Curr Opin Opthalmol.
2014 Jul:25(4):291-7.
9. Tu E. Cornea Day, ASCRS 2011.
10. Kim P, Plugfelder S, Slomovic A. Top
5 pearls to consider when implanting
advanced-technology IOLs in patients with
ocular surface disease. Int Ophthalmol Clin.
2012;52(2):51–8.
11. Goldberg D. Preoperative evaluation of patients before cataract and refractive surgery.
Int Ophthalmol Clin. 2011;51(2):97–107.
12. Ram J, Gupta A, Brar G, et al. Outcomes of
phacoemulsification in patients with dry eye. J
Cataract Refract Surg. 2002;28(8):1386–9.
13. Luchs J, Buznego C,Trattler W. Prevalence
of blepharitis in patients scheduled for routine
cataract surgery. Poster presented at: ASCRS
Symposium on Cataract, IOL and Refractive
Surgery. April 11, 2010;Boston, MA.
14. Mohsen BK, Fazel AJ, Kiavash V, et al. Oral
azithromycin versus doxycycline in meibomian gland dysfunction: a randomized double
masked open label clinical trial. Br J Opthalmol. 2015 Feb;99(2):199-204.
15. Lemp MA, Crews LA, Bron AJ, et al. Distribution of aqueous-deficient and evaporative
dry eye in a clinic-based patient cohort: a retrospective study. Cornea. 2012 May;31(5):472-8.
16. Trattler W, Goldberg D, Reilly C. Incidence
of concomitant cataract and dry eye: prospective health assessment of cataract patients.
Presented at: Wold Cornea Congress; April 8,
2010;Boston, MA.
Keep An Eye Out
Other anterior segment
and corneal problems that
can limit surgical outcomes
need to be diagnosed prior
to surgery. These include:
• Anterior basement
membrane dystrophy
• Salzmann’s nodular
dystrophy
• Fuchs’ corneal dystrophy
or non-Fuchs’ corneal
guttata, which creates
a higher risk for
postoperative corneal
edema and damage to
the endothelium, resulting
in decreased vision
• Corneal scars
• Lagophthalmos
• Exposure keratitis
There are also several
complications that can arise
following surgery. These
include:
• Acute increased IOP from
retained viscoelastic,
causing corneal edema or
microcystic corneal bullae
• Wound leak, causing
hypotony
REVIEW OF CORNEA & CONTACT LENSES | NOVEMBER 2015
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Something to
SMILE About?
How does the newest refractive procedure measure up against LASIK?
By John F. Doane, MD, and Jace J. Rickstrew, BS
S
ince the early 1990s,
more than 17.4
million eyes have
undergone excimer
laser vision correction
(i.e., PRK, LASIK and LASEK)
worldwide. The procedure could
be said to be the most successful
refractive surgery based upon the
absolute number of procedures
performed—and also one of the
most controversial. Entire web
sites are devoted to publicizing
poor surgical outcomes and
marketing misrepresentations,
both real and perceived. Critics
argue that surgeons fail to
adequately disclose the risks
associated with the procedure and
overpromise on results.
Surgical procedures such
as LASIK can be seen as both
success stories and failures at the
same time, depending on one’s
evaluation criteria. Baseball
legend Reggie Jackson is still
considered one of the premier
power hitters in the sport,
but he also holds the dubious
distinction of most recorded
strikeouts. LASIK, too, has
achieved successes that few other
surgeries have matched, but still
has failed to reduce complication
rates to negligible levels.
Complications well documented
in the literature include post-
22
surgical irregular astigmatism,
epithelial ingrowth into the flap
interface, postoperative dry eye
and over- and undercorrection.
Post-surgical interventions—such
as surgical retreatment, corrective
lenses, ocular surface therapies—
remain higher than patients or
practitioners would like.
Our practice is one of the US
sites engaged in studies of a new
procedure striving to overcome
these limitations. This article
shares our anecdotal impressions
and provides an overview of
the concept. Note: the surgical
procedure was developed in
conjunction with Carl Zeiss
Meditec, and our practice receives
research funding and consultation
fees as part of its ongoing
development.
LESS IS MORE
Currently, our practice and four
others in the United States are
investigating a new refractive
surgery technique that seeks
to reduce complications, side
effects and retreatments needed
compared with excimer-based
methods. All-femtosecond corneal
refractive surgery—known as
small-incision lenticule extraction
(SMILE)—differs from traditional
LASIK in that the excimer laser is
not used for tissue sculpting, nor
is any photoablation performed.
Instead, a lenticule of tissue is
created using the femtosecond
laser and removed manually
through a short arc-length
incision.
Additionally, rather than
creating a hinged-flap lift, two
passes of the femtosecond laser
are performed: the first pass
creates the posterior aspect of
the lenticule and a peripheral
stromal bed, while the second
creates the anterior surface of the
lenticule and one or two small
access incisions of approximately
60 degrees at the 7.5mm optical
zone. This gives the surgeon an
entrance to dissect the remaining
corneal attachments of the
anterior and posterior surfaces
and remove the lenticule through
a small incision, usually 3mm or
less.
ABOUT THE AUTHORS
John F. Doane, MD, FACS,
is a cornea and refractive
surgeon with Discover Vision
Centers in Kansas City, MO.
He is also Clinical Assistant
Professor at Kansas University
Medical Center Department of
Ophthalmology.
Jace Rickstrew is currently a
second-year medical student
at the University of Kansas.
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SUMMARY OF BENEFITS
The advantages of the SMILE
concept are numerous. The use
of femtosecond laser technology
reduces the invasiveness of the
procedure and also removes the
possibility of flap dislocation.
Additi
ll the
th cornea inherently
i h
tl
Additionally,
maintains a greater biomechanical
structure and fewer corneal nerves
are incised; as a result, a lower
frequency of dry eye complaints
and a shorter healing cycle are
expected. As in LASIK, contact
lenses can be worn after SMILE.
However, because of the
newness of the procedure, several
considerations remain unknown.
At this point, we have limited
data on procedure success and
complications beyond five years.
Our experience with other lamellar
t h i
t th
techniques
suggests
thatt we may
be able to surmise that what we
see early (i.e., at three months) will
persist long-term (i.e., beyond five
years), but this remains speculative
at this time. More research is also
needed on certain details of the
procedure. For example, can small
refractive errors (i.e., 1D or less)
be effectively treated, and what
approach will be taken for small
residual refractive errors after an
initial SMILE procedure has been
performed? With LASIK, we do
LASIK
ReLEx smile
ca. 20 mm Flap Side-Cut
< 4 mm minimal-invasive inzision
Source: www.premiumeyes.de/de/augenlasern/relex-versus-lasik
The SMILE procedure was
d l
developed
d att six
i sites
it on three
th
continents. Reported clinical
outcomes suggested refractive
results that mirror current LASIK
outcomes, with predictability
measures indicating that 95%
of the eyes are +/- 0.5D from
refractive target. With SMILE,
outcomes are similar for low,
moderate or high myopia; the same
cannot be said for LASIK, where
refractive accuracy diminishes as
myopia increases.
Efficacy rates for the SMILE
procedure from international study
centers have demonstrated that
95% of treated eyes achieve at
least 20/30 uncorrected distance
visual acuity at three months for
even moderate to high myopia
levels (data on file, CZM). Safety
results seem promising, with only
1% to 2% of eyes losing two
or more lines of best spectaclecorrected visual acuity. Refractive
stability is typically achieved at one
week, with little to no change seen
between this interval and the one
and three month data sets.
ReLEx smile: Ø 7,5 mm
LASIK: Ø 9,0 mm inkl. Übergangszone
Difference in corneal incision in LASIK vs. SMILE. 1
REVIEW OF CORNEA & CONTACT LENSES | NOVEMBER 2015
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SOMETHING TO SMILE ABOUT?
A
B
C
D
A SMILE procedure: (A) A femtosecond laser creates a lenticule of tissue and an access port; (B) the surgeon dissects between
tissue planes anteriorly and posteriorly of the lenticule; (C) the lenticule is detached and removed through the corneal incision in
a "rhexis"-like procedure similar to that of cataract surgery; (D) the lenticule is then placed on the front of the corneal epithelium
for inspection. To view a video of this proceudre, scan the QR code below or visit www.reviewofcontactlenses.com.
treat less than 1D for primary
procedures and enhancements.
Enhancements with SMILE are
currently done by creating a
LASIK flap or performing a PRK
procedure.
There are at least a handful
of theoretical and speculative
benefits of SMILE as compared to
LASIK. Eliminating flap creation
leads to complete avoidance of
flap displacement, dislodgement
and slippage with associated
epithelial ingrowth. Additionally,
because of its minimally invasive
nature, the procedure negligibly
violates Bowman’s layer and
excises less of the anterior stroma.
SMILE’s diameter of treatment
field is typically 7.5mm, while
in LASIK the treatment field
To see a video of
is usually at least 8.5mm.
this procedure, please visit
This smaller diameter leads
www.reviewofcontactlenses.com,
to improved corneal tensile
or scan the QR code.
strength by preserving the
24
most biomechanically significant
anterior one-third of the cornea.
Since there is greater preservation
of the anterior cornea with less
corneal nerve interruption, one
would speculate that fewer dry
eye complaints from neurotrophia
would occur.
Another unique feature of
SMILE is that it is completed
intrastomally—for all intents and
purposes, it is completed in a
vacuum. By contrast, the excimer
laser energy must traverse the final
lens in the optical train of the laser
REVIEW OF CORNEA & CONTACT LENSES | NOVEMBER 2015
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COMING IN
DECEMBER...
and pass the air environment of the working distance
to the environmentally exposed corneal surface.
Because of this, certain factors must be considered
during the LASIK procedure—namely, air purity,
humidity, barometric pressure and temperature of the
operating room—that can affect the photoablation
ability of the excimer beam and the amount of dry
cornea removed with each pulse. This results from
variable hydration of the tissue, which is dependent on
the time from start to finish of the photoablation. In
addition, this can change from case to case and surgeon
to surgeon, in the same and variable environments.
By performing the refraction treatment intrastromally,
the SMILE procedure eliminates such variables. This
explains why a -10D treatment is just as predictable
as a -1D treatment with SMILE, compared with
comparable excimer laser treatments. Similarly, in
my personal experience, I have found a -1D SMILE
procedure is just as predictable as a -1D excimer laser
correction.
Despite these perceived benefits, only time will
tell if SMILE can compete on the playing field of a
commercial refractive practice. More research is needed
to determine the predictability, effectiveness, stability
of result, safety and quality of vision of the procedure,
as well as reversibility and adjustability, minimal
wound healing, immediacy of final refractive outcome
and comparison with other vision modalities such as
glasses and contact lenses. Although flap complications
are obviated, other complications typical of refractive
surgery (e.g., ectasia, residual refractive error, dry eye,
infection, inflammation) are possible—but less likely,
given the increased structural integrity and less invasive
nature of the SMILE procedure.
The Review of Optometry
2016
Conference Planner
A comprehensive guide to
optometric education events.
This special supplement to
December 2015 Review
of Optometry will
list all known CEaccredited meetings
and conferences
currently slated
for 2016 as of press
time—from local and
state events all the way
up to the major conferences.
DON’T MISS OUT!
•
Dates, locations, key faculty, number of credit
hours available, contact information and
registration instructions for each optometric CE
meeting scheduled for 2016 (at press time).
•
Simple at-a-glance calendars that list every
educational event, month by month throughout
2016 for easy reference.
•
An online edition will enhance and extend the
content with new meetings added throughout the
year as details are released.
P
rocedure counts provide an indication of SMILE’s
ability to compete with LASIK. Approximately
20,000 SMILE procedures were performed by
December 2012; this increased to 50,000 by the
end of July 2013. Carl Zeiss Meditec reports that
200,000 eyes have undergone SMILE worldwide since
February 2015 (data on file, CZM). It is clear SMILE
is gaining interest among surgeons throughout the
world. Pending FDA approval, will the same hold true
for surgeons within the US? As more data continually
becomes available, it will likely tell us what impact
a femtosecond laser could achieve as a stand-alone
refractive surgical device.
RCCL
1. Premium Eyes. Available at: www.premiumeyes.de/de/augenlasern/relexversus-lasik. Accessed October 23, 2015.
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Staying in Shape:
Post-Surgical Keratoconic
Lens Placement
W
hen fitting
contact
lenses for a
compromised
cornea,
practitioners must remain aware of
the complex challenges inherentthe
processes that relate to vision,
comfort and ocular health. First
and foremost, patients expect good
vision. In some cases, this is easy
to achieve; in others, trial fitting
is essential to finding the right
lens. A patient can perceive and
process basic visual information
without having achieved
adequate functional vision.
Optical aberrations induced by a
compromised ocular surface can
create too much visual noise and
distraction to allow the patient to
be able to see comfortably.
Empirical fitting in such
circumstances leaves too much
unanswered; trial fitting allows
you to determine the patient’s
ability to tolerate the lens, assess
lid comfort and perform an
overrefraction to determine an
expected visual outcome. The true
test comes after the initial design
is dispensed, however—only then
can you adequately assess how
well corneal health is maintained.
Note, visual expectations vary
based on a patient’s lifestyle and
daily activities. Some—for example,
26
surgeons and aviators—have
extremely high visual demands that
do not allow for subpar vision.
Beyond visual acuity, it is
important consider on-eye comfort;
an uncomfortable lens can have a
life-altering impact on the patient.
Patients have varying comfort
thresholds: some will adapt just
fine, while others can experience
minor discomfort and a few may
report excruciating pain. In patients
who have undergone multiple
surgical procedures and lens fits,
managing patient expectations is
especially fundamental to overcome
pessimism and encourage good
compliance.
From an ocular health
standpoint, patients with
compromised corneas can be
especially sensitive to debris buildup under the lens or to lenses
not staying clean throughout the
day. They are also susceptible
to dryness and discomfort with
increased wearing time, particularly
when blinking is reduced while
performing prolonged near tasks.
Thus, it is important to always be
proactive about ocular allergies
in patients with compromised
corneas, as they have an especially
difficult time tolerating allergic
compromise.
Finally, ensure good corneal
health with a lens and fit that offers
adequate oxygen and minimal
interference of normal corneal
physiology. Similarly, as the CLEK
study shows, apical clearance
is important in patients with
keratoconus and scarring.
CASE IN POINT
In 2014, I was faced with one of
the most unique and challenging
cases I’ve encountered in my many
years of practice. The patient’s
history was truly stunning, as was
his central corneal topography,
which was the worst I have
ever seen. Over the years, this
keratoconus patient had undergone
several surgeries, both in the US
and internationally, aimed at
improving his functional vision.
In fact, he had already undergone
RK three times in his right eye and
once in his left eye, two corneal
transplants, DALK/AK three times,
and a cataract extraction.
To further complicate matters,
the patient’s medical records
ABOUT THE AUTHOR
Dr. Super is the founder of a
specialty contact lens and
primary care practice in
Brentwood, Los Angeles;
assistant clinical professor at
Salus and Western College
of Optometry; Immediate Past
Chair of Optometry at Cedars Sinai Medical Center; and Optometry Advisor for
Eye Defects Research Foundation.
REVIEW OF CORNEA & CONTACT LENSES | NOVEMBER 2015
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Can additional surgery be avoided in a keratoconus
patient who requires better functional vision?
By Paul Super, OD, FAAO
contained
several obvious
inconsistencies,
making it difficult
to ascertain the
rationale for so
many surgeries
and impossible to
piece together an
accurate timeline.
Nonetheless, I
Fig. 2. Topography OS.
Fig. 1. Topography OD.
was committed to
The referring ophthalmologist
that the distorted vision was likely
finding a nonsurgical solution for
diagnosed the patient with dry
due to irregular astigmatism OD,
this patient.
eye syndrome and recommended
which did not improve significantly
The 45-year-old Italian male was
use of artificial tears three to four
with refraction. As such, the patient
referred to my office in October
times per day. The patient was
was now considering PTK. In
2014 to determine whether his
also administering prednisolone
light of his long and complicated
vision could be improved without
surgical history, the ophthalmologist acetate 1% TID in the right eye to
another surgery. He had recently
prevent complications from a recent
presented to a local ophthalmologist referred him to me with the hope
cataract extraction. Systemic history
that we might find a nonsurgical
here in the US with complaints of
included seasonal allergies.
distorted vision. The MD concluded intervention.
Table 1. Diagnostic Trial Lenses and Failed Lens Designs
Eye: Lens
Base Curve
Overall Diameter
Power
Central Fit
Peripheral Fit
OD: Rose K2 XL
7.4
14.6
-2.00
Slight Steep
Alignment with no
seal off
OD: Rose K2 XL
7.6
14.6
-1.00
Alignment
Good PC alignment
with no seal off
OS: Rose K2 XL
7.6
14.6
-1.00
Flat
Too much edge lift
DIAGNOSTIC DATA
The patient presented in my office
with a corneal scar and irregular
astigmatism OD as well as dry eye.
The central zone of the cornea was
not smooth. Best vision correction
was as follows:
OD 20/70 PH 20/50+ +0.50/-2.75 x 170 20/40-3
OS 20/100 PH 20/25- -1.75/-1.75 x 045 20/ 30-1
OS: Rose K2 XL
7.1
14.6
-5.00
Lens
popped out
OS: Rose K2 XL
6.7
14.6
-9.00
Flat
Edge lift; steepen PC
Dispensed Lens
OD: Rose K2 XL
7.6
14.6
-0.25
Alignment
Good PC alignment
with no seal off
IOP was 13mm Hg OD and
15mm Hg OS. Pachymetry revealed
396µm OD and 603µm OS.
Corneal topography is shown in
Figures 1 and 2.
REVIEW OF CORNEA & CONTACT LENSES | NOVEMBER 2015
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27
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STAYING IN SHAPE: POST-SURGICAL KERATOCONIC LENS PLACEMENT
Table 2. Reverse Geometry Lens Trials
Right Eye
Base Curve
8.54
10.0
8.54
11.0
Overall
Power
Optic Zone
+0.75
6.5
49.25/6.85/0.6
+1.75
6.5
49.25/6.85/0.6
Diameter
Due to corneal instability and
the patient’s irregular corneal
surface, we initially tried three
different approaches—all of which
were unsuccessful. Scleral lens
designs that vaulted the cornea
caused a central air bubble, which
consistently created epithelial loss.
When we tried semi-scleral lens
designs, they also failed due to
spoiling and the cornea’s inability
to tolerate the mechanical fit and
physiological compromise of the
lenses. Next, we tried to piggyback
a scleral lens over a soft lens, but
this too was unsuccessful. Table 1
illustrates our experiences during
these trials.
During the course of fitting
various diagnostic lenses, the
patient made the decision to be
fitted for his right eye.
Baseline OS.
The final lens fit OD.
28
Peripheral Fit
43.00/7.85/1.0
30.75/11/0.4
43.00/7.85/1.0
30.75/11/0.4
At the follow-up visit, the patient
displayed dry central pooling
and central epithelial loss. I had
exhausted all the options likely to
work and had to try something
outside of what I previously would
have considered. Our next option
was to design a lens that aligned
over the central optical zone with
lid attachment. We trialed the
reverse geometry lenses shown in
Table 2.
By December 10, 2014, we had
designed and dispensed the lens.
The reverse geometry corneal lens
aligned over the central optical
zone while the lid attachment
allowed for a more customary fit
profile. The patient reported the
11mm diameter of the lens was
comfortable and examination
indicated it supported the ocular
health of the cornea. Subsequent
follow-up visits showed good vision
(i.e., 20/25) and lens toleration.
There was no staining on removal
and the patient reported he was
able to wear the lens during waking
hours.
DISCUSSION
It is well known that post-surgical
corneas present specific challenges.
Inadequate visual acuity and
optical aberrations resulting from
post-surgical procedures have a
significant impact on quality of
life. To complicate matters, these
corneas tend to be unstable due
to thickness and rigidity of the
surface; thus, predicting outcomes
can be difficult.
The challenge in this case was to
fit a lens that would improve vision
over a cornea that had already been
surgically treated multiple times. I
did not want to subject this patient
to any more surgery. However, as
I began fitting lenses, everything I
thought would work didn’t work
well at all.
After the first round of fitting,
the patient returned complaining
of a scratchy feeling, and that
he couldn’t wear the lenses for
more than a couple of hours. As
such, regardless of the patient’s
history, such a fit could not be
considered a suitable solution.
Qualitative responses are every
bit as important as visual acuity
when it comes to functional vision.
Corneal anatomical shape factor,
lid forces, optical power of the lens
(i.e., thickness) and tear quality all
impact outcomes. Furthermore,
visual acuity alone does not provide
enough tangible information on
how a patient sees. It disregards
visual noise.
W
e have to use all technologies,
past and present, to find
suitable solutions for patients
like this one who continue to
struggle with poor functional
vision after surgery. As this case
illustrates, we are sometimes
called upon to dig deep into our
toolboxes and try things we never
previously considered. It can be
time consuming and it can test our
skills and fortitude as optometrists.
However, it’s cases like this one
that draw attention to our unique
and specialized skill set and clearly
demonstrate the profound effect
that nonsurgical options can have
on patients’ everyday lives.
RCCL
Thank you to my friend and colleague
Alan Saks, OD, for his help, as well as
Art Epstein, OD, and Barry Eiden, OD,
for their valuable suggestions.
REVIEW OF CORNEA & CONTACT LENSES | NOVEMBER 2015
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w Tech
Ne
n
MEETINGS
REVIEW OF OPTOMETRY®
s
ogie and
ol
N T
& T
ments
eat
Tr
2016
IN VISION CARE
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2016
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Review of Optometry®
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RESHAPING THE OUTCOME:
CORNEAL ASTIGMATISM
CORRECTION DURING
CATARACT SURGERY
Surgeons have more options—and decisions—than ever before.
By Harmohina Bagga, MD, and Kerry K. Assil, MD
C
ataract surgery has
evolved from a
high-risk medical
procedure that once
required a hospital stay to the most commonly
performed refractive procedure
worldwide. Its ubiquity has given
surgeons ample opportunity to
refine the outcomes with great
precision. Advancements in preand intraoperative diagnostic
testing and surgical techniques, as
well as increased availability of
premium intraocular lens (IOL)
implants, have escalated patient
expectations, thus mandating consistently accurate management of
pre-existing astigmatism in order
to deliver on expectations.
When planning astigmatism
correction, consider the magnitude
and axis of the astigmatism, corneal
pachymetry, incision location, degree
of irregular or asymmetric astigmatism, desired entry site, corneal
pathology, patient age and the status
of the fellow eye. Since most eyes
exhibit against-the-rule astigmatism
over time, some surgeons advocate
an under-correction of with-the-rule
30
cylinder. Furthermore, mild astigmatism of about 1D with or against
the rule with a spherical equivalent
of -0.5D may aid in expanding the
depth of focus.1
Research has suggested that residual with-the-rule astigmatism may
favor better uncorrected distance
acuity (as most visual stimuli are
of a vertical nature), with residual
against-the-rule cylinder improving
uncorrected near vision.2,3
Measurement modalities also
weigh into the equation. Corneal
power is typically calculated using
a keratometric refractive index of
1.3375D, which is the power of a
hypothetical single refractive surface
without factoring in the curvature of
the posterior corneal surface. Since
the advent of slit-scanning topography and Scheimpflug imaging, the
impact of posterior corneal astigmatism has been revisited. Because of
the opposing power of the anterior
and posterior corneal surfaces,
the vector difference between the
magnitude of keratometric astigmatism and total corneal astigmatism
is higher than 0.50D in up to 28.8%
of eyes.4 The difference between
the location of the steep meridian
in keratometric astigmatism vs. the
total corneal astigmatism is higher
than 10 degrees in more than 17%
of eyes.3 However, some reports did
not identify this compensatory effect
of posterior corneal astigmatism, but
rather found that the total corneal
astigmatism exceeded the keratometric astigmatism.5
PREOPERATIVE
MEASUREMENT
No single method has been identified as being the most accurate for
ABOUT THE AUTHORS
Dr. Bagga is a board-certified,
fellowship-trained cataract
and glaucoma specialist, She
joined the Assil Eye Institute
in Los Angeles as head of its
glaucoma services in March
2015.
Dr. Assil is regarded as one of the world’s
foremost experts in refractive surgery,
having made significant
advances in the field with
his numerous inventions. He
has trained thousands of
eye surgeons in the latest
refractive surgical techniques
and has authored more than one
hundred textbooks, textbook chapters
and articles on refractive surgery.
REVIEW OF CORNEA & CONTACT LENSES | NOVEMBER 2015
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erative imaging and
guidance to assist
with the proper alignment and positioning
of the incisions and
IOL.
Intraoperative aberrometry has minimized the guesswork
in refining outcomes.
The ORA (short for
optiwave refractive
analysis, Alcon) intraoperative aberrometer is a miniaturized A limbal relaxing incision is commonly combined with
wavefront device that a toric IOL when the need for astigmatism correction
attaches onto the bot- exceeds the toricity of currently available IOLs.
tom of nearly any operinclude ensuring a smooth corneal
ating microscope and works using a
Talbot-Moiré waveform aberrometer surface, maintaining physiologic
IOP, absence of corneal edema from
to measure the optical power of the
stromal hydration of the wound,
eye at the time of surgery. It takes
thorough washout of dispersive visinto account anterior and posterior
colelastic from the eye and absence
corneal astigmatism, as well as
of air bubbles/cortical matter.
axial length, to generate IOL power
and astigmatism measurements. It
TREATING ASTIGMATISM
has proven to be an essential tool,
There are a number of methods to
especially in eyes with previous
reduce astigmatism prior to and
refractive surgery or in instances
during cataract surgery, depending
where topography and keratometry
measurement do not correlate. Stud- on the magnitude of astigmatism.
The simplest way is to position the
ies have reported more than a 50%
cataract incision on the steep axis
increase in accuracy with use of the
to induce wound flattening, which
device in eyes with previous myopic
results in a decrease in cylinder. This
LASIK or photorefractive keratectechnique works well in patients
tomy, compared with the surgeon’s
with pre-existing astigmatism of less
best preoperative choice, the Haigis
than 1.0D7 However, some limitaL formula and the Shammas IOL
6
formula.
tions with this approach include
Note, some important guidelines
unpredictable healing of the corneal
to obtain accurate measurements
incision with inconsistent results,
Release Date: November 2015
Expiration Date: November 1, 2018
Goal Statement: This course reviews surgical treatment options for managing astigmatism, including complications.
Faculty/Editorial Board:
Harmohina Bagga, MD, and
Kerry K. Assil, MD
Credit Statement:
COPE approval for 1 hour of continuing
Photo: Uday Devgan, MD
measuring true astigmatism. Though
refraction is an important component of preoperative evaluation, the
presence of a cataract will call into
question its reliability due to subjective error. Accurate keratometry and
corneal topography are essential in
the planning and management of
astigmatism; however, it is important to ensure absence of dry eye,
excessive pooling of tears, blinking,
fixation errors and misalignment to
obtain good quality, reliable scans,
since tear film abnormalities can
introduce artifactual irregular astigmatism. Commonly used methods to
assess preoperative astigmatism include keratometry (optical biometry,
manual biometry, or both) and corneal topography (e.g., Placido-based,
slit-scan imaging and Scheimpflug
imaging). Both measurements need
to be assessed and taken into consideration.
The Cassini Corneal Shape Analyzer (i-Optics) is a relatively new
device designed to measure anterior
and posterior corneal curvature
to create a complete picture of the
cornea. It uses multicolor LED raytracing technology to capture radial
and circumferential measurements
with an accuracy of less than 2µm,
which results in precise corneal axis
measurements to within three degrees (as compared with 13 degrees
with Placido technology) and the
magnitude to within clinical margins
(2%).
One of the key elements in the
precise management of astigmatism
is prevention of the bias induced
by cyclotorsion of the eye intraoperatively. The Cassini registers
and digitally records conjunctival
features and vessels, as well as the
exact location of the visual axis and
the magnitude of astigmatism. Intraoperatively, the Cassini can link to
femtosecond laser-assisted cataract
surgery platforms or 3D intraop-
education 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 jointsponsored by the Pennsylvania College
of Optometry.
Disclosure Statement: Dr. Bagga and
Dr. Assil have no financial interest in any
products mentioned.
REVIEW OF CORNEA & CONTACT LENSES | NOVEMBER 2015
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CORNEAL ASTIGMATISM CORRECTION DURING CATARACT SURGERY
and difficulty placing the incision at
certain axes, especially in patients
with prominent brow or nasal
bridge. Another technique, limbal
relaxing incisions (LRIs), involves
the placement of incisions corresponding to the steep meridian,
which leads to corneal flattening and
a reduction in astigmatic power. The
advantage to this approach is the resulting coupling effect, in which the
amount of flattening that occurs in
the incised meridian is nearly equal
to the amount of steepening that
occurs 90 degrees away, with little
resulting change in spheroequivalent.
This obviates the need to make any
change in implant power and, when
coupled with intraoperative aberrometry, can be used to treat up to
3.0D of preoperative cylinder.
Several nomograms are available to calculate accurate location
and length of LRIs. The length is
usually expressed in degrees of arc
or clock hours, rather than chord
length, to diminish overcorrections
and undercorrections for unusually
small or large corneas. Practitioners
must keep in mind that the goal is to
reduce the patient’s cylinder without
overcorrecting or shifting the resultant axis. While some surgeons prefer an empiric blade depth setting,
our preference is to use adjustable
diamond blade depth settings based
on pachymetry. Readings should be
set at 90% depth of the perilimbal
corneal thickness.
Patients who have undergone
radial keratometry surgery require
smaller sized incisions or alternate
techniques such as toric IOLs or
enhancement with PRK/LASIK to
address astigmatism. Our preference
is to perform the LRI after inserting
the IOL; we use the ORA to confirm
magnitude and axis of astigmatism
and then re-measure the residual
astigmatism, making depth or length
refinements based upon the readings.
32
Table 1. Guidelines for Treating Astigmatism
•
•
Magnitude of Astigmatism
Treatment Options
1
<1.0D
Incision rotation on steep axis
2
1D to 3.5D
LRI
3
1.5D to 4.0D
Toric IOL
4
>4.0D
Toric IOL + LRI
Final treatment titrated based on ORA measurements.
Astigmatism up to 3D to 4D may still be treated with LRI and
postoperative excimer laser ablation in patients with multifocal implants.
To correct high levels of astigmatism,
usually above 4.0D, LRIs may be
used in conjunction with a toric IOL
or excimer laser surgery. However,
success of LRIs can be limited by
lack of precision, variable healing
response and regression.8-11
Femtosecond laser-assisted
arcuate incisions offer the potential
advantage of being more precise
with improved accuracy and safety
and enhanced reproducibility than
manual incisions. The LensAR laser
system with Streamline is the first
femtosecond laser platform to offer
wireless integration with the Cassini
Corneal Shape Analyzer, allowing
preoperative data transfer from the
device. The iris registration feature
automatically compensates for
cyclotorsion and the need to manually mark the eye. Surgeons have the
flexibility to use their preferred LRI
nomogram. Because of its ability
to perform OCT imaging of the
cornea, incisions can not only be
programmed to an exact 90% depth
of the pachymetry readings, but can
also be customized more precisely in
terms of length and angulation. Additionally, surgeons have the option
of titrating the correction of astigmatism by opening the incisions intraoperatively after obtaining measurements with ORA or postoperatively
at the slit lamp. However, the wound
healing characteristics and sustained,
long-term efficacy of femtosecond
laser-created incisions still needs to
be determined. Additionally, the
rate-limiting step for femtosecond
laser arcuate incisions is its inability
to perform reliable limbal incisions
due to frequent presence of corneal
opacification from arcus in this
region (Table 1).
Toric IOLs are another option for
astigmatism correction during cataract surgery, especially in cases of
higher amounts of astigmatism. The
ideal patients for toric IOL implantation are those with regular astigmatism; however, good outcomes
have been reported in cases of mild
to moderate irregular astigmatism
with fairly symmetrical preoperative
readings within the central 4mm
cornea.12-14 It is important to take
into account the vector sum of the
preexisting corneal astigmatism and
the surgeon-induced astigmatism
when determining the power and
meridian of a toric IOL.
Another factor to consider is the
impact of effective lens position and
of the spheroequivalent power of
the IOL on the effective toricity of
the IOL at the corneal plane. The
effective toricity diminishes with increasing anterior chamber depth and
lower IOL spherical power. Some of
the nomograms like the Holladay
IOL Consultant Program (Holladay
Consulting) and the Tecnis Toric
Calculator (Abbott Medical Optics)
take these factors into account when
calculating toric IOL power. Studies
have reported comparable correction
REVIEW OF CORNEA & CONTACT LENSES | NOVEMBER 2015
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of astigmatism with LRIs and toric
IOLs in mild to moderate astigmatism.15 Since multifocal toric IOLs
are not yet available in United States,
our preference is to perform LRIs for
preoperative astigmatism of up to
3D, especially in combination with
multifocal IOLs. We prefer toric
IOLs with or without LRIs for astigmatism greater than 3.0D to 3.5D.
Correct intraoperative alignment
of the IOL and good postoperative
rotational stability are critical factors
for achieving the desired astigmatic
correction. When a toric IOL is misaligned, there is a reduction in the
cylinder correction along the desired
meridian and induction of cylinder
at a new meridian. Bench studies
suggest a 33% loss of astigmatic
correction if the optic rotates 10
degrees.16
Until recently, marking the eye
with the patient in the upright,
seated position before surgery to
compensate for ocular torsion
during surgery was a key step to
achieve correct lens position. Even
then, there was a higher potential for
error since the measurements were
generated from the anterior cornea.
With intraoperative aberrometry,
more accurate measurements, as well
as confirmation of the correct axis
after IOL implantation, has become
Photo: Walter Whitley, OD
possible. This allows intraoperative
measurement of residual refractive
astigmatism and, consequently, live
adjustments of the toric IOL axis.
However, as discussed earlier, several
intraoperative variables—such as the
use of an eyelid speculum, squeezing
of the eyelids during surgery and the
cataract surgery procedure itself—affect intraoperative measurements of
aberrometry.
Postoperatively, the orientation
axis of the toric IOL can be verified
to confirm that no IOL rotation
has occurred. Toric IOL misalignment can be determined by using
the slit lamp biomicroscope (with
rotating slit and full mydriasis), the
postoperative residual refraction and
keratometry values and wavefront
aberrometry. Web-based calculators are available. Misalignment is
determined by using postoperative
manifest refraction, the amount of
astigmatism at the corneal plane
and the IOL axis to determine the
magnitude of misalignment, direction of rotation needed and the
residual astigmatism after IOL rotation. Realignment of a rotated toric
IOL should be performed as soon
as possible because adhesions form
between the capsular bag and the
IOL optic. We prefer to wait about
a month, which allows enough time
for refraction to stabilize but before fibrotic
adhesion between the
anterior and posterior capsules and
IOL haptics. If IOL
rotation is not expected to improve the
residual astigmatism
to <0.75D or less, our
approach is excimer
laser ablation or IOL
exchange, depending
on the magnitude of
the refractive surprise
A limbal relaxing incision created by femtosecond
and corneal thickness.
laser.
Occasionally there are unsatisfactory
outcomes with residual refractive
error after cataract surgery. Secondary options for astigmatism correction include LRI augmentation, IOL
exchange, PRK or LASIK.
I
n summary, cataract surgery offers a second window of opportunity to improve visual acuity
with minimal spectacle dependence.
Recent innovations in preoperative and intraoperative diagnostic
techniques allow a more precise
measurement of astigmatism. With
careful planning and a treatment
plan customized to the individual
patient’s needs, expectations and
ocular anatomy, it is possible to
achieve excellent visual outcomes
with cataract surgery.
RCCL
1. Savage H, Rothstein M, Davuluri G, et al.
Myopic astigmatism and presbyopia trial. Am J
Ophthalmol. 2003 May;135(5):628-32.
2. Novis C. Astigmatism and toric intraocular
lenses. Curr Opin Ophthalmol. 2000;11:47–50.
3. Trindade F, Oliveira A, Frasso M. Benefit of
against-the-rule astigmatism to uncorrected
near acuity. J Cataract Refract Surg. 1997;23:82–
5.
4. Ho JD, Tsai CY, Liou SW. Accuracy of corneal
astigmatism estimation by neglecting the
posterior corneal surface measurement. Am J
Ophthalmol. 2009;147:788–795
5. Srivannaboon S, Soeharnila, Chirapapaisan
C, Chonpimai P. Comparison of corneal
astigmatism and axis location in cataract
patients measured by total corneal power,
automated keratometry, and simulated
keratometry. J Cataract Refract Surg. 2012;
38:2088–93.
6. Ianchulev T, Hoffer KJ, Yoo SH, et al.
Intraoperative refractive biometry for predicting
intraocular lens power calculation after prior
myopic refractive surgery. Ophthalmology.
2014;121:56–60.
7. Borasio E, Mehta JS, Maurino V. Torque and
flattening effects of clear corneal temporal
and on-axis incisions for phacoemulsification. J
Cataract Refract Surg. 2006;32:2030-2038.
8. Kaufmann C, Peter J, Ooi K, et al. Limbal
relaxing incisions versus on-axis incisions
to reduce corneal astigmatism at the time
of cataract surgery. J Cataract Refract Surg
2005;31:2261–5.
9. Budak K, Yilmaz G, Aslan BS, et al. Limbal
relaxing incisions in congenital astigmatism:
6 month follow-up. J Cataract Refract Surg
2001;27:715–19.
10. Bayramlar HH, Daglioglu MC, Borazan M.
Limbal relaxing incisions for primary mixed
astigmatism and mixed astigmatism after
cataract surgery. J Cataract Refract Surg
2003;29:723–8.
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CORNEAL ASTIGMATISM CORRECTION DURING CATARACT SURGERY
CE TEST ~ NOVEMBER 2015
EXAMINATION ANSWER SHEET
Corneal Astigmatism Correction During Cataract Surgery
1. The Cassini Corneal Shape Analyzer has the ability to measure corneal cylinder
axis within:
a. 3 degrees.
b. 5 microns.
c. 12 degrees.
d. 15 degrees.
2. Which of the following is true regarding calculating corneal power using
standard equipment?
a. The measure is based on a refractive index of 1.47.
b. The curvature of the posterior surface is taken into account with each reading.
c. The exact corneal power is often difficult to measure in a cornea with marked
irregularity.
d. Most corneas will show significiant against-the-rule astigmatism.
3. When planning astigmatism correction with cataract surgery, which of the
following is not an important consideration?
a. The patient's age.
b. The magnitude and axis of astigmatism.
c. Any corneal pathology.
d. All of the above are important factors to consider.
4. When an unsatisfactory amount of residual correction results after cataract
surgery, which of the following procedures are most suitable to fix the issue?
a. PRK or LASIK.
b. Diamond burr debridement.
c. IOL exchange after six months.
d. Orthokeratology.
5. The "rate limiting step" in creating reliable femtosecond laser arcuate incisions
is:
a. Corneal scarring in that region.
b. With-the-rule refractive astigmatism.
c. Oblique corneal astigmatism.
d. Against-the-rule corneal astigmatism.
6. A 10-degree rotation of two diopters of astigmatic correction results in what
percentage of loss of astigmatic correction?
a. 33%.
b. 10%.
c. Depends on the cylinder axis to be corrected.
d. 25%.
7. Which procedure performed during cataract surgery results in a more accurate
measure of cylinder axis and a better outcome in correcting refractive cylinder?
a. Manual keratometry.
b. Scheimpflug topography.
c. Intraoperative aberrometry.
d. Cassini topography.
8. When correcting corneal cylinder with limbal relaxing incisions, corneal
incisions can be made where?
a. Along the steepest axis.
b. Along the flat meridian.
c. 45 degrees from the steep axis.
d. Outside the host-graft junction in a keratoplasty patient.
9. Intraoperative aberrometry measured by the ORA unit has added significantly
to correcting refractive errors during cataract surgery. Which of the following
statements is true?
a. Uses a Talbot-Moire waveform aberrometry.
b. Measures only the corneal power of the eye.
c. Measures anterior and posterior corneal astigmatism.
d. A and C are correct.
10. When creating corneal incisions to reduce or eliminate corneal astigmatism,
what should the blade depth be set at?
a. 75% of the central corneal thickness.
b. 85% of the peripheral corneal thickness.
c. 90% of the peripheral corneal thickness.
d. 90% of the central corneal thickness.
Valid for credit through November 1, 2018
Online: This exam can also be taken online at www.reviewofcontactlenses.com.
Upon passing the exam, you can view your results immediately. You can also
view your test history at any time from the website.
Directions: Select one answer for each question in the exam and completely
darken the appropriate circle. A minimum score of 70% is required to earn credit.
Mail to: Jobson Optometric CE, Canal Street Station, PO Box 488, New York, NY 10013.
Payment: Remit $20 with this exam. Make check payable to Jobson Medical
Information LLC.
Credit: COPE approval for 1 hour of CE credit is pending for this course.
Sponsorship: Joint-sponsored by the Pennsylvania College of Optometry.
Processing: There is an eight-to-10 week processing time for this exam.
Answers to CE exam:
A
B
C
1.
A
B
C
2.
A
B
C
3.
A
B
C
4.
A
B
C
5.
6.
7.
8.
9.
10.
D
D
D
D
D
B
C
D
A
B
C
D
A
B
C
D
A
B
C
D
A
B
C
D
Evaluation questions: (1 = Excellent, 2 = Very Good, 3 = Good, 4 = Fair, 5 = Poor)
Rate the effectiveness of how well the activity:
1
2
3
4
5
11. Met the goal statement:
12. Related to your practice needs:
1
2
3
4
5
13. Will help improve patient care:
1
2
3
4
5
1
2
3
4
5
14. Avoided commercial bias/influence:
15. How do you rate the overall quality of the material? 1
2
3
4
5
16. Your knowledge of the subject increased: Greatly
Somewhat
Little
17. The difficulty of the course was:
Complex
Appropriate Basic
18. How long did it take to complete this course? _________________________
19. Comments on this course: _________________________________________
___________________________________________________________________
20. Suggested topics for future CE articles: ______________________________
___________________________________________________________________
Identifying information (please print clearly):
First Name
Last Name
Email
The following is your:
Home Address
Business Address
Business Name
Address
City
State
ZIP
Telephone #
-
-
Fax #
-
-
By submitting this answer sheet, I certify that I have read the lesson in its entirety
and completed the self-assessment exam personally based on the material presented. I have not obtained the answers to this exam by fraudulent or improper means.
Signature: ________________________________________ Date: _____________
Please retain a copy for your records.
34
A
LESSON 112020, RO-RCCL-1115
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Out of the Box
By Gary Gerber, OD
Reach Out
Want to increase revenue for your contact lens practice? Aim for the sky.
W
ith 2016 only
a few months
away, it’s
time to start
planning
for next year’s successes. While
many of us likely define the
success of our contact lens practice
in terms of revenue, since the
term is individually defined by
each practitioner, it would be
impossible for a single article to
apply perfectly to every reader’s
own definition. Instead, let’s use an
increase in practice revenue as the
definition of success here.
There are three ways to generate
more revenue in your contact lens
practice: increase the number of
patients, raise fees or see the same
patients more frequently. Let’s
focus on increasing the number of
patients.
Industry-wide, the net growth
of total contact lens patients has
been increasing at a snail’s pace.
immediately jump to exactly
that—acquiring more patients. Yet,
the premise would be better stated
and your practice better suited
if you also incorporate patient
retention in your thought process.
Remember that dropout rates are
nearly on par with new wearers.
So, if you are able to stem the
outflow of patients and keep more
patients in lenses, your revenue will
increase in successive years. This
concept isn’t breakthrough math
by any means, but it is a significant
shift in practice management
mindset—that is, putting an
inordinate amount of leverage on
keeping current patients vs. always
chasing new ones.
A great way to plug the holes in
the patient dropout bucket is to
continually survey your current
patient base about their level of
satisfaction with their lenses. While
you likely already ask those who
return for follow-up appointments
“HOW CAN YOU PREPARE
FOR A BETTER 2016?”
That’s because the number of new
wearers is just slightly more than
the number of dropouts. As we
know, most patients cease contact
lens wear due to decreased comfort
(typically stemming from dryness)
or vision (usually from inadequate
presbyopic correction.)
MAKING YOUR MOVE
So, keeping that in mind, how can
you prepare for a better 2016?
As we think about getting more
patients, our “business brains”
about their lenses, you can’t do
the same for those who do not
return—at least, not face to face.
However, proactively addressing
even minor patient complaints
can change a patient’s mind from
marginally happy and subsequently
eventually dropping out to
remaining in the practice for life.
How can you reach these
patients, who are already
delinquent on their follow-up
appointments? Try communicating
with them either online, via snail
mail surveys or phone interviews.
Be sure to word your questions
such that patients know there’s a
solution to the problem they are
having. For example, don’t simply
ask, “On a scale of one to 10, how
happy are you with the comfort
of your contact lenses?” Instead,
follow that up with an additional
question like, “If you answered
eight or less, have you contacted
our office to discuss why your
lenses are not a nine or 10?”
The same goes for probing about
vision concerns. You could ask
your presbyopes, “How satisfactory is your far and near vision
with contact lenses?” As above,
when a response is less than a
certain predetermined point, ask,
“If your vision isn’t as clear as
you’d like, have you scheduled an
appointment with us to help you
see better?”
O
f course, some readers may
read this and think, I’d rather
not know! or Why open up the
can of worms? Keep in mind, this
technique isn’t essential to your
success—rather, it’s a suggestion.
But if you really want to decrease
the rate of dropouts from your
practice, you need to be proactive
in doing so. Patients who are marginally happy and at risk of abandoning lenses are not necessarily as
apt to complain as loudly as those
who perceive their problems to be
more significant. To ensure those
patients with minimal end-of-day
dryness or less-than-perfect vision
don’t silently disappear, you need
to actively reach out and attempt
to solve their problems before you
lose them—possibly forever.
RCCL
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Corneal Consult
By James Thimons, OD
When the Going Gets Tough
How do you handle a complex bacterial complication from a simple LASIK procedure?
A
.T. is a 26-year-old
Caucasian male who
was seen for initial
consultation for
refractive surgery to
address his moderate myopia (i.e.,
-4.25 OD and -3.75 OS). A comprehensive examination revealed no
contraindications to the procedure,
and the patient’s medical/ocular history was negative for allergies and
family-related ophthalmic concerns.
Following appropriate counseling
and review, the patient elected to
undergo a bilateral LASIK procedure for full distance correction.
The procedure was completed without complication, and the patient
was discharged on QID Zymaxid
and Pred Forte.
The patient’s day one postoperative visit was unremarkable. His
clinical examination revealed wellpositioned flaps with full closure
of the flap margins in both eyes,
and no evidence of underlying flap
complications. His visual acuity
without correction was 20/20-1
OD and 20/20+1 OS. The patient
was advised to maintain his current
treatment regimen for one week,
and follow up as scheduled.
On postoperative day two, the
patient contacted the office and
indicated a need to push his oneweek appointment to a later date
due to a personal commitment.
However, on Saturday (i.e., four
days postoperative), the patient
contacted the service again to
report that he developed a foreign
body sensation in his left eye, accompanied by mild photophobia
and some blur. After discussing the
concerns with the patient, and due
36
to an inability on the part of the
patient to present to the office in
the next 48 hours, I recommended
increasing the Zymaxid to every
two hours and decreasing the Pred
Forte to twice daily until he could
be seen.
Sunday evening (i.e., five days
postoperative), the patient contacted the service a third time to report
that there had been an increase in
symptomatology over the last 24
hours, and that he had returned to
the area to be seen as soon as possible. Clinical examination on that
date demonstrated a completely
healed flap on the right side, with
uncorrected vision at 20/15-1. The
left eye, however, showed an area
of sub-flap infiltrate measuring
roughly 2mm to 2.5mm. This did
not extend into the epithelial space,
but did have a crystallized-like
appearance around the margins.
There were no cells in the anterior
chamber. Minimal injection was
present. Applanation pressures
were 15mm Hg OD and 16mm Hg
OS. There was no overlying epithelial staining, but there was a noticeable negative stain over the area,
indicating a volume displacement
under the cap with epithelial elevation. The patient’s vision was 20/50
uncorrected and 20/25 pinhole.
Given that the patient was almost
six days postoperative, and the reason for the onset of this lesion was
unclear, I decided to treat the lesion
as infectious keratitis. The patient
was placed on Q1hr therapy of
vancomycin at 30mg/ml and Q1hr
Zymaxid alternating at Q one-half
hour. Steroids were discontinued.
I discussed treatment options and
recommended that, in addition to
the topical therapy, cultures should
be obtained from underneath the
lifted flap. Additionally, I recommended rinsing with fortified
vancomycin. This was done the following morning, and the patient returned for a one-day postoperative
follow-up on the treatment, where
he demonstrated improvement in
his symptoms with an uncorrected
acuity of 20/30.
The treatment was continued
aggressively for 24 more hours,
and then tapered. There was small
improvement in the physical appearance of the lesion, but not
complete extinction. So, four days
into the treatment process, I added
a steroid to the regimen; the patient
subsequently demonstrated additional clinical improvement with
no evidence of AC reaction, and
injection significantly reduced. By
the end of seven days, the patient
had returned to 20/25 uncorrected
acuity. At seven days out, further
tapering of all topical therapy was
initiated over a one-week period.
THE TWIST
At four days into the final taper of
the medications, the patient contacted the office to indicate that the
symptoms had returned. He was
seen that afternoon for follow-up
evaluation, which revealed that the
lesion had increased with the reduction in topical treatment and was
exhibiting a larger and denser atypical crystalline pattern than previously noted. Additionally, there
was also a small (less than 1mm)
corneal defect overlying the lesion.
This was unlike the typical infiltrate
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that is seen with either leukocytes
or neutrophils, based on whether
viral or bacterial etiology was the
source of the infectious process. I
discontinued steroids and put the
patient on full therapeutic regimen.
Visual acuity dropped to 20/100
uncorrected (20/50+ pinhole) and
the AC had a trace reaction.
After two days on the full therapeutic regimen, monitoring showed
no notable improvement, and the
cultures demonstrated no significant growth of either Gram-positive
or Gram-negative organisms. The
patient’s course was maintained,
but because of the unusual appearance of the lesion, I decided to add
an antiviral treatment (1,000mg
Valtrex TID postoperative).
The lesion remained effectively
unchanged, with a slow decrease
in vision over a three-day period in
the presence of full topical therapeutic intervention as previously
mentioned. There was no satellite
lesion development, nor did the basic presentation change materially,
other than a slight increase in size
of the underlying opacity beneath
the flap, a slow decrease in vision
and a notable increase in discomfort and photophobia.
On the fourth day, due to the
progression of the lesion in the face
of maximum therapeutic intervention, I decided to amputate the flap
and re-culture the eye, which was
accomplished the following day.
The goal of the amputation was to
allow better access of the antibiotics to the underlying lesion. The
patient showed an initial improvement with this therapeutic intervention, but subsequently the lesion
Post-LASIK corneal ulcer.
continued to slowly worsen, with
vision declining to 20/150 pinhole
and then approximately 20/60 at its
worst.
The treatment was now approximately three weeks out from the
initial procedure, and the patient
still showed no notable improvement with multiple antibiotic
systems and oral antiviral therapy.
At this point, the material that was
captured from the original culture
came back from the laboratory
with a positive identification of
an acid-fast bacillus, which was
identified subsequently as Mycobacterium chelonae. It was noted to
be sensitive to amikacin, which was
ordered at an appropriate concentration. Therapy was initiated
Q1hr over and above the current
treatment with the vancomycin and
gatifloxacin until a response was
obtained.
While M. chelonoe is a relatively
rare organism in general cases of
microbial keratitis following refrac-
tive surgery, it has been identified
as a possible opportunistic organism. Standard postsurgical prophylaxis is directed toward the most
common organisms and usually
involves the use of a fourth-generation FQ as the antibiotic of choice.
Of the unusual organisms that must
be included in the differential diagnosis of postoperative microbial
keratitis, MRSA is the most typical
and thus prompted the use of the
vancomycin empirically in this case.
On the new therapeutic regimen, the patient showed an initial
response, but it was slow, so
additional investigation was accomplished, and it was found that
the organism was also susceptible
to clarithromycin. A compounded
version of this was obtained via
overnight shipping and the patient
was prescribed continued application of topical amikacin and clarithromycin, alternately. This led to
a rapid improvement in symptoms,
(Continued on page 39)
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Practice Progress
By Mile Brujic, OD, and Jason Miller, OD, MBA
New Kid on the Block
Got a problem post-surgical patient? Try looking at the newest modalities for answers.
I
n any profession, new
products and designs drive
innovation. Within the
scope of contact lenses, it
is important to discuss new
products, materials and fitting modalities with appropriate patients,
including early cataract and postsurgical patients. These individuals may be considered “medical”
patients rather than “contact lens”
patients because of their recent
history, but they too may benefit
from corrective lenses. Below, Dr.
Miller describes three cases.
CASE 1: CATARACT
CONUNDRUM
A 54-year-old female patient presented with complaints of blurred
vision at both distance and near
while wearing her soft toric monovision contact lenses. Specifically,
vision in her right eye fluctuates
throughout the day more so than
her left eye. She is considering discontinuing contact lens wear due
to the loss of clear, crisp vision.
Her average wear time is eight to
10 hours; however, she has steadily decreased this time due to her
visual and comfort symptoms. The
patient is a teacher who works in
Fig. 1. Posterior subcapsular cataract OD.
38
front of a computer; she has experienced dryness, discomfort and
ocular fatigue with her current
lenses. She also reported that night
driving is becoming increasingly
difficult. She has been wearing her
current prescription for the past
three years. She reported vitreous
floaters in the past that seem to
have remained about the same.
An external ocular examination
revealed both eyes were slightly
dry with a tear film breakup time
of six to seven seconds, but no
fluorescein staining present OU.
These signs are consistent with
grade 1 dry eye. Dilating drops
were administered, and a subsequent internal ocular examination revealed a small “off-center”
posterior subcapsular cataract
OU (Figures 1 and 2). The patient
reported this finding in her history
as being present since she was a
child; no prior treatment or surgery had been recommended.
After reviewing various contact
lens options, the patient and I
concluded a hybrid multifocal was
the best choice for her particular
combination of astigmatism and
cataract. The design also alleviates discomfort due to her mild
dry eyes. I discussed appropriate
visual expectations and the basics
of the lens design, including the
expected time it would take for
the fitting appointment and subsequent visits. She adapted nicely to
the lens and her visual needs were
satisfactory.
CASE 2: POST-LASIK
MULTIFOCAL FIT
A 49-year-old female patient
presented looking to wear contact
lenses again. She underwent
LASIK 10 years ago and reported
satisfaction with the results up
until the last few years, as she was
needing to wear her readers more
and more often. Her refraction
was slightly hyperopic (+0.25D
OD and +0.50D OS) at distance
and required a +2.00 near add.
All other ocular health evaluation
points were unremarkable.
The challenge with these
patients is that many wore soft
contact lenses preoperatively and,
often, they expect they can also
wear them postoperatively. Some
have this ability, but for others,
it is difficult to maintain stable
vision because of alterations in
corneal architecture. The central
flattened cornea can be difficult for soft lenses to conform
to and will, at times, lead to
the lens vaulting the cornea.
This will result in visual instability between blinks.
I discussed these challenges
with her and recommended
starting with a daily disposable multifocal lens due to her
history of soft lens wear prior
to LASIK. She tried two difFig. 2. Posterior subcapsular cataract OS.
ferent multifocal lens designs
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that ultimately did not work: after
allowing them to settle for a few
minutes, her vision was not nearly
good enough at distance or near,
even with an over-refraction. I
tried one more daily multifocal
design with a slightly flatter base
curve and achieved much better
initial results.
CASE 3: POST-SURGICAL FIX
A 41-year-old post-refractive
surgical patient presented looking for better vision in her contact
lenses. Her RK and AK scars were
distorted and wavy in both eyes.
Her MR was +3.00-2.75x004
OD and +3.50-3.00x175 OS
postoperatively after unsuccessful refractive procedures OU. Her
corneas were extremely irregular,
with best-corrected visual acuity
being 20/25- OD and 20/30+ OS.
She had a history of unsuccessful
contact lens wear and was looking
for some relief.
I recommended large diameter,
reverse geometry GP lenses for
this patient. Reverse geometry GP
lenses allow for complete vaulting of the central cornea and
enhance patient comfort, improve
centration and visual acuity in
cases such as this one. The patient
elected to try the lenses and, at her
follow-up visit, she reported bet-
ter comfort. Her vision was also
slightly better at 20/25+ OD and
20/25-2 OS.
B
eing comfortable and proficient with satisfying a wide
variety of patients’ visual needs
is critical to the success of your
contact lens practice. Always
choose a design that will provide
good optics and comfort. Discuss
the benefits first, then touch on the
challenges associated with correcting their visual needs. Remember,
these lenses may require some creativity on the part of the doctor,
so always be prepared to accommodate necessary changes.
RCCL
WHEN THE GOING GETS TOUGH
(Continued from page 37)
visual acuity and lesion size over a
seven-day period. The patient continued on this therapy, and at the
six-week postoperative visit was
20/30 with minimal-to-no photophobia and complete reduction of
the hyperemia.
However, one small area of
probable continued activity of the
organism was noted, so therapy
was continued for approximately
eight additional weeks. Final
visual acuity was 20/30+ uncorrected and 20/25 pinhole. Because
of the crystallization of the lesion
and due to the chronic state of
the presentation, at some point
in the future, if vision does not
significantly improve, the patient
should undergo a scraping of the
material to provide a better refractive surface for improved visual
performance.
DISCUSSION
As seen in the above case, treating
a postoperative refractive surgery
infection can be both challenging
and complex. In patients in which
a 48- to 72-hour window takes
place, treatment with fortified
antibiotic systems like vancomycin,
tobramycin and/or a topical fourthgeneration fluoroquinolone fits
the standard protocol; however, in
patients for whom the organism
is either nonresponsive to that
protocol or in which onset of the
lesion occurs at a later date, it
is assumed that a more atypical
organism is the driving force.
Note, it is in no way unusual for
the patient to be treated as having
a possible herpetic viral infection
over the course of therapy, given
the relatively atypical presentation
that lesions like this create.
Additionally, note that because of
the extreme delay in the ability to
culture organisms of this type, the
clinician must demonstrate a level
of patience for the treatment that
can sometimes be quite trying.
C
ertain organisms such as
atypical mycobacteria,
nocardia and fungi are frequently
treated empirically due to
appearance, symptomatology or
both. In the case of A.T., it was
fortunate that the original cultures
were obtained so they could be
used to identify the organism.
Overall, as LASIK is one of the
most popular and successful
procedures ever, it is important
that in the case of a complication,
clinicians do not forget the
potential for an even more complex
complication.
RCCL
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The GP Expert
By Stephanie L. Woo, OD
Playing the Field:
How Manufacturers Can Help You
Having trouble fitting GP lenses in your practice? Don’t be afraid to ask for help
from the outside.
W
e all learned
in optometry
school about
the amazing
benefits of gas
permeable (GP) lenses. Durable
and affordable, they provide
significantly crisp, clear vision,
especially for patients with irregular corneas who otherwise may
be unable to wear contact lenses.
However, many practitioners stop
fitting GP lenses after they graduate optometry school, in part
because of the intimidation factor.
This is the result of a variety of
issues, including lack of real-world
fitting experience, patient expectations—with soft lenses the norm,
they need education about GP lens
benefits and the wearing experience differs—and increased chair
time. Some of these problems
can be alleviated with in-office
alterations; others may require the
help of lens manufacturers. What
resources do manufacturers offer,
and how should a practitioner go
about selecting one?
Contact lens laboratories that
are members of the Contact
Lens Manufacturer’s Association
(CLMA) have high standards to
ensure quality products and support practitioner success. Their
goal is to produce contact lenses
that serve the needs of practitioners and patients. The CLMA
has a code of ethics to encourage
confidence in practitioners who use
their products; as such, place the
use of sophisticated and advanced
40
manufacturing technology at the
top of the checklist when selecting
a laboratory.
The next step is to consider
contacting a consultant. Contact
lens consultants are one of the best
resources that a fitter can use: they
routinely design lenses, co-analyze
the fit and assist with the process
of problem-solving when a fit is
not correct. Consultants know of
different lens designs and fitting
characteristics that are available,
and can assist the practitioner
in making the best selection for
the patient during the lens design
consultation.
As such, there are a number of
benefits when partnering with a
laboratory that has invested in the
latest technology and who has a
team of consultants available. Such
a partnership can reduce chair
time; educate practitioners on fitting techniques and unfamiliar lens
designs; make the practice more
efficient and the patient more satisfied; and increase patient confidence in the practitioner’s abilities.
KEEP IN MIND
Different manufacturers offer varying services depending on the size
and scope of operation. Some will
come directly to the office to train
both the practitioner and staff on
fitting specialty lenses—including
insertion, removal and evaluation
of fit of scleral lenses. Additionally, many laboratories offer free
online educational resources such
as webinars or fitting guides; some
have also created social media
pages to encourage practitioners
to discuss and ask questions about
their products.
I asked the current president of
the CLMA, Jan Svochak of TruForm Optics, to make a few statements about how labs and consultants can help practitioners with
specialty lens fittings. In particular,
I wanted to know what he wishes
practitioners would understand.
Here are his thoughts:
1. There are no dumb questions.
We want you to be comfortable
using our lenses, so ask away.
Don’t cut yourself short by not
calling and asking for consultant
help. Many of your colleagues
most certainly are.
2. Consultants live and breathe
challenging issues. It is rare that
we haven’t already run across a
similar situation to the one you
may be experiencing.
3. We learn from you, too. There
is a lot of give-and-take in a
practitioner/consultant relationship. The better the exchange
of information, the better the
relationship.
4. Having patient history readily
available is a huge help. Knowing what has or hasn’t worked in
the past in given situations helps
us better determine where to go
next with lens design.
ASK A CONSULTANT
“Consultants have a vision to see
every fitter become an optometric
superhero—a fitter who changes
REVIEW OF CORNEA & CONTACT LENSES | NOVEMBER 2015
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lives,” say consultants Kelsey Roberts and Janice Adams from Valley
Contax. “Each of the consultants
view themselves as a partner as
well as a friend to all of the fitters
that they consult with throughout
the day. Whether it is a discussion
about fitting a challenging patient
or simply discussing decisions
already made regarding a contact
lens fit, the consultants want fitters
to know that they are ready to
share their knowledge and experience in designing lenses and problem solving to achieve a successful
fit for a happy patient.”
Having multiple consultants with
fitting experience can be invaluable, says Tom Shone of Alden
Optical, because together they
may be able to solve more complicated cases that a single consultant
could not. “I’d encourage ECPs
to find great consultants and then
develop mutual trust. Great things
can happen that way. I’d say the
best portal into the lab is a good
Bitoric GP with 5D of astigmatism.
consultant. They are best able to
translate ECPs’ fitting challenges
into solutions, both obvious and
sometimes not so obvious.”
“Specialty lens manufacturers usually have deep benches for
consultation, with many years of
contact lens application experience
for all sorts of indications,” says
Mark Parker from X-cel Contacts.
“In our own case, we have 13
National Contact Lens Examiner
(NCLE)-certified consultants with
more than 250 years of consultation experience.”
Cassandra Gordon from Visionary Optics points out that giving
consultants certain information can
help improve results. “In order for
a consultant to be the most effective in providing the best resolution
to successfully fit your patient, detailed comprehensive information
relating to central and limbal clearance—or lack thereof—peripheral
impingement/compression or edge
lift, and signs such as debris in
the lens-cornea
interface, is very
much appreciated. Inclusion of
pictures, videos
and/or OCT is
even better.”
Keith Parker
from Advanced
Vision Technologies also has a
few tips for practitioners. “When
sending topographical maps,
use an axial map and an elevation
map,” he says. “When working
with corneal reshaping patients,
using tangential maps to assess
the overnight treatment is recommended. Also, please remember
the basics: HVID, pupil size and lid
positions along with Ks and Rx.
Use photos and video whenever
possible. Perform spherical overrefractions and always compare to
spherocylinder overrefractions, as
the cylinder might not be worth the
trouble.”
PICK A TREATMENT
Plasma treating is suitable for most
gas permeable lenses, says Valley
Contax. An often-misunderstood
process, plasma treatment is a
‘super cleaning’ of the lenses in
which they are treated with ions
in a vacuum, imbuing them with
a hydrophilic surface. The coating
lasts for an average of two weeks
depending on the patient’s care
and handling regimen and significantly increases initial comfort
and wettability for up to a year.
Note, plasma-treated lenses should
be cleaned with clear, non-milky
cleaners; more abrasive cleaners
will affect the length of treatment.
Most laboratories, however, can
re-treat a lens as needed.
Another common point of
discussion is the use of diagnostic
lens fitting sets. Diagnostic sets
save a large amount of chair time
and reduce the number of lenses
ordered by at least half. Most
laboratories offer them either for
REVIEW OF CORNEA & CONTACT LENSES | NOVEMBER 2015
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41
10/29/15 2:00 PM
The GP Expert
By Stephanie L. Woo, OD
Translating GP multifocal.
loan or sale, so if you do not want
to invest money in a fitting set, ask
the laboratory to borrow one. Generally, sets are loaned out for 90
days to give practitioners enough
time to try them out on patients.
When ordering lenses, communication between the doctor and
the staff member processing the
order is extremely important, says
Corey Reynolds from Advanced
Vision Technology. Often, technicians don’t know the basics of the
lens designs they are ordering, and
many doctors don’t pass on effective notes to them about what they
want to change. This can lead to a
lot of mistakes due to incorrect or
missing information.
A CLICK AWAY
The Gas Permeable Lens Institute
(GPLI) is the go-to website for
many practitioners and patients.
The GPLI has everything you need
to become more comfortable with
fitting GP lenses. One of the greatest features of the website is “Ask
42
an Expert,” a free question-andanswer section with access to some
of the best experts in the world on
different subjects—for example,
orthokeratology. Several experts
are GPLI advisory board members,
who offer their advice for free.
The website also hosts archived
webinars ranging in subject from
gas permeable lens fittings and
specialty lens tips to common GP
problems and billing and coding
issues.
Another online resource, the
Scleral Lens Education Society
(SLS), teaches contact lens
practitioners the science and art of
prescribing sclerals. SLS supports
public education that highlights the
benefits and availability of scleral
contact lenses. This website is a
great resource for practitioners
and patients. Embedded within
the website is an area to email
questions to experts in the scleral
lens field. A unique feature to this
organization is the Scleral Lens
Fellowship (FSLS), in which a
practitioner demonstrates extensive
knowledge of scleral lenses though
case reports, posters, papers and
lectures. The “Find a Fitter” tab
helps patients and practitioners
locate scleral lens experts
throughout the world. The SLS
is a fantastic site for patients and
practitioners looking for any and
all information related to scleral
lenses.
I-site is an educational newsletter
that is distributed on a monthly
basis and provides an update on
GP-related topics (i.e., scientific
research, case reports and other
publications worldwide). I-site
is objective and non-political.
Its editor, Eef van der Worp, is
a lecturer and a consultant for
a variety of industry partners,
but is not related to any specific
company.
W
ith such a plethora of
knowledge and assistance
from a variety of sources, all
practitioners should embrace the
power of GP lenses! Manufacturers
and consultants are some of the
greatest resources for contact lens
practitioners. Their ultimate goal
is to help you succeed with all of
your contact lens patients. They
help you look like a superhero
and will assist you and your
office in any way possible to
ensure that your patient is happy
and healthy. GP lenses can help
provide tremendous benefits to
your patients and can aid practice
growth. Set yourself apart from
other practitioners while improving
patient lives.
I would like to thank all of the
laboratories and consultants for
their advice and comments in the
development of this article.
RCCL
Review of Cornea & Contact Lenses
would like to thank Stephanie Woo
for her contributions to the magazine over the past year. Dr. Woo is
retiring as the GP Expert columnist
after this issue, but will continue to
contribute to our coverage of GP
and scleral lens topics.
REVIEW OF CORNEA & CONTACT LENSES | NOVEMBER 2015
040_RCCL1115_gpe-1.indd 42
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