MARCH/APRIL 2020

PRESBYOPIA REVIEW OF ISSUE & CONTACT LENSES

ET AHEAD OF PRESB TO G YOPI W A, P HO . 14 PTIC OCAL O S EXPLO LTIF RED U , P. M 18

® Make BAUSCH + LOMB ULTRA the MULTIFOCAL Most of FOR THEIR SUCCESSMULTIFOCALS IS YOUR SUCCESS. Inside: Expert advice on optics, options, fi tting The vision correction patients prefer is also the that’s giving patients a more favorable impressionprotocols of you. and1,2 ideal patients.

87% 91% 4 2 of patients prefer it over W of patients had a more P. H E, their previous contacts, EN favorable impression of their ID readers, or eyeglasses.1 .2 L 8 PR L . 2 ES CO P PR BYO ISM S, ES PIA AND ASTIGMAT NT BY ME Fit the lens that’sOP fit for success. AT IA TRE SUR URE GERY: CURRENT & FUT

REFERENCES: 1. Results of an online survey 435 patients who completed an evaluation program for Bausch + Lomb ULTRA® Multifocal for Astigmatism contact lenses. Survey results include 391 patients who indicated that they had a preference. 2. Results of an online survey 435 patients who completed an evaluation program for Bausch + Lomb ULTRA® Multifocal for Astigmatism contact lenses. Survey results include patients who strongly agreed, agreed, or slightly agreed (on a 6-point agreement scale) with a margin of error of +/- 2.7%.

®/™ALSO: are trademarks REAL-WORLD of Bausch & Lomb Incorporated LENSor its affiliates. CARE PROBLEMS • PEDIATRIC GP FITTING • NEOPLASIA • EPITHELIAL INGROWTH ©2020 Bausch & Lomb Incorporated or its affiliates. UMT.0043.USA.20

MARCH/APRIL 2020

PRESBYOPIA REVIEW OF CORNEA ISSUE & CONTACT LENSES

ET AHEAD OF PRESB TO G YOPI W A, P HO . 14 PTIC OCAL O S EXPLO LTIF RED U , P. M 18

Make the Most of MULTIFOCALS Inside: Expert advice on optics, options, fi tting protocols and ideal patients.

24 W P. H E, EN ID P LL 28 RE CO P. P SBY M S, RE OPIA ATIS T SB AND ASTIGM EN YOP ATM IA TRE SUR URE GERY: CURRENT & FUT

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1. CVI Data on file 2018. Non-dispensing, subject masked, randomized, bilateral, cross-over short-term clinical evaluation. 27 astigmatic, presbyopic soft CL wearers at 2 sites (UK & US) fitted using CVI fit guide. 2. CVI data on file 2019. Based on total number of prescription option combinations manufactured (for sphere, cylinder, axis and add – including D & N combinations). ©2020 CooperVision. 8947 01/20 contents Review of Cornea & Contact Lenses | March/April 2020

features How to Get Ahead of Presbyopia Intervening earlier on is key in successfully working through this inevitable condition. 14 By Erin Rueff, OD, PhD Multifocal Optics Explored Recent research may give insight on departments how to better implement these lenses for presbyopic patients. By Mark De Leon, Associate Editor 4 News Review OCT and keratic precipitates, NSAIDs, serum eye drops and LSCD, 18 lasers and Fuchs’ When Presbyopia and Astigmatism Collide My Perspective 8 A multitude of options Coronavirus: Ready for the Questions exist for the independent correction By Joseph P. Shovlin, OD of astigmatism and presbyopia. Let’s discuss the options when these occur simultaneously. Practice Progress 24 10 By Robert Ensley, OD, and Jessica Presbyopia: Knowing is Half the Jose, OD Battle By Mile Brujic, OD, and David Kading, OD Presbyopia Treatment: Current and Future Options Fitting Challenges 12 Make sure you’re in the know about Little Eyes, Big Solutions long-term solutions for the conditon. By Vivian P. Shibayama, OD, and Cory By Larry Baitch, OD, PhD Collier, OD 28 38 The GP Experts Managing Presbyopia With Sclerals 5 Real-world Contact Lens By Lindsay Sicks, OD, and Thanhan Andy Care Problems Nguyen, OD Poor lens care and handling practices can lead to infections, drop-outs and even vision loss. Here’s how you can 40 Corneal Consult help patients avoid them. When a Prompts a Red 34 By Jane Cole, Contributing Editor Alert By Aaron Bronner, OD, and Alison Bozung, OD

42 The Big Picture Early Adopter, Chronic Sufferer By Christine W. Sindt, OD

REVIEW OF CORNEA & CONTACT LENSES | MARCH/APRIL 2020 3 News Review

IN BRIEF ■ Researchers recently reported Keratic Precipitates that LASIK and photorefractive keratectomy are safe and e ective in breastfeeding women. After evaluating Trouble for OCT 237 eyes of 168 women who were breastfeeding during either procedure esearchers in Scotland In the patient with infective in- or stopped breastfeeding at least recently looked at the terface , keratic precipitates three months beforehand, the team potential diagnostic role were evident on the endothelial sur- found no signifi cant intraoperative or postoperative complications. No of anterior segment OCT face but no changes were identifi ed signifi cant di erences were found R(AS-OCT) and realized clinicians at the graft-host interface. When between the groups in visual acuity, should not use it to differentiate patients first present with postoperative spherical equivalent, e cacy index, predictability, safety infective infi ltrates from infl amma- and keratic precipitates one week index or retreatment. They noted that tory keratic precipitates for patients following surgery, AS-OCT did not no infants experienced adverse e ects. presenting with postoperative demonstrate any morphological Alonso-Santander N, Ortega-Usobiaga J, Beltrán-Sanz J, et al. Laser in situ keratomileusis infl ammation. differences between the precipitates and surface ablation in breastfeeding patients. Still, AS-OCT may be a good compared with the other non-infec- Cornea. January 30, 2020. [Epub ahead of print]. diagnostic and monitoring tool tious cases in this series. Therefore, ■ A systematic review found no to assess response to treatment the researchers noted that there evidence of statistically signifi cant di erences in IOP or safety between in cases where anterior segment were no signifi cant differences benzalkonium chloride (BAK)- infl ammation of uncertain etiology between infective and infl ammato- preserved eye drops, preservative- is present, they noted. If AS-OCT ry precipitates to help distinguish free and alternatively preserved prostaglandin analog and beta- only identifi es endothelial depos- between the two. blockers. IOP was 0.15mm Hg lower in its, clinicians should still suspect The researchers noted that it the BAK group than in the other groups, interface infection. The researchers could be possible that the presence but this di erence was not statistically signifi cant or clinically relevant. Meta- could differentiate endothelial pig- of hyperreflective keratic precip- analyses also revealed no di erences ment deposits from keratic precip- itates on AS-OCT could be more with regard to conjunctival hyperemia, itates with smaller, poorly defi ned, suggestive of newly deposited ocular hyperemia, total ocular adverse events or tear break-up time. The review hyporefl ective deposits. precipitates and active inflamma- noted that tolerability of eye drops with The case-based review included tion as well as keratic precipitates or without preservatives was generally six patients with infl ammatory of herpetic origin. This may be reported as good. keratic precipitates, one patient helpful if corneal edema or opacity Hedengran A, Steensberg AT, Virgili G, et al. E cacy and safety evaluation of benzalkonium with infective interface keratitis otherwise prevents visualization of chloride preserved eye-drops compared with alternatively preserved and preservative-free eye- following Descemet membrane cells in the anterior chamber. drops in the treatment of : a systematic endothelial keratoplasty and one review and meta-analysis. Br J Ophthalmol. Shipton C, Hind J, Biagi J, Lyall D. Anterior seg- February 12, 2020. [Epub ahead of print]. patient with endothelial pigment. ment optical coherence tomographic characterisa- tion of keratic precipitates. Cont Lens Anterior Eye. ■ A study conducted in Shanghai AS-OCT images in acute and active January 13, 2020. [Epub ahead of print].

has established that accelerated infl ammation generally Photo: Christopher Kuc, OD, and Richard Mangan, OD transepithelial corneal crosslinking demonstrated hyperre- (ATE-CXL) can be safe and e ective fl ective keratic precipi- for up to 36 months for pediatric patients with progressive . tant variants compared The researchers examined 53 eyes of with other conditions 41 pediatric patients with progressive patients who received ATE-CXL. with moderate or After 36 months, corrected distance longstanding infl amma- visual acuity (CDVA) improved from tion. The presence of 0.32±0.28logMAR to 0.26±0.25logMAR. The study found corneal pachymetry, hyperreflective precipi- central thickness and epithelial tates on AS-OCT may thicknesses remained stable throughout help clinicians decide the three-year follow-up period. whether there may be Tian M, Jian W, Zhang X, et al. Three-year follow- up of accelerated transepithelial corneal cross- active infl ammation in New data suggest AS-OCT might not be a good linking for progressive pediatric keratoconus. Br J Ophthalmol. February 12, 2020. [Epub ahead the anterior chamber that option to image this patient’s keratic precipitates of print]. requires treatment. due to DSAEK rejection.

4 REVIEW OF CORNEA & CONTACT LENSES | MARCH/APRIL 2020 The Role of NSAIDs Clarifi ed wo studies now clarify low-to-medium risk of bias across head match-up, steroids alone have the benefi ts of topical the included trials. The mean pain a lower rate of posterior capsule non-steroidal anti-infl am- score was signifi cantly lower follow- opacifi cation than NSAIDs alone.2 matory drugs (NSAIDs) ing topical NSAID administration The researchers took a retrospec- Tfor patients undergoing an ocular relative to controls at every time tive look at 13,368 uncomplicated procedure. point, adding that administering cases who presented to the NSAIDs before vs. after intravit- hospital between 2014 and 2018. PRE-INJECTION: A PLUS real injection, as well as topical Some were treated with steroids Patients heading in for an intrav- nepafenac relative to ketorolac or alone (28.9% of cases), while itreal injection may cope with the diclofenac, had a greater effect. others were treated with NSAIDs post-procedure pain better after “Given the lack of diversity of alone (62.2%) and 8.9% were administration of a pre-emptive top- studies and associated sample size, treated with a combination of both. ical NSAID, a new study suggests. our fi ndings should be regarded as Treatment with steroids resulted Researchers found that administer- hypothesis-generating,” the study in signifi cantly lower Nd:YAG ing NSAIDs pre-procedure—specifi - authors concluded. capsulotomy rates compared with cally, topical nepafenac—was associ- NSAIDs alone, the research shows. ated with the greatest improvement POST-OP: NOT SO MUCH Additionally, the combination in pain.1 Following cataract surgery, patients therapy method showed no added The study evaluated 598 eyes are often prescribed a cocktail of eye benefi ts over steroids alone.2 from nine randomized controlled drops to help them recover. These The patients had a mean age of trials that treated patients with can include antibiotics, NSAIDs 73.2±9.7 years and 61.7% were a topical NSAID and analyzed and steroids. But new research is female. Their mean follow-up time post-procedure pain. The team as- showing that, in most cases, NSAID was 22.8±15.7 months.2 sessed pain on the zero- to 10-point drops don’t really do much for the 1. Popovic MM, Muni RH, Nichani P, et al. Topical Visual Analog Scale and categorized patient. According to a study out non-steroidal anti-infl ammatory drugs for pain from intravitreal injections: a meta-analysis. Ophthalmolo- the data into post-procedure time of the Helsinki University Hospital gy. February 13, 2020. [Epub ahead of print]. points of less than one hour, six in Finland, combining steroids and 2. Hecht I, Karesvuo P, Achiron A, et al. Anti-in- 1 fl ammatory medication after cataract surgery and hours and more than 24 hours. NSAIDs gets the same results as posterior capsular opacifi cation. A, J Ophthalmol. The investigators observed a steroids alone and, in a head-to- February 14, 2020. [Epub ahead of print]. Serum Eye Drops Heal CL-induced LSCD utogous serum eye drops Aggressive treatment with the tients wearing CLs, particularly soft may be able to reverse serum eye drops was successful in CLs, receive annual examinations severe contact-lens all eyes, with signs and symptoms of with a high degree of suspicion for induced limbal stem cell LSCD stabilizing within two weeks. the condition.” Adefi ciency (LSCD) and prevent the Complete resolution occurred in The investigators emphasized need for surgery, especially when 30% at the two-week mark, in 45% the importance of early identifi ca- the condition is treated early and at four weeks and in 25% after tion and suggested an aggressive aggressively, a team of Taiwan eight weeks. treatment of analogous serum eye researchers suggest. “There is a high prevalence of drops for CL-induced ocular surface Their study enrolled 20 eyes of severe CL-induced LSCD among diseases in an attempt to reverse the 14 patients with severe CL-induced symptomatic patients that sought limbal damage and prevent the need LSCD. All eyes underwent the help because of painful eye and for further surgical intervention.

serum eye drop treatment for at blurred vision in our case series,” Yeah SI, Chu TW, Cheng HC, et al. The use of autolo- least two weeks with a follow-up of the researchers wrote in their paper. gous serum to reverse severe contact lens-induced limbal stem cell defi ciency. Cornea. January 24, approximately two months. “Therefore, it is essential that pa- 2020. [Epub ahead of print].

REVIEW OF CORNEA & CONTACT LENSES | MARCH/APRIL 2020 5 RCCL News Review REVIEW OF CORNEA & CONTACT LENSES

19 Campus Blvd., Suite 101 Newtown Square, PA 19073 Telephone (610) 492-1000 Fax (610) 492-1049 Laser: A Graft-less Editorial inquiries: (610) 492-1006 Advertising inquiries: (610) 492-1011 Fuchs’ Treatment? Email: [email protected] EDITORIAL STAFF

Photo: Mitch Ibach, OD EDITOR-IN-CHIEF or patients with Jack Persico [email protected] MANAGING EDITOR Fuchs’ endothe- Rebecca Hepp [email protected] lial corneal dys- ASSOCIATE EDITOR Catherine Manthorp [email protected] trophy (FECD), ASSOCIATE EDITOR Fan endothelial graft is Mark De Leon [email protected] CLINICAL EDITOR often the best treatment Joseph P. Shovlin, OD, [email protected] path. While surgery is of- ASSOCIATE CLINICAL EDITOR Christine W. Sindt, OD, [email protected] ten successful, research- EXECUTIVE EDITOR ers are still on the hunt Arthur B. Epstein, OD, [email protected] CONSULTING EDITOR for a better solution. Milton M. Hom, OD, [email protected] Now, excimer laser ASSOCIATE ART DIRECTOR Jared Araujo [email protected] ablation shows prom- AD PRODUCTION MANAGER ise as an experimental Farrah Aponte [email protected] approach to remove BUSINESS STAFF diseased tissue from the Patients such as this one with classic endothelial PUBLISHER changes due to FECD may one day have laser James Henne [email protected] Descemet membranes of REGIONAL SALES MANAGER FECD patients, which ablation as a treatment option. Michele Barrett [email protected] REGIONAL SALES MANAGER could allow corneal Michael Hoster [email protected] endothelial cells to migrate more closure was accomplished after 26 EXECUTIVE STAFF easily to the wounded area and help to 38 days in the treated . CEO, INFORMATION SERVICES GROUP in the healing process, a new study The study noted that imaging Marc Ferrara [email protected] SENIOR VICE PRESIDENT, OPERATIONS in Acta Ophthalmologica suggests. also showed a layer of fl at endothe- Je Levitz [email protected] In the investigation, Descemet lial cells after the procedure, and SENIOR VICE PRESIDENT, HUMAN RESOURCES membranes of FECD patients and cellular markers of neurotransmit- Tammy Garcia [email protected] the corneal endothelium of normal ter activity could only be observed VICE PRESIDENT, CREATIVE SERVICES & PRODUCTION human corneas were ablated ex on the inner side of the Descemet Monica Tettamanzi [email protected] VICE PRESIDENT, CIRCULATION vivo using an excimer laser. The membrane. Emelda Barea [email protected] samples were then kept in a cell While the study pointed to the CORPORATE PRODUCTION MANAGER culture medium supplemented with potential of excimer laser ablations John Caggiano [email protected] 10µm of the rho-kinase inhibitor as a graft-less FECD treatment EDITORIAL REVIEW BOARD ripasudil. option, they cited several method- Mark B. Abelson, MD James V. Aquavella, MD The research team used light and ological problems that need to be Edward S. Bennett, OD Aaron Bronner, OD electron scanning microscopy to resolved in clinical trials, in addition Brian Chou, OD Kenneth Daniels, OD discover that guttae and corneal en- to in vivo research. S. Barry Eiden, OD dothelium could be ablated with the The laser option could pose some Desmond Fonn, Dip Optom, M Optom Gary Gerber, OD laser without total damage to the advantages, including the avoidance Robert M. Grohe, OD Susan Gromacki, OD Descemet membrane or stroma, and of a corneal graft in combination Patricia Keech, OD nearly complete endothelial wound with the creation of a wound that Bruce Koffler, MD Pete Kollbaum, OD, PhD does not present bare stroma, a Jeffrey Charles Krohn, OD Kenneth A. Lebow, OD Advertiser Index favorable stromal healing response Jerry Legerton , OD Kelly Nichols, OD CooperVision ...... Cover 2 and faster cell migration over an Robert Ryan, OD intact basement membrane. RCCL Jack Schaeffer, OD Oculus ...... Cover 4 Charles B. Slonim, MD Kirk Smick, OD Visioneering Kassumeh S, Studnitz A, Priglinger SG, et al. Ex vivo Mary Jo Stiegemeier, OD excimer laser ablation of cornea guttata and ROCK Loretta B. Szczotka, OD Technologies ...... Cover 3 inhibitor-aided endothelial recolonization of ablated Michael A. Ward, FCLSA central cornea. Acta Ophthalmol. February 3, 2020. Barry M. Weiner, OD VSP ...... 22-23 [Epub ahead of print]. Barry Weissman, OD

6 REVIEW OF CORNEA & CONTACT LENSES | MARCH/APRIL 2020 Earn up to 29 CE Credits* A CONFERENCE

New Technologies & Treatments in Eye Care & OCCRS: AUSTIN, TX

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PROGRAM CHAIRS: LOCATION: Omni Barton Creek 8212 Barton Club Drive Austin, TX 78735 (512) 329-4000 Paul M. Karpecki, OD, FAAO Tracy Schroeder Swartz, OD, MS, FAAO Discounted room rate: $275/night + taxes & fees. Review Program Chair OCCRS President, Program Chair Some resort fees may apply for additional amenities.

THREE WAYS TO REGISTER: Online: www.ReviewEducationGroup.com/Austin2020 Call: 866-658-1772 or E-mail: [email protected] Opportunities to register for one or both meetings. See website for detailed fees.

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Review Education Group partners with Salus University for those ODs who are licensed in states that require university credit. See event website for complete details. My Perspective By Joseph P. Shovlin, OD

Coronavirus: Ready for the Questions Following these preparative measures will help minimize risk and keep patients at ease.

imilar to the MERS (Mers- Symptoms range from fever, cough • Stay home when sick. CoV) and SARS (Sars-CoV) and shortness of breath to diarrhea • Clean and disinfect exposed insurgence and hysteria and vomiting.2-4 surfaces. experienced in the past, the A recent alert from the American This infection can have implica- Snewest version of the coronavirus, Academy of tions for the cornea, and the Global COVID-19, has unfolded rapidly, suggests the virus can cause con- Alliance of Eye Bank Associations receiving much attention. With junctivitis and may be transmitted (GAEBA) has consolidated respons- all this attention, are you ready to by aerosol contact to the ocular es related to ocular tissue donation respond to questions and, more surface.4 The coronavirus spreads for transplants and lamellar surgery. importantly, do you know what do via respiratory droplets. Patients They advise precautionary measures. to with a patient who presents with may be infectious to others prior to “Exclude or defer potential donors signs and symptoms of this disease? experiencing their own symptoms, for ocular tissue who resided or although asymptomatic transmission traveled to mainland China (regard- THE FACTS has not been confi rmed.4 less of symptoms) or to other geo- The coronaviruses, novel pathogens, You might just be the fi rst pro- graphical areas designated as areas are a frequent cause of the common vider to evaluate an infected person of active transmission by the CDC,” cold and other respiratory infections with a co-morbid and the GAEBA says.6 including pneumonia.1,2 Health respiratory infection.4 Review infec- offi cials in China reported this tion control practices for patients ontinue to monitor your state outbreak in Wuhan in December under investigation and obtain ad- Cand local health department 2019. Apparently the coronavirus- equate travel or other exposure his- alerts for any viral activity in your es are found in different species of tory including travel dates and cities area, be prepared for questions your animals and can evolve to infect and visited in the past 14 days.5 Check patients might ask regarding the 1 spread among humans. As this is your inventory for any needed offi ce coronavirus. RCCL published, the Centers for Disease items such as masks, gloves, gowns, 1. Greenhaigh T. What you should know about Control and Prevention (CDC) has goggles and disinfectant. the coronavirus outbreak. Pulmonary Advisor. so far confi rmed 423 cases detect- www.pulmonologyadvisor.com/home/topics/ 2 lung-infection/what-you-should-know-about- ed in the United States. More, of SAFETY MEASURES the-coronavirus-outbreak. January 30, 2020. course, are sure to be on the way It’s key for healthcare providers to Accessed February 6, 2020. 2. Centers for Diseases Control and Preven- as the virus spreads. Because of immediately notify their state or lo- tion. 2019 novel coronavirus: information for the uptick in the infected numbers cal health department if they suspect healthcare professionals. www.cdc.gov/coro- navirus/2019-ncov/hcp/index.html. Accessed in China, authorities there have COVID-19 infection. Public health March 9, 2020. imposed an unprecedented lock- offi cials can then decide whether 3. Palus S. How worried should you be about the new coronavirus? (Update: still not time to down on travel, affecting more than patients should be admitted to panic). Slate. slate.com/technology/2020/01/ coronavirus-outbreak-china-sars-worry-level. a dozen cities in China (a combined airborne isolation or monitored at html. January 24, 2020. Accessed February population of at least 50 million).1 home with appropriate precautions.5 6, 2020. 4. American Academy of Ophthalmology. Though there are many cases In the absence of a viable vaccine, Alert: important coronavirus context for already reported, a lot of the infec- the CDC recommends these tips to ophthalmologists. www.aao.org/headline/ alert-important-coronavirus-context. January 3 tions are not as severe as infl uenza. minimize exposure and risk to the 28, 2020. Accessed February 19, 2020. The recovery period only gener- virus.1-4 5. Pavia AT. Novel coronavirus (2019-nCoV): frequently asked questions for clincians. Med- ally lasts for just a few days, but • Avoid touching your eyes, nose scape Infectious Diseases. www.medscape. com/viewarticle/924555. January 30, 2020. the young, elderly and those who and mouth with unwashed hands. Accessed February 6, 2020. have a compromised immune state • Keep a distance from those who 6. Global Alliance of Eye Bank Associations. Alert: coronavirus (COVID-2019) and ocular are the most vulnerable. They can are sick, especially those who recent- tissue donation. www.gaeba.org/2020/ surface in as few as two days and ly traveled internationally—to China alert-coronavirus-2019-ncov-and-ocular-tis- 1-3 sue-donation. February 3, 2020. Accessed up to two weeks after exposure. in particular. February 19, 2020.

8 REVIEW OF CORNEA & CONTACT LENSES | MARCH/APRIL 2020 Earn up to NEW TECHNOLOGIES 2020 & TREATMENTS IN 19 CE Credits* Eye Care San Diego May 29-31, 2020 - Manchester Grand Hyatt

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Review Education Group partners with Salus University for those ODs who are licensed in states that require university credit. †Rooms limited. See website for additional details. Practice Progress By Mile Brujic, OD, and David Kading, OD

Presbyopia: Knowing is Half the Battle Many of these patients require some type of refractive correction but aren’t even aware of their contact lens options.

resbyopia is a near-certainty for anyone who lives to reach the age at which the Peye’s natural accommodative ability begins to fail. By the time patients are 50 years old, nearly 100% require some type of refractive correction. There is no other condition we manage where the same holds true. Yet only a small Fig. 1. Topography of a successful orthokeratology patient’s cornea (left). Topography percentage of these patients over the surface of a distance-centered multifocal contact lens (right). wear contact lenses. We have the opportunity to step in and satis- day. Daily disposables are an ideal opportunity to wear contact lenses. fy this unmet need. option for patients who stand to The inherent challenge with these Ophthalmic lens and contact lens benefi t from contact lenses and lenses is that they are custom made technologies present solutions for prefer part-time wear. and come with a wait time for initial these patients. Unfortunately, many One complaint patients may have access and orders and reorders in aren’t aware that there are contact about daily disposable lenses is the the case of modifi cations. lens options available, as they may amount of waste they produce. Presbyopic lenses with astig- not have been given the chance to Fortunately, TerraCycle offers a pro- matic correction have experienced try them. In the near future, there gram for patients to recycle lenses advances in recent years. There is will also be pharmaceutical options and packaging, and manufacturers now a monthly disposable silicone to treat the symptoms of presby- like Bausch + Lomb have taken the hydrogel lens Ultra Multifocal for opia. It is critical that we help our initiative to encourage recycling. Astigmatism (Bausch + Lomb) with patients understand all of their op- toric and multifocal correction. The tions so that we can improve their SPECIALTY LENSES lens is made of samfi lcon A and is outcomes and our standard of care. There are currently no daily dispos- 46% water. This lens is unique in able options available to presby- that it is available in a diagnostic set DAILY DISPOSABLES opic patients who have astigmatic to help you avoid much of the wait Historically, daily disposable lenses . Those interested in time in the ordering process. have been somewhat limited in their daily disposables are often limited parameter availability, making it to best-corrected distance vision in OTHER OPTIONS diffi cult for some patients to suc- contact lenses and a combination of As a profession, optometry has cessfully wear them. This should not reading glasses and contact lenses become increasingly aware of line overshadow their advantages, espe- to see at near. Monovision could of sight and how it may affect a cially as there has been an expan- help reduce the dependency for near patient’s visual performance in soft sion in power ranges. These lenses glasses over contact lenses. multifocal designs. This can be seen are worn and disposed of on a daily We have had access to specialty through the advancements the fi eld basis, so there is no interaction with soft contact lens designs for decades. has made. We now have a contem- cleaning and disinfecting solutions, These lenses give patients with mul- porary soft multifocal design and a and patients are guaranteed a clean, tifocal requirements who also need scleral lens design we can customize fresh lens wearing experience each astigmatic refractive correction the to offset the optics nasally to corre-

10 REVIEW OF CORNEA & CONTACT LENSES | MARCH/APRIL 2020 spond with a patient’s line of sight. opposed to placing pressure on the some functionality. PRX-100 by Gas permeable (GP) lenses are a central portion of the cornea, they Presbyopia Therapies, CSF-1 by viable option for presbyopes, even put pressure on more peripheral Orasis Pharmaceuticals and AGN- though they often are thought of as portions of the cornea, steepening 199201 and AGN-190584 by a secondary option for patients who the central cornea and inducing Allergan are miotic treatments that may experience initial lens aware- myopic refractive correction. When create a pinhole effect to allow for a ness. GPs provide optical clarity and done over the non-dominant eye, greater depth of focus.5-8 are intuitively designed to provide it can have a monovision effect, Leveraging these technologies to distance vision correction in the promoting better near vision.1,2 enhance contact lens success will im- center of the lens while progressing prove the presbyopic experience by to the near powers toward more PHARMACEUTICAL giving patients more freedom from peripheral portions. Translation of TREATMENTS spectacle wear. the lens in downgaze allows patients There are several pharmaceutical to acquire more near power. options on the horizon. It is criti- ith current contact lens tech- Hybrid lenses provide opportu- cal that contact lens practitioners Wnologies and the promise of nities for presbyopes as well. These understand how to use these new future therapies, we should have no lenses have a GP center that is technologies to supplement the con- problem helping presbyopic patients surrounded by a soft lens skirt. This temporary contact lens practice. achieve clear vision and a comfort- makes initial lens awareness subtler, In early presbyopes, this may re- able lifestyle and fulfi lling a need similarly to soft lenses, and offers place the need for multifocal contact that has been neglected. RCCL comparable optical quality proper- lenses, allowing patients to continue 1. Williams BT. Orthokeratology for hyperopia ties to standard GP lenses. with single vision lenses while using and presbyopia. Contact Lens Spectrum. www. Although much of the conver- drops. Depending on the effi cacy clspectrum.com/issues/2016/august-2016/or- thokeratology-for-hyperopia-and-presbyopia. sation surrounding orthokeratol- of the drop, it may negate the need August 1, 2016. Accessed February 7, 2020. ogy over the last several years has for multifocal technologies for 2. Gi ord P, Swarbrick HA. Refractive changes from hyperopic orthokeratology monovision in revolved around managing , more advanced presbyopes as well. presbyopes. Optom Vis Sci. 2013;90(4):306-13. we certainly can’t overlook our Some s may still need presbyopic 3. Pending presbyopia treatments edge closer to disrupting the marketspace. presbyopic patients as potential can- refractive correction in addition to Healio. www.healio.com/ophthalmolo- gy/cornea-external-disease/news/print/ didates who are looking for alterna- pharmaceutical assistance, although ocular-surgery-news/%7Ba40b0eb9- tives to glasses or traditional contact to a lower degree than what would cddf-4908-b9bb-9911bef60bf1%7D/pend- ing-presbyopia-treatments-edge-closer-to-dis- lenses. As such, myopic presbyopes be expected. This could be achieved rupting-the-marketspace. March 25, 2019. are a logical group to consider with with lower add-powered multifo- Accessed February 7, 2020. 4. A study of safety and e cacy of UNR844 this lens technology. Because of the cals, which are benefi cial because chloride (UNR844-Cl) eye drops in subjects with presbyopia. ClinicalTrials.gov. clinicaltrials. reverse curve in the lens design, the there is less of a discrepancy be- gov/ct2/show/NCT03809611. January 18, 2019. cornea has a prominent steep curve tween the distance and near optics Accessed February 7, 2020. 5. Evaluation of the e cacy and safety of around the . We could look at within the lens, maximizing the PRX-100 in the treatment of early to moderate orthokeratology as having a similar chances of a patient’s success. presbyopia. ClinicalTrials.gov. clinicaltrials.gov/ ct2/show/NCT02554396. September 18, 2015. effect as distance-centered, near pe- There are several presbyopic Accessed February 7, 2020. riphery soft multifocal lenses (Figure drops currently under develop- 6. Safety, tolerability and e cacy of Pres- biDrops (CSF-1) in presbyopia subjects. 1). As presbyopia progresses, the ment to be aware of. EV06 1.5% ClinicalTrials.gov. clinicaltrials.gov/ct2/show/ appropriate next step would seem (UNR844-Cl) by Novartis is a NCT02965664. November 17, 2016. Accessed February 7, 2020. to be inducing monovision with the lipoic acid choline ester that breaks 7. Orasis Pharmaceuticals. www.orasis-pharma. lens by under-correcting the level of disulfi de bonds, which are thought com/. Accessed February 7, 2020. 3,4 8. A safety, e cacy and pharmacokinetic study myopia in the non-dominant eye. to harden the lens over time. By of AGN-199201 and AGN-190584 in patients Hyperopic-correcting ortho-K disrupting these bonds, the lens with presbyopia. ClinicalTrials.gov. clinicaltrials. gov/ct2/show/NCT02780115. May 23, 2016. lenses are also now available. As becomes more elastic and regains Accessed February 7, 2020.

REVIEW OF CORNEA & CONTACT LENSES | MARCH/APRIL 2020 11 Fitting Challenges By Vivian P. Shibayama, OD, and Cory Collier, OD

Little Eyes, Big Solutions Pediatric specialty contact lenses make a world of di erence in this younger patient population.

hile specialty contact decentered superior and temporal, lenses in the infant and displayed a lack of sodium and toddler popula- fl uorescein (NaFL) centrally (Figure tions present unique 1). This lens was promptly removed Wchallenges to even the most adept and replaced with a steeper one. The fi tters, they also offer incredible, parameters of the second lens were life-changing potential. The value of +18.50D/6.72mm BCR/10.00mm mastering fi tting techniques in these OAD. The lens was centered on the patients is indisputable. This case cornea and displayed a moderate focuses on an infant with corneal Fig. 1. Note the lack of NaFL centrally density, green central NaFL pattern scarring and traumatic , and in this fl at-fi tting diagnostic lens. consistent with clearance of the cen- provides rationale and fi tting advice tral cornea without bubbles. Relative for pediatric specialty lens use. out of infancy and into toddler age, alignment was observed mid-periph- contact lens fi tting, parent-toddler in- erally with a thin line of NaFL at the THE CASE teraction and contact lens adaptation edge signifying inadequate edge lift. A 13-month-old female was referred usually become increasingly more Over-retinoscopy yielded -3.50D. for a contact lens fi tting by her diffi cult. At times, this may result in The red refl ex was noted as more reg- cornea specialist. She had sustained a the inability to fi t contact lenses until ular with the GP lens in place. penetrating corneal injury in the right much later in adolescence. With this As is typical in infant aphakia, a eye approximately three months ear- reassurance, the parents elected to 2.50D to 3.00D myopic endpoint lier, resulting in central perforation proceed with a fi tting. was designed to optimize the patient’s and a traumatic cataract. At presen- visual development.2 The periphery tation, she was aphakic and had an DIAGNOSTIC FITTING of the lens was fl attened to increase elevated, 4.00mm linear scar extend- Due to the presence of both aphakia edge lift. The following lens of ing across the central cornea from and corneal irregularity, a gas perme- Menicon Z material was ordered: superior nasal to inferior temporal. able (GP) lens was selected. As there +15.00D/6.72mm BCR/10.00mm Retinoscopy resulted in +13.00D were no reliable keratometry values OAD with an axial edge lift fl at- OD and +1.00D OS. The right eye to guide base curve selection, a diag- tened from the standard 0.12mm displayed a high degree of scissoring nostic lens was prescribed based on to 0.16mm. In addition, plano and an overall dim refl ex. The patient diameter and estimated reasonable polycarbonate over-spectacles were was resistant to occlusion of the left starting base curve radius (BCR). It prescribed for full-time wear. eye and became visibly agitated, was assumed that the central cornea started crying and was no longer co- was relatively steep from the reti- DISPENSING operative with patching. Horizontal noscopy value of +13.00D, lower The patient returned for a dispens- visible diameter (HVID) was than the +18.00D to +40.00D range ing visit one week later. The lens 11.00mm. typically expected in an infant with was centrally located with mild The patient’s parents quickly aphakia.1 It was therefore assumed central clearance without bubbles, understood the visual benefi ts of the patient had a steep central cornea mid-peripheral alignment and im- contact lenses vs. spectacles for their offsetting, to some degree, the highly proved edge lift with a visible band infant daughter; however, they were hyperopic correction anticipated in approximately 1.00mm in width. concerned about the insertion and pediatric aphakia. Approximately 0.50mm to 1.00mm removal process and questioned her The diagnostic lens selected was of lens movement was visible with ability to adapt to lens wear. We +20.00D/6.92mm BCR/10.00mm blink and normal eye movement. explained that the younger the child, overall diameter (OAD). A hand- Over-retinoscopy was approximated the easier the process and the faster held blue light was used to grossly at -3.00D, consistent with the desired the adaptation. As children move assess the fi t. This diagnostic lens myopic endpoint. The parents were

12 REVIEW OF CORNEA & CONTACT LENSES | MARCH/APRIL 2020 instructed on proper lens care and anatomy of an infant. These patients vature lies between the two points. trained on insertion and removal are highly active, requiring a lens that In this patient, a lens with a until they demonstrated profi ciency. provides excellent stability. Larger BCR of 6.92mm/48.75D displayed The lens was dispensed for daytime corneal lenses typically offer this touch and a lens with a BCR of wear and permitted napping. through improved centration and 6.72mm/50.25D displayed clearance. decreased movement. These patients It can therefore be assumed the cor- FOLLOW-UP also nap daily. Using materials that neal curvature was between 48.75D The patient returned one week later allow adequate oxygen fl ow while and 50.25D. We ended up ordering with her contact lens in place. The napping is essential to minimize lens the 50.25D BCR lens, as it displayed parents noted no dislocations with insertion and removal during the day. adequate centration and clearance about 12 hours of daily wear. The Vision correction depends on the and had no bubble formation. patient was, for the fi rst time since indication for lens wear. If the patient Continuing with this example, if the her injury, cooperative with patch- is phakic, full distance correction 50.25D lens displayed excess clear- ing. While patched, she was able to with an equalized stimulus for ance with bubble formation, the fi tter pick up and play with toys within is the goal. If the would know to order a lens with a arm’s reach. Lens tolerance had patient is bilaterally or unilaterally BCR with less than 50.25D but more increased rapidly over the fi rst two to aphakic, a 3.00D myopic refrac- than 48.75D. As noted previously, three days. At this point, the patient tive endpoint should be the target. corneal lenses with a large diameter demonstrated no eye-rubbing, red- This will place the child’s far point are commonly preferred due to their ness or excess tearing with the lens in near 33.00cm, allowing the child to stability and centration. “Larger” place following a fi ve- to 10-minute develop vision and visual motor skills in this situation is a relative term, as period of active distraction by her within their typical viewing and play- the diameter relies on the HVID. A parents. The lens fi t and ocular health ing range. Polycarbonate over-specta- reasonable starting point is 1.50mm were unchanged from the dispensing. cles are advised. to 1.00mm smaller than the HVID, Continued success and adaptation Infant eyes typically have steeper commonly resulting in diameters were noted at her subsequent fol- corneas and smaller HVIDs com- ranging from 9.50mm to 11.00mm. low-up one month later. pared with adults.4 As a result, GPs with a relatively steep BCR are he importance of providing a DISCUSSION common in this patient population. Tclear image for visual develop- Three primary options exist for Consistent with the fi tting strategy ment at a young age is inarguable. correcting ametropia in infants with used in the Infant Aphakia Treatment While there are several options for contact lenses: corneal GP lenses, Study, I target the central curvature vision correction in infants and tod- silicone elastomer lenses and custom at approximately 1.00D to 1.50D dlers, none rival the versatility of cor- soft lenses. While each lens option steeper than the keratometry value, neal GP lenses. With nearly unlimited is feasible in infant management, commonly siding on the smaller end parameters and an excellent safety GPs tend to be the preferred choice. of this spectrum due to my preference profi le, this modality is the standard 5 Benefi ts include ease of handling, for larger corneal lenses. in pediatric contact lens fi tting. RCCL nearly unlimited physical and visual As keratometry is often not feasible 1. McQuaid K, Young TL. Rigid gas permeable customization and a relatively low in- or reliable in this age group, a brack- contact lens changes in the aphakic infant. CLAO J. 3 1998;24(1):36-40. fection risk. In addition, for children eted fi tting strategy is recommended. 2. Moore BD. Optometric management of congenital with corneal scarring, these lenses This entails using GPs to estimate . J Am Optom Assoc. 1994;65(10):719-24. 3. Keay L, Edwards K, Naduvilath T, et al. Factors provide optimal vision correction by the corneal curvature by identifying a ecting the morbidity of contact lens-related microbial keratitis: a population study. Invest Ophthalmol Vis Sci. masking anterior corneal irregularity. a BCR that displays touch over the 2006;47(10):4302-8. 4. Borish IM. Clinical Refraction. 3rd ed. Chicago, IL: We can explain the rationale central cornea and the next closest Professional Press; 1975: 61-74. behind our fi tting patterns with the BCR that displays clearance. It can 5. Lambert SR, Buckley EG, Drews-Botsch C, et al. The infant aphakia treatment study: design and clinical mea- lifestyle, vision requirements and then be assumed that the corneal cur- sures at enrollment. Arch Ophthalmol. 2010;128(1):21-7.

REVIEW OF CORNEA & CONTACT LENSES | MARCH/APRIL 2020 13 How to Get Ahead of PRESBYOPIA Intervening earlier on is key in successfully working through this inevitable condition. By Erin Rue , OD, PhD

resbyopia can seemingly mains relatively stable throughout specifi c symptoms of discomfort happen overnight. One childhood and into our mid-20s, resulting from near and computer day, your 40-something when it starts to rapidly decline.1 work. “Discomfort” can describe patient can read the text Between the ages of 30 and 40, symptoms that stem from different Pon their phone screen, and the accommodative amplitude can etiologies. While symptoms of dis- next, their arm is suddenly not decrease by up to 3.00D.1 This comfort such as dryness, itchiness long enough. In reality, presbyopia means that we lose almost half and burning can be caused by an is a process that progresses as we of our accommodative amplitude ocular surface or fi t issue, symp- move through adulthood. Contact before even reaching an age many toms such as eyestrain, headaches lens wearers may experience associate with presbyopia onset. and blurry/variable vision are subtle, early presbyopic symptoms While patients approaching likely associated with discomfort before they reach their mid- presbyopia may be able to visual- related to presbyopic accommoda- 40s, including eyestrain, fatigue ize clear images, they may not be tive fatigue and insuffi ciency.2,3 with near work and headaches. able to do so comfortably, espe- Initiating presbyopic contact lens cially after a long day of near or PERFORM REFRACTION correction efforts earlier on can computer work. Symptoms associ- The fi rst step to ensuring your ease adaptation and prevent un- ated with accommodative fatigue emerging presbyope is optimally necessary contact lens dropout. and insuffi ciency can contribute corrected in their contact lenses is to symptoms of asthenopia and to confi rm that their lenses refl ect INITIATE MANAGEMENT discomfort.2 Myopic patients who your refraction, which you’ve The discussion about presbyopic wear glasses may be able to alle- confi rmed is accurate. To do this, contact lens options typically starts viate some of this accommodative focus on accurate myopic and full when patients complain of near fatigue by removing their glasses astigmatic correction. blur. It is important to remember, when doing near work. When cor- As our accommodative ampli- however, that near blur is not the rected with contact lenses, how- tude is robust from childhood only symptom associated with ever, these myopes cannot escape ABOUT THE AUTHOR presbyopia, and it may not be the their waning accommodation and fi rst symptom to present. Blurry may mistakenly assume discomfort Dr. Rue is an assistant professor and the chief of the cornea and near vision may not occur for associated with accommodative contact lens service at the most patients until their mid-40s, fatigue is related to their contact Southern California College of Optometry at Marshall but symptoms associated with de- lenses. B. Ketchum University. She clining accommodative amplitude Recognize that presbyopic graduated from the Ohio can begin as early as age 30. Be accommodative decline happens State University College of Optometry where she proactive and address presbyopic before a patient experiences sus- completed a fellowship in symptoms before complete near tained near blur. You can uncover cornea and contact lenses and PhD in vision science. She is a fellow of blur occurs. other signs by asking those in the American Academy of Optometry. Accommodative amplitude re- their 30s and early 40s about

14 REVIEW OF CORNEA & CONTACT LENSES | MARCH/APRIL 2020 until early adulthood, eyestrain, it’s time to myopic patients who introduce a multi- prefer “smaller, dark- focal contact lens. er” distance vision Especially earlier on, (i.e., overcorrected a multifocal contact myopia) can over- lens is the best option come the increased to alleviate symp- accommodative de- toms of presbyopia mand that “over-mi- while maintaining nusing” causes. As at all these patients enter distances. their 30s, that extra Multifocal contact accommodative de- lenses are sometimes mand, however, can associated with a bad exacerbate symp- reputation and are toms related to their consequently woeful- natural decline in ly under-prescribed accommodation. Recommend multifocal contact lenses early for easier adaptation. in presbyopic contact Make sure the lens wearers.8 The manifest refraction doesn’t include correction compared with spher- simultaneous, aspheric optics used any myopic power that these ical correction.5,6 Patients tend to in today’s modern multifocals patients do not actually need to prefer having their astigmatism sometimes compromise near, in- achieve acceptable distance vision. maximally corrected when wear- termediate and/or distance vision. Also ensure you have appropriate- ing contact lenses, and full toric Patients may also experience glare ly vertexed the manifest refection correction may alleviate symptoms in low light situations when pupil on which you are basing your con- associated with eyestrain and dis- size increases. Prescribers assume tact lens power. Accounting and comfort at near.7 these are deal breakers and tend correcting for even small amounts Failing to correct astigmatism to to shy away from considering (0.25D to 0.50D) of myopic over- the best of your ability could cause multifocals, suggesting an over- correction can alleviate discomfort visual strain and result in a patient the counter reading spectacle or associated with near work. removing their contact lenses and turning to monovision contact lens With glasses, we almost always relying on their spectacles that ful- correction. prescribe exactly what we fi nd ly correct for astigmatism. Before Contact lens wearers, however, in our phoropter. Rarely do we even initiating presbyopic contact typically prefer multifocal contact round up to the major meridian or lens correction, ensure the patient’s lens correction to other presbyopic totally disregard cylinder pow- distance prescription, including contact lens options when given er. Unfortunately, with contact spherical and astigmatic elements, the chance to try them. Compared lenses, we commonly ignore small is optimally corrected with their with monovision, multifocal amounts of astigmatism if the contact lenses. This alone may contact lenses consistently provide patient is “fi ne” in a spherical eliminate symptoms associated superior overall visual experiences lens. About half of all contact lens with declining accommodation for and have similar acuities at all dis- wearers have at least 0.75D of the next year or so or, at the very tances in high contrast conditions astigmatism, but we only prescribe least, will optimally position you and superior stereoacuity.9-11 Even toric contact lenses for about to choose how to proceed with though objective low contrast 25%.4 presbyopic contact lens correction. visual acuity is sometimes better Uncorrected astigmatism can with monovision, patients usually contribute to overall and visual INTRODUCE MULTIFOCALS lean toward the vision and over- discomfort.3 Studies have shown When a patient consistently com- all wearing experience multifocal that, even in cases of low astig- plains of early presbyopic symp- contact lenses offer.9,11 When your matism, visual acuity and perfor- toms, including diffi culty concen- patient begins having presbyopic mance in low light/glare conditions trating, tiredness while reading symptoms, it’s worth taking a look improve with toric contact lens and consistent headaches and at multifocals.

REVIEW OF CORNEA & CONTACT LENSES | MARCH/APRIL 2020 15 HOW TO GET AHEAD OF PRESBYOPIA

a patient experiences multifocal lenses for what could be the fi rst time will make them more willing to work through any frustrations they have until they reach a more successful outcome.

OPTIMIZE THE FIT In recent years, the parameters and modalities of soft multifocal contact lenses have expanded signifi cantly. An increase in daily disposable options and myopic and hyperopic spherical powers and the emergence of soft toric multifocals means that there are solutions available for the majority of presbyopic patients. When pos- sible, start with a daily disposable. The frequent replacement schedule associated with these lenses allows for the most consistent and com- Contact lens parameters must line up with your refraction for optimal correction. fortable experience. When a daily disposable is not an option, fi nd SET EXPECTATIONS that as we get older, our eyes are another lens with an appropriate Before beginning the multifocal unable to focus up close as effec- replacement schedule, and pre- fi tting process, make sure your tively because we spend so much scribe a solution that works best patient is educated, optimistic and of our time looking at a screen and with that lens material. confi dent so that compliance isn’t reading. Regardless of what lens you an issue down the road. Successful It also helps to use clear lan- choose, make sure to follow the multifocal contact lens fi ttings are guage when describing how vision manufacturer’s fi tting guide for achieved during patient education. correction lenses work, especially initial lens selection and trou- If you take a few extra minutes as the optics of these lenses are bleshooting. While suggestions during the initial fi tting to explain complex. Combining your de- included in these guides often seem why you are introducing a new scription of the lenses with what like common sense, some recom- contact lens, what the patient patients can expect may be an mended adjustments and starting can expect during the adaptation effective way to do this. Note that points that have proven to be suc- period and how they will benefi t because these lenses focus images cessful through extensive research from the change, your success rate from multiple distances on your may not be intuitive to you. Save will dramatically increase. It’s also eye at the same time with your yourself chair time and frustration worth mentioning the consequenc- brain deciding what image to pay by implementing these guides in es of improper wear and care attention to based on what you are your practice. Most fi tting guides practices in this stage. looking at, it may take a few days suggest initial lens powers based Especially in early and emerging to fi gure out how to fi nd the sweet on add power. If your emerging presbyopes, explaining presbyopia spot in your vision. presbyope does not require an add can be diffi cult. This age group Patients benefi t from reassurance yet but is experiencing symptoms may not know what presbyopia is that any preliminary issues they of accommodative fatigue, select a or that they will inevitably experi- may experience are normal and lens with the minimum add power ence it. Be concise when introduc- will gradually subside with your the manufacturer advises. ing the condition to patients who help or with time. Displaying con- Assessing vision with a multifo- may have no prior knowledge or fi dence in the lenses and commu- cal contact lens is different than understanding of it and explaining nicating openly about them before taking entering acuities at the

16 REVIEW OF CORNEA & CONTACT LENSES | MARCH/APRIL 2020 beginning of your exam, especially on the fi rst day. It is common for vision to improve with adaptation, so don’t be discouraged if your patient can’t see their best-correct- ed line right after you insert the multifocal. Make sure they know what to expect too; their fi rst im- pression is important. Assess what they can see with the new lenses, and don’t make what they cannot see the focus of the conversation. Remember, you want the patient to leave your offi ce optimistic about the wearing experience they are about to embark on. Evaluate vision binocularly and with normal room illumination. At distance, start with large, isolated lines, and go down in size as long as the patient is able to easily read Use di erent resources to educate your patients and make sure you’re always each visual target. If you have on the same page. good refractive data and began with the lenses suggested by the these can be addressed at follow up 1. Anderson HA, Hentz G, Glasser A, et al. Minus lens-stimulated accommodative amplitude fi tting guide, you should not need visits. This is when you can lean on decreases sigmoidally with age: a study of to make many, if any, changes on the corresponding fi tting guide for objectively measured accommodative ampli- tudes from age 3. Invest Ophthalmol Vis Sci. the initial fi tting day. solutions to near and/or distance 2008;49:2919-26. The impressive moment with vision issues. If comfort isn’t de- 2. Reindel W, Zhang L, Chinn J, et al. Evalu- ation of binocular function among pre- and a multifocal comes when a pres- sirable and/or satisfaction cannot early-presbyopes with asthenopia. Clin Optom byope is able to read small print be reached after one or two lens (Auckl). 2018;10:1-8. without reading aids. You will swaps, consider switching brands. 3. Sheedy JE, Hayes JN, Engle J. Is all asthenopia the same? Optom Vis Sci. 2003;80(11):732-9. not get this opportunity with an 4. Morgan PB, Efron N, Woods CA. An interna- emerging presbyope who can still anaging early presbyopic tional survey of toric contact lens prescribing. read small print clearly. Because symptoms by keeping Eye Contact Lens. 2013;39(2):132-7. M 5. Black AA, Wood JM, Colorado LH, et al. The you are introducing a new optical patients informed and prescribing impact of uncorrected astigmatism on night system, these patients may actually multifocal contact lenses will pre- driving performance. Ophthalmic Physiol Opt. 2019;39(5):350-7. report that their vision feels dif- vent premature, unnecessary con- 6. Richdale K, Berntsen DA, Mack CJ, et al. Visual ferent at all distances initially. In tact lens dropout. Transitioning acuity with spherical and toric soft contact lens- es in low- to moderate-astigmatic eyes. Optom these instances, remind the patient presbyopes when the discrepancy Vis Sci. 2007;84(10):969-75. that the purpose of the lenses is between distance and near powers 7. Cox SM, Berntsen DA, Bickle KM, et al. E cacy of toric contact lenses in fi tting and patient-re- to alleviate symptoms of focusing is the least problematic also helps ported outcomes in contact lens wearers. Eye fatigue. After the patient adapts ensure your patient experiences Contact Lens. 2018;44 Suppl 1:S296-9. to the lenses and wears them for a minimal negative symptoms and 8. Morgan PB, Efron N, Woods CA. An inter- national survey of contact lens prescribing for full day of work, reading or com- their more easily presbyopia. Clin Exp Optom. 2011;94(1):87-92. puter use, they will be able to fully adapts to future changes as you 9. Richdale K, Mitchell GL, Zadnik K. Comparison of multifocal and monovision soft contact lens appreciate them. introduce greater add powers. corrections in patients with low-astigmatic pres- Once the patient is ready to Multifocal contact lenses are a byopia. Optom Vis Sci. 2006;83(5):266-73. leave your offi ce on the fi rst day, great solution for patients who are 10. Situ P, Du Toit R, Fonn D, et al. Success- ful monovision contact lens wearers refi tted make sure they understand the entering a stage in their life when with bifocal contact lenses. Eye Contact Lens. importance of communicating any things are starting to become blur- 2003;29(3):181-4. 11. Woods J, Woods CA, Fonn D. Early symp- negative experiences they have rier and they need an option to tomatic presbyopes—what correction modality after the initial adaption period, as correct this unwanted change. RCCL works best? Eye Contact Lens. 2009;35(5):221-6.

REVIEW OF CORNEA & CONTACT LENSES | MARCH/APRIL 2020 17 Multifocal Optics Explored Recent research may give insight on how to better implement these lenses for presbyopic patients.

By Mark De Leon, Associate Editor

atients with presbyopia defocus is more likely.1 The small- larger weighed in with even who wish to wear contact er pupils in older eyes effectively higher LDI values when wearing lenses require a lens with correct for the increased aberrations multifocal lenses, shifting from more complex goals than found in these eyes.1 However, the 4.5% (in 3.0mm pupils) to 6.1% Pa standard spherical lens—namely, decrease in photopic and mesopic (in 5.0mm pupils). The elliptical- to expand the depth of focus or pupil diameters in 65-year-old eyes shaped pupil produced the largest allow the presbyope to see at more fails to sufficiently expand the depth discrepancy in the distortion size than one viewing distance—all with of field for observers, who typically between the vertical and horizontal the highest image quality possible. require some optical correction to directions. The team didn’t note Optics are a crucial aspect of a mul- read at near.1 any difference between the center- tifocal contact lens, as they inform Unfortunately, the same multifo- distance and center-near designs. how the lens is designed and impact cal contact lens optics that help a Optical aberrations play a patients differently depending on patient address their decreasing pu- significant role in light disturbances, their anatomical conditions and pil size can also cause other compli- which are magnified with increasing visual scenarios. cations. In a recent study published pupil size. Thus, multifocal lenses Several recent studies highlight the in Contact Lens & Anterior Eye, with high amounts of spherical ab- ongoing development in multifocal researchers show that multifocal erration (or distance defocus)—i.e., contact lens research that may inter- contact lenses can increase light progressives with higher add est today’s practitioners. distortion effects under low light powers—are more likely to generate conditions. In addition, the study significant light disturbances under PUPIL SIZE found the size and shape of the pu- low light conditions. The changes that occur to the pupil pil correlates with the size and shape The authors concluded that, as patients age can have lasting of the distortion.2 although no statistically significant implications on their ability to The investigators looked at 14 differences were detected, multifo- focus at near, something multifocal eyes of seven contact lens patients. cal contact lens wearers will find lenses have to take into account. The light distortion index (LDI) was themselves in everyday situations Pupil size generally decreases over generally higher with multifocal that might compromise their visual the age of 50, and the retention of lenses, varying from 3.7% with performance due to greater light dis- near vision pupil in older single vision lenses to 6.1% with the tortion effects, especially with larger eyes can further reduce pupil size multifocal center-distance designs pupils. A signifi cant percentage of for near-viewing conditions where and the 5.0mm pupil. Patients with light distortion effects would be

18 REVIEW OF CORNEA & CONTACT LENSES | MARCH/APRIL 2020 produced by the presence of Photo: Alex Nixon, OD, MS, and Erin Rueff, PhD overall satisfaction level was out-of-focus images given by not affected. Participants a multifocal lens, rather than were willing to tolerate other optical phenomena.2 slight discomfort if they could perform their tasks PINHOLE OPTICS effectively.3 The need for multiple op- tical powers in one lens is DESIGN AND often avoidable by employing ABERRATIONS pinhole optics, which will Radially symmetric or con- alleviate presbyopia symptoms centric multifocal lenses are through enhancing the depth the most common designs. of focus.1 Many factors affect The concentric multifocal the selection of pinhole pupil design is rotationally insen- size, but clinicians must strike sitive and includes two or a balance when improving more powers contained in defocused near vision with- geometrically separate zones out compromising focused Making sense of multifocal optics can help you located at different distances distance vision.1 Three pa- better fit presbyopes with the right lens. from the lens center.1 Designs rameters are key: pupil axial that incorporate two powers location, pupil size and whether to enrolled 29 patients with presbyopia in alternating annular zones often employ a fixed pupil or one that who wore the Eyelike Pinhole II for also include significant regions of varies with light level.1 more than three hours per day for the lens in which there is a gradual As pupil size decreases, the role of one week. The mean distance-cor- power change with increasing radial diffraction blur in degrading image rected near VA of the treated distance.1 quality is amplified, but the impact eye and the mean binocular dis- When the outer zone of a two- of higher-order aberrations (HOAs) tance-corrected near VA improved zone concentric design is defocused, is reduced, which produces a peak after pinhole contact lens wear from the defocused point-spread-function image quality in a focused eye for −5.00D to −1.00D. Although the will be an annulus. In this case, the pupil diameters between 2.0mm and mean corrected distance VA of the resulting annular halo will increase 3.0mm.1 At low photopic and meso- treated eye deteriorated, there was in size as the pupil dilates and be pic light levels, reducing retinal illu- no signifi cant change in the mean most visible when the stimulus con- minance lowers contrast sensitivity binocular corrected distance VA. trast is highest, as it is when viewing due to photon noise effects, and the The researchers believe their lights at night—a common source of combined effects of diffraction and fi ndings suggest that the pinhole visual disturbance clinically reported reduction in retinal illuminance can lens can allow the wearer to with multifocal optics.1 significantly impair distance vision perform daily tasks such as reading In addition to reducing the size when pupil diameters are decreased books or newspapers, texting on of these haloes by reducing the add below 2.5mm.1 mobile phones and working on power (with either low add multi- A study based in Seoul, South the computer in a more convenient focal lenses or extended depth-of- Korea, evaluated the effi cacy and manner. VA values before lens wear focus lenses), an alternative strategy safety of a novel presbyopia-correct- did not signifi cantly exceed those proposed is reducing the size of the ing pinhole soft contact lens. The after lens wear in any case, which defocused halo by coupling positive Eyelike Pinhole II (Koryo Eyetech) indicated that the lens didn’t seem to defocus with negative spherical ab- includes an additional light-trans- worsen the vision quality. erration (including negative spheri- mitting ring in the lens’ mid-periph- The majority of participants cal aberration in the add zone) and ery. The researchers found that the were satisfi ed with the overall vice versa. This produces a smaller lens improved distance-corrected outcome, and 66% recommended but higher contrast halo. near visual acuity (VA). The binoc- the lens to others. Although the Nevertheless, the naturally occur- ular-corrected distance VA was not scores for visual symptoms and ring changes in the refractive state affected by the pinhole contact lens.3 discomfort were lower than the across the pupil will add to (or sub- This prospective clinical study work performance scores, the tract from) any multifocality pro-

REVIEW OF CORNEA & CONTACT LENSES | MARCH/APRIL 2020 19 MULTIFOCAL OPTICS EXPLORED

1 vided by a contact lens. Therefore, however, they also observed certain Up the Power, Up the Success the significant positive spherical similarities between some of the aberration exhibited by older eyes center-near designs.4 Fitting multifocal contact lenses and the corneas of pseudophakes “For the more recently released can be a time-consuming pro- may augment any center-distance lens types, there seems to be a trend cess, often requiring the trial of several different lens parameters multifocal that also contributes emerging to reduce the add am- before landing on a good fit for more positive power with increasing plitude, include negative spherical each patient. Knowing this is radial distance from the lens center, aberration, keep the power profi les likely a barrier to the implementa- or positive spherical aberration. consistent across the power range tion of multifocal contact lenses Importantly, ocular spherical and offer lenses in at least three add in practice, researchers tried a aberration may help or hinder the powers and a daily disposable wear- modified fitting guide that added +0.25D binocularly to the spheri- multifocal optics, depending on the ing mode,” the researchers wrote in cal equivalent distance prescrip- 4 type of design being fit and may their paper. tion. Preliminary results suggest likely contribute to the variable The study measured power pro- the small change could have a big patient responses common during fi les of 38 types of multifocal con- impact.1,2 multifocal contact lens fi ts.1 In the tact lenses—in powers of +6.00D, The researchers fit 183 presby- case of center-near designs that +3.00D, +1.00D, −1.00D, −3.00D opic patients using either the tra- ditional or modified fitting guides. inherently contain negative spheri- and −6.00D (three lenses each). The The lenses all shared the same cal aberration, for example, ocular study identifi ed three basic types of common optical design with positive spherical aberration will power profi les: center-near, cen- either lotrafilcon B, nelfilcon A or subtract from the add power pro- ter-distance, and concentric-zone delefilcon A materials. All partic- vided by the multifocal lens.1 ring-type designs. For most of the ipants were current soft contact Achieving the desired level of lens types, the relative plus with lens wearers needing presbyopia correction.2 multifocality in the corrected eye respect to prescription power was The team found practitioners requires larger radially varying pow- lower than the corresponding needed to trial 1.2±0.5 lenses er changes in the correcting lens of spectacle add. For some lens types, when using the modified fitting a center-near design compared with however, the measured power guide, compared with 1.4±0.5 a center-distance design. Although profi les were shifted by up to 1.00D lenses with the traditional fitting it could be simple to add the extra across the power range relative to guide, which met the study’s pre- determined criteria for superiori- power needed for the center-near their labeled power. ty. On the first fitting visit, 82.8% designs, high levels of spherical In most lenses, the measured add of presbyopic patients required aberration in a contact lens will amplitude was substantially lower only one multifocal lens to find introduce more coma as the lens than what would be required to the right fit using the modified decenters.1 Peak and overall image provide the full reading compared guide, while 65.1% were fit with quality are ultimately affected more with the corresponding recommend- one lens using the traditional guide. By the second visit, 98% by lens decentration in the cen- ed spectacle add power. Most of the of patients were fit using one or ter-near design because of the higher lenses were designed with noticeable two trial pairs of lenses when the levels of lens spherical aberration amounts of spherical aberration. practitioners used the modified required to achieve multifocality.1 The researchers noted that the sign fitting guide.2 and magnitude of spherical aberra- In addition, more clinicians preferred the modified guide, tion can be either power-dependent POWER DYNAMICS with 63.6% of participating clini- A study conducted by researchers or consistent across the power cians giving the modified version at the Brien Holden Vision Institute range.4 the highest ranking for ease of assessed the effect of spherical “When the fi rst bi- and multifocal use—only 33.3% did so for the aberration as a function of power soft contact lenses appeared on the traditional fitting guide.

by evaluating the optical power market, the lenses were labeled with 1. Kunnen C, Nixon L, Merchea M. Subjective profi les of all the most commonly their distance and add power,” the functional quality of vision and ease of fi t rating of three multifocal contact lenses with similar optical prescribed multifocal contact lenses researchers noted. “In recent years, design using two di erent fi tting guides. Cont across a wide range of prescription most of the newly released lenses Lens Ant Eye. 2019;42(6, Supp 1):e31. 2. Merchea M, Evans D, Kannarr S, et al. Assessing powers. The researchers found that only use descriptors like low, medi- a modifi ed fi tting approach for improved mul- tifocal contact lens fi tting. Cont Lens Ant Eye. power profi les can vary widely um and high add power and make 2019;42(5):540-45. between the different lens types; reference to the equivalent spectacle

20 REVIEW OF CORNEA & CONTACT LENSES | MARCH/APRIL 2020 Image: Robert L. Davis, OD insight Making sense of the optics —and into the changing up their design as new distribution ideas come out—can help you and better fi t presbyopes with the right magnitude lensIn clinical practice, doctors must of relative provide the best image quality or plus with vision correction possible. With this respect to the in mind, multifocal contact lenses prescription can provide patients good vision power in at all distances and, theoretically, multifocal optimal image quality with the right contact design. RCCL Achieving the desired level of multifocality requires larger, lenses. radially varying power changes in the correcting lens of a Practitioners 1. Kollbaum PS, Bradley A. Multifocal contact center-near design compared with a center-distance design. lenses can provide patients good vision at all can use such distances. Clin Exp Optom. 2020;103(1):21-30. add power in the fi tting guide.”4 profi les to discriminate lens designs 2. Monsalvez-Romin D, Gonzazlez-Meijome J, Esteve-Taboada J, et al. Light distortion of soft Although some of the reasons and to correlate design features with multifocal contact lenses with di erent pupil 4 size and shape. Cont Lens Ant Eye. December for dissatisfaction with multifocal visual performance. 4, 2019. [Epub ahead of print]. soft lenses are generally age-related 3. Jun I, Cho JS, Kang MG, et al. Clinical out- discomfort and handling issues, key understanding of the comes of a novel presbyopia-correcting soft contact lens with a small aperture. Cont Lens unwarranted visual compromise Astrengths and limitations Ant Eye. December 24, 2019. [Epub ahead of does not make them an attractive of multifocal contact lens optics print]. 4. Kim E, Bakaraju RC, Ehrmann K. Power option for the potential presbyopic and how they might be applied profi les of commercial multifocal soft contact lens wearer. Power profi les give in clinical practices is critical. lenses. Optom Vis Sci. 2017;94(2):183-96.

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©2020 Vision Service Plan. Unity is a registered trademark of Plexus Optix, Inc. BioSync and HydraMist are trademarks of Plexus Optix, Inc. WHEN PRESBYOPIA & ASTIGMATISM COLLIDE A multitude of contact lens options exist for the independent correction of astigmatism and presbyopia. Let’s discuss the options when these occur simultaneously. By Robert Ensley, OD, and Jessica Jose, OD

he loss of accommodation Despite the interest in contact lens cornea and use the smooth refracting can be frustrating, especially wear, there are challenges for the surface of the lens in combination for today’s busy and some- presbyopic patient. Physiological with the post-lens tear layer to neu- what demanding presbyope. changes to the tear fi lm and ocular tralize corneal astigmatism and pro- TDigital devices combined with active surface can contribute to contact lens vide crisp, stable optics. Before the lifestyles can simultaneously increase discomfort, which is commonly cited rise of contemporary GP multifocals, demands on near vision while also as the main reason for dropout.3,4 presbyopic patients resorted to using making wearing spectacles seem bur- However, poor vision is equally re- reading glasses over their spherical, densome. Meeting the needs of our sponsible for discontinuation among distance-only contact lenses or using presbyopic patients, especially those presbyopic patients.5 One perceived monovision contact lenses. with astigmatism, may sound chal- barrier to optimal vision in contact Monovision. This option provides lenging; however, there is a growing lenses is the presence of astigmatism. near vision by reducing minus power number of contact lens options at Nearly 50% of contact lens pa- or adding plus power, typically over our fi ngertips. tients have astigmatism of 0.75D or the non-dominant eye. Although According to the 2018 US Census greater in at least one eye, yet only effective, especially for early presby- Bureau, approximately 119 million 30% of contact lenses are prescribed opes, there are drawbacks to this set- people, or nearly 40% of the popu- for astigmatism.6,7 This discrepan- up. As the power difference between lation are between the age of 40 and cy is concerning, considering the eyes increases, it can become more 69.1 Patients in this age range may decrease in acuity and symptoms diffi cult to suppress blur, affecting have the inability to keep up with the of eyestrain that occurs from not demands on their accommodative correcting astigmatism as low as ABOUT THE AUTHORS system. One approach to provide 0.75D.8,9 Accordingly, as astigmats Dr. Ensley practices at functional near vision is with the use become presbyopic, their astigma- Gaddie Eye Centers in of contact lenses. In fact, many pa- tism can play a crucial role in the Louisville, KY. He is a Fellow of the American tients entering their presbyopic years ability to achieve the desired range Academy of Optometry currently wear contact lenses or of vision. and the Scleral Lens have previous experience. For these Education Society. patients, maintaining independence MULTIPLE CHOICES Dr. Jose is an assistant professor at Midwestern from the use of spectacles is often Early contact lenses made from University-Chicago College a priority. Additionally, at least one polymethyl methacrylate evolved to of Optometry in Downers Grove, IL. She is a Fellow study suggests that spectacle wearing higher oxygen-permeable gas perme- of the American Academy presbyopes would prefer contact able (GP) lenses, which have re- of Optometry and the lens use, if using them would achieve mained a mainstay in the correction Scleral Lens Education Society. good vision and comfort.2 of astigmatism. GP lenses rest on the

24 REVIEW OF CORNEA & CONTACT LENSES | MARCH/APRIL 2020 binocularity and depth perception. Multifocal Lens Options Monovision has also been shown to reduce both contrast sensitivity Lens Type Advantages Disadvantages and acuity.10 Despite these issues, Soft toric • Initial comfort • Toric stability critical to success multifocal • Available in stock and custom • Possible greater cost monovision is still commonplace, designs • Limited lens materials with reduced chair time commonly • Planned replacement schedule cited as a reason for prescribing.11 Gas permeable • Superior optics to soft multifocals • Adaptation to comfort However, when comparing monovi- multifocal • Unlimited range of refractive cor- • Potential for dislodgement or sion with multifocal contact lenses, rection lost lenses studies consistently show patients • Available in segmented or aspheric preferring multifocals.12,13 multifocal designs Hybrid • GP optics with comfort closer to • Strict replacement schedule Multifocal lenses. GP multifocals multifocal soft lenses • Lens handling possibly tough for can be split into two categories, • Center-distance and center-near a novice segmented and aspheric multifocals. designs Segmented or translating multifocals Scleral • GP lens optics • No lens translation are similar to lined bifocals in that multifocal • Initial comfort • Higher expertise required to fit distance and near optics are separat- • Cost ed into distinct segments. In primary gaze, the distance segment is in front and center-distance designs. The cen- lenses are signifi cantly more popular. of the pupil and visual axis, allowing ter-near design has a set 3.0mm zone Contemporary soft toric lenses use for uninterrupted distance clarity. size with three different add powers, superior lathing technology to create The reading segment is positioned while the center-distance design has highly reproducible lenses in both at the pupil margin with the inferior a fl exible zone size with variable add disposable and custom modalities. lens edge resting on the lower . powers up to 5.00D. Disposable soft toric lenses can On down gaze, the reading segment Although the popularity of GP correct up to 2.75D of astigmatism translates upwards to move the near multifocals has remained relatively with around the clock axis in 10-de- optics into the necessary position. stagnant, one growing market is gree increments. Although there has Aspheric multifocals have both scleral multifocals.14 Scleral lenses are been one monthly replacement toric distance and near zones, but the large diameter GP lenses that vault multifocal available for more than optics for both distance and near the cornea and align with the , a decade (Proclear Toric Multifocal, are presented in front of the pupil providing stable optics and great Cooper Vision), prescribing soft simultaneously. Near add power is comfort when fi t properly. Their toric multifocal lenses never gained created by a change in curvature on primary indication is for the irregu- much traction. The recent launch of either the anterior or posterior curva- lar cornea, but their popularity has Bausch + Lomb’s Ultra Multifocal ture of the lens. These changes can led to an increase in normal cornea for Astigmatism in June 2019 has create a smooth transition between applications, including multifocals, brought soft toric multifocals back working distances, but the brain using smaller diameter (<15.5mm) to the forefront. must still adapt to the simultaneous scleral lenses. If parameter availability is an vision optics. Because there is no translation, issue, custom lens laboratories such Moving established GP wearers to many scleral lenses use center-near as SpecialEyes or Art Optical are multifocal designs is an easy transi- aspheric designs to provide near op- capable of customizing all parame- tion, but having GP neophytes adapt tics, though there are a few designs ters of the lens from the fi t of the lens to the initial comfort is a hurdle. If capable of center-distance optics. to the power of the astigmatism and comfort is an obstacle, hybrid lenses Additionally, at least one scleral the add power. Additionally, these provide GP optics with comfort multifocal design (Zenlens, Bausch + custom lenses have the capability to similar to a soft lens. The smooth Lomb) is currently capable of decen- adjust zone sizes and decenter the junction between the GP center and tering their optics to align with the optics to help optimize vision. the soft skirt reduces lid interaction, true visual axis, rather than with the while the skirt maintains centration geometric center of the lens. ASTIGMATISM MATTERS and keeps the optics stable. Hybrid The optics of a GP lens is widely Perhaps the most important factor in multifocals are available with recognized as superior to their soft selecting a contact lens for a patient aspheric optics in both center-near lens counterparts; however, soft toric is their refractive error.

REVIEW OF CORNEA & CONTACT LENSES | MARCH/APRIL 2020 25 WHEN PRESBYOPIA & ASTIGMATISM COLLIDE

vertical blink forces. ATR corneal than can incorporate both astigmatic astigmatism will have a steeper hor- and presbyopic correction simultane- izontal meridian, which may result ously. While most patients are open in lateral decentration of a corneal to switching lens brand and material GP lens. If there is concern about to accommodate their changing the centration of a corneal GP lens, visual needs, there are some who are particularly with ATR or oblique a bit more hesitant. For example, corneal astigmatism, then soft toric daily disposable toric lens wearers lenses, hybrids or scleral lenses may may be the most diffi cult, and these be a better choice. wearers may be relegated to readers Also consider astigmatic power or monovision if they aren’t willing Astigmatism up to 2.50D can be when selecting lenses. Astigmatism or able to budge from the daily dis- addressed easily in both soft toric up to 2.50D can be fi t easily in both posable route. Thorough education and GP lens modalities. soft toric and GP lens modalities. is key when determining the best Correcting higher levels of astigma- options for your patients. For astigmats, correcting the tism can be more complex. When Visual demands and expectations. astigmatism is the fi rst priority. The choosing a soft toric, consider cus- Learning the patient’s demands and total refractive astigmatism of the tom design lenses, given their ability expectations for their vision is critical eye combines the power from both to correct higher cylinder powers to understand their motivation level the cornea and the crystalline lens. If with a refi ned axis in one-degree and to recommend a contact lens. the amount of refractive astigmatism increments. If the lens is not perfect- Patients with higher demands and a is equal to the corneal astigmatism, ly centered or rotationally stable, higher sensitivity to blur would likely the astigmatism is derived primarily manipulate custom lenses to change do better with a GP lens modality from the cornea. Both soft and base curve, diameter and prism-bal- due to the crisper optics and stability. GP lenses can correct corneal last amount to improve the lens fi t. The desire for a full range of vision astigmatism effectively. A highly toric cornea can also will make a multifocal lens of any If the refractive astigmatism is cause decentration or poor alignment modality a great choice. However, different than the amount of corneal with a corneal GP lens. In these situ- simultaneous vision designs may astigmatism, the residual astigmatism ations, adding back-surface toricity involve some manipulation of the originates internally, or from the will improve the lens fi t, but the lens range of vision. Knowing if the lens. When lenticular astigmatism may no longer have rotationally sta- patient prefers a stronger distance or is 0.50D or greater, soft toric lenses ble optics. Another option is scleral near range is useful in designing the or toric GP lenses are ideal. Toric lenses, which vault the toric cornea lens parameters. Conversely, some GPs require lathing the astigmatic while neutralizing astigmatism. patients cannot tolerate any compro- power into the front surface of the mise in their range of vision. These lens, which also requires rotational AN ADD FOR THE NEAR patients will not be good multifocal stability, much like a soft toric lens. With as many contact lens options as candidates, despite the available The majority of astigmatic patients we have in our tool bag, incorporat- have regular astigmatism, in which ing the near power for each patient the meridional power is 90 degrees requires careful consideration of two apart. Regular astigmatism can be main factors. further classifi ed into with-the-rule Previous experience. Satisfi ed (WTR), against-the-rule (ATR) or contact lens wearers may not require oblique astigmatism. WTR astig- a signifi cant deviation from their cur- matism happens when the vertical rent contact lenses. GP lens, hybrid meridian is steeper, resulting in more and scleral lens wearers can typically power needed, while the fl atter have multifocal optics incorporated meridian is along the horizontal into their current designs without the axis. When fi tting GP lenses, they need for refi t. Soft toric lens wear- Segmented or translating multifocals will tend to move along the steep- ers may require a discussion about are similar to lined bifocals in er meridian, which makes a WTR changing lens materials or modality that distance and near optics are cornea a more natural fi t due to since there are fewer soft lens options separated into distinct segments.

26 REVIEW OF CORNEA & CONTACT LENSES | MARCH/APRIL 2020 If refi nements are necessary, these Clinical Pearls changes are often minor since em- pirically designed lenses can be quite • Check vision binocularly at both accurate. distance and near . Scleral multifocals are best fi t diag- • Perform the over-refraction in nostically because haptic alignment free space with loose lenses. and lens centration are imperative. • Use real-world examples to Lens power can also vary based on assess near vision (i.e., a com- lens vault and variable tear layer. puter screen, phone or tablet). Although it is time consuming, fi t scleral multifocals in two phases— • Avoid making changes too Moving established GP wearers to early—adaptation time is key. multifocal designs can be an easy fi rst perfect the lens fi t and then add transition. the multifocal optics. • Follow the fitting guide when Once lenses are dispensed, evalu- available. Lab consultants are technology. Presenting the potential ate progress after one to three weeks, another great resource. lens options, using patient-focused as it allows for adequate adaptation terminology and including them in to both fi t and vision. If trouble- • Don’t be afraid to change the lens selection process can keep shooting is required, evaluate lens fi t designs if your first doesn’t work. them involved in the fi tting process. and visual performance. 1. United States Census Bureau. Age and sex com- Thorough education and setting For lenses of all modalities and position in the United States: 2018. www.census. expectations is also critical to the design, centration is critical to the gov/data/tables/2018/demo/age-and-sex/2018- age-sex-composition.html. Last revised July 11, patient’s contact lens success. success of the multifocal optics. 2019. Accessed February 5, 2020. For contact lens neophytes, there If distance and near optics aren’t 2. Rue EM, Bailey MD. Presbyopic and non-presbyopic contact lens opinions and vision is one additional factor to consider presented properly, then vision will correction preferences. Cont Lens Anterior Eye. other than meeting vision demands. be poor at one or both working dis- 2017;40(5):323-8. 3. Dumbleton K, Woods CA, Jones LW, Fonn D. Initial adaptation to contact lens tances. If soft toric multifocals have The impact of contemporary contact lenses on wear, including application and been fi t, confi rm rotational stability. contact lens discontinuation. Eye Contact Lens. removal, can be a barrier to new A rotationally unstable lens is useless 2013;39:92-98. 4. Richdale K, Sinnott LT, Skadahl E, Nichols JJ. wearers of any age. During prelimi- and must be corrected fi rst. Frequency of and factors associated with contact lens dissatisfaction and discontinuation. Cornea. nary testing, if a patient shows high Visual performance is best evaluat- 2007;26:168-74 sensitivity to approaching objects ed binocularly at both distance and 5. Rue EM, Varghese RJ, Brack TM, et al. A survey of presbyopic contact lens wearers in a university near the ocular surface, a soft lens near; however, monocular assess- setting. Optom Vis Sci. 2016;93:848-54. might provide an easier adaptation ment can be useful if the patient feels 6. Young G, Sulley A, Hunt C. Prevalence of astig- to initial comfort. Patients with small off-balance. When distance vision is matism in relation to soft contact lens fi tting. Eye Contact Lens. 2011;37:20-5. apertures, deep set orbits or large the concern, modify distance power, 7. Efron N, Nichols JJ, Woods CA, Morgan PB. fi ngers may also have more diffi culty reduce add power or change zone Trends in US contact lens prescribing 2002 to 2014. Optom Vis Sci. 2015;92:758-67. with application and removal and sizes. Conversely, if near vision needs 8. Richdale K, Berntsen DA, Mack CJ, et al. Visual may do better with a smaller diame- improvement, push plus power in the acuity with spherical and toric soft contact lenses in low- to moderate-astigmatic eyes. Optom Vis ter corneal GP lens. distance prescription, increase add Sci. 2007;84:969-75. power or change zone size. If small 9. Berntsen DA, Cox SM, Bickle KM, et al. A ran- domized trial to evaluate the e ect of toric versus REFINING THE FIT refi nements are needed, it is good spherical contact lenses on vision and eyestrain. Providing that initial wow factor is practice to adjust only one variable Eye Contact Lens. 2019;45(1):28-33. 10. Wol sohn JS, Davies LN. Presbyopia: e ective- the best way to start off on the right at a time. ness of correction strategies. Prog Retin Eye Res. foot. Multifocals can be fi t both em- 2019;68:124-43. 11. Bennett ES. Contact lens correction of presby- pirically and diagnostically. Although any viable contact lens opia. Clin Exp Optom. 2008;91:265-78. diagnostic fi tting sets are available Moptions are available for 12. Richdale K, Mitchell GL, Zadnik K. Comparison of multifocal and monovision soft contact lens cor- for custom soft toric multifocals, you your patients with presbyopia and rections in patients with low astigmatic presbyopia. can order corneal GP multifocals and astigmatism. Communicating with Optom Vis Sci. 2006;83:266-73. now hybrid multifocals empirically. them and making them aware 13. Woods J, Woods C, Fonn D. Visual performance of a multifocal contact lens versus monovi- This method can save chair time of the solutions at their disposal sion in established presbyopes. Optom Vis Sci. by producing an initial lens based can help reach or exceed their 2015;92(2):175-182. 14. Nichols JJ, Fisher D. Contact lenses 2018. CL off data provided to the laboratory. expectations. RCCL Spectrum. 2019;34:18-23.

REVIEW OF CORNEA & CONTACT LENSES | MARCH/APRIL 2020 27 PRESBYOPIA TREATMENT: Make sure you’re in the know about long-term solutions CURRENT & for the condition. By Larry Baitch, OD, PhD FUTURE OPTIONS Photo: Minoru Tomita, MD resbyopia is the only ocular PEARL. Soosan Jacob, MD, and condition with a preva- her team based in India introduced lence of 100% in patients the presbyopic allogenic refractive older than 50.1 While not lenticule (PEARL) procedure to help Pall presbyopes require correction, avoid the pitfalls of corneal melt, im- due to congenital monovision, it’s plant fi brosis, opacifi cation and haze important to realize that accommo- associated with synthetic corneal dation declines steadily with age for implants (Figure 2).4 everyone. A serologically tested donor To many, presbyopia may seem lenticule harvested from the small-in- Fig. 1. The Kamra is designed to like it’s just another annoyance that increase depth of focus. cision lenticule extraction (SMILE) comes with aging. Uncorrected pres- surgery of a -2.00D to 2.50D patient byopia, however, can result in severe directly within the optical pathway, is trephined to form a 1.0mm stro- and deprive some- (2) altering the underlying architec- mal disc that is implanted over the one of a satisfactory quality of life ture and function of the accommo- center of the pupil in a 120.0µm-deep and opportunities requiring working dative mechanism outside the optical femtosecond laser-created pocket.4 near vision. The global burden of pathway and (3) inducing changes Once the cornea heals, the lenticule is uncorrected presbyopia in terms of within the lens itself. invisible to the naked eye and results productivity loss is estimated to be Kamra (AcuFocus). Launched in in a hyperprolate central cornea, cre- just over $11 billion annually.2 2015, this is the only FDA-approved ating the multifocal optic necessary Luckily, the condition is correct- synthetic corneal presbyopic im- for excellent near and far vision.4 The able. Those who are motivated to plant.3 It consists of a 6.0µm-thick la- allograph is completely permeable to shed their spectacles can pursue ser-fenestrated disc of polyvinylidene oxygen and corneal nutrients.4 contact lenses. Some go a step further fl uoride that is 3.8mm in diameter VisAbility micro-insert (Refocus and seek complete visual indepen- with a 1.6mm central aperture.3 The Group). This was conceived on the dence, and many surgical options device is positioned over the pupillary theory that presbyopia is primarily are available. This article discusses axis inside a femtosecond laser-creat- due to decreasing space between the current and future therapies available ed pocket at a corneal depth of 40% lens equator and the ciliary mus- to the presbyopic population beyond to achieve near monovision.3 The cle as the diameter increases with spectacles and contact lenses. Kamra’s small aperture extends the age.5 It consists of four 5.0mm-long eye’s depth of focus (DOF), provid- SURGICAL THERAPIES ing uncorrected near visual acuity ABOUT THE AUTHOR Device companies have come up with (UCNVA) of about 20/32 and Dr. Baitch is a professor and associate dean for research at three basic surgical strategies for pro- distance of about 20/25 (Figure the MCPHS University School 3 of Optometry in Worcester, MA. viding permanent, or at least long- 1). A refractive error of -0.75D He researches new ophthalmic term, correction of near vision loss is optimal for maximal near and diagnostic and therapeutic devices and pharmaceutical therapies. in presbyopes: (1) making changes distance coverage via DOF.

28 REVIEW OF CORNEA & CONTACT LENSES | MARCH/APRIL 2020 PhD, DMSc Photo: Anders Ivarsen, MD, PhD, Jesper Hjortdal, The procedure involves a series of Both techniques can be performed scleral laser perforations using the using LASIK or PRK. company’s VisioLite Er-YAG laser.6 Supracor (Bausch + Lomb). This Four 5.0mm2 ablation matrices are creates a variable-focus corneal applied in a diamond-shaped confi g- profi le with a 12.0µm elevation in the uration to the four quadrants 4.0mm central 3.0mm, and provides a near peripherally to the limbus.6 Each ma- addition power of approximately trix of laser perforations overlies fi ve 2.00D.8 Peripheral to the central near key anatomical constituents of the portion is an aspheric annular zone, accommodative mechanism, afford- which provides intermediate and 6 8 Fig. 2. A donor lenticule harvested ing more elasticity to the sclera. As distance vision. It is best performed from a SMILE refractive patient is biomechanical effi ciency increases, it on hyperopic patients.8 ready for trephining into a 1.0mm- translates to the lens during accom- Supracor outcomes vary depending diameter intrastromal implant. modation.6 The procedure has not on the technique’s magnitude and polymethyl methacrylate segments yet entered into FDA investigational whether it is performed in tandem implanted 4.0mm from the limbus be- device exemption clinical trials.6 with a refractive procedure, as a tween the in the Ocufi t (Sooft Italia). This stimu- singular presbyopic treatment or four quadrants of the eye (Figure 3).5 lates the ciliary muscle to increase its binocularly.8 While patients have As a scleral treatment peripheral potency so that it can overcome the generally been satisfi ed with their to the cornea, VisAbility completely higher resistance of the system asso- resulting near vision, distance vision avoids the eye’s optical pathway.5 ciated with aging.7 It avoids altering disturbances have limited the proce- Rather than offering a monovision the optics of the eye and aims to dure’s acceptance.8 treatment for presbyopia, it aims to restore dynamic accommodation.7 Intracor (Bausch + Lomb). This provide natural, binocular vision The device consists of a 20.0mm employs a femtosecond laser to without adverse effects on distance scleral lens with four electrodes posi- ablate concentric circles deep in the vision.5 FDA trial data revealed a tioned 3.5mm from the limbus at the corneal stroma, inducing 90% patient satisfaction rate with four quadrants.7 Electricity, which shrinkage and causing a hyperpro- most patients reaching a UCNVA of causes the ciliary muscle to spasm, late central near zone.9 Studies have 20/32 by three months after surgery.5 is pulsed for two seconds with a rest demonstrated signifi cant near vision Disadvantages include extended time of six seconds for eight min- improvement, but reductions in postoperative conjunctival injection utes.7 Four treatments are performed distance vision do occur and have due to the conjunctival resection nec- at two-week intervals.7 More exten- precluded robust application.9 No essary to create the scleral tunnel and sive studies are needed to consider clinical trials are currently in progress implant the micro inserts, prolonged electrostimulation a contender for in the United States.9 optimal near visual acuity attainment presbyopia treatment. until weeks or months after surgery PHARMA TREATMENTS and signifi cant perioperative pain.5 CORNEAL PROCEDURES The medication realm may be home The device is currently awaiting pre- Aside from monovision correction, to the most encouraging class of market approval from the FDA.5 there have been a number of attempts treatment for presbyopic near vision

LaserAce (Ace Vision Group). at presbyopia correction through Photo: Refocus Group This is a less invasive, less surgi- multifocal corneal laser refractive cal binocular treatment that does procedures. PresbyLASIK describes a not alter the optics of the lens or procedure that reshapes the cor- cornea.6 It is based on the belief nea using standard laser refractive that scleral rigidity is the primary methods but alters the corneal laser culprit in presbyopia.6 In a young ablation profi le. This involves either eye, the sclera is more elastic and making the peripheral cornea hyper- gives slightly with accommodative prolate to create a central distance traction from the ciliary muscles. In zone and a peripheral near zone or an aging eye, the sclera is more rigid making the central cornea hyper- Fig. 3. The VisAbility o ers natural, and resists movement associated with prolate for a central near zone and a binocular vision without a ecting the accommodation. peripheral distance zone (Figure 4). eye’s optical pathway.

REVIEW OF CORNEA & CONTACT LENSES | MARCH/APRIL 2020 29 PRESBYOPIA TREATMENT: CURRENT & FUTURE OPTIONS

loss. The aim in this case is threefold: Many investigators are in the pro- soften the age-stiffened crystalline cess of testing drugs and combination lens matrix to allow for recovery of therapies to improve near vision, natural dynamic accommodation nearly all of which involve pupillary with the , produce miosis miosis. Most are not in the FDA of the pupil to allow for expansion pipeline yet, but all have achieved of optical DOF, and increase corneal similar outcomes in terms of time 15,16 tissue pliability to allow for rigid con- Fig. 4. There are two confi gurations to onset and duration of effect. tact lens molding of the cornea and a of PresbyLASIK: a near peripheral International examples include multifocal shape profi le. corneal annular zone with a distance FOV Tears produced by Luis Felipe Dioptin. This topical eye drop central zone (a) and a near central Vejerano, MD, Método Benozzi by (UNR844, Novartis) is a lipoic corneal zone with a peripheral Jorge Benozzi, MD, and PresbiPlus annular distance zone (b). acid-based, topically instilled prodrug by Roberto Pinelli, MD.15,16 that penetrates into the lens.10 A The FDA Phase IIb study found prospective double-blind FDA Phase that miosis took place about 30 min- LENS REPLACEMENT I/II trial reported no serious adverse utes after eye drop instillation, with Intraocular lenses (IOLs) are not con- results and comparable comfort in 47.2% of eyes gaining at least three sidered a treatment for presbyopia participants and controls.10 After the lines of DCNVA and 91.7% gaining per se, but many ophthalmologists 90-day dosing period, Dioptin-dosed at least two.12 The drug’s effect lasted who lens replacement surgery on pa- subjects had achieved a distance-cor- as long as seven hours, and there was tients without cataracts by substitut- rected near visual acuity (DCNVA) no discomfort or adverse effect on ing the healthy crystalline lens with of 20/22 and controls, 20/40.10 The distance visual acuity.12 The medica- an IOL to correct the refractive error near acuity improvement persisted tion will enter FDA Phase III clinical while providing near vision, interme- through the 301-day follow-up.10 trials in the fi rst half of 2020.12 diate vision or both. This surgery is TVT. Yolia Health’s True Vision PresbiDrops. This drop (CSF-1, also referred to as clear lens replace- Treatment (TVT) is a seven-day Orasis) combines a parasympathomi- ment or refractive lens exchange combo therapy involving an eye drop metic with an NSAID in an oil-based (RLE). Three types of IOL confi gura- to make the cornea more malleable vehicle to preclude discomfort due to tions can be employed in RLE: and a cornea-shaping contact lens ciliary spasm and minimize the risk Monofocal monovision. designed for eight hours of wear.11 of uveitis.13 The Phase IIb clinical Monofocal IOLs (spherical or The company claims the molding trial met the three-line improvement spherocylindrical) are geared toward effect lasts more than seven months.11 criteria for DCNVA and achieved patients who have had success with The twofold nature of this treat- good comfort with no signifi cant ad- contact lens monovision. However, ment has complicated the FDA trial verse effect on distance vision.13 The monofocal IOLs have a minimal process.11 However, results have been company claims that the drug has a DOF, so it must be decided prior to encouraging, with reports of binoc- fast onset of action and its effects are surgery whether intermediate or near ular UCNVA improving from 20/80 long-lasting and is now recruiting for vision is more important to the pa- to 20/40.11 Distance acuity was not FDA Phase III clinical trials.13 tient based on their working distance adversely affected, but it is unknown Oxymetazoline. This drug (AGN- demands. whether aberrations typical of multi- 199201, Allergan) is a vasoconstric- EDOF, trifocal IOLs. Extended focals caused visual disturbances.11 tion decongestant, a direct-acting DOF (EDOF) and trifocal IOLs are a Liquid Vision. These eye drops alpha-1 adrenergic agonist and new generation of IOLs that provide (PRX-100, Presbyopia Therapies) en- alpha-2a adrenergic partial agonist, clearer vision at all working distanc- courage pupil miosis to improve both traditionally used to treat sinus con- es. Sometimes promoted as presby- near and far visual acuity via DOF gestion and conjunctival hyperemia.14 opia-correcting IOLs, these lenses can expansion.12 In younger presbyopes, In the Phase II trial, about 70% of be used in a modifi ed monovision the myopic shift of the crystalline lens subjects had at least a two-line im- confi guration or they can be binoc- associated with the ciliary spasm can provement in UCNVA.14 Allergan is ularly employed. For the most part, result in reduction of distance visual currently recruiting for Phase III trials they have largely replaced multifocals acuity. This drop is meant to solve for two preparations (AGN-190584 as the ultimate choice for continuous these problems with its preparation and AGN-199201), individually and vision at a full range of distances. of aceclidine.12 in combination with each other.14 FDA-approved in 2016, the Tecnis

30 REVIEW OF CORNEA & CONTACT LENSES | MARCH/APRIL 2020 Innovation Summit Photo: Adapted from Ophthalmology has wavefront-guided progressive op- should be able to provide a continu- tics without diffractive lens zones, a ous range of focus for the patient.23 peripheral monofocal distance optic, A study reported good visual a middle distance optic with oppo- acuity at every distance, with mean sitely-signed spherical aberration and distance vision at 20/20, interme- a central distance zone.20 This combi- diate vision at 20/20 to 20/25 and nation precludes halos and provides a near vision at 20/20 to 20/27.23 20 Fig. 5. In the un-accommodated continuous range of vision. Accommodation was measured at state (a), a minute amount of fl uid Accommodating IOLs. The race a mean of 2.00D, and accommo- streams from the central optic is on for a lens that will fi t into the dative amplitudes as high as 5.00D into the peripheral balloon haptics capsular bag and re-establish normal were achieved with accommodative of the lens, and the distance 23 power of the optic is obtained. dynamic accommodation. This is effort. Alcon named the newest Upon accommodation and radial what accommodating IOLs (AIOLs) version the NextGen 20/20 and is contraction of the lens capsule by aim to do. currently undergoing an international the ciliary body (b), the fl uid streams The only AIOLs approved so far multicenter clinical trial.23 into the central optic, increasing its in the US are the Crystalens AO Certain AIOL designs depend on plus power for near vision provided 21,22 by the FluidVision AIOL (c). and HD (Bausch + Lomb). The the compressive action of the ciliary Crystalens has articulating haptics muscle to produce axial movement Symfony EDOF IOL (Johnson & that are supposed to bend on accom- of the IOL optic, which has proved Johnson) has a lens surface that modative effort and translate the problematic.24 In addition, IOLs carries achromatic diffractive grating optic forward.21,22 Research, however, positioned inside the capsular bag elements called echelettes, which has demonstrated that it does not have been subject to capsular fi brosis, extend DOF and concurrently correct accommodate as earlier stated; rather shrinkage and stenosis of the haptics, chromatic dispersion.17 Rather than than the 1.50D to 1.90D theorized compounding the loss of IOL func- prismatically splitting light to pro- by a 1.0mm displacement of the optic tionality over time.24 duce a second near focal point like with accommodation, forward trans- The Lumina AIOL (AkkoLens) multifocals, echelettes offer a more lation of the optic has been measured went in a different direction, using an continuous range of visual work- at roughly 0.4mm and has even been opposing pair of optics called Alvarez ing distances.17 Reduced chromatic observed to tilt backward, creating lenses—freeform progressive lenses dispersion results in higher contrast aberrations that would account for a that vary the dioptric power through sensitivity, reduction of glare and near increase in DOF.21,22 the pair when the lens elements move halos and higher visual quality.17 There are many AIOLs not yet ap- transversely to each other at a 90o an- Near vision can be compromised, proved in the United States that show gle to the pupillary axis (Figure 6).25 so patients may occasionally need true optical change with accommo- When the ciliary body compresses assistance from near spectacles for dative effort. the AIOL haptics with near accom- close targets.17 The FluidVision AIOL (Alcon) modative effort, elements of the lens The Acrysof IQ PanOptix trifocal is promoted as the fi rst true transverse one another with the net IOL (Alcon), which received FDA ap- shape-changing, fl uid-driven AIOL.23 optical combination increasing the proval in August 2019, has a trifocal The lens has three main components: plus power of the lens.25 For distance diffractive surface.18 Its three dioptric (1) a fl exible central optic reservoir, vision, the ciliary body relaxes and powers are targeted for 40.0cm, (2) fl exible pontoon-like haptics that decompresses the haptics, allowing 60.0cm and infi nity, and it is avail- also serve as reservoirs and (3) about the lens elements to realign.25 able with astigmatic correction.18 30µL of fl uid (Figure 5).23 Its method Rather than being located in the Other EDOF and trifocal IOLs in of action is based on the principle of bag and subjected to fi brosis, the development that have found success ciliary compression; accommodative Lumina AIOL is positioned at the internationally are the AT Lisa effort causes the ciliary body to com- sulcus plane where the ciliary body trifocal IOL (Carl Zeiss Meditec), the press the haptics, which causes fl uid muscle contacts the opposing ele- Alsafi t trifocal VF lens (Alsanza), the to stream out to the central optic.23 ments of the lens, moving them trans- FineVision Triumf trifocal EDOF lens As the central optic fi lls, the plus versely and engendering the accom- (PhysIOL) and the Mini Well Ready power of the lens increases, focusing modative myopic shift.25 Breaking up EDOF lens (SiFi Medtech).19,20 The the IOL for near.23 Theoretically, the capsule can overcome restriction Mini Well Ready is unique in that it graded action from the ciliary body by capsular bag fi brosis.25

REVIEW OF CORNEA & CONTACT LENSES | MARCH/APRIL 2020 31 PRESBYOPIA TREATMENT: CURRENT & FUTURE OPTIONS

Photo: Adapted from AkkoLens Refract Surg. 2017;33(9):578-83. While a study found a positive 8. Ryan A, O’Keefe M. Corneal approach to hyperopic accommodative response to a stim- presbyopia treatment: six-month outcomes of a new multifocal excimer laser in situ keratomileusis proce- ulus—up to 4.50D—in the Lumina dure. J Cataract Refract Surg. 2013;39(8):1226-33. 9. Thomas BC, Fitting A, Khoramnia R, et al. Long- AIOL compared with an absent re- term outcomes of intrastromal femtosecond laser presbyopia correction: 3-year results. Br J Ophthalmol. sponse in a monofocal IOL, there are 2016;100(11):1536-41. issues with accommodative response 10. Stein JM, Robertson, SM, Evans DG, et al. An 25 observational follow-up study assessing the long-term variability from patient to patient. e ects of bilaterally dosed topical lipoic acid choline ester eye drops for the treatment of presbyopia. Inv The Juvene AIOL (LensGen) uses a Ophthalmol Vis Sci. 2017;58(8):330. two-part system that can be inserted 11. Plenilunia Salud Mujer. Presenting a non-surgi- cal procedure for presbyopia, which represents an into a smaller incision and assembled Fig. 6. As the ciliary body of the option for patients with tired eyesight. plenilunia. com/noticias-2/presentan-procedimiento-no-quirur- in the eye: a peripheral carrier that Lumina AIOL compresses the lens gico-para-presbicia-representa-opcion-para-pacien- fi lls the capsular bag and a central haptics (a), the lenses translate in tes-con-vista-cansada/55306/. July 5, 2018. Accessed apposition to each other, increasing February 25, 2020. fl uid-fi lled optic that deforms to 12. Lipner M. EyeWorld. A unique drop. www.eyeworld. plus power. With relaxation of the org/article-a-unique-drop. October 2014. Accessed become more prolate as the carrier is ciliary body (b), the lenses line up February 25, 2020. 13. ClinicalTrials.gov. Safety, tolerability, and e cacy compressed by the ciliary body. The with the appropriate distance power. of PresbiDrops (CSF-1), a topical ophthalmic drug for device is simple and relatively clear of presbyopia. clinicaltrials.gov/ct2/show/NCT02745223. April 20, 2016. Accessed February 25, 2020. 26 higher-order aberrations. gence and probable dominance of 14. ClinicalTrials.gov. A Phase 3 e cacy study of AGN- 190584 in participants with presbyopia. clinicaltrials. Data from clinical trials in Mexico AIOLs, it is unlikely that multifocal gov/ct2/show/study/NCT03804268?term=Allergan %2C+agn-190584&draw=2&rank=2. January 15, 2019. and the Dominican Republic indicate and EDOF IOLs will go away, as the Accessed February 25, 2020. that patients can maintain 2.50D of quality of vision from these lenses 15. Vargas V, Vejarano F, Alió JL. Near vision improve- ment with the use of a new topical compound for accommodation and achieve up to continues to improve with each presbyopia correction: a prospective, consecutive 27 interventional non-comparative clinical study. Oph- 3.00D. Another study reported that generation. thalmol Ther. 2019;8(1):31-9. about 50% of Juvene-implanted pa- Just as the exact cause of presby- 16. Healio. Clinicians anticipate treating presbyopia with eye drops. www.healio.com/optometry/optics/ tients can achieve a DCNVA of 20/32 opia is not entirely known, neither news/print/primary-care-optometry-news/%7B47b- 27 f090e-50e5-4c49-aa96-d49d9843d2e1%7D/ and 70%, 20/40. is the ideal treatment for the con- clinicians-anticipate-treating-presby- opia-with-eye-drops?page=7. August 2017. Accessed IOLs that employ electro-optics dition—one that reverses the pres- February 25, 2020. and contain artifi cial intelligence soft- byopic process and restores natural 17. Cochener B, Boutillier G, Lamard M, et al. A com- parative evaluation of a new generation of di ractive ware sense pupil constriction due to accommodation with the native trifocal and extended depth of focus intraocular lenses. J Refract Surg. 2018;34(8):507-14. accommodation—distinct from the crystalline lens. We can only hope 18. Lawless M, Hodge C, Reich J, et al. Visual and pattern and speed of constriction due that when one does emerge, it is refractive outcomes following implantation of a new trifocal intraocular lens. Eye Vis (Lond). 2017;4:10. to light reaction. Electro-optical IOLs affordable and accessible to the mil- 19. Esteve-Taboada JJ, Domínguez-Vicent A, Del Águila-Carrasco AJ, et al. E ect of large apertures on may be incorporated into the long- lions of people who experience the the optical quality of three multifocal lenses. J Refract term outlook on IOL technologies, handicap of near vision loss around Surg. 2015;31(10):666-76. 20. Savini G, Schiano-Lomoriello D, Balducci N, et al. but far simpler solutions exist that do the world. RCCL Visual performance of a new extended depth-of-focus intraocular lens compared to a distance-dominant not require nearly as much hardware 1. Duane A. Studies in monocular and binocular di ractive multifocal intraocular lens. J Refract Surg. or software. accommodation with their clinical applications. Am J 2018;34(4):228-35. Ophthalmol. 1922;5(11):865-77. 21. Marcos S, Ortiz S, Pérez-Merino P, et al. Three-di- 2. Markets Insider. Myopia & presbyopia treatment mensional evaluation of accommodating intraocular market size worth $28 billion by 2026: Grand View Re- lens shift and alignment in vivo. Ophthalmology. n the near future, it is likely that search, Inc. markets.businessinsider.com/news/stocks/ 2014;121(1):45-55. a pharmaceutical solution will be myopia-presbyopia-treatment-market-size-worth-28- 22. Pérez-Merino P, Birkenfeld J, Dorronsoro C, et al. I billion-by-2026-grand-view-research-inc-1028570106. Aberrometry in patients implanted with accom- the fi rst big wave of treatment, and, October 2, 2019. Accessed February 25, 2020. modative intraocular lenses. Am J Ophthalmol. 3. Vukich JA, Durrie DS, Pepose JS, et al. Evaluation 2014;157(5):1077-89. in that case, a combination approach of the small-aperture intracorneal inlay: three-year 23. DeBoer CM, Lee JK, Wheelan BP, et al. Biomimetic results from the cohort of the U.S. Food and Drug accommodating intraocular lens using a valved would be the most effective. Years Administration clinical trial. J Cataract Refract Surg. deformable liquid balloon. IEEE Trans Biomed Eng. from now, these drops may be 2018;44(5):541-56. 2016;63(6):1129-35. 4. Jacob S, Kumar DA, Agarwal A, et al. Preliminary 24. Alió JL, Ben-Nun J. Study of the force dynam- available over-the-counter on shelves evidence of successful near vision enhancement with ics at the capsular interface related to ciliary body a new technique: PrEsbyopic Allogenic Refractive stimulation in a primate model. J Refract Surg. in pharmacies next to dollar readers. Lenticule (PEARL) corneal inlay using a SMILE lenti- 2015;31(2):124-8. Presbyopic surgical methods are also cule. J Refract Surg. 2017;33(4):224-9. 25. Alió JL, Simonov A, Plaza-Puche AB, et al. Visual 5. Baitch L, Schanzlin D, Iskander D. One-year outcomes and accommodative response of the Lumi- always developing, further encourag- post-operative wavefront and refractive map changes na accommodative intraocular lens. Am J Ophthalmol. following scleral implant surgery. Presented at the 15th 2016;164:37-48. ing the rise of combination therapies. International Congress on Wavefront & Presbyopic 26. Devgan U, Kohnen T, Donnenfeld E, et al. Dual-op- Refractive Correction; 2014; Dana Point, California. tic curvature-changing modular-design presbyopic Patients over 60 will undergo RLE 6. Hipsley A, Hall, B, Rocha KM. Long-term visual IOL. Presented at the 37th Congress of the European more often as procedures and AIOL outcomes of laser anterior ciliary excision. Am J Oph- Society for Cataract and Refractive Surgery; 2019; thalmol Case Rep. 2018;10:38-47. Paris, France. technologies improve and receive 7. Gualdi L, Gualdi F, Rusciano D, et al. Ciliary muscle 27. Pepose JS, Burke J, Qazi M. Accommodating electrostimulation to restore accommodation in intraocular lenses. Asia Pac J Ophthalmol (Phila). FDA clearance. Despite the emer- patients with early presbyopia: preliminary results. J 2017;6(4):350-7.

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Review Education Group partners with Salus University for those ODs who are licensed in states that require university credit. †Rooms limited. See website for additional details. REAL-WORLD CONTACT LENS CARE PROBLEMS Poor lens care and handling practices can lead to infections, drop-outs and even vision loss. Here’s how you can help patients avoid them. By Jane Cole, Contributing Editor

5 Photo: Mile Brujic, OD ou know the scenarios. A cycles or even sleep in patient recently fi t with their lenses on occa- a monthly soft contact sion, upping their risk lens (CL) is sitting in of infection.2 Those in Yyour chair, complaining of constant monthly and two-week redness. And then there’s the veter- regimens are prone to an two-week wearer who made an ocular discomfort, in- urgent appointment due to severe fections or even vision ocular pain, and dis- loss if they skimp on charge, which you suspect could be proper lens care, stor- microbial keratitis. While myriad age and disinfection. reasons exist for these symptoms, “Some of the most poor CL care is likely at the top of common problems your list of differentials. happen because Most of the 45 million contact patients are trying to lens wearers in the United States save time or money,” practice at least some behaviors says Teresa Narayan, that put them at risk for serious eye OD, who practices at Patients who ignore proper lens care and infections, according to a recent MedStar Georgetown handling may fi nd themselves battling a contact report from the CDC.1 One third of University Hospital lens peripheral ulcer. lens wearers who responded to the Department of Ophthalmology contact lens wear and then empha- study’s survey recalled never hear- in Washington DC, and is also an size that the risks are minimized ing any lens care recommendations assistant professor at Georgetown with proper contact lens care,” Dr. from their eye doctor, even though University School of Medicine. Narayan says. most clinicians reported sharing Improper contact lens care can Here, your colleagues share their recommendations always or most lead to complications such as giant fi ve biggest contact lens-related of the time.1 So, despite the educa- papillary conjunctivitis, corneal problems and some pearls on how tional efforts going on in the exam neovascularization, corneal edema to counter them. rooms, the importance of lens care and microbial keratitis, to name isn’t always getting through. a few. “Some of these are more PROBLEM #1: HYGIENE While daily disposable CLs have serious than others and many can HORROR STORIES ushered in a healthier alternative be treated, but there is a chance Washing your hands may seem with a care-free routine and report- of potential permanent vision simple enough, but poor hygiene is ed better compliance, some wear- decrease. I always make sure to a common problem in CL wear- ers may still extend their wearing educate patients on the risks of ers that can lead to issues such as

34 REVIEW OF CORNEA & CONTACT LENSES | MARCH/APRIL 2020 microbial keratitis and corneal Table 1. Contact Lens Do’s and Don’ts infl ammatory events.3,4 Microbes that can cause infec- DO: DON’T: • Wash hands before touching lenses. • Sleep in lenses (unless specifi- tions are auto-inoculated from • Replace lens cases at least monthly. cally instructed by your doctor). a person’s fi ngers, so daily dis- • When cleaning reusable lenses, rub and rinse with mul- • Use any type of water on the posable, two-week and monthly tipurpose solution. lenses—use only approved wearers need to make sure they • Replace lenses on schedule. contact lens solutions. are washing their hands prior to • Call the office ASAP if experiencing pain, redness, or • Refresh/top off solution in lens insertion and removal, says change in vision. cases; instead, empty out and Mile Brujic, OD, who practices at • Scleral and sleep shape wearers: sterilize insertion and fill with fresh solution daily. removal tools regularly with alcohol wipes and air dry. • Wear lenses while swimming or Premier Vision Group in Bowling in a hot tub. Green, OH. • Return for annual contact lens evaluations and eye “A lack of hand washing is far exams. and away the most common prob- lem I see,” adds Andrew Fischer, PROBLEM #2: solutions and the failure to renew OD, of Professional Eyecare CREEPY LENS CASES lens cases.2 Other researchers found Associates in Jasper, IN. “We have At Cascadia Eye in the Seattle, 47% of patients said they never sinks in every room, and for a ma- WA, area, Steven Turpin, OD, fi nds replaced their lens cases or only did jority of my contact lens patients, I that infrequent case replacement is so if their doctor gave them a new fi nd that I have to remind them to the issue he sees the most. During one during their annual visit.6 wash their hands before removing application and removal training, At Dr. Brujic’s practice, he has the lenses. If they aren’t washing in the patient is usually focused on all CL patients bring in both their the offi ce, you can bet they aren’t getting the lenses on and off, and lens cases and solutions during the washing at home.” they forget about case replacement, exam. “I’m still shocked at some of To counter this, at every visit— he says. “People often come into the the conditions these patients place whether the patient is a new wearer offi ce with their lenses in a case that medical devices in. The lenses sit all or has been in lenses for 20 years— looks like its been dropped in the day long on the patients’ eyes, and Dr. Fischer does a quick review of mud before they walked in. There at night, they store them in these key hygiene tips, including the im- was even a patient that came in with horrifi c cases.” When Dr. Brujic portance of washing hands, replac- his lenses in a case used in the old sees this, he throws the case in the ing cases, not sleeping in lenses not thermal disinfection units from the garbage. “I tell the patient, ‘you designed to be slept in and avoiding ’80s,” Dr. Turpin says. “That’s one won’t be using that case anymore, contact with water. Dr. Fischer reason we generally recommend and make sure you clean or replace also gives patients a “Contact Lens peroxide products as our primary it every three months.’” Do’s and Don’ts” handout after the lens care system. Once the neutraliz- contact lens evaluation as a helpful ing disc wears out, patients have to PROBLEM #3: TERRIFYING reminder (Table 1). change their case.” TALES OF SOLUTIONS

Photo: Mile Brujic, OD A recent study in Contact Lens Contact lens solutions are another & Anterior Eye found storage cases real-world issue, and this is height- and mobile phones of 63 contact ened if patients opt for generic lens-wearing university students products not recommended by their were highly contaminated with doctor. pathogenic bacteria.5 The investi- CL solution sensitivity can be gation found the highest level of problematic for some patients, and contamination was detected in CL it’s hard to pinpoint and treat the storage cases where 18 (52%) bacte- problem if the person is switch- rial isolates were detected.5 Another ing between solutions, especially study of 2,267 patients that looked with some of the generic ones, Dr. at contact lenses and infectious ker- Narayan says. The biggest danger is These non-infectious infi ltrates are a atitis reported the most important saline solution and patients confus- tell-tale sign that the patient needs to be re-educated on proper lens risk factors in the non-daily dispos- ing it with a multipurpose solution, care. able lens groups were lens cleaning she adds.

REVIEW OF CORNEA & CONTACT LENSES | MARCH/APRIL 2020 35 FIVE REAL-WORLD CONTACT LENS CARE PROBLEMS Photo: Mile Brujic, OD I recommend name brand of soak time, never rinsing with the multipurpose solutions to solution directly and replacing the ensure product consistency,” case as recommended, she says. “I Dr. Turpin says. haven’t experienced any patient hav- The most common issue Dr. ing a complication with a peroxide Fischer encounters with ge- solution if the usage instructions are neric multipurpose solutions followed properly.” is solution toxicity resulting in However, Crystal Brimer, OD, fi ne, diffuse punctate kera- owner of Focus Eye Care and titis. “In the same brand of creator of The Dry Eye Institute in generic solution, additives and Wilmington, NC, still sees patients preservatives can change from who’ve used peroxide-based cleans- one month to another, so if a ers directly on the eye or before lens patient has a sensitivity to one insertion, which has the potential Infectious ulcers such as this one are a of the ingredients, it is impos- to cause signifi cant corneal toxicity possible complication for patients who sible to always avoid it.” and keratitis. “We see both corneal don’t replace their contact lens cases in a For patients who are symp- staining and infi ltrates that may or timely manner. tomatic and have signs of an may not be induced partly from CL “I’ve seen patients with cases of allergic reaction, Dr. Turpin will solution. I immediately ask what preventable microbial keratitis suggest trying a different solution or they’re using and change it in those because they were using a plain switching to a daily disposable lens. cases, and more so switch them saline that they thought was a “We tend to pitch dailies initial- to daily disposables and avoid the cleaning/disinfection solution. If ap- ly because it removes a variable. cleaning regimen altogether,” she propriate, I try to recommend two We don’t have to guess at which says. brands of specifi c contact lens solu- solution to try next. We just get rid Another solution issue: patients tions that would work for them and of solutions all together. That said, will often “hoard” supplies, even their lenses. I specify two because if patients are resistant to move after the expiration date, Dr. Brujic that way if the store doesn’t have into a daily modality, we always says. Since he asks his CL patients one, or if it’s too expensive, they can recommend a peroxide solution to bring in their solutions during the get the other option rather than a fi rst if they are currently using a evaluation, if he sees any expired generic or use saline or water,” she multipurpose.” bottles, he’ll throw them away. “I says. If a patient is using peroxide, and tell the patient why I am throwing Generic or “cheap” solutions Dr. Turpin suspects it is causing it away and explain why I make a aren’t inherently problematic, but a problem—high plus or minus specifi c suggestion for a solution. issues can certainly arise, Dr. Turpin patients may not have full neutral- Sometimes, it’s as simple as saying, adds. If a patient is solely concerned ization of the peroxide due to lens ‘The contact lenses you’re wearing with cost, they will often pick up thickness and experience stinging are the highest level of lenses avail- the fi rst bottle that says it can be from the remaining peroxide—he able and this solution works best used with contacts, which is often recommends sticking to a name with them.’” just saline solution. “This is always brand multipurpose solution. why we ask for specifi c brands of Dr. Narayan routinely recom- PROBLEM #4: THE solution so we can confi rm they are mends hydrogen peroxide solutions, NON-RUBBERS using something that keeps the nasty which she says are a great alter- For patients in reusable lens modal- bugs away,” Dr. Turpin says. native, especially if someone has a ities, few rub their lenses prior to With generics, problems usually history of solution sensitivity. Those placing them in their case for over- crop up suddenly because these with allergies and dry eye can really night storage, Dr. Fischer says. brands will often alter formula- benefi t, she adds. The system also One study found compliance rates tion without changing any of the seems to help deep clean lenses for in patients who used CL disinfection labeling, he adds. “A patient may those with a history of contact lens systems that require rinsing and rub- be using a generic successfully for a build-up and deposits. For peroxide bing were 45% and 69%, respec- number of years and suddenly have solutions, it’s important to educate tively, despite the resultant increased a reaction to it. For this reason, patients on the appropriate length risk of biofi lms and pathogens,

36 REVIEW OF CORNEA & CONTACT LENSES | MARCH/APRIL 2020 which can cause contact lens-related Prevention always circles back to ed lenses because of the perceived dry eye.7 patient education, for old and new hassle or danger, Dr. Narayan Lens deposits from non-rubbing wearers alike. “Don’t assume that a suggests. “Now more than ever, are another issue Dr. Turpin sees in patient is taking proper care of their contact lenses are a great option for patients who are non-compliant in lenses just because they have been a majority of patients,” she says. their lens care. “It is not necessarily wearing contact lenses for years. “With new technology and a wid- a solution issue itself, just a simple Those patients can have some of the ened range of parameters, especially misunderstanding in the handling worst habits, especially if nothing in daily lenses, patients should be process. Once we remind patients bad has happened to them. I always aware that with proper care, risks that mechanically rubbing lenses is make sure to emphasize that noth- are minimized and they can enjoy the best defense, the problem usual- ing bad has happened yet and that healthy contact lens wear for years ly resolves quickly,” he says. they need to practice appropriate to come.” RCCL To correct handling issues, Dr. contact lens care if they want to 1. Healthy contact lens behaviors communi- Turpin observes patients’ insertion continue a lifetime of healthy eyes cated by eye care providers and recalled by and removal routines in-offi ce, and good vision,” Dr. Narayan says. patients—United States, 2018. MMWR Morb “without trying to be obvious or Another tactic Dr. Brujic uses is Mortal Wkly Rep. 2019;68(32):693-97. 2. Sauer A, Greth M, Letsch J, et al. Con- overbearing for patients to give us to remind patients that the subtle tact lenses and infectious keratitis: from a case-control study to a computation of the a true representation of how they symptoms they are complaining risk for wearers. Cornea. January 27, 2020. handle their lenses.” He then makes about may be due to their non-com- [Epub ahead of print]. notes of issues and reviews any pliant habits. 3. Fonn D, Jones L. Hand hygiene is linked to microbial keratitis and corneal infl am- useful improvements casually at the “One of the worst things a patient matory events. Cont Lens Anterior Eye. end of the visit to avoid any sense of can do is replace their lenses when 2019;42(2):132-35. 4. Carnt N, Ho man JJ, Verma S, et al. accusation or disapproval, he says. they feel like they need to be re- : confi rmation of the “More often than not, compliance placed, because at that point, there UK outbreak and a prospective case-control study identifying contributing risk factors. Br is improved at their next visit,” Dr. are often chronic issues occurring J Ophthalmol. 2018;102(12):1621-28. Turpin says. that are getting to the point of 5. Waleed AM, Lua’i AI, Wisam S, Sana J. Antimicrobial susceptibility of bacterial feeling different to the patient, and isolates from the , storage cases that’s a problem because it may be and mobile phones of university students PROBLEM #5: THE TOPPING- using contact lenses. Cont Lens Anterior Eye. OFFERS & OTHER SUSPECTS diffi cult to revert many of those November 10, 2019. [Epub ahead of print]. Many age-old problems are still changes,” Dr. Brujic says. 6. Robertson DM, Cavanagh HD. Non-com- pliance with contact lens wear and care around, Dr. Brimer says. “But During an exam, if Dr. Brujic no- practices: a comparative analysis. Optom Vis perhaps we hear less about them tices any signs that indicate contact Sci. 2011;88(12):1402-8. 7. Ramamoorthy P, Nichols JJ. Compliance because the percentage of daily lens abuse, he’ll take a picture of the factors associated with contact lens-related disposable wearers has increased.” fi ndings with anterior segment pho- dry eye. Eye Contact Lens. 2014;40(1):17-22.

Patients still store their lenses with- tography and show Photo: Mile Brujic, OD out any rubbing or cleaning, and it to the patient. many top off their solution instead “This seems to hit of changing it, or don’t even bother home with most to top off. Added to that, some still patients, and they extend the wearing cycle beyond the generally will start indications for their lens modality, curbing some of she explains. their poor hygiene Some of these bad habits have habits.” actually increased over the years as In addition to contact lens technology and mate- making sure new rials have improved, Dr. Narayan and existing con- says. Many lenses are quite com- tact lens patients fortable, so patients think they don’t are following prop- need to clean them, it’s okay to er care procedures, stretch the replacement or even sleep clinicians shouldn’t While many CL-related complications can be treated, in the lenses as long as they still feel overlook those some could lead to lasting visual e ects, such as this fi ne, she adds. who have avoid- stomal scar from a previous ulcer.

REVIEW OF CORNEA & CONTACT LENSES | MARCH/APRIL 2020 37 The GP Experts By Lindsay Sicks, OD, and Thanhan Andy Nguyen, OD

Managing Presbyopia With Sclerals With this patient population, it is vital to manage expectations.

one are the days having successful follow-up prior of reading glasses to adding multifocal optics. This as your fi rst, last can take up to four or more visits, and only option for depending on the cornea, the presbyopia. Whether complexity of the fi t and the expe- Gyour scleral lens patient has a rience of the fi tter.2 The addition of regular or irregular cornea, you can multifocal optics to the lens design present the option of multifocal may add another visit or two to optics more confi dently than ever achieve success. before. Laboratories are offering simultaneous multifocal optics in SPECIAL FEATURES their scleral designs, and the ability When fi tting multifocal sclerals, This multifocal scleral was ordered after to customize them contributes the single vision lens was fi t successfully focus on two features: to their success. Today, you can and best distance acuity achieved. Decentered optics. Large- change add power or zone size diameter scleral lenses often and decenter the optics in the lens. move or translate on-eye.1 While decenter and can present a challenge A methodical approach to patient this effect can contribute to stability, to the practitioner. Lenses with education and fi tting can improve the optics must be centered properly excessive central vault also tend to your success when offering these over the visual axis for success. In decenter.3 lenses to patients. irregular cornea patients who have One study showed that it is more reduced distance acuity, wearing common for a lens to decenter than MANAGE EXPECTATIONS glasses over their contact lenses may to properly center.4 The lens tends With multifocal lenses, the visual provide the best near vision. to follow the contours of the sclera, outcome can hinge on a patient’s The cost of a multifocal scleral positioning in the opposite direction expectations of what is considered may also be a deciding factor for of the patient’s line of sight. Adding successful completion of the fi t. A some patients. Educate them that simultaneous vision optics in a de- patient’s visual demands are going the cost may be similar to a daily centered lens can cause issues with to largely determine their defi nition disposable soft multifocal lens. distance acuity, near acuity or both. of success. Before you offer a mul- For patients who are not willing Studies suggest visual improvement tifocal to your scleral lens patient, to make the investment, you can when soft lens optics are decentered a detailed case history will allow consider a monovision or modifi ed (and over the line of sight), and that you to determine their near vision monovision scleral lens option or improvement is the impetus for de- demands, daily tasks and work envi- a monthly/biweekly multifocal soft centered optics in scleral designs.5,6 ronment. Also, gauge their potential contact lens. Demonstrating the Some fi tting sets include lens mark- for dissatisfaction with less than monovision experience in-offi ce can ings that help determine the appro- perfect vision based on their person- be useful for these patients. Keep priate angle and offset amount for ality and lens wear history. in mind that patients may still need the near zone, while other sets use a For regular cornea patients who to supplement with reading glasses, standard design you can modify. demand the highest quality vision, so discuss this possibility upfront to Variable zones. Consider whether consider whether a translating reduce disappointment later. changes to the near zone size can gas permeable (GP) lens may be Manufacturers recommend improve your results with multifocal an option instead of a scleral lens. achieving a satisfactory fi t (central lenses. Most designs on the market Simultaneous vision optics are really clearance, limbal vault, edge align- today have a center-near zone. the only option with scleral and hy- ment, patient vision and comfort) Assess the patient’s pupil size, as brid lenses because the lenses do not with a single-vision product and a smaller pupil may experience

38 REVIEW OF CORNEA & CONTACT LENSES | MARCH/APRIL 2020 diffi culties in bright light since more tration option. Theoretically, this of the near zone is being viewed should sharpen the distance vision through the pupil. A larger pupil without a substantial loss in near may have diffi culty using the near acuity, as the near optics are no lon- zone at all if the pupil does not ger in the patient’s visual axis. With constrict enough or the light is dim. this small adjustment incorporated, The multiple zones of scleral lens the patient was thrilled with both power require the proper alignment her distance and near vision. to deliver light to the and provide good near, intermediate here are several different ways and distance vision simultaneously. Tto approach troubleshooting Having a variable near zone option when a distance or near complaint allows for more fl exibility to reach exists with a multifocal scleral lens. the patient’s visual goals if the acuity Markings on some scleral lens fi tting Much of your decision-making will is at a suboptimal level despite sets can assist you in evaluating lens depend on the lens design and the zones and centration. proper lens centration. fi tting guide. A quick call to the vision OU at near. Adding Hydra- laboratory consultation department CASE ONE PEG (Tangible Science) to each lens can also point you in the right A 67-year-old Caucasian male ensured optimal comfort, given the direction. We fi nd it especially useful presented with complaints of dis- entering complaint of discomfort in tough cases to consider lens comfort and blur at near with his with his habitual hybrid lenses. designs that have special features habitual multifocal hybrid lenses. such as decentered optics and/ As a longstanding patient, we were CASE TWO or custom near zone sizes. Your aware of his Type A personality and A 47-year-old Caucasian female presbyopic patients often have the particular visual demands. We spent presented complaining of blur, disposable income to invest in these extensive time detailing realistic haloes and photophobia OS related technologies, and they will surely expectations with multifocal lenses, to corneal scarring secondary to appreciate your dedication to their including a range of refi t options— herpes zoster viral infection. She visual needs. RCCL modifying the current hybrid lens had been wearing multifocal soft 1. van der Worp E, Bornman D, Ferreira DL, et al. design, switching to a GP design or lenses for the last three years with Modern scleral contact lenses: a review. Cont Lens attempting a scleral multifocal de- a best-corrected visual acuity of Anterior Eye. 2014;37(4):240-50. sign. The patient insisted on trying 20/20 OD, 20/30 OS and J3 OU 2. Macedo-de-Araújo RJ, van der Worp E, & González-Méijome JM. Practitioner learning curve the multifocal scleral. So, he was at near. The patient was refi t into a in fi tting scleral lenses in irregular and regular fi t in a Zen RC (Bausch + Lomb) Zen Multifocal OS while continuing corneas using a fi tting trial. BioMed Res Int. 2019.2019;1-11. initially with the later addition of wear of the soft multifocal lens OD. 3. van der Worp E. A Guide to Scleral Lens Fitting, multifocal optics (Zen Multifocal) Upon dispense of her new lens OS, Version 2.0. Forest Grove, OR: Pacifi c University; 2015. Available: commons.pacifi cu.edu/mono/10/. after the single vision lens was fi t vision was 20/20 OD, 20/25 OS Accessed February 5, 2020. successfully and best distance acuity and J2 OU at near. She was satisfi ed 4. Ramdass S, Rosen C, Norman C, Buckingham R. Clinical analysis of scleral lenses on regular achieved. with her overall vision improvement corneas. Presentation at: Global Specialty Lens We reduced the add and included at both distance and near but still Symposium. Las Vegas, NV. January 2016. 5. Brujic M. The importance of optical place- a smaller near zone to the design of wished to have sharper distance ment in multifocal lenses. Presentation at: the Zen RC for the dominant eye. vision OS. Global Specialty Lens Symposium. Las Vegas, NV. January 2015. The axis was shifted OU to account In cases of a distance vision com- 6. Zheng F, Caroline P, Lampa M, et al. Visual e ects of centered and decentered multifocal for lens rotation, and the fi nal lens plaint, the laboratory recommends optics. Poster presented at the Global Special- allowed the patient to achieve 20/20 removal of the near zone decen- ty Lens Symposium, January 2016, Las Vegas.

REVIEW OF CORNEA & CONTACT LENSES | MARCH/APRIL 2020 39 Corneal Consult By Aaron Bronner, OD, and Alison Bozung, OD

When a Red Eye Prompts a Red Alert Be on the lookout for neoplastic ocular surface lesions and know proper management techniques if you run into one.

52-year-old black male agnoses should remain broad initially. was referred by his pul- Common lesions include pinguecula, monary transplant team , nevus, papilloma and for persistent redness that pyogenic granuloma. When we begin Ahad plagued his left eye for nearly two to suspect neoplastic cells, we should months. The patient was asymptom- become familiar with OSSN. atic for pain, discharge, itching and OSSN lesions are associated with a vision loss. thickened epithelium near the limbus Ocular history was signifi cant for Fig. 1. photo of the ocular and may possess certain qualities, surface lesion involving the nasal remote trauma of the right eye nearly conjunctiva and limbus. such as “feeder” vessels, local injec- 10 years prior, which had resulted in tion and overlying keratinization. rupture and subsequent enu- was immunosuppressed but also Compared to conjunctival intraepithe- cleation. He presented for his annual reported a history of signifi cant UV lial neoplasia (CIN), the term OSSN exams initially but was lost to fol- exposure after living in southern may be more favorable clinically due low-up for fi ve years. Medical history Florida his entire life. He denied to our inability to assess the lesion’s was signifi cant for pulmonary fi brosis any history of skin cancer, human depth and defi ne it by its extension that led to a double lung transplant immunodefi ciency virus or cutaneous without an invasive . For exam- four years ago. He was taking chronic human papillomavirus.1 ple, if a neoplasia is contained within tacrolimus and low-dose prednisone. Imaging helps determine lesion the epithelium and has not pene- On examination, the right lids and progression or therapeutic response in trated the basement membrane, it is visible conjunctiva appeared normal, cases of suspected neoplasm. Slit lamp termed CIN. Full-thickness epithelial and the prosthetic was in a good photography and ultra-high-res OCT involvement with signifi cant cellular position. The patient refused prosthe- (UHR-OCT) shed light on baseline atypia on histopathology but an intact sis removal to view the remainder of fi ndings, including a diffusely thick- basement membrane is considered the conjunctiva and ensure no orbital ened and hyper-refl ective epithelium squamous carcinoma in situ. If the implant exposure. with an abrupt transition zone consis- basement membrane is not intact and In the left eye, vision was 20/20 and tent with OSSN (Figures 1, 2 and 3). there is invasion of underlying tissue, intraocular pressure was 17mm Hg. The patient was referred to an it is considered invasive squamous cell Pupillary function and extraocular anterior segment surgeon who spe- carcinoma. motilities were normal. The posterior cializes in ocular surface tumors. He segment was also unremarkable. On was prescribed 5-fl uorouracil (5-FU) DIAGNOSIS slit lamp exam, there were scattered, QID for one week and advised to Differentiation of lesions may include thickened leukoplakic lesions over the then take three weeks off treatment. the use of clinically available dyes, nasal and inferior bulbar conjunctiva It was expected that he would need with attendant moderate injection. eight one-month cycles of treatment. Near the limbus, the lesions became Unfortunately, at his six-week follow more gelatinous in appearance and up, he had not yet obtained the top- involved nearly six clock hours, from ical chemotherapeutic agent and his 6:00 to 12:00. There were fl at, opales- lesion had progressed (Figure 4). cent lesions peripherally with fi mbri- ated extension onto the cornea, which OCULAR SURFACE LESIONS stained positively with rose bengal. Ocular surface lesions can vary widely The concern for ocular surface in presentation and morphology. Fig. 2. Gelatinous and leukoplakic squamous neoplasia (OSSN) prompt- When evaluating any conjunctival or features of the lesion, with attendant ed further questioning. The patient corneal lesion, our list of potential di- vascular engorgement.

40 REVIEW OF CORNEA & CONTACT LENSES | MARCH/APRIL 2020 such as rose bengal, methylene blue logic evaluation remain useful in and toluidine blue. Each dye will stain the diagnosis of suspicious lesions. devitalized or degenerated epithelial carry inherent risks of bleed- cells, which are commonly seen in ing, scarring, incomplete excision, epithelial neoplasms. The dye uptake recurrence, further seeding of neoplas- is not specifi c to neoplasms, howev- tic cells, limbal stem cell defi ciency er, and may be seen in some benign and inadequate sampling in cases of lesions or severe .2 incisional biopsy. Excisional biopsy In recent years, UHR-OCT has of a suspected neoplastic lesion uses garnered attention as a noninvasive, a “no-touch” technique, in which Fig. 4. Ten weeks later, the lesion had slightly progressed, as the patient in vivo imaging technique for ocular conjunctival lesions are completely ex- had not obtained his medication. surface neoplasms. It is a specially de- cised with 3mm to 4mm margins and signed anterior segment OCT instru- cryotherapy is applied to the edges of tolerability and low side effect profi le ment with a resolution of 3µm that excision.7 Absolute alcohol is often but is often the most costly of the can reveal abnormal characteristics. applied, and an amniotic membrane three medications. In cases of OSSN, UHR-OCT shows may also be used. a thickened, highly hyper-refl ective n our patient, the clinical suspicion epithelium (>120µm) that abruptly TREATMENT Ifor OSSN was supported by UHR- transitions to a normal epithelium.3,4 OSSN treatment has vastly changed OCT. This “optical biopsy” can aid in Pterygia imaging demonstrates a over the last 15 to 20 years. While both initial diagnosis and continued normal to mildly thickened epithelium excisional biopsy is still used for management of ocular surface lesions. with moderate hyper-refl ectivity and a ocular surface tumors, topical chemo- We hope that our patient responds hyper-refl ective fi brillary layer under therapy has increased in popularity positively to topical therapy and will the conjunctival or corneal epithelium. due to its less invasive nature, reduced follow him on a regular basis with An amelanotic melanoma is associ- complication rate and ability to treat repeat UHR-OCT imaging to monitor ated with a normal to slightly thick the entire surface, including areas of for improvement. RCCL epithelium over a signifi cantly hy- subclinical disease that could lead to 1. Carreira H, Coutinho F, Carrilho C, et al. HIV per-refl ective subepithelial lesion with recurrence. The three most common- and HPV infections and ocular surface squamous 5,6 neoplasia: systematic review and meta-analysis. posterior shadowing. Though UHR- ly used topical agents are interferon Br J Cancer. 2013;109(7):1981-8. OCT is not adapted for mainstream alpha-2b (IFN), 5-FU and mitomycin 2. Nanji AA, Mercado C, Galor A, et al. Updates in 5,8 ocular surface tumor diagnostics. Int Ophthalmol use, there are commercially available C (MMC). Each is effi cacious, but Clin. 2017;57(3):47-62. instruments with resolutions of 5µm there are no randomized controlled 3. Sepulveda R, Pe’er J, Midena E, et al. Topical chemotherapy for ocular surface squamous to 7µm that may provide diagnostic trials to compare them directly. neoplasia: current status. Br J Ophthalmol. data to help differentiate lesions.5 MMC has the highest reported 2010;94(5):532-5. 4. Nanji AA, Sayyad FE, Karp CL. Topical chemo- Surgical excision and histopatho- complication rates of epitheliopathy, therapy for ocular surface squamous neoplasia. Curr Opin Ophthalmol. 2013;24(4):336-42. redness, keratitis, lim- 5. Nanji AA, Sayyad FE, Galor A, et al. High-resolu- bal stem cell defi ciency tion optical coherence tomography as an adjunc- tive tool in the diagnosis of corneal and conjuncti- and punctal stenosis. val pathology. Ocul Surf. 2015;13(3):226-35. 6. Shields JA, Shields CL, De Potter P. Surgical Punctal plugs must management of conjunctival tumors: the 1994 be used with MMC. Lynn B. McMahan lecture. Arch Ophthalmol. 1997;115(6):808-15. While 5-FU’s side 7. Shousha MA, Karp CL, Canto AP, et al. Diagnosis effects are similar to of ocular surface lesions using ultra-high-resolu- tion optical coherence tomography. Ophthalmolo- MMC, they’re also less gy. 2013;120(5):883-91. profound. IFN is often 8. Kieval JZ, Karp CL, Abou Shousha M, et al. Fig. 3. UHR-OCT captured the thickened, hyper- Ultra-high resolution optical coherence tomog- the treatment of choice raphy for di erentiation of ocular surface squa- refl ective epithelium (star) and the abrupt refl ectivity mous neoplasia and pterygia. Ophthalmology. change (arrow), both of which are consistent with OSSN. due to its improved 2012;119(3):481-6.

REVIEW OF CORNEA & CONTACT LENSES | MARCH/APRIL 2020 41 The Big Picture By Christine W. Sindt, OD

Early Adopter, Chronic Su erer A 1990s LASIK patient’s troubled course continues nearly 30 years later.

53-year-old female with a of patients when cells extend into the areas of necrotic cells more than 2mm history of bilateral myopic visual axis and reduce vision, induce from the fl ap edge, with no demar- LASIK, performed in astigmatism and/or cause keratolysis cation line; the fl ap is rolled with a 1992, was referred with or foreign-body sensation.1 thickened, whitish-grey appearance. Aepithelial ingrowth OU. She previ- Risk factors include type of refrac- Stage 4 shows aggressive growth and ously underwent enhancement proce- tive correction (hyperopic>myopic), strands of epithelial cells near the vi- dures in each eye (radial keratotomy surgical instrumentation (microker- sual axis. As there is concern for fl ap OS, astigmatic keratotomy OU) and atome>femtosecond), retreatment, melt, it requires urgent treatment.2 had a fl ap lift for epi ingrowth OD location of fl ap hinge, corneal The most common intervention 10 years prior. She complained of de- epithelial injury, fl ap dislocation, is mechanical debridement of the creased vision (OD>OS) but denied type 1 diabetes, epithelial basement fl ap-stromal interface. Amniotic pain, discomfort or irritation. membrane dystrophy and possibly membrane graft may be used in cases Post-LASIK epithelial ingrowth is increasing age.1 associated with fl ap injury or melting. a rare complication characterized by Ingrowth is staged into four cate- Our patient was diagnosed with the ingrowth of corneal epithelium gories. Stage 1 is non-progressive; one Stage 1 epithelial ingrowth and at the interface between the fl ap and to two cells within 2mm of the fl ap surgical treatment was deferred. She stromal bed. It has been reported in edge with a well-delineated white line was referred for contact lens fi tting to up to 3.9% of patients after initial on the advancing edge. Stage 2 has help with her blurred vision. RCCL

surgery but up to 20% if the fl ap is thicker cell growth with no demarca- 1. Ting DSJ, Srinivasan S, Danjoux JP. Epithelial ingrowth 1 following LASIK: prevalence, risk factors, maangement lifted for retreatment. While most tion line; the leading edge of the fl ap and visual outcomes. BMJ Ophthalm. 2018 Mar 29;3(1). cases are self-limited, surgical treat- is rolled or grey with no melt. Stage 3 2. Yesilirmak N, Chhadva P, Cabot F, et al. Post-LASIK epithelial ingrowth: treatment, recurrence and long- ment is required in 0.92% to 3.2% has thick ingrowth with geographic term results. Cornea. 2018;37(12)`51`7-21.

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