Orthokeratology Expert Not Just for Adults Don’T Let Misconceptions Stop You from by Elyse L

RCCL REVIEW OF CORNEA & CONTACT LENSES

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RCCL0217_Coopervision Biofinity.indd 1 1/24/17 10:06 AM contents Review of Cornea & Contact Lenses | January/February 2017

departments features

Myopia on the Move News Review 4 Steady growth in the prevalence of this Evidence Supports Long-term deceptively simple condition will expose Effi cacy of Collagen Crosslinking half the world’s population to visual impairment. Here’s what to expect and what we should do. My Perspective 12 6 By Monica Jong, PhD, BOptom, Padmaja Sankaridurg, PhD, BOptom, Get to Know Your Genes Timothy R. Fricke, BOptom, MSc, By Joseph P. Shovlin, OD Thomas John Naduvilath, PhD, Serge Resnikoff , MD, PhD, and 7 Guest Editorial Kovin Naidoo, OD, PhD Combating Online Contact Lens Sales CE — Fitting Multifocal By Andrea P. Thau, OD, AOA president Contact Lenses for Myopia Control Fitting Challenges 8 These practice The Right Lens for a Corneal Scar pearls aid in myopia management, By Vivian P. Shibayama, OD 16 including avoiding The GP Experts onset and slowing 34 progression in Treating Infantile Aphakia: Think GPs patients of all ages. By Robert Ensley, OD, and By Padmaja Sankaridurg, PhD, BOptom Heidi Miller, OD 36 Pharma Science and Practice 10 Tips From an Corneal Collagen Crosslinking: Orthokeratology Expert Not Just for Adults Don’t let misconceptions stop you from By Elyse L. Chaglasian, OD, and using this treatment modality that can Tammy Than, MS, OD provide a huge beneﬁ t to patients with 22 myopia. 38 Corneal Consult By Cary M. Herzberg, OD A New Year, A New Look at the Cornea Reshaping Ortho-K By Aaron Bronner, OD Toric Lenses can expand myopia Practice Progress management to include patients with 40 astigmatism. Daily Disposables: Eff ective From By Daddi Fadel, DOptom Allergy to Astigmatism 26 By Mile Brujic, OD, and David Kading, OD

The Big Picture Keys to a Pediatric 42 Soft Lens Fitting Retained PK Sutures From infancy to adolescence, contact By Christine W. Sindt, OD lenses prove a viable and beneﬁ cial treatment option for a range of conditions. 30 By Erin C. Jenewein, OD, MS, and Kriti Bhagat, OD Become a Fan on Follow Us On Facebook Twitter

/ReviewofCorneaAndContactLenses @RCCLmag REVIEW OF CORNEA & CONTACT LENSES | JANUARY/FEBRUARY 2017 3 News Review

IN BRIEF ■ Meibomian gland damage may be re- Evidence Supports Long-term versible in patients with meibomian gland dysfunction (MGD), a recent study in Cor- Effi cacy of Collagen Crosslinking nea suggests.1 The key treatment used in the study was an artifi cial lubricant four times a day, coupled with eyelid hygiene orneal collagen crosslink- Lens division at the Center for once a day. Researchers found the dual ing (CXL) may be effec- Keratoconus-Cornea and Laser Eye approach resulted in a 5.4% decrease in MG dropout in upper eyelids and a tive in managing kerato- Institute, Teaneck, NJ. “Therefore, 4.6% decrease of MG dropout in lower Cconus for longer than two it is important to minimize or eyelids, as well as improvement across all clinical indices for study participants who years, according to a recent study eliminate extrinsic factors that heeded the instructions to take care of in the journal Cornea. A possible can exert mechanical strain on the eyelid hygiene.Participants who ignored reversal of CXL effects after four ocular surface, which presumably doctors’ orders did not experience the same improvement, save for some in the years was also discovered. can destabilize therapeutic effects ocular surface disease index. The study followed 377 eyes conferred by CXL.” 1. Yin Y, Gong L. Reversibility of gland dropout and in pediatric patients ages eight Clinicians must remain vigilant in signifi cance of eyelid hygiene treatment in meibomian gland dysfunction. Cornea. October 14, 2016. [Epub to 18, all of whom had progres- managing ocular comorbidities such ahead of print]. sive keratoconus and underwent as dry eye and atopic or allergic ■ The fi rst Descemet’s membrane endo- CXL. Of the eyes tracked, 194 conditions, Dr. Chang says, as well thelial keratoplasty (DMEK) patient re- had follow-ups more than two as educate patients about both the cently presented for a 10-year follow up, and the clinical outcomes are encourag- years post-treatment, the results of risks of long-term regression and ing, according to a recent report.1 The pa- which show a signifi cant improve- the importance of compliance with tient showed all the short- and long-term ment in mean spectacle-corrected clinical monitoring to detect the characteristics of this endothelial keratoplasty technique, including outstanding distance visual acuity (CDVA), a potential need for retreatment. patient satisfaction, quick visual recovery, reduction in mean topographic The study also found that 17.1% low incidence of complications and graft longevity. Best spectacle-corrected visual astigmatism, fl attening of ker- of eyes in the study presented acuity in both eyes remained stable from atometry (Kmax) and corneal thin- topographic coupling effects—in the initial postoperative improvements. ning of 31.1 ± 36.0µm. which fl attening of one meridian is While this case covers just one patient’s Despite these promising results, accompanied by steepening of the outcome, results such as these may show the potential for DMEK to be adopted as the study also revealed the effects orthogonal meridian—suggesting the preferred treatment option for corne- of CXL reversed after four years a compensatory biomechanical al endothelial disorders in the future. post-treatment in some eyes. response. “If we can control and 1. Baydoun B, Müller T, Lavy I. Ten-year clinical outcome of the fi rst patient undergoing Descemet membrane The researchers noted stabili- maximize such coupling effects, endothelial keratoplasty. Cornea. December 8, 2016. [Epub ahead of print]. zation or fl attening of Kmax in then better visual outcome after 85% of eyes at two years, which CXL may be achieved,” Dr. Chang With this issue, Review of Cornea & Contact Lenses adopts a bimonthly publishing dropped to 76% after four years. says. “Thus, it is essential for future frequency with more content per issue, as it CDVA improved in 80.1% of eyes investigations to identify patient expands its slate of contributors: at two years, but only in 69.1% at variables associated with such A new Guest Editorial column will tackle controversies of the day, starting this month four years. After four years, 24% topographic coupling events, as well with AOA President Andrea Thau, OD, showed steepening of the cornea as determine clinical characteristics addressing online contact lens sales, p. 7. Expert specialty contact lens practitioner and 30.9% showed reduced visual that may better predict the dura- Vivian Shibayama, OD, explains how to acuity, suggesting possible progres- tion of CXL stabilization effects in approach hard-to-fi t patients in Fitting Challenges, p. 8. sion of the disease after four years. different patient subgroups.” Aaron Bronner, OD, gives advice from his Some note that these fi ndings unique multispecialty comanagement setting are not statistically signifi cant 1. Padmanabhan P, Reddi SR, Rajagopal R, et al. in the Corneal Consult column, p. 38. Corneal collagen cross-linking for keratoconus in the current study, however. in pediatric patients—long-term results. Cornea. David Kading, OD, joins long-time RCCL 2017;36(2):138-143. contributor Mile Brujic, OD, in coauthoring “Confounding factors like thinner Practice Progress, p. 40. corneal pachymetry expected after Associate Clinical Editor Christine Sindt, OD, Advertiser Index shares large-format images from her university- CXL further make it challenging based practice in The Big Picture, p. 42. to diagnose regression at its im- Alcon ...... Cover 4 Additional enhancements will debut later this mediate resurgence,” says Clark CooperVision...... Cover 2 year online at reviewofcontactlenses.com. Chang, OD, director of the Contact X-Cel Specialty Contacts ...... Cover 3

4 REVIEW OF CORNEA & CONTACT LENSES | JANUARY/FEBRUARY 2017 Up to 18-28 CE NEW TECHNOLOGIES 2017 & TREATMENTS IN RCCL Credits* REVIEW OF CORNEA & CONTACT LENSES Eye Care

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EDITORIAL REVIEW BOARD Mark B. Abelson, MD James V. Aquavella, MD Edward S. Bennett, OD Aaron Bronner, OD Orlando, FL Philadelphia, PA Brian Chou, OD Kenneth Daniels, OD June 8-11, 2017 November 3-5, 2017 S. Barry Eiden, OD Disney’s Yacht & Beach Club Loews Philadelphia Hotel Desmond Fonn, Dip Optom M Optom Gary Gerber, OD Program Chair: Paul Karpecki, OD Program Chair: Paul Karpecki, OD Robert M. Grohe, OD Susan Gromacki, OD Patricia Keech, OD Bruce Koffler, MD Pete Kollbaum, OD, PhD Jeffrey Charles Krohn, OD Kenneth A. Lebow, OD Check Our Website for the Latest Information! Jerry Legerton , OD Kelly Nichols, OD Robert Ryan, OD Jack Schaeffer, OD www.reviewofoptometry.com/events Charles B. Slonim, MD Kirk Smick, OD E-mail: [email protected] | Call: 866-658-1772 Mary Jo Stiegemeier, OD Loretta B. Szczotka, OD Michael A. Ward, FCLSA Barry M. Weiner, OD Barry Weissman, OD 14th Annual Education Symposium Administered by Joint Meeting with NT&T In Eye Care OPTOMETRIC CORNEA, CATARACT ® AND REFRACTIVE SOCIETY San Diego, CA, April 22-23, 2017 Review of Optometry *Approval pending

†Workshops not available for “Aspen, CO” meeting. See Review website for any meeting schedule changes or updates. Stock Images: ©iStock.com/JobsonHealthcare My Perspective By Joseph P. Shovlin, OD

Get to Know Your Genes One day, genetic testing and gene therapy may help patients avoid corneal disease altogether.

esearch suggests there is now available to identity Avelli- patients.6 When ordering tests, it are nearly 500 different no’s corneal dystrophy. is the clinician’s duty to educate eye-related diseases, • The Asper Biotech test screens patients on the likelihood that they with more than 800 for 333 mutations in 13 genes for have a particular disease, the spec- Rocular and periocular corneal dystrophy.5 trum of disease possibilities (from manifestations of systemic disease. • Researchers have been investi- mild to severe), recurrence rates, Hundreds of genes, if mutated, can gating gene therapy to improve the chance of passing the condition to cause disease isolated to the eye.1 quality of donor tissue for corneal offspring, possible treatments and Fortunately, genetic testing can aid grafts, which might decrease the reproductive alternatives.5,6 health care providers in managing risk of graft failure and rejection. The ramifi cations of knowing inherited diseases. Specifi cally, that you have the genes for a genetic testing is benefi cial for (1) a THERAPY ADVANCES particular disease without a current confi rmational diagnosis, (2) new- The key is to target therapy with treatment can be traumatic. For- born screening, (3) carrier screen- testing prior to gene expression. tunately, patients are protected by ing and (4) forensic testing.1-3 Gene augmentation—treatment the Genetic Nondiscrimination Act, Exciting new frontiers are for defi cient genes—is easier than which does not allow health care providing measures for pharmaco- gene knock-out therapy (blocking a insurers or employers to discrimi- genomics, whole genome and gene causing a detrimental effect).4 nate based on genetic predisposi- whole exome sequencing, and even For example, gene augmentation tion or pre-existing conditions.5 tumor analysis.2 The latter, for ex- therapy is now possible for Leb- ample, looks at genetic alterations er’s congenital amaurosis when a he last two decades have seen that drive tumor growth and the RPE65 defi ciency is found. Tan explosion of research in genetics that help predict therapeu- Using nanoparticles as vectors genomics, with rapidly expanding tic response. for delivering DNA is an exciting genetic medicine. Gene therapy Identifi cation of susceptibility advancement.4,5 For example, specifi c to the cornea and anterior loci has helped researchers better researchers recently used lentivi- segment is a particularly exciting understand the complex patho- ral-mediated genetic modifi cation frontier, considering corneal disease physiology of several ocular and of cultured endothelial cells to is responsible for a signifi cant neurologic diseases.4 deliver genes to the endothelium.5 amount of blindness worldwide. Creating new viral vectors with Ocular gene testing and therapy CLINICAL APPLICATIONS directed evolution is the key to research is robust with a high pri- Many recent fi ndings in eye care timely adoption. Researchers can ority in funding and should prove are a result of genetic testing, and now create viruses in the lab to fruitful in the very near future. RCCL some are applicable to therapy maximize their diversity and can 1. Uthra S, Kumaramanickavel G. Gene ther- today: promote the evolution of viruses, apy in ophthalmology. Oman Ophthalmol. • Though controversial, research through an artifi cial selection pro- 2009:2(3):108-10. 2. American Medical Association. Genetic Testing. suggests there may be a different cess, that have the traits researchers Available at www.ama-assn.org/content/genet- response to the AREDS formula need.3 ic-testing. Accessed December 5, 2016. 3. Bethke W. The future of gene therapy. Rev based on specifi c genotypes, and Ophthalmol. 2016:23(4):36-9. testing for the genotype for which KEEP PATIENTS INFORMED 4. Fritsche LG, Fariss RN, Stambolian D, et al. Age related macular degeneration: genetics and biolo- zinc supplementation may be As helpful as genetic testing can gy coming together. Annu Rev Genomics Hum pro-infl ammatory in patients with be, it can raise both social and Genet. 2014;15:151-71. 5. John T. Decoding the genetics of corneal macular degeneration could impact ethical issues, and clinicians must disease. Rev Cornea Contact Lenses. 2014 June:24-8. therapy. be careful to discuss the value and 6. Bateman B, Silva E. AAO Task Force on Genetic • For the cornea, genetic testing limitations of genetic testing with Testing. Ophthalmol 2013;120(10):e72-3.

6 REVIEW OF CORNEA & CONTACT LENSES | JANUARY/FEBRUARY 2017 Guest Editorial By Andrea P. Thau, OD, AOA President

Combating Online Contact Lens Sales We must stand together to protect healthy vision and responsible enterprise.

ptometrists are fi eld- forms to obtain copies of cus- gressively building support for the ing attacks from all tomer contact lens prescriptions. bipartisan Contact Lens Consumer sides—not simply on This is further evidenced by the Health Protection Act. The bill our profession, but Federal government’s suit against calls for bolstering patient safety Oactions that could ul- 1-800-Contacts for alleged activities requirements, increasing account- timately fracture the doctor-patient that “had the purpose, capacity, ability for internet contact lens sales relationship and potentially put tendency and likely effect of re- and reinforcing the distinction that our patients’ health at risk. Online straining competition unreasonably contact lenses are medical devices contact lens retailers are primary and injuring consumers.”1 and should be treated that way—all and long-time aggressors who use But along with wins, there are of which the FTC should support. deceptive practices, underhanded sometimes setbacks, and the Federal The health and safety of the pa- loopholes and, sometimes, blatantly Trade Commission’s (FTC) recent tients we serve is at the heart of this illegal tactics to line their pockets proposed rule is just that. matter, and the AOA, along with and build their bottom lines. The AOA vigorously objects member ODs, our paraoptometric Like other physicians, eye doctors to the FTC’s misguided propos- colleagues and optometric students, take an oath and hold ourselves to al, which adds new prescription will continue to fi ght for patient the highest standards to protect our requirements to the Contact Lens safety. For every doctor of optom- patients’ health. The oath guides Rule. The proposal makes clear that etry in America, the surest way to the way we practice and compels the agency is hearing from those fi ght back against internet sellers us to advise patients of all their who question whether doctors of and the harm they cause patients is options to restore, maintain or optometry are following the law to support the AOA and your state enhance vision, as well as eye and and does not take the illegal practic- optometric association. overall health. We do this within es of some retailers into account. a competitive marketplace bound With the active involvement of ur past advocacy efforts show by laws and regulations, which our member doctors, state optomet- Othat optometry is stronger are constantly evolving as care ric associations, concerned physi- when we all work together, and we advances. cians, as well as public health and ask every doctor to join in the fi ght consumer protection organizations, with the AOA to uphold patient LEGISLATIVE LANDSCAPE we are making the case for changes safety against online contact lens Unfortunately, the full picture of and will not stop until our concerns retailers and their profi t-driven the 2016 contact lens legislative and are clearly understood by agency business practices. regulatory landscape made it clear offi cials. This will not be a quick or 1. Federal Trade Commission. Complaint In the Mat- online contact lens retailers are us- easy process, but one the AOA will ter of 1-800 Contacts, Inc., a corporation. August 8, 2016. Available at www.ftc.gov/system/fi les/docu- ing misinformation and subterfuge see through to the end. ments/cases/160808_1800contactspt3cmpt.pdf. to divert attention away from their Accessed December 21, 2016. unscrupulous business practices and A UNITED FRONT gain advantage in the marketplace. We need the involvement and ABOUT THE AUTHOR The American Optometric activism of all of our colleagues to Dr. Thau is president of the American Association (AOA), doctors of get this proposal changed. The FTC Optometric Association (AOA). She was optometry and the patients we asked for public comments and is elected to the AOA Board of Trustees in 2007 and president in July 2016. Dr. Thau serve are gaining ground in the fi ght now considering the issue further. also serves as chair of the AOA’s Executive against these abusive and illegal Moreover, we need to hold and Agenda Committees and is a member of the Personnel Committee. She serves as practices. We’ve exposed deceptive internet sellers accountable, and the liaison trustee for the American Academy tactics—such as 1-800-Contacts’ AOA and state optometric associ- of Optometry (AAO) and the College of Optometrists in Vision Development (COVD). improper use of pre-checked order ations are leading the effort by ag-

REVIEW OF CORNEA & CONTACT LENSES | JANUARY/FEBRUARY 2017 7 Fitting Challenges By Vivian P. Shibayama, OD

The Right Lens for a Corneal Scar It’s not easy ﬁ tting a ﬁ ve-year-old with a specialty lens to correct irregular astigmatism.

hildren younger than and quiet OU. Exam of the corneal DISPENSING seven who need a surface revealed a clear right cornea The patient presented with her specialty contact lens and an elevated 2.7mm horizontal mother with no new complaints and fi tting can be some of inferior temporal scar on her left I inserted the lens (Figure 2). The Cthe most challenging cornea—no staining or vessels OU. lens exhibited light one-third touch patients we encounter. Kids are vul- Manifest refraction OD was plano inferotemporally with pooling over nerable to amblyopia, which makes VA 20/20, OS was +4.25+5.50x075 the rest of the cornea. The peripher- the stakes even higher. The need for VA 20/30-. Corneal topography real edge was wide with good overall specialty lenses at a young age can vealed a fl at cornea with steepening centration of the lens and movement occur for a variety of reasons, such at the corneal scar (Figure 1). Sim with blink. VA measured 20/25 with as aphakia, high refractive error, K measured 46.17/40.62 OS and the GP in place OD. The patient’s anisometropia, iris defects, irregular 5.62D of astigmatism. mother was instructed on care, in- astigmatism from corneal scarring sertion and removal, and advised to or keratoconus. Let’s discuss a chal- DIAGNOSTIC FITTING build wearing time, starting at two lenging case in which a child with Although we started with a scleral hours a day with the goal of eight to irregular astigmatism from a corneal lens due to the irregularity of the 10 hours a day. scar needed a specialty contact lens. periphery, insertion was unsuccessful. The patient was very reactive FOLLOW-UP #1 CASE REPORT and could not fi xate her eyes so that One week later, the patient present- A fi ve-year-old female presented for the lens could be inserted without a ed with complaints that the lens a contact lens evaluation to correct bubble inside the lens. After several hurt after a few hours of wear, and irregular astigmatism from a corneal attempts, I decided to try a corneal she was unable to wear it more than scar. Her pediatric ophthalmologist gas permeable (GP) lens instead. I three hours per day. Some redness, referred her for a unilateral contact chose a large diameter intralimbal but no discharge, was observed. lens fi t over an eye that had a cor- GP design (GBL, Concise) as the di- Presenting VA was 20/25 OD with neal dermoid removed at age three. agnostic lens. This lens also features the contact lens. No over-refraction She was currently managed with a reverse geometry design in the mid was measured. Fluorescein was glasses and was patched two hours periphery, which would allow it to instilled, and I observed that the per day with good compliance. clear the steep elevation in the mid lens had adhered to the cornea, Medical history was positive for periphery without adding too much exhibiting little movement and was Goldenhar syndrome and negative clearance over the central cornea. I decentered temporally over the scar. for systemic medications. She ex- fi rst tried a 45.00D (7.50) lens based With the lens removed to evaluate hibited no other ocular history and off the average of the steeper cur- the cornea, there was 1+ punctate neither did her family. Presenting vature readings over the scar. The staining over the corneal scar. best-corrected visual acuity (VA) lens was slightly fl at over the cornea Modifying the GP would unlikely was 20/20 OD, 20/50 OS. Her scar with a somewhat tight edge achieve better results, as opening the current spectacle Rx was -0.50+0.50 and pooling superior nasal. Over- periphery to increase movement and x168 OS: +3.00+3.75x070. refraction resulted in VA of 20/25. increasing the vault over the scar Pupils were round and reactive to I ordered the lens 0.75D steep to would likely still result in the lens light, with no relative afferent pupil- take the lens pressure off the scar migrating towards the steep eleva- lary defect in either eye. Extraocular with fl atter peripheral curves than tion of the scar. I decided to piggy- movements were full OU. A slit standard to assist in distributing the back the GP with a soft lens. lamp exam demonstrated that the weight of the lens across the cornea. I used a +3.00 Air Optix Night & lids were clear, the conjunctiva First lens: Base curve 7.38, power: Day (Alcon) to create a buffer be- white and quiet, the iris and lenses +3.25, diameter:11.2, P1:0.4/9, tween GP and eye. I chose a higher clear, and the anterior chamber deep P2:0.4/10.5, P3:0.4/12. plus lens to aid in shifting the steep

8 REVIEW OF CORNEA & CONTACT LENSES | JANUARY/FEBRUARY 2017 Up to 10 CE Credits* 14TH ANNUAL EDUCATION SYMPOSIUM

Optometric Cornea, Cataract and Refractive Society lubrication with artifi cial tears. On slit lamp exam April 22-23, 2017 and instillation of fl uorescein, Marriott Del Mar the lens was San Diego, CA again decentering temporally with little movement. The meeting of the year for Fig. 1. Topography of left eye. An overall fl at cornea with When the lens inferior temporal steepening at the corneal scar. ODs involved and interested was removed, no in advanced ocular disease area centrally so the lens would staining was observed. Other than management, refractive decenter less. On slit lamp exam, the the scar, the cornea was clear. surgery, cataract surgery and GP moved well over the soft lens. Because any GP would most VA was 20/30. Over-refraction of likely shift towards the elevation, we innovative technologies. the combined system (-0.50) would discussed using a scleral lens again be added to the GP if the patient did and I performed an in-offi ce evalu- well. I prescribed Polytrim (poly- ation, during which the patient was Interactive Workshops:** myxin B/trimeth o prim, Allergan) very cooperative. I used a Europa for a few days to prevent infection (Visionary Optics) fi tting set and • Therapeutics and and advised her to start lens wear chose a 45.00D/16.0 diameter lens Post-Op Complications after fi nishing the antibiotic course. as the fi rst diagnostic lens simply be- Mom was again trained on insertion cause it was in the middle of the set. • Pre-Operative Diagnostics and removal and instructed to have Upon insertion, the child noted an her daughter wear the lens no more immediate improvement in comfort. Up to 10* hours of COPE CE than four hours per day as long as Slit lamp exam revealed excessive will be provided to attendees. the lens is comfortable. clearance of about 450µm. When I See registration website for tried a 42D lens, it exhibited about more details. FOLLOW-UP #2 200µm of central clearance on The patient presented the next initial evaluation, which was ideal. week. Though lens tolerance was The lens landed outside the limbus much improved, she didn’t think she and centered well. The periphery REGISTER ONLINE: could wear it more than four hours appeared tight, exhibiting slight www.reviewofoptometry.com/sandiego2017 per day, as she needed frequent conjunctival vessel compression. Given the child’s positive initial re- action, I ordered a 42.50/+6.25/16.0 For more information contact: diameter, 1 fl at periphery lens to be dispensed the next week. The base Andrew Morgenstern, OD, [email protected] curve was slightly steepened to compensate for the change in the sagittal Clark Chang, OD depth with a 1 fl at periphery. [email protected] Visit www.occrs.org SCLERAL LENS DISPENSE At the second lens dispense a week Fig. 2. GBL lens on fi rst dispense. Note the light touch of the lens over later, the patient hadn’t been wear- OPTOMETRIC CORNEA, CATARACT the area of the corneal scar. ing any lenses for the past week. AND REFRACTIVE SOCIETY

Administered by ® Review of Optometry *Approval pending

**Separate registration required. Agenda is subject to change. Fitting Challenges By Vivian P. Shibayama, OD

The scleral lens cleared the cen- preferable to a spectacle correction. tral cornea by about 200µm. The Additionally, the process of accli- fl uorescein extended from limbus to mating a child to lens wear can be limbus and the lens landed on the emotionally taxing on the parents, conjunctiva without impinging on and they need to be reassured they the sclera. VA was 20/25 OS. Mom are not hurting their child. Spending was trained on insertion, removal time on this conversation is essential and care. The patient was instructed to the child’s visual success. to return the following week. Fig. 3. Scleral lens in place at fi rst or children with irregular astig- FOLLOW-UP #3 follow-up. A white and quiet eye after eight hours of successful wear. Fmatism or high refractive error, One week later, the patient said she vision rehabilitation should begin was able to wear the lens for 10 them home with artifi cial tears or right away to prevent amblyopia. hours a day without any complaint even a soft contact lens to practice. This case emphasizes the impor- (Figure 3). Uncorrected VA mea- This will help acclimate the child to tance of using your full arsenal of sured 20/20 OD and 20/25 OS. No the task, as with this patient. contact lens options to address the over-refraction was noted over the The process of fi tting a contact different needs of each child. RCCL left lens. The lens was fi nalized and lens can vary from child to child. 1. Luo W, Tong JP, Shen Y. Rigid gas permeable con- the patient was asked to return in With younger or less cooperative tact lens for visual rehabilitation in aphakic following six months for a follow-up. children, GP diagnostic lenses of trauma. Clin Exp Optom. 2012;95:499-505. 2. Pieramici DJ, Sternberg P Jr, Aaberg TM Sr, et al. A known base curves and their fl uo- system for classifying mechanical injuries of the eye DISCUSSION rescein patterns can help determine (globe). The Ocular Trauma Classifi cation Group. Am J Opthalmol. 1997;123:820-31. Several studies show that vision corneal curvature. 3. Netto AL, Fioravanti Lui AV, Fioravanti Lui GA. rehabilitation of irregular astigma- To fi t a corneal scar, the fl uoresce- Visual rehabilitation with contact lenses after ocular trauma. Arq Bras Oftalmol. 2008;71:23-31. tism or high refractive error with in pattern of an GP should exhibit 4. Lin PW, Chang HW, Lai IC, Teng MC. Visual out- contacts lenses is more effective two-thirds pooling and one-third comes after spectacles treatment in children with bilateral high refractive amblyopia. Clin Exp Optom. than spectacles.1-4 GPs are able to light touch over the entire cornea. 2016;99:550-4. 5. Jupiter DG, Katz HR. Management of irregular correct irregular astigmatism as well The lens should center well and astigmatism with rigid gas permeable contact lens- as eliminate the aniseikonia from move adequately to provide tear ex- es. CLAO J. 2000;26:14-7. 6. Kanpolat A, Ciftci OU. The use of rigid gas unequal prescriptions when the change for optimal corneal health. permeable contact lenses in scarred corneas. CLAO irregularity is unilateral.5,6 For chil- In cases where GPs fail, sclerals can J. 1995:2. 7. Shaughnessy MP, Ellis FJ, Jeff rey AR, Szcotka L. dren, the high oxygen material of be effective, as they are tolerated Rigid gas permeable contact lenses are a safe and the lenses combined with involving well in the pediatric population.10,11 eff ective means of treating refractive abnormalities in the pediatric population. CLAO J. 2001-27:195-201. the parents in the care lowers the The lens can often compensate for 8. Pradhan Z, Mittal R, Jacob P. Rigid gas-permeable risk for contact lens complications.7 GP issues such as ocular surface dis- contact lenses for visual rehabilitation of trauma- 12 tized eyes in children. Cornea. 2014;33:486-9. Children younger than seven are ease, decentration or intolerance. 9. Walters JL, Paules MG. Review of preclinical often too young to understand what studies on pediatric general anesthesia-induced developmental neurotoxicity. Neurotoxicology and needs to be done, but old enough EDUCATION IS ESSENTIAL Teratology. 2016 Nov 18. [Epub ahead of print]. to be traumatized by an aggressive Despite vision improvement for 10. Rathi V, Mandathara P, Vaddavalli P, et al. Fluid fi lled scleral contact lens in pediatric patients: Chal- approach, which may give them a most children, studies indicate a lenges and outcome. Contact Lens and Anterior Eye. negative association with the lens. contact lens dropout rate as high as 2012;35(4):189-92. 11. Gungor I, Schor K, Rosenthal P, Jacobs DS. The Using a soft approach is ideal, 36.8% in patients with unilateral ir- Boston scleral lens in the treatment of pediatric and you should always tell the child regular astigmatism.13 To help avoid patients. J AAPOS. 2008:12(3):263-7. 12. Pullum KW, Whiting MA, Buckley RJ. Scler- what you are doing and why. If you this, clinicians should ensure parent al contact lenses: the expanding role. Cornea. can, show them that you and their buy-in and educate them on why 2005:24(3):269-7. 13. Ozkan B, Elibol O, Yuksei N, et al. Why do parents wear contact lenses. If a the contact lens is necessary. They patients with improved visual acuity drop out of GP contact lens use? Ten year follow-up results in child is particularly resistant to any- also need to understand the risk of patients with scarred corneas. Eur J Opthalmol. thing being inserted in the eye, send amblyopia and why a contact lens is 2009:19:343-7.

10 REVIEW OF CORNEA & CONTACT LENSES | JANUARY/FEBRUARY 2017 Your job is about more than providing good patient care. To succeed, you have to navigate changing healthcare policies, keep up with the latest clinical advancements, manage your staff and run a successful business. Zero in on the topics impacting every aspect of your practice and career at SECO 2017, the largest conference in the world for optometric professionals and staff, and let us bring it all into sharp focus for you.

RO0217_House Seco.indd 1 1/17/17 3:51 PM on Myopia the MOVEMOVEMMOVEMOVEOVE

Steady growth in the prevalence of this deceptively simple condition will expose half the world’s population to visual impairment. Here’s what to expect and what we should do.

he general public has the data to predict trends and esti- at risk of developing permanent traditionally considered mate future prevalence. vision impairment and blindness myopia a simple refrac- associated with high myopia.6 tive condition correct- THE GLOBAL PREVALENCE Approaching 2050, the differ- Table by spectacles and A study by the Brien Holden Vision ence in prevalence rates between contact lenses with limited impact Institute (BHVI), published in Asia and the rest of the world start on permanent visual impairment. Ophthalmology in 2016, report- to decrease, with many regions This is not the case, however; myo- ed a meta-analysis of the global reaching a prevalence of more than pia is increasingly associated with a prevalence data on myopia and 50%, presumably due to increasing heightened risk of permanent vision high myopia since 1995.6 Using urbanization and socioeconomic impairment, as evidenced by reports the PubMed (National Library of development. For example, in 2010, of myopic macular degeneration as Medicine) database to review the the high-income Asia-Paciﬁ c nations a frequent cause of vision impair- literature, this study highlights the had a prevalence of 48.8%, while ment and blindness in Asia and condition’s prevalence across the 21 Eastern Europe and North Africa Western nations.1-5 regions of global burden of disease and the Middle East had prevalenc- Myopia already affects a mas- (GBD), which are countries grouped es of 25% and 14.2%, respectively. sive proportion of the population together based on their geographic in Asia.1 For example, Taiwan location and socioeconomic status ABOUT THE AUTHORS has rates of myopia of up to 84% (http://ghdx.healthdata.org/coun- Dr. Jong is senior research in school children, and 97% of tries). Evidence of varying preva- fellow at the Brien Holden 19-year-old South Korean male lence over time enabled our research Vision Institute (BHVI) in 2,3 Sydney, Australia, and a military conscripts are myopic. team to create functions to predict visiting fellow at the University Myopia is also becoming a problem the future prevalence of myopia and of New South Wales (UNSW), Australia. beyond East Asia, with the United high myopia from 2000 through How Dr. Sankaridurg is program States reporting increases in prev- 2050 by decade. (see, “ leader for the Myopia Program alence from 25% to 42% between BHVI Estimated Prevalence Rates at BHVI and an associate 1972 and 2002, and high myopia, Through 2050.”) professor at UNSW. in particular, increasing eightfold The model indicated the glob- from 0.2% to 1.6% in those older al prevalence of myopia affected Dr. Fricke is a consultant at than 30 over the same period.4 In almost 23% of the population in BHVI. Australia, where myopia levels are 2000. More importantly, it predicted generally considered to be low, the that amount would grow to 50% Sydney Adult Vascular and Eye of the world’s population by 2050 Dr. Naduvilath is head Study recently reported that almost (Figure 1). Nearly 1.5 billion people biostatistician at BHVI. 30% of 17-year-olds are myopic.5 were affected in 2000, and by 2050

Although individual studies this is expected to increase to almost Dr. Resnikoff is a consultant at provide essential information on fi ve billion.6 BHVI and a visiting professor the prevalence of myopia, they are High myopia is also set to rise at UNSW. diffi cult to generalize, as they cover from an initially low prevalence of Dr. Naidoo is CEO of BHVI, a specifi c ages, groups or places. For almost 3% in 2000 to close to 10% visiting fellow at UNSW and effective planning, policymaking in 2050. This equates to 163 million founder of the African Vision Research Institute, University and interventions regarding myopia, people in 2000, and by 2050 almost of Kwa Zulu Natal, South we must organize and understand one billion people will be potentially Africa.

12 REVIEW OF CORNEA & CONTACT LENSES | JANUARY/FEBRUARY 2017 By Monica Jong, PhD, BOptom, Padmaja Sankaridurg, PhD, BOptom, Timothy R. Fricke, BOptom, MSc, Thomas John Naduvilath, PhD, Serge Resnikoff , MD, PhD, and Kovin Naidoo, OD, PhD

But by 2050, the research suggests, The BHVI study results show annually, of which myopia was the the gap will close, with Eastern that, in the year 2000, the majority main cause.16 As a consequence of Europe reaching a prevalence rate of myopia was occurring in those rising myopia levels, the prevalence of 50.4%, North Africa and the younger than 40, refl ecting the of uncorrected refractive error and Middle East jumping to 52.2% and major change in lifestyle in children the associated burden will increase. high-income East Asia moving up and young people over the last two High myopia also increases the risk less signifi cantly to 66.4% (Figure decades, especially in Asia.6 Due to of potentially sight-threatening con- 2).6 urbanization and development, sim- ditions such as glaucoma, myopic ilar lifestyle factors will likely spread macular degeneration, cataracts and WHY THE INCREASE? to other parts of the world that are retinal detachment.17 One billion The projected increases in myo- still developing. people are predicted to be highly pia and high myopia are largely myopic by 2050, and the number considered to be driven by environ- IMPLICATIONS of people with vision loss resulting mental factors and lifestyle changes, As a consequence of the rising prev- from high myopia is predicted to such as reduced time outdoors and alence of myopia, there will be sub- increase sevenfold from 2000 to increased near-based activities.1 stantial demand for increased eye 2050.6 Based on these projections, Genetic predisposition is also a fac- care resources for refractive services, myopia is set to become a leading tor, but it cannot explain the rapid such as spectacles and contact lens- cause of blindness worldwide. changes in prevalence seen in such a es, in correcting the refractive error short timespan.7 and treating myopia progression. NEXT STEPS: MANAGEMENT Research suggests the high-pres- In addition, there will be a need for Many unanswered questions sure educational systems children managing and preventing high myo- remain. To intervene at the ap- are subjected to at very young ages pia–related ocular complications. propriate stage, we need to better in countries such as Singapore, Uncorrected refractive error is al- understand the risk factors associat- Korea, Taiwan and China may be a ready the primary cause of distance ed with myopia onset and progres- major contributing lifestyle factor.1 vision impairment globally, affecting sion—such as ethnicity, lifestyle and Excessive use of electronic devices 108 million people.15 It is also the parental myopia. It is important to could also play a role.1 second most common cause of glob- regularly monitor population trends Other factors thought to be in- al blindness.15 The economic burden and characteristics to identify risk volved in myopia development and of uncorrected distance refractive er- factors and adjust behaviors and progression include light levels and ror was estimated to be $202 billion management accordingly to limit specifi c wavelengths, time outdoors, Fig. 1. Estimated Global Prevalence of Myopia and High Myopia, vitamin D and peripheral defocus in 2000 to 2050 the corrected and uncorrected my- Source: Adapted from Holden BA, et al. opic eye, stimulating axial elonga- 5,000 tion.8 Different light levels, different Myopia 49.8% 4,500 wavelengths and duration of light High Myopia 45.2% have been shown to affect axial 4,000 elongation in animal studies, but are 3,500 yet to be tested in humans.8 Trials 39.9% conducted in Taiwan and China 3,000 indicate time outdoors reduces risk 34.0% 2,500 of developing myopia, with less

myopia progression seen in summer 2,000 28.3% 6 9-11 vs. winter months. The role of vi- 1,500 tamin D in myopia is unclear; some 9.8% 1,000 22.9% 7.7% reports suggest it is linked with 6.1% myopia, while others have found 500 4.0% 5.2% no association.12,13 Investigators Number of people (in millions) 2.7% also found diet was not associated 0 with myopia in a group of healthy 2000 2010 2020 2030 2040 2050 children in Singapore.14 Year

REVIEW OF CORNEA & CONTACT LENSES | JANUARY/FEBRUARY 2017 13 MYOPIA ON THE MOVE

Fig. 2. Regional Prevalence of Myopia in 2000, 2030 and 2050 the burden of rising myopia. For example, myopia has traditionally 2000 2030 2050 been treated with single vision spectacles and contact lenses, but now 15.2 Andean Latin America 36.2 we know there are other options. 50.7 Research has made considerable 46.1 headway in identifying optical Asia-Paciﬁ c, high income 58 66.4 interventions that might aid in pre-

19.7 venting the onset and progression Australasia 43.8 of myopia. Optical interventions 55.1 provide myopic defocus—bringing 15.7 Caribbean 37.4 the image in front of the retina to 51.7 slow axial elongation.18 The myopic 5.1 eye tends to have relative peripheral Central Africa 14.1 27.9 hyperopia, and these interventions 11.2 address this key risk factor. These Central Asia 32.9 47.4 strategies include bifocal spectacles, multifocal soft contact lenses and 20.5 Central Europe 41.8 ortho-k—in combination with be- 54.1 havioral strategies such as reduced 3.2 Central Latin America 12.3 near work and more time outdoors, 22.7 and pharmacological agents such as 38.8 low-dose atropine. All these meth- East Africa 56.9 65.3 ods can help reduce the number of 19 18 people with myopia progression. Eastern Europe 38.9 There is still much debate about 50.4 when to start myopia control, 14.6 North Africa and Middle East 38.8 what treatments should be used on 52.2 whom and at what age. Optical 28.3 treatments such as bifocal spectacles North America, high income 48.5 58.4 and multifocal soft contact lenses

5 can be used full time as soon as Oceania 12.5 a child is becoming myopic, and 23.8 ortho-k is a good option if the child 14.4 South Asia 38 is a suitable candidate in terms of 53 refractive error and their ability to 33.8 perform extended wear. Concerning Southeast Asia 52.4 62 efﬁ cacy, the average slowing of 5.1 myopia achieved across the bifocal Southern Africa 17.5 30.2 spectacles, ortho-k and multifocal

15.6 soft contact lenses are comparable, 20-22

Southern Latin America 40.7 Source: Adapted from Holden BA, et al. ranging from 35% to 50%. 53.4 The choice often depends on the 14.5 Tropical Latin America 35.9 patient’s lifestyle and the rate of 50.7 slowed progression achieved. 5.2 Low-dose atropine (0.01%) is West Africa 13.6 36.8 commonly prescribed for myopia

21.9 progression in places such as Hong Western Europe 44.5 Kong, Taiwan and Singapore, and, 56.2 more recently, in some Western 0 20 40 60 nations, one drop daily before

Myopia Prevalence Per Region (%) 6 sleep. Research shows the use of

14 REVIEW OF CORNEA & CONTACT LENSES | JANUARY/FEBRUARY 2017 pharmacologic treatments such as sus through collaboration with Want to learn more? low-dose atropine for myopia is researchers, clinicians and health safe in those as young as six, with bodies using our experience in ad- Access the freely available study at: the longest study being ﬁ ve years.23 vocacy in areas such as uncorrected www.sciencedirect.com/ science/article/pii/ The mechanism by which low-dose refractive error. S0161642016000257 atropine works to slow myopia More research is required to

remains unclear, but it signifi cantly fully understand the mechanisms of 6. Holden BA, Fricke TR, Wilson DA, et al. Global slows the change in the spherical myopia development and progres- prevalence of myopia and high myopia and temporal trends from 2000 through 2050. Ophthalmolo- equivalent by 60% after two years, sion and identify those at risk of gy. 2016 May;123(5):1036-42. although this is not seen in a change developing high myopia. Public 7. Lim LT, Gong Y, Ah-Kee EY, et al. Impact of parental history of myopia on the development of myopia 23 in the axial length. Some caution health advocates will also need to in mainland china school-aged children. Ophthal- is still required, as the effects of develop wellness promotion strate- mology and Eye Diseases. 2014;6:31-5. 8. Smith EL 3rd, Hung LF, Arumugam B. Visual chronic treatment with low-dose gies and provide resources such as regulation of refractive development: insights from atropine are unknown, including clinical guidelines to respond to this animal studies. Eye. 2014;28:180-8. 9. Wu PC, Tsai CL, Wu HL, et al. Outdoor activity the overall level of myopia control signifi cant public health challenge. during class recess reduces myopia onset and progression in school children. Ophthalmology. when combining behavioral, optical Industry can also take a leadership 2013;120:1080-5. and pharmacologic treatments. role by working with researchers 10. He M, Xiang F, Zeng Y, et al. Eff ect of time spent outdoors at school on the development of myopia Although consensus surround- and clinicians to develop FDA- among children in China: a randomized clinical trial. ing myopia management has not approved myopia treatments that JAMA. 2015;314:1142-8. 11. Donovan L, Sankaridurg P, Ho A, et al. Myopia yet been achieved, it is critical to will have a positive impact. progression in Chinese children is slower in summer successfully address the issue of than in winter. Optom Vis Sci. 2012;89:1196-202. 12. Williams KM, Bentham GC, Young IS, et al. myopia. The Brien Holden Vision verall, the world is becoming Association between myopia, ultraviolet B radiation Institute hopes to further foster exposure, serum vitamin D concentrations, and Omore myopic—a trend that genetic polymorphisms in vitamin D metabolic the movement towards consen- has signifi cant fi nancial and societal pathways in a multicountry European study. JAMA Ophthalmol. 2017;135:47-53. implications. More importantly, 13. Tideman JW, Polling JR, Voortman T, et al. Low How BHVI Estimated Myopia high levels of myopia pose a threat serum vitamin D is associated with axial length and risk of myopia in young children. European J Epide- Rates Through 2050 to sight that reduces quality of life miology. 2016;31:491-9. and exposes those affected to great- 14. Lim LS, Gazzard G, Low YL, et al. Dietary factors, • Selected 145 relevant studies myopia, and axial dimensions in children. Ophthal- from a pool of 4,288 PubMed er health risks. Evidence suggests mology. 2010;117:993-7e4. articles, representing 2.1 million 15. Bourne RR, Stevens GA, White RA, et al. Causes myopia can be managed better by of vision loss worldwide, 1990-2010: a systematic individuals with myopia. reducing the risk of the eye becom- analysis. The Lancet Global Health. 2013;1:e339-49. • Combined myopia prevalence ing more myopic with a number of 16. Fricke TR, Holden BA, Wilson DA, et al. Global data with world population cost of correcting vision impairment from uncor- lifestyle, optical and pharmaceutical rected refractive error. Bulletin of the World Health data and stratifi ed data into age Organization. 2012;90:728-38. cohorts in fi ve-year increments. interventions. The BHVI will be 17. Flitcroft DI. The complex interactions of retinal, • Defi ned myopia as spherical releasing the fi rst online myopia optical and environmental factors in myopia ≤ aetiology. Progress in Retinal and Eye Research. equivalent -0.50D and high management education program for 2012;31:622-60. myopia as spherical equivalent optometrists in March 2017. Please 18. Sankaridurg P, Holden B, Smith E 3rd, et al. ≤-5.00D.* Decrease in rate of myopia progression with a go to www.brienholdenvisioninsti- contact lens designed to reduce relative peripheral • Grouped countries by GBD hyperopia: one-year results. Invest Ophthalmol Vis region for applicability to other tute.org for details. RCCL Sci. 2011;52:9362-7. epidemiological studies. (Results 19. Sankaridurg PR, Holden BA. Practical applica- were extrapolated for GBD 1. Morgan IG, Ohno-Matsui K, Saw SM. Myopia. tions to modify and control the development of regions lacking myopia data). Lancet. 2012;379:1739-48. ametropia. Eye. 2014;28:134-41. 2. Lin LL, Shih YF, Hsiao CK, Chen CJ. Prevalence of 20. Cheng D, Woo GC, Drobe B, Schmid KL. Eff ect • Performed meta-analysis of myopia in Taiwanese schoolchildren: 1983 to 2000. of bifocal and prismatic bifocal spectacles on prevalence data, combined with Annals of the Academy of Medicine, Singapore. myopia progression in children: three-year results myopia change over time, to 2004;33:27-33. of a randomized clinical trial. JAMA Ophthalmol. project prevalence rates for each 3. Jung SK, Lee JH, Kakizaki H, Jee D. Prevalence of 2014;132:258-64. myopia and its association with body stature and 21. Si JK, Tang K, Bi HS, et al. Orthokeratology for decade from 2000 to 2050. educational level in 19-year-old male conscripts myopia control: a meta-analysis. Optom Vis Sci. in seoul, South Korea. Invest Ophthalmol Vis Sci. 2015;92:252-7. *Spherical equivalent ≤-0.50D, the most 2012;53:5579-83. commonly used myopia defi nition, is 22. Li SM, Kang MT, Wu SS, et al. Studies using beyond the refraction measurement error 4. Vitale S, Sperduto RD, Ferris FL 3rd. Increased concentric ring bifocal and peripheral add multifo- and captures children at the start of their prevalence of myopia in the United States between cal contact lenses to slow myopia progression in progression. Spherical equivalent ≤-5.00D for 1971-1972 and 1999-2004. Arch Ophthalmol. school-aged children: a meta-analysis. Ophthalmic high myopia identifi es people at higher risk of 2009;127:1632-9. & Physiological Optics. 2017;37:51-9. pathologic myopia and, if uncorrected, causes 5. French AN, Morgan IG, Burlutsky G, et al. Preva- 23. Chia A, Lu QS, Tan D. Five-year clinical trial on vision impairment equivalent to the World lence and 5- to 6-year incidence and progression of atropine for the treatment of myopia 2: myopia Health Organization’s blindness defi nition. myopia and hyperopia in Australian schoolchildren. control with atropine 0.01% eyedrops. Ophthalmolo- Ophthalmology. 2013;120:1482-91. gy. 2016;123:391-9.

REVIEW OF CORNEA & CONTACT LENSES | JANUARY/FEBRUARY 2017 15 1 CE Credit (COPE APPROVED)

Fitting Multifocal Contact Lenses for MYOPIA CONTROL

yopia affected the burden of myopia. Several of the risk-benefi t ratio compared approximately one randomized clinical trials suggest with other interventions for myo- and a half billion a lifestyle intervention with more pia control. For example, atro- people in 2010, time spent outdoors reducing the pine has greater effi cacy rates but Mand that number risk of onset.5,6 However, because an increased risk of side effects is expected to rise to nearly fi ve this involves education and be- compared with contact lenses; in billion by 2050.1 It is the single havioral modifi cation in the years addition, myopia rebounds once most signifi cant cause of distance prior to the onset of myopia, treatment is stopped.7,8 Clinical vision impairment, and high comprehensive community-based trials and case studies show myopia (i.e., worse than -5.00D) programs that involve parents, specially designed contact lenses is associated with a number of caregivers, teachers, governmen- slow myopia progression from sight-threatening complications tal and non-governmental organi- 25% to 72% compared with such as myopic macular degen- zations and eye care practitioners spectacles.9-21 eration, retinal detachment, (ECPs) must be implemented for Contact lenses used for myopia cataract and glaucoma.2-4 This this approach to be effective. control can be either bifocal or signifi cant burden highlights the Despite the crucial role ECPs play multifocal soft contact lenses, need for strategies and solutions in educating parents and com- as well as the rigid contact lens to reduce the risk of onset and munities, their role is limited by designs used in orthokeratology. slow the progression in those the fact that fi rst contact with a Investigators have proposed already affected by myopia. practitioner usually comes after ABOUT THE AUTHOR the onset of symptoms and signs. STRATEGIES FOR CONTROL Once a patient is diagnosed Prof. Sankaridurg is the program leader for the Myopia Program Myopia is a complex trait infl u- with myopia, the ECP becomes at the Brien Holden Vision In- enced by a number of environ- the central care provider and is stitute. She was awarded her BOpt degree from the Elite mental and genetic factors, and integral to evaluating the risk of School of Optometry, Chen- the mechanisms underlying onset further progression. ECPs now nai, India, in 1989, her PhD in 1999 from the University of and progression are not fully have many options for correct- New South Wales, Australia, and understood. Although there is ing distance vision impairment her MIP in 2012 from University of Technology, a great deal to learn about the and slowing its progression. Australia. After working for a number of years at the L.V. Prasad Eye Institute, India, as the mechanisms of myopia and why These options include more time chief of Contact Lens Services, she took a individuals respond differently to spent outdoors, atropine thera- position at the Brien Holden Vision Institute and the Vision Cooperative Research Centre. different stimuli and treatments, py (including low-dose atropine She was appointed a conjoint professor at the some behavioral, pharmaceutical 0.01%), spectacles (progressives, School of Optometry and Vision Science, Uni- versity of New South Wales, Australia, in 2016. and optical strategies already peripheral defocus management She has been actively researching myopia for show promise in clinical trials and executive bifocals), contact approximately 13 years. She is also involved in in combating myopia—many of lenses that impose myopic defo- postgraduate supervision and manages the institute’s Intellectual Property portfolio. She which can be incorporated into cus across sections of the retina, has more than 50 articles in peer reviewed current day practice.5-26 and orthokeratology.5-26 journals, is a co-inventor on nine patents/ applications, has authored several book Prevention is obviously the Of these various interventions, chapters and has delivered many podium most effective strategy to reduce contact lenses fare well in terms presentations including keynote lectures.

16 REVIEW OF CORNEA & CONTACT LENSES | JANUARY/FEBRUARY 2017 These practice pearls aid in myopia management, including avoiding onset and slowing progression in patients of all ages. By Padmaja Sankaridurg, PhD, BOptom, MIP Photo: Brien Holden Vision Institute several mechanisms to explain The Proclear their myopia control effect, center- including: (1) contact lenses distance multifocal correct or reduce accommodative using the Brien lag, which is considered a stim- Holden Vision ulus for eye elongation; (2) they Institute’s reduce the peripheral retinal de- contact lens optical quality focus, which is considered to in- analyzer crease the risk of eye elongation demonstrates by shifting the image closer to the two distinct retina; and (3) the lenses impose zones in the myopic defocus across areas of optical zone of the lens and a the retina, which is considered to fl at peripheral inhibit eye growth.16-21,25,26 carrier. These practice pearls can help you better understand the use of soft contact lenses for myopia and hyperopic refractive errors.27 of the patient or, in the case control and how to incorpo- Because of this, ECPs should note of a child, the caregiver. When rate them into your practice. that a patient without myopia fi tting contact lenses for myopia Currently, no products are on could be classifi ed incorrectly control, clinicians should take the market specifi cally for use in as having myopia; likewise, the into consideration the minimum myopia control; thus, this discus- magnitude of myopia could be age at which contact lenses can sion is based on clinical trial data found to be higher than it actual- be fi tted, contact lens design for on the use of multifocal contact ly is in a patient with myopia. myopia control, tests to perform, lenses for myopia control. ECPs can decide to fi t contact the wear and care schedule, lenses based on an assessment of managing visual performance and WHERE TO BEGIN the risk profi le or at the request follow-up intervals. All individuals presenting with myopia should be assessed for Release Date: February 2017 Sankaridurg, PhD, BOptom, MIP risk of progression based on Expiration Date: February 1, 2020 Credit Statement: This course is COPE age, ethnicity, family history of Goal Statement: Myopia is the single approved for 1 hour of continuing education myopia and past history of pro- most signifi cant cause of distance vision credit. Course ID is 52285-CL. Check with impairment, and high myopia (worse your state licensing board to see if this gression. The ocular examination than -5.00D) is associated with a number counts toward your CE requirements for should include a cycloplegic as- of sight-threatening complications— relicensure. sessment of the refractive error. A highlighting the need for strategies and Joint-Sponsorship Statement: This solutions to reduce the risk of onset and contin uing education course is joint- non-cycloplegic refraction often slow progression. This article discusses sponsored by the Pennsylvania College of results in a more myopic refrac- the use of soft contact lenses for myopia Optometry. tion, and the difference is greatest control and how to incorporate them into Disclosure Statement: The author’s in younger children and those your practice. employer has a commercial interest in with low myopic, emmetropic Faculty/Editorial Board: Padmaja myopia control.

REVIEW OF CORNEA & CONTACT LENSES | JANUARY/FEBRUARY 2017 17 FITTING MULTIFOCAL CONTACT LENSES FOR MYOPIA CONTROL

Let’s take a look at these con- prescribing them. lenses have proven effective for siderations in more detail: In addition to correcting and myopia control.16-21,25,26 controlling progression of my- The lens design research- FITTING AGE opia, studies indicate children ers found effective for myopia Studies show children as young and teenagers wearing contact control was a center-distance as eight can successfully man- lenses had improved quality of multifocal that had two distinct age lens insertion, removal and life with respect to appearance portions within the optical zone: care.17-21,25,28,29 Other clinical stud- and satisfaction with correction.29 a central portion that corrected ies found children achieved the However, not all children can for the distance refractive er- required duration of lens wear successfully wear contact lens- ror and an outer zone that was (including full-time lens wear), es. Conditions such as allergic relatively positively powered and the reported duration of conjunctivitis have an onset in compared with the central por- lens wear was comparable with childhood and, in such instances, tion.16-21 The relatively positive that seen in adult contact lens contact lens wear may aggravate power was intended to reduce wearers.30 Evidence shows no or increase the risk of ﬂ are-up. hyperopic defocus, induce myo- increased risk of complications Clinicians should ask about any pic defocus or both across areas associated with lens wear in chil- previous history of allergic or of the retina. The tested lenses dren compared with adults.30,31 vernal conjunctivitis, and exam- were experimentally designed While it is common practice to inations should include an ever- with the exception of two trials teach both the child and the par- sion of the tarsal conjunctiva. that used commercially available ent, the ECP should ensure the multifocal soft contact lenses: child can independently manage CONTACT LENS DESIGN Acuvue bifocal (center distance, all aspects of lens wear before Bifocal or multifocal contact alternating ﬁ ve ring bifocal,

HE ET AL. 2015 11 Outdoors WU ET AL. 2013 34 SHIH ET AL. 1999; 0.10% 56 SHIH ET AL. 1999; 0.25% 58 SHIH ET AL. 1999; 0.5% 96 CHUA ET AL. 2006; 1% 77 CHIA ET AL. 2012; 0.01% 59 Atropine CHIA ET AL. 2012; 0.10% 68 CHIA ET AL. 2012; 0.5% 75 CHO ET AL. 2005 (LORIC) 46 WALLINE ET AL. 2009 56 KAKITA ET AL. 2011 36 CHO AND CHEUNG 2012 (ROMIO) 43 Orthokeratology SANTODOMINGO ET AL. 2012 31 HIROAKA ET AL. 2012 30

ALLER ET AL. 2016 79 CHENG ET AL. 2015 39 ANSTICE AND PHILLIPS 2011 50 LAM ET AL. 2014 32 Soft contact lenses SANKARIDURG ET AL. 2011 33 HOLDEN ET AL. 2012 44 WALLINE ET AL. 2013 29 HASEBE, 2014 PA PALS +1.5D 20 HASEBE, 2014 PA PALS +1.0D 14 SANKARIDURG ET AL. 2010 15 CHENG ET AL. 2014 +1.50, 3DBI 51 CHENG ET AL. 2014 +1.50 39 BERNTSEN ET AL. 2012 33 Spectacles COMET 2 24 GWIAZDA ET AL. 2003 13 YANG ET AL. 2008 17 EDWARDS ET AL. 2002 11 LEUNG AND BROWN 1999 46 LEUNG AND BROWN 1999 38 Percent reduction in progression relative to control group (Spherical equivalent) group control to relative in progression reduction Percent

Myopia control with various interventions. Note the effi cacy of these interventions compared with standard, single vision spectacles or contact lenses.

18 REVIEW OF CORNEA & CONTACT LENSES | JANUARY/FEBRUARY 2017 Vistakon) and Proclear multifocal D (Coopervision).19,21 Practice Pearls on Myopia Control: Depending on the lens design, 1. Your toolkit for myopia management should include the central distance portion varies myopia control contact lenses. in diameter, and the relative pos- 2. Assess the risk of progression of myopia for a patient and itive power is delivered as either tailor the management based on the risk. concentric rings or as a gradient 3. A cycloplegic assessment of the refractive error is power rising from the center essential, particularly in children, as non-cycloplegic to the periphery. The dioptric refractive assessment often results in a more myopic magnitude of the relative positive refractive error. or plus power—which is fi xed 4. Children eight years and older can successfully be fi t for use across the population and with contact lenses and can independently manage not individualized—commonly and care for their lenses. In children, clinicians should ranging in power from +1.50D to examine the anterior segment before prescribing contact +2.50D. There is still a dearth of lenses, including eversion and examination of the tarsal information regarding whether conjunctiva. increasing the relative positive 5. Contact lens designs employed for myopia control are power or providing individual- multifocal or multifocal-like lenses with a portion of the ized treatment is likely to deliver optical zone devoted to correcting the distance myopic improved myopia control. refractive error and the remainder being relatively positive compared with the distance power by an average of ASSESSING FIT AND +1.50D to +2.50D. PERFORMANCE 6. Wait 20 to 30 minutes to allow lenses to settle prior to The initial lens selection should examining lens fi t and visual performance. Optimize lens be based on cycloplegic spher- fi t prior to measuring visual performance with the lenses. ical equivalent refractive error 7. A daily disposable option or a frequent replacement and appropriately adjusted for schedule minimizes the risk of complications associated vertex distance. The contact with contact lens wear. lenses employed in clinical trials 8. When fi tting children with contact lenses, ensure the were spherical lenses that masked children can independently manage lens insertion and low amounts of astigmatism removal, as well as lens care procedures. (commonly <0.75D and based on the spherical component of the refractive error). Clinicians with multifocal lens wear such they should do so using a trial should refer to the manufactur- as ghosting, poor contrast and frame rather than a phoropter to er’s guidelines for lens selection haloes. minimize errors related to head wherever possible. Poor visual performance may tilt and movement behind the Patients generally fi nd the fi rst be related to a number of factors, phoropter. few minutes of lens wear unset- including: strength of the rela- tling but tend to adapt quickly. tive positive power in the optical WEAR TIME AND Clinicians should wait to evaluate zone; power profi le of the lens REPLACEMENT MODALITY visual performance until 20 to (for example, concentric rings of Patients should be advised to 30 minutes after lens insertion. plus power vs. gradient increase wear myopia control contact To ensure a successful fi t, ECPs in plus power); pupil size; am- lenses for all waking hours, as should examine and optimize the bient illumination and contrast. improved lens wear compliance lens centration and movement A thorough clinical evaluation results in better outcomes.18 Also, before addressing visual perfor- taking these factors into account patients should have an up-to- mance. Issues with lens fi t such may determine if the patient date spectacle prescription for as decentration or excessive lens requires a change in lens fi t, lens occasions when lens wear may movement on the eye may mimic design or simply reassurance that not be feasible. or increase the severity or fre- the lens is properly fi t. If clini- Contact lens wear does not quency of symptoms associated cians perform over-refraction, appear to pose an increased risk of

REVIEW OF CORNEA & CONTACT LENSES | JANUARY/FEBRUARY 2017 19 FITTING MULTIFOCAL CONTACT LENSES FOR MYOPIA CONTROL

9-21 15. Berntsen DA, Sinnott LT, Mutti DO, Zadnik K. complications in children com- myopia control. Since progres- A randomized trial using progressive addition 32,33 lenses to evaluate theories of myopia progres- pared with adults. To reduce sion of myopia is rapid in child- sion in children with a high lag of accommoda- the risk of complications associat- hood, treatment strategies should tion. Invest Ophthalmol Vis Sci. 2012;53(2):640- 9. ed with lens wear, whatever they be directed mostly to children 16. Anstice NS, Phillips JR. Eff ect of dual-focus may be, ECPs should prescribe and young adults, for whom soft contact lens wear on axial myopia progression in children. Ophthalmology. 2011;118(6):1152- a regimen that minimizes lens studies show contact lenses 61. handling and the consequent risk provide a better risk-benefi t than 17. Sankaridurg P, Holden B, Smith E 3rd, et al. Decrease in rate of myopia progression with of microbial contamination of the other forms of myopia control. a contact lens designed to reduce relative peripheral hyperopia: one-year results. Invest lenses. Education is key, and ECPs Taking into consideration patient Ophthalmol Vis Sci. 2011;52(13):9362-7. should emphasize the risks asso- expectations and their ability to 18. Lam, CS, Tang WC, Tse DY, et al. Defocus Incorporated Soft Contact (DISC) lens slows ciated with overnight lens wear manage lens wear, ECPs should myopia progression in Hong Kong Chinese such as increased risk of infection opt for myopia control contact schoolchildren: a 2-year randomised clinical trial. Br J Ophthalmol. 2014;98(1):40-5. and focus on properly training lenses in treating individuals at 19. Aller TA, Wildsoet C, Results of a one-year RCCL prospective clinical trial (CONTROL) of the use patients in appropriate lens care risk of onset and progression. of bifocal soft contact lenses to control myopia and handling techniques. A daily progression. Ophthalmic Physiol Opt. 2006;26 1. Holden BA, Fricke TR, Wilson DA, et al. Global Suppl 1:1-67. wear, daily disposable or frequent prevalence of myopia and high myopia and temporal trends from 2000 through 2050. Oph- 20. Holden BA, Sankaridurg P, Lazon de la Jara replacement schedule is often the thalmology. 2016;123(5):1036-42. P, et al. Decreasing peripheral hyperopia with distance centre relatively plus powered periph- most successful approach. 2. Chen SJ, Cheng CY, Li AF, et al. Prevalence ery contact lenses reduced the rate of progress and associated risk factors of myopic maculop- of myopia : A 5 year Vision CRC study. ARVO E Also, while it is common prac- athy in elderly Chinese: the Shihpai eye study. abstract 6300. 2012. Invest Ophthalmol Vis Sci. 2012;53(8):4868-73. tice to teach both the child and 21. Walline JJ, Greiner KL, McVey ME, Jones-Jor- 3. Sun J, Zhou J, Zhao P, et al. High prevalence dan LA. Multifocal contact lens myopia control. the parent, practitioners should of myopia and high myopia in 5060 Chinese uni- Optom Vis Sci. 2013; 90(11):1207-14. versity students in Shanghai. Invest Ophthalmol ensure the child is fully adept at Vis Sci. 2012;53(12):7504-9. 22. Hiraoka T, Kakita T, Okamoto F, et al. Long- term eff ect of overnight orthokeratology on managing all aspects of lens wear 4. Li T, Du L, Du L. Prevalence and Causes of axial length elongation in childhood myopia: a such as insertion and removal, Visual Impairment and Blindness in Shanxi 5-year follow-up study. Invest Ophthalmol Vis Province, China. Ophthalmic Epidemiol. Sci. 2012;53(7):3913-9. 2015;22(4):239-45. lens disinfection as well as taking 23. Cho P, Cheung SW. Retardation of myopia 5. Wu PC, Tsai CL, Wu HL, et al. Outdoor activity necessary steps to prevent adverse in prthokeratology (ROMIO) study: a 2-year during class recess reduces myopia onset and randomized clinical trial. Invest Ophthalmol Vis progression in school children. Ophthalmology. Sci. 2012;53(11):7077-85. events, such as avoiding lens wear 2013;120(5):1080-5. 24. Santodomingo-Rubido J, Villa-Collar C, when unwell or avoiding use of 6. He M, Huang W, Zheng Y, et al. Refractive Gilmartin B, Gutiérrez-Ortega R. Myopia control error and visual impairment in school chil- with orthokeratology contact lenses in Spain: solutions other than those provid- dren in rural southern China. Ophthalmology. refractive and biometric changes. Invest Oph- 2007;114(2):374-82. ed by the ECP. thalmol Vis Sci. 2012;53(8):5060-5. 7. Chia A, Lu Q, Tan D. Atropine for the treat- For patients with myopia pro- ment of childhood myopia: safety and effi cacy 25. Aller TA, Wildsoet C. Bifocal soft contact lenses as a possible myopia control treatment: gression, a three- to six-month of 0.5%, 0.1%, and 0.01% doses (Atropine for the Treatment of Myopia 2). Ophthalmology. a case report involving identical twins. Clin Exp follow-up schedule is ideal for 2012;119(2):347-54. Optom. 2008;91(4):394-9. 8. Shih YF, Chin CH, Chou AC, et al. Eff ects 26. Turnbull PR, Munro OJ, Phillips JR. Contact avoiding potential adverse effects of diff erent concentrations of atropine on lens methods for clinical myopia control. Optom such as blurred vision. Any drop controlling myopia in myopic children. J Ocul Vis Sci. 2016;93(9):1120-6. Pharmacol Ther. 1999;15(1):85-90. 27. Hu YY, Wu JF, Lu TL, et al. Eff ect of cy- in visual acuity of one line or 9. Edwards MH, Li RW, Lam CS, et al. The Hong cloplegia on the refractive status of children: more or over-refraction of 0.25D Kong progressive lens myopia control study: the Shandong children eye study. PLoS One. study design and main fi ndings. Invest Ophthal- 2015;10(2):e0117482. or more necessitates the need for mol Vis Sci. 2002;43(9):2852-8. 28. Walline JJ, Jones LA, Rah MJ, et al. Contact a refractive error assessment so 10. Gwiazda J, Hyman L, Hussein M, et al. A lenses in pediatrics (CLIP) study: chair time and randomized clinical trial of progressive addition ocular health. Optom Vis Sci. 2007;84(9):896- the lens power can be appropri- lenses versus single vision lenses on the progres- 902. sion of myopia in children. Invest Ophthalmol Vis 29. Cheng X, Xu J, Chehab K, et al. Soft contact ately adjusted. Sci. 2003;44(4):1492-500. lenses with positive spherical aberration for my- 11. Sankaridurg P, Donovan L, Varnas, S, et al. opia control. Optom Vis Sci. 2016;93(4):353-66. Spectacle lenses designed to reduce progres- 30. Walline JJ, Guame A, Jones LA, et al. Bene- OUR RESPONSIBILITY sion of myopia: 12-month results. Optom Vis Sci. fi ts of contact lens wear for children and teens. The rising prevalence of myopia 2010;87(9):631-41. Eye Contact Lens. 2007;33(6.1):317-21. 12. Leung, JT, Brown B. Progression of myopia 31. Li L, Moody K, Tan DT, et al. Contact lenses in and its notably progressive nature in Hong Kong Chinese schoolchildren is slowed pediatrics study in Singapore. Eye Contact Lens. is an increasingly signifi cant con- by wearing progressive lenses. Optom Vis Sci. 2009;35(4):188-95. 1999;76(6):346-54. 32. Sankaridurg P, Chen X, Naduvilath T, et al. cern for ECPs and their patients. 13. Yang Z, Lan W, Ge J, et al. The eff ectiveness Adverse events during 2 years of daily wear of of progressive addition lenses on the progres- silicone hydrogels in children. Optom Vis Sci. While further research regarding sion of myopia in Chinese children. Ophthalmic 2013;90(9):961-9. the underlying mechanisms of Physiol Opt. 2009;29(1):41-8. 33. Chalmers RL, Wagner H, Mitchell GL, et al. 14. Hasebe S, Jun J, Varnas SR. Myopia control Age and other risk factors for corneal infi ltrative myopia is needed, current data with positively aspherized progressive addition and infl ammatory events in young soft contact points to contact lenses as a safe lenses: a 2-year, multicenter, randomized, lens wearers from the Contact Lens Assessment controlled trial. Invest Ophthalmol Vis Sci. in Youth (CLAY) study. Invest Ophthalmol Vis and effective means of delivering 2014;55(11):7177-88. Sci. 2011;52(9):6690-6.

20 REVIEW OF CORNEA & CONTACT LENSES | JANUARY/FEBRUARY 2017 CE TEST ~ FEBRUARY 2017 EXAMINATION ANSWER SHEET

1. Which of these complications is associated with high myopia? Fitting Multifocal Contact Lenses for Myopia Control a. Retinal detachment. Valid for credit through February 1, 2020 b. Cataract. Online: This exam can also be taken online at www.reviewofcontactlenses.com. c. Glaucoma. Upon passing the exam, you can view your results immediately. You can also view d. All of the above. your test history at any time from the website. Directions: Select one answer for each question in the exam and completely dark- 2. What is the most eff ective strategy to reduce the burden of myopia? en the appropriate circle. A minimum score of 70% is required to earn credit. a. Contact lenses. Mail to: Jobson Medical Information, Dept.: Optometric CE, 440 9th Avenue, 14th b. Prevention. Floor, New York, NY 10001. c. Vision therapy. Payment: Remit $20 with this exam. Make check payable to Jobson Medical d. Refractive surgery. Information LLC. Credit: This lesson is approved for 1 hour of CE credit. Course ID is 52285-CL. 3. Studies show contact lenses can slow myopia progression by what percent? a. 1% to 10%. Sponsorship: Joint-sponsored by the Pennsylvania College of Optometry b. 10% to 20%. Processing: There is an eight-to-10 week processing time for this exam. c. 25% to 72%. Answers to CE exam: d. 60% to 70%. 1. A B C D 6. A B C D 2. A B C D 7. A B C D 4. Most clinical trials employ this type of contact lens design: 3. A B C D 8. A B C D a. Center-distance multifocal. 4. A B C D 9. A B C D b. Translating multifocal. 5. A B C D 10. A B C D c. Hybrid multifocal d. Concentric bifocal. Evaluation questions (1 = Excellent, 2 = Very Good, 3 = Good, 4 = Fair, 5 = Poor) Rate the effectiveness of how well the activity: 5. At what age can clinicians consider prescribing myopia control contact 11. Met the goal statement: 1 2 3 4 5 lenses to patients? 12. Related to your practice needs: 1 2 3 4 5 a. Six. 13. Will help improve patient care: 1 2 3 4 5 b. Eight. 14. Avoided commercial bias/influence: 1 2 3 4 5 c. Ten. 15. How do you rate the overall quality of the material? 1 2 3 4 5 d. Twelve. 16. Your knowledge of the subject increased: Greatly Somewhat Little 17. The difficulty of the course was: Complex Appropriate Basic 6. Why should clinicians perform a cycloplegic refraction before prescribing contact lenses for myopia control? 18. How long did it take to complete this course? ______a. Avoid a more myopic refraction. 19. Comments on this course: ______b. Check visual performance. c. Examine the tarsal conjunctiva. ______d. Adjust the lens power. 20. Suggested topics for future CE articles: ______

7. Which of these complications can mimic or increase the severity or frequency of ______symptoms associated with multifocal lens wear? Identifying information (please print clearly): a. Part-time lens wear. b. Vernal conjunctivitis. First Name c. Incorrect plus power. d. Excessive lens movement. Last Name Email 8. How long after lens placement should clinicians wait until evaluating visual performance? The following is your: Home Address Business Address a. Visual performance can be evaluated immediately after lens placement. Business Name b. Five to 10 minutes. c. 20 to 30 minutes. Address d. 30 to 45 minutes. City State

9. All of these can lead to poor visual performance, except: ZIP a. Strength of the relative positive power in the optical zone. b. Power proﬁ le of the lens. Telephone # - - c. Lens replacement modality. Fax # - - d. Pupil size. By submitting this answer sheet, I certify that I have read the lesson in its entirety 10. How long should patients be advised to wear contact lenses for myopia and completed the self-assessment exam personally based on the material present- control? ed. I have not obtained the answers to this exam by fraudulent or improper means. a. All waking hours. b. Overnight. Signature: ______Date: ______c. Eight to 10 hours a day. d. Six to eight hours a day. Please retain a copy for your records. LESSON 113633, RO-RCCL-0217

REVIEW OF CORNEA & CONTACT LENSES | JANUARY/FEBRUARY 2017 21 from an 10 Orthokeratology Expert Don’t let misconceptions stop you from using this treatment TIPS modality that can provide a huge beneﬁ t to patients with myopia.

By Cary M. Herzberg, OD

rthokeratology control.4 Yet, ECPs are still reluc- Even spherical aberration, initially (ortho-k) is one of tant to embrace the procedure, thought to be a negative side effect the more challenging possibly because there are few of ortho-k, actually offers many treatment modali- procedures with a higher perceived positives when it comes to advanced Oties in an eye care risk than fi tting adolescents with custom ortho-k lens design. For ex- practitioner’s toolbox, especially ortho-k. Risk aversion may inform ample, by manipulating the positive considering effective myopia control some of this reticence, but a further asphericity in ortho-k designs, along treatment needs to begin by the understanding of the benefi ts of the with reducing the size of the treat- age of six or seven.1 As challenging procedure proves to overshadow ment zone, you increase the eleva- as these young patients may be, the potential risks such as microbial tion of the reverse curve, resulting in treating them with corneal reshap- keratitis, corneal abrasions, central an increase in spherical aberration ing can be immensely rewarding. corneal staining, lens binding and with more effective myopia control. Orthokeratology has grown dra- tear fi lm instability. The FDA is Introducing a negative asphericity, matically internationally; in China, willing to consider even a 30% however, can help increase add for example, close to two million reduction in myopia resulting from power while also manipulating ortho-k lenses have been fabricated.2 use of a medical device as clinically spherical aberration. However, less than 300,000 lenses signifi cant; orthokeratology—with have been dispensed in the United close to a 50% reduction—serves CONSULT AND EXAMINE States—less than 1% market share as the gold standard. In my offi ce, we ask that of the entire contact lens industry.3 Safety concerns tend to be based 2patients attend a free consul- Additionally, the nature of our more in perception than fact. There tation before making an appoint- practice environment for contempo- are scores of studies showcasing ment for an ortho-k evaluation. It is rary eye care practitioners (ECPs)— the safety of this procedure.5-8 Out crucial that parents accompany any which emphasizes low reimburse- of the 5,000+ ortho-k lenses I’ve fi t adolescent patients. Often, I fi nd the ments and ever-increasing numbers in the last 25 years, I’ve only had parents do little to explain ortho-k of patients—makes it diffi cult to one incident of microbial keratitis. to their children because they don’t fi nd the time to focus on corneal Early diagnosis and treatment, understand it themselves, and the reshaping. But with myopia on the combined with effective antibiotic consultation ensures both the parent rise, it’s time we use all of our tools. therapy, kept this patient’s micro- and the patient are educated prop- I feel ortho-k is the best possible bial keratitis episode from causing erly. During the consultation we treatment for eligible patients; using vision loss. My longest wearing ABOUT THE AUTHOR the human cornea in its new-engi- ortho-k patient just passed year 25, Dr. Herzberg has been neered shape to limit the progres- and his seven diopters of myopia practicing in Aurora, Ill., for 40 sion of myopia has proven hugely at age seven hasn’t changed. Many years—25 of which he has specialized in ortho-k. He is successful in my practice. Here are of my patients are in year 15 to co-founder and president of 10 tips to help you successfully 20 and still wearing lenses safely. the International Academy of Orthokeratology and integrate ortho-k into yours. While we have had our share of Myopia Control (IAOMC) and corneal abrasions and superfi cial founder and co-president of the American Academy of Orthokeratology KNOW THE RISKS AND punctate keratitis, these have been and myopia control (AAOMC). He serves BENEFITS easily remedied and haven’t negated as a consultant to the contact lens industry and lectures and writes on the topic of 1Over 80% of orthokeratology the many benefi ts ortho-k has pro- orthokeratology and myopia control around fi ts on adolescents are for myopia vided to my patients. the world.

22 REVIEW OF CORNEA & CONTACT LENSES | JANUARY/FEBRUARY 2017 answer questions and provide literature on the procedure while also gathering information about a patient’s eligibility. It’s also the perfect time to evaluate fi rst impressions of the maturity level of an adolescent patient. Finally, after reviewing the risks and benefi ts, you should have parents, and the child if he or she is old enough, sign off on all the key points of an informed consent. Topography needs to be near perfect The accumulation of ortho-k trial During the initial examination to to ensure a proper fi t. sets over the last 20 years. determine suitability, clinicians must thoroughly rule out all complicating results each time a map is taken. It Haloes in younger patients usually conditions. For example, the pres- can be challenging to know which aren’t an issue, particularly after ex- ence of any corneal pathology (such one of those 10 is the one to use as plaining how they are integral to the as keratoconus) is a contraindica- the reference. In my practice, I take myopia control effect. The change tion. Practice extra caution when an auto-k reading and match that to from the prolate to oblate surface considering cases with irregular, the topographies I have taken until created after ortho-k causes haloes limbus-to-limbus or against-the-rule I fi nd the closest one to the topog- as it defi nes a new myopic image astigmatism or decentered corneal raphy reading. Avoid using topog- shell on the peripheral retina. Still, caps—particularly if you are new raphies with missing data points or it’s helpful to know how sensitive to ortho-k. Factors such as dry eye irregularities caused by tear pooling patients are to slightly blurry visual should always be dealt with prior to or lid infringement. effects such as haloes at distance. fi tting. Topography provides valuable Education is a key to success, so It is extremely important, espe- information on the cornea itself, make sure parents and patients un- cially when treating the pediatric including the much-needed ec- derstand these myopia-controlling population, that your staff knows centricity; however, be wary of a devices are not intended to give the how to gather this pertinent clinical topographer’s accuracy. Besides ultimate in fi ne distance acuity but information so the appointment can pre-fi t data, the evaluating treatment rather are a method of reducing be fl agged if they note complicating progress is one of its greatest bene- myopia progression. factors. fi ts. All of the necessary information Prior to fi tting any lenses, discuss you need for evaluating the fi t is how the patient’s accommodative EVALUATE AND ASSESS at your fi ngertips, including axial, system may need help with vision Following the initial exam- tangential, refractive, elevation training during treatment. This is 3ination is the actual ortho-k and difference maps. Axial maps especially true with newer custom evaluation. This should begin with determine the radius of curvature designed lenses that address the lack topography, which is the standard- at each particular point, which is of peripheral defocus in patients of-care for ortho-k. The baseline helpful in determining the refractive with low myopia by creating more topography will remain the refer- change. Axial maps are also good demand and a resulting moderately ence for a patient’s fi tting through- for determining the type, shape and high hyperopia after lens removal out their lifetime of ortho-k use, position of any corneal astigmatism. during treatment (>1D). so it needs to be performed with Tangential maps are best used for great precision, and it’s imperative lens positioning in ortho-k, while SIGN A CONTRACT to take more than one topography refractive maps speak to the quality If at this point all looks well reading. It’s not uncommon to need of vision. Subtractive or difference 4and all parties involved opt 10 or more readings on a patient maps are ideal for showing the over- for ortho-k, prepare a contract and per eye to arrive at an accurate night change after ortho-k. go through it with the patient and assessment of the cornea prior to The ortho-k evaluation is also a parent before having them sign it. fi tting, considering corneal topogra- good time to discuss other consid- The contract should address all phers using a Placido disc are often erations such as haloes and adapta- expectations and contingencies. inaccurate and provide different tion for moderate-to-high myopia. Possible side effects need to be

REVIEW OF CORNEA & CONTACT LENSES | JANUARY/FEBRUARY 2017 23 10 TIPS FROM AN ORTHOKERATOLOGY EXPERT

covered, and suitable alternatives it provides additional information addressed. Lastly, payment expec- that helps me customize each fi t. For tations should also be included. instance, I can evaluate possible lid Always remember when structuring interactions such as overly tight lids. your fees for this procedure to allow When you are ready to trial fi t, an extra margin in your fi nal fees be sure to have the necessary time to account for additional lenses or and space for ortho-k patients by extra time needed to achieve the providing a reclining chair so they necessary precision. This is especial- can lay down with eyes closed for at ly important for myopia control, least 15 minutes. This is much more where the initial lens selection may valuable than open-eye assessment fail to deliver a satisfactory result. for lens fi t and treatment. A mere 20 minutes of wear will often correct CHECK THE CORNEA signifi cant levels of myopia and When performing ortho-k, astigmatism. 5it’ s imperative to consider Clinicians should evaluate the Many practitioners instill a drop factors such corneal volume: the orthokeratology fi t at the slit lamp of topical anesthetic before lens before dispensing. more volume you have the easier it insertion to aid a young patient’s is to move tissue, even with higher roughly 10µm to 15µm, permitting adaptation. myopia. Be wary of small, fl at cor- an accurate assessment of corneal With many different trial set neas due to low volume, as they can eccentricity and best-fi t profi le. diameters at my disposal, I can nail test your fi tting abilities, even in low When taking topographies on covering 95% of corneal surface, prescriptions. Extremely fl at corneas children, take note that they tend to which is necessary for best results.9 can also pose a challenge, especially be more fearful and fi dgety during in higher prescriptions. For exam- examinations. If you are unable to DISPENSE AND FOLLOW ple, 34.00D is about as fl at as you acquire that “perfect” topography When the lenses have arrived can expect after ortho-k, so a 6D reading, it may be best to send 7and passed inspection, bring myope with a fl at K of 39.00D may the child home with eye drops to the patient into the offi ce and insert be out of reach. Remember, over practice keeping their eyes open and the lenses to make sure they fi t well. 40 microns of elevation difference inform the parents of the need for a If the patient and parent are satis- between steep and fl at meridians precise topography. Have the child fi ed, educate them on safe insertion, usually means a toric alignment open their eyes wide as they instill removal and care. If the patient is zone with its increased complexity. the drops. Often on return visits, under eight years of age, it’s likely Eccentricity of the cornea is ex- they are more relaxed, giving you the parents will need to step in and tremely important to know to help a better opportunity to document provide support here, which may you determine how much fl attening their topography. mean all of the insertion, removal to expect on the cornea as you move and care. Allow enough time in towards the periphery and wheth- BE READY FOR your schedule for this process and, er a fi ve curve or higher design FITTINGS again, make sure this time is refl ect- is warranted due to that change. 6The next step is fi tting and ed in your fee structure. Familiarize yourself with your to- ordering the lenses. The most Once you have dispensed the pographer’s intricacies and margins popular methods for doing this are lenses, active follow up is necessary. of error, as most will either over empirically, through trial lens fi tting In my practice, we see the patient or understate the “e” value. When or custom design. Many ECPs forgo the next day and then again in one possible, also evaluate the “e” value trial lenses and order an empirical month. Further follow-up visits are with other methods such as a trial or custom topographic design as scheduled at three-month intervals. lens fi tting. This is done by deter- “trial” lenses. In 80% of cases, they If it’s a higher amount of myopia or mining the best fl uorescein pattern will work effectively and require other factors such as high astigma- available underneath that trial lens. minimal, if any, changes.7 Even tism are present, we ask patients Ortho-k designs are accurate to per- though I have diagnostic data to to come in for follow-up appoint- haps 5µm, and the human eye can help fi t a patient, I often feel a trial ments at two weeks as well. We also pick up a difference in patterns of fi tting is much more accurate, as schedule the following year’s lens

24 REVIEW OF CORNEA & CONTACT LENSES | JANUARY/FEBRUARY 2017 replacements and evaluations during DON’T STOP TOO SOON a positive difference in your young the initial year. A common mistake parents patients’ lives. Controlling myopia I replace lenses for a child yearly 9make is assuming that, once progression at age six or seven by because I personally believe that the riskiest years of myopic pro- just 30% will eliminate 75% of all will provide the healthiest and safest gression have passed, their child of high myopia (>5D) cases and the outcomes, given children cannot should switch from ortho-k to daily subsequent increased risk of ocular legally take responsibility for their wear lenses or glasses. This is nearly pathology.12 Further, evidence shows decisions, particularly when it always the wrong route to take, ortho-k is impactful on adolescents’ comes to lens care. as many younger patients have no visual performance and binocular desire to limit their much-improved function.1 The improvement in qual- ADJUST ACCORDINGLY quality of life by making that ity of life afforded by ortho-k lenses Effective myopia control switch. Further, in my experience, is extremely rewarding to witness. 8requires A-scans to deter- long-term wear of ortho-k lenses mine axial length before and during shows no signs of increased risk. I ith myopia rates increasing, treatment. You should take a new have many patients who have been Wit’s time to fully consider all measurement every year. These wearing their ortho-k lenses for the options at our disposal. As far readings, along with any changes more than a decade with no signs of as I’m concerned, ortho-k is the in the over-refraction with ortho-k any adverse corneal changes. In fact, way of the future. Don’t waste the lenses at six and 12 months after their corneas remain pristine even opportunity to provide this amazing initial fi tting, will either confi rm after years of overnight wear. specialty to your pediatric patients. successful myopia control or lead to I consult with my long-term Taking the road less traveled can a new treatment strategy. wearers at least once a year on their indeed make all the difference. RCCL Modifi cations such as increasing success with the procedure. When 1. Eiden B. Lets not forget that most of us use two the Jessen factor, using newer de- they are ready for LASIK or feel eyes together; Binocular vision implications in signs relying on six or more curves wearing the lenses nightly is impact- corneal reshaping treatment. CL Today Newsletter. December 11, 2016. Available at www.clspectrum. or using eccentricity in the base ing their lifestyle, I wash them out com/newsletters/contact-lenses-today/december-11,-2016. Accessed January 6, 2017. curve can lead to a greater eleva- of their lenses. This process may 2. Oh S. Statistical data in the fi eld of ortho- tion of the reverse curve and better take up to six months to accomplish keratology and myopia control in the US and the world. Korean Contact Lens Study Society. myopic defocus in the periphery. in long-term wearers (>10 years). Korean Ophthalmology Contact Lens Society. Nov The Jessen factor is the amount of 2016;9:79-85. 3. Nichols J. Contact lenses 2015. Contact Lens lens fl attening over and above the WATCH YOUR Spectrum. January 1, 2016. Available at www. clspectrum.com/issues/2016/january-2016/con- patient’s current prescription needs, PATIENTS AND tact-lenses-2015. Accessed January 6, 2017. which allows the eye to remain free 10PRACTICE GROW 4. Kojima R, Caroline P. IQ Scleral Lenses. Presented at Vision By Design 2014., April 24-27; Chicago, Ill. from myopia, even after all-day Ortho-k can dominate a practice. 5. Walline JJ, Rah MJ, Jones LA. The children’s wear. Research shows increasing My specialty practice is now about overnight orthokeratology investigation (COOKI) pilot study. Optom Vis Sci. 2004 Jun;81(6):407-13. the Jessen factor and reducing the 80% corneal reshaping, which has 6. Cho P, Cheung SW, Edwards M. The longi- treatment zone can create a better translated into a healthy practice. tudinal orthokeratology research in children (LORIC) in Hong Kong: a pilot study on refractive myopic image shell in the peripheral Once you decide to incorporate changes and myopic control. Curr Eye Res. 2005 retina.10 Simply adding low-dose ortho-k into your practice, be pre- Jan;30(1):71-80. 7. Davis RL, Eiden SB, Bennett ES, et al. Stabilizing atropine (0.01%) in addition to or- pared for a younger patient base. At myopia by accelerated reshaping technique (SMART)-study three year outcomes and over- tho-k also may lead to better control the same time, my younger corneal view. Adv Ophthalmol Vis Syst. 2015;2(3):00046. without changing the lens. reshaping patients have proven 8. Walline JJ, Jones LA, Sinnott LT. Corneal reshaping and myopia progression. Br J Ophthalmol. Management decisions should extremely loyal, and I have a special 2009 Sep;93(9):1181-5. be based on any changes in the opportunity to participate with par- 9. Global OK-Vision. GOV General Fitting Guide. Available at www.global-ok.com/html/GOVFitting- axial length after the beginning of ents in fostering their growth. While Guide.html. Accessed January 12, 2017. treatment. Even high myopia is kids may be resistant to parental 10. Chan B, Cho P, Mountford J. The validity of the Jessen formula in overnight orthokeratology: within reach—although ortho-k advice, they will often listen to an a retrospective study. Ophthalmic Physiol Opt. 2008;28(3):265-8. may only get you part of the way authority fi gure such as their ECP. 11. Charm J, Cho P. High myopia–partial reduction there. Correcting at least 4D with Don’t waste that opportunity. ortho-k: a 2-year randomized study. Optom Vis Sci. 2013;90(6):530-9. corneal reshaping and then the rest Taking a proactive role in the 12. Holden BA, Fricke TR, Wilson DA, et al. Global with glasses can still reduce myopic myopia epidemic and incorporating prevalence of myopia and high myopia and temporal trends from 2000 through 2050. Ophthal- 11 progression by at least 50%. ortho-k into your practice can make mology. 2016;123(5):1036-42.

REVIEW OF CORNEA & CONTACT LENSES | JANUARY/FEBRUARY 2017 25 RESHAPING By Daddi Fadel, DOptom Ortho-K ith myopia on patients with myopia with astig- face’ (high ride) or ‘frowny face’ the rise, it’s matism.10-11 A study investigating (low ride) topography patterns, in- more im- the effectiveness of toric ortho-k duced astigmatism, glare and poor portant than lenses for myopia control in chil- vision (Figures 1a and 1b).16-19 As ever to treat dren ages six to 12 with myopia a result, symmetric reverse ortho-k W 1-2 patients as early as possible. from 0.50D to 5.00D and with- designs can only fl atten the fl attest Luckily, eye care practitioners the-rule astigmatism from -1.25D meridian, which may actually have several treatment options to -3.50D found that, after one cause the astigmatism to increase.16 available, including corneal year of therapy, the axial elon- A toric ortho-k design will extend reshaping with orthokeratology gation in subjects wearing toric the bearing area of the lens circum- (ortho-k). Several studies show the ortho-k lenses increased by an av- ferentially to improve both lens fi t effectiveness of ortho-k in slowing erage of 0.15mm.10 This was 58% and clinical outcome. myopia progression in children.3-8 slower than the control group, all Second, spherical reverse Researchers found axial elongation of whom wore spectacles. After geometry lenses cannot achieve was 51% to 57.1% less compared two years of therapy, the axial the peripheral touch necessary to with a control group wearing spec- elongation in the toric ortho-k ensure stabilization, centration tacles or soft contact lenses.6,8 group increased by 0.31mm, 52% and properly modulated hydro- But many patients with myo- slower than the control group.10 dynamic forces. Ortho-k treat- pia have astigmatism, which can In another study—comprised of ment is achieved by combining sometimes complicate ortho-k 24 treated patients without a con- two pressures: the positive push therapy. Nearly one quarter of trol group—researchers noted no force in the central cornea and the patients wearing soft contact myopia progression and no alter- negative pull force in the mid-pe- lenses require astigmatism correc- ation in the axial length in myopic ripheral cornea.20 The negative tion, and 32% of patients with children ages nine to 16 after one fl uid pressure necessitates a 360° myopia present with astigmatism year of toric ortho-k lens wear.11 total touch in the landing zone to of 0.75D or greater in both eyes.9 prevent fl uid outfl ow along the These statistics suggest the number CLINICAL NEED steepest meridian (Figures 2a and of patients with astigmatism is as- Ortho-k treatment with spherical 2b).21 Therefore, the total periph- sociated with the increasing of the reverse geometry lenses presents eral touch is important not only number of patients with myopia. two signifi cant problems for To effectively treat this patient patients with astigmatism, limiting ABOUT THE AUTHOR population, clinicians must fi nd their use to with-the-rule astigma- Dr. Fadel is an optometrist specializing in contact lenses creative alternatives to traditional tism up to 1.50D and against-the for irregular cornea, scleral ortho-k therapy. This article takes rule and oblique astigmatism up to lenses and orthokeratology. 12-15 She has a contact lens a closer look at the use of toric 0.75D. private practice in Italy, ortho-k lenses for myopia control First, a spherical accelerated where she designs special customized contact lenses. in patients with astigmatism. ortho-k lens on a toric cornea will She lectures and publishes, have poor centration because the especially on contact lenses for the irregular cornea, scleral lenses and ortho-k. She is the EFFICACY OF lens’s sagittal depth is equal in founder and president of the Italian Academy TORIC ORTHO-K each meridian and the cornea’s of Scleral Lenses (AILeS), a board member of the Italian Academy of Contact Lenses Researchers have suggested toric sagittal depth is different in each (AILAC) and a member of the Scleral Lens lenses can slow axial elongation in meridian. This leads to ‘smiley Society (SLS). Email: [email protected].

26 REVIEW OF CORNEA & CONTACT LENSES | JANUARY/FEBRUARY 2017 Toric lenses can expand myopia management to include patients with astigmatism. for better lens stabilization and ans is greater than 25µm, or 1.00D centration, but also to modulate of toricity.23 This might be better the hydrodynamic forces that lead managed with a toric ortho-k to corneal fl attening in each me- design, especially for toric cor- ridian.16 In case of limbus-to-lim- neas. The majority of eyes looked bus astigmatism, the semi-closed, at in the study had a peripheral fl uid-fi lled system in the reverse astigmatism greater than central zone is achieved only with a toric astigmatism. ortho-k design.21 DIFFERENT DESIGNS WHEN TO FIT Since their fi rst introduction at TORIC ORTHO-K the Global Orthokeratology Corneal astigmatism can be clas- Symposium in 2005 for the correc- sifi ed as apical, limbus-to-limbus tion of astigmatism, toric ortho-k or peripheral.22 In the apical form, lens designs have varied across astigmatism is greater centrally studies and case reports.10,13,16,18,21, than peripherally. In limbus-to-lim- 24-28 bus, central and peripheral astigmatisms are equal. Finally, in the CLINICAL STUDIES third category, astigmatism is A study involving patients with greater peripherally than centrally. astigmatism greater than 1.25D Figs. 1a and 1b. Above, superior The evaluation between corneal at any principal corneal meridi- decentration of a spherical ortho-k and refractive astigmatism can an orientation used a lens design lens on a toric cornea with no either be equal or different.22 containing fi ve toric zones, with corneal touch in the steepest Research suggests toric ortho-k reverse curves in the second and meridians. Below, the topography 21 pattern of the same lens shows a lenses be used for apical astig- the fourth. This design is known decentrated treatment zone forming matism, measured with a corneal as the “full toric double reservoir.” a ‘smiley face’ pattern. topographer, higher than 1.75D, The researchers suggested that to limbus-to-limbus astigmatism achieve an adequate effect with allow for better centration.11 The higher than 1.25D and peripheral a toric ortho-k lens, mechanical corneal astigmatism was gradually astigmatism higher than -1.00D. 22 and hydrodynamic forces must decreased, resulting in a success Using the toric back optic zone is occur differently in each corneal rate of 92.8%.11 This suggests that recommended for corneal astig- meridian, with greater fl attening toric ortho-k designs are able to matism that differs from refractive in the meridian where the my- reduce moderate-to-high corneal astigmatism. If the axes of corneal opia is greater. Results demon- astigmatism. and refractive astigmatism do not strated an 85% change in initial coincide, the optical and the align- astigmatism.21 CASE REPORTS ment zones require different axes.22 An additional study, with sub- One case report used a toric align- A recent study suggests toric or- jects age nine to 16, used a design ment zone and spherical back optic tho-k use may be benefi cial when with reverse and alignment toric and reverse zone for a 13-year-old the sagittal height differential zones, which are more appropri- patient with spectacle correction between the two principal meridi- ate for toric corneas because they of -4.25 -1.50x165° OD and -4.25

REVIEW OF CORNEA & CONTACT LENSES | JANUARY/FEBRUARY 2017 27 RESHAPING ORTHO-K

-2.50x180° OS.18 According to the report’s authors, the advantage of placing a spherical optic zone on a toric cornea is that the fl attest lens meridian creates a normal ortho-k effect while the steepest meridian results in a greater ortho-k effect—leading to the correction of the corneal astigmatism. Other case reports used the same design, Figs. 2a and 2b. At left, a toric ortho-k lens on a toric cornea showing 360° as did the fi rst studies on toric or- total touch in the landing zone. At right, the topography pattern of the same tho-k lenses for astigmatism.10,13,26 lens shows a centered fl attening treatment zone. These studies demonstrated a 95% toric ortho-k fi rst lens fi t success and vice versa in the optical zone. oblique in any axis astigmatism rate in correcting low-to-moderate Three months after ortho-k fi tting, up to -4.00D. Additionally, they myopia in children with moder- the subjective correction was show that possibilities exist for ate-to-high astigmatism, which +0.50 -0.50x10° (uncorrected VA correction of different corneal and was better than the trial lens rate of 20/16) OD and +0.25 -1.00x5° refractive toricity, as well as lim- of 73.5%, as well as a reduction in (uncorrected VA 20/16) OS. bus-to-limbus astigmatism. the axial elongation amount.10,13 In a more recent case report, a In another case report, of a 48-year-old female presented with aving a wide range of toric 22-year-old patient presenting with -0.75 -2.50x170° add 1.50D OD Hortho-k lens designs available -4.25 -3.75x8° OD and corne- and -1.50 -1.50x20° add 1.50D expands the therapeutic options al astigmatism of -3.10x7°, the OS.28 Her best-corrected VA was for the vast majority of patients. authors fi t a reverse ortho-k lens 20/16 in both eyes. The patient’s Practitioners can also design their with two toric zones: the reverse cylindrical component was three own lenses, whether through and the landing.16 The correction times larger than the spherical contact lens fi tting simulations in of high corneal astigmatism needs component in the right eye, while free style upon the corneal map a perfectly closed reverse zone in the two were equal in the left eye. with topography; empirical fi tting each meridian to properly mod- Also, she had refractive astigma- software using keratometry and ulate the hydrodynamic forces, tism higher than corneal astigma- eccentricity through topography allowing for separate corneal tism (i.e., -1.82D OD and -1.39D and refraction data; or download- fl attening in each meridian. At OS) and low eccentricity. The able topography software. two months post-treatment, the lens fi t was a tetracurve toric with Evidence suggests children and patient’s corneal astigmatism was optical, reverse and landing zones. adolescents with astigmatisms up largely reduced, and the subjective According to the author, having to 4.00D in all directions, even correction was cyl -0.50Dx8° with the cylindrical component three limbus-to-limbus, can benefi t from uncorrected visual acuity (VA) of times higher or equal to the spher- ortho-k and myopia control, as 20/20.16 ical component and the refractive toric ortho-k lenses have proven One case report used a hexa- astigmatism greater than the to be effi cient in reducing mod- curve (i.e., six back curves) design corneal astigmatism was necessary erate-to-high astigmatism and 22 with two back toric zones, as for the toric optical zone. The toric slowing axial elongation. RCCL well as optic and landing zones reverse and alignment zones pro- 1. Holden BA, Fricke TR, Wilson DA, et al. Global for a 44-year-old patient with moted the negative and hydrody- prevalence of myopia and high myopia and temporal trends from 2000 through 2050. Ophthal- mixed astigmatism in which the namic forces needed for treatment, mology. 2016;123(5):1036-42. cylindrical component was great- better stability and centration of 2. Holden BA, Jong M, Davis S, et al. Nearly 1 billion myopes at risk of myopia-related sight-threat- er than the spherical, the patient the lens. ening conditions by 2050 - time to act now. Clin presented with + 1.00 -2.00x180° While these reports are not Exp Optom. 2015;98:491-3. 27 3. Walline JJ, Rah MJ, Jones LA. The children’s OD and +1.25 -2.25x180° OS. conclusive, they do illustrate that overnight orthokeratology investigation (COOKI) The vertical meridian was steeper various designs have proven useful pilot study. Optom Vis Sci. 2004;81:407–13. 4. Cho P, Cheung SW, Edwards M. The longitudinal than the horizontal meridian in for specifi c patients presenting orthokeratology research in children (LORIC) in the midperipheral landing zone with-the-rule, against-the-rule or Hong Kong: a pilot study on refractive changes

28 REVIEW OF CORNEA & CONTACT LENSES | JANUARY/FEBRUARY 2017 Up to NEW TECHNOLOGIES 2017 & TREATMENTS IN 19 CE Credits* Eye Care

REVIEW OF OPTOMETRY® EDUCATIONAL MEETINGS OF CLINICAL EXCELLENCE and myopic control. Curr Eye Res. 2005;30:71–80. 5. Kakita T, Hiraoka T, Oshika T. Inﬂ uence of overnight orthokeratology on axial elongation in childhood myopia. Invest Ophthalmol Vis Sci. 2011;52:2170–4. 6. Zhu MJ, Feng HY, He XG, et al. The control effect of orthokeratology on axial length elongation in Chinese children with myopia. BMC Ophthalmol. 2014;14:141. CHARLESTON 7. Li SM, Kang MT, Wu SS, et al. Effi cacy, safety and acceptability of orthokeratology on slowing axial elongation in myopic children by meta-analysis. Curr Eye Res. 2016;14:600-8. 8. He, M, Du, Y, Liu, Q, et al. Eff ects of orthokeratology on the progression of low to moderate MARCH 24-26, 2017 myopia in Chinese children. BMC Ophthalmology. 2016;16:126. 9. Young G, Sulley A, Hunt C. Prevalence of astigmatism in relation to soft contact lens ﬁ tting. Eye Contact Lens. 2011 Jan;37(1):20–5. 10. Chen C, Cheung SW, Cho P. Myopic control Join Review of Optometry’s New Technologies & Treatments using toric orthokeratology (TO-SEE study). Invest in Eye Care on March 24-26, 2017 in Charleston, South Opthalmol Vis Sci. 2013;54:6510–7. * 11. Luo M, Ma S, Liang N. Clinical effi cacy of toric Carolina. This meeting provides up to 19 COPE CE credits orthokeratology in myopic adolescent with ** moderate to high astigmatism. Eye Sci. 2014 including interactive workshops! Registration cost: $495 Dec;29(4):209-18. 12. Ruston D, Van Der Worp E. Is ortho-k ok? Optometry Today. 2004 Dec;17:25-32. 13. Chen CC, Cheung SW, Cho P. Toric orthokeratology for highly astigmatic children. Optom Vis Charleston Marriott Sci. 2012;89:849-55. 14. Mountford J, Pesudovs K. An analysis of the astigmatic changes induced by accelerated ortho- 170 Lockwood Boulevard Interactive keratology. Clin Exp Optom. 2002;85:284–93. 15. Cheung SW, Cho P, Chan B. Astigmatic Charleston, SC 29403 Workshops changes in orthokeratology. Optom Vis Sci. Available! 2009;86:1352–8. (843) 723-3000 ** 16. Baertschi M, Wyss M. Correction of high amounts of astigmatism through orthokeratology. $ † A case report. J Optom. 2010;3:182-4. Discounted room rate 219/night 17. Chan B, Cho P, Cheung SW. Orthokeratology practice in children in a university clinic in Hong Kong. Clin Exp Optom. 2008;91:453–60. 18. Chan B, Cho P, De Vecht A. Toric orthokeratol- PROGRAM CHAIR: ogy: a case report. Clin Exp Optom. 2009;92:387- Paul Karpecki, OD, FAAO 91. 19. Mountford J, Pesudovs K. An analysis of the FACULTY: Douglas Devries, OD astigmatic changes induced by accelerated orthokeratology. Clin Exp Optom. 2002;85:284–93. Diana Shechtman, OD, FAAO 20. Mountford J, ed. Orthokeratology: Principles and Practice. Oxford: Butterworth Heinemann; Robert Wooldridge, OD, FAAO 2004;69–107. 21. Pauné J, Gardona G, Quevedo L. Toric double Jerry Godwin, MBA reservoir contact lens in orthokeratology for astigmatism. Eye Contact Lens. 2012;38:245-51. 22. Pauné J. From bowtie to casual: dealing with toric corneas in ortho-k. Lecture at GSLS, January 21-24, 2016; Las Vegas, NV. 23. Kojima R, Caroline P, Morrison S, et al. Should all orthokeratology lenses be toric? Poster pre- THREE WAYS TO REGISTER sented at GSLS, January 21-24, 2016; Las Vegas, NV. 24. Baertschi M. Short and long term success with correction of high astigmatism in OK. Lecture at • www.reviewofoptometry.com/Charleston2017 the Global Orthokeratology Symposium, July 28- 31, 2005; Chicago, IL. • [email protected] 25. Beerten R, Christie C, Sprater N, Ludwig F. Improving orthokeratology results in astigmatism. Poster presented at the Global Orthokeratology • 866-658-1772 Symposium, July 28–31, 2005, Chicago, IL. 26. Chen C, Cho P. Toric orthokeratology for high myopic and astigmatic subjects for myopic control. Clin Exp Optom. 2012;95:103–8. 27. Calossi A. Mixed astigmatism treated with a dual-toric ortho-k design. Contact Lens Spectrum. 2013 Feb;28:49. 28. Fadel D. Unusual clinical cases in orthokeratology. Review of Cornea & Contact Lenses. Jun, 2016:22-27. Administered by ® Review of Optometry *Approval pending †Rooms limited. **Separate REVIEWregistration OF CORNEA required. & See CONTACT event website LENSES for |complete JANUARY/FEBRUARYJANUARY/FEJANUARY/FEB details. BRUARYB 2017 29 Photos ©istock.com/JobsonHealthcare Keys to a diatric Pe Soft Lens Fitting

s eye care practi- themselves in the areas of athletic be delegated to staff members. tioners (ECPs), we are competence, social acceptance and Another notable concern clinicians often faced with the physical appearance compared have in fi tting children—particular- question, “How old with study participants wearing ly younger ones—in contact lenses Adoes my child need spectacles.1 In children who are is the risk of an adverse event. to be before he can wear contact not compliant with spectacle wear However, younger children are ac- lenses?” Although answers to this because of cosmetic concerns, tually less likely to have an adverse question will vary, most doctors feel contact lenses can lead to an event during contact lens wear than confi dent in fi tting children older overall improvement in compliance teenagers and young adults, and than 10 in contact lenses. Younger with refractive correction. This is microbial keratitis is uncommon in children such as toddlers (from one particularly important for children this population.4 to three years of age) can also be with signifi cant refractive errors, as safely and successfully fi t in contact contact lenses will increase the fi eld READY OR NOT lenses when they are necessary to of view particularly well in patients (TO WEAR CONTACTS) enhance visual function or provide with a high refractive error. Patients Determining if a child is ready therapeutic benefi ts. Important with corneal irregularities or high for contact lens wear is one of the considerations when fi tting children refractive errors may experience most challenging parts of the fi tting in contact lenses include: the bene- improved visual acuity and comfort process. Although most parents ask fi ts of lenses for the child, the risks with contact lenses. Children with at what age we begin fi tting contact associated with fi tting the child in signifi cant anisometropia benefi t lenses, the patient’s age is generally contact lenses and whether the child from the decrease in aniseikonia not the limiting factor. The pediatric and parents are ready for contact with contact lens wear compared population is not homogeneous, lens wear. Although fi tting pediatric with spectacle wear, which not only and each patient must be treated and adolescent patients in contact decreases asthenopia, but also can individually. While some children as lenses seems intimidating, these improve binocularity.2 young as seven may prove ready for patients are often less complex and contact lens wear, some adolescents more compliant than adult patients. CONCERNS FOR CLINICIANS are not good candidates. Unpacking these considerations can One of the fi rst concerns that many Often to the caregiver’s surprise, boost your clinical knowledge and practitioners have when fi tting give you the confi dence to care for children in contact lenses is the ABOUT THE AUTHORS this patient population. potential increase in chair time. Contrary to popular belief, fi tting Dr. Jenewein completed a residency in pediatrics and BENEFITS TO FITTING a young child does not necessarily binocular vision at Nova PEDIATRIC PATIENTS take more time than fi tting an older Southeastern University. She is an assistant For the adult population, improved child or an adult. The Contact Lens professor at Salus University Pennsylvania College of cosmesis is one of the most common In Pediatrics study found that it Optometry. reasons patients choose contact takes, on average, only 15 more Dr. Bhagat is a faculty member lenses over spectacles—and the minutes to fi t children age eight to at the Pennsylvania College same could be said about pediat- 12 compared with children older of Optometry at Salus 3 University. She specializes ric patients. The ACHIEVE study than 12. Most of this extra time in managing ocular surface found children wearing contact was spent on insertion and removal disease and fi tting specialty contact lenses. lenses felt signifi cantly better about training, a task that can generally

30 REVIEW OF CORNEA & CONTACT LENSES | JANUARY/FEBRUARY 2017 From infancy to adolescence, contact lenses prove a viable and beneﬁ cial treatment option for a range of conditions.

By Erin C. Jenewein, OD, MS, and Kriti Bhagat, OD

the best resource for pia, either by overplussing answering the question the non-amblyopic eye of a child’s readiness is to cause blur signifi cant the parents or guardians enough to switch fi xa- themselves. Questioning tion to the amblyopic eye parents about the overall or using a lens with an responsibility level of the opaque pupil to occlude child will help to deter- the non-amblyopic eye. mine if the child is ready When using the plus At left, a custom prosthetic lens decreases the amount for the responsibility of of light entering the pupil and the cosmetic appearance therapy, the lens-induced contact lens wear. Are of the iris irregularity. At right, an inferior iris coloboma blur must be greater than they able to take respon- causes increased light sensitivity and haloes around the blur experienced by the sibility for homework objects. amblyopic eye.6 or chores at home? Does the child the best option for the pediatric pa- Additionally, tinted lenses can make their bed every morning and tient, regardless of the patient’s age. be fi t for patients with achroma- keep a clean room? Will they re- In these cases, parental motivation topsia or other cone dystrophies to member to remove the lenses before and support is the key to successful decrease photophobia and enhance bed every night and clean them contact lens wear. Children who are color perception. Patients with properly? The parent can also give aphakic—either from congenital achromatopsia often prefer red, insight into the child’s personal hy- aphakia or from cataract removal at magenta or brown lenses in lieu of giene, which can impact their ability an early age—are often fi t in contact wearing tinted spectacles. Although to properly care for contact lenses. lenses as infants or toddlers. Infants the contact lens tint can be seen Both patient and parent motiva- and toddlers with extremely high under the slit lamp, it is not detect- tion is essential to successful lens refractive error or high amounts of able under normal viewing condi- wear in pediatric patients. If a child anisometropia may benefi t from tions, providing a more cosmetically is reluctant to wear lenses, it can be contact lens wear to improve acuity appealing option. Colored lenses challenging to successfully fi t them and binocularity. can decrease photophobia, improve in contact lenses. Similarly, if a par- Contact lenses can also be used vision and provide better cosmesis ent is reluctant to allow a child to for penalization therapy in amblyo- for patients with iris abnormalities wear lenses, it may be an indication such as iris coloboma and aniridia. the parent realizes the child is not Pediatric patients with corneal ready for contact lens wear. irregularities may experience better vision as well as increased comfort SPECIAL INDICATIONS with contact lenses. Some pediatric patients who may not be ideal candidates for contact CHOOSING THE RIGHT LENS lens wear may, nevertheless, need to Options for fi tting children in con- be fi t in contact lenses to improve During a prostehtic lens fi tting, tact lenses are similar to those with vision, comfort or binocularity. The contact lenses can be layered to any other age group. Soft lenses are overwhelming benefi ts of contact show the patient how the fi nal the most commonly used modality product may look. Here is an lenses over spectacles in these pa- occluded pupil contact lens with a for general refractive cases such tients may make contact lens wear brown underprint layered on top. as myopia, hyperopia and regular

REVIEW OF CORNEA & CONTACT LENSES | JANUARY/FEBRUARY 2017 31 astigmatism. Many manufacturers guardians should be present to COMPLIANCE offer extended range parameters listen to the instructions given to the Children are more likely to share for patients with high amounts of pediatric patient so the parent also their lenses with friends, so it is myopia and hyperopia, keeping the learns about proper contact lens important to educate them that they overall cost to a minimum for the care in case they need to assist the cannot do so with anyone else or patient and avoiding the need to child. This is crucial for children too allow anyone try their lenses on. As switch to custom soft lenses. young to insert and remove the lens- with any medical device, compliance Daily lenses decrease the likeli- es themselves, as the parent will be is always an issue. A handout that hood of contact lens-related adverse handling this process for the child. details how lenses are to be worn events. Daily disposables can also With every new pediatric patient, and the proper care method can be easier for children to handle, there is always an insertion and re- help with this. Written instructions eliminating the need for cases and moval training in-offi ce. For parents that includes the solution names, solution bottles.5 of infants and toddlers, clinicians replacement schedules, wearing time Children with aphakia, signifi cant should stress the importance of hav- and signs and symptoms of com- corneal cylinder, irregular corneas ing a secure hold of the infant’s head mon complications can be extremely or ocular surface disease can be fi t and body. Many times, this becomes helpful. Regardless of age, clinicians with rigid gas permeable lenses, a two-person effort, as one person should also warn against swimming including scleral lenses. When fi tting holds the infant while the other in lenses, and stress the need to rigid lenses in children, it may be inserts or removes the contact lens. always rub the lenses with solutions, benefi cial to use a Burton lamp or a For children able to insert and restore them with new solution each Bluminator for lens evaluation out- move lenses on their own, clinicians night and replace the case every side of the slit lamp. This allows the should begin by emphasizing the three months. child to sit comfortably in a stroller need to wash your hands before in- or parent’s lap during the lens eval- sertion and removal. Generally, the any pediatric patients can uation. Prosthetic contact lenses are practitioner places the lenses fi rst, Measily and safely use contact an option for children with iris or so the child will have the lenses in lenses, even young children, with corneal irregularities. These lenses during the fi tting process. Therefore, proper oversight. Contact lenses can help decrease photophobia, training will entail teaching removal can provide improved confi dence, diplopia or improve cosmesis. skills fi rst, followed by lens storage better visual acuity, higher levels of and ending with insertion tech- comfort and better potential for bin- INSERTION AND REMOVAL niques. It is important to guide the ocular vision in pediatric patients. Training in the pediatric population child the fi rst time to help increase Although fi tting young children can be slightly more challenging confi dence and then let them do it can be intimidating at fi rst, it can than in adult patients. Parents or on their own. This will show them be equally rewarding for both the they can do it and indicate they may patient and practitioner. RCCL be ready to take the lens home. 1. Walline J, Jones L, Sinnott L, et al. Randomized Clinicians should watch the child trial of the eff ect of contact lens wear on self-perception in children. Optometry and Vision Science. insert and remove the lenses at 2009;86(3):222-32. least twice before dispensing. This 2. Winn B, Acherley RG, Brown CA, et al. Reduced aniseikonia in axial anisometropia with contact ensures patient and parent have the lens correction. Ophthalmic Physiological Optics. proper technique and are comfort- 1988;8(3): 341-4. 3. Walline, J, Jones L, Rah M, et al. Contact able with the lenses. If the fi rst train- lenses in pediatrics (CLIP) Study: chair time and ocular health. Optometry and Vision Science. ing is unsuccessful, stop before the 2007;84(9):896-902. patient and parent become frustrat- 4. Wagner H, Richdale K, Mitchell G, et al. Age, behavior, environment, and health factors in the ed and have them return to attempt soft contact lens risk survey. Optometry and Vision training on a different day. Science. 2014;91(3):252-61. 5. Chalmers RL, Hickson-Curren SB, Keay L, et al. Laying a towel over the sink drain Rates of adverse events with hydrogel and silicone hydrogel daily disposable lenses in a large postmar- can help young patients avoid losing ket surveillance registry: the TEMPO Registry. Invest lenses, and labeling solution bottles Ophthalmol Vis Sci. 2015;56(1):654-63. Even with a lighter iris, it’s hard to 6. Walline J, Rah M. Contact lenses for amblyopia tell a patient is wearing a tinted and contact lens boxes and cases Treatment. Contact Lens Spectrum. 2008. Available carefully can avoid misusing the at www.clspectrum.com/issues/2008/novem- contact lens, which help avoid the ber-2008/treatment-plan. Accessed January 17, use of red glasses. solution or wearing incorrect lenses. 2017.

32 REVIEW OF CORNEA & CONTACT LENSES | JANUARY/FEBRUARY 2017 IT’S TIME TO SEE A SPECIALIST. (For your practice, that is.)

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RO0217_House Seco Med.indd 1 1/17/17 3:54 PM The GP Experts By Robert Ensley, OD, and Heidi Miller, OD

Treating Infantile Aphakia: Think GPs This lens modality is a great alternative to soft contact lens correction. Photo: Viola Kanevsky, OD lthough it may not age.4 However, contact lenses can seem common, the be fi t on infants and may even be prevalence of congen- a preferable long-term option. The ital cataracts ranges Infant Aphakia Treatment Study from one to 15 per Contact Lens Experience, which A 1 10,000 children. Approximately compared contact lens correction one-third of congenital cataracts for unilateral aphakia with IOL are inherited, while the remaining implantation for children between This well-centered GP lens shows causes are associated with in utero one and six months of age, showed good apical alignment. drug reactions, systemic diseases visual acuity outcomes were similar such as rubella and measles or at age one and four and a half.4 The ized to the desired power and base idiopathic.1 In addition to obstruct- rate of adverse events was lower in curve. They are durable and simple ing vision, congenital cataracts may the study’s contact lens wearers, and to handle, often making it easier on cause other complications including few patients in that group required parents to insert and remove. pediatric glaucoma and strabismus.2 additional intraocular procedures.4 Although GP lenses provide the For at-risk patients, cataract surgery These outcomes demonstrate that least incidence for microbial kera- is indicated; however, there is some contact lenses are a viable option titis, lens loss and ocular irritation uncertainty regarding the best age to for managing aphakia—and rushing tend to be the most common issues perform the surgery. Generally, cata- into IOL implantation is not always with this lens material.5,6 ract extraction should be performed the right answer for patients who around six weeks of age for unilat- are less than ideal candidates. FITTING GPs FOR APHAKIA eral cataracts and between six and Because most patients are initially eight weeks for bilateral cataracts CHOOSING A LENS examined under anesthesia, corneal with a one- to two-week period Silicone elastomer soft contact measurements, keratometry values between surgeries for each eye.3 lenses are commonly used in the and a refraction by retinoscopy Post cataract surgery, eye care early treatment of aphakia; how- should be available prior to the providers face the challenge of fi nd- ever, they present challenges that contact lens fi tting appointment. ing the proper refractive correction may be exacerbated when treating When fi tting a patient in GP lenses, to reduce the risk of amblyopia. the pediatric population: (1) while clinicians should select a base curve If suffi cient capsular support is highly permeable to oxygen, they that is 1mm to 1.5mm steeper than present, intraocular lens (IOL) are prone to surface deposits, (2) the fl attest keratometry read- implantation can be performed limited power and fi tting parame- ing—a value based off the Infantile once the patient is two years of ters can make it diffi cult to properly Aphakia Treatment Study Protocol.8

Photo: Viola Kanevsky, OD manage a patient and (3) fi nancial Evaluating the fl uorescein pattern costs associated with contact lens may lead to a change in base curve. replacement, either due to power The overall lens diameter is usually changes or lens loss, can result in 10mm or larger, although this can poor compliance and follow up. vary depending on the patient’s Gas permeable (GP) lenses are a corneal diameter. The optimal fi tting great resource for managing aphakic lens displays a well centered align- infants. Due to infants’ small corne- ment fi t, with adequate edge clear- al diameter and narrow lid fi ssures, ance evidenced by an approximately they can easily tuck underneath the 1mm band of fl uorescein around taut lids and stay in place.5 They the lens edge.7 Topical anesthetics Too steep a fi t results in inferior decentration and accummulation of are available in a wide range of to facilitate the contact lens fi tting bubbles underneath the lens. prescriptions and can be custom- evaluation, and during insertion

34 REVIEW OF CORNEA & CONTACT LENSES | JANUARY/FEBRUARY 2017 and removal training are typically vided in the event the contact lens lay bifocal spectacles with a +3.00 not required, because the child’s is lost to allow continued optical add power. Choosing bilateral or fear is usually what makes these fi ts correction to prevent amblyopia.8 unilateral bifocals is often left to the diffi cult, not lens awareness.8 clinician’s preference. Once clinicians determine the CORRECTION AFTER TWO Generally speaking, if a patient appropriate cornea-to-lens relation- Bifocal lenses are prescribed for the has unilateral aphakia, unilateral ship, they can refi ne lens powers by child around age two, when the bifocals are prescribed to allow the retinoscopy over the diagnostic lens. added power of over-plussed lenses phakic eye to accommodate freely In children under the age of two, 2D begins to interfere with distance without creating unnecessary blur. to 3D of additional plus are added viewing.8 Often, the GP lens is made Progressive lenses can also be used if to the lens to provide clear near for full distance correction, and the patient has bilateral aphakia. vision. Spare lenses should be pro- the clinician then prescribes over- (Continued on page 37)

CASE EXAMPLE

A two-month-old female patient was referred for a demonstrated a steep fi t with bubbles and poor contact lens evaluation following cataract extraction. centration. Flatter diagnostic lenses were trialed The patient presented wearing a Silsoft Super Plus until an apical alignment or minimal apical clearance (Bausch + Lomb) 7.5 base curve, 11.3 overall diameter pattern was evident. Over-refraction was completed (OAD) and +32.00D power—inserted by her cataract and the new power was determined by adding an surgeon for extended wear until she could be seen by additional +3D to ensure the patient was left 3D a specialty contact lens fi tting optometrist. myopic. A larger OAD lens was ordered, along with a At the fi rst contact lens visit, retinoscopy showed larger optic zone to maintain alignment pattern and a +4.50D over-refraction. Examining the contact lens improve centration. The new lens parameters were fi t using a 20D lens and transilluminator revealed 7.34 base curve, 9.20 OAD and +40.00D. adequate centration, good movement and full corneal coverage. Although an adequate fi t, the Silsoft DISPENSING contact lens has a maximum power of +32.00D, and a On the dispensing visit, the lens was slightly too GP contact lens was considered in the near future. steep and was decentering temporally. A few The parents were trained on insertion and removal modifi cations to the base curve assisted with of the soft contact lens and advised to remove centration and overall fi t. The parents were trained the lens each night and clean it with a hydrogen on GP insertion and removal, and hydrogen peroxide peroxide solution. An online video on insertion and solution was recommended for lens care. Once removal was recommended in case at-home review the lens was fi nalized, a spare lens was ordered was necessary. A multipurpose solution safe for and dispensed as well. The patient was followed immediate contact with the eye was also dispensed every one to two months initially, then by three- in the event the lens required immediate cleaning. month intervals once lens changes became less frequent. She was routinely seen by the pediatric RECHECK ophthalmologist and prescribed aggressive occlusive Two weeks later, during the recheck, retinoscopy therapy for amblyopia management. revealed an over-refraction of +3.75D. Examination At age two, the patient returned for a contact lens demonstrated good centration and movement of the evaluation. The lens power was modifi ed to correct contact lens. Because the patient needed additional for distance, and overlay polycarbonate unilateral plus power, a GP contact lens fi tting was initiated. bifocals were prescribed for full-time wear. The The initial lens trialed was a 6.75 base curve, 8.5 patient was seen every three months until age three, OAD and +20.00D. Examination using a blue light then followed every three to six months.

REVIEW OF CORNEA & CONTACT LENSES | JANUARY/FEBRUARY 2017 35 Pharma Science & Practice By Elyse L. Chaglasian, OD, and Tammy Than, MS, OD

Corneal Collagen Crosslinking: Not Just for Adults Treatment plans for pediatric patients with keratoconus may get an upgrade soon with this newly approved technology.

orneal collagen cross- children is often associated with topical anesthesia and removal of linking (CXL) is quick- vernal keratoconjunctivitis and eye the corneal epithelium, followed ly becoming a fi rst-line rubbing, which can lead to hydrops, by a soak of 0.1% ribofl avin/20% approach for managing so care must be taken to quell the dextran solution (varied from progressive keratoco- surface infl ammation with topical 10 to 30 minutes) and then 30 C 4 nus in adults, accelerated by the anti-allergy and steroid drops. minutes of UVA irradiation (six FDA’s approval of the Avedro sys- Additionally, keratoconus in times for fi ve minutes each), with tem in early 2016 for patients older children tends to be more severe at instillation of ribofl avin/dextran than 14. CXL photosensitizes the initial presentation and progresses every fi ve minutes. Post-procedure, collagen of the corneal stroma and more quickly than in newly diag- antibiotic and cycloplegic drops increases its biomechanical rigidity, nosed adult patients.5 A retrospec- were instilled, along with a ban- thus halting or possibly reversing tive study of 49 patients younger dage contact lens. Some children the progression of keratoconus. than 15 and 167 older than 27 with required general anesthesia, while But adults aren’t the only ones in keratoconus at initial presentation others required only topical.6-8 need of treatment. A retrospective found the disease was more severe One study evaluated patients age study to determine the incidence at diagnosis in subjects in the fi rst 10 to18, divided into two groups by and presentation of pediatric ker- group: 27.8% were already at corneal thickness: less than 450µm atoconus (younger than 14) found stage 4 using Krumeich’s classifi - and greater than 450µm.6 At 36 that over a fi ve-year period, 541 cation, as compared with 7.8% of months post-CXL treatment, no ad- of 2,972 patients were diagnosed adult subjects.5 Stage 4 includes verse events were reported and both with keratoconus—an incidence of non-measurable refraction; mean groups showed an improvement in 0.53%, representing 2.96% of all central keratometry readings >55 uncorrected Snellen visual acuity cases diagnosed during that time.1 diopters; central corneal scarring (VA), topography and coma. There In comparison, the incidence in the and a minimum corneal thickness was a faster functional response in adult population is 3.78%.1 of 200µm.The younger subjects also patients with thinner corneas. Because studies evaluating the had more advanced slit lamp signs Another study evaluated the re- effi cacy of CXL have focused on and keratometry readings.5 fractive, topographic, aberrometric adults, the incidence and severity of and tomographic results in patients keratoconus in children is poorly CXL IN KIDS: THE LITERATURE ages nine to 18 for up to two years.7 understood, as is the potential role Given the diffi culties in fi tting the There was a slow but continuous for CXL in the pediatric population. pediatric population with contact improvement of most of the indices lenses and the greater propensity for up to 24 months after surgery, with PEDIATRIC CHALLENGES full thickness corneal graft rejection, no adverse events noted. Treating children presents a number CXL could be the answer, as pre- Finally, a study evaluating pa- of unique challenges. Most man- liminary studies indicate it stabilizes tients age nine to 19 for progression agement strategies successful with the disease process and reduces the of keratoconus and the effi cacy of adults, such as specialty contact need for keratoplasties. So far, three CXL up to three years postopera- lenses, are less so with children, studies have evaluated the effi cacy tively found 88% exhibited progres- given complications such as diffi cul- of CXL—with a standard epi-off sion (an increase in the maximum ty with wear and care compliance treatment—and the progression of keratometry of at least 1.00D over and poor outcomes with corneal keratoconus in the pediatric popula- a one-year period).7 The researchers transplantation.2,3 Keratoconus in tion. Patients were pretreated with analyzed maximum keratometry

36 REVIEW OF CORNEA & CONTACT LENSES | JANUARY/FEBRUARY 2017 distance VA continued to be better treatment of keratoconus for pa- 8 than pre-CXL. tients as young as 14. RCCL One study performed transepi- 1. el-Khory S, Abdelmassih Y, Hamade A, et al. thelial (epi-on) CXL on 13 eyes in Pediatric keratoconus in a tertiary referral center: patients ages eight to 18.9 While the incidence, presentation, risk factors and treatment. J refract Surg. 2016;32(8):534-41. procedure was safe, well tolerated 2. Vanathi M, Panda V, Vengayil S, et al. Pediatric and the corrected distance visual keratoplasty. Surv Ophthalmol. 2009;54:245-71. 3. Lowe MT, Keane MC, Coster DJ, Williams KA. The acuity was improved at 18 months outcome of corneal transplantation in infants, chil- of follow-up, it did not halt the pro- dren and adolescents. Ophthalmology. 2011;118:492-7. 4. Rehaney U, Reumelt S. Corneal hydrops associat- A Fleischer ring, as seen in some gression of keratoconus as seen with ed with vernal keratoconjunctivitis as a presenting keratoconus patients. the standard epi-off treatment.9 sign of keratoconus in children. Ophthalmology. 1995:1021(12):2046-9. 5. Leoni-Mesplie S, Moortemousque B, Touboul values, corrected distance VA, cor- his research suggests keratoco- D, et al. Scalability and severity of keratoconus in children. Am J Ophthalmol. 2012;154:56-62. neal thickness and the keratoconic Tnus in pediatric patients is more 6. Caporossi A, Mazzotta C, Baiocchi S, et al. Ribo- index. They found the maximum severe and progresses more quickly ﬂ avin-UVA-induced corneal collagen crosslinking in pediatric patients. Cornea. 2012;31(3):227-31. keratometry value was reduced than in adults, and standard CXL is 7. Vinciguerra P, Albé E, Frueh BE, et al. Two-year by three months and remained for safe and effective, although perhaps corneal cross-linking results in patients younger than 18 years with documented progressive kerato- up to 24 months. However, at 24 more transient, in patients younger conus. Am J Ophthalmol. 2012 Sep;154(3):520-6. months, it began to show progres- than 18. 8. Chatzis N, Hafezi F. Progression of keratoconus and effi cacy of pediatric corneal collagen crosslink- sion, suggesting pediatric corneas More studies with longer follow ing. J Refract Surg. 2012 Nov;28(11):753-8. do not allow for long-term improve- up are needed, but it appears CXL 9. Buzzonetti L, Petrocelli G. Transepithelial corneal cross-linking in pediatric patients: early results. J ment, although the best-corrected can be seriously considered in our Refract Surg. 2012 Nov;28(11):763-7.

THE GP EXPERTS: TREATING INFANTILE APHAKIA: THINK GPS (Continued from page 35) 3. Lambert SR. The timing of surgery for congenital FOLLOW UP oncompliance is one of the cataracts: Minimizing the risk of glaucoma following Close follow up is imperative for Nbiggest problems with aphakic cataract surgery while optimizing the visual outcome. Journal of AAPOS : the offi cial publication of success with GP contact lenses in management. Loss of contact lenses, the American Association for Pediatric Ophthalmol- managing infantile aphakia. The poor fi t and cost of lenses are some ogy and Strabismus. Jun 2016;20(3):191-192. 4. Russell B, DuBois L, Lynn M, Ward MA, Lambert corneal radius and diameter rapidly reasons for noncompliance in pedi- SR, Infant Aphakia Treatment Study G. The Infant Aphakia Treatment Study Contact Lens Experience change during infancy, resulting in atric patients. to Age of 5 Years. Eye Contact Lens. Jul 27 2016. several lens changes throughout the Although managing aphakia can 5. Baradaran-Rafi i A, Shirzadeh E, Eslani M, Akbari M. Optical correction of aphakia in children. Journal fi rst year. be challenging, clinicians should of ophthalmic & vision research. Jan 2014;9(1):71-82. Questions regarding photopho- consider GP lenses due to their 6. Liesegang TJ. Contact lens-related microbial keratitis: Part I: Epidemiology. Cornea. Mar bia, irritation, excessive blinking, continued success in visual rehabili- 1997;16(2):125-131. redness or discharge should to be tation. RCCL 7. Amos CF, Lambert SR, Ward MA. Rigid gas permeable contact lens correction of aphakia following addressed at each visit. Contact lens congenital cataract removal during infancy. Journal wearing time should be gradually 1. Foster A, Gilbert C, Rahi J. Epidemiology of cat- of pediatric ophthalmology and strabismus. Jul-Aug aract in childhood: a global perspective. J Cataract 1992;29(4):243-245. Refract Surg. 1997;23 Suppl 1:601-604. increased starting with a few hours 8. Wilson ME, Rupal H. Trivedi , Suresh K. Pandey. initially until wear time during all 2. Lim ME, Buckley EG, Prakalapakorn SG. Update Pediatric cataract surgery: techniques, compli- on congenital cataract surgery management. Curr cations, and management. Lippincott Williams & waking hours is achieved. Opin Ophthalmol. Jan 2017;28(1):87-92. Wilkins; 2005.

REVIEW OF CORNEA & CONTACT LENSES | JANUARY/FEBRUARY 2017 37 Corneal Consult By Aaron Bronner, OD

A New Year, a New Look at the Cornea Learning to recognize the processes that govern corneal health and function will allow you to gain a deeper understanding of pathologies and their treatments.

magine a new patient presenting offi ce for Pacifi c Cataract and Laser VAMC clinic in Walla Walla, Wash., to your offi ce with a painful eye Institute (PCLI), a multicenter, co- and you’ll be reading about them and profoundly reduced acuity. management group. from time to time. There is no infi ltrate, but the PCLI was one of the fi rst coman- Icornea appears hazy, perhaps agement groups in the nation and MY INTERESTS edematous, though it’s diffi cult to was one of the earliest to perform I became interested in both cor- tell. What would your working Medicare-approved outpatient cata- neal care and teaching during my diagnosis be? What happens to your ract surgery. Our mission statement residency, which was performed diagnosis if the patient is an extend- is to provide the best care possible at Davis Duehr Dean Eye Care ed wear contact lens user? What if to our optometric referral network, in Madison, Wis., about 10 years they qualify their pain as superfi cial, and we deal exclusively with refer- ago. During my residency, I rotated or deep? What if they had a corneal ral-based care. through some amazing ophthalmo- transplant to this eye six months, At my facility, beyond the stan- logic clinics; I spent about half of or even 20 years, ago? What if they dard menu of cataract and refractive my time in the cornea clinic of Chris had a transplant, but to the fellow surgeries, we provide surgical and Croasdale, MD. During this time, eye? Finally, what happens if your medical corneal care for a large part I realized that, despite my training, original treatment fails? of Eastern Washington and Oregon. I was a fi sh out of water with com- These situations come up period- In addition to the 100 or so great plex surgical or severe corneal dis- ically in my clinic and each subtle ODs I work with indirectly through ease cases—they were so far outside variation in history should generate comanagement, I work directly my experience I couldn’t formulate a separate primary differential and with two skilled optometrists, Brian effective diagnoses or treatments. treatment. Transitioning smoothly Johnson and Bruce Flint, and fi ve After taking a mental accounting among these differentials, being able gifted, gracious ophthalmologists, of how and why I was struggling, to separate the important clinical Jim Guzek, Jason Leng, Loren Seery, my initial step to remedying the situ- fi nding or historic element from Ron Sugiyama and Marshall Ford— ation was to observe Dr. Croasdale’s the red herring, is key to effectively they all bear mentioning because approach to clinical problems. First managing these patients. they are, unwittingly, contributors of all, he just knew way more than Welcome to my fi rst edition of to this column. (Thanks, guys!) me. Given where I was in my career Corneal Consult, a column in which At PCLI, ODs maintain some path, and where he was in his, I hope to explore the diagnostic and level of involvement at all levels of there was nothing I could do about therapeutic challenges we face when perioperative and medical care— this gap—research and continued dealing with corneal pathology and even in very complex medical cases, learning were the only tools I could provide real-world, clinically useful we stay involved with clinical de- use to help narrow that difference to practice pearls each edition. cision making and will collaborate a more acceptable margin. In my fi rst column, I’d like to with our MDs rather than simply But there was one area I could introduce myself and share my referring to our MDs for consulta- address immediately: the stark background, training and current tive services. It’s an exciting, some- difference in how we mentally clinic environment, as well my times stressful, way to practice and approached cases. He employed future goals for this column. provides a phenomenal opportunity what I’d call a process-driven ap- to continue learning. I hope to proach, while I, at the time, used a MY CLINICAL WORLD draw on this experience and make results-driven approach. Most of you (statistically, it’s closer this column as useful to the readers to “all of you”) don’t know me. as possible. In addition to clinical MY FIRST PRACTICE SHIFT I’m Aaron Bronner, an optometrist responsibilities, I also teach residents My results-driven approach to working in the Kennewick, Wash., though the Jonathan Wainwright clinical cases was perfected by four

38 REVIEW OF CORNEA & CONTACT LENSES | JANUARY/FEBRUARY 2017 years of optometry school and its MY COLUMN GOALS incumbent testing. I had learned to I have two goals for this column. assess each fi nding not as a process First, I hope to share some of these taking place within the eye, but only diagnostic and therapeutic associa- as a piece of a puzzle that, once put tions and hopefully help you, too, together, led to a diagnosis—fi nding realize a deeper understanding of X is tied to diagnosis Y. In essence, what is actually taking place in cor- I simply memorized a large num- neal pathologies and their respective ber of fi ndings and their respective treatments. I believe understanding diagnoses, and if a case I encoun- The Bronner family—Aaron and mechanisms involved will encour- tered showed enough associated Becky, Zoë and Liam—enjoying age a process-driven approach and Disneyland at Academy 2016. fi ndings, I would have a diagno- benefi t you in clinic. sis. At its root, this results-driven With no diagnosis tethered to these Second, I’d like to revisit some of approach was not based on any unfamiliar fi ndings, an accurate the vast corneal fi ndings we learn actual understanding of pathologic diagnosis is impossible; a fi nding about in our training. The nature of and physiologic processes, but on without a linked diagnosis becomes our optometric education requires memorization. Perhaps this was less meaningless or, worse, confusing. us to assimilate so much infor- elegant, clinically, than an in-depth Unusual cases demand clinicians mation so rapidly that it becomes understanding of pathophysiology, interpret a series of often unfamiliar impossible to assign the appropriate but it was effective much of the time fi ndings and assimilate them into context to register all of it in our and was adequate during school. a useful differential based on the long-term memory. I hope to re-ex- Dr. Croasdale, however, ap- processes taking place in the eye. plore some of these fi ndings and proached cases quite differently. Once I realized this fl aw, I sought, help assign more clinical relevance Rather than focusing exclusively during my residency (and during my to them to allow better recall. on a fi nding tied to a diagnosis, his career), to better understand the dis- It takes a certain amount of ego process-driven strategy emphasized ease processes encountered in clin- to think you can offer to teach a what pathologic and physiologic ical practice. The tricky thing with similarly credentialed group of process the fi nding represented learning in a postgraduate setting colleagues, and academic lecturing within the eye. is that you never know what you is not my intention in these pages. This was a revolutionary discov- didn’t know until you know it. For A smart person once told me that ery for me. By shifting from my own you to realize a gap in your knowl- “study is a means to an end, it isn’t memorization-based approach to edge base, someone who knows the end itself.” As ODs, academic Dr. Croasdale’s process-driven ap- more has to point it out. I’ve tried knowledge supports clinical prac- proach, I focused on understanding to get around this limitation with tice, not the other way around. So the processes taking place and real- literature research, practicing in a while occasionally the column may ized a deeper understanding of the challenging clinical setting where I delve into academics, I will always pathology and the appropriate diag- am routinely exposed to new things attempt to tie it back into a concept noses, which was particularly useful and, most importantly, collaborat- with clinical value. Each of the con- for cases that weren’t textbook. ing with more experienced ODs and cepts I will discuss started as some- Though both of these approaches MDs (in addition to those already thing I was initially unaware of, and work when a clinician is familiar named, I’d be remiss if I didn’t upon learning the concept, felt it with the underlying diagnosis, the mention Walt Whitley, OD, Doug helped shape my clinical thinking. results-driven approach breaks Devries, OD, James Adamek, OD, I enjoy presenting information in down immediately when faced with and Jeff Urness, OD, as profession- a new manner, and I hope you enjoy an unfamiliar constellation of fi nd- als from whom I’ve directly drawn a the column and learn as much from ings on non-textbook presentations. lot of information). my experiences as I have. Cheers! RCCL

REVIEW OF CORNEA & CONTACT LENSES | JANUARY/FEBRUARY 2017 39 Practice Progress By Mile Brujic, OD, and David Kading, OD

Daily Disposables: Eff ective From Allergy to Astigmatism More patients than you might think can benefi t from this contact lens modality. aily disposable lenses wear.11 After treating the underlying The availability of toric contact have revolutionized our condition, daily disposable lenses lens options in a daily disposable patient care. Not only are a benefi cial option, considering modality is critical when fi tting the do our current contact allergens and other immune com- contact lens neophyte, including Dlens wearers benefi t plexes commonly seen in the tears pediatric patients. One study dis- from daily disposable lens, but also of allergy sufferers will be disposed proved the preconceived notion that those new to contact lenses or those of at the end of the day.12,13 patients younger than 13 cannot who are interested in wearing them Giant papillary conjunctivitis wear contact lenses.17 The advent of on a part-time basis. Other than dai- (GPC), in particular, is a much more daily disposable astigmatic designs ly replacement, there are a number chronic form of allergy that usually offers more individuals the comfort of other indications when dailies requires more aggressive medical and convenience our spherical lens may be appropriate, including: therapy. GPC is typically caused by wearers currently enjoy. Solution sensitivity. Individuals excessive deposition on contact lens wearing a frequent replacement lens surfaces, causing an immunological ASTIGMATISM not approved for extended wear re- response of the conjunctival tissue Healthy ocular fi ndings, high moti- quire multipurpose disinfecting solu- and leading to “giant papillae.”14,15 vation and maturity are the markers tions to care for their lenses. Some These cases often warrant tem- of a good pediatric candidate for individuals may experience solution porary discontinuation of contact astigmatic correction though con- sensitivities over time.1,2,3 Removing lenses and topical corticosteroid tact lenses. These daily disposable care solutions by prescribing daily therapy.16 Although lens wear astigmatism correcting contact lens- disposable lenses will often alleviate can continue after the response is es are well suited for any individuals the signs and symptoms associated controlled, the cleanest surface will requiring astigmatic correction, with solution sensitivity. ultimately provide the best patient especially children: Compliance issues. Research outcomes and the least likelihood of • 1-Day Acuvue Moist for demonstrates a clear link between recurrence. Astigmatism (Johnson & Johnson noncompliance with manufactur- Vision Care). This lens material is ers’ recommended replacement NEW TECHNOLOGIES the same technology in the 1-Day frequency (a common problem with With so many advantages to daily Acuvue Moist spherical lens: etafi l- frequent replacement lens wearers) disposable lens wear, it is no won- con A and 58% water.18 It provides and a degradation in contact lens der that we are more frequently stability through a blink stabilized comfort levels.4,5 reaching for this modality with design based on a dual thin zone, In addition, studies show most our contact lens wearers. Limited individuals do not clean and replace parameter availability has tradi- their storage solution appropriate- tionally hindered our ability to fi t a ly.6-8 Daily disposables help avoid number of our contact lens wearers these challenges, as cleaning and for daily disposable lenses. But, in storage are not required.9 Further, at the last several years, contact lens least one study shows daily dis- manufacturers have introduced a posable lens wearers are the most variety of technologies that allow compliant of all lens wearers.10 our patients to have an enhanced Medical history. Certain medical daily disposable lens wearing experi- conditions such as seasonal allergic ence through new materials and the Fig. 1. Small mark located at the conjunctivitis warrant consid- availability of multifocal and toric six o’clock position as seen in most eration for daily disposable lens contact lens options. lenses for astigmatism.

40 REVIEW OF CORNEA & CONTACT LENSES | JANUARY/FEBRUARY 2017 along with additional stabilization nelfi lcon A and is 69% water, the factors that interact with both the same as the Dailies AquaComfort upper and lower lid. The orienta- Plus sphere and multifocal lenses. tion markers are located at the six This lens contains hydroxypropyl and 12 o’clock position (Figure 1). methylcellulose, which aids in initial Notably, there is no fear of placing comfort. Additionally, moisturizing this lens upside down on the eye; agents polyvinyl alcohol and poly- either orientation will feel identical ethylene glycol are released from to the patient and provide the same the lens throughout the day.21 The visual experience. lens is stabilized through a dual thin Fig. 2. ‘OK’ marking along with three • Biotrue OneDay for zone along with a back surface toric and nine o’clock markings with the Astigmatism (Bausch + Lomb). This design with scribe marks located at Dailies AquaComfort Plus Toric Lens. lens is made of the same material the three and nine o’clock positions. international analysis of contact lens compliance. as its spherical predecessor, the There is also an “OK” inversion Cont Lens Anterior Eye. 2011 Oct;34(5):223-8. Figure 2 9. Dumbleton K, Richter D, Bergenske P, Jones LW. Biotrue OneDay lens: nesofi lcon A indicator on the lens ( ). The Compliance with lens replacement and the interval and 78% water content. It contains back of the “K,” located 90 degrees between eye examinations. Optom Vis Sci. 2013 Apr;90(4):351-8. polyvinylpyrrolidone (PVP) that fa- from the horizontal meridian, can 10. Dumbleton K, Richter D, Woods C, et al. cilitates the high water content and be used as an indicator of rotation. Compliance with contact lens replacement in Canada and the United States. Optom Vis Sci. 2010 poloxamer 407, which helps retain Feb;87(2):131-9. 11. Siddique M, Manzouri B, Flynn TH, Ono SJ. moisture and prevent dehydration ith the growing number of Allergy and contact lenses. Chem Immunol Allergy. on the lens. The lens is stabilized on Wdaily disposable toric lens op- 2007;92:166-75. 12. Nichols KK, Morris S, Gaddie IB, Evans D. the eye with a peri-ballast design tions, we can provide more patients Epinastine 0.05% ophthalmic solution in contact and has a light blue visibility tint. than ever with the benefi ts they lens-wearing subjects with a history of allergic conjunctivitis. Eye Contact Lens. 2009 Jan;35(1):26-31. The orientation marker on this lens bring, especially for new contact 13. Brodsky M, Berger WE, Butrus S, et al. Evalua- tion of comfort using olopatadine hydrochloride is located at the six o’clock position lens wearers and children. Make 0.1% ophthalmic solution in the treatment of allergic and is easily seen at the slit lamp. A use of these ever-improving options conjunctivitis in contact lens wearers compared to placebo using the conjunctival allergen-challenge fi ne laser-etched mark indicates the when appropriate to offer your model. Eye Contact Lens. 2003 Apr;29(2):113-6. axis of the lens.19 pediatric patients the benefi ts of a 14. Solomon A. Allergic manifestations of contact lens wearing. Curr Opin Allergy Clin Immunol. 2016 • Clariti 1 Day Toric (Cooper daily disposable lens. RCCL Oct;16(5):492-7. Vision): This lens is a silicone hy- 15. Elhers WH, Donshik PC. Giant papillary con- 1. Kalsow CM, Reindel WT, Merchea MM, et al. Tear junctivitis. Curr Opin Allergy Clin Immunol. 2008 drogel daily disposable made of so- cytokine response to multipurpose solutions for Oct;8(5):445-9. mofi lcon A and is 56% water. The contact lenses. Clin Ophthalmol. 2013;(7):1291-302. 16. Bartlett JD, Howes JF, Ghormley NR, et al. 2. Choy CK, Cho P, Boost MV. Cytotoxicity and ef- Safety and effi cacy of loteprednol etabonate for material is the same as that in the fects on metabolism of contact lens care solutions treatment of papillae in contact lens-associated on human corneal epithelium cells. Clin Exp Optom. giant papillary conjunctivitis. Curr Eye Res. 1993 Clariti 1 Day sphere and multifocal 2012 Mar;95(2):198-206. Apr;12(4):313-21. lens.20 The modulus of the lens is 3. Epstein AB. Contact lens care products eff ect 17. Walline JJ, Jones LA, Rah MJ, et al. Contact on corneal sensitivity and patient comfort. Eye Lenses in Pediatrics (CLIP) Study: chair time and relatively low for a silicone hydrogel Contact Lens. 2006 May;32(3):128-32. ocular health. Optom Vis Sci. 2007 Sep;84(9):896- 902. lens, which makes it feel similar to 4. Ramamoorthy P, Nichols JJ. Compliance factors associated with contact lens-related dry eye. Eye 18. Acuvue. Available at www.acuvueprofessional. com/product/moist-astigmatism. Accessed Janu- a hydrogel when handling the it. Contact Lens. 2014 Jan;40(1):17-22. ary 4, 2017. 5. Dumbleton K, Woods C, Jones L, et al. Comfort The stability of the lens is created 19. Bausch + Lomb. BioTrue oneday for astigma- and vision with silicone hydrogel lenses: eff ect of tism. Available at www.bausch.com/our-prod- through a prism ballast design in ad- compliance. Optom Vis Sci. 2010 Jun;87(6):421-5. ucts/contact-lenses/lenses-for-astigmatism/ dition to a back surface toric profi le. 6. Robertson DM, Cavanagh HD. Non-compli- biotrue-oneday-for-astigmatism. Accessed January ance with contact lens wear and care practices: 4, 2017. The orientation marker is located at a comparative analysis. Optom Vis Sci. 2011 20. Cooper Vision. Clariti 1 day toric. Available the six o’clock position, making it Dec;88(12):1402-8. at http://coopervision.com/contact-lenses/clari- 7. Dumbleton KA, Spaff ord MM, Sivak A, Jones LW. ti-1-day-toric. Accessed January 4, 2017. easily visible at the slit lamp. Exploring compliance: a mixed-methods study of 21. Alcon. Dailies aquacomfort plus contact lenses. contact lens wearer perspectives. Optom Vis Sci. Available at www.myalcon.com/products/con- • Dailies AquaComfort Plus 2013 Aug;90(8):898-908. tact-lenses/dailies/aquacomfort-plus-technology. Toric (Alcon). This lens is made of 8. Morgan PB, Efron N, Toshida H, Nichols JJ. An shtml. Accessed January 6, 2017.

REVIEW OF CORNEA & CONTACT LENSES | JANUARY/FEBRUARY 2017 41 The Big Picture By Christine W. Sindt, OD

Retained PK Sutures This graft patient showed suture fragments on follow-up. Is it a cause for concern?

hown here is a 26-year- is two years out from the trans- a vector for microbial infection, old female patient who plant with all her corneal sutures requiring heightened vigilance from previously underwent removed, although the broken both the clinician and patient. RCCL penetrating keratoplasty suture remnants visible here will (PK) for Acanthamoeba permanently remain in her cornea. CALL FOR ENTRIES: Do you have S great clinical images of fascinating keratitis (AK) unresponsive to Healing response to graft placement cases you would like to share with medical therapy. The graft size is positive, with no evidence of re- your colleagues on this page and is larger than average due to the jection or failure. The corneal scar- online? Send large, high resolution advanced state of the AK ulcer and ring and suture fragments will not photos (corneal disease or contact the need for sufﬁ cient border zone affect vision. However, the retained lens wear only) and a brief case of healthy, unaffected tissue. She suture fragments could provide description to: [email protected].

42 REVIEW OF CORNEA & CONTACT LENSES | JANUARY/FEBRUARY 2017 RRCCL0217_Xcel.inddCCL0217_Xcel.indd 1 11/26/17/26/17 2:542:54 PMPM WH2 O 2 A! Patients Love Our Bubbles

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References: 1. Gabriel M, Bartell, J, Walters R, et al. Biocidal effi cacy of a new hydrogen peroxide contact lens care system against bacteria, fungi, and Acanthamoeba species. Optom Vis Sci. 2014;91:E-abstract 145192. 2. Alcon data on fi le, 2014. 3. Alcon data on fi le, 2015. © 2016 Novartis 04/16 US-CCS-16-E-1913

RCCL0216_Alcon Clear Care.indd 1 1/30/17 11:28 AM