MAY/JUNE 2020

REVIEW OF CORNEA & CONTACT LENSES

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MAY/JUNE 2020

REVIEW OF CORNEA & CONTACT LENSES

CONTACT LENS PROBLEM SOLVING Here’s how to work through the puzzles posed by dry eyes, abnormal lids, tricky topographies, lens deposits and more.

• Fixing Ocular Surface Impediments to GP Lens Wear, p. 8 • Lids and Lenses: Three Snags to Success, p. 14 • Five Conjunctival Findings to Look Out For in Contact Lens Wearers, p. 18 • Irregular Corneas Meet Their Match With GP Lenses, p. 22 • Soft or Scleral Lenses for Dry Eye Patients?, p. 26 • The How and Why of Contact Lens Deposits, p. 30 —EARN 2 CE CREDITS • Embrace the Oddball Cases and Thrive, p. 40

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Toll free 888-519-5375 Follow us! [email protected] www.pentacam.com contents Review of Cornea & Contact Lenses | May/June 2020

features Four Reasons Contact Lens Wear Isn’t a Problem With COVID-19 Despite conflicting reports, patients are just as safe as ever, as long as they adhere to proper wear and care 11 instructions. By Daddi Fadel, DOptom

Lids and Lenses: Three departments Snags to Fitting Success Surgical and anatomical considerations could throw a wrench News Review in your contact lens fitting process. 4 Here’s what to keep in mind. COVID-19 exposure; epi-on CXL and By Steven Turpin, OD, and corneal haze 14 Leonid Skorin Jr., OD, DO, MS 6 My Perspective Five Conjunctival Findings Time to Rethink Trial Lens Safety? to Look Out For in Contact By Joseph P. Shovlin, OD Lens Wearers Learn the basics so you can better manage these conditions in your 8 The GP Experts patients. By Paymaun Asnaashari, OD Fixing Ocular Surface Impediments 18 By Lindsay Sicks, OD Irregular Corneas Meet Their Fitting Challenges Match with GP Lenses 38 These other modalities can provide When Lashes, Not Lenses, are the solutions and improve vision in these Problem unique cases. By Vivian P. Shibayama, OD By Tiffany Andrzejewski, OD, and 22 John Gelles, OD 40 Practice Progress Embrace the Oddballs Soft or Scleral Lenses By Mile Brujic, OD, and David Kading, OD For Dry Eye Patients? Determine the best option that treats your patient’s symptoms and 42 The Big Picture expectations. Vessels Sound the Alarm By David Sweeney, OD By Christine W. Sindt, OD 26 CE: The How and Why of Contact Lens Deposits Optometrists need a comprehensive understanding of this complication to help patients avoid it. 30 By Heidi Wagner, OD, MPH

REVIEW OF CORNEA & CONTACT LENSES | MAY/JUNE 2020 3 News Review

IN BRIEF Keeping Patient COVID-19 ■ For low to intermediate levels of myopia—with or without regular astigmatism—macular OCT imaging Exposure Low didn’t improve with the placement of a soft or gas permeable contact wo studies have provided discontinued if a patient falls sick or lens. They found no added benefi t in removing a spherical soft lens in several considerations to take receives a positive diagnosis. habitual wearers prior to scanning. into account to limit exposure As the situation evolves, so too Their study also found no correlation T to COVID-19. does new guidance. Now more than between sphere power and the change in image quality in any of the three ever, clinicians must look to patient groups, nor were di erences observed CONTACT LENS RISKS communication and compliance for between OCT-derived macular While no current fi ndings support the best chance at success.1 thickness measurements from scans with and without a contact lens. concerns that healthy contact lens Aviram T, Beeri I, Berkow D, et al. The e ect of wearers are at a higher risk of con- OCULAR SURFACE SAFE contact lens wear on retinal spectral domain tracting COVID-19, these patients Researchers recently found that in- optical coherence tomography. Clin Exp Optom. March 30, 2020. [Epub ahead of print]. should be aware of certain factors to patients and hospital workers could remain safe in their lenses.1 be exposed to COVID-19 through ■ Researchers suggest the prevalence of patient-reported scleral lens midday First, switching to spectacle wear the eyes; however, the incidence of fogging is similar to previously reported may actually pose a greater risk COVID-19 transmission through rates. An electronic survey distributed of exposure, as intermittent use the ocular surface is extremely low to scleral lens practitioners asked them to describe their most recent increases face touching, and plastic overall. To lower the risk of expo- established scleral lens patient. As far surfaces serve as virus transmitters. sure, the researchers support the as risk factors go, the study notes that Second, with how often we touch push for all health care profession- no specifi c lens design or care product 2 is associated with midday fogging. our faces, proper hygiene becomes als to wear protective goggles. Of the 248 survey respondents, 25.8% even more crucial. This includes This cross-sectional study eval- had patients who self-reported midday washing hands with soap and water uated 102 patients with a positive fogging. Patients who reported midday fogging more commonly reported for at least 20 seconds after encoun- COVID-19 diagnosis. The 48 males redness or irritation associated with tering anything that may not have and 54 females were an average of scleral lens wear. been disinfected, using hand sanitiz- 57.63 years old. Schornack MM, Fogt J, Harthan J, et al. Factors associated with patient-reported midday fogging er containing at least 60% alcohol The team discovered that 72 of in established scleral lens wearers. Cont Lens Ant if soap and water are not readily the total patients identifi ed were Eye. March 20, 2020. [Epub ahead of print]. available and avoiding touching confi rmed to have COVID-19 by ■ For keratoconus patients, contact mucous membranes with unwashed laboratory diagnosis. Of this small- lens fi t, wearing comfort and cost hands. Contact lens wearers should er cohort, they noted that only two may be more important than lens performance even in the most be well-versed in hand-washing, patients (2.78%) had conjunctivitis. advanced designs. A study measured especially before inserting and re- They added that only one of the spatial vision, stereoacuity and optical moving lenses. two patients had COVID-19 RNA quality in 28 KCN patients and 10 controls in spectacle lenses, gas Third, the report adds that no fragments in their ocular discharge. permeable, Kerasoft, Rose K2 and contact lens material is more likely “The ineffi cient diagnostic meth- scleral rigid GP lenses. All outcomes to enhance or reduce the risk of od and the sampling time lag may deteriorated with keratoconus severity and improved with lens wear relative COVID-19, but following the rec- contribute to the lower positive to spectacles. The improvement was ommended replacement schedule is rate of conjunctival swab samples smaller for Kerasoft lenses and higher more important than ever. It notes of COVID-19,” the study authors but comparable for the other three 2 designs across all disease severities. that daily disposable contact lenses concluded in their paper. Visual function and optical quality substantially diminish the risk of outcomes never reached control infl ammatory complications and 1. Jones L, Walsh K, Willcox M, et al. The levels for any correction modality, the COVID-19 pandemic: important consider- investigators said. should be disposed of each evening. ations for contact lens practitioners. Cont Lens Ant Eye. April 3, 2020. [Epub ahead of Kumar P, Bandela PK, Bharadwaj SR. Do visual Monthly and two-week lenses print]. performance and optical quality vary across di erent contact lens correction modalities in should be disinfected regularly and 2. Zhang X, Chen X, Chen L, et al. The evi- keratoconus? Cont Lens Anterior Eye. March 29, according to manufacturer instruc- dence of SARS-CoV-2 infection on ocular 2020. [Epub ahead of print]. surface. Ocul Surf. April 11, 2020. [Epub tions. Contact lens use should be ahead of print].

4 REVIEW OF CORNEA & CONTACT LENSES | MAY/JUNE 2020 RCCL REVIEW OF CORNEA & CONTACT LENSES

19 Campus Blvd., Suite 101 Newtown Square, PA 19073 Telephone (610) 492-1000 Fax (610) 492-1049 Editorial inquiries: (610) 492-1006 Post-CXL Haze Resolves By Advertising inquiries: (610) 492-1011 Email: [email protected]

EDITORIAL STAFF One Year After Treatment EDITOR-IN-CHIEF Jack Persico [email protected] eratoconus (KCN) patients Photo:Clark Chang, OD, and Aaron Bronner,OD MANAGING EDITOR Rebecca Hepp [email protected] who undergo transepithe- ASSOCIATE EDITOR lial, or “epi-on,” corneal Catherine Manthorp [email protected] K ASSOCIATE EDITOR collagen crosslinking (CXL) may Mark De Leon [email protected] have haze issues in the months fol- CLINICAL EDITOR Joseph P. Shovlin, OD, [email protected] lowing treatment, but this should ASSOCIATE CLINICAL EDITOR resolve within a year of the proce- Christine W. Sindt, OD, [email protected] EXECUTIVE EDITOR dure, a study in Cornea reports. Arthur B. Epstein, OD, [email protected] The researchers found that after CONSULTING EDITOR Milton M. Hom, OD, [email protected] epi-on CXL, corneal haze increased GRAPHIC DESIGNER slightly at one month, plateaued Corneal haze post-CXL improves Jared Araujo [email protected] between three and 12 months. AD PRODUCTION MANAGER between months one and three and Farrah Aponte [email protected] returned to baseline between three BUSINESS STAFF and 12 months. ceived ribofl avin 0.1% every minute PUBLISHER “Transepithelial CXL appears to and group two received treatment James Henne [email protected] REGIONAL SALES MANAGER be effective in decreasing maximum every two minutes during ultraviolet Michele Barrett [email protected] keratotomy and uncorrected vision exposure. Scheimpfl ug densitometry REGIONAL SALES MANAGER Michael Hoster [email protected] in KC but perhaps less robust than was measured pre-op and at one, standard CXL,” researcher Peter three, six and 12 months. The re- EXECUTIVE STAFF CEO, INFORMATION SERVICES GROUP S. Hersh, MD, says. “Corneal haze searchers also correlated densitome- Marc Ferrara [email protected] associated with CXL is substantially try measurements with visual acuity SENIOR VICE PRESIDENT, OPERATIONS Je Levitz [email protected] less using the transepithelial tech- (VA), pachymetry and topography SENIOR VICE PRESIDENT, nique. How this relates to procedure results. HUMAN RESOURCES Tammy Garcia [email protected] effi cacy remains unclear.” Baseline pre-op corneal densi- VICE PRESIDENT, The team enrolled 59 eyes of tometry was 20.45±2.79, which in- CREATIVE SERVICES & PRODUCTION Monica Tettamanzi [email protected] KCN patients who underwent epi- creased at one month (22.58±3.79). VICE PRESIDENT, CIRCULATION Emelda Barea [email protected] on CXL and then were randomized While no signifi cant change was CORPORATE PRODUCTION MANAGER into two groups. Group one re- observed between months one John Caggiano [email protected] and three (22.64±3.83), a signifi - EDITORIAL REVIEW BOARD CXL PROTOCOLS TESTED cant improvement was noted after Mark B. Abelson, MD month six and 12 (21.59±3.39 and James V. Aquavella, MD Researchers from New Zealand Edward S. Bennett, OD recently compared the corne- 20.80±3.27, respectively). Aaron Bronner, OD Brian Chou, OD al densitometry changes after No difference was found between Kenneth Daniels, OD S. Barry Eiden, OD three styles of accelerated CXL: preoperative densitometry measure- Desmond Fonn, Dip Optom, M Optom transepithelial pulsed (t-ACXL), ments and those taken at one year. Gary Gerber, OD Robert M. Grohe, OD epithelium-o continuous The study also found that corneal Susan Gromacki, OD (c-ACXL) and epithelium-o densitometry readings at three Patricia Keech, OD pulsed (p-ACXL). They found that Bruce Koffler, MD months and one year didn’t ap- Pete Kollbaum, OD, PhD c-ACXL induced more corne- Jeffrey Charles Krohn, OD pear to correlate with uncorrected Kenneth A. Lebow, OD al haze than either p-ACXL or Jerry Legerton , OD t-ACXL in the early post-op peri- distance VA, corrected distance VA Kelly Nichols, OD Robert Ryan, OD od, but these di erences resolved or maximum keratometry one year Jack Schaeffer, OD in approximately six months. after CXL. RCCL Charles B. Slonim, MD Kirk Smick, OD Mary Jo Stiegemeier, OD Kocabeyoglu S, Colak D, Mocan M, et al. Sen- Nanji A, Redd T, Chamberlain W, et al. Application Loretta B. Szczotka, OD sory adaptation to silicone hydrogel contact of corneal optical coherence tomography angiog- Michael A. Ward, FCLSA lens wear is not associated with alterations raphy for assessment of vessel depth in corneal Barry M. Weiner, OD in the corneal subbasal nerve plexus. Cornea. neovascularization. Cornea. December 20, 2019. 2019;38(9):1142-6. Barry Weissman, OD [Epub ahead of print].

REVIEW OF CORNEA & CONTACT LENSES | MAY/JUNE 2020 5 My Perspective By Joseph P. Shovlin, OD

Time to Rethink Trial Lens Safety? When handling the same contacts with multiple patients, remember these in-o ce tips.

ye care providers have guidelines, contact lenses are catego- (1) Ensure consistent handwashing struggled with, and often rized by material and design, listed as with soap and water for at least 20 debated, the best practices rigid, soft or hybrid lenses. seconds and dry with clean paper for caring for multi-pa- Remember, our patients poten- towels for technicians, providers and Etient, reusable trial contact lenses. tially are exposed to a wide variety patients. Disposable lenses are available in of pathogens when subjected to (2) Carefully inspect each lens many parameters, obviating the reusable trial lenses in our offi ce. after cleaning with a vigorous rub need for reusable trial lenses in many The wide range of pathogens could and rinse. cases. Nevertheless, we’re still called include both gram-positive and (3) Always use approved rinses upon to care for trial lenses with the gram-negative bacteria, fungi (mold with sterile solution after disinfecting insurgence of scleral lens use. Using and yeast), protozoa and several trial lenses. these lenses has forced us to take an- different viruses, whose survivability (4) Avoid tap or well water expo- other look at in-offi ce, multi-patient depends on lens material and varia- sure after disinfecting. guidelines, especially in light of the tions in polymer differences.3 (5) Use clean, new cases for COVID-19 pandemic. A vigorous rub and rinse of any storage. lens surface will easily remove a (6) Color-code bottles with stickers HYGIENIC STANDARDS good portion of any microbial depending on in-offi ce expiration. An excellent summary of in-offi ce contamination, along with most de- (7) Repeat the disinfection cycle handling of reusable trial lens sugges- posits, particulate and debris.3 Train every three to six months even with- tions is available using the standards staff and reinforce this important out use; if bottles are opened and from the International Organization fi rst step. Keep in mind that several not reused, repeat disinfection steps for Standardization (ISO).1 In addi- disinfection methods depend on lens every month. tion, the contact lens groups of the type and material. Remember, while Be mindful to record the dates and American Academy of Optometry the recommended steps do not ster- number of clinic uses for every trial and the American Optometric ilize, following them does more than lens. Consult each manufacturer on Association have updated guidelines simply sanitize lenses. their disposal recommendations after for in-offi ce disinfection of trial In order to ensure safety, employ so many uses. lenses.2 a broad-spectrum disinfectant. For those who haven’t already Chemical disinfecting solutions have special thank you to the many digested the main elements of the not been tested for HTLV-III/LAV Aindividuals who have worked 2018 ISO guidelines, these pertinent effi cacy, so oxidative systems seem to tirelessly on the updated guidelines. key points might help you and your win the day.1 A three-hour, non-neu- Kudos to our eye care groups who staff ensure minimal transmission tralizing soak in 3% hydrogen have collaborated in such a collegial risk of any infection to your patients, peroxide seems to be the most effec- fashion. RCCL especially since offi ce staff hygiene tive eradicator of pathogens and is can be a signifi cant factor in disease recommended for all lenses. Soft and 1. ISO. Ophthalmic optics—contact lens- es—Hygienic management of multi-patient 3 transmission. hybrid lenses should then be placed use trial contact lenses. www.iso.org/stan- The ISO 19979 provides guidance in a neutralizing case with fresh 3% dard/67859.html. March 2018. Accessed April 6, 2020. to manufacturers for the develop- hydrogen peroxide for a minimum of 2. AAO, AOA. In-o ce disinfection of ment of information provided to eye six hours, rinsed and then stored in multi-patient use diagnostic contact lenses. fi les.constantcontact.com/fd2dfe10101/ care practitioners for the hygienic a multi-purpose disinfecting solution b82a6f1b-8373-42f9-9a25-72 50af9d64.pdf. management of trial hydrogel, and disinfected case. March 17, 2020. Accessed April 6, 2020. composite and rigid gas permeable 3. The AOA Health Policy Institute. Disinfec- tion of multi-patient contact lenses in the contact lenses intended for multi-pa- SYSTEMS IN CHECK clinical setting. www.aoa.org/documents/ 1,3 HPI/HPI_Report_Disinfection of Multipatient tient use. These documents are It’s key for eye care providers and CLs in the Clinical Setting_2018.pdf. October updated every fi ve years. Within the staff to keep these things in mind: 2018. Accessed April 6, 2020.

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Registration opens on May 12, 2020. Learn more at www.academymeeting.orG. The GP Experts By Lindsay Sicks, OD

Fixing Ocular Surface Impediments Corneal staining and lens non-wetting are common complications that refi tting and proper hygiene education can help resolve.

hen fi tting any fi lm abnormalities with tear supple- type of gas mentation and blinking exercises.2 permeable (GP) contact lens, CASE TWO issues with A 40-year-old African American Wdryness and non-wetting can arise. male presented for his annual evalu- They can often occur if a patient has tion wearing a piggyback system for a poor-quality tear fi lm, improper keratoconus OU. He complained lid hygiene or lens handling or of fogginess and reduced vision in demonstrates non-compliance with the right eye that had been getting the prescribed care regimen. Lens fi t worse over the past six months. and care system changes along with Fig. 1. Temporal corneal staining Vision in the left eye was stable, and periodic lens replacement can help present at follow-up on a the patient had recently purchased keratoconic corneal GP lens. address these concerns. a replacement GP lens for that eye can occur in keratoconic patients after breaking it when cleaning it CASE ONE who may have dry eye associated a month ago. The blur OD was A 23-year-old Hispanic male with with atopic disease and meibomian constant through all 16 hours of keratoconus presented for a contact gland dysfunction. Other causes of daily wear. He did not adhere to lens evaluation wearing ill-fi tting, 3 o’clock and 9 o’clock staining are the recommended rubbing steps in three-year-old GP corneal lenses. He a thick edge profi le or a high axial either regimen due to fear of lens noted occasional dryness with his edge clearance.1 We observed mini- breakage. There was some apical lenses but found relief with occa- mal edge clearance in the horizontal scarring OS, limiting best-corrected sional use of artifi cial tears. meridian of the lens, as opposed to vision. The tear break-up time was We diagnostically fi t and ordered high clearance (Figure 1). normal at 15 seconds per eye. a new pair of aspheric corneal lenses We reordered the lens with a The patient’s entering acuity was with the addition of a toric periph- fl atter edge and an increased toricity 20/50 OD and 20/300 OS. There eral curve system. Toric peripheries (1.3mm) in the periphery to im- was independent movement of both are indicated when topography prove comfort. We also initiated the soft lens and GP lens on each suggests the steeper inferior cornea aggressive lubrication at nighttime, blink. The entering OD GP lens was is inferiorly displaced and causes recommended warm compresses showing extensive surface deposits the lower edge of the lens to lift up and proper lid hygiene and then (Figure 2). Factors that cause depos- and irritate the lower eyelid.1 The reviewed proper rubbing with the its include lens replacement frequen- patient achieved 20/20 vision OU, multipurpose GP solution. Upon cy, hand contamination and tear but, a few weeks later, he again follow-up of the re-designed lens, fi lm properties of the patient.3 The complained of increased dryness the staining resolved and symptoms most common tear-derived lens de- and discomfort OU during the latter improved. The patient successfully posits are proteins and lipids, which half of his daily wear time. The pa- wore the lenses for the following 18 in-offi ce cleaning can remove.3 tient did admit he was not rubbing months. Laboratory-grade cleaning the lenses with the multipurpose GP If 3 o’clock and 9 o’clock staining solution in-offi ce cleaned the GP lens cleaning solution for the recom- are present, increase the lens’s over- lenses, leading to visual acuities mended length of time at night. all diameter. This will cover more 20/30 OD and 20/125 OS. After adding sodium fl uorescein, of the cornea, reduce exposure and Despite the improvement, we still we noted moderate staining on the improve comfort. Ensure appropri- recommended that a new GP lens be temporal side of each cornea, closer ate edge thickness, edge clearance ordered for the right eye. to the limbus. This type of staining and movement. Address any tear We reviewed with the patient

8 REVIEW OF CORNEA & CONTACT LENSES | MAY/JUNE 2020 solution with no conditioner and did not heed our recommendation of monthly Progent (Menicon) use. This non-wetting did not im- prove, even after use of in-offi ce laboratory cleaner. We recommend- ed the patient continue with his ha- bitual spectacles until receiving his new pair of sclerals. A less oxygen permeable material could improve the wettability, and adding a surface coating might improve the lens’s surface properties. Fig. 2 and 3. Piggyback system with large central area of non-wetting on the GP lens (left). Extensive front surface non-wetting on a 16.0mm scleral lens (right). hen investigating signs of Wdryness in the setting of any proper lens care and hygiene, in- toric intraocular lens (IOL) implant type of GP lens wear, it is crucial cluding how to properly rub the GP OS. The ocular surface showed ex- to determine the root cause of and soft lens to clean each appro- tensive tear fi lm debris, reduced tear the problem. There can be ocular priately without excessive force. break-up time of three seconds and surface- and lens-related causes for The patient switched to a hydrogen punctate conjunctival staining OU. any associated symptoms. In the peroxide-based care system. By us- We had the patient apply the lens case of untreated or undertreated ing two cases, he could use the same in-offi ce for evaluation and found dry eye disease, consider changing solution for each of the four lenses, his entering acuity with the lens in to a preservative-free care system reduce confusion and increase ad- place was 20/70 OS. The patient or adding lubricating drops, gels herence to our recommendations. had been able to achieve 20/20 OS or ointments. More aggressive While GP lenses have a negligible the year before with this spherical management of any associated water content and high modulus lens, which was unusual at the time, ocular surface disease is a boon to of elasticity that contribute to their considering we expect to employ continued, ncomfortable lens wear. long life expectancy, replace them a front toric scleral design for full Don’t forget about the lens surface periodically to ensure optimal wet- correction in a patient with a toric either, as any areas of non-wetting tability, comfort and vision.1,4,5 IOL. No over-refraction improved can cause reduced vision and the acuity in this case, presumably discomfort and warrant immediate CASE THREE due to the severe non-wetting. lens cleaning or replacement. RCCL A 30-year-old Asian male present- (Figure 3). 1. Sorbara, L. Correction of keratoconus with GP ed one year overdue for an annual Tear fi lm debris and poor lid lenses. Centre for Contact Lens Research, Universi- evaluation of his spherical scleral hygiene, as well as lack of adherence ty of Waterloo. 2010. 2. Bennett ES, Weissman BA, ed. Clinical Contact lenses. He was experiencing blurry to the prescribed cleaning regimen, Lens Practice. 4th Ed. Philadelphia, PA: Lippincott, vision OU at distance and near and were all contributing factors. We Williams & Wilkins; 2005. had recently broken his habitual prescribed Clear Care (Alcon) 3. Efron N. Contact Lens Complications. 4th Ed. Philadelphia, PA: Elsevier; 2019. two-year-old scleral OD. He had nightly and advised the patient to 4. Efron N. Contact Lens Practice e-Book. Elsevier a history of bilateral keratoconus fi ll the lens with preservative-free Health Sciences. 2016. 5. Jones L, Woods CA, Efron N. Life expectancy and was s/p deep anterior lamellar 0.9% NaCl inhalation saline for of rigid gas permeable and high water content keratoplasty OD, and s/p corneal insertion. Instead, he used Boston contact lenses. CLAO J. 1996;22(4):258-61. crosslinking OS with a complicated Advance (Bausch + Lomb) cleaning

REVIEW OF CORNEA & CONTACT LENSES | MAY/JUNE 2020 9 WE’RE SEEING AMAZING RESULTS. AND SO ARE THEY.

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Help accelerate our mission by donating at ECPs4Cures.org. FightingBlindness.org REASONS CONTACT LENS WEAR ISN’T A PROBLEM WITH COVID-19 Despite confl icting reports, patients are just as safe as ever, as long as they adhere to proper wear and care 4instructions. By Daddi Fadel, DOptom popular Italian saying goes, “there’s no Author’s Note: COVID-19 From the Frontlines two without three,” which, in the US, Until the United States took the lead on March 26, 2020, Italy— translates to “bad things come in threes.” where I live—had the highest rate of confirmed cases. At the After the severe acute respiratory syn- time of this writing (April 1), we are on the 25th day of lockdown, Adrome coronavirus (SARS-CoV) and the Middle East staying home. respiratory syndrome coronavirus (MERS-CoV), the Our country seems to be moving through the seven stages of third novel iteration, SARS-CoV-2, could not miss. grief. After the denial phase, which unfortunately lasted too long, The fatal consequences of the fi rst two should have, costing thousands of human lives, we are now through the pain but didn’t, serve to alarm the population about the and guilt phase. We have looked for the guilty party to blame for risks of the coronavirus. this disaster of human lives, personal finances and the world SARS-CoV-2, commonly known as COVID-19, is economy. We have even passed through the bargaining phase— a signifi cant global health emergency with substan- that period of singing and dancing on the balconies to ward off the tial psychosocial and business implications. As of virus, or at least its psychological implications. April 14, 2020, there are 2,001,267 confi rmed cases We are currently working on the second half of that phase, globally and 130,487 deaths.1 Generally, patients anger, and perhaps are moving into depression. At this moment, infected with COVID-19 have the fi rst symptom of unfortunately, some people have run out of money and no longer fever and then may develop a respiratory disorder, have enough to eat, so they either attack the supermarkets or cough and fatigue that can quickly progress into shop and sneak out without paying. These violent and impulsive pneumonia.2 Other signs such as conjunctivitis have behaviors ignore social distancing and could potentially worsen been observed on occasion.3 the spread of the virus. Our healthcare system is already at risk of Researchers have identifi ed several different poten- collapse. tial transmission routes, including respiratory drop- Fortunately, the depression phase is still limited to a few des- lets and close contact, and have hypothesized others, perate people, but the rumors of an extended lockdown, do not such as contact with the ocular surface.4 Studies promise positive psychological reactions and impact. show the virus can be transmitted through the mucus From a professional point of view, optometrists are considered ABOUT THE AUTHORS an essential service, and we remain open. Some practices are open during a narrow time slot (only two to three hours in the Dr. Fadel is a contact lens designer and a specialist in contact lenses for irregular morning), while others are available only for emergencies. cornea, myopia control and orthokeratology. As in other countries, we find ourselves inundated with She studied optometry at Istituto Superiore di Scienze Optometriche (ISSO) in Rome. misinformation and fake news. Here, I am personally She runs an optometric practice specializing trying to provide credible and evidence-based infor- in contact lenses in Italy where she designs and fi ts special customized contact lenses. mation and sources from which professionals and She is a well-known international speaker and patients may benefit. author in the area of specialty contact lenses.

REVIEW OF CORNEA & CONTACT LENSES | MAY/JUNE 2020 11 4 REASONS CONTACT LENS WEAR ISN’T A PROBLEM WITH COVID-19

membranes, including the tears and conjunctiva.5-10 Even with this recent research, controversies exist surrounding the transmission of COVID-19 through the contact lens (CL). Myriad editorials and articles have addressed this topic, ranging from reputable information to speculative and even incredible reporting. These four scenarios refute the concept that CLs should be avoided during the COVID-19 pandemic:

Let’s assume that the virus reaches the eyes by ad- 1.hering to the surface of the CL and then migrating to the ocular mucous membrane, infecting the individ- ual. Perhaps the virus even penetrates the contact lens material, not just adhering to the surface. This adherence can happen either with airborne contact or from contam- hydrogel or a mixture of hydrogel and silicone. Research inated fi ngers during insertion or removal. shows that COVID-19 can survive on metal and plastic Even if this proves to be true with further study, pa- surfaces for up to nine days but only up to fi ve days on tients are not necessarily at an increased risk of exposure silicone rubber.11 Additionally, patients apply CLs with due to CL wear. If the virus reaches the lens, it also washed hands, while people wearing spectacles tend to reaches the exposed parts of the eye, providing direct touch their spectacles frequently during the day—espe- contact with the ocular mucous membrane, still infecting cially presbyopes—with unwashed hands, transferring the individual. The virus infects the patient in both cases, the virus from fi ngers to face. whether they are wearing CLs or not. Even if the virus is embedded within the lens material, the infected droplets Some believe that even appropriate hand washing in contact with the exposed mucous membrane will 3.does not eliminate all the microbes and viruses penetrate the organism faster compared with the droplets from hands, suggesting CL wearers remain at risk even absorbed by the lens material, as the latter must fi rst be with proper hygiene. If this is true, studies demonstrate released by the material before infecting the organism. that ethanol is excellent in inactivating human corona- Various studies investigating the potential transmission virus.11 Clinicians can suggest patients use disposable route of human coronaviruses through the eye found gloves, ethanol or alcohol wipes to disinfect their fi ngers the virus in the conjunctival sac of infected patients, yet before lens handling as an extra precaution.12 they did not note viral transmission via the conjunctival route.5,7,8 However, more studies are needed to better Realistically, patients won’t stop wearing their understand if the eye may be an alternative transmission 4.lenses. Instead of banning CL wear, clinicians route of COVID-19 specifi cally. Still, even if the virus is should use this as an opportunity to educate patients on: transmitted through eyes, the virus will infect the subjects a. Proper handwashing. through the ocular mucous membrane, whether they b. Adequate disinfection of CLs every evening (ethanol, wear CLs or not. hydrogen peroxide and sodium hypochlorite all inacti- vate human coronaviruses).11 Some think spectacles provide some sort of pro- c. Compliance with case hygiene and care solutions. 2.tection from viruses. In this case, clinicians should d. Proper spectacle disinfection often during the day. consider the international experts and the World Health We want to protect the eyes, but contact lenses and Organization irresponsible for not recommending spectacles are not the issue. Patients, whether or not they spectacle wear, whether eyeglasses or sunglasses. In this wear CLs, should instead use compliant masks, remem- scenario, manufacturers of spectacles should recommend bering to disinfect them often and correctly. them to the entire world population. In addition, clini- Suggesting patients limit their CL wear to emergencies cians should recommend CL wearers wear sunglasses to only and to wear spectacles instead makes no sense. protect themselves for viral spread. Various CL experts have provided their own evi- However, spectacles do not represent adequate pro- dence-based statements on CL wear safety.13-16 tection.10 In fact, they may represent a potential source Another essential and sensible factor to consid- of contagion, probably more than CLs. Spectacles may er during this pandemic is the psychological impact. be made of metal and plastic, while contact lenses are COVID-19 has signifi cant psychosocial implications, and

12 REVIEW OF CORNEA & CONTACT LENSES | MAY/JUNE 2020 Earn up to 18-29 CE Credits*

NEW TECHNOLOGIES 2020 & TREATMENTS IN Eye Care CLs have shown to improve patients’ quality of life com- pared with spectacles correction, not only by correcting refractive errors but also by providing better appearance and fewer physical limitations.17,18 This last factor should not be underestimated. Ongoing research on this topic is needed to truly 2020 understand the role of CLs with COVID-19. While the literature is emerging, clinicians should be practical in MEETINGS their recommendations with conservative precautions for patients. Practitioners must keep up-to-date on the OCTOBER 30-NOVEMBER 1 evidence-based recommendations in this fast-changing pandemic situation and refer to credible sources such as AUSTIN, TEXAS academic institutions and global organizations’ regulato- Omni Barton Creek ry and government sources. Program Chair: Paul Karpecki, OD, FAAO

opefully, by the time this editorial makes it to REGISTER: Hprint, Italy will have made the upward turn toward www.ReviewEdu.com/Austin2020 reconstruction, acceptance and hope. Together, we can all work through this pandemic to keep our families and NOVEMBER 5-8 patients as safe as possible. RCCL PHILADELPHIA, PENNSYLVANIA 1. World Health Organization. Coronavirus disease (COVID-2019) situation reports. Joint meeting with OCCRS** www.who.int/emergencies/diseases/novel-coronavirus-2019/situation-reports. Ac- cessed March 27, 2020. Philadelphia Marriott Downtown 2. Huang C, Wang Y, Li X, et al. Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China. Lancet. 2020;395:497-506. Review Program Chair: 3. Rothe C, Schunk M, Sothmann P, et al. Transmission of 2019-nCoV Infection from an 205 Asymptomatic Contact in Germany. N Engl J Med. 2020;382(10):970-71. Paul Karpecki, OD, FAAO 4. Brankston G, Gitterman L, Hirji Z, et al. Transmission of infl uenza A in human beings. Lancet Infect Dis. 2007;7:257e265. OCCRS Program Chair: 5. Xia J, Tong J, Liu M, et al. Evaluation of coronavirus in tears and conjunctival secre- Tracy Schroeder Swartz, OD, MS, FAAO tions of patients with SARS-CoV-2 infection. J Med Virol. February 26, 2020. [Epub ahead of print]. REGISTER: 6. Lu CW, Liu XF, Jia ZF. 2019nCoV transmission through the ocular surface must not be ignored. Lancet. 2020;395:e39. www.ReviewEdu.com/Philadelphia2020 7. Zhou YY, Zeng YY, Tong YQ, et al. Ophthalmologic evidence against the interperson- al transmission of 2019 novel coronavirus through conjunctiva. 2020. 8. Seah I, Agrawal R. Can the coronavirus disease 2019 (COVID-19) a ect the eyes? A review of coronaviruses and ocular implications in humans and animals. Ocul Immunol DECEMBER 11-13 Infl amm. 2020;16:1-5. 9. Dai X. Peking University Hospital Wang Guangfa disclosed treatment status on Wei- ORLANDO, FLORIDA bo and suspected infection without wearing goggles. Beijing News. January 22, 2020. 10. Centers for Disease Control and Prevention. Interim infection prevention and con- Disney’s Yacht & Beach Club trol recommendations for patients with suspected or con-fi rmed coronavirus disease 2019 (COVID-19) in healthcare settings. www.cdc.gov/coronavirus/2019-ncov/infec- Program Chair: Paul Karpecki, OD, FAAO tion-control/control-recommendations.html#minimize. Accessed March 30, 2020. 11. World Health Organization. Coronavirus disease (COVID-19) advice for the public. www.who.int/emergencies/diseases/novel-coronavirus-2019/advice-for-public. Ac- REGISTER: cessed March 30, 2020. www.ReviewEdu.com/Orlando2020 12. Fonn D, Jones L. Hand hygiene is linked to microbial keratitis and corneal infl am- matory events. Cont Lens Ant Eye. 2019;42:132-35. 13. Walsh K. COVID-19 and contact lens wear: what do eye care practitioners and patients need to know? Contact lens Update. March 16, 2020. 14. Centre for Ocular Research & Education. Top contact lens experts dispel misin- For the latest information visit: formation regarding coronavirus / COVID-19 protections for contact lens wearers. https://core.uwaterloo.ca/news/top-contact-lens-experts-dispel-misinformation-re- garding-coronavirus-covid-19-protections-for-contact-lens-wearers. Accessed March www.ReviewEdu.com/Events 30, 2020. 15. Centre for Ocular Research & Education. Contact lens update special edition: e-mail: [email protected] COVID-19 and contact lens wear. https://core.uwaterloo.ca/news/contact-lens-update- special-edition-covid-19-and-contact-lens-wear. Accessed March 30, 2020. call: 866-658-1772 16. British Contact Lens Association. Contact lens wear and coronavirus (COVID-19) guidance. www.bcla.org.uk/Public/Public/Consumer/Contact-Lens-Wear-and-Corona- virus-guidance.aspx. Accessed March 30, 2020. Administered by: 17. Fadel D, Walsh K. Covid-19, [when the use of lenses is safe]. www.b2eyes.com/

news/covid-19-quando-l%E2%80%99uso-delle-lenti-%C3%A8-sicuro. Accessed March OPTOMETRIC CORNEA, CATARACT 30, 2020. AND REFRACTIVE SOCIETY **17th Annual Education *Approval pending 18. Queirós A, Villa-Collar C, Gutiérrez AR, et al. Quality of life of myopic subjects with Symposium di erent methods of visual correction using the NEI RQL-42 questionnaire. Eye Cont Joint Meeting with NT&T Lens. 2012;38(2):116-21. in Eye Care

Review Education Group partners with Salus University for those ODs who are licensed in states that require university credit. See www.reviewedu.com/events for any meeting schedule changes or updates. LIDS AND LENSES: Three Snags to Fitting Success

Surgical and anatomical complications could throw a wrench in your contact lens fi tting process. Here’s what to keep in mind. By Steven Turpin, OD, and Leonid Skorin Jr., OD, DO, MS Photo: Pratik Patel, OD hen fi tting contact anterior lamella (skin side of the lenses, the status of lids) from the posterior lamella the ocular surface is (conjunctival side) with a #11 or our primary focus. #15 blade. Next, they remove the WThe cornea, conjunctiva and sclera epithelium from the lid margin. support the lens and are the major Separating the anterior and posteri- contributors to the fi t. But, by or portions of the lid and removing focusing solely on these structures, the lid margin tissue allow the upper we often fail to acknowledge the and lower portions of the anterior equally important role the eyelids and posterior lamella to heal. The play. The interaction between the posterior lamella of the upper and eyelids and a contact lens can sig- lower lid is then connected using nifi cantly contribute to contact lens Fig. 1. Note the narrowing of absorbable sutures, and the anterior palpebral fi ssure vertically and success. This article reviews compli- horizontally in this partial temporary lamella of the upper and lower lid cations that may arise from surgical tarsorrhaphy. is connected using non-absorbable alterations to the lids, including sutures. Patients are still able to lid closure and lesion removal, phies, the lids can be partially or see, but the interpalpebral fi ssure is and investigates how anatomical completely closed. Non-absorbable narrower vertically and horizontally variations, such as lid tension, can sutures create “drawstrings” that to protect a portion of the ocular infl uence the lens fi t. can be tightened or loosened to surface from exposure (Figure 1).1 control the size of the interpalpebral EYES WIDE SHUT fi ssure. ABOUT THE AUTHORS One of the most diffi cult eyelid Fully opening the lids is crucial Dr. Turpin is an optometrist issues to overcome when fi tting con- for examining the entire ocular at North Cascade Eye tact lenses is a partial tarsorrhaphy, surface at follow-up and ensuring Associates in northwest or surgical closure of the eyelids, proper healing. As ocular surface Washington. He is building a specialty contact lens which is primarily indicated to pre- healing takes place, the degree of lid clinic within the larger vent exposure of the ocular surface. closure can be optimized for visual practice. He is the founder of Practically Abstract, a The etiology of the exposure may quality, patient comfort and ocular website and newsletter include non-resolving Bell’s palsy, health. The ability to control fi ssure dedicated to reviewing contact lens and dry eye research. acoustic neuroma causing seventh size makes this technique more pop- cranial nerve paresis, exophthalmos ular than permanent closure. Dr. Skorin is a consultant 1 in the Department of or neurotrophic disease. In the case of permanent closure, Surgery, Community The surgical technique depends usually only the lateral-most portion Division of Ophthalmology at the Mayo Clinic Health on how long the lids should be of the lids is approximated. During System in Albert Lea, MN. closed. For temporary tarsorrha- surgery, the surgeon separates the

14 REVIEW OF CORNEA & CONTACT LENSES | MAY/JUNE 2020 Drawbacks of tarsorrhaphy risk. Fortunately, approximately include poor functionality and aes- 80% of lesions are benign and do thetics. In addition, the procedure not require excision.3 However, even may not provide adequate corneal if a lesion is benign and possesses coverage or allow segmental deteri- no threat of malignancy, its location oration over time. Examination of may eventually damage the ocular the cornea is usually diffi cult, and surface and potentially complicate the patient’s vision and visual fi eld contact lens wear. are restricted.2 A lesion or tumor can form in any Despite partial surgical closure of the four layers of the eyelid (skin of the lids, some patients may still and subcutaneous tissue, striated need protection from ocular surface muscle, tarsus or conjunctiva), but Fig. 2. A pigmented basal cell exposure. In these cases, a bandage nearly all lesions are cutaneous in carcinoma margin lesion is noticeable soft contact lens is often indicated. origin and can be categorized as on this eyelid. While a scleral lens may be an effec- epithelial or melanocytic. tive treatment option, the large di- Lesions primarily affect the source—the lesion. If the lesion is ameter of the lens makes placement outermost layer of the lid, meaning removed, the regularity of the lid on the eye diffi cult. In most cases, it they interact with the ocular surface margin can be restored. is easiest to start with standard-sized if located along the upper or lower Whether a lesion is benign or bandage soft lenses, which range lid margins. The irregular mass malignant is crucial to determining from 13.8mm to 14.0mm in diam- disrupts normal function, and the how it is removed. For lid margin eter. Standard lenses may prove to lid no longer acts as a “squeegee” lesions, a shave excision is often be too large but are often readily to move tears on the ocular surface. preferred to prevent lid margin available in most clinical settings. Poor distribution of the tear fi lm notching that can occur with other Trial and error informs the and damage to the corneal epithe- excision techniques.4,5 provider on what adjustments are lium can occur and may eventually To perform a shave excision, necessary or if a custom lens is lead to surface scarring and reduced an anesthetic is injected under the required. Diameters of custom soft vision. lesion. The skin is then stabilized or lenses usually range anywhere from While contact lens wear can help stretched using the non-dominant 11.0mm to 22.0mm to fi t the var- protect the ocular surface, it may hand, and, using the dominant ious needs of patients. Regardless cause other problems. If the lesion hand, the lesion is separated from of base curve and diameter, the lens is made up of keratinized epithelial the underlying tissue with a #11 may need to be partially folded to cells (not smooth palpebral tissue), blade, curette or fi ne wire electro- “tuck” one edge under the upper lid it may snag on the lens. Although it surgical loop. This is done horizon- and then position the inferior edge seems contradictory, sometimes this tally with the eyelid margin serving under the lower lid. Patients who can be benefi cial (e.g., an upper lid as a guide. The technique maintains are unable to place the lens them- lesion may help keep a gas perme- the integrity of the underlying tissue selves should return every three to able lens attached). More often, and prevents excessive scarring. four weeks for lens replacement. the lesion causes the lens to move After removal, the tissue should erratically and pop out. As the be sent to pathology to confi rm A BUMPY ROAD patient blinks, the margins of the whether it is benign or malignant. As eyecare providers, we are no lesion slide under the lens edge and The patient should use antibiotic strangers to lid lesions. Patients the lens falls out (Figure 2). We have ointment following the procedure to with lesions often present with seen this happen with every single prevent infection. concerns about their aesthetics and modality of lens, including sclerals. For known malignant lesions, to determine if they pose any health The simplest solution, from a lens excision that allows for an addition- fi tting standpoint, is to increase the al 3.0mm to 4.0mm margin ensures lens diameter to prevent the lid mar- that all of the malignant tissue is re- To see a video of a shave gin from crossing over the upper or moved. Part or all of the lid margin excision, visit www. reviewofoptometry.com lower edge of the lens. may need to be removed in some or scan the QR code. However, it is often more effec- cases. Bandage contact lenses—ei- tive to address the problem at its ther soft or scleral—can be applied

REVIEW OF CORNEA & CONTACT LENSES | MAY/JUNE 2020 15 LIDS AND LENSES: THREE SNAGS TO FITTING SUCCESS

after the procedure to protect the designs. Most recommend ordering ocular surface. While smaller cus- a lens in the power, base curve and tom bandage lenses are needed to diameter you desire, fi tting the accommodate the narrower lid fi s- lens to measure the amount of lens sure created by a tarsorrhaphy, larg- decentration and then re-ordering er lenses (>16.0mm) are required in the decentered optic lens. Keep in the case of a lid lesion to protect the mind that, if lid tension does play more peripheral conjunctival tissue. a role, the amount of decentration When a signifi cant amount of the will change over time as a patient’s eyelid is removed, tissue grafts can lid laxity increases with age and will help restore lid integrity over time. have to be managed accordingly. Until then, regular monitoring of ocular surface health is essential. Fig. 3. Note superior lens decentration when the upper lid is he role the eyelids play in con- manually elevated and the lower lid is Ttact lens management is often DOWN AND OUT in normal position. ignored or overlooked. However, in It is well known that soft contact certain circumstances, the lids can lenses tend to decenter down and to decenter more in the pre-presby- have a major impact not only when out. We often attribute lens decen- opic population.8 Another found fi tting gas permeable lenses but also tration to the height differences of that soft lenses tended to decenter when fi tting soft or scleral lenses. the sclera. Usually, the nasal sclera superiorly when the upper eyelid Whether the lids are too narrow, is higher than the temporal sclera. was held up, which the researchers wide, loose, tight or bumpy, having This difference may occur as a result noted could be explained by the a few tricks up your sleeve that you of the medial rectus being inserted lower lid pushing the lens up, but it can turn to will help improve your closer to the limbus than the lateral did not mention the decrease in re- success rate. Additionally, don’t be rectus. Similarly, the inferior sclera sistance from the upper lid when it afraid to make a referral for surgery 9 tends to be lower than the superior was held as a possible explanation. if restoration of normal lid structure sclera. While scleral height most To our knowledge, no studies spe- makes the fi tting process easier. certainly plays a signifi cant role in cifi cally compare upper lid tension Generally, the less the lids and lens lens decentration, it could be that and soft contact lens decentration interact, the better. RCCL the lids—specifi cally the upper lid— (Figure 3). contribute as well. Regardless of the exact mecha- 1. Rajak S, Rajak J, Selva D. Performing a tarsorrha- Researchers have not reached a nism causing soft lenses to decenter, phy. Community Eye Health 2015;28(89):10-1. 2. Sei SR, Choo PH, Carter SR. Facial nerve consensus on the role of superior the result is the same. The optical paralysis. In: Mauriello JA, eds. Unfavorable Results of Eyelid and Lacrimal Surgery: Prevention and lid tension in soft contact lens wear. center of the contact lens settles Management. Boston: Butterworth Heinemann; There are a number of competing inferiorly and temporally to our 2000: 227-41. 3. Yu SS, Zhao Y, Zhao H, et al. A retrospective theories suggesting it plays very line of sight. For patients who wear study of 2228 cases with eyelid tumors. Int J Oph- different roles in the fi tting pro- soft spherical lenses or even most thalmol. 2018;11(11):1835-41. 4. Sundar G, Manjandavida FP. Excision of eyelid cess. One theory proposes that the toric lenses, this mismatch between tumors: principles and techniques. In: Chaugule SS, closer the upper lid is to the globe, optical center and line of sight is Honavar SG, Finger PT, eds. Surgical Ophthalmic Oncology: A Collaborative Open Access Refer- the greater the resistance the lens inconsequential. The optic zone of ence. Vol Cham: Springer International Publishing; encounters when trying to move the lens is large enough to provide a 2019: 15-32. 6 5. Skorin L, Goemann L. Lumps and bumps be superiorly. As a result, those with high quality image. gone. Rev Optom. 2018;155(2):104-5. greater superior lid tension have However, for those who wear 6. Cui L, Li M, Shen M, et al. Characterization of soft contact lens fi tting using ultra-long scan more inferior lens decentration. The multifocal contact lenses for myopia depth optical coherence tomography. J Ophthal- theory also suggests that, on aver- or presbyopia, decentration can mol. 2017;2017:5763172. 7. Yamaguchi M, Shiraishi A. Relationship between age, younger patients have more in- have a big impact on visual quality. eyelid pressure and ocular surface disorders in ferior soft lens decentration. Recent Many believe this is a primary fac- patients with healthy and dry eyes. Invest Ophthal- mol Vis Sci. 2018;59(14):DES56-63. evidence seems to support this, as tor in the relatively high failure rate 8. Fedtke C, Ehrmann K, Thomas V, et al. As- the phenomenon that superior lid of soft multifocal contact lenses. sociation between multifocal soft contact lens decentration and visual performance. Clin Optom tension decreases with age is well Fortunately, more custom soft lens (Auckl). 2016;8:57-69. documented.7 One study revealed manufacturers are offering decen- 9. El-Nimri NW, Walline JJ. Centration and decen- tration of contact lenses during peripheral gaze. that various soft lens designs tended tered optic options for their lens Optom Vis Sci. 2017;94(11):1029-35.

16 REVIEW OF CORNEA & CONTACT LENSES | MAY/JUNE 2020 Earn up to

19 CE NEW TECHNOLOGIES 2020 Credits* & TREATMENTS IN Eye Care

Austin, Texas October 30 - November 1, 2020 at the Omni Barton Creek

Review's New Technologies & Treatments in Eye Care proudly presents Austin 2020! Join us for three days of education detailing the latest ideas and innovations in eye care.

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LOCATION: REGISTRATION COST: Omni Barton Creek Early Bird Special: $420 8212 Barton Club Drive Full Conference after September 4: $495 Austin, TX 78735 See event website for daily fees. (512) 329-4000 A limited number of rooms have been reserved at the group rate of $275/night + tax and fees. Call the hotel directly at the number above and identify yourself as a participant of “Review’s New Tech” for group rate.

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Review Education Group partners with Salus University for those ODs who are licensed in states that require university credit. CONJUNCTIVAL FINDINGS TO LOOK OUT FOR IN CONTACT LENS WEARERS

Learn the basics so you can better manage these conditions in your patients. By Paymaun Asnaashari, OD

he conjunctiva—the thin, Giant Papillary Conjunctivitis polymers that have higher water 5translucent membrane (GPC) content and ionic properties attract 1 that lines the inside of the This is a non-infectious infl am- larger amounts of protein deposits eyelids (palpebral conjunc- matory response of the superior compared with lenses with lower Ttiva) and covers the sclera (bulbar tarsal palpebral conjunctiva due to water content.5,6 The push toward conjunctiva)—is thinnest along mechanical irritation from chronic increased oxygen permeability with the eyelid margin and thickest in eyelid movement over a foreign silicone hydrogel contact lenses the fornices. It is composed of two object. Most commonly, GPC is unfortunately makes the lenses more layers: a stratifi ed, non-keratinized associated with contact lens wear; susceptible to protein deposits. In epithelial layer consisting mostly of however, similar reactions have been addition, the higher modulus of goblet cells and a submucosa layer noted with exposed ocular sutures, silicone hydrogel lenses makes them containing mostly antimicrobial and fi ltering blebs, ocular prosthesis, stiffer, which can cause even more infl ammatory response cells, such scleral buckles and elevated corneal mechanical trauma.7 as macrophages and mast cells.1 Its scars.2 Management. Since the patho- main functions include protecting Pathophysiology. GPC results in physiology of GPC involves im- the soft tissues of the eyelid and papillary changes in the palpebral mune and mechanical components, orbit, allowing extensive movement conjunctiva as part of an immuno- treating both is important. GPC of the eye without damaging soft globulin E–mediated hypersensitivi- is manageable with nonthera- tissue, serving as a source of anti- ty reaction to the presence of a for- peutic or therapeutic methods. microbial and other immunological eign object.2 Eyelid movement can Nontherapeutic methods that can agents and producing the mucin stimulate the resulting infl ammatory effectively prevent and treat GPC layer of the tear fi lm. response, especially as people blink include discontinuing lens wear tem- Soft contact lens wear causes the tens of thousands of times per day.3 porarily or permanently, changing conjunctiva to respond in various With age, this rate increases even to a daily disposable—or at least a ways. The association between more.3 The papillary infl amma- more frequent replacement cycle to conjunctival changes and symptom- tion causes papillae to grow in size accommodate lens parameters that otology is important to consider, as as GPC advances. Large papillae it can play a role in the outcome of a (greater than 0.3mm in diameter) on ABOUT THE AUTHOR fi tting. However, it is not always en- the tarsal conjunctiva are a classic Dr. Asnaashari graduated 4 from the UC Berkeley tirely clear whether these physiologi- sign of the disease. School of Optometry in cal changes are the underlying cause The polymer of a contact lens can 2018 and is a therapeutic- of contact lens discomfort. This also infl uence GPC development. and glaucoma- certifi ed optometrist in article describes several conjunctival The type of polymer can impact the Sacramento, CA. One of fi ndings that are important to con- amount of deposits that form on his areas of expertise is specialty contact lenses. sider in soft contact lens wearers. the surface of a lens. For example,

18 REVIEW OF CORNEA & CONTACT LENSES | MAY/JUNE 2020 aren’t offered in a daily disposable junctiva, chalasis tends to increase option—or gas permeable lens, in incidence and magnitude with switching to a preservative-free age.10,11 Many symptoms associated disinfectant solution and using cold with chalasis are similar to those of compresses or lubricating eye drops. dry eye disease and could include Taking into account contact lens eye pain, blurred vision, epiphora, edge thickness and design are other discomfort and dryness.12 strategies to prevent recurrence. Pathophysiology. While the true One therapeutic option that can cause of chalasis is not yet known, be helpful in treating the infl amma- it is hypothesized that the etiology is tion associated with GPC is topical multifactorial.13 It may result from steroids. Although steroids can local trauma, age-related connective provide prompt symptom relief, tissue degradation, infl ammation or they can cause potential complica- delayed tear clearance.13,14 The dom- tions, such as healing impairment Temporarily discontinuing lens wear inant theory was derived from the and infection risk, and side effects, can help manage GPC. thought that chalasis is the result of including cataracts, glaucoma and an age-related degradation of con- increased intraocular pressure. cytes, plasma cells and scattered junctival elastic fi bers from repeated Another option is antihistamines or neutrophils. Newly exhibited blood mechanical insult of the eyelids on mast cell stabilizers. Although GPC vessels are immature. the conjunctiva.15 This may escalate is not primarily a mast cell–mediat- Vascular proliferation occurs in with contact lens use, seeing how ed reaction, these alternatives may three stages: cellular phase, capillary contact lens wearers, especially gas allow us to get ahead of the disease or vascular phase and involution- permeable users, are more likely before it progresses. ary phase.8 Early lesions contain to have conjunctivochalasis.16 This Proactively trying to understand numerous capillaries and venules risk increases with years of wear, as GPC could ultimately help prevent with prominent endothelial cells mechanical insult causes the elastic it and promote a healthy interaction arrayed radially toward the epitheli- fi bers to degrade over time and between the conjunctiva and the al surface. Mature lesions exhibit a creates redundant tissue.15,16 ocular surface. fi bromyxoid stroma that separates The mechanical trauma is also the lesion into lobules. A major thought to activate an infl ammatory Pyogenic Granuloma (PG) driver in the pathogenesis of PG cascade that breaks down the con- 2These benign vascular prolif- appears to be a mutation within the junctival connective tissue, which erations can occur on the skin and endothelial cells.8 may lead to chalasis.17 Another mucous membranes, including the Management. A fi rst-line thera- study proposed the idea that chronic conjunctiva.8 They appear as small peutic treatment for PG is ophthal- infl ammation from decreased tear or large and smooth or lobulated mic drops. Since the pathophysiolo- clearance allows infl ammatory or vascular nodules that can grow gy of PG is infl ammatory, treatment degradation mediators to build up rapidly. Symptoms include irritation, with topical corticosteroids is on the ocular surface and break foreign body sensation and bleed- effective in controlling and reducing down the conjunctival fi bers over ing.8 PGs can occur in all age groups the size of the lesion. For those who time, creating redundant tissue.18 and appear to affect both men and do not respond to topical agents, It showed that stress on the ocular women equally. surgical excision or cryotherapy is surface from ultraviolet radiation, Pathophysiology. PGs are pre- advised. oxidative stress, dry eyes and me- sumed to represent an abnormal chanical trauma could lead to an reaction to healing, most commonly Conjunctivochalasis increased production of infl ammato- occurring in sites of injury that 3This is defi ned as a loose, ry molecules.18 involve chronic chalazia or surgery.9 redundant conjunctiva. As we age, The increase in infl ammatory However, the true etiology remains our body’s tissues, including the molecules due to insult can acti- unknown. Histological slides reveal ocular surface, lose their elasticity. vate matrix metalloproteinases a mixture of infl ammatory cells, A common sign the ocular surface is (MMPs).18,19 The decreased tear blood vessels and connective tissue.9 experiencing this is chalasis. Often clearance encourages MMPs to re- Infl ammatory cells include lympho- located in the inferior-temporal con- main on the ocular surface for even

REVIEW OF CORNEA & CONTACT LENSES | MAY/JUNE 2020 19 FIVE CONJUNCTIVAL FINDINGS TO LOOK OUT FOR IN CONTACT LENS WEARERS

longer, allowing for compounding the lid wiper region during contact conjunctival damage that leads to lens discomfort, indicating that more redundant tissue. This creates LWE may have an infl ammatory a continuous cycle of worse tear component.26 LCs act as antigens fl ow, more redundant tissue and within the squamous epithelium of possible punctum blockage to keep the epidermis and help lymphocytes more toxic tears on the conjunctiva recognize and react to an immune for longer periods of time. response.27 Management. Treatment of Management. Adequately lubri- chalasis varies depending on the cating the ocular surface is essential severity of each case. Generally, no to minimize friction and manage treatment is needed for asymptom- LWE. Rewetting drops containing atic patients. Topical pharmaceu- carboxymethylcellulose and hyal- tical intervention can help address uronic acid can improve comfort 28 infl ammation and stabilize the tear A pyogenic granuloma can appear and LWE staining. Metastable lip- fi lm in symptomatic patients. Soft small or large and smooth or lobular. id emulsion drops are also effective corticosteroids can target infl am- in diminishing the severity of LWE mation but may require extended friction could be due to inadequate and any associated symptoms.29 periods of use. In addition, anti- lubrication, contact lens wear or Other options include using punctal histamines and mast cell stabilizers environmental factors. You can plugs, applying ointment at night can assist in managing any con- observe the disturbance to the con- and decreasing the modulus of the current allergic-like conjunctivitis. junctival epithelium of the lid wiper contact lens. Lubricants, such as artifi cial tears region through vital staining of the and gels, can help stabilize the tear upper and lower lid margins. Chalazion fi lm. If discomfort continues to LWE is more prevalent in contact 5This benign infl ammatory persist despite maximum therapy, lens wearers and has been ob- condition of the eyelid starts as consider conjunctivoplasty. served in both gas permeable and a tender swelling of the upper or soft lens users.22 One study found lower eyelid. While styes are caused Lid Wiper Epitheliopathy LWE in over 80% of contact lens by an infected hair follicle along the 4(LWE) participants.23 It can be seen in lid margin, chalazia are the result of This refers to an epithelial distur- both symptomatic and asymptom- blockage and infl ammation of the bance of the marginal conjunctiva atic patients.20 Histological studies oil-secreting glands of the eyelid.30 of the upper and lower eyelids. It is demonstrated that the goblet cells They are common, but their exact an epitheliopathy of the squamous in the lid wiper epithelium produce incidence is unknown.30 They occur epithelium of the conjunctiva. The gel-forming mucins, which create a more commonly in adulthood and lid wiper region is the portion of the thin mucin-water gel that lubricates affect males and females equally. marginal conjunctiva of the upper the surfaces of the lid wiper region Patients with underlying conditions, and lower eyelid that spreads the and the ocular surface.24 The thin such as rosacea, seborrheic derma- tear fi lm over the ocular surface.20 gel protects the lid wiper region titis and blepharitis, are more prone It is located in the area of the eyelid from damage by facilitating low to multiple and recurrent chalazia.30 that rubs against the ocular surface, friction during blinking. Contact Pathophysiology. Blockages in the posterior to the line of Marx (the lenses can separate the thin gel, eyelid glands that secrete oil create mucocutaneous junction between causing inadequate lubrication. lipid inspissation in the meibomian the palpebral conjunctiva and the A study found that the micro- gland that can lead to the rup- eyelid positioned posterior to the vascular response of the lid wiper ture and release of lipids into the meibomian glands). region was signifi cantly correlated surrounding tissues.31 This results Pathophysiology. LWE is thought with contact lens discomfort, sug- in a granulomatous infl ammatory to be the result of increased mechan- gesting that friction could be related reaction. A study looking into the ical friction between the lid wiper to both the hyperemic response and cytopathology of chalazia revealed region and the ocular surface that lid wiper staining.25 Another team that this condition may involve two leads to epithelial compromise and of researchers observed an upregu- patterns of granulomatous infl am- infl ammation.21 This increase in lation of Langerhans cells (LCs) in mation.32 A chalazion may either be

20 REVIEW OF CORNEA & CONTACT LENSES | MAY/JUNE 2020 13. Lozano AFI, Larrazabal LI, Nallasamy N, et a mixed-cell or a suppurating granu- al. Conjunctivochalasis. American Academy loma.32 These two patterns of gran- of Ophthalmology. eyewiki.aao.org/conjuncti- vochalasis. October 13, 2019. Accessed March ulomatous infl ammation refl ect the 26, 2020. spectrum of changes in the course 14. Meller D, Tseng SC. Conjunctivochalasis: lit- erature review and possible pathophysiology. of the condition. The infl ammatory Surv Ophthalmol. 1998;43(3):225-32. response from lipid inspissation can 15. Watanabe A, Yokoi N, Kinoshita S, et al. Clinicopathologic study of conjunctivochala- create a continuous cycle that causes sis. Cornea. 2004;23(3):294-8. the chalazion to enlarge and break 16. Mimura T, Usui T, Yamamoto H, et al. Conjunctivochalasis and contact lenses. Am J through the tarsal plate. Ophthalmol. 2009;148(1):20-5.e1. Management. It is common prac- 17. Huang Y, Sheha H, Tseng S. Conjuncti- tice to treat chalazia conservatively. vochalasis interferes with tear fl ow from fornix to tear meniscus. Ophthalmology. Employ noninvasive methods, such 2013;120(8):1681-7. as lid scrubs and hot compresses 18. Meller D, Li DQ, Tseng SC. Regulation of collagenase, stromelysin, and gelatinase B in with or without a digital massage. human conjunctival and conjunctivochalasis fi broblasts by interleukin-1beta and tumor The majority of chalazia clear up necrosis factor-alpha. Invest Ophthalmol Vis within one month of these conser- Sci. 2000;41(10):2922-9. Treat chalazia conservatively by vative measures.30 Although antibi- 19. Erdogan-Poyraz C, Mocan MC, Bozkurt B, employing noninvasive methods. et al. Elevated tear interleukin-6 and interleu- otics are generally not indicated for They should resolve within a month. kin-8 levels in patients with conjunctivochala- chalazia, consider a short course of sis. Cornea. 2009;28(2):189-93. 20. Srinivasan S. Lids, friction and contact lens systemic therapy for lesions with these conditions, we can use our wear. Rev Cornea Cont Lens. 2016;153(7):20-2. associated blepharitis. Doxycycline knowledge in clinical practice to 21. Efron N, Brennan NA, Morgan PB, et al. Lid wiper epitheliopathy. Prog Retin Eye Res. is the drug of choice because of more effectively diagnose and treat 2016;53:140-74. its dual antimicrobial and anti-in- them in our patients. RCCL 22. Shiraishi A, Yamaguchi M, Ohashi Y. Preva- lence of upper- and lower-lid-wiper epitheli- fl ammatory properties, but azith- opathy in contact lens wearers and non-wear- 33 1. Remington LA, Goodwin D. Clinical Anatomy ers. Eye Cont Lens. 2014;40(4):220-4. romycin can be effective as well. and Physiological of the Visual System, 3rd Ed. Boston: Butterworth-Heinemann; 1988. 23. Schulze MM, Srinivasan S, Hickson-Cur- In patients who don’t respond to ran SB, et al. Lid wiper epitheliopathy in conservative therapy, intralesional 2. Barnett M. Rethinking GPC: a new look soft contact lens wearers. Optom Vis Sci. at an old problem. Rev Cornea Cont Lens. 2016;93(8):943-54. steroid injection has long been an 2015;152(2):10-3. 24. Knop N, Korb DR, Blackie CA, et al. The 3. Sforza C, Rango M, Galante D, et al. Spon- lid wiper contains goblet cells and goblet cell effective option because the infl am- taneous blinking in healthy persons: an opto- crypts for ocular surface lubrication during electronic study of eyelid motion. Ophthalmic matory cells comprising chalazia are the blink. Cornea. 2012;31(6):668-79. Physiol Opt. 2008;28(4):345-53. 25. Deng Z, Wang J, Jiang H, et al. Lid wiper sensitive to steroids. Alternatively, 4. Allansmith MR, Korb DR, Greiner JV, et al. surgical incision and drainage may Giant papillary conjunctivitis in contact lens microvascular responses as an indicator of wearers. Am J Ophthalmol. 1977;83(5):697- contact lens discomfort. Am J Ophthalmol. be necessary. 708. 2016;170:197-205. 5. Fowler SA, Korb DR, Allansmith MR. De- 26. Alzahrani Y, Colorado L, Pritchard N, et posits on soft contact lenses of various water al. Infl ammatory cell upregulation of the lid ost of the focus remains contents. CLAO J. 1985;11(2):124-7. wiper in contact lens dry eye. Optom Vis Sci. 2016;93(8):917-24. Mon the cornea and ocular 6. Minno GE, Eckel L, Groemminger S, et al. Quantitative analysis of protein deposits on 27. Jaitley S, Saraswathi TR. Pathophysiology surface when it comes to contact hydrophilic soft contact lenses: I. Comparison of Langerhans cells. J Oral Maxillofac Pathol. lenses; however, it is important to visual methods of analysis. II. Deposit varia- 2012;16(2):239-44. tion among FDA lens materials groups. Optom 28. Nichols JJ, Lievens CW, Bloomenstein not to overlook the conjunctiva. Vis Sci. 1991;68(11):865-72. MR, et al. Dual-polymer drops, contact lens Contact lenses interact with both 7. Kim E, Saha M, Ehrmann K. Mechanical comfort, and lid wiper epitheliopathy. Optom properties of contact lens materials. Eye Con- Vis Sci. 2016;93(8):979-86. the bulbar and palpebral conjunc- tact Lens. 2018;44(Suppl 2):S148-56. 29. Herman JP, Korb DR, Greiner JV, et al. tival regions and, thus, they can 8. Efron N. Contact Lens Complications, 4th Treatment of lid wiper epitheliopathy with a Ed. Philadelphia: Elsevier; 2019. metastable lipid emulsion or a corticosteroid. have adverse effects on a contact 9. Norn MS. Fluorescein vital staining of the Invest Ophthalmol Vis Sci. 2005;46(13). lens wearer. There are multiple cornea and conjunctiva. Acta Ophthalmol 30. Jordan GA, Beier K. Chalazion. StatPearls. conjunctival considerations to (Copenh). 1964;42:1038-45. www.ncbi.nlm.nih.gov/books/NBK499889/. 10. Gumus K, Pfl ugfelder SC. Increasing preva- February 11, 2020. Accessed March 26, 2020. take into account with contact lence and severity of conjunctivochalasis with 31. Gilchrist H, Lee G. Management of chalazia aging detected by anterior segment optical in general practice. Aust Fam Physician. lens wear. Contact lens users can coherence tomography. Am J Ophthalmol 2009;38(5):311-4. present with conditions that are 2013;155(2):238-42. 32. Dhaliwal U, Arora VK, Singh N, et al. 11. Balci O. Clinical characteristics of patients Cytopathology of chalazia. Diagn Cytopathol, multifactorial, so understanding with conjunctivochalasis. Clin Ophthalmol. 2004;31(2):118-22. conjunctival comorbidities is of 2014;8:1655-60. 33. The Wills Eye Manual: O ce and Emergen- extreme importance. Now that 12. Bert BB. How to manage conjunctivocha- cy Room Diagnosis and Treatment of Eye lasis. Rev Ophthalmol. September 12, 2017. Disease, 7th Ed. Philadelphia: Wolters Kluwer; we have a better understanding of [Epub ahead of print]. 2017.

REVIEW OF CORNEA & CONTACT LENSES | MAY/JUNE 2020 21 IRREGULAR CORNEAS MEET THEIR MATCH WITH GP LENSES This modality can provide solutions and improve vision in these unique cases. By Ti any Andrzejewski, OD, and John Gelles, OD

rregular astigmatism can arise 1. Maintaining corneal and anteri- error. However, this task becomes from a multitude of causes, and or segment health increasingly diffi cult with increases a variety of different lens designs 2. Maximizing comfort in irregularity. can help manage it. Nonetheless, 3. Improving vision When fi tting corneal GP designs, Imost practitioners consider gas Topography is essential to under- avoid heavy apical bearing. A mild permeable (GP) lenses the standard standing corneal shape. It includes touch that provides divided support of care for rehabilitating vision due knowing the profi le (prolate or and doesn’t result in corneal staining to irregular astigmatism. A GP-type oblate), symmetry, location, area is appropriate. At the conclusion of lens, whether it be corneal GPs, hy- and magnitude of curvature and the eight-year CLEK study, 31% of brids or sclerals, works well to mask elevation. To start, evaluate anterior patients who wore fl at-fi tting lenses corneal irregularities and diminish segment health to collect baseline with apical touch developed corneal higher-order aberrations. measurements and rule out com- scarring, whereas only 9% of steep One study reports that GP lenses plicating factors. An attempt at fi ts with apical clearance developed provide superior visual performance manifest refraction is also necessary. scarring.5 Along with lens discom- and a greater reduction in third-or- All this data will help determine an fort, fl atter fi ts were associated with der aberrations compared with soft appropriate lens design and fi tting an increased likelihood of penetrat- toric contact lenses in keratoconus method (diagnostic vs. empirical). ing keratoplasty.6 Therefore, avoid- patients.1 GP lenses reduce corneal Let’s see which options can best ing apical bearing is crucial to avoid aberrations induced by irregular benefi t your patients. astigmatism by masking the irregu- ABOUT THE AUTHORS lar corneal surface with the regular CORNEAL GPs refractive surface of the rigid GP These lenses were the mainstay for 2,3 Dr. Andrzejewski works lenses and a liquid tear lens. irregular cornea management for de- at Chicago Cornea A GP contact lens is indicated in cades, but developments with scleral Consultants with special areas of interest in the the presence of irregular astigmatism and hybrid lens designs have demot- management of cornea- and when a manifest refraction does ed corneal designs to a secondary and contact lens-related issues. She is an adjunct not yield acceptable visual acuity status. A recent survey indicated clinical faculty member with no other ocular pathology that 36% of practitioners fi t corneal of the Illinois College of present. Since irregular corneas are (including intralimbal) GP lenses on Optometry. unique, there is no one lens type that the majority of their keratoconus Dr. Gelles is the director of will work for all. Thus, clinicians patients, second to scleral lenses at the specialty contact lens division at the Cornea 4 need to be profi cient at fi tting 39%. and Laser Eye Institute different specialty lens modalities to Fitting a corneal GP on a cornea (CLEI) and the CLEI Center for Keratoconus in improve the likelihood of success. with very mild irregularity or form Teaneck, NJ. The three keys to contact lens fruste keratoconus is similar to success are: fi tting a normal cornea for refractive

22 REVIEW OF CORNEA & CONTACT LENSES | MAY/JUNE 2020 corneal complications and improve may be more appropriate in the case peripheral lens alignment. of keratoconus, as it has an artifi cial Depending on the lens design, the fl attening effect and will allow use of diameter and curve widths can be a fl atter and lower power GP lens.11 variable or fi xed. Small overall di- The power effect from the soft lens ameter (OAD) and back optic zone will be much less than you would diameter (BOZD) lenses are best expect by just adding the powers of suited for relatively well-centered the two lenses together—the result ectasias or irregularities (Figure 1).7 will be 21% of the labeled soft lens As irregularities such as decentered power.12 ectasias and mild pellucid marginal The patient’s comfort and toler- degeneration become steeper and Fig. 1. The “three-point touch” ability of the lenses largely deter- pattern of a small (9.2mm) OAD lens more peripheral, they require an for a patient with keratoconus. mines a successful piggyback fi t. increasingly larger OAD and BOZD. The soft lens and GP should move There are many ways you can difference along the greatest meridi- independently of one another, and choose your fi rst diagnostic lens, an of change.8 This is a good option the GP periphery should align nicely but, as designs vary, it is typically for challenging scleral obstacles to fi t with the soft lens to avoid both ad- best to follow the fi tting guide. around, such as fi ltering blebs. herence and excessive edge lift. When in doubt, choosing a diagnos- If a standard disposable soft lens tic lens with a base curve (BC) close PIGGYBACK SYSTEMS does not achieve an adequate fi tting to average keratometry value can Patients who desire the optics of a relationship, a custom soft lens may be a good place to start. Let the lens corneal GP with the comfort and be necessary. This will allow for a settle so the fl uorescein can dissipate protection of a soft lens underneath custom diameter base curve and for a few minutes and then evaluate can consider this modality, which is power to aid the piggyback system. the fl uorescein pattern. often overlooked. Only around 2% When using custom soft lenses with If apical clearance or bearing is of keratoconus patients use it, yet it a recessed cavity in the center, the present, modify the base curve in can be a real problem-solver.9 recess should be larger and deeper 0.50D to 1.00D steps until feather There are two main fi tting than the diameter and thickness of touch is achieved.7 A “three-point approaches for this modality. The the GP lens, which will facilitate touch” pattern or minimal apical fi rst is to fi t the corneal GP and then some movement while keeping the clearance is the goal. With three- use a low-powered, low modulus, lid interaction minimal and stable. point touch, there is light bearing in hyper-Dk soft lens underneath, When to choose this lens. Choose the periphery nasally and temporally which will minimally affect the this option when a corneal GP fi ts (two points) and at the apex of the fi tting relationship and the power well and is the correct lens option, irregularity (third point) and defi nite of the system. The second option is but awareness or diffi culty adapting peripheral clearance. With both to fi t the soft contact lens to arti- is preventing success. This can also smaller-diameter and intralimbal fi cially change the contour of the improve the centration of the GP, designs, you can customize the pe- cornea to aid in the fi tting process. protect a focal elevation, such as an ripheral curves with toric or quad- Topography over the soft lens maps apical nodule or scar, or prevent epi- rant-specifi c curves to improve edge the new contour, and guides how to thelial disruption from an otherwise alignment and centration. Generally, fi t the GP lens on top. well-fi tting corneal GP. an oblate cornea can be effectively fi t Corneal GP lenses will tend to with a reverse geometry curve. center on the steepest area of the HYBRIDS When to choose this lens. Many cornea, therefore a moderate- to These lenses have a GP center irregular cornea patients are al- plus-powered (approximately hyper-bonded to a soft skirt. In the ready habitual GP lens wearers. +6.00D) soft lens with a thicker United States, there is only one man- If they have acceptable vision, are center can be benefi cial in patients ufacturer (SynergEyes) that offers well-adapted and maintain corneal who have decentered irregularities multiple designs and geometries to health, continue. Corneal GPs work or who have oblate corneas to accommodate a variety of corneal well for mild to moderate corneal bulk up the center to aid in GP lens shapes, while the OAD and GP irregularity and when there is less centration (Figure 2).10 A mild minus diameter is fi xed. The GP portion of than 350µm of corneal elevation soft lens (approximately -3.00D) the lens uses variable base curves or

REVIEW OF CORNEA & CONTACT LENSES | MAY/JUNE 2020 23 IRREGULAR CORNEAS MEET THEIR MATCH WITH GP LENSES

sagittal depths to align with or vault SCLERALS scleral alignment and complete cus- the cornea, while the soft skirt has Scleral lenses are large diameter GP tomization of the lens optics (sphere, three to four different base curve lenses that rest on the sclera, tucking front toric, multifocal). Some designs radii that help facilitate movement, under the lids and vaulting the also incorporate additional custom- centration and tear exchange. The cornea. This creates a tear reservoir izations of notches, peripheral lifts, newer generation designs are avail- behind the lens bathing the cornea channels or microvaults to account able in higher oxygen-permeable in preservative-free saline, improving for scleral obstructions. materials for both lens portions and vision when other modalities were There are three primary objec- are designed specifi cally for vault- unsuccessful. These lenses are avail- tives in fi tting a scleral lens—the ing the irregular cornea. This may able with an abundance of modifi - lens must vault the cornea, clear the reduce complications with neovascu- cations depending on the laboratory limbus and align with the sclera. A larization found in designs with low and their design. range of 100µm to 300µm of apical Dk materials. Overall, diameters can be variable clearance and about 50µm over the An appropriately fi tting hybrid or fi xed, and you can adjust their limbus after settling is deemed ac- lens will exhibit approximately vault by changing their base curves ceptable. These lenses are primarily 100µm clearance at insertion, as the or sagittal depths. Some designs fi t diagnostically. lens may settle 30µm to 60µm after compensate for changes to individ- When to choose this lens. This several hours of wear. The central ual curves, allowing for a single pa- is the go-to for moderate to severe GP portion should clear the cornea, rameter change to occur without af- irregularities where there is signifi - with light touch on the mid-pe- fecting the rest of the fi t. Many come cant asymmetry of the inferior and ripheral cornea at the GP-soft lens in various geometries (oblate and superior cornea. Sclerals are a good junction (the inner-landing zone) prolate) with variable haptic designs second-line option when patients fail and land evenly on the soft skirt (toric and quad-specifi c) to enhance with other lens modalities and are without fl uting or impingement. The benefi cial for patients with ocular soft skirt (the outer-landing zone) surface disease and those suffering bears 80% of the weight of the lens from contact intolerance due to dry system, making it more comfortable eye. than corneal GPs.13,14 There should be movement upon blink initially, SCAN/IMPRESSION-BASED but movement after a few hours of SCLERALS wear may not be seen although there The availability of free-form, ele- is tear exchange. vation-specifi c scleral designs allow When to choose this lens. Hybrids practitioners to achieve an optimal serve as a great fi rst-line option for fi t on the most irregular and chal- mild to moderate central corneal lenging cases. irregularities or ectasias as well as An impression-based scleral for patients experiencing discomfort prosthetic is developed in a process or centration problems with corneal similar to those used in orthodon- GPs. It’s a logical transition for pre- tics. The impression is 3D-scanned, vious soft lens wearers who need a a model is generated, a points fi le is GP lens for improved vision, patients developed and the device is manu- with a suboptimal experience with factured. A scan-based scleral uses a piggyback systems or those with profi lometer, similar to a wide fi eld complications from scleral lens wear, topographer. particularly lens reservoir fogging. This technology will drive empir- Patients with signifi cantly decentered ical fi tting of scleral lenses, such as irregularities, intracorneal rings, Fig. 2. Intralimbal GP on sunken the EyePrintPro, as well as further poor corneal rigidity (i.e., radial corneal transplant. The steep central customization options. This is the keratotomy), cornea transplants or BC causes a central bubble, but ultimate in scleral technology and those with signifi cant ocular surface midperiphery is aligned on the graft/ offers an option for those who have host junction (top). The same GP disease are less ideal candidates for piggybacked with a +7.00D silicone failed with traditional sclerals or for hybrid lenses. hydrogel soft lens (bottom). whom traditional sclerals are not an

24 REVIEW OF CORNEA & CONTACT LENSES | MAY/JUNE 2020 Table 1. Pros and Cons of Each Lens Type Scan/Impression-based Corneal GP Piggyback Hybrid Scleral Sclerals (+) Healthy cornea (+) Avoids need for more (+) Improves comfort com- (+) Great comfort—better (+) Great comfort even when physiology complex/expensive pared with GPs; vaults than GPs and hybrids; commercial sclerals fail lens design the central cornea stable optics (+) Lower cost to (+) Soft lens cushions and (+) Convenience of a one (+) Complete customization (+) Precise first-lens fit; less manufacture protects the cornea; lens sytem of parameters revisions/chair time aids in stability/centra- tion of the GP (+) Ease of handling (+) Eliminates discomfort (+) Soft skirt improves (+) Ability to vault over any (+) Can be used for the most from debris centration and stability; corneal irregularity complex ocular geometries eliminates discomfort (prism, HOA correction); from debris can incorporate complex optics

(–) Patient comfort (–) Care of two different (–) Limited customization of (–) Multiple office visits/ (–) Cost lenses parameters revisions required for proper fit (–) Discomfort from (–) Dk/t of the “system” (–) Nuanced fitting, evaluat- (–) Requires a great deal of (–) Not covered by many debris under ing and troubleshooting; pracitioner experience insurances lens possibly more chair time at the initial fitting (–) Potential to scar (–) Mass-manufactured (–) Older generation designs (–) Difficult handling due to (–) Limited patient access the cornea soft lenses have limited have a higher risk for the filling solution and parameters neovascularization increased size

option. Currently, impression- and are in immediate need of a per- 5. Zadnik K, Barr JT, Steger-May K, et al. Comparison of fl at and steep rigid contact lens scan-based sclerals are limited to fect-fi tting lens for ocular protection fi tting methods in keratoconus. Optom Vis Sci. those practitioners who are certifi ed (i.e., Stevens-Johnson syndrome, 2005;82(12):1014-21. 6. Gordon MO, Steger-May K, Szczotka-Flynn L, et and have the necessary devices. persistent epithelial defect and other al. Baseline factors predictive of incident penetrat- When to choose this lens. If you severe ocular surface disease). Lastly, ing keratoplasty in keratoconus. Am J Ophthalmol. 2006;142(12):923-30. have this option at your disposal, it can be a last line of contact lens 7. Bennett ES, Barr JT, Szczotka-Flynn L. Kera- use it when a patient presents after therapy before considering surgical toconus. In Bennett ES, Henry VA, eds., Clinical Manual of Contact Lenses (4th ed.). Philadelphia, being unsuccessful other commer- intervention. Lippincott Williams & Wilkins; 2014:518-77. cially available scleral lenses. It can 8. Zheng F, Caroline P, Kojima R, et al. Corneal elevation di erences and the Initial selection of help patients who need a scleral P lenses are vital to vision corneal and scleral contact lens. Poster presented at the Global Specialty Lens Symposium. Las lens but have signifi cant time and/or Grehabilitation for our irregular Vegas, January 2015. travel constraints and cannot make cornea patients. We are fortunate 9. Zadnik K, Barr JT, Edrington TB, et al. Baseline fi ndings in the Collaborative Longitudinal Evalua- the required multiple offi ce visits to have many options to offer them tion of Keratoconus (CLEK) Study. Invest Ophthal- sometimes necessary for the fi tting (Table 1). Being skilled in fi tting mol Vis Sci. 1998;39(13):2537-46. 10. Bennett ES, Grohe RM, Anderson BW, et al. of commercial scleral lenses. different lens modalities will help Piggyback applications in modern contact lens This modality can benefi t fi rst- clinicians make the best choices and practice. Contact Lens Spectrum. 2007; 22(12):17. 11. Romero-Jiménez M, Santodomingo-Rubido J, time scleral fi ts that have signifi cant meet the visual needs of these chal- González-Méijome JM, et al. Which soft lens power corneal irregularities, especially pe- lenging but rewarding patients. RCCL is better for piggyback in keratoconus? Part II. Cont Lens Anterior Eye. 2015;38(1):48-53. ripheral ectasias where decentering 12. Michaud L, Brazeau D, Corbeil ME, et al. Con- 1. Jinabhai A, Radhakrishnan H, Tromans C, O’Don- the optic zone can be key to achiev- nell C. Visual performance and optical quality with tribution of soft lenses of various powers to the soft lenses in keratoconus patients. Ophthalmic optics of a piggy-back system on regular corneas. ing a successful fi t, conjunctival Physiol Opt. 2012;32(2):100-16. Cont Lens Anterior Eye. 2013;36(6):318-23. abnormalities (such as pingueculae, 2. Gri ths M, Zahner K, Collins M, Carney L. Mask- 13. Sclafani L, Alvis C. Utilizing technology instead ing of irregular corneal topography with contact of time to successfully fi t the irregular cornea with pterygiums and/or fi ltering blebs) lenses. CLAO J. 1998;24(2):76-81. hybrid lenses. Presented at the 2020 Global Spe- and/or asymmetric scleral contours. 3. Kosaki R, Maeda N, Bessho K, et al. Magnitude cialty Lens Symposium. Las Vegas, NV. January and orientation of Zernike terms in patients 2020. It is a great fi rst-line option for pa- with keratoconus. Invest Ophthalmol Vis Sci. 14. Nau AC. A comparison of synergeyes versus tients who have especially complex 2007;48(7):3062-8. traditional rigid gas permeable lens designs for 4. Bennett ES. GP annual report 2019. Contact patients with irregular corneas. Eye Contact Lens. anterior segment pathologies and Lens Spectrum, 2019; 34(10):22-7. 2008;34(4):198-20.

REVIEW OF CORNEA & CONTACT LENSES | MAY/JUNE 2020 25 SOFT OR SCLERAL LENSES FOR DRY EYE PATIENTS? Determine the best option that treats your patient’s symptoms and expectations. By David Sweeney, OD

ften, patients believe they are not candidates thyroid disease and allergies, as well as the medica- for contact lenses because of their chronic tions they use that may contribute to dry eye, such as dry eyes. Lens-induced dry eye can cause anti-anxiety/antidepressant medications, anti-hyperten- associated symptoms to appear or even sives and oral antihistamines. Consider all the different Oworsen, while pathologic causes of dry eye include more behavioral and environmental factors that could exac- common etiologies such as evaporative meibomian gland erbate their dry eyes. Ask them how much of their day dysfunction (MGD).1,2 Aqueous defi ciency is another less is spent looking at their computer. Then, thoroughly common cause of dry eye due to lacrimal gland dysfunc- assess their ocular surface and tear fi lm with numerous tion associated with systemic diseases, such as Sjögren’s tests, including Oculus Keratograph 5M imaging. After syndrome or chronic graft-vs.-host disease (GVHD). thoroughly assessing and determining the patient’s dry In addition to ocular surface and tear quality con- eye severity, prescribe treatments to manage the condi- cerns, other factors contribute to the complexity of tion and prepare the eye for contact lens success. fi tting contact lenses, such as patient’s refractive error, Lastly, determine the patient’s visual demands. We corneal or conjunctival irregularities and poor blink want to provide them the best possible vision, ease of function. Perhaps they have tried contact lenses in the handling, comfort and relief of dry eye symptoms. past and were not successful due to comfort, vision or handling. However, much has changed with con- SOFT LENS BENEFITS tact lens materials and design over the last 10 years in This lens type may be the preferred choice for patients regards to access, comfort and variety. with mild dry eye or patients who are consistent Dry eye patients who are not great candidates for with their dry eye treatment. These lenses are made refractive surgery should consider the appropriate of fl exible materials that drape over elevations or contact lens as an alternative.3 Improving the ocular depressions in the conjunctiva, often making them surface and tear fi lm prior to contact lens fi tting is the easier to fi t. One key measurement for fi tting contact key to success. lenses is corneal diameter. For example, with smaller corneas, select smaller diameter soft lenses and fl atter TREATMENT AND PREP base curves to improve edge alignment and tear Start dry eye treatment as early as you can in the fi tting fl ow under the lens for improved comfort.4 Soft lens process, and take the time to assess the severity of the handling may be easier for patients with previous soft patient’s condition. If you provide them the optimal lens experience. Unfortunately, some may still need dry eye treatment while stressing the importance of instruction on better techniques. compliance, you will be giving them the tools they need to achieve the highest level of contact lens wear success ABOUT THE AUTHOR and adherence. Determining the root cause of dry eye will help make Dr. Sweeney practices at Vision Source Insight in Atlanta and is a member of both the the contact fi tting process successful. Review the pa- Georgia Optometric Association and American tient’s symptoms with the Ocular Surface Disease Index Optometric Association (AOA). He is a member of the AOA’s Cornea and Contact Lens and Low (OSDI) questionnaire and medical history and note any Vision sections. infl ammatory conditions, such as rheumatoid arthritis,

26 REVIEW OF CORNEA & CONTACT LENSES | MAY/JUNE 2020 Daily disposable lenses provide fresh, clean and convenient lenses. In my practice, I have found this option better for people with allergies. Also, stor- age solutions used with reusable lenses may result in toxicity.5-7 Soft lenses are available in new breathable silicone hydrogel materials with high-water gel-like surface treatments (Precision1 and Dailies Total1, Alcon) for enhanced comfort and increased wearing time. Fortunately, new daily disposable lenses are available to correct higher prescriptions, astigmatism as well as presbyopia with multifocal designs. Consider trying soft lenses fi rst if you note irregular conjunctival anatomy on the slit lamp exam. Also consider lenses such as Acuvue Transitions (Johnson & Johnson) for patients who are light sensitive due to retinal or macular dystrophy or albinism. Fig. 1. A depression in this patient’s conjunctiva, due the removal of a tube shunt, allowed debris to be sucked SCLERAL BENEFITS under the loose scleral lens edge, clouding vision. Scleral lenses made of rigid, gas permeable (GP) ma- terials provide crisper vision to patients with irregular scleral lens diameter that is too large may complicate corneas due to keratoconus or other corneal diseases, the fi t as the conjunctival anatomy gets more irregular or due to corneal trauma or refractive surgery such further from the limbus.13-15 Alignment with the con- as radial keratotomy, photorefractive keratectomy, junctiva can be perfected with use of toric peripheral LASIK or cataract surgery.8-11 curves, custom vaults over pingueculas and custom Still, fi tting scleral lenses often requires additional depressions if there is a valley following surgery follow up to fi ne tune the fi t and monitor lens settling. (Figures 1 and 2). Another deterrent to this modality is the higher cost OCT imaging can guide where edge alignment needs attributed to doctor training, equipment and multiple to be enhanced to avoid tear debris getting sucked scleral lens trial sets and replacement costs. under a loose edge. Tear layer debris under the lens In my practice, patients with moderate to severe dye will blur vision after just a few hours of wear. Corneal eye often fi nd scleral lens often more comfortable than topography over the scleral lens can be helpful to as- soft lenses for the following reasons: sess multifocal add location and to determine the need • The thick 0.25mm tear layer across the back sur- to decenter the reading add for better distance and face of the contact lens and over the cornea provides near vision (Figure 3). constant lubrication. Only use preservative-free saline A well-aligned scleral lens will be more diffi cult in the bowl of the lens before application. Consider for the patient to remove. However, if they rotate the preservative-free Nutrifi ll (Contamac) saline solution lens 90 degrees with their fi nger to misalign the lens or even autologous serum in the bowl of lens for with the sclera, the lens is easily removed with a lens severe dry eye patients. remover. • Breathable high-oxygen transmissible materials such as Boston XO2 (Bausch + Lomb) and Optimum Infi nite (Contamac) provide superior corneal health by allowing more oxygen to reach the cornea. • New Hydra-PEG (Tangible Science) surface treatments improve wettability and reduce protein deposition.12 Patients notice signifi cant improvement in dryness, lens comfort and vision. Fig. 2. The patient in Figure 1 was refi t with a scleral lens with a lower Scleral lenses should be large enough to edge to better align with the conjunctival depression. The patient not touch the cornea. However, selecting a reported better vision throughout the day.

REVIEW OF CORNEA & CONTACT LENSES | MAY/JUNE 2020 27 SOFT OR SCLERAL LENSES FOR DRY EYE PATIENTS?

Fig. 3. This presbyopic dry eye patient placed their scleral multifocal lens with a decentered add on the eye upside down (left). After rotating the lens 180 degrees, the reading add was positioned correctly (right).

Patients with Sjögren’s or GVHD will do best with Fig. 4. To correct edge lift in the vertical meridian in this well-fi tted scleral lenses because of their ability to re- trial fi t spherical scleral lens, we ordered toric peripheral lieve their disabling dryness by bathing the ocular sur- curves fl atter along the horizontal and steeper along the face with a tear reservoir between their compromised vertical meridians. ocular surface and back surface of the scleral lens.16-18 Scleral lenses provide a smooth ocular surface over toric peripheral curves that provided better alignment. irregular or diseased corneas, resulting in best possible The fi nal lens noticeably improved the patient’s com- vision and greatly improving quality of life. fort and protected his cornea. He noted better visual quality, as the scleral lens provided a smooth surface CASE 1 over his compromised cornea. Scleral lenses helped A 36-year-old Caucasian male presented to the offi ce relieve his severe dry eye, and his drop frequency even- requesting a scleral lens fi t. He complained of dry eye, tually reduced and light sensitivity improved. He could discomfort and severe light sensitivity, which made function better at work and have fun with his children. him unable to function at work and play with his three young children. He was diagnosed with GVHD after CASE 2 an allogeneic stem cell transplant to treat his leukemia An 84-year-old Caucasian female was referred by her diagnosed three years ago. optometrist for scleral lens fi tting to treat her advanced Ocular history was remarkable for LASIK surgery keratoconus and discomfort with corneal GP lenses. to correct his -3.00D myopia in each eye. He used She reported spending only 30 minutes per day on her autologous serum eye drops Q2H to QID OU and Pred computer. Her ocular history was positive for cataract Forte (prednisolone acetate ophthalmic suspension 1%, extraction with peripheral-curve IOL implantation and Allergan) 1% eye drops BID OU. He had discontinued nodules were removed from her left cornea. She had Restasis (cyclosporine A 0.05%, Allergan) and Xiidra contact lens-induced dry eye resulting in her corneal (lifi tegrast 5%, Novartis) due to increased burning with GP lenses becoming less tolerable over the years. Her use. To improve his ocular surface and prepare it for manifest refraction was +3.75 – 1.00 x 125 20/50 OD scleral lens wear, we prescribed erythromycin antibi- and +6.50 – 1.50 x 180 20/30 OS with +1.50 add otic ointment two to three times a day. His Pred Forte OU. Autorefractor K’s were 54.00/56.75 @48 OD was changed to Lotemax SM (loteprednol etabonate and 58.50/62.50 @98 OS. Her corneal diameter was 0.38%, Bausch + Lomb) TID, as it has less risk of 11.90mm, she was OD dominant and pupil size was intraocular pressure spikes and cataract development. 3mm OU. Oculus K5M revealed mild MGD and kera- During the course of the scleral lens fi tting we ad- toconus, worse in OD (Figure 5). dressed severe meibomian gland obstruction, infl amma- We initially tried improving the GP fi t with custom tion, eyelid biofi lm formation and tear fi lm instability corneal topography-based lenses, but comfort did to help repair the cornea and conjunctiva. not improve signifi cantly. She was successful for the We selected Jupiter scleral lenses with initial trial lens fi rst couple of weeks using scleral lenses, with good diameter of 16.6mm with spherical peripheral curves. 20/30 vision in each eye. But on two occasions in To improve comfort and prevent tear debris due to the fi rst month, she had diffi culty removing the lens. edge lift in the vertical meridian (Figure 4), we ordered Unfortunately, she lived about three hours from the

28 REVIEW OF CORNEA & CONTACT LENSES | MAY/JUNE 2020 Fig. 5. Corneal topography of advanced keratoconus OU successfully fi t with Kerasoft IC Toric lenses.

offi ce, which worried her enough to strongly request a different solution. To improve her success with contact lenses, we recommended: warm compresses and lid massage for her moderate MGD, triglyceride form of omega-3s for Fig. 6. This toric lens has a thicker edge profi le for infl ammation, 0.01% hypochlorous acid lid hygiene improved lens stability, while the edge is parallel to the conjunctiva for good comfort. spray for her eyelid biofi lm and artifi cial tears for tear fi lm instability. 3. Chuck RS, Jacobs DS, Lee JK, et al. Refractive errors & refractive surgery We then offered her Kerasoft IC Toric (Bausch + Preferred Practice Pattern. Ophthalmology. 2018;125(1):P1-P104. 4. Caroline PJ, André MP. The e ect of corneal diameter on soft lens fi tting, part Lomb) soft lenses that are designed to correct kera- 1. Cont Lens Spectrum. 2002;17(4):56. 19 toconus and other irregular corneas. Single lenses 5. Stapleton F, Naduvilath T, Keay L, et al. Risk factors and causative organ- were ordered and then second lens dispensed with fi nal isms in microbial keratitis in daily disposable contact lens wear. PLoS One. prescription and vision: 8.0 base curve, 14.50 +5.50- 2017;12(8):e0181343. 6. Wu YT, Teng YJ, Nicholas M, et al. Impact of lens case hygiene guidelines on 1.25 x 138 20/25 OD and 7.80 base curve, 14.50 contact lens case contamination. Optom Vis Sci. 2011;88(10):e1180-1187. +7.25 - 1.75 x 176 20/40 OS with standard peripheral 7. Wu Y, Carnt N, Willcox M, Stapleton F. Contact lens and lens storage case curves. She was delighted with her vision, all-day lens cleaning instructions: whose advice should we follow? Eye & Cont Lens. 2010;36(2):68-72. comfort and handling (Figure 6). With her small pupils, 8. Alipour F, Kheirkhah A, Jabarvand Behrouz M. Use of mini scleral contact she only needed +1.50D readers for fi ne print. lenses in moderate to severe dry eye. Cont Lens Anterior Eye. 2012;35(6):272-6. Her toric silicone-hydrogel contact lenses provided 9. Walker MK, Bergmanson JP, Miller WL, et al. Complications and fi tting challenges associated with scleral contact lenses: a review. Cont Lens and Ant conservative dry eye therapy, and she found lens wear Eye. 2015;39:88-96. to be comfortable all day. The high plus power she 10. Visser E-S, Visser R, van Lier H, Otten H. Modern scleral lenses part II: patient needed resulted in a thicker lens that corrected her satisfaction. Eye Contact Lens. 2007;33:21-5. 11. Romero-Rangel T, Stavrou P, Cotter J, et al. Gas permeable scleral contact irregular astigmatism and maintained excellent vision lens therapy in ocular surface disease. Am J Ophthal. 2000;130:25-32. despite her irregular cornea from keratoconus. 12. Mickles C, Harthan J, Barnett M. A surgace treatment solution for scleral lens wearers with dry eye. Presentation at the Global Specialty Lens Symposium. ontact lenses can improve quality of life at work, Las Vegas. January 2019. 13. van der Worp E, Graf T, Caroline PJ. Exploring beyond the corneal borders. Chome and play for many dry eye patients. They are Cont Lens Spectrum. 2010;25(6):26-32. happy seeing well with more comfortable eyes while 14. Ritzmann M, Morrison S, Caroline P, et al. Scleral shape and asymmetry as free of glasses during the day. You can improve your measured by OCT in 78 normal eyes. Poster presented at the Global Specialty Lens Symposium, Las Vegas, January 2016. patient’s contact lens success by reducing symptoms of 15. van der Worp E. A Guide to Scleral Lens Fitting, Version 2.0. Forest Grove, dry eyes with timely diagnosis and appropriate treat- OR: Pacifi c University; 2015. Available: commons.pacifi cu.edu/mono/10/. ment. Determining whether soft or scleral lenses will Accessed April 21, 2020. 16. Jacobs DS, Rosenthal P. Boston scleral lens prosthetic device for treat- better address the patient’s problems due to dry eye will ment of severe dry eye in chronic graft-versus-host disease. Cornea. help provide your patients the vision and comfort they 2007;26(10):1195-9. need and improve their quality of life. RCCL 17. Schornack MM, Baratz KH, Patel SV, Maguire LJ. Jupiter scleral lenses in the management of chronic graft versus host disease. Eye Cont Lens. 2008;34(6):302-5. 1. Molina K, Graham AD, Yeh T. et al. Not all dry eye in contact lens wear is contact lens-induced. Eye Contact Lens. September 10, 2019. [Epub ahead of 18. Alipour F, Kheirkhah A, Jabarvand Behrouz M. Use of mini scleral contact print]. lenses in moderate to severe dry eye. Cont Lens Anterior Eye. 2012;35(6):272-6. 2. Lemp MA, Crews LA, Bron AJ, et al. Distribution of aqueous-defi cient and 19. Kumar P, Bandela PK, Bharadwaj SR. Do visual performance and optical evaporative dry eye in a clinic-based patient cohort: a retrospective study. quality vary across di erent contact lens correction modalities in keratoconus? Cornea. 2012;31(5):472-8. Cont Lens Anterior Eye. March 29, 2020. [Epub ahead of print].

REVIEW OF CORNEA & CONTACT LENSES | MAY/JUNE 2020 29 2 CE Credits (COPE APPROVED)

The How and Why of Contact Lens Deposits Optometrists need a comprehensive understanding of this complication to help patients avoid it. By Heidi Wagner, OD, MPH

n this era of disposability, many punctate keratitis, corneal infl am- with all types of lens materials and eye care providers are less con- matory events and even microbial replacement regimens. cerned about contact lens depos- keratitis.3,4 This article reviews how Contact lens deposits are best its. In 2019, daily disposable soft to identify various types of lens identifi ed through observation of Icontact lenses (SCLs) accounted for deposits, describes the impact of the lens on the eye with biomicros- 35% of international lens prescrib- lens material choices on comfort copy under varying illumination ing and 44% of lenses prescribed and vision and delineates how lens and magnifi cation. A lens loupe is in the United States.1 As the market care options and surface treatments a practical alternative, particularly share of conventional and planned impact deposition. if the lens is damaged and could replacement SCLs shrinks, lens de- potentially harm the eye. posits may be less prevalent and less UNDERLYING MECHANISMS Lens deposits can be distinguished severe; still, lens deposition remains A general understanding of the un- by color, structure and location. a factor, especially with the expand- derlying mechanisms of lens depos- Identifi cation of the predominant ed use of specialty contact lenses. its and an awareness of strategies deposit can guide the practitioner in Specialty SCLs, gas permeable to reduce them remain integral to management decisions. There are a (GPs) lenses and hybrids play an contemporary contact lens prac- number of common types of depos- important role in the United States tice. Lens depositing is infl uenced its practitioners should be aware of. market of 45 million contact lens by many factors, including patient Proteins and lipids. These are wearers.2 Specialty SCLs and hy- compliance, individual tear chem- long-recognized lens deposits in brids are typically replaced far less istry and environment. Individual contact lens practice.8,9 Protein frequently than daily disposables— tear chemistry is evidenced by lipid deposits occur as lysozyme binds often at quarterly or six-month composition, protein profi le, mucin to the lens surface and undergoes intervals. In contrast to SCLs, GPs and electrolyte analysis—charac- structural changes that impair its are often replaced “reactively” teristics that manifest in the wearer function. These changes, termed (i.e., when the patient requires a response.5 Understanding these protein denaturation, are infl uenced change in lens power or experiences interactions can help the eye care by numerous factors such as the reduced comfort, degraded vision or provider optimize lens performance lens substrate, pH and temperature.6 lens loss or damage) rather than on and minimize adverse events. Protein deposits are characterized a planned schedule. by an opaque fi lm on the lens that Contact lens deposits signifi cantly IDENTIFYING DEPOSITS becomes more obvious over time. In impact the patient’s lens wearing Lens deposition begins within min- contrast, lipid deposition is char- experience and ocular health. Lens utes of wear.6 While surface deposits acterized by a shiny, lubricious ap- spoilage can potentially reduce lens may be minimized by increasing surface wettability and adversely the frequency of lens replacement, ABOUT THE AUTHOR impact patient comfort, wearing variation exists among individual Dr. Wagner is a professor time and quality of vision. Further, patients with regards to tear chem- of clinical optometry lens deposits can result in contact istry and compliance with the lens and director of extern 7 programs at Ohio State lens-related ocular pathology, care regimen. Practitioners must be University. including papillary conjunctivitis, vigilant in identifying lens deposits

30 REVIEW OF CORNEA & CONTACT LENSES | MAY/JUNE 2020 Fig. 1. Patients can present with both protein and lipid deposits. These common lens deposits are shown here at (left) low and (right) high magnifi cation. pearance. Both are present in SCLs or more frequently. Thus, if prac- of deposit, which is often character- and GPs. Protein and lipid deposits titioners observe lens calculi in ized by a fi lamentary appearance, is can be observed in combination in patients wearing lenses with shorter more commonly observed in soft or an individual patient (Figure 1). replacement cycles, wearers may hybrid lenses.12 Lens calculi. Sometimes referred be “stretching” their replacement Fungal deposits may be associated to as “jelly bumps,” these deposits cycles. As the deposit is embed- with poor disinfection regimens. are distinct, localized elevations ded within the matrix of the lens, This can occur when patients use on the anterior surface of the SCL. replacement is necessary. saline instead of a multipurpose Lens calculi are composed of calci- This type of deposit is more disinfection solution or when part- um, lipid and mucoprotein inherent commonly observed in high-water, time wearers or multiple pair (e.g., in the tear fi lm (Figure 2).10 Their ionic (group IV), hydrogel lens colored lenses) wearers store lenses formation is attributed to depletion materials.11 The practitioner can in solution for extended periods of of the aqueous tear layer that results address this problem by refi tting the time. Additionally, patients who in a hydrophobic zone that, in turn, patient into a different lens material, disinfect lenses with hydrogen per- promotes deposition.11 If signifi - though simply reinforcing the lens oxide systems may be unaware that cant in number and size, they can replacement schedule or refi tting the neutralized disinfection solution degrade comfort and vision. into daily disposable contact lenses is saline and that the solution must While frequently observed in the may address the problem. be replaced every seven days if the era of conventional SCL lens wear, Fungal deposits. Given the predi- lenses are not worn.13 Therefore, they are relatively uncommon in lection of fungus for lens materials it is important to prescribe a lens lenses that are replaced monthly of a higher water content, this type care system that is appropriate for

Release Date: May 15, 2020 activity has been planned and implemented by the Postgraduate Institute Expiration Date: May 15, 2023 for Medicine and Review Education Group. Postgraduate Institute for Estimated time to complete activity: 2 hours Medicine is jointly accredited by the Accreditation Council for Continuing Medical Education, the Accreditation Council for Pharmacy Education, Jointly provided by Postgraduate Institute for and the American Nurses Credentialing Center, to provide continuing

Medicine (PIM) and Review Education Group. TM JOINTLY ACCREDITED PROVIDER education for the healthcare team. Postgraduate Institute for Medicine is Educational Objectives: After completing this INTERPROFESSIONAL CONTINUING EDUCATION accredited by COPE to provide continuing education to optometrists. activity, the participant should be better able to: Faculty/Editorial Board: Heidi Wagner, OD, MPH, Ohio State University • Discuss the underlying mechanisms of contact lens deposits. Credit Statement: This course is COPE approved for 2 hours of CE credit. • Identify contact lens deposits in their patients. Course ID is 67922-CL. Check with your local state licensing board to see • Recommend changes to reduce deposits in their contact lens wearers. if this counts toward your CE requirement for relicensure. • Factor in lens material choices to improve comfort and vision. • Describe how lens care options and surface treatments impact Disclosure Statements: deposition. Dr. Wagner has contracted research with Alcon and has received honoraria from Wink Productions. Target Audience: This activity is intended for optometrists engaged in Managers and Editorial Sta : The PIM planners and managers have the care of patients with contact lens deposits. nothing to disclose. The Review Education Group planners, managers and Accreditation Statement: In support of improving patient care, this editorial sta have nothing to disclose.

REVIEW OF CORNEA & CONTACT LENSES | MAY/JUNE 2020 31 THE HOW AND WHY OF CONTACT LENS DEPOSITS

the patient’s wearing schedule and On occasion, topical and system- ensure that the patient understands ic medications have been associated how to use it. with lens discoloration in SCLs. Iron deposits. Characteristically For example, rifampin, a drug used round and brown-to-orange in to treat tuberculosis, can cause an color, such deposition may be a orange discoloration of contact consequence of incorporating tap lenses.18 A similar phenomenon has water into the lens care regimen, been reported with sulfasalazine, despite published evidence of the Fig. 2. This patient presented with which is used to manage infl amma- association of Acanthamoeba with distinct, localized elevations on the tory bowel disease.19 Lens discolor- water exposure.14 In a survey of anterior surface of the lens—lens ation, ranging from pink to brown, calculi. more than 1,000 SCL wearers, 31% has also been observed with some reported rinsing their SCLs with tap While eye make-up may be easily topical medications, such as the water on at least one occasion, and identifi ed by color and texture, epinephrine ophthalmic drops used 10% reported always or fairly often identifying the source of other con- in the past to treat glaucoma. rinsing their lenses with tap water.15 taminants degrading the lens surface While these conditions are not Of the wearers who reported rinsing may prove to be more elusive.17 observed in every day clinical their lenses with tap water, 41% Lotions transferred from fi nger- practice, the practitioner should be reported also storing their lenses in tips and aerosol hairspray can also aware of the potential of oral and tap water.15 bind to the lens. These types of de- topical medications to infl uence the Upon identifying iron deposits, posits can be eliminated by proper tear ocular environment.20 eye care providers should emphasize hand washing before lens handling Lysozyme deposits. Notably, that no amount of water exposure and applying make-up after lens lysozyme deposition may provide is acceptable. This message may be insertion (Figure 4). benefi cial effects during contact reinforced by promotional materi- Other potential sources of en- lens wear, as lysozyme exhibits als, such as the “no water” stickers vironmental lens deposits include antibacterial and anti-infl amma- distributed by the Cornea, Contact organic debris such as leaf litter and tory properties.6 Research also Lenses and Refractive Technologies inorganic contaminants such as a shows that lactoferrin in the Diplomate Section of the American metallic foreign body. If you suspect tears has the potential to work in Academy of Optometry (Figure 3). a metallic foreign object, always concert with lysozyme to inhibit Mucin balls. These deposits are perform a more extensive eye exam- gram-positive and gram-negative round, semitransparent spheres ination, given the possibility of an bacteria.6 However, further study is ranging in size between 40µm and intraocular foreign body. needed to better understand these 120µm. While mucin balls have Lipid, protein and exogenous interactions. been observed in a variety of lens contaminants are likely to deposit Lens materials infl uence the materials, they are more frequently on both GP and SCL lens materials. deposition of tear-derived prod- associated with silicone hydrogels Unique to GP lenses, however, is ucts that, in turn, infl uences lens (SiHy). Research suggests that their poor wetting exhibited in newly dis- comfort.21 Some investigators have formation is based on a mechanical pensed lenses. This is somewhat less also challenged the belief that interaction between the cornea and common as water-soluble products lens deposition negatively impacts high modulus SiHy materials.16 currently used in the manufacturing comfort, noting that lysozyme has, Mucin balls do not appear to process have largely eliminated the on occasion, been associated with impact vison or comfort and, there- oily residue (i.e., “pitch”) that was increased comfort in HEMA-based fore, can easily be differentiated previously part of the manufactur- lens materials. This was attributed from other types of lens deposits. ing process. to the fact that lysozyme retains They are more likely observed in This problem can generally be a higher degree of activity when fi rst-generation SiHy products that solved by plasma cleaning or soak- deposited on traditional hydrogel are characterized by “stiffer” (high ing lenses in an appropriate condi- lens materials compared with sili- modulus) lens materials. tioning solution prior to dispensing. cone hydrogels.22 They propose the Environmental debris. Make-up, Lens cleaners can also be used with development of lens materials that such as mascara and eyeliner, is a appropriate materials, as discussed can selectively bind “good” depos- common source of lens deposits. below. its and inhibit “bad” deposits.23

32 REVIEW OF CORNEA & CONTACT LENSES | MAY/JUNE 2020 LENS MATERIAL This resulted in an increased oxygen modality and patient. In a recent The FDA classifi es hydrogel contact permeability but more protein survey administered by the Centers lenses as ionic (groups III and IV) deposition. for Disease Control and Prevention, and nonionic (groups I and II). Fluorine was then added to six of seven contact lens wearers Groups II and IV exhibit a higher maintain oxygen permeability and acknowledged at least one behav- water content (≥50% water) than improve wettability of the current ior that places them at risk for a groups I and III. SiHy, in gen- generation of fl uorosilicone acrylate contact lens-related adverse event.2 eral, are characterized by lower (FSA) lens materials. Earlier gener- Eye care providers play an import- water content but higher oxygen ation SA lenses tended to deposit ant role in educating all contact lens permeability.6 proteins while newer FSA lenses wearers at the initial fi tting as well The rate of protein deposition tend to deposit lipids.28 as reinforcing best practices at every is signifi cantly related to the lens Given these various material char- follow-up visit. material. Polymethyl methacrylate acteristics, clinicians should custom- Clinicians should provide spe- (PMMA) and SiHy lens materials ize the lens material to the individu- cifi c guidance based on the unique deposit less lysozyme than hydro- al patient. For example, a hyper-Dk needs of the patient, including the gels, and lysozyme is particularly lens material may be desirable for lens material, replacement schedule, prevalent in high-water, ionic lens overnight wear in orthokeratology contact lens care, tear chemistry and (group IV) materials.24 The exter- while a moderate-Dk lens material history of compliance. nal environment and lens han- may be ideal for a patient who tends SCLs. Appropriate lens care goes dling further expose the lenses to to deposit lipids. a long way in maintaining a clean contaminants. In addition, the provider can lens surface. Chemical disinfection SCLs provide an ideal medium further tailor the lens care regimen systems (commonly designated to attract lens deposits, given the to the needs of the lens wearer. For as multipurpose solution [MPS]) hydrophilic surface. Hydrogel lenses example, a heavy lipid depositor combine cleaning, rinsing and contain methacrylic acid to increase who also requires a high-Dk lens disinfection. While MPS is integral water content and oxygen permea- material could benefi t from a more to lens care, it is useful to remember bility.25 Consequently, HEMA-based rigorous lens care system as de- that its success is based on its ability lens materials exhibit a predisposi- scribed below. to deliver key components of the tion toward protein deposition, as lens care regimen: cleaning, rinsing, the negatively charged methacrylic LENS WEAR AND CARE disinfecting and storage. acid binds to positively charged pro- Proper contact lens wear and care Cleaning removes loosely ad- teins, including lysozyme.26 Thus, practices are essential for all contact hered deposits, as does lubrication. refi tting patients wearing SCLs from lens modalities, and they should Rinsing removes the debris and high-water, ionic lens (group IV) be tailored to the particular lens avoids the introduction of addition- materials to low-water, non-ionic lens (group I) materials may reduce Other Considerations protein deposits. SiHy lenses, while Further consideration for giant papillary conjunctivitis (GPC) is highly oxygen permeable, are warranted, given its association with lens deposits. GPC is most potentially hydrophobic in nature. commonly associated with SCLs but can be associated with GPs, as They may exhibit reduced wettabil- well as sutures following surgery.3 While the condition was initially ity and a greater tendency towards described as a “reaction” to soft contact lenses, the term was later lipid deposition compared with their redefi ned by researchers who postulated that the syndrome was HEMA-based counterparts.27 immunologic in origin with deposits on the lenses serving as an 35 Rigid lens materials exhibit a antigen (type IV immune response). A mechanical component has also been suggested, although there is no consensus on this issue.36 parallel story. All but obsolete, GPC is characterized by papillae on the tarsal conjunctiva. In mild PMMA contact lenses were deposit cases, patients may have symptoms of lens awareness. In severe resistant but impervious to oxygen. cases of GPC, patients may experience excessive lens movement, GP lenses are permeable to oxygen substantial lens depositing and lens intolerance. Contact lens-induced in varying degrees based on the GPC can be managed by increasing lens replacement frequency, polymer components. Silicone was decreasing lens wearing time or changing lens materials. Concurrent added to the lens material to create pharmacological management, such as mast-cell inhibitors/ antihistamine combination drugs and topical steroids, can be added. silicone acrylate (SA) lens materials.

REVIEW OF CORNEA & CONTACT LENSES | MAY/JUNE 2020 33 THE HOW AND WHY OF CONTACT LENS DEPOSITS

lenses with one million organisms cleaners are less accessible than in to study the effi cacy of a lens care the past, patients may require addi- system, the inclusion of a clean- tional direction regarding where to ing step removed one log unit of purchase them. microorganisms from the lens. If the Hydrogen peroxide systems cleaner was rinsed from the lens, are a particularly effective pre- two additional log units of microor- servative-free disinfection option. ganisms were further eliminated.17 Contemporary systems contain a This work reinforces the need for surfactant and, in one system, a digital cleaning, even with MPS. wetting agent. However, anecdotal The FDA further discouraged the reports suggest lens residue may promotion of “no rub” lens care be associated with solutions that systems after the voluntary remov- contain a proprietary wetting agent. al of two lens care products from This can be resolved by switching to the marketplace following their another hydrogen peroxide product association with Fusarium and without the wetting agent. 29-31 Fig. 3. These “no water” stickers, Acanthamoeba. Further studies Practitioners should be cognizant distributed by the American have supported digital rubbing and of current MPS systems, make an Academy of Optometry, can help rinsing to minimize deposits and initial prescribing decision and mod- reinforce to patients that no amount limit bacterial contamination in ify as needed. They should also be of water exposure is acceptable. reusable soft and GP lenses.32,33 alerted to potential patient pitfalls, al external contaminants. Proper A separate surfactant or enzy- such as “topping off” (which can disinfection and storage limits matic cleaner is rarely indicated for reduce disinfection effi cacy), pur- microbial intrusion. It is important two-week or monthly replacement chasing alternate products and not that patients remember that all lens SCLs, although these products completing the cleaning regimen as care components—including the may be added to the care regimen directed. It should also be noted that lens case, when applicable—are part for “heavy depositors.” Surfactant SCL wearers who have an ample of the lens care system. cleaners remove loosely adhered supply of lenses are more likely to In studies where the FDA required lens debris, unbound protein and replace their lenses at recommended the manufacturers to inoculate the microbial contamination. As these intervals.34 GPs. One-bottle care systems for cleaning, rinsing, disinfection and storage are also available for GP lenses. As with MPS SCL solutions, digital cleaning can enhance the effi cacy of the process. For example, Unique pH (Menicon) and Boston Simplus (Bausch + Lomb) provide one-bottle convenience. Two-bottle systems, such as Boston Original and Advance (Bausch + Lomb), incorporate a separate abrasive cleaner that enhances the clean- ing regimen. Boston Original was designed for lower-Dk SA lenses, which tend to deposit proteins, while Boston Advance was devel- oped for higher-Dk FSA lens materi- als that deposit lipids. Clinicians can also manage lens Fig. 4. In this case, lip balm was inadvertently transferred to the lens, deposits by being judicious in the resulting in poor GP lens wetting. addition of Hydra-PEG (Tangible

34 REVIEW OF CORNEA & CONTACT LENSES | MAY/JUNE 2020 soft and gas-permeable contact lens wearers. Science) and surface treatments. because of the lens geometry (e.g., Cornea. 2017;36(8):995-1001. Hydra-PEG is a biocompatible lenses for keratoconus with steep 16. Tan J, Keay L, Jalbert I, et al. Mucin balls with wear of conventional and silicone hydrogel contact polymer that may be applied to base curves) may also benefi t from lenses. Optom Vis Sci. 2003;80(4):291-7. GP or hybrid lenses as part of the incorporating periodic cleaners. 17. Weisbarth R, Henderson B. Hydrogel Lens Care manufacturing process. As de- Regimens and Patient Education. In: Bennett ES, Weissman BA, eds. Clinical Contact Lens Practice. scribed by the manufacturer, the ontact lens deposits are a Philadelphia, PA: Lippincott Williams & Wilkens; coating promotes a lubricious lens Cwell-known clinical challenge. 2005. 18. Lyons RW. Orange contact lenses from rifampin. surface that is designed to inhibit This challenge can lead to reduced N Engl J Med. 1979;300(7):372-3. lens deposits and fogging. Tangible comfort and vision and negatively 19. Krezanoski JZ. Topical medications. Int Oph- Clean (Tangible Science) is an MPS thalmol Clin. 1981;21(2):173-6. impact ocular health. Often, chang- 20. Miller D, Brooks SM, Mobilia E. Adrenochrome solution designed for Hydra-PEG ing the contact lens or care regimen staining of soft contact lenses. Ann Ophthalmol. coated lenses. It can also be used for is not enough to ward off deposits. 1976;8(1):65-67. 21. Jones L, Brennan NA, Gonzalez-Meijome J, et al. uncoated lenses. Many factors impact a patient’s The TFOS international workshop on contact lens Abrasive cleaners are contrain- discomfort: report of the contact lens materials, chances of experiencing this compli- design, and care subcommittee. Invest Ophthalmol dicated in plasma-treated lenses, cation, including the lens material, Vis Sci. 2013;54(11):TFOS37-70. hyper-Dk lens materials and with surface treatments, wear schedules, 22. Subbaraman LN, Glasier MA, Varikooty J, et al. Protein deposition and clinical symptoms in Hydra-PEG. Non-abrasive cleaners care regimens and the patient’s indi- daily wear of etafi lcon lenses. Optom Vis Sci. 2012;89:1450-9. that contain alcohol are particu- vidual tear fl uid composition. RCCL 23. Subbaraman LN. Is contact lens deposition larly effective with lipid removal good or bad? Contact Lens Update. 2016. https:// and are compatible with hyper-Dk 1. Morgan PB. International contact lens prescribing contactlensupdate.com/2016/06/25/is-contact- in 2019. Contact Lens Spectrum. 2020;35(1):26-32. lens-deposition-good-or-bad. lens materials; however, no consen- 2. Cope JR, Collier SA, Nethercut H, et al. Risk 24. Subbaraman LN, Glasier MA, Senchyna M, sus exists regarding their use with behaviors for contact lens–related eye infections et al. Kinetics of in vitro lysozyme deposition among adults and adolescents—United States, on silicone hydrogel, PMMA, and FDA groups I, plasma-treated lenses, and they are 2016. MMWR Morb Mortal Wkly Rep. 2017;66:841-5. II, and IV contact lens materials. Curr Eye Res. contraindicated with Hydra-PEG. 3. Allansmith MR, Korb DR, Greiner JV, et al. Giant 2006;31(10):787-96. papillary conjunctivitis in contact lens wearers. Am 25. Tighe B. Rigid lens materials. In: Efron N, ed. Given that tap water is contrain- J Ophthalmol. 1977;83(5):697-708. Contact Lens Practice. Oxford, United Kingdom: dicated with all contact lenses, low 4. Aswad MI, John T, Barza M, et al. Bacterial Butterworth-Heinemann; 2010. adherence to extended wear soft contact lenses. 26. Jones L, Mann A, Evans K, et al. An in vivo viscosity solutions such as saline or Ophthalmology. 1990;97(3):296-302. comparison of the kinetics of protein and lipid MPS should be employed to rinse 5. Mann A, Tighe B. Contact lens interactions with deposition on group II and group IV frequent-re- the cleaner from the lens. As this the tear fi lm. Exp Eye Res. 2013;117(12):88-98. placement contact lenses. Optom Vis Sci. 6. Omali NB, Subbaraman LN, Coles-Brennan C, et 2000;77(10):503-10. inadvertently introduces a third al. Biological and clinical implications of lysozyme 27. Nicolson PC, Vogt J. Soft contact lens poly- step, one-step hydrogen peroxide deposition on soft contact lenses. Optom Vis Sci. mers: an evolution. Biomaterials. 2001;22(24):3273- 2015;92(7):750-7. 83. systems provide a practical alter- 7. Ilhan B, Irkec M, Orhan M, et al. Surface deposits 28. Bennett ES, Henry VA, eds. Clinical Manual of native whereby the disinfection on frequent replacement and conventional daily Contact Lenses. 4th ed. Philadelphia: Lippincott wear soft contact lenses: a scanning electron Williams & Wilkins; 2013. solution also contains a surfactant microscopic study. Clao J. 1998;24(4):232-5. 29. Centers for Disease Control and Preven- cleaner and the solution neutralizes 8. Lin ST, Mandell RB, Leahy CD, et al. Protein tion. Update: Fusarium keratitis--United States, accumulation on disposable extended wear lenses. 2005-2006. MMWR Morb Mortal Wkly Rep. to saline. CLAO J. 1991;17(1):44-50. 2006;55(20):563-4. Anecdotally, patients who 9. Jones L, Evans K, Sariri R, et al. Lipid and protein 30. Joslin CE, Tu EY, Sho ME, et al. The associa- deposition of N-vinyl pyrrolidone-contacting group tion of contact lens solution use and Acanthamoe- successively use MPS systems with II and group IV frequent replacement contact ba keratitis. Am J Ophthalmol. 2007;144(2):169-80. corneal GPs may require a more lenses. CLAO J. 1997;23(2):122-6. 31. Food and Drug Administration. FDA Letter rigorous system with scleral lenses, 10. Begley CG, Waggoner PJ. An analysis of nod- to Firms with Marketing Clearance for No-rub ular deposits on soft contact lenses. J Am Optom Multipurpose Contact Lens Solutions. 2019. www. presumably because corneal lenses Assoc. 1991;62(3):208-14. fda.gov/medical-devices/contact-lenses/fda-letter- exhibit more tear exchange. Heavy 11. Hart DE, Tidsale RR, Sack RA. Origin and com- fi rms-marketing-clearance-no-rub-multipurpose- position of lipid deposits on soft contact lenses. contact-lens-solutions. depositors may also benefi t from Ophthalmology. 1986;93(4):495-503. 32. Cho P, Poon HY, Chen CC, et al. To rub or not periodic cleaners such as enzymatic 12. Chen J, Fraser T, Fisher D, et al. Characteristics to rub? - e ective rigid contact lens cleaning. of fungal growth in soft contact lenses. Int Contact Ophthalmic Physiol Opt. 2020;40(1):17-23. cleaners that remove protein or Lens Clin. 2000;26(4):84-91. 33. Cho P, Cheng SY, Chan WY, et al. Soft contact Progent (Menicon), which exhib- 13. Kilvington S, Lam A, Nikolic M, et al. Resis- lens cleaning: rub or no-rub? Ophthalmic Physiol tance and growth of Fusarium species in contact Opt. 2009;29(1):49-57. its both cleaning and disinfection lens disinfectant solutions. Optom Vis Sci. 34. Schnider C. The ‘Pantry Load’ E ect – Can it properties. Progent may be used as 2013;90(5):430-8. help drive more compliant contact lens replace- 14. Radford CF, Minassian DC, Dart JK. Acan- ment? Optom Vis Sci. 2012;89:E-abstract 120652. frequently as every two weeks for thamoeba keratitis in England and Wales: inci- 35. Spring TF. Reaction to hydrophilic lenses. Med heavy depositors and can be used in dence, outcome, and risk factors. Br J Ophthalmol. J Aust. 1974;1(12):449-50. offi ce. Patients who experience dif- 2002;86(5):536-42. 36. Donshik PC, Ehlers WH, Ballow M. Giant papil- 15. Zimmerman AB, Richdale K, Mitchell GL, et al. lary conjunctivitis. Immunol Allergy Clin North Am. fi culty digitally cleaning their lenses Water exposure is a common risk behavior among 2008;28(1):83-103, vi.

REVIEW OF CORNEA & CONTACT LENSES | MAY/JUNE 2020 35 THE HOW AND WHY OF CONTACT LENS DEPOSITS

CE TEST ~ MAY/JUNE 2020 ou can obtain continuing c. Lubrication of the lens. 14. Contact lens discoloration is education credit through the d. Lens disinfection. associated with: YOptometric Study Center. a. Systemic medications but not Com plete the test form and return 6. Iron deposition in soft contact topical medications. it with the $35 fee to: Jobson lenses is associated with: b. Topical medications but not Healthcare Information, LLC, Attn.: a. Improper contact lens systemic medications. CE Processing, 395 Hudson Street, disinfection practices. c. Topical and systemic 3rd Floor New York, New York b. Poor hygiene. medications. 10014. To be eligible, please return c. Water exposure. d. No medications. the card within three years of d. Silicone hydrogel lens materials. publication. You can also access the 15. Hydrogen peroxide disinfection test form and submit your answers 7. High-water content, ionic, HEMA- systems are characterized by all of and payment via credit card at based lens materials are associated the following, except: Review Education Group online, with what type of deposition? a. Preservative-free system. www.revieweducationgroup.com. a. Protein. b. Well-documented disinfection You must achieve a score of 70 or b. Lipid. capabilities. higher to receive credit. Allow four c. Cholesterol. c. E cacy as a lens lubricant. weeks for processing. For each d. Iron. d. Appropriate use with gas Optomet ric Study Center course you permeable and soft contact pass, you earn 2 hours of credit from 8. Which of the following is exhibited lenses. Pennsyl vania College of Optometry. by lysozyme? Please check with your state a. Antibacterial properties. 16. High-Dk fl uorosilicone acrylate licensing board to see if this approval b. Anti-infl ammatory properties. contact lenses are more likely to counts toward your CE requirement c. Antibacterial and anti- deposit ___ than low-Dk silicone for relicensure. infl ammatory properties. acrylate contact lenses. d. None of the above. a. Lipid. 1. Silicone hydrogel contact lenses b. Protein. tend to deposit ____ while 9. Silicone is characterized by which c. Sodium. hydrogel contact lenses tend to of the following properties? d. Potassium. deposit____. a. Hydrophilicity. a. Protein; lipid. b. Hydrophobicity. 17. Mucin balls are associated with b. Lipid; protein. c. Low oxygen permeability, which type of contact lens? c. Fungus; bacteria. relative to HEMA-based lens a. Low-modulus silicone hydrogels. d. Bacteria; fungus. materials. b. High-modulus silicone d. Low modulus. hydrogels. 2. Enzymatic contact lens cleaners c. Low-modulus hydrogels. remove: 10. In a recent survey of more than d. High-modulus hydrogels. a. Protein. 1,000 soft contact lens wearers, b. Lipid. what proportion reported always 18. The FDA classifi es a high-water, c. Bacteria. or fairly often rinsing their lenses ionic hydrogel contact lens d. Fungus. with tap water? material as: a. ~ 1%. a. Group I. 3. Contact lens deposits may begin b. ~ 5%. b. Group II. to form in: c. ~ 10%. c. Group III. a. Minutes. d. ~ 30%. d. Group IV. b. Hours. c. Days. 11. “Topping o ” ______: 19. In a recent survey administered d. Weeks. a. Reduces disinfection e cacy. by the Centers for Disease Control b. Increases disinfection e cacy. and Prevention, what proportion 4. In studies where the FDA required c. Reduces lens wettability. of lens wearers acknowledged the manufacturers to inoculate the d. Increases lens wettability. at least one behavior that places lenses with one million organisms them at risk for a contact lens- to study the e cacy of a lens care 12. Alcohol in lens care products is related adverse event? system, how many microorganisms known for all of the following, a. One out of seven. were removed with the inclusion of except: b. Two out of seven. a cleaning and rinsing step? a. Antimicrobial activity. c. Four out of seven. a. 1,000. b. Moisture-enhancing properties. d. Six out of seven. b. 10,000. c. Lipid removal. c. One log unit. d. All of the above. 20. Which of the following describes d. Three log units. distinct, localized elevations on 13. Abrasive cleaners are the anterior surface of the soft 5. Which of the following are contraindicated in which type of contact lens that are composed of attributes of a surfactant cleaner? contact lens? calcium, lipid and mucoprotein? a. Removal of loosely adhered lens a. Low-Dk materials. a. Fungus. debris, unbound protein and b. Silicone acrylate materials. b. Lens calculi. microbial contamination. c. Fluorosilicone acrylate materials. c. Lysozyme. b. Elimination of bound protein. d. Lenses treated with Hydra-PEG. d. Acanthamoeba.

36 REVIEW OF CORNEA & CONTACT LENSES | MAY/JUNE 2020 Mail to: Jobson Healthcare Information, LLC, Attn.: CE Processing, Examination Answer Sheet 395 Hudson Street, 3rd Floor New York, New York 10014 The How and Why of Contact Lens Deposits Payment: Remit $35 with this exam. Make check payable to Valid for credit through May 15, 2023 Jobson Healthcare Information, LLC. Online: You can take this exam online at www. Credit: This course is COPE approved for 2 hours of CE credit. revieweducationgroup.com. Upon passing the exam, you can Course ID is 67922-CL. view the results immediately and download a real-time CE certificate. You can view your test history any time on the Jointly provided by Postgraduate Institute for Medicine and website. Review Education Group. Salus University has sponsored the review and approval of this Select one answer for each question in the exam and Directions: activity. completely darken the appropriate circle. A minimum score of 70% is required to earn credit. Processing: There is a four-week processing time for this exam.

Answers to CE exam: Post-activity evaluation questions: 1. A B C D Rate how well the activity supported your achievement of these learning objectives: 2. A B C D 1=Poor, 2=Fair, 3=Neutral, 4=Good, 5=Excellent 3. A B C D 21. Discuss the underlying mechanisms of contact lens deposits. 1 2 3 4 5 4. A B C D 22. Identify contact lens deposits in their patients. 1 2 3 4 5 5. A B C D 23. Recommend changes to reduce deposits in their contact lens wearers. 1 2 3 4 5 6. A B C D 24. Factor in lens material choices to improve comfort and vision. 1 2 3 4 5 7. A B C D 25. Describe how lens care options and surface treatments impact deposition. 1 2 3 4 5 8. A B C D

9. A B C D

10. A B C D 26. Based upon your participation in this activity, do you intend to change your practice behavior? 11. A B C D

12. A B C D (choose only one of the following options)

13. A B C D A I do plan to implement changes in my practice based on the information presented. 14. A B C D B My current practice has been reinforced by the information presented. A B C D 15. C I need more information before I will change my practice. 16. A B C D 17. A B C D 27. Thinking about how your participation in this activity will influence your patient care, 18. A B C D how many of your patients are likely to benefit? (please use a number): 19. A B C D

20. A B C D 30. Which of the following do you 28. If you plan to change your practice behavior, what type of changes do you plan to anticipate will be the primary barrier to implement? (check all that apply) implementing these changes? a Apply latest guidelines b Change in pharmaceutical therapy c Choice of a Formulary restrictions treatment/management approach b Time constraints d Change in current practice for referral e Change in non-pharmaceutical therapy f Change in differential diagnosis g Change in diagnostic testing h Other, please c System constraints specify: ______d Insurance/financial issues ______e Lack of interprofessional team 29. How confident are you that you will be able to make your intended changes? support a Very confident b Somewhat confident c Unsure d Not confident f Treatment related adverse events g Patient adherence/compliance Please retain a copy for your records. Please print clearly. h Other, please specify:

First Name 31. Additional comments on this Last Name course: ______E-Mail ______The following is your: Home Address Business Address ______Business Name Rate the quality of the material provided: Address 1=Strongly disagree, 2=Somewhat disagree, City State 3=Neutral, 4=Somewhat agree, 5=Strongly agree ZIP 32. The content was evidence-based.

Telephone # - - 1 2 3 4 5 Fax # - - 33. The content was balanced and free of bias. By submitting this answer sheet, I certify that I have read the lesson in 1 2 3 4 5 its entirety and completed the self-assessment exam personally based 34. The presentation was clear and effective. on the material presented. I have not obtained the answers to this exam 1 2 3 4 5 by any fraudulent or improper means.

Signature Date Lesson 119563 I RO-RCCL-0520 REVIEW OF CORNEA & CONTACT LENSES | MAY/JUNE 2020 37 Fitting Challenges By Vivian P. Shibayama, OD

When Lashes, Not Lenses, are the Problem Demodex is common in patients with rosacea and can really throw a wrench in contact lens wear.

emodex is a common rosacea, which yet often overlooked was mild and condition among our under control. patients. Even though Her ocular Dsigns and symptoms may not be history was obvious under a slit lamp, they not signifi cant, are sure to cause discomfort. This but she did makes it even more imperative report that she that we catch and treat these tiny had taken oral mites as early as possible. The doxycycline in following case example will give the past. you a good idea of how to go Her pupils about this. were reactive to light, with no THE CASE relative afferent A 23-year-old female patient pupillary defects presented with complaints of in either eye, contact lens intolerance for the and extraocular past two years. The itching and movements were discomfort she experiences worsen full OU. Slit lamp when she wears contact lenses, examination despite only using them for sport. revealed clear She has tried many different corneas OU, a contact lens brands and modalities clear palpebral but has found no success. Further conjunctiva with exacerbating her symptoms is eye no papillae OU makeup, which she has stopped and a deep and wearing altogether to avoid ocular quiet anterior irritation. She was diagnosed with chamber OU. Fig. 1. Lid margin examination revealed lashes that dry eye, but warm compresses and Examination pouted at the base (OD on the top). artifi cial tears have not improved of the lid margin her signs and symptoms. She revealed telangiectasia OU and THE VERDICT was also told she is not a good cylindrical collarettes with lashes The patient’s soft contact lenses candidate for LASIK surgery due that pouted at the base (Figure fi t well and centered with good to her reduced corneal thickness 1). The patient’s meibomian movement. While the lid margin and unique lens prescription. glands expressed clear oil. initially appeared relatively clear The patient’s presenting visual Her non-contact tear breakup and clean, the lashes pouted at acuity was 20/20 OU with time was fi ve seconds OD and the base. That, along with the fact her spectacles, which had a four seconds OS, keratometry that the patient had a history of prescription of -8.00D OD and readings were 45.00/46.00@045 facial rosacea, made me suspicious -9.00D OS. She wore Acuvue OD and 44.00/44.50@150 OS of possible Demodex burrowed in Oasys 1-Day HydraLuxe lenses and intraocular pressures were her lash follicles. with a base curve of 8.50mm and 10mm Hg OD and 11mm Hg I temporarily suspended a prescription of -7.00D OD and OS. Undilated posterior segment contact lens wear and put the -8.00D OS. She was receiving evaluation revealed a normal patient on a regimen that would topical treatment for facial fundus OU. treat her ocular rosacea and

38 REVIEW OF CORNEA & CONTACT LENSES | MAY/JUNE 2020 Demodex—twice daily Oust or intense pulsed Demodex cleanser (OcuSoft) light therapy, if and Avenova spray (NovaBay). her condition I asked her to avoid common worsened. The triggers of rosacea, including patient was sun, dairy, alcohol and caffeine, happy with her and to continue application of current situation, warm compresses daily for 10 and the fi t was minutes with a plug-in eye mask. fi nalized. I advised her to discontinue makeup use indefi nitely. If she DISCUSSION made the decision to wear it, Demodex is I recommended she purchase a common products with clean ingredients condition in and no irritants and ensure patients who also complete removal after each use. have rosacea.1 The skin FOLLOW-UPS infl ammation The patient came back one week associated with later stating her itching had rosacea makes slightly improved but was still these patients present. Upon examining the more prone anterior segment, I found clear to blepharitis, and clean lashes, but the lash the bacteria of base was still pouted (Figure 2). which Demodex I performed in-offi ce BlephEx on like to feed on. both eyelids with tea tree oil and Even when the asked the patient to continue lid blepharitis seems cleansing with the same regimen. to be under Fig. 2. After discontinuing contact lens wear for a week, She returned after another control, the mites the patient’s lashes were still pouted (OD on the top). week had passed with improved can embed in the symptoms. Slit lamp examination lash follicle and cause discomfort. for patients with rosacea. revealed clear lids and lashes. I Rosacea is more common in Inform patients that long-term gave her permission to resume women and light-skinned patients treatment is usually required to contact lens wear and asked her to but can be underdiagnosed in control the effects of rosacea—a follow up in a week. those who have darker skin. chronic condition that requires The patient was now able Patients with rosacea are typically daily maintenance to manage its to wear her lenses for eight more sensitive to facial products symptoms. RCCL hours at a time, which was a since the blood vessels lay close signifi cant improvement from her to the top layer of skin.2 They 1. Gonzalez-Hinojosa D, Jaime-Villalonga A, Aguilar-Montest G, et al. Demodex and previous experience. I suggested should avoid food triggers and rosacea: is there a relationship? Indian J she increase lubrication with use hypoallergenic products and Ophthalmol. 2018;66(1):36-8. 2. Knox C. Rosacea: a review of a common preservative-free artifi cial tears, sunscreen to protect them from disorder. The Internet Journal of Academic and we discussed scleral lenses and ultraviolet light.3 Physician Assistants. 2006;4(2). more aggressive treatment of her Tea tree oil lid washes are a 3. National Rosacea Society. www.rosacea. org. Accessed April 10, 2020. rosacea, such as oral antibiotics form of preventative therapy

REVIEW OF CORNEA & CONTACT LENSES | MAY/JUNE 2020 39 Practice Progress By Mile Brujic, OD, and David Kading, OD

Embrace the Oddballs Better serving your more di cult cases will prove to be highly benefi cial.

ftentimes, PROGRESSIVE your most KERATOCONUS loyal This clinical condition patients can range in severity. are Early on, mild corneal Othose who believe that thinning causes a you would go above protrusion of the cornea and beyond to meet in the area of thinning. their visual needs As the condition appropriately while progresses, further still allowing them to thinning and steepening wear contact lenses. In of the cornea occur, turn, they’re more than increasing the sagittal willing to refer others depth of the cornea to you without a second and creating irregular thought or any type of astigmatism. Keratoconic incentive. eyes have a hard time We can take patient succeeding with standard Irregular thickness secondary to a corneal injury can cause satisfaction a step an irregular surface. soft contact lenses. further when handling Earlier on in particularly challenging cases patients with standard soft contact the condition, the irregular that require specialty care and lenses. These lenses often vault astigmatism may be correctable advanced knowledge. Here, we over the surgically altered cornea, with a standard soft toric contact discuss several examples of oddball leading to vision that is clear lens. However, as the condition ocular surface issues among shortly after blinking but becomes progresses, you can prescribe contact lens wearers and how to blurrier as the eye remains open. specialty soft contact lenses, such appropriately address them to Post–refractive surgery patients as KeraSoft (UltraVision) and optimize the patient experience. require contact lenses with a lower Novakone (Bausch + Lomb). sagittal depth to mitigate the GP and standard hybrid lenses POST-REFRACTIVE SURGERY vaulting. This is diffi cult to achieve are also options. As corneal These corneas typically have with standard soft contact lenses, steepening begins to take place, it’s a lower sagittal depth than but other options are available for likely that you’ll need to turn to normal because the central these types of corneas. Reverse- specialty hybrid lenses, including cornea is thinned and fl attened geometry gas permeable (GP) UltraHealth (SynergEyes), and during the refractive procedure, lenses provide a fl at central curve scleral lenses to correct for the whether it be photorefractive that transitions to a steeper irregular cornea. Discuss corneal keratectomy, laser-assisted in situ peripheral curve joined by a crosslinking with progressive keratomileusis or laser-assisted reverse curve. Hybrid and scleral keratoconus patients when epithelial keratomileusis. Although lenses can also optimize vision for necessary. radial keratotomy doesn’t thin these surgically altered corneas. the cornea, it does alter its When fi tting scleral lenses, be IRREGULAR OR architecture. As such, if suboptimal cognizant of the need to establish SCARRED CORNEA refractive results occur with any appropriate clearances over post- Injuries and infections can refractive procedure, resulting in refractive corneas, as these patients cause permanent architectural an irregular corneal surface, it tend to have excessive central changes to the cornea that may becomes very diffi cult to fi t these corneal clearance. affect the cornea’s shape and

40 REVIEW OF CORNEA & CONTACT LENSES | MAY/JUNE 2020 clarity. They can also IRREGULAR permanently alter SCLERAL SHAPE the corneal epithelial A decade ago, discussion thickness, creating about the importance additional abnormalities of the shape of the to the ocular surface. sclera was just starting Depending on the level to emerge. We used to of irregularity present, be limited to scleral a high-modulus silicone lenses with a spherical hydrogel lens may mask landing zone that these abnormalities. GP, caused unintended hybrid and scleral lenses consequences, such as are also all options. discomfort, more lens awareness in certain HIGH ASTIGMATISM regions where the lens Moderate corneal lifted away from the astigmatism can be sclera, impingement in adequately corrected areas where the landing Centrally located astigmatism can often be fi t with a spherical with soft toric lenses. GP lens. zone was steeper than The technology, the scleral profi le and contemporary design and patient’s vision by correcting less post-lens tear clouding wide range of disposable options of the corneal astigmatism. By throughout the day. provide a reliable, predictable fi t. fi tting the cornea with a back- It is critical to understand the As corneal astigmatism increases toric GP lens, the lens toricity is relationship between the landing and becomes the main refractive designed to match the corneal zone of the lens and the often error causing visual disturbance, toricity, mitigating lens fl exure and irregular scleral shape. There are however, it becomes increasingly optimizing vision. technologies that guide clinicians diffi cult to correct with soft Of course, don’t forget about in measuring the scleral profi le and toric lenses. Smaller rotations of the option of scleral contact producing the appropriate landing soft toric lenses create greater lenses, which are typically made zone on the lens. Many scleral lens changes with higher amounts at a thickness of between 300µm diagnostic sets now come with a of astigmatism, oftentimes to 400µm centrally to provide a standard toric landing zone. This compromising it. This is where GP surface that resists fl exure. This provides the practitioner with the designs come into play and provide creates a predictable tear lens for added advantage of an adequate superior vision. patients with regular astigmatism. starting point that may require A tear lens is created between Those patients whose corneal only minor modifi cations to the posterior surface of a GP astigmatism is similar to their optimize the landing zone. lens and the cornea to correct refractive astigmatism tend to see the corneal astigmatism. If the very well with scleral lenses. Keep ddball ocular surfaces astigmatism is centrally located, in mind that regular astigmatism Opresent unique challenges to high amounts may be correctable can extend onto the sclera as well, clinicians as they work to restore with a standard spherical lens. If so make sure to appropriately appropriate vision. Keep these the corneal astigmatism extends align the landing zone of the lens examples and fi tting strategies in closer to the limbus, the lens is with the scleral shape by designing mind when managing tricky cases. at greater risk of fl exure, which the lens with the appropriate Your patients and your practice are ultimately compromises the toricity. sure to benefi t. RCCL

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

Vessels Sound the Alarm These painful eyes need steroids—and immunosuppressives when they fall short.

51-year-old white female ways: anterior or posterior, nod- nodosa, the seronegative spondy- presented after a week ular or diffuse, necrotizing or loarthopathies and multiple forms of right eye tenderness, non-necrotizing, and infectious or of systemic vasculitis.3 especially upon eye move- non-infectious. The fi rst-line therapy for non- Ament. The nasal quadrant appeared Anterior, non-necrotizing, non-in- infectious scleritis is oral NSAIDs hyperemic and slightly edematous fectious scleritis is the most common and prednisone. Topical steroids are and did not fully blanch with 2.5% form. In the nodular version, there useful when there is coexisting intra- phenylephrine. Her intraocular exam is visible elevation with engorged ocular infl ammation or mild disease was unremarkable. She was diag- scleral vessels. Vision is rarely but typically fail if used without nosed with mild scleritis and conser- affected, unless there is concurrent systemic medications. Steroid- vatively started on 800mg ibuprofen involvement of the cornea or uveal sparing immunosuppressives, such and topical 1% prednisolone acetate tract. Infection is responsible for as methotrexate, are started if four times a day. about 5% to 10% of cases of anteri- the patient cannot be successfully Scleritis is an infl ammatory or scleritis and is typically associated tapered below 10mg of prednisone process that involves dilation of with trauma (89%) or surgery.1,2 without symptoms or clinical signs the superfi cial and deep episcleral Visual prognosis is guarded with of active scleritis. RCCL

vessels, resulting in a bluish-red hue infectious scleritis. 1. Guerrero-Wooley RL, Peacock JE Jr. Infectious and the sclera becoming edematous Systemic diseases associated with scleritis: what the ID clinician should know. Open Forum Infect Dis. 2018;5(6):ofy140. and painful. The patient may com- scleritis include rheumatoid arthritis 2. Hodson KL, Galor A, Karp CL, et al. Epidemiology plain of tearing, blurred vision and (89% of scleritis), systemic lupus and visual outcomes in patients with infectious scleritis. Cornea. 2013;32(4):466-72. photophobia. erythematosus, infl ammatory bowel 3. Akpek EK, Thorne JE, Qazi FA, et al. Evaluation of patients with scleritis for systemic disease. Ophthal- Scleritis is classifi ed in several disease, sarcoidosis, polyarteritis mology. 2004;111(3):501-6.

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