RCCL OCTOBER 2016 REVIEW OF CORNEA & CONTACT LENSES
Lids & Lenses How eyelid disease can compromise contact lens wear, and what to do about it.
Supplement to
MMWR Alerts • Drug-Eluting Contact Lenses • Refractive Surgery Controversies • Branding
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RCCL0916_Coopervision Biofinity.indd 1 8/29/16 11:01 AM contents Review of Cornea & Contact Lenses | October 2016
departments features
Beat the Blepharitis Blues News Review 4 To understand and treat this common lid US Refractive Surgeons Now Ready condition, make sure you’re clear on its to SMILE; Microbiota Protects many diff erent presentations. Against P. aeruginosa Infections By Abby Gillogly Harsch, OD, Nicole 12 Stout, OD, and Nathan Lighthizer, OD 6 My Perspective MMWR and Contact Lens Alerts The Chicken-and-Egg By Joseph P. Shovlin, OD Problem of MGD and Contact Lens Wear Which came fi rst, the dysfunction or the 8 Pharma Science & Practice discomfort? Researchers aren’t sure, 16 but clinicians need to manage them Is a Sustained Medication Delivery simultaneously. System on the Horizon? By Arthur B. Epstein, OD By Elyse L. Chaglasian, OD, and Tammy Than, MS, OD Lids, Friction and 10 Practice Progress Contact Lens Wear Put a Lid on CL Discomfort Does a relatively new phenomenon help explain contact lens discomfort? By Mile Brujic, OD, and Jason R. Miller, OD, MBA By Sruthi Srinivasan, PhD, BSOptom, 20 FAAO 36 The GP Experts Don’t Forget to Check the Lids By Robert Ensley, OD, and CE — How Lid Malposition Heidi Miller, OD Can Compromise Contact Lens Wear 38 Out of the Box Keep these conditions in mind Brand Yourself, and They Will Come 24 to prevent or By Gary Gerber, OD rectify potential obstacles to a successful fi t. By Steven Turpin, MS, and Leonid Skorin Jr., OD, DO, MS
How Would You Handle These Refractive Surgery Controversies? Despite the procedure’s popularity, some issues still remain. How should you 30 address them? By Aaron McNulty, OD, and Ian McWherter, OD
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/ReviewofCorneaAndContactLenses @RCCLmag REVIEW OF CORNEA & CONTACT LENSES | OCTOBER 2016 3
003_1016RCCL_TOC.indd 3 9/29/16 6:31 PM News Review
IN BRIEF US Refractive Surgeons Now ■ Conjunctival chemosis may be a mark- er to help clinicians predict Pseudomo- nas aeruginosa as the bacterial agent Ready to SMILE responsible for certain corneal ulcers, new research suggests. A masked review looked at 62 infective corneal ulcers new refractive surgery femtosecond laser—translates into and found 14 of 16 cases of P. aerugino- option, Zeiss’s VisuMax better outcomes, and newer studies sa–related corneal ulcers presented with conjunctival chemosis, compared with small incision lenticule report refractive outcomes superior only six of the remaining 46 cases caused extraction (SMILE) to the 2008-2009 results.4,5 1 A by other organisms. Whether or not che- procedure, recently received FDA The FDA’s approval came on the mosis was present predicted or excluded P. aeruginosa with roughly 87% accuracy, approval. The SMILE procedure in- heels of a study demonstrating posi- the researchers conclude.1 volves the creation of a disc-shaped tive visual acuity and refractive pre- 1. Michael KB, Rotchford A, Ramaesh K. lenticule in the stroma using a fem- dictability outcomes for 336 eyes Conjunctival chemosis as a specifi c feature of Pseudomonas aeruginosa corneal ulcers. Cornea. tosecond laser, which the surgeon treated with the SMILE procedure, 2016;35(9):1182-4. removes through a small incision— according to a Zeiss press release.6 ■ A new study sheds light on the impact obviating both the creation of a fl ap The study found participants had environmental conditions have on tear infl ammatory mediators in contact lens and use of an excimer laser needed stable vision six months post-pro- wearers.1 Fifty-four CL wearers were for LASIK. cedure, and all but one subject had exposed to two environmental condi- “Since there is no fl ap, there are uncorrected visual acuity of 20/40 tions: standard (50% relative humidity) or adverse (5% relative humidity). The no fl ap related issues. There is also or better; 88% had uncorrected researchers analyzed changes in concen- vastly less interruption of nerve visual acuity of 20/20 or better. tration of: epidermal growth factor (EGF); interleukin (IL)-1 receptor antagonist, IL- fi bers so one would anticipate The SMILE procedure is indicat- 1β, IL-2, IL-4, IL-6 and IL-8; tumor necrosis less dry eye,” says John F. Doane, ed for the reduction or elimination factor α; monocyte chemoattractant protein-1; and matrix metalloproteinase MD, of Discover Vision Centers in of myopia of -1.00 D to -8.00D, (MMP)-9. Under standard conditions, EGF Kansas City, MO, a clinical inves- with ≤ -0.50D cylinder and MRSE increased signifi cantly while IL-1β and IL-2 tigator for Zeiss. “The refractive -8.25D in patients at least 22 years decreased signifi cantly. Under adverse conditions, IL-6 increased signifi cantly. results are essentially the same. old with documented stable refrac- During CL wear, secretion of several in- Interestingly, since the surgery is tion over the past year, Zeiss says. fl ammatory mediators varies, depending on the type of CL and the environmental done in a vacuum—i.e., the corneal “If worldwide acceptance fore- conditions at play, the study concludes.1 stroma that is not exposed to the shadows what will occur in the 1. Martín-Montañez V, Enríquez-de-Salamanca A, atmosphere—the procedure is dose United States, we can expect quick López-de la Rosa A, et al. Eff ect of environ- mental conditions on the concentration of tear independent. We are just as predict- uptake of the SMILE procedure,” infl ammatory mediators during contact lens able with a -1D as we are with a Dr. Doane suggests. Over half a wear. Cornea. 2016;35(9):1192-8. -10D, which is unique to all prior million procedures have been per- ■ Researchers recently evaluated the effi cacy and safety of transcutaneous corneal refractive procedures.” formed worldwide, Zeiss says. electrical stimulation for symptoms A recent study examined the fi ve- and clinical signs of dry eye. The study 1. Blum M, Täubig K, Gruhn C, et al. Five-year results year results of the fi rst 56 eyes treat- of small incision lenticule extraction (ReLEx SMILE). included 27 patients with dry eye who Br J Ophthalmol. 2016;100:1192–5. underwent transcutaneous electrostim- ed with SMILE for myopia in 2008- 1 2. Zalentein WN, Tervo TM, Holopainen JM. Sev- ulation, wherein electrodes were placed 2009 using the 200kHz VisuMax. en-year follow-up of LASIK for myopia. J Refract onto the periorbital region of both Researchers found a mean regres- Surg. 2009;25:312–8. eyes in addition to manual stimulation 3. Sekundo W, Bönike K, Mattausch P, et al. Six-year with a hand-piece conductor.1 Results sion of −0.48D over fi ve years, follow-up of laser in situ keratomileusis for moderate showed the Ocular Surface Disease Index and extreme myopia using a fi rst-generation excimer improved from 43.0±19.2 at baseline to which is at least as good as the data laser and microkeratome. J Cataract Refract Surg. 25.3±22.1 at the completion of treatment.1 of other procedures, they noted— 2003;29:1152–8. 4. Ivarsen A, Asp S, Hjortdal J. Safety and complica- These improvements were maintained at the mean regression for LASIK is six- and 12-month follow-up evaluations. tions of more than 1500 small-incision lenticule ex- 0.63D to 0.97D after six to seven traction procedures. Ophthalmology. 2014;121:822–8. As the study suggests it improves dry eye 5. Blum M, Kunert KS, Gille A, et al. LASIK for myopia without adverse eff ects, transcutaneous years.2,3 They conclude SMILE is an using the Zeiss VisuMax femtosecond Laser and MEL electrical stimulation shows potential to effective, stable and safe procedure 80 Excimer Laser. J Refract Surg. 2009;25:350–6. widen the scope of treatment options for 6. Zeiss. Zeiss receives US FDA Approval for dry eye. for myopia and myopic astigmatism VisuMax SMILE vision correction procedure, the 1 latest advancement in laser eye surgery. Press 1. Pedrotti E, Bosello F, Fasolo A, et al. Transcu- treatment. They also note that la- Release. September 14, 2016. Available at www.zeiss. taneous periorbital electrical stimulation in the com/meditec/en_de/media-news/press-releases/ treatment of dry eye. Br J Opthalmol. September ser technology advances—the newly us-fda-approval-visumax-smile-vision-correc- 4, 2016. [Epub ahead of print]. approved procedure uses a 500kHz tion-procedure-in-laser-eye-surgery.html.
4 REVIEW OF CORNEA & CONTACT LENSES | OCTOBER 2016
0004_RCCL1016_News.indd04_RCCL1016_News.indd 4 99/29/16/29/16 6:206:20 PMPM RCCL REVIEW OF CORNEA & CONTACT LENSES
11 Campus Blvd., Suite 100 Newtown Square, PA 19073 Telephone (610) 492-1000 Fax (610) 492-1049 Editorial inquiries: (610) 492-1006 Advertising inquiries: (610) 492-1011 Microbiota Protects Against Email: [email protected]
EDITORIAL STAFF P. aeruginosa Infections
EDITOR-IN-CHIEF Photo: Christine Sindt, OD Jack Persico [email protected] cular microbiota plays ASSOCIATE EDITOR Adrienne Taron [email protected] a role in protecting CLINICAL EDITOR against Pseudomonas Joseph P. Shovlin, OD, [email protected] aeruginosa ASSOCIATE CLINICAL EDITOR O –induced Christine W. Sindt, OD, [email protected] infections, a recent study suggests. EXECUTIVE EDITOR Arthur B. Epstein, OD, [email protected] The reasons for the common CONSULTING EDITOR association between contact lens Milton M. Hom, OD, [email protected] GRAPHIC DESIGNER wear and P. aeruginosa–induced Ashley Schmouder [email protected] keratitis have been unclear. While Pseudomonas ulcers could be more AD PRODUCTION MANAGER likely in patients with compromised Scott Tobin [email protected] the existence of ocular microbiota ocular microbiota, a new study says. is not news, there has been a dearth BUSINESS STAFF PUBLISHER of functional analyses to probe the They posit that these events James Henne [email protected] signifi cance of its role in ocular may result from coagulase neg- REGIONAL SALES MANAGER Michele Barrett [email protected] immunity. ative Staphylococcus, a frequent REGIONAL SALES MANAGER CL wearers, according to recent gram-positive commensal. Further, Michael Hoster [email protected] VICE PRESIDENT, OPERATIONS genomics-based approaches, the authors note that, in addition Casey Foster [email protected] harbor altered ocular commen- to the impact of ocular microbiota, EXECUTIVE STAFF sal communities compared with gut microbiota may play a signif- CEO, INFORMATION SERVICES GROUP non-lens wearers. This has given icant role in regulating the pool Marc Ferrara [email protected] SENIOR VICE PRESIDENT, OPERATIONS rise to important questions regard- of mature neutrophils and their Jeff Levitz [email protected] ing the nature of contamination activation state. In fact, protective SENIOR VICE PRESIDENT, HUMAN RESOURCES and the frequency of keratitis. immunity was found to be depen- Tammy Garcia [email protected] More specifi cally, is this increased dent on both eye and gut microbio- VICE PRESIDENT, CREATIVE SERVICES & PRODUCTION frequency of contaminated lens-in- ta, “with the eye microbiota having Monica Tettamanzi [email protected] VICE PRESIDENT, CIRCULATION duced keratitis a result of species a moderate, but signifi cant impact Emelda Barea [email protected] deriving from the skin, or does on the resistance to infection,” the CORPORATE PRODUCTION MANAGER John Caggiano [email protected] ocular microbiota exert immune study says. This work is the fi rst to functions that are required for oc- demonstrate microbiota as a regu- EDITORIAL REVIEW BOARD ular health? Researchers found the latory agent regarding susceptibility Mark B. Abelson, MD James V. Aquavella, MD presence of microbiota in healthy to P. aeruginosa-induced keratitis. Edward S. Bennett, OD Aaron Bronner, OD subjects served to strengthen the This previously unappreciated role Brian Chou, OD ocular immune barrier, resulting of microbiota will hopefully help Kenneth Daniels, OD S. Barry Eiden, OD from microbiota’s role in increasing push forward more research to Desmond Fonn, Dip Optom M Optom Gary Gerber, OD concentrations of immune effectors broaden the understanding of vul- Robert M. Grohe, OD in the tear fi lm. nerability and treatment regarding Susan Gromacki, OD Patricia Keech, OD Using Swiss Webster mice— infections of the ocular surface. RCCL Bruce Koffler, MD which are typically resistant to P. Pete Kollbaum, OD, PhD Kugadas A, Christiansen SH, Sankaranarayanan S, Jeffrey Charles Krohn, OD aeruginsa-induced keratitis but et al. Impact of microbiota on resistance to ocular Kenneth A. Lebow, OD pseudomonas aeruginosa-induced keratitis. PLoS Jerry Legerton , OD become susceptible alongside a lack Pathog. 12(9): e1005855. Kelly Nichols, OD of microbiota—researchers demon- Robert Ryan, OD Jack Schaeffer, OD strated that commensal bacteria at Advertiser Index Charles B. Slonim, MD the ocular surface serve to deliver Kirk Smick, OD Alcon ...... Cover 3 Mary Jo Stiegemeier, OD regulatory signals regarding the Loretta B. Szczotka, OD Bausch + Lomb ...... Page 7 Michael A. Ward, FCLSA scale of neutrophil recruitment Barry M. Weiner, OD CooperVision ...... Cover 2 Barry Weissman, OD during infection, according to a study in PLoS Pathology. Menicon ...... Cover 4
REVIEW OF CORNEA & CONTACT LENSES | OCTOBER 2016 5
004_RCCL1016_News.indd 5 9/29/16 6:20 PM My Perspective By Joseph P. Shovlin, OD
MMWR and Contact Lens Alerts Timely information on these issues is at our fi ngertips, thanks to the CDC.
ften referred to as the and Acanthamoeba concerns recurrent (often daily) offi ce visits, “voice of the CDC,” showed concurrent outbreaks in frequent administration of topi- the Morbidity and contact lens users from two differ- cal eye drops and missed work or Mortality Weekly ent non-bacterial sources using two school during the acute phase of in- OReport (MMWR) is separate multipurpose solutions. fection.4 The reports further identify the agency’s vehicle for providing Research showed the solutions had several modifi able risks, including objective and useful information insuffi cient antimicrobial effi cacy overnight wear (11.3%), over-wear and recommendations. Readership against specifi c organisms, result- beyond prescribed periods (7.0%), is primarily comprised of physicians ing in safety concerns.2,3 Although storing lenses in tap water (0.8%), and other health care providers, the attack rate was low, getting the using expired lenses or products epidemiologists and scientists.1 message out quickly was crucial due (0.7%) and swimming in contact to signifi cant morbidity rates—espe- lenses (0.9%).4 Tragically, approxi- CLs IN THE NEWS cially in cases of delayed diagnosis. mately 20% of the MDRs describe Recently, contact lens-related patients who suffered permanent adverse events—specifi cally con- LATEST DEVELOPMENTS eye damage, reduced acuity or both. tact lens-associated corneal infec- The most recent MMWR dispatch, At least 25% had a modifi able risk tion—have received much attention based on a decade of national lens that could have been prevented.4 in these reports. Two memorable wear data, includes a policy state- reports related to unexpected ment for prevention and treatment STAY UP-TO-DATE non-bacterial clusters prompted following an epidemiologic report MMWRs alert health care providers voluntary manufacturer recalls. The on contact lens-related corneal to pertinent public health issues and fi rst highlighted concerns with a infections. Researchers tracked data are often successful in minimiz- resurgence of Fusarium infections from 2005-2015, looking at trends ing ongoing risks. They are vital associated with the use of Bausch + and impacts to public health. The tools that help protect the public. Lomb’s ReNu with MoistureLoc. authors analyzed 1,075 medical Kudos to the entire CDC team The second discussed an unusu- device reports (MDRs) containing for an admirable program, which ally high geographical uptick in the terms ulcer or keratitis received also includes Contact Lens Health Acanthamoeba keratitis in patients by the FDA.4 Contact lens manu- Week each year. I encourage you using Advanced Medical Optics’ facturers were responsible for 86% to visit the CDC’s site, www.cdc. Complete Moisture Plus. of the reports, while 14% were gov/contactlenses, for more infor- Fusarium infections received submitted by eye care providers. mation on this worthy initiative. focused attention when the CDC The MDRs contain device-related Practitioners should continue to received multistate cluster reports safety information to help develop monitor and report any signifi cant in 2005-2006.2 A similar report benefi t/risk assessments. The FDA adverse event to the FDA through surfaced in 2007 when Chicago uses these reports to monitor device its Safety Information and Adverse eye care providers relayed fears performance in a post-approval Reporting program at www.fda.gov/ 4 of a resurgence of Acanthamoeba surveillance fashion. medwatch. RCCL keratitis in lens wearers using a Notably, 3.1% of cases reported 1. Centers for Disease Control and Prevention. specifi c multipurpose disinfection were associated with decorative About the Morbidity and Mortality Weekly Report 3 (MMWR) Series. Available at www.cdc.gov/mmwr/ solution. In both cases, MMWR or cosmetic contact lens use, and about.html. Accessed September 20, 2016. dispatches provided helpful lens care 1.5% involve lenses obtained from 2. Centers for Disease Control and Prevention. MMWR, Fusarium keratitis-multiple states, 2006. tips for the public to help minimize unapproved sources without a valid MMWR Morb Mortal Wkly Rep. 2006;55(14):400-1. 3. Centers for Disease Control and Prevention. risk. Further, the reports included prescription (i.e., fl ea market or Acanthamoeba keratitis multiple states, 2005–2007. management updates for clini- costume shop). Twenty-fi ve patients MMWR Morb Mortal Wkly Rep. 2007;56:532–4. 4. Centers for Disease Control and Prevention. cians suspecting possible infection. (2.3%) required hospitalization. Contact lens related corneal infections-United States, 2005-2015. MMWR Morb Mortal Wkly Rep. Commonality between the Fusarium The majority of reports refl ected 2016;65(32);817-20.
6 REVIEW OF CORNEA & CONTACT LENSES | OCTOBER 2016
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RRCCL1016_CCL1016_ BLBL Specialty.inddSpecialty.indd 1 99/27/16/27/16 11:1311:13 AMAM Pharma Science & Practice By Elyse L. Chaglasian, OD, and Tammy Than, MS, OD
Is a Sustained Medication Delivery System on the Horizon? Research reveals latanoprost-eluting contact lenses may one day replace daily eye drops.
owering a patient’s in- another three-week break. Photo: Amy Ross and Lokendra Bengani, Massachusetts Eye & Ear traocular pressure (IOP) Finally, the high-dose CL is critical for glaucoma was worn continuously management—but it’s for seven days. The study Lalso one of the most was powered to only detect challenging aspects of a patient’s large differences in IOP re- care. Topical glaucoma medica- duction between treatment tions, the go-to treatment option groups. for most practitioners, come with a IOP measurements host of potential issues, the biggest performed with a pneu- being patient noncompliance, due matonometer before, to physical diffi culty with drop ad- during and after treatment To create the sustained medication delivery ministration, fi nancial constraints revealed the sustained system, researchers added a thin latanoprost- and side effects such as burning delivery of medication was polymer fi lm within the periphery of a and hyperemia. at least as effective as the methafi lcon hydrogel, which was then lathed Alternatively, what if patients use of daily latanoprost into a contact lens. only had to put contact lenses in ophthalmic solution, and to deliver their daily glaucoma at some time points showed a eye drops on the fi fth day showed medication? Results of a study re- statistically signifi cant difference a reduction of -3.0±0.4mm Hg
cently published in Ophthalmology in reduction. For example, CLHI before drop instillation, a peak of suggest this could be the future of reduced IOP by as much as 34% -6.5±0.6mm Hg two hours later glaucoma management. on day three, compared to the 10% and then a decrease to 3.5±0.3mm Investigators from Massachusetts seen with the topical treatment. Hg four hours after that. Eye and Ear Infi rmary encapsulated On the last day the difference was a latanoprost-polymer fi lm into 32% vs. 21%. Researchers were MORE TO COME a hydrogel lens to create latano- surprised by this fi nding in par- Constant therapeutic effect, as seen prost-eluting low-dose (97g) and ticular, given that topical 0.005% with the drug-eluting contact lens- high-dose (149g) contact lenses— latanoprost ophthalmic solution is es, could have signifi cant impact on
CLLO and ClHI. They then studied considered the optimal treatment treatment for patients with glauco- the effects of these lenses in glau- option for IOP reduction. ma. This study comes with limita- comatous eyes of four cynamolgus In addition, the latanoprost-elut- tions, however, including the small monkeys (induced by argon laser ing contact lenses provided relative- sample size and minimal ocular trabeculoplasty) and compared it ly steady IOP reduction throughout safety assessment. with treatment using traditional the study—a key difference from More research is needed to 0.005% latanoprost ophthalmic topical treatment, which resulted determine the optimal continu- solution. in more variation in IOP reduction ous-release dose that would be well The low-dose CL was worn con- during diurnal measurements. For tolerated by patients and provide tinuously for seven days, followed example, CLHI lowered IOP by maximally effective, the researchers by a three-week hiatus in treat- -10.5±1.4mm HG on day three, conclude. RCCL ment as a washout period. Topical -11.1±4mm Hg on day fi ve and Ciolino JB, Ross AE, Tulsan R, et al. Latano- prost-eluting contact lenses in glaucomatous treatment was then administered -10.0±2.5mm Hg on day eight. monkeys. Ophthalmology. 2016 Oct;123(10):2085- for another fi ve days, followed by In contrast, treatment with daily 92. Epub 2016 Aug 29.
8 REVIEW OF CORNEA & CONTACT LENSES | OCTOBER 2016
008_RCCL1016_PSP.indd 8 9/29/16 11:30 AM Up to 16-20 CE Credits* 2017
REVIEW OF OPTOMETRY EDUCATIONAL MEETINGS OF CLINICAL EXCELLENCE
2017 MEETINGS
Hands-on Workshops Aspen, CO Charleston, SC † February 17-21, 2017 March 24-26, 2017 Program Chairs: Program Chair: Murray Fingeret, OD & Leo P. Semes, OD Paul Karpecki, OD
San Diego, CA Orlando, FL Philadelphia, PA April 20-23, 2017 June 8-11, 2017 November 3-5, 2017 Program Chair: Paul Karpecki, OD Program Chair: Paul Karpecki, OD Program Chair: Paul Karpecki, OD
CHECK OUR WEBSITE FOR THE LATEST INFORMATION Online: www.reviewofoptometry.com/events E-mail: [email protected] Call: 866-658-1772
Administered by †Workshops not available for “Aspen, CO” meeting. See Review website for any meeting schedule ® changes or updates. Stock Images: ©iStock.com/JobsonHealthcare Review of Optometry *Approval pending
2017_Meetings_HouseAd-R6.indd 1 9/14/16 2:35 PM Practice Progress By Mile Brujic, OD, and Jason Miller, OD, MBA
Put a Lid on CL Discomfort Know the signs, symptoms and treatment options for CLIDE and non-obvious MGD.
he biggest risk factor for Consider fl oppy eyelid syndrome. discontinuing contact The lid tarsus is often irregular, lens wear is discomfort.1,2 causing eyelids to fl ip easily. It is Certainly, an underlying associated with sleep apnea, which Tdry eye can decrease lens should be discussed with the patient, comfort. But contact lens–induced along with a number of other local dry eye, or CLIDE, gives name to the symptoms.4 Because of the loose lid individual who has no symptoms of apposition, the lids may inadvertent- dry eye without contact lenses but ly open and possibly evert, often in Fig. 2. Transillumination of the is symptomatic during contact lens the evening, causing hyperemia and palpebral conjunctiva. wear.3 Although CLIDE is not tradi- discomfort.5 Contact lens wear can tionally associated with primary dry be diffi cult for these individuals. (2) Educate patients. Making sure eye, contact lens discomfort may be Another increasingly prevalent patients understand their condi- an early symptom of a compromised condition is non-obvious meibomian tion is just as critical as identifying tear fi lm. Let’s discuss why this oc- gland dysfunction (MGD). Through potential defi ciencies. One of the curs and how to promote healthier, a standard exam the lid margin most powerful educational tools is more comfortable contact lens wear. will typically appear normal, but high-quality imaging, which pro- dysfunction can be uncovered in a vides patients a better perspective THREE STEPS FOR SUCCESS number of ways.6 The simplest test and actual visualization of their Here are a few strategies that is to provide pressure to the upper condition. Educating our patients is have worked well in our practice and lower lid margin and assess the the fi rst step to ensuring they comply to help optimize the lens wearing meibum expressed. Thickened lipids with treatment. experience: or lack of secretions indicate produc- (3) Help maintain, or regain, (1) Identify underlying risk tion abnormalities. The meibomian health. Following identifi cation and factors. Although it is relatively easy gland evaluator (TearScience) is a education, we must treat the under- to identify obvious eyelid margin specialized instrument that applies lying condition. For individuals with diseases such as anterior blepharitis, a standard force to the lid margin, fl oppy eyelid syndrome, for example, lid margin irregularities or posterior allowing an evaluation of the quality it is paramount to decrease infl am- blepharitis, other clinical entities are of meibum expressed. mation and ensure the ocular surface much less obvious. We can also perform a gross is protected in the evening. This may inspection of the glands by having include an ointment or the use of a a patient look up and then pulling Lacrisert (hydroxypropyl cellulose their lower lids down (Figure 1). ophthalmic insert, Bausch + Lomb). At the slit lamp, lid transillumi- Additionally, the patient may benefi t nation can also help us visualize the from eye shields or taping their glands. With the slit beam turned eyes shut in the evening. In severe off (a handheld transilluminator instances, patients may also require provides the only light source), have eyelid surgery to re-establish normal- the patient look up, then place the cy to the lid/globe interaction.7 transilluminator on the lower eyelid and slightly turn the lid down so that CHEMICAL VS. PHYSICAL the palpebral conjunctiva is visible While there are many approaches to (Figure 2). Higher-level diagnostic non-obvious MGD treatment, we imaging is also available to help bet- believe there are two global strate- Fig. 1. Gross observation of the ter image the structure of the glands gies: chemical and physical improve- meibomian glands on the lower lid. (Figure 3). ment of meibum production.
10 REVIEW OF CORNEA & CONTACT LENSES | OCTOBER 2016
010_RCCL1016_PP.indd 10 9/29/16 4:20 PM Image: Dave Kading, OD with a number of ways to physi- your contact lens wearers. If you cally soften and evacuate stagnant discover them, educate patients and meibum to allow healthier secre- provide your best clinical judgment tions. Traditionally, warm compress- on the appropriate treatment. Your es once or twice a day were recom- patients will thank you for taking mended. Although this can be done the appropriate steps to improve with warm, moist washcloths, there their wearing experience and provide are logistical challenges to keeping more comfortable lens wear. RCCL Fig. 3. Meibography provides greater detail on meibomian gland status the washcloths at the appropriate 1. Rueff EM, Varghese RJ, Brack TM, et al. A survey than clinical examination alone. temperature for the intended time of presbyopic contact lens wearers in a university period. Many practitioners now setting. Optom Vis Sci. 2016;93(8):848-54. 2. Nichols JJ, Jones L, Nelson JD, et al., members Chemical. Topical cyclosporine recommend commercially available of the TFOS International Workshop on Contact Lens Discomfort. The TFOS international workshop can promote healthier meibum heating pads for at-home treatment. on contact lens discomfort: introduction. Invest Ophthalmol Vis Sci. 2013;54(11):TFOS1-6. production, and research shows the The Lipifl ow (TearScience) in-of- 3. Fonn D. Targeting contact lens induced dryness newly approved Xiidra (lifi tegrast, fi ce treatment applies heat to the pal- and discomfort: what properties will make lenses more comfortable. Optom Vis Sci. 2007;84(4):279- Shire) improves symptoms of dry eye pebral conjunctiva while simultane- 85. 4. Skorin L Jr, Knutson R. Ophthalmic diseases in and may have a role in non-obvious ously applying pressure through an patients with obstructive sleep apnea. J Am Osteo- MGD treatment as well.8,9 Topical infl atable air bladder on the anterior path Assoc. 2016;116(8):522-9. 14 5.Mastrota KM. Impact of fl oppy eyelid syndrome in azithromycin is another option for surface of the eyelid. One study ocular surface and dry eye disease. Optom Vis Sci. improving meibum production.10,11 shows a single treatment improved 2008;85(9):814-6. 6. Blackie CA, Korb DR, Knop E, et al. Nonobvious Essential fatty acids (omega-3s both signs and symptoms in individ- obstructive meibomian gland dysfunction. Cornea. 15 2010;29(12):1333-45. and omega-6s) have also been shown uals with MGD over 12 months. 7. Pham TT, Perry JD. Floppy eyelid syndrome. Curr to improve meibum secretion.12,13 MiBoFlo Thermofl o (Mibo Medical) Opin Ophthalmol. 2007;18(5):430-3. 8. Prabhasawat P, Tesavibul N, Mahawong W. Additionally, oral doxycycline and and the MGD 3000 (Ophthalmic A randomized double-masked study of 0.05% cyclosporine ophthalmic emulsion in the treat- oral azithromycin have proven effec- Concepts) also heat the eyelid while ment of meibomian gland dysfunction. Cornea. tive in improving meibum produc- gently massaging the lids.16,17 2012;31(12):1386-93. 9. Holland EJ, Whitley WO, Sall K, et al. Lifi tegrast tion; although typically used with clinical effi cacy for treatment of signs and symp- toms of dry eye disease across three randomized obvious forms of MGD, they may SEEING THE UNSEEN controlled trials. Curr Med Res Opin. 2016 Jul 22:1-7. have a role here as well.13 We challenge you to look for [Epub ahead of print]. 10. Foulks GN, Borchman D, Yappert M, et al. Physical. Clinicians have come up non-obvious clinical conditions in Topical azithromycin therapy for meibomian gland dysfunction: clinical response and lipid alterations. Cornea. 2010;29(7):781-8. Look for Signs Early 11. Liu Y, Kam WR, Ding J, Sullivan DA. One man’s poison is another man’s meat: using azithromy- cin-induced phospholipidosis to promote ocular The signs we use to diagnose dry eye are often late changes in the surface health. Toxicology. 2014 Jun 5;320:1-5. 12. Liu Y, Kam WR, Sullivan DA. Infl uence of omega disease state. Corneal staining, for instance, signifi es an ocular surface 3 and 6 fatty acids on human meibomian gland not adequately protected by the tear fi lm. If these are the signs that epithelial cells. Cornea. 2016;35(8):1122-6. 13. Qiao J, Yan X. Emerging treatment options for prompt initial treatment, we may be waiting too long before starting. meibomian gland dysfunction. Clin Ophthalmol. For comparison, we would never wait to treat glaucoma patients 2013;7:1797-803. 14. Zhao Y, Veerappan A, Yeo S, et al. Clinical trial until they become symptomatic. Glaucomatous damage is considered of thermal pulsation (Lipifl ow) in meibomian gland permanent, irreversible vision loss, so we seem to take it more dysfunction with preteatment meibography. Eye Contact Lens. 2016 Jan 27. [Epub ahead of print]. seriously than dry eye, which improves wth treatment. However, this 15. Blackie CA, Coleman CA, Holland EJ. The sus- isn’t necessarily the right perspective. We now know there are early tained eff ect (12 months) of a single-dose vectored thermal pulsation procedure for meibomian gland signs of damage or decreased functionality within the eyelid well dysfunction and evaporative dry eye. Clin Ophthal- before we see the consequences manifest on the ocular surface. mol. 2016 Jul 26;10:1385-96. 16. Mibo Medical Group. MiBoFlo ThermoFlo It is critical to become hyper-observant of the lid to ensure Management of Dry Eye. Available at http://mibo- appropriate care and maintenance of the lid margin, ultimately medicalgroup.com. 17. Ophthalmic Concepts. MGD 3000. Available at providing a higher quality tear fi lm to help support lens wear. www.ophthalmicconcepts.com.
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010_RCCL1016_PP.indd 11 9/29/16 4:20 PM BEAT the
To understand and treat this common lid condition, make sure you’re clear on its many diff erent presentations.
By Abby Gillogly Harsch, OD, Nicole Stout, OD, and Nathan Lighthizer, OD
e as optome- medical conditions. His vision was choosing the appropriate treatment trists hear com- 20/25 OD and 20/20 OS, while slit regimen. plaints of dry, lamp examination revealed trace The three major forms of anteri- itchy eyes on a superfi cial punctate keratitis (SPK) or blepharitis are staphylococcal, Wweekly basis, in the inferior half of the cornea seborrheic, and Demodex blepha- at least. Depending on the physical OU, along with grade II conjunc- ritis, also known as ocular demodi- signs and symptoms that present tival injection OU. Osmolarity test cosis. Anterior blepharitis typically with these reports, we can head (TearLab) fi ndings were 312mOs- presents with symptoms of bilateral down any of a dozen diagnostic m/L OD and 318mOsm/L OS. itchy, matted and/or crusty lid mar- roads—creating a potential man- Lid evaluation revealed signs of gins and ocular discomfort, often agement dilemma if we only focus blepharitis as the likely cause of worse in the morning. Symptoms on the dry eye signs and symptoms the patient’s issue (Figures 1-4). do not always correlate well with and fail to identify lid involvement The diagnosis may, however, be signs, so patients may occasionally as the true culprit. Blepharitis more complicated than that. Let’s present with asymptomatic disease. frequently compromises the ocular delve into the details of lid margin A careful anterior segment exam surface by creating an unstable tear disease before revisiting this case. can help identify the type of bleph- fi lm prone to evaporation. This aritis present. can be especially troublesome in DIFFERENTIATING Staphylococcal (or bacterial) our contact lens wearers, and may THE CONDITION blepharitis is commonly seen encourage them to drop out of lens If a patient presents with generic in clinical practice. Distinctive wear if they mistakenly blame the complaints of ocular discomfort features include collarettes at the lens itself for a problem that is in and dryness, many ECPs may be fact much more complex. tempted to skip straight to diag- ABOUT THE AUTHORS Fortunately, most eye care practi- nosis and management of ocular Dr. Harsch completed a tioners (ECPs) have the diagnostic surface disease. Though initiating cornea and contact lens skills to uncover the underlying treatment can improve patient residency at NSU Oklahoma College of Optometry. She cause of these complaints. Take the symptomology initially, failing is currently in practice at following case, for example: to address any underlying eyelid Nittany Eye Associates in A 47-year-old male presented to pathology that may also exist can State College, PA. the clinic with a primary complaint exacerbate the problem long- Dr. Stout recently completed a family practice residency that his eyes have been itchy over term. Blepharitis—infl ammation with an emphasis in ocular the past few weeks to months. He of the lash follicle, lid margins disease at NSU Oklahoma College of Optometry. She revealed upon further questioning or meibomian glands—can lead is currently working as a that he also had a secondary com- to a build-up of bacterial debris, clinical supervisor at the University of Waterloo School plaint of dry eyes for many years, keratinization of gland orifi ces and of Optometry and Vision Science.
for which he had been using an off- alterations of the normal tear com- Dr. Lighthizer is the assistant brand nighttime gel. The patient position. In contact lens wearers, dean for clinical care services, director of continuing reported occasional but minimal this may result in lens discomfort, education and chief of both success with the gel, was not decreased wear time and lens wear the specialty care clinic and the electrodiagnostics taking any medications that may dropout. Identifying the type of clinic at Northeastern State have been contributory to the case blepharitis present in a patient’s University (NSU) Oklahoma College of Optometry. and did not report any signifi cant ocular environment is crucial for
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012_RCCL1016_Bleph_F1.indd 12 9/29/16 4:17 PM base of the lashes; those present at the tip of the lash indicate a more chronic condition, as it can take eyelashes about 16 weeks to grow to their typical length. Thickened, telangiectatic lid margins and conjunctival and corneal irritation or infection are also commonly Fig. 1. Exam fi ndings of the right Fig. 2. A closer look at the right encountered in cases of bacterial upper lid. What form of blepharitis upper eyelashes reveals a clear blepharitis. Chronic cases can also does this patient likely have? sleeve of debris on multiple lashes. lead to notched, irregular lid mar- gins that exacerbate the patient’s symptoms of dryness. Staph. blepharitis is often caused by the normal fl ora present on the eyelid, which is most commonly either Staphylococcus epidermidis or Staphylococcus aureus. In these cases, the clinical signs are con- Fig. 3. Lid examination fi ndings of Fig. 4. Further examination of the sidered a result of cell-mediated the left upper lid. lids reveals what condition? responses to endotoxins that are fi nding that is pathognomonic for margin hyperemia, telangiectat- produced in response to an over- a Demodex infestation (Figures 5 ic vessels along the lid margins, growth of the bacteria.1 and 6).2 notching of the lid margins and Cases of seborrheic blepharitis Chronic Demodex infestations inspissated meibomian gland ori- tend to occur in an older popula- can result in trichiasis and madaro- fi ces. Signs of posterior blepharitis tion and clinically appear as a mix sis, the latter of which is more are also evident in the tear fi lm, of dandruff and oily debris with commonly a result of Demodex including the saponifi cation of tear slightly hyperemic upper lids. The than staphylococcal blepharitis.1,3 fi lm and also an oily appearance. term “scurf” has been applied to The mites can physically block the Meibomian gland dysfunction the scaly debris, with similar debris sebaceous ducts and cause hyper- (MGD) is the most common cause often seen throughout the patient’s keratinization of the lid margins. of posterior blepharitis. If fi rm, eyebrows. More dermatologic in Defi nitive diagnosis of a Demodex mild pressure is applied directly to nature than Staph. blepharitis, this infestation can be obtained by the lid margins, healthy meibomian type is less frequently associated epilating a few lashes and ex- gland secretions appear clear and with infections or other corneal amining them for mites under a oily, while more turbid secretions fi ndings.1 microscope. Demodex blepharitis with opaque to yellow coloration Demodex overpopulation of is considered by some clinicians are abnormal. Presence of acne the lids may also cause blepha- to be underdiagnosed; one study rosacea may also lead to chronic ritis. Two species of Demodex reports that 100% of patients posterior blepharitis, known as mites have been identifi ed on the over 70 years of age have some ocular rosacea.5 In some cases, lids: Demodex folliculorum and amount of infestation.4 Demodex clogged meibomian glands from Demodex brevis. The former, D. mites may also carry bacteria such posterior blepharitis can form a folliculorum, is primarily found as Staphylococcus sp., which can sterile, granulomatous chalazion, in the eyelash follicles and around exacerbate the bacterial load on which presents as a painless, pal- the base of the eyelashes and can the lids and lashes. Several studies pable lump in the eyelid. Chalazia cause chronic anterior blepharitis, have also found a higher density may resolve with warm compress- while D. brevis can be found in the of Demodex in patients with acne es, systemic tetracycline antibiotics sebaceous and meibomian glands rosacea.1,2 or both; many cases, however, and can cause posterior blepharitis. Posterior blepharitis is character- require steroid injection or surgical Demodex mites create waste that ized by infl ammation and obstruc- excision. accumulates as cylindrical dandruff tion of the meibomian glands. There are numerous other around the base of the eyelashes, a Signs and symptoms include lid anterior segment fi ndings that can
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012_RCCL1016_Bleph_F1.indd 13 9/29/16 4:17 PM BEAT THE BLEPHARITIS BLUES
result from blepharitis, such as SPK HypoChlor (OcuSoft), are increas- (particularly in the areas where the ingly popular for blepharitis treat- lid margins contact the cornea) and ment. In vivo, hypochlorous acid is bulbar conjunctival hyperemia. produced by neutrophils as part of A reduced tear break-up time can the body’s natural defense system be a sign of posterior blepharitis against infection. Hypochlorous resulting from MGD. Marginal acid is microbicidal, which is why corneal infi ltrates and phlyctenules lid hygiene products containing Fig. 5. Demodex organism under low can occur in response to Staph. hypochlorous acid are an excellent magnifi cation. hypersensitivity in patients with option to decrease the microbial Staph. blepharitis. Corneal pannus load on the eyelids and lashes. and corneal neovascularization are Furthermore, products containing signs of chronic blepharitis and hypochlorous acid are generally may be indicative of ocular rosa- non-antibiotic antimicrobials and cea. In cases of untreated chronic do not contribute to the ever-grow- blepharitis, irreversible corneal ing issue of antibiotic resistance.7,8 scarring and subsequent vision loss Acute fl are-ups of staphylococcal can result. blepharitis are treated using anti- Fig. 6. Highly magnifi ed picture of biotic ointments, such as erythro- the Demodex organism. TREATMENT mycin or bacitracin, massaged onto These conditions may coexist in the lid margins. The short-term lashes of both debris and collarettes many patients. Mainstay therapies use of a topical antibiotic-steroid and removes any bacterial biofi lm for long-term blepharitis include combination can also be considered from the lid margins. lid hygiene efforts and heat therapy in moderate-to-severe cases that Posterior blepharitis necessi- with warm compresses, followed present with concurrent corneal tates the use of warm compresses by eyelid massage. Warm compress and conjunctival infl ammation. followed by manual expression masks are convenient to use and Seborrheic blepharitis is typically or massage, though many more hold heat longer than a warm, treated with dermatologic forma- adjunct treatment options have wet washcloth. This is important tion triamcinolone 0.1% cream come into play in recent years. because it is recommended that the or, in the case of patients who Topical azithromycin 1% has warm compresses remain heated to may have diffi culties with keeping proven effective in the treatment of 45°C and be applied for a mini- the ointment out of their eyes, signs and symptoms of MGD; its mum of four minutes for optimal Lotemax (loteprednol, Bausch + cost, however, has limited its use in treatment.6 While baby shampoos Lomb) gel or ointment. some practices.10 Oral tetracyclines can be recommended for lid scrub- Demodex blepharitis can be are benefi cial for their anti-infl am- bing, certain branded lid scrubs are treated using in-offi ce 50% tea tree matory properties, including the capable of targeting specifi c types oil applied to the lashes and eye- reduction of MMP-9.11 Studies of blepharitis as well. Regardless brows. Tea tree oil lid wipes such also show low-dose doxycycline of the type of scrub recommenda- as Cliradex (Bio-Tissue) that are (sub-antimicrobial dose) improves tion, however, educate the patient indicated for home use can also be the symptoms of MGD in affected that a gentle wipe across the lid recommended. Cliradex contains patients with a lower incidence of margin is ideal, as more vigorous terpinen-4-ol, the most active ingre- side effects, resulting in better pa- scrubbing can cause lid irritation dient of tea tree oil.4,9 In addition tient compliance.12 Pregnancy and and increase infl ammation. Patient to tea tree oil treatment, patients childhood are contraindications for education should also speak to the should be directed to discard any even the non-antimicrobial doses chronic nature of the condition and current eye makeup and launder all of tetracyclines. Oral azithromycin emphasize the need for long-term bedding on a high heat setting to also shows promise for improving maintenance of good eyelid and avoid reinfection. In-offi ce treat- signs and symptoms of MGD, lash care. ments such as BlephEx (RySurg) though further studies are neces- Lid and lash hygiene products may be a benefi cial adjunct pro- sary to better determine its ideal that contain hypochlorous acid, cedure in the management of all dosage for success.13 such as Avenova (NovaBay) and types of blepharitis. It cleans the The role of omega-3 and
14 REVIEW OF CORNEA & CONTACT LENSES | OCTOBER 2016
012_RCCL1016_Bleph_F1.indd 14 9/29/16 4:17 PM omega-6 essential fatty acids in tients present with ocular surface managing posterior blepharitis irritation, dry eyes and decreased is ever-evolving. Well known for contact lens wearing time. With their anti-infl ammatory properties, a better understanding of these omega-3 fatty acids must exist in different forms of blepharitis and an adequate ratio, together with their appropriate treatments, eye pro-infl ammatory omega-6 fatty care practitioners can improve acids. Omega-3 fatty acid supple- their patients’ quality of life and, Fig. 7. Demodex blepharitis: mentation with fi sh oil containing Improvement but not complete consequently, their ocular disease EPA and DHA is commonly rec- resolution at follow up. practice. RCCL ommended for patients with MGD. 1. Gadaria-Rathod N, Fernandez K, Asbell P. Research suggests gamma-linolenic Blepharitis. In: Yanoff M, Duker JS, ed. Ophthal- acid (GLA), an omega-6 fatty acid, mology, 4th edition. Philadelphia: Elsevier Health Sciences; 2014:177-9. is effective in the management of 2. Cheng AMS, Sheha H, Tseng SCG. Recent ad- blepharitis. One study found that vances on ocular Demodex infestation. Curr Opin Ophthalmol. 2015;26(4):295-300. dietary supplementation with fi sh 3. Jingbo L, Hosam S, Tseng SC. Pathogenic role oil and black currant seed oil (a of Demodex mites in blepharitis. Curr Opin Aller- gy Clin Immunol. 2010;10(5):505-10. known source of GLA) signifi - 4. Kemai M, Sümer Z, Toker MI, et al. The prev- cantly improved both the signs Fig. 8. Improvement and near alence of Demodex folliculorum in blepharitis resolution at the fi nal follow up. Total patients and the normal population. Ophthal and symptoms of ocular surface Epidem. 2005;12(4):287-90. resolution can be diffi cult to achieve infl ammation and irritation.14 5. Nijm LM. Blepharitis. In: Holland EJ, Mannis and will require long-term chronic MJ, Lee WB. Ocular Surface Disease: Cornea, HydroEye (ScienceBased Health) is management. Without this, future Conjunctiva and Tear Film. Philadelphia: Elsevier; one example of a supplement that fl are-ups are much more likely. 2013:55-60. 6. Blackie CA, Solomon JD, Greiner JV, et al. contains both fi sh oil and black posterior blepharitis due to MGD. Inner eyelid surface temperature as a function 14-16 of warm compress methodology. Optom Vis Sci. currant oil. Careful epilation of several lashes 2008;85:675-83. In-offi ce warm compress appli- and examination of their follicles 7. Ono T, Yamashita K, Murayama T, Sato T. Micro- bicidal eff ect of weak acid hypochlorous solution cation followed by manual gland under the microscope revealed on various microorganisms. Biocontrol Science. expression behind the slit lamp can such. The patient was treated 2012;17(3):129-33. 8. Debabov D, Noorbakhsh C, Wang L, et al. be performed using a Mastrota with Cliradex pads twice daily for Avenova with Neutrox (pure 0.01% HOCl) com- paddle (OcuSoft) or similar instru- two weeks, then once daily for an pared with OTC produce (0.02% HOCl). NovaBay Pharmaceuticals:1-5. ment. MiBoFlo Thermofl o (MiBo additional two weeks. The patient 9. Tighe S, Gao YY, Tseng SC. Terpinen-4-ol is the Medical Group) and LipiFlow was also instructed to use OcuSoft most active ingredient of tea tree oil to kill mites. Transl Vis Sci Technol. 2013 Nov;2(7):2. (TearScience) are devices that use Lid Scrub Plus Foam once daily in 10. Optiz DL, Tyler KF. Effi cacy of azithromycin thermal energy to soften gland the shower to cleanse his eyelids 1% ophthalmic solution for treatment of ocular surface disease from posterior blepharitis. Clin contents for removal. MiBoFlo and lashes indefi nitely. Warm Exp Optom. 2011;94:200-6. is applied to the outside of the compresses with a lipid-based 11. Duncan K, Jeng BH. Medical manage- ment of blepharitis. Curr Opin Ophthalmol. lid, together with slight pressure artifi cial tear were also prescribed 2015;26(4):289–94. applied by the eye care practitioner, QID, and HydroEye fi sh oil soft 12. Yoo SE, Lee DC, Chang MH. The eff ect of low-dose doxycycline therapy in chronic meibo- to encourage expression of the gels were recommended for long- mian gland dysfunction. Korean J Ophthalmol. meibum, while the LipiFlow system term supplementation to assist with 2005;19:258-63. 13. Kashkouli MB, Fazel AJ, Kiavash V, et al. Oral applies heat from the palpebral side alleviating further MGD. Multiple azithromycin versus doxycycline in meibomian gland dysfunction: a randomized double-masked of the eyelids during application follow-up visits over the next open-label clinical trial. Br J Ophthalmol. of pulsatile pressure on the outer three months demonstrated slow 2015;99:199-204. 14. Sheppard JD Jr, Singh R, McClellan AJ, et al. surface of the lids to promote gland but continual improvement of the Long-term supplementation with n-6 and n-3 PU- expression.17 condition, with near resolution at FAs improves moderate-to-severe keratoconjunc- tivitis sicca: a randomized double-blind clinical the three-month follow-up appoint- trial. Cornea. 2013;32(10):1297-304. REVISITING THE CASE ment (Figures 7 and 8). 15. Horn M, Asbell P, Barry B. Omegas and dry eye: more knowledge, more questions. Optom & Vis Ultimately, the patient described at Sci. 2015;92(9):948-56. the outset was diagnosed as having o ensure treatment success, 16. Pinna A, Piccinini P, Carta F. Eff ect of oral linoleic and ϒ-linolenic acid on meibomian gland multiple forms of blepharitis, with Tclinicians must focus on the dysfunction. Cornea. 2007:26(3):260-4. Demodex predominating along different forms of anterior and 17. Lane SS, Dubiner HB, Epstein RJ, et al. A new system, the LipiFlow, for the treatment of meibo- with a secondary component of posterior blepharitis when pa- mian gland dysfunction. Cornea. 2012;31:396–404.
REVIEW OF CORNEA & CONTACT LENSES | OCTOBER 2016 15
012_RCCL1016_Bleph_F1.indd 15 9/29/16 4:17 PM By Arthur B. Epstein, OD The ChickenChicken--and-and-EggEgg ProProblemblem of MGD and Contact Lens Wear Which came fi rst, the dysfunction or the discomfort? Researchers aren’t sure, but clinicians need to manage them simultaneously.
ur understanding of confused regarding the cause of The interface between this outer, the ocular surface dry eye, which is now increasingly nonpolar lipid layer and the rest has increased dra- recognized as more of a misnomer of the tears occurs through the matically over the than a descriptive diagnosis. interfacial action of phospholipids, Opast few years, and Refl ex tears serve the critical which bond polar and nonpolar much of the research has highlight- purpose of fl ushing irritants and components, effectively anchoring ed the role the eyelids and meibo- foreign bodies from the ocular the outer lipid layer to the mostly mian glands play in supporting a surface before they cause signifi cant aqueous sub-layer below. stable tear layer. At the same time, damage to the corneal surface. This renewed interest in the causative reduces the potential for abrasion MGD factors for contact lens discomfort and infection with subsequent loss Dry eye has historically been and dropout have fueled innovation of vision and function. In contrast, viewed as the result of an aqueous in contact lens material formula- basal tears arising from the accesso- tear defi ciency.2 Normal meibomian tion, tear chemistry and environ- ry glands of Krause and Wolfring, gland function has increasingly mental factors impacting lens wear. with possible contribution from been recognized as an essential Disagreement abounds regarding the lacrimal glands, are structural element in the maintenance of the role meibomian gland dysfunc- in nature—an often overlooked ocular surface health and function. tion (MGD) and function play in property. The tear foundation Contemporary literature confi rms contact lens wear. Contact lenses’ transforms the naturally hydro- that MGD is a primary or major impact on the meibomian glands phobic surface into a hydrophilic contributory factor in nearly 90% also remains the subject of ongo- entity, allowing the tears to remain of patients complaining of dry ing debate. This article reviews in place, defying gravity and other eye—which is borne out in clinical the literature and explores current extrinsic and intrinsic forces. The practice.3 More recently, research- thinking regarding contact lenses majority of tears consist of a visco- ers questioned whether dry is more and meibomian gland function, elastic gel made up of mucins and frequently an erroneous description while examining the broader issues other components. This structural of a disorder driven by abnormal of tear fi lm/contact lens interaction. layer offers protection and smooth- meibomian gland function.4 ing, and likely changes its behavior MGD is defi ned as “a chronic, UNDERSTANDING THE TEARS during different phases of the blink. diffuse abnormality of the meibo- While tears serve numerous The outer layer is derived from mian glands, commonly character- well-recognized purposes, their pri- the meibomian glands, which ized by terminal duct obstruction mary functions are refractive and express a complex lipid with each and/or qualitative/quantitative protective. This sometimes causes blink; however, the function and changes in the glandular secretion. confusion among patients who clinical importance of meibum is not This may result in alteration of the assume tears exist only to keep the broadly understood. Hydrophobic ABOUT THE AUTHOR eyes wet and believe their absence bonding causes lipid to attract lipid. leads to dry eye and discomfort. When suffi cient lipid is present to This can be especially confusing for cover the interpalpebral globe, a co- Dr. Epstein is co-founder of Phoenix Eye Care, where he contact lens wearers who mistake herent layer stretches over the outer heads the Ocular Surface Disease Center and serves contact lens-related discomfort surface of the eye. The tear lipid as the Center’s director of for ocular dryness.1 Similarly, eye layer provides signifi cant structure clinical research. care practitioners are also often to the tear fi lm.
16 REVIEW OF CORNEA & CONTACT LENSES | OCTOBER 2016
016_RCCL1016_ChickvsEgg_F2.indd 16 9/29/16 11:29 AM functional meibomian glands in contact lens wearers worsens with duration of contact lens wear.12 The association of contact lens wear with MGD still remains somewhat controversial—perhaps because of the complexity and multifactorial nature of MGD and contact lens interaction with the ocular environment. While several MGD with telangiectatic vessels and Frothing due to saponifi cation. inspissated meibomian glands. studies failed to demonstrate a link between MGD and contact lens tear fi lm, symptoms of eye irrita- Researchers postulate alterations wear, a recent report offers compel- tion, clinically apparent infl amma- in normal blink patterns and shifts ling evidence for the role contact tion and ocular surface disease.”5 in dietary intake of essential fatty lenses play in predisposing patients While the exact causes of MGD acids are causal factors in MGD.6,7 to meibomian gland and related lid remain unclear and are likely Blink frequency and rate of blink abnormalities.13-16 multifactorial, healthy meibomian completion is reduced during tasks Contact lenses can lead to MGD gland function is better understood. requiring concentration, reading in a variety of ways. Blink rates and Driven by the force of the blink, text and especially during computer meibomian gland function may be normal gland expression produces use.8-10 Likewise, shifts in dietary affected by lens wear, intense visual a clear, free fl owing, complex oil. intake over recent decades have tasks and concentration. With Exiting through orifi ces on the lid resulted in an imbalance in ome- rigid lenses, blinking may decrease, margin, meibum intermixes with ga-3 vs. omega-6 free fatty acids. resulting in lower amounts of the tears, resulting in an effective Reduced levels of omega-3 fatty ac- meibomian gland secretions. In evaporative barrier, decreased ids have been implicated as factors soft lens wearers, studies associate surface tension and friction and in the pathophysiology of MGD. decreased tear stability and adverse increased tear stability. environmental conditions with There are a greater number CONTACT LENS WEAR increased blinking, which may be and length of glands in the upper Researchers fi rst described the an adaptive mechanism resulting eyelid, likely producing additional association of MGD with contact in increased meibomian gland lipid meibum compared with the lower lens intolerance in 1980.11 They production.17,18 lid. The glands are buried deep reported obstructive meibomian Meibomian gland loss is strong- within the lids and protected by the gland disease due to blockage of ly correlated with decreased lipid tarsal plate, subcutaneous fat and the glands by desquamated epithe- layer thickness and tear instabili- overlaid by a robust vascular net. lial cells as the cause of dryness and ty.19 Although meibomian glands Meibum production occurs in the discomfort in intolerant contact are mechanically compressed and acini, the grape-like clusters present lens wearers. Other studies report meibum expressed as a function of along the length of the glands that a decrease in the number of the blink, higher-order control is and remains relatively constant. However, the amount of meibum delivered by each gland varies over time and tends to decrease with age. Structural changes with MGD include atrophy, truncation, gland loss (which can be complete, sectoral or segmental) and convo- lution. Dilation of the distal duct, sometimes referred to as tooth sign, refl ects obstruction and is likely caused by back-pressure. Tear fi lm scans provide non-invasive assessment of tear fi lm break-up time.
REVIEW OF CORNEA & CONTACT LENSES | OCTOBER 2016 17
016_RCCL1016_ChickvsEgg_F2.indd 17 9/29/16 11:29 AM THE CHICKEN-AND-EGG PROBLEM OF MGD AND CONTACT LENS WEAR
likely active in regulating tear lipid contact lens materials can exacer- tact lens wearers who have MGD and aqueous levels. Decreased tear bate the situation. Silicone hydrogel should be treated before initiating lipid levels result in tear instability materials, especially early gener- contact lens wear to help ensure and is likely to reactively prompt ation lenses, are known for their success. Before attributing patient increased compensatory meibum propensity to bind lipids onto their complaints to problems with their and tear secretion in healthy surfaces.22 Further, some modern contact lenses or solutions, a thor- patients.20,21 contact lens materials are report- ough workup is indicated, includ- Typical contact lenses are signifi - edly formulated to integrate lipids ing assessment of meibomian gland cantly thicker than the normal tear within their structure. While this function and structural integrity. fi lm. This disparity causes the tears may improve surface compatibility, An experienced clinician can to essentially stretch to accommo- it can also result in compensatory evaluate meibomian gland function date the relatively massive thickness up-regulation of lipid production with diagnostic expression using of the contact lens, resulting in and an eventual adverse impact on either fi ngertip pressure applied to thinning of the pre- and post-lens meibomian glands. the lids or the Korb Meibomian tear fi lm and destabilization of Gland Evaluator (TearScience). the tear structure. This can lead DIAGNOSIS AND Interferometry can assess meibo- to a cycle of increasing tear insta- MANAGEMENT mian gland lipid production as well bility and compensatory meibum Regardless of whether contact lens as track changes during treatment. overproduction, eventually taxing wear causes MGD or MGD causes Because of the sensitivity of inter- gland capability—especially in the contact lens discomfort and intoler- ferometry, clinicians must be care- presence of MGD or frank gland ance, comorbidity between the two ful when removing contact lenses loss. It is possible, if not likely, that is highly likely, if not certain. Since before testing to avoid interference chronically overproducing meibo- the overwhelming majority of dry with lipid layer thickness readings. mian glands can burn out, lead- eye is directly caused by or closely Although transillumination of the ing to damage and overall gland associated with MGD, contact lens lid margin can be helpful in evalu- down-regulation and loss. wearers experiencing dryness and ating gland structure, meibography Uptake and sequestration of discomfort should always be evalu- is superior at documenting MGD- lipids by hydrophobic moieties in ated for MGD. Prospective con- related gland loss and structural
1. Hold your fi ngers at the corners of your eyes and BLINK EXERCISES blink. If you feel anything, you are using your defense muscles that run along the side of your head. Your Blinking Sequence: blinking muscles are above your eyelids. 2. Read the blinking sequence. It is very important to do the pause step to make complete contact between the CLOSE - PAUSE - PAUSE - OPEN upper and lower lids (partial blinking is very common in RELAX people with dry eyes). When you are doing it correctly, you should feel no movement under your fi ngers. CLOSE - PAUSE - PAUSE - SQUEEZE - OPEN - RELAX 3. Blinking is very task-dependent. For example, if you spend a lot of time on the computer, you are probably CLOSE OPEN blinking much less frequently and might want to post a copy of the blinking exercises nearby as a friendly
PAUSE - PAUSE reminder. (Other pastimes that decrease blink rate are driving, reading, watching TV, working at your desk, or any concentrated visual task, etc.) 4. Lastly, if you having diffi culty consciously incorporating the blinking exercise into your schedule (i.e. 5X/hour) CLOSE SQUEEZE OPEN - RELAX you might want to think about something you do often in your daily routine, such as answering phone calls, PAUSE - PAUSE sending emails, drinking sips of water, getting dressed, etc. If you can condition yourself to make a full blink and give a little squeeze every time you perform this action it helps to make complete blinking a habit.
TearScience’s Donald Korb Blink Training app off ers directions to help patients with MGD learn proper blink technique to mitigate symptoms.
18 REVIEW OF CORNEA & CONTACT LENSES | OCTOBER 2016
016_RCCL1016_ChickvsEgg_F2.indd 18 9/29/16 11:29 AM refractive index shifts after wear. Clin Ophthalmol. supplements have also proven help- 2015;9:1973-9. ful in managing MGD.26 A recently 8. Argilés M, Cardona G, Pérez-Cabré E, Rodríguez M. Blink rate and incomplete blinks in six diff erent published study investigating the controlled hard-copy and electronic reading condi- tions. Invest Ophthalmol Vis Sci. 2015;56(11):6679- role of oral re-esterifi ed omega-3 85. nutritional supplementation on dry 9. Chu CA, Rosenfi eld M, Portello JK. Blink pat- terns: reading from a computer screen versus hard eyes showed signifi cant treatment copy. Optom Vis Sci. 2014;91(3):297-302. benefi ts.27 10. Patel S, Henderson R, Bradley L, et al. Eff ect of visual display unit use on blink rate and tear stabili- Beyond identifying and man- ty. Optom Vis Sci. 1991;68:11:888-92. aging MGD, clinicians must be 11. Korb DR, Henriquez AS. Meibomian gland dysfunction and contact lens intolerance. J Am aware of the role different contact Optom Assoc. 1980;51(3):243-51. lens materials play in exacerbating 12. Arita R, Itoh K, Inoue K, et al. Contact lens wear is associated with decrease of meibomian glands. lens-related evaporative dry eye. Ophthalmology. 2009;116(3):379-84. We should prescribe materials 13. Ong BL. Relation between contact lens wear Meibography shows the tooth sign on and meibomian gland dysfunction. Optom Vis Sci. the distal upper and lower lid glands. that adsorb signifi cant amounts 1996;73(3):208-10. 14. Marren SE. Contact lens wear, use of eye cos- of lipid cautiously. Solutions and metics, and meibomian gland dysfunction. Optom changes. The high-quality images lens materials designed to increase Vis Sci. 1994;71(1):60-2. 15. Pucker AD, Jones-Jordan LA, Li W, et al. generated by meibography are surface wettability may help reduce Associations with meibomian gland atrophy in daily contact lens wearers. Optom Vis Sci. also a useful educational tool for the potential adverse impact of lens 2015;92(9):e206-13. patients in discussing the disease. wear on MGD. 16. Machalińska A, Zakrzewska A, Adamek B, et al. Comparison of morphological and functional Tear break-up time is an ex- meibomian gland characteristics between daily tremely useful measure of tear CLINICIAN TAKEAWAY contact lens wearers and nonwearers. Cornea. 2015;34(9):1098-104. stability and lipid layer integri- A steady increase of patients 17. Kojima T, Matsumoto Y, Ibrahim OM, et al. Eff ect of controlled adverse chamber environment ty. Noninvasive measurements presenting with dry eye threatens exposure on tear functions in silicon hydrogel and can be performed with lenses in to complicate contact lens man- hydrogel soft contact lens wearers. Invest Ophthal- mol Vis Sci. 2011;52(12):8811-7. place, which can reveal important agement. While changes in visual 18. Jansen ME, Begley CG, Himebaugh NH, Port NL. information. demands and diet likely play sig- Eff ect of contact lens wear and a near task on tear fi lm break-up. Optom Vis Sci. 2010;87(5):350-7. Both traditional and con- nifi cant roles, awareness of MGD 19. Eom Y, Lee JS, Kang SY, et al. Correlation temporary MGD management and the resulting tear dysfunction between quantitative measurements of tear fi lm lipid layer thickness and meibomian gland loss in approaches may be useful for helps the clinician troubleshoot patients with obstructive meibomian gland dys- function and normal controls. Am J Ophthalmol. symptomatic contact lens patients and address patients’ discomfort 2013;155(6):1104-10. who have MGD. Lid scrubs can be and dryness. With ever-increasing 20. Arita R, Morishige N, Koh S, et al. Increased tear fl uid production as a compensatory response benefi cial in managing symptom- patient expectations and an aging to meibomian gland loss: a multicenter cross-sec- atic contact lens wearers.23 More population, understanding risk fac- tional study. Ophthalmology. 2015;122(5):925-33. 21. Baudouin C, Messmer EM, Aragona P, et al. recently, several studies (including tors and appropriate MGD man- Revisiting the vicious circle of dry eye disease: a focus on the pathophysiology of meibomian gland an as yet unpublished multicenter agement will become increasingly dysfunction. Br J Ophthalmol. 2016;100(3):300-6. study) have investigated the use vital tools in the armamentarium of 22. Nichols JJ. Deposition on silicone hydrogel lenses. Eye Contact Lens. 2013;39(1):20-3. RCCL of LipiFlow (TearScience) thermal the successful contact lens fi tter. 23. Paugh JR, Knapp LL, Martinson JR, et al. Mei- pulsation therapy in contact lens bomian therapy in problematic contact lens wear. 1. Kadence International. Exploring Comfort and Optom Vis Sci. 1990;67(11):803-6. wearers with MGD. Researchers Vision Survey. 2012. 24. American Academy of Optometry. A single saw signifi cant improvement in 2. Murube J. History of the Dry Eye. In: The Dry lipifl ow treatment increases soft contact lens Eye: A Comprehensive Guide. Lemp MA, Mar- wearing time and reduces lid wiper epitheliopathy MGD scores and patient symptoms quardt R, eds. Heidelberg, Germany: Springer; and dry eye symptoms. Available at www.aaopt. 24 1992:3-34. org/single-lipifl ow-treatment-increases-soft-con- after a single treatment. Another tact-lens-wearing-time-and-reduces-lid-wiper. 3. Lemp MA, Crews LA, Bron AJ, et al. Distribution Accessed September 15, 2016. device that applies heat to reported- of aqueous-defi cient and evaporative dry eye in a clinic-based patient cohort: a retrospective study. 25. Epstein A, Pang L, Noorbakhsh C, et al. Com- ly improve gland expression is the Cornea. 2012;31(5):472-8. parison of bacterial lipase activity in the presence of eye lid cleansers. Available at http://novabay. MiBoFlo Thermafl o. 4. Korb DR, Blackie CA. “Dry eye” is the com/wp-content/uploads/2016/07/Epstein-AR- wrong diagnosis for millions. Optom Vis Sci. Pure hypochlorous acid applied VO-2015-Comparison-of-Bacterial-Lipase-Ac- 2015;92(9):e350-4. tivity-in-the-Presence-of-Eye-Lid-Cleansers.pdf. to the lids in products such as 5. The International Workshop on Meibomian Accessed September 15, 2016. Gland Dysfunction. Invest Ophthalmol Vis Sci. 26. Macsai MS. The role of omega-3 dietary sup- Avenova (Novabay) may be ben- 2011;52(4):1917–2085. plementation in blepharitis and meibomian gland efi cial by triggering antimicrobial 6. Shine WE, McCulley JP. Meibomian gland dysfunction (an AOS thesis). Trans Am Ophthalmol triglyceride fatty acid diff erences in chronic bleph- Soc. 2008;106:336-56. activity on lid fl ora overpopula- aritis patients. Cornea. 1996;15(4):340-6. 27. Epitropoulos AT, Donnenfeld ED, Shah ZA, et 7. Schafer J, Steff en R, Reindel W, Chinn J. Eval- al. Eff ect of oral re-esterifi ed omega-3 nutri- tion and inhibition of associated uation of surface water characteristics of novel 25 tional supplementation on dry eyes. Cornea. lipolysis in the tear fi lm. Omega-3 daily disposable contact lens materials, using 2016;35(9):1185-91.
REVIEW OF CORNEA & CONTACT LENSES | OCTOBER 2016 19
016_RCCL1016_ChickvsEgg_F2.indd 19 9/29/16 11:29 AM By Sruthi Srinivasan, PhD, LIDS, FRICTION BSOptom, FAAO and Contact Lens Wear
Does a relatively new phenomenon help explain contact lens discomfort?
lthough the eye (3) the lid wiper region.2 The ed movements on a much smaller care community wiper region in the upper lid is the scale than the upper lid wiper and, has well over 100 palpebral marginal conjunctiva in as a result, has less opportunity years of experience contact with the ocular surface. to suffer friction-related damage; Ain studying, fi tting This area, about 1mm in height, any epitheliopathy observed may and observing contact lenses, our ranges from the crest of the sharp more likely be due to hyperosmot- understanding continues to evolve posterior lid border to the sub-tar- ic changes.5 Although the upper in the face of new fi ndings and sal fold superiorly and from the eyelid wiper has captured the theories. Lid wiper epitheliopathy upper punctum to the lateral can- most attention of researchers— (LWE), fi rst described in 2002, thus horizontally (Figure 3).1,3 It likely due to the large, sweeping has since attracted considerable is wider in the nasal and temporal movements it makes—the upper attention among researchers and regions compared with the center lid typically glides over a vast ex- clinicians in the dry eye world— of the eyelid.2 panse of generally well-lubricated especially as it challenges conven- The conjunctiva of this region ocular surface. In fact, the fric- tional notions of diagnosis and contains goblet cells that secrete tional effects that cause LWE may management.1 And it may underlie soluble mucins onto the surface of be expressed more explicitly in the some of the factors that degrade the LW. These mucins and other lower eyelid than the upper. the on-eye performance of con- components of the tear fi lm form Investigators evaluated the tact lenses and threaten to reduce a hydrated gel between the LW prevalence and type of lid mar- patient satisfaction. and the ocular surface, providing gin staining and found that LWE The lid wiper (LW) region is the lubrication and keeping the lid is seen in 25% of a population portion of the marginal conjunc- and the ocular surface separated. presenting to an eye clinic.14 tiva of the upper and lower eyelid Impression cytology of the LW re- Others examined LWE in non- that acts as a wiping mechanism gion shows the presence of goblet CL wearers, soft CL wearers and to spread the tear fi lm over the cells, mucins, cell nuclei and vari- ocular surface or, if present, a ous degrees of pre- and parakera- ABOUT THE AUTHOR contact lens (CL). LWE describes tinization.4 Researchers also found a disturbance to the epithelium metabolic activity, compromised Dr. Srinivasan is a research assistant professor and a of the lid wiper region and is cell membranes, nucleic acids and clinical research manager observed through vital staining of apoptosis in cells stained with at the Centre for Contact Lens Research (CCLR), the upper and lower lid margin calcein AM, ethidium and annexin School of Optometry and regions that are in contact with V dyes.4 Vision Science, University of Waterloo, Canada. She is the ocular surface or CL (Figures actively involved in various UPPER VS. LOWER LWE clinical trials conducted at the CCLR. Dr. Sri- 1 and 2). nivasan graduated from the Elite School of The primary hypothesis for the Optometry, India, obtained her PhD in vision science from the University of Waterloo in LID MARGIN UP CLOSE cause of LWE is increased friction 2008 and did her postdoctoral fellowship The eyelid margin is divided between the LW and ocular or CL at the Ohio State University College of Optometry. Dr. Srinivasan is a fellow of the into three regions: (1) the skin surface due to inadequate lubrica- American Academy of Optometry as well epidermis that extends over the tion, leading to infl ammation and as a Scientifi c Program Committee member. She is also a member of the Association for meibomian gland orifi ces, (2) the epithelial compromise. Research in Vision & Ophthalmology and mucocutaneous junction, which Researchers proposed that the the International Society for Contact Lens Research. represents the line of Marx, and lower lid wiper makes blink-relat-
20 REVIEW OF CORNEA & CONTACT LENSES | OCTOBER 2016
020_RCCL1016_LidWiper_F3.indd 20 9/29/16 4:20 PM rigid CL wearers and found that fl uorescein (NaFl), lissamine green simplifi ed pictorial severity grad- the prevalence and mean grade (LG), fl uorescein and rose bengal ing scale (0=none and 3=severe).10 of lower LWE was signifi cantly (RB), fl uorescein and LG and a Research reports the length of higher than that of upper LWE combination of fl uorescein, LG the band of staining while grading in non-lens wearers. LWE (both and RB.1,6 However, lissamine LWE (Figure 1), and some report upper and lower) was detected in green has been the dye of choice more complex patterns of staining a higher percentage of CL wearers for visualizing LWE over the past including fi mbriated or feathery than in non-lens wearers.15 three years, likely due to the ease extensions from the superior Researchers examined images of visualization without any bar- margin of the subtarsal fold onto of upper eyelid wiper staining of rier fi lter. Researchers have moved the upper tarsal plate.1,7,11 A non-CL wearers, including the away from RB because of its rela- recent study of silicone hydrogel area of the line of Marx in the tively greater toxicity profi le. CL wearers shows six patterns measurement of lid wiper staining When NaFl is used to visualize of upper lid margin staining (in area.16 They also measured the LWE, a Kodak Wratten 12-barrier addition to no staining): vertical tarsal length, height and area of yellow fi lter (transmitting above streaks, short horizontal band, the tarsal plate in these subjects, 495nm) is employed to enhance broad horizontal band, speckled but found none of these measures the view. The slit lamp beam is appearance, comb-shaped and correlated with the area of lid set to maximum width and 10mm atypical appearance.11 wiper staining. Another study height, and the potentiometer is Due to growing interest in found no difference in the sever- set to provide maximum illumi- understanding LWE, researchers ity of LWE between current CL nation through the Wratten 47 or have developed automated grad- wearers, previous CL wearers and 47A cobalt blue exciter fi lter. ing methods to assess LWE, but non-lens wearers.17 Clinicians can use both sub- they are mainly used for research jective and objective/automated purposes. Two recently developed TESTING techniques to grade the severity methods of automating grading Researchers use a variety of of LWE. Subjective grading—the of LW staining involve digital staining methods to examine the fi rst and most frequently used image capture of the stained lid lid wiper region, including sodium system—is based on the appear- wiper followed by image anal- ance of the lid ysis.12,13 While these techniques Photos: Jalaiah Varikooty, Centre for Contact Lens Research wiper following are novel and useful in deter- instillation of vital mining the severity and extent of dyes. Severity of LWE, they are neither quick nor LWE is graded for clinician-friendly. each eye on a scale of 0 to 3 or 0 to FRICTION, CL 4 on the basis of WEAR AND LWE the horizontal and Measuring friction under the Fig. 1. Lid wiper staining extending from the nasal to vertical extent of human eyelid during blinking the canthal area of the upper lid margin (Top: sodium fl uorescein. Bottom: lissamine green.) lid margin staining is complicated. Tear fi lm com- with NaFl, LG or ponents, including proteins and RB vital stains.7,8 lipids, are attracted within the Investigators fi rst few minutes of CL insertion.18 graded on a 0 to This deposition alters surface 3 subjective scale properties of the lens material, (0=none, 1=mild, signifi cantly impacting lid/CL 2=moderate, and interaction. Studies suggest CL 3=severe, using frictional properties may also 0.5 steps).9 Others be associated with LWE and used LG to grade lid parallel conjunctival folds 19, 20 Fig. 2. Lid wiper staining extending from the nasal to the severity of (LIPCOF). Thus, measuring the canthal area of the lower lid margin (Top: sodium LWE in 0.5 steps the coeffi cient of friction (COF) fl uorescein. Bottom: lissamine green.) using a 4-point over CLs has attracted interest
REVIEW OF CORNEA & CONTACT LENSES | OCTOBER 2016 21
020_RCCL1016_LidWiper_F3.indd 21 9/29/16 4:20 PM LIDS, FRICTION AND CONTACT LENS WEAR
5. McMonnies CW. An examination of the rela- among researchers. COF can be values are likely to be more com- tionship between ocular surface tear osmolarity 25 compartments and epitheliopathy. The Ocular measured by different techniques fortable. However, no studies Surface. 2015;13:110-7. such as microtribometry, inclined to date have demonstrated a link 6. Korb DR, Herman JP, Finnemore VM, et al. An evaluation of the effi cacy of fl uorescein, rose plane method or atomic force between CL surface lubricity and bengal, lissamine green, and a new dye mixture microscopy.21-23 The recent TFOS LWE. Other management strate- for ocular surface staining. Eye & Contact Lens. 2008;34:61-4. report on contact lens discomfort gies under investigation include 7. Korb DR, Herman JP, Greiner JV, et al. Lid wiper indicates that COF is the only CL altering lens wear modalities, us- epitheliopathy and dry eye symptoms. Eye & Contact Lens. 2005;31:2-8. material property that correlates ing lubricant drops and improving 8. Willis T, Blackie CA, Korb D. Meibomian gland with discomfort.24 function, lid wiper epitheliopathy, and dry eye blinking behavior. symptoms. Ophthalmol Vis Sci. 2011;52:ARVO COF values can vary depending EAbstract 3740. 9. Stahl UG, Delaveris A, Madigan M, Jalbert I. Lid on technique and testing condi- CORRELATION OR wiper epitheliopathy: exploring the links to com- tions, and there is no standardized CAUSATION? fort and osmolality in contact lens wear. Contact Lens Ant Eye. 2011:(Suppl. 1):34. method to assess COF. It is there- Although the relationship between 10. Jalbert I, Rejab S. Increased numbers of fore vital to be cautious when in- LWE and symptoms of dryness or Demodex in contact lens wearers. Optom Vis Sci. 2015;92:671-8. terpreting results presented in the discomfort in CL wearers has been 11. Varikooty J, Srinivasan S, Subbaraman L, et al. literature. Researchers have made Variations in observable lid wiper epitheliopathy widely studied, the literature is in- (LWE) staining patterns in wearers of silicone signifi cant advances in trying to consistent in demonstrating a link hydrogel lenses. Contact Lens & Anterior Eye: The Journal of the British Contact Lens Association. develop models that mimic on-eye between LWE and CL-associated 2015;38:471-6. conditions, and further research dryness and discomfort. For 12. Varikooty J, Lay B, Kier N, et al. The relationship between clinical grading and objective image anal- is warranted in understanding every publication that has found ysis of lid wiper epitheliopathy. Invest Ophthalmol the role of friction, LWE and CL Vis Sci. 2013;54:ARVO E-Abstract 5460. LWE to be greater in CL wearers, 13. Kunnen CK, Lazon De La Jara P, Holden BA, wear. another one has found no differ- Papas EB. Automated assessment of lid margin lissamine green staining. Invest Ophthalmol Vis What we do know for sure is ences. These inconsistencies could Sci. 2014;55:ARVO E-Abstract 1976. that a lubricious ocular surface be due to low sample size, record- 14. Guillon M, Maissa C. Assessment of upper and lower lid margin with lissamine green. Optom Vis is essential to minimize friction. ing inconsistencies (time of day, Sci. 2008;84:E-abstract 80088. Switching to a lens with high sur- length of lens wear), or insensitive 15. Shiraishi A, Yamaguchi M, Ohashi Y. Prevalence of upper- and lower-lid-wiper epitheliopathy in face lubricity may decrease LWE techniques for assessing LWE, contact lens wearers and non-wearers. Eye & associated with CL wear. Research Contact Lens. 2014;40:220-4. comfort or dryness. Any of these 16. Navascues-Cornago M, Maldonado-Codina C, shows that contact lenses have factors may have confounded the Gupta R, Morgan PB. Characterization of upper a wide range of surface lubricity eyelid tarsus and lid wiper dimensions. Eye & capacity to detect differences or Contact Lens. 2016 Sep;42(5):289-94. 21 values. One study demonstrates associations. 17. Alghamdi WM, Markoulli M, Holden BA, Papas that lenses with higher lubricity EB. Impact of duration of contact lens wear on the structure and function of the meibomian glands. Ophthalmic & Physiological Optics. 2016;36:120-31. Photos: Jalaiah Varikooty, Centre for Contact Lens Research id wiper epitheliopathy is a 18. Bontempo AR, Rapp J. Protein and lipid Lcondition seen in both contact deposition onto hydrophilic contact lenses in vivo. CLAO J. 2001;27:75-80. lens wearers and non-wearers, as 19. Berry M, Pult H, Purslow C, Murphy PJ. well as asymptomatic and symp- Mucins and ocular signs in symptomatic and asymptomatic contact lens wear. Optom Vis Sci. tomatic individuals. Future studies 2008;85:E930-938. are warranted to understand its 20. Pult H, Purslow C, Berry M, Murphy PJ. Clinical tests for successful contact lens wear: relation- cause, nature (i.e., acute or chron- ship and predictive potential. Optom Vis Sci. ic), time of development, diurnal 2008;85:E924-929. 21. Roba M, Duncan EG, Hill GA, et al. Friction variation and long-term effects. RCCL measurements on contact lenses in their operating environment. Tribol. 2011;Lett. 44:387-97. 1. Korb DR, Greiner JV, Herman JP, et al. Lid-wiper 22. Tucker RC, Quinter B, Patel D, et al. Qualitative epitheliopathy and dry-eye symptoms in contact and quantitative lubricity of experimental contact lenses. Invest Ophthalmol Vis Sci. 2012;53:ARVO lens wearers. CLAO J. 2002;28:211-16. E-Abstract 6093. 2. Knop E, Knop N, Zhivov A, et al. The lid wiper 23. Kim SH, Marmo C, Somorjai GA. Friction and muco-cutaneous junction anatomy of the hu- studies of hydrogel contact lenses using AFM: man eyelid margins: an in vivo confocal and histo- non-crosslinked polymers of low friction at the logical study. Journal of Anatomy. 2011;218:449-61. surface. Biomaterials. 2001;22:3285-94. 3. Knop N, Korb DR, Blackie CA, Knop E. The lid 24. Jones L, Brennan NA, Gonzalez-Meijome J, et wiper contains goblet cells and goblet cell crypts al. The TFOS International Workshop on Contact for ocular surface lubrication during the blink. Lens Discomfort: report of the contact lens Fig. 3. Representation of histology of Cornea. 2012;31:668-79. materials, design, and care subcommittee. Invest the lid wiper region. Vertical width of 4. Muntz A, van Doorn K, Subbaraman LN, Jones Ophthalmol Vis Sci. 2013;54:TFOS37-70. LW. Impression cytology of the lid wiper area. 25. Coles CML, Brennan NA. Coeffi cient of friction the lid wiper region is indicated by Investig Ophthalmol Vis Sci. 2015;56:ARVO E-Ab- and soft contact lens comfort. Optom Vis Sci. the red line. stract 4432. 2012;88:E-abstract 125603.
22 REVIEW OF CORNEA & CONTACT LENSES | OCTOBER 2016
020_RCCL1016_LidWiper_F3.indd 22 9/29/16 4:20 PM Up to 2016 MEETINGS 12 CE Credits* MEETINGS CO-CHAIRS: MURRAY FINGERET, OD ROBERT N. WEINREB, MD
CE CONFERENCES
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Up to 6 COPE Credits for $125! www.reviewofoptometry.com/SWOGS2016 Please call the hotel directly at 713-961-1500 and identify yourself as a participant of the Southwest Optometric Glaucoma Symposium.
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call 877-451-6514, or email [email protected] *Approval pending
2016_OGS_SW-WC_HouseAd.indd 1 9/27/16 3:37 PM 1 CE Credit (COPE Approval Pending) HOW LID MALPOSITION CAN COMPROMISE CONTACT LENS WEAR
hile the cor- SURGERY AS A rigid gas permeable lenses (es- nea and sclera FIRST-LINE STRATEGY pecially translating multifocals), are consid- For patients who present to the which rely on the wearer’s lids ered critical clinic with a lid malposition for positioning and movement, points to issue, surgery is often considered making them least suited for W 3 monitor during the contact lens the fi rst-line treatment to correct use by patients with lid issues. fi t, the patient’s eyelid anatomy their problem. Regardless of the Taking into account the level and tear fi lm are also important. condition, the primary goal of of lid dependency of a lens can Some of the fi rst lenses ever made the eye care practitioner is to increase the chance of lens wear were designed to prevent corneal restore both form and function success by patients with more exposure in a patient whose eye- to the eyelid and relevant perioc- severe lid abnormalities or in lieu lid had been partially destroyed ular structure by addressing the of further surgical correction. by cancer, highlighting the cause of the problem—that is, Below, lid conditions and their importance of these parts of the the undesirable alteration in the treatments for rectifi cation are ocular anatomy.1 Approximately patient’s lid anatomy. covered. 130 years after this fi tting, op- Once this is done, the contact tometrists are still using contact lens fi tting process following sur- PTOSIS lenses to manage eyelid disor- gery is similar to that of fi tting a Also known as blepharoptosis, ders; as such, adequate awareness patient who has not undergone a this common lid malady man- of the interaction between the procedure, as almost all existing ifests from one of a variety of contact lens and eyelids for the lens modalities can be considered different causes including con- purpose of preventing additional for use. However, if surgery is genital developmental malforma- problems is a skill that eye care contraindicated, the procedure’s tions, trauma, myasthenia gravis practitioners should focus on and outcome is not optimal, or the or Horner’s syndrome (Figure keep up to par. patient simply has additional lid 1). Regardless of any underlying Among other concerns, certain issues (e.g., narrow palpebral etiology, however, the prob- lid issues that can arise may lead fi ssures, excessively tight lids or lem most often involves either to an increased risk of infection large lid angles), then certain insuffi cient levator contraction due to ocular adnexa dysfunc- contact lenses are contraindi- due to incorrect or weak muscle tion such as misdirected lashes, cated for fi tting, limiting practi- abnormal lid anatomy, cranial tioners to the selection of a lens ABOUT THE AUTHORS nerve palsies and blepharitis. from options that are considered These issues and their treatments more lid independent.2 can further impede contact lens For such patients with subopti- Mr. Turpin, an optometry student at Pacifi c University success, resulting in patient dis- mal eyelid anatomy or function, College of Optometry, plans comfort and possibly even drop- scleral contact lenses are the best to graduate in 2017. out from lens wear altogether. option, as they are generally least
This article will primarily focus infl uenced by lid anatomy. In Dr. Skorin practices on the presentation of abnormal decreasing order of suitability, ophthalmology at the Mayo Clinic Health System in lid anatomy and the existing sclerals are followed by spherical Albert Lea, MN. strategies for management of soft lenses, multifocal and toric these scenarios. soft lenses and, fi nally, corneal
24 REVIEW OF CORNEA & CONTACT LENSES | OCTOBER 2016
024_RCCL1016_AbnormalLidsCE.indd 24 9/29/16 5:31 PM Keep these conditions in mind to prevent or rectify potential obstacles to a successful fi t.
By Steven Turpin, MS, and Leonid Skorin Jr., OD, DO, MS
insertion into the superior tarsal plate or myogenic issues like those seen in muscular dystro- phy or various nerve conduction problems.4 For example, paresis of the third cranial nerve causes severe ptosis as a result of inner- vation to the levator being lost in some fashion. Ptosis is typically graded based on an assessment of remaining levator function and treated accordingly: mild to moderate ptosis (i.e., greater Fig. 1. Ptosis of the right upper eyelid in a patient with Horner’s syndrome. Note the miotic right pupil. than 4mm of levator function remaining), for example, is man- scleral lenses in moderate to se- keep in mind that long-term aged via the reattachment of the vere cases.6 Increasing the thick- wear of scleral lenses in this aponeurosis of the levator to the ness of a standard scleral lens scenario simply masks the lid tarsal plate, or by the shortening can also help with improving the problem rather than permanent- of the levator above Whitnall’s cosmetic appearance of the eye- ly correcting it at the source: in ligament, which both serve to lids and also prevent the upper effect, the lenses act as crutches, improve function. lid from covering the pupillary and so should only be used as Patients with complex or more axis; this solution can prevent temporary measures or if surgery severe cases of ptosis (i.e., less restriction of the superior visual has entirely been ruled out. than or equal to 4mm of levator fi eld if the patient elects to forgo If the patient does undergo function), however, are treated surgery or if the operation itself surgery for the lid condition via the insertion of a silicone is contraindicated.7 and wishes to return to soft lens rod or other suspensory material Specialty scleral contact lenses wear afterwards, corneal chang- to enable frontalis suspension. can also be manufactured with es resulting from the operation Twenty-fi ve percent of severe either a shelf for the lid to rest should be kept in mind as these ptosis patients who undergo this on or props to hold it in place.7,8 can adversely impact the success procedure also end up suffering However, practitioners should of the lens fi t. Pressure from the post-surgery from some form of Release Date: October 2016 is pending for this course. Check with exposure keratopathy.5 The risk Expiration Date: October 1, 2019 your state licensing board to see if this of corneal damage also increases Goal Statement: Eyelid anatomy and counts toward your CE requirements for signifi cantly if ocular motility the tear film are important structures to relicensure. is restricted or if orbicularis consider during a contact lens fit. This Joint-Sponsorship Statement: This article addresses abnormal lid anatomy and function is reduced, so addition- contin uing education course is joint- strategies for managing these scenarios. al measures are often taken in sponsored by the Pennsylvania College of Faculty/Editorial Board: Optometry. order to maintain the integrity of Steven Turpin, MS, and the ocular surface. These include Leonid Skorin, Jr., OD, DO, MS Disclosure Statement: Drs. Turpin and the use of artifi cial tears or lubri- Credit Statement: COPE approval for Skorin have no financial interest in any cants in mild cases to therapeutic 1 hours of continuing education credit products mentioned in this article.
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uneven upper lid prior to surgery patient’s risk of developing ptosis can also cause the superior cor- 17-fold.1 Those patients who do nea to steepen, altering corneal use gas permeable lenses and astigmatic power and axis.9 The exhibit CLIP should cease wear superior cornea then fl attens fol- for at least one month to allow lowing the lid procedure and can for spontaneous resolution. If infl uence both the refraction and this does occur, refi tting the the fi t of the lens. patient in soft lenses is often a The eye care practitioner viable solution, though soft lens should fully reevaluate all wear also does increase the risk contact lens patients wishing to for ptosis development up to return to contact lens wear fol- fi ve times more compared with lowing lid surgery to record any non-lens wearers.1 If resolution Fig. 2. Severe ectropion of the left changes that might necessitate does not occur, surgical interven- inferior lid. Note that the inferior alterations in lens parameters. tion is indicated, with selection punctum is also turned out. Note, gas permeable lens wear of the technique determined by nal position quickly); mild (i.e., is not recommended for patients the amount of remaining leva- the lid slowly returns); moderate who have undergone ptosis sur- tor function as detailed above. (i.e., the lid incompletely returns gery as rigid lens wear is linked Regardless of the cause of ptosis, on its own, requiring the patient to the development of ptosis however, consider a different mo- to blink); or severe (i.e., even itself.1 dality other than gas permeable with blinking, the lid does not Contact lens-induced ptosis lenses for wear following resolu- return to its original position).12 (CLIP), a variation on the previ- tion of the issue.12 Cases of lid laxity can be local- ous condition, is a phenomenon ized to either the medial or later- that has been observed since ECTROPION al canthi or the tarsal portion of the 1980s; however, its exact Present almost exclusively in the the lid, which may infl uence the pathophysiology has yet to be lower lid, this condition involves selection of surgical technique established. An existing hypoth- the outward turning of the lid for repair. In most instances of a esis for its onset involves the margin (Figure 2). The most patient with involutional ectro- occurrence of a forced blinking common subtype of ectropion, pion, a simple tightening of the action during which the patient involutional ectropion, results lateral canthus and performance attempts to open their eyes wide from tissue changes made that of a tarsal strip procedure works enough to remove their con- increase the laxity of the tarsus to solve the problem; however, if tact lenses. In this instance, the or canthal tendons.4 In the case malpositioning of the punctum is resulting simultaneous contrac- of ectropion, it is also common a concern, a medial spindle pro- tions of both the levator and for the inferior punctum to turn cedure may also be necessary.13 orbicularis oculi are believed to outwards, where it impedes For patients in which canthal increase traction on the levator normal tear drainage; as a result, laxity is not a problem, a pen- aponeurosis, causing its de- epiphora is a frequent com- tagonal wedge resection of the hiscence.10 Different theories plaint among patients with this tarsal portion of the lid is pref- suggest that it may be the lateral condition. erable to other procedures to fi x pulling of the eyelid—common Practitioners should keep in the issue.4 Furthermore, in the during lens removal—that cre- mind that just a few simple tests case of an uncontrolled systemic ates high amounts of lid tension can be used to assess lid laxity: disease presenting in conjunc- followed by repeated hard blinks one example, the snap-back test, tion with the lid problem (i.e., that then lead to the exertion of involves asking the patient to hypertension, diabetes, vascular high amounts of pressure on the look upwards as their lower lid disease or cardiac disease) that palpebral portion of the upper is pulled down gently. Depending makes surgery too risky to per- lid.11 on the lid’s response following form, a scleral lens can be used However, regardless of the release, the condition can be to prevent corneal exposure.14,15 possible anatomical changes, graded as either normal (i.e., the Patients with involutional rigid lens wear can increase a patient’s lid returns to its origi- ectropion who wear either soft
26 REVIEW OF CORNEA & CONTACT LENSES | OCTOBER 2016
024_RCCL1016_AbnormalLidsCE.indd 26 9/29/16 5:31 PM or rigid lenses may experience Bell’s palsy. This is subcatego- this is the diagnosis, treatments discomfort prior to surgery, both rized as paralytic ectropion and include injections of botulinum from the lenses riding low and may be associated with a larger toxin made to the orbicularis oc- also from a decrease in tear fi lm number of possible complica- uli muscle for temporary relief, distribution, which can lead to tions. As such, the reduction or as the botulinum toxin breaks lens dryness. These issues are loss of orbicularis oculi function the involuntary muscle contrac- generally solved and normal lid may require a more complex tion pattern characteristic of function is restored following the surgical intervention than in the spastic entropion.12 A more per- appropriate surgical intervention. case of involutional ectropion; manent solution is for the patient As mentioned earlier, changes in additionally, induction of artifi - to undergo capsulopalpebral lid structure—both before and cial ptosis either via a botulinum reattachment to the base of the after surgery—signifi cantly af- toxin injection or lid weight can tarsal plate to restore both form fect the fi t of rigid corneal lenses; lessen levator activity, temporar- and function to the lower lid. thus, they often require adjust- ily protecting the cornea from Ensuring corneal protection is ments accordingly. exposure.18 This way, ocular imperative for patients suffering Corneal changes can also take lubricants and other necessary from entropion, as the inward place after lower lid tension is topical medications can still turning of the eyelashes can restored, as the increased pres- be instilled as needed. In some cause epithelial erosion or even sure on the inferior cornea can cases, treatment may need to go corneal ulceration or stromal increase the degree of with-the- as far as the performance of a scarring. If surgery to correct the rule astigmatism that a patient tarsorrhaphy procedure (i.e., the lid problem cannot be performed may have, possibly affecting the suturing of the superior and in- promptly, a bandage soft lens soft lens fi t or making a toric ferior lids together to protect the can help protect the ocular sur- lens a more appropriate option.16 corneal surface).4 Placement of a face. Scleral contact lenses may If a toric soft lens is indicated for scleral contact lens is also once also help shield the cornea from the patient, lid procedures can again an option in such cases. insult, though they themselves help improve rotational stability can cause a pseudoentropion if by reducing the palpebral fi s- ENTROPION fi t with an insuffi cient diameter.1 sure.2 Better lid tension has yet Many of the physiological Postoperative fi tting issues in to be proven to make any signifi - changes that result in ectropi- patients with resolved entropion cant difference in the case of lens on may also lead to entropion, are similar to those found in stability, however.2,17 which is the inward turning of individuals who have undergone Ectropion may also result from the lid margin (Figure 3). The ectropion surgery because good damage done to the seventh snap-back test used to assess lid lid tension is restored in both cranial nerve, either by trauma, function in the case of ectropion cases. Keratometric readings pre- surgery or conditions such as can also be useful here if entro- operatively and postoperatively pion is sus- are not usually signifi cantly dif- pected: practi- ferent, though key changes can tioners should be found if corneal topography simply look for is performed correctly.19 the lower lid margin turn- KERATOCONUS AND ing in instead FLOPPY EYELID of outwards. SYNDROME Directing the Traditionally, the standard patient to close for correction of patients with their eyes tight- keratoconus has been the use of ly can also elic- corneal gas permeable contact it an entropic lenses. These typically provide turning in of patients with optimal vision; the lid margin. however, one consideration that Fig. 3. Severe lid laxity manifesting as entropion. Ultimately, if can change the eye care prac-
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titioner’s treatment strategy is with this condition with irri- wearers apply to these patients when a keratoconic patient has tation and damage being made as well. RCCL concurrent fl oppy eyelid syn- to the ocular surface. It can be 1. Efron N. Eyelid ptosis. Contact Lens Compli- drome (FES), which is charac- treated using ocular lubricants cat. 2012;4:47–55. terized by excessive lid elasticity, or eye shields worn while sleep- 2. Jin W, Jin N, Chen Y, et al. The impact of eyelid and eye contour factors on a toric soft especially in the upper eyelid ing; should these fail, however, contact lens fi tting in Chinese subjects. Eye (Figure 4). In one study, 11 out another option is surgical repair, Contact Lens. 2014;40:65–70. 3. Hom MM, Bruce AS. Rigid Gas Permeable of 60 subjects with FES also during which the medial can- Lens Fitting. 3rd ed. St. Louis: Butterworth exhibited corneal changes that thopexy and lateral tarsal strip Heinemann Elsevier; 2006. 4. Dutton JJ, Gayre GS, Proia AD. Diagnostic were characteristic of kerato- procedures are combined. This Atlas of Common Eyelid Diseases. Infroma conus, while other research has procedure can reduce lid elastic- Healthcare USA Inc.; 2007. found that an underlying con- ity while maintaining both the 5. Van Sorge AJ, Devogelaere T, Sotodeh M, et al. Exposure keratopathy following silicone nective tissue defect may link upper eyelid tarsus and punctal frontalis suspension in adult neuro- and myo- 20,21 22 genic ptosis. Acta Ophthalmol. 2012;90:188– the two conditions together. positioning. 92. Regardless, however, it can be 6. Grey F, Carley F, Biswas S, Tromans C. Scleral contact lens management of bilateral diffi cult to fi t these patients with hough it can result in chang- exposure and neurotrophic keratopathy. Con- corneal gas permeable lenses due Tes to the anterior segment, tact Lens Anterior Eye. 2012;35:288–91. to the level of existing lid laxity, surgery remains the best option 7. Shah-Desai SD, Aslam SA, Pullum K, et al. Scleral contact lens usage in patients with so other modalities like scleral, for fi xing eyelid malposition complex blepharoptosis. Ophthal Plast Recon- hybrid or keratoconic-specifi c problems. Eye care practitioners str Surg. 2011;27:95–8. 8. Lindsay RG, Ezekiel DF. Ptosis prop gas soft lens designs can stand in as should remain aware of the permeable scleral lens fi tting for a patient with suitable alternatives. Such op- changes associated with eyelid ocular myopathy. Clin Exp Optom. 1997:123–6. 9. Savino G, Battendieri R, Riso M, et al. Cor- tions may provide these patients procedures and be willing to neal topographic changes after eyelid ptosis with good vision without the make changes in their selection surgery. Clin Sci. 2016;35:501–5. 10. Epstein G, Putterman AM. Acquired blepha- need to rely on the eyelids for of contact lenses following the roptosis secondary to contact-lens wear. Am J proper lens positioning. procedure. They must also keep Ophthalmol. 1981;91:634–9. Aside from addressing a in mind that bandage soft or 11. van den Bosch WA, Lemij HG. Blepharopto- sis induced by prolonged hard contact lens patient’s visual needs, eye care scleral lenses can temporari- wear. Ophthalmology. 1992;99:1759–65. practitioners must also ensure ly protect the ocular surface. 12. Skorin L. A review of entropion and its management. Contact Lens Anterior Eye. the patient’s cornea is protect- Though the peak age of occur- 2003;26:95–100. ed at night in cases of FES. rence of many lid problems is 13. Clement CI, O’Donnell BA. Medial canthal tendon repair for moderate to severe tendon Spontaneous eversion during long after the peak age of habit- laxity. Clin Exp Ophthalmol. 2004;32:170–4. sleep is a problem that is com- ual contact lens wear, the fi tting 14. DeBacker C. Entropion and Ectropion Re- mon among keratoconic patients principles common to normal pair. Medscape 2015. 15. van der Worp E, Bornman D, Ferreira DL, et al. Modern scleral contact lenses: A review. Contact Lens Anterior Eye. 2014;37:240–50. 16. Detorakis ET, Ioannakis K, Kozobolis VP. Corneal topography in involutional ectropion of the lower eyelid: preoperative and postop- erative evaluation. Cornea. 2005;24:431–4. 17. Young G, Hunt C, Covey M. Clinical evalu- ation of factors infl uencing toric soft contact lens fi t. Optom Vis Sci. 2002;79:11–9. 18. Alsuhaibani AH. Facial nerve palsy: provid- ing eye comfort and cosmesis. Middle East Afr J Ophthalmol. 2010;17:142–7. 19. Monga P, Gupta VP, Dhaliwal U. Clinical evaluation of changes in cornea and tear fi lm after surgery for trachomatous upper lid en- tropion. Eye (Lond). 2008;22:912–7. 20. Culbertson WW, Tseng S. Corneal dis- orders in fl oppy eyelid syndrome. Cornea. 1994;13:33–42. 21. Ezra DG, Beaconsfi eld M, Collin R. Floppy eyelid syndrome: stretching the limits. Surv Ophthalmol. 2010;55:35–46. 22. Compton CJ, Melson AT, Clark JD, et al. Fig. 4. Floppy eyelid syndrome increases the risk of spontaneous eversion of Combined medial canthopexy and lateral tarsal strip for fl oppy eyelid syndrome. Am J the upper lid during sleep and subsequent corneal damage. Otolaryngol. 2016;37:240–4.
28 REVIEW OF CORNEA & CONTACT LENSES | OCTOBER 2016
024_RCCL1016_AbnormalLidsCE.indd 28 9/29/16 5:31 PM CE TEST ~ OCTOBER 2016 EXAMINATION ANSWER SHEET
1. Eyelid issues that can create ocular adnexa dysfunction and increase risk of How Lid Malposition Can Compromise Contact Lens Wear infection among contact lens wearers include all of the following except: Valid for credit through October 1, 2019 a. Misdirected lashes. Online: This exam can also be taken online at www.reviewofcontactlenses.com. b. Giant papillary conjunctivitis. Upon passing the exam, you can view your results immediately. You can also c. Cranial nerve palsies. view your test history at any time from the website. d. Blepharitis. Directions: Select one answer for each question in the exam and completely darken the appropriate circle. A minimum score of 70% is required to earn credit. 2. In patients with suboptimal eyelid anatomy or function, the best contact lens option is which of the following? Mail to: Jobson Optometric CE, Canal Street Station, PO Box 488 New York, NY 10013 a. Scleral lenses. Payment: Remit $20 with this exam. Make check payable to Jobson Medical b. Spherical soft lenses. Information LLC. c. Multifocal or toric soft lenses. Credit: COPE approval for 1 hour of CE credit is pending for this course. d. Corneal rigid gas permeable lenses. Sponsorship: Joint-sponsored by the Pennsylvania College of Optometry 3. Which of the following surgical techniques is used to manage mild to Processing: There is an eight-to-10 week processing time for this exam. moderate ptosis (i.e., greater than 4mm of levator function remaining)? a. Reattachment of the aponeurosis of the levator to the tarsal plate. Answers to CE exam: b. Insertion of a silicone rod or other suspensory material to enable frontalis 1. A B C D 6. A B C D suspension. 2. A B C D 7. A B C D c. Shortening of the levator above Whitnall’s ligament. 3. A B C D 8. A B C D d. Both (a) and (c). 4. A B C D 9. A B C D 4. Rigid contact lens wear has been shown to increase a patient’s risk of 5. A B C D 10. A B C D developing ptosis by what magnitude? Evaluation questions (1 = Excellent, 2 = Very Good, 3 = Good, 4 = Fair, 5 = Poor) a. 5x Rate the effectiveness of how well the activity: b. 8x 11. Met the goal statement: 1 2 3 4 5 c. 17x 12. Related to your practice needs: 1 2 3 4 5 d. 25x 13. Will help improve patient care: 1 2 3 4 5 5. In severe ptosis patients who undergo a frontalis suspension procedure, 14. Avoided commercial bias/influence: 1 2 3 4 5 what is the rate of exposure keratopathy that occurs post-surgery? 15. How do you rate the overall quality of the material? 1 2 3 4 5 a. 7% 16. Your knowledge of the subject increased: Greatly Somewhat Little b. 18% 17. The difficulty of the course was: Complex Appropriate Basic c. 25% d. 100% 18. How long did it take to complete this course? ______
6. Tissue changes that increase the laxity of the tarsus and/or canthal tendons 19. Comments on this course: ______are known to result in: ______a. Distichiasis. b. Involutional ectropion. 20. Suggested topics for future CE articles: ______c. Blepharoptosis. ______d. Lid wiper epitheliopathy.
7. Surgical restoration of lower lid tension to correct ectropion can cause Identifying information (please print clearly): which of the following corneal changes? First Name a. Keratoconus. b. Pellucid marginal degeneration. Last Name c. With-the-rule astigmatism. d. Against-the-rule astigmatism. Email
8. One clinical technique that can be used to diagnose entropion is: The following is your: Home Address Business Address a. The snap-back test. Business Name b. Directing the patient to open their eyes wide. c. Retroillumination of the eyelid. Address d. Estimation of palpebral fissure size. City State 9. A poorly designed scleral contact lens can cause a pseudoentropion if the design suffers from this flaw: ZIP a. Excessively steep haptics. Telephone # - - b. Insufficient diameter. c. Insufficient corneal vault. Fax # - - d. Central thickness >250µm. By submitting this answer sheet, I certify that I have read the lesson in its entirety 10. In a keratoconus patient with concomitant floppy eyelid syndrome, the and completed the self-assessment exam personally based on the material present- corneal surface can be protected from exposure due to spontaneous lid ed. I have not obtained the answers to this exam by fraudulent or improper means. eversion by which of the following interventions? a. Collagen crosslinking. Signature: ______Date: ______b. Ocular lubricants or eye shields worn while sleeping. c. Combined medial canthopexy and lateral tarsal strip procedures. Please retain a copy for your records. LESSON 113570, RO-RCCL-1016 d. Both b and c.
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024_RCCL1016_AbnormalLidsCE.indd 29 9/29/16 5:31 PM HOW WOULD YOU HANDLE THESE Refractive Surgery Controversies?
Despite the procedure’s popularity, some issues still remain. By Aaron McNulty, OD, and How should you address them? Ian McWherter, OD
o matter what an keratoconus, though his vision atoconus can increase the risk of eye care practice corrects to 20/20 with refraction. postoperative complications. focuses on, many He exhibits 3D of myopia, 1D Low residual stromal bed practitioners likely of astigmatism and a corneal (RSB) thickness. Research sug- N fi eld questions re- thickness of 560µm, along with gests that a minimum of 250µm garding the potential for LASIK a patient history that reveals to 300µm of stromal tissue treatment. Patients ask for our refractive stability maintenance should be left intact following opinions and recommendations over the past fi ve years, suggest- surgery to help ensure the patient on the procedure’s suitability for ing he might be a good candidate does not develop issues after the them, as many have more than for LASIK. However, due to his procedure. If the RSB is thin- likely read reports of complica- irregular corneal shape, he is at ner than this range, the risk of tions in the media and remain risk for possibly the most con- ectasia is higher.2 Expected RSB wary. So, what should we tell cerning complication that can thickness can be estimated using them? Below is a summary of follow refractive surgery. the following rule of thumb: the some of the latest data and Most individuals who develop femtosecond fl ap should be made consensus opinions regarding post-surgical ectasia suffer from approximately 100µm thick, questions that many of us may structural and visual distortions, with the laser removing roughly face during the perioperative care somewhat akin to keratoconus, 15µm of stroma per diopter of of a refractive surgery patient. that are not adequately con- myopia to be corrected. As such, trolled either with spectacles or the preoperative pachymetry POST-LASIK ECTASIA contact lenses, leaving them with values and the patient’s level of The fi rst example is limited options should further refractive error can be predicted 1 bilateral thinning of adjustment be necessary. To help to determine anticipated postop- the cornea post-procedure, or prevent this problem following erative corneal thickness. corneal ectasia, which occurs in surgery, the Ectasia Risk Score Age. Though keratoconus typ- some patients with a thin residu- System was created to assist ically presents itself during ado- al stromal bed, particularly those with the screening of high-risk lescence, some cases can manifest with high preoperative myopia, patients prior to the procedure.1 an occurrence that alters the The system is based on a series ABOUT THE AUTHORS structural integrity of the cornea. of post-LASIK ectasia cases from Dr. McNulty is in private practice at the Louisville Eye Those patients with uncommon 2008, during which several risk Center in Kentucky, where corneal shapes pre-procedure are factors for the development of he practices comprehensive optometry with an even more at risk of onset. the issue were identifi ed. These emphasis on the fi tting of Take this example: a 31-year- include: contact lenses for irregular corneas, as well as optometric old male presented to the clinic Abnormal preoperative cor- laser surgery. wearing monthly disposable con- neal topography. Moderate-to- Dr. McWherter is a consultative tact lenses and expressed interest severe keratoconus is a defi nitive optometrist at Bennett in LASIK. Corneal topography contraindication for refractive and Bloom Eye Centers in Louisville, KY, and the indicates that he has mild corneal surgery due to the severe insta- director of research at irregularity and inferior steepen- bility of the cornea’s structural the University of Pikeville– Kentucky College of ing. Ultimately, the practitioner bonds, while even milder corneal Optometry in Pikeville, KY. suspects that his patient has mild irregularities or forme fruste ker-
30 REVIEW OF CORNEA & CONTACT LENSES | OCTOBER 2016
030_RCCL1016_LasikControversies_F5.indd 30 9/29/16 5:31 PM in adulthood as well. In younger patients with a family history of keratoconus (and thus a higher genetic predisposition towards developing the disease), a prac- titioner might consider delaying LASIK treatment until later in the patient’s life. The creators of the Ectasia Risk Score System hy- pothesized that some of the indi- viduals who ended up developing ectasia following surgery in their study sample did so at a younger age without any other recogniz- able risk factors noted, and may have eventually developed forme fruste or manifest keratoconus, even if LASIK had not been per- This corneal topography shows minimal anterior corneal elevation and formed. As such, LASIK surgery astigmatism. However, there is a signifi cant posterior elevation, which runs the risk of preempting the suggests early posterior keratoconus. The thinnest area of the cornea also onset of keratoconus and exacer- corresponds to the apex of the posterior elevation. This patient would be a bating progression of the disease. poor LASIK candidate. Lower amount of preoperative ing scale is its reliance on placido al tomography to confi rm that he corneal thickness. This factor is disc-based topography systems, exhibits a normal posterior cor- directly related to the presence which are incapable of demon- neal surface; if so, he may in fact of low RSB thickness. In cases in strating posterior corneal curva- be a better candidate for PRK which the patient has less total ture. Today’s corneal tomogra- than LASIK (given his mild topo- tissue and some is removed, com- phy systems, however, can more graphical irregularity). His resid- plications are more likely. accurately measure both the an- ual stromal bed thickness can be Higher degree of myopia. This terior and posterior corneal sur- estimated at 560µm minus about is related to residual stromal faces than earlier technologies. 53µm of stroma (15µm x 3.5D of bed thickness in that a higher Recent data based on modern spherical equivalent myopia lost degree of stromal tissue must be corneal tomography collected us- to ablation), for about 507µm. removed to allow for the success- ing devices such as the Pentacam Since PRK might be recommend- ful correction of higher levels of (Oculus) or Orbscan (Bausch + ed for this patient over LASIK, ametropia. Lomb) also suggest that PRK (in- there would be no fl ap thickness This rating system is not with- stead of LASIK) could be safely to account for, meaning more out controversy, as some sur- performed on mildly irregular stromal tissue is left behind. As geons fi nd it too simplistic and cornea patients, provided that such, assuming that this patient limiting, especially in its admo- the following conditions hold exhibits a typically regular poste- nition against performing LASIK true: First, the patient’s posterior rior corneal curvature, he may be in some younger patients. While corneal surface must be normal a candidate for PRK. imprecise, it does raise valuable (underscoring the importance The recent FDA approval of points for discussion that should of modern tomography’s ability corneal crosslinking and the be individualized to each patient to image it); second, the cornea emerging technology of topogra- in your evaluation. must be suffi ciently thick; third, phy-guided PRK may mean that At fi rst look, it appears that the patient must have good pre- performing refractive surgery on the patient mentioned above operative best-corrected specta- irregular corneas will become should undoubtedly be excluded cle acuity to be considered for more common. By crosslinking from refractive surgery due to his PRK.3 the collagen fi bers and strength- corneal topography fi ndings. But In this case, the practitioner ening the stroma, the corneal another shortcoming of the rat- should consider obtaining corne- ectatic disease process can be
REVIEW OF CORNEA & CONTACT LENSES | OCTOBER 2016 31
0030_RCCL1016_LasikControversies_F5.indd30_RCCL1016_LasikControversies_F5.indd 3131 99/29/16/29/16 5:315:31 PMPM HOW WOULD YOU HANDLE THESE REFRACTIVE SURGERY CONTROVERSIES?
slowed and possibly even halted simple criteria and metrics such study considered results from if the procedure is performed pri- as these to estimate a patient’s nearly 11,000 eyes of patients or to refractive surgery; however, risk and help them weigh the aged 18 to 40 who had under- further research is necessary to options. This counseling can be gone wavefront-guided LASIK better quantify this effect. done in the optometrist’s offi ce with a 6mm optical zone with Though the patient here has as part of a preoperative surgical mean scotopic pupil diameter be- mild corneal irregularity, it’s consultation appointment. ing 6.6mm.5 Nearly 27% of these worth noting that some cases of eyes had a pupil diameter of ectasia occur in eyes that were SMALL PUPIL 8mm or larger, yet at six months topographically regular preoper- Pupil size is another fac- the researchers observed no cor- atively. So, how do we quantify 2 tor to consider prior to relation between pupil diameter the ectasia risk in these patients? recommending LASIK. Consider and patient-reported outcomes A recently proposed metric the following case: such as satisfaction, presence of known as percent tissue altered A 26-year-old female contact night glare or onset of halos. (PTA) may help. It states that lens wearer with good ocular The dissociation between during calculation, fl ap thickness health presents for a consultation pupil size and visual disruptions (FT) should be added to the abla- with refraction values of -5D can possibly be explained by tion depth (AD), then divided by in each eye and central corne- a number of factors. First, the the preoperative central corneal al thicknesses of 580µm. The typical treatment zone for LASIK thickness (CCT), or PTA = (FT + practitioner also notices that the increased from 4mm during the AD) / CCT.4 The study that gave patient’s pupils are 8mm in dim procedure’s earlier days to a rise to this equation determined illumination and questions her more pupil-sparing diameter of that a PTA higher than 40% was regarding the presence of glare or 6mm today. Furthermore, some the strongest predictive factor of halos during contact lens wear, newer ablation algorithms de- ectasia risk (more so than age, to which the patient responds liver extra pulses to the mid-pe- RSB thickness and total Ectasia negatively. She does, however, ripheral cornea in an attempt to Risk Score). Because this study report some glare while wear- decrease spherical aberration. was done using topographically ing her spectacles, and wants In this context, how then normal eyes, however, a lower to know whether she is a good should we approach a preoper- threshold may be applicable candidate for LASIK. ative discussion with a patient in the case of mildly irregular Many patients who undergo with larger pupils? Someone corneas. refractive surgery have reported with 8mm pupils historically The risk of post-surgical ecta- the presence of postoperative would have been discouraged sia can never be eliminated, of glare and halos, especially in from undergoing LASIK; nowa- course, but practitioners can use dim illumination. Conventional days, perhaps these individuals wisdom tells us that pupils can simply be counseled that measuring larger than the laser there are confl icting reports in treatment optical zone prior the literature about a higher risk to surgery increase the risk of for glare and halos after surgery visual disruption after surgery. In but that it need not be a contra- fact, this relationship has served indication if they are willing to as fodder for many malprac- accept the possibility. However, tice lawsuits—so much so that if the patient is on a systemic many practitioners now advise medication that causes mydriasis these patients against refractive (including tricyclic antidepres- surgery. sants and anticholinergics), the This corneal topography shows a regular LASIK-naïve cornea with Despite this, however, other risk is defi nitively higher. average keratometry reading of recent research has disputed the In conclusion, this patient 40.62D. Flat postoperative corneas connection between pupil size should be counseled regarding may increase the risk of aberration- and visual disturbances, possibly the theoretical risk and historical induced visual disturbances; therefore presurgical keratometry opening the door for a better association between large pupils readings should be considered. understanding. One retrospective and nighttime glare and halos.
32 REVIEW OF CORNEA & CONTACT LENSES | OCTOBER 2016
0030_RCCL1016_LasikControversies_F5.indd30_RCCL1016_LasikControversies_F5.indd 3232 99/29/16/29/16 5:315:31 PMPM But she should also be notifi ed is fl attened by that more recent research has about 0.75D, found no association between with particu- pupil size and visual complaints. larly excessive Assuming she is otherwise a good fl attening candidate for the procedure, her leading to the pupil size should not exclude her onset of aber- from LASIK treatment. rations such as spherical HIGH MYOPIA aberration Patients with higher de- or coma. 3 grees of myopia are also Though well at risk for suboptimal refractive studied in the surgery outcomes. For such literature, patients, several considerations there’s no must be accounted for preopera- consensus on This patient demonstrates marked punctate epithelial tively. First and foremost, some the minimum staining associated with dry eye syndrome. Aggressive may be at greater risk for post- recommended treatment would be indicated before considering LASIK. LASIK ectasia, since the correc- postoperative tion of higher degrees of myopia keratometry measurements— Postoperative corneal thick- entails the removal of more proposed minimum limits range ness. Based on the formula stromal tissue, leading to thin- from 33D to 39D. The topic above, it can be estimated that ner postoperative corneas and warrants greater scrutiny and this patient’s post-op RSB thick- higher PTA values. Though PRK consideration. ness following LASIK would is a better option than LASIK to In considering, for instance, be: 590µm - 100µm - (15µm x reduce the risk of ectasia, since it a 34-year-old lifetime specta- 7D) = 385µm. This results in an results in a thicker residual stro- cle wearer who presents for a adequate post-surgical corneal mal bed, PRK also increases the LASIK consultation, three main stromal bed thickness, so she risk of corneal haze developing variables should be examined to would therefore qualify to under- in individuals with high myopia.6 determine her LASIK candidacy. go LASIK. LASIK still remains the preferred Manifest refraction reveals 7D Percent tissue ablation. The treatment for high myopes de- of myopia in each eye, central PTA value for this patient can spite these issues. corneal thickness is 590µm and also be calculated as (100µm + Practitioners should also pay keratometry readings are 40D. 105µm) / 590µm = 34.7%. Since attention to the preoperative Additionally, her ocular health is this result is less than the pro- keratometry readings of high my- suitable in both eyes. However, posed threshold of 40%, she also opes—for each diopter reduction her attending practitioner should meets this qualifi cation for the in spectacle myopia, the cornea consider the following: procedure.
THE COURT OF PUBLIC OPINION
Most debates about medical and surgical procedures remain within the professional sphere. Not so with refractive surgery. Our internal discussions and concerns have long since spilled over into the lay media, with Morris Waxler, former FDA chair of ophthalmic devices—and one of today’s most vocal critics of LASIK—speaking on the limitations of the data used as the basis for the treatment’s approval in 1998.10 His recent speeches have led to public disagreements, with his supporters on one side aligned against the FDA and various ophthalmology organizations on the other. As these feuds have been covered by popular media outlets, patients may mention them in the exam room. Regardless of which side a practitioner may stand on for any given issue, it is helpful to be aware of these ongoing conversations so that we can continue to be educators and advocates for all patients who enter the clinic.
REVIEW OF CORNEA & CONTACT LENSES | OCTOBER 2016 33
0030_RCCL1016_LasikControversies_F5.indd30_RCCL1016_LasikControversies_F5.indd 3333 99/29/16/29/16 6:386:38 PMPM HOW WOULD YOU HANDLE THESE REFRACTIVE SURGERY CONTROVERSIES?
Postoperative keratometry before considering treatment of done by the referring optometrist reading. Keeping in mind that hyperopic regression in eyes that prior to surgery to help the OD 0.75D of corneal fl attening oc- had initially undergone PRK.7 and MD alike in counseling the curs per diopter of myopia, her So, while LASIK has demon- patient about their suitability for postop K can be calculated to be strated good refractive stability surgery. 40D - (7D x 0.75) = 34.75D. The in hyperopic eyes, performance estimated postsurgical corneal of PRK in hyperopic eyes may ince LASIK’s approval by the steepness of just under 35D in raise the potential for hyperopic SFDA nearly 20 years ago, the this patient is within the gray regression for six months to one procedure has improved by leaps area between acceptable and year postoperatively. Patients and bounds. Today, the rate of inadvisable. Counseling this who experience this, including postoperative complications is patient that she is a fair candi- the one mentioned here, should lower than ever. Nevertheless, it date to consider LASIK is war- wait until stability is demonstrat- remains important for optom- ranted; however, she should also ed so that enhancement efforts etrists to be aware of current be made aware of the potential can be adequately tailored. controversies in care and recent aberration-induced visual distur- advances in pre- and perioper- bances stemming from her fl at- POST-LASIK ative care of refractive surgery tened postsurgical corneal shape. DRY EYE patients. Such clinical know-how 5 A 23-year-old female will enable a more effective con- HYPEROPIC presented to the clinic wear- sultation of patients who may be 4 REGRESSION ing disposable contact lenses entertaining the idea of undergo- Though refractive sur- and complained of end-of-day ing refractive surgery. RCCL gery is most commonly used to dryness while wearing her lenses. 1. Randleman JB, Woodward M, Lynn MJ, treat myopia, it is also effective She commented that it would Stulting RD. Risk assessment for ectasia after in managing hyperopia; however, be great if she could eliminate corneal refractive surgery. Ophthalmology. 2008;115:37–50. patients who underwent PRK the need for contact lens wear 2. Santhiago MR, Giacomin NT, Smadja D, may be at risk for hyperopic with a LASIK procedure. Ocular Bechara SJ. Ectasia risk factors in refractive sur- regression for six months to one examination revealed moderate gery. Clin Ophthalmol. 2016 Apr 20;10:713-20. 3. Alpins N, Stamatelatos G. Customized year after the procedure. dry eye syndrome and meibo- photoastigmatic refractive keratectomy using combined topographic and refractive data for Consider a 35-year-old male mian gland dysfunction; as such, myopia and astigmatism in eyes with forme with 3D of hyperopia in each though she is an otherwise ex- fruste and mild keratoconus. J Cataract Refract eye who was referred for PRK. cellent candidate for LASIK, the Surg. 2007;33(4):591602. 4. Santhiago MR, Smadja D, Gomes BF, Mello Though initially satisfi ed with ocular surface disease should be GR, Monteiro ML, Wilson SE, Randleman JB. Association between the percent tissue altered the results, four months follow- treated prior to surgery. and post-laser in situ keratomileusis ectasia in ing the procedure he began to Several studies cite dry eye eyes with normal preoperative topography. Am complain of diffi culty viewing syndrome as the most common J Ophthalmol. 2014 Jul;158(1):87-95. 5. Schallhorn S, Brown M, Venter J, et al. The computer screens. The attend- postoperative complication in re- role of the mesopic pupil on patient-reported outcomes in young patients With myopia 1 ing practitioner found 1.5D of fractive surgery patients, possibly month after wavefront-guided LASIK. J Refract refractive hyperopia present, and due to disruption of the feedback Surg. 2014;30: 159-165. the patient requested a surgical loop between the cornea and the 6. Pietilä J, Mäkinen P, Pajari T, et al. Eight-year follow-up of photorefractive keratectomy for 8,9 enhancement. lacrimal glands during surgery. myopia. J Refract Surg. 2004;20:110-5. A recent study of retreatment For instance, corneal nerves can 7. Frings A, Richard G, Steinberg J, et al. LASIK and PRK in hyperopic astigmatic eyes: is early to manage hyperopic regres- be severed by the fl ap creation retreatment advisable? Clin Ophthalmol. 2016 sion following LASIK or PRK in a LASIK procedure, reducing Mar 31;10:565-70. 8. Golas L, Manche EE. Dry eye after laser in in hyperopic astigmatic eyes the capacity for refl ex tearing. situ keratomileusis with femtosecond laser and found signifi cantly higher levels Patients who have collagen vas- mechanical keratome. J Cataract Refract Surg. 2011 Aug;37(8):1476-80. of hyperopic regression present cular disease may be at a partic- 9. Shoja MR, Besharati MR. Dry eye after LASIK at six months post-op in eyes ularly high risk for development for myopia: Incidence and risk factors. Eur J treated with PRK vs. LASIK.7 of denervation and subsequent Ophthalmol. 2007 Jan-Feb;17(1):1-6. 10. LASIK Newswire. FDAer Who OK’s LASIK The researchers’ recommenda- dry eye; as such, aggressive treat- Petitions for Revocation. Available at www. lasiknewswire.com/2011/01/fdaer-who-okd-lasik- tion was to wait at least six to ment of even mild cases of dry petitions-for-revocation.html. Accessed July 12 months after the procedure eye is recommended. This can be 18, 2016.
34 REVIEW OF CORNEA & CONTACT LENSES | OCTOBER 2016
030_RCCL1016_LasikControversies_F5.indd 34 9/29/16 5:31 PM Up to 20 CE Credits* ANNUAL
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2017_WinterOphth-HouseAd.indd 1 9/30/16 11:13 AM The GP Experts By Robert Ensley, OD, and Heidi Miller, OD
Don’t Forget to Check the Lids While always important to lens wear, the eyelids also play a vital role in GP lens success.
hen deciding lid position is important for proper which contact orientation and lens movement. lens modality The lid position is also crucial in is the best for a determining whether an aspheric, Wpatient, contact concentric or translating design will lens specialists always consider be successful for the patient. When curvature of the cornea, contact considering an aspheric lens, the lens diameter and ocular surface best candidates are those with lower conditions; however, the eyelids are lid margins well above or below often easily forgotten. The lids are the limbus, loose lids that will not Fig. 1. The natural tendency of a taken into account when evaluating support prism ballast or those with scleral lens to decenter inferiorly for blepharitis or meibomian gland steep corneal curvatures.2 As with can be exacerbated in patients with dysfunction, but they may be an any multifocal, centration and tighter lids or a narrow palpebral afterthought during a contact lens minimal movement is critical for aperture. evaluation. When fi tting GP lens- providing optimal vision with less es—whether corneal, intralimbal or aberrations at all distances. Good scleral—it is important to evaluate candidates for a concentric or trans- lid position in relation to the cornea. lating design are those with a lower The eyelids play a vital role in how lid margin tangent to or slightly a lens will fi t and what options will above the lower limbus, a normal- be possible when troubleshooting a to-large vertical fi ssure width and problem lens fi t or potential design. normal-to-tight lid tension.2 Loose lids will not do well with these POSITIONING CORNEAL GPs lenses, as they limit translation of In our approach to fi tting corneal the lens, preventing the patient from Fig. 2. A decentered lens results in asymmetrical clearance, with the GP lenses, practitioners tend to seeing through the full reading add. greatest amount noted inferiorly. provide an apical alignment fi t with slight upper lid attachment. In cases LIDS AND SCLERALS shooting options such as incorporat- where a patient may have extremely Eyelids also play a role in the way ing toric peripheral landing curves, taut lids, this may cause the lens to a scleral contact lens fi ts on an eye. decreasing overall clearance or ride higher than average and result Naturally, scleral lenses have a decreasing the overall contact lens in corneal molding due to the pres- tendency to decenter inferiorly. This diameter, sometimes the lens will sure provided by the superior lid. can be exacerbated by having tight- continue to sit lower than normal Modifi cations in overall diameter or er lids or a narrow palpebral aper- because of lid positioning. In situa- base curve of the lens may be neces- ture (Figure 1). When fi tting scleral tions such as this, practitioners may sary to bypass these issues. On the lenses, hypoxia and corneal edema have to leave the fi t as is, as long as contrary, patients with dermatocha- are two complications practitioners adequate central corneal and limbal lasis may have the opposite problem need to watch for closely. A decen- clearance is provided. It is import- in that the lens sits low or decenters tered lens results in asymmetrical ant to minimize lens thickness and due to the narrowed palpebral clearance throughout the lens, with use the highest Dk lens materials to aperture and reduced elasticity of the greatest amount of clearance allow better oxygen transmissibility. the skin.1 In these patients, it may inferiorly (Figure 2). This can lead It is also crucial to provide closer be necessary to consider a scleral to a decrease in oxygen permeabil- follow-up care and thorough patient instead, to prop the lid up and pro- ity inferiorly, making hypoxia and education on symptoms that could vide better overall centration. corneal edema more of a concern. indicate hypoxic conditions. In presbyopic patients, inferior Even after exhausting trouble- Fitting front surface toric lenses
36 REVIEW OF CORNEA & CONTACT LENSES | OCTOBER 2016
036_RCCL1016_GPE.indd 36 9/29/16 6:38 PM is another instance in which the eyelids can affect a scleral lens fi t. If an overrefraction indicates the need for astigmatic correction, a front surface toric may be needed. To stabilize the lens on the eyes, double slab-off ballasting stabilization can minimize rotation. Unfortunately, eyelids can have an effect on lens ro- Fig. 3. A long-time GP lens wearer with bilateral blepharoptosis of unequal tation, making it diffi cult to achieve magnitude (greater OS vs. OD). Lid manipulation during lens insertion and stabilized vision.3 removal can contribute to the development of blepharoptosis. According to one expert, front toric against-the-rule cylinders will Patients typically present with mild anges vary per study, but pro- naturally align on axis in eyes that to moderate ptosis of one or both Rlonged GP contact lens wear is have eyelid margins that oppose eyes, good levator function and the only identifi able cause of ptosis 6 each other in the vertical meridian elevated lid crease. in up to 47% of patients under the due to the thin zones at 6 and 12. If There are two main theories for age of 50.6,8 Studies also suggested the eyelids oppose more obliquely, the mechanism behind contact lens– there is an increased risk of blepha- the lens will rotate obliquely.3 This induced ptosis. The fi rst involves the roptosis in soft contact lens wearers is important when the lens contin- manipulation of the upper eyelid compared with non-wearers.9 While ues to rotate out of position despite during contact lens removal. The the percentage may seem high, the toric peripheral landing curves and pulling of the eyelid laterally fol- average duration of contact lens good centration of the lens. lowed by a harsh blink can lead to wear was 15 years, and not all pa- 6 There are several ways eyelids thinning of the levator aponeurosis. tients are symptomatic.8 Unless the can affect lens position and fi t. Research shows eyelid irritation and superior visual fi eld is obstructed, However, it is important to keep edema from constant interaction surgical intervention is not typically in mind the changes gas permeable with the contact lens edge can lead warranted. RCCL 7 lenses can have on the eyelids with to a reversible ptosis. Figure 3 1. Benjamin WJ, Borish IM. Physiology of aging prolonged lens wear. Research re- demonstrates a patient and its infl uence on the contact lens prescription. ports non-senile blepharoptosis, or who has worn gas permeable con- J Am Optom Assoc. 1991;62(10):743-753. 2. Bennett ES, Weissman BA. Clinical contact lens drooping of the upper lid, as a com- tact lenses for over 20 years. Her practice. Philadelphia: Lippincott; 1991. plication of long-term contact lens history consisted of mild keratoco- 3. van der Worp E SS. A Guide to Scleral Lens Fitting: College of Optometry, Pacifi c University. wear.4 Ptosis results from dysfunc- nus in the right eye and prior radial 2010. tion of either the levator palpebrae keratometry surgery in the left. 4. Friedman NJ, Pineda R. The Massachusetts Eye and Ear Infi rmary Illustrated Manual of Ophthal- superioris or Müller’s muscle, which She has worn lenses that were mology. 3rd ed. Philadelphia: Elsevier; 2009. are responsible for elevation of the two different sizes to allow for bet- 5. Watanabe A, Araki B, Noso K, et al. Histopa- ter centration and overall alignment thology of blepharoptosis induced by prolonged eyelids. hard contact lens wear. Am J Ophthalmol. Etiologies for ptosis include on the cornea. As evident in Figure 2006;141(6):1092-6. 3, the degree of blepharoptosis is 6. Thean JH, McNab AA. Blepharoptosis in RGP neurogenic, myogenic, mechanical and PMMA hard contact lens wearers. Clin Exp and aponeurogenic mechanisms. different between the two eyes, with Optom. 2004;87(1):11-4. the left eye having a greater degree. 7. Jupiter D, Karesh J. Ptosis associated with The most common acquired form is PMMA/rigid gas permeable contact lens wear. aponeurotic, in which disinsertion Lid manipulation during insertion CLAO J. 1999;25(3):159-62. and removal along with the amount 8. Kersten RC, de Conciliis C, Kulwin DR. Acquired or dehiscence of the levator aponeu- ptosis in the young and middle-aged adult popu- rosis leads to ptosis.4,5 This form is of lid interaction with the lens could lation. Ophthalmology. 1995;102(6):924-8. cause the asymmetrical blepharo- 9. Kitazawa T. Hard contact lens wear and the risk often associated with age, ocular of acquired blepharoptosis: a case-control study. surgery and contact lens wear. ptosis noted. Eplasty. 2013;13:e30.
REVIEW OF CORNEA & CONTACT LENSES | OCTOBER 2016 37
036_RCCL1016_GPE.indd 37 9/29/16 6:38 PM Out of the Box By Gary Gerber, OD
Brand Yourself, and They Will Come This requires work, but is much more valuable to the growth and sustainability of your practice than just about anything else.
Coca-Cola execu- more importantly, what patients undivided attention. I genuinely tive was famously believe and expect you to be. If that felt like they cared about me.” quoted as saying, “If is destroyed, no frame displays, Alternatively, it could be, “I felt Coca-Cola were to new contact lenses or ultramodern like they were more concerned Alose all of its pro- piece of technology can replace it. about making sure the boxes on duction-related assets in a disaster, It takes work to continually sup- the insurance form were all fi lled the company would survive. By port and protect your brand. This out than they did about my eyes.” contrast, if all consumers were to isn’t about reputation management. Or, “They just cared about selling have a sudden lapse of memory A strong brand can manage that me glasses—the ones they wanted and forget everything related to for you. If you get a bum new to sell me, not ones that I wanted.” Coca-Cola, the company would go iPhone, you expect it to be replaced These scenarios can help initiate out of business.” with no hassle. If it isn’t, and you the evolution of your brand. write a bad review about it, Apple’s MIND OVER MATTER existing strong brand will negate STAY TRUE TO YOUR BRAND How would your practice fare in your review. You’ll be seen as a Take some of the positive attri- a similar situation? Which would whiner, complainer and outlier. butes above and start to build your hurt your business more—a physi- Brand management goes beyond brand around them. For example: cal disaster of your equipment and getting good Yelp reviews. if undivided attention is a key part inventory or wiping out your pa- of your brand message, challenge tients’ and community’s perception MAKE YOUR PRACTICE your staff with the question, “How of your brand? How strong is your MATCH YOUR BRAND will you handle a situation where brand and your brand awareness? To protect and build your brand, you’re on the phone with one pa- Do people really emotionally con- you must clearly articulate what tient, two others are on hold, one nect with who you are and what it is—a diffi cult task that often patient is waiting at the front desk you do? requires professional help. to pay his bill and a new patient walks in 20 minutes early for her appointment? How can all of those DO PEOPLE REALLY patients experience undivided attention?” EMOTIONALLY CONNECT WITH Such situations might lead to responses like, “We have to ensure we have enough staff so that never WHO YOU ARE AND WHAT happens.” If it turns out that really is the best solution, and you are go- YOU DO? ing to be true to your brand, then you must hire more staff. After all, If you think loss of your physical To start, fi rst think in terms of you are either about providing un- assets would be more devastating what you want patients to feel after divided attention—to every patient than mass memory loss, you’ve got doing business with you. Or, what every time—or you’re not. Create a work to do—a lot. While it’s certain- do you want a current patient to sincere brand and practice loyal- ly not easy to physically rebuild a relay to others about their experi- ty to it; and, if you have a minor practice, in the fi nal analysis, as the ence with your practice? Consider disaster—your topographer keeps saying goes, it really is “just stuff.” these examples of patient reactions: shutting off between imaging the Your brand, on other hand, is “There were eight other patients in right and left eye, for instance— so much more. It’s who you are or, the offi ce. I counted. Yet, I received your patients will be forgiving. RCCL
38 REVIEW OF CORNEA & CONTACT LENSES | OCTOBER 2016
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