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RCCL JUNE 2016 REVIEW OF CORNEA & CONTACT LENSES

SPECIAL ISSUE: Research and Clinical Practice

New Ideas from ARVO 2016 P. 10 Post-Refractive Rigid Lens Use P. 16 Fitting Orthokeratology Lenses P. 22 CXL and Semi-Sclerals P. 28 Reinventing Brimonidine P. 40

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RCCL0416_Coopervision.indd 1 3/22/16 3:24 PM contents Review of Cornea & Contact Lenses | June 2016

departments features Building a Foundation for a 4 News Review Better Future: ARVO 2016 Considering New Treatments for Abstract Review Neovascularization; Study on SPK An expert weighs in on new ideas in the Lesion Size May Lead to Better ﬁ eld of cornea and contact lens care. Equipment 10 By Joseph P. Shovlin, OD 6 My Perspective Corneal Crosslinking: Fitting Rigid Lenses After Its Time Has Come Refractive Surgery By Joseph P. Shovlin, OD Corneal and scleral GP lenses cover the ‘last mile’ for patients who need 8 Pharma Science & Practice correction after LASIK and PRK. By Melanie Frogozo, OD Recycling Cyclosporine 16 By Elyse L. Chaglasian, OD, and Tammy Than, MS, OD Unusual Clinical Cases in Orthokeratology 40 Practice Progress For the right patient, these lenses may Brimonidine Breakup be life-changing. Two challenging cases provide insights into the ﬁ tting process. By Mile Brujic, OD, and Jason R. Miller, OD, MBA 22 By Daddi Fadel, DOptom

Out of the Box Contact Lens Use Following 42 Corneal Crosslinking Making the Best of It An irregular cornea patient presents By Gary Gerber, OD needing better vision following a corneal stabilization procedure. What do you do? 28 By Boris Severinsky, OD Case Report: Look Before You Judge The most unique cases sometimes present as the most mundane. 34 By Mohammad Tallouzi, OD Medically Necessary Contact Lenses: Medical Plan or Vision Plan Responsibility? Do you know how to work with the ON THE COVER 36 insurance company to achieve the Optometry student photoshoot image biggest bang for your buck? courtesy of Cardiff University in Cardiff , By Robert L. Davis, OD Wales, United Kingdom.

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IN BRIEF Considering New Treatments ■ Certain characteristics including increased vascularity may be a risk factor for Neovascularization for recurrence of pterygium following surgery, reports research published online in the journal Cornea.1 Researchers in Korea collected data on clinical and demographic fl ibercept may be a diameter and comprising approx- variables of 149 subjects including length, better alternative than imately 15% of the total corneal width, area and vascularity of pterygium and age and sex of patients. Anterior seg- bevacizumab in regulat- area. Corneal samples were collect- ment photos were taken prior to the proce- Aing the advancement of ed on day 21 for histological and dure, and patients were followed up with at one year postoperatively. Recurrence rate corneal neovascularization, reports fl at-mount immunofl uorescence was measured at 18.8% of the patients, with research published online in the analyses. Results in all three groups univariate analysis demonstrating that rela- 1 tive length and width of the pterygium and journal Cornea. Previous studies indicated that neovascular sprout- degree of vascularity were all correlated have investigated whether target- ing began at the limbal area on day with the trend. Multivariate analysis, however, demonstrated only higher vascularity ing vascular endothelial growth three following injury and reached was correlated with recurrence. As such, factor—a key cytokine in the de- maximum intensity around days automated image analysis of anterior segment photos could assist with determining velopment of blood vessels in both seven through nine; however, those which patients might develop pterygium normal and abnormal patients (i.e., subjects treated with afl ibercept again, the researchers concluded. in the case of a tumor or in tissues exhibited a signifi cantly smaller 1. Han SB, Jeon HS, Kim M, et al. Risk factors for recurrence after pterygium surgery: an image anal- undergoing abnormal angiogene- relative area of neovasculariza- ysis study. Cornea. 2016. [Epub ahead of print.] sis)—is a good way to possibly treat tion than either the control or the ■ Soft contact lens wearers with dry eye this condition. bevacizumab groups. Additionally, symptoms may also exhibit reduced tear menisci, reports a study in the May 2016 Researchers from Tel Aviv a difference in the rate of change of issue of Eye and Contact Lens.1 A reduction University in Israel investigated the the neovascularized area over time in tear volume is one of the common factors associated with ocular surface disease; in- effects of afl ibercept or bevacizum- between the afl ibercept group and deed, previous research has indicated there ab administered to Sprague-Dawley both the control and bevacizumab are more abnormal corneal nerve morpho- logic changes in patients with the aqueous rats with induced chemical burns. groups was observed, but not be- tear defi ciency form of dry eye. However, Thirty-one animals were random- tween the control and bevacizumab to date no research has examined whether symptomatic contact lens wearers have ized to receive either subconjuncti- groups, suggesting the latter is not had a similar reduction in corneal nerve val injections of 0.08mL afl ibercept as effective in this application. density due to reduced tear volume. In this study, scientists in China found that upper (25mg/mL), 0.05mL bevacizumab “In conclusion, this suggests that and lower tear menisci height and area (25mg/mL) or 0.05mL physiologic afl ibercept may hold promise as an were signifi cantly lower in patients who wore soft contact lenses, compared with saline using a 30-G needle applied effective modality for use in patients those who did not. Interestingly, this eff ect 1mm distal to the limbus at the 6 with corneal neovascularization,” occurred specifi cally in the midperipheral area of the cornea. o’clock and 12 o’clock positions. the researchers conclude. As such, 1. Hu L, Chen J, Zhang L, et al. Eff ects of long- Afl ibercept is a VEGF-trap mole- “further investigation is warranted term soft contact lenses on tear menisci and corneal nerve density. Eye Contact Lens. 2016 cule that is both known to act as to determine the effi cacy of sub- May;42(3):196-201. a receptor decoy for all isoforms conjunctival afl ibercept in inducing ■ A study investigating corneal densitom- of VEGF-A and also bind VEGF-B regression of preformed versus etry and higher-order aberrations (HOAs) one year post-transplantation of Bowman’s and placental growth factors 1 mature corneal vessels, its minimum layer found that corneal HOAs decreased and 2 to enhance the antiangio- effective dose and safety profi le and for both anterior and posterior corneal surfaces following surgery, while corneal genic response, while bevacizumab other possible modes of application backscattering increased. Neither trend has previously been confi rmed to in animals and humans.” RCCL correlated with alterations in corrected inhibit chemically-induced neovas- distance visual acuity, however. These re- 1. Gal-Or O, Livny E, Sella R, et al. Effi cacy of sults, published online in the journal Cornea, cularization via its own action on subconjunctival afl ibercept versus bevacizumab for suggest further research involving larger 2,3 preventional of corneal neovascularization in a rat populations with patient-subjective visual VEGF-A. model. outcomes and contrast sensitivity analysis is Degree of corneal neovascular- 2. Sener E, Yuksel N, Yildiz DK, et al. The impact of needed to help further explain the eff ect of subconjunctivally injected EGF and VEGF inhibitors corneal backscattering on optical quality.1 ization was evaluated on post-in- on experimental corneal neovascularization in rat model. Curr Eye Res. 2011;36:1005-1013. 1. Luceri S, Parker J, Dapena I, et al. Corneal jury days one, three, seven, nine 3. Oner V, Kucukerdonmez C, Akova YA, et al. densitometry and higher order aberrations after and 13 via corneal photography, Topical and subconjunctival bevacizumab for corne- bowman layer transplantation: 1-year results. Cor- al neovascularization in an experimental rat model. nea. 2016. [Epub ahead of print.] with burn area measuring 2mm in Ophthalmic Res. 2012;48:118-123.

4 REVIEW OF CORNEA & CONTACT LENSES | JUNE 2016

0004_RCCL0616_News.indd04_RCCL0616_News.indd 4 55/31/16/31/16 4:384:38 PMPM RRCCLCCL 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 Study on SPK Lesion Size May Email: [email protected]

EDITORIAL STAFF Lead to Better Equipment EDITOR-IN-CHIEF Jack Persico [email protected] SENIOR ASSOCIATE EDITOR ata from a study on Institut Universitaire de France Aliza Becker [email protected] epithelial lesion size in su- instilled fl uorescein into 10 pa- CLINICAL EDITOR Joseph P. Shovlin, OD, [email protected] perfi cial punctate keratitis tients with dry eye graded using the ASSOCIATE CLINICAL EDITOR (SPK) could help with the Oxford Scheme. Pictures were tak- Christine W. Sindt, OD, [email protected] D EXECUTIVE EDITOR development of automated algo- en using a standard slit lamp with Arthur B. Epstein, OD, [email protected] CONSULTING EDITOR rithms to obtain more objective and cobalt blue light and no barrier Milton M. Hom, OD, [email protected] reliable classifi cations for corneal fi lter to simulate the most common SENIOR GRAPHIC DESIGNER Matthew Egger [email protected] staining, report researchers from conditions of image acquisition. GRAPHIC DESIGNER France in the journal Cornea.1 Two magnifi cation settings (i.e., Ashley Schmouder [email protected] AD PRODUCTION MANAGER The isolated lesions that so often x10 and x16) were used to focus on Scott Tobin [email protected] characterize SPK are small fl uores- the corneal objects in question that BUSINESS STAFF cent dots of differing size and incan- measured 14.40µm and 7.81µm PUBLISHER descent intensity that are scattered under each setting, respectively. SPK James Henne [email protected] across the corneal surface. In some size did not differ between the fi ve REGIONAL SALES MANAGER Michele Barrett [email protected] cases, they can become confl uent, Oxford Scheme grades of dry eye, REGIONAL SALES MANAGER Michael Hoster [email protected] creating fl uorescent areas in which but did appear to be slightly smaller VICE PRESIDENT, OPERATIONS the individual lesions are no longer than typical superfi cial epithelial Casey Foster [email protected] distinguishable. Because the number cells, which measure approximately EXECUTIVE STAFF and specifi c locations of these dots 25x50µm. CEO, INFORMATION SERVICES GROUP Marc Ferrara [email protected] is an important clinical criterion “Our data on the size of SPK SENIOR VICE PRESIDENT, OPERATIONS directly connected to the level of staining lesions in this study is not Jeff Levitz [email protected] surface integrity, differentiating directly relevant to clinicians,” SENIOR VICE PRESIDENT, HUMAN RESOURCES between them is critical—especially the researchers acknowledged. Tammy Garcia [email protected] VICE PRESIDENT, during clinical trials. The new algo- “However, it will prove useful for CREATIVE SERVICES & PRODUCTION rithms could help ease this issue. researchers developing new devic- Monica Tettamanzi [email protected] VICE PRESIDENT, CIRCULATION In this study, the team from Jean es and image analysis algorithms Emelda Barea [email protected] Monnet University, the University to improve SPK severity grad- CORPORATE PRODUCTION MANAGER John Caggiano [email protected] Hospital of Saint-Etienne and the ing. Indeed, if the size of isolated epithelial lesions characterizing EDITORIAL REVIEW BOARD Mark B. Abelson, MD Surgical Trends SPK is known, it will be possible James V. Aquavella, MD A national study from Switzerland to optimize device resolution to Edward S. Bennett, OD Aaron Bronner, OD suggests the number of detect individual lesions using the Brian Chou, OD keratoconus-related corneal appropriate fi lters or thresholds Kenneth Daniels, OD transplants has decreased in S. Barry Eiden, OD and ultimately to precisely quantify Desmond Fonn, Dip Optom M Optom the last 10 years, while lamellar Gary Gerber, OD techniques are being increasingly corneal staining.” RCCL Robert M. Grohe, OD Susan Gromacki, OD performed. Furthermore, among 1. Courrier E, Lepine T, Hor G, et al. Size of the Patricia Keech, OD anterior lamellar keratoplasty lesions of superfi cial punctate keratitis in dry eye syndrome observed with a slit lamp. Cornea. 2016. Bruce Koffler, MD techniques, maximal depth DALK Pete Kollbaum, OD, PhD [Epub ahead of print.] Jeffrey Charles Krohn, OD is the most prevalent keratoplasty. Kenneth A. Lebow, OD Frequency of penetrating Jerry Legerton, OD Kelly Nichols, OD keratoplasty (PKP) is expected to Advertiser Index Robert Ryan, OD remain stable.1 Jack Schaeffer, OD Charles B. Slonim, MD CooperVision...... Cover 2 Kirk Smick, OD 1. Godefrooij DA, Gans R, Imhof SM, Wisse RPL. Mary Jo Stiegemeier, OD Trends in penetrating and anterior lamellar Alcon...... Cover 3 Loretta B. Szczotka, OD corneal grafting techniques for keratoconus: a national registry study. Acta Ophthalmologica. Menicon...... Cover 4 Michael A. Ward, FCLSA 2016 Apr 7. [Epub ahead of print.] Barry M. Weiner, OD Barry Weissman, OD

REVIEW OF CORNEA & CONTACT LENSES | JUNE 2016 5

0004_RCCL0616_News.indd04_RCCL0616_News.indd 5 55/31/16/31/16 4:394:39 PMPM My Perspective By Joseph P. Shovlin, OD

Corneal Crosslinking: Its Time Has Come Though the main treatment for ectasia remains contact lens use, a new procedure could ease the ﬁ tting ordeal.

he Food and Drug vin) that helps “cure” the cornea because irradiation is part of the Administration’s recent with application of UVA light at procedure. approval of the corneal 365nm to 370nm for approxi- Interestingly, adjunct studies collagen crosslinking mately 30 minutes provided at to evaluate corneal crosslinking’s Tprocedure in the United well-defi ned intervals and strength effi cacy in treating corneal infec- States means that we have gained levels. The goal of the procedure tions are still being conducted; another valuable tool for treating is to halt further progression of however, results to date remain eye disease. Photrexa Viscous corneal disease and reduce corneal mixed. Additionally, though this (ribofl avin 5’-phosphate in 20% surface and posterior irregularity is less of a concern in cases when dextran ophthalmic solution) in patients with corneal ectasia.2 the epithelium remains in place 0.146%, Photrexa (ribofl avin Total offi ce visit time for both eyes during the procedure, corneal 5’-phosphate ophthalmic solution) is roughly 90 minutes. thickness cannot be exceedingly 0.146%, and the KXL system thin or there is risk of toxicity to (Avedro) will be promoted as the IN THE CHAIR the endothelium. only current FDA-approved ther- The procedure works on the apeutic treatment for progressive principle that when collagen fi brils nvestigators continue to look ectatic disorders like keratoconus. are crosslinked, they form strong Ifor alternatives for crosslinking The approval process for this chemical bonds with one another.2 beyond use of ribofl avin and UVA, technology included three separate As we age, the cornea naturally such as use of rose Bengal as a studies over a period of several forms stronger bonds due to an marker and green light for treat- years that were ultimately com- oxidative process that occurs ment. In the meantime, however, bined for meta-analysis to provide during end-stage changes to the Avedro should be congratulated reasonable assurance of both safe- collagen. This may help explain for sponsoring several well-de- ty and effi cacy. The NDA submis- the fast progression of corneal signed clinical trials that went sion studies were randomized (i.e., weakening that happens earlier beyond simply including the treatment eye vs. sham treatment), in life in patients who develop observational evidence that was parallel group, open label pla- keratoconus.2,3 The Europeans originally submitted for review. cebo-controlled 12-month trials were the fi rst to employ corneal Considering the limited num- conducted in the United States. crosslinking at the University of ber of potential patients and the Resulting data found that the col- Dresden in 1998 when animal uncertainty regarding whether lagen crosslinked eyes demonstrat- model corneas exposed to ribofl a- insurance carriers will provide ed increased improvement in their vin and treated with UV light were coverage, Avedro remained com- steepest keratometric readings found to be “stiffer” and resistant mitted throughout the approval from month three to month 12.1 to enzymatic change over time.2 process. They may eventually be Yet while the system has been Potential candidates for the able to expand indications for this approved for use, many eye procedure include anyone with procedure to include treatment care practitioners may still have progressive ectasia, though most of infectious keratitis, pain relief questions regarding the proce- often the procedure is performed in bullous keratopathy and other dure itself—namely, what does it on those with keratoconus. Note, novel indications. RCCL involve and what are the goals to however, there are a few contra- 1. Avedro. Avedro Receives FDA Approval for Pho- focus on when recommending cor- indications like advanced ocular trexa Viscous, Photrexa and the KXL System for Corneal Cross-Linking. Available at: avedro.com/ neal crosslinking to a patient? In surface or autoimmune disease, press-releases/avedro-receives-fda-approval/. general, the procedure is simple to signifi cant corneal scarring or Accessed May 10, 2016. 2. EyeWiki. Corneal Collagen Cross-Linking. perform. It involves use of a pho- opacity, infection or prior herpetic Available at: eyewiki.aao.org/Corneal_Collagen_ tosensitizer/enhancer (i.e., ribofl a- disease. These are listed as such Cross-Linking. Accessed May 10, 2016.

6 REVIEW OF CORNEA & CONTACT LENSES | JUNE 2016

0006_RCCL0616_MP.indd06_RCCL0616_MP.indd 6 55/31/16/31/16 4:384:38 PMPM Save the Date!

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RCCL0616_House AAO.indd 1 5/23/16 3:10 PM Pharma Science & Practice By Elyse L. Chaglasian, OD, and Tammy Than, MS, OD

Recycling Cyclosporine New formulations of an old drug may mean better treatments for dry eye.

hese days, it seems that for these medications.5,6 CyclASol bic core surrounded by a hydro- there is such a heavy em- contains cyclosporin A in combina- philic shell that measure 10nm phasis on drug delivery tion with perfl uorobutylpentane, a to 100nm large. They are used to systems that many of unique formulation with an SFA. solubilize hydrophobic drugs and Tour current ophthalmic Earlier this year, 207 patients are believed to increase ocular pharmaceuticals are simply being were enrolled in a Phase II clinical bioavailability, minimize degrada- reformulated as “novel” thera- trial of CyclASol’s safety, tolerabili- tion and improve penetration of the pies, rather than replaced entirely.1 ty and effi cacy in treating moderate drug—all of which make them an Because the shortcomings of topical to severe dry eye disease. Patients excellent drug delivery method. Use drops are well-known, these deliv- were randomized into one of four of nanomicelles allows for cyclo- ery systems are aimed at eliminating treatment groups, including two sporine to be formulated in a clear, variability in drug concentration CyclAsol groups (each containing a preservative-free, isotonic aqueous with each dose to decrease dose different concentration of cyclospo- solution.9,10 frequency and increase absorption.2 rin A), a vehicle control group and In a Phase IIB/III clinical trial, an open-label cyclosporin A 0.05% 455 patients in a randomized, FIRST OUT ophthalmic emulsion (Restasis) double-masked study at 28 sites One such drug is CyclASol group. Patients were directed to use received either 0.05% cyclosporine, (Novaliq), which incorporates the study medication twice a day 0.09% cyclosporine or the vehicle EyeSol, an ophthalmic drug delivery for four months; researchers will as the control. All drops were ad- technology based on semi-fl uori- then evaluate the primary outcome ministered twice a day for 84 days. nated alkanes (SFAs).3 SFAs have measure of corneal fl uorescein Co-primary outcome measures been used for over a decade in the staining. Results are expected by the consisted of changes in both con- management of retinal detachments end of 2016.8 junctival staining and global symp- and overall have been well-tolerated Other research has already tom scores from baseline. Results by patients. They are physically, demonstrated the drug’s absorp- indicated both concentrations of chemically and physiologically inert tion profi le. In a pharmacokinetic Seciera were statistically superior and stable as well as water insolu- study involving rabbits, CyclASol to the placebo on both co-primary ble.4-7 Research shows the EyeSol penetrated the lacrimal gland sig- endpoints. Additionally, the 0.09% preparation does not require pre- nifi cantly better (14-fold increase) concentration also demonstrated servatives, so a multidose bottle can than an oil-in-water emulsion.5 an improvement in tear production be prepared without concern for Additionally, results from a Phase and corneal staining. contamination. Droplet size of SFAs I trial of healthy volunteers who Ultimately, however, the 0.09% is only 15µl compared with the received CyclASol eye drops or a concentration was superior to the 40µl or 50µl size of aqueous drops. placebo and then switched to the 0.05% and so will be used in an SFAs also exhibit low viscosity and alternate option in the second phase additional Phase III trial to recon- low surface tension, making them of the study found the drug offered fi rm some of the earlier fi ndings.8,11 less likely to cause blurry vision and excellent tolerability and safety.2 This study will enroll 700 patients allowing for better wettability.3 at 50 sites who will be random- Viscous vehicles like polyethylene SECOND ONE ized to receive either cyclosporine glycol and hyaluronic acid currently IN THE RUNNING 0.09% or the vehicle (control) for used for ophthalmic solutions can Another drug under consideration 12 weeks. Researchers will look effectively solubilize hydrophilic is Seciera (Auven Therapeutics), for the number of subjects with drugs. However, drugs that are a nanomicellar formulation of a clinically signifi cant increase lipophilic (i.e., hydrophobic) like cyclosporine previously known as in Schirmer’s score as compared cyclosporin A are more challenging; OTX-101. Nanomicelles are tiny with baseline. Secondary measures as such, SFAs are effective solvents particles comprised of a hydropho- include lissamine green conjunctival

8 REVIEW OF CORNEA & CONTACT LENSES | JUNE 2016

0008_RCCL0616_PSP.indd08_RCCL0616_PSP.indd 8 55/31/16/31/16 4:384:38 PMPM staining, fl uorescein corneal staining A for the treatment of severe active 1. Novack GD. Eyes on new product development. J Ocul Pharmacol Ther. 2016 Mar;32(2):65-6. and changes in symptom score. vernal keratoconjunctivitis (VKC) 2. Drug Development & Delivery. EyeSol: a novel Enrollment for this study began in in Europe. The drug—tentatively topical ocular drug delivery system for poorly soluble drugs. Available at: www.specialtyphar- February 2016. It is expected to named Vekacia—met its primary ma.com/Main/Back-Issues/EyeSol-a-Novel-Top- conclude by the end of the year.8 and key secondary endpoints in ical-Ocular-Drug-Delivery-System-137.aspx. Accessed Mar 1, 2016. Reports suggest a long-term safety a multicenter, randomized, pla- 3. ONdrugDelivery. An integrated pipeline of study is also planned for 2016 that, cebo-controlled study of patients ophthalmic products based on eyeSol delivery technology. Available at: www.ondrugdelivery. if successful, may yield a new drug ranging in age from four to 18 years com/publications/54/Novaliq.pdf. Accessed Mar application for Seciera in 2017.11 old. 1, 2016. 4. Meinert H, Roy T. Seminfl uorinated alkanes – a new class of compounds with outstanding prop- KICKING KERATITIS CYCLOSPORINE REBORN erties for use in ophthalmology. Eur J Ophthal- TO THE CURB mol. 2000 Jul-Sep,10(3):189-97. Allergan announced last fall it had 5. Steven P, Scherer D, Krosser S, et al. Semifl uo- Ikervis (Santen Pharmaceutical) submitted a supplemental document rinated alkane eye drops for treatment of dry eye disease – a prospective, multicenter noninter- was approved last year as the fi rst to the FDA for approval of a multi- ventional study J Ocul Pharmacol Ther. 2015 ophthalmic drug to treat severe dose preservative-free bottle of Oct;31(8):498-503. 14 6. Dutescu R, Panfi l C, Merkel O, Schrage N. keratitis in adults with dry eye in cyclosporin A 0.05%. The bottle Semifl uorinated alkanes as a liquid drug carrier Europe. Ikervis contains 1mg/mL will contain the equivalent amount system for topical ocular drug delivery. Eur J of cyclosporin A and is formulated of 60 single-unit vials and is a fi rst- Pharm Biopharm. 2014 Sep;88(1):123-8. 7. Broniatowski M, Dynarowicz-Latka P. Semi- as a cationic oil-in-water emulsion. of-its-kind product with a unidirec- fl uorinated alkanes – primitive surfactants of fascinating properties. Adv Colloid Interface Sci. Drug retention time was improved tional valve and air fi lter technology 2008 May 19;138(2):62-83. using a cationic nanoemulsion plat- designed to prevent the need for 8. Novaliq. Novaliq announces last patient en- form technology (i.e., Novasorb). a preservative to be included. The rolled in phase 2 clinical trial of cyclasol for the treatment of moderate to severe dry eye disease. The drug is formulated as a series of FDA did request more chemistry, Available at: www.novaliq.de/en/news/press-re- nano-sized droplets, which increase manufacturing and control (CMC) leases/. Accessed May 15, 2016. 9. Vadlapudi AD, Mitra AK. Nanomicelles: an the surface area-to-volume ratio information regarding the bottle. emerging platform for drug delivery to the eye. and improve ocular surface expo- Ther Deliv. 2013 Jan;4(1):1-3 10. Guo C, Zhang Y, Yang Z, et al. Nanomicelle sure to the drug, allowing Ikervis to onitoring clinical trial out- formulation for topical delivery of cyclosporine be given to the patient just once a Mcomes of these drugs will A into the cornea: in vitro mechanism and in vivo 12,13 permeation evaluation. Nature. 2015;Aug:1-14. day. surely be an interesting process. 11. Auven Therapeutics. Auven Therapeutics an- Also, Santen recently completed a Restasis may soon have to share nounces positive results from pivotal clinical trial of seciera (OTX-101) in dry eye disease. Available Phase III study, Vektis, evaluating a the limelight with more cyclospo- at: www.auventherapeutics.com/pr/Seciera%20 1mg/mL formulation of cyclosporin rine-based cousins. RCCL P3%20Results%20Release.pdf. Accessed: Mar 1, 2016. 12. Santen. Santen announces approval of Ikervis What’s In a Name? for EU marketing authorization. Available at: www.santen.com/en/news/20150325.pdf. Ac- Cyclosporine was initially developed to suppress the immune cessed: May 15,2016. response and prevent organ rejection in transplant patients. It was 13. The Ophthalmologist. Introducing Ikervis. later brought to market in 1983 for oral and parenteral administra- Available at: theophthalmologist.com/issues/0615/introducing-ikervis/. Accessed: May tions; however, the drug exhibited poor solubility and had widely 15, 2016. variable bioavailability, so it was then formulated as a microemul- 14. EyeWireToday. In complete response letter, sion in 1995 to address some of the malabsorption concerns. The FDA requests more information from Aller- gan for multi-dose preservative-free restasis. drug is referred to by at least three nonproprietary names: cyclo- Available at: eyewiretoday.com/2016/03/11/ sporine by the United States Adopted Names Council, cyclosporin allergan-receives-complete-response-letter- from-fda-for-prior-approval-supplement-for- by the British Pharmacopoeia and ciclosporin as the drug’s inter- restasis-cyclosporine-ophthalmic-emulsion-005- national non-proproprietary name designed by the World Health multi-dose-preserv. Accessed: May 15, 2016. Organization.15 It is also commonly referred to as cyclosporin A, as 15. David Moore’s World of Fungi. Origin of drugs in current use: the cyclosporine story. Available an alternative to cyclosporine, in some applications. at: www.davidmoore.org.uk/Sec04_01.htm. Accessed May 26, 2016.

REVIEW OF CORNEA & CONTACT LENSES | JUNE 2016 9

008_RCCL0616_PSP.indd 9 5/31/16 4:38 PM BUILDING A FOUNDATION FOR A BETTER FUTURE: ARVO 2016 ABSTRACT REVIEW

An expert weighs in on new ideas in the ﬁ eld of cornea and contact lens care. By Joseph P. Shovlin, OD

idespread These results are concerning be- higher rates of opposition observed change is cause resistance to multiple antibi- to azithromycin, ciprofl oxacin happening otics means treatment options are and oxacillin/methicillin. At least at a break- limited. 70% of the methicillin-resistant Wneck pace in Antibiotic resistance trends staphylococci samples collected the ophthalmic fi eld, though new should be kept in mind when demonstrated multidrug resistance; research and concepts for future selecting therapy preoperative- furthermore, among S. pneumoniae studies remain cornerstones for ly, researchers from New York isolates, resistance was highest to all advancements. This year’s suggest.2 Use of topical antibiotics azithromycin, chloramphenicol and Association for Research in Vision is key to help with minimizing oral penicillin. and Ophthalmology’s (ARVO) intraocular infections prior to and Another study evaluated po- meeting in Seattle, Wa. offered following surgery, as bacterial re- vidone iodine (PI) as a potential practitioners a peek at some of the sistance continues to be a prevalent disinfecting solution for contact newest discoveries and advances issue and can inhibit an otherwise lenses, focusing on its antimicrobial designed to aid in clinical practice. positive therapeutic effect. In this effi cacy against ocular bacterial Areas of study included dry eye and study, the investigators examined strains in planktonic form and associated comfort issues, keratoco- the resistance profi les of common following biofi lm formation in the nus and its treatments and bacterial bacterial pathogens to the anti- contact lens case.3 Researchers in infections related to contact lens biotics that are routinely used by New South Wales, Australia found wear. ophthalmologists. One hundred that the PI solution performed ex- and seventy-two aqueous and ceptionally well against the plank- INFECTION AND vitreous humor isolates of note tonic forms of all bacteria strains INFLAMMATION were collected from the ARMOR tested; in fact, no viable organisms Data collected on antibiotic resis- surveillance study, including 11 were recovered following the tant-bacteria highlights changing with Haemophilus infl uenzae, 10 minimum recommended disin- trends, report researchers who with Pseudomonas aeruginosa, 21 fection time. The PI solution was evaluated the frequency of meth- with Streptococcus pneumoniae, also effective to varying degrees icillin-resistant Staphylococcus 30 with Staphylococcus aureus, at removing the bacterial biofi lm; (MRS) keratitis as it appeared in and 100 with coagulase-negative air-drying or wiping the lens case a referral ophthalmology center staphylococci (CoNS). Minimum in Mexico City, Mexico from inhibitory concentrations (MICs) ABOUT THE AUTHOR 1 February 2014 to February 2015. were determined by broth micro- Dr. Shovlin is the senior optom- The bacteria identifi ed via diagnosis dilution and the isolates were cate- etrist at Northeastern Eye Institute and a member of the of infectious keratitis and positive gorized as susceptible, intermediate adjunct faculty at the Penn- culture predominantly included or resistant according to systemic sylvania College of Optom- etry. He is also the clinical Staphylococcus, with those organ- breakpoints. Results from the study editor for Review of Cornea isms that were drug resistant noted indicated antibiotic resistance was & Contact Lenses, associate clinical editor for Review of as being non-responsive to oxacillin most prevalent among staphylo- Optometry and president-elect for and/or cefoxitin disk diffusion. cocci, particularly CoNS, with the American Academy of Optometry.

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0010_RCCL0616_F1_ARVO.indd10_RCCL0616_F1_ARVO.indd 1100 55/31/16/31/16 4:394:39 PMPM Photo: Christine W. Sindt, OD

From left to right: Moraxella nonliquefaciens ulcer, Pseudomonas ulcer and HZO neurotrophic cornea with bacterial superinfection. Research from this year’s ARVO conference could lend insight into treating these issues.

with a tissue and then air-drying joules/cm² x 100 for a time length Finland and Lithuania.6 In this was deemed most effective (71% of 180 minutes is required to elimi- study, six-week-old mice were of the biofi lm was removed), while nate the presence of Acanthamoeba exposed to a desiccating envi- recapping the lens case wet was less castellanii in all three groups. ronmental chamber with airfl ow so (55% removed). As such, results Though the rate of complications and humidity levels set at 15 L/ demonstrate not only that ocular associated with scleral lens wear min and 5%, respectively, for strains of bacteria are susceptible to remains low, certain issues con- 10 days. Each mouse received povidone iodine in planktonic and tinue to be prevalent and should transdermal scopolamine in their biofi lm form, but also reiterates the be further monitored, according left eyes twice daily with super- importance of air-drying in main- to researchers from Minnesota, oxide dismutase (SOD) mimetic taining lens case hygiene. Illinois, Ohio and Massachusetts, Manganese (III)-5,10,15,20-tetrakis Directed energy at certain wave- who collected data from a 19-ques- (N-methylpyridinium-2-yl) porphy- lengths may be capable of eliminat- tion survey regarding scleral lens rin Pentachloride (MnTM-2-PyP, ing the presence of Acanthamoeba wear and management practices EMD Millipore) diluted in physio- from contact lenses and lens cases, administered to eye care practi- logical saline at 0.05%. Their right report researchers in Pennsylvania, tioners between January 12, 2015 eyes served as controls and were who hypothesized that certain and March 31, 2015 by the Mayo treated with saline. Study results levels of ultraviolet energy admin- Clinic Survey Research Center.5 indicated the topical administration istered with and without ribofl a- Nine hundred and eighty nine of the MnTM-2-PyP signifi cantly vin will eradicate Acanthamoeba individuals responded to the survey, improved lacrimal gland pathology while maintaining the clarity of the 723 of whom reported fi tting fi ve compared with the effects of the contact lens.4 To test this theory, or more patients with scleral lenses saline control, suggesting topical the team administered multiple for a total of 84,735 scleral lens pa- antioxidant therapy may be feasible modes of energy in microjoules/ tients represented. Reported issues as a treatment for KCS. cm² x 100 in a dose-dependent included edema, neovasculariza- A study from investigators at manner. Three groups were pre- tion, infi ltrates, toxic keratopathy, Cornell Medical College, University pared: Acanthamoeba castellanii bullae and microbial keratitis as of Illinois College of Medicine and (106 cysts in saline) exposed to well as limbal stem cell compro- Indiana University of Medicine just UVE; Acanthamoeba castel- mise, elevated intraocular pressure, suggested exposure of the corne- lanii (106 cysts in saline) plus soft uveitis and retinal detachment. al surface to hyperosmotic tears contact lens exposed to just UVE; Handling error was reported as the may cause considerable damage to and Acanthamoeba castellanii (106 primary cause of these problems in corneal subbasal nerve fi bers.7 The cysts) plus soft contact lens exposed 448 patients. researchers studied the relationship to UVE in a saline solution or between tear hyperosmolarity and 0.01% ribofl avin. The soft contact DRY EYE corneal nerve abnormalities for lenses were evaluated for clarity Keratoconjunctivitis sicca (KCS) the recorded fi rst time ever in an following exposure via spectropho- pathology may be improved via effort to explain the common signs tometry. Results indicated a total topical antioxidant therapy, report and symptoms associated with dry UVE amount of 89,991 micro- researchers from the United States, eye disease. Results indicated the

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010_RCCL0616_F1_ARVO.indd 11 6/1/16 3:34 PM ARVO 2016 ABSTRACT REVIEW Photo: Christine W. Sindt, OD with untreated controls or another treatment. The amount of tear fl uid also increased following 03F/F6H8 treatment as compared with levels of the same in untreated controls or those treated with F6H8 alone or with artifi cial tears, as did the number of goblet cells. Additionally, anterior segment optical coherence tomography (AS-OCT) may be appropriate for clinicians to use in assessing the level of ocular dryness in patients with conjunctivochalasis, report researchers from the University of Jukui in Japan, who compared tear meniscus area and height in patients with the disease and those with normal eyes.10 Potential rela- Anterior segment OCT measurements could help practitioners assess ocular tionships between TMA or TMH surface dryness in patients with conjunctovochalasis. and fl uorescein fi lm tear-breakup time, fl uorescein staining score and responses of the corneal neurons ease from donor mice onto recipi- the extent of conjunctivochalasis to the drying of the cornea were ent mice. Graft survival rates and were also evaluated in the con- depressed or completely abolished opacity scores were evaluated with junctivochalasis group. Results by hyperosmolar tears in a time- slit lamp biomicroscopy. Corneas indicated that conjunctivochalasis ly and dose-dependent manner. and draining lymph nodes were eyes exhibited a reduced TMA The researchers observed that the harvested at day 14 post-transplant and increased TMH as compared disappearance of action potentials and fi ndings demonstrated that the with the normal eyes. Note, a more occurred as quickly as two min- transplant recipients with the DED severe dry eye condition in conjunc- utes, but generally within three donor corneas demonstrated signifi - tivochalasis is commonly associated hours following application of the cantly reduced graft survival (i.e., with a reduction in TMA, despite tear solutions and suggested these 10%) as compared with control a high level of TMH due to the fi ndings are consistent with the mice (50% survival). conjunctival fold. As such, AS-OCT abnormal activities of trigeminal Other research from Germany on technology may be appropriate for ganglion neurons demonstrated omega-3 fatty acids (O3F) indicates use in this type of patient scenario. by electrophysiological recordings they could be used as potential Japanese researchers in the and may account for the signs (i.e., topical adjunct therapy for dry fi eld also suggest that address- morphological abnormalities) and eye.9 Oral and topical treatments ing the presence of patient sleep symptoms (i.e., abnormal sensa- that use omega-3 fatty acids have disorders may help alleviate cases tions) reported in dry eye patients. previously demonstrated positive of dry eye.11 A cross-sectional Dry eye disease may also play a effects on the severity of dry eye. In case control study involving 715 role in inhibition of corneal graft the current study, experimental dry outpatients diagnosed with DED, survival, says a team of scien- eye (EDE) was induced in mice and chronic conjunctivitis or allergic tists from Schepens Eye Research topical therapy was administered. conjunctivitis incorporated the Institute, Harvard Medical School Therapeutic treatment of mice Pittsburgh Sleep Quality Index and the Juntendo University School with omega-3-fatty acids using a (PSQI) and Hospital Anxiety and of Medicine in Japan.8 These semi-fl uorinated alkane (F6H8) Depression Scale (HADS) as a researchers evaluated the effect of as a preservative-free lipophilic means to evaluate their well-being. the condition on allosensitization carrier demonstrated a signifi cantly Regression analysis of patients with and graft rejection by transplanting earlier decrease of epithelial dam- DED revealed correlations between healthy corneas with dry eye dis- age following EDE as compared higher PSQI and HADS and the

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010_RCCL0616_F1_ARVO.indd 12 5/31/16 4:40 PM Photos: Jennifer Harthan, OD presence of DED, rather than other forms of ocular surface disease. There was also a connection to the condition’s level of severity, further raising quality-of-life concerns and supporting the theory that providing psychiatric help to address a patient’s sleep issue may have a direct effect on the improvement of their ocular health. Meibomography images demonstrating the eff ects of electronic device use Patients who use digital devices on ocular dryness. throughout the day, regardless of their age, may experience adverse ly results in a notable decrease in Disease Index score, there is a impacts on their work perfor- quality of life. This study attempted correlation between patients with mance, productivity and quality of to quantify the symptoms most fre- a discrepancy of signs and symp- vision, suggests a team of research- quently associated with eye fatigue toms in dry eye that are resistant ers from Illinois, Pennsylvania, while using digital devices in soft to therapy and the presence of California and Tennessee.12 Overall, contact lens wearers, who were psychosomatic diseases and/or eye care practitioners have noted asked to complete a survey with previous eye surgery.14 Typically, in an increase in dry eye symptoms as questions pertaining to the condi- these cases of symptoms without the use of digital devices—includ- tion. Eighty-eight percent reported signs, corneal neuralgia is postulat- ing handheld tablets, smartphones, experiencing eye fatigue once per ed; however, the results from this laptops and computers—increases. month, while 74% reported experi- study that indicate the co-morbid- Data collected from questionnaires encing eye fatigue at least once per ities of psychosomatic disease or related to digital device use as well week. Reported symptoms included prior eye surgery suggest there may as additional answers regarding dryness, eye irritation, eyestrain be different sensitization pathways vision fl uctuation concerns and and tired eyes. Strain, soreness, for the proposed development of contact lens wear were used to tiredness and headache comprised corneal neuralgia than previously generate results for the study. Six primary sensation factors, while believed. Furthermore, incomplete hundred and eighty-six subjects burning, irritation and dryness analgesia following topical corneal were evaluated, with the average comprised the secondary sensation anesthesia supports the assumption number of hours spent on devices factors in the study. Additionally, of a central sensitization that would per day noted at 6.35 hours for the blurring, doubling and moving/ explain the resistance to topical <40 age group and 4.83 hours for fl oating were noted as visual sensa- therapy, the researchers concluded. the >40 age group. Average ocular tion factors. The researchers con- A cross-sectional study open to comfort was recorded on a scale of cluded that frequent and severe eye all participants of the American one to 10 as one at the beginning fatigue is highly prevalent among Academy of Optometry’s 2015 of the day and seven at the end of the population of soft contact lens annual meeting suggested that the the day following gratuitous digital wearers that use digital devices, and Photo: Christine W. Sindt, OD device use, further demonstrating a that the recorded symptoms can be positive correlation. used to better identify members of A second study organized by re- this population. searchers in Indiana and California According to German investiga- in cooperation with CooperVision tors in Cologne who examined the found that frequent and severe onset of DED pain symptoms like eye fatigue is prevalent among burning, stabbing or photophobia soft contact lens wearers who use that presented without accom- digital devices.13 Previous reports panying clinical signs including have found that eyestrain or eye normal visual acuity, intraocular Pseudophakia and severe dry eye fatigue occurs in roughly 60% of pressure, Schirmer test and corneal from graft-versus-host disease. Researchers presenting at this year’s student and working populations fl uorescein staining in combination ARVO conference found that dry eye that use digital devices and typical- with pathological Ocular Surface may inhibit survival of corneal grafts.

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010_RCCL0616_F1_ARVO.indd 13 5/31/16 4:40 PM ARVO 2016 ABSTRACT REVIEW

Standard Patient Evaluation of Eye group with ocular surface symp- and their association with other Dryness (SPEED) questionnaire toms that responded to artifi cial clinical parameters in keratoconus may not be as successful at detect- tear treatment, and a group with patients.17 Ocular symptoms using ing dry eye in contact lens wearers similar ocular surface symptoms validated questionnaires, corneal as it is in those who do not wear that did not respond to the tears. topography, tear osmolarity, tear lenses.15 One-hundred and fi fty No signifi cant difference in stan- meniscus height measurement, contact lens wearers and 134 non- dard Schirmer test scores, modifi ed tear volume, ocular surface stain- lens wearers elected to participate Schirmer test scores, punctate epi- ing with fl uorescein and lissamine in the study by answering the ques- thelial erosion presentation (PEE), green dye, corneal sensitivity using tions listed as part of the SPEED meibomian gland dysfunction Cochet-Bonnet aesthesiometer questionnaire and undergoing (MGD), blepharitis tear break-up and corneal nerve mapping using tear meniscus height photographic time (TBUT) or Ocular Surface HRT II confocal microscopy were assessment and tear volume testing. Disease Index (OSDI) scores was recorded, and correlations were Unfortunately, while the question- noted in any group. The researchers made using either Spearman’s or naire was accurately able to predict concluded that current clinical tests Pearson’s coeffi cient. Subjects were the dry eye status in non-contact are not able to adequately identify graded as having either mild or lens wearers, it was unable to the subset of patients who might severe keratoconus, and partial cor- predict the same in those wearing most benefi t from artifi cial tear use. relation was performed to control lenses. The researchers concluded Given the low cost and morbidity the effect of confounding factors. additional work should be con- of artifi cial tear treatment, they Only data from each patient’s most ducted to further assess the study’s suggest a trial treatment of the severe eye was included in the usefulness in contact lens wearers. prescribed drops be performed in study. Results found central corneal Furthermore, artifi cial tears may patients with chronic ocular surface sensitivity to be lower in the severe be less benefi cial than initially symptoms and add that future keratoconus group, while in bivar- believed for patients with ocular studies should take into account the iate correlations, decreased corneal surface disease, according to inves- type of artifi cial tears used as well sensitivity in keratoconus was tigators from Virginia who incor- as frequency of use. associated with condition severity, porated a modifi ed version of the lower central nerve fi ber density, Schirmer test into their research.16 KERATOCONUS AND ITS contact lens wear, contact lens Study participants were divided POTENTIAL REMEDIES tolerance, patient age and duration into three groups: a control group In Australia, investigators exam- of disease. Researchers further ob- not treated with artifi cial tears, a ined changes in corneal sensitivity served a distinctive trend in which age and duration of keratoconus Photo: Christine W. Sindt, OD was also associated with decreased corneal sensitivity, and that contact lens wear-intolerants exhibited higher corneal sensitivity compared with tolerant wearers. They concluded that decreased corneal sensitivity was associated with age and duration of disease, and that reduced tolerance of keratoconic patients to contact lens wear was associated with increased corneal sensitivity. Hair cortisol concentration as a biochemical correlate of chronic psychological stress may be an observable risk factor for kerato- A slit lamp view of a keratoconic patient with hydrops. Research is conus, report German scientists increasingly looking at the implications of this irregular corneal condition who analyzed strands of hair taken and potential methods for its management. from both healthy and keratoconic

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010_RCCL0616_F1_ARVO.indd 14 5/31/16 4:40 PM 18 system against bacterial biofi lm. Program 1454. patients. As hair segments of 3cm tive observational case study to Association for Research in Vision and Ophthalmol- in length represent the prior three- monitor post-operational results ogy Meeting 2016. 4. Ross AGG, Kowalski RP, Dhaliwal D, KArenchak month stress profi le of an individ- of 11 patients who had under- LM. The threshold of light energy to eliminate acan- 20 thamoeba. Program 1456. Association for Research ual, the researchers used sections gone surgery for the condition. in Vision and Ophthalmology Meeting 2016. of hair this length located most Patient best-corrected visual acuity 5. Schornack M, Harthan J, Barr et al. Complica- tions of scleral lens wear. Program 1467. Associ- proximal to the scalp. Cortisol lev- (BCVA), intraocular pressure and ation for Research in Vision and Ophthalmology els were determined using the hair corneal thickness were examined Meeting 2016. 6. Kaja S, Kourlen P, Puranen J, Symantas R. A by the Institute of Biopsychology prior to treatment, as well as at topically delivered synthetic metalloporphyrin SOD mimetic improves hallmarks of dry eye disease of the TU Dresden; a standardized one-week, and three-, six- and pathology. Program 396. Association for Research questionnaire for chronic stress was 12-month intervals following treat- in Vision and Ophthalmology Meeting 2016 7. Mizerska KK, Hirata H, Dallacasagrande V, et al. also administered to all subjects. ment. Intensity and frequency of Short exposure to hyperosmolar tears produces profound anatomical and physiological changes Results indicated hair cortisol was pain were scaled from zero to 10, in rodent corneal nerves: implications for dry eye higher in patients with progres- while after 12 months of treat- disease. Program 403. Association for Research in Vision and Ophthalmology Meeting 2016. sive keratoconus compared with ment, corneal stromal depths of 8. Inomata T, Hua J, Shiang T, et al. Is dry eye those with a stabilized form of the 100µm and 200µm were observed disease in donors a risk factor for corneal graft rejection? Program 1438. Association for Research disease or those who were healthy. using confocal microscopy. Density in Vision and Ophthalmology Meeting 2016. 9. Gehlsen U, Braun T, Steven P. Omega-3 fatty Furthermore, the study suggested of the patients’ keratocytes and acids using a F6H8-carrier as topical therapy in increased hair cortisol concentra- nerve fi bers was also calculated. experimental dry eye disease. Program 417. Asso- ciation for Research in Vision and Ophthalmology tion could be a risk factor for the Results indicated that BCVA did Meeting 2016. progression of keratoconus. not signifi cantly improve following 10. Kimura K, Takamura Y, Gozawa M, et al. Diff erence in tear meniscus between conjunctivochalasis Other research from Germany treatment, but pain—which was eyes and normal eyes using anterior segment optical coherence tomography. Program 2836. supports the concept that axis initially scored at an average of Association for Research in Vision and Ophthalmol- alignment could be used in an 6.27—decreased. Furthermore, the ogy Meeting 2016. 11. Ayaki A, Kawashima M, Negishi K, et al. Sleep algorithm to support the diagno- mean pain frequency score of 5.45 disorders in dry eye disease and allied irritating 19 ocular diseases. Program 2840. Association for Re- sis and staging of keratoconus. also decreased following treatment search in Vision and Ophthalmology Meeting 2016. Scientists compared the power and to 1.27 at 12 months post-opera- 12. Harthan J, O’Dell L, Kwan JT, et al. Dry eye symptoms and visual function with digital device axis orientation of anterior and tion, while keratocytes and nerve use. Program 2843. Association for Research in posterior astigmatism in 861 eyes fi bers were rarely observed at 12 Vision and Ophthalmology Meeting 2016. 13. Kollbaum PS, Meyer D, Huenick S, et al. Digital with keratoconus and 500 healthy months following the procedure. Device user survey of eye fatigue. Program 1492. Association for Research in Vision and Ophthalmol- eyes as part of a retrospective study, Persistence of pain relief was ulti- ogy Meeting 2016. fi nding posterior axis alignment mately attributed to the inadequate 14. Steven P, Schneider T, Ramesh I, et al. Pain in dry-eye patients without corresponding clinical of corneal astigmatism is in line regeneration of nerve fi bers in the signs – a retrospective analysis. Program 2848. with the alignment of the anterior corneal stroma. Association for Research in Vision and Ophthalmol- ogy Meeting 2016. surface in the majority of cases 15. Pucker AD, Jones-Jordan L, Kwan JT, et al. A comparison of SPEED scores in contact lens and of keratoconus. In contrast, the ther abstracts from ARVO non-contact lens wearers. Program 2855. Associ- majority of the healthy eye group O2016 highlight alternative ation for Research in Vision and Ophthalmology Meeting 2016. demonstrated a vertical posterior treatment options, surgical tech- 16. Young M, Zhong H, Peterson E, et al. Clinical axis alignment independent of niques and potential concerns on evaluation of Schirmer test variations on the predictability of benefi t from artifi cial tears. Program the anterior surface. These results the horizon to be aware of. As al- 2882. Association for Research in Vision and Ophthalmology Meeting 2016. indicate that with progression ways, practitioners are encouraged 17. Mandathara PS, Stapleton F, Kokkinakis J, of the disease and a decrease in to review the full list of available Willcox MD. A pilot study of corneal sensitivity and its associations in keratoconus. Program 2896. pachymetry, corneal resistance to abstracts, not just those chosen for Association for Research in Vision and Ophthalmol- ogy Meeting 2016. vertical forces—most likely the eye- this report. So, go take a look! RCCL 18. Lenk J, Spoerl E, Pillunat LE, Raiskup F. Hair cor- lids—decreases and axis orientation tisol analysis in progressive and stable keratoconus 1. Avila-Lule I, Teran-Tejada T, Betancourt NR, et patients. Program 2906. Association for Research becomes increasingly vertical. al. Methicillin-resistant staphylococcus keratitis in in Vision and Ophthalmology Meeting 2016. Corneal crosslinking may a referral ophthalmology center. Program 2354. 19. Schmack I, Shajari G, PourSadeghian M, et al. Association for Research in Vision and Ophthalmol- Characteristics of corneal astigmatism of anterior effectively relieve the intensity ogy Meeting 2016. and posterior surface in healthy individuals and 2. Asbell PA, DeCory H, Sahm D, Sanfi lippo CM. In keratoconus patients. Program 2913. Association and frequency of pain associated vitro antibiotic susceptibility of ocular pathogens for Research in Vision and Ophthalmology Meeting with bullous keratopathy for at collected from the aqueous and vitreous humor 2016. during the ARMOR surveillance study. Program 20. Ono T, Terada Y, Mori Y, et al. The persistence of least one year following treat- 2348. Association for Research in Vision and Oph- pain relief after corneal crosslinking in mild bullous ment, report researchers in Tokyo, thalmology Meeting 2016. keratopathy eyes. Program 2919. Association for 3. Vijay AK, Liu L, Nguyen TC, et al. Effi cacy a novel Research in Vision and Ophthalmology Meeting Japan, who conducted a retrospec- povidone iodine based contact lens disinfection 2016.

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0010_RCCL0616_F1_ARVO.indd10_RCCL0616_F1_ARVO.indd 1155 55/31/16/31/16 4:404:40 PMPM Corneal and scleral GP Fitting Rigid Lenses lenses cover the ‘last mile’ for patients who need correction after After Refractive Surgery LASIK and PRK. By Melanie Frogozo, OD

espite the advances good choice for fi tting patients af- prolate shape, i.e., steeper centrally in PRK and LASIK in ter refractive surgery. These lenses with fl attening towards the periph- the past two decades, have excellent optics and can mask ery. The rate of fl attening towards there are still patients several diopters of regular and ir- the periphery can be described Dwho have complica- regular astigmatism. Additionally, by its eccentricity value. Normal tions from these procedures that the practitioner has complete con- corneas typically have eccentricity keep them from experiencing the trol over the lens parameters and values of 0.5 to 0.7. vision they expected. In these the lenses can be made in high Dk Hyperopic LASIK/PRK is accom- circumstances, contact lenses can materials. This article will review plished by ablating the peripheral help restore vision. However, many GP lens fi tting after refractive sur- cornea in order to steepen the individuals who have elected to gery using a series of case studies. central cornea. These patients have undergo surgery are often unhappy a corneal profi le similar to kerato- about the idea of wearing correc- CORNEAL SHAPE conus and an eccentricity value of tion again. Therefore, it is import- CONSIDERATIONS greater than 1.0. And so, kerato- ant to be both skilled and effi cient Fitting patients who have under- conic design lenses can be helpful at fi tting contact lenses for this gone refractive surgery is challeng- in fi tting those who have had a population. ing due to their altered corneal hyperopic procedure done. Gas permeable (GP) lenses are a shape. A typical cornea has a Myopic surgery is accomplished by ablating the central cornea in order to make it fl atter, which causes the peripheral cornea to steepen. This reverse corneal confi guration is oblate in shape and has a negative eccentricity value. A reverse geometry design contact lens can be used to align better with the corneal profi le of a patient who has had myopic refractive surgery. The initial contact lens design after refractive surgery can be determined by looking at the eccentricity value. Values greater than

ABOUT THE AUTHOR

Dr. Frogozo, a fellow of the AAO, is the owner and director of Alamo Eye Care and the Contact Lens Institute of San Antonio in San Antonio, Texas. She specializes in diffi cult-to-ﬁ t contact lenses for both adult Fig. 1. Right eye axial power corneal topography post-hyperopic LASIK. and pediatric patients.

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016_RCCL0616_F2_GP-PostRefractive.indd 16 5/31/16 4:35 PM 1.0 could be fi t into a keratoconic lens. If the eccentricity value is negative, consider fi tting a reverse geometry design.3 Corneal topography can also help practitioners choose contact lens parameters after refractive surgery. The initial base curve of a corneal GP lens can be determined after refractive surgery by taking Fig. 2. A regular geometry tricurve Fig. 3. LASIK fl ap interface with an average dioptric curvature corneal GP lens design on a post- fold irregularity OS. Note the arrow, 4.0mm away from the center on hyperopic LASIK eye. which points towards the defect. axial curvature maps and 2.0mm on tangential curvature maps.4 a reverse geometry design in which manifest refraction corrected her Additionally, a height map shows the base curve is fl atter than the to 20/20 and J1 (-0.50-0.75x035 linear distances between positions adjacent peripheral curve will align OD and plano OS with a +2.25 on the cornea and a reference better in oblate corneas.1,3 add). sphere. This reference sphere over Iatrogenic corneal ectasia follow- Prior to the LASIK procedure, the cornea gives an idea of what ing myopic corneal refractive sur- she had been a long-time mono- the GP fl uorescein pattern may gery results in anterior bulging of vision corneal GP wearer and look like.5 And so, a base curve the ablated cornea to cause a kera- desired to have her vision correct- calculated from a tangential or toconus-like situation. This poses a ed with this same modality. Since axial map could be applied as a unique challenge in fi tting corneal she was fully corrected for distance curvature reference sphere on a GP lenses because the topography in the left eye, we only fi tted the height map to see how a corneal will have a combination of steeper GP lens may fi t on the eye. areas at the apex of the cone and in the untreated periphery, and CORNEAL GP LENSES will be fl atter in the non-ectatic The notable differences in shape ablated areas. If the apex of the present between ablated and cone is central, a prolate kerato- non-ablated corneal areas after conus design lens can be fi tted. In refractive surgery can make GP contrast, oblate reverse geometry lenses challenging to fi t. Often, designs will work better if the apex corneal GPs do not exhibit a clas- is decentered. In cases of iatrogenic sic alignment pattern on a surgi- corneal ectasia, consider a large Fig. 4. Tangential power corneal cally altered cornea. Instead, there diameter lens (i.e., greater than topography showing oblate-shaped will be pooling in fl atter ablated 10mm), as the increased size typ- OS cornea after LASIK in a patient areas and bearing over the steep- ically centers better over broader with fl ap fold irregularity. er untreated areas. Nonetheless, areas of irregularity.1 this may be acceptable as long as there is adequate lens movement Refractive Error After and room for a healthy tear pump Hyperopic LASIK. A behind the lens, and if the lens 158-year -old female presented does not cause any harsh areas of with complaints of blurry vision punctate erosion. while reading at near. She had Hyperopic procedures leave the undergone monovision hyperopic cornea highly prolate. Patients LASIK four years prior, during who have had hyperopic refractive which her right eye was corrected surgery can be fi t into keratoconic for near reading and her left eye lens designs.1,3 In contrast, myopic for distance. Although she present- Fig. 5. Reverse geometry corneal GP for correction of irregular refractive surgery will cause the ed with 20/20 distance vision OU, astigmatism from fl ap fold after cornea to become oblate in shape; she could only read J5 at near. Her myopic LASIK.

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016_RCCL0616_F2_GP-PostRefractive.indd 17 5/31/16 4:36 PM FITTING RIGID LENSES AFTER REFRACTIVE SURGERY

right eye. Her topography showed a normal eccentricity value and a topographic keratometry reading of 47.00@40/47.67@130 OD (Figure 1). Because her eccentricity values were normal (steep E value of 0.64 and fl at E value of 0.59), she was fi t into a regular geometry tricurve corneal GP lens. This lens was fi t half a diopter fl atter than K. Her fi nal lens parameters were: Fig. 6. Multiple stromal folds within a LASIK fl ap OD (left) and OS (right). 46.50/+2.00/9.60 OD, and the lens demonstrated a close-to-alignment fl uorescein pattern (Figure 2). She reported successful wear of this lens about three times a week when she wanted to be free of spectacles.

Flap Fold Irregularities Corrected with Corneal 2GP. A 65-year-old female with a history of myopic LASIK Fig. 7. Tangential power corneal topography showing myopic ablation profi le presented with complaints of light OU. sensitivity and glare OS while driving at night. These symptoms ultimately appeared to be about subsequent follow-up visits. were caused by irregular astig- 0.75D too steep with minimal edge The patient was happy with her matism from a fl ap fold (Figure lift. A new lens with a fl atter base improved visual acuity and night- 3). Her vision was 20/40 with curve and periphery was created time vision and was able to wear a spectacle correction of -0.25- with an over-refraction of +0.25D. her lens for the entire day. 0.75x085 and her corneal topog- The fi nal lens parameters were raphy showed an oblate corneal 39.25/+1.00/10.8, and she was SCLERAL LENSES shape with keratometry values of able to see 20/20. This lens showed In contrast to fi tting corneal GP 39.09@164/39.56@074 (Figure 4). mild apical touch and moderate lenses—a process in which cor- Since her eccentricity value was bearing in the horizontal mid-pe- neal topography is crucial to lens negative, a 4D reverse geometry riphery (Figure 5). Nonetheless, the design—a scleral lens has the corneal GP with the following lens had great movement and good advantage of being able to vault parameters was trialed: 40.00/ tear exchange, and the patient’s the cornea and rest on the anato- plano/10.8. However, the lens corneal health looked great at my of the scleral-conjunctival area. This makes scleral lenses ideal for INDICATIONS fi tting over highly irregular corneas Patient complications following refractive surgery include after refractive surgery, such as in the overcorrection or undercorrection of refractive error, the case of uneven ablation zones anisometropia, a decentered or uneven ablation zone, fl ap or iatrogenic corneal ectasia. These irregularities and the development of iatrogenic corneal ectasia. large lenses center well and offer Any of these may lead to symptoms of reduced spectacle- stable vision and good comfort; corrected acuity and contrast sensitivity, or ghost images.1 additionally, their fl uid-fi lled reser- LASIK-induced dry eye is another common complication. While voir offers therapeutic applications its pathophysiology is unknown, it is believed to result from in the case of LASIK-induced dry neurotrophic epitheliopathy due to damage of the sub-basal eye.6 Scleral lenses are available in nerve plexus from the creation of the LASIK fl ap.2 GP lenses are capable of addressing all of these concerns. both regular and reverse geometry designs.

18 REVIEW OF CORNEA & CONTACT LENSES | JUNE 2016

016_RCCL0616_F2_GP-PostRefractive.indd 18 5/31/16 4:37 PM LASIK OS presented to the clinic having formed subsequent iatrogenic corneal ectasia and dry eye four months after the procedure. Additionally, he had undergone intracorneal ring segment im- plantation in his right eye. The patient admitted to using preservative-free artifi cial tears once every hour to treat his dry eyes. His keratometry values were 47.25@032/43.12@125. Though he was corrected to 20/25 with a spectacle prescription of -4.25- 2.50x140, he desired to be free of glasses. Due to his dry eye syndrome, he wanted to try a scleral lens to gain some symptomatic relief. A 45.00/-1.50/18.0 lens was trialed Fig. 8. A 16mm diameter scleral lens with a toric peripheral haptic over and with a -1.00 over-refraction, patient with multiple folds of LASIK fl ap. the patient could see 20/20. This lens also demonstrated adequate Flap Fold Irregularities central corneal surface, and the vault over the limbus and aligned Corrected with Scleral lens decentered inferiorly OU. in the periphery (Figure 9). A fi nal 3 Lens. A 31-year-old male Overrefraction values of -9.50D lens was ordered with the param- presented to the clinic with and -7.50D were found in the eters of 45.00/-2.50/18.0. The pa- complaints of seeing glare around right and left eye, respectively, tient reported improved nighttime lights and decreased vision OU for which led to the 20/30 OD and vision and was able to decrease his the past year. The patient has a 20/20 OS visual acuity. As such, drops to application once every history of myopic LASIK OU and, the following fl atter lenses with four hours. within a week of undergoing the compensated powers were or- procedure, reported being aware dered: 40.00/-8.50/16.0 OD and Lagophthalmos of his symptoms. Anterior biomi- 40.00/-6.75/16.0 OS with a 2.00 Complicates LASIK- croscopy revealed multiple LASIK D peripheral haptic OU (Figure 8). 5 Induced Dry Eye fl ap folds OD>OS (Figure 6). Following dispensing, the lenses Syndrome. A 73-year-old female His manifest refraction was centered well and had approxi- with a history of myopic LASIK plano-1.00x065 OD and pla- mately 250µm of vault centrally no OS, which corrected him to after 40 minutes of allowance 20/50 and 20/25, respectively. for settling OU. The lenses were Corneal topography indicat- dispensed to the patient and he re- ed a myopic ablation profi le ported less glare and better quality with keratometry readings of of vision in both eyes at the three- 38.26@012/38.71@102 OD week follow-up appointment. The and 39.40@126/39.00@036 patient also had healthy corneas OS (Figure 7). A 16mm 4.00D and noted being able to wear the reverse geometry scleral lens with lenses comfortably for 12 hours. a 42.00D base curve and plano power was trialed in both the Intacs and LASIK- Fig. 9. An scleral lens fi t on a patient right and the left eyes. The lens Induced Dry Eye with iatrogenic corneal ectasia and dry eye syndrome after myopic demonstrated excessive vault of 4 Syndrome. A 54-year-old LASIK OS. This patient also has 500µm upon insertion over the male with a history of myopic intra-corneal ring segments in place.

REVIEW OF CORNEA & CONTACT LENSES | JUNE 2016 19

016_RCCL0616_F2_GP-PostRefractive.indd 19 5/31/16 4:37 PM FITTING RIGID LENSES AFTER REFRACTIVE SURGERY

45.00/-1.50/18.0 OS. Following 45 minutes of wear in the ofﬁ ce, the patient stated 60% relief of her symptoms. A -3.00D OD and 2.00D OS overrefraction was added to the front surface of the ﬁ nal scleral lens order. The lenses showed good vault over the corneal surface and aligned well with the scleral shape of both eyes (Figure 11). Following one month of wear, the patient stated that her symptoms were completely resolved and that she had discon- tinued all of her topical drops.

hough most patients who Tundergo refractive surgery exhibit good visual outcomes, there Fig 10. Tangential corneal topography OU of a patient with dry eye syndrome are still some who need to wear after myopic LASIK procedure. The patient’s dry eye symptoms were contact lenses afterwards to reha- exacerbated by lagophthalmos caused by her systemic Parkinson’s disease. bilitate their vision and/or health of their eyes. Fitting contact lenses OU 14 years prior was referred hyclate 50mg tablets PO daily and after these procedures can be in for scleral lens fi tting to treat 1,000mg of omega-3 PO daily. challenging due to altered corneal her severe dry eye symptoms. The Additionally, she had installed shape and unenthusiastic patient patient stated that her eyes had humidifi ers in all the rooms of her attitudes about wearing lenses remained relatively dry since her house to help with her dry eye again. Knowledge of the various LASIK procedure, but that the symptoms. contact lens designs and the ability severity of dryness had increased Despite all of these efforts, to interpret corneal shape after three years ago with the advance- however, none of the treat- LASIK and PRK is key to helping ment of her Parkinson’s disease. ments gave her signifi cant relief. this population succeed in contact The patient reported self-admin- Additionally, she stated that her lens wear. In most cases, GP lenses istering autologous serum drops eyes constantly felt like they were are a great choice and offer relief hourly, topical steroids BID, pre- “on fi re.” A slit lamp examination for surgically altered corneas. RCCL servative-free artifi cial tears every demonstrated inferior punctate 1. Steele C and Davidson J. Contact Lens fi tting 15 to 30 minutes, doxycycline staining and a decreased blink post-laser-in situ keratomileusis (LASIK). Contact rate of once every 30 seconds. Lens and Anterior Eye. 2007 May;30(2):84-93. 2. Garcia-Zakisbak D, Nash D, Yeu D. Ocular The patient was correctable to Surface diseases and corneal refractive surgery. 20/20 at distance and J1 at near Current Opinions in Ophthalmology. 2014 Jul;25(4):264-269. with a mild hyperopic and astig- 3. Gruenauer-Kloevenkorn C et al. Varieties of matic correction of +0.50-0.75x contact lens fi ttings after complicated hyperopic and myopic laser in situ keratomileusis. Eye and 040 OD and +0.50-0.75x180 OD Contact Lens .2006 Sep;32(5):233-39. with a +3.00 add. Her topography 4. Szczotka-Flynn L, Jani BR. Comparison of axial and tangential topographic algorithms for showed a myopic ablation profi le contact lens fi tting after LASIK. Eye Contact Lens. OU and keratometry readings 2005;31:257–62. 5. Rabinowitz YS. “Corneal Topography: Corneal of 43.87@062/43.12@152 OD Curvature and Optics, Clinical Applications, Fig. 11. An 18mm diameter scleral and 43.75@128/41.12@038 and Wavefront Analysis ” Clinical Contact Lens lens with 4D reverse geometry OS (Figure 10). The following Practice. ES Bennett, BA Weissman. Philadelphia, used to treat the LASIK- and Lippincott Williams & Wilkins: 215-32. 4D reverse geometry diagnostic 6. Parminder A, Jacobs DS. Advances in scleral lagophthalmos-induced dry eye lenses for refractive surgery complications. symptoms of the patient from Figure scleral lenses were placed on her Current Opinions in Ophthalmology 2015 8. OD lens shown here. eyes: 46.00/-2.00/18.0 OD and Jul;26(4):243-248.

20 REVIEW OF CORNEA & CONTACT LENSES | JUNE 2016

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2016_Philadelphia_HouseAd-R3.indd 1 4/28/16 1:49 PM Unusual Clinical Cases in Orthokeratology

For the right patient, these lenses may be life-changing. Two challenging cases provide insights into the ﬁ tting process. By Daddi Fadel, DOptom

he use of custom rigid had myopia in both eyes corrected ble to use different formulas.4-7 lenses to reshape the with eyeglasses (sph -18D). She Additionally, instead of selecting cornea is increasingly presented with moderate myopia the BOZR, it’s possible to use sag prevalent throughout (-5.50D), a steep and small cornea fi tting methods.7,8 The indications Tthe world, albeit more and a medium-to-low eccentricity to calculate these orthokeratology so in Asia than in Europe and value. Her refractive and corneal lens parameters (using the Jessen the United States.1-3 Therapeutic data were as follows: Rx sph -5.50 Factor formula) are demonstrated orthokeratology lenses are typically cyl -0.50x175° BCVA 20/20, Ks in Table 1, while the parameters fi t in Europe to eliminate the need 7.26/7.09mm, average corneal of the fi rst pair of lenses fi t on the for glasses or contact lenses, while eccentricity E = 0.24, horizontal patient in question are shown in in Asia they are primarily used to visible iris diameter 10.60mm and Table 2. For the purpose of this dis- control the progression of myopia.1 pupil size 3.60mm in the right eye; cussion, however, it is not relevant Europe’s orthokeratology fi tting and Rx sph -5.00 cyl -0.50x10° which formula is used to calculate process employs corneal topogra- BCVA 20/20, K 7.24/7.03mm, av- the fi rst lens back surface param- phy with a software-based ap- erage corneal eccentricity E = 0.30, eters, because the fi nal parameters proach that is supplemented with horizontal visible iris diameter were revised after evaluating the trial lenses. This is achieved via the 10.70mm and pupil size 3.70mm in lens fi t on the eye as well as its manufacturing of contact lenses by the left eye. position, its movement and its fl uo- a third party, so the practitioner’s For this patient, the prescribed rescein pattern. knowledge of back surface pa- lens back surface exhibited a tetra- In comparing these parameters rameters remains limited. In Asia, curve design with a back optic zone with those indicated in the litera- however, the fi tting process for or- (BOZ); a fi rst peripheral zone or ture, note that the chosen BOZR thokeratology incorporates topog- reverse curve steeper than the BOZ is 0.36mm shorter; from this, a raphy, trial lenses and fl uorescein (BPZ1); a second peripheral zone residual refractive error of 1.75D pattern evaluation, meaning prac- or landing zone fl atter than the in the right eye (OD) and 1.25D in titioners typically achieve a greater previous one (BPZ2); and a third the left eye (OS) was then expect- amount of confi dence and success peripheral zone steeper than the ed. Additionally, the BPR1 was with the fi tting process, though this second one (BPZ3). This approach longer with a lower inversion than is not always the case. This article uses one of several different mod- will discuss the orthokeratology ern reverse orthokeratology lens ABOUT THE AUTHOR lens fi tting process in the context designs available on the market. Dr. Fadel specializes in fi tting of calculating back lens parameters In theory, more curves could occur contact lenses for the individually for unusual cases. to smooth the junction’s angle irregular cornea as well as in scleral lens fi ttings between one curve and another to and orthokeratology. She TEENAGE PATIENT produce conformal periphery and has a contact lens private practice in Italy where she Presentation. A 17-year-old to increase the lens centration. designs special customized 1patient underwent an ortho- Methods. When choosing the contact lenses. She lectures and publishes especially on the keratology fi tting to control her back optical zone radius (BOZR) aforementioned subjects. She can be reached myopic progression, as her mother for the fi rst trial lens, it’s possi- at [email protected].

22 REVIEW OF CORNEA & CONTACT LENSES | JUNE 2016

022_RCCL0616_F3_Orthokeratology.indd 22 5/31/16 4:34 PM Fig. 1. Fluorescein patterns of the fi rst pair of lenses, three nights after Fig. 2. Note the corneal staining in initiation of treatment. Note, the steep pattern of the lenses is clear. the central area. normal, while the BPR2 was longer tient was fi t with an orthokeratol- has suggested that low corneal than 0.40mm; this could mean a ogy lens, her UDVA was 20/25+2 eccentricity is predictive of a lower possible lifting of the optical zone OD with residual refractive errors refractive error change. As such, with modest result in the treatment. present in the spectacle plane sph these results are in agreement Additionally, note that the lens is fi t -1.00D and 20/20 OS with resid- with other studies demonstrating steeply with central corneal stain- ual refractive errors sph -0.50D. that low eccentricity may not be ing most visible after lens removal Twenty days after the fi tting, the an absolute contraindication to (Figures 1 and 2). Corneal topog- patient’s UNVA was 20/16-1 OD orthokeratology, despite the fact raphy demonstrated the typical with residual refractive errors: sph that the patient’s cornea was small central islands that can be induced -0.25D; 20/16 OS with no resid- and steep with a medium-to-high from a steep lens. ual refractive errors; and 20/12.5 degree of myopia.8-12 In these cases, Following this evaluation, new in both eyes (OU). The patient the corneal shape becomes oblate lenses were calculated based on the reported having good vision with due to the negative eccentricity parameter analysis of the fi rst trial the lenses for up to 15 hours per (i.e., E = -1.62 OD and E = -1.50 lenses and the fl uorescein pattern. day, but complained that she some- OS). In the case of this patient, her The BOZ was fl attened according times observed visual halos around issue was resolved using a four- to calculations made previously, lights. At her three-and-a-half curve reverse lens with a mean which automatically increased the month follow-up appointment, the back optic zone diameter and reverse curve, leaving the same UDVA was 20/16 OD with resid- relatively small total diameter. BPR1 (Table 3). The BPZ2 was ual refractive errors sph -0.25D also fl attened to allow a lifting of and 20/16 OS with no residual CONTACT LENS the optical zone to prevent corneal refractive errors. The low contrast DROPOUT abrasions and allow for a better UNVA was 20/25 OD, 20/25 OS 2Presentation. A 48-year-old distribution of epithelial tissue. and 20/12.5 OU. patient presented to the clinic wish- Results. Five days after the pa- Discussion. Previous research ing to try wearing orthokeratology

Table 1. Tetracurve Lens Parameter Calculations for Myopia up to 4.25D14

Tetracurve RGL for Myopia < -4.25D BPR2 alignment with peripheral cornea (Jessen Factor (JF) 0.50 - 1.00D • 0 < e < 0.30 BPR2 = K • 0.31 < e < 0.55 BPR2 = K + 0.05mm BOZR = Kp + m. target + J.F. • 0.56 < e < 0.70 BPR2 = K + 0.10mm BOZR = 7.25 + 1.15 + 0.15 BPR2 = 7.20mm BOZR = 8.56mm W2 = 1.0 -1.3mm BOZD = 5.80 - 6.40 W2 = 1.2mm BPR1 = 6.00mm BPR3 = 10.5 - 12.5mm BOZD = BOZR-2x/2.6x(m.t.+J.F.) BPR3 = 10.5mm BPR1 = 8.56 - 2 x (1.15 + 0.15) BPR1 = 5.96mm W3 = 0.4mm W1 = 0.4 - 0.6 mm TD = 10.0 - 11.50mm W1 = 0.6mm TD = 10.4mm

*The spherical equivalent was considered as the myopic target (-5.75D) and Jessen factor value of 0.75D.

REVIEW OF CORNEA & CONTACT LENSES | JUNE 2016 23

022_RCCL0616_F3_Orthokeratology.indd 23 5/31/16 4:34 PM UNUSUAL CLINICAL CASES IN ORTHOKERATOLOGY

Table 2. Parameters of the First Pair of Lenses Fit in Case 1 K f K s OD 7.26 7.09 OS 7.24 7.03 Inv. 1.8 BOZR BOZD BPR1 W1 BPR2 W2 BPR3 W3 OD 8.20 6.00 6.40 0.60 7.60 1.15 10.0 0.50 OS 8.20 6.00 6.40 0.60 7.60 1.15 10.0 0.50 TD 10.50mm; BVP +0.50D.

lenses to eliminate the need for eye- -1.50x20° BCVA 20/16 add 1.50D, astigmatism (i.e., -1.82D OD and glasses. She had previously worn K 7.51/7.29mm E = 0.20, horizon- -1.39D OS) and low eccentricity soft contact lenses, but had stopped tal visible iris diameter 11mm and present. Additionally, though the due to resulting dry eye symptoms. pupil size 3.50mm OS. patient’s marginal dry eye was not Her refractive and corneal data at It was noted the patient’s cylin- an absolute contraindication to the time of presentation was Rx drical component was three times orthokeratology lens wear, it could sph -0.75 cyl -2.50x170° BCVA larger than the spherical one in the challenge the practitioner’s ability 20/16 Add 1.50D, K 7.81/7.49mm, right eye, while in the left eye they to create a reliable topography E = 0.10, horizontal visible iris were equal. Also, there was refrac- map, since corneal topographers diameter 11.60mm and pupil size tive astigmatism (cyl -2.50 OD and are typically more effective at gen- 3.40mm OD; and Rx sph -1.50 cyl cyl -1.50 OS higher than corneal erating a clear image when evaluating a wetter corneal surface.12 Potential Orthokeratology Contraindications Few published studies currently exist on the subject of toric ortho- A better understanding of lens parameters and fi tting techniques may allow practitioners to beat some of these typical keratology for astigmatism, though orthokeratology contraindications: conference abstracts and case 1. Myopia correction up to -6.00D, due to a lack of predictability of reports on the subject are numer- 13-21 the treatment.8,12 ous. One study was conducted 2. Correction of with-the-rule corneal astigmatism higher than on patients who have astigmatism 1.50D.22-25 The most common problem in patients with high corneal greater than 1.25D at any orien- astigmatism is spherical lens decentration, which can lead to further tation.13 The lenses used in this induced astigmatism and poor vision.24,26 project contained fi ve toric zones 3. Correction of against-the-rule and oblique corneal astigmatism with double reverse curves, with higher than 0.75D.18,19,25,26 This is due to lens decentration, which can the second and the fourth zones be- induce more astigmatism.24,26 ing the reverse ones. This design is 4. Correction of corneal astigmatism. Residual astigmatism can known as a full toric double reser- aff ect refractive outcomes post-treatment.27 voir. The researchers suggested that 5. The need for spectacle lens cylinder to always be less than the to achieve an adequate effect with a spherical power (i.e., less than one-third of the sphere).8 toric orthokeratology lens, me- 6. Astigmatism spanning limbus-to-limbus because of lens chanical and hydrodynamic forces decentration.8 must occur in different ways in 7. Irregular corneal astigmatism, given the diffi culty to stabilize the each corneal meridian, with greater lens on the cornea.8 fl attening in the meridian where the 8. Pupil size of about 5mm to 6mm or larger under dim light myopia is greater.20 Results demon- conditions.12 Orthokeratology can induce higher-order aberrations, strated an 85% change in initial especially spherical aberrations. In patients who have a pupil size astigmatism. greater than 5mm, the amount of high order aberrations increases Another study on patients dramatically. ranging from six to 12 years old 9. Low corneal eccentricity, in that the correlation between with myopia of 0.50D to 5.00D eccentricity and the predictability of the treatment is not well defi ned, so orthokeratology is only considered safe for correction of and with-the-rule astigmatism of myopia less than -4.00D.8,12 1.25D to 3.50D incorporated a lens characterized by an alignment

24 REVIEW OF CORNEA & CONTACT LENSES | JUNE 2016

0022_RCCL0616_F3_Orthokeratology.indd22_RCCL0616_F3_Orthokeratology.indd 2424 55/31/16/31/16 4:354:35 PMPM Table 3. Comparison of the First and Second Pair of Lenses in Case 1 K f K s OD 7.26 7.09 OS 7.24 7.03 BOZR BOZD BPR1 W1 BPR2 W2 BPR3 W3 OD 8.20 6.00 6.40 0.60 7.60 1.15 10.0 0.50 OS 8.20 6.00 6.40 0.60 7.60 1.15 10.0 0.50 TD 10.50mm; BVP +0.50 D BPR2 = BOZR - 2x/2.6x (m. t. + J.F.) K f K s BPR1 = 8.20 - 2 x (1.15 + 0.15) BPR1 = 6.00mm (inv. 2.6 mm) OD 7.26 7.09 OS 7.24 7.03 Inv. 2.2/2 BOZR BOZD BPR1 W1 BPR2 W2 BPR3 W3 OD 8.60 6.00 6.40 0.60 8.00 1.15 10.0 0.50 OS 8.40 6.00 6.40 0.60 8.20 1.15 10.0 0.50 TD 10.50mm; BVP 0.00D. toric zone with spherical back op- -3.10x7°, and the lens used had on this patient was a hexacurve tics and a reverse zone design.14,15 two toric zones: the reverse and the (i.e., six back curves) design with According to the authors of this landing zone.19 The reduction of a two back toric zones, dual toric study, the advantage of placing a high CA can be achieved if the re- zones and optical and landing spherical optic zone on a toric cor- verse zone design allows for a close zones. Also, the vertical meridian nea is that the fl attest lens meridian tangential or alignment in each me- was steeper than the horizontal creates a normal orthokeratology ridian to properly modulate the hy- meridian in the landing zone and effect, while the steepest meridian drodynamic forces, which enables vice versa in the optical zone. Three results in a greater orthokeratology for the fl attening of each meridian months post-orthokeratology fi t- effect, leading to the correction to establish the orthokeratology ting, the subjective correction was of the corneal astigmatism. The effect. In the presented case, at two sph + 0.50 cyl -0.50x10° (UNVA study results demonstrated a fi t months post-treatment the CA was 20/16) OD and sph+0.25 cyl success rate of 95% with a sig- largely reduced, and the subjective -1.00x5° (UNVA 20/16) OS. nifi cant reduction in myopia and correction was cyl -0.50Dx8° with Methods. Because there do not astigmatism. UNVA 20/20. appear to be any set guidelines for Some of the case reports in exis- • A case of a 44-year-old patient toric orthokeratology lens param- tence in which authors fi t different with a mixed astigmatism in which eter calculation in the literature, toric orthokeratology lens designs the cylindrical component was indications for spherical ortho- include: greater than spherical one. The keratology lenses were followed • A case of a 22-year-old patient, patient presented with sph + 1.00 instead. The fi rst pair of lenses used sph -4.25 cyl -3.75x8° OD. The cyl -2.00x180° OD and sph +1.25 demonstrated a tetracurve design corneal astigmatism (CA) was cyl -2.25x180° OS.20 The lens fi t with two toric zones—one in the optical zone to correct the astigmatism and another in the landing zone to help achieve a centered lens. Parameters are listed in Table 4. Fluorescein patterns for this lens fi t demonstrated the presence of an upward decentration in the right eye, while in the left eye the pattern was suitable as the BPZ2 was Fig. 3. Fluorescein patterns of the second pair of lenses, 20 days post-orthokeratology. Both lenses are decentered, compromising the aligned over the corneal peripheral refractive outcome. meridians. The spectacle correc-

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0022_RCCL0616_F3_Orthokeratology.indd22_RCCL0616_F3_Orthokeratology.indd 2525 55/31/16/31/16 4:354:35 PMPM UNUSUAL CLINICAL CASES IN ORTHOKERATOLOGY

UNVA for more than 13 hours a day. Additionally, topoaberrometry showed that corneal higher-order aberrations were not relevant except the spherical ones, which allowed the patient to have a good VA at different distances and hence setting up close. The slit lamp examination showed instability of the tear fi lm in both eyes but the patient Fig. 4. Fluorescein patterns of the third pair of lenses, 20 days post- reported no presence of symptoms orthokeratology. In this instance, the lenses were centered. throughout the day. Discussion. As seen before, in tion was OD sph +1.00 cyl -1.25 For example, the width of the the published studies, conference x 145°(UNVA 20/32) and OS cyl reverse zone (W1) was larger than abstracts and case reports, there 1.00 x 40° (UNVA 20/25). Once the landing one (W2) to achieve a are a number of designs of toric the treatment effect was underway greater hydrodynamic force action, contact lenses to treat astigmatism in the left eye, the design was main- allowing a higher closing lens in that work equally well.13-21 This tained via fl attening of the BOZ by each meridian to increase the effect second case was solved using a 0.2mm in the horizontal meridian. of orthokeratology. For the lens four-toric zone reverse lens, even if The second pair of lenses was stability, it was decided that the it was an apparently contraindicat- calculated and a tetracurve lens BPZ2 should be fl atter than K. In ed scenario for this type of lens. In with three toric areas—the opti- this case, the BPZ3 was steeper fact, the cylindrical component in cal zone, the reverse zone and the than most literature indications to the OD was three times larger than landing zone—was selected based allow for a tear exchange, and the the spherical one, while in the OS on the residual refraction with the width of the third peripheral zone they were equal. Also there was a fi rst lenses (Table 5). Fluorescein (W3) was the same as W2 to help refractive astigmatism (OD -2.50D, patterns and corneal maps post-fi t balance corneal touch around all OS -1.50D) higher than CA (OD demonstrated lens decentration in meridians. -1.82D and OS -1.39D) and a low both eyes, leading to poor refrac- Results. Twenty days post-treat- eccentricity. The parameters of the tive results and visual acuity (Figure ment, the fl uorescein patterns back curve were then calculated 3). Parameters were sph +1.00 cyl looked good, with regular and manually. -1.25x145°(UNVA 20/32) OD and constant (real or apparent) touch cyl -1.00x40° (UNVA 20/25) OS. in all the corneal meridians (Figure hough FDA approval criteria Next, a third pair of lenses was 4). The corneal profi le post-ortho- Tstates that orthokeratology ordered; the parameters are shown keratology is shown in the corneal is appropriate for myopia correc- in Table 6. It should be noted that maps (Figure 5). The subjective cor- tion up to -6.00D, there is enough the majority of new lens parame- rection was cyl -0.75x150° (UNVA evidence to suggest that orthokera- ters do not necessarily respect the 20/16) OD, cyl -0.50x30° (UNVA tology also has function for higher indication reported in literature for 20/16-1) OS and UNOU 20/16. myopia and astigmatism. As such, spherical orthokeratology lenses. The patient demonstrated good the orthokeratology fi tting process

Table 4. Parameters of the First Pair of Lenses Fit in Case 2 K f K s OD 7.81 7.49 OS 7.51 7.29 Inv. 1.8 BOZR BOZD BPR1 W1 BPR2 W2 BPR3 W3 OD 8.25/8.10 6.20 7.40 0.70 8.15/8.00 1.10 11.10 0.50 OS 7.90/7.75 6.20 7.15 0.70 7.85/7.65 1.10 10.50 0.50 TD 10.80mm; BVP +0.50D. BOZ and BPZ2 are toric.

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0022_RCCL0616_F3_Orthokeratology.indd22_RCCL0616_F3_Orthokeratology.indd 2626 55/31/16/31/16 4:354:35 PMPM Table 5. Parameters of the Second Pair of Lenses Fit in Case 2 K f K s OD 7.81 7.49 OS 7.51 7.29 Inv. 1.8 BOZR BOZD BPR1 W1 BPR2 W2 BPR3 W3 OD 8.35/8.00 6.50 7.50/7.20 0.50 7.90/7.60 1.25 11.00 0.75 OS 8.10/7.80 6.50 7.35/7.15 0.50 8.10/7.90 1.25 11.00 0.75 TD 11.50mm; BVP 0.00D. Table 6. Parameters of the Third Pair of Lenses Fit in Case 2 K f K s OD 7.81 7.49 OS 7.51 7.29 Inv. 1.8 BOZR BOZD BPR1 W1 BPR2 W2 BPR3 W3 OD 8.00/7.70 6.30 7.60/7.30 0.80 7.90/7.60 0.70 9.00 0.70 OS 8.00/7.90 6.50 7.50/7.30 0.70 8.10/7.90 0.60 9.00 0.60 TD OD 10.70; OS 10.30mm; BVP 0.00D.

tional contact lens prescribing in 2012. Contact 12. Van der Worp E, Ruston D. Orthokeratology: in these instances could be made Lens Spectrum 2013 January; 28: 31-44. an update. Optom in Practice 2006;7:47-60. easier with the knowledge of all 4. Luk BMW, Bennett ES, Barr JT. Fitting ortho- 13. Paunè J, Gardona G, Quevedo L. Toric double keratology contact lenses. Contact lens Spectrum reservoir contact Lens in orthokeratology for the lens’ back surface parameters. 2001 October, 16(10):22-32. astigmatism. Eye Contact Lens 2012;38:245-251. It enables the contact lens prac- 5. Jessen GN. Orthofocus techniques. Contacto 14. Chen C, Cheung SW, Cho P. Myopia control titioner to become more familiar 1962; 6(7):200-204. using toric orthokeratology. Invest Ophthalmol 6. Chan B, Cho P, Mountford J. The validity of the Vis Sci 2013; 54: 6510-6517. with the functionality of each jessen formula in overnight orthokeratology: a 15. Chen C, Cho P. Toric orthokeratology for high retrospective study. Ophtalmic Physiol Opt 2008 myopic and astigmatic subjects for myopic con- parameter so that it can easily be May;28(3):265-268. trol. Clin Exp Optom 2012;95:103–108. changed to further improve the 7. Swarbrick HA. Orthokeratology review and 16. Beerten R, Christie C, Sprater N, Ludwig F. Im- update. Clin Exp Optom 2006; 89; 124-143. proving orthokeratology results in astigmatism. lens ﬁ t. These cases also suggest Poster presented at the Global Orthokeratology 8. Mountford J, Ruston D, Dave T. Orthokeratol- Symposium, Chicago, IL, July 29–31, 2005. that a “simple” tetracurve lens ogy. Principles and Practice. London, Butter- worth-Heinemann, 2004. 17. Baertschi M. Short and long term success with could be considered as an option correction of high astigmatism in OK. Poster 9. Mountford J. Orthokeratology. In Phillips AJ & RCCL presented at the Global Orthokeratology Sympo- to resolve complex cases as well. Speedwell L. Contact lenses. Edinburgh, Butter- sium, Chicago, IL, July 29–31, 2005. worth-Heinemann. 2007:423-450. 18. Chan B, Cho P, de Vecht A. Toric orthokeratol- 1. Chetty E, Jackson S, Mitton C, Phillips TK. A 10. Joe JJ, Marsden HJ, Edrington TB. The ogy: a case report. Clin Exp Optom 2009;92:387– look at important issues regarding safe ortho- relationship between corneal eccentricity and 391. keratology. The South African Optometrist, improvement in visual acuity with orthokeratolo- December 2007. gy. J Am Optom Assoc 1996; 67:87-97. 19. Baertschi M, Wyss M. Correction of high amounts of astigmatism through orthokeratolo- 2. Morgan PB, Woods CA, Tranoudis IG, Helland 11. Lui WO, Edwards MH. Orthokeratology in gy. A case report. J Optom 2010;3:182-184. M. International contact lens prescribing in 2014. low myopia. Part I: effi cacy and predictability. Contact Lens Spectrum 2015 January; 30: 28-33. Contact 20. Calossi A. Mixed astigmatism treated with a Dual-Toric ortho-k design. Contact Lens Spec- 3. Morgan PB, Woods CA, Jones D, et al. Interna- Lens Anterior Eye 2000;23:90-99. trum 2013, February;28:49. 21. Jackson JM. Advanced corneal reshaping for astigmatism. Contact Lens Spectrum 2013, February;28:42. 22. Ruston D, Van Der Worp E. Is ortho-K ok? Optometry Today 2004; Dec 17:25-32. 23. Chen CC, Cheung SW, Cho P. Toric orthokeratology for highly astigmatic children. Optom Vis Sci 2012; 89:849-855. 24. Mountford J, Pesudovs K. An analysis of the astigmatic changes induced by acceler- ated orthokeratology. Clin Exp Optom 2002; 85:284–293. 25. Cheung SW, Cho P, Chan B. Astigmatic changes in orthokeratology. Optom Vis Sci 2009;86:1352–1358. 26. Chan B, Cho P, Cheung SW. Orthokeratology practice in children in a university clinic in Hong Kong. Clin Exp Optom 2008;91:453–460. 27. Van der Worp E. Correcting astigmatism with orthokeratology. Contact Lens Spectrum 2006 Fig. 5. Corneal topographies after removing the third pair of lenses. July, 21(7):21.

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An irregular cornea patient presents needing better vision following a corneal stabilization procedure. What do you do? CORNEAL

CROSSLINKINGBy BBorisoris SSeverinksky,everinksky OD

ornealo collagen cross- The lens’ central thickness varies of these designs is limited entirely linkingli (CXL) avail- from 0.5mm to 0.6mm and is to therapeutic purposes due to ablea internationally responsible for the neutralization their inability to correct irregular forf over a decade and of corneal irregularity and the astigmatism. C nown newly approved creation of a regular front refrac- So, with the CXL era fi nally in tthehe UUnitednited States, is the only tive surface. Scleral support also about to begin in the US, let us surgical procedure capable of slow- results in the formation of a true consider whether the approach to ing down or stopping the progres- aqueous tear lake underneath the contact lens fi tting shortly after sion of keratoconus and secondary lens, which enhances the ability CXL should be different from keratectasia after laser in-situ ker- to correct irregular astigmatism, what we consider a standard atomileusis (LASIK) and photore- similar to gas permeable (GP) of care for the irregular cornea fractive keratectomy (PRK).1,2 CXL scleral lenses (Figure 1). One major patient through a series of case is also considered by many to be a indication for this type of lens is vi- reports. vision-saving procedure, especially sual rehabilitation following CXL, when performed on younger pa- with the goal of the fi tting being STANDARD PROCEDURE tients with the goal of preventing to provide a stable, distortion-free A 29-year-old woman with the need for future keratoplasty. refractive surface and minimize 1a diagnosis of surgically-in- Research suggests CXL may have interference between the recover- duced keratectasia was referred in benefi cial visual and optical effects, ing ocular surface—especially the for a specialty contact lens fi tting as evidenced by the reduction in epithelium—and the contact lens.6 due to decreased vision in her left corneal steepness and improve- Examples of custom soft contact eye for the last nine months. She ment in uncorrected visual acuity lenses for keratoconus include reported that she had undergone and best corrected visual acuity the NovaKone (Alden Optical), LASIK for moderate myopia 12 (BCVA).3,4 Despite these impressive Flexlens Tricurve (X-Cel Specialty years prior. The patient’s unaided outcomes, however, in many cases Contacts), and Eni-Eye Soft-K lens visual acuities were 20/80 OD and corrective lenses are still necessary (Acculens). 20/200 OS, and her refraction was to achieve the best possible vision Semi-scleral soft lenses can +1.25/-3.75x140 OD and -5.00/- following CXL. also be used as therapeutic ban- ABOUT THE AUTHOR Specialty soft contact lenses in dage lenses following refractive particular continue to gain popu- or ocular surface reconstructive Dr. Severinsky recently completed a two-year doctor larity among eye care practitioners surgery, especially in eyes with of optometry program for international graduates at due to advancements in lens mate- high corneal toricity or steeper the New England College of rials and lathing technology.5 One than average curvature, since a Optometry. Since 2001 he has specialized in specialty such example is the silicone hy- higher sagittal depth helps stabilize contact lens fi tting and drogel mini-scleral (SHmS): a large lens fi t and reduce excessive lens especially scleral lenses. Today his primary area of interest is designing and 17mm diameter lens that vaults movement. Examples include the fi tting contact lens for keratoconus and after the limbus and central cornea with Kontur (Kontur Kontact Lens) or corneal collagen cross-linking. He is a Fellow of the American Academy of Optometry, minimal bearing on the corneal T74/85 (David Thomas Contact British Contact Lens Association and Scleral apex to rest on the patient’s sclera. Lenses); however, the application Lens Education Society.

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028_RCCL0616_F4_LensUsePostCXL.indd 28 5/31/16 4:33 PM 5.00x170 OS with best-corrected time gradually, and was scheduled visual acuity (BCVA) of 20/30 for a follow-up appointment in the and 20/80, respectively. Corneal next 10 days. topography revealed advanced During the follow-up appoint- keratectasia predominantly in the ment, a slight reduction in visual left eye (as compared with her acuity (i.e., 20/50) was noted, but right) with maximum keratometry the patient reported noticeable

(Kmax) values of 55.4D OD and improvement in vision clarity and 59.7D OS (Figure 2). The patient her ability to perform daily tasks, was subsequently evaluated by a as well as good lens tolerance and cornea specialist and scheduled to average lens wear of nine hours undergo an epithelium-off corneal a day. An examination revealed collagen crosslinking procedure to the presence of a well-centered halt further progression. She was lens with about 1mm of on-blink also given temporary spectacles movement (Figure 3). An over- with partial astigmatic correction refraction of plano/-1.50x175 was in the right lens and plano correc- able to improve her vision to 20/25 tion in the left to wear following OS and signifi cantly reduce the the surgery. Two weeks after, the amount of ghost images seen. A patient underwent CXL in her left new lens with an updated power Fig. 1. Optimal fl uorescein pattern eye. was ordered; three weeks later, of silicone hydrogel mini-scleral Five weeks later, following the patient was able to wear the contact lens. complete epithelial healing and revised lens up to 10 hours a day eters BC 7.00, diameter 14.20 an the discontinuation of all steroid with stable contact lens-corrected power -8.00. Additionally, he had medications, the patient’s left cor- vision. As a result of successful been able to achieve a visual acuity nea exhibited no signs of epithelial restoration of vision in the treat- of 20/40-. Unaided vision in his hypertrophy or superfi cial punctate ed eye, the patient underwent an left eye was 20/400. staining. As such, she was sched- uneventful CXL procedure eight However, in early 2014 his right uled for a contact lens fi tting and weeks later for her other eye. eye had begun to exhibit signs of given a front toric, prism-ballasted keratoconus progression along version of the SHmS lens with PROGRESSION with a consecutive decrease in a base curve of 7.3mm and the PROTECTION BCVA. A new attempt to fi t a GP power of -3.75/-2.25x180. The 2A 29-year-old male con- lens also failed. The patient was lens was manufactured in a Filcon struction worker was diagnosed referred to a cornea clinic for the V3 silicone hydrogel material with bilateral keratoconus possible necessity of CXL, who di- (Defi nitive 74, Contamac). At the (OS>OD) 12 years prior to pre- rected him to delay the procedure dispensing visit, the patient’s BCVA senting to the clinic. He reported due to borderline corneal thickness was 20/30 OS, with a minor com- he had undergone penetrating of 408µm. He was scheduled for plaint of ghost images. She was keratoplasty in his left eye in 2011; a follow up in six months but instructed to increase lens wearing however, shortly after the proce- later the same year, the patient’s dure, the corneal transplant had best-corrected vision dropped to begun to show signs of endothelial 20/60, with marked steepening rejection, which eventually led noted on corneal topography. To to scarring and reduced vision. halt further deterioration of vision, Numerous GP lens fi ts had been an epithelium-on CXL procedure attempted but the patient had was performed. The postoperative continued to demonstrate a severe recovery was uneventful, and four intolerance to rigid lenses, especial- weeks later the patient had been ly while outdoors. In the last three scheduled for contact lens fi tting. years, he had successfully managed An examination at the time of Fig. 2. Corneal topography of the left using a soft lens made for kerato- the contact lens fi tting revealed eye reveals advanced keratoectasia. conus (Soft-K, Sofl ex) with param- the following fi ndings: manifest

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with a SHmS Vision upon dispensing was lens made from 20/50. At the one-month follow-up Defi nitive 65 appointment, the patient reported (Filcon V4) good lens tolerance with 12 to 14 rather than hours a day of lens wearing. Visual the practice’s acuity had decreased to 20/60, default materi- but improved back to 20/40- with al (Filcon V3, overrefraction of +2.50/-1.50x050. Contamac). The patient’s central cornea exhib- Filcon V4 ited trace central superfi cial punc- is a polymer tate keratopathy, which appeared with a high- to relate to corneal apex bearing. er silicone A new lens with base curve of content than 6.4mm, similar peripheral geom- Fig. 3. Well fi tted SHms lens. Proper allocation of the its predecessor, etry and a power of -10.5D was fenestration holes (at 3 and 9 o’clock) indicates absence of Filcon V3. dispensed. Overrefraction demon- lens rotation. Other than the strated similar residual astigmatism high oxygen fi ndings of +0.50/-1.50x55. The refraction of -5.00/-6.50x125 VA permeability (Dk = 62) previously patient was advised to wear poly- 20/150 OD and -4.50/-7.50 x 110 mentioned, the Filcon V4 material carbonate spectacles for correction VA 20/70 OS. Central keratome- also possesses the highest mod- of residual astigmatism and ocular try readings of the right eye were ulus of elasticity in the family of protection. Final visual acuity of

56.0/57.4D with a Kmax value of lathable silicone hydrogels (MPa = the right eye improved to 20/30-. 62.5D (Figure 4). A slit lamp ex- 1.0). Typically, lenses with a higher No signifi cant corneal staining or amination revealed a faint anterior modulus are stiffer and will correct corneal neovascularization were stromal haze with an intact corneal the underlying corneal irregularly present at three-month follow-up. epithelium (Figure 5). Fit assess- more effectively, while those lenses Current daily lens wearing time ment using the old right contact with a lower modulus will simply stands at 12 hours a day with lens demonstrated an excessive drape over the cornea. Fitting of the occasional use of lubrication rocking movement of the lens with contact lenses with a higher modu- agents for comfort. fl uting edges upon blink. Attempts lus may be advantageous in terms to refi t the patient’s right eye with of vision correction success, since HYDROPS HIJINKS a steeper Soft-K lens did not pro- lenses made of these materials help Successful use of full-size vide suffi cient visual improvement mask the entirety of corneal astig- 3scleral lenses after corneal (BCVA of 20/60). Instead, the pa- matism and eliminate the need for crosslinking has also been previ- tient was selected for a trial fi tting a toric design. On the other hand, ously reported in the literature.7 wear of stiffer lenses can lead to Regular sclerals offer the advan- edge fl uting, tarsal irritation and tage of minimal mechanical inter- mechanically-induced allergy. In action with the treated zone and these cases, additional adjustment help promote ocular surface heal- of the peripheral curves is often ing and provide optical benefi ts. required for successful lens wear. In this third case report, a This patient was fi t into a spher- 19-year-old male with advanced ical version of the SHmS lens with keratoconus OS and documented a base curve of 6.5mm, “steep” progression underwent an epi- peripheral curve, diameter of thelium-off corneal crosslinking 17mm and central lens thickness of procedure in May 2013. Prior to 0.6mm (Figure 5). The lens power the surgery, his maximum corne- was -12.5D. Four fenestration al steepness was 64.5D with an Fig. 4. Corneal topography of the holes were added at the lens limbal unaided vision measurement of right eye demonstrating a classic zone to increase oxygen delivery 20/800 (Figure 6a). Unfortunately, keratoconic nipple cone appearance. and tear mixing. no pre-treatment refractive data

30 REVIEW OF CORNEA & CONTACT LENSES | JUNE 2016

028_RCCL0616_F4_LensUsePostCXL.indd 30 5/31/16 4:33 PM was available for this patient patient’s complex corneal geometry but postoperative recovery was and decompensated ocular sur- positive for hypertrophic epi- face, we decided to manage this thelium formation and delayed patient with a 18.5mm GP scleral healing, which was treated using lens. Incorporating the advances antibiotics and a bandage contact of reverse geometry technology, lens during the course of four we were able to design a lens with weeks. At week fi ve, the patient a fl at enough base curve to more presented back to the clinic with precisely follow an oblate central complaints of signifi cant pain cornea (Figure 8). The patient’s and cloudy vision OS. His vision lens-corrected visual acuity was was reduced to CF at three feet 20/40, and, after a short adapta- and severe stromal edema with tion period, he was able to achieve ruptures in Descemet’s membrane day-long uncomplicated lens wear. was observed (Figure 7). At his one-month follow-up, his The patient was treated for BCVA was unchanged, the corne- corneal hydrops with a fi ve-week al epithelium was intact and his course of topical steroids, in com- TBUT values had improved to 15 bination with antibiotic coverage seconds. during the fi rst seven days and hyperosmotic eye drops. After the KEEP IN MIND Fig. 5. This image represents 6.50mm patient’s cornea cleared up and the Though CXL is considered a po- lens with an excessive central touch and minimal mid-peripheral edema diminished, the patient was tentially vision-saving procedure in clearance. Note the presence of referred for a contact lens fi tting. many cases, it is not free of compli- the anterior corneal haze. The lens A slit lamp examination re- cations. The most common side ef- thickness is 600µm. vealed a stromal scar of moderate fects are delayed epithelial healing, density at the inferior pupillary longstanding SPK, noninfectious it’s safe to begin or resume contact margin, trace punctate keratop- infi ltrates and stromal edema with lens wear after corneal collagen athy of the inferior cornea, signs scarring (i.e., corneal hydrops) crosslinking. Post-CXL corneal of meibomian gland dysfunction as well as minimal reduction in recovery can fl uctuate over time. and fl oppy lid syndrome. Tear endothelial cell count secondary to Crosslinking research with data on break-up time (TBUT) values were UV irradiation damage.8 Despite long-term follow-up has demon- also low at seven to eight seconds. the ocular surface complications strated that corneal thickness, Corneal topography demonstrated attributed to crosslinking, however, as well as central keratometry, a highly irregular corneal surface the risks associated with corneal follows a dynamic curve in the with signifi cant fl attening of the transplantation surgery still signifi - fi rst six months.9,10 While patients

center and (Kmax value of ~50D) as cantly outweigh those of CXL. following an epithelium-on proce- compared to pre-treatment fi nd- Currently, there are no clear dure may be fi tted in a time frame ings (Figure 6b). Considering the recommendations regarding when of one to two weeks, patients who undergo the epithelium-off treatment may need a signifi cantly longer recovery time and may also experience a higher rate of corneal healing-related complications. Though the epithelial defect typically closes four to seven days after the procedure, continuous epithelial remodeling followed by the modifi cation in the arrange- ment of stromal collagen fi bers Fig. 6. (A) pre-treatment corneal topography of the right eye; and (b) topography of the same eye after the resolution of corneal hydrops. Note 14D and corneal nerve proliferation

ﬂ attening of Kmax. may be seen over several months.

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Fig. 7. Corneal hydrops four weeks Fig. 8. A properly ﬁ tted 18.50mm Fig. 9. Dense central corneal scar after performance of the CXL scleral lens on the eye with resolved after an episode of microbial keratitis. procedure in the eye with delayed post-CXL corneal hydrops. Note We assume that the infection was ocular surface healing. the scar-induced central corneal propagated by the unauthorized ﬂ attening. resumption of GP lens wear three weeks after uneventful CXL.

1. Wollensak G, Spoerl E, Seiler T. Ribofl avin/ Consequently, it is imperative that of the left cornea. After being on ultraviolet-A–induced collagen crosslinking for healing is achieved prior to lens fortifi ed cefazolin and gentamicin the treatment of keratoconus. Am J Ophthalmol. 2003;135:620-7. fi tting to avoid mechanical disrup- for almost two weeks, the ulcer- 2. Hafezi F, Kanellopoulos J, Wiltfang R, Seiler T. tion. These changes are also re- ation resolved but left him with a Corneal collagen crosslinking with ribofl avin and ultraviolet A to treat induced keratectasia after la- fl ected in the further fl attening and dense corneal scar and best-correct- ser in situ keratomileusis. J Cataract Refract Surg. regularization of the central cornea, ed vision of 20/50 (Figure 9). 2007; 33:2035–40. 3. Caporossi A, Mazzotta C, Baiocchi S, Caporossi and may often lead to improved One study reports that patients T. Long-term results of ribofl avin ultraviolet A corneal collagen cross-linking for keratoconus in spectacle-corrected visual acuity fi t with GP lenses three months Italy: the Siena Eye Cross Study. Am J Ophthalmol. and more success with contact after the procedure demonstrated 2010; 149:585–93. 4. Greenstein SA, Fry KL, Hersh PS. Corneal topog- lenses. For epithelium-off patients, evidence of epithelial cell stress raphy indices after corneal collagen crosslinking for keratoconus and corneal ectasia: One-year we recommend resuming contact with an increase in superfi cial results. J Cataract Refract Surg. 2011; 37:1282–1290 lens wear fi ve to six weeks after epithelial cell size and a decrease in 5. Fernandez-Velazquez FJ. Kerasoft IC compared 13 to Rose-K in the management of corneal ectasias. the procedure, similar to post-PRK basal epithelial cell density. These Cont Lens Anterior Eye. 2012;35(4):175-9. contact lens fi tting indications.11 fi ndings are also accompanied by a 6. Severinsky B, Wajnsztajn D, Frucht-Pery J. Silicone hydrogel mini-scleral contact lenses in In the fi rst months following decrease in corneal sub-basal nerve early stage after corneal collagen cross-linking for keratoconus: a retrospective case series. Clin Exp CXL, the cornea may exhibit a plexus density. The other area of Optom. 2013;96(6):542-6. thinner epithelial profi le with concern regarding GP lens wear 7. Visser ES, Soeters N, Tahzib NG. Scleral lens tolerance after corneal cross-linking for keratoconus. decreased quality of adherence after CXL is that contact lens-in- Optom Vis Sci. 2015;92:318-23. between the epithelial layers. duced mechanical irritation may 8. Wajnsztajn D, Strassman E, David Landau D, Frucht-Pery J. Ocular surface-related complica- These changes may cause a higher lead to infl ammation and consecu- tions after corneal crosslinking for keratoconus. corneal vulnerability to contact tive keratocyte loss in the anterior 19th Congress of ESCRS, Vienna, Austria, 2011. 9. Greenstein SA, Shah VP, Fry KL, Hersh PS. lens-induced mechanical trauma. stroma, in addition to apoptosis Corneal thickness changes after corneal collagen 14 crosslinking for keratoconus and corneal ectasia: As such, fi tting of traditional GP infl icted by UV irradiation. One-year results. J Cataract Refract Surg. 2011; lens designs may prove problematic 37:691–700. 10. Greenstein SA, Fry KL, Bhatt J, Hersh PS. shortly after CXL; one of the most n summary, scleral and silicone Natural history of corneal haze after collagen crosslinking for keratoconus and corneal ectasia: frustrating cases I have encountered Ihydrogel mini-scleral lenses in Scheimpfl ug and biomicroscopic analysis. J Cata- recently is that of a 17-year-old particular continue to possess clin- ract Refract Surg. 2010; 36:2105–14. 11. Woodward MA, Randleman JB, Russell B, et male with advanced keratoconus ical importance in today’s specialty al. Visual rehabilitation and outcomes for ectasia (K of 63D), who resumed wear- contact lens practice. The use of after corneal refractive surgery. J Cataract Refract max Surg. 2008;34:383–8. ing his old GP lenses three weeks these new lens designs may become 12. Rocha KM, Perez-Straziota CE, Stulting RD, Randleman JB. Epithelial and stromal remodeling after an epithelium-off procedure. a preferred alternative shortly after after corneal collagen cross-linking evaluated by One week later, he was admitted CXL. In addition to providing spectral-domain OCT. J Refract Surg. 2014;3:122-7. 13. Sehra SV, Titiyal JS, Sharma N, Tandon R, Sinha to the clinic with a complaint of successful visual rehabilitation, R. Change in corneal microstructure with rigid gas signifi cant eye pain, light sensitivity they minimize contact lens infl u- permeable contact lens use following collagen cross-linking: an in vivo confocal microscopy and blurred vision in the treated ence on epithelial remodeling and study. Br J Ophthalmol. 2014;98:442-7. 14. Kallinikos P, Efron N. On the etiology of eye. Exam revealed dense infi ltra- allow uncomplicated ocular surface keratocyte loss during contact lens wear. Invest tive ulcerative keratitis at the center recovery after the procedure. RCCL Ophthalmol Vis Sci. 2004;45:3011–20.

32 REVIEW OF CORNEA & CONTACT LENSES | JUNE 2016

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RCCL REVIEW OF CORNEA & CONTACT LENSES

2016_rccl website house.indd 1 5/27/16 11:33 AM CASE REPORT: By Mohammad Tallouzi, OD Look Before You Judge The most unique cases sometimes present as the most mundane.

ontact lenses are some systemic medications at the time of Culture results indicated the of the smallest and admittance and her best-corrected presence of Staphylococcus aureus, least visible devices for visual acuities were 20/30 OD and which proved sensitive to the ofl ox- correction of refrac- 20/25 OS. Pupils were round and acin. The patient reported no issue Ctive error. Considered reactive to light, with no relative on follow-up, and was asked to medical devices, they can be worn afferent pupillary defect in either continue the drop regimen for an- for therapeutic reasons; however, eye. Extraocular movements were other week. A two-week follow-up other reasons for wearing contact full OU. A slit lamp examination appointment revealed everything lenses exist, such as for cosmetic demonstrated that the left eyelid had healed well. purposes.1 Contact lenses are an was normal. Additionally, the left important part of the ophthalmol- conjunctiva was white and quiet; DISCUSSION ogist practice, with the demand for the cornea, iris and lens were clear; Gas permeable contact lenses (GPs) them increasing day-by-day; indeed, and the anterior chamber was deep are made of a complex polymer millions worldwide currently wear and quiet. Regarding the right eye, that includes silicone, PMMA and them.2 Therefore, it is also import- a 1.0mm by 0.7mm fi rm nodule on others. These lenses permit excel- ant to take precautions and educate the center of the upper left eyelid lent perfusion of oxygen and are people when prescribing and fi tting was visible, with no periorbital used to improve vision by correct- these lenses.3 erythema or edema or skin breaks ing refractive errors.4 They work (Figure 1). The right conjunctiva by focusing light so that it enters HISTORY displayed hyperemic traits and the the eye with the proper power for A 47-year-old female patient pre- cornea was characterized by a few clear vision.5 GP lenses have the sented to the clinic with a red left punctate epithelial erosions. The an- main advantage of being durable eye that had been present for the terior chamber was deep and quiet, with longer lifespans as compared past seven days. This was accom- the iris was round and regular and with soft contact lenses. Modern panied by a foreign body sensation the lens was clear. GP lenses require a relatively short and watering, but no discharge. Upon inversion of the left upper adaptation time as compared with She noted the presence of localized eyelid, a circular foreign body was older hard lenses, but patients still swelling on her left upper eyelid made visible, surrounded by the tar- need some time to get used to them. with a nodular-looking lesion. She sal conjunctiva (Figure 2). Attempts Additionally, the size of the lenses was treated for lid cyst with chlor- to shift it with a cotton bud were is benefi cial as it provides for easy amphenicol ointment by the general unsuccessful and subsequently, oxy- insertion and the fl exibility to allow practitioner. Since then, however, buprocaine eye drops were instilled. them to move freely on the eye with the condition had not improved and The object—a contact lens—was each blink; however, their small size so she decided to consult an eye spe- removed using typing forceps. A cialist. The right eye appeared to be yellow pus discharge on the con- ABOUT THE AUTHOR without complaint or redness. The tact lens was observed immediately Dr. Tallouzi is a surgical practitioner working patient was a gas permeable contact (Figure 3). Both the lens and the at Birmingham and Midland eye Hospital. He specializes in lens wearer with her last wear time discharge was sent for culture and treatment of ocular surface occurring eight days ago. sensitivity. The patient reported in- and infl ammatory eye diseases and was awarded The patient exhibited no other creased comfort, and was sent home the NIHR Clinical Research ocular history, and her family ocular with topical ofl oxacin eye drops Training Fellowship in 2015. He is currently working on history was negative for ocular and the expectation that she would his PhD at the University of problems. She wasn’t taking any return in three days. Birmingham.

34 REVIEW OF CORNEA & CONTACT LENSES | JUNE 2016

034_RCCL0616_F5_GP-Eyelid.indd 34 5/31/16 4:32 PM Fig. 1. The patient presented with a ﬁ rm nodule near the center of the eyelid of unknown origin.

can be disadvantageous as the lens may move from its position during daily activities or sports and be lost. This also increases risk for debris to become trapped underneath the lens. Fig. 2. Everting the patient’s left eyelid revealed the presence of a GP contact This patient in particular dis- lens. lodged her contact lens from its original position to where it sat on logical reaction may also induce the above mentioned conditions so the palpebral or tarsal conjunctiva. corneal changes like microcysts and that necessary medical help can be The conjunctiva then began to fold striae such that GPs may not allow sought. RCCL over the lens. The patient report- enough transmission of oxygen for 1. Farandos M, Yetisen K, Monteiro J, et al. Contact ed she was aware of the time she successful long-term extended wear. lens sensors in ocular diagnostics. Advanced placed the contact lens on the eye, Wear of the lens may also result in Healthcare Materials. 2015 Apr 22;4(6):792-810. 2. Lemp M and Bielory L. Contact lenses and asso- but that she was not aware if and disruption of the corneal epitheli- ciated anterior segment disorders: dry eye disease, 2 blepharitis and allergy. Immunol Allergy Clin North when she had lost the lens. um, corneal erosion and keratitis Am. 2008 Feb;28(1):105-17. vi-vii. if not treated promptly. Corneal 3. Dart JK, Saw VP, Kilvington S. Acanthamoeba keratitis: diagnosis and treatment update 2009. Am ontact lens complications can edema and corneal ulcers are two J Ophthalmol. 2008 Oct:148(4):487-499.e2. Cvary from mild irritation to sight-threatening complications that 4. Denniston A and Murray P. Oxford Handbook of 2,7,8 Ophthalmology. 2nd edition. Oxford: Oxford Univer- sight-threatening issues, with result- can occur with contact lens wear. sity Press; 2009. ing problems leading to disturbanc- Regardless of the brand of contact 5. Benjamin L. Training in Ophthalmology: The Essential Curriculum. Oxford: Oxford University es of the eyelids and ocular surfaces lenses, however, their use requires Press; 2009. 6. Beljan J, Beljan K and Beljan Z. Complications that can result in long-term changes accompanying care to prevent caused by contact lens wearing. Coli Antropol. 2013 and a reduction in contact lens damage and avoid sight-threatening Apr;37 Suppl 1:179-87. 7. Compan V, Andrio A, Lopez-Alemany A, et al. tolerance. In this case, the extended complications. The majority of con- Oxygen permeability of hydrogel contact lenses wear of a GP lens led to complica- tact lens complications are caused with organosilicon moieties. Biomaterials. 2002 Jul;23(13)2767-72. tions that likely began as a result by careless handling and overwear 8. Ehler J, Shah C, Fenton G, Hoskins E. The Wills of abnormal blinking of the eyelid, of lenses. As such, patient education Eye Manual: Offi ce and Emergency Room Diagnosis and Treatment of Eye Disease. 4th edition. Philadel- ptosis due to a reduction of the is key, as is early identifi cation of phia: Lippincott Williams & Wilkins. palpebral slit and meibomian gland dysfunction.6 Other complications that might present may relate to the tear fi lm and result in dry eye due to the lack of lipids. This can lead to papillary conjunctivitis, which is intensifi ed by the mechanical irritation of the conjunctiva. Additionally, the presence of hypoxia below the lid, accompanied with an immuno- Fig. 3. Lens removal led to the discovery of discharge.

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034_RCCL0616_F5_GP-Eyelid.indd 35 5/31/16 4:32 PM Medically Necessary Contact Lenses: Medical Plan or Vision Plan Responsibility?

Do you know how to work with insurance companies to BY ROBERT L. DAVIS, OD achieve the biggest bang for your buck?

or those patients with cal procedures (i.e., surgery and seikonia and anisometropia, as well certain medical con- medical treatment) they may have as glare and light sensitivity result- ditions, contact lens- to undergo to enable the treatment ing from aniridia and anisocoria. es provide a distinct to work. Ultimately, for patients to • High myopic or hyperopic pre- Fopportunity to improve benefi t, the medical portion must scriptions if visual improvement (as patient quality of life in cases in be covered under both the vision defi ned using Snellen acuity) with which corneal shape is distorted care and medical care sides of an contact lenses surpasses that which or if a spectacle correction fails to insurance plan. is possible with spectacle wear. provide adequate vision. Visual • Lens use following refractive phenomena like glare, double vision INDICATIONS AND OPTIONS surgery and other traumatic cases, and sensitivity to light can make As specialty lenses are indicated in which improved visual acuity can processing images more diffi cult primarily for patients with irreg- be demonstrated with lens wear. for patients; as such, in many cases ular corneas (e.g., in the case of However, some disputes remain non-elective procedures are the keratoconus, pellucid marginal regarding insurance coverage. only solution to recapture a normal degeneration, scarring, post-surgical Though patients and/or health care lifestyle. However, even when faced corneal abnormalities), gas perme- providers may defi ne a condition as with the same procedures and diag- able materials fi gure prominently in medically necessary, guidelines for nostic codes, each vision insurance the approach to care. GPs provide a specifi c health care plan may not company has its own guidelines a rigid surface that neutralizes the agree. to determine what constitutes a corneal irregularity, in effect replac- Consider, for example, the role “medically necessary” contact lens. ing it with the controlled regular of scleral lenses. The lens design As such, the imbalance in coverage surface of the lens. Some conditions includes a fl uid compartment between vision insurance compa- are better served by sclerals rather underneath the lens’s surface to nies, coupled with rising health care than corneal GP lenses due to their keep the cornea hydrated; as such, costs, often means a policy night- design with an elevated dome and ABOUT THE AUTHOR mare for the eye care practitioner. haptic zone that vaults the cornea Dr. Davis practices in Oak Lawn, Today, most medical plans are to land on the sclera, respectively. Ill., where he is the director coupled with vision care plans, Hybrids that combine a GP center of the contact lens clinic at Davis EyeCare. He is also though many limit medical cover- with a soft lens periphery may be a co-founder of EyeVis age for specialty services to just the also be possible to improve comfort Eye and Vision Research Institute, where he works diagnosis of the condition and cov- while custom soft lenses may suffi ce developing contact lens designs and furthering research erage of the treatment. This creates for some patients. on anterior segment pathophys- a problem for patients seeking reso- Beyond irregular cornea indica- iology. Dr. Davis has been recognized as a diplomate in the corneal, contact lens and lution for an ocular issue: they have tions, specialized custom contact refractive technology section of the American covered access to the diagnostic lenses are typically also appropri- Academy of Optometry and is an inductee in the National Academy Practice in Optometry services used to identify the condi- ate for most medically necessary as well as an advisor to the Gas Permeable tion and the actual medical devices criteria like: Lens Institute and a recipient of the Gas Permeable Practitioner of the Year Award. He (i.e., corrective lenses) necessary to • Binocular vision issues caused has also been honored as one of the 50 most treat the issue, but not the medi- by the presence of nystagmus, an- infl uential optometrists in 2015.

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036_RCCL0616_F6_Billing-and-Coding.indd 36 5/31/16 5:12 PM Table 1. A Comparison of Medically Necessary Contact Lens Vision Care Plans Condition EyeMed Davis VSP Superior Humana Spectera >3.5D with 4D and VA diplopia or ≥4D BVA ≥ 20/40 Anisometropia 3D in any meridian. 3D improves With specs. >3.5D. Intact epithelium. ≥20/60 aestheno- pia. High ±-10D ±-8D ±-10D ±-10D Ametropia K readings or topog- Two lines raphy BVA ≤20/40 Topogra- Not correctable to K readings, improve- Two lines improve- phy or K Keratoconus 20/25 Two lines OCT or topog- ment. With ment. Absence of readings better than 20/25. raphy. documen- hydrops. Intact epi- and notes. tation. thelium. Achieve comfort and/or vision correction not possible Corneal with mid- to mod- Ectasia erate keratoconus. Suitable for contact lens applications. Acuity <20/70 in spectacles Vision Two lines better and better Improvement than specs. than 20/70 in contact lenses. Doctor BVA ≥20/100 Aphakia Glasses must without implant. No provided certify that Aphakia corneal or vitreous Included. together contact opacity. Intact macu- with con- lenses are la. Intact epithelium. tact lenses. medically necessary. Unequal image size between the two eyes. Intermittent Aniseikonia or constant diplopia. Less than 100 degrees stereopsis. Intact epithelium. Aniridia Surgical or traumatic. ≥2D principle meridians are separated < Irregular 90 degrees. Two lines Included. Astigmatism of improvement. BVA <20/70. Nystagmus Included. Corneal Included. Transplant Corneal Included. Dystrophy For achroma- topsia, albi- Colored nism, aniridia, Contact Lenses anisocoria, or polycoria pupil abnormality.

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0036_RCCL0616_F6_Billing-and-Coding.indd36_RCCL0616_F6_Billing-and-Coding.indd 3737 55/31/16/31/16 4:584:58 PMPM MEDICALLY NECESSARY CONTACT LENSES

these lenses are well-suited for the fi tting process.1 Failure on the part patient lens wear and replacement treatment of severe ocular surface of the practitioner to adhere to schedule; recommended care and diseases like corneal stem cell defi - these criteria may lead to disqualifi - cleaning instructions; any data ciency, Stevens-Johnson syndrome, cation from reimbursement. from the fi tting appointment; visual chemical and thermal injuries to the Table 1 correlates the different acuity measurements taken both eye, ocular pemphigoid, neuro- covered conditions with corre- through the lenses and overrefrac- trophic corneas, severe dry eye from sponding vision care plans. Note tion; and the date the fi nal lenses Sjögren’s syndrome, chronic graft- that each offers different coverage were dispensed. Additionally, versus-host disease, ocular radia- for different conditions; uniformity practitioners should ensure they tion, corneal exposure and corneal is rare and should not be expected. have a documented contact lens disorders associated with systemic As such, it is the responsibility of history on fi le. This should include autoimmune diseases such as rheu- the practitioner to inform the in- information on the use and care of matoid arthritis. The question is, surance carrier of the needs of their the patient’s lenses in their work however, whether these are medical patient population. environment; hobbies and daily conditions, or whether they covered Because we live in an era where routines; previous lens experience under primary vision care. It often most doctors are held accountable and any type of lens accoutrement varies among providers. for their actions—including and used. especially billing policies—proper The patient’s lens fi t and evalu- TAKING RESPONSIBILITY documentation is the best way to ation appointment should include Most health care plans determine guarantee passing an audit and keratometry or topography, with the criteria for their respective receiving payment for the work proper diagnosis made if a corneal covered population. For example, provided. As such, the contact lens anomaly like corneal distortion or contact lenses for masking irreg- fi tting, dispensing and follow-up an ectatic disease is initially suspect- ular astigmatism associated with visit must each be separately doc- ed. Recorded observations from keratoconus and other corneal umented in the practice’s medical a slit lamp should document both disorders requires certain documen- records, with a thorough record views with a diagnostic contact lens tation from the initial exam and made of all services provided. for the purpose of assessing fi t and follow-up visits to cover requests This includes patient pick-up of a the patient’s eye sans-lens to assess for coverage.1 Additionally, the reordered contact lens prescription the ocular health of the cornea, patient’s fi rst visit to the clinic must or other ancillary events that may conjunctiva, sclera, tear fi lm and include a comprehensive eye exam, occur later on. eyelids. Overrefraction with the performance of advanced corneal Typically, records should include contact lenses should be recorded topographic modeling or keratom- the prescription, number and mate- monocularly, with visual acuities etry and documentation of the lens rial type of contact lenses dispensed; noted for each trial lens tested,

Table 2. EyeMed Insurance Coverage for Contact Lens Wearers Test New Wearer Existing Wearer Contact Lens-Related History Required Required Keratometry and/or Corneal Topography Required Required Anterior Segment Analysis with Dyes As Indicated As Indicated Biomicroscopy of Eye and Adnexa Required Required Biomicrscopy with Lens: Fluorescein Pattern (Rigid Lenses) or Required As Indicated Orb Movement and/or Centration (Soft Lenses) Overrefraction As Indicated As Indicated Visual Acuity with Diagnostic Lenses Required As Indicated Determination of Contact Lens Speciﬁ cations Determined to As Indicated As Indicated Obtain the Final Prescription Member Instructions and Consultations Required Required Proper Documentation with Assessment and Plan Required Required

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0036_RCCL0616_F6_Billing-and-Coding.indd36_RCCL0616_F6_Billing-and-Coding.indd 3838 55/31/16/31/16 4:584:58 PMPM as well as the fi nal contact lens both NaFl and lissamine green, ploy. Customizing the coverage of prescription. A short narrative as- meniscus height, tear break-up time medically necessary contact lenses sessment of the patient’s subjective and the status of the meibomian may also help insurance companies response and/or the doctor’s ob- glands. develop a competitive advantage for jective response regarding the state Table 2 lists an example of one their products in the marketplace. of the contact lens ordered should company’s (EyeMed) test require- Creating clear guidelines may also also be written; this should include ments for provision of coverage help develop a more uniform cate- comments on the clinical fi ndings, to new and existing contact lens gorization system for practitioners impressions and diagnosis. wearers. In comparison, other to divide patients into, leading to Additionally, practitioners should companies require itemized fi nan- improved effi ciency of submission add notes on their planned treat- cial records for medically necessary for reimbursement and a reduction ment plan to the patient’s fi le, with contact lenses to include: patient in the costs associated with billing information like the contact lens name; date of service; contact lens for services. materials and parameters included. brand, type, quantity and date dis- Many industry watchers believe Dispensing visit documentation pensed; customary costs for services that separating the refraction tests should contain instructions pre- and materials; amount billed to from the medical eye health exam scribed to the patient for their lens the insurance, amount paid by the is coming in the future. The era of care regime, handling and wear patient and method of payment. bundling services is a concept of schedule. Finally, a description on the past. Each procedure will have the patient’s ability to apply and RETURN TO BASE its own billing code with corre- remove the contact lenses, as well as Going back to the question at sponding payment. ICD-10 is the fi nancial records relating to the or- hand—whether medical care plans fi rst attempt to breakout diagnostic dering of the fi nal lens prescription and vision care plans should make codes, and procedure codes will be and a comment regarding whether a greater effort to overlap coverage the next project CMS will attempt the contact lenses were dispensed for the patient—a related point to streamline. With the consolida- from stock for record-keeping is this: even with dual coverage, tion of medical insurance compa- purposes may also be prudent to many of the medically necessary nies in our immediate future, the include. treatments fall through the cracks trickle-down effect will soon reach Records taken at follow-up ap- because vision care plan providers the vision care plan providers with pointments of the patient’s progress and medical care plan providers medical guidelines fi ltering into our should document their positive and believe the procedure in question is vision insurance plans. Educating negative comments related to wear- not in their sphere of coverage. As administrators with regards to the ing the lens, as well as the patient’s such, both practitioners and their complete needs of our patients— report of their level of compliance patients are the ones to take the hit. both on the vision care side as well with practitioner instructions. However, we may have the ability as the medical care side—will also Notes on the patient’s advances in to make a difference. allow patients that may not be their lens wear should include mon- First and foremost, we as prac- aware of current options to receive ocular acuities and overrefraction as titioners must educate the medical the services they require. well as slit lamp observations docu- plan coordinator as to the differ- menting the lens on the cornea and ence between a vision care expense ealth care insurance is an the health of the corneal surface and the need for coverage for a Hever-evolving entity, and con- and surrounding tissues. Finally, medical condition. If this need is tact lens practitioners must remain any new clinical fi ndings or changes not successfully communicated, the informed of changes that impact the in lens care, wearing or replacement patient is left with the confusing care we provide. We must remem- recommendations should be written scenario of not understanding why ber that some medical conditions down for the purposes of updating their medical condition is not cov- require contact lenses as a serious treatment plan records. When docu- ered by the vision care plan. Vision form of treatment. For some peo- menting medical necessity, it may be care plans should strive to provide a ple, they are not simply a cosmetic useful to include pachymetry, specu- better environment for our patients, option. RCCL

lar microscopy, tear fi lm assessment streamline the approval process 1. Aetna. Contact Lenses and Eyeglasses. including osmolarity, Infl ammaDry and create improved billing effi ca- Available at: www.aetna.com/cpb/medical/ data/100_199/0126.html. Accessed February 3, scores, staining assessment with cy for eye care providers to em- 2016.

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0036_RCCL0616_F6_Billing-and-Coding.indd36_RCCL0616_F6_Billing-and-Coding.indd 3939 55/31/16/31/16 4:584:58 PMPM Practice Progress By Mile Brujic, OD, and Jason Miller, OD, MBA

Brimonidine Breakup Consider these alternative uses for this common glaucoma treatment.

rimonidine is an which allows the tonus of the orthokeratology treatment, as interesting molecule sphincter muscle to take over the pupil has the opportunity to consider. As an and ultimately reduces the pupil’s to dilate out to the edge of the alpha-2 adrenergic size (Figure 1).2 Here, we will treatment zone in certain condi- B agonist, many prac- discuss three common uses for tions, potentially affecting vision. titioners may most often think brimonidine in the contact lens Increasing the size of the treat- of this medicine for its use in wearer. ment zone with modifi cations to treating glaucoma. The majority Orthokeratology. Some pa- the lens size or decreasing the of brimonidine’s activity resides tients are able to wear ortho- sagittal depth of the lens can in its ability to decrease aqueous keratology lenses overnight assist with increasing the size production from the ciliary body, to facilitate gentle progressive of the treatment zone. In this though it also helps to facilitate remodeling of the cornea’s shape case, one alternative is to have some extra aqueous drainage to remove the need for spectacle a patient use a drop of brimo- through the trabecular mesh- or contact lens wear during the nidine in mesopic and scotopic work. Currently, brimonidine day. The most common type of conditions where vision may be is available in three commercial refractive error corrected using sub-par. concentrations: 0.1%, 0.15% orthokeratology lenses is my- Multifocal Gas Permeable and 0.2%.1 opia, though advanced designs Lenses. Some of these rigid lenses So the question is, why would now also allow for higher levels may at times have their optical we bring this drug up in a of astigmatism to be corrected as zones located on their front contact lens column? Because well via fl attening of the central surface, while other options will brimonidine has an interesting topography of the cornea to cre- contain some of the multifocal side effect profi le that may prove ate a midperipheral steep curve. optics on both the anterior and useful to some lens wearers. Due This results in a corneal appear- posterior surfaces of the lens. to its activity on the alpha-2 ance topographically similar to Multifocal GP lenses are typi- receptor, it also acts to prevent that of a postoperative LASIK cally designed with the distance pupil dilation under mesopic cornea (Figure 2). optics located in the middle of and scotopic conditions. This But, just as physiological pupil the lens and slowly progressing is done via the inhibition of the dilation can affect a postoper- to the near optics towards the release of norepinephrine from ative LASIK patient’s vision in midperipheral and peripheral the pre-synaptic nerve terminal the evening, so too can it affect portions of the lens. Success in the cleft of the dilator muscle, a patient who has undergone with multifocal GPs requires appropriate centration both horizontally and vertically. Any signifi cant displacement from the location of the pupil in either of these meridians will affect visual clarity for the patient. When appropriately aligned, multifocal GPs provide excellent distance vision and the opportunity for translation into the near optics of the lens. Of course, there are environments that may Fig. 1. (a) infrared pupil readings prior to the instillation of brimonidine; (b) make the vision somewhat more fi ve minutes after the instillation of 0.1% brimonidine. challenging for these individuals.

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0040_RCCL0616_PP.indd40_RCCL0616_PP.indd 4400 55/31/16/31/16 4:314:31 PMPM One example is levels of low light, such as when driving near sunset. Depending on the amount of pupil dilation that occurs in these individuals, their pupils may widen into the region of the lens in which the distance optics begin to transition into the near optics. Fortunately, most GP lens designs can be altered to increase the distance center portion of the lens to allow for pupil dilation Fig. 2. Orthokeratology lens on the eye (left) and the topography of the cornea when the lens is removed (right). with less interference of the near optics. However, controlling pupil size 1 gt OU prn for critical viewing It is in this case that topical with brimonidine may also be an tasks. This statement provides brimonidine may be benefi cial option if the patient wishes for appropriate guidance to the as an alternative to moving the the lens characteristics to remain pharmacist that the drug is not zones of the lens to compensate the same. to be used on a chronic basis. for mesopic and scotopic conditions. This would provide poten- PRESCRIBING HABITS eeping this solution in mind tial visual benefi ts to the patient Take note that while the above Kto enhance the vision for without the need to change the information constitutes sugges- those who may be having some properties of the lens itself. tions for brimonidine use, min- diffi culties will help enhance Additionally, since the GP lens imizing pupil dilation with this their visual outcomes as nothing material won’t absorb the med- drug is not an FDA-approved else can. So, look into it. RCCL ication, the drug can be applied indication for the product. As 1. Allergan. Alphagan P Prescribing Information. without removing the lens. such, before proceeding with a Available at: www.allergan.com/assets/pdf/al- Small Diameter Lenses for prescription for patients in the phaganp_pi.pdf. Accessed May 8, 2016. Corneal Ectasia. At times, the instances discussed, we feel it 2. Shemesh G, Moisseiev E, Lazar M, Kesler A. Eff ect of brimonidine tartrate 0.10% ophthalmic GP lenses that practitioners fi t necessary to mention this fact to solution on pupil diameter. J Cataract Refract their irregular corneal patients them to ensure they are com- Surg. 2011 Mar;37(3):486-9. with are slightly smaller than fortable using the medication typical to compensate for how in such a manner. As with any steep the curves on the back of off-label indication, the benefi ts the lenses are. Interestingly, this of treatment must outweigh the can create challenges for patients risk of adverse events that may wearing these lenses in the eve- result from it. Note, brimonidine ning, as their pupils may dilate use can in some cases lead to dry outside of the optical zones of mouth or a tired feeling. the lenses (Figure 3). In these We typically prefer to pre- instances, we can create larger scribe brimonidine in its lowest lenses with aspheric back surfac- commercially available concen- es to compensate. Additionally, tration, which is 0.1% available semiscleral, scleral and hybrid as Alphagan P 0.1% (Allergan). Fig. 3. Small diameter lens off - lenses are often times options We also send instructions with center in which the lens edge is for these individuals as well. the prescription as follows: Sig: approaching the pupil margin nasally.

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040_RCCL0616_PP.indd 41 5/31/16 4:31 PM Out of the Box By Gary Gerber, OD

Making the Best of It Sometimes the situation does not go the best way it can. Here’s how the right attitude can make the diff erence for your patients.

he airline recently lost willingness to help, and the clear Yet, few people recognize that my bag. Nothing is acknowledgment that I was truly even in day-to-day interactions notable about this fact inconvenienced by the lost luggage with patients—whether things go in and of itself—actual- was even further helped when she smoothly from the get-go or not— Tly, it’s happened before. said, at least what you’re wearing an unexpectedly pleasant doctor And indeed, the initial drill this now will work great for everything and staff demeanor can be just as time was the same as every other from a corporate business meeting memorable. This behavior should time: wait in a line and fi ll out to a rock concert to a trip to the be an integral part of your practice a form describing what the bag beach. But, I understand—you’d culture, as there are invariably looked like, give the agent your the prefer the gold tuxedo in your many more times that things will baggage stub and pray. Sometimes suitcase. I’ll try and get it to you as go right instead of wrong as a you get lucky and they fi nd the bag quickly as I can. result, and many more patients— with enough time to put it on the essentially all of them—that will next fl ight; other times, you may KEEP ONE HAND be impacted in a better way. As receive it a few days later having ON THE WHEEL an exercise for your staff mem- survived with just your carry-on. There are many things that occur bers, work out some hypothetical I knew that chances were I’d get it in the eye care offi ce that to a patient encounters that happen back eventually, I just didn’t know large extent, we cannot control. frequently and challenge your staff when. Take for example, a patient with to consider the following: how can This particular time took a dif- an insurance benefi ts package that a routine, mundane patient-facing ferent turn, however, once I arrived only covers the cost of a single task be changed in such a way at the front of the line to speak to examination every two years. that patients immediately see it as the agent there. Admittedly, she When you recommend to them a positive encounter instead of a had a pretty thankless job since by that they come in each year, they negative or even neutral one? And, defi nition, everyone she deals with may become frustrated. How do how can our personal execution is unhappy, so I wasn’t expecting you soothe this situation? The and involvement in this task be much. Of note, however, was the knee-jerk response for many modifi ed so patients see us as a way in which she dealt with me practitioners is to simply tell the more memorable and positive specifi cally—it made me think patient, we’re sorry, that’s how advocate for their care? about the way many of us and our your insurance works. It’s not Though the answer to these staff members deal with the pa- our fault and send the patient on questions likely depends on the tients who come into our practices. their way. However, though this is dynamics of the practice and its Now, there isn’t much she could factually accurate, it’s not the best staff members, one factor to note: have done in terms of recovery way to deliver this information. don’t think in terms of “big heroic short of snapping her fi ngers What if the luggage hunter (her actions” like getting a certain pair and producing the lost luggage self-given name) I encountered at of back-ordered lenses in faster. then and there. What she did do, the airport said, yeah, I agree— Instead, focus on the key “daily however, was display a funny and it’s too bad the airline lost your grind” items like booking appoint- empathetic personality that helped luggage. Nothing I can do about ments, escorting patients, com- ease the otherwise negative ordeal. it, though! pleting clinical tests and all of the Thinking about every other Many of us understand the other small tasks that, when done employee I’ve ever encountered or benefi ts of turning a bad custom- correctly and in a timely manner, seen at the airport, she stood out er service situation into a good gel together to form your patient’s as different to me in a profoundly one by going above and beyond good experience with your prac- positive way. My impression of her using a service recovery strategy. tice. RCCL

42 REVIEW OF CORNEA & CONTACT LENSES | JUNE 2016

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