SEPTEMBER/OCTOBER 2018

REVIEW OF & CONTACT LENSES

Fighting Infections How to defeat the bugs behind corneal and conjunctival compromise.

Also: Take the Anxiety Out of Specialty Fittings RCCL0918_Cooper Biofinity.indd 1 8/27/18 12:39 PM contents Review of Cornea & Contact Lenses | September|October 2018

departments features

4 News Review : Making the Call Good judgment and a comprehensive A Call for Standardized DED look beyond the signs and symptoms Monitoring; Scleral Lens Wear are integral to knowing whether it’s Raises IOP allergic, bacterial or viral. By Stephanie Fromstein, OD My Perspective 14 6 HZO: Prevention is the Best Therapy By Joseph P. Shovlin, OD Your Corneal Infection Care Questions—Answered The GP Experts Here’s how you can overcome 8 your top three microbial Climb on the Health Bandwagon challenges. By Robert Ensley, OD, 18 By Doan Huynh Kwak, OD and Heidi Miller, OD

10 Fitting Challenges CE — Corneal Hard Case, Hard Lenses Ulcers: Sterile But By Vivian P. Shibayama, OD Not Benign Even if they aren’t 38 Corneal Consult infectious, these are no laughing matter. In fact, many ocular Fungal Ulcers: Missed and 24 and systemic conditions may be at Misunderstood play. By Aaron Bronner, OD By Elizabeth Escobedo, OD, and Nate Lighthizer, OD 40 Practice Progress Multifocals: A Roadmap to Success Fighting Corneal Infections By Mile Brujic, OD, and David Kading, OD with CXL: A New Ally? Evaluate the strengths and weaknesses 42 The Big Picture of this newfound application before considering it an alternative treatment Shape Shifter for keratitis. By Christine W. Sindt, OD 30 By Aaron Bronner, OD

Take the Anxiety Out of Specialty Lens Fittings Smarter clinical strategies and useful new technologies help ensure a smoother process. 33 By Clark Chang, OD, and Jeff rey Sonsino, OD

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/ReviewofCorneaAndContactLenses @RCCLmag REVIEW OF CORNEA & CONTACT LENSES | SEPTEMBER/OCTOBER 2018 3 News Review

IN BRIEF ■ Research suggests decreasing the A Call for Standardized center thickness of a high Dk, low modulus miniscleral lens from 350μm to 150μm results in less than a 0.25D DED Monitoring increase in lens fl exure. Nine healthy Photo: Chandra Mickles, OD patients with normal were hile diagnostic fi t with miniscleral lenses with center testing for dry thicknesses of 150μm, 250μm and 350μm. On average, lens fl exure in- disease (DED) in creased as center thickness decreased, WSjögren’s syndrome but remained below 0.50D. In addition, (SS) is well described, the same scleral toricity was positively correlated cannot be said for monitoring, as with in vivo fl exure for the 150μm and 250μm lenses, and with greater it’s not uniform across and between than 200μm of scleral toricity exhibited academic and private practice sites greater in vivo fl exure than eyes with in North America. A multi-centered less than 200μm, on average. retrospective study analyzed 123 Vincent SJ, Kowalski LP, Alonso-Caneiro D, et al. SS charts to describe the custom- Importance of decreasing the center thickness on miniscleral lens fl exure. Cont Lens Anterior ary DED monitoring practices at Eye. July 12, 2018. [Epub ahead of print]. six sites. Although DED symptoms ■ Data from 3,851 eyes were the most common chart entry that underwent excisional surgery re- (98.4% of charts), the absence of vealed that 1.4% developed conjunc- standardized DED questionnaires tival granuloma (CG) within a 13-year was noteworthy. period—although most arose within The next three frequently record- Sodium fl uorescein in an SS patient 12 to 90 days. All the CGs developed before scleral wear, top, around the free conjunctival fl ap and ed variables were meibomian gland and three weeks post-scleral lens involved large amounts of infl am- dysfunction (76.4%), corneal stain- wear, bottom. matory cell infi ltration. Treatment, ing with fl uorescein (75.6%) and which was successful for all patients, anterior (73.2%). with standardizing our approach included surgical resection combined with corticosteroid eye drops. Private practice sites were more to care. Instead of implementing a likely to use symptom question- strict battery of tests for all Sjögren’s Zhang Z, Yang Z, Pan Q, et al. Clinicopatho- logic characteristics and the surgical outcome naires and grading scales and to patients, a fl exible protocol with of conjunctival granulomas after pterygium describe anterior blepharitis, while options for different types of tests surgery. Cornea. 2018;37(8):1008-12. academic sites were more likely to would be more practical.” ■ Researchers recently looked at record tear break-up time and tear She suggests a thorough follow-up monthly injections of platelet-rich meniscus height. with a exam, symptom plasma (PRP), which is known to be The lack of a standardized symp- assessment, staining and tear pro- benefi cial for ocular surface resto- ration in dry eye patients when in tom assessment, wide differences duction test. But clinicians choose a topical form. Of 30 patients with in ocular surface stains and scales range of options in each category: Sjögren’s syndrome, 15 received and lack of a tear fl ow assessment an OSDI in one patient but the monthly injections of PRP in con- concerned researchers considerably. DEQ-5 for another, or phenol red junction with hyaluronic acid fi ve They suggested applying the Dry thread for quicker follow-up and times per day for three months. The 15 control patients only received Eye Workshop II report’s recom- Schirmer’s every six to 12 months. hyaluronic acid fi ve times daily. The mended testing protocol to test the “Standardizing the types of tests investigational group had improve- proscribed testing’s validity in SS. may ultimately allow us to more ments in all dry eye parameters, “How to implement a protocol sensitively detect change—improve- including reduced corneal staining, increased mean Schirmer value and such as this is challenging,” says ment or worsening—so that we increased tear break-up time. Jillian F. Ziemanski, OD, MS, clini- know whether to maintain or alter Avila MY, Igua AM, Mora AM. Randomized, cal assistant professor at University our current therapy,” she says. prospective clinical trial of platelet-rich plas- of Alabama at Birmingham’s School ma injection in the management of severe Acs M, Caff ery B, Barnett M, et al. Customary dry eye. Br J Ophthalmol. July 3, 2018. [Epub of . “First, ‘standardizing practices in the monitoring of dry in ahead of print]. Sjögren’s syndrome. J Optom. July 17, 2018. [Epub care’ is not necessarily synonymous ahead of print].

4 REVIEW OF CORNEA & CONTACT LENSES | SEPTEMBER/OCTOBER 2018 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 Scleral Lens Wear Raises IOP Email: [email protected]

EDITORIAL STAFF ow that scleral lenses are questions than they answer, says EDITOR-IN-CHIEF back in vogue, researchers Melissa Barnett, OD, who practic- Jack Persico [email protected] are busy trying to update es at the UC Davis Eye Center in MANAGING EDITOR Rebecca Hepp [email protected] Ntheir assessment of this Sacramento, CA. “Should different ASSOCIATE EDITOR Catherine Manthorp [email protected] modality’s risk profi le. Recent fi nd- scleral lens designs be manufactured ASSOCIATE EDITOR ings of a group from the Université that rest differently on the scleral Mark De Leon [email protected] CLINICAL EDITOR de Montréal may provide cause to prevent IOP eleva- Joseph P. Shovlin, OD, [email protected] for concern: tion? Should scleral lenses not be fi t ASSOCIATE CLINICAL EDITOR Christine W. Sindt, OD, [email protected] (IOP) during scleral lens wear may in patients with ? Are oth- EXECUTIVE EDITOR increase by an average of 5mm Hg, er parameters, such as ocular blood Arthur B. Epstein, OD, [email protected] CONSULTING EDITOR regardless of the lens diameter. fl ow or corneal hysteresis, valuable Milton M. Hom, OD, [email protected] A prospective randomized study in this population?” she adds. “Of GRAPHIC DESIGNER Ashley Schmouder [email protected] conducted with 21 Caucasian sub- utmost importance is that there are AD PRODUCTION MANAGER jects (16 female, fi ve male) evaluated numerous studies that need to be Scott Tobin [email protected] the variation of IOP during scleral performed.” BUSINESS STAFF lens wear and the infl uence of lens Until then, clinicians simply need PUBLISHER James Henne [email protected] diameter. Researchers compared one to exercise good judgment. “When REGIONAL SALES MANAGER eye randomly fi t with a 15.8mm fi tting scleral lenses in patients with Michele Barrett [email protected] REGIONAL SALES MANAGER diameter scleral lens with the fellow glaucoma, Michael Hoster [email protected] eye fi t with an 18mm lens of the or status post a fi ltration device, VICE PRESIDENT, OPERATIONS Casey Foster [email protected] same design, thickness and material. caution may be advised,” says Dr, Anterior segment tomography was Barnett. “It is important to establish EXECUTIVE STAFF taken pre- and post-lens removal. baselines parameters of IOP, visual CEO, INFORMATION SERVICES GROUP Marc Ferrara [email protected] In those wearing the 15.8mm fi elds, OCT and pachymetry prior SENIOR VICE PRESIDENT, OPERATIONS Jeff Levitz [email protected] lens, transpalpebral IOP (IOPt) to fi tting scleral lenses and habitual- SENIOR VICE PRESIDENT, rose from 10.1 ±1.9mm Hg to 14.4 ly with scleral lens wear. At each vis- HUMAN RESOURCES Tammy Garcia [email protected] ±5.5mm Hg after 4.5 hours, while it, monitor IOP in those diagnosed VICE PRESIDENT, those fi t with the 18mm lens saw with and at risk for glaucoma. If CREATIVE SERVICES & PRODUCTION Monica Tettamanzi [email protected] IOPt rise from 9.2 ±2.1mm Hg scleral lens wear is of substantial VICE PRESIDENT, CIRCULATION to 14.4 ±4.8mm Hg. Researchers concern or is contraindicated, other Emelda Barea [email protected] CORPORATE PRODUCTION MANAGER found the difference based on wear options may be considered.” RCCL John Caggiano [email protected] time, but not on the lenses them- Michaud L, Samaha D, Giasson CJ. Intra-ocular pres- selves, to be statistically signifi cant. sure variation associated with the wear of scleral EDITORIAL REVIEW BOARD lenses of diff erent diameters. Cont Lens Ant Eye. Mark B. Abelson, MD Anterior segment parameters did July 24, 2018. [Epub ahead of print]. James V. Aquavella, MD Edward S. Bennett, OD not vary except for the ante- Photo: Christine W. Sindt, OD Aaron Bronner, OD Brian Chou, OD rior chamber volume and the Kenneth Daniels, OD corneal thickness. Baseline S. Barry Eiden, OD Desmond Fonn, Dip Optom M Optom Goldmann-correlated IOP re- Gary Gerber, OD Robert M. Grohe, OD vealed no signifi cant diurnal Susan Gromacki, OD variations. Patricia Keech, OD Bruce Koffler, MD The researchers conclude Pete Kollbaum, OD, PhD Jeffrey Charles Krohn, OD that more work is needed Kenneth A. Lebow, OD Jerry Legerton, OD to confi rm if practitioners Kelly Nichols, OD should be warned when using Robert Ryan, OD Jack Schaeffer, OD scleral lenses on populations Charles B. Slonim, MD Kirk Smick, OD at risk for glaucoma. While a great option for many patients, Mary Jo Stiegemeier, OD Studies such as this Loretta B. Szczotka, OD scleral lenses may pose some problems for Michael A. Ward, FCLSA one tend to create more patients already at risk for glaucoma. Barry M. Weiner, OD Barry Weissman, OD

REVIEW OF CORNEA & CONTACT LENSES | SEPTEMBER/OCTOBER 2018 5 My Perspective By Joseph P. Shovlin, OD

HZO: Prevention is the Best Therapy Clinicians must participate in the discourse regarding the importance of vaccination.

f the more than one Patients with a history of HZO may • Stopping antivirals before/after million new cases of have recurrent ophthalmic, derma- vaccination. This is not necessary herpes zoster virus tologic or even disseminated disease for Shingrix since it maintains over (HZV) reported after vaccination. 70% “potency,” even when patients Oeach year, about Despite the benefi ts this vaccines are on antivirals.2 Zostavax requires 20% result in ocular complications, provides, health care providers cessation two days prior to and two including corneal insult.1 As eye care have done a poor job educating weeks following vaccination.4 providers, we should be prepared to patients on the benefi ts of shingles • Vaccination for patients with recommend the vaccine to patients vaccination; only 28% of eligible active keratouveitis or corneal older than 50, considering HZV is patients have been vaccinated with dendritiform. Authorities suggest a relatively common cause of ocular Zostavax. waiting until there is some improve- disease. ment with chronic or recurrent A NEW OPTION disease states; beyond one to two WHAT’S AT STAKE Recent approval of a new vaccine, years is reasonable. Herpes zoster ophthalmicus (HZO) Shingrix (recombinant, sub-unit • Shingrix after Zostavax. presents with a long list of ocular vaccine, GlaxoSmithKline), has Because they have different formula- complications both infectious and renewed interest in shingles vacci- tions, Shingrix can still be given. infl ammatory in nature, such as nation. The vaccine combines an • Vaccination for immunosup- persistent keratitis, conjunctivitis, antigen (glycoprotein E) and an pressed or compromised patients. , , acute retinal necro- adjuvant system (AS01B) to gener- While no formal recommendation sis, cranial nerve palsies and optic ate a strong, long-lasting immune against vaccination has been issued neuropathy.1 Long-term complica- response. Shingrix has shown an for Shingrix, immunocompromised tions include , glaucoma, incredible age-independent effi cacy or compromised patients should not corneal scarring and postherpetic of 92.7% and an 88.8% effi cacy receive Zostavax since it’s a live-at- neuralgia (PHN). At least 30% against PHN.4 The vaccination tenuated vaccine and comes with and as many as 50% of HZO stimulates the cellular immune concern for disseminated disease. patients will experience chronicity.1 system for at least one year. The Associated complications include a new vaccine requires a two-dose onsidering the overall morbid- 4.5x increased risk of stroke within schedule (two to six months apart) City of this potentially devas- the fi rst year of being infected. with an 11% adverse event rate tating disease, we should defi nitely To ward off these ill effects, (severe headache, pain and fatigue).4 advise eligible patients to receive clinicians should recommend Because up to 6% of those affected the new vaccine for herpes zoster. vaccination when the opportunities by HZO may experience recurrent Taking the opportunity to have the arise. The Shingles Prevention Study eye disease, patients with active appropriate discussion with patients showed reasonable effi cacy for the disease should hold off vaccination might just prevent a debilitating vaccine Zostavax (live-attenuated for a year or two. disease. Prevention is the only fool- 2 vaccine, Merck). Studies estimate proof treatment. RCCL a 38% to 70% reduction in HZV QUESTIONS AND CONCERNS 1. Cornea Society, Ocular Microbiology & Immunology after vaccination (age-dependent) Uncertainties and controversies can Group and AAO Quality of Care Secretariat, Hoskins Center for Quality Eye Care. Recommendations for and a 60% to 70% reduced risk of cause widespread falsehoods, most herpes zoster vaccine for patients 50 years and older. PHN. Cost analysis studies suggest of which can be easily explained: . 2016. www.aao.org/clinical-state- ment/recommendations-herpes-zoster-vaccine-pa- younger patients accrue the greatest • Vaccination after shingles. The tients-50-. Accessed September 15, 2018. benefi t, as the vaccine’s effect wanes CDC has not made a formal state- 2. Gelb LD. Preventing herpes zoster through vaccina- tion. Ophthalmology. 2008;115(2):35-8. in older patients—most studies ment except to say that the vaccine 3. Merck Medical Advisory, April 2016. Personal suggest fi ve to eight years of protec- shouldn’t be given during the acute communication. 3 4. GlaxoSmithKline Medical Advisory, January 2018. tion that decreases after fi ve years. phase. Personal communication.

6 REVIEW OF CORNEA & CONTACT LENSES | SEPTEMBER/OCTOBER 2018 Review Group Earn up to Vision Care Education, LLC NEWNEEWTEW TECHNOLOGIEST CHNOLOGIESES 18-28 CE 2019 & TTREATMENTS IN Credits* EyeEy Care Join us for our 2019 MEETINGS FEBRUARY 15-19, 2019 - ASPEN, CO Annual Winter Ophthalmic Conference Westin Snowmass Conference Center Program Co-chairs: Murray Fingeret, OD, and Leo Semes, OD REGISTER ONLINE: www.skivision.com

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th Review Group Vision Care Education, LLC *Approval pending **16 Annual Education Symposium Joint Meeting with NT&T in Eye Care Review Group Vision Care Education, LLC partners with Salus University for those ODs who are licensed in states that require university credit. See www.reviewsce.com/events for any meeting schedule changes or updates. The GP Experts By Robert Ensley, OD, and Heidi Miller, OD

Climb on the Health Bandwagon Known primarily for their quality of vision, an easily overlooked benefi t of GP lenses is their excellent ocular health profi le.

lthough the gas-per- and contact lens- meable (GP) lens associated red market has been eye (CLARE). In stable for the past the non-contact Aseveral years, there lens-wearing is no denying the general decline population, the in GP lens fi tting since the intro- prevalence of duction of soft contact lenses.1,2 asymptomatic Compared with the soft lens CIEs can be as fi tting experience, a survey found high as 4%.10 eye care practitioners often cite Although initial discomfort and increased incidence rates chair time as reasons for hesita- vary among tion with fi tting GPs.3 Despite studies, the Extended wear of SiHy lenses increases risk of these perceived drawbacks, GP symptomatic CIEs, such as a sterile marginal ulcer. relative risk of lenses are still highly regarded for symptomatic their ocular health profi le. entirely. A review of the literature CIEs increases signifi cantly with reveals only one case of LSCD extended contact lens wear for AVOIDING THE LIMBUS attributed to GP lenses, while both higher Dk silicone hydrogel Anatomically, the limbus is the remaining cases involve soft (SiHy) lenses and hydrogel the junction between corneal lenses.8 The incidence of corneal lenses.11-13 One study compared and conjunctival tissue. In neovascularization is also lower the clinical success of 30-day addition to containing a vascular with GP lenses than soft lenses, continuous wear high Dk GP supply and aqueous humor which may be attributed in part to lenses with extended wear SiHy pathways, the limbus is also the lack of limbal disruption.9 lenses. The GP group contained home to limbal epithelial stem half as many adverse events as cells (LESCs).4 These supply THE ROLE OF OXYGEN the SiHy group, with the study basal cells that migrate and In an open-eye environment, the classifying two events as a CIE for proliferate into corneal epithelial atmosphere is the main supply the GP group and nine events for cells. Mechanical disruption of oxygen to the cornea. Placing the SiHy group.14 Other studies or hypoxia of these LESCs can a contact lens on the eye can have also confi rmed lower rates of lead to limbal hyperemia and reduce this supply by 8% to CIE for GP lenses.12,15 corneal neovascularization.5 In 15% depending on the oxygen Even with similar Dk between the event of signifi cant insult or permeability (Dk) of the lens.9 If GP and SiHy lenses, some injury, limbal stem cell defi ciency oxygen levels decrease enough to speculate GPs are safer due to (LSCD) can also occur. Although leave the cornea in a hypoxic state, tear exchange. Compared with this condition is rare, the multiple physiological changes the general tear stasis underneath resultant epitheliopathy, corneal can occur, including epithelial a soft lens, the smaller diameter conjunctivalization and scarring defects, neovascularization, acute of a GP lens promotes a fl ushing can be devastating.6,7 stromal edema and endothelial mechanism that improves oxygen While soft lenses drape over polymegethism.9 tension reaching the corneal the entire cornea, small-diameter Commonly associated with surface.16 Additionally, research corneal GPs have minimal hypoxia, corneal infl ammatory shows tear fi lm has bacteriostatic interaction with the limbus and events (CIEs) include infi ltrative activity, although the exact typically avoid compression keratitis, sterile marginal ulcers mechanism is unknown.17

8 REVIEW OF CORNEA & CONTACT LENSES | SEPTEMBER/OCTOBER 2018 5. Papas EB. The role of hypoxia in the limbal REDUCED MICROBIAL LOAD present in most forms of water, vascular response to soft contact lens wear. Eye Contact Lens. 2003;29(1 Suppl):S72-4; discussion When comparing SiHy and including tap water. GP lens S83-4, S192-194. hydrogel lenses, SiHy lenses wearers are far more likely 6. Sangwan VS. Limbal stem cells in health and disease. Biosci Rep. 2001;21(4):385-405. actually have higher risk of to rinse and store their lenses 7. Chan CC, Holland EJ. Severe limbal stem cell CIEs—suggesting hypoxia is not with tap water than soft lens defi ciency from contact lens wear: patient clinical features. Am J Ophthalmol. 2013;155(3):544-9. 18 23 the only risk factor. While CIEs wearers. Although the literature 8. Rossen J, Amram A, Milani B, et al. Contact are considered sterile, many think investigating Acanthamoeba lens-induced limbal stem cell defi ciency. Ocular Surface. 2016;14(4):419-34. bacterial bioburden plays a part keratitis and GP lenses have 9. Liesegang TJ. Physiologic changes of the cornea to their pathogenesis. However, typically involved orthokeratology with contact lens wear. CLAO J. 2002;28:12-27. 10. Hickson S, Papas E. Prevalence of idiopathic the larger concern of bacterial lenses, there are still relatively corneal anomalies in a non-contact lens wearing exposure is microbial keratitis few reports of Acanthamoeba population. Optom Vis Sci. 1997;74:293-7. 11. Stapleton F, Keay L, Jalbert I, Cole N. The (MK), which, although rare, can keratitis among GP wearers.24 epidemiology of contact lens related infi ltrates. Optom Vis Sci. 2007;84:257-72. be sight threatening. The lack of water content in GP 12. Morgan PB, Efron N, Brennan NA, et al. Risk In one study, the annual lenses, compared with soft lenses, factors for the development of corneal infi ltrative events associate with contact lens wear. Invest incidence rate of MK among all is one contributing factor that Ophthalmol Vis Sci. 2005;46:3136-43. contact lens wearers was 4.2 signifi cantly reduces the rate of 13. Szczotka-Flynn L, Ying J, Raghupathy S, et al. Corneal infl ammatory events with daily silicone per 10,000.19 When comparing Acanthamoeba’s adherence.25 hydrogel lens wear. Optom Vis Sci. 2014;91:3-12. modalities, the rate for soft lens 14. Morgan PB, Efron N, Maldonado-Codina C, Efron S. Adverse events and discontinuations wearers was 1.9 per 10,000 and ike any contact lens, GP lenses with rigid and soft hyper Dk contact lenses 19 used for continuous wear. Optom and Vis Sci. 11.9 for SiHys. When worn Lare not without risk or com- 2005;82:528-35. as extended wear, these rates plication; however, when weigh- 15. Lin MC, Yeh TN, Graham AD, et al. Ocular sur- face health during 30-day continuous wear: Rigid increased to 19.5 for soft lenses ing the benefi ts of different lens gas-permeable versus silicone hydrogel hyper-02 19 transmitted contact lenses. Invest Ophthalmol Vis and 25.4 for SiHys. However, in modalities, practitioners should Sci. 2011;52:3530-8. GP daily wearers the rate was only strongly consider GP lenses for 16. Weissman BA. Corneal oxygen: 2015. CL Spec- trum. 2015;30:25-29, 55. 19 RCCL 1.2 per 10,000. An earlier study their safety profi le. 17. Fleiszig SM. The pathogenesis of con- had similar annual incidence rates tact lens-related keratitis. Optom Vis Sci. 1. Nichols JJ. Contact lenses 2017. CL Spectrum. 2006;83:E866-73. of 2.0 per 10,000 for GP lenses 2018;(1):20-25, 42. 18. Szczotka-Flynn L, Diaz M. Risk of corneal and 2.2 to 4.1 per 10,000 for daily 2. Efron N, Nichols JJ, Woods CA, Morgan PB. infl ammatory events with silicone hydrogel and Trends in US contact lens prescribing 2002 to low Dk hydrogel extended contact lens wear: A 20 soft lenses. 2014. Optom Vis Sci. 2015;92:758-67. meta-analysis. Optom Vis Sci. 2007;84(4):247-56 All of this boils down to the fact 3. Gill FR, Murphy PJ, Purslow C. A survey of 19. Stapleton F, Keay L, Edwards K, et al. The inci- UK practitioner attitudes to the fi tting of rigid dence of contact lens-related microbial keratitis in that GP lenses have a lower risk gas permeable lenses. Ophthal Physiol Opt. Australia. Ophthalmology. 2008;115:1655-62. 2010;30:731-9. 20. Liesegang TJ. Contact lens-related micro- profi le for MK than soft lenses. In 4. Van Busbirk EM. The anatomy of the limbus. bial keratitis: Part I: Epidemiology. Cornea. addition to having a 10 to 20 times Eye. 1989;3:101-8. 1997;16:125-31. 21. Polse KA.Tear fl ow under hydrogel contact greater tear exchange lenses. Invest Ophthalmol Vis Sci. 1979;18:409-13. than a soft lens, GP 22. Ladage PM, Yamamoto K, Ren DH, et al. Ef- fects of rigid and soft contact lens daily wear on lens surfaces have corneal epithelium, tear lactate dehydrogenase, and bacterial binding to exfoliated cells. Ophthal- lower adherence mology. 2001;108:1279-88. rates of bacteria, 23. Zimmerman AB, Richdale K, Mitchell GL, et al. Water exposure is a common risk behavior among according to at least soft and gas-permeable contact lens wearers. one study.21,22 Cornea. 2017;36:995-1001. 24. Cope JR, Collier SA, Schein OD, et al. Acan- Another major thamoeba keratitis among rigid gas permeable contact lens wearers, United States, 2005-2011. concern for contact Ophthalmology. 2016;123(7):1435-41. lens wearers is 25. Seal DV, Bennett ES, McFadyen AK, et al. Dif- ferential adherence of Acanthamoeba to contact the exposure to lenses: Eff ects of material characteristics. Optom Acanthamoeba seldom occurs in GP wearers. Vis Sci. 1995;72(1):23-8.

REVIEW OF CORNEA & CONTACT LENSES | SEPTEMBER/OCTOBER 2018 9 Fitting Challenges By Vivian P. Shibayama, OD

Hard Case, Hard Lenses Although RGPs can be diffi cult to fi t, the right technique can provide challenging patients clearer vision.

ongenital cataracts can vision. He currently wears Alden HP lead to deprivational 49 lenses at 8.3/+22.00/14.5 OD, in children. 8.4/+20.00/14.5 OS. However, a good visual Cprognosis is possible CONTACT LENS EVALUATION with early detection and removal Subjective visual acuity was not of infantile cataracts—as long as measurable; however, the patient the subsequent visual rehabilitation was able to fi x and follow OU. with contact lenses is successful.1,2 over contact lenses Children should be fi t in lenses that revealed: provide the best optical quality and • -2.50+2.50x090 OD the highest oxygen permeability Fig. 1. To determine this patient’s K • -2.00+2.00x100 OS because the lenses are usually of a readings, I fi rst had to fi nd the fl at On exam, the child’s were high plus power and, consequently, K. Note the light horizontal band equally round and reactive to light; touch with excessive edge lift at the are thicker. vertical axis. This is a spherical RGP no afferent defect was noted OU. The initial contact lens fi tting often lens fi t on fl at K: 8.33 BC/10.0D lens. were unrestrict- occurs during infancy and is some- ed in all gazes, and was times done under anesthesia. Infants polymicrogyria, which is a condition noted. The patient’s intraocular pres- are relatively easy to swaddle, which associated with abnormal brain de- sures were 11mm Hg OD and 12mm makes taking measurements easier. velopment before birth.3 The patient Hg OS, as measured by a Tonopen If the fi tting occurs when the child is has a history of infantile spasms and (Reichert). His anterior segment older, however, ocular measurements is psychologically and physically evaluation was unremarkable. The can be more diffi cult to obtain due to delayed in his development. dilated view of the posterior fundus a lack of cooperation. When he was four months old, was also within normal limits, with a As a solution, creative fi tting the child developed cataracts (from cup-to-disc ratio of 0.1/0.1 OU. Due techniques are designed to help suc- an unknown origin) that progressed to the surgery, natural lens cessfully fi t these patients in the rigid rapidly within a short period of was absent in both eyes. I did not gas permeable (RGP) lenses they four weeks. was perform a confrontation visual fi eld need. This case highlights a method performed, and the child was fi t with exam because of age limitations. of fi tting aphakic bitoric lenses using soft spherical lenses that he has been After assessing the patient, I spherical diagnostic aphakic lenses wearing with no issues for the past diagnosed him with OU and in a toddler when keratometry (K) 16 months. progressing . readings are unattainable. Currently at 24 months, he does I discussed the pros and cons of not speak and is not ambulating. He three lens options with the patient’s THE CASE regularly receives behavioral, speech parents: The parents of a two-year-old apha- and physical therapy. Soft toric lenses pros: no change kic child with developmental delay During the child’s most recent visit in lens modality, familiarity with soft presented and claimed that their with his pediatric ophthalmologist lenses; cons: variable retinoscopy due child was unable to see clearly in his six weeks ago, fi ndings showed to soft lens movement, low Dk, not soft aphakic lenses. They had noticed that his eyes had experienced an easily verifi ed in-offi ce. a decrease in his visual attention increase in the amount of cylinder, Cylinder-correcting glasses (worn and felt he was relying more on his from 1.00D to 1.75D OU. The over soft lenses) pros: more control hearing than his sight. child was corrected for full distance of astigmatism (does not change with The child had been born full-term in his contact lenses while wearing rotation), do not dislodge easily, no but was diagnosed soon after with bifocal glasses to correct for near change in lens modality, familiarity

10 REVIEW OF CORNEA & CONTACT LENSES | SEPTEMBER/OCTOBER 2018 Earn up to NEW TECHNOLOGIES 2018 & TREATMENTS IN 19 CE

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with soft lenses; cons: must be up- dated to match prescription changes, not as precise optics as RGP lenses,4 soft lenses are not easily verifi ed in-offi ce, low Dk. Bitoric RGP lenses pros: more ARLINGTON, VIRGINIA consistent , high Dk, better optical quality, easily veri- NOVEMBER 2-4, 2018 fi ed in-offi ce, extensive parameters, Fig. 2. A 2D steep (7.94D) spherical easy to insert and remove; cons: RGP lens on a toric cornea. The Westin Arlington Gateway must learn insertion and removal techniques, more challenging to fi t, glasses prescription or the amount 801 North Glebe Road K readings are not attainable, lens of edge lift in a spherical lens fi tting. Arlington, Virginia 22203 may eject more easily, risk of corneal A 2D steep spherical RGP lens was See event site for discounted room rates. abrasions. chosen as a starting point to reduce vertical edge lift (Figure 2). Program Chair CONTACT LENS FITTING Step 3. As outlined in the fi tting The parents were most interested guide, fi nd the diameter by sub- in contact lenses that would pro- tracting 1.0mm from the horizontal vide their son with the best optical visible diameter (HVID). quality. Bitoric RGP lenses may be a After estimating the K readings, challenge to fi t, but they are the lens I ordered Pediasite SPE bitoric of choice when fi tting patients with optimum extreme lenses (Advanced Paul Karpecki, OD, FAAO high astigmatism.5,6 K readings were Vision Technologies) with the fol- unattainable due to poor coopera- lowing parameters: Faculty tion, so I used diagnostic spherical • 8.33/7.94 (drum reading) Doug Devries, OD RGP lenses from a Pediasite apha- +20.00/+18.00 (back vertex power) kic fi tting set (Advanced Vision 10.5 (diameter) OD Jeffry Gerson, OD Technologies) and fl uorescein • 8.33/7.94 (drum reading) Justin Schweitzer, OD patterns to estimate the patient’s K +18.00/+16.00 (back vertex power) readings through the following steps: 10.5 (diameter) OS Step 1. Determine the fl at K read- THREE WAYS TO REGISTER ing. Spherical lenses should exhibit CONTACT LENS DISPENSING band-like astigmatism fl uorescein The patient returned, and I placed ONLINE: patterns (Figure 1). the lenses on his eyes. I observed www.reviewsce.com Step 2. Estimate the toricity based good centration, peripheral fi t and on the amount of cylinder in the alignment (Figures 3 and 4). The par- /Arlington2018 ents were trained on insertion and EMAIL: [email protected] removal techniques, which weren’t CALL: 866-658-1772 a problem; in fact, they were able to handle the rigid lenses better than the soft lenses. They were then instructed Administered by Review of Optometry ® to use Unique pH multipurpose GP cleaning solution (Menicon) to clean Fig. 3. These bitoric contact lenses *Approval pending are properly aligned OU. and store the lenses. Partially supported by an unrestricted educational grant from Alcon

Review of Optometry® partners with Salus University for those ODs who are licensed in states that require university credit. See event website for up-to-date information. Fitting Challenges By Vivian P. Shibayama, OD

because these lenses are a bitoric lens or increase the toricity heavy, which changes the of the current lens. For heavy lenses dynamics of the fi t and that displace easily, the optic cap size may require clinicians to or center thickness of the lens should manipulate the con- be reduced.8 Lastly, the diameter tact lens parameters to should be large enough to optimize achieve better centration. lens stability. If the cornea is highly astigmatic, bitoric diag- pherical diagnostic contact lenses nostic sets are not always Sare valuable tools for fi tting both available. However, as spherical and bitoric RGP lenses on Fig. 3. Above is a close-up of the right eye fi t presented in this case, infants and children when K readings with a bitoric lens. bitoric lenses can be are unavailable. When managing designed using spherical aphakic lenses in young patients, FOLLOW-UP diagnostic lenses. the optic cap, lens thickness and Two weeks later, the patient and his After determining the fl at curva- diameter size can be manipulated by mom presented with no new com- ture reading, the practitioner must clinicians to improve stability and plaints. The child’s visual attention then determine how much toricity to centration. Although initially more had noticeably improved, according add by either matching the amount challenging, RGP lenses can provide to his mom and behavioral therapist. of cylinder in the spectacle prescrip- more stable and precise vision for The patient’s parents were happy tion or observing the amount of edge young patients. As these children with his new contact lenses, and a lift and lens rock with the spherical age, clinicians should consider a sec- follow-up appointment was sched- diagnostic contact lens. Toricity ondary lens implantation for better uled for six weeks later. should be increased if the lens is dis- results. RCCL Six years later, the patient is still lodging or exhibiting excessive edge doing well in his bitoric RGP lenses. lift. Toricity should be decreased if 1. Taylor D, Vaegan, Morris JA, et al. Amblyo- pia in bilateral infantile and juvenile cataract. Some modifi cations were made to the lens is not exhibiting enough Relationship to timing of treatment. Trans fl atten the lens and change the power movement.4 Against-the-rule corneas Ophthalmol Soc UK. 1979;99(1):170-5. as the patient aged. should be fi t as close to alignment as 2. Neumann D, Weissman BA, Isenberg SJ, et al. The eff ectiveness of daily wear contact possible for stability, and with-the- lenses for the correction of infantile aphakia. DISCUSSION rule corneas can be fi t with low toric Arch Ophthalmol. 1993;111(7):927-30. Although they are optically superior simulation to allow for adequate tear 3. Chang BS, Piao X, Giannini C, et al. Bilateral generalized polymicrogyria (BGP): a distinct 7 to soft contact lenses, RGP lenses exchange. syndrome of cortical malformation. Neurolo- can be challenging to fi t in young Ejection, a common challenge with gy. 2004;62(10):1722-8. 4. Silbert J. Rigid contact lenses and astigma- patients due to a lack of cooper- pediatric RGP lens fi ttings, could oc- tism. Contact Lens Practice. 2nd ed. London: ation and an inability to obtain cur for a number of reasons. A lens Butterworth-Heineman Elsevier. 2005:488- K readings. Bitoric lenses can be that is too steep will eject on blink 514. 5. Sarver M. Visual correction with contact especially challenging because most and requires a fl atter base curve that lenses. Clinical Refraction. 3rd ed. Chicago: are fi t empirically.7 While not usually will need to be adjusted as the child Professional Press, 1977. necessary, performing an exam under grows. A sudden increase in eye 6. Weissman BA, Chun MW. The use of spher- ical power eff ect bitoric rigid contact lenses anesthesia may be required if a child pressure can also cause the lens to in hospital practice. J Am Optom Assoc. is uncooperative and measurements eject and should be carefully moni- 1987;58(8):626-30. 7. Hom M, Bruce A. Manual of contact lens are unattainable. tored in aphakic patients. Excessive prescribing and fi tting. 3rd ed. Missouri: But- For aphakic contact lenses, toricity of the cornea can cause lens terworth-Heinemann. Elsevier. 2006:227-34. in-offi ce diagnostic fi tting with high rock and decentration. In this case, 8. Lindsay RG, Chi JT. Contact lens manage- ment of infantile aphakia. Clin Exp Optom. plus lenses is highly recommended a clinician should fi t the patient in 2010;93(1):3-14.

12 REVIEW OF CORNEA & CONTACT LENSES | SEPTEMBER/OCTOBER 2018 Advertorial AIR OPTIX® PLUS HYDRAGLYDE® CONTACT LENSES AND HYDRAGLYDE® LENS CARE: COMFORT, VISION AND LENS SURFACE MOISTURE ALL MONTH LONG

Susan J. Gromacki, OD, MS, FAAO, FSLS Silver Spring, MD

Dr. Gromacki was compensated by Alcon for her participation in this advertorial.

I recently welcomed a longtime wearer of frequent- contain HydraGlyde® Moisture Matrix, so pairing AIR OPTIX® plus replacement contact lenses to my practice. After finding that HydraGlyde® lenses with one of these solutions for daily cleaning she wore an older brand of lenses, I explained that the latest lens and disinfection helps provide consistent comfort and long lasting technologies—especially if paired with the right lens care—may lens surface moisture during the entire month-long wearing period.1 offer an improved experience. Newer lens designs, I explained, In a recent clinical study and patient survey, habitual wearers of include advanced materials and wetting agents to better “keep other contact lenses tried AIR OPTIX® plus HydraGlyde® lenses up” with a modern lifestyle.1,2 My patient agreed to try something along with a HydraGlyde®-containing lens care solution for daily new, and—as I expected—she was amazed. The regimen we cleaning and disinfection for 1 month. Patients in both cases tried? AIR OPTIX® plus HydraGlyde® monthly replacement agreed their trial lenses stayed comfortable, even during contact lenses paired with CLEAR CARE® PLUS Cleaning and challenging real-life situations like long work days,1 outdoor activity Disinfecting Solution. and active environments,1,12 during digital device use1,2 and in air- A modern lifestyle is a digitally-connected lifestyle, but conditioned environments.12 Additionally, in the survey, 4 times as devices like computers and smartphones can stress our eyes, many patients preferred AIR OPTIX® plus HydraGlyde® lenses to drastically decreasing our blink rate—from a normal 19 to 23 their habitual brand after trying them for 1 month while using a blinks/min to between 4 and 8 blinks/min while concentrating on lens care solution containing HydraGlyde® Moisture Matrix (73% a digital device.3,4 I recommend this regimen because AIR OPTIX® vs 18%, respectively; p<0.05).12 plus HydraGlyde® contact lenses—which combine two unique New lens materials and wetting technologies have brought us technologies—are designed to work synergistically with either very far in the realm of contact lens comfort. So, even if patients CLEAR CARE® PLUS or OPTI-FREE® PureMoist® Multipurpose are used to their habitual brand, they should be presented the Disinfecting Solution. This provides my patients with comfort opportunity to experience all the benefits of the latest and subjective visual quality throughout the 30-day wearing technologies. AIR OPTIX® plus HydraGlyde® contact lenses paired period—even during digital device use.1 with HydraGlyde® lens care solutions offer a uniquee Exclusive SmartShield® technology, present in all AIR OPTIX® combination of technologies that meets the needss contact lenses, is an advanced plasma surface technology that of the modern lifestyle, providing outstandingg creates an ultra-thin protective shield around the outer surface to comfort, vision and lens surfacece minimize exposed silicone at the lens surface.5 This helps moisture during the entire wearingng provide lipid deposit resistance and supports consistent comfort period.1,11 Recommend AIR OPTIX® plusus from Day 1 to Day 30.6-10* HydraGlyde® contact lenses paireded HydraGlyde® Moisture Matrix is a proprietary lens wetting agent, with either CLEAR CARE® PLUS oorr a block copolymer that attracts and retains moisture on the lens OPTI-FREE® PureMoist® to help yourur surface of AIR OPTIX® plus HydraGlyde® lenses in an envelope of frequent-replacement long-lasting moisture.11 The premium lens care solutions from lens wearers see, look Alcon—CLEAR CARE® PLUS and OPTI-FREE® PureMoist®—also and feel their best.

*Based on clinical studies with AIR OPTIX® AQUA, AIR OPTIX® AQUA Multifocal and AIR OPTIX® for Astigmatism contact lenses. Important information for AIR OPTIX® plus HydraGlyde® (lotrafilcon B) contact lenses: For daily wear or extended wear up to 6 nights for near/far-sightedness, and/or astigmatism. Risk of serious eye problems (i.e., ) is greater for extended wear. In rare cases, loss of vision may result. Side effects like discomfort, mild burning or stinging may occur. References 1. Alcon data on file, 2017. 2. Merchea M, Matthew J, Mack C. Assessing satisfaction with lotrafilcon B packaged with an EOBO wetting agent combined with EOBO-based lens care solutions. Poster presented at American Academy of Optometry annual meeting, 11-14 October 2017; Chicago, IL. Poster 143. 3. Patel S, Henderson R, Bradley L, et al. Effect of visual display unit use on blink rate and tear stability. Optom Vis Sci. 1991;68:888-892. 4. Tsubota K, Nakamori K. Dry eyes and video display terminals. N Engl J Med. 1993;328:584. 5. Rex J, Knowles T, Zhao X, Lemp J, Maissa C, Perry SS. Elemental composition at silicone hydrogel contact lens surfaces. Eye Contact Lens. 2018; doi 10.1097/ICL.0000000000000454. [Epub ahead of print] 6. Nash W, Gabriel M. Ex vivo analysis of cholesterol deposition for commercially available silicone hydrogel contact lenses using a fluorometric enzymatic assay. Eye Contact Lens. 2014;40(5):277-282. 7. Nash W, Gabriel M, Mowrey-Mckee M. A comparison of various silicone hydrogel lenses; lipid and protein deposition as a result of daily wear. Optom Vis Sci. 2010;87:E-abstract 105110. 8. Lemp J, Kern J. On-eye performance of lotrafilcon B lenses packaged with a substantive wetting agent. Poster presented at Optometry’s Meeting, the Annual Meeting of the American Optometric Association; June 21-25, 2017; Washington, D.C. 9. Eiden SB, Davis R, Bergenske P. Prospective study of lotrafilcon B lenses comparing 2 versus 4 weeks of wear for objective and subjective measures of health, comfort, and vision. Eye Contact Lens. 2013;39(4):290-294. 10. Lemp J, Kern J. A comparison of real time and recall comfort assessments. Optom Vis Sci. 2016;93:E-abstract 165256. 11. Lemp J, Muya L, Driver-Scott A, Alvord L. A comparison of two methods for assessing wetting substantivity. Poster presented at: 2016 Global Specialty Lens Symposium (GSLS); January 21-24, 2016; Las Vegas, NV. 12. Based on a U.S. survey wherein selected eye care professionals recruited and fit contact lens patients in AIR OPTIX® plus HydraGlyde sphere lenses for a 30 day trial. The surveyed patients used OPTI-FREE® PureMoist® or AOSEPT® Plus with HydraGlyde® lens care solutions throughout the survey period. Surveys were completed by patients at baseline, and after trying the study lenses (and the lens care solutions) for 30 days (n=59); Alcon data on file, 2017.

See product instructions for complete wear, care and safety information. © 2018 Novartis 7/18 US-AOH-18-E-0876 Sponsored by

RCCL0918_Alcon Adv.indd 1 8/23/18 3:28 PM CONJUNCTIVITIS: Making the Call

Good judgment and a comprehensive look beyond signs and symptoms are integral to knowing whether it’s allergic, bacterial or viral. By Stephanie Fromstein, OD

onjunctivitis is a com- RECOGNIZING THE period for the virus is fi ve to 12 mon, costly and, at times, USUAL SUSPECTS days, meaning that patients often confounding condition. Conjunctivitis has a host of etiol- shed the active virus in advance of CIt accounts for 1% of all ogies, both infectious (viral and symptoms. Carriers are contagious primary care visits and costs the bacterial) and sterile (allergic, toxic, for a period of 10 to 12 days, with healthcare system anywhere from contact lens-related, etc.). The symptoms sometimes lasting up $377 to $857 million dollars annu- most common cause of infectious to three weeks, an ample amount ally.1 Known colloquially as “pink conjunctivitis is viral, responsible of time to spread the condition. eye,” it can present with non-specif- for up to 80% of acute cases of Patients and family should be coun- ic symptoms, such as lacrimation, conjunctivitis.1,4 Bacterial conjunc- seled accordingly. grittiness, stinging and burning. tivitis, while less common, is more The consequent non-specifi c Signs include hyperemia, chemosis likely to cause infection in children acute follicular conjunctivitis is and hemorrhages.2 (50% to 75% of cases).1,5 Allergic the most common type of viral While clinicians tend to rely on conjunctivitis is the most common conjunctivitis and usually results traditional signs—papillae, follicles, overall (up to 40% of all cases) but in mild ocular involvement with discharge, etc.—to distinguish the vastly under-diagnosed, with only concurrent systemic fi ndings, etiology, a recent meta-analysis sug- about 10% of allergy sufferers with such as a sore throat or cold. gests that these familiar signs and acute ocular symptoms seeking Pharyngoconjunctival fever (PCF), symptoms do not correlate with medical care.1,5 With each case caused by adenovirus strains 3, 4 any one specifi c etiology of con- of conjunctivitis, clinicians must and 7, most commonly affects chil- junctivitis.3 Consequently, clinicians carefully judge the whole clinical dren. It is usually associated with are frequently misjudging viral, bac- picture to uncover the true etiology. mild pharyngitis and a low-grade terial and sterile causes, with one Viral conjunctivitis. While a wide fever and often spreads within study showing only 50% accuracy variety of viruses are implicated in families.2,6 Epidemic keratoconjunc- in diagnosing viral conjunctivitis this condition, the most common tivitis (EKC), caused by adenovirus when confi rmed with laboratory culprit by far is the adenovirus.6 strains 8, 19 and 37, is the most testing.1 With so few standard Viruses that infect the conjuncti- ABOUT THE AUTHOR tests available, a more thoughtful va less frequently include herpes diagnosis requires knowledge of the simplex virus (often with associated Dr. Fromstein completed her Doctor of prevalence, pathogens and clinical keratitis), varicella-zoster, picor- Optometry degree at experience—with an eye for atyp- navirus, infl uenza A, Epstein-Barr, Nova Southeastern University in Davie, ical presentations. Here, we take a poxvirus, Newcastle disease and, Fla., and pursued a look at what we know—and what rarely, HIV.7,8 residency in Cornea and Contact Lens at remains to be resolved—about Adenovirus is a nonenveloped, the Illinois College of conjunctivitis and how best to double-stranded DNA virus that Optometry, where she is currently an assistant professor and the distinguish between the condition’s can survive on dry surfaces for up coordinator of the Cornea and various forms. to seven weeks.2 The incubation Contact Lens residency program.

14 REVIEW OF CORNEA & CONTACT LENSES | SEPTEMBER/OCTOBER 2018 Photo: Marc Bloomenstein, OD The condition typically presents mast cell degranulation and the with conjunctival injection, papillae release of infl ammatory modulators and mucopurulent discharge. In se- and causes a host of symptoms vere cases, the patient may present traditionally associated with allergic with edema and erythema. conjunctivitis.6 Hyperacute purulent discharge is Simple is associated with infections by gono- caused by a reaction to an envi- coccal or meningococcal bacteria, ronmental allergen, such as pollen, predominantly in infants born to or to eye medications or solutions infected mothers or adults infected or to the preservatives contained 1 2,6 Filled with lymphocytes and plasma via sexual contact. This is a serious within. Seasonal conjunctivitis cells, follicles tend to localize to the infection that may develop a per- refers to the exacerbation of allergic fornices and lack a central vessel. forating keratitis within 48 hours.1 symptoms most frequently in the Chlamydia trachomatis infections spring and summer as the result severe type of viral conjunctivitis, are also possible, often with corneal of tree and grass pollens, while typically occurs in middle-aged involvement.1 Coinfection with perennial conjunctivitis presents adults (men and women equally) gonorrhea and chlamydia is com- symptoms year-round as the result and is most likely to involve corneal mon, and clinicians should initiate of house dust mites, animal dander changes.2,6 treatment for both conditions if and fungal allergens.2 Signs of viral conjunctivitis either is found. Vernal include prominent conjunctival Finally, blepharoconjunctivitis, (VKC) is a severe allergic infl amma- hyperemia and follicles, lid edema often mild and overlooked, involves tory condition that mainly affects and pre-auricular lymphadenopa- the interaction between lid margin young males, with an average onset thy.2 In severe cases, conjunctival secretions, microbial organisms of fi ve to seven years old.3 The hemorrhages, pseudomembranes and tear fi lm abnormalities. This condition is often associated with and true membranes may also be causes a chronic and episodic personal or family history of VKC observed. Keratitis is seen in a third conjunctivitis.11 or other atopies (e.g., asthma or of cases and ranges from punctate Allergic conjunctivitis. This eczema). While the condition often staining to subepithelial infi ltrates— comes in several varieties, each resolves in their late teens, some signs representative of an immune mediated by a type 1 hypersensi- of these patients go on to develop response to the virus. Watery dis- tivity reaction to an environmental atopic keratoconjunctivitis (AKC), charge may also be noted.2 immune mediator. The allergen re- a rare, bilateral disease with onset Acute bacterial conjunctivitis. acts with IgE antibodies, stimulates in late adolescence to adulthood. This is a common, often self-limit- ing condition that affects all races The Treatment Dilemma and genders. It is caused by direct Proper diagnosis is critical to avoid unnecessary therapy and contact with infected secretions, antibiotic resistance. Since both types of infectious conjunctivitis most commonly Streptococcus resolve spontaneously in seven to 14 days, clinicians should use pneumoniae, Haemophilus infl u- antibiotic therapy judiciously. Unfortunately, treatment is often enzae, Staphylococcus aureus and mandatory before children can return to school; this approach Moraxella catarrhalis, with the encourages unnecessary therapy and can send the child back fi rst two agents comprising 85% to school well within the period of contagion. Furthermore, to 98% of all infections.9 However, patients of all ages often expect therapy regardless of etiology hyperacute infections with Neisseria and effi cacy and will seek care at another provider’s offi ce if not gonorrhoeae pose a far greater properly educated before leaving your offi ce empty-handed. threat to sight.1 Infections with If treatment is indicated for bacterial infections, fl uoro- methicillin-resistant Staph. aureus quinolones can combat the most common causative agents with (MRSA) are also of increasing little resistance. A potent antibiotic at the appropriate dosage is concern in the general population. critical in eliminating the pathogen before it has the opportunity Molluscum contagiosum and mi- to mutate. Antibiotic therapy should never be reduced below the therapeutic dose, as this can further contribute to antibiotic crosporidia should be considered as resistance. possible etiologies as well.10

REVIEW OF CORNEA & CONTACT LENSES | SEPTEMBER/OCTOBER 2018 15 CONJUNCTIVITIS: MAKING THE CALL Photo: Marc Bloomenstein, OD The condition is marked by chronic non-infl uenza viruses. and unremitting conjunctival Clinicians should also infl ammation in patients with a perform an out-of-slit history of atopy elsewhere, often lamp view of the pattern dermatologic.2,6 Symptoms of VKC of injection, so as not to and AKC are similar, though those lose the proverbial forest associated with AKC are more for the trees; viral infec- severe and unremitting. tions may initially have Giant papillary conjunctivitis more infl ammation and (GPC) involves a combination of an injection inferiorly than allergic reaction and a mechanical superiorly, though severe Papillae often arrange in a cobblestone irritation from a foreign body (in cases will appear more confi guration of fl attened nodules with a central 1 most cases, a contact lens). diffuse. vascular core. Signs of allergic conjunctivitis Conjunctival lumps include redness, itching and chemo- and bumps may point to a cause, charge due to the systemic associa- sis. Watering may also be noted and though not always. Bacterial and tion. The type of discharge should is associated with nasal discharge. allergic conjunctivitis tend to not be considered in isolation, as VKC may present with a collec- present with a papillary reaction—a research shows it is not specifi c to tion of eosinophils at the limbus cobblestone arrangement of fl at- any class of conjunctivitis.1 Any eye (Horner-Trantas dots) and large tened nodules with central vascular under stress will self-lubricate as a papules under the conjunctiva. No cores.10 Papillae are more gener- means of protection.13,14 preauricular node is typically noted. alized markers of infl ammation, Corneal changes may give fur- while follicles are more diagnostic ther insight as well. Subepithelial ATYPICAL PRESENTATIONS of a particular brand of infl am- infi ltrates are associated with EKC Other non-infectious forms of mation, occurring mainly in viral, and present several days into the in- conjunctivitis can include contact toxic and chlamydial infections. fectious period. Bacterial conjuncti- lens-related, mechanical/traumatic Follicles—fi lled with lymphocytes vitis typically does not present with (including , and and plasma cells—tend to local- corneal fi ndings, though serious in- ), toxic, and neonatal.6 ize to the fornices, be smaller and fections can cause infi ltrates and, in lack a central vessel.2,12 As follicles some cases, .15 VKC can EXAM POINTERS associated usually tend to present present with a shield ulcer second- Clinicians performing adnexal exam inferiorly, while papillary reaction ary to the close apposition between should look at the periorbital skin are often most pronounced on the the conjunctiva and the cornea. and lymph nodes. Herpetic conjunc- upper tarsal plate, lid eversions can Chlamydial infections may present tivitis may present with lid involve- hold important diagnostic clues with peripheral corneal infi ltrates.1 ment before (simplex) or after and should be performed on every Even knowing these common (zoster) conjunctival involvement. patient. Chlamydial conjunctivitis signs and symptoms, clinicians Periorbital edema could point to a classically presents with a mixed often have to look beyond the obvi- viral etiology. Lymphadenopathy papillary or follicular response, ous to ensure the right diagnosis by is also most likely to occur in viral worse inferiorly, in the context of a obtaining the following: infections (EKC more so than chronic, low-grade conjunctivitis. Patient history. While signs and PCF), though it may be noted in Discharge can narrow the differ- symptoms may not be diagnostic severe bacterial infections, chla- ential causes, as watery discharge is for an etiology, patient history can mydial infections and Parinaud’s more indicative of viral conjunctivi- provide invaluable clues about the oculoglandular syndrome as well. tis, while purulent or mucopurulent cause of conjunctivitis. The preauricular node is typically discharge is often associated with Data as simple as a patient’s affected, though clinicians should bacterial conjunctivitis. Hyperacute age or the time of year can help to also check the submandibular in all conjunctivitis tends to be associated narrow down the differential diag- cases of conjunctivitis of unknown with copious amounts of discharge nosis. Viral conjunctivitis is more etiology. Tonsillar nodes may also that reappears immediately after common in adults, while bacterial give an indication of previous or wiping it away. Allergic conjunctivi- conjunctivitis is more common in current infection with infl uenza or tis is also associated with nasal dis- children. One in eight children has

16 REVIEW OF CORNEA & CONTACT LENSES | SEPTEMBER/OCTOBER 2018 an episode every year, with fi ve Laterality can also be indicative cy. Certain combinations have been million pediatric cases reported an- of etiology. Viral conjunctivitis shown to be predictive; bilateral nually.9 Allergic conjunctivitis has pathognomonically starts in one matting of the , no itching little preponderance for age, though eye and spreads to the other within and no history of conjunctivitis are certain types (e.g., VKC) tend to a few days, almost always with indicative of a bacterial infection.5 target younger patients.2 The time varying severity. Bacterial conjunc- On the other hand, if the patient of year can also give a clue; viral tivitis has no clear pattern of later- is also older than six, is presenting and allergic conjunctivitis are most ality and can be unilateral, bilateral between April and November, has common in the spring and summer, or asymmetric. If presenting bilat- watery or no discharge and does while bacterial conjunctivitis is erally, allergic cases almost always not have glued eyes in the morn- most common in the winter. present with varying severity. ing, this is highly predictive of a History of present illness ques- Visual acuity. Vision can be negative bacterial culture. Signs and tions may also point toward an notably reduced in adenoviral symptoms only form part of the etiology. As viral cases are often infections compared with other diagnostic picture; other factors, connected with upper respiratory forms of conjunctivitis, especially in including patient history, are just tract infections, asking whether cases with corneal involvement or as crucial to diagnosing the various the patient feels sick or has in the signifi cant infl ammation. forms of conjunctivitis. RCCL recent past can help differentiate Additional tests. Some cases may between PCF and EKC, respective- warrant specifi c testing to pinpoint 1. Azari AA, Barney NP. Conjunctivitis: a system- atic review of diagnosis and treatment. JAMA. ly. Patients with viral conjunctivitis the underlying etiology. AdenoPlus 2013;310(16):1721-9. will often report recent contact (Quidel Corporation), a point- 2. Rietveld RP, van Weert HC, ter Riet G, Bindels PJ. Diagnostic impact of signs and symptoms in acute with a sick individual. Bacterial of-care immunochromatography infectious conjunctivitis: systematic literature search. infection is moderately less conta- test for adenoviral infection, takes BMJ. 2003;327(7418):789. 3. Kanski JJ. Clinical Ophthalmology: A Systematic gious and more likely to arise de 10 minutes in-offi ce and is highly Approach. 6th ed. Edinburgh: Butterworth-Heine- novo. Both bacterial and allergic sensitive to adenoviral infections. mann/Elsevier; 2007. 4. Sethuraman U, Kamat D. The : eval- causes are less commonly linked to Specifi city ranges widely in studies, uation and management. Clin Pediatr (Phila). an acute bout of illness. with some showing high false-nega- 2009;48(6):588-600. The disease course can also be a tives. Additional testing is typically 5. Rosario N, Bielory L. Epidemiology of allergic conjunctivitis. Curr Opin Allergy Clin Immunol. good diagnostic clue. While allergic not indicated in bacterial conjuncti- 2011;11(5):471-6, conjunctivitis likely is associated vitis, although severe cases—includ- 6. American Optometric Association. Care of the patient with conjunctivitis. Optometric Clinical Prac- with a long course of exacerbation ing those with corneal fi ndings and tice Guideline. St Louis, MO: American Optometric and remission, both bacterial and those suspected to be hyperacute, Association; 2002. 7. Newman H, Gooding C. Viral ocular mani- viral likely have an acute presenta- recurrent or recalcitrant cases— festations: a broad overview. Rev Med Virol. tion and a protracted (fewer than may warrant conjunctival swabs to 2013;23(5):281-94. 8. Pavan LD. Ocular viral infections. Med Clin North 14 days) course to improvement. rule out gonococcal and meningo- Am. 1983;67(5):973-90. As such, sudden onset of symptoms coccal infection. While false-posi- 9. Høvding G. Acute bacterial conjunctivitis. Acta may point to an infectious cause. tives are possible (Staphylococcus Ophthalmol. 2008;86(1):5-17. 10. Blomquist PH. Methicillin-resistant Staphylo- Viral infections tend to last longer and Streptococcus are found in nor- coccus aureus infections of the eye and (an american ophthalmological society thesis). Trans than bacterial, but neither is likely mal lid fl ora and will often show up Am Ophthalmol Soc. 2006 Dec;104:322-45. to recur several times in succession. on the swabs), atypical fi ndings can 11. O’Gallagher M, Bunce C, Hingorani M, et al.

Photo: Marc Bloomenstein, OD Topical treatments for blepharokeratoconjunctivitis be diagnostic. Investigations are in children. Cochrane Database Syst Rev. 2017 Feb typically not performed for allergic 7;2:CD011965. 12. Solano D, Czyz CN. Conjunctivitis, viral. StatPearls conjunctivitis. https://www.ncbi.nlm.nih.gov/books/NBK470271/. Published December 12, 2017. Accessed September he most common causes of 15, 2018. 13. Tarabishy AB, Jeng BH. Bacterial conjunc- Tconjunctivitis are diffi cult to tivitis: a review for internists. Cleve Clin J Med. distinguish based on signs and 2008;75(7):507-12. 14. Rietveld RP, ter Riet G, Bindels PJ, et al. Predicting symptoms alone. With a broader bacterial cause in infectious conjunctivitis: cohort study on informativeness of combinations of signs understanding of the various distin- and symptoms. BMJ. 2004;329(7459):206-10. guishing factors, clinicians will be 15. Abbott R, Halfpenny C, Zegans M, Kremer P. Purulent or mucopurulent discharge Bacterial Corneal Ulcers. Duane’s Clinical Ophthal- is often associated with bacterial prepared to diagnose every case of mology, 12th ed. Volume 4. Philadelphia: Lippincott, conjunctivitis. conjunctivitis with relative accura- Williams & Wilkins; 2013.

REVIEW OF CORNEA & CONTACT LENSES | SEPTEMBER/OCTOBER 2018 17 Your Corneal Infection Care Questions— ANSWERED Here’s how you can overcome your top three microbial keratitis challenges. By Doan Huynh Kwak, OD

icrobial keratitis is a trend and recommends culturing previous surgery, larger central ul- well-known condition infi ltrates that are larger than 2mm, cers and referred an average of nine that has the potential to of a suspected unusual organism, in days after the onset of symptoms.7 Mcause the visual axis or unresponsive to Of the ulcers that needed modifi ed and blindness. Corneal opacities, initial treatment.5 treatment based on their culture typically a sequela of infectious ker- For example, a survey of commu- and sensitivity testing, several were atitis, are responsible for 5.1% of nity ophthalmologists in southern of unusual etiology (Aspergillus, visual impairments worldwide and California found that 48.7% of Acanthamoeba and Actinomyces) up to 10% of avoidable blindness in corneal ulcers were treated without and others were of S. epidermidis the world’s least developed coun- taking cultures.6 The discrepancy and resistant to fortifi ed cefazolin.7 tries.1,2 Diagnosis and timely initi- between formal recommendations? This study recommends those who ation of appropriate antimicrobial and community practice may be due treat severe cases culture most ulcers treatment are imperative in patients to the time and cost associated with and general practitioners culture if presenting with a red, painful eye performing cultures and maintain- the patient presents with a signifi - indicative of infection, as research- ing materials and the high success cant corneal ulcer.7 ers speculate only 50% of eyes heal rate of empirical antibiotic therapy. When initial treatment fails, pa- with good visual outcome without In a comparison of a tertiary tients are usually referred to a cor- either.2,3 However, treating corneal cornea clinic and general ophthal- nea specialist for further investiga- infections is fraught with challenges mology clinic, 10% of ulcers in the tion or treatment. However, current and uncertainties that can make a cornea clinic were resistant to em- antibiotic therapy often complicates clinician hesitant to move forward pirical antibiotics, did not improve the question of whether to culture. with any one management plan, clinically and needed a therapy Studies found that patients on even when confi dent of the diagno- modifi cation based on the culture antibiotic therapy were only slightly sis. This article addresses several of and sensitivity testing. However, more likely to be culture negative. these roadblocks to help you treat culture results in the general oph- Nevertheless, the pathogen recovery microbial keratitis patients promptly thalmology clinic did not lead to an may be somewhat delayed com- and correctly. alteration of therapy for patients.7 pared with cultures that were not This discrepancy is likely due to the ABOUT THE AUTHOR SHOULD I CULTURE? varying patient presentations be- In the past, textbooks and guides tween the cornea clinic and general Dr. Kwak is an Illinois such as the Wills Eye Manual ophthalmology clinic, the research- College of Optometry graduate and completed recommended culturing suspicious ers note.7 The general clinic patients her primary care residency at Salus infectious keratitis prior to treat- had smaller peripheral ulcers and University’s Pennsylvania ment.4 However, in practice, many were treated within three days of the College of Optometry. After years at an anterior start empirical treatment without onset of symptoms; the cornea clinic segment practice, she recently culturing. The most recent edition patients, however, were older, more joined Salus University as a clinical of the Wills Eye Manual refl ects this likely to have corneal disease or faculty member.

18 REVIEW OF CORNEA & CONTACT LENSES | SEPTEMBER/OCTOBER 2018 pretreated. The delay in diagnosis with the modifi cation in molecu- Begin with Questions does not necessarily lead to a nega- lar structure of fourth-generation tive outcome.8 In corneal ulcers with fl uoroquinolones.10 Gathering a thorough case history will help categorize delayed healing, the causative or- Fortifi ed topical antibiotics such a patient as having risk ganism may be fungal or protozoan. as cefazolin sodium (50mg/mL) and factors of infection. High- Thus, in patients not responsive to fortifi ed tobramycin sulfate (14mg/ risk characteristics include a treatment, it is imperative to make a mL) are an alternate empirical history of trauma, contact lens quick referral to a cornea specialist treatment option. A randomized use, recurrent topical steroid or have the patient cultured. controlled trial found gatifl oxacin use, immunosuppression Patients with corneal ulcers that monotherapy was equivalent to and ocular surface disease.4 are central in location, have a signif- combination therapy with cefazolin Patients without these icant anterior chamber reaction or and tobramycin treatment for histories are categorized as have corneal infi ltrates larger than nonperforated bacterial corneal low risk. 4mm should be cultured, referred ulcers.11 For patients with high-risk From here, clinicians can to a cornea specialist or both.3 In characteristics, another study rec- diff erentiate between a sterile practice, clinicians should start con- ommends treatment with a fortifi ed infi ltrate and an infectious sidering culturing infi ltrates larger antibiotic, such as vancomycin, for keratitis and then plan the than 2mm.9 gram-positive coverage, in addition appropriate treatment to a fourth-generation fl uoroquino- approach. An epithelial defect overlying an infi ltrate is HOW SHOULD I CHOOSE lone, fortifi ed aminoglycoside or generally present in microbial THE RIGHT ANTIBIOTIC? fortifi ed third- or fourth-generation keratitis, although some Factors to consider when choosing cephalosporin for broad-spectrum Acanthamoeba keratitis and an antibiotic treatment include gram-negative coverage.12 fungal infections, especially broad-spectrum coverage, toxicity, Because tetracyclines have molds, can have an intact availability, cost and region-specifi c anticollagenolytic activity and epithelium. The defect should ? epidemiology of pathogens.2 First- inhibit metalloproteinases, they can be as large or larger line treatment for most keratitis is suppress connective tissue break- than the infi ltrate. topical and empirical. For bacte- down.2,13 Thus, oral tetracyclines rial keratitis, fourth-generation such as doxycycline may help to superior to voriconazole for topical fl uoroquinolone monotherapy is stabilize the corneal melting pos- treatment of fungal keratitis, and a common treatment approach. sible in aggressive infections such Fusarium keratitis in particular.2 Fluoroquinolones are broad-spec- as Pseudomonas aeruginosa.2,13 The Mycotic Ulcer Treatment Trial trum antibacterials that cover Despite the widespread use of adju- II found no signifi cant difference in gram-negative and anaerobic species vant oral doxycycline among cornea the rate of perforation, visual acuity responsible for ocular infections. specialists, high quality randomized or rate of re-epithelization between They are also effective against a va- controlled trials in humans do not adjuvant oral voriconazole or oral riety of gram-positive organisms; the exist to support its use.2 placebo. Subgroup analysis showed spectrum of activity has improved Patients with suspected fungal there may be a possible benefi t

Photo: Christopher Croasdale, MD Photo: Christopher Croasdale, MD keratitis should be to oral voriconazole in Fusarium treated with topi- ulcers. Thus, topical cal natamycin 5%. remains the treatment of choice for Topical voriconazole, fi lamentous fungal keratitis, and the a newer generation tri- addition of oral voriconazole should azole, has excellent oc- be considered in Fusarium ulcers.2 ular penetration com- Intrastromal injection of antifungal pared with natamycin agents, such as voriconazole, may and is a good alterna- be useful for patients with deep tive. However, results recalcitrant fungal keratitis.2,14 from the Mycotic While successful cases with intras- Ulcer Treatment tromal injections exist, randomized This patient has an advanced P. aeruginosa corneal Trial I demonstrate controlled trials are necessary to ulcer. that natamycin was determine their benefi t.2,14

REVIEW OF CORNEA & CONTACT LENSES | SEPTEMBER/OCTOBER 2018 19 YOUR CORNEAL INFECTION CARE QUESTIONS—ANSWERED Photo: Scott G. Hauswirth, OD, Richard Mangan, OD Treatment with oral nonsteroidal Acanthamoeba infection, infections anti-infl ammatory drugs, systemic that are thought to be exacerbated steroids or other systemic immuno- by topical steroid use.16,17 However, suppressive drugs such as cyclospo- no conclusive evidence exists to rine may be needed in patients with demonstrate whether the adjunctive extracorneal manifestations.15 use of topical steroids in bacterial keratitis is harmful or benefi cial. WHEN SHOULD I ADD The Steroids for Corneal Ulcers CORTICOSTEROIDS? Trial (SCUT), a large randomized, The use of these medications in the double-masked, placebo-controlled Here is an example of a Nocardia- induced keratitis. treatment of infectious keratitis is trial that aimed to determine controversial and, despite many whether adjunctive topical steroids In patients with suspicious herpes studies researching the benefi ts of for bacterial keratitis improve long- simplex virus (HSV) keratitis, adding a corticosteroid to an antibi- term clinical outcomes, found no topical treatments include antiviral otic treatment, no formal standard signifi cant difference in best specta- medications such as trifl uridine of care exists for the use of steroids cle-corrected visual acuity (BSCVA), and ganciclovir. Topical cortico- in bacterial keratitis. scar size or rate of perforation at steroids are added in patients with Supporters for their adjunctive three months between patients in HSV stromal keratitis. Steroids are use rationalize that the addition will the placebo and topical steroid typically avoided in HSV keratitis help minimize corneal scarring and adjunctive therapy groups.17 It also during the active infectious stage. opacifi cation. Both infection and in- found no differences in healing rates Oral treatments such as oral acyclo- fl ammation play a role in the patho- or safety concerns with the use of vir and valacyclovir have become genesis and resulting clinical signs adjunctive steroids. more common in HSV keratitis of infectious keratitis.16 In addition The timing of adding a steroid secondary to the ocular toxicity that to the corneal injury induced by may be crucial, research suggests. may develop with topical therapy. the bacteria, the host infl ammatory After studying the duration of Topical medications may be added response to the infection contrib- topical antibiotic treatment before when oral medications are not utes to decreased corneal healing, adding topical steroids, research adequate or in patients who are ultimately leading to scarring.16 In shows a signifi cant improvement not good candidates for systemic the host, T-cells and macrophages in visual acuity when the topical therapy.2 respond to the bacterial invaders, steroid treatment was administered Contact lens wearers are at risk producing cytokines. These then within two to three days of initia- of Acanthamoeba keratitis (AK). facilitate neutrophil migration and tion of topical antibiotic treatment. Biguanides and diamidines are the degranulation, leading platelet-acti- Therefore, in non-Nocardia ulcers, most effective cysticidal antiamebics vating factors to upregulate metal- steroids are benefi cial when admin- for these cases. Commonly used loproteinases and cause stromal istered earlier, within two to three biguanides include polyhexameth- necrosis.16 Because corticosteroids days, and neutral when adminis- ylene biguanide 0.02% to 0.06% decrease infl ammatory factors, tered later.18 Because the original and chlorhexidine 0.02% to 0.2%. using them in addition to antibiotics SCUT results were inconclusive Biguanides disrupt the cytoplasmic in the treatment of bacterial kerati- and the timing of steroid use was a membrane and damage cell compo- tis can limit the host’s infl ammatory non-prespecifi ed group analysis, the nents and respiratory enzymes, all response and target the infection.16 authors recommend considering the with low levels of corneal epithelial Others believe the addition of a results with caution and do not rec- toxicity. They provide a synergistic steroid may potentiate the bacte- ommend changing clinical practice effect when used in combination rial infection and lead to corneal protocols.18 with diamidines, which include pro- thinning and, possibly, stromal Clinicians should take these pamidine isethionate 0.1% and hex- melt. Additionally, steroids may factors into consideration when amidine 0.1%. Diamidines are ef- increase the duration of an infection treating various cases of bacterial fective against both the trophozoite or the risk of recurrent infection. keratitis with steroids: and cystic forms of Acanthamoeba. Inappropriate addition of a ste- Nocardia infections. Subgroup First-line therapy is the combina- roid to antibiotic treatment may analyses showed that ulcers caused tion of a biguanide and diamidine. occur in patients with a fungal or by Nocardia species had worse

20 REVIEW OF CORNEA & CONTACT LENSES | SEPTEMBER/OCTOBER 2018 Photos: Christine W. Sindt, OD rates of P. aeruginosa ulcers a culture and how to tailor therapy treated with steroids, many based on initial response or the clinicians remain uncertain about culture results will ensure patients using steroids in these corneal receive the care they need and avoid infections. However, the SCUT negative outcomes. RCCL subanalysis found that when 1. World Health Organization. Causes of blindness compared with other bacterial and visual impairment. www.who.int/blindness/ ulcers of similar severity, P. aeru- causes/en. Accessed July 29, 2018. 2. Austin A, Lietman T, Rose-Nussbaumer J. Update ginosa corneal ulcers responded on the management of infectious keratitis. Ophthal- better to treatment, resulting in mology. 2017;124(11):1678-89. 3. Bennett HGB, Hay J, Kirkness CM, et al. Anti- greater improvement in visual microbial management of presumed microbial keratitis: guidelines for treatment of central and acuity from presentation to three peripheral ulcers. Br J Ophthalmol. 1998;82:137-45. 20 months. Additionally, the study 4. Friedberg MA, Rapuano CJ, eds. Wills Eye Hospital offi ce and emergency room diagnosis did not fi nd a signifi cant differ- and treatment of eye disease. First ed.Philadelphia: ence in three-month BSCVA or Lippincott; 1990:66. 5. Gerstenblith AT, Rabinowitz MP, eds. Wills Eye infi ltrate/scar size among the P. Hospital offi ce and emergency room diagnosis and aeruginosa ulcers treated with treatment of eye disease. Sixth ed. Philadelphia: Lippincott; 2012:435. adjunctive steroids compared 6. McDonnell PJ, Nobe J, Gauderman WJ, et al. with placebo, nor was there an Community care of corneal ulcers. Am J Ophthal- mol. 1992;114:531-8. These images depict the progression of increase in adverse events with 7. Rodman RC, Spisak S, Sugar A, et al. The utility of steroid treatment.20 culturing corneal ulcers in a tertiary referral center AK over two months. versus a general ophthalmology clinic. Ophthalmol- In practice, clinicians may ogy. 1997;104:1897-1901. clinical outcomes with adjunctive consider adding a steroid to the 8. Marangon FB, Miller D, Alfonso EC. Impact of prior therapy on the recovery and frequency of steroid use. However, they found antibiotic treatment of P. aeruginosa corneal pathogens. Cornea. 2004;23(2):158-64. that patients in the adjunctive but should use clinical judgment 9. Weiner G. Confronting corneal ulcers: pinpointing etiology is crucial for treatment decision making. steroid treatment arm with worst and consider the specifi c corneal Eyenet. 2012;45-52. baseline visual acuity (counting ulcer. 10. Blondeau JM. Fluoroquinolones: mechanism of action, classifi cation, and development of resis- fi ngers or worse), ulcers located in Acanthamoeba keratitis. In tance. Surv Ophthalmol. 2004;49(2):S73-8. and covering the central 4mm or one review, researchers state that 11. Sharma N, Arora T, Jain V, et al. Gatifl oxacin 0.3% versus fortifi ed tobramycin-cefazolin in treating ulcers with the deepest infi ltrates steroids are usually not required in nonperforated bacterial corneal ulcers: randomized, controlled trial. Cornea. 2016;35(1):56-61. at baseline experienced signifi cant AK cases that are diagnosed early 12. Amescua G, Miller D, Alfonso EC. What is causing positive effects on their BSCVA.17 and respond to antiamebic therapy. the corneal ulcer? Management strategies for unre- sponsive corneal ulceration. Eye. 2012;26:228-36. Subsequent analysis at 12 months However, steroids may be useful 13. McElvanney AM. Doxycycline in the management revealed that steroids may be when signifi cant anterior segment of Pseudomonas corneal melting: two case reports and a review of the literature. Eye Contact Lens. associated with improved long-term infl ammation exists to facilitate rap- 2003;29(4):258-61. visual outcomes among non-Nocar- id resolution of symptoms. Again, 14. Kalaiselvi G, Narayana S, Krishnan T, et al. Intras- 17 tromal voriconazole for deep recalcitrant fungal ker- dia ulcers. Thus, it is possible that clinicians should proceed with atitis: a case series. Br J Ophthalmol. 2015;99:195-8. steroids require longer periods of caution as steroids may worsen the 15. Maycock NJR, Jayaswal R. Update on Acan- 19 thamoeba keratitis: diagnosis, treatment, and time to reveal clinical benefi ts. condition by dampening the host’s outcomes. Cornea. 2016;35(5):713-20. Pseudomonas aeruginosa. Often infl ammatory response.15 Evidence 16. Ni N, Srinivasan M, McLeod SD, et al. Use of ad- junctive topical corticosteroids in bacterial keratitis. associated with contact lens use also suggests that steroid use may Curr Opin Ophthalmol. 2016;27(4):353-7. in developed countries such as result in increased pathogenicity of 17. Srinivasan M, Mascarenhas J, Rajaraman R, et al. Corticosteroids for bacterial keratitis: The Steroids 15 the United States, P. aeruginosa is the amoebas. for Corneal Ulcers Trial (SCUT). Arch Ophthalmol. a causative agent in a large pro- 2012;130(2):143-50. 18. Ray KJ, Srinivasan M, Mascarenhas J, et al. portion of bacterial keratitis.20 linicians will never be able to Early addition of topical corticosteroids in the treatment of bacterial keratitis. JAMA Ophthalmol. P. aeruginosa corneal ulcers are Cavoid seeing corneal infections 2014;132(6):737-41. more severe, highly virulent, more in their practice. While many con- 19. Srinivasan M, Mascarenhas J, Rajaraman R, et al. The Steroids for Corneal Ulcers Trial (SCUT): sec- diffi cult to treat and result in worse troversies in corneal ulcer treatment ondary 12-month clinical outcomes of a randomized visual outcomes compared with can make these some of the tough- controlled trial. Am J Ophthalmol. 2014;157(2):327- 33. other bacterial corneal ulcers. est patients, a healthy mix of litera- 20. Sy A, Srinivasan M, Mascarenhas J. Pseudomo- Because of this and animal studies ture review and clinical acumen can nas aeruginosa keratitis: outcomes and response to corticosteroid treatment. Invest Ophthalmol Vis Sci. describing increased recurrence go a long way. Knowing who needs 2012;53(1):267-72.

REVIEW OF CORNEA & CONTACT LENSES | SEPTEMBER/OCTOBER 2018 21 Advertorial

How to Overcome Cost by Offering Value

Practitioners share advice on how to help patients recognize the many benefits of silicone hydrogel 1-day lenses.

esearch shows that, if costs were equivalent, 95% of eye care practitioners would choose silicone hydrogel over hydrogel for their 1-day contact lens The Practitioners patients. This obviously demonstrates that doctors recognize the true value Melanie Frogozo of silicone hydrogel 1-day lenses and understand that they can off er more OD, FAAO, FSLS R The Contact Lens oxygen1, healthier2 corneas, and added convenience. However, many doctors struggle Institute of San with how to convey this message to patients without getting hung up on price. Antonio We asked three optometrists who regularly refi t wearers into silicone hydrogel San Antonio, Texas 1-day lenses to share advice on how they move the conversation from price to value. Here, they share their strategies on how to more eff ectively engage wearers, Ethan E. Huisman strengthen the doctor-patient relationship, and overcome perceived cost barriers. OD, FAAO Elite Eye Care West Des Moines, Some doctors are uncomfortable with How do you introduce patients Iowa the transactional nature of making a to silicone hydrogel 1-day contact lenses? contact lens recommendation, which Steve Rosinski makes them hesitant to suggest lens Dr. Huisman: By asking the right OD upgrades. What is your advice for questions, you can get patients to Crozet Eye Care overcoming this hesitation? Charlottesville, identify their needs. For example, ask Virginia patients if they LOVE their contact Dr. Rosinski: Contact lens dispensing lenses. Or, ask what they would change is, by nature, transactional—no matter about their lenses if they could. This what lens you fi t. It’s also important to opens the door and creates connections Research shows that 56% of eye- note that there is value to what we do to the benefi ts of 1-day silicone care professionals view the cost to as doctors. It’s up to us to explain why hydrogel lenses. the patient as the greatest barrier we prescribe certain things. Being honest to the increased adoption of silicone and knowledgeable makes you a doctor, Dr. Rosinski: The reputation I’ve built hydrogel 1-day contact lenses3. not a salesman. Furthermore, it earns with my patients plays a signifi cant How do you overcome price trust and patients will be more likely to role. They expect me to always have barriers in your practice? the newest and greatest products and come back on a regular basis. anticipate that I will tell them about Dr. Rosinski: I fi nd it’s helpful to tell Dr. Frogozo: I believe silicone hydrogel it every year. You don’t need to make patients that the cost disparity has is the healthiest option. In fact, 87% of it complicated; just deliver the facts. dropped dramatically over the years. eye care professionals agree with me I simply explain that silicone hydrogel Plus, they’ll receive rebates. I also that silicone hydrogel material should 1-day contact lenses off er high oxygen, point out that patients won’t have to all-day comfort and great vision for a be the fi rst choice of material for daily spend approximately $100 per year for few cents more per day. disposable lenses. solutions and cases. And, if a lens tears Dr. Frogozo: The patient education in or becomes lost for some reason, they Dr. Huisman: Be confi dent. Steer your my practice focuses on ocular health and are only out a single use 1-day lens. All focus away from cost and focus instead the importance of oxygen transmission. of this combined makes the conversation on the professional service you provide Beyond that, I strive to be frank with my surrounding 1-day much easier. With when you prescribe what you believe is patients. I tell them what I think is best regard to material, patients want to best for the patient’s ocular health. for them and they trust me. know why it is better for their eyes, so

RO0518_CoopervisionS.indd 2 4/30/18 12:18 PM Dr. Huisman: I say, “this is more money, What role does the lens trial process but here is why I’m prescribing it for have in moving patients to silicone you.” While cost is a genuine concern for hydrogel 1-day lenses? Four Steps to many patients, it’s not the doctor’s job to Converting Patients make assumptions about what patients Dr. Huisman: Trials are the tipping point, but I believe in educating patients on to Silicone Hydrogel value or how they choose to spend their money. The doctor’s job is to educate the benefi ts of silicone hydrogel 1-day 1-Day Lenses patients. lenses prior to fi tting them in trial lenses. If a patient is satisfi ed with a less Dr. Frogozo: I agree. The trial is FF1. Ask the patient to expensive lens, is presenting silicone important, but the patient education describe a typical day hydrogel 1-day worthwhile, or might is a more signifi cant driving force in it jeopardize the doctor-patient my practice. I educate up front, so the FF2. Ask the patient to relationship? patient understands why I am selecting describe how the current a particular lens. The trial is secondary— lenses feel. Listen carefully Dr. Huisman: Patients prefer honesty although it is great to hear patients and candor. The greater risk to the for identifi ers such as describe how happy they are with relationship occurs when a patient discomfort, dryness, their new lenses. reduced wearing time, suspects you’re holding something back. Dr. Rosinski: Patients are usually or redness Dr. Rosinski: The greater detriment stems from failure to off er the best willing to try new technology. We just FF3. Propose a better need to do our part by giving them experience and why options to our patients. They should hear it from us fi rst instead of hearing about the opportunity! You may be surprised FF4. Trial a silicone hydrogel new technology online, via social media by how many patients ask to switch 1-day lens or by word-of-mouth. to silicone hydrogel 1-day lenses aft er trialing them. My patients come back Dr. Frogozo: You also jeopardize saying their eyes feel better and they retention if the patient is uncomfortable have better vision. And when this or develops a problem. Silicone hydrogel happens, they start referring more share with them what you know about 1-day lenses help us to keep patients family and friends. silicone hydrogel and how it compares comfortable in their lenses, which is to hydrogel. The key is to believe it good for them and for our practice. yourself and share your honest opinion. My patients trust what I have to say Bring Value into Perspective and take my recommendations seriously. Yours will too. CooperVision’s portfolio of silicone hydrogel 1-day contact lenses off ers a lens for virtually every eye—and every budget. From the breadth of the clariti® Dr. Frogozo: There is not a huge 1 day family to the uncompromising performance of MyDay®, CooperVision cost diff erence. As with many things provides the options needed to meet the demands of almost any patient. that relate to our wellbeing, healthier options can be more cost eff ective in For more information, visit CooperVision.com the long run.

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1 Manufacturer stated oxygen transmissibility values (Dk/t): MyDay® daily disposable (100), clariti® 1 day (86), 1-DAY ACUVUE® MOIST® (25.5), SofLens® daily disposable (24). 2 With higher oxygen permeability than hydrogel materials, silicone hydrogel contact lenses minimize or eliminate hypoxia-related signs and symptoms during lens wear. 3 Cello Health Insight. June 2017. Base: All US ECPs (n=61); US committed SiHy users (n=28); US non-committed SiHy users (n=33) Q203. Q204A/B/C/D. Question text in notes. * With manufacturer’s rebate. $200 rebate applies to patients new to CooperVision contact lenses.. © 2018 CooperVision, Inc. 6047 04/18

RO0518_CoopervisionS.indd 3 4/30/18 12:18 PM 1 CE Credit (COPE APPROVED)

Corneal Ulcers: Sterile But Not Benign Even if they aren’t infectious, these are no laughing matter. In fact, many ocular and systemic conditions might be at play.

By Elizabeth Escobedo, OD, and Nate Lighthizer, OD

onsider this clinical themselves with infectious etiolo- eyelid anatomy, malfunction of the encounter: a patient gies, it’s imperative they be familiar nervous system and many sys- presents to the emergency with the possible causes of each temic conditions, progression and Croom with a red left eye and know how to differentiate be- management can become complex. that has persisted for several days tween the two presentations, as the Here is a look at many common (Figure 1). The patient denies any treatments can be drastically dif- ocular sterile etiologies and how to vision changes or . ferent. This discussion zeroes in on treat them: Slit lamp examination reveals a the different types of non-infectious Marginal keratitis. This is a severely injected temporal bulbar ulcers and reviews their etiologies, type IV hypersensitivity reaction conjunctiva located near an area of presentations and treatments. to bacterial antigens in the pres- corneal thinning and opacifi cation. ence of Staphylococcal blepharitis. Upon questioning regarding the NO BUGS HERE Patients will commonly present clinical history and events leading Cases with a non-infectious etiolo- with red, irritated eyelid margins up to the symptoms, the patient re- gy tend to have variable presenta- that are thickened, with prominent ports minimal pain and denies both tions but often share a few similar blood vessels.1 Anterior segment contact lens wear and any mucus components such as location and examination can also reveal pe- discharge. progression, keeping in mind that ripheral corneal infi ltrates that can This patient has a corneal ulcer, any systemic condition contribut- be unilateral or bilateral and are a condition eye care providers en- ing to the ulceration is being con- found near the limbal area. These counter on a routine basis. Ulcers trolled. Most sterile ulcerations in- infi ltrates are often accompanied are defi ned as tissue loss located volve infi ltration or thinning of the by sectoral conjunctival injection. within the stroma or subepithelial cornea near the limbus and have In cases where the etiology is layers of the cornea and are often an associated injection of either the indeterminate, it is helpful to accompanied by infi ltrates, an bulbar conjunctiva or . ABOUT THE AUTHORS infl ux or migration of white blood This peripheral location is a

cells. The defi nition purposefully critical factor in determining an Dr. Escobedo is a graduate of does not mention whether an ulcer infectious vs. sterile etiology, with a Midwestern University, Arizona College of Optometry and is infectious or sterile—because it peripheral location strongly point- is the current Cornea and can be either. Thus, in cases such ing more toward a sterile cause. Contact Lens Resident at Northeastern State as this, clinicians should always Pain, mucopurulent discharge University (NSU) Oklahoma ask, “Is this condition infectious or and anterior chamber reaction all College of Optometry. sterile?” The fi rst step to answering tend to be much less prominent, Dr. Lighthizer is the assistant this question is to analyze critical or even non-existent, compared dean for clinical care services, director of continuing components such as pain, epithelial with infectious etiologies. In ad- education and chief of both the specialty care clinic and defect, anterior chamber reaction dition, because these ulcerations the electrodiagnostics clinic and location. are commonly associated with at NSU Oklahoma College of While practitioners often concern other conditions, such as irregular Optometry.

24 REVIEW OF CORNEA & CONTACT LENSES | SEPTEMBER/OCTOBER 2018 Severe and chronic cases, es- and switching to a daily disposable pecially those managed with lens should be considered follow- oral antibiotics, should be ing resolution of the acute event. followed more closely with In the event sterility is questionable a tapering over the course and contact lens wear is a contrib- of three to six months, utor, the recommended approach depending on presentation for treatment is a broad-spectrum and the patient’s overall antibiotic to cover for any possible systemic health.1 infectious pathogens. Contact lens-associated Neurotrophic keratopathy. ulcer. A similar presentation This is a rare degenerative corneal is that of a contact lens disease caused by impairment of peripheral sterile infi ltrate, trigeminal innervation, leading to a hypersensitivity reaction corneal epithelial breakdown, im- to bacterial antigens or pairment of healing and develop- chemicals involved in lens ment of corneal ulceration, melting 2 Fig. 1. Peripheral corneal ulceration with care (Figure 2). Infi ltrates and perforation. The hallmark of adjacent bulbar conjunctival injection. can also occur secondary neurotrophic keratitis is decreased to functional changes in the corneal sensitivity, which can result investigate whether the patient has corneal tissue, such as a reduction from acquired damage to the tri- ever been diagnosed with rosacea. in epithelial mitosis and a decrease geminal ganglion, stroke, aneurysm These patients commonly present in the density of terminal nerve or tumor.4 Systemic diseases and with poor eyelid hygiene along endings due to contact lens wear.3 congenital disorders, including with associated facial symptoms Like marginal keratitis, a contact diabetes, multiple sclerosis and such as facial fl ushing and papular lens-associated ulcer presents with Goldenhar syndrome, are also skin lesions.1 peripheral corneal infi ltrates com- associated with neurotrophic ker- Treatment for these patients monly accompanied by sectoral atopathy.5 Ocular conditions that begins with lid scrubs and warm conjunctival injection and minimal can lead to a decrease in corneal compresses to improve lid margin to no epithelial defects. If epithelial sensitivity include herpes simplex, presentation. Antibiotic ointment, defects are present, they tend to be herpes zoster keratitis, chronic use such as erythromycin, can also help much smaller than the underlying of eye drops such as nonsteroidal to reduce the over-proliferation infi ltrate. anti-infl ammatory drugs (NSAIDs) of eyelid bacteria. Patients who With the exception of oral and anesthetics, chemical burns present with corneal involvement antibiotics, treatment is similar to and refractive corneal surgeries. should be prescribed a topical that of marginal keratitis. While The clinical presentation of neu- antibiotic, and possibly a topical the patient is being treated, contact rotrophic keratitis is a persistent, steroid, to reduce infl ammation lens wear should be discontinued, non-healing epithelial defect with and irritation. Due to the chronic nature of rosacea, it is likely these Release Date: September 15, 2018 counts toward your CE requirements for relicensure. patients will experience recurrent Expiration Date: August 16, 2021 episodes of marginal keratitis. Goal Statement: While practitioners often Joint-Sponsorship Statement: This contin uing education course is joint- In these cases, clinicians should concern themselves with infectious etiologies of corneal ulcers, it is imperative they be just sponsored by the Pennsylvania College of consider prescribing oral antibi- as familiar with the possible causes of sterile Optometry. otics, such as doxycycline, to help ulcers and know how to diff erentiate between Disclosure Statement: the two presentations, as the treatments can Authors: Dr. Escobedo has no disclosures. counteract damaging chronic in- diff er drastically. This discussion zeroes in on fl ammation. They should follow up the diff erent types of non-infectious ulcers Dr. Lighthizer is a consultant for and reviews their etiologies, presentations Aerie Pharmaceuticals and Nova Oculus in two to seven days to manage lid and treatments. and has received honoraria from Alcon, Bio- hygiene and corneal presentation Faculty/Editorial Board: Elizabeth Escobedo, Tissue, Diopsys, MacuLogix, Nidek, Optovue, Quantel, Reichert, RevolutionEHR and Shire. for mild to moderate cases. OD, and Nate Lighthizer, OD Credit Statement: This course is COPE Editorial staff : Jack Persico, Rebecca Hepp, Clinicians should also manage approved for 1 hour of continuing education William Kekevian, Catherine Manthorp and intraocular pressure in patients credit. Course ID is 58983-AS. Check with Mark De Leon all have no relationships to who are prescribed topical steroids. your state licensing board to see if this disclose.

REVIEW OF CORNEA & CONTACT LENSES | SEPTEMBER/OCTOBER 2018 25 CORNEAL ULCERS: STERILE BUT NOT BENIGN

heaped-up edges that stains readily and patient symptoms are two key volve heavy lubrication during the with fl uorescein. If progression components that help differentiate day and ointment application at occurs, stromal haze, scarring and the conditions. Unlike neurotroph- night. Taping of the eyelids or the thinning can present and lead to ic keratitis, patients that present use of a patch can be alternatives corneal melting. with will to ointment with a sterile presen- Due to the decrease in corneal be symptomatic of severe dryness, tation. Other viable options for sensitivity, patients often present ocular injection and possibly pain these cases include bandage silicone with few symptoms. The man- depending on the chronicity and hydrogel lenses, scleral contact agement of neurotrophic keratitis severity of the condition. Punctate lenses and temporary tarsorrha- can be complex, depending on the epithelial defects will be noted in phy. Severe and chronic cases that severity. In any case, heavy lubri- the inferior third of the corneal lead to permanent exposure can be cation with artifi cial tears is highly surface and, in severe cases, pan- treated with a permanent tarsor- recommended to improve the nus, sterile ulceration or infectious rhaphy, gold weights or conjuncti- health of the corneal surface. keratitis may occur. Under rare val fl aps. When managing exposure Topical steroid and nonsteroidal circumstances, stromal melting can keratopathy in patients with severe drops should be avoided due to the eventually lead to perforation.1 proptosis, orbital decompression is inhibition of stromal healing and Treatment for these patients is also an option. increased risk of corneal melting.5 based on the severity of the condi- In severe cases with stromal in- tion and expected timeline of re- MORE THAN MEETS THE EYE volvement, collagenase inhibitors, covery.5 In mild to moderate cases, When dealing with a suspected such as tetracyclines and acetylcys- causes of exposure are commonly sterile corneal ulcer, clinicians teine, should be considered. reversible, and treatment can in- should always consider systemic Other possible treatments in- clude therapeutic corneal or scleral contact lenses with consideration The Other Side of the Coin of autologous serum and amniotic Infectious corneal ulcers, better membranes to promote corneal known as infectious keratitis, are healing.4 those that become infi ltrated Exposure keratopathy. This is a by either a bacterial or non- bacterial pathogen (i.e., , result of an unhealthy corneal sur- protozoan or herpes virus). The face and irregular anatomical func- most ubiquitous of all pathogens tion, such as ocular surface dryness is Pseudomonas aeruginosa, secondary to abnormal eyelid covering 60% of contact lens- blinking or incomplete eyelid clo- related keratitis.5 Other common sure.2,5 Possible causes of exposure pathogens include Moraxella, keratopathy include Bell’s palsy or S. pneumonia, S. epidermidis, This suspected Acanthamoeba ulcer Serratia and Klebsiella. Common (based on clinical presentation) has a facial nerve palsy secondary to a central location and a signifi cant symptoms of infectious keratitis surgery of an acoustic neuroma or amount of ulceration. include pain, photophobia, parotid tumor, reduced muscle tone blurred vision and mucopurulent associated with Parkinsonism and or purulent discharge.5 Anterior segment signs tend to present in a severe proptosis due to thyroid eye certain chronological order that can help determine causation. Early disease or orbital tumor. Abnormal stages include an epithelial defect with a large infi ltrate that is often anatomical structural causes can accompanied by stromal edema and anterior uveitis. Severe, chronic include ectropion, nocturnal la- cases can result in rapid progression of infi ltration with an enlarging gophthalmos and tight facial skin hypopyon.5 following or eyelid Early treatment is critical for these patients to prevent aggressive excision of tumors.2 infl ammation and possible perforation. First-line therapy usually consists of a broad-spectrum fl uoroquinolone; however, advanced With similar etiologies, neu- central corneal ulcers suspicious of methicillin-resistant Staphylococcus rotrophic keratitis and exposure aureus will require either fortifi ed tobramycin or vancomycin. Lastly, keratopathy may be diffi cult to depending on the pathogen and severity, some cases may need distinguish without a clear histo- surgical intervention or hospital admission. ry. However, clinical presentation

26 REVIEW OF CORNEA & CONTACT LENSES | SEPTEMBER/OCTOBER 2018 conditions, such as these, as a affects young boys in their fi rst de- potential cause: cade of life, and the sequelae may Peripheral ulcerative keratitis result in permanent visual impair- (PUK). This is a severe peripheral ment.7 These patients have a family corneal infi ltration, ulceration or history of atopic diseases in 49% thinning that cannot be explained of cases and a personal medical by evident ocular disease. These history of other atopic conditions cases should be highly suspicious such as asthma (26.7%), rhinitis for associated collagen vascular (20%) and eczema (9.7%).7 diseases, which account for 50% of Clinical presentation of a shield PUK cases.6 Rheumatoid arthri- Fig. 2. This peripheral infi ltrate is due ulcer is commonly associated with to contact lens wear. tis, which can lead to some of palpebral VKC, which primarily the worst presentations of sterile for the few patients without an involves the upper tarsal conjunc- corneal ulceration, is the most underlying systemic disease who tiva and is characterized by diffuse common associated systemic disor- have an associated marginal or pe- papillae that eventually progresses der, presenting in 34% of noninfec- ripheral ulcerative keratitis. These into giant papillae, greater than tious cases, with 30% of patients patients should be given topical 1mm in size, with mucus discharge having bilateral fi ndings (Figure antibiotics along with education on between the papillae. The close 3).6 Wegener’s granulomatosis is the importance of eyelid hygiene. apposition of the superior con- the second most common associat- Topical corticosteroids can also be junctival papillae to the corneal ed systemic condition and almost prescribed and tapered based on epithelium results in corneal sur- always presents with scleritis.6 Less clinical response.6 face disease, including shield ulcers common systemic conditions that Systemic corticosteroids are the and Trantas’ dots, an aggregate of can lead to PUK include relapsing traditional fi rst-line therapy for epithelial cells and eosinophils at polychondritis and systemic lupus acute PUK and are often accompa- the limbus. VKC generally sub- erythematosus. nied by an immunosuppressant due sides with the onset of puberty, but PUK presents clinically with a to their inability to inhibit disease some therapeutic measures may be crescent ulceration and stromal progression or overcome the sys- required beyond this age to control infi ltration located at the limbus temic autoimmune disease.6 the course of the disease.7 and is commonly associated with Surgical treatment options Treatment options begin with a or scleritis. Chronic include the use of a tissue adhesive, prophylactic approach for season- cases of PUK can spread centrally bandage contact lens, lamellar al atopic conditions and extend on the cornea and extend into the graft, tectonic corneal grafting and into surgical procedures for more sclera. The depth of peripheral amniotic membrane transplant.6 devastating cases involving sterile corneal thinning is variable, with Despite the improvements that ulceration. Prophylactic measures severe cases leading to perforation, have been made in cytotoxic thera- include patients becoming aware with or without trauma.6 py, studies show ulcerative keratitis of their vulnerability, commonly by The goal of treatment for these has the highest likelihood of a an allergy specialist, and avoiding patients is to reduce ocular in- regraft.6 Overall, controlling ocular the triggering allergen to reduce the fl ammation, promote epithelial infl ammation is critical in these pa- chances of infl ammation. Common healing and minimize stromal loss. tients, but making sure the under- triggers include sun, dust, wind Unfortunately, unless the associat- lying systemic disease is controlled and other general environmental ed systemic disease is appropriately can be life saving. Due to potential factors.7 managed, treatment results are not side effects from the use of cortico- In these cases, cold compresses promising.6 In Wegener’s, coman- steroids and immunosuppressants, and proper lid hygiene are recom- agement with a rheumatologist is it is important to follow up with mended to help with symptoms indicated to manage a potentially these patients regularly and stay up of irritation and signs of possible life-threatening systemic vasculitis. to date with lab testing.6 Staphylococcal hypersensitivity, Treatment for PUK can be Shield ulcer. This is a sterile respectively. Topical antihista- further broken down into local, corneal ulceration found in patients mines are commonly used in acute systemic and surgical options. with vernal keratoconjunctivitis episodes but are less effective when Solely local treatments are reserved (VKC). The condition mainly used alone during chronic disease.

REVIEW OF CORNEA & CONTACT LENSES | SEPTEMBER/OCTOBER 2018 27 CORNEAL ULCERS: STERILE BUT NOT BENIGN

Mast-cell stabilizers are frequently autoimmune component and possi- should comanage with the patient’s used in combination with NSAIDs bly be associated with environmen- primary care physician to make for the long-term.5 Topical ste- tal factors of corneal insult such as sure any underlying systemic con- roids are considered when a quick surgery, trauma or infection. The ditions are being addressed. tapering is expected and are often disease may present itself unilater- prescribed in heavy doses, with the ally or bilaterally. It is rare in the ain, photophobia and discharge possibility of a supratarsal ste- northern hemisphere but common Pare common signs and symp- roid injection in cases with severe in the southern hemisphere and toms a patient mentions when they palpebral disease. Immune mod- other geographical locations such present with a corneal ulcer. While ulators, such as cyclosporine and as China, Africa and India.8 infectious causes are often the tacrolimus, are viable options for Clinically, Mooren’s ulcer is focus of discussion, sterile ulcers high-risk steroid patients.5 characterized by a progressive come with their own concerns Surgical treatments such as circumferential peripheral stromal worth understanding—as the right superfi cial keratectomy are con- ulceration, which has the poten- treatment depends on it. A widely sidered for the removal of plaques tial to spread centrally. There are agreed upon treatment approach or the debridement of a corneal two types of presentations, with with an unknown etiology is a ulcer. Furthermore, patients being the fi rst being unilateral and more broad-spectrum antibiotic, such treated with topical steroids should benign. It predominantly affects as a fl uoroquinolone, to cov- be strictly monitored due to the the elderly and responds well to er for severe pathogens such as incidence of glaucoma in VKC pa- treatment. The second type is Pseudomonas. However, treatment tients (2%). Once the acute phase more aggressive, predominantly must be far more tailored to ensure runs its course, steroids should be affects young males, has a bilat- successful resolution. discontinued and replaced with eral presentation and does not Once an infectious etiology has alternatives such as mast-cell stabi- respond well to medical therapy. been eliminated due to a lack of lizers, antihistamines or NSAIDs.7 Vascularization of the stromal bed common fi ndings such as mucus Patients with VKC generally can also be present in terminal discharge, anterior chamber reac- have spontaneous resolution of the stages of the condition and eventu- tion and contact lens wear, clini- disease after puberty without any ally leads to scarring as the cornea cians should then consider the pos- further symptoms or visual compli- begins to heal.5 Mooren’s ulcer is a sibility of an associated systemic cations. However, corneal ulcers, diagnosis of exclusion and is often condition and other ocular surface which are reported to develop in diagnosed once other etiologies, diseases, as both are common with 9.7% of patients, can produce a such as PUK, have been eliminated. a sterile ulcer. Knowing the etiolo- permanent visual impairment.7 Topical treatments for Mooren’s gies of sterile ulcers will guide the Mooren’s ulcer. Unfortunately, ulcer include combinations of clinician through potential treat- clinicians may sometimes encoun- steroids, antibiotics, artifi cial tears ment options, both systemic and ter a case in which etiology is and, in some cases, collagenase topical, to best care for each and controversial or indeterminate, as inhibitors such as acetylcysteine. every patient. RCCL is often the case with this presenta- Unfortunately, for those within the 1. Bagheri N, Wajda B, Calvo C, Durrani A. The tion. Mooren’s ulcer is a rare, idio- second group, visual prognosis is Wills Eye Manual: Offi ce and Emergency Room pathic disease thought to have an poor, even with treatment. Diagnosis and Treatment of Eye Disease. 8th ed. Philadelphia: Wolters Kluwer; 2016. Systemic therapy includes im- 2. Rapuano CJ. The Wills Eye Institute: Cornea. 2nd munosuppressants and collagenase ed. Philadelphia: Wolters Kluwer; 2012:30-231. 3. Ammer R. Eff ect of contact lens wear on cornea. inhibitors such as doxycycline. J Ophthalmol. 2016. 32(4):216-20. Surgical options include conjuncti- 4. Sacchetti M, Lambiase A. Diagnosis and man- agement of neurotrophic keratitis. Clin Ophthal- val resection and lamellar keratec- mol. 2014;8:571. tomy, as well as penetrating kera- 5. Kanski JJ, Bowling B. Clinical Ophthalmology: A Systemic Approach. 7th ed. Edinburgh: Elsevier; toplasty. Post-surgical intervention 2012. includes vision rehabilitation once 6. Yagci A. Update on peripheral ulcerative kerati- tis. Clin Ophthalmol. 2012;6:747. 5 infl ammation has settled. During 7. Bonini S, Coassin M, Aronni S, Lambiase A. Ver- follow-up exams, these patients nal keratoconjunctivitis. Eye. 2004;18(4): 345. 8. Yang L, Xiao J, Wang J, Zhang H. Clinical char- Fig. 3. Stable PUK in a long-standing should be monitored for second- acteristics and risk factors of recurrent Mooren’s RA patient. ary infections. Eye care providers ulcer. J Ophthalmol. 2017;2017:8978527.

28 REVIEW OF CORNEA & CONTACT LENSES | SEPTEMBER/OCTOBER 2018 CE TEST ~ SEPTEMBER 2018 EXAMINATION ANSWER SHEET

1. Which of these is the etiology of marginal keratitis? Corneal Ulcers: Sterile But Not Benign a. Type I hypersensitivity. Valid for credit through August 16, 2021 b. Chemical burns and trauma. Online: This exam can also be taken online at www.reviewofoptometry.com/ce. Upon passing the exam, you can view your results immediately. You can also view c. Type IV hypersensitivity. your test history at any time from the website. d. Rheumatoid arthritis. Directions: Select one answer for each question in the exam and completely darken 2. Which of the following is not a management option for a contact the appropriate circle. A minimum score of 70% is required to earn credit. lens-related infi ltrate? Mail to: Jobson Medical Information, Dept.: Optometric CE, 440 9th Avenue, 14th Floor, New York, NY 10001. a. Fit patient in a lower oxygen permeable lens. Payment: Remit $20 with this exam. Make check payable to Jobson Medical b. Discontinue lens wear. Information LLC. c. Prescribe a broad-spectrum antibiotic when suspicious for an Credit: This lesson is approved for 1 hour of CE credit. Course ID is 58983-AS. infection. Sponsorship: Joint-sponsored by the Pennsylvania College of Optometry d. Switch patient into a daily lens. Processing: There is an four-week processing time for this exam. 3. What is the most common pathogen responsible for infectious Answers to CE exam: keratitis in contact lens wearers? 4. A B C D 8. A B C D

a. S. epidermidis. 1. A B C D 5. A B C D 9. A B C D b. Klebsiella. 2. A B C D 6. A B C D 10. A B C D c. Pseudomonas. 3. A B C D 7. A B C D d. Moraxella. Post-activity evaluation questions: Rate how well the activity supported your achievement of these learning objectives: 4. Which of the following is not a clinical sign of vernal keratoconjunctivitis (VKC)? 1=Poor, 2=Fair, 3=Neutral, 4=Good, 5=Excellent 11. Better understand how to differentiate between infectious a. Shield ulcer. 1 2 3 4 5 and sterile corneal ulcers. b. Trantas’ dots. 12. Improve my knowledge of the common ocular etiologies of c. Giant papillae. sterile ulcers. 1 2 3 4 5 d. Pseudodendrites. 13. Increase my diagnostic acumen for systemic etiologies of sterile ulcers. 1 2 3 4 5 5. Which of the following statements is true regarding Mooren’s ulcer? 14. Better recognize the common presentations of corneal a. It is more common in the northern hemisphere. sterile ulcers. 1 2 3 4 5 b. The second type is more severe and commonly aff ects young 15. Increase my knowledge of the treatment approaches for 1 2 3 4 5 males. each sterile etiology. c. The second type responds well to treatment. 16. Increase my ability to properly manage sterile corneal ulcers, regardless of etiology. 1 2 3 4 5 d. There is no systemic condition associated with Mooren’s ulcer. 6. Which of the following is not a surgical treatment option for PUK? Rate the quality of the material provided: a. Amniotic membrane transplant. 1=Strongly disagree, 2=Somewhat disagree, 3=Neutral, 4=Somewhat agree, 5=Strongly agree

b. Bandage contact lens. 17. The content was evidence-based. 1 2 3 4 5

c. Corneal collagen crosslinking. 18. The content was balanced and free of bias. 1 2 3 4 5

d. Corneal lamellar graft. 19. The presentation was clear and effective. 1 2 3 4 5 7. Exposure keratopathy is a result of: 20. Additional comments on this course: a. Facial nerve palsy. b. Severe proptosis. c. Reduced muscle tone. Identifying information (please print clearly): d. All of the above. First Name 8. What percentage of VKC patients develop glaucoma? Last Name a. 10%. Email b. 15%. The following is your: Home Address Business Address c. 2%. Business Name d. 5%. Address 9. What percentage of noninfectious PUK cases is associated with RA? City State a. 50%. ZIP b. 70%. Telephone # - - c. 62%. Fax # - - d. 34%.

10. Which of the following is the hallmark of neurotrophic keratitis? By submitting this answer sheet, I certify that I have read the lesson in its entirety and completed the self-assessment exam personally based on the material presented. I have a. Corneal perforation. not obtained the answers to this exam by fraudulent or improper means. b. Corneal melting. c. Decrease in corneal sensation. Signature: ______Date: ______d. Corneal ulceration. Please retain a copy for your records. LESSON 117046, RO-RCCL-0918

REVIEW OF CORNEA & CONTACT LENSES | SEPTEMBER/OCTOBER 2018 29 FIGHTING CORNEAL INFECTIONS WITH CXL: A NEW ALLY?

Evaluate the strengths and weaknesses of this newfound application before considering it an alternative treatment for keratitis.

By Aaron Bronner, OD

orneal infections con- THE HYPE specifi c pathogen, as all ulcers are tinue to trouble patients PACK-CXL follows the same general going to benefi t from increased tec- of all ages and lifestyles protocol as crosslinking for kerato- tonics, and all free-living pathogens Cworldwide. Infectious conus. The cornea is saturated with (i.e., non-viral), in theory, would be keratitis occurs in 20 to 50 people ribofl avin, a UVA source of 365µm is susceptible to the massive quanti- per 100,000 in the United States, applied to the cornea for a period of ties of ROS. One meta-analysis of and the risk increases following any time and then the patient recovers at the available literature shows good compromise to the corneal epitheli- home. More so than with traditional susceptibility to the ROS across bac- um.1 These infections resist conven- crosslinking, the exact protocol for terial, fungal and protozoan sources tional therapies and can be diffi cult PACK-CXL varies from center to of corneal infection. In this analysis, to differentiate clinically, adding to center and relies on surgeon prefer- 85.7% of bacterial keratitis cases, the challenges posed by this already ences, fl uences of the UV lamp and 91.7% of Acanthamoeba cases and sight-threatening group of patholo- the exact topical ribofl avin concen- 78.1% of fungal cases healed.3 Both gies. If you were to create an ideal tration. Case-dependent features such cases of herpes simplex virus (HSV) treatment for corneal ulcers, you’d as ulcer depth and degree of thinning keratitis in this review went on to probably want something like this: also play a part. melt and required a therapeutic ker- • The treatment should be safe to Regardless of the precise protocol, atoplasty, so PACK-CXL is probably the patient’s own tissue. the mixture of UV radiation, ribo- best avoided in HSV cases.3 • Its effi cacy should cover a broad fl avin and oxygen creates reactive Ignoring the terrible outcomes spectrum of pathogens, eliminating oxygen species (ROS). In conven- reported with HSV, this review the need to differentiate clinically or tional crosslinking, these ROS lead indicates that PACK-CXL actually with cultures prior to treating. to the activation of the lysyl oxidase has a broad spectrum of activity that • The treatment’s dosage should pathway and the development of isn’t affected by the pathogenic group allow patients to have a relatively “crosslinks.” This activation also (fungal, Acanthamoeba or bacte- normal schedule compared with takes place with PACK-CXL, and rial) or its antimicrobial resistance hourly, or more frequent, administra- the result is a stiffer cornea.2-4 This profi le, meaning, it should work on tion of topical antimicrobials. bolsters it against proteolytic melts methicillin-resistant Staphylococcus • Cost should be affordable to al- common with infectious keratitis. aureus (MRSA) just as effective- low use as needed, without worry of The “photo-activated ribofl avin” ly as on Methicillin-susceptible reimbursement or patient fi nances. in PACK-CXL disrupts base pairing Staphylococcus aureus (MSSA). On paper, corneal collagen cross- of both pathogenic RNA and DNA, These attributes and strengths could linking (CXL) for microbial keratitis, thereby inhibiting replication. In present a signifi cant benefi t to the a treatment known as photo-activat- addition, oxidative destruction of clinician who, in theory, would ed chromophore for infectious kera- the pathogen occurs via the ROS.2-4 ABOUT THE AUTHOR titis (PACK-CXL), checks all of these PACK-CXL therefore theoretically boxes. In application, PACK-CXL, kills the pathogen, blocks its repli- Dr. Bronner is a staff vaguely recognized by optometry cation and makes the cornea more optometrist at Pacifi c Cataract and Laser as a treatment option for infectious resistant to further tissue destruction. Institute in Kennewick, keratitis, has several limitations that In addition, effectiveness of PACK- WA. stymie its widespread use. CXL should be independent of the

30 REVIEW OF CORNEA & CONTACT LENSES | SEPTEMBER/OCTOBER 2018 Photo: Joseph W. Sowka, OD, and Alan G. Kabat, OD widely available. For most of the keratitis, corticosteroids aren’t used world, PACK-CXL as a standalone in studies on PACK-CXL, which may therapy would represent a signifi - have led to unnecessary, untreated cant improvement in average cost of exacerbations of sterile infl ammatory therapy compared with conventional problems. In fact, one large study treatment. In fact, Farhad Hafezi, found a transient increase in the size MD, past chair of Ophthalmology at of hypopyon following PACK-CXL University of Geneva and a prima- in some patients, likely indicating not ry proponent of PACK-CXL, has a worsening of infectious infl amma- pointed out that the benefi t of CXL tion but a sterile infl ammation.2 as a treatment for infectious keratitis Effi cacy. While most research of to impoverished parts of the world is PACK-CXL has been positive for the PACK-CXL may be more successful for potentially greater than CXL’s global most part, there are some important early corneal ulcers such as this, rather than more severe presentations. benefi t in treating . holes in the research. Probably most important for understanding reports no longer be required to accurate- THE REALITY of the procedure’s effi cacy is that the ly differentiate based on clinical On a cursory review and ignoring majority of available research has not features or culture results. As an the details, PACK-CXL seems like an directly compared PACK-CXL with effective one-size-fi ts-all treatment, amazing treatment option that could conventional topical antimicrobial PACK-CXL could possibly take the address nearly all of the shortcom- treatment. Instead, the bulk of the re- guesswork out of selecting the initial ings and headaches associated with search compares the combination of management. modern antimicrobial regimens for PACK-CXL plus antimicrobials with If PACK-CXL were effective as a corneal infections. But as is often the topical antimicrobials alone. In one standalone treatment, patients could case, the devil is in the details, and large meta-analysis, only 16 of the avoid the need to adhere to the chal- signifi cant limitations exist with what 175 eyes received PACK-CXL alone; lenging drop regimen characteristic exactly the research of PACK-CXL all others continued with combined of microbial treatment. Regimens is suggesting in regards to effi cacy, typical antimicrobials and PACK- that require some level of continuous protocol and practical hurdles prac- CXL.3 With this in mind, the most therapy are standard in the early titioners face—all of which may be we can say about these eyes is the ad- management of microbial keratitis barriers to its widespread use. dition of PACK-CXL to conventional and can stretch on for several weeks. Protocol. There has been little therapy did not worsen outcomes In all cases, those treatments create formal standardization of the actual compared with conventional therapy a signifi cant burden to the patient treatment protocol of the PACK- alone. This is starkly different than regarding both quality of life and CXL procedure. “Dresden protocol” suggesting that PACK-CXL alone is compliance. If a single in-offi ce CXL (UVA fl uence of 3mW/mm2 equivalent to conventional therapy. treatment with PACK-CXL could for 30 minutes) has been the most So if a center uses PACK-CXL, the eliminate or at least reduce the fre- common published approach, but patient should still expect to use quency of topical antimicrobial use, others have advocated for accelerated topical antimicrobials (with all the it would present a tangible benefi t to treatments with greater fl uences, as associated cost and inconvenience),

the patient management. well as longer treatments Photo: Christine W. Sindt, OD The potential to reduce or elimi- with standard fl uences but nate an extensive eye drop regimen a lower concentration of is the theoretic impact on cost. ribofl avin.3 The postopera- Treatments often take several weeks, tive course for PACK-CXL and occasionally months, with fre- has also yet to be defi ned quent follow-up. In addition to cost as well. Clinicians often use of clinic care, the expense of conven- corticosteroids in the early tional antimicrobial treatment can postoperative period with be high and, in certain parts of the conventional CXL to con- world, cost prohibitive. For PACK- trol infl ammation, but given CXL, on the other hand, ribofl avin their potentially confound- While research suggests good effi cacy for AK, is inexpensive and UV lamps are ing effects on microbial seen here, animal studies are less promising.

REVIEW OF CORNEA & CONTACT LENSES | SEPTEMBER/OCTOBER 2018 31 FIGHTING CORNEAL INFECTIONS WITH CXL: A NEW ALLY?

selection of appropriate antimicro- CXL was halted due to an increasing resistance) and lesser activity against bials is still important, and clinical- rate of perforation in the treatment fungus and AK makes it not a one- and culture-based differentiation of arm.6 In addition, we also know that size-fi ts-all treatment, but perhaps the infectious etiologies is still necessary. fungal keratitis treated with PACK- next best thing. That said, it is not Obviously, this reduces some of the CXL is less likely to resolve than currently advocated as a replacement appeal of PACK-CXL. bacterial keratitis.3 of conventional therapy but as an Further, the available research on For Acanthamoeba keratitis (AK), adjunct treatment. Further, the exact PACK-CXL seems to suggest that the 10 out of 11 successfully treated place of PACK-CXL in the therapeu- the procedure works best with early eyes mentioned in the meta-analysis tic paradigm is hard to pin down. superfi cial ulcers that are bacteri- contradict animal studies of the dis- The procedure seems to perform al in nature and works poorly in ease. One rabbit study of AK marked better with early ulcers, making it severe ulcers, most particularly with worsening of keratitis after CXL more of a fi rst-line therapy. However, those that are fungal in nature—not with ribofl avin and UVA compared its cost, off-label and experimental surprising given the expected depth with those that did not receive treat- status and poorly defi ned protocol all of treatment with conventional CXL. ment.6 These discrepancies between serve to undermine its use as a fi rst- One article makes a compelling clinical- and lab-based research line treatment. As costs come down argument about the expected effi cacy should give pause to those widely and the protocol becomes more of PACK-CXL being relative to the embracing the procedure for these defi ned, this may change. Currently, depth of the ulcer. Pointing to previ- more uncommon forms of keratitis. however, the dissemination of PACK- ously determined depth of irradiance Practice hurdles. In the US, the CXL in the United States will prob- studies, the authors remind clinicians only FDA-approved platform for ably remain a secondary treatment that 50% of irradiance is absorbed crosslinking is the Avedro KXL option, likely to the detriment of its in the anterior 100µm of the cor- System with Photrexa ribofl avin effectiveness. RCCL nea, 25% in the second 100µm and drops. While PACK-CXL is an 1. Pepose J, Wilhelmus K. Divergent approaches to the remaining 25% irradiates the off-label application of the device, the management of corneal ulcers. Am J Ophthal- remaining cornea at increasingly low most US centers offering CXL use mol. 1992;114:630-2. 2.Said DG, Elalfy MS, Gatzioufas Z, et al. Collagen levels, and it could be expected that the Avedro system. Recently, the cross-linking with photoactivated ribofl avin (PACK- CXL) for the treatment of advanced infectious dense ulcers may reduce the pene- cost of Photrexa drops has increased keratitis with corneal melting. Ophthalmology. trance of UV energy even further.2 signifi cantly, a material cost to a 2014;121:1377-82. 3. Papaioannou L. Corneal collagen cross-linking The authors note that the procedure center that is then passed on to the for infectious keratitis: a systemic review and meta could produce better results for early patient. Because of this, PACK-CXL, analysis. Cornea. 2015;0:1-10. 4.Price MO, Price FW. Corneal cross-linking in the and anterior ulcers and worse results in the United States at least, is almost treatment of corneal ulcers. Curr Opin Ophthalmol. with increasing depth of involve- certainly not going to offer a cost 2015;26:1-6. 5. Uddaraja M, Mascarenhas J, Das MR, et al. Corneal ment. This concept corresponds with savings compared with conventional cross-linking as an adjuvant therapy in the manage- ment of recalcitrant deep stromal fungal keratitis: a results of other studies that suggest antimicrobials. However, with the randomized trial. Am J Ophthalmol. 2015;160:131-4. the procedure’s effi cacy diminishes availability of lower-cost systems 7. Berra M, Galperín G, Boscaro G, et al. Treat6ent 3,5 of Acanthamoeba keratitis by corneal cross-linking. with increasingly severe ulcers. across the , PACK-CXL still Cornea. 2013;32:174-8.

Compounding its greater effi cacy may offer savings in other Photo: Christine W. Sindt, OD with superfi cial ulcers is the fact countries. that it seems to perform different- ly among pathogen groups. For THE VERDICT bacterial sources, most agree that Based on the current PACK-CXL produces a bacteriocidal research, PACK-CXL and bacteriostatic effect.2-4 This con- might fi t in nicely to the cept supports the clinical outcomes therapeutic algorithm seen with PACK-CXL for bacterial for microbial keratitis keratitis. For fungal keratitis, both treatment in well-chosen lab and animal models appear split cases (namely, superfi cial on UVA+ribofl avin producing any bacterial ulcers). Its effi ca- antifungal effect, and it is worth cy and wide spectrum of noting that a study of eyes with deep activity against bacteria PACK-CXL is least eff ective for severe cases of fungal keratitis treated with PACK- (regardless of antibiotic fungal keratitis, seen here secondary to Fusarium.

32 REVIEW OF CORNEA & CONTACT LENSES | SEPTEMBER/OCTOBER 2018 Take the Anxiety out of Specialty Lens Fittings

Smarter clinical strategies and useful new technologies help ensure a smoother process.

By Clark Chang, OD, and Jeff rey Sonsino, OD

ven though soft contact lenses are heavily infl uenced by MEASURE THE VAULT lenses dominate the market, the corneo-conjunctival junction 1 The long-term objectives of a gas permeable (GP) lenses angle and scleral shape profi le. contact lens fi t are to meet meta- Eremain essential for many Consequently, if a scleral GP cannot bolic requirements of the corneal patients, providing superior optics, be customized to align with these tissue and reduce hypoxic risks. durability, higher oxygen transmis- anatomical features, fi tting- and Compared with the vaulting abilities sibility and a lower propensity for vision-related adverse reactions may of corneal-fi t GP lenses and soft surface deposits and microbial inoc- develop.6 To make matters worse, lenses, a scleral lens’s ability to vault ulations within the GP lens matrix. slit lamp fi ndings alone do not usu- over the cornea helps avoid epithe- Modern specialty lenses, especially ally offer suffi cient clinical clues for lial trauma and, in turn, improves scleral-fi t GP lenses, offer better out- clinicians who are looking to take comfort. Vaulting also allows the come expectations for patients with advantage of the latest lens customi- accumulation of tears to neutralize a wide range of visual and clinical zation concepts. anterior corneal toricity and irreg- needs—from optical rehabilitation Fortunately, numerous technolo- ularities. The vaulting distance of a in patients with corneal irregular- gies are available to help overcome scleral lens, however, may act as a ities to therapeutic protection in some of these challenges and deliver pathway that resists effi cient oxygen patients with dry eye and other optimal results. This article walks permeation. Researchers tend to ocular surface diseases.1,2 As such, through fi ve key steps clinicians agree that long-term monitoring global clinical trends demonstrate should take to successfully complete and using lens materials with high a growing rate of GP contact lens a specialty contact lens fi tting and oxygen permeability (>100 Dk/l) use.3-5 This fi nding especially holds explains how several newer diag- true for scleral lenses specifi cally.3-5 nostic instruments can be clinically ABOUT THE AUTHORS While specialty lenses are be- helpful for novices and veterans Dr. Chang is the Director of Cornea Specialty Lenses coming more popular, fi tting them alike. at Wills Eye Hospital can sometimes intimidate clinicians Strictly speaking, you do not need and the Director of Clinical Services at TLC who are less familiar with custom any of these devices to be successful Vision. He is also the designs. This is primarily due to with scleral lenses in a number of host of a new podcast series called “Chang the perceived extensive chair time routine cases. But these tools will Reaction.” and potential patient discomfort help you solve problems, save time Dr. Sonsino is a partner in with corneal GP lenses. However, and fi ne-tune results to give each a specialty contact lens as corneal GP technology advances, patient the most customized experi- and anterior segment practice in Nashville, new lens designs—like the design of ence possible. An important mark of Tenn. He is a diplomate a scleral lens, for example—make it expertise in all contact lens spe- of the Cornea and Contact Lens section possible to improve initial lens com- cialists is whether they use the best of the American Academy of Optometry and fort and reduce adaptation time. available tools of the trade and stay the past chairman of the Cornea and The on-eye position and associ- both well equipped and well versed Contact Lens section of the American ated fi tting characteristics of scleral in their product knowledge. Optometric Association.

REVIEW OF CORNEA & CONTACT LENSES | SEPTEMBER/OCTOBER 2018 33 TAKE THE ANXIETY OUT OF SPECIALTY LENS FITTINGS

guideline, this proposed fi tting condi- lens fi tting relationship by grading tion might be the most challenging to vasculatures within selected areas fulfi ll. This is largely due to the vari- under the haptic zone, which may ability in tear lens measurement via further aid clinicians in deciding slit lamp biomicroscopy. Research whether to incorporate customizable shows that a variance of up to features, such as a back-toric haptic 207µm may occur when estimating (Figure 2). scleral lens vault using a slit lamp.11 Thus, if clinicians are expected to PERFECT THE DESIGN follow the 200µm clearance sug- 2 Even with a history of corneal gestion but must rely on slit lamp GP non-adaptation, most patients observations to guide vaulting modi- can still comfortably wear modern fi cations, patients may be exposed to hybrid lenses and scleral lenses. undue risk of hypoxia. When patients present with a histo- A more precise and objective ry of contact lens failure, clinicians

method of measuring corneal vault Image: John Gelles, OD is anterior segment optical coherence tomography (AS-OCT). The technol- ogy’s caliper tool is accurate within 6µm, offering more precise clearance data in multiple locations under scleral lenses and other specialty lenses (Figure 1). Nonetheless, this Fig. 1. This hybrid lens shows a mild technology comes with limitations; amount of corneal clearance (41μm). it assumes the measurement path The patient needs an increased lens vault to properly compensate for the travels from the refractive indices of lens settling throughout the day. air to cornea and does not currently account for the additional medium are prudent practices when fi tting of contact lens material. Despite this, scleral GP lenses.7-10 AS-OCT is still substantially more A team of researchers sug- accurate and repeatable than slit gests three clinical criteria must be lamp biomicroscopy. checked off to achieve maximum ox- If you do not currently have access ygenation under a scleral lens: (1) the to AS-OCT, new software that lens must be constructed from a ma- analyzes the ocular surface—AOS terial with the highest Dk available, (Advanced Ophthalmic Systems)— (2) it must have a maximum center may be worth pursuing as a cheaper thickness of 250µm and (3) it must alternative. While validation between be fi t with no more than 200µm of AS-OCT and AOS measurements clearance.7 Perhaps surprisingly, the is currently limited, this Windows- third criterion appears to have the based technology can analyze and largest clinical signifi cance; another enhance any digital image, whether it group of researchers also concludes originates from an anterior segment Fig. 2. The ruler function in the AOS that tear vault has a bigger impact camera or a smartphone. software calibrates itself by using the on corneal oxygen tension than lens This software package has various known lens center thickness value (i.e., 350μm) and then calculates 9 Dk. To support previous fi ndings, clinical grading scales for con- the corneal clearance and thickness a follow-up study demonstrates that junctival redness, vascular status, as shown on the imported digital corneal oxygenation levels drop by punctate epitheliopathy and more. It image (top). After an OCT image as much as 30% when scleral vault also includes a specialty lens-fi tting of the same patient is uploaded to the software, the calibrated ruler 10 increases from 200µm to 400µm. module that measures scleral lens function yields nearly identical Despite the clinical importance of clearance. Additionally, this software measurements for corneal clearance the recommended 200µm clearance indirectly assesses the peripheral and thickness (bottom).

34 REVIEW OF CORNEA & CONTACT LENSES | SEPTEMBER/OCTOBER 2018 typically place more emphasis on drical over-refrac- lens comfort than sight. For exam- tion fi ndings are ple, a patient with severe keratoco- clinically signifi - nus but relatively clear corneas and cant, incorporating otherwise normal ocular fi ndings front-toric optics may be conditioned by their doctor into a lens with to be content with a visual outcome toric haptics will of 20/40, provided their lenses are promote rotational comfortable. Fortunately, tech- stability, yielding a nologies are available to help give higher success rate. patients comfort and optimal vision. Optical com- Despite improved fi tting success plexities can vary with today’s hybrid lenses and depending on sclerals, anatomical variations in the individual case Fig. 3. In this wavefront over-refraction performed on a severe keratoconus patient who wears scleral lenses, the corneo-conjunctival junction angle presentations, and 3mm measurement zone shows a -3.00D residual and the scleral profi le often affect some patients may cylinder OD and a -5.25D residual cylinder OS. the scleral lens fi tting and visual continue to suffer outcome. As a result, scleral lenses from compromised tion. To combat this major barrier, may cause misalignment between visual function. A study suggests that clinicians must perfectly match the visual axis and the optical the clinical benefi ts of modifying the scleral lens profi les, limbal transition center, inducing lens instability and front surface eccentricity of scleral angles and conjunctiva-sclera angles producing unintended higher-order lenses to 0.6 or 0.8 are analogous in all meridians. aberrations (HOAs)—all of which to adding wavefront-guided optics, This is where a corneo-scleral can lead to unsatisfactory visual whereby improvements in both high- topographer comes in handy. It performances. Modern scleral lenses, and low-contrast visual acuity can be can capture circumferential ocular however, have design-specifi c angu- observed.13 Thus, it is worth inquir- surface elevation data at a speci- lar geometry built into the transition ing about this new customization fi ed chord diameter and guide the zone—new scleral lens designs tend feature with lab consultants. manufacturing process to produce to use a transition zone that assumes the appropriate amount of haptic a tangential angular profi le—which FINESSE THE FIT toricity and the desired total lens increase fi tting stability because the 3 A recent study demonstrates sagittal depth. In addition, new scleral lens is able to better align that most eyes have some level of software can compute the height and with the anatomy of the corneo-con- scleral asymmetry or irregularity.6 size of a lesion, such as a , junctival junction. Using a corneo-scleral topographer and create a focalized vaulting area Recent studies show that scleral to scan ocular surfaces at 16mm under the scleral lens to best match lenses become increasingly rota- diameters—a commonly used scleral the ocular surface profi le.14 This tionally asymmetrical as the chord lens diameter length—researchers software can greatly reduce the chair diameter on the ocular surface wid- found that only 5.7% and 28.6% of time traditionally associated with ens. Thus, incorporating back-toric evaluated eyes had scleral profi les re- designing a scleral lens notch. in the haptic zone may improve both sembling spherical and regular toric comfort and stability.6,12 To make shapes, respectively.6 These fi ndings SHARPEN THE OPTICS the process easier, some scleral lens imply that, when using a 16mm 4 The customization strategies technologies can develop different mini-scleral lens, haptic misalign- discussed thus far help enhance haptic angles for right and left eyes ment could potentially be observed specialty lens fi tting outcomes. Some in diagnostic sets. in up to 71.4% of eyes even if a patients, however, will continue If the patient’s vision remains standard toric haptic design is used. to experience reduced vision due below clinical expectations, even Misaligned scleral lens haptics to the presence of residual HOAs. with enhanced centration and may lead to discomfort, air bubble Therefore, measuring these HOAs stability through the use of toric hap- formation and debris trapped in the will assist you in fi nding ways to tics, clinicians can perform a toric lens reservoir. Signifi cant debris en- address continued visual challenges. over-refraction to see if better visual trapment can result in visual fogging, To account for the optical summa- acuity is attainable. If spherocylin- which drastically decreases satisfac- tion of both anterior and posterior

REVIEW OF CORNEA & CONTACT LENSES | SEPTEMBER/OCTOBER 2018 35 TAKE THE ANXIETY OUT OF SPECIALTY LENS FITTINGS

corneal profi les, diagnostic instru- aberrometer, an , a Thus, capturing HOA data will ments capable of registering corneal Scheimpfl ug-enabled corneal to- help guide the process of designing data points beyond anterior corneal mographer, an optical pachymeter specialty contact lenses for your shape can further elucidate sources and a non-contact tonometer. This more challenging patients. As lab of visual disturbance. Scheimpfl ug single instrument allows clinicians manufacturers further refi ne their imaging devices, such as the to visualize the differential spatial own proprietary algorithms, patients Pentacam (Oculus), can analyze arrangements between the anterior will continue to benefi t from the use anterior and posterior corneal pro- and posterior cornea and provides of these advanced technologies. fi les through a rotating mirror that a wavefront over-refraction to help travels in an arc around the eye and guide contact lens modifi cations KEEP IN TOUCH produces a 3D biometry of the eye. (Figure 3). 5 Constructing the perfect spe- Many will fi nd that accounting In some cases, clinicians can cialty lens for each patient requires for posterior corneal contributions is compensate for residual HOA con- a high level of clinical expertise, suffi cient in obtaining desired clinical tributions with a spherocylindrical in addition to patient motivation outcomes. However, using a wave- over-refraction, proving that wave- and compliance. Although perhaps front aberrometer to precisely map front aberrometry refraction over a a controversial subject, telehealth HOAs will give you more data to specialty lens can be helpful during applications can greatly benefi t consider when fi ne-tuning lens specs. the initial fi tting and subsequent fol- patient-doctor communication when Popular devices include the OPD- low-up. Nonetheless, depending on used appropriately. III (Nidek), KR-1W (Topcon) and the magnitude of posterior optical As is often the case with specialty iTrace (Tracey Technologies). complexities and the on-eye position contact lens evaluations, patients Some newer devices combine mul- of the lens, additional anti-aberra- travel long distances to seek the ex- tiple diagnostic capacities to render a tion mechanisms could be required. pertise of clinicians who have a limit- comprehensive analysis of the ante- Researchers and manufacturers ed amount of time. Consequently, rior segment. The VX130 (Visionix) have already found success when clinicians must identify ways to is equipped with the functionalities incorporating wavefront-guided achieve the best clinical results with- of a Shack-Hartmann wavefront corrections into scleral lenses.15,16 in a limited number of offi ce visits.

A LENS THAT FITS LIKE A GLOVE

When a patient’s ocular, and especially scleral, anatomy is highly atypical (e.g., due to trauma, surgery or advanced disease), the best solution may be to abandon conventional fi tting ap- proaches. Rather than tinker with lens param- eters in an attempt to approximate the scleral In this patient, the haptic is applying excessive shape, mimic it. pressure to an elevated glaucoma bleb. Patency is not EyePrint Prosthetics (EPP) introduced a man- seen on these OCT scans. ufacturing technology that aims to replicate the contours of a patient’s ocular surface by using an ophthalmic-friendly molding mate- rial that captures the exact impression of the anterior ocular anatomy. The resultant impres- sion is shipped to a manufacturing lab, where With EPP lenses, the haptic can easily be redesigned one to two million data points are scanned and to reduce pressure over the bleb. Patency to the bleb converted into computer-aided design images, is now seen on scans in the form of black spaces under producing precise scleral lens geometry. the haptic. Designing such a highly customized lens makes a wide range of clinical applications possible. EPP technology can accurately position itself on-eye, regardless of irregular conjunctiva-sclera angles or scleral elevations, such as ptery- gia, severe pingueculae and glaucoma blebs/shunts.

36 REVIEW OF CORNEA & CONTACT LENSES | SEPTEMBER/OCTOBER 2018 Earn up to 10TH ANNUAL 12 CE Credits* 2018

WEST COAST Optometric Glaucoma Symposium DECEMBER 14-15

Fig. 4. Eyecare Live allows patients to send ocular images securely to their eye doctors via telemedicine. Before a follow-up, digital interactions Join our faculty of renowned with their doctor give patients the chance to ask questions and express ODs and MDs at the Monarch concerns while adapting to their newly prescribed specialty lenses. Hotel in Dana Point, CA, for 1. Barnett M, Mannis MJ. Contact lenses in a highly interactive meeting One solution may be a doc- the management of keratoconus. Cornea. tor-to-patient telehealth platform 2011;30(12):1510-6. covering the most up-to-date 2. Bavinger JC, DeLoss K, Mian SI. Scleral lens called Eyecare Live. The clinical use in . Curr Opin Ophthal- information in glaucoma care. objective is to use this platform to mol. 2015;26(4):319-24. 3. Morgan PB, Woods CA, Tranoudis IG, et al. Up to 12* CE credits check in with specialty contact lens International contact lens prescribing in 2016. patients prior to their follow-up Contact Lens Spectrum. 2017;32(1):30-5. for only $275. 4. Morgan PB, Woods CA, Tranoudis IG, et al. exams and complete non-offi ce-relat- International contact lens prescribing in 2017. ed tasks online. From the comfort of Contact Lens Spectrum. 2018;33(1):28-33. 5. Nichols JJ. Contact lenses 2017. Contact their homes, patients can communi- Lens Spectrum. 2018;33(1):20-5,42. MEETING CO-CHAIRS: cate questions and submit lens-relat- 6. DeNaeyer G, Sanders D, van der Worp E, et al. Qualitative assessment of scleral shape Murray Fingeret, OD ed ocular images for analysis (Figure patterns using a new wide fi eld ocular surface elevation topographer. J Cont Lens Res Sci. Robert Weinreb, MD 4). This process aims to improve 2017;1(1):12-22. patient compliance and motivate 7. Michaud L, van der Worp E, Brazeau D, et al. Predicting estimates of oxygen transmis- SPEAKERS: patients to continue their lens adap- sibility for scleral lenses. Cont Lens Anterior Eye. 2012;35(6):266-71. Ben Gaddie, OD tation efforts for a greater chance of 8. Jaynes JM, Edrington TB, Weissman BA. fi tting success. Predicting scleral GP lens entrapped tear lay- Alex Huang, MD, PhD er oxygen tensions. Cont Lens Anterior Eye. 2015;38(1):44-7. Richard Madonna, OD 9. Compañ V, Aguilella-Arzo M, Edrington TB, A WIN-WIN SCENARIO et al. Modeling corneal oxygen with scleral A specialty lens fi tting can signifi - gas permeable lens wear. Optom Vis Sci. 2016;93(11):1339-48. cantly improve a patient’s quality of 10. Giasson CJ, Morency J, Melillo M, et MONARCH HOTEL al. Oxygen tension beneath scleral lens- life if done successfully. However, es of diff erent clearances. Optom Vis Sci. 1 Monarch Beach Resort selecting the most appropriate lens 2017;94(4):466-75. Dana Point, CA 92629 11. Brujic M. Poster Presented at the Global requires a high level of clinical Specialty Lens Symposium, Las Vegas, NV, 949-234-3900 expertise and the right pieces of January, 2016. 12. Visser ES, Visser R, Van Lier, HJ. Advan- equipment. Rather than focus on tages of toric scleral lenses. Optom Vis Sci. traditional specialty lens designs, 2006;83(4):233-6. 13. Hussoin T, Le HG, Carrasquillo KG, et al. clinicians should update their fi tting The eff ect of optic asphericity on visual reha- Three Ways to Register bilitation of corneal ectasia with a prosthetic strategies based on the most re- device. Eye Contact Lens. 2012;38(5):300-5. cent evidence-based data available, 14. Achenbach P, DeNaeyer G, Sanders www.reviewsce.com D. Simplifying Scleral Lens Fitting in The selectively adopting new diagnostic Presence of Localized Elevations with a New /WCOGS2018 Corneo-Scleral Topography System: Notches instruments and exploring alternate and Lifts. Poster Presented at the American email: [email protected] Academy of Optometry, Chicago, IL, October, interfaces that can enhance clinical 2017. call: 877-451-6514 interactions and improve standards 15. Slater DJ, Lay B, Sindt CW. Using corneal elevation specifi c technology to anti-aberrate of care. As a result, clinicians and a contact lens. Invest Ophthalmol Vis Sci, patients alike will have better expe- 2016;57(12):1489. Administered by 16. Sabesan R, Johns L, Tomashevskaya O, et Review Group Vision Care Education, LLC riences, feel more satisfi ed and see al. Wavefront-guided scleral lens prosthet- ic device for keratoconus. Optom Vis Sci. successful outcomes. RCCL 2013;90(4):314-23.

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Review Group Vision Care Education, LLC partners with Salus University for those ODs who are licensed in states that require university credit. See event website for up-to-date information. Corneal Consult By Aaron Bronner, OD

Fungal Ulcers: Missed and Misunderstood They may be less common, but they’re also more severe.

hough familiar corne- prognosis exist, including limited, KEEP YOUR EYES OPEN al pathogens, such as poorly penetrating ophthalmic Clinicians may also assume fungal Staphylococcus epider- preparations of antifungal medi- ulcers can be differentiated by their midis and aureus and cation. Perhaps more important is clinical appearance. Fungal ulcers TPseudomonas aerugi- the missed opportunity for early are known to have a number of nosa, cause the majority of ulcers recognition of fungal keratitis due supposed “classic fi ndings,” such as clinicians see, a small percentage are to a lack of knowledge about the feathery margins, satellite infi ltrates, caused by protozoan and fungal eti- infection’s risk factors. pigmented infi ltrates and endothe- ologies. Of these atypical microbial lial plaques, that doctors can lean keratitis sources, fungal origins are LOOK AT THE BIG PICTURE on to achieve a timely diagnosis. encountered most frequently and Fungal keratitis is widely associated Unfortunately, nearly 60% of have a worse prognosis than many with organic trauma—the most fre- fungal ulcers do not have any classic other corneal infection sources. A quent risk factor for fungal disease clinical features related to fungal number of fungal species that cause across the globe.1 Unfortunately, keratitis. When a lack of fi ndings corneal infection only cause one the index of suspicion drops when characteristic of fungal keratitis is disease—keratitis—and haven’t the historic risk of trauma is absent. paired with mundane risk factors, been documented to cause infection Organic trauma, however, is not the such as contact lens use and OSD, it anywhere else in the body.1 This only cause, and clinicians should is no wonder fungal keratitis is fre- illustrates how the cornea is perfect consider other risk factors when quently misdiagnosed and wrongly for incubating fungal infections; it’s weighing the likelihood of a fungal managed as bacterial keratitis. One a warm, damp environment isolated ulcer. One study found that while study suggests that nearly 90% of from the immune response—a fun- 25% of fungal ulcers were associat- the fungal ulcers reviewed were gal infection trifecta. This column ed with trauma, 37% were associ- originally being treated for bacterial will review this group of pathogens ated with contact lens use and 29% keratitis.9 Given this fi nding, it is and the challenges they present. with opportunistic infections in important to understand how to de- patients with ocular surface disease velop appropriate clinical suspicion A GLOOMY FORECAST (OSD).7 Though the study notes the regarding fungal keratitis. The incidence of fungal keratitis percentage of cases associated with varies based on geographic loca- contact lens use dropped after an of- IS IT FUNGAL OR BACTERIAL? tion. In the northern temperate and fending cleaner was pulled from the An article on Acanthamoeba kera- southwestern desert parts of North market, lens use is still associated titis (AK) notes that the initial step America, the incidence is relatively with approximately as many cases in diagnosing AK is to suspect it.10 low, accounting for 6% to 10% of of fungal keratitis as trauma.7,8 This mindset holds true when deal- all ulcers encountered, whereas in More perplexing is the associa- ing with fungal keratitis as well; a tropical parts of the continent, the tion with OSD. While clinicians are more varied set of risk factors and a incidence approximately doubles.2-5 often more concerned about mem- vaguer clinical appearance than clas- The prognosis of fungal keratitis bers of the normal ocular fl ora and sic cases leads to delays in diagnosis is startling; 43% of emergent kera- less about atypical etiologies, they and treatment for a condition that toplasties performed out of Bascom should also remember that fungal already has a greater risk of surgical Palmer are fungal keratitis surgeries, elements can be components of the treatment. Keeping a fungal etiology though the incidence is about 20% normal fl ora and cause opportu- somewhere on your differential until in Southern Florida—meaning that nistic corneal infection in patients you achieve treatment success or fungal keratitis is more than twice with OSD.7,8 In fact, yeast sources receive culture results is critical to as likely as bacterial keratitis to lead of fungal keratitis predominate in prevent further delays in diagnosis. to emergent transplant.5,6 cases related to OSD, exposure and While culturing is important in Many reasons for this negative ophthalmic surgery.7,8 the diagnosis of fungal keratitis,

38 REVIEW OF CORNEA & CONTACT LENSES | SEPTEMBER/OCTOBER 2018 it isn’t always timely; fungal Fungal sources are also char- cultures can take nearly a acterized by an indolent course. month to produce a defi ni- While the slow metabolic rate tively negative result, thus, it typical of fungal organisms is important to consider the reduces the rate of proliferation possibility that you may be and spread, it also causes a slow dealing with a fungal pathol- response to therapy; full recov- ogy when treating a micro- ery may take several months, bial keratitis, even without a with the fi nal treatment in a positive culture. This doesn’t disproportionately high number mean that clinicians should of cases being therapeutic start each patient who has a keratoplasty. corneal ulcer on an antifungal, Despite the absence of classic clinical fi ndings, but until a positive response this severe corneal ulcer is fungal in nature. iven the varied risk factors to therapy is observed or a Gand clinical appearances culture result is obtained, clinicians yeasts. In these cases, clinicians can of fungal keratitis, diagnosis can be need to at least consider the possi- use fortifi ed AmBisome 1.5mg/ml very diffi cult. Therefore, it is critical bility that they may be dealing with (amphotericin B, Gilead Sciences) or that a clinician keeps fungal keratitis a fungal ulcer, especially if the ulcer fortifi ed Vfend (voriconazole 1%, in the back of their mind until they worsens after initial treatment. Pfi zer). All topical antifungals can receive culture results or a patient This further illustrates the impor- be paired with oral agents, particu- responds positively to treatment. tance of aggressively treating infec- larly in cases of deep keratitis where Doctors who are uncomfortable car- tions with modern, broad-spectrum penetration of the topical agent is ing for true or suspected cases of fun- or fortifi ed agents as initial therapy. a concern, but tolerance can be an gal keratitis should promptly refer If an unspecifi ed ulcer is treated issue with systemic antifungals. these patients to a cornea service. RCCL with a dated antibiotic QID and Fungal ulcers are generally 1. Alfonso EC, Rosa RH, Miller D. Fungal keratitis. In: doesn’t respond, no clinically rele- typifi ed by a lower grade of infl am- Krachmer JH, Mannis MJ, Holland EJ, eds. Cornea. 2nd ed. St. Louis: Mosby; 2004:1043-74. vant conclusion can be drawn from mation than their bacterial counter- 2. Lichtinger A, Yeung SN, Kim P, et al. Shifting that treatment failure. However, parts, the clinical manifestation of trends in bacterial keratitis in Toronto: an 11-year review. Ophthalmology. 2012;119(9):1785-90. if initial treatment with a modern, which is the ulcer’s ability to deepen 3. Ni N, Nam EM, Hammersmith KM, et al. Sea- sonal, geographic and antimicrobial resistance broad-spectrum agent fails, fungal despite the epithelium healing over patterns in microbial keratitis: 4-year experience in keratitis suddenly becomes a more the ulcer bed. In most microbial ker- eastern Pennsylvania. Cornea. 2015;34:296-302. 4. Sand D, She R, Shulman IA, et al. Microbial reasonable etiology to suspect. Your atitis cases, stromal infl ammation keratitis in Los Angeles: the Doheny Eye Institute and the Los Angeles County Hospital experience. initial treatment should be valuable, precludes epithelial healing, which Ophthalmology. 2015;122(5):918-24. 5. Liesegang TJ, Forster RK. Spectrum of micro- even if it eventually fails. is why most of these ulcers have bial keratitis in south Florida. Am J Ophthalmol. epithelial defects equal in size to 1980;90(1):38-47. 6. Amescua G, Miller D, Alfonso EC. What is GOING THE DISTANCE their infi ltrates. Stromal infl amma- causing the corneal ulcer? Management strategies for unresponsive corneal ulceration. Eye (Lond). When starting therapy for a fungal tion in fungal keratitis, however, can 2012;26(2):228-36. ulcer, there is only one commer- be mild enough that the epithelium 7. Keay LJ, Gower EW, Iovieno A, et al. Clinical and microbiological characteristics of fungal keratitis in cially available topical antifungal, may heal despite the active under- the United States, 2001-2007: a multicenter study. Ophthalmology. 2011;118(5):920-6. Natacyn (natamycin 5%, Novartis), lying infection. This further lowers 8. Williamson J, Gordon AM, Wood R, et al. Fungal fl ora of the conjunctival SAC in health and disease. that exists—all others must be stromal concentrations of antifun- Br J Ophthalmol. 1968;52:127-37. compounded. The medication gals and subsequently reduces their 9. Yildiz EH, Abdalla YF, Elsahn AF, et al. Update on fungal keratitis from 1999-2008. Cornea. has reasonable effi cacy against effectiveness, making it necessary to 2010;29(12):1406-11. fi lamentous fungal pathogens but debride fungal ulcers to make topi- 10. Hammersmith KM. Diagnosis and management of Acanthamoeba keratitis. Curr Opin Ophthalmol. doesn’t perform as well against cal medications more successful. 2006;17(4):327-31.

REVIEW OF CORNEA & CONTACT LENSES | SEPTEMBER/OCTOBER 2018 39 Practice Progress By Mile Brujic, OD, and David Kading, OD

Multifocals: A Roadmap to Success A good presbyopic contact lens fi t starts with communication—and ends with a well- informed patient.

linicians have been Photo: Stephanie L. Woo, OD inform the patient that, while fi tting presbyopic they have advantages, progres- contact lenses for sive and bifocal glasses also have almost as long as limitations. Knowing alternative Ccontact lens wearers options present challenges as well have been struggling with the loss helps patients realize they are of that comes gaining something by wearing with age. This uphill battle often lenses over glasses. culminates in patients choosing to stop wearing their lenses. LENS OPTIONS Nonetheless, contact lens wear is The key to successfully fi tting attainable, especially with today’s With today’s advances, soft multifocal multifocal contact lenses is to lens improvements and patient lenses present many benefi ts to patients. follow the fi tting guide. Even education strategies. though it might be tempting for An eye care provider’s success rate rection be discussed, even with pa- providers to take the fi tting process depends on their ability to educate tients who have worn contact lenses into their own hands, the guide lays patients about both presbyopia for years and have already tried out exactly what to do if the initial and contact lenses. Patients who multifocals. Letting patients know lens fi t is not successful. Following have been properly informed about that their vision will likely never the fi tting guide can help clinicians the condition and the advantages return to what it was when they reach at least a 90% success rate and disadvantages of the available were 30 sets the foundation for the with the second and third lens. correction options walk into the discussion about lens options. While While most commercially avail- multifocal fi tting process far more possibly the most important step, able lenses are limited in that they prepared and come out far more this is also the one that is most often do not correct for astigmatism, soft successful. These tips can help you skipped. Ensuring that the patient lens companies continue to innovate become a better multifocal contact and the provider are on the same with new materials and designs, and lens fi tter, boosting your practice in page by setting realistic expectations spherical multifocal lenses usually the process. is critical for success. help the vast majority of patients. When discussing the available The following lens options may be COMMUNICATION IS KEY corrective options, it is vital to a pa- available for presbyopic patients Many presbyopic patients do not tient’s lens-wear success that a clini- depending on their circumstances: understand why they are struggling cian covers both the advantages and Toric soft multifocal lenses. A or why their vision continues to disadvantages of multifocal contact substantial percentage of our prac- worsen, let alone what the root lens wear. Despite the negative tice’s patients has astigmatism and of the problem is, and may falsely perception toward multifocal lenses can only be fi t with custom-ordered assume that their eyes are getting in the past, they allow patients the lenses. It is important to inform worse because of the lenses or opportunity to gain independence these patients that the fi tting and glasses they wear. To correct this from glasses and acquire a full range their lenses will both cost more to misconception, a clinician’s fi rst step of vision in all fi elds of gaze. In accommodate the astigmatism. If has nothing to do with multifocal addition, prescription lenses have a a patient chooses to continue with lenses; it is having a conversation non-glare coating that helps reduce the fi tting process, clinicians should with patients about presbyopia as visual problems patients often have then provide their custom soft lens an identifi able condition. while driving at night, looking at manufacturer with the patient’s Only after the patient understands computer screens and using digi- sphere, toric, add power, keratom- presbyopia should methods of cor- tal devices. Clinicians should also etry readings, horizontal visible iris

40 REVIEW OF CORNEA & CONTACT LENSES | SEPTEMBER/OCTOBER 2018 Earn up to 11 CE SAVE THE DATE! Credits*

The Optometric Society & Review Group Vision Care Education Present RETINAUPDATE Nov. 30 - Dec. 1, 2018 diameter and pupil size in photopic be presented as an alternate choice and scotopic lighting to ensure the for completing specifi c visual tasks. most effective lens is created. Most patients do not need them, but Hybrid lenses. These lenses those who do usually fi nd them to FAIRMONT consist of a gas permeable center be a great option for the times they SCOTTSDALE and a soft skirt and are designed for could use a boost in their distance 7575 E Princess Drive spherical and toric patients. To pro- or near vision. Scottsdale, AZ 85255 duce the best fi t and calculate power Patients fi t with multifocal contact 480-585-4848 measurements, clinicians should use lenses may face different obstacles See event website for discounted room rate. a fi tting set and do an over-refrac- depending on their add power, tion. If a provider has not fi t a hy- cylinder amount, pupil size and PROGRAM CHAIR: brid lens in the last couple of years, visual demand. Because a patient they should contact a colleague, with multifocal lenses looks through attend a workshop at a conference distance and near correction at all or reach out to SynergEyes—the times, they will notice a difference in only manufacturer of hybrid contact their vision. lenses in the United States—to A patient’s initial lens experience Mohammad Rafieetary, OD, FAAO discuss the process and learn how to is usually the most uncomfortable produce the best results. and unnatural because cortical ad- FACULTY: Gas permeable lenses. These are aptation needs to take place. Once Mark Barakat, MD usually successfully fi t because clini- the patient’s brain realizes what to Steven Ferrucci, OD, FAAO cians are able to modify the lenses focus on, it will likely ignore areas Jeffry Gerson, OD, FAAO until a patient’s vision is maximized. of vision that are not as important Leo Semes, OD, FAAO Scleral lenses. Although they for visual tasks. While clinicians Brad Sutton, OD, FAAO have grown more popular over should work diligently to reduce the last fi ve years, some consider the shadows and glare patients REGISTRATION COST: scleral lenses overkill for patients sometimes experience, they must ORS Member: $405 with normal corneas because of the also realize they may not be able to Non-member: $ larger size and increased cost of the get rid of either entirely, even with 450 lenses. Regardless, scleral lenses are careful lens selection. EARLY BIRD DEADLINE: fantastic options for presbyopic and September 28, 2018 toric patients. resbyopic contact lenses should Paccount for a majority of the FITTING CHALLENGES lenses clinicians fi t because all pa- For some patients with adequate tients who wear contact lenses age, THREE WAYS TO REGISTER pupil size who are fi t in the right and the vast majority want to con- www.reviewsce.com lens design, multifocal lenses pro- tinue wearing their lenses. By having vide a suitable depth-of-focus. For detailed conversations before lens /orsretupdate2018 others, the combination of limited fi ttings, understanding the various email: [email protected] lens options and their anatomy and lens designs and being prepared to call: 800-999-0975 lifestyle may reduce their chance troubleshoot when patients struggle of success with lenses alone. In with adaptation and anatomical or this case, clinicians often elect to lifestyle challenges, clinicians can Administered by prescribe over-glasses for either help their patients fi nd satisfaction Review Group Vision Care Education, LLC distance or near. Over-glasses can through presbyopia correction. RCCL

*Approval pending

Review Group Vision Care Education, LLC partners with Salus University for those ODs who are licensed in states that require university credit. See event website for up-to-date information. The Big Picture By Christine W. Sindt, OD

Shape Shifter If you see a ‘squiggle’ on the endothelium, what’s your fi rst suspicion?

14-year-old boy pre- lamp by retroillumination with a peripheral iridocorneal adhesions in sented with bilateral widely dilated pupil. It appears as about 25% of cases. IOP should be decreased vision. Ocular gray collagenous tissue at the level of monitored, as it will be elevated in examination showed Descemet’s membrane and can form about 15% of cases.1 Agray linear deposits on various shapes, including isolated While asymptomatic cases do the posterior central cornea but no dots, diffuse clusters or linear lesions. not require treatment, patients with edema. The patient was refractable Lesions range from small (0.1mm corneal edema, vision decrease or to 20/40 OD, 20/30 OS. to 1mm) vesicles to bands anywhere increased IOP require intervention. did not reveal anterior synechiae. His from 2mm to 10mm in length. These Mild corneal edema can be managed intraocular pressures (IOPs) were are differentiated from tapered, with sodium chloride 5% drops and 16mm Hg OD and 17mm Hg OS. smooth-edged Descemet’s tears seen ointment, a soft bandage contact The patient was given his refrac- in congenital glaucoma, trauma and lens for ruptured bullae, and stromal tive correction and counseled about hydrops by the presence of parallel micropuncture for areas of local- posterior polymorphous dystrophy scalloped edges; they also do not ta- ized swelling and poor endothelial (PPMD), a rare autosomal-dominant per toward the ends. Numerous oth- adherence.2 Severe cases may require dystrophy that causes abnormal er dystrophies are in the differential. surgical intervention, such as some developmental differentiation of en- PPMD generally does not progress form of or dothelial cells. It can present in early and can remain unchanged for many . The presence of childhood, but symptoms generally years. However, patients should be anterior synechiae signifi es a poor 1 appear in the second or third decade. monitored for endothelial decompen- visual prognosis. RCCL

While is, by defi - sation. It is rarely extensive enough 1. Dahrouj M, Vislisel JM, Raecker M, Maltry AC, Goins nition, a bilateral condition, PPMD to cause visual impairment; how- KM. Posterior Polymorphous Corneal Dystrophy (PPMD). www.eyerounds.org. Accessed Aug. 21, 2018. 1 may be asymmetric or unilateral. ever, or stromal 2. The IC3D Classifi cation of the Corneal Dystrophies. PPMD is best viewed at the slit clouding can develop. There can be Cornea. 2008;27(Suppl. 2).

42 REVIEW OF CORNEA & CONTACT LENSES | SEPTEMBER/OCTOBER 2018 FOCUS ON CONTACT LENS FIT SUCCESS

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