— MAY/JUNE 20190119 — — — — REVIEW OF CORNEA — & CONTACT LENSES — — — THE IRREGULAR CORNEA — — GETTING — — ASTIGMATISM IN — — — — — — F CUS — — WITH ADVANCED IMAGING, PAGE 16 — — • Fitting the Irregular Cornea: Nuts and Bolts, PAGE 22 — • Does CXL for Keratoconus Improve Contact Lens Success?, PAGE 28 — EARN 1 CE CREDIT: Pathologic Causes of Irregular Astigmatism, PAGE 30 • — — — — — ALSO: ARVO 2019 HIGHLIGHTS • HOW CONTACT LENS WEAR DISRUPTS THE TEAR FILM — — RCCL0619_Coopervision Clariti.indd 1 5/29/19 9:43 AM contents Review of Cornea & Contact Lenses | May/June 2019 departments features Highlights from ARVO 2019: 4 News Review Abstract Review The Dry Eye-Neuro Link; Get the scoop on new research that Contact Lens Rule Update may change your approach to many aspects of anterior segment care. By Review of Optometry staff My Perspective 10 7 The Mystique of Conjunctivochalasis By Joseph P. Shovlin, OD Getting Astigmatism in Focus with Advanced Imaging Four cases provide insight into The GP Experts diagnosing and managing patients 8 with the latest options. Spirits in the Material World 16 By S. Barry Eiden, OD By Robert Ensley, OD, and Heidi Miller, OD Corneal Consult Fitting the Irregular Cornea: 44 Nuts and Bolts Trust the Process Here’s a beginner’s guide to help you By Aaron Bronner, OD get started. 22 By Lindsay A. Sicks, OD 46 Fitting Challenges The More the Merrier Does CXL for Keratoconus By Vivian P. Shibayama, OD Improve Contact Lens Success? A review of the literature shows scant evidence for this eff ect. 48 Practice Progress 28 By Brian Chou, OD, and John Gelles, OD Special Considerations for Specialty Lenses By Mile Brujic, OD, and David Kading, OD CE — Pathologic Causes of Irregular Astigmatism The Big Picture Thin is in—but not in 50 the cornea. Here’s a Spread Too Thin 30 rundown of non-infl ammatory corneal By Christine W. Sindt, OD thinning disorders that lead to irregular astigmatism. By Thomas Stokkermans, OD, PhD Contact Lens Wear and its Disruption of the Tear Film A better understanding of the intricacies of the tear fi lm can help put patients’ discomfort and other issues 38 into better context. By Karen Walsh, BSc(Hons), PGDip, Jaya Dantam, PhD, and Doerte Luensmann, PhD REVIEW OF CORNEA & CONTACT LENSES | MAY/JUNE 2019 3 RRCCLCCL News Review 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 The Dry Eye-Neuro Link Advertising inquiries: (610) 492-1011 Email: [email protected] recent study suggests compared with controls, researchers EDITORIAL STAFF nerve dysfunction may said. This suggests dry eye symp- EDITOR-IN-CHIEF be the root cause of dry toms in those with migraine may Jack Persico [email protected] MANAGING EDITOR Aeye symptoms in some be driven by nerve dysfunction, not Rebecca Hepp [email protected] patients with migraines.1 ocular surface abnormalities.1 ASSOCIATE EDITOR Catherine Manthorp [email protected] Researchers evaluated symp- ASSOCIATE EDITOR toms and signs of dry eye—in- HYPERSENSITIVE CORNEAS Mark De Leon [email protected] CLINICAL EDITOR cluding those suggestive of nerve Short tear fi lm break-up time dry Joseph P. Shovlin, OD, [email protected] dysfunction—in 250 individuals, eye (sBUT), a subcategory of evap- ASSOCIATE CLINICAL EDITOR Christine W. Sindt, OD, [email protected] including 31 who met International orative dry eye, may signifi cantly EXECUTIVE EDITOR Classifi cation of Headache affect patient complaints of ocular Arthur B. Epstein, OD, [email protected] 2 CONSULTING EDITOR Disorders criteria for migraine based pain, new study found. Patients Milton M. Hom, OD, [email protected] on a validated screening.1 with sBUT dry eye—an sBUT of <5 GRAPHIC DESIGNER Ashley Schmouder [email protected] The study found individuals with seconds, a normal Schirmer test and AD PRODUCTION MANAGER migraine were signifi cantly younger few epithelial lesions—were hyper- Scott Tobin [email protected] and more likely to be female com- sensitive to corneal pain, suggesting BUSINESS STAFF pared with the controls. Patients corneal hyperalgesia could partly PUBLISHER James Henne [email protected] with migraine also had more severe account for subjective symptoms in REGIONAL SALES MANAGER dry eye symptoms and ocular pain patients with sBUT dry eye.2 Michele Barrett [email protected] REGIONAL SALES MANAGER compared with the control group. The study enrolled 60 patients Michael Hoster [email protected] Individuals with migraine had with sBUT dry eye and 46 healthy VICE PRESIDENT, OPERATIONS Casey Foster [email protected] a different dry eye symptom—but controls. Patients with sBUT dry eye a similar dry eye sign—profi le had higher corneal pain sensitivities EXECUTIVE STAFF CEO, INFORMATION SERVICES GROUP than healthy subjects but similar Marc Ferrara [email protected] corneal tactile sensations. In the SENIOR VICE PRESIDENT, OPERATIONS Contact Lens Rule Update Jeff Levitz [email protected] 36% of patients with sBUT dry eye The Federal Trade Commission (FTC) is SENIOR VICE PRESIDENT, and corneal hyperalgesia, defi ned HUMAN RESOURCES seeking additional input on its next phase Tammy Garcia [email protected] of proposed changes to the Contact Lens as a pain sensitivity ≥40mm, the VICE PRESIDENT, Rule. Elements of the latest proposal: team observed a strong signifi cant CREATIVE SERVICES & PRODUCTION • Prescribers must satisfy the “Confi r- Monica Tettamanzi [email protected] mation of Prescription Release” with correlation between the subjective VICE PRESIDENT, CIRCULATION a signed confi rmation statement by Emelda Barea [email protected] pain score and the objective corneal CORPORATE PRODUCTION MANAGER the patient; a prescriber-retained John Caggiano [email protected] copy of the prescription signed by the pain sensation. For the entire cohort patient; a patient-signed copy of the they found a weak positive correla- EDITORIAL REVIEW BOARD sales receipt confi rming they received tion between the subjective pain Mark B. Abelson, MD the prescription; or proof that they James V. Aquavella, MD received a digital copy. score and the objective corneal pain Edward S. Bennett, OD 2 • Prescribers must give a copy to the pa- RCCL Aaron Bronner, OD sensation. Brian Chou, OD tient’s designated agent upon request. Kenneth Daniels, OD • Robocall information must be delivered 1. Farhangi M, Diel R, Buse DC, et al. Individuals with S. Barry Eiden, OD slowly, at a reasonable volume and migraine have a diff erent dry eye symptom profi le Desmond Fonn, Dip Optom, M Optom allow prescribers to repeat it. than individuals without migraine. Br J Ophthalmol. Gary Gerber, OD Robert M. Grohe, OD • A seller must send the prescriber a ver- April 30, 3019. [Epub ahead of print]. 2. Tagawa Y, Noda K, Ohguchi T, et al. Corneal hy- Susan Gromacki, OD ifi cation request with the manufacturer peralgesia in patients with short tear fi lm break-up Patricia Keech, OD name or brand if diff erent than the one time dry eye. The Ocular Surface. 2019;17(1):55-9. Bruce Koffler, MD specifi ed. Pete Kollbaum, OD, PhD Jeffrey Charles Krohn, OD • Sellers must provide a way for patients Advertiser Index Kenneth A. Lebow, OD to present their prescriptions directly Jerry Legerton , OD to the seller. Alcon ..............................13, Cover 3 Kelly Nichols, OD Bausch + Lomb ..............................5 Robert Ryan, OD FTC seeks additional public comment on proposed Jack Schaeffer, OD changes to the contact lens rule. www.ftc.gov/news- CooperVision ......................Cover 2 Charles B. Slonim, MD events/press-releases/2019/05/ftc-seeks-additional- Kirk Smick, OD public-comment-proposed-changes-contact-lens. May Menicon .............................. Cover 4 Mary Jo Stiegemeier, OD 2, 2019. Accessed May 14, 2019. Oculus .............................................6 Loretta B. Szczotka, OD Michael A. Ward, FCLSA Barry M. Weiner, OD Barry Weissman, OD 4 REVIEW OF CORNEA & CONTACT LENSES | MAY/JUNE 2019 BALANCE POWER AND SIMPLICITY #1 DOCTOR-PRESCRIBED SCLERAL LENS* SIMPLIFIED FITTING FCLSA-CERTIFIED EXPANDED OFFERINGS ® ® with SmartCurve™ technology ••CONSULTANTS with Tangible Hydra-PEG offer individualized support and Zen™ Multifocal *Based on US lens sales between December 2018 and February 2019. Zen, Zenlens, and SmartCurve are trademarks of Bausch & Lomb Incorporated or its affi liates. Tangible and Hydra-PEG are trademarks of Tangible Science, LLC used under license. ©2019 Bausch & Lomb Incorporated or its affi liates. ALZN.0040.USA.19 RO0519_BL SVP.indd 1 4/30/19 3:34 PM NEW Cornea Scleral Profile Scan for the Pentacam® Beyond the Cornea! The new Pentacam® CSP Report measures, where others are just estimating Measure beyond past boundaries when fitting scleral lenses. The new CSP Report creates 250 images within the measuring process. The tear film independent measurement with automatic release allows coverage up to 18 mm with the same fixing point. Contact OCULUS today for more details! Toll free 888 - 519 - 5375 Follow us! [email protected] www.oculususa.com RCCL0619_Oculus.indd 1 5/29/19 3:10 PM My Perspective By Joseph P. Shovlin, OD The Mystique of Conjunctivochalasis Be vigilant when examining the entire ocular surface to avoid confusion. t’s likely that, at one point or These two cases keep infl ammatory ointment and patching at night may another, every eye care provid- cytokines (IL-6 and IL-8) on the oc- provide some relief if the CCh is er has diagnosed dry eye and ular surface, increasing the chances severe.1 Also address all additional Ieventually discovered that the of MMP activation and discomfort. confounders, including any ocu- masquerader conjunctivochalasis An additional breakdown of con- lar-related allergy, meibomian gland (CCh) was actually the cause of junctival elasticity and progression disease and blepharitis. their patient’s discomfort. How of CCh is possible.1 Surgery is a reasonable option many times have we placed punctal An interesting study performed in when targeted medical management plugs in the inferior punctum with 2015 at a Veterans Affairs hospi- fails.