CASE REPORT: A TRICKY POST- SURGICAL CONTACT LENS FIT … · strains demonstrating multidrug...

SURGERY ISSUE

ASTIGMATISM CORRECTIONASTIGMATISM CORRECTIONDURING CATARACT SURGERYDURING CATARACT SURGERY

CASE REPORT: A TRICKY POST-SURGICAL CONTACT LENS FIT P. 26

THE CATARACT PATIENT ISA DRY EYE PATIENT P. 18

SURGICAL PROBLEMS= CL Opportunities P. 38

MANAGING INFECTIONAFTER LASIK P. 36

PREPPING THE SURGICAL EYE P. 14

CAN SMILE TOP LASIK? P. 22

Earn 1 CE Credit, p. 30

NOVEMBER 2015

RCCLRCCLREVIEW OF CORNEA & CONTACT LENSES

ALSO INSIDE: Boost Your Contact Lens Profits • Lifitegrast in Limbo • Advice From GP Labs

Supplement to

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contentsReview of Cornea & Contact Lenses | November 2015

/ReviewofCorneaAndContactLenses #rcclmag

departments

10Supercharge Your Contact Lens Practice Profi tabilitySpecialty lenses and properly priced professional expertise can boost the revenue in your contact lens business.By Jane Cole, Contributing Editor

14Prepping the Surgical EyeIn many anterior ocular surgeries, good ocular surface integrity is vital to postoperative success.By Marc Bloomenstein, OD

30CE — Corneal Astigmatism Correction During Cataract SurgerySurgeons have more options—and decisions—than ever before.By Harmohina Bagga, MD, and Kerry K. Assil, MD

News Review4Topical Presbyopia Correction

Takes a Step; Contact Lenses

Further Dilute Topical Drops

My Perspective 6Generic Drugs:

More Than Meets the Eye?

By Joseph P. Shovlin, OD

Pharma Science & Practice8 Lifi tegrast in Limbo

By Elyse L. Chaglasian, OD, and Tammy Tham, MS, OD

Reach Out

By Gary Gerber, OD

Corneal Consult36

Out of the Box35

When the Going Gets Tough

By James Thimons, OD

features

fea- New Kid on the Block

By Mile Brujic, OD, and Jason R. Miller, OD, MBA

Practice Progress38

Cover design by Ashley Schmouder©iStock.com/Jobsonhealthcare

REVIEW OF CORNEA & CONTACT LENSES | NOVEMBER 2015 3

1822

The Cataract Patient is a Dry Eye PatientBoth conditions require attention and intervention.By Josh Johnston, OD, FAAO

Something to SMILE About?How does the newest refractive procedure measure up against LASIK?By John F. Doane, MD,

and Jace J. Rickstrew, BS

42 The GP Expert

Playing the Field:

How Manufacturers Can Help You

By Stephanie L. Woo, OD

26Staying in Shape: Post-Surgical Keratoconic Lens PlacementCan additional surgery be avoided in a keratoconus patient who requires better functional vision? By Paul Super, OD, FAAO

Lens Care Insights7The Never-ending Story

By Christine W. Sindt, OD

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Chemically-induced pupil contraction may soon emerge as an alternative

treatment for patients with pres-byopia, reports a new study in the September 2015 Eye & Contact Lens.1 The research accompanies other recent attempts to manage the age-related condition using topical drops.2

External methods like pinhole spectacles and multifocal contact lenses are current treatments for presbyopia; however, these must be removed regularly. Patients can also opt for surgical options like intraocular lens implantation and refractive lens replacement, but face complex recovery processes with the potential for procedure failure or infection.

In this study, researchers in Egypt investigated the use of a parasympathomimetic drug (carbachol) and an alpha agonist (brimonidine) in a double-masked, randomized placebo-controlled clinical trial involving 48 natu-rally emmetropic and presbyopic subjects. A treatment group (n=30 eyes) received a single dose of car-bachol 2.25% plus brimonidine 0.2% eye drops, and a control group (n=18) received placebo drops. Pupil size at both near and distance visual acuities was evalu-ated before and after treatment at one-, two-, four-, eight- and 10-hour increments.

Mean near visual acuity in patients older than 50 improved from J-7.68±1.62 pre-treatment

to J-3±1.6 at one hour, J-3.4±1.4 at two hours, J-4±1.26 at four hours, J-4.75±1.09 at eight hours and J-5.6±1.3 at 10 hours. Mean pupil size decreased sig-nifi cantly from 4.77±0.47mm pre-treatment to 2.5±0.51mm at one hour, 2.8±0.7mm at two hours, 3.13±0.6mm at four hours, 3.48±0.36mm at eight hours and 3.881±0.35mm at 10 hours.

No statistically signifi cant differ-ence was found in mean near vi-sual acuity and pupil size between initial application and one month and three months later, as well as between patients older than 50 and those younger than 50. There were no serious adverse ocular ef-fects reported from carbachol plus brimonidine application; however, one patient did experience a mild burning sensation, and another re-ported temporary visual diffi culty in low light.

The protocol “permits accept-able reading vision for many pres-byopes, even in older subjects,” the researchers conclude. “Because of increased depth of focus from the smaller pupil, it does not blur distance vision or immediate vi-sion as does typical monovision therapy, and the perception of normal brightness in the untreated eye eliminates symptoms of dim-ming from the smaller pupil of the treated eye.” RCCL

1. Abdelkader A. Improved presbyopic vision with miotics. Eye & Contact Lens. Sept 2015;41(5):323-327.2. Is a topical treatment for presbyopia on the horizon? Review of Cornea & Contact Lenses. Jun. 2014;5.

News Review

Topical Presbyopia Correction Takes Another StepEye drops may one day compete with lenses.

4 REVIEW OF CORNEA & CONTACT LENSES | NOVEMBER 2015

IN BRIEF

• Bausch + Lomb has announced the five-year results from its Antibiotic Resistance Monitoring

in Ocular Microorganisms

(ARMOR) surveillance study.The study pinpointed significant methicillin resistance among staphylococcal isolates from ocular infections, with many strains demonstrating multidrug

resistance. While overall resis-tance did not increase during the study period, the authors stress continued monitoring of ocular isolates is needed.

• The Brien Holden Vision

Institute has released a set of grading scales that can be used as an in-office reference tool for determining the severity and

progression of complications such as bulbar redness, limbal redness and corneal staining. It also includes descriptions

and photographs of adverse effects associated with contact

lens wear. You can download the scale for free at academy.brienholdenvision.org.

• Hyperopic patients can now try the Dailies Total1 contact lens from Alcon, as the company has announced new plus power ver-sions. The daily disposable lens-es, manufactured with Alcon’s water gradient technology designed to mimic the environ-ment of the cornea, are available with a power range of -0.50D to -6.00D in 0.25 steps and -6.50D to -10.00D in 0.50 steps. The latest release adds +0.50D to

+6.00D in 0.25D steps.

• Bausch + Lomb acquired Doctor’s Allergy Formula, LLC.The company’s diagnostic

system can be used to pinpoint the cause of a patient’s ocular

surface disease from a panel of 60 potential allergens.

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Silicone hydrogel contact lenses may signifi cantly limit absorption of certain

anti-infective agents used to treat ocular surface diseases such as infectious keratitis, reports a new study in the September 2015 Eye & Contact Lens.1 Interactions between contact lenses and topi-cal drugs have become a much-examined topic in recent years, as lenses are known to stimulate biochemical changes that alter the composition of the ocular surface and tear fi lm.2,3 This can lead to issues with drug effectiveness. Ad-ditionally, when used in conjunc-tion with topical drops, therapeu-tic soft contact lenses may also act as a physical barrier to topical drug absorption and contribute to formula dilution by trapping debris underneath.

Researchers from the University

of Pittsburgh School of Medicine performed a biological assay to determine the activity of diffused moxifl oxacin, polyhexamethylene biguanide (PHMB) and ampho-tericin B (AmB) against Staphylo-coccus epidermidis and Saccharo-myces cerevisiae. Results indicated suffi cient diffusion of moxifl oxa-cin and PHMB at 30 minutes, but not AmB. Ultimately, however, only moxifl oxacin demonstrated effi cacy at the 60-minute mark, and at 10 times the amount of the most common commercial formu-lation; thus, the researchers say, further study is needed. RCCL

1. Zambelli AM, Brothers KM, Hunt KM, et al. Diff usion of antimicrobials across silicone hydrogel contact lenses. Eye & Contact Lens. Sept. 2015;41(5):277-280. 2. Mann A, Tighe B. Contact lens interactions with the tear fi lm. Exp Eye Res 2013;117:88-98.3. Craig JP, Willcox MD, Argueso P, et al. The TFOS International Workshop on Contact Lens Discom-fort: Report of the contact lens interactions with the tear fi lm subcommittee. Invest Opthalmol Vis Sci. 2013:54:TFOS123-TFOS156.


Contact Lenses FurtherDilute Topical Drops

Advertiser Index

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EDITORIAL STAFF

EDITOR-IN-CHIEFJack Persico [email protected]

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CLINICAL EDITORJoseph P. Shovlin, OD, [email protected]

EXECUTIVE EDITORArthur B. Epstein, OD, [email protected]

ASSOCIATE CLINICAL EDITORChristine W. Sindt, OD, [email protected]

CONSULTING EDITORMilton M. Hom, OD, [email protected]

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EDITORIAL BOARD

Mark B. Abelson, MD

James V. Aquavella, MD

Edward S. Bennett, OD

Aaron Bronner, OD

Brian Chou, OD

S. Barry Eiden, OD

Gary Gerber, OD

Susan Gromacki, OD

Bruce Koffler, MD

Pete Kollbaum, OD, PhD

Jeffrey Charles Krohn, OD

Kenneth A. Lebow, OD

Kelly Nichols, OD

Robert Ryan, OD

Jack Schaeffer, OD

Kirk Smick, OD

Barry Weissman, OD

REVIEW BOARD

Kenneth Daniels, OD

Desmond Fonn, Dip Optom M Optom

Robert M. Grohe, OD

Patricia Keech, OD

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Charles B. Slonim, MD

Mary Jo Stiegemeier, OD

Loretta B. Szczotka, OD

Michael A. Ward, FCLSA

Barry M. Weiner, OD

RCCLRCCLREVIEW OF CORNEA & CONTACT LENSES

Focus on HOAs May Increase Surgery Success

Managing quality of vision after lamellar keratoplasty was the subject of a recent literature review published in the November 2015 Cornea.1 With respect to the studies evaluated, researchers found no signifi cant diff erence in postoperative visual acuity between DALK and PKP; however, outcomes after DSAEK were signifi cantly better than after PKP. The researchers also considered the concept of parallelism of anterior and posterior surfaces following surgery as a means to reduce higher-order aberrations (HOAs), which have been linked to poor visual acuity outcomes; ultimately, they sug-gest, “in clinical settings, increased attention to HOAs will avoid irregularity of the DSAEK grafts or uneven residual stromal tissues in DALK and amend the postoperative visual outcome.”

1. Yamaguchi T, Satake Y, Dogru M, et al. Visual function and higher-order aberrations in eyes after corneal transplantation: how to improve postoperative quality of vision. Cornea. 2015 Nov;43(11):S128-S135.

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Current concerns over prescription costs put generic drugs at the forefront of prescrib-ing. Most patients

think they have hit the jackpot if a medicine they need is available in generic form. But, have they really found a pot of gold—or are they meddling with an impostor likely to do harm?

BRAND NAMES

DON’T LAST FOREVER

As we know, patents are awarded for approximately 20 years, de-pending on the country in which they are issued.1-3 While this time span may seem excessive, it takes time for the drug to go through the approval and manufacturing pro-cess. Consequently, the drug’s ac-tual marketing or “money-making” time is reduced to an average of seven to 10 years.2 Manufacturers can extend the patent by making a “signifi cant” formulation change, but additional trials are often neces-sary to re-verify the patent, bogging the process down further.

GENERIC REGULATIONS

When the patent is no longer in force, the generic drug steps up to the plate. Currently, generic drugs account for nearly 80% of all pre-scriptions written.2 But, what scruti-ny does the generic drug undergo to deem it a suitable replacement for the branded drug?

Policies and regulations for generic drugs have changed signifi cantly over the years. Ad-ditionally, the FDA also allows for a 10% variance in active and

inactive ingredients in branded drugs; the same variance is accept-able in generic versions.4 Prior to regulatory changes made in 1992, the FDA permitted generic drug manufacturers to use different inac-tive ingredients from the innovator drug, as long as the active ingre-dients were the same. This poses a problem for some medications we use today, as generics approved before 1992 were labeled the same as medications we currently use, but are not truly equivalent. Changes in tonicity and demulcents can affect retention time and alter absorption.4 A simple pH difference between generics and a brand name may affect compliance and result in detrimental long-term effects to the eye.2

Wiley Chalmers of the FDA’s ophthalmology division notes that ointments and other non-solution dosage forms present different considerations.”4 These ophthalmic drugs can be signifi cantly affected by different manufacturing pro-cesses, even when the active and inactive ingredients are qualitatively and quantitatively the same. Since 1992, comparative clinical trials to dispel these concerns have been implemented by FDA.1,3,4

An additional problem is the lack of bioequivalency trials required of generic drugs. Variances can occur due to differences in bottle size, shape and material; additionally, cap colors don’t have to match.3

Drop size (based on the diameter of the bottle opening) may be different among generics, and the appear-ance of the bottle may change from month to month. Oddly, generic

manufacturers are not required to alert physicians or patients of any problems on the package insert, since the label can’t be altered from the branded innovator product.3

STRANGER IN

A STRANGE LAND

Patients who shop online for gener-ics expose themselves to even more risks. Many times, these medica-tions are produced outside of the US. Generic drug manufacturing practices in other countries are sometimes not closely monitored. As such, a number of potential problems exist: products can have impurities, imperfect ingredi-ent matches and even fraudulent formulations.2,3 This can lead to ineffective treatment regimens, with morbidity and vision loss.

With the increasing frequency in which insurance provid-

ers require generic substitution for a brand name, it’s imperative that we watch for any new signs or symptoms related to generic drug use. Although generics are gener-ally safe, effective and can provide substantial savings, I have concerns when this savings comes at the expense of drug standardization and safety. Even with revised FDA requirements that on the surface appear to be adequate, the safety and effi cacy of some generic drugs remains in dispute. RCCL

1. Mandal A: Drug patents and generic pharma-ceutical drugs. News Medical, Aug., 2015.2. Zore M, Harris A, Tobe LA, et al: Generic medi-cations in ophthalmology. Medscape, Aug., 2015.3. Kahook MY: Branded vs. generic: Proceed with caution. Review of Ophthalmology, April, 2015.4. Chalmers WA: Ophthalmic generics-Are they really the same? Ophthalmology, 119:6, 2012.

Generic Drugs: More Than Meets the Eye?Not all drugs are created equal. Be aware of these potential diff erences.

My Perspective By Joseph P. Shovlin, OD


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Compliance with contact lens care and cleaning has always been viewed as a key factor in reducing

complications; however, it has gained greater scrutiny since the microbial keratitis outbreaks near-ly a decade ago. There have been a number of improvements in contact lens materials, an increase in recommended lens replacement frequency and new lens solution compositions.

The FDA recently removed the “no-rub” indication from contact lens solution bottles, citing the need for mechanical disruption of the microorganisms and deposits on the lens surface. There is also a strong indication that lens cases should be wiped down daily to remove biofi lm formation, which harbors microorganisms.1 Despite these changes, research indicates rates of infection are still signifi -cant.

In an effort to better understand the noncompliance issue and pre-vent future problems, the Centers for Disease Control (CDC) pub-lished a study in its Morbidity and Mortality Weekly Report on the demographics and risk behaviors in contact lens-related eye infec-tions.2

The CDC analyzed an online survey of 4,269 adults over 18 years old from the United States, approximately 1,000 of whom were contact lens wearers. The survey was statistically weighted to make the panel representative of the US population. Participants were asked demographic questions, if and what type of lenses they

wore and contact lens hygiene-related risk behaviors. The survey estimated there are nearly 40.9 million adult contact lens wear-ers in the US—and nearly 99% of them exhibit at least one contact lens hygiene risk behavior.2

About half of all wearers report overnight wear, with 87% stat-ing they nap in lenses. Fifty-fi ve percent top off solutions, while 50% replace lenses less frequently than recommended. Most shock-ing, but least surprising, was the rampant exposure of contact lenses to water-borne sources of infec-tion: 84.9% reported showering in lenses, 61% swim with lenses in and 35.5% of all contact wearers rinse lenses in water (91% of GP wearers).2

A PRACTITIONER’S

PERSPECTIVE

I found the risk behaviors of daily disposable wearers particularly interesting. Daily disposable lenses are supposed to reduce complica-tions by eliminating the lens care compliance problems associated with storing lenses overnight. Perhaps, however, in our effort to eliminate lens care products and increase compliance, we have un-wittingly increased daily disposable wearer noncompliance risk. Are we putting our daily disposable patients at risk by not talking to them about lens care hygiene and lens cases?

According to the CDC report on soft lens wearers, daily lens wear-ers have the highest level of storing lenses in tap water (28% of daily wearers, compared with 12.4% of planned replacement wearers) and

rinsing lenses in tap water (40.3% of daily wearers compared with 27.2% of planned replacement wearers). Sixty percent of daily wearers use a contact lens case, and most of those report topping off solution (72% of daily wearers compared with 51.3% of planned replacement wearers).

The lens care compliance “talk” remains diffi cult, tedious

and never-ending. I’m sure many practices were happy to shorten the lens care discussion when daily disposables arrived on the scene. However, daily disposable wearers also have signifi cant noncompli-ance habits, and in the absence of proper instruction on lens care, they increase their risk with water exposure.

So, perhaps the conversation should go something like this: “Re-placing your lenses daily decreases your risk of infection and red eyes. Always carry a replacement pair of lenses with you, so you never have to reuse a lens. And if you fi nd yourself in a situation where you do have to reuse a lens, there are some safer practices that can be used, such as rubbing, rinsing and storing the lens in a disinfect-ing solution and never using tap water on the lens.” These kinds of reminders will help us increase patient compliance one step at a time. RCCL

1. Wu YT, Willcox M, Zhu H, Stapleton F. Contact lens hygiene compliance and lens case contamination: A review. Cont Lens Anterior Eye. 2015 Oct;38(5):307-16.2. Cope JR, Collier SA, Rao MM, et al. Contact lens wearer demographics and risk behaviors for contact lens-related eye infections. Morbidity and Mortality Weekly Report. 2015;64(32):865-70.

The Never-ending StoryWhen we already struggle with patient compliance, how are we going to getpatients to add even more steps?

By Christine W. Sindt, OD

Lens Care Insights


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In April of this year, the FDA granted priority review to the lifi tegrast new drug applica-tion (NDA) for the treatment of dry eye disease. Priority

review is granted to drugs believed to have the potential to improve the treatment, diagnosis or prevention of serious diseases. Priority review accelerates the review process, re-ducing it from 12 to eight months.1

Lifi tegrast’s developer, Shire Pharmaceuticals, obtained it in 2013 when it acquired SARcode Bioscience. FDA approval would make it the fi rst prescription dry eye drug available to treat both signs and symptoms of the disease.3 The fi rst Phase III study demonstrated improvement in signs but not symptoms, while the second met the co-primary endpoint of relieving dry eye symptoms, but missed the second endpoint: improvement in corneal staining.3,5,6

The FDA was expected to release a decision on October 25, 2015 regarding lifi tegrast; however, eight days prior, the agency declined ap-proval of the drug at this time, cit-ing the need for additional clinical tests and further information about product quality.2 This column will provide some background.

BENEATH THE SURFACE

Lifi tegrast is a fi rst-in-class, small-molecule antagonist of the lympho-cyte function-associated antigen-1 (LFA-1) integrin, inhibiting interac-tion with its cognate ligand, called intercellular adhesion molecule-1 (ICAM-1).7,8 Whew! That’s a sentence-full. So, what does this mean clinically?

Integrins are heterodimeric (i.e., a protein composed of two differ-ent polypeptide chains) cell surface receptors found in nearly all cell types that act as bridges for cell-to-cell and cell-to-extracellular matrix interactions. They are comprised ofα and β subunits, which determine the ligand specifi city for a particular integrin. The ligand is described as cognate, meaning that a specifi c ligand normally interacts with a given integrin. The ligand is usually the signal-triggering molecule that, upon binding to the integrin, results in a wide range of integrin-mediated interactions, including pathologi-cal processes such as infl ammation, wound healing, angiogenesis and tumor metastasis.8-10 The ligand ICAM-1 is a protein normally present in low levels on the sur-face of lymphocytes, macrophages and vascular endothelium, but is overexpressed in the presence of infl ammation.

The binding of LFA-1, a cell surface adhesion molecule found on all leukocytes, with ICAM-1, is essential for the migration and pro-liferation of T-cells at infl ammatory sites as well as subsequent cytokine release. This T-cell-mediated infl am-mation is a mechanism known to be present in dry eye disease.6 Block-ing the interaction of integrins with their ligands is a major target for new pharmaceutical agents, with recent drugs approved or in trials for conditions such as multiple scle-rosis, Crohn’s disease, osteoporosis, cancer, AMD and now dry eye.9,10

Lifi tegrast acts as an ICAM-1 de-coy, preventing LFA-1 from binding to ICAM-1, which presents abun-

dantly on infl amed cells. This inhi-bition of LFA-1 binding to ICAM-1 is believed to break the infl amma-tory cycle, thereby reducing a dry eye patient’s signs and symptoms.8

MAGNUM OPUS

The original lifi tegrast NDA includ-ed one Phase II study, two Phase III effi cacy and safety studies (OPUS-1 and OPUS-2) and one long-term Phase III safety study (SONATA). More than 1,800 patients were enrolled in these four randomized clinical trials.4

A Phase II study of lifi tegrast conducted from 2009 to 2010 recruited 230 dry eye patients at fi ve sites. Typically in Phase II studies, the drug concentration and dos-ing frequency are established; in this study, lifi tegrast was evaluated at 0.1%, 1% and 5% concentra-tions. Subjects used the drops for 12 weeks and were evaluated at several screening and on-treatment visits. Using the controlled adverse environmental (CAE) procedure to reduce variables, signs and symp-toms were assessed before and after ocular surface drying. The CAE is a chamber that regulates environ-mental factors including humid-ity (<10%), temperature (76±6º), airfl ow and lighting. In this study, there was an improvement in signs and symptoms of dry eye in the lifi tegrast group as compared to placebo with a dose response for staining.11 A clinically meaningful response, as defi ned by the FDA, requires statistically signifi cant improvement in one sign and one symptom that must be replicated in Phase III studies.7,12

Pharma Science & PracticeBy Elyse L. Chaglasian, OD, and Tammy Than, MS, OD

Lifi tegrast in Limbo


The FDA recently requested more data on this investigational dry eye drug. What’s known—and what’s next?

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Entering Phase III studies, lifi tegrast at a concentration of 5% dosed twice a day was selected. OPUS-1 was conducted from 2011 to 2012 involving 13 sites enroll-ing 588 dry eye patients. Patients were randomized at a ratio of 2:1 (lifi tegrast:placebo) and used the eye drops twice a day for 12 weeks. The primary objective outcome measure was inferior corneal fl uorescein staining and the primary subjective outcome measure was visual-related function subscale of the Ocular Surface Disease Index (VR-OSDI). The visual-related function involved questions six to nine on the OSDI. Unlike the Phase II study, the CAE was used during the screening process, but not once patients were on treatment. Objective fi ndings including corneal fl uorescein stain-ing and conjunctival lissamine green staining were signifi cantly reduced in the lifi tegrast group as compared to placebo. There was symptomatic improvement in ocular discomfort and dryness in the treatment group. However, the co-primary endpoint of VS-OSDI was not met.5,12

OPUS-2 was then conducted from 2012 to 2013 at 30 sites involving 718 dry eye patients. Participants were randomized to use either lifi tegrast 5% or placebo twice a day for 12 weeks. The sub-jective primary outcome measure was altered from VR-OSDI to Eye Dryness Score (EDS), which assesses seven subject-reported symptoms using a visual analog scale for each item with zero representing no discomfort and 100 indicative of maximum discomfort. The subjec-tive primary outcome measure was

a single score that combined the EDS from both eyes. In contrast to OPUS-1, OPUS-2 demonstrated sig-nifi cant improvement in the subjec-tive endpoint (i.e., eye dryness), but failed to show signifi cant improve-ment in the objective measure of corneal fl uorescein staining.6,12

SONATA was a multicenter (23 sites) Phase III safety study enroll-ing 331 dry eye patients conducted from 2012 to 2014. Patients were randomized; 220 received lifi tegrast and 111 received placebo. Patients used the eye drops twice a day for one year. No serious ocular adverse events occurred in either group; however, those receiving lifi tegrast had more ocular and nonocular ad-verse events than the placebo group. Approximately half the study sub-jects reported adverse events, with the most common being dysgeusia and irritation upon instillation. Secondary safety measures showed no signifi cant changes, including plasma concentration.12,13

OPUS-3 concluded in October. This Phase III study involved 41 sites enrolling 711 patients. Like prior OPUS studies, dry eye patients either received lifi tegrast or placebo twice a day for 12 weeks; however, the main difference in this study compared with the others is the in-clusion of just a single primary out-come measure—the subjective eye dryness score.12 Preliminary results from this study released on Octo-ber 27 indicated that the primary endpoint was met with signifi cant improvement in patient-reported symptoms in the group receiving lifi tegrast. Other key secondary endpoints evaluating symptoms at

days 14 and 42 were also met. Shire reportedly plans to resubmit the lifi tegrast NDA to the FDA in the fi rst quarter of 2016.

For now, the waiting continues. These positive results from

OPUS-3 will hopefully address the FDA’s concerns and ultimately give us a new fi rst-in-class medication to offer relief of both the signs and symptoms of dry eye. RCCL

1. FDA Grants Priority Review to Lifi tegrast NDA for Treatment of Dry Eye Disease in Adults. Available at https://www.shire.com/newsroom/2015/april/fda-grants-priority-review-to-lifi tegrast-nda-for-treatment-of-dry-eye-disease-in-adults. Accessed Oct 5, 2015.2. FDA Declines Approval of Shire’s Eye Drug Lifi tegrast. Available at http://www.techtimes.com/articles/96514/20151017/fda-declines-approval-of-shires-eye-drug-lifi tegrast.htm. Accessed Oct 19, 2015.3. Lifi tegrast Heads Up Promising Dry Eye Pipeline. Available at: http://ois.net/lifi tegrast-heads-up-promising-dry-eye-pipeline/. Accessed Oct 5, 2015.4. Press Release: Shire Provides Update on Next Steps for Lifi tegrast in Light of FDA Complete Re-sponse Letter. Available at: https://www.shire.com/newsroom/2015/october/shire-provides-update-on-next-steps-for-lifi tegrast-in-light-of-fda-complete-response-letter. Accessed Oct 19, 2015.5. Sheppard JD, Torkildsen GL, Lonsdale JD, D’Ambrosio FA, et al. Lifi tegrast ophthalmic solution 5.0% for treatment of dry eye disease: results of the OPUS-1 phase 3 study. Ophthalmology. 2014 Feb;121(2):475-83.6. Tauber J, Karpecki P, Latkany R, Luchs J, et al. Lifi tegrast ophthalmic solution 5.0% versus placebo for treatment of dry eye disease. Results of the ran-domized phase III OPUS-2 study. Ophthalmology. 2015 Sep 10. pii: S0161-6420(15)00777-0.7. Semba CP, Swearingen D, Smith VL, et al. Safety and pharmacokinetics of a novel lymphocyte function-associated antigen-1 antagonist ophthal-mic solution (SAR 1118) in healthy adults. J Ocul Pharmacol Ther. 2011 Feb;27(1):99-104.8. Zhong M, Gadek Tr, Bui M, et al. Discovery and Development of Potent LFA-1/ICAM-1 Antagonist SAR 1118 as an Ophthalmic Solution for Treating Dry Eye. ACS Med Chem Lett. 2012 Jan;31;3(3):203-6. 9. Millard M, Odde S, Neamati N. Integrin Targeted Therapeutics. Theranostics. 2011;1:154-188.10. Takada Y, Ye X, Simon S. The integrins. Genome Biology. 2007; 8(5):215.11. Ousler GW, Gomes PJ, Welch D, Abelson MB. Methodologies for the Study of Ocular Surface Dis-ease. The Ocular Surface. 2005 July;3(3):143–154. 12. ClinicalTrials.gov. Accessed: Oct 19, 2015.13. SONATA: 50% Adverse Event Rate Reported for Lifi tegrast. Available at http://www.medscape.com/viewarticle/8443968_print. Accessed: Oct 5, 2015.


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Optometrists domi-nate the contact lens market, writing nearly an estimated 90% of contact lens

prescriptions annually.1 However, many practitioners are still not taking full advantage of the revenue potential from the contact lens arm of their practices, instead relying on it as a supplemental source of income.1 Cutthroat pricing by the big box retailers and online suppli-ers makes contact lenses a losing proposition, many still believe.

Some optometrists say it’s time to rethink that tired mindset. “Em-brace contact lenses as a practice builder and not a loss leader in your practice,” says Glenda Secor, OD, of Huntington Beach, CA. “Increas-ing your enthusiasm for new prod-ucts, introducing opportunities for new wearers and offering to address problems will reduce dropouts, cre-ate loyalty and increase revenue.”

DON’T SHY AWAY FROM

SPECIALTY LENSES

Optometrist Ken Krivacic of Irving, TX, believes the most profi table contact lenses are specialty lenses like sclerals, hybrids and multifocals. “They generally cost more, but you can also charge more, and profi t margins are much

larger than standard disposables or gas permeables. If you can train yourself in those areas and then market to your existing and potential patients, this will allow you to charge more and increase your net,” Dr. Krivacic says. Equally important: specialty lenses provide your patients with better vision correction than conventional lenses do, and that elevated level of care bonds the patient to your practice.

Offering specialty lenses in your practice helps to distinguish you from your peers, adds Jason Jedlicka, OD, of Edina, MN. A common mistake is underpricing your professional services. “I’m not talking about disposable bifocal lenses; those are a commodity and anyone can fi t them. I’m talking about GP multifocal, ortho-k and sclerals,” Dr. Jedlicka says.

Additionally, patients usually don’t shop around for specialty services and lenses, says Justin Bazan, OD, of Brooklyn, NY. “If patients are referred to you or they are coming to you because they did their own research, they probably aren’t overly concerned with saving a few bucks,” he explains, adding that specialty lenses are often unavailable for the consumer to purchase directly, which guarantees

the optometrist additional revenue from dispensing in-offi ce.

Patients who are fi t with specialty lenses are also likely to refer other patients to your practice. “I saw a new patient this week who came to me for sclerals because he knows someone who I fi t in sclerals post-RK. He didn’t even need contacts, but was persuaded to see me for sclerals because of word of mouth,” Dr. Jedlicka says.

Specialty lenses are more mainstream than ever, with new modalities that are easier to fi t and are also affordable for patients. One caveat with specialty lenses, however, is that over time, they may not be so unique, Dr. Bazan says. “As technology advances and doctors look for other revenue streams, you will see more and more providers doing specialty ‘whatever.’ As history shows, it will probably lead to a form of commoditization, and we will see a dip in profi tability.”

DON’T LOWBALL

YOUR SERVICES

To build a thriving contact lens practice, be careful not to undervalue your expertise. Most doctors lowball their fees and try to garner most of their contact lens revenue from the material

SuperchargeProfi tability

Your Contact Lens Practice

010_RCCL1115_F1-1.indd 10010_RCCL1115_F1-1.indd 10 10/29/15 2:20 PM10/29/15 2:20 PM

side, Dr. Krivacic explains. In fact, the revenue from the professional fees can be substantial if you price yourself correctly, and no direct cost is involved, he adds.

Optometrists should provide a higher level of service—and then charge accordingly, Dr. Jedlicka says. This includes performing topography on all new contact lens fi ts and refi ts; staining the patient’s eyes and everting their lids to look for any issues; using photography when possible to back up your recommendations; and individualizing product offerings for different patients.

When patients perceive a higher level of service, they are either willing to pay more for it—these are the patients you want—or not willing to pay for it. “Focus on taking exceptional care of the patients that appreciate the higher level of care and are willing to pay for it,” Dr. Jedlicka says.

By setting higher fees, many patients will consider you to be better at what you do since you are more expensive, Dr. Jedlicka points out. In turn, patients will often consider you the expert.

“I know a doctor whose ortho-k practice was languishing. In an effort to grow it, he considered lowering his fees. Instead, he was persuaded

to raise his fees considerably. Doing so caused his ortho-k practice to grow signifi cantly as patients perceived that—based on his higher fees—he was the best, and they wanted the best,” Dr. Jedlicka says.

For years, doctors have made the mistake of giving away their contact lens services with “free contact lens evaluations,” says Dr. Bazan. “Doctors would simply not charge if there was no change in the contact lens brand.” However, he suggests, it is important for patients to recognize that your services are worth paying for. This can be done by offering a higher level of service and charging accordingly.

“Do you just simply fl ick a slit lamp light on and off, or do you explain what you’re doing as you’re doing it? Do you simply ask how a patient is doing with their contacts, hoping to hear ‘fi ne’ so you can just move on, or do you get better answers because you ask better questions? Do you fi nd out how the patient is wearing and caring for their lenses, or is re-education needed? Do you let them know about new options and why you are going to let them try them?” Dr. Bazan asks. The bottom line, he says, is that most patients are used to getting a subpar contact lens exam “and they feel like it’s worth

not much more than free. It’s time for us to change that.”

You should, of course, monitor what the competition is charging, advises practice management consultant Bryan Rogoff, OD, of Baltimore, MD. If your practice is not established, you can’t charge $150 if the going rate is $100, or you’ll price yourself out of the market. “If you build up your brand and your reputation, you can charge higher prices,” Dr. Rogoff says.

STAFF TAKES THE BATON

Staff is a tremendous resource when promoting a contact lens practice. At Dr. Krivacic’s offi ce, he relies on his staff to make all the contact lens sales. “They work with the patient after the exam and go over fees and material costs and are instructed to promote yearly supplies. If staff are properly trained and incentivized, they can improve your bottom line,” he says.

Dr. Jedlicka’s staff members are fi tted for and wear the contacts that are offered at his practice, making them the ideal ambassadors to discuss the highlights and positive experiences of their lens wear.

“Staff needs to hear the success stories you have, so they can get in your camp and become excited about what you do as a practice.


Specialty lenses and properly priced

professional expertise can boost the revenue

in your contact lens business.

By Jane Cole, Contributing Editor

©iStockkk.k com/Jobsb onHenHealthalthcacareare


Staff will often end up talking fees with the patients, so they need to believe in what you do and in the level of care you provide, so they are completely comfortable explaining fees and why the fees you charge are worth it,” Dr. Jedlicka says.

When assessing your staff’s role in contact lens sales, consider whether you look at your staff as “order takers or sales makers,” Dr. Bazan suggests. Educate staff why the annual supply is best for the patient and the practice, he says. Then train your staff on a script that makes it easy for them to sell the annual supplies to the patient. “The annual supply sale should be the norm, not the exception,” Dr. Bazan says.

LOOK TO YOUR

SPECTACLE LENS PATIENTS

If a spectacle patient is a good candidate for contact lenses, Dr.

Krivacic will ask if the patient has considered them. He will also mention the availability of one-day options, which are often easier to wear and easier to take care of, and would therefore be able to be worn easily on a part-time basis. He also explains that contacts are a good option for someone who only wants them for sporting activities, or for those with allergy issues.

In Dr. Jedlicka’s practice, he concludes every exam with a discussion of all available options for refractive correction: glasses, contact lenses and surgical procedures. If a patient is a natural candidate for contact lenses, he offers them a chance to try lenses. “Dailies are the perfect way [to ease] into this, since they are low maintenance and commitment,” Dr. Jedlicka says.

A good opportunity to market contact lenses to your spectacle wearers is to offer a patient the

chance to try the lenses on while they are waiting for their glasses in the optical department, Dr. Rogoff suggests. Also, don’t discount contact lenses for special occasions, such as weddings or other special events where your patients might want to opt out of wearing their glasses, Dr. Secor says.

PRICING 'UPPS' AND DOWNS

Although contact lenses are medical devices, they’re also a consumer product, subject to all the same incentives and disincentives to purchase as any other. Pricing matters, and patients want to be treated fairly, the experts say. Disposable lenses are the same no matter where they are purchased, so charging a premium for them, Dr. Jedlicka feels, is “sticking it to patients for their loyalty to your practice.” He believes optometrists should be competitive with product pricing and place the premium on

SUPERCHARGE YOUR CONTACT LENS PRACTICE PROFITABILITY


Specialty contact lenses like this scleral lens could give your practice an edge over others.

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services—making sure, of course, that the services offered are top-notch.

With the advent of the unilateral pricing policy (UPP) from many manufacturers, which dictates the minimum price that can be charged for certain brands of contact lenses, some doctors feel UPP has benefi ted private practice by leveling the pricing playing fi eld. They do say UPP has posed some disadvantages as well, however. News reports on UPP, especially in states with legislative efforts against it, tend to misrepresent the policy as one of price fi xing or artifi cial infl ation at the consumer’s expense. Explaining UPP to the patient can help keep the sale in the practice instead of having them search online or seek out a cheaper retailer.

“UPP is helping, though most patients are unaware of this until we explain it to them,” Dr. Jedlicka says. “When they fi nd out, many patients do elect to purchase their lenses from us instead of going elsewhere, as we point out the other benefi ts to buying lenses from us such as exchanges, trials, rebates and free shipping.”

As doctors consider which brands to keep in stock, they may want to opt for lenses that can’t be ordered for a cheaper price elsewhere.

“Why would any business sell a product that can easily be found for less online? I just don’t get it,” Dr. Bazan says. “When there are so many contact lens options that are clinically equivalent, why not go with the lenses that ensure your doors will remain open for you to see patients?”

Dr. Bazan says he is seeing some slippage in UPP policies, so he believes it is important to research the brands you use to check on current pricing. It’s also important to remember the listed price is

probably not the fi nal price. He suggests setting up an account with the vendors your patients use—or, hopefully, formerly used—and actually go through with the purchase until the site asks for a credit card. You want to know the bottom line price for the same supply after all the extras like shipping and handling are added in, he says.

For Dr. Krivacic, he believes UPP pricing has been both good and bad for the industry. The good is that it has helped level the playing fi eld. If a lens is distributed using UPP, the prices at his practice are the same as the big retailers. The price incentive is then eliminated and most patients would rather buy directly from the doctor. “In our practice, this has helped,” Dr. Krivacic says.

However, the downside is that since all prices are now the same, there is less incentive for the patient to purchase a larger quantity unless a rebate is involved, Dr. Krivacic adds. Also, if the price is the same, patients may opt for convenience and purchase a lens online or at a retailer.

One fi nal tip—you must have enough volume to generate

good profi ts from the contact lens side of your practice, Dr. Krivacic says. This goes back to the basics of practice management and keeping your appointment book full.

“The contact lens patient is still our most loyal patient, and they appreciate and value the care you provide,” Dr. Secor says. “They are best at referring their friends and family, and they share word of your expertise with potential new patients more effectively than you can ever imagine.” RCCL

1. The State of the Optometric Profession: 2013. American Optometric Association, Jobson Medical Information. 5-6.

How much money can you expect to generate from contact lens sales?

The unilateral pricing policy has set a profitability bar for optometrists in sales of specific lenses made by the manufacturers, says Dr. Krivacic. “The average net seems to be about $100 per annual supply sold for most basic spherical lenses. It’s slightly higher for torics and multifocals. Specialty lenses can generate much larger profits,” he says. “Personally, I concentrate more on the ability to profit from professional fees, and the fact that most contact lens patients return to the practice for their exams almost twice as often as a spectacle wearer does.”

For Dr. Bazan, his practice earns a net profit of $188 on all his best selling annual supplies of spherical monthly sales and $220 on his best-selling annual supplies of spherical daily disposables.

“The mix of product costs should be below 30% of gross sales,” suggests optometrist Clarke Newman of Dallas. In a large contact lens practice, roughly a third of the total cost of goods should be allocated to contact lens costs, he suggests. How you set your fees and retail costs determines the profitability of your overall contact lens enterprise, Dr. Newman adds.

Benchmarksfor ProductProfi tability



The ocular surface is the thin yet complex layer of defense against potentially devastating adverse

effects on the refractive ability of the eye. Its tear fi lm is comprised of nutrients, proteins and anti-infl ammatory components within a rich mucin-laden adhesive that is kept intact by an even thinner layer of meibum. The successful production of this muco-adhesive layer is dependent on an intact sensory-autonomic refl ex, comprised of a healthy corneal sensation and lacrimal gland function. This delicate homeostatic balancing act has no safety net to catch a failing ocular surface, with one exception: us.

Optometrists know fi rsthand how essential this layer is to maintaining the optical qualities that our patients demand. As innovation created new opportunities to care for patients, modern technology has provided patients with ways to correct their ametropia without the need for spectacles and contact lens materials and solutions have fl ourished. Such technological advancement has also been witnessed in the area of refractive surgery, which has

evolved from its rather primitive origins into a highly precise and predictable protocol for refractive error correction. However, the quality of these results still rests on the continued sustainability of that minuscule layer coating the epithelium. Any imbalance in the delicate system—comprised of a healthy and functioning tear fi lm plus a normal blink refl ex with well-positioned eyelid apposition—will ultimately lead to an unhealthy ocular surface.

The defi nition of refractive surgery has changed signifi cantly in the two decades since LASIK was approved, blurring the line between refractive and cataract surgeries. The use of smaller corneal incisions during cataract surgery and the ability to incorporate laser into our surgical suite, as well as the increase in lens options (both multifocal and toric) has repositioned the pseudophake under the refractive umbrella. Cataract surgery in particular has been made better with the introduction of the femtosecond laser; however, laser surgery also comes with some complications.

Virtually all laser eye surgery patients experience some degree of dry eye in the fi rst six months after surgery, with symptoms persisting

beyond that in nearly 20% of patients.1 Subclinical preexisting dry eye demonstrates the highest risk of long-term postoperative dry eye symptoms, possibly for up to 16 months postoperatively.1

Peak dryness in cataract surgery patients in particular occurs around one month after surgery, and may last longer than three.2 Some practitioners believe that the damage to the corneal nerve plexus during both cataract and refractive procedures leads to neurotrophic dry eye. The incisions used to enter the epithelium, deep stromal nerve changes during ablation, application of suction rings to the mucin-secreting goblets cells and microvilli all play a role in perpetuating infl ammatory dry eye.3 The increase in this dryness may also be exacerbated by the necessary use of topical medications, whereby their sequelae is toxic to the epithelium.

Dr. Bloomenstein is the director

of optometric services at the

Schwartz Laser Eye Center

in Scottsdale, Arizona. He is

a founding member of the

OCRT and a past-president

of the Arizona Optometric

Association.

ABOUT THE AUTHOR

PREPPINGthe Surgical Eye

014_RCCL1115_F2.indd 14014_RCCL1115_F2.indd 14 10/29/15 2:16 PM10/29/15 2:16 PM

PREPARATION

As partners in our patients’ desire to obtain the best quality of vision, we need to be able to recognize and treat any irregularities in the patient’s ocular surface. Thus, we need to identify these patients by any means necessary to prevent complications. Historically, we have relied on patient complaints or corneal staining to identify these abnormalities; however, these methods can be misleading since the predictive diagnostic value is not consistently high.

The fi rst step toward achieving a successful surgical outcome is to record a thorough medical history. Common preoperative and intraoperative risk factors for dry eye with refractive surgery include the depth of the laser incision, degree of preoperative myopia, female gender, contact lens use, diabetes and eyelid disorders; thus, the evaluation should include an examination of lid anatomy and function, blink rate and tear fi lm composition (including osmolarity). Clinicians should also inquire about patients’ concurrent use of systemic medications that may increase dryness, the frequency with which they use artifi cial tears and the humidity of their living environment, as these can

inhibit recovery following surgery. Note, patients with systemic infl ammatory diseases, such as Sjögren’s syndrome and rheumatoid arthritis, are often poor surgical candidates based on their pro-infl ammatory status.

IDENTIFICATION

Several procedures can help detect preoperative dry eye in cataract patients. Tear hyperosmolarity, defi ned as a tear concentration with a greater than average mOsm/L, is a highly accurate marker of dry eye and can also adversely affect cataract outcomes: one study found 21% of patients with hyperosmolarity had a measurement between 0.5D and 1.0D, and 16% had more than 1D of change in keratometry readings.4 The TearLab osmolarity test can be used both to identify dry eye and quantify its severity.

The presence of certain levels of matrix metalloproteinase (MMP) infl ammatory mediators can also

be used to indicate an abnormal ocular environment. Infl ammaDry (RPS) is one method of objectively determining the levels of MMP-9, which has been associated with infl ammatory dry eye disease.5

Tear analysis can also be used to assess dry eye conditions in pre-operative patients by exposing the tear fi lm and meibomian glands to a light source to highlight any abnormalities. Equally important is an assessment of the number and functional level of lipid-secreting meibomian glands, as well as an evaluation of meibum consistency. This can be done using meibography. In addition to evaluating meibum quality, gland integrity should also be considered. Using a transilluminator to evert the lid and viewing the


In many anterior ocular surgeries, good ocular

surface integrity is vital to postoperative success.

By Marc Bloomenstein, OD

TearLab can be used to quantify a patient's dry eye.


retroillumination at the slit lamp can be a way to see these glands without a meibography.

POSTOPERATIVE

EVALUATION

Because postoperative dry eye can compromise visual acuity and adversely affect an otherwise near-perfect visual outcome, it is important to evaluate the patient’s refractive ability postoperatively to ensure the results are adequate. Whereas in the past we could anticipate patients being within a diopter or two of the intended goal, we now measure success in quarter-diopter steps.

Dry eye can lead to different postoperative complications depending on the procedure. In the case of the KAMRA corneal inlay (AcuFocus), for example, which allows only central light rays to reach the retina through a 1.6mm diameter hole, the presence of dryness on the central aspect of the cornea can distort the fi nal image.

Cyclosporine is a useful treatment for reducing postoperative dry eye in patients with marked preoperative hyperosmolarity or tear fi lm abnormality. Starting your patient on a twice-daily dose of Restasis (Allergan), combined with an artifi cial tear that is refl ective of their lid and osmolarity readings, can foster a more hospitable environment. Typically, the patient should stay on this regimen for

a minimum of four to six weeks before measurements are retaken. Macrolide drops or lid scrubs such as HypoChlor (OcuSoft) can be used to reduce bacterial colonization on the lid margin to prevent infection, while warm compresses can help to soften meibomian gland issues. Punctal plugs are also extremely useful in the treatment of dry eye and can be placed before any surgery is performed; however, infl ammation should be reduced prior to insertion.

Lastly, nutritional therapy may also play an important role in preoperative treatment of dry eye. Fish oil containing eicosapentaenoic and docosapentaenoic polyunsaturated fatty acids have been shown to reduce infl ammation, while omega-3 fatty acids decrease infl ammation, increase tear production and may potentiate the regeneration of nerves.6 Directing patients to take high-dose capsules containing omega-3 and omega-6 fatty acids on a daily basis beginning one month before surgery can help maintain the tear fi lm.

Postoperative dry eye treatment should follow the same steps of detection and therapy as in the preoperative period. Note, however, since patients are now dealing with severed nerves and the potential adverse response to their medication, they should stay

on any therapy instituted prior to surgery. Restasis drops and artifi cial tears should be used for a minimum of 90 days postoperatively, with further testing to determine the long-term use. Lid disease should be treated on the same level. Additionally, check for variations in best-corrected visual acuity on every follow-up visit.

Patient expectations are increasing to match advances

in ocular surgery; thus, clinical management of the ocular surface before and after arguably becomes as critical to cataract and refractive surgeries as the actual surgical process. Evaluation of patients with diligence toward improving quality of vision and minimizing dry eye symptoms is a responsibility we all share. This is a process that should start from the moment the patient wants to improve their vision through any intervention—be it glasses, contacts or surgery. Yet, one can always stop wearing contacts or change the lenses in glasses; refractive surgical outcomes are not as pliable. So, remember: surgical success starts with a good consultation, diagnosis and unique ocular surface treatments. RCCL

1. Bailey, MD, Zadnik K. Outcomes of LASIK for myopia with FDA-approved lasers. Cornea. 2007;26(3):246-254.2. Li XM, Hu L, Hu J, Wang W. Investigation of dry eye disease and analysis of the pathogen factors n patients after cataract surgery. Cornea. 007 Oct;26(9 Suppl 1):S16-20.3. Oh T, Jung Y, Chand D, et al. Changes in the tear fi lm and ocular surface after cataract surgery. Jpn J Ophthalmol. 2012 Mar;56(2):113-8.4. Epitropoulos AT, Matossian C, Berdy GJ, et al. Eff ect of tear osmolarity on repeatability of kera-tometry for cararact surgery planning. J Cataract Refract Surg. 2015 Aug;41(8):1672-7.5. Kaufman HE. The practical detection of MMP-9 diagnoses ocular surface disease and may help prevent its complications. Cornea. 2013 Feb;32(2):211-6.6. Root M, Collier SR, Zwetsloot KA, et al. A randomized trial of fi sh oil omega-3 fatty acids on arterial health, infl ammation and metabolic syndrome in a young healthy population. Nutrition Journal 2013 Apr 8;8:40.

PREPPING THE SURGICAL EYE


Oculus meibography.


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A63-year-old female presented in the clinic for an eye exam for the fi rst time in fi ve years

with a best-corrected visual acuity of 20/40 OD and 20/30 OS, with glare disability of 20/80 OU. She reported decreased vision in both eyes and noted she often has diffi culty driving at night along with a dry feeling and occasional burning. The patient admitted she uses an unknown brand of eye drops to lubricate her eyes, which provides her with some temporary relief; however, she also stated concern that her symptoms were getting worse.

Following an examination, the patient was educated about chronic dry eye from decreased tear production and increased tear evaporation from meibomian gland dysfunction—the cause of her burning and dryness symptoms. The patient was also informed of the different surgical options and intraocular lens choices available for cataract treatment. The two, it turns out, go hand in hand. Cataract patients need a full dry eye workup to achieve the best possible outcome.

EXAMINING THE CATARACT

Considered the most common

cause of vision loss in patients over 40, cataract formation has been linked to a number of factors including exposure to ultraviolet radiation from sunlight and other sources, diabetes, hypertension, obesity, smoking and the use of certain medications.1-5 Cataracts can be subdivided into three types based on location: nuclear—the most common type—affects the middle of the lens, while cortical is located in the center of the lens and subcapsular affects the back. Subcapsular cataracts typically progress more quickly than the other two. Each type has different risk factors that contribute to its development, and each must be handled differently.6

Regardless of cataract type, however, many patients develop similar postoperative complications due to untreated ocular surface disease and residual refractive error, even as small as 0.50D.7,8 Uncontrolled ocular disease may lead to residual refractive errors of as much as 1.0D to 2.0D due to its effect on preoperative calculations, which can lead to incorrect toric IOL power or axis placement.9

Research has shown ocular surface disease can also limit the accuracy of preoperative testing like topography and biometry.10-12

So, why do so many patients end up with postoperative residual refractive error? Are the available technology options in fact limited for treating refractive error in our cataract patients? This article will review several corneal and ocular surface considerations to help practitioners successfully manage cataract surgery patients.

LIDS AND LASHES

The fi rst step to take when a patient presents for a cataract consultation is to perform a full ocular exam from the front to the back of the eye to identify any possible conditions that may limit visual outcome. Begin by looking at the external ocular adnexa. Look for any redness of the face or periorbital area, rhinophyma or other classic signs of rosacea. Finding signs of rosacea can alert you to more advanced meibomian gland dysfunction. Perform a gross examination of the periorbital

Dr. Johnston practices at

Georgia Eye Partners in

Atlanta, GA, where he

serves as the clinical

director and residency

director. He focuses on

ocular surface disease and

has experience in comanaging

cataract and refractive surgery patients.

ABOUT THE AUTHOR

Both conditions require attention and intervention.

The Cataracta Dry


anatomy to identify any lid dermatochalasis that might cause functional limitations on vision. If the patient has droopy eyelids or dermatachalasis, vision can be limited from these functional problems that can decrease the visual fi eld.

After examining the ocular adnexa, focus on the lids. Demodexis an often ignored and untreated problem that can cause ocular surface issues and other chronic symptoms of itching, irritation and discomfort. This can compound dry eye symptoms that can be made worse after surgery, as patients are often using three to four preserved topical eye drops. If a diagnosis of Demodex is confi rmed by plucking a few eyelashes and viewing them under magnifi cation with a microscope, there are a variety of treatment options available today, including commercially prepared kits for in-offi ce administration. Many prescription and OTC treatment options offer a wide range of effi cacy against severe and mild cases of Demodex. Lid scrubs and other cleaners contain various combinations of tea tree oil preparations and other active therapeutic ingredients.

Blepharitis is another common complication—up to 59% of patients undergoing cataract

surgery present with this disease.13 Classifi ed as either anterior or posterior and chronic or acute, the disease can lead to an array of complications. In the case of cataract patients, anterior blepharitis in particular must be treated prior to surgery by having the patient clean the eyelid margin with prescribed lid hygiene scrubs, foams or cleansers. This decreases the load of bacteria around the lids and reduces the chance of postoperative endophthalmitis. Signs and symptoms of staphylococcalblepharitis—the most common type of anterior blepharitis seen in practice—include lid irritation, scurf, erythema, loss of lashes, crusting and matting with lid debris and red irritated eyelids. Patients with chronic staphylococcalblepharitis are also at increased risk for hordeolum and staphylococcalblepharoconjunctivitis.

As with any lid disease, good lid hygiene is critical to successfully managing staphylococcalblepharitis; I typically prescribe lid cleansing products that contain hypochlorous acid BID for two weeks, then QD as symptoms

improve prior to cataract surgery. Presentations of more severe or

chronic staphylococcal blepharitis are typically characterized by some eyelid infl ammation. Treatment for these cases involves use of topical antibiotics like topical azithromycin, and/or topical antibiotic/steroid combinations, or both, in addition to lid hygiene regimens. Infectious staphylococcusshould be treated with an antibiotic ophthalmic ointment or drop to prevent continued issues. The inclusion of a steroid—as in the case of combination drugs—can also help decrease infl ammation resulting from the infection.

Oral medications such as doxycycline dosed at 50mg BID PO or a dose pack of oral azithromycin tapered over fi ve days can be used


By Josh Johnston, OD, FAAO

Patient is

Eye Patient

Pseudophakia and severe dry eye from Graft-

versus-host disease.

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: Ch

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to treat chronic staphylococcal blepharitis. A comparison of the safety and effi cacy of these two in the treatment of patients with meibomian gland dysfunction who had failed to respond to prior conservative management found both drugs improved signs and symptoms signifi cantly, with one caveat: ocular surface staining and bulbar conjunctival redness were signifi cantly better in the azithromycin group, suggesting it may lead to a better overall clinical response with shorter treatment duration.14

OCULAR SURFACE

Both aqueous-defi cient dry eye and evaporative dry eye caused by meibomian gland dysfunction must be treated prior to surgery to prevent complications from ocular surface disease. Typically, I feel most dry eye patients present with both types, and so are treated concurrently. A study looked at the prevalence of these two forms of

dry eye and found 49% of patients had evaporative dry eye disease, 14% had aqueous defi cient and 35% had both forms.15

Common management approaches begin with a baseline palliative treatment using artifi cial tears. If meibomian gland dysfunction and evaporative dry eye are the primary issues, lipid-based artifi cial tears can be used to supplement the lipid layer, which is often depleted or even missing entirely. For aqueous-defi cient dry eye, artifi cial tears can provide relief. These can be used four times a day; however, if application is needed more frequently due to continued patient symptoms, more viscous tears or nonpreserved artifi cial tears can also be used. More viscous tears have a longer residence time, offering longer periods of symptomatic relief. Patients with lagophthalmus and incomplete nocturnal lid closure can also be prescribed nighttime ointments, sleep goggles and

THE CATARACT PATIENT IS A DRY EYE PATIENT


The Prospective Health Assessment of Cataract Patients’ Ocular Surface (PHACO) conducted by William Trattler, MD, sheds light on just how dispropor-tionately cataract patients are aff ected by ocular sur-face disease. The purpose of the study was to deter-mine the prevalence of dry eye in patients undergoing cataract surgery. The results were very compelling:16

• 171 eyes (62.9%) had a tear break-up time of less than fi ve seconds.

• 209 eyes (76.8%) showed positive corneal staining.

• 136 eyes (50%) showed central corneal staining.

• Shirmer scores: 132 eyes (48.5%) had a score of 10 or less, and 58 eyes (21.3%) scored less than fi ve.

Not only does this segment of patients have a higher percentage of clinically sig-nifi cant dryness and meibo-mian gland dysfunction, but these two chronic diseases are often ignored and not properly diagnosed and treated.

Dry Eye in Cataract

Patients: Prevalent

and Pervasive

Subconjunctival hemorrhage after cataract surgery.

Ph

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Other anterior segment and corneal problems that can limit surgical outcomes need to be diagnosed prior to surgery. These include:

• Anterior basement membrane dystrophy

• Salzmann’s nodular dystrophy

• Fuchs’ corneal dystrophy or non-Fuchs’ corneal guttata, which creates a higher risk for postoperative corneal edema and damage to the endothelium, resulting in decreased vision

• Corneal scars

• Lagophthalmos

• Exposure keratitis

There are also several complications that can arise following surgery. These include:

• Acute increased IOP from retained viscoelastic, causing corneal edema or microcystic corneal bullae

• Wound leak, causinghypotony

Keep An Eye Outhumidifi ers to help with dryness. For clinically signifi cant dry

eye, immunosuppressive topical drops like cyclosporine 0.05% BID and ester-based steroids used short-term can be used to relieve infl ammation. Studies have suggested nutritional supplements such as EPA, DHA, GLA, omega-3 and omega-6 may also reduce infl ammation, increase tear production and improve meibomian gland secretions. Use of lid scrubs and lid massage after application of heat with eye masks may also improve secretion from the meibomian glands. Meibomian gland expression and meibomian gland probing are other therapeutic options for more advanced gland obstruction. Topical antibiotics, steroids and combination topical drops and ointments can be effi cacious in treating meibomian gland dysfunction.

NEW IOLS

The newest generation of multifocal IOLs approved for use in the United States aim to achieve good distance, intermediate and near vision while decreasing glare and halos. This is done by altering the lens design, including the optics, of earlier multifocal IOLs. Reducing the number of diffractive rings decreases the add power. This reduces the diffractive or refractive surface area, allowing less light scatter to decrease glare and halos. Aspheric IOLs also allow for better mesopic contrast sensitivity for better vision at night and improved distance vision. Even though the add powers are decreased, the lower add multifocal IOLs are said to actually deliver better near and intermediate vision than the higher add IOLs while decreasing symptomatic glare and halos.

Cataract surgery has evolved to now be a refractive

procedure, giving our patients more options than ever before. The current treatment options are safe, accurate and can treat all types of refractive errors. Staying abreast of the latest advancements is essential to being a part of the co-management process. RCCL

1. Roberts JE. Ultraviolet radiation as a risk fac-tor for cataract and macular degeneration. Eye Contact Lens. 2011 Jul;37(4):246-9.2. Obrosova IG, Chung SS, Kador PF. Diabetic cataracts: mechanisms and management. Dia-betes Metab Res Rev. 2010 Mar;26(3):172-80.3. Glynn RJ, Christen W, Manson JE, et al. Body mass index. An independent predictor of cataract. Arch Ophthalmol. 1995;113:1131-7.4. Ye J, He J, Wang C, et al. Smoking and risk of age-related cataract: a meta-analysis. Invest Ophthalmol Vis Sci. 2012 Jun 22:53(7):3885-95.5. Urban RC Jr, Cotlier E. Corticosteroid-induced cataracts. Surv Opthalmol. 1986 Sep-Oct;31(2):102-10.6. Foster PJ, Wong TY, Machin D, et al. Risk factors for nuclear, cortical and posterior sub-capsular cataracts in the Chinese population of Singapore: the Tanjong Pagar Survey. Br J Opthalmol. 2003;87:1112-20. 7. Roberts CW, Elie ER. Dry eye symptoms following cataract surgery. Insight. 2007 Jan-Mar;32(1):14-21.8. Alio JL, Abdelghany AA, Fernandez-Buena-ga R. Management of residual refractive error after cataract surgery. Curr Opin Opthalmol. 2014 Jul:25(4):291-7. 9. Tu E. Cornea Day, ASCRS 2011. 10. Kim P, Plugfelder S, Slomovic A. Top 5 pearls to consider when implanting advanced-technology IOLs in patients with ocular surface disease. Int Ophthalmol Clin. 2012;52(2):51–8. 11. Goldberg D. Preoperative evaluation of pa-tients before cataract and refractive surgery. Int Ophthalmol Clin. 2011;51(2):97–107. 12. Ram J, Gupta A, Brar G, et al. Outcomes of phacoemulsifi cation in patients with dry eye. J Cataract Refract Surg. 2002;28(8):1386–9.13. Luchs J, Buznego C,Trattler W. Prevalence of blepharitis in patients scheduled for routine cataract surgery. Poster presented at: ASCRS Symposium on Cataract, IOL and Refractive Surgery. April 11, 2010;Boston, MA.14. Mohsen BK, Fazel AJ, Kiavash V, et al. Oral azithromycin versus doxycycline in meibo-mian gland dysfunction: a randomized double masked open label clinical trial. Br J Opthal-mol. 2015 Feb;99(2):199-204.15. Lemp MA, Crews LA, Bron AJ, et al. Distri-bution of aqueous-defi cient and evaporative dry eye in a clinic-based patient cohort: a ret-rospective study. Cornea. 2012 May;31(5):472-8.16. Trattler W, Goldberg D, Reilly C. Incidence of concomitant cataract and dry eye: prospec-tive health assessment of cataract patients. Presented at: Wold Cornea Congress; April 8, 2010;Boston, MA.




Since the early 1990s, more than 17.4 million eyes have undergone excimer laser vision correction

(i.e., PRK, LASIK and LASEK) worldwide. The procedure could be said to be the most successful refractive surgery based upon the absolute number of procedures performed—and also one of the most controversial. Entire web sites are devoted to publicizing poor surgical outcomes and marketing misrepresentations, both real and perceived. Critics argue that surgeons fail to adequately disclose the risks associated with the procedure and overpromise on results.

Surgical procedures such as LASIK can be seen as both success stories and failures at the same time, depending on one’s evaluation criteria. Baseball legend Reggie Jackson is still considered one of the premier power hitters in the sport, but he also holds the dubious distinction of most recorded strikeouts. LASIK, too, has achieved successes that few other surgeries have matched, but still has failed to reduce complication rates to negligible levels. Complications well documented in the literature include post-

surgical irregular astigmatism, epithelial ingrowth into the fl ap interface, postoperative dry eye and over- and undercorrection. Post-surgical interventions—such as surgical retreatment, corrective lenses, ocular surface therapies—remain higher than patients or practitioners would like.

Our practice is one of the US sites engaged in studies of a new procedure striving to overcome these limitations. This article shares our anecdotal impressions and provides an overview of the concept. Note: the surgical procedure was developed in conjunction with Carl Zeiss Meditec, and our practice receives research funding and consultation fees as part of its ongoing development.

LESS IS MORE

Currently, our practice and four others in the United States are investigating a new refractive surgery technique that seeks to reduce complications, side effects and retreatments needed compared with excimer-based methods. All-femtosecond corneal refractive surgery—known as small-incision lenticule extraction (SMILE)—differs from traditional LASIK in that the excimer laser is not used for tissue sculpting, nor

is any photoablation performed. Instead, a lenticule of tissue is created using the femtosecond laser and removed manually through a short arc-length incision.

Additionally, rather than creating a hinged-fl ap lift, two passes of the femtosecond laser are performed: the fi rst pass creates the posterior aspect of the lenticule and a peripheral stromal bed, while the second creates the anterior surface of the lenticule and one or two small access incisions of approximately 60 degrees at the 7.5mm optical zone. This gives the surgeon an entrance to dissect the remaining corneal attachments of the anterior and posterior surfaces and remove the lenticule through a small incision, usually 3mm or less.

By John F. Doane, MD, and Jace J. Rickstrew, BS

Something to

SMILE About?

John F. Doane, MD, FACS,

is a cornea and refractive

surgeon with Discover Vision

Centers in Kansas City, MO.

He is also Clinical Assistant

Professor at Kansas University

Medical Center Department of

Ophthalmology.

Jace Rickstrew is currently a

second-year medical student

at the University of Kansas.

ABOUT THE AUTHORS

How does the newest refractive procedure measure up against LASIK?


The SMILE procedure was developed at six sites on three continents. Reported clinical outcomes suggested refractive results that mirror current LASIK outcomes, with predictability measures indicating that 95% of the eyes are +/- 0.5D from refractive target. With SMILE, outcomes are similar for low, moderate or high myopia; the same cannot be said for LASIK, where refractive accuracy diminishes as myopia increases.

Effi cacy rates for the SMILE procedure from international study centers have demonstrated that 95% of treated eyes achieve at least 20/30 uncorrected distance visual acuity at three months for even moderate to high myopia levels (data on fi le, CZM). Safety results seem promising, with only 1% to 2% of eyes losing two or more lines of best spectacle-corrected visual acuity. Refractive stability is typically achieved at one week, with little to no change seen between this interval and the one and three month data sets.

SUMMARY OF BENEFITS

The advantages of the SMILE concept are numerous. The use of femtosecond laser technology reduces the invasiveness of the procedure and also removes the

possibility of fl ap dislocation. Additionally, the cornea inherently maintains a greater biomechanical structure and fewer corneal nerves are incised; as a result, a lower frequency of dry eye complaints and a shorter healing cycle are expected. As in LASIK, contact lenses can be worn after SMILE.

However, because of the newness of the procedure, several considerations remain unknown. At this point, we have limited data on procedure success and complications beyond fi ve years.

Our experience with other lamellar techniques suggests that we may be able to surmise that what we see early (i.e., at three months) will persist long-term (i.e., beyond fi ve years), but this remains speculative at this time. More research is also needed on certain details of the procedure. For example, can small refractive errors (i.e., 1D or less) be effectively treated, and what approach will be taken for small residual refractive errors after an initial SMILE procedure has been performed? With LASIK, we do

ReLEx smile< 4 mm minimal-invasive inzision

LASIKca. 20 mm Flap Side-Cut

ReLEx smile: Ø 7,5 mm

LASIK: Ø 9,0 mm inkl. Übergangszone


Diff erence in corneal incision in LASIK vs. SMILE. 1

The SMILE procedure was d l d t i it th

possibility of fl ap dislocation.Additi ll th i h tl

Our experience with other lamellart h i t th t

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treat less than 1D for primary procedures and enhancements. Enhancements with SMILE are currently done by creating a LASIK fl ap or performing a PRK procedure.

There are at least a handful of theoretical and speculative benefi ts of SMILE as compared to LASIK. Eliminating fl ap creation

leads to complete avoidance of fl ap displacement, dislodgement and slippage with associated epithelial ingrowth. Additionally, because of its minimally invasive nature, the procedure negligibly violates Bowman’s layer and excises less of the anterior stroma. SMILE’s diameter of treatment fi eld is typically 7.5mm, while

in LASIK the treatment fi eld is usually at least 8.5mm. This smaller diameter leads to improved corneal tensile strength by preserving the

most biomechanically signifi cant anterior one-third of the cornea. Since there is greater preservation of the anterior cornea with less corneal nerve interruption, one would speculate that fewer dry eye complaints from neurotrophia would occur.

Another unique feature of SMILE is that it is completed intrastomally—for all intents and purposes, it is completed in a vacuum. By contrast, the excimer laser energy must traverse the fi nal lens in the optical train of the laser

SOMETHING TO SMILE ABOUT?


A SMILE procedure: (A) A femtosecond laser creates a lenticule of tissue and an access port; (B) the surgeon dissects between

tissue planes anteriorly and posteriorly of the lenticule; (C) the lenticule is detached and removed through the corneal incision in

a "rhexis"-like procedure similar to that of cataract surgery; (D) the lenticule is then placed on the front of the corneal epithelium

for inspection. To view a video of this proceudre, scan the QR code below or visit www.reviewofcontactlenses.com.

A B

C D

To see a video of

this procedure, please visit

www.reviewofcontactlenses.com,

or scan the QR code.


and pass the air environment of the working distance to the environmentally exposed corneal surface. Because of this, certain factors must be considered during the LASIK procedure—namely, air purity, humidity, barometric pressure and temperature of the operating room—that can affect the photoablation ability of the excimer beam and the amount of dry cornea removed with each pulse. This results from variable hydration of the tissue, which is dependent on the time from start to fi nish of the photoablation. In addition, this can change from case to case and surgeon to surgeon, in the same and variable environments. By performing the refraction treatment intrastromally, the SMILE procedure eliminates such variables. This explains why a -10D treatment is just as predictable as a -1D treatment with SMILE, compared with comparable excimer laser treatments. Similarly, in my personal experience, I have found a -1D SMILE procedure is just as predictable as a -1D excimer laser correction.

Despite these perceived benefi ts, only time will tell if SMILE can compete on the playing fi eld of a commercial refractive practice. More research is needed to determine the predictability, effectiveness, stability of result, safety and quality of vision of the procedure, as well as reversibility and adjustability, minimal wound healing, immediacy of fi nal refractive outcome and comparison with other vision modalities such as glasses and contact lenses. Although fl ap complications are obviated, other complications typical of refractive surgery (e.g., ectasia, residual refractive error, dry eye, infection, infl ammation) are possible—but less likely, given the increased structural integrity and less invasive nature of the SMILE procedure.

Procedure counts provide an indication of SMILE’s ability to compete with LASIK. Approximately

20,000 SMILE procedures were performed by December 2012; this increased to 50,000 by the end of July 2013. Carl Zeiss Meditec reports that 200,000 eyes have undergone SMILE worldwide since February 2015 (data on fi le, CZM). It is clear SMILE is gaining interest among surgeons throughout the world. Pending FDA approval, will the same hold true for surgeons within the US? As more data continually becomes available, it will likely tell us what impact a femtosecond laser could achieve as a stand-alone refractive surgical device. RCCL

1. Premium Eyes. Available at: www.premiumeyes.de/de/augenlasern/relex-versus-lasik. Accessed October 23, 2015.

COMING IN

DECEMBER...

A comprehensive guide to optometric education events.

The Review of Optometry

2016 Conference Planner

This special supplement to

December 2015 Review

of Optometry will

list all known CE-

accredited meetings

and conferences

currently slated

for 2016 as of press

time—from local and

state events all the way

up to the major conferences.

DON’T MISS OUT!

READER COMMENTS FROM LAST ISSUE

• Dates, locations, key faculty, number of credit hours available, contact information and registration instructions for each optometric CE meeting scheduled for 2016 (at press time).

• Simple at-a-glance calendars that list every educational event, month by month throughout 2016 for easy reference.

• An online edition will enhance and extend the content with new meetings added throughout the year as details are released.

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When fi tting contact lenses for a compromised cornea,

practitioners must remain aware of the complex challenges inherentthe processes that relate to vision, comfort and ocular health. First and foremost, patients expect good vision. In some cases, this is easy to achieve; in others, trial fi tting is essential to fi nding the right lens. A patient can perceive and process basic visual information without having achieved adequate functional vision. Optical aberrations induced by a compromised ocular surface can create too much visual noise and distraction to allow the patient to be able to see comfortably.

Empirical fi tting in such circumstances leaves too much unanswered; trial fi tting allows you to determine the patient’s ability to tolerate the lens, assess lid comfort and perform an overrefraction to determine an expected visual outcome. The true test comes after the initial design is dispensed, however—only then can you adequately assess how well corneal health is maintained. Note, visual expectations vary based on a patient’s lifestyle and daily activities. Some—for example,

surgeons and aviators—have extremely high visual demands that do not allow for subpar vision.

Beyond visual acuity, it is important consider on-eye comfort; an uncomfortable lens can have a life-altering impact on the patient. Patients have varying comfort thresholds: some will adapt just fi ne, while others can experience minor discomfort and a few may report excruciating pain. In patients who have undergone multiple surgical procedures and lens fi ts, managing patient expectations is especially fundamental to overcome pessimism and encourage good compliance.

From an ocular health standpoint, patients with compromised corneas can be especially sensitive to debris build-up under the lens or to lenses not staying clean throughout the day. They are also susceptible to dryness and discomfort with increased wearing time, particularly when blinking is reduced while performing prolonged near tasks. Thus, it is important to always be proactive about ocular allergies in patients with compromised corneas, as they have an especially diffi cult time tolerating allergic compromise.

Finally, ensure good corneal health with a lens and fi t that offers

adequate oxygen and minimal interference of normal corneal physiology. Similarly, as the CLEK study shows, apical clearance is important in patients with keratoconus and scarring.

CASE IN POINT

In 2014, I was faced with one of the most unique and challenging cases I’ve encountered in my many years of practice. The patient’s history was truly stunning, as was his central corneal topography, which was the worst I have ever seen. Over the years, this keratoconus patient had undergone several surgeries, both in the US and internationally, aimed at improving his functional vision. In fact, he had already undergone RK three times in his right eye and once in his left eye, two corneal transplants, DALK/AK three times, and a cataract extraction.

To further complicate matters, the patient’s medical records

Staying in Shape:

Post-Surgical Keratoconic

Lens Placement

Dr. Super is the founder of a

specialty contact lens and

primary care practice in

Brentwood, Los Angeles;

assistant clinical professor at

Salus and Western College

of Optometry; Immediate Past

Chair of Optometry at Cedars Sinai Medi-

cal Center; and Optometry Advisor for

Eye Defects Research Foundation.

ABOUT THE AUTHOR


contained several obvious inconsistencies, making it diffi cult to ascertain the rationale for so many surgeries and impossible to piece together an accurate timeline. Nonetheless, I was committed to fi nding a nonsurgical solution for this patient.

The 45-year-old Italian male was referred to my offi ce in October 2014 to determine whether his vision could be improved without another surgery. He had recently presented to a local ophthalmologist here in the US with complaints of distorted vision. The MD concluded

that the distorted vision was likely due to irregular astigmatism OD, which did not improve signifi cantly with refraction. As such, the patient was now considering PTK. In light of his long and complicated surgical history, the ophthalmologist referred him to me with the hope that we might fi nd a nonsurgical intervention.

The referring ophthalmologist diagnosed the patient with dry eye syndrome and recommended use of artifi cial tears three to four times per day. The patient was also administering prednisolone acetate 1% TID in the right eye to prevent complications from a recent cataract extraction. Systemic history included seasonal allergies.

DIAGNOSTIC DATA

The patient presented in my offi ce with a corneal scar and irregular astigmatism OD as well as dry eye. The central zone of the cornea was not smooth. Best vision correction was as follows:OD 20/70 PH 20/50+ +0.50/-2.75 x 170 20/40-3

OS 20/100 PH 20/25- -1.75/-1.75 x 045 20/ 30-1

IOP was 13mm Hg OD and 15mm Hg OS. Pachymetry revealed 396µm OD and 603µm OS. Corneal topography is shown in Figures 1 and 2.


Can additional surgery be avoided in a keratoconus patient who requires better functional vision?

By Paul Super, OD, FAAO

Table 1. Diagnostic Trial Lenses and Failed Lens Designs

Fig. 1. Topography OD. Fig. 2. Topography OS.

Eye: Lens Base Curve Overall Diameter Power Central Fit Peripheral Fit

OD: Rose K2 XL 7.4 14.6 -2.00 Slight SteepAlignment with no

seal off

OD: Rose K2 XL 7.6 14.6 -1.00 AlignmentGood PC alignment

with no seal off

OS: Rose K2 XL 7.6 14.6 -1.00 Flat Too much edge lift

OS: Rose K2 XL 7.1 14.6 -5.00Lens

popped out

OS: Rose K2 XL 6.7 14.6 -9.00 Flat Edge lift; steepen PC

Dispensed Lens OD: Rose K2 XL

7.6 14.6 -0.25 AlignmentGood PC alignment

with no seal off


Due to corneal instability and the patient’s irregular corneal surface, we initially tried three different approaches—all of which were unsuccessful. Scleral lens designs that vaulted the cornea caused a central air bubble, which consistently created epithelial loss. When we tried semi-scleral lens designs, they also failed due to spoiling and the cornea’s inability to tolerate the mechanical fi t and physiological compromise of the lenses. Next, we tried to piggyback a scleral lens over a soft lens, but this too was unsuccessful. Table 1illustrates our experiences during these trials.

During the course of fi tting various diagnostic lenses, the patient made the decision to be fi tted for his right eye.

At the follow-up visit, the patient displayed dry central pooling and central epithelial loss. I had exhausted all the options likely to work and had to try something outside of what I previously would have considered. Our next option was to design a lens that aligned over the central optical zone with lid attachment. We trialed the reverse geometry lenses shown in Table 2.

By December 10, 2014, we had designed and dispensed the lens. The reverse geometry corneal lens aligned over the central optical zone while the lid attachment allowed for a more customary fi t profi le. The patient reported the 11mm diameter of the lens was comfortable and examination indicated it supported the ocular health of the cornea. Subsequent follow-up visits showed good vision (i.e., 20/25) and lens toleration. There was no staining on removal and the patient reported he was able to wear the lens during waking hours.

DISCUSSION

It is well known that post-surgical corneas present specifi c challenges. Inadequate visual acuity and optical aberrations resulting from post-surgical procedures have a signifi cant impact on quality of life. To complicate matters, these corneas tend to be unstable due to thickness and rigidity of the surface; thus, predicting outcomes can be diffi cult.

The challenge in this case was to fi t a lens that would improve vision over a cornea that had already been surgically treated multiple times. I did not want to subject this patient to any more surgery. However, as I began fi tting lenses, everything I thought would work didn’t work well at all.

After the fi rst round of fi tting, the patient returned complaining of a scratchy feeling, and that he couldn’t wear the lenses for more than a couple of hours. As such, regardless of the patient’s history, such a fi t could not be considered a suitable solution. Qualitative responses are every bit as important as visual acuity when it comes to functional vision. Corneal anatomical shape factor, lid forces, optical power of the lens (i.e., thickness) and tear quality all impact outcomes. Furthermore, visual acuity alone does not provide enough tangible information on how a patient sees. It disregards visual noise.

We have to use all technologies, past and present, to fi nd

suitable solutions for patients like this one who continue to struggle with poor functional vision after surgery. As this case illustrates, we are sometimes called upon to dig deep into our toolboxes and try things we never previously considered. It can be time consuming and it can test our skills and fortitude as optometrists. However, it’s cases like this one that draw attention to our unique and specialized skill set and clearly demonstrate the profound effect that nonsurgical options can have on patients’ everyday lives. RCCL

Thank you to my friend and colleague Alan Saks, OD, for his help, as well as Art Epstein, OD, and Barry Eiden, OD, for their valuable suggestions.

STAYING IN SHAPE: POST-SURGICAL KERATOCONIC LENS PLACEMENT


Table 2. Reverse Geometry Lens Trials

Right Eye Base CurveOverall

DiameterPower Optic Zone Peripheral Fit

8.54 10.0 +0.75 6.5 49.25/6.85/0.643.00/7.85/1.030.75/11/0.4

8.54 11.0 +1.75 6.5 49.25/6.85/0.643.00/7.85/1.030.75/11/0.4

The fi nal lens fi t OD.

Baseline OS.


Approval pending

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RESHAPING THE OUTCOME:

CORNEAL ASTIGMATISM CORRECTION DURING CATARACT SURGERY

Surgeons have more options—and decisions—than ever before.

By Harmohina Bagga, MD, and Kerry K. Assil, MD

Cataract surgery has evolved from a high-risk medical procedure that once required a hospi-

tal stay to the most commonly performed refractive procedure worldwide. Its ubiquity has given surgeons ample opportunity to refi ne the outcomes with great precision. Advancements in pre- and intraoperative diagnostic testing and surgical techniques, as well as increased availability of premium intraocular lens (IOL) implants, have escalated patient expectations, thus mandating con-sistently accurate management of pre-existing astigmatism in order to deliver on expectations.

When planning astigmatism correction, consider the magnitude and axis of the astigmatism, corneal pachymetry, incision location, degree of irregular or asymmetric astig-matism, desired entry site, corneal pathology, patient age and the status of the fellow eye. Since most eyes exhibit against-the-rule astigmatism over time, some surgeons advocate an under-correction of with-the-rule

cylinder. Furthermore, mild astig-matism of about 1D with or against the rule with a spherical equivalent of -0.5D may aid in expanding the depth of focus.1

Research has suggested that re-sidual with-the-rule astigmatism may favor better uncorrected distance acuity (as most visual stimuli are of a vertical nature), with residual against-the-rule cylinder improving uncorrected near vision.2,3

Measurement modalities also weigh into the equation. Corneal power is typically calculated using a keratometric refractive index of 1.3375D, which is the power of a hypothetical single refractive surface without factoring in the curvature of the posterior corneal surface. Since the advent of slit-scanning topogra-phy and Scheimpfl ug imaging, the impact of posterior corneal astigma-tism has been revisited. Because of the opposing power of the anterior and posterior corneal surfaces, the vector difference between the magnitude of keratometric astigma-tism and total corneal astigmatism is higher than 0.50D in up to 28.8% of eyes.4 The difference between

the location of the steep meridian in keratometric astigmatism vs. the total corneal astigmatism is higher than 10 degrees in more than 17% of eyes.3 However, some reports did not identify this compensatory effect of posterior corneal astigmatism, but rather found that the total corneal astigmatism exceeded the kerato-metric astigmatism.5

PREOPERATIVE

MEASUREMENT

No single method has been identi-fi ed as being the most accurate for

Dr. Bagga is a board-certifi ed,

fellowship-trained cataract

and glaucoma specialist, She

joined the Assil Eye Institute

in Los Angeles as head of its

glaucoma services in March

2015.

Dr. Assil is regarded as one of the world’s

foremost experts in refractive surgery,

having made signifi cant

advances in the fi eld with

his numerous inventions. He

has trained thousands of

eye surgeons in the latest

refractive surgical techniques

and has authored more than one

hundred textbooks, textbook chapters

and articles on refractive surgery.

ABOUT THE AUTHORS

1 CE Credit

(COPE Approval Pending)

030_RCCL1115_F6_CE.indd 30030_RCCL1115_F6_CE.indd 30 10/29/15 2:05 PM10/29/15 2:05 PM

measuring true astigmatism. Though refraction is an important compo-nent of preoperative evaluation, the presence of a cataract will call into question its reliability due to subjec-tive error. Accurate keratometry and corneal topography are essential in the planning and management of astigmatism; however, it is impor-tant to ensure absence of dry eye, excessive pooling of tears, blinking, fi xation errors and misalignment to obtain good quality, reliable scans, since tear fi lm abnormalities can introduce artifactual irregular astig-matism. Commonly used methods to assess preoperative astigmatism in-clude keratometry (optical biometry, manual biometry, or both) and cor-neal topography (e.g., Placido-based, slit-scan imaging and Scheimpfl ug imaging). Both measurements need to be assessed and taken into consid-eration.

The Cassini Corneal Shape Ana-lyzer (i-Optics) is a relatively new device designed to measure anterior and posterior corneal curvature to create a complete picture of the cornea. It uses multicolor LED ray-tracing technology to capture radial and circumferential measurements with an accuracy of less than 2µm, which results in precise corneal axis measurements to within three de-grees (as compared with 13 degrees with Placido technology) and the magnitude to within clinical margins (2%).

One of the key elements in the precise management of astigmatism is prevention of the bias induced by cyclotorsion of the eye intra-operatively. The Cassini registers and digitally records conjunctival features and vessels, as well as the exact location of the visual axis and the magnitude of astigmatism. Intra-operatively, the Cassini can link to femtosecond laser-assisted cataract surgery platforms or 3D intraop-

erative imaging and guidance to assist with the proper align-ment and positioning of the incisions and IOL.

Intraoperative aber-rometry has mini-mized the guesswork in refi ning outcomes. The ORA (short for optiwave refractive analysis, Alcon) intra-operative aberrom-eter is a miniaturized wavefront device that attaches onto the bot-tom of nearly any oper-ating microscope and works using a Talbot-Moiré waveform aberrometer to measure the optical power of the eye at the time of surgery. It takes into account anterior and posterior corneal astigmatism, as well as axial length, to generate IOL power and astigmatism measurements. It has proven to be an essential tool, especially in eyes with previous refractive surgery or in instances where topography and keratometry measurement do not correlate. Stud-ies have reported more than a 50% increase in accuracy with use of the device in eyes with previous myopic LASIK or photorefractive keratec-tomy, compared with the surgeon’s best preoperative choice, the Haigis L formula and the Shammas IOL formula.6

Note, some important guidelines to obtain accurate measurements

include ensuring a smooth corneal surface, maintaining physiologic IOP, absence of corneal edema from stromal hydration of the wound, thorough washout of dispersive vis-colelastic from the eye and absence of air bubbles/cortical matter.

TREATING ASTIGMATISM

There are a number of methods to reduce astigmatism prior to and during cataract surgery, depending on the magnitude of astigmatism. The simplest way is to position the cataract incision on the steep axis to induce wound fl attening, which results in a decrease in cylinder. This technique works well in patients with pre-existing astigmatism of less than 1.0D7 However, some limita-tions with this approach include unpredictable healing of the corneal incision with inconsistent results,

Release Date: November 2015Expiration Date: November 1, 2018Goal Statement: This course reviews surgi-cal treatment options for managing astig-matism, including complications.Faculty/Editorial Board:

Harmohina Bagga, MD, andKerry K. Assil, MDCredit Statement:

COPE approval for 1 hour of continuing

education credit is pending for this course. Check with your state licensing board to see if this counts toward your CE require-ments for relicensure.Joint-Sponsorship Statement: This continuing education course is joint-sponsored by the Pennsylvania College of Optometry.Disclosure Statement: Dr. Bagga and Dr. Assil have no financial interest in any products mentioned.


A limbal relaxing incision is commonly combined with

a toric IOL when the need for astigmatism correction

exceeds the toricity of currently available IOLs.

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, MD


and diffi culty placing the incision at certain axes, especially in patients with prominent brow or nasal bridge. Another technique, limbal relaxing incisions (LRIs), involves the placement of incisions cor-responding to the steep meridian, which leads to corneal fl attening and a reduction in astigmatic power. The advantage to this approach is the re-sulting coupling effect, in which the amount of fl attening that occurs in the incised meridian is nearly equal to the amount of steepening that occurs 90 degrees away, with little resulting change in spheroequivalent. This obviates the need to make any change in implant power and, when coupled with intraoperative aber-rometry, can be used to treat up to 3.0D of preoperative cylinder.

Several nomograms are avail-able to calculate accurate location and length of LRIs. The length is usually expressed in degrees of arc or clock hours, rather than chord length, to diminish overcorrections and undercorrections for unusually small or large corneas. Practitioners must keep in mind that the goal is to reduce the patient’s cylinder without overcorrecting or shifting the resul-tant axis. While some surgeons pre-fer an empiric blade depth setting, our preference is to use adjustable diamond blade depth settings based on pachymetry. Readings should be set at 90% depth of the perilimbal corneal thickness.

Patients who have undergone radial keratometry surgery require smaller sized incisions or alternate techniques such as toric IOLs or enhancement with PRK/LASIK to address astigmatism. Our preference is to perform the LRI after inserting the IOL; we use the ORA to confi rm magnitude and axis of astigmatism and then re-measure the residual astigmatism, making depth or length refi nements based upon the readings.

To correct high levels of astigmatism, usually above 4.0D, LRIs may be used in conjunction with a toric IOL or excimer laser surgery. However, success of LRIs can be limited by lack of precision, variable healing response and regression.8-11

Femtosecond laser-assisted arcuate incisions offer the potential advantage of being more precise with improved accuracy and safety and enhanced reproducibility than manual incisions. The LensAR laser system with Streamline is the fi rst femtosecond laser platform to offer wireless integration with the Cassini Corneal Shape Analyzer, allowing preoperative data transfer from the device. The iris registration feature automatically compensates for cyclotorsion and the need to manu-ally mark the eye. Surgeons have the fl exibility to use their preferred LRI nomogram. Because of its ability to perform OCT imaging of the cornea, incisions can not only be programmed to an exact 90% depth of the pachymetry readings, but can also be customized more precisely in terms of length and angulation. Ad-ditionally, surgeons have the option of titrating the correction of astigma-tism by opening the incisions intra-operatively after obtaining measure-ments with ORA or postoperatively at the slit lamp. However, the wound healing characteristics and sustained, long-term effi cacy of femtosecond laser-created incisions still needs to

be determined. Additionally, the rate-limiting step for femtosecond laser arcuate incisions is its inability to perform reliable limbal incisions due to frequent presence of corneal opacifi cation from arcus in this region (Table 1).

Toric IOLs are another option for astigmatism correction during cata-ract surgery, especially in cases of higher amounts of astigmatism. The ideal patients for toric IOL implanta-tion are those with regular astig-matism; however, good outcomes have been reported in cases of mild to moderate irregular astigmatism with fairly symmetrical preoperative readings within the central 4mm cornea.12-14 It is important to take into account the vector sum of the preexisting corneal astigmatism and the surgeon-induced astigmatism when determining the power and meridian of a toric IOL.

Another factor to consider is the impact of effective lens position and of the spheroequivalent power of the IOL on the effective toricity of the IOL at the corneal plane. The effective toricity diminishes with in-creasing anterior chamber depth and lower IOL spherical power. Some of the nomograms like the Holladay IOL Consultant Program (Holladay Consulting) and the Tecnis Toric Calculator (Abbott Medical Optics) take these factors into account when calculating toric IOL power. Studies have reported comparable correction



Magnitude of Astigmatism Treatment Options

1 <1.0D Incision rotation on steep axis

2 1D to 3.5D LRI

3 1.5D to 4.0D Toric IOL

4 >4.0D Toric IOL + LRI

Table 1. Guidelines for Treating Astigmatism

• Final treatment titrated based on ORA measurements.

• Astigmatism up to 3D to 4D may still be treated with LRI and

postoperative excimer laser ablation in patients with multifocal implants.



of astigmatism with LRIs and toric IOLs in mild to moderate astigma-tism.15 Since multifocal toric IOLs are not yet available in United States, our preference is to perform LRIs for preoperative astigmatism of up to 3D, especially in combination with multifocal IOLs. We prefer toric IOLs with or without LRIs for astig-matism greater than 3.0D to 3.5D.

Correct intraoperative alignment of the IOL and good postoperative rotational stability are critical factors for achieving the desired astigmatic correction. When a toric IOL is mis-aligned, there is a reduction in the cylinder correction along the desired meridian and induction of cylinder at a new meridian. Bench studies suggest a 33% loss of astigmatic correction if the optic rotates 10 degrees.16

Until recently, marking the eye with the patient in the upright, seated position before surgery to compensate for ocular torsion during surgery was a key step to achieve correct lens position. Even then, there was a higher potential for error since the measurements were generated from the anterior cornea. With intraoperative aberrometry, more accurate measurements, as well as confi rmation of the correct axis after IOL implantation, has become

possible. This allows intraoperative measurement of residual refractive astigmatism and, consequently, live adjustments of the toric IOL axis. However, as discussed earlier, several intraoperative variables—such as the use of an eyelid speculum, squeezing of the eyelids during surgery and the cataract surgery procedure itself—af-fect intraoperative measurements of aberrometry.

Postoperatively, the orientation axis of the toric IOL can be verifi ed to confi rm that no IOL rotation has occurred. Toric IOL misalign-ment can be determined by using the slit lamp biomicroscope (with rotating slit and full mydriasis), the postoperative residual refraction and keratometry values and wavefront aberrometry. Web-based calcula-tors are available. Misalignment is determined by using postoperative manifest refraction, the amount of astigmatism at the corneal plane and the IOL axis to determine the magnitude of misalignment, direc-tion of rotation needed and the residual astigmatism after IOL rota-tion. Realignment of a rotated toric IOL should be performed as soon as possible because adhesions form between the capsular bag and the IOL optic. We prefer to wait about a month, which allows enough time

for refraction to stabi-lize but before fi brotic adhesion between the anterior and pos-terior capsules and IOL haptics. If IOL rotation is not ex-pected to improve the residual astigmatism to <0.75D or less, our approach is excimer laser ablation or IOL exchange, depending on the magnitude of the refractive surprise and corneal thickness.

Occasionally there are unsatisfactory outcomes with residual refractive error after cataract surgery. Second-ary options for astigmatism correc-tion include LRI augmentation, IOL exchange, PRK or LASIK.

In summary, cataract surgery of-fers a second window of oppor-tunity to improve visual acuity

with minimal spectacle dependence. Recent innovations in preopera-tive and intraoperative diagnostic techniques allow a more precise measurement of astigmatism. With careful planning and a treatment plan customized to the individual patient’s needs, expectations and ocular anatomy, it is possible to achieve excellent visual outcomes with cataract surgery. RCCL

1. Savage H, Rothstein M, Davuluri G, et al. Myopic astigmatism and presbyopia trial. Am J Ophthalmol. 2003 May;135(5):628-32.2. Novis C. Astigmatism and toric intraocular lenses. Curr Opin Ophthalmol. 2000;11:47–50. 3. Trindade F, Oliveira A, Frasso M. Benefi t of against-the-rule astigmatism to uncorrected near acuity. J Cataract Refract Surg. 1997;23:82–5. 4. Ho JD, Tsai CY, Liou SW. Accuracy of corneal astigmatism estimation by neglecting the posterior corneal surface measurement. Am J Ophthalmol. 2009;147:788–795 5. Srivannaboon S, Soeharnila, Chirapapaisan C, Chonpimai P. Comparison of corneal astigmatism and axis location in cataract patients measured by total corneal power, automated keratometry, and simulated keratometry. J Cataract Refract Surg. 2012; 38:2088–93. 6. Ianchulev T, Hoff er KJ, Yoo SH, et al. Intraoperative refractive biometry for predicting intraocular lens power calculation after prior myopic refractive surgery. Ophthalmology. 2014;121:56–60. 7. Borasio E, Mehta JS, Maurino V. Torque and fl attening eff ects of clear corneal temporal and on-axis incisions for phacoemulsifi cation. J Cataract Refract Surg. 2006;32:2030-2038.8. Kaufmann C, Peter J, Ooi K, et al. Limbal relaxing incisions versus on-axis incisions to reduce corneal astigmatism at the time of cataract surgery. J Cataract Refract Surg 2005;31:2261–5.9. Budak K, Yilmaz G, Aslan BS, et al. Limbal relaxing incisions in congenital astigmatism: 6 month follow-up. J Cataract Refract Surg 2001;27:715–19.10. Bayramlar HH, Daglioglu MC, Borazan M. Limbal relaxing incisions for primary mixed astigmatism and mixed astigmatism after cataract surgery. J Cataract Refract Surg 2003;29:723–8.

A limbal relaxing incision created by femtosecond

laser.

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: Walte

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1. The Cassini Corneal Shape Analyzer has the ability to measure corneal cylinder

axis within:

a. 3 degrees.b. 5 microns.c. 12 degrees.d. 15 degrees.

2. Which of the following is true regarding calculating corneal power using

standard equipment?

a. The measure is based on a refractive index of 1.47.b. The curvature of the posterior surface is taken into account with each reading.c. The exact corneal power is often difficult to measure in a cornea with marked irregularity.

d. Most corneas will show significiant against-the-rule astigmatism.

3. When planning astigmatism correction with cataract surgery, which of the

following is not an important consideration?

a. The patient's age. b. The magnitude and axis of astigmatism. c. Any corneal pathology. d. All of the above are important factors to consider.

4. When an unsatisfactory amount of residual correction results after cataract

surgery, which of the following procedures are most suitable to fix the issue?

a. PRK or LASIK.b. Diamond burr debridement.c. IOL exchange after six months.d. Orthokeratology.

5. The "rate limiting step" in creating reliable femtosecond laser arcuate incisions

is:

a. Corneal scarring in that region.b. With-the-rule refractive astigmatism.c. Oblique corneal astigmatism.d. Against-the-rule corneal astigmatism.

6. A 10-degree rotation of two diopters of astigmatic correction results in what

percentage of loss of astigmatic correction?

a. 33%.b. 10%.c. Depends on the cylinder axis to be corrected.d. 25%.

7. Which procedure performed during cataract surgery results in a more accurate

measure of cylinder axis and a better outcome in correcting refractive cylinder?

a. Manual keratometry.b. Scheimpflug topography.c. Intraoperative aberrometry.d. Cassini topography.

8. When correcting corneal cylinder with limbal relaxing incisions, corneal

incisions can be made where?

a. Along the steepest axis.b. Along the flat meridian.c. 45 degrees from the steep axis.d. Outside the host-graft junction in a keratoplasty patient.

9. Intraoperative aberrometry measured by the ORA unit has added significantly

to correcting refractive errors during cataract surgery. Which of the following

statements is true?

a. Uses a Talbot-Moire waveform aberrometry.b. Measures only the corneal power of the eye.c. Measures anterior and posterior corneal astigmatism.d. A and C are correct.

10. When creating corneal incisions to reduce or eliminate corneal astigmatism,

what should the blade depth be set at?

a. 75% of the central corneal thickness.b. 85% of the peripheral corneal thickness.c. 90% of the peripheral corneal thickness.d. 90% of the central corneal thickness.

CE TEST ~ NOVEMBER 2015 EXAMINATION ANSWER SHEET

Corneal Astigmatism Correction During Cataract Surgery

Valid for credit through November 1, 2018

Online: This exam can also be taken online at www.reviewofcontactlenses.com. Upon passing the exam, you can view your results immediately. You can also view your test history at any time from the website.

Directions: Select one answer for each question in the exam and completely darken the appropriate circle. A minimum score of 70% is required to earn credit.

Mail to: Jobson Optometric CE, Canal Street Station, PO Box 488, New York, NY 10013.

Payment: Remit $20 with this exam. Make check payable to Jobson Medical Information LLC.

Credit: COPE approval for 1 hour of CE credit is pending for this course.

Sponsorship: Joint-sponsored by the Pennsylvania College of Optometry.

Processing: There is an eight-to-10 week processing time for this exam.

Answers to CE exam:

1. A B C D 6. A B C D

2. A B C D 7. A B C D

3. A B C D 8. A B C D

4. A B C D 9. A B C D

5. A B C D 10. A B C D

Evaluation questions: (1 = Excellent, 2 = Very Good, 3 = Good, 4 = Fair, 5 = Poor)Rate the effectiveness of how well the activity: 11. Met the goal statement: 1 2 3 4 5

12. Related to your practice needs: 1 2 3 4 5

13. Will help improve patient care: 1 2 3 4 5 14. Avoided commercial bias/influence: 1 2 3 4 5

15. How do you rate the overall quality of the material? 1 2 3 4 5

16. Your knowledge of the subject increased: Greatly Somewhat Little 17. The difficulty of the course was: Complex Appropriate Basic

18. How long did it take to complete this course? _________________________

19. Comments on this course: _________________________________________

___________________________________________________________________

20. Suggested topics for future CE articles: ______________________________

___________________________________________________________________

Identifying information (please print clearly):

First Name

Last Name

Email

The following is your: Home Address Business Address

Business Name

Address

City State

ZIP

Telephone # - -

Fax # - -

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 present-ed. I have not obtained the answers to this exam by fraudulent or improper means.

Signature: ________________________________________ Date: _____________

Please retain a copy for your records. LESSON 112020, RO-RCCL-1115





With 2016 only a few months away, it’s time to start planning

for next year’s successes. While many of us likely defi ne the success of our contact lens practice in terms of revenue, since the term is individually defi ned by each practitioner, it would be impossible for a single article to apply perfectly to every reader’s own defi nition. Instead, let’s use an increase in practice revenue as the defi nition of success here.

There are three ways to generate more revenue in your contact lens practice: increase the number of patients, raise fees or see the same patients more frequently. Let’s focus on increasing the number of patients.

Industry-wide, the net growth of total contact lens patients has been increasing at a snail’s pace.

That’s because the number of new wearers is just slightly more than the number of dropouts. As we know, most patients cease contact lens wear due to decreased comfort (typically stemming from dryness) or vision (usually from inadequate presbyopic correction.)

MAKING YOUR MOVE

So, keeping that in mind, how can you prepare for a better 2016? As we think about getting more patients, our “business brains”

immediately jump to exactly that—acquiring more patients. Yet, the premise would be better stated and your practice better suited if you also incorporate patient retention in your thought process. Remember that dropout rates are nearly on par with new wearers. So, if you are able to stem the outfl ow of patients and keep more patients in lenses, your revenue will increase in successive years. This concept isn’t breakthrough math by any means, but it is a signifi cant shift in practice management mindset—that is, putting an inordinate amount of leverage on keeping current patients vs. always chasing new ones.

A great way to plug the holes in the patient dropout bucket is to continually survey your current patient base about their level of satisfaction with their lenses. While you likely already ask those who return for follow-up appointments

about their lenses, you can’t do the same for those who do not return—at least, not face to face. However, proactively addressing even minor patient complaints can change a patient’s mind from marginally happy and subsequently eventually dropping out to remaining in the practice for life.

How can you reach these patients, who are already delinquent on their follow-up appointments? Try communicating with them either online, via snail

mail surveys or phone interviews. Be sure to word your questions such that patients know there’s a solution to the problem they are having. For example, don’t simply ask, “On a scale of one to 10, how happy are you with the comfort of your contact lenses?” Instead, follow that up with an additional question like, “If you answered eight or less, have you contacted our offi ce to discuss why your lenses are not a nine or 10?”

The same goes for probing about vision concerns. You could ask your presbyopes, “How satisfac-tory is your far and near vision with contact lenses?” As above, when a response is less than a certain predetermined point, ask, “If your vision isn’t as clear as you’d like, have you scheduled an appointment with us to help you see better?”

Of course, some readers may read this and think, I’d rather

not know! or Why open up the can of worms? Keep in mind, this technique isn’t essential to your success—rather, it’s a suggestion. But if you really want to decrease the rate of dropouts from your practice, you need to be proactive in doing so. Patients who are mar-ginally happy and at risk of aban-doning lenses are not necessarily as apt to complain as loudly as those who perceive their problems to be more signifi cant. To ensure those patients with minimal end-of-day dryness or less-than-perfect vision don’t silently disappear, you need to actively reach out and attempt to solve their problems before you lose them—possibly forever. RCCL

Reach OutWant to increase revenue for your contact lens practice? Aim for the sky.

Out of the Box By Gary Gerber, OD

“HOW CAN YOU PREPARE FOR A BETTER 2016?”

035_RCCL1115_otb.indd 35035_RCCL1115_otb.indd 35 10/29/15 2:33 PM10/29/15 2:33 PM

A.T. is a 26-year-old Caucasian male who was seen for initial consultation for refractive surgery to

address his moderate myopia (i.e., -4.25 OD and -3.75 OS). A com-prehensive examination revealed no contraindications to the procedure, and the patient’s medical/ocular his-tory was negative for allergies and family-related ophthalmic concerns. Following appropriate counseling and review, the patient elected to undergo a bilateral LASIK proce-dure for full distance correction. The procedure was completed with-out complication, and the patient was discharged on QID Zymaxid and Pred Forte.

The patient’s day one postopera-tive visit was unremarkable. His clinical examination revealed well-positioned fl aps with full closure of the fl ap margins in both eyes, and no evidence of underlying fl ap complications. His visual acuity without correction was 20/20-1 OD and 20/20+1 OS. The patient was advised to maintain his current treatment regimen for one week, and follow up as scheduled.

On postoperative day two, the patient contacted the offi ce and indicated a need to push his one-week appointment to a later date due to a personal commitment. However, on Saturday (i.e., four days postoperative), the patient contacted the service again to report that he developed a foreign body sensation in his left eye, ac-companied by mild photophobia and some blur. After discussing the concerns with the patient, and due

to an inability on the part of the patient to present to the offi ce in the next 48 hours, I recommended increasing the Zymaxid to every two hours and decreasing the Pred Forte to twice daily until he could be seen.

Sunday evening (i.e., fi ve days postoperative), the patient contact-ed the service a third time to report that there had been an increase in symptomatology over the last 24 hours, and that he had returned to the area to be seen as soon as pos-sible. Clinical examination on that date demonstrated a completely healed fl ap on the right side, with uncorrected vision at 20/15-1. The left eye, however, showed an area of sub-fl ap infi ltrate measuring roughly 2mm to 2.5mm. This did not extend into the epithelial space, but did have a crystallized-like appearance around the margins. There were no cells in the anterior chamber. Minimal injection was present. Applanation pressures were 15mm Hg OD and 16mm Hg OS. There was no overlying epithe-lial staining, but there was a notice-able negative stain over the area, indicating a volume displacement under the cap with epithelial eleva-tion. The patient’s vision was 20/50 uncorrected and 20/25 pinhole.

Given that the patient was almost six days postoperative, and the rea-son for the onset of this lesion was unclear, I decided to treat the lesion as infectious keratitis. The patient was placed on Q1hr therapy of vancomycin at 30mg/ml and Q1hr Zymaxid alternating at Q one-half hour. Steroids were discontinued. I discussed treatment options and

recommended that, in addition to the topical therapy, cultures should be obtained from underneath the lifted fl ap. Additionally, I recom-mended rinsing with fortifi ed vancomycin. This was done the fol-lowing morning, and the patient re-turned for a one-day postoperative follow-up on the treatment, where he demonstrated improvement in his symptoms with an uncorrected acuity of 20/30.

The treatment was continued aggressively for 24 more hours, and then tapered. There was small improvement in the physical ap-pearance of the lesion, but not complete extinction. So, four days into the treatment process, I added a steroid to the regimen; the patient subsequently demonstrated ad-ditional clinical improvement with no evidence of AC reaction, and injection signifi cantly reduced. By the end of seven days, the patient had returned to 20/25 uncorrected acuity. At seven days out, further tapering of all topical therapy was initiated over a one-week period.

THE TWIST

At four days into the fi nal taper of the medications, the patient con-tacted the offi ce to indicate that the symptoms had returned. He was seen that afternoon for follow-up evaluation, which revealed that the lesion had increased with the reduc-tion in topical treatment and was exhibiting a larger and denser atyp-ical crystalline pattern than previ-ously noted. Additionally, there was also a small (less than 1mm) corneal defect overlying the lesion. This was unlike the typical infi ltrate

Corneal Consult By James Thimons, OD

When the Going Gets ToughHow do you handle a complex bacterial complication from a simple LASIK procedure?


036_rccl1115_CC-PP.indd 36036_rccl1115_CC-PP.indd 36 10/29/15 2:02 PM10/29/15 2:02 PM

that is seen with either leukocytes or neutrophils, based on whether viral or bacterial etiology was the source of the infectious process. I discontinued steroids and put the patient on full therapeutic regimen. Visual acuity dropped to 20/100 uncorrected (20/50+ pinhole) and the AC had a trace reaction.

After two days on the full thera-peutic regimen, monitoring showed no notable improvement, and the cultures demonstrated no signifi -cant growth of either Gram-positive or Gram-negative organisms. The patient’s course was maintained, but because of the unusual appear-ance of the lesion, I decided to add an antiviral treatment (1,000mg Valtrex TID postoperative).

The lesion remained effectively unchanged, with a slow decrease in vision over a three-day period in the presence of full topical thera-peutic intervention as previously mentioned. There was no satellite lesion development, nor did the ba-sic presentation change materially, other than a slight increase in size of the underlying opacity beneath the fl ap, a slow decrease in vision and a notable increase in discom-fort and photophobia.

On the fourth day, due to the progression of the lesion in the face of maximum therapeutic interven-tion, I decided to amputate the fl ap and re-culture the eye, which was accomplished the following day. The goal of the amputation was to allow better access of the antibiot-ics to the underlying lesion. The patient showed an initial improve-ment with this therapeutic interven-tion, but subsequently the lesion

continued to slowly worsen, with vision declining to 20/150 pinhole and then approximately 20/60 at its worst.

The treatment was now approxi-mately three weeks out from the initial procedure, and the patient still showed no notable improve-ment with multiple antibiotic systems and oral antiviral therapy. At this point, the material that was captured from the original culture came back from the laboratory with a positive identifi cation of an acid-fast bacillus, which was identifi ed subsequently as Myco-bacterium chelonae. It was noted to be sensitive to amikacin, which was ordered at an appropriate con-centration. Therapy was initiated Q1hr over and above the current treatment with the vancomycin and gatifl oxacin until a response was obtained.

While M. chelonoe is a relatively rare organism in general cases of microbial keratitis following refrac-

tive surgery, it has been identifi ed as a possible opportunistic organ-ism. Standard postsurgical prophy-laxis is directed toward the most common organisms and usually involves the use of a fourth-genera-tion FQ as the antibiotic of choice. Of the unusual organisms that must be included in the differential di-agnosis of postoperative microbial keratitis, MRSA is the most typical and thus prompted the use of the vancomycin empirically in this case.

On the new therapeutic regi-men, the patient showed an initial response, but it was slow, so additional investigation was ac-complished, and it was found that the organism was also susceptible to clarithromycin. A compounded version of this was obtained via overnight shipping and the patient was prescribed continued applica-tion of topical amikacin and clar-ithromycin, alternately. This led to a rapid improvement in symptoms,


(Continued on page 39)

Post-LASIK corneal ulcer.


In any profession, new products and designs drive innovation. Within the scope of contact lenses, it is important to discuss new

products, materials and fi tting mo-dalities with appropriate patients, including early cataract and post-surgical patients. These individu-als may be considered “medical” patients rather than “contact lens” patients because of their recent history, but they too may benefi t from corrective lenses. Below, Dr. Miller describes three cases.

CASE 1: CATARACT

CONUNDRUM

A 54-year-old female patient pre-sented with complaints of blurred vision at both distance and near while wearing her soft toric mono-vision contact lenses. Specifi cally, vision in her right eye fl uctuates throughout the day more so than her left eye. She is considering dis-continuing contact lens wear due to the loss of clear, crisp vision. Her average wear time is eight to 10 hours; however, she has steadi-ly decreased this time due to her visual and comfort symptoms. The patient is a teacher who works in

front of a computer; she has ex-perienced dryness, discomfort and ocular fatigue with her current lenses. She also reported that night driving is becoming increasingly diffi cult. She has been wearing her current prescription for the past three years. She reported vitreous fl oaters in the past that seem to have remained about the same.

An external ocular examination revealed both eyes were slightly dry with a tear fi lm breakup time of six to seven seconds, but no fl uorescein staining present OU. These signs are consistent with grade 1 dry eye. Dilating drops were administered, and a subse-quent internal ocular examina-tion revealed a small “off-center” posterior subcapsular cataract OU (Figures 1 and 2). The patient reported this fi nding in her history as being present since she was a child; no prior treatment or sur-gery had been recommended.

After reviewing various contact lens options, the patient and I concluded a hybrid multifocal was the best choice for her particular combination of astigmatism and cataract. The design also allevi-ates discomfort due to her mild

dry eyes. I discussed appropriate visual expectations and the basics of the lens design, including the expected time it would take for the fi tting appointment and subse-quent visits. She adapted nicely to the lens and her visual needs were satisfactory.

CASE 2: POST-LASIK

MULTIFOCAL FIT

A 49-year-old female patient presented looking to wear contact lenses again. She underwent LASIK 10 years ago and reported satisfaction with the results up until the last few years, as she was needing to wear her readers more and more often. Her refraction was slightly hyperopic (+0.25D OD and +0.50D OS) at distance and required a +2.00 near add. All other ocular health evaluation points were unremarkable.

The challenge with these patients is that many wore soft contact lenses preoperatively and, often, they expect they can also wear them postoperatively. Some have this ability, but for others, it is diffi cult to maintain stable vision because of alterations in corneal architecture. The central

fl attened cornea can be diffi -cult for soft lenses to conform to and will, at times, lead to the lens vaulting the cornea. This will result in visual insta-bility between blinks.

I discussed these challenges with her and recommended starting with a daily dispos-able multifocal lens due to her history of soft lens wear prior to LASIK. She tried two dif-ferent multifocal lens designs

New Kid on the BlockGot a problem post-surgical patient? Try looking at the newest modalities for answers.

By Mile Brujic, OD, and Jason Miller, OD, MBA

Practice Progress


Fig. 2. Posterior subcapsular cataract OS.Fig. 1. Posterior subcapsular cataract OD.


that ultimately did not work: after allowing them to settle for a few minutes, her vision was not nearly good enough at distance or near, even with an over-refraction. I tried one more daily multifocal design with a slightly fl atter base curve and achieved much better initial results.

CASE 3: POST-SURGICAL FIX

A 41-year-old post-refractive surgical patient presented look-ing for better vision in her contact lenses. Her RK and AK scars were distorted and wavy in both eyes. Her MR was +3.00-2.75x004 OD and +3.50-3.00x175 OS

postoperatively after unsuccess-ful refractive procedures OU. Her corneas were extremely irregular, with best-corrected visual acuity being 20/25- OD and 20/30+ OS. She had a history of unsuccessful contact lens wear and was looking for some relief.

I recommended large diameter, reverse geometry GP lenses for this patient. Reverse geometry GP lenses allow for complete vault-ing of the central cornea and enhance patient comfort, improve centration and visual acuity in cases such as this one. The patient elected to try the lenses and, at her follow-up visit, she reported bet-

ter comfort. Her vision was also slightly better at 20/25+ OD and 20/25-2 OS.

Being comfortable and profi -cient with satisfying a wide

variety of patients’ visual needs is critical to the success of your contact lens practice. Always choose a design that will provide good optics and comfort. Discuss the benefi ts fi rst, then touch on the challenges associated with correct-ing their visual needs. Remember, these lenses may require some cre-ativity on the part of the doctor, so always be prepared to accom-modate necessary changes. RCCL


WHEN THE GOING GETS TOUGH(Continued from page 37)

visual acuity and lesion size over a seven-day period. The patient con-tinued on this therapy, and at the six-week postoperative visit was 20/30 with minimal-to-no photo-phobia and complete reduction of the hyperemia.

However, one small area of probable continued activity of the organism was noted, so therapy was continued for approximately eight additional weeks. Final visual acuity was 20/30+ uncor-rected and 20/25 pinhole. Because of the crystallization of the lesion and due to the chronic state of the presentation, at some point in the future, if vision does not signifi cantly improve, the patient should undergo a scraping of the material to provide a better refrac-tive surface for improved visual performance.

DISCUSSION

As seen in the above case, treating a postoperative refractive surgery infection can be both challenging and complex. In patients in which a 48- to 72-hour window takes place, treatment with fortifi ed antibiotic systems like vancomycin, tobramycin and/or a topical fourth-generation fl uoroquinolone fi ts the standard protocol; however, in patients for whom the organism is either nonresponsive to that protocol or in which onset of the lesion occurs at a later date, it is assumed that a more atypical organism is the driving force.

Note, it is in no way unusual for the patient to be treated as having a possible herpetic viral infection over the course of therapy, given the relatively atypical presentation that lesions like this create.

Additionally, note that because of the extreme delay in the ability to culture organisms of this type, the clinician must demonstrate a level of patience for the treatment that can sometimes be quite trying.

Certain organisms such as atypical mycobacteria,

nocardia and fungi are frequently treated empirically due to appearance, symptomatology or both. In the case of A.T., it was fortunate that the original cultures were obtained so they could be used to identify the organism. Overall, as LASIK is one of the most popular and successful procedures ever, it is important that in the case of a complication, clinicians do not forget the potential for an even more complex complication. RCCL


We all learned in optometry school about the amazing benefi ts of gas

permeable (GP) lenses. Durable and affordable, they provide signifi cantly crisp, clear vision, especially for patients with irregu-lar corneas who otherwise may be unable to wear contact lenses. However, many practitioners stop fi tting GP lenses after they gradu-ate optometry school, in part because of the intimidation factor. This is the result of a variety of issues, including lack of real-world fi tting experience, patient expecta-tions—with soft lenses the norm, they need education about GP lens benefi ts and the wearing experi-ence differs—and increased chair time. Some of these problems can be alleviated with in-offi ce alterations; others may require the help of lens manufacturers. What resources do manufacturers offer, and how should a practitioner go about selecting one?

Contact lens laboratories that are members of the Contact Lens Manufacturer’s Association (CLMA) have high standards to ensure quality products and sup-port practitioner success. Their goal is to produce contact lenses that serve the needs of practitio-ners and patients. The CLMA has a code of ethics to encourage confi dence in practitioners who use their products; as such, place the use of sophisticated and advanced

manufacturing technology at the top of the checklist when selecting a laboratory.

The next step is to consider contacting a consultant. Contact lens consultants are one of the best resources that a fi tter can use: they routinely design lenses, co-analyze the fi t and assist with the process of problem-solving when a fi t is not correct. Consultants know of different lens designs and fi tting characteristics that are available, and can assist the practitioner in making the best selection for the patient during the lens design consultation.

As such, there are a number of benefi ts when partnering with a laboratory that has invested in the latest technology and who has a team of consultants available. Such a partnership can reduce chair time; educate practitioners on fi t-ting techniques and unfamiliar lens designs; make the practice more effi cient and the patient more satis-fi ed; and increase patient confi -dence in the practitioner’s abilities.

KEEP IN MIND

Different manufacturers offer vary-ing services depending on the size and scope of operation. Some will come directly to the offi ce to train both the practitioner and staff on fi tting specialty lenses—including insertion, removal and evaluation of fi t of scleral lenses. Addition-ally, many laboratories offer free online educational resources such as webinars or fi tting guides; some

have also created social media pages to encourage practitioners to discuss and ask questions about their products.

I asked the current president of the CLMA, Jan Svochak of Tru-Form Optics, to make a few state-ments about how labs and consul-tants can help practitioners with specialty lens fi ttings. In particular, I wanted to know what he wishes practitioners would understand. Here are his thoughts: 1. There are no dumb questions.

We want you to be comfortable using our lenses, so ask away. Don’t cut yourself short by not calling and asking for consultant help. Many of your colleagues most certainly are.

2. Consultants live and breathe challenging issues. It is rare that we haven’t already run across a similar situation to the one you may be experiencing.

3. We learn from you, too. There is a lot of give-and-take in a practitioner/consultant relation-ship. The better the exchange of information, the better the relationship.

4. Having patient history readily available is a huge help. Know-ing what has or hasn’t worked in the past in given situations helps us better determine where to go next with lens design.

ASK A CONSULTANT

“Consultants have a vision to see every fi tter become an optometric superhero—a fi tter who changes

Playing the Field:How Manufacturers Can Help YouHaving trouble fi tting GP lenses in your practice? Don’t be afraid to ask for help from the outside.


The GP Expert


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lives,” say consultants Kelsey Rob-erts and Janice Adams from Valley Contax. “Each of the consultants view themselves as a partner as well as a friend to all of the fi tters that they consult with throughout the day. Whether it is a discussion about fi tting a challenging patient or simply discussing decisions already made regarding a contact lens fi t, the consultants want fi tters to know that they are ready to share their knowledge and experi-ence in designing lenses and prob-lem solving to achieve a successful fi t for a happy patient.”

Having multiple consultants with fi tting experience can be invalu-able, says Tom Shone of Alden Optical, because together they may be able to solve more compli-cated cases that a single consultant could not. “I’d encourage ECPs to fi nd great consultants and then develop mutual trust. Great things can happen that way. I’d say the best portal into the lab is a good

consultant. They are best able to translate ECPs’ fi tting challenges into solutions, both obvious and sometimes not so obvious.”

“Specialty lens manufactur-ers usually have deep benches for consultation, with many years of contact lens application experience for all sorts of indications,” says Mark Parker from X-cel Contacts. “In our own case, we have 13 National Contact Lens Examiner (NCLE)-certifi ed consultants with more than 250 years of consulta-tion experience.”

Cassandra Gordon from Vision-ary Optics points out that giving consultants certain information can help improve results. “In order for a consultant to be the most effec-tive in providing the best resolution to successfully fi t your patient, de-tailed comprehensive information relating to central and limbal clear-ance—or lack thereof—peripheral impingement/compression or edge lift, and signs such as debris in

the lens-cornea interface, is very much appreciat-ed. Inclusion of pictures, videos and/or OCT is even better.”

Keith Parker from Advanced Vision Technolo-gies also has a few tips for prac-titioners. “When sending topo-graphical maps,

use an axial map and an elevation map,” he says. “When working with corneal reshaping patients, using tangential maps to assess the overnight treatment is recom-mended. Also, please remember the basics: HVID, pupil size and lid positions along with Ks and Rx. Use photos and video whenever possible. Perform spherical over-refractions and always compare to spherocylinder overrefractions, as the cylinder might not be worth the trouble.”

PICK A TREATMENT

Plasma treating is suitable for most gas permeable lenses, says Valley Contax. An often-misunderstood process, plasma treatment is a ‘super cleaning’ of the lenses in which they are treated with ions in a vacuum, imbuing them with a hydrophilic surface. The coating lasts for an average of two weeks depending on the patient’s care and handling regimen and sig-nifi cantly increases initial comfort and wettability for up to a year. Note, plasma-treated lenses should be cleaned with clear, non-milky cleaners; more abrasive cleaners will affect the length of treatment. Most laboratories, however, can re-treat a lens as needed.

Another common point of discussion is the use of diagnostic lens fi tting sets. Diagnostic sets save a large amount of chair time and reduce the number of lenses ordered by at least half. Most laboratories offer them either for


Bitoric GP with 5D of astigmatism.



loan or sale, so if you do not want to invest money in a fi tting set, ask the laboratory to borrow one. Gen-erally, sets are loaned out for 90 days to give practitioners enough time to try them out on patients. When ordering lenses, commu-nication between the doctor and the staff member processing the order is extremely important, says Corey Reynolds from Advanced Vision Technology. Often, techni-cians don’t know the basics of the lens designs they are ordering, and many doctors don’t pass on effec-tive notes to them about what they want to change. This can lead to a lot of mistakes due to incorrect or missing information.

A CLICK AWAY

The Gas Permeable Lens Institute (GPLI) is the go-to website for many practitioners and patients. The GPLI has everything you need to become more comfortable with fi tting GP lenses. One of the great-est features of the website is “Ask

an Expert,” a free question-and-answer section with access to some of the best experts in the world on different subjects—for example, orthokeratology. Several experts are GPLI advisory board members, who offer their advice for free. The website also hosts archived webinars ranging in subject from gas permeable lens fi ttings and specialty lens tips to common GP problems and billing and coding issues.

Another online resource, the Scleral Lens Education Society (SLS), teaches contact lens practitioners the science and art of prescribing sclerals. SLS supports public education that highlights the benefi ts and availability of scleral contact lenses. This website is a great resource for practitioners and patients. Embedded within the website is an area to email questions to experts in the scleral lens fi eld. A unique feature to this organization is the Scleral Lens Fellowship (FSLS), in which a practitioner demonstrates extensive knowledge of scleral lenses though case reports, posters, papers and lectures. The “Find a Fitter” tab helps patients and practitioners locate scleral lens experts throughout the world. The SLS is a fantastic site for patients and practitioners looking for any and all information related to scleral lenses.

I-site is an educational newsletter that is distributed on a monthly basis and provides an update on

GP-related topics (i.e., scientifi c research, case reports and other publications worldwide). I-site is objective and non-political. Its editor, Eef van der Worp, is a lecturer and a consultant for a variety of industry partners, but is not related to any specifi c company.

With such a plethora of knowledge and assistance

from a variety of sources, all practitioners should embrace the power of GP lenses! Manufacturers and consultants are some of the greatest resources for contact lens practitioners. Their ultimate goal is to help you succeed with all of your contact lens patients. They help you look like a superhero and will assist you and your offi ce in any way possible to ensure that your patient is happy and healthy. GP lenses can help provide tremendous benefi ts to your patients and can aid practice growth. Set yourself apart from other practitioners while improving patient lives. RCCL

I would like to thank all of the laboratories and consultants for their advice and comments in the development of this article.

Translating GP multifocal.

Review of Cornea & Contact Lenses would like to thank Stephanie Woo for her contributions to the maga-zine over the past year. Dr. Woo is retiring as the GP Expert columnist after this issue, but will continue to contribute to our coverage of GP and scleral lens topics.


The GP Expert


AN INITIATIVE OF

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