IN THIS ISSUE · natives for treatment. Over the years, Intacs (Addition Technology) corneal ring segments and collagen cross-linking with UV light and riboflavin (C3R) have received

J A N / F E B 2 0 0 9

IN THIS ISSUE:• Aberration Correction: Part One• All About Acanthamoeba• Keeping Solutions Safe

and Effective • Lids & Lenses• No-Fee CE: Develop Your

Specialty Contact Lens PracticeSUPPLEMENT TO

JANUARY 2009

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REVIEW OF CORNEA & CONTACT LENSES | JAN/FEB 2009 1

Keratoconus: Navigating the MazePractitioners must understand the entire disease process—its natural history, clinicalsigns, corrective techniques and the emotional aspects involved.

EditorialBy Joseph P. Shovlin, O.D., F.A.A.O.

The treatment of keratoconus and other non-inflammatory thinning disorders presents manyrobust challenges. Contact lens wearers with ker-

atoconus need functional vision with adequate wearingtime and reasonable comfort. Each of these items hasthe potential to greatly influence quality of life, butwhen such a condition starts during adolescence, itresults in the ultimate challenge in contact lens practice.The quality of life for people with keratoconus isalmost as dismal as it is for those afflicted with maculardegeneration.1 So, you should do all you can to under-stand the disease process and help improve the patient’squality of life.

Natural HistoryThe Collaborative Longitudinal Evaluation in Kera-

toconus (CLEK) study has shed a vast amount of lighton this condition. Perhaps the study’s most valuablecontributions are its general description of the course ofkeratoconus and discussion of factors related to visionand disease progression. Please visit the CLEK studyWeb site (https://vrcc.wustl.edu/clekarchive) to becomefamiliar with the many publications generated from thisNIH-funded study. Progression is generally over adecade or slightly longer in the majority of cases.1

Individuals with an early onset generally have moreadvanced disease forms. In addition, they found moremales than females affected (55% male vs. 45%female). The study also showed that more males thanfemales are affected.

New Treatment OptionsQuality of life surveys showed that 18% of these

patients could not wear lenses to read at night, 10%were unable to wear lenses for leisure, and 35% had toundergo a “refit” within the past year.1 The disease canbe morbid; approximately 5,000 corneal transplantsare performed annually for keratoconus.1 Fortunately,there are a host of new contact lens options, such aslarge-diameter GP lenses like the Rose K 2 and severalquadrant-specific designs and new hybrid designs likeSynergEyes. Rigid lenses are the mainstay of correctivelens therapy and the alternative to surgery for most,but they may not provide the improvement in visionthat you expect due to uncorrected posterior corneal

aberrations.2 Also, patients may not be able to wearthem for adequate periods of time.

When standard lens therapies fail, a surgicalapproach provides practitioners with additional alter-natives for treatment. Over the years, Intacs (AdditionTechnology) corneal ring segments and collagen cross-linking with UV light and riboflavin (C3R) havereceived much attention. When all else fails, deep ante-rior lamellar keratoplasty (DALK) is an alternative topenetrating keratoplasty. DALK allows for faster recov-ery, greater tectonic support, less risk for rejection, andgenerally a better visual outcome with minimal refrac-tive change.2

Current and Future ResearchWe do know that there are molecular differences

between patients who have this disease and those whodon’t. For example, an Aquaporin 6 deficiency has beendiscovered in keratoconus. These important waterchannels play a major role in collagen matrix stability.Interleukin-6, TNF-alpha, and matrix metallopro-teinase-9 are over-expressed in the tears of patients withkeratoconus, indicating that its pathogenesis mayinvolve chronic inflammatory events.3 Hopefully, theinformation gleaned from research will help us treatand manage patients with ectasia and thinning disor-ders in the future.

Eye-care practitioners who navigate the maze oftreating keratoconus are not likely to make a significantprofit; it takes endless amounts of time to manage thesepatients, and the cost of materials is high. Nonetheless,caring for these patients will keep your practice inter-esting, and the pay-off is huge: an improved quality oflife for a group of patients who desperately need it, anda tremendous sense of fulfillment for you.

1. Zadnik K, Barr, JT, Edrington TB, et al. Baseline findings in the Collaborative Longitudinal Evalua-tion of Keratoconus Study. Invest Ophthalmol Vis Sci 1998 Dec;39(13):2537-46 2. Augenchirurgie. Available at: www.augenoperation.de/index.php/keraengl.html.(Accessed Dec2008).3. Lerna I, Duran JA. Inflammatory molecules in the tears of patients with keratoconus. Ophthalmol-ogy 2005 Apr;112(4):654-659.

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Joseph P. Shovlin, O.D., F.A.A.O., Clinical Editor

001_rccl0109editorial 1/6/09 3:39 PM Page 1

Soft Lenses and MyopiaManagement

News Review

VOL. 146, NO. 1

Soft contact lens wear does notresult in clinically significantacceleration in the develop-

ment of nearsightedness in childrenand does not cause relevant increas-es in axial length or corneal curva-ture, a new study shows. This partof the Adolescent and Child HealthInitiative to Encourage VisionEmpowerment (ACHIEVE) Studyset out to compare the rate ofmyopic progression of eight to 11-year-old children randomly assignedto wear single vision glasses or 1-Day Acuvue soft contact lenses(Vistakon) for three years.

According to the results, there isno clinically meaningful differencebetween the two forms of visioncorrection for the treatment ofnearsightedness, a vision problemexperienced by approximately one-third of the population. The newresearch further dispels a long heldnotion that soft contact lenses

increase myopia progression(“Myopic Creep”) in children morethan other vision correctionoptions.

“Recent clinical studies havedemonstrated that contact lensesprovide a number of quality of lifebenefits to children beyond simplycorrecting their myopia,” says Jef-frey J. Walline, O.D., Ph.D., OhioState University College of Optom-etry and leader of the ACHIEVEStudy. “The combined body ofresearch should give both doctorsand parents greater confidence inpresenting children with the optionof contact lens wear when visioncorrection is required.”

Findings from the multi-sitewearing trial study, appear in theNovember issue of InvestigativeOphthalmology & Visual Science.

Walline JJ, Jones LA, Sinnott L, et al. A randomized trial of theeffect of soft contact lenses on myopia progression in children.Invest Ophthalmol Vis Sci. 2008 Nov;49(11):4702-6.

Ocular NutritionFor the first time, EyeScience

Macular Health Formula and Eye-Science Dry Eye Formula from Eye-Science Labs will be available atCVS Pharmacy stores nationwide.

EyeScience Macular Health For-mula contains 14 nutrients to sup-port a healthy retina, includingomega-3, lutein, zeaxanthin, bil-berry, grape seed extract, selenium,L-glutathione and alpha lipoicacid. EyeScience Dry Eye Formulais a nutritional supplement thataddresses the underlying causes of

dry eye syndrome. It contains aproprietary blend of an omega-3essential fatty acid, flaxseed oil,lactoferrin, magnesium, and Vita-mins B6, C and E.

For more information, go towww.EyeScience.com.

IN THE NEWS

• In an approval review processfor new drug applications, theU.S. Food and Drug Admi-nistration (FDA) Dermatologic andOphthalmic Drugs AdvisoryCommittee recommends approvalof Bausch & Lomb’s broad-spec-trum, anti-infective drop, besi-floxacin ophthalmic suspension0.6%, for the treatment of bacter-ial conjunctivitis.

• CooperVision has revamped itscorporate website www.CooperVision.com, updatingtechnology, content, design, navi-gation and other helpful features,such as new search function andnew modules that allow practi-tioners to customize and managetheir online experience. Fromaccount information to news feedsfrom eye care-related websites,practitioners will have the infor-mation they choose to be mostrelevant right at their fingertips.

• SynergEyes, Inc., will launchthe SynergEyes EnrichmentProgram, a new marketing initia-tive designed to help practitionersgrow their specialty contact lenspractices.The SynergEyesEnrichment Program will include aseries of live lectures, interactiveWeb trainings, and peer-to-peerroundtable discussions, coveringpractice management topics suchas increasing contact lens prof-itability, making a difference withnew technology, and implement-ing effective patient marketingcampaigns.

2 REVIEW OF CORNEA & CONTACT LENSES | JAN/FEB 2009

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Jobson Medical Information LLC11 Campus Blvd., Suite 100Newtown Square, PA 19073Telephone (610) 492-1000Fax (610) 492-1049Editorial inquiries (610) 492-1003Advertising inquiries (610) 492-1011E-mail [email protected]

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ASSOCIATE CLINICAL EDITOR Ernie Bowling, O.D.,[email protected]

ASSOCIATE CLINICAL EDITOR Alan G. Kabat, O.D.,[email protected]

ASSOCIATE CLINICAL EDITOR Christine W. Sindt, O.D.,[email protected]

ASSOCIATE EDITOR Izabella [email protected]

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EDITORIAL BOARDMark B. Abelson, M.D.James V. Aquavella, M.D.Edward S. Bennett, O.D.Brian Chou, O.D.S. Barry Eiden, O.D.Gary Gerber, O.D.Susan Gromacki, O.D.Brien Holden, Ph.D.Bruce Koffler, M.D.Jeffrey Charles Krohn, O.D.Kenneth A. Lebow, O.D.Kelly Nichols, O.D.Robert Ryan, O.D.Jack Scheffer, O.D.Kirk Smick, O.D.Barry Weisman, O.D.

REVIEW BOARDKenneth Daniels, O.D.Michael DePaolis, O.D.Desmond Fonn, Dip. Optom. M. Optom.Robert M. Grohe, O.D.Patricia Keech, O.D.Jerry Legerton, O.D.Charles B. Slonim, M.D.Mary Jo Stiegemeier, O.D.Loretta B. Szczotka, O.D.Michael A. Ward, F.C.L.S.A.Barry M. Weiner, O.D.

Advertiser IndexArt Optical . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Cover 4Benz Research . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Cover 2

Relief for Patients with Keratoconus According to a survey by Addition Technology, Inc., 93% of the

time, Intacs help delay corneal transplantation for contact lens intol-erant keratoconus patients. Of the 2,136 Intacs surgeries performedbetween August 2004 and April 2008, 584 patients were specificallyidentified as having keratoconus. Forty-one later received trans-plants, which amounted to 1.9% of all procedures performed.

The survey also asked surgeons the reason for performing a trans-plant following the removal of Intacs. In less than 1% of all casesperformed, the patients didn’t receive a satisfactory visual effect afterIntacs. Surgeons also indicated that they didn’t envision any difficul-ties with performing a corneal transplant post Intacs removal.

“We are very satisfied with the survey results, which support ourview that Intacs are a standard of care for keratoconic patients whoare contact lens intolerant,” said William M. Flynn, president andchief executive officer of Addition Technology. “We are also gratefulto the surgeons who responded to this survey; their feedback helpsus assess the benefits Intacs offer’s patients and provides valuableinsights on where to extend our technology.”

According to recent Eye Bank Association of America data, thereare approximately 4,700 to 4,800 corneal transplants performed inthe U.S. annually for keratoconus. Intacs are approved for the reduc-tion of myopia and astigmatism in patients who suffer from kerato-conus, who are contact lens intolerant, have clear corneas, andwhere a corneal transplant is imminent and may be potentiallydeferred. Prior to Intacs, a corneal transplant was the only optionfor contact lens intolerant keratoconus patients.


Ten Years of Top PerformancePolyquad and Aldox, the dual disinfectants in both the Opti-Free

RepleniSH and Opti-Free Express Multi-Purpose Disinfecting Solu-tions from Alcon, were first introduced as the disinfecting system inthe Opti-Free franchise in 1998. Over the past decade, Opti-Freebrands containing Polyquad/Aldox have performed extremely well inthe market. In fact, since launch, approximately 147 million soft con-tact lens wearers have used these solutions to care for their lenses.

Polyquad, like many single entity PHMB products, provides gener-ally good coverage against bacteria, fungi, yeasts and molds.ALDOX was added to increase coverage against fungi and provideadditional activity against Acanthamoeba cysts and trophs. the com-pany says.

“Dual disinfection optimizes disinfection efficacy while minimizingcorneal staining,” explains David Meadows, Alcon’s vice president,R&D, Consumer Products.

002_rccl0109_SharpFocus 1/7/09 2:09 PM Page 3


1 EditorialKeratoconus: Navigating the Maze

Joseph P. Shovlin, O.D., F.A.A.O.

2 News Review

5 Guest EditorialInterferometry and Dysfunctional Tear Syndrome

Ashley Behrens, M.D.

7 Down on the PharmA New Anti-Infective

Ernie Bowling, O.D., M.S., F.A.A.O., Dipl.

8 Out of the BoxOut with the Old

Gary Gerber, O.D.

10 Derail DropoutsCompliance in the New Year

Mile Brujic, O.D., and Jason Miller,O.D., M.B.A.

12 Lens Care UpdateA New Dry Eye Therapy?

Christine W. Sindt, O.D., F.A.A.O.

13 Gas-Permeable StrategiesMystery Solved!

John M. Rinehart, O.D., F.A.A.O.

14 Naked EyeSjögren’s Syndrome and Dry Eye

Mark B. Abelson, M.D., C.M.,F.R.C.S.C., and Dan Dewey-Mattia

Depar t ments

contentsReview of Cornea & Contact Lenses Jan/Feb 2009

18 Keeping Solutions Safe and EffectiveA look at current test procedures, what the FDA-commissionedOphthalmic Devices Panel has recommended and what isplanned for the future.Susan J. Gromacki, O.D., M.S., F.A.A.O.

ON THE COVER

15 All AboutAcanthamoebaIn this virtual roundtable, clinicians discuss how to detect, treat and helppatients avoid this vision-threateningkeratitis.H. Dwight Cavanagh, M.D., Ph.D.,Joseph P. Shovlin, O.D., F.A.A.O.,and Christine W. Sindt, O.D., F.A.A.O.

23 Aberration Correction:Part OneBy applying today’s technology to an oldscience, we can offer patients a chanceat acuity previously unattainable.Pete S. Kollbaum, O.D., Ph.D.,F.A.A.O.

27 No-Fee CE: DevelopYour Specialty ContactLens PracticeBy utilizing newer lens technologies andunderstanding the benefits they can offer,the practitioner will keep patients happyand realize significant practice benefits.Mile Brujic, O.D.

35 Lids and LensesHere is what you need to look for toensure proper eyelid analysis, diagnosis and appropriate therapy.Katherine M. Mastrota, M.S., O.D.,F.A.A.O.

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This technology accurately measures tear film parameters, which may answer questions about the various disorders of the ocular surface.

Guest EditorialBy Ashley Behrens, M.D.

Interferometry and Dysfunctional Tear Syndrome

Dysfunctional Tear Syndrome (DTS) is a commonailment of the ocular surface. It affects 14% ofthe adult population in the U.S.1 Although sev-

eral etiologic classifications for this disease have beenproposed, recent research has been directed toward a“tear quality” problem as the major player in thepathophysiology of the syndrome.

One of the problems that clinicians and researchersconfront in DTS is the lack of uniform criteria to deter-mine what are “normal” parameters of the tear film. Inall published categorizations of DTS, there is a certainsubjectivity present when assessing these parametersand staging the disease. The lack of standardized,objective methods to confidently assign a particularseverity level of DTS has been a major barrier in per-forming comparisons in systematic reviews of random-ized controlled clinical trials. In previous panels ofexperts, specialists tend to rely more on the symptomsof the disease, while others tend to rely on clinical signs,and still others stress the importance of “tests,” such asSchirmer and tear break-up time (TBUT).2,3 Unfortu-nately, it is difficult to find a reliable range of parame-ters due to the low correlation between tests,symptoms, and signs.

Composition and ThicknessThe tear film is possibly one of the most important

components of the ocular surface and a major determi-nant of problems related to DTS. Tear film compositionand thickness are objective values that may reveal cru-cial information regarding the health of the eye’s sur-face. The lack of methods that consistently image andmeasure the tear film thickness has guided researchersto evaluate more sophisticated technologies. An idealapproach to measuring tear film thickness should benon-contact and non-invasive, in order to avoid distur-bances that may trigger reflex responses, which couldchange the basal properties of the unperturbed tearfilm. Thickness and composition all over the cornealsurface are parameters that may correlate with signsand symptoms of DTS. Potential candidates in the listof available technologies are confocal microscopy(CM), optical coherence tomography (OCT) and

interferometry. CM has an excellent resolution in a con-tact mode, but the objective’s power should be consid-erably reduced to be used in a non-contact fashion,affecting the final resolution (>1µm).4 OCT has similarlimitations, with resolutions close to 10µm and ultra-high resolution capabilities in the vicinity of 3µm.5,6

Interferometry seems to be the ideal method to evaluatetear film thickness with sub-micron resolutions (0.3µmto 0.5µm). In addition, interferometry may scan a widefield of the corneal surface.7

Technology at WorkThe optical principle of interferometry relies on the

reflection of the general hue of light through interfer-ence patterns. Hue and saturation are functions of thetransparent layer causing the interference—in this case,the tear film. A single ray emerging from the lightsource of the instrument is reflected on two differentsurfaces, creating two rays. The interference phenome-na should be observed by specular reflection that comesfrom the tear film. The generation of thin film interfer-ence derives from each incident light that is reflected bythe film—one from the surface of the tears and anotherfrom the layer in contact with the cornea.8

The Interferometry DifferencePublished studies have shown high variability in the

mean values of normal tear film thickness.7,9 These dis-crepancies are related in great part to the methods usedand the difficulties in achieving an accurate measure-ment of such a thin layer. Due to the higher resolutionof this instrument, an interferometric analysis is moreappropriate in detecting minor changes. Interferencepatterns may also detect changes in the composition ofthe different layers of the tear film, especially the lipidlayer, in various topographical areas of the ocular sur-face to determine regional defects of the tear film. Inaddition, there is the possibility of analyzing thechanges associated with blinking in real time, whichis extremely difficult to assess with other availabletechnologies.

One of the most important benefits that interferom-etry may provide to clinicians is the possibility of


6 REVIEW OF CORNEA AND CONTACT LENSES JAN/FEB 2009

imaging the effects of different environmental condi-tions in tear film quality. One study used tear lipidinterferometry to analyze the effects of smoking in tearfilm lipid layer spread times, and the researcher found ahighly significant difference between chronic smokersand non-smokers.10 They found that smokers had a sig-nificantly reduced spread time and multiple prematurebreaks in the lipid layer.10

Clinical TrialsOther important use of tear film interferometry is

the detection of immediate, mid- and long-termresponse to various therapeutic alternatives. Most ofthe available prototypes include video capabilities toallow real-time assessment of the data. Goto and asso-ciates reported the results of a study on the use of anantibiotic ointment for two weeks to improve the lipidlayer in the tear film of thirty patients with lipid defi-ciency.11 They were able to demonstrate a significantincrease of the tear lipid layer, from 39nm ± 4nm to161nm ± 91nm, after two weeks of treatment, whichcorrelated well to a significant improvement in symp-toms (decrease from 91.4 ± 11.9 to 33.6 ± 21.0 insymptoms score questionnaire) and signs/tests (fluo-rescein staining and tear break-up time).11 In a studycomparing the effects of two lubricants in the lipidlayer thickness, researchers were able to show signifi-cant differences using a metastable oil-in-water emul-sion vs. hydroxypropyl guar.12 In this report, theeffects of the instilled drops in short-term tear filmlipid layer thickness were analyzed at different timepoints using interferometry. Forty patients were select-ed for the study, and eyes were randomized for the useof one different eye drop in each eye. The oil-in-wateremulsion was able to double the lipid layer thicknesswhen compared to hydroxypropyl guar in their seriesat all time points recorded.12

In patients who had undergone keratorefractive pro-cedures, tear film lipid layer thickness assessed by inter-ferometry is an important parameter to measure. Anexample of this is a study that evaluated a group of 46patients, of which 22 underwent laser in situ ker-atomileusis (LASIK). At 14 weeks postoperatively, themean tear film lipid layer thickness was significantlythinner in the LASIK group (p=0.032), which may beassociated with the DTS symptoms frequently reported

after this type of surgery.13

A New HorizonAs demonstrated by presented evidence, tear film

thickness assessed by interferometry appears to be asensitive factor in detecting ocular surface changes asso-ciated with DTS. One of the major challenges of thisrecently “reborn” technology is the standardization ofthe different instruments available worldwide. Sincemost of the published studies have used prototypes ormodified devices to detect interference, the standardsused may vary between apparatuses. On the otherhand, most of the reports in the literature are based onsmall sample sizes, which may not be representative ofthe general population and may induce bias in theanalysis of the data. For this reason, the lack of consis-tent interferometry results to correlate with signs andsymptoms of DTS in large population studies is hinder-ing the popularization of this approach in clinical trials.But, with the renewed interest in research and develop-ment of this technology in the last decade, we mightwitness the beginning of the first objective method tostage DTS for further therapeutic guidance.

Dr. Behrens is Assistant Professor of Ophthalmology at theWilmer Eye Institute and Johns Hopkins University School ofMedicine, Baltimore, Md. Contact him at [email protected].

1. Schein OD, Muñoz B, Tielsch JM, et al. Prevalence of dry eye among the elderly. Am J Ophthalmol1997;124:723-8. 2. DEWS International Panel. Methodologies to diagnose and monitor dry eye disease: report of theDiagnostic Methodology Subcommittee of the International Dry Eye WorkShop (2007). Ocul Surf 2007Apr;5(2):108-52. 3. Behrens A, Doyle JJ, Stern L, et al. Dysfunctional tear syndrome study group. Dysfunctional tearsyndrome: a Delphi approach to treatment recommendations. Cornea 2006 Sep;25:900-7.4. Böhnke M, Masters BR. Confocal microscopy of the cornea. Prog Retin Eye Res 1999Sep;18(5):553-628.5. Wang J, Fonn D, Simpson TL, Jones L. Precorneal and pre- and postlens tear film thickness meas-ured indirectly with optical coherence tomography. Invest Ophthalmol Vis Sci 2003 Jun;44:2524-8.6. Hermann B, Fernández EJ, Unterhuber A, et al. Adaptive-optics ultrahigh-resolution optical coher-ence tomography. Opt Lett 2004 Sep;15;29(18):2142-4.7. King-Smith PE, Fink BA, Nichols JJ, et al. Interferometric imaging of the full thickness of the pre-corneal tear film. J Opt Soc Am A Opt Image Sci Vi. 2006 Sep;23(9):2097-104. 8. Doane MG, Lee ME. Tear film interferometry as a diagnostic tool for evaluating normal and dry-eyetear film. Adv Exp Med Biol 1998;438:297-303.9. Prydal JI, Campbell FW. Study of precorneal tear film thickness and structure by interferometry andconfocal microscopy. Invest Ophthalmol Vis Sci 1992 May;33(6):1996-2005.10. Matsumoto Y, Dogru M, Goto E, et al. Alterations of the tear film and ocular surface health inchronic smokers. Eye 2008 Jul;22(7):961-8.11. Goto E, Dogru M, Fukagawa K, et al. Successful tear lipid layer treatment for refractory dry eye inoffice workers by low-dose lipid application on the full-length eyelid margin. Am J Ophthalmol 2006Aug;142(2):264-70.12. Korb DR, Scaffidi RC, Greiner JV, et al. The effect of two novel lubricant eye drops on tear film lipidlayer thickness in subjects with dry eye symptoms. Optom Vis Sci 2005 Jul;82(7):594-601.13. Patel S, Pérez-Santonja JJ, Alió JL, Murphy PJ. Corneal sensitivity and some properties of thetear film after laser in situ keratomileusis. J Refract Surg 2001 Jan-Feb;17(1):17-24.

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By Ernie Bowling, O.D., M.S., F.A.A.O. Dipl.

A New Anti-InfectiveThis antibiotic helps treat bacterial infections and lid disease with as little as ninedrops, over a five-day period.

Every eye-care practitioner hasencountered bacterial con-junctivitis. The condition is

quite common, but fortunately theinfections are usually self-limiting.Most cases of bacterial conjunctivi-tis in both adults and children canbenefit from topical anti-infectivetherapy, which shortens the courseof the disease, prevents reinfectionand reduces the risk of complica-tions. New ocular antibiotics areconstantly needed to keep pace withthe increasing incidence of bacterialresistance and to provide optionsthat allow a decrease in dosing regi-mens, with the ultimate goal ofimproving patient compliance.

AzithromycinAzithromycin is a macrolide-

class anti-infective that is synthe-sized from erythromycin andpossesses a well-known safety andtolerability profile in both its oraland intravenous forms.1,2 The med-ication is widely used to treat softtissue infections. In eye care,azithromycin is used in its oralform to treat chlamydia infections.3

Azithromycin has the unique quali-ty of achieving extremely high con-centrations in tissues, and it has along elimination half-life—both ofthese properties have been found totranslate to the eye.4,5

Clinical UseAzaSite (azithromycin oph-

thalmic solution 1%, Inspire) wasapproved by the U.S. Food andDrug Administration (FDA) for thetreatment of bacterial conjunctivi-tis. The azithromycin is compound-ed in a vehicle called DuraSite, a

gel-forming polymer of polyacrylicacid. DuraSite allows azithromycinto be formulated in liquid formand also increases the drug's con-tact time, which could potentiallyincrease drug tissue concentrationsin the eye.6 Because the tissue con-centration is so high, dosing isreduced. The entire treatment regi-men for bacterial conjunctivitisconsists of two drops the first day,two drops the second day, and onedrop the following five days, whichadds up to nine drops. Reports bythe manufacturer cite a clinicalimprovement in 94% of bacterialconjunctivitis patients by day threeand a favorable safety profile inpatients at least a year old.7

A growing number of eye-carepractitioners are finding a role forAzaSite in treating lid margin dis-ease. Erythromycin ointment iswidely used in the treatment ofanterior or posterior blepharitis;and azithromycin, belonging to thesame macrolide class of drugs, hasa similar spectrum of activity. Theanti-inflammatory properties ofmacrolide antibiotics have beenrecognized for over 20 years.8

Macrolides have been shown toaffect several inflammatory path-ways, including neutrophil migra-tion and the production ofproinflammatory cytokines.9

Recent studies indicate thatazithromycin suppresses matrixmetalloproteinases, with effectssimilar to doxycycline in humanand animal ocular tissue.10 Becauseof the anti-inflammatory effects ofazithromycin, many doctors rec-ommend AzaSite to patients withmeibomian gland dysfunction,

blepharitis and rosacea.11 A recentrandomized study found that com-bining AzaSite with warm com-presses may help treat patients withposterior blepharitis significantlybetter than using warm compressesalone. Patients using AzaSite inconjunction with warm compresseshad significantly more improve-ment in meibomian gland plugging,meibomian gland secretions andeyelid redness than patients whoused warm compresses alone.12

A Welcome AdditionFor patients who suffer from

bacterial conjunctivitis or lid mar-gin disease, we have a new thera-peutic ally. With its broad spectrumof antimicrobial activity andreduced dosing profile, AzaSiteplays an important role in our anti-infective arsenal.

1. Pfizer. Zithromax. Package Insert. (Oct 2008).2. Pfizer. Zithromax for IV infusion only. Package insert. (Oct2008).3. Solomon AW, Holland MJ, Alexander ND, et al. Mass treat-ment with single dose azithromycin for trachoma. N Engl J Med2004 Nov 4;351(19):1962-71.4. Piscitelli SC, Danzinger LH, Rodvold KA. Clarithromycin andazithromycin: new macrolide antibiotics. Clin Pharm 1992Feb;11(2):137-52.5. Kuehne JJ, Yu AL, Holland GN, et al. Corneal pharmacokinet-ics of topically applied azithromycin and clarithromycin. Am JOphthalmol 2004 Oct;138(4):547-53.6. Expert explains latest advances in ophthalmic antibiotics. Ocu-lar Surgery News 10/25/2008.7. Manufacturer Web site. Inspire Pharmaceuticals. Available at:www.AzaSite.com. (Accessed Oct 2008).8. Scaglione F, Rossoni G. Comparative anti-inflammatory effectsof roxithromycin, azithromycin, and clarithromycin. J AntimicrobChemo 1998 Mar;41 Suppl B:47-50.9. Ianaro A, Ialenti A, Maffia P, et al. Anti-inflammatory activity ofmacrolide antibiotics. J Pharmacol Exp Therapeutics 2003Jul;64(1):85-93. 10. Jacot JL, Jacot TA, Sheppard JD, et al. Evaluation of MMP2/9 modulation by AzaSite and durasite in human corneal epithe-lial cells and bovine corneal endothelial cells in vitro. Poster pre-sented at ARVO, 2008. 11. Caceres V. A new possibility for lid margin treatment. Eye-World 2008 Oct;6(10):42.12. Luchs J. Efficacy of topical azithromycin ophthalmic solution1% in the treatment of posterior blepharitis. AdvTher 2008;25(9):858-870.

RCCL

Down on the Pharm

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Out with the OldLearn how to present new-generation lenses to your patients, regardless of the price tag.

By Gary Gerber, O.D.Out of the Box

Over the last few years, I'vedone a lot of speaking andconsulting in Europe, and

in discussions with practitioners,I've learned that their training isless extensive than our traininghere in the U.S., particularly inthe medical area. Unlike the Unit-ed States, while a smaller percent-age of European patients needingvision correction wear contactlenses, the majority of thosepatients who DO wear lenses arewearing daily disposable and sili-cone hydrogel lenses. So, whilethe uptake of lenses overall hasbeen slow, the usage of newerlenses is not. As it turns out, thisphenomenon is common in manyother countries, as well. Thisobservation begs the question,“Why do we fit so many morepatients in contact lenses, yet useolder technology lenses?”

The Path of Least ResistanceSome have suggested our higher

level of training might be the rootcause of this phenomenon. Duringmy recent trip to Italy, this topiccame up with several Italian contactlens company reps. Considering allour education, you would thinkthat we would lean toward fittingnewer lenses, which are generallyregarded as healthier and safer.

My discussions with Europeancontact lens practitioners points tohealth and safety as the key reasonsfor choosing newer types of lenses.Comments like, “Gary, daily dis-posable lenses are essentially prob-lem-free and so easy to fit. So, whyfit anything else?” are common.Admittedly, that’s a simplistic

comment. But, it’s accurate. Perhapsdue to less intensive pathologydetection and treatment training,these practitioners may take thepath of least resistance in anattempt to avoid problems.

The Issue of Price So, is our higher level of training

getting in the way of moving for-ward and embracing newer materi-als and modalities? Surely, we can’tbe fitting older modalities becausewe have the skill to deal with theextra problems they might cause!That would be like a highly skilledheart surgeon saying, “I’m so goodat what I do that I’ll use an archaicpacemaker with a higher chance offailure, because if it does fail, Iknow I can fix it!”

No, I don’t think we would riskour patients’ ocular health bydeploying that sort of convolutedlogic. So, while lesser training maybe the reason for more high-techlens dispensing in Europe, I hopemore training won’t account for lessusage here.

Rather, our reluctance hinges onthe economics of the equation,which apparently isn’t an impedi-ment for our colleagues abroad.This is certainly true with eyeglasses,

where the average sale of a pair ofglasses is higher than it is here inthe U.S. and more often includespremium products like anti-reflec-tive technology and newer progres-sive lens designs.

Foreign practitioners do notstumble and fumble over price dis-cussions with their patients like U.S.practitioners do. In fact, many ofthem charge little or no professionalfees—only product fees. That’s adiscussion for another column, butthe point is, the higher price ofnewer lenses is readily discussedwith patients. In fact, lesser quality,older technology lenses are typicallynot even mentioned during patientencounters. There is rarely a choicegiven to the patient. Instead, as Ibelieve things should be here,patients are guided by the practi-tioner’s clinical judgment regardingwhat is best for the patient.

Take a ChancePerhaps the conditioning that

comes with selling higher-end eye-glasses is at the core of their easewith contact lens pricing discus-sions. And, maybe this condition-ing, when coupled with the desireto avoid corneal complications, isthe reason for their success in usinga higher percentage of newer tech-nology lenses. Regardless of thereason for their comfort with feediscussions, there are two impor-tant lessons for us to learn from thesuccess of our foreign colleagues.First, when given a chance to trynew technology lenses, patients willindeed choose them. Second, theprice of lenses should not serve asan impediment. RCCL

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10 REVIEW OF CORNEA AND CONTACT LENSES | JAN/FEB 2009

By Mile Brujic, O.D., and Jason Miller, O.D., M.B.A.Derail Dropouts

Compliance in the New YearComfortable, healthy contact lens wear is based on many factors, including the lensmaterial, the care solutions and our patients’ compliance habits.

Contact lenses have guide-lines for optimal wear, andlack of compliance with

these guidelines can have detri-mental effects on the ocular healthof the patient, threatening com-fortable contact lens wear. We willlook at compliance as it relates tothe modality of wear and pre-scribed care regimens and learnhow to mitigate the effects of non-compliance on successful contactlens wear.

ModalityModality is an important topic

to address, because patients whodo not comply with their wearschedule often have comfort issuesthat affect their lens wearing expe-rience. The key here is to listen toyour patients and understand whatthey are looking for in a contactlens. For example, patients whowear glasses most of the time butprefer to wear contact lenses whenthey play hockey three times aweek would be poorly served bybeing fit with a pair of two-weekor monthly-replacement lenses—

try daily disposable lenses instead.The irregularity of such patients’wearing schedules would make itdifficult to keep track of the age ofthe lenses and would unintention-ally force non-compliance.

Try to avoid fitting the sametype or modality of contact lens onevery patient. Individualize yourcontact lens prescribing habits tobest meet each patient’s lifestyleand to maximize compliance. Weall have our favorite lens, but it’sbest to make specific recommenda-tions based on patient preferences,which will ultimately lead toimproved compliance.

Contact Lens Care SystemsJust as important as the replace-

ment schedule is the cleaning andcare of contact lenses. The unfor-tunate reality is that there is sig-nificant room for increasing ourpatients’ compliance levels. RalphStone, Ph.D., presented a paper atthe British Contact Lens Associa-tion meeting in 2007 that lookedat compliance rates over a numberof steps. Dr. Stone reported that

more than 44% of patients alwaysor occasionally top off or re-usetheir contact lens solution, that35% of patients do not wash theirhands before handling their lens-es, and that only 25% of patientsreport rinsing their contact lensesbefore lens storage.1

Even if they do rinse the con-tact lens, odds are, they are notperforming the step as recom-mended by the manufacturer.There are currently five care sys-tems that currently have “no rub”approval: AQuify (CIBA Vision),Complete Easy Rub (AMO),Renu MultiPlus (Bausch &Lomb), Opti-Free Express (Alcon)and Opti-Free RepleniSH (Alcon).Under the “no rub” instructionson each of the package inserts forall of the products described, therinse cycle is five seconds per side(except for Complete Easy Rub,which is packaged and marketedas requiring a 10-second rubbefore rinsing the lens). It is veryrare that this level of complianceoccurs when patients do utilizethese solutions and do not rubtheir contact lenses. It is impor-tant for those who utilize caresystems to be constantly re-edu-cated on the specifics of their careregimen. We recommend rubbingand rinsing as important steps forcomfortable contact lens wear.

Compliance and YourPractice

Complying with prescribed con-tact lens replacement schedules isimportant for health reasons, butalso to maximize comfort. We

The inside of a contact lens case utilized by a patient who routinely “topped off” hissolution (left). The photo on the right shows lens deposits in the eye of a patient whowore two-week replacement contact lenses for two months.

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Derail Dropouts


have all seen patients who have asignificant number of deposits ontheir contact lenses; this presenta-tion is directly related to “stretch-ing out” the wearing schedule. Ifwe can eliminate these habits, wewill increase the patient’s chanceof comfortable, healthy contactlens wear.

Additionally, non-compliancewith prescribed wearing regimenswill directly affect the profitabilityof your practice. Let’s take threepatients, all of whom wear two-week disposable contact lenses,and analyze the effect that variouslevels of compliance bear on prac-tice profitability. Consider patientnumber one, who replaces his con-tact lenses twice a month as pre-scribed; patient number two, whoreplaces his lenses every month;and patient number three, whoreplaces his lenses every twomonths. The profitability will bedirectly related to the level of com-pliance. Table 1 summarizes thethree patient scenarios discussed:

This is a clear example of howprescribing and reinforcing areplacement schedule that is in thepatient’s best interest will ulti-mately lead to what’s in the bestinterest of the practice. Increase

patient compliance with replace-ment schedules by encouragingthe purchase of a one-year supplyof contact lenses. Usually this typeof purchase will be accompaniedwith some form of mail-in rebatethat will also financially benefitthe patient.

A New Year’s ResolutionPractitioners must take time

during every visit to constantly re-educate lens wearers on thespecifics of their care regimen.What we typically do with all ofour contact lens wearers is askthem to describe the way they carefor their contact lens in a step bystep manner, and then re-educatethem as needed, spending extratime on those steps that are beingperformed incorrectly. Patients areusually very receptive and willingto modify those steps that are notbeing carried out properly.

A Case in Point “Samantha,” a 38-year-old

patient new to our practice, hasbeen wearing contact lenses formany years, but she recentlynoticed a decrease in near focus-ing. She attributes this to manyhours spent on the computer. She

typically changes her contact lens-es once monthly, even though sheadmitted they were prescribed astwo-week lenses. She stated thatshe can “usually tell when tochange them, based on how theyfeel.” Samantha also stated thatshe never rubs her lenses, and thatshe uses the store brand multipur-pose solution for cleaning andstorage. After her new prescrip-tion was determined, we discussedthe many types of contact lensesavailable and determined thatbased on her habits, monthly dis-posable contact lenses matchedher lifestyle best. She was refit ina contact lens in the monthlymodality category. Her care sys-tem was changed to improve com-patibility, and dry eye treatmentwas initiated due to her high com-puter use. Samantha realized rela-tively quickly how comfortableher wearing experience could be.She currently wears her contactlenses more successfully due to thesimple steps that were taken toincrease her level of compliancewith her contact lens wear andcare regimen.

1. Stone R. The importance of compliance: Focusing on thekey steps. Poster. Presented at BCLA, May 2007, Manches-ter, UK.

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Table 1.

Patient #1 Patient #2 Patient #3

Cost Per Box $20.00 $20.00 $20.00

Selling Price Per Box $30.00 $30.00 $30.00

Boxes Per Year 8 (6) Packs 4 (6) Packs 2 (6) Packs

Profit Per Year $80.00 $40.00 $20.00

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For decades, ophthalmologistshave used sodium hyalu-ronate extensively in

cataract surgery, glaucoma filtra-tion surgery, corneal transplanta-tion, vitreous substitution andretinal attachment surgery. Ortho-pedists regularly utilize it in intra-articular treatment forosteoarthritis of the knee.

Sodium hyaluronate is alsobecoming increasingly popular forthe treatment of dry eye.

Where It’s Found and HowIt’s Used

Since hyaluronic acid is unsta-ble as an acid, it is typically usedwith sodium as a salt. Hyaluronicacid is a naturally occurring poly-saccharide found in large quanti-ties in rooster combs, sharkskin,whale cartilage, umbilical cordsand serum. It is widely distributedin bodily tissues and intracellularfluids—specifically the aqueousand vitreous humor, synovialfluid, and the ground substancesurrounding cells. Hyaluronicacid plays an importantrole in the maintenance ofstructure, moisture andlubrication, and it aids inprotection against inva-sion of bacteria. Theexcellent water-holdingcapacity of hyaluronicacid makes it retain mois-ture better in the eyes,joints and skin tissues. Itis used in a number ofcommercial over-the-counter products, includ-ing premium lip balmsand ocular wetting drops.

Clinical DataSodium hyaluronate has been

shown to protect the corneal epithe-lium from dryness and promoteepithelial healing.1-5 It holds waterlike a sponge and slowly releases itto the epithelium. It has been stud-ied as a dry eye tear therapy sincethe mid 1980s, but in recent years,a number of randomized, double-blind, multi-centered, crossoverclinical trials involving 0.1% to0.4% sodium hyaluronate havefound statistically significantimprovement in subjective symp-toms, slit lamp examination find-ings and bulbar impression cytologyin patients with moderate to severedry eyes.1-5 In all cases, the studymedication was well tolerated andno adverse events were reported.1-5

The molecular structure of sodi-um hyaluronate provides a uniqueability to change viscosity with theblink. When the eye is open, themolecule is highly coiled and vis-cous; it resists drainage and reducestear film break-up time. By remain-ing on the eye and contact lens, it

protects and hydrates the epitheli-um. When the lid is closed, lid fric-tion and pressure uncoil themolecule. This lowers the viscosity,making the solution more spread-able, promoting a smooth blink.After the blink is complete, the mol-ecule recoils and viscosity againincreases, mimicking the behaviorof the body’s natural tears.

On the Horizon Current sodium hyaluronate

lubrication drops, such as AQuifyDrops (CIBA Vision) and Blink(Advanced Medical Optics), aremarketed as contact lens lubricationdrops. Blink Tears (AMO) alsocombines sodium hyaluronate withpolyethylene glycol 400, an FDA-approved dry eye ingredient, tomarket as a dry eye lubricant fornon-contact lens wearers. Currentresearch studies are looking intocombining sodium hyaluronate inother solutions, such as hypotonicformulations, for combined benefi-cial effects. With good results andminimal blur on insertion, we will

be seeing more of this dropin years to come.

1. Johnson ME, Murphy PJ, Boulton M. Carbomerand sodium hyaluronate eyedrops for moderate dryeye treatment. Optom Vis Sci 2008 Aug;85(8):750-7. 2. Prabhasawat P, Tesavibul N, Kasetsuwan N. LinksPerformance profile of sodium hyaluronate inpatients with lipid tear deficiency: randomised, dou-ble-blind, controlled, exploratory study. Br J Oph-thalmol 2007 Jan;91(1):47-50. 3. Troiano P, Monaco G. Effect of hypotonic 0.4%hyaluronic acid drops in dry eye patients: a cross-over study. Cornea 2008 Dec;27(10):1126-30.4. Johnson ME, Murphy PJ, Boulton M. Effective-ness of sodium hyaluronate eyedrops in the treat-ment of dry eye. Graefes Arch Clin Exp Ophthalmol2006 Jan;244(1):109-12.5. Brignole F, Pisella PJ, Dupas B, et al. Efficacyand safety of 0.18% sodium hyaluronate in patientswith moderate dry eye syndrome and superficialkeratitis. Graefes Arch Clin Exp Ophthalmol 2005 Jun;243(6):531-8.

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A New Dry Eye Therapy?Could hyaluronic acid be instrumental in the treatment of dry eye?

By Christine W. Sindt, O.D., F.A.A.O.Lens Care Update

Sodium hyaluronate improves both signs and symptoms ofdry eye.

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Gas-Permeable StrategiesBy John M. Rinehart, O.D., F.A.A.O.

Most contact lens fittershave at one time oranother come upon one

of the following situations: 1. You replace a lost lens for a

satisfied GP patient, but the newlens does not provide the samelevel of comfort as the lost lens.

2. You see a GP lens wearer,new to your practice, and eventhough the lenses have similarbase curves, the fits are grosslydissimilar.

What happened? To put itbluntly, the lab most likely wasnot provided with all the infor-mation necessary to duplicate thelens. This can happen in a num-ber of ways—it could be a simpleclerical error (which should becaught when the lenses are veri-fied), or, more likely and mostcommonly, the lab was given thebase curve, lens diameter andpower and instructed to finish thelens with their “standard periph-ery,” or the lab was given K val-ues and a refraction, but aconsultant designed the lenses.Regardless of the situation, besure to record all lens parametersand insist that your lab send youall lens parameters with the fin-ished lenses. This is especiallyimportant when you change labs.The new lab may have a differentfitting philosophy, and their“standard periphery” may be sig-nificantly different from that ofyour previous lab.

The Not-So-StandardPeriphery

As a test, I supplied the basecurve, power and diameter and

requested lens parameters for the“standard periphery” from sevendifferent labs. I found that a lab’s“standard periphery” can havevarying intermediate and periph-eral curve radii and widths. I didthis not to test my impression ofthe quality of the lab designs, butrather, to determine if there is asignificant difference in standardlens design from lab to lab. Thefacilities I selected ranged fromvery large, nationally known labsto small local labs. Most designedsimilar lenses, but the range var-ied significantly—the most signif-icant variable was the opticalzone diameter (The lab was sup-plied with the following informa-tion: base curve= 8.13D; power = -2.00D; diameter = 9.6mm. Theradii of the intermediate andperipheral curves were very simi-lar, but the widths did vary,which resulted in the different

optical zone diameters (OZD).The range of OZD was from7.6mm to 8.4mm, which createsa significant difference in thesagittal depth of the lens, and asa result, a significant difference infit. The lower sagittal depth ofthe 7.6mm OZD would be amuch looser fit than the lens withthe 8.4mm OZD, on a normallyshaped cornea. This difference isdemonstrated in figures 1 and 2.

Ensure a Successful FitTo avoid these problems,

record all lens information, andwhen duplicating lenses, provideall of it to the lab. This willassure that your patient will con-tinue to wear the well-fit lens youprescribed. Otherwise, when youchange labs, their “standardperiphery” may be significantlydifferent from that of the lab youare currently using. RCCL

Mystery Solved!Similar parameters, but different fit... What went wrong?

1,2. This fluorescein pattern shows a lens with a 7.6mm OZD that centers superiorly—aloosely fitting lens on this patient. Note the excessive fluorescein in the intermediateand peripheral zones of the lens (left). The lens with an 8.4mm OZD lens provides a snugfit for this patient (right). It centers well, but may be slightly tight in the area of theperipheral curve.

008_rccl0109gps 1/7/09 2:59 PM Page 13


Dr.Cavanagh isthe Dr. WMaxwellThomas

Chair Professor at theUniversity of TexasSouthwestern MedicalCenter in Dallas, Tex.

Dr. Shovlinis a clinicaleditor forRCCL and asenior

optometrist at the North-eastern Eye Institute inScranton, Pa.

Dr. Sindt isdirector ofContact LensService at theUniversity of

Iowa Hospitals and Clin-ics, Iowa City, Iowa.

Rate of InfectionWhat is the current estimate of

infection rate? Do you think thenumbers are increasing or decreas-ing since the recall of CompleteMoisture Plus (Advanced MedicalOptics)?

DC: If I were to take a guess, Iwould say that the pre-recall ratewas one to two cases per millionlens wearers. The “epidemic” isnow over. Some major centersthink that the numbers are increas-ing, but there really are no com-pelling data published. Beyond anydispute, however, the number ofcases in Chicago are up due to adecrease in Illinois’s water purifica-tion standards.1

JS: A recent CDC investigationhad determined that the number ofconfirmed cases of Acanthamoebakeratitis has increased since 2004.There apparently are some signifi-cant geographic variations by U.S.region, just as there are worldwide

differences in rates of infection.During the peak year, the estimatesranged from one in 30,000 to onein 100,000 wearers per year.2 Therereally is no way to know for surewhether the rates have stabilized orhave actually decreased since theinitial outbreak and recall of theproduct.

CS: Unlike with fungal keratitisand the recall of ReNu with Mois-tureLoc (Bausch & Lomb), we arestill seeing Acanthamoeba infec-tions after the recall of CompleteMoisture Plus (Advanced MedicalOptics). The true incidence ofAcanthamoeba keratitis may beregional, but here in Iowa, we haveseen a three-fold increase in cornealtransplants secondary to Acan-thamoeba infections since 2001.3

DiagnosisWhat key features or signal data

help make a timely diagnosis in anon-specific keratitis?

All About Acanthamoeba

In this virtual roundtable, clinicians discuss how to detect, treat and help patientsavoid this vision-threatening keratitis.By H. Dwight Cavanagh, M.D., Ph.D., F.A.C.S.; Joseph P. Shovlin, O.D., F.A.A.O.;and Christine W. Sindt, O.D., F.A.A.O.

015_rccl0109Round 1/7/09 2:21 PM Page 15


DC: The confocal microscope isthe best way to make the mostrapid and accurate diagnosis.4 Wecannot make the diagnosis of AKbased only on how the eye looksat the slit lamp. And cultures, amethod of certain diagnosis, arehard to do for most primary carephysicians—not to mention time-consuming.

JS: Making a diagnosis can bemenacing, and confirmation canbe challenging. In the ideal world,confocal microscopy is the mostaccurate and timely method todiagnose the disease and avoids alarge or painful scraping (biopsy)of the cornea. However, a trainedobserver is needed; the tropho-zoite form of Acanthamoeba ismore difficult to recognize and isapproximately the same size askeratocyte nuclei.

Scrapings can be plated ontonon-nutrient agar with an overlayof heat-killed Escherichia coli orKlebsiella, and direct and indirectimmunoflurescence can beobtained when necessary by look-ing for capsid or nuclear staining.But, not many labs are equippedto provide this service.

So, assorted stains may aid inyour diagnosis, including calcofluor

white, hemotoxylin/eosin andWright’s stain. Slit lamp appear-ance in an otherwise non-specifickeratitis is not particularly diag-nostic, with the exception of radi-al nerve infiltrates or lightningflash depictions. Even radial nerveinfiltrates are not pathognomonic,since they can be found in non-ulcerative Pseudomonas keratitisand leprosy. Ring infiltrates aregenerally late to appear and arealso not pathognomonic. Keep inmind that pain disproportionateto the clinical picture can accom-pany this disease.

CS: More than 50% of patientsare going to present with punctateepithelial erosions, while only 4%present with a ring infiltrate.Other features may include peril-imbal neuritis and dendrite-likelesions. As Dr. Shovlin said,though, one feature that isextremely common is severepain—these patients will typicallypresent with pain that seemsmuch greater than the cornealfindings.

TreatmentWhat first-line agents do you use

in treating this disease? Are youwilling or likely to treat without

laboratory confirmation, and ifso, when?

DC: There is currently no FDA-approved drug for AK, despite thefact that in 1991, Brolene (pro-pamidine isethionate, Bausch &Lomb, Inc., was shown to be effec-tive in an FDA Orphan Drug Study.

I use a combination of Broleneisethionate, chlorhexidine 0.02%,polyhexamethylene biguanide(PHMB) 0.1% and neomycin 1%.But, before I prescribe, I confirmmy diagnosis via confocalmicroscopy—it’s so easy that nopatient should be treated withoutconfirmatory diagnosis. A drugregimen to combat AK is toxic,painful and goes on for months,so a confirmed diagnosis is essen-tial to begin a patient on such acourse of medication.

JS: When there is compelling orheightened awareness and astrong clinical picture, we general-ly initiate treatment immediately,even before the diagnosis is con-firmed. The cystic form of Acan-thamoeba is highly resistant tomany forms of systemic and topi-cal therapy. Biocides, cationicantiseptics and anti-parasitic ther-apy are generally employed.

Treatment with either PHMB orchlorhexidine is often combinedwith a diamidine, such as Broleneor Desomedine (hexamidine,Chauvin). Brolene is readily avail-able outside of the U.S. It is a pre-sulfa era drug that is availableover-the-counter in many coun-tries. The dosing of the biocide (orcationic antiseptic) is every houraround the clock for the first fewdays. Treatment is then taperedbased on clinical response overseveral months.

Possible new therapies includeanti-neoplastic and anti-malarialdrugs.5

The timing of topical steroiduse to control inflammation

This photo shows the eye of a patient with Acanthamoeba keratitis with a significantepithelitis and radial neuritis.



during the course of treatmentremains controversial and shouldgenerally be avoided in the initialstages of treatment.5

Surgical intervention includesthe use of amniotic membranetransplants for progressive stro-mal loss and persistent epithelialdefects and may delay the needfor penetrating keratoplasty. Pene-trating keratoplasty should beperformed only after the infectionis under control unless there isemergent need. But, a minimum ofthree months between discontinu-ation of treatment and subsequentkeratoplasty is recommended toavoid toxicity and resultantpotential graft failure.5

CS: Typically, these patients arestarted on a broad-coverageantibiotic and 0.02% chlorhexi-dine every hour while awake, incombination with 200mg to 600mg of oral itraconazole or keto-conazole per day (divided b.i.d.)Cycloplegia is recommended.Steroids are not advised early on,but may be used later in thecourse of treatment to controlinflammation and scarring.

When looking for cysts, thefastest diagnosis is made withconfocal microscopy. If the cyst islocated anterior to Bowman’smembrane—not in the stroma—this is a fairly good predictor oflikely resolution with topicaldrops, as opposed to cornealtransplantation. A deeper cyst, onthe other hand, could necessitatetransplantation.

After confocal microscopy,corneal scrapings should be eval-uated by a pathologist. Culturingon the E. coli bed with non-nutri-ent agar was the standard of carein the past, but results take sometime to develop. So, treatmentcan and should typically be start-ed with confocal microscopyresults alone.

AvoidanceWhat can you tell patients who

want to reduce their risk of Acan-thamoeba infection?

DC: I warn patients againstswimming in lenses and recom-mend that they use peroxide dis-infection systems. I believe thatthere is not yet enough data onthe risk of showering with lensesto discuss that with patients.Also, animal and human studydata suggest that we may in thefuture be able to immunizeagainst AK in patients with lowtear IgA levels.6

JS: Contact lens wear remainsthe key risk factor for acquiringthis disease. Additional risk fac-tors include swimming in contactlenses, irregular or inadequatedisinfection, exposure to contami-nated water (e.g., well water orhot tubs) and corneal trauma.Additional surveillance of everycontact lens wearer is paramountand should help to minimize therisk of acquiring this dreaded disease.

CS: Contact lens wear andexposure to water seem to be thegreatest risk factors. Peroxideshows excellent rates of cystreduction when used at 3%strength for four hours beforeneutralization.7

The currently marketed peroxidedisinfectants begin the neutraliza-tion process immediately andtherefore do not provide 3%hydrogen peroxide for a longenough period of time to killcysts, and therefore, have aboutthe same kill rate for cysts as thechemically-based disinfectingsolutions.7

Acanthamoeba cysts can live inthe biofilm of contact lens cases,which is why I recommend thatpatients scrub the contact lenscase weekly and “sterilize” thecase periodically—not to mention,it’s just good hygiene. And,patients should replace their lenscases every three months.

1. Joslin CE, Tu EY, Shoff ME, et al. The association of con-tact lens solution use and Acanthamoeba keratitis. Am JOphthalmol 2007 Aug;144(2):169-180.2. Schein O. Shaepero Award Lecture, American Academy ofOptometry. Tampa. October 2007.3. Auran JD, Dubord PJ, Glasser DB. A retrospective reviewof outcomes of penetrating keratoplasty for Acanthamoebakeratitis. Paper presented at the American academy of oph-thalmology. November 10, 2008.4. Parmar DN, Awwad ST, Petroll WM, et al. Tandem scan-ning confocal corneal microscopy in the diagnosis of sus-pected Acanthamoeba keratitis. Ophthalmology 2006Apr;113(4):538-47.5. Hammersmith KM. Diagnosis and management of Acan-thamoeba keratitis. Curr Opin Ophthalmol 2006Aug;17(4):327-31.6. Alizadeh H, Neelam S, Niederkorn JY. Effect of immuniza-tion with the mannose-induced Acanthamoeba protein andAcanthamoeba plasminogen activator in mitigating Acan-thamoeba keratitis. Invest Ophthalmol Vis Sci 2007Dec;48(12):5597-604.7. Hughes R, Kilvington S.Comparison of hydrogen peroxidecontact lens disinfection systems and solutions againstAcanthamoeba polyphaga. Antimicrob Agents Chemother2001 July;45(7):2038–43.

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A late presenting ring infiltrate and contiguous scleritis in a patient with AK.



Dr. Gromackiis a Diplo-mate in theSection onCornea and

Contact Lenses of theAmerican Academy ofOptometry. She lives inWest Point, New York.

We are all familiar with theFusarium and Acan-thamoeba keratitis out-

breaks. Our patients are likely to beas well, as the lay media was quick toreport the recalls of the two contactlens multipurpose solutions associat-ed with the respective outbreaks.ReNu with MoistureLoc (Bausch &Lomb) was permanently recalled in2006, followed by Complete Mois-ture Plus (Advanced Medical Optics)in 2007.

Having passed the FDA’s recom-mended testing guidance with flyingcolors, both solutions were, ofcourse, approved by the United StatesFood and Drug Administration(FDA). So, it’s no surprise that theFDA has taken this seriously. Theorganization has begun steps toreview its testing methods for evaluat-ing the activity of contact lens careproducts. Let’s review the currenttesting methods, the outbreaks, whatthe FDA has already done, and whatit is planning to do in the future.

Current FDA Testing Methods A contact lens solution is a Class

II device and must demonstrate dis-infection efficacy before it can becleared for marketing in the U.S.For example, a disinfection solutionmust undergo stand-alone and regi-men testing.

The FDA and the InternationalOrganization for Standards (ISO)have a protocol to evaluate themicrobial activity of a disinfectingsolution. As outlined in the 2001document listed on the FDA Website, the FDA specifies the testorganisms, media, equipment, sam-ples and procedure.1

Stand-alone testing evaluates a sin-gle solution and determines whetherit can effectively kill certain microor-ganisms that are inoculated into it.The microorganisms include threebacteria (Staphylococcus aureus,Pseudomonas aeruginosa and Serratiamarcescens) and two fungi (Candidaalbicans and Fusarium solani). Forthe stand-alone test, the solution isrequired to reduce each bacterium byat least 3.0 log units of 1.0 x 105 to1.0 x 106 colony-forming units(cfu)/ml inoculum and each fungus byat least 1.0 log unit. Additionally, thefungi must not demonstrate anincrease in numbers following a peri-od four times greater than the mini-mum recommended soak time.

The selected microbial strains represent a variety of microorgan-isms encountered in the environment,including two gram-negative bacteria(Pseudomonas aeruginosa and Serra-tia marcescens), one gram-positivebacterium (Staphylococcus aureus), amold (Fusarium solani) and a yeast

A look at current test procedures, what the FDA-commissioned Ophthalmic DevicesPanel has recommended and what is planned for the future.By Susan J. Gromacki, O.D., M.S., F.A.A.O.

Keeping SolutionsSafe and Effective

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(Candida albicans). The strains areobtained from the standardizedAmerican Type Culture Collection(ATCC). The advantage of alwaysutilizing the same five strains is, ofcourse, consistency in testing.However, this method does omitseveral “real world” microorgan-isms relevant to microbial keratitis,such as Acanthamoeba. For exam-ple, there were at least 19 differentFusarium genotypes responsible forthe recent outbreak.2 The FDA iscertainly considering how to aug-ment the current list with addition-al clinical isolates (those micro-organisms collected from clinicallyworn contact lenses or used lenscases) and/or more relevant strains.

The secondary criteria of thestand-alone test states that if thesolution fails the stand-alone test, itmay be evaluated by the regimentest described below, given that itfirst passes the “regimen qualifica-tion.” That is, it reduces theamount of the test bacteria by noless than 1.0 log unit per single testbacterium and 5.0 log units com-bined. Yeast and mold must demon-strate stasis (no additional growth).

The regimen test evaluates thedisinfection solution and, if pres-ent, all of the additional compo-nents of a care system’s cleaningand disinfection procedure. Select-ed contact lenses of various materi-als, for which the manufacturerseeks approval for use with thesolution regimen being tested, areinoculated with the same organismsused in the stand-alone procedure.

Lenses are then cleaned, rinsed andsoaked in the manufacturer’s rec-ommended manner. After soaking,the lenses are analyzed to deter-mine microbial growth. Therequirements are less than 10cfurecovered from each lens, followingthe cleaning/soaking regimen foreach test organism.

It is important to note that theregimen test is performed accordingto package instructions, whichinclude a lengthy rinse for all cur-rently approved no-rub solutions.Currently, the FDA reviews a caresystem based on its labeled direc-tions for use as if it were used withcomplete compliance. But, as weknow, such practices are not alwaysreflected in real-world settings.

In addition to disinfection effica-cy, the FDA also evaluates cleaningefficacy. And, the FDA uses thetests, whether for a single bottle ofsolution or for a system that uses acombination of separate bottles ofsolution with specific purposes,such as for cleaning, rinsing anddisinfecting, to ensure that all prod-ucts meet its requirements. Obvi-ously, a multipurpose solution(MPS) must be as effective with onesolution as would a care system ofseparate solutions.

As with other Class II medicaldevices, a contact lens solutionmust show a “substantial equiva-lency” to comparable productspreviously approved. In otherwords, it must be as safe and effec-tive as other solutions for the sameintended use or function. Assuming

the solution undergoing testing hassimilar chemical components andpercentages as the approved solu-tions, any recommended clinicaltesting may need only 30 subjectsfor 30 days.

Additional testing is recommend-ed for new ingredients withoutprior history of ophthalmic use. Ifthe chemical components are newor are present in different percent-ages, the same or additional in vitrotesting is recommended. In thesecases, clinical testing is more exten-sive and may include about 60 sub-jects for 90 days.1,3

The Fusarium andAcanthamoeba KeratitisOutbreaks

The United States Centers forDisease Control and Prevention(CDC) and the Fusarium KeratitisInvestigation Team found 164 con-firmed cases of Fusarium keratitis inthe U.S. between June 1, 2005, andJune 30, 2006. There are approxi-mately 30 million lens wearers,0.04% (daily wear) to 0.21%(extended wear) of whom developmicrobial keratitis annually.2,4-6 Lessthan 5% of contact lens-related ker-atitis is caused by a fungus of anykind.2 Even during the outbreak, thepercentage of those with Fusariumwas relatively small.

Of the 164 patients affected, 154were soft contact lens wearers.Approximately one-third of the 154wore their lenses overnight. Onehundred and forty-six could identifytheir contact lens care systems.

ISO/FDA Disinfection Efficacy CriteriaTest Organism Reduction of Inoculum of Organisms Reduction of Inoculum of Organisms

in Stand-Alone Criteria in Regimen CriteriaPseudomonas aeruginosa Reduces the bacterial level by an average at least Staphylococcus aureous 3.0 log units within the recommended disinfectionSerratia marcescens time.Candida albicans Reduces the fungi level by an average at least 1.0 Fusarium solani log unit within the recommended disinfection time.

For each microbe species, the average count for alllots tested be no more than 10cfu for each lens-solution combination following cleaning/soaking regimen.

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Ninety-four (57%) used ReNu withMoistureLoc (Bausch & Lomb)exclusively; 21 (13%) used ReNuwith MoistureLoc in addition toanother product; nine (5%) used anunspecified ReNu solution; and 22(18%) used products other thanMoistureLoc.2

The 75% MoistureLoc associa-tion was disproportionate to itsmarket share, 10.7%. After muchinvestigation by Bausch & Lomb,the FDA and the CDC, Bausch &Lomb voluntarily removed the solu-tion from the U.S. market on April13, 2006 and from the world mar-ket on May 15 of that year.

After the investigation, there wasno evidence of contamination. Peo-ple initially assumed the culprit tobe MoistureLoc’s preservative,alexidine. However, during non-compliant conditions, “the concen-tration of the polymers included inthe formula to enhance comfortmay make the solution more likelyto be contaminated with Fusarium

in the environment,” said formerBausch & Lomb CEO Ron Zarellain an American Academy ofOpthalmology member alert.7 Non-compliant conditions were definedas allowing the solution to evapo-rate or not regularly replacing it inthe lens case; leaving the bottleopen between uses; not cleaning thecase properly or replacing regularly.MoistureLoc contains a higher con-centration of polymers than anymajor lens care product.8 In otherwords, it is likely that during non-compliant conditions, the wettingagent (poly-quaternium 10, a poly-saccharide) encapsulated the Fusar-ium spores, allowing them tosurvive and germinate. Additionalstudies have demonstrated othercare products’ reduced efficacyagainst Fusarium under sustainedhigh temperature conditions.9

Current testing standards do notinclude solution testing duringadverse environments or noncom-pliant care. In addition, the cur-rent FDA guidance and theinternational standards do notrequire testing for a solution’s effi-cacy against amoebae.10-12

Acanthamoeba keratitis (AK) isa rare condition, affecting just oneto two lens wearers per millionannually.13 Of these patients, 40%are typically noncompliant withlens care, and 32% wear theirlenses while swimming.14 In themost recent outbreak (138 caseswere documented by the CDC inMay 2007), 58% of culture-con-firmed soft contact lens-wearingpatients had been using CompleteMoisturePlus Multipurpose Solu-tion, which is again dispropor-tionate to its approximate 9%market share.14-17 As a result,AMO voluntarily recalled theproduct on May 29, 2007.

Beginning in March 2007, theCDC began a multi-state outbreakinvestigation, using the same

controls as in the Fusarium study.On multivariate analysis, only threevariables were statistically signifi-cant. First, affected patients were2.8 times more likely to report“topping off” of solution and 2.8times more likely to have worn lens-es for less than five years. In addi-tion, Complete MoisturePlus userswere 16.8 times more likely todevelop AK than patients who usedall other solutions. The CDC attrib-uted this to insufficient anti-Acan-thamoeba activity of the solution.This may be, in part, due to theaddition of propylene glycol, asugar-based polymer that aids inmoisture retention.13

However, after several monthsof the recall, AK rates have nei-ther increased nor decreased. Thisraises the question: What role doenvironmental risk factors, suchas water contamination, have inthe outbreak?13

The FDA’s Actions After the outbreaks, the FDA

took action, investigating theiretiologies and alerting health careprofessionals and their patients.Education regarding healthy con-tact lens wear included recom-mendations, such as removingcontact lenses prior to contactwith water, washing hands beforehandling lenses, never topping offsolution, and scheduling regulareye examinations.

On June 10, 2008, the FDA con-vened the Ophthalmic DevicesPanel of the Medical Devices Advi-sory Committee to discuss “generalissues concerning post-market expe-rience with various contact lens careproducts.” The session began withan Open Public Hearing, in whichthe public was given an opportunityto provide testimony. Eighteen pre-senters, including academicresearchers, practicing clinicians,professional society representatives

1. Fusarium keratitis. ReNu with MoistureLoc was recalled after beinglinked with this condition.

2. Acanthamoeba Keratitis. An outbreakof this condition led to the recall of Complete Moisture Plus.

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and industry personnel, spoke.18-21

The FDA sought advice from itsOphthalmic Devices Panel, a neu-tral group of experts, regardingmodifications to preclinical andclinical testing for contact lens careproducts and to product labeling.The panel’s recommendations onthe six topics requested by the FDAwere as follows:13,18-21

• Neither the panel’s nor theFDA’s recommended changes intesting or labeling should be swayedby patient compliance. And, a prod-uct label should include a warningagainst “topping off” or reusingsolution. Lenses should not bestored in water or non-sterile solu-tions of any kind. Frequent casereplacement should be specified, butadditional research is needed todetermine the exact interval of time.A solution label should include awarning against wearing lenses dur-ing water activities, although therewas difficulty finding consensus onwhat to recommend. A lens careproduct’s discard date after opening(as in Europe) would be welcomed,although it may be difficult forpatients to follow.

• Instructions should include ruband rinse steps for existing careproducts. Both rubbing and rinsingshould be part of product instruc-tions, but there is not enough dataat this time to specify the exact rins-ing times. “Rinsing works some-what; rubbing works even better.The combination of the two is bestof all, and not doing either is worstof all,” said Timothy McMahon,O.D., Ph.D., to those attending dur-ing the panel meeting. The panelrecommended that the FDA not banno-rub regimens, in order toencourage industry to create moreeffective products in the future.

• An additional two-hour follow-up visit in manufacturers’ clinicalstudies to perform a fluoresceinstaining evaluation would not be

beneficial, because there is nodemonstrated correlation betweenstaining and keratitis. In addition,the panel recommended includingsilicone hydrogel lenses in the clini-cal investigations of contact lenscare products.

• Testing for solution approvalshould include a contact lens andcase and utilize a more diverse andrepresentative set of infectious orga-nisms, including Acanthamoeba.Testing should be made more rigor-ous to include “real world” scenar-ios, such as solution evaporation.

• Silicone hydrogel contact lensesshould be separated from the cur-rent FDA lens material classificationsystem, and further subdivided intothree or four groups of their own.

• Unlike the current stand-alonetest, FDA cytotoxicity testing usedto evaluate multipurpose solutionsshould include a contact lens andcontact lens case. And, it shouldincorporate both conventional andsilicone hydrogel lenses.

What’s Next for the FDABased on the results of the June

meeting, the FDA has scheduled aContact Lens Microbiology Work-shop for January 22 to 23, 2009, tohelp develop new methods to evalu-ate the disinfection efficacy of con-tact lens care products againstAcanthamoeba, as well as “realworld” and ”worst case” scenarios.They have invited experts in thearea of Acanthamoeba with anemphasis on care systems andmicrobiology. Among the sponsorsof the meeting are the AmericanAcademy of Optometry, the Ameri-can Optometric Association, theAmerican Academy of Ophthalmol-ogy and the Contact Lens Associa-tion of Ophthalmologists.

This is an important next step, asit is in everyone’s best interest toexpedite the development of newtesting standards for contact lens

care products to ensure, once andfor all, that keratitis outbreaksamong contact lens wearers are athing of the past.

1.International Standards Organization ISO 14729. OphthalmicOptics – Contact Lens Care products. Microbiological require-ments and test methods for products and regimens for hygienicmanagement of contact lenses, 2001.2. Chang DC, Grant GB, O’Donnell K, et al. Multistate outbreak ofFusarium keratitis associated with use of a contact lens solution.JAMA 2006 Aug 23;296(8):953-63.3. Gromacki SJ. Hydrogel and silicone hydrogel lens care. ContLens Spect 2008 Feb;23(2): 26-32. 4. Poggio EC, Glynn RJ, Schein OD, et al. The incidence ofulcerative keratitis among users of daily wear and extended wearsoft contact lenses. N Engl J Med 1989 Sep 21;321(12):779-8.5. Poggio EC, Abelson M. Complications and symptoms in dis-posable extended wear lenses compared with conventional softdaily wear and soft extended wear lenses. CLAO 1993Jan;19(1):31-9.6. Schein OD, Glynn RJ, Poggio EC, et al. The relative risk ofulcerative keratitis among users of daily-wear and extended-wearsoft contact lenses. N Engl J Med 1989 Sep;321(12): 773-778. 7. American Academy of Ophthalmology Member Alert, May 16,2006.8. Bausch & Lomb. Fusarium keratitis. Special report. Cont LensSpect. 2006 Sept;21(9):Suppl:1-8.9. Rosenthal RA, Henry CL, Buck SL, et al. Extreme testing ofcontact lens disinfecting products. Cont Lens Spect 2002Jun;17(7):40-45. 10. Borazjani RN, Kilvington S. Efficacy of multipurpose solu-tions against Acanthamoeba species. Cont Lens Anterior Eye2005 Dec;28(4):169-75. 11. Borazjani RN, Kilvington S. Effect of a multipurpose contactlens solution on the survival and binding of Acanthamoebaspecies on contact lenses examined with a no-rub regimen. EyeContact Lens 2005 Jan;31(1):39-45.12. Shoff M, Rogerson A, Schatz S, Seal D. Variable responsesof Acanthamoeba strains to three multipurpose lens cleaningsolutions. Optom Vis Sci 2007 Mar;84(3):202-7.13. FDA. Summary minutes. Medical devices advisory commit-tee. Ophthalmic devices panel, the United States Food and DrugAdministration, June 10, 2008, Gaithersburg, Maryland. Avail-able at: www.fda.gov/ohrms/dockets/ac/08/minutes/2008-4363m1.pdf. (Accessed November 2008).14. Guttman C. Acanthamoeba keratitis increasing at alarmingrate. Ophthalmol Times 2006 Jan 1;31:1-2.15. Bennett ES. Acanthamoeba keratitis in 2007: Stay informedbut calm. Cont Lens Spect 2007 Jun;22(7):50-2.16. FDA. Advanced Medical Optics voluntarily recalls CompleteMoisturePlus contact lens solution. FDA News May 26, 2007.Available at: www.fda.gov/bbs/topics/NEWS/2007/NEW01641.html. (Accessed Nov 2008).17. AC Nielsen. Solution use in 2006, percentage by brand. 12week period ending 5/13/06.18. FDA. Transcript. Medical devices advisory committee. Oph-thalmic devices panel, the United States Food and Drug Admin-istration. June 10, 2008. Gaithersburg, Maryland. Available at:www.fda.gov/ohrms/dockets/ac/08/transcripts/2008-4363t1-01.pdf. (Accessed Nov 2008).19. FDA. Transcript. Medical devices advisory committee. Oph-thalmic devices panel, the United States Food and Drug Admin-istration, June 10, 2008, Gaithersburg, Maryland. Available at:www.fda.gov/ohrms/dockets/ac/08/transcripts/2008-4363t1-02.pdf. (Accessed Nov 2008).20. FDA. Transcript. Medical devices advisory committee. Oph-thalmic devices panel, the United States Food and Drug Admin-istration, June 10, 2008, Gaithersburg, Maryland. Available at:www.fda.gov/ohrms/dockets/ac/08/transcripts/2008-4363t1-03.pdf. (Accessed Nov 2008).21. FDA. Transcript. Medical devices advisory committee. Oph-thalmic devices panel, the United States Food and Drug Admin-istration, June 10, 2008, Gaithersburg, Maryland. Available at:www.fda.gov/ohrms/dockets/ac/08/transcripts/2008-4363t1-04.pdf. (Accessed Nov 2008).

RCCL


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By utilizing newer lens technologies and understanding the benefits they can offer,you can keep patients happy and realize significant practice benefits.By Mile Brujic, O.D.

Contact lens wearers are achallenging—yet reward-ing—part of many of our

practices. The ultimate goal forour contact lens wearers is com-fort, good vision and healthy eyes.The unfortunate reality, however,is that many of our contact lenswearers become complacent abouttheir lens wearing experience, andthey accept a certain level of com-promised comfort and vision assomething that accompanies con-tact lens wear. As a result, manypatients discontinue contact lenswear. The good news is that manyof these same patients may be ableto successfully wear contact lensesagain. This will lead to more satis-fied patients and significant prac-tice benefits.1

By embracing contemporarycontact lens options you can

improve patient outcomes and dif-ferentiate the services that you offerto your patients.

The Value of the ExaminationThe examination process is

composed of three elements: thepatient history, the actual exami-nation and medical decision-making. Don’t undervalue the his-tory; it helps you to understandwhat contact lens may be bestsuited for the patient’s hobbies,lifestyle and occupation.

During the exam, a number oftools aid the process consider-ably. Two, in particular, shouldbe employed in every patientencounter: fluorescein dye andlissamine green.

Fluorescein is a hydrophilicmolecule that hyperfluorescesupon accumulation and when

viewed with a cobalt blue lightand Wratten filter (figure 1).

Lissamine green stains cellsthat are devitalized. Conjuncti-val staining with this dye isoften the initial sign of oculardryness (figure 2). Guillon andMaissa examined contact lenswearers and showed a greaterspecificity of bulbar conjunctivallissamine green staining in thosepatients who demonstrated dryeye symptoms.2

Numerous studies establish acorrelation between patients withcorneal staining, decreased tearfilm break-up times, reduced tearprism, lid wiper epitheliopathy ormeibomian gland disease with atear film that could potentiallyundermine comfortable contactlens wear (figure 3).3-8 Also, neo-vascularization of the cornea and

Develop Your SpecialtyContact Lens Practice

Release Date: January 2009

Expiration Date: January 31, 2010

Goal Statement: By utilizing newer lens technologies and understanding

the benefits they can offer, the practitioner will keep patients happy and

realize significant practice benefits.

Faculty/Editorial Board: Mile Brujic, O.D.

Credit Statement: This course is pending approval for 2 hours of CE

credit. Check with your local state licensing board to see if this counts

toward your CE requirement for relicensure.

Joint-Sponsorship Statement: This continuing education course is

joint-sponsored by the University of Alabama.

Disclosure Statement: Dr. Brujic has no relationships to disclose.

This course is supported byan unrestricted educational

grant from

RE

VIE

W O

F CORNEA & CONTACT LENSE

S

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limbal hyperemia are typically signsassociated with corneal hypoxia.9,10

Utilizing the vital dyes andunderstanding the importance ofthe findings will help us deliverbetter care to our patients andguide our contact lens prescribinghabits. This testing regimen willalso begin the process of differen-tiating your practice as one with acontact lens specialty.

Understanding the MaterialsTraditionally, hydroxyethyl

methacrylate (HEMA) was themainstay material in soft contactlenses. HEMA-based contact lens-es, often referred to as hydrogels,worked well because of their easi-ly wettable surfaces and the ability to provide an initially com-fortable contact lens wearingexperience.11 The Dk, or oxygenpermeability of a hydrogel lens, isdirectly related to the water con-tent of the lens. Thus, a contactlens that is higher in water con-tent is also more oxygen perme-able than a contact lens with alower water content. Recentresearch has shown that there isan association between contactlens-related dry eye and highwater content contact lenses. Thisis potentially due to protein depo-sition and spoilage of these lenses(figure 4).12,13

Silicone hydrogel contact lenseswere manufactured as an attemptto balance water content and oxy-gen permeability. The original con-

tact lenses in the category werePureVision (Bausch & Lomb) andFocus Night & Day (CIBAVision).14,15 These contact lensesdelivered high amounts of oxygento the cornea in a low water con-tent material. The intricacies in thecombination of silicone, whichallows significant oxygen diffu-sion, and hydrogel, which attractswater, allows this delicate relation-ship to be manipulated to optimizeboth oxygen delivery and watercontent. In addition to thosealready listed, other contact lensesin this category include the AcuvueAdvance and Acuvue Oasys (Vis-takon), the Biofinity and Avaira(CooperVision) and the O2Optixand Air Optix (CIBA Vision).15-17

(See “Silicone Hydrogel Options,”pg. 29.)

Silicone hydrogel lenses retainsignificantly less protein deposits ontheir surfaces than their hydrogelpredecessors.18,19 But, they are morelikely to retain lipid-rich deposits ontheir surfaces.20 So, minimizing thecomfort limitations that result fromthese deposits requires selecting thesolutions that are superior at pro-tein and lipid removal. And, inaddition to selecting solutions thatinherently remove these compo-nents, it is also important to pre-scribe a lens-cleaning regimen thatwill involve a digital rub and rinsestep prior to soaking contact lensesin the evening.

Each silicone hydrogel lens isdesigned differently to maximize

surface wettablility in an effort tocreate a comfortable contact lenswearing experience. The AcuvueAdvance (galyfilcon A) and AcuvueOasys (senofilcon A) contact lensesutilize a wetting agent that containspolyvinyl pyrrolidone (PVP), whichallows for comfortable contact lenswear. In a study by Riley and asso-ciates that looked at several mark-

ers for healthy, comfortable contactlens wear, 88% of contact lens wear-ers refit into senofilcon A contactlenses reported better comfort.21

The Biofinity (comfilcon A) andAvaira (enfilcon A) contact lensesare unique, in that the siliconehydrogel polymer used in theselenses is hydrophilic, resulting in alens with a relatively low modu-lus.16 The Focus Night & Day(lotrafilcon A), O2Optix (lotrafilconB) and Air Optix (lotrafilcon B)lenses each undergo a surface plas-ma treatment, which results in ahydrophilic surface. One studyshowed that, out of several siliconehydrogel lenses challenged in vitro,various lipids deposited less onboth lotrafilcon A and B lensesthan on any of the other lenses test-ed.22 The PureVision line of contactlenses (balafilcon A) utilizes N-vinyl pyrrolidone, which becomesan inherent part of the lens matrixand allows for enhanced wettabilityand deposit resistance.14

The increased ability of siliconehydrogel lenses to deliver largeramounts of oxygen to the corneasignificantly decreases risk ofhypoxia and conjunctival hyper-emia, two effects of lower Dk lens-es. Limbal and bulbar hyperemia isalso often associated with low Dklenses and will typically decreasewhen fit with a silicone hydrogel.23

Research has shown that com-fort increases when patients whowear hydrogel contact lenses arerefit with silicone hydrogel con-tacts.24,25

There are many health benefitsrealized by embracing this categoryof lenses; yet, there still seems to be

1. Remember to use sodium flourescein during every patient encounter. This patienthas a cornea that looks healthy and normal when viewed with a regular slit lampbeam (left), vs. viewing the same cornea after instillation of flourescein and utilizing a cobalt blue light and Wratten filter (right).


027_rccl0109_CE_F 1/8/09 10:33 AM Page 28


a lack of consensus on how muchoxygen is sufficient to maintainhealthy corneal physiology. Onestudy suggested that a minimumDk/t of 125 is required to main-tain normal corneal function on anextended wear basis. It also sug-gested a minimum Dk/t of 35 isneeded to maintain normal cornealphysiology during daily wear.26

Researchers in another study pro-posed a minimum Dk/t of 90 fordaily wear.27

But, although oxygen perme-ability is important to maintainnormal corneal physiology, itwill not prevent microbial infec-tions. Recent research has exam-ined rates of microbial keratitisin those who wear siliconehydrogel contact lenses and hasfound that infection rates areequal to those who wear hydro-gel contact lenses.28 But, regard-less of the material, daily wearseems to result in the lowest rateof microbial keratitis.29

I hope all practitioners embracethese contact lenses for theirpotential to minimize oxygendemand to the cornea and offerpatients superior comfort. Manylens wear dropouts, who ceasedlens wear due to comfort issues,may once again be able to wearcontact lenses successfully.

Toric Contact LensesMany patients with astigma-

tism are often not properly edu-cated about their contact lensoptions and associate their lenswearing experience with a lensthat they were fit with manyyears ago. These patients maybenefit significantly fromnewer materials and designsthat offer both comfort andstable vision. These patientsmay be corrected with theirspherical equivalent, andalthough there have been majoradvancements in asphericoptics, this correction is notenough to result in adequate

visual improvement for suchastigmatic patients.30,31

Additionally, many practitionersmay hesitate to fit patients withhigher amounts of astigmatismwith soft toric contact lensesbecause of concern about the rota-tional stability of the design. For-tunately, the numerous contactlens options available allow us toaccurately and comfortably fitthose astigmats who may not havebeen satisfied in the past.

The successful implementationof comfort and visual stability willultimately determine the success ofa patient’s contact lens wearingexperience. There are many differ-ent designs incorporated into atoric contact lens to add stability,and the practitioner should becomfortable utilizing them inorder to maximize the chance ofsuccess when fitting these patients.

CooperVision offers an exten-sive line of toric contact lensoptions. The two-week dispos-able lenses include the BiomedicsToric and Vertex Toric, andmonthly replacement contactlenses, such as the Frequency 55Toric and the Proclear Toric, arealso available. Additionally, theProclear toric lens is available ina daily disposable modality.These designs offer stability andthe ability to “customize” theamount of astigmatic correctionin the lens (see “Toric ContactLenses” pg. 30).

Bausch & Lomb manufacturesboth the SofLens 66 Toric and thePureVision Toric contact lens.These are available in a prism-ballasted design and a wide vari-ety of powers. Many of thefeatures of the SofLens 66 Torichave been incorporated into thePureVision Toric, offering thebenefits of a proven design in asilicone hydrogel material. This isespecially important for the infe-rior portion of the contact lens,where a prism ballast typicallyprogresses to a slightly thickerprofile. The high oxygen perme-ability provided by a high Dk lensdiminishes this concern.

Vistakon’s Acuvue Advance forAstigmatism (AAFA) and AcuvueOasys for Astigmatism (AOFA)are made with a unique accelerat-ed stabilization design. TheAAFA is composed of galyfilconA. The AOFA (senofilcon A) isthe most recent generation of

2. Lissamine green staining of the nasal con-junctiva, which can be the first sign of under-lying dry eye.

Table 1. Silicone Hydrogel Options

Manufacturer Contact Lens Material Water Dk/t Content (at -3.00D)

Bausch & Lomb PureVision balafilcon A 36% 112CIBA Vision Air Optix Aqua lotrafilcon B 33% 138

Focus Night & Day lotrafilcon A 24% 17502Optix lotrafilcon B 33% 13802Optix Custom sifilcon A 32% 117

CooperVision Avaira enafilcon A 46% 125Biofinity comfilcon A 48% 160

Vistakon Acuvue Advance galyfilcon A 47% 86Acuvue Oasys senofilcon A 38% 147

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toric lenses from Vistakon. Smalldesign modifications have beenmade to the AOFA in order tocreate a lens that is easier to han-dle than it’s predecessor. TheAcuvue family of toric contactlenses has been studied extensive-ly and has been shown to haveless rotation when patients werepositioned on their side, on infe-rior-nasal version and duringlarge versional eye movements vs.prism-ballasted contact lenses.32,33

CIBA Vision’s Air Optix forAstigmatism is a silicone hydro-gel prism-ballast design and is amonthly replacement contact

lens. This lens has markingsat three, six and nine o’clock,allowing for easy observation.The stability of the designallows practitioners to confi-dently fit this contact lenswith a high level of success.

Understanding the manyavailable designs will certain-ly benefit your patients byallowing you to individualizetheir contact lens prescrip-tion. And, utilizing thenewest toric options improvesthe practitioner’s chances ofsuccessfully fitting patientswith challenging astigmatic

visual demands.

Multifocal Contact LensesPatient demographics are chang-

ing at an alarming rate, and by theyear 2010, more than one-third of the U.S. population will be be-tween the ages of 40 and 59.34

These patients have different needsthan presbyopes did ten years ago,thanks to the changing role oftechnology in our society. Withincreasing utilization of cellphones and computers, today’spresbyopes will require greatervisual functionality. Today’s dis-posable contact lens options will

give these patients the ability tolead more versatile lives by mini-mizing their dependency on sup-plemental eyewear.

The technology behind multi-focal contact lenses has pro-gressed significantly since theywere first introduced. Now, prac-titioners can offer their presby-opic patients the opportunity tofunction similarly to the way theydid before presbyopia set in. Thekey to successfully fitting thesecontact lenses is understandingthe designs of the currently avail-able multifocal contact lensoptions and the many benefitsthey offer (see “Multifocal Con-tact Lenses,” pg. 31).

CooperVision has a number ofcontact lenses available for pres-byopic patients. The Proclearmultifocal and the Frequency 55multifocal contact lenses havevery similar designs but vary intheir material. The Frequency 55multifocal is made of methafilconA, while the Proclear multifocalis made from omafilcon A, whichhas been shown to help patientswith contact lens relateddryness.35-37 Such lenses may bean ideal choice for this patientpopulation, as the prevalence of

3. Lid wiper epitheliopathy results in staining onthe area posterior to the meibomian gland orifices on the superior lid. Staining of this areais highly correlated with dry eye symptoms in contact and non-contact lens wearers.

Table 2. Toric Contact Lenses

Manufacturer Contact Lens Material Cylinder up to:

Bausch & Lomb PureVision Toric balafilcon A 2.25SofLens Toric alphafilcon A 2.75

CIBA Vision Air Optix for Astigmatism lotrafilcon B 2.25Focus Dailies Toric with AquaRelease nefilcon A 1.50Focus Toric vifilcon A 2.50

CooperVision Biomedic Toric ocufilcon D 2.25Clearsight 1 Day Toric ocufilcon D 1.25Frequency 55 Toric (XR) methafilcon B 2.25 (5.75)Proclear Toric (XR) omafilcon A 2.25 (5.75)Vertex Toric (XR) methafilcon A 2.25

Vistakon Acuvue Advance for Astigmatism galyfilcon A 2.25Acuvue Oasys for Astigmatism senofilcon A 2.25

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ocular surface disease increaseswith age.38 These contact lenseshave an aspheric design and arebased on the principal of simulta-neous vision. The Proclear multi-focal lens is produced with twodesigns: a distance center, nearperipheral design (D lens), andnear center, distance peripheraldesign (N lens). It is recommend-ed to fit the D lens on the domi-nant eye and the N lens on thenon-dominant eye.16 Practitionersultimately determine how thelenses are fit and can utilize twoD or two N lenses the way theydeem appropriate. The BiomedicsEP, also made of omafilcon A, isa multifocal contact lens madefor the emerging presbyope,whose add is less than +1.50D.Patients’ powers are selectedbased on their distance prescrip-tion as the add power is fixed.16

The Focus Progressives line ofmultifocal contact lenses (CIBAVision) also utilizes asphericoptics to meet patients’ distance,intermediate and near visionneeds. This line of contact lensesis unique—there is a daily dispos-able multifocal contact lensoption available. These contactlens powers are determined andordered by adding half of thespectacle add to the distance cor-rection, resulting in one powerthat is listed on the package.15

Bausch & Lomb is the onlycompany that currently offers amultifocal in a silicone hydrogelmaterial. This design offers the

benefits of aspheric optics, allow-ing multiple focal distances. Thislens comes in a monthly replace-ment modality and is FDA-approved for extended-wear ofup to 30 days. These lenses areavailable in low add and highadd options. This provides thepractitioner with some flexibilitywhen fitting presbyopes with avariety of add powers and vari-ous lifestyle requirements.

Vistakon’s Acuvue Bifocal,which uses a concentric ringdesign that alternates between thedistance and near optical zonesthroughout the lens, is available inadd powers from +1.00D to+2.50D, in 0.50D steps. Theselenses are made of etafilcon Amaterial, the same HEMA-basedmaterial that is used in the Acuvue2 contact lens. They come in alarge range of powers and oftensatisfy most patients’ visual needs.Interestingly, Vistakon will bereleasing a new silicone hydrogelmultifocal lens, which will be com-posed of senofilcon A. This lenswill offer the proven comfort ben-efits that senofilcon A has demon-strated and will be available inmultiple add powers to satisfy awide variety of patient needs.

There are two factors toremember when fitting multifocalcontact lenses: setting properpatient expectations; and possess-ing a thorough knowledge of thedifferent options, designs andmodalities and how they meetyour patients’ varying demands.

The goal of multifocal contactlenses is to increase patients’ func-tionality with minimal use of sup-plemental eyewear. If the patientcannot read the 20/20 line on thenear-point card, this does not nec-essarily mean that the fit wasunsuccessful. Rather, some peoplewill need supplemental eyewear inaddition to their multifocal con-tact lenses for certain viewingtasks, such as reading the smallprint on a medication bottle.

Colored Contact LensesThe numerous colored contact

lenses available offer patients theopportunity to change the appear-ance of their eyes with either atinted or an opaque contact lens.

Tinted contact lenses work wellfor those patients who have alighter colored iris, but those witha darker colored iris will not see asignificant change in the appear-ance of their eyes with tints. Forthese patients, opaque contactlenses work best.

Table 3. Multifocal Contact Lenses

Manufacturer Contact Lens Material DescriptionBausch & Lomb PureVision Multifocal balafilcon A Low and high add options

SofLens Multifocal polymacon Low and high add optionsCIBA Vision Focus Progressives nefilcon A Power is distance Rx + 1/2 add

Focus Dailies Progressives nefilcon A Power is distance Rx + 1/2 addCooperVision Frequency 55 multifocal methafilcon A Dominant and non-dominant design

Proclear multifocal omafilcon A Dominant and non-dominant designProclear Toric multifocal omafilcon A Dominant and non-dominant design

Vistakon Acuvue Bifocal etafilcon A Concentric zone design

4. This is a patient with significantprotein deposition.

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In certain patients, combiningopaques and tints in unique wayscan change the appearance of adisfigured iris or a corneal opacity.CIBA Vision, CooperVision andVistakon all offer such lenses.

Tinted and opaque contact lens-es offer patients the chance toalter their appearance while pro-viding good vision and ocularhealth. Consider this option foryour patients as a means of cus-tomizing their contact lens wear-ing experience.

Specializing Your PracticeUnderstanding the intricacies of

silicone hydrogel, toric, multifocaland tinted contact lens options isthe first step to developing a spe-cialty contact lens practice. Thenext step is cultivating loyaltyamong your patients by creatingadvocates for your contact lensservices. Start by creating an expe-rience for your contact lenspatients, and begin with the newwearer. Training first-time contactlens wearers how to insert contactlenses into their eyes and care fortheir contact lenses is somethingthat happens at most offices, butcommunication with the patientbefore their follow-up visit is rare.Change that protocol slightly byasking staff members to follow-upwith a phone call a day or twoafter they have gone through thetraining. This will keep the com-munication line open between thepractice and the patient, enhanc-ing the relationship.

When you feel that you haveexceeded the expectations of aparticular patient, use the oppor-tunity to tell him or her aboutyour passion to help others withsimilar conditions. Encourage suchhappy patients to refer friends andfamily members whom they mayknow have a similar problem. Forexample, an emerging presbyopewho sees you for the first timeexpects glasses. These patients areusually thrilled when they are suc-

cessfully fit with contact lenses.With patients such as these, conclude the final fitting visit bysaying, “I am so glad that we wereable to correct your vision andmake you more functional withoutthe need for supplemental eyewear.If you know anyone whom youfeel would benefit from the servic-es that you received, feel free to letthem know about our office.”This creates a patient-centeredmonologue that shows how yougenuinely want to help people whomay be limited by the same visualproblems. Incorporate such a mes-sage, and watch your specialty lenspractice soar.

Create an ExperienceEmbrace new contact lens

options as an opportunity tohelp your patients exceed theircomfort and visual expectations.Create an experience by cultivat-ing loyalty and advocates foryour practice. Share your pas-sion—and your willingness tohelp others with the same con-cerns—with your patients. Whenyou implement these concepts,you will be well on your way tocreating a successful specialtycontact lens practice.

1. Ritson M. Which patients are more profitable? ContactLens Spect 2006 Mar;21(3):38-42.2. Guillon M, Maissa C. Bulbar conjunctival staining in con-tact lens wearers and non lens wearers and its associationwith symptomatology. Cont Lens Anterior Eye 2005Jun;28(2):67-73. 3. Nichols KK, Nichols JJ, Lynn Mitchell G. The relationbetween tear film tests in patients with dry eye disease. Oph-thalmic Physiol Opt 2003 Nov;23(6):553-60.4. Pult H, Purslow C, Berry M, Murphy PJ. Clinical tests forsuccessful contact lens wear: relationship and predictivepotential. Optom Vis Sci 2008 Oct;85(10):E924-9.5. Korb DR, Greiner JV, Herman JP, et al. Lid-wiper epithe-liopathy and dry-eye symptoms in contact lens wearers.CLAO J 2002 Oct;28(4):211-6.6. Korb DR, Herman JP, Greiner JV, et al. Lid wiper epithe-liopathy and dry eye symptoms. Eye Contact Lens 2005Jan;31(1):2-8.7. Henriquez AS, Korb DR. Meibomian glands and contactlens wear. Br J Ophthalmol 1981 Feb;65(2):108-11.8. Gilbard JP, Rossi SR, Heyda KG. Tear film and ocular sur-face changes after closure of the meibomian gland orifices inthe rabbit. Ophthalmology 1989 Aug;96(8):1180-6.9. DeDonato LM. Corneal vascularization in hydrogel contactlens wearers. J Am Optom Assoc 1981 Mar;52(3):235-6.10. Papas EB. The role of hypoxia in the limbal vascularresponse to soft contact lens wear. Eye Contact Lens 2003Jan;29(1 Suppl):S72-4.11. Nixon G. Contact lens materials update 2008. ContactLens Spect 2008 Nov;23(10):33-40.

12. Ramamoorthy P, Sinnott LT, Nichols JJ. Treatment, mate-rial, care, and patient-related factors in contact lens-relateddry eye. Optom Vis Sci 2008 Aug;85(8):764-72.13. Nichols JJ, Sinnott LT. Tear film, contact lens, andpatient-related factors associated with contact lens-relateddry eye. Invest Ophthalmol Vis Sci 2006 Apr;47(4):1319-28.14. Manufacturer Web site. Bausch & Lomb. Available at:www.bausch.com. (Accessed Nov 2008).15 Manufacturer Web site. CIBA Vision. Available at:www.cibavision.com. (Accessed November 2008).16. Manufacturer Web site. CooperVision. Available at:www.coopervision.com. (Accessed Nov 2008).17. Manufacturer Web site. Vistakon. Available at: www.vis-takon.com. (Accessed Nov 2008).18. Santos L, Rodrigues D, Lira M, et al. The influence ofsurface treatment on hydrophobicity, protein adsorption andmicrobial colonisation of silicone hydrogel contact lenses.Cont Lens Anterior Eye 2007 Jul;30(3):183-8.19. Suwala M, Glasier MA, Subbaraman LN, Jones L. Quan-tity and conformation of lysozyme deposited on conventionaland silicone hydrogel contact lens materials using an in vitromodel. Eye Contact Lens 2007 May;33(3):138-43.20. Cheung SW, Cho P, Chan B, et al. A comparative study ofbiweekly disposable contact lenses: silicone hydrogel versushydrogel. Clin Exp Optom 2007 Mar;90(2):124-31.21. Riley C, Young G, Chalmers R. Prevalence of ocular sur-face symptoms, signs, and uncomfortable hours of wear incontact lens wearers: the effect of refitting with daily-wear sil-icone hydrogel lenses (senofilcon a). Eye Contact Lens 2006Dec;32(6):281-6.22. Carney FP, Nash WL, Sentell KB. The adsorption of majortear film lipids in vitro to various silicone hydrogels overtime. Invest Ophthalmol Vis Sci 2008 Jan;49(1):120-4.23. Dumbleton K, Keir N, Moezzi A, et al. Objective and sub-jective responses in patients refitted to daily-wear siliconehydrogel contact lenses. Optom Vis Sci 2006Oct;83(10):758-68.24. Dillehay SM. Does the level of available oxygen impactcomfort in contact lens wear? A review of the literature. EyeContact Lens 2007 May;33(3):148-55.25. Chalmers R, Long B, Dillehay S, Begley C. Improvingcontact-lens related dryness symptoms with silicone hydro-gel lenses. Optom Vis Sci 2008 Aug;85(8):778-84.26. Harvitt D, Bonanno J. Re-evaluation of the oxygen diffusionmodel for predicting minimum contact lens Dk/t values neededto avoid corneal anoxia. Optom Vis Sci 1999;76:712-719.27. Ostrem E, Fink B, Hill R. A hypoxic response line modelfor the human cornea. Br J Optom Disp 1996;4:53-55.28. Dart JK, Radford CF, Minassian D, et al. Risk factors formicrobial keratitis with contemporary contact lenses: a case-control study. Ophthalmology 2008 Oct;115(10):1647-54.29. Stapleton F, Keay L, Edwards K, et al. The incidence ofcontact lens-related microbial keratitis in Australia. Ophthal-mology 2008 Oct;115(10):1655-62.30. Richdale K, Berntsen DA, Mack CJ, et al. Visual acuitywith spherical and toric soft contact lenses in low- to moder-ate-astigmatic eyes. Optom Vis Sci 2007 Oct;84(10):969-75.31. Morgan PB, Efron SE, Efron N, Hill EA. Inefficacy ofaspheric soft contact lenses for the correction of low levels ofastigmatism. Optom Vis Sci 2005 Sep;82(9):823-8.32. Young G, McIlraith R. Toric soft contact lens visual acuitywith abnormal gaze and posture. AAO October 2008. 33. Zikos GA, Kang SS, Ciuffreda KJ, et al. Rotational stabili-ty of toric soft contact lenses during natural viewing condi-tions. Optom Vis Sci 2007 Nov;84(11):1039-45.34. Census Bureau. U.S. Interim Projections by Age, Sex,Race, and Hispanic Origin: 2000-2050. Available at:www.census.gov/population/www/projections/usinterimproj(Accessed November 2008).35. Lemp MA, Caffery B, Lebow K, et al. Omafilcon A (Pro-clear) soft contact lenses in a dry eye population. CLAO J1999 Jan;25(1):40-7.36. Young G, Bowers R, Hall B, Port M. Clinical comparisonof Omafilcon A with four control materials. CLAO J 1997Oct;23(4):249-58.37. Riley C, Chalmers RL, Pence N. The impact of lenschoice in the relief of contact lens related symptoms andocular surface findings. Cont Lens Anterior Eye 2005Mar;28(1):13-9.38. The epidemiology of dry eye disease: report of the Epi-demiology Subcommittee of the International Dry EyeWorkShop (2007). Ocul Surf 2007 Apr;5(2):93-107.

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1. Flourescein works well in examining the integrity of the corneabecause of its ____________ properties.a. Hydrophilic.b. Hydrophobic.c. Bipolar.d. None of the above.

2. All of the following are examination findings that may underminecomfortable contact lens wear EXCEPT:a. Corneal staining.b. Increased tear film break-up time.c. Presence of lid wiper epitheliopathy.d. Meibomian gland disease.

3. Guillon and Maissa examined contact lens wearers and found agreater specificity of ____________________ staining for thosewho showed symptoms of dry eye.a. Corneal lissamine green.b. Conjunctival lissamine green.c. Corneal flourescein.d. Conjunctival flourescein.

4. Oxygen permeability in a hydrogel contact lens is:a. Directly related to its water content.b. Inversely related to its water content.c. Directly related to its modality.d. Directly related to its parameters.

5. The examination process is comprised of:a. Lens selection, fitting, and asking the patient for a referral.b. Conversations about new lens technologies and ocular examination.c. A visual acuity test.d. Gathering patient history, the actual exam and medical decision-mak-

ing.

6. A silicone hydrogel contact lens will typically deposit ________ proteins and _________ lipids than their hydrogel predecessors.a. More, more.b. More, less.c. Less, less.d. Less, more.

7. Neovascularization of the cornea and limbal hyperemia are usuallysigns of:a. Dry eye.b. MGD.c. Corneal hypoxia.d. Infection.

8. A hydrogel contact lens that is higher in water content:a. Is ideal for pediatric patients.b. Is more oxygen permeable.

c. Is rotationally stable.d. Is less oxygen permeable.

9. In a recent study by Riley and associates, what percent of contactlens wearers refit into the senofilcon A material reported bettercomfort? a. 35%.b. 70%.c. 88%.d. 90%.

10. Which of the following signs will typically decrease when a patientis fit with silicone hydrogel lenses?a. Limbal and bulbar redness.b. Palpebral papillary response and bulbar redness.c. Hyperopic refractive error and limbal redness.d. Corneal neovascularization.

11. Ostrem, Fink and Hill have proposed a minimum Dk/t of ____ tomaintain normal corneal physiology during daily wear of contactlenses.a. 35.b. 70.c. 90.d. 125.

12. What seems to result in the lowest rate of microbial keratitis?a. Utilizing lenses made of silicone hydrogel.b. Utilizing lenses that are HEMA based.c. Utilizing daily disposable contact lenses.d. Wearing contacts on a daily wear schedule.

13. How can practitioners maximize the comfort of lenses known todeposit protein and lipids on their surfaces?a. Prescribe a solution that effectively removes lipids and protein.b. Advise patients to include a rub-and-rise step in their care regimen

before soaking their lensesc. Both a and b.d. Advise patients to choose another lens.

14. What design does the Acuvue Oasys for Astigmatism utilize to stabi-lize the contact lens?a. Double thin zone.b. Prism ballast design.c. Accelerated stabilization design.d. Distance-center design.

15. Research has shown that comfort ________when patients whowore hydrogel lenses are refit with silicone hydrogel lenses.a. Decreases significantly.b. Remains the same.c. Increases.d. Decreases slightly.

Self-Assessment Examination:Develop Your Specialty Contact Lens Practice

DIRECTIONS: To obtain 2 hours of continuing education credit, complete the exam by recording the best answer to each self-assessment question on the ExaminationAnswer Sheet on Page 34. Mail the answer sheet to Optometric CE, P.O. Box 488, Canal Street Station, New York, NY 10013. A minimum score of 70 is required toobtain a certificate of completion. There is no fee for this course.

027_rccl0109_CE_F 1/8/09 10:38 AM Page 33

Examination Answer Sheet Valid for credit through January 31, 2010

Develop Your Specialty Contact Lens Practice

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

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

COPE approval for 2 hours of CE credit is pending.

This course is joint-sponsored by the University of Alabama School of Optometry and support-ed by an unrestricted educational grant from The Vision Care InstituteTM, LLC.

There is an eight-to-ten week processing time for this exam.

1. A B C D 21. The goal statement was achieved:2. A B C D Very Well Adequately Poorly3. A B C D

4. A B C D 22. The information presented was:5. A B C D Very Useful Useful Not Very Useful6. A B C D

7. A B C D 23. The difficulty of the course was:8. A B C D Complex Appropriate Basic9. A B C D

10. A B C D 24.Your knowledge of the subject was increased:11. A B C D Greatly Somewhat Hardly12. A B C D

13. A B C D 25. The quality of the course was:14. A B C D Excellent Fair Poor15. A B C D How long did it take to complete this course?16. A B C D

17. A B C D Comments on this course:18. A B C D

19. A B C D Topics you would like in the future CE articles:20. A B C D

Please retain a copy for your records. Please print clearly.

You must choose and complete one of the following three identifier types:

1 SS # - -

Last 4 digits of your SS # and date of birth State Code and License #: (Example: NY12345678)

2 - 3

First Name

Last Name

E-Mail

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 presented. I have not obtained the answersto this exam by any fraudulent or improper means.

Signature Date

Lesson 106026 RCCL-UAB-0109

16. Although they have similar designs, the Frequency 55 multifocal is made of________, whereas the Proclear Multifocal is made of __________.a. Methafilcon A, omafilcon A.b. Omafilcon A, methafilcon A.c. Lotrafilcon A, omafilcon A.d. Methafilcon A, lotrafilcon A.

17. Knowledge and utilization of the latest _________contact lenses helps the practitioner successfully fit astigmats with challenging visual demands.a. Silicone hydrogel.b. Toric.c. Multifocal.d. Colored.

18. _______ of the American population will be between the ages of 40 and 59 by the year 2010.a. One-half.b. One-eighth.c. One-fourth.d. One-third.

19. The Acuvue bifocal:a. Is a silicone hydrogel multifocal contact lens.b. Is based on a concentric ring platform.c. Has different contact lens designs designated as

dominant and non-dominant.d. Is made of lotrafilcon A.

20. What type of contact lens is ideal for changing the color of the iris in a patient with a dark colored iris?a. Opaque.b. Tinted.c. Daily disposable.d. Hydrogel.


027_rccl0109_CE_F 1/8/09 10:43 AM Page 34

Here is what you need to look for to ensure proper eyelid analysis, diagnosis andappropriate therapy. By Katherine M. Mastrota, M.S., O.D., F.A.A.O.


Dr. Mastrotais CenterDirector atthe NewYork Office

of Omni Eye Services.She has lectured locallyand nationally on her spe-cial areas of interest,which include ocular sur-face disease and pseudoex-foliation syndrome.

Clear, comfortable vision canonly be achieved with opti-mum interaction of the lids

with the eye and the balance main-tained by a normal tear film. Anyviolation of the lid architectureand/or disruption of the tear filmwill inevitably lead to compromisedvisual clarity and a constellation ofpathologic symptoms that includecontact lens intolerance.

Let’s take a closer look at theclose connection between the lids,the eye and the contact lens.

Lid Health is Skin DeepThe practitioner is encouraged

to carefully evaluate the visage

of every patient. This is bestaccomplished in the examinationchair under a bright light withthe examiner scanning the faceand neck of the patient for scar-ring, change in facial or eyelidtonus or dermatologic disease.Eye-care practitioners mustassess the skin of the patient’sface and adnexa. Any change innormal appearance should benoted; the skin’s texture, color, pigmentation and overall condi-tion all require attention. Often,skin disease is reflected in theeyelids and lid margins and willultimately have an impact onocular surface function.

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If you see scarring, query thepatient as to the origin and cir-cumstances of its presence. Ofparticular concern are scars on thelids, face and neck that resultfrom cosmetic surgery or treat-ments, neck or carotid surgery,trauma, chalazion removal, scarsincurred from past thyroid sur-gery, acoustic neuroma surgery ordermatologic concerns.

Cosmetic surgery (e.g., ble-pharoplasty) or therapy withBotox injection (Botulinum toxintype A, Allergan), can alter theposition and function of the eye-lids and surrounding tissues.Exposure of the ocular surfaceafter blepharoplasty is not uncom-mon. Similarly, over-injection ormissed injections of Botuliumtoxin could result in ptosis orincomplete lid closure.1,2

Possible complications of neckor carotid surgery includeHorner’s syndrome with anisoco-ria and ptosis on the ipsilateralside.3 Trauma or excision of lidlesions can result in lid notchingthat alters the tear-spreadingcapabilities of the blink. Prior history of chalazia removal canattest to the chronicity of a pa-tient’s disease.

A neck scar could indicate sur-gical management of thyroid dis-ease (surgical removal of the

thyroid gland). Such presentationswarrant further testing in order torule out ocular manifestations ofthe disease, such as immune-medi-ated dry eye. Signs of hyperthy-roidism include proptosis or lidlag, both of which allow forincreased tear evaporation. Eye-brow and eyelash loss is also seenin dysthyroidism.

Ectropion or entropion, com-monly associated with age, canalso develop from pathologicstates; intuitively, these lid malpo-sitions will create a compromisedlid-surface system and ultimatelylead to patient symptoms. Theweight of sagging jowls of apatient with age-related mid-facialdescent can draw down the lowereyelids, allowing for scleral showand increased tear film evapora-tion. Similarly, patients with shal-low cheekbones can lack adequatebony support of the lower lids,again allowing for incompleteinferior ocular surface coverage.

Seborrhea, a hyperkeratiniza-tion of the skin rich in sebaceousglands, is thought to be caused bythe yeast Pithyosporin ovale andcan lead to a scaly anterior ble-pharitis and cause keratinizationof the eyelid margin, contributingto obstruction of the meibomiangland orifices.4 More common inmen, this condition will present

as flaking in the eyebrow area,scalp and facial skin. Antifungaldandruff shampoos can be effec-tive in controlling symptoms inthese patients.

Ocular rosacea may exist alone,but often accompanies other sub-types of rosacea, which includeerythematotelangiectatic, papulo-pustular, and phymatous rosacea.Rosacea is an inflammatory dis-ease of unknown etiology. Thereare many trigger factors—includ-ing sun exposure, Demodex miteinfestation, stress, hot weatherand certain foods—that exacer-bate the dermatologic symptomsof rosacea. Characteristic changesof the skin include facial rednessor flushing, at times accompaniedby skin stinging and burning, visi-ble blood vessels and skin rough-ness. Papules and pustules canoccur in rosacea, and/or phyma-tous (thickening) changes of theskin (nose, chin, forehead, ears)with large, irregular pores andbumps. Pathology in ocularrosacea includes mild to signifi-cant telangiectatic vessel develop-ment on the eyelid margin,meibomian gland sebborhea anddysfunction, keratitis and, ifaggressive, corneal ulceration withpossible perforation.

Rosacea and, to a lesser extent,rosacea-associated MGD areresponsive to oral administrationof low-dose tetracyclines, whichhave been shown to reduce bacte-rial lipases and inhibit college-nase, thereby temperinginflammation.5 Two conveniencekits available by prescription arethe Alodox Kit (Cynacon OCu-SOFT) and the Nutridox kit(Advanced Vision Research). Eachincludes doxycycline tablets, lidcleaning products, and an eyelid-warming device. Of course,adverse effects to oral tetracy-clines exist, and effective local

1, 2. Lash misdirection and lid notching. Note lid debris (left). Pearly keratinizationalong the lid margin obstructing meibomain gland orifices (right). Note scaly debris atthe eyelash base.

035_rccl0109_Lids 1/7/09 3:57 PM Page 36


application would be preferable.Pharmacy-compounded topicaltetracyclines are being studied fortheir effect in MGD, and topicaladministration of the highly-absorbed macrolide azithromycin(AzaSite, Inspire Pharmaceuticals)has shown significant promise inimproving MGD in this off-labeluse of the product.6 Additionally,the meibomian gland is a hor-mone target, therefore sparkinginterest in the potential for treat-ing MGD with topical administra-tion of hormone compounds.

Finally, the practitioner mustquestion patients regarding theirhistory of atopic disease. Patchesof eczema or psoriasis may be evi-dent in elbow or wrist skin creas-es; dermal changes in appearanceand function of the eyelid mayalert the practitioner to the aller-gic status of the patient. In theyoung patient, look for a MorganDennie fold or atopic pleat, a fold(or multiple folds) of eyelid skincreated by lid edema in the aller-gic patient. Likewise, infraorbitalcongestion creates dark circlesunder the eyes (allergic shiner).Ocular allergy is a major contrib-utor to ocular surface dysfunctionand long-term changes in itsanatomy and function.

A Look BeyondAcoustic neuromas affect approx-

imately 2,500 people in the UnitedStates annually.7 As schwannomasthat surround the acoustic nerve,these brain tumors cause tinnitus.Patients who undergo surgicalremoval of the tumor are at signifi-cant risk for postoperative compli-cations associated with inadvertentdamage to the VII nerve. Theseinclude corneal hypoesthesia, pooreyelid tonus and lagophthalmos.8

Similarly, any cause of VII nervepalsy may leave lid function com-promised in affected patients.

Eyelid tonus is an often-over-looked cause of ocular surface dis-ease and contact lens-wear failure.Laxity of either the upper or lowereyelid allows for faulty blinkmechanics and inadequate tearresurfacing. Lagophthalmos andnocturnal lagophthalmos, whichat times may be challenging todetect, are important conditions toconsider during the external evalu-ation.9 Every patient’s blink shouldbe examined for rate, excursionand completeness; any gap or driftin eyelid closure will set the stagefor evaporative surface problems.

The classic triad of Floppy Eye-lid Syndrome (FES), firstdescribed by Culbertoson in 1981,is over-weight, middle-aged maleswith lax, rubbery eyelids associat-ed with papillary conjunctivitis.10

We have come to learn, however,that FES is not exclusive to over-weight individuals or men, andthat it can present in patientsyoung and old, svelte or obese,male or female and in any agegroup, including infants. Unlesspurposely evaluated, the presenceof FES can be easily overlookedduring routine examination.11

Clinical signs of FES includeptosis, eyelash ptosis, derma-tochalasis, eyelid hyperpigmenta-tion and lacrimal gland prolapse.FES is associated with rosacea,meibomian gland dysfunction(MGD) and the presence of thefollicular and sebaceous glandmite Demodex. Patients shouldbe evaluated for sleep apnea,because there is a strong associa-tion with FES.12

Contact lens fitters are particu-larly interested in the associationof keratoconus with FES.13 Me-chanical trauma, a proposed mech-anism both of flaccid lids and ofthe conjunctival pathology of FES,has also been implicated in thedevelopment of keratoectasia.14-17

Chronic eye-rubbing, triggered bya variety of factors (most notablyrubbing in response to itch precip-itated by allergic disease), hasbeen considered as an inciting fac-tor for corneal ectasia.

Life on the EdgeCritical evaluation of the eyelid

margin is essential in routine eyeevaluations and especially impor-tant for characterizing ocular sur-face disease states in contact lenswearers pre- and post-fitting.

Starting anteriorly, carefulexamination of the eyelashes isnecessary; the lashes should beexamined for number, placement,misdirection, color, integrity andease of epilation from the follicle.Easily epilated lashes suggest lashfollicle edema, prompting concernfor inflammatory conditions of thelash follicle. Causes of madarosismust be explored and taken under

3. Normal, regular appearance of theMarx line stained with lissamine green.

4. Undulating lissamine green-stainedMarx line in a patient with MGD. A waterytear film is obvious.

035_rccl0109_Lids 1/7/09 3:57 PM Page 37


consideration. There are manycauses of madarosis, such as thy-roid disease and diabetes, whichwill also impact the normal func-tioning of the ocular surface. Cos-metic treatments of lids andlashes, such as eyelid tattooing oreyelash extensions (natural or syn-thetic “lashes” individually bond-ed to the natural lashes) may beassociated with meibomain glanddysfunction and blepharitis aswell.11 Blepharitis, however, is theprimary cause of eyelash loss orabnormal growth (figure 1).18

BlepharitisBlepharitis, or lid margin disease,

is generally divided into two classes,anterior and posterior blepharitis—although the two forms impact eachother and are seldom found inde-pendent of one another. Both formscan be inflammatory or infectious,is usually chronic with periods ofexacerbation, and it is typicallybilateral. Long-standing lid margindisease leads to keratinization of thelid margin and rounding and undu-lation of the formerly-sharp lidmargin edge (figure 2).

Anterior blepharitis describespathologic lid changes surroundingthe eyelash margin. Most common-ly caused by staphylococcal or seb-borheic skin inflammation, it isidentified by flaky, scaly changes of

the eyelid skin and accumulationof debris at the eyelash base.Ulceration may be present underthe flaky debris. Lipolyticenzymes produced by the residentbacteria hydrolyze tear film lipid,releasing highly irritating freefatty acids (saponification), whichdisrupt the tear film and its prop-erties and causes the characteristicfoamy appearance commonly seenin lid disease.

Similarly, in angular blepharitis,bacterial overpopulation causesexcoriation of the skin at the can-thi. Both are managed withcleansing of the area, preferablywith a commercially developedproduct such as OCuSOFT lidscrubs (Cynacon-OCuSOFT).OCuSOFT lid scrub productsrecently have been demonstratedto kill Demodex folliculorum,which is associated with blephari-tis.19 Home made shampoo-typesolutions expose the patient tounnecessary fragrances and color-ings and may contribute to thedisease process or precipitate anallergic reaction. Application ofantimicrobial ointment or, forexample, the DuraSite (InSiteVision) based macrolide AzaSite(azithromycin, Inspire, off-labeluse) to the cleaned lid margin isappropriate therapy to reduce thebacterial load on the skin.

Posterior blepharitis, or MGD,commonly refers to inflammationor changes in function of the mei-bomian glands. Critical examina-tion of the lid margin behind theeyelash line is necessary to evalu-ate patients with MGD. Movingposteriorly from the eyelash line,the examiner should identify eyelid margin landmarks, includ-ing the mucocutaneous junction,the gray line, and the meibomiangland orifices. The gray line delin-eates the lid into anterior and pos-terior lamella and represents

Riolan’s muscle, the most anteriorsegment of the obicularis oculi.The mucocutaneous border of thelid margin, a line of squamouscells also known as Marx’s line,runs a course parallel to the eyelidmargin. Marx’s line stains clearlywith lissamine green and inadvanced lid disease, will becomescalloped and irregular. Charac-terization of changes in Marx’sline has been suggested as a sim-ple tool in grading MGD and iseasily performed in any clinicalsetting (figures 3 and 4).20

The meibomian gland orificesopen to the margin surface behindthe gray line. The production ofmeibum and proper function ofthe glands and the lipid they pro-duce is essential for reducingevaporation of the tear film. Theanatomy of the meibomian glandsshould be appreciated as well asthe quality and quantity of thelipid they produce.

Examination of the meibomianglands begins with a look at thequantity of gland orifices, theirposition and regularity. The glandorifice, which is surrounded by asmall translucent cuff, should bechecked for patency vs. stenosis.Normal orifices will most often besituated at regular intervals—inMGD, the orifices may be pouted,plugged, capped or positionedirregularly due to traction or scar-ring (figure 5). The orifices canbecome keratinized, which leadsto gland obstruction and itssequelae that includes inflamma-tion and in advanced disease,atrophy. Loss of adequateamounts of meibomian glandlipid, or abnormal lipid, allows forincreased tear evaporation. Thecompromised tear film in MGDcan make contact lens wear chal-lenging by reducing wearing time,causing lens awareness, and taxingthe corneal surface. The tear film

5. Excessive meibomian gland capping ina patient with both anterior and posteriorblepharitis.

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can become watery, as it is thelipid layer that holds the tears film“tight to the eye.” Frequent cha-lazia are not uncommon in thesepatients; however, a history thatsuggests a focal, recurrent lesionshould prompt an investigation inorder to rule out meibomian glandcarcinoma or perhaps, a discoidlupus lesion of the lid margin.

Changes in lid margin vascular-ity also accompany MGD. Thenormal small capillary loopsunder the lid epithelium and thesuperficial vessels derived fromthe conjunctiva become engorged,and fine filigree telangiectatic ves-sels develop, especially in ocularrosacea (figure 6). Advanced casesof ocular rosacea can manifestwith punctate epithelial keratopa-thy, marginal corneal infiltrates,corneal neovascularization,corneal thinning, ulceration andperforation.

Treatment and ManagementMechanical expression of the

meibomian gland and examina-tion of its contents is a usefuldiagnostic practice and may be oftherapeutic value in patients withMGD.21 There are a variety ofmethods used to express meibumfrom the meibomian glands; thegoal of expression is characteriza-tion of the produced lipid and anestimation of functioning glands.Korb has recently described atechnique that quantifies the forceof expression.22

Knowing that not all glands areproducing lipid at the same time, itis helpful to perform meibography(meibomian gland transillumina-tion, easily accomplished at theslit lamp with a muscle light) forevaluation of gland morphologyand density corresponding to theidentified orifice. “Dimpling” or“divoting” of the lid margin sug-gests focal gland contraction,

dropout or atrophy (figure 7).Every exam should include inspec-tion of the meibomian gland onthe palpebral side of the eyelid,looking for cystic changes or com-paction of the gland.

Normal meibum egresses withminimal pressure to the meibomiangland and is clear; any opacifica-tion, “granulation” or thickeningof meibum indicates gland dys-function. Lipid may be copious

(meibomian gland seborrhea) andeasily evacuated or scant and paste-like, suggesting obstruction. Recentrecommendations for gradingexpressible meibum have beenintroduced and can prove useful ingauging gland disease and theimpact of applied therapies.Expressable lipid can be gradedfrom clear and free-flowing, toopaque and stagnant on a four-point scale.

Therapy for posterior blepharitisis guided by the severity of its pres-entation. Early disease is best man-aged by routine warming of the lidsto soften congested meibum withinthe gland, followed by mechanicalmassage to aid in thickened oilegress. Cool compresses followingmassage can reduce swelling andvasodilatation and may prove com-forting to your patients.

Omega-3 fatty acids have beendemonstrated to play a positiverole in the normalization of themeibum. Best choices for supple-mentation would include pharma-ceutical grade, cold-pressedcommercially-prepared productsthat ensure the purity and qualityof the product, avoiding solventsand heat which can damage oils.Also, topical ester-based steroids,such as Lotemax and Alrex(Bausch & Lomb) alone or inantibiotic combination with Zylet(loteprednol etabonate 0.5% andtobramycin 0.3%, Bausch &Lomb) are a good choice for man-aging lid disease and inflammatorykeratitis. It should be noted thatRestasis (cyclosporine A, Allergan)has been identified to reduce signsof posterior blepharitis and can bean effective long-term manage-ment strategy.23

Under the LidThorough lid examination

requires a look at the palpebralconjunctival surface of the eyelid.

6. Lid margin telangetasia in a patientwith ocular rosacea. Notice the roundingand irregularity of the lid margin edgeand lid debris.

7. Focal lid margin “divot” secondary tofocal meibomian gland dropout (palearea).

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Without exception, every patient’spalpebral conjuctiva (everted supe-rior and inferior) should beinspected under white light, fol-lowed by re-examination with vitaldye staining. Findings such ashyperemia, papillary or follicularreactions, lesions, granulomas orconcretions, scarring and fibrosis,abnormal pigmentation or depositsare all possible and require diagno-sis and management.

The tarsal conjunctiva of theupper lid features a stratifiedcolumnar epithelium with strati-fied squamous epithelia on thedistal lid margins (the lid wiper).It has been suggested that traumato the cuboidal lid epithelium,sensitive and reactive to rubbing,results in secretion of mucous andactivation of the inflammatorycascade, ultimately leading to thedevelopment of giant papillae onthe upper tarsal conjunctiva.24

Giant papillary conjunctivitis(GPC), is generally grouped intoallergy-type responses. It is thoughtto be precipitated by a combina-tion of mechanical and autoim-mune components.25 Althoughmost often associated with softcontact lens wear (contact lenspapillary conjunctivitis, or CLPC),GPC can develop in response toany mechanical irritation, such asexposed sutures, or any other anti-genic material , especially thosethat can accumulate on the contactlens. Besides large tarsal papillae,patients with GPC or CLPC mayexperience itching, excessive lensmovement and a mucoid discharge.If the papillae are excessive, therecan be a resultant ptosis.

The portion of the marginalconjunctiva of the upper eyelidthat “wipes” the ocular surfaceduring blinking has been referredto as “the lid wiper.” Changes inthe lid wiper can be highlightedwith vital dyes. Termed “lid wiper

epitheliopathy,” identification ofan altered lid wiper region corre-lates well with dry eye symptomsin both contact lens wearers andnon-lens wearers , even in theabsence of other signs of ocularsurface disease.26,27 Thus, we mustpay particular attention to the lidwiper region in patients whoreport symptoms consistent withocular surface dysfunction, yetpresent with minimal signs ofcorneal surface staining and tearbreak-up time abnormalities.

Evaluation of the palpebralconjunctiva will, every now andagain, disclose the presence ofconjunctival concretions, other-wise known as conjunctival lithia-sis. Occasionally, concretions willerode through the conjunctiva andabrade the corneal surface. Oncethought to be of calcific nature,concretions have been demon-strated to be composed of muci-nous secretions and degeneratedepithelial cells. It may be, as pro-posed by Duke-Elder in 1965,that concretions arise from chron-ic conjunctival inflammation.28

Knowing this, clinicians should beclued into those mechanisms ofchronic, low-grade inflammation,such as allergy and perhapschronic staphylococcal infectionand/or hypersensitivity.

All Things ConsideredThe many facets of lid disease

require thoughtful evaluation and astep-wise plan for amelioratingsymptoms related to its pathologiceffects. Therapy may be mechanical,nutritional or can employ a varietyof therapeutic agents. Pa-tience and patient education are keyto management of this frustratingubiquitous disease. Finally, atten-tion must be given to characteriza-tion of the position and the tone ofthe eyelid itself and how it inter-plays with the ocular surface.

1. Carruthers A, Carruthers J. Clinical indications and injectiontechnique for the cosmetic use of botulinum A exotoxin. Derma-tol Surg 1998 Nov;24(11):1189-94.2. Northington ME, Huang CC. Dry eyes and superficial punctatekeratitis: a complication of treatment of glabelar dynamicrhytides with botulinum exotoxin A. Dermatol Surg 2004Dec;30(12 Pt 2):1515-7. 3. Perry C, James D, Wixon C, et al. Horner’s syndrome aftercarotid endarterectomy—a case report. Vasc Surg 2001 Jul-Aug;35(4):325-7.4. Bergbrant IM. Seborrhoeic dermatitis and Pityrosporumyeasts. Curr Top Med Mycol. 1995;6:95-112.5. Dougherty JM, McCulley JP, Silvany RE, Meyer DR. The roleof tetracycline in chronic blepharitis: Inhibition of lipase pro-duction in Staphylococci. Invest Ophthalmol Vis Sci 1991:32:2970-5.6. Luchs J. Efficacy of topical azithromycin ophthalmic solution1% in the treatment of posterior blepharitis. Adv Ther 2008Sep;25(9):858-70.7. Acoustic Neuroma (1991) NIH Conseus Dev Conf ConsensStatement 9:1–24,8. Mulhern MG, Adruriz-Lorenzo PM, Rawluk D, et al. Ocularcomplications of acoustic neroma surgery. Br J Ophthalmol1999 Dec;83(12):1389-92.9. Latkany RL, Lock B, Speaker M. Nocturnal lagophthalmos: anoverview and classification. Ocul Surf 2006 Jan;4(1):44-53 .10. Culbertson WW, Ostler HB. The floppy eyelid syndrome. AmJ Ophthalmol 1981 Oct;92(4):568-75.11. Mastrota KM. Impact of floppy eyelid syndrome in ocularsurface and dry eye disease. Optom Vis Sci 2008Sep;85(9):814-6. 12. Van Nouhuys HM, van den Bosch WA, Lemij HG, Mooy CM.Floppy eyelid syndrome associated with Demodex Brevis. Orbit1994 Sep;13(3):125-9.13. Negris R. Floppy eyelid syndrome associated with kerato-conus. J Am Optom Assoc 1992 May;63(5):316-9. 14. Mc Monnies CW. The evidentiary significance of casereports: eye rubbing and keratoconus. Optom Vis Sci 2008Apr;85(4):262-9.15. Korb DR, Greiner JV, Leahy CD. Forceful eye rubbing as acausative factor in keratoconus. Ophthalmol1995;102(suppl):152.16. Mc Monnies CW, Boneham GD. Keratoconus, allergy, itch,eye rubbing and hand dominance. Clin Exp Optom 2003Nov;86(6):376-84.17. Mc Monnies CW. Abnormal rubbing and keratectasia. EyeContact Lens 2007 Nov;33(6 Pt 1):265-71. 18. Khong JJ, Casson RJ, Huilgol SC, Selva D. Madarosis. SurvOphthalmol 2006 Nov-Dec;51(6):550-60. Review.19. Yee R. Efficacy of OCuSOFT lid scrub plus on eradication ofocular demodex. July 2008. Study on file, Cynacon OCuSOFT.20. Yamaguchi M, Kutsuna M, Uno T, et al. Marx Line: fluores-cein staining line on the inner lid as indicator of meibomiangland function. Am J Ophthalmol 2006 Apr;141(4):669-75.21. Paranjpe DR, Foulks GN. Therapy of meibomian gland dis-ease. Ophthalmol Clin North Am. 2003 Mar;16(1):37-42.Review.22. Korb DR, Blackie CA. Meibomian gland diagnostic express-ibility: correlation with dry eye symptoms and gland location.Cornea 2008 Dec;27(10):1142-7.23. Perry HD, Doshi-Carnevale S, Donnenfeld ED, et al. Efficacyof commercially available topical cyclosporine A 0.05% in thetreatment of meibomian gland dysfunction. Cornea 2006Feb;25(2):171-5.24. Personal communication. Donald Korb. (September 02,2008)25. Elhers WH, Donshik PC. Giant papillary conjunctivitis. CurrOpin Allergy Clin Immunol 2008 Oct;8(5):445-926. Korb DR, Greiner JV, Herman JP, Hebert E, Finnemore VM,Exford JM, Glonek T, Olson MC. Lid-wiper epitheliopathy anddry-eye symptoms in contact lens wearers. CLAO J 2002Oct;28(4):211-6.27. Korb DR, Herman JP, Greiner JV, et al. Lid wiper epithe-liopathy and dry eye symptoms. Eye Contact Lens 2005Jan;31(1):2-8.28. Duke-Elder S. Diseases of the outer eye. Conjunctiva. In:System of Ophthalmology. Vol 8. St. Louis. CV Mosby.1965.RCCL


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IN THIS ISSUE · natives for treatment. Over the years, Intacs (Addition Technology) corneal ring segments and collagen cross-linking with UV light and riboflavin (C3R) have received