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ALSO: Genetics • Online CL Sales • CXL for Kids • Rethinking Corneal Disease • Daily Disposables • Retained PK Sutures

RCCLRCCLREVIEW OF CORNEA & CONTACT LENSES

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Review of Cornea & Contact Lenses | January/February 2017

departments features

contents

16CE — Fitting Multifocal Contact Lenses for Myopia Control

These practice pearls aid in myopia management, including avoiding onset and slowing progression in patients of all ages.

By Padmaja Sankaridurg, PhD, BOptom

News Review4Evidence Supports Long-term

Effi cacy of Collagen Crosslinking

My Perspective 6

Guest Editorial7

Get to Know Your Genes

By Joseph P. Shovlin, OD

Combating Online Contact Lens

Sales

By Andrea P. Thau, OD, AOA president

12Myopia on the MoveSteady growth in the prevalence of this deceptively simple condition will expose half the world’s population to visual impairment. Here’s what to expect and what we should do.By Monica Jong, PhD, BOptom,

Padmaja Sankaridurg, PhD, BOptom,

Timothy R. Fricke, BOptom, MSc,

Thomas John Naduvilath, PhD,

Serge Resnikoff , MD, PhD, and

Kovin Naidoo, OD, PhD

22

30

26

10 Tips From an Orthokeratology ExpertDon’t let misconceptions stop you from using this treatment modality that can provide a huge benefi t to patients with myopia.By Cary M. Herzberg, OD

Keys to a Pediatric Soft Lens FittingFrom infancy to adolescence, contact lenses prove a viable and benefi cial treatment option for a range of conditions.By Erin C. Jenewein, OD, MS, and

Kriti Bhagat, OD

Reshaping Ortho-KToric Lenses can expand myopia management to include patients with astigmatism.By Daddi Fadel, DOptom

Treating Infantile Aphakia: Think GPs

By Robert Ensley, OD, andHeidi Miller, OD

The GP Experts34

The Right Lens for a Corneal Scar

By Vivian P. Shibayama, OD

Fitting Challenges8

Corneal Collagen Crosslinking:

Not Just for Adults

By Elyse L. Chaglasian, OD, andTammy Than, MS, OD

A New Year, A New Look at

the Cornea

By Aaron Bronner, OD

Retained PK Sutures

By Christine W. Sindt, OD

Daily Disposables: Eff ective From

Allergy to Astigmatism

By Mile Brujic, OD, andDavid Kading, OD

Pharma Science and Practice36

Corneal Consult38

The Big Picture42

Practice Progress40

4 REVIEW OF CORNEA & CONTACT LENSES | JANUARY/FEBRUARY 2017

News Review

Evidence Supports Long-term

Effi cacy of Collagen Crosslinking

IN BRIEF

■ Meibomian gland damage may be re-versible in patients with meibomian gland dysfunction (MGD), a recent study in Cor-nea suggests.1 The key treatment used in the study was an artifi cial lubricant four times a day, coupled with eyelid hygiene once a day. Researchers found the dual approach resulted in a 5.4% decrease in MG dropout in upper eyelids and a 4.6% decrease of MG dropout in lower eyelids, as well as improvement across all clinical indices for study participants who heeded the instructions to take care of eyelid hygiene.Participants who ignored doctors’ orders did not experience the same improvement, save for some in the ocular surface disease index. 1. Yin Y, Gong L. Reversibility of gland dropout and signifi cance of eyelid hygiene treatment in meibomian gland dysfunction. Cornea. October 14, 2016. [Epub ahead of print].

■ The fi rst Descemet’s membrane endo-thelial keratoplasty (DMEK) patient re-cently presented for a 10-year follow up, and the clinical outcomes are encourag-ing, according to a recent report.1 The pa-tient showed all the short- and long-term characteristics of this endothelial kerato-plasty technique, including outstanding patient satisfaction, quick visual recovery, low incidence of complications and graft longevity. Best spectacle-corrected visual acuity in both eyes remained stable from the initial postoperative improvements.

While this case covers just one patient’s outcome, results such as these may show the potential for DMEK to be adopted as the preferred treatment option for corne-al endothelial disorders in the future. 1. Baydoun B, Müller T, Lavy I. Ten-year clinical outcome of the fi rst patient undergoing Descemet membrane endothelial keratoplasty. Cornea. December 8, 2016. [Epub ahead of print].

Advertiser Index

Alcon .......................................... Cover 4

CooperVision.............................Cover 2

X-Cel Specialty Contacts ........Cover 3

Corneal collagen crosslink-ing (CXL) may be effec-tive in managing kerato-conus for longer than two

years, according to a recent study in the journal Cornea. A possible reversal of CXL effects after four years was also discovered.

The study followed 377 eyes in pediatric patients ages eight to 18, all of whom had progres-sive keratoconus and underwent CXL. Of the eyes tracked, 194 had follow-ups more than two years post-treatment, the results of which show a signifi cant improve-ment in mean spectacle-corrected distance visual acuity (CDVA), a reduction in mean topographic astigmatism, fl attening of ker-atometry (Kmax) and corneal thin-ning of 31.1 ± 36.0µm.

Despite these promising results, the study also revealed the effects of CXL reversed after four years post-treatment in some eyes.

The researchers noted stabili-zation or fl attening of Kmax in 85% of eyes at two years, which dropped to 76% after four years. CDVA improved in 80.1% of eyes at two years, but only in 69.1% at four years. After four years, 24% showed steepening of the cornea and 30.9% showed reduced visual acuity, suggesting possible progres-sion of the disease after four years.

Some note that these fi ndings are not statistically signifi cant in the current study, however. “Confounding factors like thinner corneal pachymetry expected after CXL further make it challenging to diagnose regression at its im-mediate resurgence,” says Clark Chang, OD, director of the Contact

Lens division at the Center for Keratoconus-Cornea and Laser Eye Institute, Teaneck, NJ. “Therefore, it is important to minimize or eliminate extrinsic factors that can exert mechanical strain on the ocular surface, which presumably can destabilize therapeutic effects conferred by CXL.”

Clinicians must remain vigilant in managing ocular comorbidities such as dry eye and atopic or allergic conditions, Dr. Chang says, as well as educate patients about both the risks of long-term regression and the importance of compliance with clinical monitoring to detect the potential need for retreatment.

The study also found that 17.1% of eyes in the study presented topographic coupling effects—in which fl attening of one meridian is accompanied by steepening of the orthogonal meridian—suggesting a compensatory biomechanical response. “If we can control and maximize such coupling effects, then better visual outcome after CXL may be achieved,” Dr. Chang says. “Thus, it is essential for future investigations to identify patient variables associated with such topographic coupling events, as well as determine clinical characteristics that may better predict the dura-tion of CXL stabilization effects in different patient subgroups.”

1. Padmanabhan P, Reddi SR, Rajagopal R, et al. Corneal collagen cross-linking for keratoconus in pediatric patients—long-term results. Cornea. 2017;36(2):138-143.

With this issue, Review of Cornea & Contact Lenses adopts a bimonthly publishing frequency with more content per issue, as it expands its slate of contributors:

A new Guest Editorial column will tackle controversies of the day, starting this month with AOA President Andrea Thau, OD, addressing online contact lens sales, p. 7.

Expert specialty contact lens practitioner Vivian Shibayama, OD, explains how to approach hard-to-fi t patients in Fitting Challenges, p. 8.

Aaron Bronner, OD, gives advice from his unique multispecialty comanagement setting in the Corneal Consult column, p. 38.

David Kading, OD, joins long-time RCCL contributor Mile Brujic, OD, in coauthoring Practice Progress, p. 40.

Associate Clinical Editor Christine Sindt, OD, shares large-format images from her university-based practice in The Big Picture, p. 42.

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EDITORIAL REVIEW BOARD

Mark B. Abelson, MD

James V. Aquavella, MD

Edward S. Bennett, OD

Aaron Bronner, OD

Brian Chou, OD

Kenneth Daniels, OD

S. Barry Eiden, OD

Desmond Fonn, Dip Optom M Optom

Gary Gerber, OD

Robert M. Grohe, OD

Susan Gromacki, OD

Patricia Keech, OD

Bruce Koffler, MD

Pete Kollbaum, OD, PhD

Jeffrey Charles Krohn, OD

Kenneth A. Lebow, OD

Jerry Legerton , OD

Kelly Nichols, OD

Robert Ryan, OD

Jack Schaeffer, OD

Charles B. Slonim, MD

Kirk Smick, OD

Mary Jo Stiegemeier, OD

Loretta B. Szczotka, OD

Michael A. Ward, FCLSA

Barry M. Weiner, OD

Barry Weissman, OD

RCCLRCCLREVIEW OF CORNEA & CONTACT LENSES

2017 MEETINGSAspen, CO

February 17-21, 2017 Winter Ophthalmic Conference (Formerly SkiVision) The Westin Snowmass

Program Chairs: Murray Fingeret, OD

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NEW TECHNOLOGIES & TREATMENTS IN

Eye Care &2017

REVIEW OF OPTOMETRY® EDUCATIONAL MEETINGS OF CLINICAL EXCELLENCE

By Joseph P. Shovlin, OD

My Perspective


Get to Know Your Genes One day, genetic testing and gene therapy may help patients avoid corneal disease altogether.

Research suggests there are nearly 500 different eye-related diseases, with more than 800 ocular and periocular

manifestations of systemic disease. Hundreds of genes, if mutated, can cause disease isolated to the eye.1

Fortunately, genetic testing can aid health care providers in managing inherited diseases. Specifi cally, genetic testing is benefi cial for (1) a confi rmational diagnosis, (2) new-born screening, (3) carrier screen-ing and (4) forensic testing.1-3

Exciting new frontiers are providing measures for pharmaco-genomics, whole genome and whole exome sequencing, and even tumor analysis.2 The latter, for ex-ample, looks at genetic alterations that drive tumor growth and the genetics that help predict therapeu-tic response.

Identifi cation of susceptibility loci has helped researchers better understand the complex patho-physiology of several ocular and neurologic diseases.4

CLINICAL APPLICATIONS

Many recent fi ndings in eye care are a result of genetic testing, and some are applicable to therapy today:

• Though controversial, research suggests there may be a different response to the AREDS formula based on specifi c genotypes, and testing for the genotype for which zinc supplementation may be pro-infl ammatory in patients with macular degeneration could impact therapy.

• For the cornea, genetic testing

is now available to identity Avelli-no’s corneal dystrophy.

• The Asper Biotech test screens for 333 mutations in 13 genes for corneal dystrophy.5

• Researchers have been investi-gating gene therapy to improve the quality of donor tissue for corneal grafts, which might decrease the risk of graft failure and rejection.

THERAPY ADVANCES

The key is to target therapy with testing prior to gene expression. Gene augmentation—treatment for defi cient genes—is easier than gene knock-out therapy (blocking a gene causing a detrimental effect).4

For example, gene augmentation therapy is now possible for Leb-er’s congenital amaurosis when a RPE65 defi ciency is found.

Using nanoparticles as vectors for delivering DNA is an exciting advancement.4,5 For example, researchers recently used lentivi-ral-mediated genetic modifi cation of cultured endothelial cells to deliver genes to the endothelium.5

Creating new viral vectors with directed evolution is the key to timely adoption. Researchers can now create viruses in the lab to maximize their diversity and can promote the evolution of viruses, through an artifi cial selection pro-cess, that have the traits researchers need.3

KEEP PATIENTS INFORMED

As helpful as genetic testing can be, it can raise both social and ethical issues, and clinicians must be careful to discuss the value and limitations of genetic testing with

patients.6 When ordering tests, it is the clinician’s duty to educate patients on the likelihood that they have a particular disease, the spec-trum of disease possibilities (from mild to severe), recurrence rates, chance of passing the condition to offspring, possible treatments and reproductive alternatives.5,6

The ramifi cations of knowing that you have the genes for a particular disease without a current treatment can be traumatic. For-tunately, patients are protected by the Genetic Nondiscrimination Act, which does not allow health care insurers or employers to discrimi-nate based on genetic predisposi-tion or pre-existing conditions.5

The last two decades have seen an explosion of research in

genomics, with rapidly expanding genetic medicine. Gene therapy specifi c to the cornea and anterior segment is a particularly exciting frontier, considering corneal disease is responsible for a signifi cant amount of blindness worldwide. Ocular gene testing and therapy research is robust with a high pri-ority in funding and should prove fruitful in the very near future. RCCL

1. Uthra S, Kumaramanickavel G. Gene ther-apy in ophthalmology. Oman Ophthalmol. 2009:2(3):108-10.2. American Medical Association. Genetic Testing. Available at www.ama-assn.org/content/genet-ic-testing. Accessed December 5, 2016.3. Bethke W. The future of gene therapy. Rev Ophthalmol. 2016:23(4):36-9.4. Fritsche LG, Fariss RN, Stambolian D, et al. Age related macular degeneration: genetics and biolo-gy coming together. Annu Rev Genomics Hum Genet. 2014;15:151-71.5. John T. Decoding the genetics of corneal disease. Rev Cornea Contact Lenses. 2014 June:24-8.6. Bateman B, Silva E. AAO Task Force on Genetic Testing. Ophthalmol 2013;120(10):e72-3.

REVIEW OF CORNEA & CONTACT LENSES | JANUARY/FEBRUARY 2017 7

By Andrea P. Thau, OD, AOA President

Guest Editorial

Combating Online Contact Lens SalesWe must stand together to protect healthy vision and responsible enterprise.

Optometrists are fi eld-ing attacks from all sides—not simply on our profession, but actions that could ul-

timately fracture the doctor-patient relationship and potentially put our patients’ health at risk. Online contact lens retailers are primary and long-time aggressors who use deceptive practices, underhanded loopholes and, sometimes, blatantly illegal tactics to line their pockets and build their bottom lines.

Like other physicians, eye doctors take an oath and hold ourselves to the highest standards to protect our patients’ health. The oath guides the way we practice and compels us to advise patients of all their options to restore, maintain or enhance vision, as well as eye and overall health. We do this within a competitive marketplace bound by laws and regulations, which are constantly evolving as care advances.

LEGISLATIVE LANDSCAPE

Unfortunately, the full picture of the 2016 contact lens legislative and regulatory landscape made it clear online contact lens retailers are us-ing misinformation and subterfuge to divert attention away from their unscrupulous business practices and gain advantage in the marketplace.

The American Optometric Association (AOA), doctors of optometry and the patients we serve are gaining ground in the fi ght against these abusive and illegal practices. We’ve exposed deceptive tactics—such as 1-800-Contacts’ improper use of pre-checked order

forms to obtain copies of cus-tomer contact lens prescriptions. This is further evidenced by the Federal government’s suit against 1-800-Contacts for alleged activities that “had the purpose, capacity, tendency and likely effect of re-straining competition unreasonably and injuring consumers.”1

But along with wins, there are sometimes setbacks, and the Federal Trade Commission’s (FTC) recent proposed rule is just that.

The AOA vigorously objects to the FTC’s misguided propos-al, which adds new prescription requirements to the Contact Lens Rule. The proposal makes clear that the agency is hearing from those who question whether doctors of optometry are following the law and does not take the illegal practic-es of some retailers into account.

With the active involvement of our member doctors, state optomet-ric associations, concerned physi-cians, as well as public health and consumer protection organizations, we are making the case for changes and will not stop until our concerns are clearly understood by agency offi cials. This will not be a quick or easy process, but one the AOA will see through to the end.

A UNITED FRONT

We need the involvement and activism of all of our colleagues to get this proposal changed. The FTC asked for public comments and is now considering the issue further.

Moreover, we need to hold internet sellers accountable, and the AOA and state optometric associ-ations are leading the effort by ag-

gressively building support for the bipartisan Contact Lens Consumer Health Protection Act. The bill calls for bolstering patient safety requirements, increasing account-ability for internet contact lens sales and reinforcing the distinction that contact lenses are medical devices and should be treated that way—all of which the FTC should support.

The health and safety of the pa-tients we serve is at the heart of this matter, and the AOA, along with member ODs, our paraoptometric colleagues and optometric students, will continue to fi ght for patient safety. For every doctor of optom-etry in America, the surest way to fi ght back against internet sellers and the harm they cause patients is to support the AOA and your state optometric association.

Our past advocacy efforts show that optometry is stronger

when we all work together, and we ask every doctor to join in the fi ght with the AOA to uphold patient safety against online contact lens retailers and their profi t-driven business practices.

1. Federal Trade Commission. Complaint In the Mat-ter of 1-800 Contacts, Inc., a corporation. August 8, 2016. Available at www.ftc.gov/system/fi les/docu-ments/cases/160808_1800contactspt3cmpt.pdf. Accessed December 21, 2016.

ABOUT THE AUTHOR

Dr. Thau is president of the American

Optometric Association (AOA). She was

elected to the AOA Board of Trustees in

2007 and president in July 2016. Dr. Thau

also serves as chair of the AOA’s Executive

and Agenda Committees and is a member

of the Personnel Committee. She serves as

liaison trustee for the American Academy

of Optometry (AAO) and the College of

Optometrists in Vision Development (COVD).


Fitting Challenges


It’s not easy fi tting a fi ve-year-old with a specialty lens to correct irregular astigmatism.

The Right Lens for a Corneal Scar

Children younger than seven who need a specialty contact lens fi tting can be some of the most challenging

patients we encounter. Kids are vul-nerable to amblyopia, which makes the stakes even higher. The need for specialty lenses at a young age can occur for a variety of reasons, such as aphakia, high refractive error, anisometropia, iris defects, irregular astigmatism from corneal scarring or keratoconus. Let’s discuss a chal-lenging case in which a child with irregular astigmatism from a corneal scar needed a specialty contact lens.

CASE REPORT

A fi ve-year-old female presented for a contact lens evaluation to correct irregular astigmatism from a corneal scar. Her pediatric ophthalmologist referred her for a unilateral contact lens fi t over an eye that had a cor-neal dermoid removed at age three. She was currently managed with glasses and was patched two hours per day with good compliance. Medical history was positive for Goldenhar syndrome and negative for systemic medications. She ex-hibited no other ocular history and neither did her family. Presenting best-corrected visual acuity (VA) was 20/20 OD, 20/50 OS. Her current spectacle Rx was -0.50+0.50 x168 OS: +3.00+3.75x070.

Pupils were round and reactive to light, with no relative afferent pupil-lary defect in either eye. Extraocular movements were full OU. A slit lamp exam demonstrated that the lids were clear, the conjunctiva white and quiet, the iris and lenses clear, and the anterior chamber deep

and quiet OU. Exam of the corneal surface revealed a clear right cornea and an elevated 2.7mm horizontal inferior temporal scar on her left cornea—no staining or vessels OU. Manifest refraction OD was plano VA 20/20, OS was +4.25+5.50x075 VA 20/30-. Corneal topography re-vealed a fl at cornea with steepening at the corneal scar (Figure 1). Sim K measured 46.17/40.62 OS and 5.62D of astigmatism.

DIAGNOSTIC FITTING

Although we started with a scleral lens due to the irregularity of the periphery, insertion was unsuccess-ful. The patient was very reactive and could not fi xate her eyes so that the lens could be inserted without a bubble inside the lens. After several attempts, I decided to try a corneal gas permeable (GP) lens instead. I chose a large diameter intralimbal GP design (GBL, Concise) as the di-agnostic lens. This lens also features a reverse geometry design in the mid periphery, which would allow it to clear the steep elevation in the mid periphery without adding too much clearance over the central cornea. I fi rst tried a 45.00D (7.50) lens based off the average of the steeper cur-vature readings over the scar. The lens was slightly fl at over the cornea scar with a somewhat tight edge and pooling superior nasal. Over-refraction resulted in VA of 20/25. I ordered the lens 0.75D steep to take the lens pressure off the scar with fl atter peripheral curves than standard to assist in distributing the weight of the lens across the cornea.

First lens: Base curve 7.38, power: +3.25, diameter:11.2, P1:0.4/9, P2:0.4/10.5, P3:0.4/12.

DISPENSING

The patient presented with her mother with no new complaints and I inserted the lens (Figure 2). The lens exhibited light one-third touch inferotemporally with pooling over the rest of the cornea. The peripher-al edge was wide with good overall centration of the lens and movement with blink. VA measured 20/25 with the GP in place OD. The patient’s mother was instructed on care, in-sertion and removal, and advised to build wearing time, starting at two hours a day with the goal of eight to 10 hours a day.

FOLLOW-UP #1

One week later, the patient present-ed with complaints that the lens hurt after a few hours of wear, and she was unable to wear it more than three hours per day. Some redness, but no discharge, was observed. Presenting VA was 20/25 OD with the contact lens. No over-refraction was measured. Fluorescein was instilled, and I observed that the lens had adhered to the cornea, exhibiting little movement and was decentered temporally over the scar. With the lens removed to evaluate the cornea, there was 1+ punctate staining over the corneal scar.

Modifying the GP would unlikely achieve better results, as opening the periphery to increase movement and increasing the vault over the scar would likely still result in the lens migrating towards the steep eleva-tion of the scar. I decided to piggy-back the GP with a soft lens.

I used a +3.00 Air Optix Night & Day (Alcon) to create a buffer be-tween GP and eye. I chose a higher plus lens to aid in shifting the steep

area centrally so the lens would decenter less. On slit lamp exam, the GP moved well over the soft lens. VA was 20/30. Over-refraction of the combined system (-0.50) would be added to the GP if the patient did well. I prescribed Polytrim (poly-myxin B/trimeth o prim, Allergan) for a few days to prevent infection and advised her to start lens wear after fi nishing the antibiotic course. Mom was again trained on insertion and removal and instructed to have her daughter wear the lens no more than four hours per day as long as the lens is comfortable.

FOLLOW-UP #2

The patient presented the next week. Though lens tolerance was much improved, she didn’t think she could wear it more than four hours per day, as she needed frequent

lubrication with artifi cial tears. On slit lamp exam and instillation of fl uorescein, the lens was again decentering temporally with little movement. When the lens was removed, no

staining was observed. Other than the scar, the cornea was clear.

Because any GP would most likely shift towards the elevation, we discussed using a scleral lens again and I performed an in-offi ce evalu-ation, during which the patient was very cooperative. I used a Europa (Visionary Optics) fi tting set and chose a 45.00D/16.0 diameter lens as the fi rst diagnostic lens simply be-cause it was in the middle of the set. Upon insertion, the child noted an immediate improvement in comfort.

Slit lamp exam revealed excessive clearance of about 450µm. When I tried a 42D lens, it exhibited about 200µm of central clearance on initial evaluation, which was ideal. The lens landed outside the limbus and centered well. The periphery appeared tight, exhibiting slight conjunctival vessel compression. Given the child’s positive initial re-action, I ordered a 42.50/+6.25/16.0 diameter, 1 fl at periphery lens to be dispensed the next week. The base curve was slightly steepened to com-pensate for the change in the sagittal depth with a 1 fl at periphery.

SCLERAL LENS DISPENSE

At the second lens dispense a week later, the patient hadn’t been wear-ing any lenses for the past week.

Fig. 1. Topography of left eye. An overall fl at cornea with

inferior temporal steepening at the corneal scar.

Fig. 2. GBL lens on fi rst dispense.

Note the light touch of the lens over

the area of the corneal scar.

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Fitting Challenges


The scleral lens cleared the cen-tral cornea by about 200µm. The fl uorescein extended from limbus to limbus and the lens landed on the conjunctiva without impinging on the sclera. VA was 20/25 OS. Mom was trained on insertion, removal and care. The patient was instructed to return the following week.

FOLLOW-UP #3

One week later, the patient said she was able to wear the lens for 10 hours a day without any complaint (Figure 3). Uncorrected VA mea-sured 20/20 OD and 20/25 OS. No over-refraction was noted over the left lens. The lens was fi nalized and the patient was asked to return in six months for a follow-up.

DISCUSSION

Several studies show that vision rehabilitation of irregular astigma-tism or high refractive error with contacts lenses is more effective than spectacles.1-4 GPs are able to correct irregular astigmatism as well as eliminate the aniseikonia from unequal prescriptions when the irregularity is unilateral.5,6 For chil-dren, the high oxygen material of the lenses combined with involving the parents in the care lowers the risk for contact lens complications.7

Children younger than seven are often too young to understand what needs to be done, but old enough to be traumatized by an aggressive approach, which may give them a negative association with the lens.

Using a soft approach is ideal, and you should always tell the child what you are doing and why. If you can, show them that you and their parents wear contact lenses. If a child is particularly resistant to any-thing being inserted in the eye, send

them home with artifi cial tears or even a soft contact lens to practice. This will help acclimate the child to the task, as with this patient.

The process of fi tting a contact lens can vary from child to child. With younger or less cooperative children, GP diagnostic lenses of known base curves and their fl uo-rescein patterns can help determine corneal curvature.

To fi t a corneal scar, the fl uoresce-in pattern of an GP should exhibit two-thirds pooling and one-third light touch over the entire cornea. The lens should center well and move adequately to provide tear ex-change for optimal corneal health. In cases where GPs fail, sclerals can be effective, as they are tolerated well in the pediatric population.10,11

The lens can often compensate for GP issues such as ocular surface dis-ease, decentration or intolerance.12

EDUCATION IS ESSENTIAL

Despite vision improvement for most children, studies indicate a contact lens dropout rate as high as 36.8% in patients with unilateral ir-regular astigmatism.13 To help avoid this, clinicians should ensure parent buy-in and educate them on why the contact lens is necessary. They also need to understand the risk of amblyopia and why a contact lens is

preferable to a spectacle correction. Additionally, the process of accli-

mating a child to lens wear can be emotionally taxing on the parents, and they need to be reassured they are not hurting their child. Spending time on this conversation is essential to the child’s visual success.

For children with irregular astig-matism or high refractive error,

vision rehabilitation should begin right away to prevent amblyopia. This case emphasizes the impor-tance of using your full arsenal of contact lens options to address the different needs of each child. RCCL

1. Luo W, Tong JP, Shen Y. Rigid gas permeable con-tact lens for visual rehabilitation in aphakic following trauma. Clin Exp Optom. 2012;95:499-505.2. Pieramici DJ, Sternberg P Jr, Aaberg TM Sr, et al. A system for classifying mechanical injuries of the eye (globe). The Ocular Trauma Classifi cation Group. Am J Opthalmol. 1997;123:820-31.3. Netto AL, Fioravanti Lui AV, Fioravanti Lui GA. Visual rehabilitation with contact lenses after ocular trauma. Arq Bras Oftalmol. 2008;71:23-31.4. Lin PW, Chang HW, Lai IC, Teng MC. Visual out-comes after spectacles treatment in children with bilateral high refractive amblyopia. Clin Exp Optom. 2016;99:550-4.5. Jupiter DG, Katz HR. Management of irregular astigmatism with rigid gas permeable contact lens-es. CLAO J. 2000;26:14-7.6. Kanpolat A, Ciftci OU. The use of rigid gas permeable contact lenses in scarred corneas. CLAO J. 1995:2.7. Shaughnessy MP, Ellis FJ, Jeff rey AR, Szcotka L. Rigid gas permeable contact lenses are a safe and eff ective means of treating refractive abnormalities in the pediatric population. CLAO J. 2001-27:195-201.8. Pradhan Z, Mittal R, Jacob P. Rigid gas-permeable contact lenses for visual rehabilitation of trauma-tized eyes in children. Cornea. 2014;33:486-9.9. Walters JL, Paules MG. Review of preclinical studies on pediatric general anesthesia-induced developmental neurotoxicity. Neurotoxicology and Teratology. 2016 Nov 18. [Epub ahead of print].10. Rathi V, Mandathara P, Vaddavalli P, et al. Fluid fi lled scleral contact lens in pediatric patients: Chal-lenges and outcome. Contact Lens and Anterior Eye. 2012;35(4):189-92.11. Gungor I, Schor K, Rosenthal P, Jacobs DS. The Boston scleral lens in the treatment of pediatric patients. J AAPOS. 2008:12(3):263-7.12. Pullum KW, Whiting MA, Buckley RJ. Scler-al contact lenses: the expanding role. Cornea. 2005:24(3):269-7.13. Ozkan B, Elibol O, Yuksei N, et al. Why do patients with improved visual acuity drop out of GP contact lens use? Ten year follow-up results in patients with scarred corneas. Eur J Opthalmol. 2009:19:343-7.

Fig. 3. Scleral lens in place at fi rst

follow-up. A white and quiet eye

after eight hours of successful wear.

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succeed, you have to navigate changing healthcare policies, keep

up with the latest clinical advancements, manage your staff and

run a successful business. Zero in on the topics impacting every

aspect of your practice and career at SECO 2017, the largest

conference in the world for optometric professionals and staff,

and let us bring it all into sharp focus for you.

Copyright © 2017 SECO International, LLC., All rights reserved.

RO0217_House Seco.indd 1 1/17/17 3:51 PM


The general public has traditionally considered myopia a simple refrac-tive condition correct-able by spectacles and

contact lenses with limited impact on permanent visual impairment. This is not the case, however; myo-pia is increasingly associated with a heightened risk of permanent vision impairment, as evidenced by reports of myopic macular degeneration as a frequent cause of vision impair-ment and blindness in Asia and Western nations.1-5

Myopia already affects a mas-sive proportion of the population in Asia.1 For example, Taiwan has rates of myopia of up to 84% in school children, and 97% of 19-year-old South Korean male military conscripts are myopic.2,3

Myopia is also becoming a problem beyond East Asia, with the United States reporting increases in prev-alence from 25% to 42% between 1972 and 2002, and high myopia, in particular, increasing eightfold from 0.2% to 1.6% in those older than 30 over the same period.4 In Australia, where myopia levels are generally considered to be low, the Sydney Adult Vascular and Eye Study recently reported that almost 30% of 17-year-olds are myopic.5

Although individual studies provide essential information on the prevalence of myopia, they are diffi cult to generalize, as they cover specifi c ages, groups or places. For effective planning, policymaking and interventions regarding myopia, we must organize and understand

the data to predict trends and esti-mate future prevalence.

THE GLOBAL PREVALENCE

A study by the Brien Holden Vision Institute (BHVI), published in Ophthalmology in 2016, report-ed a meta-analysis of the global prevalence data on myopia and high myopia since 1995.6 Using the PubMed (National Library of Medicine) database to review the literature, this study highlights the condition’s prevalence across the 21 regions of global burden of disease (GBD), which are countries grouped together based on their geographic location and socioeconomic status (http://ghdx.healthdata.org/coun-tries). Evidence of varying preva-lence over time enabled our research team to create functions to predict the future prevalence of myopia and high myopia from 2000 through 2050 by decade. (see, “How BHVI Estimated Prevalence Rates Through 2050.”)

The model indicated the glob-al prevalence of myopia affected almost 23% of the population in 2000. More importantly, it predicted that amount would grow to 50% of the world’s population by 2050 (Figure 1). Nearly 1.5 billion people were affected in 2000, and by 2050 this is expected to increase to almost fi ve billion.6

High myopia is also set to rise from an initially low prevalence of almost 3% in 2000 to close to 10% in 2050. This equates to 163 million people in 2000, and by 2050 almost one billion people will be potentially

at risk of developing permanent vision impairment and blindness associated with high myopia.6

Approaching 2050, the differ-ence in prevalence rates between Asia and the rest of the world start to decrease, with many regions reaching a prevalence of more than 50%, presumably due to increasing urbanization and socioeconomic development. For example, in 2010, the high-income Asia-Pacifi c nations had a prevalence of 48.8%, while Eastern Europe and North Africa and the Middle East had prevalenc-es of 25% and 14.2%, respectively.

ABOUT THE AUTHORS

Dr. Jong is senior research

fellow at the Brien Holden

Vision Institute (BHVI) in

Sydney, Australia, and a

visiting fellow at the University

of New South Wales (UNSW),

Australia.

Dr. Sankaridurg is program

leader for the Myopia Program

at BHVI and an associate

professor at UNSW.

Dr. Fricke is a consultant at

BHVI.

Dr. Naduvilath is head

biostatistician at BHVI.

Dr. Resnikoff is a consultant at

BHVI and a visiting professor

at UNSW.

Dr. Naidoo is CEO of BHVI, a

visiting fellow at UNSW and

founder of the African Vision

Research Institute, University

of Kwa Zulu Natal, South

Africa.

MOVEMOVEOVEMOVEMOVEMMOVEMOVEMOVEMOVESteady growth in the prevalence of this deceptively simple condition will expose half the world’s

population to visual impairment. Here’s what to expect and what we should do.

Myopiaon the


But by 2050, the research suggests, the gap will close, with Eastern Europe reaching a prevalence rate of 50.4%, North Africa and the Middle East jumping to 52.2% and high-income East Asia moving up less signifi cantly to 66.4% (Figure 2).6

WHY THE INCREASE?

The projected increases in myo-pia and high myopia are largely considered to be driven by environ-mental factors and lifestyle changes, such as reduced time outdoors and increased near-based activities.1

Genetic predisposition is also a fac-tor, but it cannot explain the rapid changes in prevalence seen in such a short timespan.7

Research suggests the high-pres-sure educational systems children are subjected to at very young ages in countries such as Singapore, Korea, Taiwan and China may be a major contributing lifestyle factor.1

Excessive use of electronic devices could also play a role.1

Other factors thought to be in-volved in myopia development and progression include light levels and specifi c wavelengths, time outdoors, vitamin D and peripheral defocus in the corrected and uncorrected my-opic eye, stimulating axial elonga-tion.8 Different light levels, different wavelengths and duration of light have been shown to affect axial elongation in animal studies, but are yet to be tested in humans.8 Trials conducted in Taiwan and China indicate time outdoors reduces risk of developing myopia, with less myopia progression seen in summer vs. winter months.9-11 The role of vi-tamin D in myopia is unclear; some reports suggest it is linked with myopia, while others have found no association.12,13 Investigators also found diet was not associated with myopia in a group of healthy children in Singapore.14

The BHVI study results show that, in the year 2000, the majority of myopia was occurring in those younger than 40, refl ecting the major change in lifestyle in children and young people over the last two decades, especially in Asia.6 Due to urbanization and development, sim-ilar lifestyle factors will likely spread to other parts of the world that are still developing.

IMPLICATIONS

As a consequence of the rising prev-alence of myopia, there will be sub-stantial demand for increased eye care resources for refractive services, such as spectacles and contact lens-es, in correcting the refractive error and treating myopia progression. In addition, there will be a need for managing and preventing high myo-pia–related ocular complications.

Uncorrected refractive error is al-ready the primary cause of distance vision impairment globally, affecting 108 million people.15 It is also the second most common cause of glob-al blindness.15 The economic burden of uncorrected distance refractive er-ror was estimated to be $202 billion

annually, of which myopia was the main cause.16 As a consequence of rising myopia levels, the prevalence of uncorrected refractive error and the associated burden will increase. High myopia also increases the risk of potentially sight-threatening con-ditions such as glaucoma, myopic macular degeneration, cataracts and retinal detachment.17 One billion people are predicted to be highly myopic by 2050, and the number of people with vision loss resulting from high myopia is predicted to increase sevenfold from 2000 to 2050.6 Based on these projections, myopia is set to become a leading cause of blindness worldwide.

NEXT STEPS: MANAGEMENT

Many unanswered questions remain. To intervene at the ap-propriate stage, we need to better understand the risk factors associat-ed with myopia onset and progres-sion—such as ethnicity, lifestyle and parental myopia. It is important to regularly monitor population trends and characteristics to identify risk factors and adjust behaviors and management accordingly to limit

By Monica Jong, PhD, BOptom, Padmaja Sankaridurg, PhD, BOptom, Timothy R. Fricke, BOptom, MSc,Thomas John Naduvilath, PhD, Serge Resnikoff , MD, PhD, and Kovin Naidoo, OD, PhD

So

urce: A

dap

ted fro

m H

old

en B

A, et al. 6

Fig. 1. Estimated Global Prevalence of Myopia and High Myopia,

2000 to 2050

5,000

4,500

4,000

3,500

3,000

2,500

2,000

1,500

1,000

500

0

Myopia

High Myopia

Nu

mb

er

of

pe

op

le (

in m

illio

ns)

Year

22.9%

2.7% 4.0% 5.2%6.1%

7.7%9.8%

28.3%

34.0%

39.9%

45.2%

49.8%

2000 2010 2020 2030 2040 2050


the burden of rising myopia. For example, myopia has traditionally been treated with single vision spec-tacles and contact lenses, but now we know there are other options.

Research has made considerable headway in identifying optical interventions that might aid in pre-venting the onset and progression of myopia. Optical interventions provide myopic defocus—bringing the image in front of the retina to slow axial elongation.18 The myopic eye tends to have relative peripheral hyperopia, and these interventions address this key risk factor. These strategies include bifocal spectacles, multifocal soft contact lenses and ortho-k—in combination with be-havioral strategies such as reduced near work and more time outdoors, and pharmacological agents such as low-dose atropine. All these meth-ods can help reduce the number of people with myopia progression.19

There is still much debate about when to start myopia control, what treatments should be used on whom and at what age. Optical treatments such as bifocal spectacles and multifocal soft contact lenses can be used full time as soon as a child is becoming myopic, and ortho-k is a good option if the child is a suitable candidate in terms of refractive error and their ability to perform extended wear. Concerning effi cacy, the average slowing of myopia achieved across the bifocal spectacles, ortho-k and multifocal soft contact lenses are comparable, ranging from 35% to 50%.20-22

The choice often depends on the patient’s lifestyle and the rate of slowed progression achieved.

Low-dose atropine (0.01%) is commonly prescribed for myopia progression in places such as Hong Kong, Taiwan and Singapore, and, more recently, in some Western nations, one drop daily before sleep. Research shows the use of

MYOPIA ON THE MOVE

Fig. 2. Regional Prevalence of Myopia in 2000, 2030 and 2050

Myopia Prevalence Per Region (%)

15.236.2

50.7

19.743.8

55.1

15.737.4

51.7

5.1

14.127.9

11.232.9

47.4

20.541.8

54.1

3.212.3

22.7

38.856.9

65.3

1838.9

50.4

14.638.8

52.2

28.348.5

58.4

512.5

23.8

14.438

53

33.852.4

62

5.117.5

30.2

15.640.7

53.4

14.535.9

50.7

5.213.6

36.8

21.944.5

56.2

46.158

66.4

0 20 40 60

Andean Latin America

Asia-Pacifi c, high income

Australasia

Caribbean

Central Africa

Central Asia

Central Europe

Central Latin America

East Africa

Eastern Europe

North Africa and Middle East

North America, high income

Oceania

South Asia

Southeast Asia

Southern Africa

Southern Latin America

Tropical Latin America

West Africa

Western Europe

2000 2030 2050

So

urce: A

dap

ted fro

m H

old

en B

A, et al. 6


pharmacologic treatments such as low-dose atropine for myopia is safe in those as young as six, with the longest study being fi ve years.23

The mechanism by which low-dose atropine works to slow myopia remains unclear, but it signifi cantly slows the change in the spherical equivalent by 60% after two years, although this is not seen in a change in the axial length.23 Some caution is still required, as the effects of chronic treatment with low-dose atropine are unknown, including the overall level of myopia control when combining behavioral, optical and pharmacologic treatments.

Although consensus surround-ing myopia management has not yet been achieved, it is critical to successfully address the issue of myopia. The Brien Holden Vision Institute hopes to further foster the movement towards consen-

sus through collaboration with researchers, clinicians and health bodies using our experience in ad-vocacy in areas such as uncorrected refractive error.

More research is required to fully understand the mechanisms of myopia development and progres-sion and identify those at risk of developing high myopia. Public health advocates will also need to develop wellness promotion strate-gies and provide resources such as clinical guidelines to respond to this signifi cant public health challenge. Industry can also take a leadership role by working with researchers and clinicians to develop FDA-approved myopia treatments that will have a positive impact.

Overall, the world is becoming more myopic—a trend that

has signifi cant fi nancial and societal implications. More importantly, high levels of myopia pose a threat to sight that reduces quality of life and exposes those affected to great-er health risks. Evidence suggests myopia can be managed better by reducing the risk of the eye becom-ing more myopic with a number of lifestyle, optical and pharmaceutical interventions. The BHVI will be releasing the fi rst online myopia management education program for optometrists in March 2017. Please go to www.brienholdenvisioninsti-tute.org for details. RCCL

1. Morgan IG, Ohno-Matsui K, Saw SM. Myopia. Lancet. 2012;379:1739-48.2. Lin LL, Shih YF, Hsiao CK, Chen CJ. Prevalence of myopia in Taiwanese schoolchildren: 1983 to 2000. Annals of the Academy of Medicine, Singapore. 2004;33:27-33.3. Jung SK, Lee JH, Kakizaki H, Jee D. Prevalence of myopia and its association with body stature and educational level in 19-year-old male conscripts in seoul, South Korea. Invest Ophthalmol Vis Sci. 2012;53:5579-83.4. Vitale S, Sperduto RD, Ferris FL 3rd. Increased prevalence of myopia in the United States between 1971-1972 and 1999-2004. Arch Ophthalmol. 2009;127:1632-9.5. French AN, Morgan IG, Burlutsky G, et al. Preva-lence and 5- to 6-year incidence and progression of myopia and hyperopia in Australian schoolchildren. Ophthalmology. 2013;120:1482-91.

6. Holden BA, Fricke TR, Wilson DA, et al. Global prevalence of myopia and high myopia and tempo-ral trends from 2000 through 2050. Ophthalmolo-gy. 2016 May;123(5):1036-42.7. Lim LT, Gong Y, Ah-Kee EY, et al. Impact of paren-tal history of myopia on the development of myopia in mainland china school-aged children. Ophthal-mology and Eye Diseases. 2014;6:31-5.8. Smith EL 3rd, Hung LF, Arumugam B. Visual regulation of refractive development: insights from animal studies. Eye. 2014;28:180-8.9. Wu PC, Tsai CL, Wu HL, et al. Outdoor activity during class recess reduces myopia onset and progression in school children. Ophthalmology. 2013;120:1080-5.10. He M, Xiang F, Zeng Y, et al. Eff ect of time spent outdoors at school on the development of myopia among children in China: a randomized clinical trial. JAMA. 2015;314:1142-8.11. Donovan L, Sankaridurg P, Ho A, et al. Myopia progression in Chinese children is slower in summer than in winter. Optom Vis Sci. 2012;89:1196-202.12. Williams KM, Bentham GC, Young IS, et al. Association between myopia, ultraviolet B radiation exposure, serum vitamin D concentrations, and genetic polymorphisms in vitamin D metabolic pathways in a multicountry European study. JAMA Ophthalmol. 2017;135:47-53.13. Tideman JW, Polling JR, Voortman T, et al. Low serum vitamin D is associated with axial length and risk of myopia in young children. European J Epide-miology. 2016;31:491-9.14. Lim LS, Gazzard G, Low YL, et al. Dietary factors, myopia, and axial dimensions in children. Ophthal-mology. 2010;117:993-7e4.15. Bourne RR, Stevens GA, White RA, et al. Causes of vision loss worldwide, 1990-2010: a systematic analysis. The Lancet Global Health. 2013;1:e339-49.16. Fricke TR, Holden BA, Wilson DA, et al. Global cost of correcting vision impairment from uncor-rected refractive error. Bulletin of the World Health Organization. 2012;90:728-38.17. Flitcroft DI. The complex interactions of retinal, optical and environmental factors in myopia aetiology. Progress in Retinal and Eye Research. 2012;31:622-60.18. Sankaridurg P, Holden B, Smith E 3rd, et al. Decrease in rate of myopia progression with a contact lens designed to reduce relative peripheral hyperopia: one-year results. Invest Ophthalmol Vis Sci. 2011;52:9362-7.19. Sankaridurg PR, Holden BA. Practical applica-tions to modify and control the development of ametropia. Eye. 2014;28:134-41.20. Cheng D, Woo GC, Drobe B, Schmid KL. Eff ect of bifocal and prismatic bifocal spectacles on myopia progression in children: three-year results of a randomized clinical trial. JAMA Ophthalmol. 2014;132:258-64.21. Si JK, Tang K, Bi HS, et al. Orthokeratology for myopia control: a meta-analysis. Optom Vis Sci. 2015;92:252-7.22. Li SM, Kang MT, Wu SS, et al. Studies using concentric ring bifocal and peripheral add multifo-cal contact lenses to slow myopia progression in school-aged children: a meta-analysis. Ophthalmic & Physiological Optics. 2017;37:51-9.23. Chia A, Lu QS, Tan D. Five-year clinical trial on atropine for the treatment of myopia 2: myopia control with atropine 0.01% eyedrops. Ophthalmolo-gy. 2016;123:391-9.

Access the freely available study at:

www.sciencedirect.com/science/article/pii/

S0161642016000257

Want to learn more?

• Selected 145 relevant studies from a pool of 4,288 PubMed articles, representing 2.1 million individuals with myopia.

• Combined myopia prevalence data with world population data and stratifi ed data into age cohorts in fi ve-year increments.

• Defi ned myopia as spherical equivalent ≤-0.50D and high myopia as spherical equivalent ≤-5.00D.*

• Grouped countries by GBD region for applicability to other epidemiological studies. (Results were extrapolated for GBD regions lacking myopia data).

• Performed meta-analysis of prevalence data, combined with myopia change over time, to project prevalence rates for each decade from 2000 to 2050.

*Spherical equivalent ≤-0.50D, the most commonly used myopia defi nition, is beyond the refraction measurement error and captures children at the start of their progression. Spherical equivalent ≤-5.00D for high myopia identifi es people at higher risk of pathologic myopia and, if uncorrected, causes vision impairment equivalent to the World Health Organization’s blindness defi nition.

How BHVI Estimated Myopia

Rates Through 2050


Myopia affected approximately one and a half billion people in 2010, and that number

is expected to rise to nearly fi ve billion by 2050.1 It is the single most signifi cant cause of distance vision impairment, and high myopia (i.e., worse than -5.00D) is associated with a number of sight-threatening complications such as myopic macular degen-eration, retinal detachment, cataract and glaucoma.2-4 This signifi cant burden highlights the need for strategies and solutions to reduce the risk of onset and slow the progression in those already affected by myopia.

STRATEGIES FOR CONTROL

Myopia is a complex trait infl u-enced by a number of environ-mental and genetic factors, and the mechanisms underlying onset and progression are not fully understood. Although there is a great deal to learn about the mechanisms of myopia and why individuals respond differently to different stimuli and treatments, some behavioral, pharmaceutical and optical strategies already show promise in clinical trials in combating myopia—many of which can be incorporated into current day practice.5-26

Prevention is obviously the most effective strategy to reduce

the burden of myopia. Several randomized clinical trials suggest a lifestyle intervention with more time spent outdoors reducing the risk of onset.5,6 However, because this involves education and be-havioral modifi cation in the years prior to the onset of myopia, comprehensive community-based programs that involve parents, caregivers, teachers, governmen-tal and non-governmental organi-zations and eye care practitioners (ECPs) must be implemented for this approach to be effective. Despite the crucial role ECPs play in educating parents and com-munities, their role is limited by the fact that fi rst contact with a practitioner usually comes after the onset of symptoms and signs.

Once a patient is diagnosed with myopia, the ECP becomes the central care provider and is integral to evaluating the risk of further progression. ECPs now have many options for correct-ing distance vision impairment and slowing its progression. These options include more time spent outdoors, atropine thera-py (including low-dose atropine 0.01%), spectacles (progressives, peripheral defocus management and executive bifocals), contact lenses that impose myopic defo-cus across sections of the retina, and orthokeratology.5-26

Of these various interventions, contact lenses fare well in terms

of the risk-benefi t ratio compared with other interventions for myo-pia control. For example, atro-pine has greater effi cacy rates but an increased risk of side effects compared with contact lenses; in addition, myopia rebounds once treatment is stopped.7,8 Clinical trials and case studies show specially designed contact lenses slow myopia progression from 25% to 72% compared with spectacles.9-21

Contact lenses used for myopia control can be either bifocal or multifocal soft contact lenses, as well as the rigid contact lens designs used in orthokeratology. Investigators have proposed

Prof. Sankaridurg is the program

leader for the Myopia Program

at the Brien Holden Vision In-

stitute. She was awarded her

BOpt degree from the Elite

School of Optometry, Chen-

nai, India, in 1989, her PhD

in 1999 from the University of

New South Wales, Australia, and

her MIP in 2012 from University of Technology,

Australia. After working for a number of years

at the L.V. Prasad Eye Institute, India, as the

chief of Contact Lens Services, she took a

position at the Brien Holden Vision Institute

and the Vision Cooperative Research Centre.

She was appointed a conjoint professor at the

School of Optometry and Vision Science, Uni-

versity of New South Wales, Australia, in 2016.

She has been actively researching myopia for

approximately 13 years. She is also involved in

postgraduate supervision and manages the

institute’s Intellectual Property portfolio. She

has more than 50 articles in peer reviewed

journals, is a co-inventor on nine patents/

applications, has authored several book

chapters and has delivered many podium

presentations including keynote lectures.

ABOUT THE AUTHOR

1 CECredit

(COPE APPROVED)

Fitting Multifocal Contact Lenses for

MYOPIA CONTROL


several mechanisms to explain their myopia control effect, including: (1) contact lenses correct or reduce accommodative lag, which is considered a stim-ulus for eye elongation; (2) they reduce the peripheral retinal de-focus, which is considered to in-crease the risk of eye elongation by shifting the image closer to the retina; and (3) the lenses impose myopic defocus across areas of the retina, which is considered to inhibit eye growth.16-21,25,26

These practice pearls can help you better understand the use of soft contact lenses for myopia control and how to incorpo-rate them into your practice. Currently, no products are on the market specifi cally for use in myopia control; thus, this discus-sion is based on clinical trial data on the use of multifocal contact lenses for myopia control.

WHERE TO BEGIN

All individuals presenting with myopia should be assessed for risk of progression based on age, ethnicity, family history of myopia and past history of pro-gression. The ocular examination should include a cycloplegic as-sessment of the refractive error. A non-cycloplegic refraction often results in a more myopic refrac-tion, and the difference is greatest in younger children and those with low myopic, emmetropic

and hyperopic refractive errors.27

Because of this, ECPs should note that a patient without myopia could be classifi ed incorrectly as having myopia; likewise, the magnitude of myopia could be found to be higher than it actual-ly is in a patient with myopia.

ECPs can decide to fi t contact lenses based on an assessment of the risk profi le or at the request

of the patient or, in the case of a child, the caregiver. When fi tting contact lenses for myopia control, clinicians should take into consideration the minimum age at which contact lenses can be fi tted, contact lens design for myopia control, tests to perform, the wear and care schedule, managing visual performance and follow-up intervals.

Release Date: February 2017Expiration Date: February 1, 2020Goal Statement: Myopia is the single most signifi cant cause of distance vision impairment, and high myopia (worse than -5.00D) is associated with a number of sight-threatening complications—highlighting the need for strategies and solutions to reduce the risk of onset and slow progression. This article discusses the use of soft contact lenses for myopia control and how to incorporate them into your practice.Faculty/Editorial Board: Padmaja

Sankaridurg, PhD, BOptom, MIP Credit Statement: This course is COPE approved for 1 hour of continuing education credit. Course ID is 52285-CL. Check with your state licensing board to see if this counts toward your CE requirements for relicensure.Joint-Sponsorship Statement: This contin uing education course is joint-sponsored by the Pennsylvania College of Optometry.Disclosure Statement: The author’s employer has a commercial interest in myopia control.

The Proclear

center-

distance

multifocal

using the Brien

Holden Vision

Institute’s

contact lens

optical quality

analyzer

demonstrates

two distinct

zones in the

optical zone of

the lens and a

fl at peripheral

carrier.

Photo: B

rien Holden V

ision Institute

These practice pearls aid in myopia management, including avoiding onset and slowing progression in patients of all ages. By Padmaja Sankaridurg, PhD, BOptom, MIP


FITTING MULTIFOCAL CONTACT LENSES FOR MYOPIA CONTROL

Let’s take a look at these con-siderations in more detail:

FITTING AGE

Studies show children as young as eight can successfully man-age lens insertion, removal and care.17-21,25,28,29 Other clinical stud-ies found children achieved the required duration of lens wear (including full-time lens wear), and the reported duration of lens wear was comparable with that seen in adult contact lens wearers.30 Evidence shows no increased risk of complications associated with lens wear in chil-dren compared with adults.30,31 While it is common practice to teach both the child and the par-ent, the ECP should ensure the child can independently manage all aspects of lens wear before

prescribing them. In addition to correcting and

controlling progression of my-opia, studies indicate children and teenagers wearing contact lenses had improved quality of life with respect to appearance and satisfaction with correction.29 However, not all children can successfully wear contact lens-es. Conditions such as allergic conjunctivitis have an onset in childhood and, in such instances, contact lens wear may aggravate or increase the risk of fl are-up. Clinicians should ask about any previous history of allergic or vernal conjunctivitis, and exam-inations should include an ever-sion of the tarsal conjunctiva.

CONTACT LENS DESIGN

Bifocal or multifocal contact

lenses have proven effective for myopia control.16-21,25,26

The lens design research-ers found effective for myopia control was a center-distance multifocal that had two distinct portions within the optical zone: a central portion that corrected for the distance refractive er-ror and an outer zone that was relatively positively powered compared with the central por-tion.16-21 The relatively positive power was intended to reduce hyperopic defocus, induce myo-pic defocus or both across areas of the retina. The tested lenses were experimentally designed with the exception of two trials that used commercially available multifocal soft contact lenses: Acuvue bifocal (center distance, alternating fi ve ring bifocal,

Myopia control with various interventions. Note the effi cacy of these interventions compared with standard, single

vision spectacles or contact lenses.

75

11HE ET AL. 2015

56SHIH ET AL. 1999; 0.10%

96SHIH ET AL. 1999; 0.5%

59CHIA ET AL. 2012; 0.01%

36KAKITA ET AL. 2011

CHIA ET AL. 2012; 0.5%

31SANTODOMINGO ET AL. 2012

34WU ET AL. 2013

58SHIH ET AL. 1999; 0.25%

77CHUA ET AL. 2006; 1%

56WALLINE ET AL. 2009

68CHIA ET AL. 2012; 0.10%

43CHO AND CHEUNG 2012 (ROMIO)

46CHO ET AL. 2005 (LORIC)

30HIROAKA ET AL. 2012

79ALLER ET AL. 2016

29

HASEBE, 2014 PA PALS +1.5D

33

GWIAZDA ET AL. 2003

50ANSTICE AND PHILLIPS 2011

14

SANKARIDURG ET AL. 2010

13

EDWARDS ET AL. 2002

33SANKARIDURG ET AL. 2011

51

CHENG ET AL. 2014 +1.50

11

LEUNG AND BROWN 1999

39CHENG ET AL. 2015

20

HASEBE, 2014 PA PALS +1.0D

24

YANG ET AL. 2008

32LAM ET AL. 2014

15

CHENG ET AL. 2014 +1.50, 3DBI

17

LEUNG AND BROWN 1999

44HOLDEN ET AL. 2012

39

COMET 2

46

38

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nt

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tive

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p (

Sp

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nt)

Outdoors

Atropine

Orthokeratology

Soft contact lenses

SpectaclesBERNTSEN ET AL. 2012

WALLINE ET AL. 2013


Vistakon) and Proclear multifocal D (Coopervision).19,21

Depending on the lens design, the central distance portion varies in diameter, and the relative pos-itive power is delivered as either concentric rings or as a gradient power rising from the center to the periphery. The dioptric magnitude of the relative positive or plus power—which is fi xed for use across the population and not individualized—commonly ranging in power from +1.50D to +2.50D. There is still a dearth of information regarding whether increasing the relative positive power or providing individual-ized treatment is likely to deliver improved myopia control.

ASSESSING FIT AND

PERFORMANCE

The initial lens selection should be based on cycloplegic spher-ical equivalent refractive error and appropriately adjusted for vertex distance. The contact lenses employed in clinical trials were spherical lenses that masked low amounts of astigmatism (commonly <0.75D and based on the spherical component of the refractive error). Clinicians should refer to the manufactur-er’s guidelines for lens selection wherever possible.

Patients generally fi nd the fi rst few minutes of lens wear unset-tling but tend to adapt quickly. Clinicians should wait to evaluate visual performance until 20 to 30 minutes after lens insertion. To ensure a successful fi t, ECPs should examine and optimize the lens centration and movement before addressing visual perfor-mance. Issues with lens fi t such as decentration or excessive lens movement on the eye may mimic or increase the severity or fre-quency of symptoms associated

with multifocal lens wear such as ghosting, poor contrast and haloes.

Poor visual performance may be related to a number of factors, including: strength of the rela-tive positive power in the optical zone; power profi le of the lens (for example, concentric rings of plus power vs. gradient increase in plus power); pupil size; am-bient illumination and contrast. A thorough clinical evaluation taking these factors into account may determine if the patient requires a change in lens fi t, lens design or simply reassurance that the lens is properly fi t. If clini-cians perform over-refraction,

they should do so using a trial frame rather than a phoropter to minimize errors related to head tilt and movement behind the phoropter.

WEAR TIME AND

REPLACEMENT MODALITY

Patients should be advised to wear myopia control contact lenses for all waking hours, as improved lens wear compliance results in better outcomes.18 Also, patients should have an up-to-date spectacle prescription for occasions when lens wear may not be feasible.

Contact lens wear does not appear to pose an increased risk of

Practice Pearls on Myopia Control:

1. Your toolkit for myopia management should include myopia control contact lenses.

2. Assess the risk of progression of myopia for a patient and tailor the management based on the risk.

3. A cycloplegic assessment of the refractive error is essential, particularly in children, as non-cycloplegic refractive assessment often results in a more myopic refractive error.

4. Children eight years and older can successfully be fi t with contact lenses and can independently manage and care for their lenses. In children, clinicians should examine the anterior segment before prescribing contact lenses, including eversion and examination of the tarsal conjunctiva.

5. Contact lens designs employed for myopia control are multifocal or multifocal-like lenses with a portion of the optical zone devoted to correcting the distance myopic refractive error and the remainder being relatively positive compared with the distance power by an average of +1.50D to +2.50D.

6. Wait 20 to 30 minutes to allow lenses to settle prior to examining lens fi t and visual performance. Optimize lens fi t prior to measuring visual performance with the lenses.

7. A daily disposable option or a frequent replacement schedule minimizes the risk of complications associated with contact lens wear.

8. When fi tting children with contact lenses, ensure the children can independently manage lens insertion and removal, as well as lens care procedures.


FITTING MULTIFOCAL CONTACT LENSES FOR MYOPIA CONTROL

complications in children com-pared with adults.32,33 To reduce the risk of complications associat-ed with lens wear, whatever they may be, ECPs should prescribe a regimen that minimizes lens handling and the consequent risk of microbial contamination of the lenses. Education is key, and ECPs should emphasize the risks asso-ciated with overnight lens wear such as increased risk of infection and focus on properly training patients in appropriate lens care and handling techniques. A daily wear, daily disposable or frequent replacement schedule is often the most successful approach.

Also, while it is common prac-tice to teach both the child and the parent, practitioners should ensure the child is fully adept at managing all aspects of lens wear such as insertion and removal, lens disinfection as well as taking necessary steps to prevent adverse events, such as avoiding lens wear when unwell or avoiding use of solutions other than those provid-ed by the ECP.

For patients with myopia pro-gression, a three- to six-month follow-up schedule is ideal for avoiding potential adverse effects such as blurred vision. Any drop in visual acuity of one line or more or over-refraction of 0.25D or more necessitates the need for a refractive error assessment so the lens power can be appropri-ately adjusted.

OUR RESPONSIBILITY

The rising prevalence of myopia and its notably progressive nature is an increasingly signifi cant con-cern for ECPs and their patients. While further research regarding the underlying mechanisms of myopia is needed, current data points to contact lenses as a safe and effective means of delivering

myopia control.9-21 Since progres-sion of myopia is rapid in child-hood, treatment strategies should be directed mostly to children and young adults, for whom studies show contact lenses provide a better risk-benefi t than other forms of myopia control. Taking into consideration patient expectations and their ability to manage lens wear, ECPs should opt for myopia control contact lenses in treating individuals at risk of onset and progression. RCCL

1. Holden BA, Fricke TR, Wilson DA, et al. Global prevalence of myopia and high myopia and temporal trends from 2000 through 2050. Oph-thalmology. 2016;123(5):1036-42.2. Chen SJ, Cheng CY, Li AF, et al. Prevalence and associated risk factors of myopic maculop-athy in elderly Chinese: the Shihpai eye study. Invest Ophthalmol Vis Sci. 2012;53(8):4868-73.3. Sun J, Zhou J, Zhao P, et al. High prevalence of myopia and high myopia in 5060 Chinese uni-versity students in Shanghai. Invest Ophthalmol Vis Sci. 2012;53(12):7504-9.4. Li T, Du L, Du L. Prevalence and Causes of Visual Impairment and Blindness in Shanxi Province, China. Ophthalmic Epidemiol. 2015;22(4):239-45.5. Wu PC, Tsai CL, Wu HL, et al. Outdoor activity during class recess reduces myopia onset and progression in school children. Ophthalmology. 2013;120(5):1080-5.6. He M, Huang W, Zheng Y, et al. Refractive error and visual impairment in school chil-dren in rural southern China. Ophthalmology. 2007;114(2):374-82.7. Chia A, Lu Q, Tan D. Atropine for the treat-ment of childhood myopia: safety and effi cacy of 0.5%, 0.1%, and 0.01% doses (Atropine for the Treatment of Myopia 2). Ophthalmology. 2012;119(2):347-54.8. Shih YF, Chin CH, Chou AC, et al. Eff ects of diff erent concentrations of atropine on controlling myopia in myopic children. J Ocul Pharmacol Ther. 1999;15(1):85-90.9. Edwards MH, Li RW, Lam CS, et al. The Hong Kong progressive lens myopia control study: study design and main fi ndings. Invest Ophthal-mol Vis Sci. 2002;43(9):2852-8.10. Gwiazda J, Hyman L, Hussein M, et al. A randomized clinical trial of progressive addition lenses versus single vision lenses on the progres-sion of myopia in children. Invest Ophthalmol Vis Sci. 2003;44(4):1492-500.11. Sankaridurg P, Donovan L, Varnas, S, et al. Spectacle lenses designed to reduce progres-sion of myopia: 12-month results. Optom Vis Sci. 2010;87(9):631-41.12. Leung, JT, Brown B. Progression of myopia in Hong Kong Chinese schoolchildren is slowed by wearing progressive lenses. Optom Vis Sci. 1999;76(6):346-54.13. Yang Z, Lan W, Ge J, et al. The eff ectiveness of progressive addition lenses on the progres-sion of myopia in Chinese children. Ophthalmic Physiol Opt. 2009;29(1):41-8.14. Hasebe S, Jun J, Varnas SR. Myopia control with positively aspherized progressive addition lenses: a 2-year, multicenter, randomized, controlled trial. Invest Ophthalmol Vis Sci. 2014;55(11):7177-88.

15. Berntsen DA, Sinnott LT, Mutti DO, Zadnik K. A randomized trial using progressive addition lenses to evaluate theories of myopia progres-sion in children with a high lag of accommoda-tion. Invest Ophthalmol Vis Sci. 2012;53(2):640-9.16. Anstice NS, Phillips JR. Eff ect of dual-focus soft contact lens wear on axial myopia progres-sion in children. Ophthalmology. 2011;118(6):1152-61.17. Sankaridurg P, Holden B, Smith E 3rd, et al. Decrease in rate of myopia progression with a contact lens designed to reduce relative peripheral hyperopia: one-year results. Invest Ophthalmol Vis Sci. 2011;52(13):9362-7.18. Lam, CS, Tang WC, Tse DY, et al. Defocus Incorporated Soft Contact (DISC) lens slows myopia progression in Hong Kong Chinese schoolchildren: a 2-year randomised clinical trial. Br J Ophthalmol. 2014;98(1):40-5.19. Aller TA, Wildsoet C, Results of a one-year prospective clinical trial (CONTROL) of the use of bifocal soft contact lenses to control myopia progression. Ophthalmic Physiol Opt. 2006;26 Suppl 1:1-67.20. Holden BA, Sankaridurg P, Lazon de la Jara P, et al. Decreasing peripheral hyperopia with distance centre relatively plus powered periph-ery contact lenses reduced the rate of progress of myopia : A 5 year Vision CRC study. ARVO E abstract 6300. 2012.21. Walline JJ, Greiner KL, McVey ME, Jones-Jor-dan LA. Multifocal contact lens myopia control. Optom Vis Sci. 2013; 90(11):1207-14.22. Hiraoka T, Kakita T, Okamoto F, et al. Long-term eff ect of overnight orthokeratology on axial length elongation in childhood myopia: a 5-year follow-up study. Invest Ophthalmol Vis Sci. 2012;53(7):3913-9.23. Cho P, Cheung SW. Retardation of myopia in prthokeratology (ROMIO) study: a 2-year randomized clinical trial. Invest Ophthalmol Vis Sci. 2012;53(11):7077-85.24. Santodomingo-Rubido J, Villa-Collar C, Gilmartin B, Gutiérrez-Ortega R. Myopia control with orthokeratology contact lenses in Spain: refractive and biometric changes. Invest Oph-thalmol Vis Sci. 2012;53(8):5060-5.25. Aller TA, Wildsoet C. Bifocal soft contact lenses as a possible myopia control treatment: a case report involving identical twins. Clin Exp Optom. 2008;91(4):394-9.26. Turnbull PR, Munro OJ, Phillips JR. Contact lens methods for clinical myopia control. Optom Vis Sci. 2016;93(9):1120-6.27. Hu YY, Wu JF, Lu TL, et al. Eff ect of cy-cloplegia on the refractive status of children: the Shandong children eye study. PLoS One. 2015;10(2):e0117482.28. Walline JJ, Jones LA, Rah MJ, et al. Contact lenses in pediatrics (CLIP) study: chair time and ocular health. Optom Vis Sci. 2007;84(9):896-902.29. Cheng X, Xu J, Chehab K, et al. Soft contact lenses with positive spherical aberration for my-opia control. Optom Vis Sci. 2016;93(4):353-66.30. Walline JJ, Guame A, Jones LA, et al. Bene-fi ts of contact lens wear for children and teens. Eye Contact Lens. 2007;33(6.1):317-21.31. Li L, Moody K, Tan DT, et al. Contact lenses in pediatrics study in Singapore. Eye Contact Lens. 2009;35(4):188-95.32. Sankaridurg P, Chen X, Naduvilath T, et al. Adverse events during 2 years of daily wear of silicone hydrogels in children. Optom Vis Sci. 2013;90(9):961-9.33. Chalmers RL, Wagner H, Mitchell GL, et al. Age and other risk factors for corneal infi ltrative and infl ammatory events in young soft contact lens wearers from the Contact Lens Assessment in Youth (CLAY) study. Invest Ophthalmol Vis Sci. 2011;52(9):6690-6.


CE TEST ~ FEBRUARY 2017

Fitting Multifocal Contact Lenses for Myopia ControlValid for credit through February 1, 2020

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

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

Mail to: Jobson Medical Information, Dept.: Optometric CE, 440 9th Avenue, 14th Floor, New York, NY 10001.

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

Credit: This lesson is approved for 1 hour of CE credit. Course ID is 52285-CL.

Sponsorship: Joint-sponsored by the Pennsylvania College of Optometry

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

Answers to CE exam:

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

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

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

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

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

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

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

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

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

16. Your knowledge of the subject increased: Greatly Somewhat Little17. The difficulty of the course was: Complex Appropriate Basic

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

19. Comments on this course: _________________________________________

___________________________________________________________________

20. Suggested topics for future CE articles: ______________________________

___________________________________________________________________

Identifying information (please print clearly):

First Name

Last Name

Email

The following is your: Home Address Business Address

Business Name

Address

City State

ZIP

Telephone # - -

Fax # - -

By submitting this answer sheet, I certify that I have read the lesson in its entirety and completed the self-assessment exam personally based on the material present-ed. I have not obtained the answers to this exam by fraudulent or improper means.

Signature: ________________________________________ Date: _____________

Please retain a copy for your records. LESSON 113633, RO-RCCL-0217

1. Which of these complications is associated with high myopia?

a. Retinal detachment. b. Cataract. c. Glaucoma. d. All of the above.

2. What is the most eff ective strategy to reduce the burden of myopia?

a. Contact lenses.b. Prevention.

c. Vision therapy. d. Refractive surgery.

3. Studies show contact lenses can slow myopia progression by what percent?

a. 1% to 10%. b. 10% to 20%. c. 25% to 72%. d. 60% to 70%.

4. Most clinical trials employ this type of contact lens design:

a. Center-distance multifocal. b. Translating multifocal. c. Hybrid multifocal d. Concentric bifocal.

5. At what age can clinicians consider prescribing myopia control contact

lenses to patients?

a. Six. b. Eight. c. Ten. d. Twelve.

6. Why should clinicians perform a cycloplegic refraction before prescribing

contact lenses for myopia control?

a. Avoid a more myopic refraction. b. Check visual performance. c. Examine the tarsal conjunctiva. d. Adjust the lens power.

7. Which of these complications can mimic or increase the severity or frequency of

symptoms associated with multifocal lens wear?

a. Part-time lens wear. b. Vernal conjunctivitis. c. Incorrect plus power. d. Excessive lens movement.

8. How long after lens placement should clinicians wait until evaluating visual

performance?

a. Visual performance can be evaluated immediately after lens placement. b. Five to 10 minutes. c. 20 to 30 minutes. d. 30 to 45 minutes.

9. All of these can lead to poor visual performance, except:

a. Strength of the relative positive power in the optical zone. b. Power profi le of the lens. c. Lens replacement modality. d. Pupil size.

10. How long should patients be advised to wear contact lenses for myopia

control?

a. All waking hours. b. Overnight. c. Eight to 10 hours a day. d. Six to eight hours a day.

EXAMINATION ANSWER SHEET


Orthokeratology (ortho-k) is one of the more challenging treatment modali-ties in an eye care

practitioner’s toolbox, especially considering effective myopia control treatment needs to begin by the age of six or seven.1 As challenging as these young patients may be, treating them with corneal reshap-ing can be immensely rewarding. Orthokeratology has grown dra-matically internationally; in China, for example, close to two million ortho-k lenses have been fabricated.2

However, less than 300,000 lenses have been dispensed in the United States—less than 1% market share of the entire contact lens industry.3

Additionally, the nature of our practice environment for contempo-rary eye care practitioners (ECPs)—which emphasizes low reimburse-ments and ever-increasing numbers of patients—makes it diffi cult to fi nd the time to focus on corneal reshaping. But with myopia on the rise, it’s time we use all of our tools.

I feel ortho-k is the best possible treatment for eligible patients; using the human cornea in its new-engi-neered shape to limit the progres-sion of myopia has proven hugely successful in my practice. Here are 10 tips to help you successfully integrate ortho-k into yours.

1 KNOW THE RISKS AND

BENEFITS

Over 80% of orthokeratology fi ts on adolescents are for myopia

control.4 Yet, ECPs are still reluc-tant to embrace the procedure, possibly because there are few procedures with a higher perceived risk than fi tting adolescents with ortho-k. Risk aversion may inform some of this reticence, but a further understanding of the benefi ts of the procedure proves to overshadow the potential risks such as microbial keratitis, corneal abrasions, central corneal staining, lens binding and tear fi lm instability. The FDA is willing to consider even a 30% reduction in myopia resulting from use of a medical device as clinically signifi cant; orthokeratology—with close to a 50% reduction—serves as the gold standard.

Safety concerns tend to be based more in perception than fact. There are scores of studies showcasing the safety of this procedure.5-8 Out of the 5,000+ ortho-k lenses I’ve fi t in the last 25 years, I’ve only had one incident of microbial keratitis. Early diagnosis and treatment, combined with effective antibiotic therapy, kept this patient’s micro-bial keratitis episode from causing vision loss. My longest wearing ortho-k patient just passed year 25, and his seven diopters of myopia at age seven hasn’t changed. Many of my patients are in year 15 to 20 and still wearing lenses safely. While we have had our share of corneal abrasions and superfi cial punctate keratitis, these have been easily remedied and haven’t negated the many benefi ts ortho-k has pro-vided to my patients.

Even spherical aberration, initially thought to be a negative side effect of ortho-k, actually offers many positives when it comes to advanced custom ortho-k lens design. For ex-ample, by manipulating the positive asphericity in ortho-k designs, along with reducing the size of the treat-ment zone, you increase the eleva-tion of the reverse curve, resulting in an increase in spherical aberration with more effective myopia control. Introducing a negative asphericity, however, can help increase add power while also manipulating spherical aberration.

2 CONSULT AND EXAMINE

In my offi ce, we ask that patients attend a free consul-

tation before making an appoint-ment for an ortho-k evaluation. It is crucial that parents accompany any adolescent patients. Often, I fi nd the parents do little to explain ortho-k to their children because they don’t understand it themselves, and the consultation ensures both the parent and the patient are educated prop-erly. During the consultation we

ABOUT THE AUTHOR

Dr. Herzberg has been

practicing in Aurora, Ill., for 40

years—25 of which he has

specialized in ortho-k. He is

co-founder and president of

the International Academy

of Orthokeratology and

Myopia Control (IAOMC) and

founder and co-president of

the American Academy of Orthokeratology

and myopia control (AAOMC). He serves

as a consultant to the contact lens industry

and lectures and writes on the topic of

orthokeratology and myopia control around

the world.

from an

Orthokeratology ExpertDon’t let misconceptions stop you from using this treatment

modality that can provide a huge benefi t to patients with myopia.

By Cary M. Herzberg, OD

10

TIPS


answer questions and provide liter-ature on the procedure while also gathering information about a pa-tient’s eligibility. It’s also the perfect time to evaluate fi rst impressions of the maturity level of an adolescent patient. Finally, after reviewing the risks and benefi ts, you should have parents, and the child if he or she is old enough, sign off on all the key points of an informed consent.

During the initial examination to determine suitability, clinicians must thoroughly rule out all complicating conditions. For example, the pres-ence of any corneal pathology (such as keratoconus) is a contraindica-tion. Practice extra caution when considering cases with irregular, limbus-to-limbus or against-the-rule astigmatism or decentered corneal caps—particularly if you are new to ortho-k. Factors such as dry eye should always be dealt with prior to fi tting.

It is extremely important, espe-cially when treating the pediatric population, that your staff knows how to gather this pertinent clinical information so the appointment can be fl agged if they note complicating factors.

3 EVALUATE AND ASSESS

Following the initial exam-ination is the actual ortho-k

evaluation. This should begin with topography, which is the standard-of-care for ortho-k. The baseline topography will remain the refer-ence for a patient’s fi tting through-out their lifetime of ortho-k use, so it needs to be performed with great precision, and it’s imperative to take more than one topography reading. It’s not uncommon to need 10 or more readings on a patient per eye to arrive at an accurate assessment of the cornea prior to fi tting, considering corneal topogra-phers using a Placido disc are often inaccurate and provide different

results each time a map is taken. It can be challenging to know which one of those 10 is the one to use as the reference. In my practice, I take an auto-k reading and match that to the topographies I have taken until I fi nd the closest one to the topog-raphy reading. Avoid using topog-raphies with missing data points or irregularities caused by tear pooling or lid infringement.

Topography provides valuable information on the cornea itself, including the much-needed ec-centricity; however, be wary of a topographer’s accuracy. Besides pre-fi t data, the evaluating treatment progress is one of its greatest bene-fi ts. All of the necessary information you need for evaluating the fi t is at your fi ngertips, including axial, tangential, refractive, elevation and difference maps. Axial maps determine the radius of curvature at each particular point, which is helpful in determining the refractive change. Axial maps are also good for determining the type, shape and position of any corneal astigmatism. Tangential maps are best used for lens positioning in ortho-k, while refractive maps speak to the quality of vision. Subtractive or difference maps are ideal for showing the over-night change after ortho-k.

The ortho-k evaluation is also a good time to discuss other consid-erations such as haloes and adapta-tion for moderate-to-high myopia.

Haloes in younger patients usually aren’t an issue, particularly after ex-plaining how they are integral to the myopia control effect. The change from the prolate to oblate surface created after ortho-k causes haloes as it defi nes a new myopic image shell on the peripheral retina. Still, it’s helpful to know how sensitive patients are to slightly blurry visual effects such as haloes at distance.

Education is a key to success, so make sure parents and patients un-derstand these myopia-controlling devices are not intended to give the ultimate in fi ne distance acuity but rather are a method of reducing myopia progression.

Prior to fi tting any lenses, discuss how the patient’s accommodative system may need help with vision training during treatment. This is especially true with newer custom designed lenses that address the lack of peripheral defocus in patients with low myopia by creating more demand and a resulting moderately high hyperopia after lens removal during treatment (>1D).

4 SIGN A CONTRACT

If at this point all looks well and all parties involved opt

for ortho-k, prepare a contract and go through it with the patient and parent before having them sign it. The contract should address all expectations and contingencies. Possible side effects need to be

Topography needs to be near perfect

to ensure a proper fi t.

The accumulation of ortho-k trial

sets over the last 20 years.


covered, and suitable alternatives addressed. Lastly, payment expec-tations should also be included. Always remember when structuring your fees for this procedure to allow an extra margin in your fi nal fees to account for additional lenses or extra time needed to achieve the necessary precision. This is especial-ly important for myopia control, where the initial lens selection may fail to deliver a satisfactory result.

5 CHECK THE CORNEA

When performing ortho-k, it’s imperative to consider

factors such corneal volume: the more volume you have the easier it is to move tissue, even with higher myopia. Be wary of small, fl at cor-neas due to low volume, as they can test your fi tting abilities, even in low prescriptions. Extremely fl at corneas can also pose a challenge, especially in higher prescriptions. For exam-ple, 34.00D is about as fl at as you can expect after ortho-k, so a 6D myope with a fl at K of 39.00D may be out of reach. Remember, over 40 microns of elevation difference between steep and fl at meridians usually means a toric alignment zone with its increased complexity.

Eccentricity of the cornea is ex-tremely important to know to help you determine how much fl attening to expect on the cornea as you move towards the periphery and wheth-er a fi ve curve or higher design is warranted due to that change. Familiarize yourself with your to-pographer’s intricacies and margins of error, as most will either over or understate the “e” value. When possible, also evaluate the “e” value with other methods such as a trial lens fi tting. This is done by deter-mining the best fl uorescein pattern available underneath that trial lens. Ortho-k designs are accurate to per-haps 5µm, and the human eye can pick up a difference in patterns of

roughly 10µm to 15µm, permitting an accurate assessment of corneal eccentricity and best-fi t profi le.

When taking topographies on children, take note that they tend to be more fearful and fi dgety during examinations. If you are unable to acquire that “perfect” topography reading, it may be best to send the child home with eye drops to practice keeping their eyes open and inform the parents of the need for a precise topography. Have the child open their eyes wide as they instill the drops. Often on return visits, they are more relaxed, giving you a better opportunity to document their topography.

6 BE READY FOR

FITTINGS

The next step is fi tting and ordering the lenses. The most popular methods for doing this are empirically, through trial lens fi tting or custom design. Many ECPs forgo trial lenses and order an empirical or custom topographic design as “trial” lenses. In 80% of cases, they will work effectively and require minimal, if any, changes.7 Even though I have diagnostic data to help fi t a patient, I often feel a trial fi tting is much more accurate, as

it provides additional information that helps me customize each fi t. For instance, I can evaluate possible lid interactions such as overly tight lids.

When you are ready to trial fi t, be sure to have the necessary time and space for ortho-k patients by providing a reclining chair so they can lay down with eyes closed for at least 15 minutes. This is much more valuable than open-eye assessment for lens fi t and treatment. A mere 20 minutes of wear will often correct signifi cant levels of myopia and astigmatism.

Many practitioners instill a drop of topical anesthetic before lens insertion to aid a young patient’s adaptation.

With many different trial set diameters at my disposal, I can nail covering 95% of corneal surface, which is necessary for best results.9

7 DISPENSE AND FOLLOW

When the lenses have arrived and passed inspection, bring

the patient into the offi ce and insert the lenses to make sure they fi t well. If the patient and parent are satis-fi ed, educate them on safe insertion, removal and care. If the patient is under eight years of age, it’s likely the parents will need to step in and provide support here, which may mean all of the insertion, removal and care. Allow enough time in your schedule for this process and, again, make sure this time is refl ect-ed in your fee structure.

Once you have dispensed the lenses, active follow up is necessary. In my practice, we see the patient the next day and then again in one month. Further follow-up visits are scheduled at three-month intervals. If it’s a higher amount of myopia or other factors such as high astigma-tism are present, we ask patients to come in for follow-up appoint-ments at two weeks as well. We also schedule the following year’s lens

10 TIPS FROM AN ORTHOKERATOLOGY EXPERT

Clinicians should evaluate the

orthokeratology fi t at the slit lamp

before dispensing.


replacements and evaluations during the initial year.

I replace lenses for a child yearly because I personally believe that will provide the healthiest and safest outcomes, given children cannot legally take responsibility for their decisions, particularly when it comes to lens care.

8 ADJUST ACCORDINGLY

Effective myopia control requires A-scans to deter-

mine axial length before and during treatment. You should take a new measurement every year. These readings, along with any changes in the over-refraction with ortho-k lenses at six and 12 months after initial fi tting, will either confi rm successful myopia control or lead to a new treatment strategy.

Modifi cations such as increasing the Jessen factor, using newer de-signs relying on six or more curves or using eccentricity in the base curve can lead to a greater eleva-tion of the reverse curve and better myopic defocus in the periphery. The Jessen factor is the amount of lens fl attening over and above the patient’s current prescription needs, which allows the eye to remain free from myopia, even after all-day wear. Research shows increasing the Jessen factor and reducing the treatment zone can create a better myopic image shell in the peripheral retina.10 Simply adding low-dose atropine (0.01%) in addition to or-tho-k also may lead to better control without changing the lens.

Management decisions should be based on any changes in the axial length after the beginning of treatment. Even high myopia is within reach—although ortho-k may only get you part of the way there. Correcting at least 4D with corneal reshaping and then the rest with glasses can still reduce myopic progression by at least 50%.11

9 DON’T STOP TOO SOON

A common mistake parents make is assuming that, once

the riskiest years of myopic pro-gression have passed, their child should switch from ortho-k to daily wear lenses or glasses. This is nearly always the wrong route to take, as many younger patients have no desire to limit their much-improved quality of life by making that switch. Further, in my experience, long-term wear of ortho-k lenses shows no signs of increased risk. I have many patients who have been wearing their ortho-k lenses for more than a decade with no signs of any adverse corneal changes. In fact, their corneas remain pristine even after years of overnight wear.

I consult with my long-term wearers at least once a year on their success with the procedure. When they are ready for LASIK or feel wearing the lenses nightly is impact-ing their lifestyle, I wash them out of their lenses. This process may take up to six months to accomplish in long-term wearers (>10 years).

10 WATCH YOUR

PATIENTS AND

PRACTICE GROW

Ortho-k can dominate a practice. My specialty practice is now about 80% corneal reshaping, which has translated into a healthy practice. Once you decide to incorporate ortho-k into your practice, be pre-pared for a younger patient base. At the same time, my younger corneal reshaping patients have proven extremely loyal, and I have a special opportunity to participate with par-ents in fostering their growth. While kids may be resistant to parental advice, they will often listen to an authority fi gure such as their ECP. Don’t waste that opportunity.

Taking a proactive role in the myopia epidemic and incorporating ortho-k into your practice can make

a positive difference in your young patients’ lives. Controlling myopia progression at age six or seven by just 30% will eliminate 75% of all of high myopia (>5D) cases and the subsequent increased risk of ocular pathology.12 Further, evidence shows ortho-k is impactful on adolescents’ visual performance and binocular function.1 The improvement in qual-ity of life afforded by ortho-k lenses is extremely rewarding to witness.

With myopia rates increasing, it’s time to fully consider all

the options at our disposal. As far as I’m concerned, ortho-k is the way of the future. Don’t waste the opportunity to provide this amazing specialty to your pediatric patients. Taking the road less traveled can indeed make all the difference. RCCL

1. Eiden B. Lets not forget that most of us use two eyes together; Binocular vision implications in corneal reshaping treatment. CL Today Newsletter. December 11, 2016. Available at www.clspectrum.com/newsletters/contact-lenses-today/decem-ber-11,-2016. Accessed January 6, 2017. 2. Oh S. Statistical data in the fi eld of ortho-keratology and myopia control in the US and the world. Korean Contact Lens Study Society. Korean Ophthalmology Contact Lens Society. Nov 2016;9:79-85.3. Nichols J. Contact lenses 2015. Contact Lens Spectrum. January 1, 2016. Available at www.clspectrum.com/issues/2016/january-2016/con-tact-lenses-2015. Accessed January 6, 2017.4. Kojima R, Caroline P. IQ Scleral Lenses. Presented at Vision By Design 2014., April 24-27; Chicago, Ill. 5. Walline JJ, Rah MJ, Jones LA. The children’s overnight orthokeratology investigation (COOKI) pilot study. Optom Vis Sci. 2004 Jun;81(6):407-13.6. Cho P, Cheung SW, Edwards M. The longi-tudinal orthokeratology research in children (LORIC) in Hong Kong: a pilot study on refractive changes and myopic control. Curr Eye Res. 2005 Jan;30(1):71-80.7. Davis RL, Eiden SB, Bennett ES, et al. Stabilizing myopia by accelerated reshaping technique (SMART)-study three year outcomes and over-view. Adv Ophthalmol Vis Syst. 2015;2(3):00046.8. Walline JJ, Jones LA, Sinnott LT. Corneal re-shaping and myopia progression. Br J Ophthalmol. 2009 Sep;93(9):1181-5.9. Global OK-Vision. GOV General Fitting Guide. Available at www.global-ok.com/html/GOVFitting-Guide.html. Accessed January 12, 2017. 10. Chan B, Cho P, Mountford J. The validity of the Jessen formula in overnight orthokeratology: a retrospective study. Ophthalmic Physiol Opt. 2008;28(3):265-8.11. Charm J, Cho P. High myopia–partial reduction ortho-k: a 2-year randomized study. Optom Vis Sci. 2013;90(6):530-9.12. Holden BA, Fricke TR, Wilson DA, et al. Global prevalence of myopia and high myopia and tem-poral trends from 2000 through 2050. Ophthal-mology. 2016;123(5):1036-42.


With myopia on the rise, it’s more im-portant than ever to treat

patients as early as possible.1-2 Luckily, eye care practitioners

have several treatment options available, including corneal reshaping with orthokeratology (ortho-k). Several studies show the effectiveness of ortho-k in slowing myopia progression in children.3-8 Researchers found axial elongation was 51% to 57.1% less compared with a control group wearing spec-tacles or soft contact lenses.6,8

But many patients with myo-pia have astigmatism, which can sometimes complicate ortho-k therapy. Nearly one quarter of patients wearing soft contact lenses require astigmatism correc-tion, and 32% of patients with myopia present with astigmatism of 0.75D or greater in both eyes.9

These statistics suggest the number of patients with astigmatism is as-sociated with the increasing of the number of patients with myopia. To effectively treat this patient population, clinicians must fi nd creative alternatives to traditional ortho-k therapy. This article takes a closer look at the use of toric ortho-k lenses for myopia control in patients with astigmatism.

EFFICACY OF

TORIC ORTHO-K

Researchers have suggested toric lenses can slow axial elongation in

patients with myopia with astig-matism.10-11 A study investigating the effectiveness of toric ortho-k lenses for myopia control in chil-dren ages six to 12 with myopia from 0.50D to 5.00D and with-the-rule astigmatism from -1.25D to -3.50D found that, after one year of therapy, the axial elon-gation in subjects wearing toric ortho-k lenses increased by an av-erage of 0.15mm.10 This was 58% slower than the control group, all of whom wore spectacles. After two years of therapy, the axial elongation in the toric ortho-k group increased by 0.31mm, 52% slower than the control group.10

In another study—comprised of 24 treated patients without a con-trol group—researchers noted no myopia progression and no alter-ation in the axial length in myopic children ages nine to 16 after one year of toric ortho-k lens wear.11

CLINICAL NEED

Ortho-k treatment with spherical reverse geometry lenses presents two signifi cant problems for patients with astigmatism, limiting their use to with-the-rule astigma-tism up to 1.50D and against-the rule and oblique astigmatism up to 0.75D.12-15

First, a spherical accelerated ortho-k lens on a toric cornea will have poor centration because the lens’s sagittal depth is equal in each meridian and the cornea’s sagittal depth is different in each meridian. This leads to ‘smiley

face’ (high ride) or ‘frowny face’ (low ride) topography patterns, in-duced astigmatism, glare and poor vision (Figures 1a and 1b).16-19 As a result, symmetric reverse ortho-k designs can only fl atten the fl attest meridian, which may actually cause the astigmatism to increase.16 A toric ortho-k design will extend the bearing area of the lens circum-ferentially to improve both lens fi t and clinical outcome.

Second, spherical reverse geometry lenses cannot achieve the peripheral touch necessary to ensure stabilization, centration and properly modulated hydro-dynamic forces. Ortho-k treat-ment is achieved by combining two pressures: the positive push force in the central cornea and the negative pull force in the mid-pe-ripheral cornea.20 The negative fl uid pressure necessitates a 360° total touch in the landing zone to prevent fl uid outfl ow along the steepest meridian (Figures 2a and 2b).21 Therefore, the total periph-eral touch is important not only

ABOUT THE AUTHOR

Dr. Fadel is an optometrist

specializing in contact lenses

for irregular cornea, scleral

lenses and orthokeratology.

She has a contact lens

private practice in Italy,

where she designs special

customized contact lenses.

She lectures and publishes,

especially on contact lenses for the irregular

cornea, scleral lenses and ortho-k. She is the

founder and president of the Italian Academy

of Scleral Lenses (AILeS), a board member

of the Italian Academy of Contact Lenses

(AILAC) and a member of the Scleral Lens

Society (SLS). Email: [email protected].

By Daddi Fadel, DOptom

RESHAPINGOrtho-K


for better lens stabilization and centration, but also to modulate the hydrodynamic forces that lead to corneal fl attening in each me-ridian.16 In case of limbus-to-lim-bus astigmatism, the semi-closed, fl uid-fi lled system in the reverse zone is achieved only with a toric ortho-k design.21

WHEN TO FIT

TORIC ORTHO-K

Corneal astigmatism can be clas-sifi ed as apical, limbus-to-limbus or peripheral.22 In the apical form, astigmatism is greater centrally than peripherally. In limbus-to-lim-bus, central and peripheral astig-matisms are equal. Finally, in the third category, astigmatism is greater peripherally than centrally. The evaluation between corneal and refractive astigmatism can either be equal or different.22

Research suggests toric ortho-k lenses be used for apical astig-matism, measured with a corneal topographer, higher than 1.75D, limbus-to-limbus astigmatism higher than 1.25D and peripheral astigmatism higher than -1.00D. 22

Using the toric back optic zone is recommended for corneal astig-matism that differs from refractive astigmatism. If the axes of corneal and refractive astigmatism do not coincide, the optical and the align-ment zones require different axes.22

A recent study suggests toric or-tho-k use may be benefi cial when the sagittal height differential between the two principal meridi-

ans is greater than 25µm, or 1.00D of toricity.23 This might be better managed with a toric ortho-k design, especially for toric cor-neas. The majority of eyes looked at in the study had a peripheral astigmatism greater than central astigmatism.

DIFFERENT DESIGNS

Since their fi rst introduction at the Global Orthokeratology Symposium in 2005 for the correc-tion of astigmatism, toric ortho-k lens designs have varied across studies and case reports.10,13,16,18,21,

24-28

CLINICAL STUDIESA study involving patients with astigmatism greater than 1.25D at any principal corneal meridi-an orientation used a lens design containing fi ve toric zones, with reverse curves in the second and the fourth.21 This design is known as the “full toric double reservoir.” The researchers suggested that to achieve an adequate effect with a toric ortho-k lens, mechanical and hydrodynamic forces must occur differently in each corneal meridian, with greater fl attening in the meridian where the my-opia is greater. Results demon-strated an 85% change in initial astigmatism.21

An additional study, with sub-jects age nine to 16, used a design with reverse and alignment toric zones, which are more appropri-ate for toric corneas because they

allow for better centration.11 The corneal astigmatism was gradually decreased, resulting in a success rate of 92.8%.11 This suggests that toric ortho-k designs are able to reduce moderate-to-high corneal astigmatism.

CASE REPORTSOne case report used a toric align-ment zone and spherical back optic and reverse zone for a 13-year-old patient with spectacle correction of -4.25 -1.50x165° OD and -4.25

Figs. 1a and 1b. Above, superior

decentration of a spherical ortho-k

lens on a toric cornea with no

corneal touch in the steepest

meridians. Below, the topography

pattern of the same lens shows a

decentrated treatment zone forming

a ‘smiley face’ pattern.

Toric lenses can expand myopia managementto include patients with astigmatism.


-2.50x180° OS.18 According to the report’s authors, the advantage of placing a spherical optic zone on a toric cornea is that the fl attest lens meridian creates a normal ortho-k effect while the steepest merid-ian results in a greater ortho-k effect—leading to the correction of the corneal astigmatism. Other case reports used the same design, as did the fi rst studies on toric or-tho-k lenses for astigmatism.10,13,26

These studies demonstrated a 95% toric ortho-k fi rst lens fi t success rate in correcting low-to-moderate myopia in children with moder-ate-to-high astigmatism, which was better than the trial lens rate of 73.5%, as well as a reduction in the axial elongation amount.10,13

In another case report, of a 22-year-old patient presenting with -4.25 -3.75x8° OD and corne-al astigmatism of -3.10x7°, the authors fi t a reverse ortho-k lens with two toric zones: the reverse and the landing.16 The correction of high corneal astigmatism needs a perfectly closed reverse zone in each meridian to properly mod-ulate the hydrodynamic forces, allowing for separate corneal fl attening in each meridian. At two months post-treatment, the patient’s corneal astigmatism was largely reduced, and the subjective correction was cyl -0.50Dx8° with uncorrected visual acuity (VA) of 20/20.16

One case report used a hexa-curve (i.e., six back curves) design with two back toric zones, as well as optic and landing zones for a 44-year-old patient with mixed astigmatism in which the cylindrical component was great-er than the spherical, the patient presented with + 1.00 -2.00x180° OD and +1.25 -2.25x180° OS.27

The vertical meridian was steeper than the horizontal meridian in the midperipheral landing zone

and vice versa in the optical zone. Three months after ortho-k fi tting, the subjective correction was +0.50 -0.50x10° (uncorrected VA of 20/16) OD and +0.25 -1.00x5° (uncorrected VA 20/16) OS.

In a more recent case report, a 48-year-old female presented with -0.75 -2.50x170° add 1.50D OD and -1.50 -1.50x20° add 1.50D OS.28 Her best-corrected VA was 20/16 in both eyes. The patient’s cylindrical component was three times larger than the spherical component in the right eye, while the two were equal in the left eye. Also, she had refractive astigma-tism higher than corneal astigma-tism (i.e., -1.82D OD and -1.39D OS) and low eccentricity. The lens fi t was a tetracurve toric with optical, reverse and landing zones. According to the author, having the cylindrical component three times higher or equal to the spher-ical component and the refractive astigmatism greater than the corneal astigmatism was necessary for the toric optical zone. The toric reverse and alignment zones pro-moted the negative and hydrody-namic forces needed for treatment, better stability and centration of the lens.

While these reports are not conclusive, they do illustrate that various designs have proven useful for specifi c patients presenting with-the-rule, against-the-rule or

oblique in any axis astigmatism up to -4.00D. Additionally, they show that possibilities exist for correction of different corneal and refractive toricity, as well as lim-bus-to-limbus astigmatism.

Having a wide range of toric ortho-k lens designs available

expands the therapeutic options for the vast majority of patients. Practitioners can also design their own lenses, whether through contact lens fi tting simulations in free style upon the corneal map with topography; empirical fi tting software using keratometry and eccentricity through topography and refraction data; or download-able topography software.

Evidence suggests children and adolescents with astigmatisms up to 4.00D in all directions, even limbus-to-limbus, can benefi t from ortho-k and myopia control, as toric ortho-k lenses have proven to be effi cient in reducing mod-erate-to-high astigmatism and slowing axial elongation.22 RCCL

1. Holden BA, Fricke TR, Wilson DA, et al. Global prevalence of myopia and high myopia and tem-poral trends from 2000 through 2050. Ophthal-mology. 2016;123(5):1036-42. 2. Holden BA, Jong M, Davis S, et al. Nearly 1 bil-lion myopes at risk of myopia-related sight-threat-ening conditions by 2050 - time to act now. Clin Exp Optom. 2015;98:491-3.3. Walline JJ, Rah MJ, Jones LA. The children’s overnight orthokeratology investigation (COOKI) pilot study. Optom Vis Sci. 2004;81:407–13.4. Cho P, Cheung SW, Edwards M. The longitudinal orthokeratology research in children (LORIC) in Hong Kong: a pilot study on refractive changes

RESHAPING ORTHO-K

Figs. 2a and 2b. At left, a toric ortho-k lens on a toric cornea showing 360°

total touch in the landing zone. At right, the topography pattern of the same

lens shows a centered fl attening treatment zone.


and myopic control. Curr Eye Res. 2005;30:71–80.5. Kakita T, Hiraoka T, Oshika T. Infl uence of overnight orthokeratology on axial elongation in childhood myopia. Invest Ophthalmol Vis Sci. 2011;52:2170–4.6. Zhu MJ, Feng HY, He XG, et al. The control ef-fect of orthokeratology on axial length elongation in Chinese children with myopia. BMC Ophthalmol. 2014;14:141.7. Li SM, Kang MT, Wu SS, et al. Effi cacy, safety and acceptability of orthokeratology on slowing axial elongation in myopic children by meta-analy-sis. Curr Eye Res. 2016;14:600-8.8. He, M, Du, Y, Liu, Q, et al. Eff ects of orthoker-atology on the progression of low to moderate myopia in Chinese children. BMC Ophthalmology. 2016;16:126. 9. Young G, Sulley A, Hunt C. Prevalence of astig-matism in relation to soft contact lens fi tting. Eye Contact Lens. 2011 Jan;37(1):20–5. 10. Chen C, Cheung SW, Cho P. Myopic control using toric orthokeratology (TO-SEE study). Invest Opthalmol Vis Sci. 2013;54:6510–7.11. Luo M, Ma S, Liang N. Clinical effi cacy of toric orthokeratology in myopic adolescent with moderate to high astigmatism. Eye Sci. 2014 Dec;29(4):209-18.12. Ruston D, Van Der Worp E. Is ortho-k ok? Optometry Today. 2004 Dec;17:25-32.13. Chen CC, Cheung SW, Cho P. Toric orthokera-tology for highly astigmatic children. Optom Vis Sci. 2012;89:849-55.14. Mountford J, Pesudovs K. An analysis of the astigmatic changes induced by accelerated ortho-keratology. Clin Exp Optom. 2002;85:284–93.15. Cheung SW, Cho P, Chan B. Astigmatic changes in orthokeratology. Optom Vis Sci. 2009;86:1352–8.16. Baertschi M, Wyss M. Correction of high amounts of astigmatism through orthokeratology. A case report. J Optom. 2010;3:182-4.17. Chan B, Cho P, Cheung SW. Orthokeratology practice in children in a university clinic in Hong Kong. Clin Exp Optom. 2008;91:453–60.18. Chan B, Cho P, De Vecht A. Toric orthokeratol-ogy: a case report. Clin Exp Optom. 2009;92:387-91.19. Mountford J, Pesudovs K. An analysis of the astigmatic changes induced by accelerated ortho-keratology. Clin Exp Optom. 2002;85:284–93.20. Mountford J, ed. Orthokeratology: Principles and Practice. Oxford: Butterworth Heinemann; 2004;69–107.21. Pauné J, Gardona G, Quevedo L. Toric double reservoir contact lens in orthokeratology for astig-matism. Eye Contact Lens. 2012;38:245-51.22. Pauné J. From bowtie to casual: dealing with toric corneas in ortho-k. Lecture at GSLS, January 21-24, 2016; Las Vegas, NV.23. Kojima R, Caroline P, Morrison S, et al. Should all orthokeratology lenses be toric? Poster pre-sented at GSLS, January 21-24, 2016; Las Vegas, NV.24. Baertschi M. Short and long term success with correction of high astigmatism in OK. Lecture at the Global Orthokeratology Symposium, July 28-31, 2005; Chicago, IL.25. Beerten R, Christie C, Sprater N, Ludwig F. Improving orthokeratology results in astigmatism. Poster presented at the Global Orthokeratology Symposium, July 28–31, 2005, Chicago, IL.26. Chen C, Cho P. Toric orthokeratology for high myopic and astigmatic subjects for myopic con-trol. Clin Exp Optom. 2012;95:103–8.27. Calossi A. Mixed astigmatism treated with a dual-toric ortho-k design. Contact Lens Spectrum. 2013 Feb;28:49.28. Fadel D. Unusual clinical cases in orthokera-tology. Review of Cornea & Contact Lenses. Jun, 2016:22-27.

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NEW TECHNOLOGIES & TREATMENTS IN

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REVIEW OF OPTOMETRY® EDUCATIONAL MEETINGS OF CLINICAL EXCELLENCE


As eye care practi-tioners (ECPs), we are often faced with the question, “How old does my child need

to be before he can wear contact lenses?” Although answers to this question will vary, most doctors feel confi dent in fi tting children older than 10 in contact lenses. Younger children such as toddlers (from one to three years of age) can also be safely and successfully fi t in contact lenses when they are necessary to enhance visual function or provide therapeutic benefi ts. Important considerations when fi tting children in contact lenses include: the bene-fi ts of lenses for the child, the risks associated with fi tting the child in contact lenses and whether the child and parents are ready for contact lens wear. Although fi tting pediatric and adolescent patients in contact lenses seems intimidating, these patients are often less complex and more compliant than adult patients. Unpacking these considerations can boost your clinical knowledge and give you the confi dence to care for this patient population.

BENEFITS TO FITTING

PEDIATRIC PATIENTS

For the adult population, improved cosmesis is one of the most common reasons patients choose contact lenses over spectacles—and the same could be said about pediat-ric patients. The ACHIEVE study found children wearing contact lenses felt signifi cantly better about

themselves in the areas of athletic competence, social acceptance and physical appearance compared with study participants wearing spectacles.1 In children who are not compliant with spectacle wear because of cosmetic concerns, contact lenses can lead to an overall improvement in compliance with refractive correction. This is particularly important for children with signifi cant refractive errors, as contact lenses will increase the fi eld of view particularly well in patients with a high refractive error. Patients with corneal irregularities or high refractive errors may experience improved visual acuity and comfort with contact lenses. Children with signifi cant anisometropia benefi t from the decrease in aniseikonia with contact lens wear compared with spectacle wear, which not only decreases asthenopia, but also can improve binocularity.2

CONCERNS FOR CLINICIANS

One of the fi rst concerns that many practitioners have when fi tting children in contact lenses is the potential increase in chair time. Contrary to popular belief, fi tting a young child does not necessarily take more time than fi tting an older child or an adult. The Contact Lens In Pediatrics study found that it takes, on average, only 15 more minutes to fi t children age eight to 12 compared with children older than 12.3 Most of this extra time was spent on insertion and removal training, a task that can generally

be delegated to staff members. Another notable concern clinicians have in fi tting children—particular-ly younger ones—in contact lenses is the risk of an adverse event. However, younger children are ac-tually less likely to have an adverse event during contact lens wear than teenagers and young adults, and microbial keratitis is uncommon in this population.4

READY OR NOT

(TO WEAR CONTACTS)

Determining if a child is ready for contact lens wear is one of the most challenging parts of the fi tting process. Although most parents ask at what age we begin fi tting contact lenses, the patient’s age is generally not the limiting factor. The pediatric population is not homogeneous, and each patient must be treated individually. While some children as young as seven may prove ready for contact lens wear, some adolescents are not good candidates.

Often to the caregiver’s surprise,

ABOUT THE AUTHORS

Dr. Jenewein completed a

residency in pediatrics and

binocular vision at Nova

Southeastern University.

She is an assistant

professor at Salus University

Pennsylvania College of

Optometry.

Dr. Bhagat is a faculty member

at the Pennsylvania College

of Optometry at Salus

University. She specializes

in managing ocular surface

disease and fi tting specialty

contact lenses.

Keys to a

Soft Lens FittingPediatric


the best resource for answering the question of a child’s readiness is the parents or guardians themselves. Questioning parents about the overall responsibility level of the child will help to deter-mine if the child is ready for the responsibility of contact lens wear. Are they able to take respon-sibility for homework or chores at home? Does the child make their bed every morning and keep a clean room? Will they re-member to remove the lenses before bed every night and clean them properly? The parent can also give insight into the child’s personal hy-giene, which can impact their ability to properly care for contact lenses.

Both patient and parent motiva-tion is essential to successful lens wear in pediatric patients. If a child is reluctant to wear lenses, it can be challenging to successfully fi t them in contact lenses. Similarly, if a par-ent is reluctant to allow a child to wear lenses, it may be an indication the parent realizes the child is not ready for contact lens wear.

SPECIAL INDICATIONS

Some pediatric patients who may not be ideal candidates for contact lens wear may, nevertheless, need to be fi t in contact lenses to improve vision, comfort or binocularity. The overwhelming benefi ts of contact lenses over spectacles in these pa-tients may make contact lens wear

the best option for the pediatric pa-tient, regardless of the patient’s age. In these cases, parental motivation and support is the key to successful contact lens wear. Children who are aphakic—either from congenital aphakia or from cataract removal at an early age—are often fi t in contact lenses as infants or toddlers. Infants and toddlers with extremely high refractive error or high amounts of anisometropia may benefi t from contact lens wear to improve acuity and binocularity.

Contact lenses can also be used for penalization therapy in amblyo-

pia, either by overplussing the non-amblyopic eye to cause blur signifi cant enough to switch fi xa-tion to the amblyopic eye or using a lens with an opaque pupil to occlude the non-amblyopic eye. When using the plus therapy, the lens-induced blur must be greater than the blur experienced by the amblyopic eye.6

Additionally, tinted lenses can be fi t for patients with achroma-topsia or other cone dystrophies to decrease photophobia and enhance color perception. Patients with achromatopsia often prefer red, magenta or brown lenses in lieu of wearing tinted spectacles. Although the contact lens tint can be seen under the slit lamp, it is not detect-able under normal viewing condi-tions, providing a more cosmetically appealing option. Colored lenses can decrease photophobia, improve vision and provide better cosmesis for patients with iris abnormalities such as iris coloboma and aniridia.

Pediatric patients with corneal irregularities may experience better vision as well as increased comfort with contact lenses.

CHOOSING THE RIGHT LENS

Options for fi tting children in con-tact lenses are similar to those with any other age group. Soft lenses are the most commonly used modality for general refractive cases such as myopia, hyperopia and regular

By Erin C. Jenewein, OD, MS, and Kriti Bhagat, OD

From infancy to adolescence, contact lenses prove a viable and benefi cial treatment option for a range of conditions.

At left, a custom prosthetic lens decreases the amount

of light entering the pupil and the cosmetic appearance

of the iris irregularity. At right, an inferior iris coloboma

causes increased light sensitivity and haloes around

objects.

During a prostehtic lens fi tting,

contact lenses can be layered to

show the patient how the fi nal

product may look. Here is an

occluded pupil contact lens with a

brown underprint layered on top.


astigmatism. Many manufacturers offer extended range parameters for patients with high amounts of myopia and hyperopia, keeping the overall cost to a minimum for the patient and avoiding the need to switch to custom soft lenses.

Daily lenses decrease the likeli-hood of contact lens-related adverse events. Daily disposables can also be easier for children to handle, eliminating the need for cases and solution bottles.5

Children with aphakia, signifi cant corneal cylinder, irregular corneas or ocular surface disease can be fi t with rigid gas permeable lenses, including scleral lenses. When fi tting rigid lenses in children, it may be benefi cial to use a Burton lamp or a Bluminator for lens evaluation out-side of the slit lamp. This allows the child to sit comfortably in a stroller or parent’s lap during the lens eval-uation. Prosthetic contact lenses are an option for children with iris or corneal irregularities. These lenses can help decrease photophobia, diplopia or improve cosmesis.

INSERTION AND REMOVAL

Training in the pediatric population can be slightly more challenging than in adult patients. Parents or

guardians should be present to listen to the instructions given to the pediatric patient so the parent also learns about proper contact lens care in case they need to assist the child. This is crucial for children too young to insert and remove the lens-es themselves, as the parent will be handling this process for the child.

With every new pediatric patient, there is always an insertion and re-moval training in-offi ce. For parents of infants and toddlers, clinicians should stress the importance of hav-ing a secure hold of the infant’s head and body. Many times, this becomes a two-person effort, as one person holds the infant while the other inserts or removes the contact lens.

For children able to insert and re-move lenses on their own, clinicians should begin by emphasizing the need to wash your hands before in-sertion and removal. Generally, the practitioner places the lenses fi rst, so the child will have the lenses in during the fi tting process. Therefore, training will entail teaching removal skills fi rst, followed by lens storage and ending with insertion tech-niques. It is important to guide the child the fi rst time to help increase confi dence and then let them do it on their own. This will show them they can do it and indicate they may be ready to take the lens home.

Clinicians should watch the child insert and remove the lenses at least twice before dispensing. This ensures patient and parent have the proper technique and are comfort-able with the lenses. If the fi rst train-ing is unsuccessful, stop before the patient and parent become frustrat-ed and have them return to attempt training on a different day.

Laying a towel over the sink drain can help young patients avoid losing lenses, and labeling solution bottles and contact lens boxes and cases carefully can avoid misusing the solution or wearing incorrect lenses.

COMPLIANCE

Children are more likely to share their lenses with friends, so it is important to educate them that they cannot do so with anyone else or allow anyone try their lenses on. As with any medical device, compliance is always an issue. A handout that details how lenses are to be worn and the proper care method can help with this. Written instructions that includes the solution names, replacement schedules, wearing time and signs and symptoms of com-mon complications can be extremely helpful. Regardless of age, clinicians should also warn against swimming in lenses, and stress the need to always rub the lenses with solutions, store them with new solution each night and replace the case every three months.

Many pediatric patients can easily and safely use contact

lenses, even young children, with proper oversight. Contact lenses can provide improved confi dence, better visual acuity, higher levels of comfort and better potential for bin-ocular vision in pediatric patients. Although fi tting young children can be intimidating at fi rst, it can be equally rewarding for both the patient and practitioner. RCCL

1. Walline J, Jones L, Sinnott L, et al. Randomized trial of the eff ect of contact lens wear on self-per-ception in children. Optometry and Vision Science. 2009;86(3):222-32.2. Winn B, Acherley RG, Brown CA, et al. Reduced aniseikonia in axial anisometropia with contact lens correction. Ophthalmic Physiological Optics. 1988;8(3): 341-4.3. Walline, J, Jones L, Rah M, et al. Contact lenses in pediatrics (CLIP) Study: chair time and ocular health. Optometry and Vision Science. 2007;84(9):896-902.4. Wagner H, Richdale K, Mitchell G, et al. Age, behavior, environment, and health factors in the soft contact lens risk survey. Optometry and Vision Science. 2014;91(3):252-61.5. Chalmers RL, Hickson-Curren SB, Keay L, et al. Rates of adverse events with hydrogel and silicone hydrogel daily disposable lenses in a large postmar-ket surveillance registry: the TEMPO Registry. Invest Ophthalmol Vis Sci. 2015;56(1):654-63.6. Walline J, Rah M. Contact lenses for amblyopia Treatment. Contact Lens Spectrum. 2008. Available at www.clspectrum.com/issues/2008/novem-ber-2008/treatment-plan. Accessed January 17, 2017.

Even with a lighter iris, it’s hard to

tell a patient is wearing a tinted

contact lens, which help avoid the

use of red glasses.

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By Robert Ensley, OD, and Heidi Miller, OD

The GP Experts

This lens modality is a great alternative to soft contact lens correction.

Treating Infantile Aphakia: Think GPs

Too steep a fi t results in inferior

decentration and accummulation of

bubbles underneath the lens.

This well-centered GP lens shows

good apical alignment.

Photo: V

iola Kanevsky, O

D

Photo: V

iola Kanevsky, O

D

Although it may not seem common, the prevalence of congen-ital cataracts ranges from one to 15 per

10,000 children.1 Approximately one-third of congenital cataracts are inherited, while the remaining causes are associated with in uterodrug reactions, systemic diseases such as rubella and measles or idiopathic.1 In addition to obstruct-ing vision, congenital cataracts may cause other complications including pediatric glaucoma and strabismus.2

For at-risk patients, cataract surgery is indicated; however, there is some uncertainty regarding the best age to perform the surgery. Generally, cata-ract extraction should be performed around six weeks of age for unilat-eral cataracts and between six and eight weeks for bilateral cataracts with a one- to two-week period between surgeries for each eye.3

Post cataract surgery, eye care providers face the challenge of fi nd-ing the proper refractive correction to reduce the risk of amblyopia. If suffi cient capsular support is present, intraocular lens (IOL) implantation can be performed once the patient is two years of

age.4 However, contact lenses can be fi t on infants and may even be a preferable long-term option. The Infant Aphakia Treatment Study Contact Lens Experience, which compared contact lens correction for unilateral aphakia with IOL implantation for children between one and six months of age, showed visual acuity outcomes were similar at age one and four and a half.4 The rate of adverse events was lower in the study’s contact lens wearers, and few patients in that group required additional intraocular procedures.4

These outcomes demonstrate that contact lenses are a viable option for managing aphakia—and rushing into IOL implantation is not always the right answer for patients who are less than ideal candidates.

CHOOSING A LENS

Silicone elastomer soft contact lenses are commonly used in the early treatment of aphakia; how-ever, they present challenges that may be exacerbated when treating the pediatric population: (1) while highly permeable to oxygen, they are prone to surface deposits, (2) limited power and fi tting parame-ters can make it diffi cult to properly manage a patient and (3) fi nancial costs associated with contact lens replacement, either due to power changes or lens loss, can result in poor compliance and follow up.

Gas permeable (GP) lenses are a great resource for managing aphakic infants. Due to infants’ small corne-al diameter and narrow lid fi ssures, they can easily tuck underneath the taut lids and stay in place.5 They are available in a wide range of prescriptions and can be custom-

ized to the desired power and base curve. They are durable and simple to handle, often making it easier on parents to insert and remove.

Although GP lenses provide the least incidence for microbial kera-titis, lens loss and ocular irritation tend to be the most common issues with this lens material.5,6

FITTING GPs FOR APHAKIA

Because most patients are initially examined under anesthesia, corneal measurements, keratometry values and a refraction by retinoscopy should be available prior to the contact lens fi tting appointment. When fi tting a patient in GP lenses, clinicians should select a base curve that is 1mm to 1.5mm steeper than the fl attest keratometry read-ing—a value based off the Infantile Aphakia Treatment Study Protocol.8

Evaluating the fl uorescein pattern may lead to a change in base curve. The overall lens diameter is usually 10mm or larger, although this can vary depending on the patient’s corneal diameter. The optimal fi tting lens displays a well centered align-ment fi t, with adequate edge clear-ance evidenced by an approximately 1mm band of fl uorescein around the lens edge.7 Topical anesthetics to facilitate the contact lens fi tting evaluation, and during insertion


A two-month-old female patient was referred for a contact lens evaluation following cataract extraction. The patient presented wearing a Silsoft Super Plus (Bausch + Lomb) 7.5 base curve, 11.3 overall diameter (OAD) and +32.00D power—inserted by her cataract surgeon for extended wear until she could be seen by a specialty contact lens fi tting optometrist.

At the fi rst contact lens visit, retinoscopy showed a +4.50D over-refraction. Examining the contact lens fi t using a 20D lens and transilluminator revealed adequate centration, good movement and full corneal coverage. Although an adequate fi t, the Silsoft contact lens has a maximum power of +32.00D, and a GP contact lens was considered in the near future.

The parents were trained on insertion and removal of the soft contact lens and advised to remove the lens each night and clean it with a hydrogen peroxide solution. An online video on insertion and removal was recommended in case at-home review was necessary. A multipurpose solution safe for immediate contact with the eye was also dispensed in the event the lens required immediate cleaning.

RECHECK

Two weeks later, during the recheck, retinoscopy revealed an over-refraction of +3.75D. Examination demonstrated good centration and movement of the contact lens. Because the patient needed additional plus power, a GP contact lens fi tting was initiated.

The initial lens trialed was a 6.75 base curve, 8.5 OAD and +20.00D. Examination using a blue light

demonstrated a steep fi t with bubbles and poor centration. Flatter diagnostic lenses were trialed until an apical alignment or minimal apical clearance pattern was evident. Over-refraction was completed and the new power was determined by adding an additional +3D to ensure the patient was left 3D myopic. A larger OAD lens was ordered, along with a larger optic zone to maintain alignment pattern and improve centration. The new lens parameters were 7.34 base curve, 9.20 OAD and +40.00D.

DISPENSING

On the dispensing visit, the lens was slightly too steep and was decentering temporally. A few modifi cations to the base curve assisted with centration and overall fi t. The parents were trained on GP insertion and removal, and hydrogen peroxide solution was recommended for lens care. Once the lens was fi nalized, a spare lens was ordered and dispensed as well. The patient was followed every one to two months initially, then by three-month intervals once lens changes became less frequent. She was routinely seen by the pediatric ophthalmologist and prescribed aggressive occlusive therapy for amblyopia management.

At age two, the patient returned for a contact lens evaluation. The lens power was modifi ed to correct for distance, and overlay polycarbonate unilateral bifocals were prescribed for full-time wear. The patient was seen every three months until age three, then followed every three to six months.

CASE EXAMPLE

(Continued on page 37)

and removal training are typically not required, because the child’s fear is usually what makes these fi ts diffi cult, not lens awareness.8

Once clinicians determine the appropriate cornea-to-lens relation-ship, they can refi ne lens powers by retinoscopy over the diagnostic lens. In children under the age of two, 2D to 3D of additional plus are added to the lens to provide clear near vision. Spare lenses should be pro-

vided in the event the contact lens is lost to allow continued optical correction to prevent amblyopia.8

CORRECTION AFTER TWO

Bifocal lenses are prescribed for the child around age two, when the added power of over-plussed lenses begins to interfere with distance viewing.8 Often, the GP lens is made for full distance correction, and the clinician then prescribes over-

lay bifocal spectacles with a +3.00 add power. Choosing bilateral or unilateral bifocals is often left to the clinician’s preference.

Generally speaking, if a patient has unilateral aphakia, unilateral bifocals are prescribed to allow the phakic eye to accommodate freely without creating unnecessary blur. Progressive lenses can also be used if the patient has bilateral aphakia.


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

Pharma Science & Practice

Corneal collagen cross-linking (CXL) is quick-ly becoming a fi rst-line approach for managing progressive keratoco-

nus in adults, accelerated by the FDA’s approval of the Avedro sys-tem in early 2016 for patients older than 14. CXL photosensitizes the collagen of the corneal stroma and increases its biomechanical rigidity, thus halting or possibly reversing the progression of keratoconus.

But adults aren’t the only ones in need of treatment. A retrospective study to determine the incidence and presentation of pediatric ker-atoconus (younger than 14) found that over a fi ve-year period, 541 of 2,972 patients were diagnosed with keratoconus—an incidence of 0.53%, representing 2.96% of all cases diagnosed during that time.1

In comparison, the incidence in the adult population is 3.78%.1

Because studies evaluating the effi cacy of CXL have focused on adults, the incidence and severity of keratoconus in children is poorly understood, as is the potential role for CXL in the pediatric population.

PEDIATRIC CHALLENGES

Treating children presents a number of unique challenges. Most man-agement strategies successful with adults, such as specialty contact lenses, are less so with children, given complications such as diffi cul-ty with wear and care compliance and poor outcomes with corneal transplantation.2,3 Keratoconus in

children is often associated with vernal keratoconjunctivitis and eye rubbing, which can lead to hydrops, so care must be taken to quell the surface infl ammation with topical anti-allergy and steroid drops.4

Additionally, keratoconus in children tends to be more severe at initial presentation and progresses more quickly than in newly diag-nosed adult patients.5 A retrospec-tive study of 49 patients younger than 15 and 167 older than 27 with keratoconus at initial presentation found the disease was more severe at diagnosis in subjects in the fi rst group: 27.8% were already at stage 4 using Krumeich’s classifi -cation, as compared with 7.8% of adult subjects.5 Stage 4 includes non-measurable refraction; mean central keratometry readings >55 diopters; central corneal scarring and a minimum corneal thickness of 200µm.The younger subjects also had more advanced slit lamp signs and keratometry readings.5

CXL IN KIDS: THE LITERATURE

Given the diffi culties in fi tting the pediatric population with contact lenses and the greater propensity for full thickness corneal graft rejection, CXL could be the answer, as pre-liminary studies indicate it stabilizes the disease process and reduces the need for keratoplasties. So far, three studies have evaluated the effi cacy of CXL—with a standard epi-off treatment—and the progression of keratoconus in the pediatric popula-tion. Patients were pretreated with

topical anesthesia and removal of the corneal epithelium, followed by a soak of 0.1% ribofl avin/20% dextran solution (varied from 10 to 30 minutes) and then 30 minutes of UVA irradiation (six times for fi ve minutes each), with instillation of ribofl avin/dextran every fi ve minutes. Post-procedure, antibiotic and cycloplegic drops were instilled, along with a ban-dage contact lens. Some children required general anesthesia, while others required only topical.6-8

One study evaluated patients age 10 to18, divided into two groups by corneal thickness: less than 450µm and greater than 450µm.6 At 36 months post-CXL treatment, no ad-verse events were reported and both groups showed an improvement in uncorrected Snellen visual acuity (VA), topography and coma. There was a faster functional response in patients with thinner corneas.

Another study evaluated the re-fractive, topographic, aberrometric and tomographic results in patients ages nine to 18 for up to two years.7

There was a slow but continuous improvement of most of the indices up to 24 months after surgery, with no adverse events noted.

Finally, a study evaluating pa-tients age nine to 19 for progression of keratoconus and the effi cacy of CXL up to three years postopera-tively found 88% exhibited progres-sion (an increase in the maximum keratometry of at least 1.00D over a one-year period).7 The researchers analyzed maximum keratometry

Corneal Collagen Crosslinking:Not Just for AdultsTreatment plans for pediatric patients with keratoconus may get an upgrade soon with this newly approved technology.


values, corrected distance VA, cor-neal thickness and the keratoconic index. They found the maximum keratometry value was reduced by three months and remained for up to 24 months. However, at 24 months, it began to show progres-sion, suggesting pediatric corneas do not allow for long-term improve-ment, although the best-corrected

distance VA continued to be better than pre-CXL.8

One study performed transepi-thelial (epi-on) CXL on 13 eyes in patients ages eight to 18.9 While the procedure was safe, well tolerated and the corrected distance visual acuity was improved at 18 months of follow-up, it did not halt the pro-gression of keratoconus as seen with the standard epi-off treatment.9

This research suggests keratoco-nus in pediatric patients is more

severe and progresses more quickly than in adults, and standard CXL is safe and effective, although perhaps more transient, in patients younger than 18.

More studies with longer follow up are needed, but it appears CXL can be seriously considered in our

treatment of keratoconus for pa-tients as young as 14. RCCL

1. el-Khory S, Abdelmassih Y, Hamade A, et al. Pediatric keratoconus in a tertiary referral center: incidence, presentation, risk factors and treatment. J refract Surg. 2016;32(8):534-41.2. Vanathi M, Panda V, Vengayil S, et al. Pediatric keratoplasty. Surv Ophthalmol. 2009;54:245-71. 3. Lowe MT, Keane MC, Coster DJ, Williams KA. The outcome of corneal transplantation in infants, chil-dren and adolescents. Ophthalmology. 2011;118:492-7. 4. Rehaney U, Reumelt S. Corneal hydrops associat-ed with vernal keratoconjunctivitis as a presenting sign of keratoconus in children. Ophthalmology. 1995:1021(12):2046-9.5. Leoni-Mesplie S, Moortemousque B, Touboul D, et al. Scalability and severity of keratoconus in children. Am J Ophthalmol. 2012;154:56-62.6. Caporossi A, Mazzotta C, Baiocchi S, et al. Ribo-fl avin-UVA-induced corneal collagen crosslinking in pediatric patients. Cornea. 2012;31(3):227-31.7. Vinciguerra P, Albé E, Frueh BE, et al. Two-year corneal cross-linking results in patients younger than 18 years with documented progressive kerato-conus. Am J Ophthalmol. 2012 Sep;154(3):520-6.8. Chatzis N, Hafezi F. Progression of keratoconus and effi cacy of pediatric corneal collagen crosslink-ing. J Refract Surg. 2012 Nov;28(11):753-8.9. Buzzonetti L, Petrocelli G. Transepithelial corneal cross-linking in pediatric patients: early results. J Refract Surg. 2012 Nov;28(11):763-7.

A Fleischer ring, as seen in some

keratoconus patients.

FOLLOW UP

Close follow up is imperative for success with GP contact lenses in managing infantile aphakia. The corneal radius and diameter rapidly change during infancy, resulting in several lens changes throughout the fi rst year.

Questions regarding photopho-bia, irritation, excessive blinking, redness or discharge should to be addressed at each visit. Contact lens wearing time should be gradually increased starting with a few hours initially until wear time during all waking hours is achieved.

Noncompliance is one of the biggest problems with aphakic

management. Loss of contact lenses, poor fi t and cost of lenses are some reasons for noncompliance in pedi-atric patients.

Although managing aphakia can be challenging, clinicians should consider GP lenses due to their continued success in visual rehabili-tation. RCCL

1. Foster A, Gilbert C, Rahi J. Epidemiology of cat-aract in childhood: a global perspective. J Cataract Refract Surg. 1997;23 Suppl 1:601-604.2. Lim ME, Buckley EG, Prakalapakorn SG. Update on congenital cataract surgery management. Curr Opin Ophthalmol. Jan 2017;28(1):87-92.

3. Lambert SR. The timing of surgery for congenital cataracts: Minimizing the risk of glaucoma following cataract surgery while optimizing the visual out-come. Journal of AAPOS : the offi cial publication of the American Association for Pediatric Ophthalmol-ogy and Strabismus. Jun 2016;20(3):191-192.4. Russell B, DuBois L, Lynn M, Ward MA, Lambert SR, Infant Aphakia Treatment Study G. The Infant Aphakia Treatment Study Contact Lens Experience to Age of 5 Years. Eye Contact Lens. Jul 27 2016.5. Baradaran-Rafi i A, Shirzadeh E, Eslani M, Akbari M. Optical correction of aphakia in children. Journal of ophthalmic & vision research. Jan 2014;9(1):71-82.6. Liesegang TJ. Contact lens-related microbi-al keratitis: Part I: Epidemiology. Cornea. Mar 1997;16(2):125-131.7. Amos CF, Lambert SR, Ward MA. Rigid gas per-meable contact lens correction of aphakia following congenital cataract removal during infancy. Journal of pediatric ophthalmology and strabismus. Jul-Aug 1992;29(4):243-245.8. Wilson ME, Rupal H. Trivedi , Suresh K. Pandey. Pediatric cataract surgery: techniques, compli-cations, and management. Lippincott Williams & Wilkins; 2005.

THE GP EXPERTS: TREATING INFANTILE APHAKIA: THINK GPS (Continued from page 35)

By Aaron Bronner, OD

Corneal Consult


Learning to recognize the processes that govern corneal health and function will allow you to gain a deeper understanding of pathologies and their treatments.

A New Year, a New Look at the Cornea

Imagine a new patient presenting to your offi ce with a painful eye and profoundly reduced acuity. There is no infi ltrate, but the cornea appears hazy, perhaps

edematous, though it’s diffi cult to tell. What would your working diagnosis be? What happens to your diagnosis if the patient is an extend-ed wear contact lens user? What if they qualify their pain as superfi cial, or deep? What if they had a corneal transplant to this eye six months, or even 20 years, ago? What if they had a transplant, but to the fellow eye? Finally, what happens if your original treatment fails?

These situations come up period-ically in my clinic and each subtle variation in history should generate a separate primary differential and treatment. Transitioning smoothly among these differentials, being able to separate the important clinical fi nding or historic element from the red herring, is key to effectively managing these patients.

Welcome to my fi rst edition of Corneal Consult, a column in which I hope to explore the diagnostic and therapeutic challenges we face when dealing with corneal pathology and provide real-world, clinically useful practice pearls each edition.

In my fi rst column, I’d like to introduce myself and share my background, training and current clinic environment, as well my future goals for this column.

MY CLINICAL WORLD

Most of you (statistically, it’s closer to “all of you”) don’t know me. I’m Aaron Bronner, an optometrist working in the Kennewick, Wash.,

offi ce for Pacifi c Cataract and Laser Institute (PCLI), a multicenter, co-management group.

PCLI was one of the fi rst coman-agement groups in the nation and was one of the earliest to perform Medicare-approved outpatient cata-ract surgery. Our mission statement is to provide the best care possible to our optometric referral network, and we deal exclusively with refer-ral-based care.

At my facility, beyond the stan-dard menu of cataract and refractive surgeries, we provide surgical and medical corneal care for a large part of Eastern Washington and Oregon. In addition to the 100 or so great ODs I work with indirectly through comanagement, I work directly with two skilled optometrists, Brian Johnson and Bruce Flint, and fi ve gifted, gracious ophthalmologists, Jim Guzek, Jason Leng, Loren Seery, Ron Sugiyama and Marshall Ford—they all bear mentioning because they are, unwittingly, contributors to this column. (Thanks, guys!)

At PCLI, ODs maintain some level of involvement at all levels of perioperative and medical care—even in very complex medical cases, we stay involved with clinical de-cision making and will collaborate with our MDs rather than simply referring to our MDs for consulta-tive services. It’s an exciting, some-times stressful, way to practice and provides a phenomenal opportunity to continue learning. I hope to draw on this experience and make this column as useful to the readers as possible. In addition to clinical responsibilities, I also teach residents though the Jonathan Wainwright

VAMC clinic in Walla Walla, Wash., and you’ll be reading about them from time to time.

MY INTERESTS

I became interested in both cor-neal care and teaching during my residency, which was performed at Davis Duehr Dean Eye Care in Madison, Wis., about 10 years ago. During my residency, I rotated through some amazing ophthalmo-logic clinics; I spent about half of my time in the cornea clinic of Chris Croasdale, MD. During this time, I realized that, despite my training, I was a fi sh out of water with com-plex surgical or severe corneal dis-ease cases—they were so far outside my experience I couldn’t formulate effective diagnoses or treatments.

After taking a mental accounting of how and why I was struggling, my initial step to remedying the situ-ation was to observe Dr. Croasdale’s approach to clinical problems. First of all, he just knew way more than me. Given where I was in my career path, and where he was in his, there was nothing I could do about this gap—research and continued learning were the only tools I could use to help narrow that difference to a more acceptable margin.

But there was one area I could address immediately: the stark difference in how we mentally approached cases. He employed what I’d call a process-driven ap-proach, while I, at the time, used a results-driven approach.

MY FIRST PRACTICE SHIFT

My results-driven approach to clinical cases was perfected by four


years of optometry school and its incumbent testing. I had learned to assess each fi nding not as a process taking place within the eye, but only as a piece of a puzzle that, once put together, led to a diagnosis—fi nding X is tied to diagnosis Y. In essence, I simply memorized a large num-ber of fi ndings and their respective diagnoses, and if a case I encoun-tered showed enough associated fi ndings, I would have a diagno-sis. At its root, this results-driven approach was not based on any actual understanding of pathologic and physiologic processes, but on memorization. Perhaps this was less elegant, clinically, than an in-depth understanding of pathophysiology, but it was effective much of the time and was adequate during school.

Dr. Croasdale, however, ap-proached cases quite differently. Rather than focusing exclusively on a fi nding tied to a diagnosis, his process-driven strategy emphasized what pathologic and physiologic process the fi nding represented within the eye.

This was a revolutionary discov-ery for me. By shifting from my own memorization-based approach to Dr. Croasdale’s process-driven ap-proach, I focused on understanding the processes taking place and real-ized a deeper understanding of the pathology and the appropriate diag-noses, which was particularly useful for cases that weren’t textbook.

Though both of these approaches work when a clinician is familiar with the underlying diagnosis, the results-driven approach breaks down immediately when faced with an unfamiliar constellation of fi nd-ings on non-textbook presentations.

With no diagnosis tethered to these unfamiliar fi ndings, an accurate diagnosis is impossible; a fi nding without a linked diagnosis becomes meaningless or, worse, confusing. Unusual cases demand clinicians interpret a series of often unfamiliar fi ndings and assimilate them into a useful differential based on the processes taking place in the eye.

Once I realized this fl aw, I sought, during my residency (and during my career), to better understand the dis-ease processes encountered in clin-ical practice. The tricky thing with learning in a postgraduate setting is that you never know what you didn’t know until you know it. For you to realize a gap in your knowl-edge base, someone who knows more has to point it out. I’ve tried to get around this limitation with literature research, practicing in a challenging clinical setting where I am routinely exposed to new things and, most importantly, collaborat-ing with more experienced ODs and MDs (in addition to those already named, I’d be remiss if I didn’t mention Walt Whitley, OD, Doug Devries, OD, James Adamek, OD, and Jeff Urness, OD, as profession-als from whom I’ve directly drawn a lot of information).

MY COLUMN GOALS

I have two goals for this column. First, I hope to share some of these diagnostic and therapeutic associa-tions and hopefully help you, too, realize a deeper understanding of what is actually taking place in cor-neal pathologies and their respective treatments. I believe understanding mechanisms involved will encour-age a process-driven approach and benefi t you in clinic.

Second, I’d like to revisit some of the vast corneal fi ndings we learn about in our training. The nature of our optometric education requires us to assimilate so much infor-mation so rapidly that it becomes impossible to assign the appropriate context to register all of it in our long-term memory. I hope to re-ex-plore some of these fi ndings and help assign more clinical relevance to them to allow better recall.

It takes a certain amount of ego to think you can offer to teach a similarly credentialed group of colleagues, and academic lecturing is not my intention in these pages. A smart person once told me that “study is a means to an end, it isn’t the end itself.” As ODs, academic knowledge supports clinical prac-tice, not the other way around. So while occasionally the column may delve into academics, I will always attempt to tie it back into a concept with clinical value. Each of the con-cepts I will discuss started as some-thing I was initially unaware of, and upon learning the concept, felt it helped shape my clinical thinking.

I enjoy presenting information in a new manner, and I hope you enjoy the column and learn as much from my experiences as I have. Cheers! RCCL

The Bronner family—Aaron and

Becky, Zoë and Liam—enjoying

Disneyland at Academy 2016.


By Mile Brujic, OD, and David Kading, OD

Practice Progress

Daily disposable lenses have revolutionized our patient care. Not only do our current contact lens wearers benefi t

from daily disposable lens, but also those new to contact lenses or those who are interested in wearing them on a part-time basis. Other than dai-ly replacement, there are a number of other indications when dailies may be appropriate, including:

Solution sensitivity. Individuals wearing a frequent replacement lens not approved for extended wear re-quire multipurpose disinfecting solu-tions to care for their lenses. Some individuals may experience solution sensitivities over time.1,2,3 Removing care solutions by prescribing daily disposable lenses will often alleviate the signs and symptoms associated with solution sensitivity.

Compliance issues. Research demonstrates a clear link between noncompliance with manufactur-ers’ recommended replacement frequency (a common problem with frequent replacement lens wearers) and a degradation in contact lens comfort levels.4,5

In addition, studies show most individuals do not clean and replace their storage solution appropriate-ly.6-8 Daily disposables help avoid these challenges, as cleaning and storage are not required.9 Further, at least one study shows daily dis-posable lens wearers are the most compliant of all lens wearers.10

Medical history. Certain medical conditions such as seasonal allergic conjunctivitis warrant consid-eration for daily disposable lens

wear.11 After treating the underlying condition, daily disposable lenses are a benefi cial option, considering allergens and other immune com-plexes commonly seen in the tears of allergy sufferers will be disposed of at the end of the day.12,13

Giant papillary conjunctivitis (GPC), in particular, is a much more chronic form of allergy that usually requires more aggressive medical therapy. GPC is typically caused by excessive deposition on contact lens surfaces, causing an immunological response of the conjunctival tissue and leading to “giant papillae.”14,15

These cases often warrant tem-porary discontinuation of contact lenses and topical corticosteroid therapy.16 Although lens wear can continue after the response is controlled, the cleanest surface will ultimately provide the best patient outcomes and the least likelihood of recurrence.

NEW TECHNOLOGIES

With so many advantages to daily disposable lens wear, it is no won-der that we are more frequently reaching for this modality with our contact lens wearers. Limited parameter availability has tradi-tionally hindered our ability to fi t a number of our contact lens wearers for daily disposable lenses. But, in the last several years, contact lens manufacturers have introduced a variety of technologies that allow our patients to have an enhanced daily disposable lens wearing experi-ence through new materials and the availability of multifocal and toric contact lens options.

The availability of toric contact lens options in a daily disposable modality is critical when fi tting the contact lens neophyte, including pediatric patients. One study dis-proved the preconceived notion that patients younger than 13 cannot wear contact lenses.17 The advent of daily disposable astigmatic designs offers more individuals the comfort and convenience our spherical lens wearers currently enjoy.

ASTIGMATISM

Healthy ocular fi ndings, high moti-vation and maturity are the markers of a good pediatric candidate for astigmatic correction though con-tact lenses. These daily disposable astigmatism correcting contact lens-es are well suited for any individuals requiring astigmatic correction, especially children:

• 1-Day Acuvue Moist for Astigmatism (Johnson & Johnson Vision Care). This lens material is the same technology in the 1-Day Acuvue Moist spherical lens: etafi l-con A and 58% water.18 It provides stability through a blink stabilized design based on a dual thin zone,

More patients than you might think can benefi t from this contact lens modality.

Daily Disposables: Eff ective From Allergy to Astigmatism

Fig. 1. Small mark located at the

six o’clock position as seen in most

lenses for astigmatism.


along with additional stabilization factors that interact with both the upper and lower lid. The orienta-tion markers are located at the six and 12 o’clock position (Figure 1). Notably, there is no fear of placing this lens upside down on the eye; either orientation will feel identical to the patient and provide the same visual experience.

• Biotrue OneDay for Astigmatism (Bausch + Lomb). This lens is made of the same material as its spherical predecessor, the Biotrue OneDay lens: nesofi lcon A and 78% water content. It contains polyvinylpyrrolidone (PVP) that fa-cilitates the high water content and poloxamer 407, which helps retain moisture and prevent dehydration on the lens. The lens is stabilized on the eye with a peri-ballast design and has a light blue visibility tint. The orientation marker on this lens is located at the six o’clock position and is easily seen at the slit lamp. A fi ne laser-etched mark indicates the axis of the lens.19

• Clariti 1 Day Toric (Cooper Vision): This lens is a silicone hy-drogel daily disposable made of so-mofi lcon A and is 56% water. The material is the same as that in the Clariti 1 Day sphere and multifocal lens.20 The modulus of the lens is relatively low for a silicone hydrogel lens, which makes it feel similar to a hydrogel when handling the it. The stability of the lens is created through a prism ballast design in ad-dition to a back surface toric profi le. The orientation marker is located at the six o’clock position, making it easily visible at the slit lamp.

• Dailies AquaComfort Plus Toric (Alcon). This lens is made of

nelfi lcon A and is 69% water, the same as the Dailies AquaComfort Plus sphere and multifocal lenses. This lens contains hydroxypropyl methylcellulose, which aids in initial comfort. Additionally, moisturizing agents polyvinyl alcohol and poly-ethylene glycol are released from the lens throughout the day.21 The lens is stabilized through a dual thin zone along with a back surface toric design with scribe marks located at the three and nine o’clock positions. There is also an “OK” inversion indicator on the lens (Figure 2). The back of the “K,” located 90 degrees from the horizontal meridian, can be used as an indicator of rotation.

With the growing number of daily disposable toric lens op-

tions, we can provide more patients than ever with the benefi ts they bring, especially for new contact lens wearers and children. Make use of these ever-improving options when appropriate to offer your pediatric patients the benefi ts of a daily disposable lens. RCCL

1. Kalsow CM, Reindel WT, Merchea MM, et al. Tear cytokine response to multipurpose solutions for contact lenses. Clin Ophthalmol. 2013;(7):1291-302.2. Choy CK, Cho P, Boost MV. Cytotoxicity and ef-fects on metabolism of contact lens care solutions on human corneal epithelium cells. Clin Exp Optom. 2012 Mar;95(2):198-206.3. Epstein AB. Contact lens care products eff ect on corneal sensitivity and patient comfort. Eye Contact Lens. 2006 May;32(3):128-32.4. Ramamoorthy P, Nichols JJ. Compliance factors associated with contact lens-related dry eye. Eye Contact Lens. 2014 Jan;40(1):17-22.5. Dumbleton K, Woods C, Jones L, et al. Comfort and vision with silicone hydrogel lenses: eff ect of compliance. Optom Vis Sci. 2010 Jun;87(6):421-5.6. Robertson DM, Cavanagh HD. Non-compli-ance with contact lens wear and care practices: a comparative analysis. Optom Vis Sci. 2011 Dec;88(12):1402-8.7. Dumbleton KA, Spaff ord MM, Sivak A, Jones LW. Exploring compliance: a mixed-methods study of contact lens wearer perspectives. Optom Vis Sci. 2013 Aug;90(8):898-908.8. Morgan PB, Efron N, Toshida H, Nichols JJ. An

international analysis of contact lens compliance. Cont Lens Anterior Eye. 2011 Oct;34(5):223-8.9. Dumbleton K, Richter D, Bergenske P, Jones LW. Compliance with lens replacement and the interval between eye examinations. Optom Vis Sci. 2013 Apr;90(4):351-8.10. Dumbleton K, Richter D, Woods C, et al. Compliance with contact lens replacement in Canada and the United States. Optom Vis Sci. 2010 Feb;87(2):131-9.11. Siddique M, Manzouri B, Flynn TH, Ono SJ. Allergy and contact lenses. Chem Immunol Allergy. 2007;92:166-75.12. Nichols KK, Morris S, Gaddie IB, Evans D. Epinastine 0.05% ophthalmic solution in contact lens-wearing subjects with a history of allergic con-junctivitis. Eye Contact Lens. 2009 Jan;35(1):26-31.13. Brodsky M, Berger WE, Butrus S, et al. Evalua-tion of comfort using olopatadine hydrochloride 0.1% ophthalmic solution in the treatment of allergic conjunctivitis in contact lens wearers compared to placebo using the conjunctival allergen-challenge model. Eye Contact Lens. 2003 Apr;29(2):113-6.14. Solomon A. Allergic manifestations of contact lens wearing. Curr Opin Allergy Clin Immunol. 2016 Oct;16(5):492-7.15. Elhers WH, Donshik PC. Giant papillary con-junctivitis. Curr Opin Allergy Clin Immunol. 2008 Oct;8(5):445-9.16. Bartlett JD, Howes JF, Ghormley NR, et al. Safety and effi cacy of loteprednol etabonate for treatment of papillae in contact lens-associated giant papillary conjunctivitis. Curr Eye Res. 1993 Apr;12(4):313-21.17. Walline JJ, Jones LA, Rah MJ, et al. Contact Lenses in Pediatrics (CLIP) Study: chair time and ocular health. Optom Vis Sci. 2007 Sep;84(9):896-902.18. Acuvue. Available at www.acuvueprofessional.com/product/moist-astigmatism. Accessed Janu-ary 4, 2017.19. Bausch + Lomb. BioTrue oneday for astigma-tism. Available at www.bausch.com/our-prod-ucts/contact-lenses/lenses-for-astigmatism/biotrue-oneday-for-astigmatism. Accessed January 4, 2017.20. Cooper Vision. Clariti 1 day toric. Available at http://coopervision.com/contact-lenses/clari-ti-1-day-toric. Accessed January 4, 2017.21. Alcon. Dailies aquacomfort plus contact lenses. Available at www.myalcon.com/products/con-tact-lenses/dailies/aquacomfort-plus-technology.shtml. Accessed January 6, 2017.

Fig. 2. ‘OK’ marking along with three

and nine o’clock markings with the

Dailies AquaComfort Plus Toric Lens.

By Christine W. Sindt, OD

The Big Picture

Shown here is a 26-year-old female patient who previously underwent penetrating keratoplasty (PK) for Acanthamoeba

keratitis (AK) unresponsive to medical therapy. The graft size is larger than average due to the advanced state of the AK ulcer and the need for suffi cient border zone of healthy, unaffected tissue. She

is two years out from the trans-plant with all her corneal sutures removed, although the broken suture remnants visible here will permanently remain in her cornea. Healing response to graft placement is positive, with no evidence of re-jection or failure. The corneal scar-ring and suture fragments will not affect vision. However, the retained suture fragments could provide

a vector for microbial infection, requiring heightened vigilance from both the clinician and patient. RCCL

This graft patient showed suture fragments on follow-up. Is it a cause for concern?

Retained PK Sutures

CALL FOR ENTRIES: Do you have

great clinical images of fascinating

cases you would like to share with

your colleagues on this page and

online? Send large, high resolution

photos (corneal disease or contact

lens wear only) and a brief case

description to: [email protected].


RCCL0217_Xcel.indd 1RCCL0217_Xcel.indd 1 1/26/17 2:54 PM1/26/17 2:54 PM

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MPS, multipurpose solution.*Compared to MPS in symptomatic users. References: 1. Gabriel M, Bartell, J, Walters R, et al. Biocidal effi cacy of a new hydrogen peroxide contact lens care system against bacteria, fungi, and Acanthamoeba species. Optom Vis Sci. 2014;91:E-abstract 145192. 2. Alcon data on fi le, 2014. 3. Alcon data on fi le, 2015.

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RCCL - Review of Cornea and Contact Lenses > Home · nea suggests.1 The key treatment used in ... joins long-time RCCL contributor Mile Brujic, OD, in coauthoring ... Jeff Levitz