How to Be
A
Contact Lens Hero
Thomas G. Quinn, OD, MS, FAAO
Athens, OH
[email protected]
Affiliations
•
•
•
•
•
•
•
•
Allergan
AMO
Bausch & Lomb
CIBA Vision
CooperVision
J&J Vistakon
Paragon Vision Science
Polymer Technology
Patient Line-Up
“My vision
fluctuates”
“I can’t read!”
“My contact
lenses feel
dry”
“My eye is red”
“My kid can’t
see”
“I can’t see
with glasses”
“My vision fluctuates”
• 29 yo, w, f
• Health care provider
• Refraction:
– OD +1.50 – 1.75 x 005 20/20
– OS +1.75 – 2.00 x 175 20/20
• Hydrogel toric lens wearer
• Some dryness late in day
• No medications
“My vision fluctuates”
• Refraction:
– OD +1.50 – 1.75 x 005 20/20
– OS +1.75 – 2.00 x 175 20/20
• K’s:
– OD 40.00/ 41.25 @ 095
– OS 40.00/ 41.75 @ 085
What do you think?
“My vision fluctuates”
Toric
Rotational
Instability
Irregular
Contact Lens
Flexure
Poor Tear
Film
Keratoconus/
Pellucid
(PMD)
CL-Induced
Topography
Change
Troubleshooting
Visual Complaints
Key Questions:
1. Is blur constant or fluctuating?
2. If fluctuating, does blinking make
your vision better or worse?
Worse
Better
Irregular
• Too loose Flexure • Too tight
• Unstable
• Dirty
orientation
“My vision keeps changing”
Irregular Lens Flexure
• Detection
– Visual complaints
– Red reflex
– Over-K
“My vision fluctuates”
Irregular Contact Lens Flexure
OverRefraction &
Adj. CL Rx
Change Base
Curve
Change Lens
Thickness
Refit to Si/Hy
Toric
Toric Rotational Instability:
Over-Refraction & Adj. CL Rx
Over-Refraction
¾
Benefits:
• lacrimal lens effects
• flexural effects
• vertexing errors
Website Wealth!
www.eyedock.com
Lindsay RG, Bruce AS, Brennan NA
And Pianta MJ, Determining Axis
Misalignment and Power Errors of
Toric Soft Lenses, ICLC, May/June
1997
Contact Lens Calculator Plus at www.palmgear.com
Toric Rotational Instability:
Over-Refraction & Adj. CL Rx
Over-Refraction
¾
Benefits:
• lacrimal lens effects
• flexural effects
• vertexing errors
¾
Only perform if fit/ vision is stable
Troubleshooting
Visual Complaints
Toric Tip:
If blur is constant,
make a power change
If blur is fluctuating,
make a design change
Fitting Soft Torics
Assessing Axis Stability:
• Effects of the Blink
• Effects of gaze change
Effects of Gaze Change
Zikos, GA, et al, Rotational Stability of Toric Soft
Contact Lenses During Natural Viewing Conditions
,Optom. and Vision Science:Volume 84(11):10391045, Nov. 2007.
Stable Toric with Gaze Change
Poor Stability with Gaze Change
Fitting Soft Torics
Assessing Axis Stability:
• Effects of the Blink
• Effects of gaze change
• Digital Displacement Test
“My vision fluctuates”
Toric Rotational Instability
OverRefraction &
Adj. CL Rx
Change Base
Curve
Change Lens
Thickness
Refit to Si/Hy
Toric
Toric Rotational Instability:
Refit to Sy/Hy Toric
• PureVision Toric (B&L)
• Acuvue Advance/ Oasys for Astigm.
(J&J Vistakon)
• Air Optix for Astigmatism (CibaVision)
• Biofinity Toric (CooperVision)
Benefits of
Silicone Hydrogel Torics
• Increased oxygen through thick toric
design
• Improved corneal health
• New design innovations
• Less dehydration
– Less tightening
– Faster settling/ rotational stabilization
Effects of Gaze Change
Zikos, GA, et al, Rotational Stability of Toric Soft
Contact Lenses During Natural Viewing Conditions
,Optom. and Vision Science:Volume 84(11):10391045, Nov. 2007.
“My vision fluctuates”
• Refraction:
– OD +1.50 – 1.75 x 005 20/20
– OS +1.75 – 2.00 x 175 20/20
• K’s:
– OD 40.00/ 41.25 @ 095
– OS 40.00/ 41.75 @ 085
What about a GP lens?
WHERE TO
Presenting GP Lenses
The Sandwich Approach
¾ Don’t dwell on comfort!
¾ Describe as lens “awareness”
¾ avoid terms such as: pain, hurt, irritation
¾ equate adaptation to adjusting to a newly worn
watch or ring
¾ emphasize lid more than the eye itself must adapt
LENS
DIAMETER
WHEN TO GO
Go Toric When:
* Corneal Toricity >2D
and Poor Sphere Lens Stability
* Sphere Lens Flexure / Warpage
* Extended Wear Schedule
GP Lens Calculator
• Bennett/Quinn Calculator (coming soon!)
• www.clma.net
• www.gpli.info
– Enter K’s and Refraction
– Choose diameter (torics)
– Lens Parameter’s derived
• SPE?
• CPE?
• Back surface toric?
Patient Line-Up
“My vision
fluctuates”
“I can’t read!”
“My contact
lenses feel
dry”
“My eye is red”
“My kid can’t
see”
“I can’t see
with glasses”
“I can’t read”
Patient RA: 48 yo female police officer
– Motivation for contact lenses: “avoid glasses
getting knocked off during an altercation”
– Some eye itching
– No medications
– Slitlamp examination: mild tarsal changes OU
– Refraction
• OD -3.00 -0.50 x 010
• OS -3.00 -0.50 x 160
+1.75 add
+1.75 add
20/20
20/20
“I can’t read”
• Patient RA
– Slitlamp examination: mild tarsal changes OU
– Refraction
• OD -3.00 -0.50 x 010
• OS -3.00 -0.50 x 160
– K’s
• OD 43.50/44.00@100
• OS 43.50/44.00@070
– Dominant eye?
+1.75 add
+1.75 add
20/20
20/20
Ocular Dominance
• Sighting dominance
• Sensory dominance
“I can’t read”
• Patient RA
– Slitlamp examination: mild tarsal changes OU
– Refraction
• OD -3.00 -0.50 x 010
• OS -3.00 -0.50 x 160
– K’s
• OD 43.50/44.00@100
• OS 43.50/44.00@070
– Dominant eye: OD
+1.75 add
+1.75 add
20/20
20/20
“I can’t read”
Soft Lens
GP Lens
Hybrid Lens
Full Time
Spectacles
“I can’t read”
Soft Lens
Monovision
Multifocal
Toric
Multifocal
Over Reading
Glasses
MULTIFOCAL vs MONOVISION:
• 50 adapted monovision wearers fit with Acuvue
bifocal
• Assessed VA and subjective vision ratings
• Subjective ratings were better with bifocal
lenses, except near vision in low light.
• At 6 months, 68% preferred bifocal lenses
Situ, P et al, Successful Monovision Contact Lens
Wearers Refitted with Bifocal Contact Lenses, Eye
Contact Lens, July 2003.
MULTIFOCAL vs MONOVISION:
• 38 subjects, cross-over study
- average spectacle add +1.50
•76% preferred multifocal correction
•Greatest challenge:
low contrast near VA for both groups
Richdale, Mitchell and Zadnik, Performance of the
B&L Soflens Multifocal and Monovision, AAO 2005.
“I can’t read”
Soft Lens
Monovision
Multifocal
Toric
Multifocal
Over Reading
Glasses
Patient Selection
Visual Demands
Soft Multifocal Contact Lenses:
Refractive Error
• Low hanging fruit
< 0.75 Cyl
> 3D Sphere
Low Add
Soft Lens:
Multifocal
• Where to start?
Setting Proper Expectations
The Sandwich Approach
New Soft Multifocal Players
Oasys for Presbyopia
(J&J Vistakon)
• senofilcon A
• Three add option
– Low, mid, high
• EW approval
• Center distance bias
Air Optix Multifocal
(CibaVision)
• lotrafilcon B
• Three add option
– Low, med, hi
• EW approval
• Center near
Acuvue Oasys for Presbyopia
10 years of dedication to fitting
the Presbyopic patients
Optical Design
•
•
•
•
570 designs evaluated
288 clinical trials
6,900+ patients fit
60 patents
Fit Recommendation
• 9 clinical Studies
• 890 Patients
NEXT GENERATION
MULTIFOCAL
LENS SELECTOR
© Johnson & Johnson Vision Care, Inc.
JJVC, data on file.
Acuvue Oasys for Presbyopia
Air Optix Aqua Multifocal
Revised Guidelines!
- Determining Initial Lens ADD Design
®
+1.25
+1.50 –
+2.00
Check Your Ego At The Door!
Multifocal
Man
FOLLOW THE FITTING GUIDE!!!!
2009-11-1119
Parting words to patients…
• Light is your friend
• These lenses are designed to work
together
• It’s a process
Key Fitting Tips
• Fit them early
• Plus is a must!
– Distance plus before increasing add
• Follow the fitting guide
• Settle down!
• Natural conditions
– Binocular
– Lights up
– Real world tasks
“I can’t read”
What we did…
• Fit with frequent replacement soft MF
• Started antihistamine/ mast cell stabilizer
“I can’t read”
Soft Lens
GP Lens
Hybrid Lens
Full Time
Spectacles
®
SynergEyes Multifocal
Distance
Near
Fitting SynergEyes® Multifocal
• 2 Segment Sizes (1.9 and 2.2 mm)
• 3 add powers (+1.25, +1.75, +2.25)
Lens Insertion
Troubleshooting
SynergEyes® Fitting
Tight Lens
seal-off
Light Landing
Heavy Bearing
8.5 mm SCR
8.2 mm SCR
Enhanced
SynergEyes Multifocal Design
• The Peripheral Blend
– Slightly flattens the lens at the GP periphery
and the soft skirt
– Less pronounced landing zone
– Enhanced comfort and wearability
– Easier removal
CL Spectrum, October 2010
Patient Line-Up
“My vision
fluctuates”
“I can’t read!”
“My contact
lenses feel
dry”
“My eye is red”
“My kid can’t
see”
“I can’t see
with glasses”
“My contact lenses feel dry”
• 47 yo, w, f
• High school administrator
• Acuvue 2, DW, Monovision
• OD -3.00
• OS -2.00 (near eye biased +2.25)
• Generic MPS care system
• Environmental allergies
– Flonase as needed
“My contact lenses feel dry”
“My contact lenses feel dry”
• 47 yo, w, f
• High school administrator
• Acuvue 2, DW, Monovision
• OD -3.00
• OS -2.00 (near eye biased +2.25)
• Generic MPS care system
• Environmental allergies
– Flonase as needed
What’s your treatment strategy?
“My contact lenses feel dry”
Treatment Strategy?
Dry Eye
Therapy
Refit with
Proclear
Refit with
Si/Hy
Change Care
System
“My contact lenses feel dry”
Solution Sensitivity
• Multi- purpose solution (MPS)
• Hydrogen Peroxide
• UV (Purilens System)
Solution-Related Discomfort
• may see staining, but asymptomatic
Solution Related Staining
[from Lyndon Jones]
Solution-Related Discomfort
• may see staining, but asymptomatic
• may be symptomatic, but no staining
• may or may not see corneal infiltrates
“My contact lenses feel dry”
Solution Sensitivity
• Reasonable initial strategy
• Didn’t help!
“My contact lenses feel dry”
Treatment Strategy?
Dry Eye
Therapy
Refit with
Proclear
Refit with
Si/Hy
Change Care
System
Refit with Proclear
“Materials such as omafilcon A (Proclear)
and Benz G, which exhibit dehydration
resistance, reportedly provide enhanced
comfort. However, many anecdotal reports
suggest that the… comfort is dependent
more on patient than on lens.”
Targeting Contact Lens Induced Dryness and Discomfort:
What Properties Will Make Lenses More Comfortable
Fonn, Desmond
Optometry & Vision Science. 84(4):279-285, April 2007
“My eyes feel dry”
Refit with Proclear
• May be patient dependent
“My contact lenses feel dry”
Refit with Si/Hy
• Some studies find no improvement in comfort
between hydrogel and silicone hydrogel lenses
• Fonn, D. and K. Dumbleton, Dryness and discomfort with
silicone hydrogel contact lenses. Eye Contact Lens, 2003.
29(1 Suppl): p. S101-4; discussion S115-8, S192-4.
• Cheung, S.W., et al., A comparative study of biweekly
disposable contact lenses: silicone hydrogel versus hydrogel.
Clin Exp Optom, 2007. 90(2): p. 124-31.
“My contact lenses feel dry”
Refit with Si/Hy
• Many studies do find improvement in comfort
between hydrogel and silicone hydrogel lenses
– Reduces dryness symptoms
• Chalmers et al, Optom Vis Sci, 2008;85:778-84.
– Improves late day comfort
• Dumbleton et al, Eye and CL, 2008;34:215-23.
“My contact lenses feel dry”
Refit with Si/Hy
• After 6 hours of lens wear:
– comfort was not influenced by in-eye
lubricant or saline use
– comfort was influenced by lens type
(hydrogel vs silicone hydrogel)
Lubricant Effects on Low Dk and Silicone Hydrogel Lens Comfort
Ozkan, Jerome; Papas, Eric
Optometry & Vision Science. 85(8):773-777, August 2008.
Contact lens dryness?
The Great Pretenders:
• hypoxia
• solution sensitivity
• low grade mechanical irritation
• high modulus material
• poor surface condition
“My contact lenses feel dry”
Treatment Strategy?
Dry Eye
Therapy
Refit with
Proclear
Refit with
Si/Hy
Change Care
System
Dry Eye WorkShop (DEWS)
Dry eye is a multifactorial disease
– Of the tears and ocular surface
– That results in symptoms of discomfort, visual
disturbance, and tear instability
– With potential damage to the ocular surface.
– It is accompanied by increased osmolarity of
the tear film and inflammation of the ocular
surface
2007 Report of the International Dry Eye WorkShop.
Ocul Surf 2007;5[2]:65-206 (www.tearfilm.org)
Clinical Assessment
• Symptoms of Dryness
– Discomfort
– Visual Disturbance
Subjective Assessment
Questionnaire Based Instruments
Simpson, Trefford L., et al. Dry Eye Symptoms Assessed by
Four Questionnaires Optometry & Vision Science.
85(8):E692-E699, August 2008.
Clinical Assessment
• Symptoms of Dryness
– Discomfort
– Visual Disturbance
• Physical Examination
– External examination
– Slitlamp examination
Physical Examination
– Tears
• Quality
• Quantity
– The ocular surface
• Bulbar injection/ integrity
• Corneal integrity
– Eyelids
• Eyelid inflammation present 67-75% of the time
with dry eye*
*Laurenzi, A, An often overlooked source of lens-related dryness,
CL Spectrum, June 2008.
Eyelid Examination (Part II)
• Blepharitis
• Meibomian Gland Dysfunction (MGD)
Eyelid Examination
• Blepharitis
• Meibomian Gland Dysfunction (MGD)
• Superior Tarsal Plate (STP)
– Insight to other etiologies?
Easy Eyelid Eversion
www.clspectrum.com, November 2007,
Easy Eyelid Eversion, T. Quinn.
Lid Wiper Epitheliopathy
Tear Break-Up Time (BUT)
Corneal Staining
Dryness on waking?
Lissamine Green Staining
Dry Eye WorkShop (DEWS)
Dry eye is a multifactorial disease
– Of the tears and ocular surface
– That results in symptoms of discomfort, visual
disturbance, and tear instability
– With potential damage to the ocular surface.
– It is accompanied by increased osmolarity of
the tear film and inflammation of the ocular
surface
2007 Report of the International Dry Eye WorkShop.
Ocul Surf 2007;5[2]:65-206 (www.tearfilm.org)
Dry Eye WorkShop (DEWS)
Dry eye is a multifactorial disease
– Of the tears and ocular surface
– That results in symptoms of discomfort, visual
disturbance, and tear instability
– With potential damage to the ocular surface.
– It is accompanied by increased osmolarity of
the tear film and inflammation of the ocular
surface
2007 Report of the International Dry Eye WorkShop.
Ocul Surf 2007;5[2]:65-206 (www.tearfilm.org)
Tear Lab Osmolarity System
• Assesses 50 nanoliters of tear film
• Cooperative Marketing Agreement with
AMO in Canada
“My contact lenses feel dry”
True Dry Eye
Lubricating
Drops
Restasis Drops
Punctal Plugs
Eyelid Therapy
Lubricating Drops
• Although lubricant use does help reduce
dryness symptoms with silicone hydrogel
lens wear, there appears to be minimal
longer-term benefit to comfort.
• Furthermore, increased lubricant viscosity
did not lead to improved longer-term
comfort.
Lubricant Effects on Low Dk and Silicone Hydrogel Lens Comfort
Ozkan, Jerome; Papas, Eric
Optometry & Vision Science. 85(8):773-777, August 2008.
True Dry Eye:
Lubricating Drops
• Among the most common treatment
strategies employed
• Limited effectiveness in treating contact
lens related dry eye complaints
“My contact lenses feel dry”
• What we did:
– Switched to Si/Hy material (Early generation)
• Discomfort
– Switched to hydrogen peroxide care system
• No help
– Switched to Proclear lens
• Similar comfort to Acuvue 2
– Instituted Restasis
• Patient never filled (cost)
– Refit into Si/Hy multifocal (New generation)
“My contact lenses feel dry”
What we did…
Patient Line-Up
“My vision
fluctuates”
“I can’t read!”
“My contact
lenses feel
dry”
“My eye is red”
“My kid can’t
see”
“I can’t see
with glasses”
“My eye is red”
• 25 yo cell culture tech
• 2 wk SCL OU x 3 yrs
– 12hr/day, 9 hrs at exam
• Brand Name MPS Care System
• Presents for annual examination reporting:
– “right eye tends to get red around the iris”
– “seems associated with lens wear”
– “worse when at work”
“My eye is red”
“My eye is red”
“My eye is red”
• OS:
– minimal injection
– 1+ infiltrates superior cornea
What To Do?
“My eye is red”
• What we did…
– Switched her to Hydrogen Peroxide-based
care system
– Asked to return in 2 weeks
“My eye is red”
Before
After
“My eye is red”
“C” is for Caution
• Care System
– Compatibility
– No “topping off”
• Case Care
– Clean with warm soapy water/ dry upside down/lids off
– Replace at least every 3 months
• Clean Hands!
– 25% don’t always wash hands
– 15% never wash hands
(Australian and New Zealand Microbial Keratitis Study, 2005)
• Continuous Wear (4-7x greater risk for MK)
– Swimming
• Googles/ removal
– Not well?
– Blepharitis?
Lens Care
• Replace lenses as prescribed
• Care for lenses as prescribed
• See your doctor regularly
Lens Care
The Case of Professor B
Hero Highlights
• Curious
– “Do you have any other concerns about your
eyes or vision?”
Hero Highlights
• Curious
• Committed
– The Team Approach
– Persistence pays
Hero Highlights
• Curious
• Committed
• Current
– Latest designs
– Latest materials
– Latest treatment strategies
Hero Highlights
•
•
•
•
Curious
Committed
Current
Creative
– Take your best (educated) guess
– Work with consultants
– Change approach if needed
Hero Highlights
•
•
•
•
•
Curious
Committed
Current
Creative
Caring
Merci Beaucoup!
[email protected]