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Sunday, April 1, 2012  
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Last week's question:
Is there clinical relevance to "solution-induced" corneal staining (e.g., symptoms, clinical inflammation)?



Editor's Commentary - Jason J. Nichols, OD, MPH, PhD, FAAO

Over the years, I've noticed that many of us really take contact lens care solutions for granted, and in particular starter kits. We, our staff, and our students hand starter kits out like handing kids candy at Halloween—that is, without giving it much of a second thought at all. And, our patients expect to be given these samples (just as kids expect their candy at Halloween). I think this behavior is problematic as, amongst other things, it has the potential to create the perception that care solutions are all the same, which they are not. So, the next time you are dispensing a care solution starter kit, take a moment and consider the approach you use.

B+L to Acquire ISTA Pharmaceuticals

Bausch + Lomb (B+L) and ISTA Pharmaceuticals, Inc. announced that they have signed a definitive agreement under which B+L will acquire ISTA for $9.10 per share in cash, or a total of approximately $500 million. The transaction, which has been unanimously approved by the boards of directors of both companies, is expected to close in the second quarter of 2012.

The combination adds ISTA's portfolio of non-steroidal, anti-inflammatory, allergy, glaucoma and spreading agents to B+L's complementary portfolio of existing Rx ophthalmology and OTC eye health products. The companies also have complementary development pipelines. According the joint release, ISTA's pipeline includes candidates in various stages of development to treat various ocular conditions including inflammation and pain, while B+L's pipeline of pharmaceutical innovations includes the first of a new class of ocular anti-inflammatory agents and a promising approach to reducing intra-ocular pressure in patients with open-angle glaucoma or ocular hypertension.

The transaction is subject to regulatory approval and other customary closing conditions, including the approval of ISTA's shareholders. The companies will continue to operate independently until completion of the transaction.

GPLI Announces 2012 Clinical Symposium

The Gas Permeable Lens Institute (GPLI) will host its next clinical symposium on June 3, 2012, in Denver (Lakewood), Colorado. The distinguished faculty will include some of the foremost GP Lens experts in the U.S., including Dr. Christine Sindt, Dr. Tom Quinn, Dr. Shawna Vanderhoof, Dr. Perry Umlauf, Dr. Mindy Toabe, and the Executive Director of the GPLI, Dr. Ed Bennett. The symposium will offer an innovative approach to education and allow attendees to select from seven courses in both fundamental and advanced GP Lens education. For the first time, the scleral course offering will feature a live fitting demonstration. Attendees can earn up to seven hours of COPE credit, NCLE credit and/or JCAHPO credit (approval pending).

The GPLI's "two track" approach to education allows doctors and staff to select courses in Track One, pertaining to: (1) Spherical Fitting, Evaluation, and Troubleshooting, (2) GP Care and Compliance, and (3) GP Multifocals, or Track Two, with presentations on (1) Toric GP Lenses, (2) GP Management of Keratoconus, and (3) Scleral Lens Fitting, Care, and Problem-Solving. Attendees can select courses from both tracks to meet their individual needs. All participants will attend a preliminary GP Update course, as well as a closing Case Grand Rounds course.

The cost to attend this all day event is $250. Attendees that register prior to Friday, May 11, 2012, will receive a $50 early registration discount. Contact lens technicians/staff will be offered a reduced registration rate of $175 and can also receive the early registration discount. For more information or to register, visit www.GPLI.info.

New AllAboutVision.com Promotion Offers Free Directory Listings, Supports Optometry Giving Sight

Without spending a penny, eyecare professionals can raise money for Optometry Giving Sight and get a free Web directory listing for their practice. For each practice that links its website to AllAboutVision.com through the end of June, AllAboutVision.com will donate $35 to Optometry Giving Sight. In addition, the linking practice will get a free listing in AllAboutVision.com's Eye Care Practitioner Directory, used by thousands of people each month.

Just $5 can provide an eye exam and eyeglasses to someone in a developing nation through Optometry Giving Sight funded programs. At least 670 million people worldwide are blind or vision impaired due to uncorrected refractive error. Optometry Giving Sight funds the solution: an eye exam and a pair of eyeglasses, delivered through sustainable primary eye care programs.

Practices can get more information about linking and the $35 donation program by visiting www.allaboutvision.com/ecp/.

BCLA Conference to Offer COPE and CET Accredited CE

Both UK and overseas delegates will be offered accredited continuing education at the upcoming 36th British Contact Lens Association (BCLA) Clinical Conference and Exhibition. Eight hours of continuing education have already received COPE (USA) accreditation, with a further 4.5 hours pending approval. All CET workshops have been approved for a total of 22.5 CET points, and clinical lectures will provide up to 24.5 CET points.

More than 1,000 delegates from across the globe are expected to participate in this year's conference, which takes place at ICC Birmingham, UK, from May 24-27. The BCLA conference is one of the only UK events to offer COPE-accredited continuing education. COPE-accredited sessions this year include:

  • Therapeutic management of the red eye with Drs. Jan Bergmanson and William Miller
  • Dry eye in contact lens wear with Professor Alan Tomlinson
  • Myopia Management Session with Professor Brien Holden and Drs. Jeff Walline, Tom Aller and Padmaja Sandrikurg
  • Taming torics and attacking astigmatism with Professors Mark Andre and Patrick Caroline
  • Keynote Session: Anterior eye and nutrition with Dr. Stuart Richer

For further information and registration, visit www.bcla.org.uk.

Your Photo Here

An image from your interesting case could appear in this column next week!

We welcome photo submissions from our readers! It is easy to submit a photo for consideration for publishing in Contact Lenses Today. Simply visit http://www.cltoday.com/upload/upload.aspx to upload your image. Please include an explanation of the photo and your full name, degree or title and city/state/country.

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Susan J. Gromacki, OD, MS, FAAO


For those of us who wash our hands before, during, and after every patient encounter, the next statement may come as a surprise. My experience has been that many patients do not wash their hands prior to handling their contact lenses. The fact is, I believe that poor hand-washing is one of the most frequent noncompliant behaviors in lens care.

Even our patients who do wash their hands may use improper technique. Here are the recommendations from the United States Centers for Disease Control and Prevention (CDC). First, wash your hands for 20 seconds or more; singing two "Happy Birthdays" takes about that long. Next, scrub all hand surfaces, including under the fingernails, as that is a common place for microorganisms. Then, rinse your hands thoroughly and either air dry or wipe with a clean towel. Note that the type of soap or the temperature of the water does not make as much impact on cleaning as does the scrubbing action itself. Of course, for contact lens wearers, always recommend a perfume and lotion-free soap.

Although we may accept good hand-washing as common practice, we cannot assume that our patients do. So, be sure to place emphasis on hand-washing during your lens care instructions; it may pay dividends towards preventing complications, and perhaps even infection.


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Guest Columnist: Ann Pyck, OD, Antwerp, Belgium

Guest Columnist: Ann Pyck, OD, Antwerp, Belgium

Belgium is a small country, but none-the-less, we are active in fitting contact lenses. In my opinion, there are two different groups of contact lens wearers in Belgium (and perhaps the rest of the world). There is one group who wants to buy contact lenses, and they usually find their way to eyecare practitioners who just want to sell them contact lenses. After a while, the contact lens patient will be fed up with lenses and will drop out because their needs are not being met. The other group of contact lens patients understands that eyes and lifestyles change and they want contact lenses that are a perfect match for their eyes and current lifestyle throughout their life. This group needs contact lens practitioners who not only correct their vision but go beyond by listening to them and preventing vision and comfort issues before these issues become problems. Of course, most patients who are fit with specialty lenses understand the need for regular exams and follow-up care. But what about the non-specialty soft lens wearers—how do we get them to the right practitioner and keep them returning for their regular exams and follow-up?

In our practice, we try to make follow-up care more than a just a check up for good vision. We show the contact lens wearers how their lenses fit and what their eyes look like through camera and topography images which we capture each time. Doing that, we not only check the curvature of the eyes but also show how good lens materials and good compliance are beneficial for a healthy cornea. In this way, our contact lens patients feel involved in the whole process and are more open minded about new materials and modalities recommended by me. It is very rewarding to see that they understand that follow-up care is not only needed when their contact lenses bother them, but that the primary goal is to ensure that their contact lenses as compatible as possible with their eyes.

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Guest Columnist: Amber Gaume Giannoni, OD, FAAO; Kelly K. Nichols, OD, MPH, PhD, FAAO

"Slobbermouth Plant" - A Potential Weapon Against Dry Eye Disease?

Most of us are familiar with topical therapy options for treating ocular surface disease; however, we may not be as well-versed with the potential use of oral medication for certain classes of dry eye syndrome.

Cholinergic agonists (CA) stimulate muscarinic receptors in moisture-producing glands to increase function. This outcome can be desirable when increased lacrimation and salivation are desired. When prescribing for the eye (which is an off-label use), two oral CA options exist: Pilocarpine (Salagen), originally derived from the jaborandi shrub (aka "the slobbermouth plant") and cerimeline (Evoxac). FDA-approved for the treatment of xerostomia (dry mouth) secondary to radiation or Sjogren's syndrome, both drugs will also stimulate the lacrimal gland to produce tears, as long as gland function remains. One study found that 20mg tid of cerimeline statistically improved patient symptoms, tear dynamics and corneo-conjunctival epithelium compared to placebo.1

We must remember, however, that muscarinic receptors are found throughout the body. Undesirable effects can include diarrhea, sweating/dehydration, heart block, headache and miosis (which can cause decreased acuity in the case of central cataract).

Despite potential undesirable outcomes, the majority of my patients choose to continue oral CAs for their dry mouth and eyes and generally report fewer side effects with cerimeline. When used appropriately and in the right patient population, oral cholinergic agonists can certainly aid our fight in the battle against dry eye disease.

1. Ono M, Takamura E, Shinozaki K, Tsumura T, Hamano T, Yagi Y, Tsubota K. Therapeutic effect of cevimeline on dry eye in patients with Sjogren's syndrome: a randomized, double-blind clinical study. Am J Ophthalmol. 2004 Jul;138(1):6-17.

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The Impact of Cellular Debris on Pseudomonas Aeruginosa Adherence to SiHy CLs and CL Storage Cases

This group of researchers wanted to evaluate neutrophil-enhanced Pseudomonas aeruginosa (PA) biofilm formation on silicone hydrogel contact lenses and to determine the effect of epithelial biodebris on PA adherence in contact lens storage cases.

A fully invasive PA corneal isolate stably conjugated to green fluorescent protein was used. Unworn lotrafilcon A contact lenses were incubated at various ratios of PA to polymorphonuclear neutrophil (PMN) for 24 hours at 37 degrees C. Lens-associated PA was evaluated using laser scanning confocal microscopy and nonviable PA were visualized using propidium iodide. Viable bacteria were enumerated by colony-forming unit (CFU) analysis. For acute epithelial cell studies, PA viability was determined after coincubation with freeze-thaw epithelial cell lysates in 96-well polystyrene plates. Levels of residual cellular debris and bacterial viability were further assessed in used contact lens storage cases.

Laser scanning confocal microscopy demonstrated that co-treatment with PMA-stimulated neutrophils increased PA adherence over 24 hours to lens surfaces with a striking alteration of PA architecture. Propidium iodide staining showed that the adherent bacteria consisted of a mixture of viable and nonviable PA; a PMN-associated increase in viable PA was confirmed by CFU (PA:PMN 0.1:1, P = 0.025; PA:PMN 1:1, P = 0.005). Acute epithelial cell debris studies revealed a significant increase in viable PA in 96-well plates in the presence of epithelial freeze-thaw lysates (PA:debris 1:1, P = 0.002; PA:debris 100:1, P = 0.002). Crystal violet staining of used lens storage cases revealed residual cellular debris at all time points, which was independent of microbial contamination; all lens cases used for periods of 9 months or more were uniformly associated with high levels of viable microorganisms.

The authors concluded that these results demonstrate that prolonged corneal inflammation with the presence of PMNs when confronted with simultaneous PA challenge in extended contact lens wear has the potential to stimulate biofilm formation on silicone hydrogel contact lenses. These findings further suggest that a persistent buildup of extracellular debris in lens storage cases may contribute to the heavy biofilms reported on these surfaces.

Burnham GW, Cavanagh HD, Robertson DM. The impact of cellular debris on Pseudomonas aeruginosa adherence to silicone hydrogel contact lenses and contact lens storage cases. Eye & Contact Lens 2012;38:7-15.

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