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Editor's Commentary - Jason J. Nichols, OD, MPH, PhD, FAAO
Modern scleral contact lenses have really re-opened another avenue of successful contact lens wear for a variety of our patients, especially those with diseased eyes. There have been clinical questions as to the proper fitting approach, including the post-lens tear film thickness associated with optimized oxygen flow to the cornea. The abstract highlighted this week helps address this important issue. We will also be on the lookout for future work that continues to address this issue for optimizing scleral lens fitting.

Contact Lens Health Week 2014
The Centers for Disease Control and Prevention (CDC), in close collaboration with partners from clinical, public health, industry and regulatory sectors, is promoting the first annual Contact Lens Health Week from November 17-21, 2014. This year’s campaign theme is “You only have one pair of eyes, so take care of them!”

The campaign aims to promote healthy contact lens wear and care practices that can help reduce the risk of eye infections and complications associated with improper contact lens use. As teens and young adults are at increased risk for eye infections associated with contact lens wear, the campaign primarily targets contact lens wearers ages 18-22 and also includes messages and materials suitable for all contact lens wearers.

Eye care providers are a critical partner in relaying campaign messages and materials to patients. For more information on Contact Lens Health Week, a campaign promotion toolkit, and resources for promoting healthy contact lens wear and care throughout the year, visit www.cdc.gov/contactlenses.

AOA Offers Exclusive 2015 ICD-10 Coding Resources
The one-year countdown begins for the widespread implementation of the International Classification of Diseases, Tenth Revision (ICD-10) code set, which health professionals will be required to use beginning October 1, 2015. To help optometric practices transition smoothly from ICD-9-CM to ICD-10-CM, the American Optometric Association (AOA) is offering a 2015 ICD-10 coding bundle for purchase.

This coding bundle is unique to the optometric profession and can only be purchased through the AOA Marketplace. The 2015 ICD-10 Coding bundle includes: 2015 AOA Codes for Optometry (ICD-10), 2015 ICD-10 CM AOA Express Mapping Card (not sold separately), and 2015 AMA CPT Professional Edition.

2015 AOA Codes for Optometry (ICD-10) helps eye care professionals learn how to make correct decisions when selecting diagnosis codes using the new system. It is written for all skill levels—from basic to advanced—and appropriate for self-learners and the classroom. AOA members will save more than $50 when they purchase the bundle, compared to non-members, but the products are available to all optometric professionals.

Click here to pre-order the 2015 ICD-10 coding bundle, or visit the AOA Marketplace at www.aoa.org/marketplace to find more products for the optometric professional.

Register Now for GSLS 2015 and Save

Make plans now to join us January 22 - 25, 2015 for GSLS 2015. Register before December 15th and save! The Global Specialty Lens Symposium (GSLS) is a comprehensive meeting focusing on the latest techniques and technologies for the successful management of ocular conditions using today's specialty contact lenses. The meeting includes information for vision care professionals in all disciplines, with both surgical and non-surgical options. Accredited for continuing education under COPE, NCLE, and JCAHPO, the meeting will offer approximately 30 credit hours.

Attended annually by more than 500 participants from 30+ countries it is the largest conference of its kind in the U.S.

For complete conference details and to register now, visit GSLSymposium.com.

--ADVERTISING

CooperVision Matching Customer Rebate Donations to Optometry Giving Sight
In recognition of the 2014 World Sight Day Challenge, CooperVision, Inc. announced an October campaign to boost rebate-related giving to Optometry Giving Sight (OGS). U.S. contact lens wearers who purchase CooperVision lenses with rebate offers have the opportunity to donate a portion or all of their rebates to Optometry Giving Sight. But through October 31, CooperVision will match all rebate donations to double these charitable contributions.

According to the company, over the last two years, thousands of CooperVision contact lens wearers have given more than $180,000 through their rebate donation program. Matching their donations over the next several weeks will make their good intentions reach even further.

In addition to the rebate donation match, CooperVision employees are once again participating in the company’s global fundraising campaign in support of Optometry Giving Sight’s World Sight Day Challenge. Many CooperVision locations worldwide have organized local activities to help raise funds toward the campaign. CooperVision and its employees, with the support of its parent company, The Cooper Companies, donated $100,000 towards Optometry Giving Sight’s World Sight Day Challenge in both 2012 and 2013.

Your patients who are CooperVision contact lens wearers interested in donating all or a portion of their rebates should consult the list of current rebate offers.

Renewal Deadline for Paraoptometric Recertification Is November 1
The Commission on Paraoptometric Certification (CPC) announced the deadline for CPC certified paraoptometrics to recertify for 2014 is November 1, 2014. Recertification requires certified paraoptometrics to continue to expand their skills and knowledge by acquiring 18 hours of continuing education throughout the three-year term of their certification period.

CPC certified paraoptometrics who are due for renewal this year will need to submit proof of their continuing education credits by the deadline. Electronic renewal notices were sent in early September to those due to renew this year. If a paraoptometric did not receive his or her renewal notice or would like to find out more about staff certification, contact the CPC at CPC@aoa.org.

The American Optometric Association (AOA) Paraoptometric Resource Center offers numerous opportunities to earn free and low-cost continuing education credits as one of many paraoptometric member benefits. Enrollment in the AOA is free for paraoptometrics, and at no dues increase to the AOA member optometrist. To find out more about how to take advantage of free continuing education and staff training, contact PRC@aoa.org.


Last week’s Editorial on the results of the September 28 poll question, in which 89% of respondents did not think that myopia was a disease, prompted some comments from our readers. Here we share a couple of those comments.

I think that the disconnect in considering myopia a disease comes from medical insurers not paying for refractive diagnosis. Is that right? No, but it could be the source of contention.

Michael I. Davis, OD
Eldersburg, MD

I believe that the reason ODs don't consider myopia a disease is multifold.

1. Historically, Optometry in the United States was unable to treat diseases of the ocular system. As a graduate of the Class of 1976 from SUNY Optometry, when I went to school and for some time afterwards, Optometry was unable to even use any diagnostic drugs. To call myopia a disease would have opened the profession up to restrictions by organized Ophthalmology who were hell-bent (at that time) on destroying our profession.

2. The strict definitions of myopia and hyperopia are oppositions to emmetropia which Ophthalmology considered "the" norm whereas historically we did not. So hyperopia of say +0.50 would be considered a disease state even though a normalized population has close to that.

3. As another example, would you consider a person with -0.50 refraction as having a "disorder of structure/function within the body that leads to signs or symptoms"? This person will have 20/20 vision, and the advantage of not needing reading glasses much further on in life than the "normal" person. I think this is why distinctions are made between "myopia" and "pathologic myopia."

4. And by extension, then, would one consider presbyopia a disease?

5. And also by extension, if myopia, hyperopia, astigmatism and presbyopia are disease states, treatment should be covered by health insurance, which it rarely is.

Stewart Gooderman, OD
San Francisco, CA

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RESEARCH REVIEW
S. Barry Eiden, OD, FAAO
It’s Just Not Getting Any Better – A Review of Therapeutic Approaches to Persistent Epithelial Defects (PEDs)

Most compromises to the corneal epithelium respond to therapy via re-epithelialization and wound healing fairly quickly and uneventfully. However, when traditional treatment fails to result in successful re-epithelialization we are faced with what is termed persistent epithelial defect or PED. A 2-week time period without epithelial healing is conventionally considered appropriate for the use of PED diagnosis.1 A recent review article was published that summarized current and developing management strategies for the treatment of PEDs.2

Initial determination of why a patient is suffering with PEDs is critical in its management. Some common reasons for PEDs include; trauma, corneal exposure, keratitis sicca, grafts vs. host disease (GVHD), limbal stem cell deficiency (LSCD) and a myriad of others. Addressing the basic etiology of the epithelial compromise is required for long term treatment success. Traditional treatment methods were initially reviewed by the authors. These included: aggressive lubrication (typically with non-preserved agents), the use of punctual occlusion to increase tear volume (to be avoided if any irritating topical agents such as preserved eye drops are needed), bandage contact lenses (with consideration of concurrent use of topical antibiotics and lubricants), temporary or permanent tarsorrhaphy (tape, suture or cyanoacrylate glue), and epithelial debridement. Of special note is the consideration of “medicamentosa” or toxic keratitis stemming from the use of topical ophthalmic medications as a common cause of PEDs. Of course discontinuation of the offending agents and use of non-preserved lubricants often helps.

The authors then review some of the newer approaches to PED management which include: autologous serum (AS) eye drops (studies show a majority of recalcitrant cases of PED respond favorably to AS), other whole blood derived products such as umbilical cord blood serum (CBS) donated by pregnant donors, application of amniotic membranes to the corneal surface (fresh frozen or freeze dried forms), limbal stem cell transplantation (auto and allografts) and the use of scleral contact lenses. Finally a review of developing novel treatment approaches was presented which indicate the potential role of agents such as Thymosin beta 4 (Tb4) with its significant anti-inflammatory effects which is delivered via a specially formulated hydrogel bandage contact lens and the transplantation of mesenchymal stem cells to severely compromised corneas.

Management of PEDs is complex and difficult, however many of the most current and effective treatment modalities are within the realm of optometric therapy. Understanding the underlying etiologies and contemporary treatment options will allow us to successfully care for these patients in need.

1. McCulley JP, Horowitz B, Husseini ZM, et al. Topical fibronectin therapy of persistent corneal epithelial defects. Fibronectin Study Group. Trans Am Ophthalmol Soc 1993;91:367-86.
2. Katzman LR, Jeng BH. Management strategies for persistent epithelial defects of the cornea. Saudi Journal of Ophthalmology (2014) 28, 168-172.

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OCULAR SURFACE UPDATE
Katherine M. Mastrota, MS, OD, FAAO

Ocular Surface Wellness Continued…

A few weeks ago I introduced a statement that attempts to define ocular surface wellness (OSW). I asked for your comment.

I was delighted to receive another email regarding the OSW topic from Professor Charles McMonnies of the School of Optometry and Vision Science, University of New South Wales in Australia. Dry eye “enthusiasts’ recognize Professor McMonnies as the clinician who developed the McMonnies questionnaire, which is among the earliest and most widely used screening instruments for dry eye syndromes.

“Ocular surface wellness”, the Professor writes, “might be provisionally diagnosed on the basis of an examination which is limited to a single instillation of sodium fluorescein.” He continues, “However, lack of wellness might sometimes be detected by also using other vital stains, or a second instillation of fluorescein with observation made after allowing time for stain to develop. Of course, lack of wellness might be indicated by any other signs of dry eye from hyperosmolarity to meibomian gland dysfunction as well as by symptoms.” Interestingly, he states, “Alternatively, lack of wellness might also be indicated by reduced conjunctival or corneal sensitivity, hyperaemia, and impaired epithelial barrier function, edema or reduced goblet cell density.”

The professor puts a subtle twist on OSW by characterizing what is ‘lack of wellness.’

Please tell me how you think about OSW at katherinemastrota@msn.com.

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Oxygen Diffusion and Edema with Modern Scleral Rigid Gas Permeable Contact Lenses
The purpose of this study was to define the theoretical oxygen tension behind modern scleral contact lenses (CLs) made of different rigid gas permeable (RGP) materials,assuming different thickness of the tear layer behind the lens. A second goal was to show clinically the effect of the post-lens tear film on corneal swelling.

The researchers simulated the partial pressure of oxygen across the cornea behind scleral contact lenses made of different lens materials (oxygen permeability Dk, 75 to 200 barrer) and different thickness (Tav, 100 to 300 microns). Post-lens tear film thicknesses (Tpost-tear) ranging from 150 to 350 microns were considered. Eight healthy subjects were randomly fitted with a scleral lens with a thin and a thick post-lens tear layer in two different sessions for a period of 3 hours under open-eye conditions.

CLs with less than 125 barrer of Dk and a thickness over 200 microns depleted the oxygen availabily at the lens-cornea interface below 55 mmHg for a post-lens tear film of 150 microns. For a post-lens tear film thickness of 350 microns, no combination of material or lens thickness will meet the criteria of 55 mmHg. The clinical measures of corneal edema showed that this was significantly higher (p<0.001, Wilcoxon signed-ranks test) with the thicker compared to the thinner Tpost-tear (mean±standard deviation, 1.66±1.12 vs 4.27±1.19%).

The authors concluded that scleral RGP CLs must be comprised of at at least 125 barrer of oxygen permeability and up to 200 microns thick in order to avoid hypoxic effects even under open eye conditions. Post-lens tear film layer should be below 150 microns in order to avoid clinically significant edema.

Compañ V, Oliveira C, Aguilella-Arzo M, Molla S, Peixoto-de-Matos SC, Gonzalez-Méijome JM. Oxygen Diffusion and Edema with Modern Scleral Rigid Gas Permeable Contact Lenses. Invest Ophthalmol Vis Sci. 2014 Sep 4. pii: IOVS-14-14038. [Epub ahead of print].


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