Thanks to those of you who sent me your top 10 list, or at least bits of it. I received some very interesting feedback about issues in the contact lens community. Some comments topping the lists related to issues with complications, particularly infiltrative keratitis and potential silicone hydrogel and care solution associations. Others related to the perceived lack of innovation in the contact lens material marketplace. And lastly, others related issues in practice, particularly factors impacting profitability. We may print a more detailed list in the future so stay tuned.

Wave Contact Lens System announced that their custom orthokeratology lenses are now approved for overnight wear as a design partner under the Bausch + Lomb (B+L) Vision Shaping Treatment (VST) program.

Wave's custom lenses are as proprietary as each patient's cornea with every design straight from the practitioner's topographer to Wave's lathes. According to the company, each lens is cut edge to edge with hundreds of curves closely matching the corneal shape; centration and comfort are ideal. In addition to Ortho K, Wave's patented method is also used to design multifocal, keratoconus, toric, and semi-scleral lenses.

Wave offers training, video clinical support, patient referrals, free topographers to users and a robust online community of fellow fitters. For more information, visit www.wavecontactlenses.com

Professor Brien Holden was honored as the recipient of the 2011 VOSH/International Lifetime Achievement Award during the organization's annual meeting in Boston. The award recognizes those who have made a global impact on visual impairment due to refractive error in their lifetime of work.

When presenting the award, VOSH/International immediate past president Dr. Greg Pearl noted that Dr. Holden was the first optometrist to serve on the International Agency for the Prevention of Blindness (IAPB) Board of Directors. He convinced the board to change the way they viewed blindness and visual impairment. Prior to Holden's involvement with the IAPB, they based their studies of the global prevalence of blindness upon visual acuity worse than 20/50 after refraction. Holden convinced them to also check uncorrected visual acuity as subjects presented to the study.

For the first time, new studies conducted in the developing world revealed that refractive error — the need for eyeglasses — is a major cause of visual impairment, second only in prevalence to cataracts. These studies clearly expressed the need to increase the availability of optometric services in the developing world.

Holden also created the global institutions to affect the changes needed. He and others created the International Centre for Eyecare Education to teach basic refractive services and to develop non-profit vision centers in the developing world. Additionally, he founded Optometry Giving Sight which solicits funding for these projects from the optical industry, optometrists and their patients.

Acculens announced the release of two new scleral lens multifocals, Maxim Plus and Comfort SL Plus.

Both new multifocals incorporate center near add technology with aspheric zone blend. The Maxim Scleral lens is indicated for the management of corneal distortion and dry eyes. The Maxim Plus will correct presbyopia while managing corneal distortion. Comfort SL Plus is indicated for normal corneas and is an alternative to soft toric lenses. Both new multifocal designs are available in custom parameters and are manufactured in Boston XO2.

Maxim's twenty-lens trial lens sets are available free of charge. No fitting set is need for Comfort XL or Comfort SL Plus, simply call in Ks, RX, corneal diameter and pupil size to Acculens.

For more information contact Acculens at 800-525-2470 or go to www.acculens.com.

This 32 year old Hispanic male patient reported with significant dry eye symptoms associated with Meibomian Gland dysfunction OU. He also had significant pterygia on both eyes. On the left eye, it was observed that several eyelashes were embedded underneath the tissue growth of the pterygium. These were not causing symptoms and were left in place at the time of treatment.

We thank Dr. Heard for her images and welcome photo submissions from our other 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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RESEARCH REVIEW
Loretta B. Szczotka-Flynn, OD, PhD, MS, FAAO

Soft Lens Options for Keratoconus

Custom soft contact lenses are becoming more popular for fitting keratoconus patients with several new fitting sets launched in the past year. My keratoconic patients often ask for them, and I have historically discounted their ability to correct the irregular astigmatism and higher order aberrations that accompany keratoconus. However, a new paper begs to differ.

Jinabhai and coworkers released a study of ocular aberrations in keratoconic patients using toric soft contact lenses, rigid-gas-permeable (GP) contact lenses and spectacle lens correction. Twenty-two keratoconus patients (16 GP lens wearers and six spectacle wearers) were fitted with toric soft lenses and ocular aberrations were measured with and without the patient's habitual correction and with the SCL in place. In the GP lens wearers both the habitual lenses and the toric soft lenses significantly reduced coma, trefoil, 3rd-order, 4th-order cylinder and higher-order root-mean-square (RMS) aberrations. Although GP lenses gave better low-contrast acuity, there were no differences between lens types for high-contrast acuity. Additionally, although visual performance with the toric soft lenses was found to be comparable to that measured with spectacles, the toric soft lenses were successful in significantly reducing uncorrected higher-order aberrations (except spherical aberration).

This is great news for GP intolerant keratoconus patients — I will certainly keep these soft lens options in mind in the future.

Jinabhai A, Radhakrishnan H, Tromans C, O'Donnell C. Visual performance and optical quality with soft lenses in keratoconus patients. Ophthalmic Physiol Opt 2012. Jan 24. doi: 10.1111/j.1475-1313.2011.00889.x. [Epub ahead of print]

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VIEWS FROM ABROAD
Brien Holden, PhD, DSc, OAM, FAAO

The Giants

At a recent Expert Panel at the World Health Organization (WHO), where I was serving as an expert on uncorrected refractive errors, much fascinating data was presented and discussed regarding strategies for dealing with non-communicable diseases. Data was presented for all the world's regions — but two countries don't fit — India and China. They are so big (1.3 and 1.2 billion people, respectively) that their situations distort regional data beyond recognition. And what a contrast these two countries are — nowhere greater than in refractive error and contact lenses.

In China, the majority are myopic and there may be as many as 25 million contact lens wearers; many part-time and a very significant percentage cosmetic tinted lens wearers. India on the other hand, has 20% myopia and maybe as little as 1 million wearers.

Both countries, however, share a common characteristic (as do many) — to be a success in China you have to be (think) Chinese and to be a success in India you have to be (think) Indian. As Kapil Sibal, one of the most articulate and visionary political leaders I have ever met says, "Don't come to India to sell Australian bits and pieces, join us in a knowledge partnership and research, develop, manufacture and market in India, for India and from India to the rest of the World."

Only those eyecare companies that understand the culture will make it in China and India. But look to these mammoth societies to catch up. And contact lenses will be no exception. In 10 years, maybe even 5, there will be more contact lens wearers in China than in the U.S. Their science is awesome; their research excellent, their need is immense. Both countries have shown that they can outstrip the rest of the world when they set their minds and resources to it — how ironic that the former colony, India, through Tata owns British Steel and Jaguar, Land Rover, Rover, Daimler.

What India and China need from "us", in contact lenses, vision correction and especially optometry and ophthalmology product development, is knowledge partnerships. And I can tell you from 25 years experience working with LV Prasad in India and 10 years working with Zhongshan Ophthalmic Centre in China, arguably the best research and clinical centers in their respective countries — such knowledge partnerships in science and education are immensely productive and very enjoyable.

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Fitting Definitive Silicone Hydrogel Material

Contamac's Definitive silicone hydrogel material has been a wonderful custom soft lens innovation. As reported previously, it is available through ABB Concise, Art Optical, Metro Optics, Unilens, and X-Cel Contacts in a number of custom designs for high ametropia, astigmatism, presbyopia, and irregular corneas. With its high Dk (60) and low modulus (0.35 MPa), it can work very well in a number of applications.

I have noticed when ordering this material that the lab consultants recommend steeper base curves than if the lens is made with a traditional HEMA-based hydrogel material. This was curious to me, so I asked representatives at Contamac why this was so. They said that because of Definitive's unique polymer chemistry, it does not lose water as much as regular hydrogels do when worn on the eye. Therefore, the lens does not tighten up, and a steeper base curve than usual is needed to provide on-eye stability.

I have found that these lenses do fit well over the course of the day, even with the steeper-than-usual base curve. And if they do not dehydrate as much, perhaps that translates into better comfort throughout the day, which is a definite plus.

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Researchers wanted to assess the effect of stage 1 keratoconus (KC) and of the two prevalent KC therapeutic options: (1) corneal collagen cross-linking (CXL) and (2) CXL combined with topography-guided photorefractive keratectomy (t-PRK) on self-reported quality of life (QOL) by means of the 25-item National Eye Institute Visual Function Questionnaire (NEI-VFQ 25).

Thirty-two patients with bilateral KC stage 1 (KC group) and best-corrected visual acuity of 20/20 in both eyes were prospectively recruited. Of them, 19 KC patients underwent typical CXL treatment (CXL group), whereas 13 underwent CXL combined with t-PRK treatment (tCXL group). Only the eye with the most advanced condition received the treatment. Subjects responded to the NEI-VFQ 25 1 day before the treatment and 1 year postoperatively. Thirty-nine age-matched contact lens users formed the control group. NEI-VFQ 25 subscale and total scores were associated with spherical equivalent, mean keratometry, and a series of Scheimpflug imaging-derived corneal variance indexes by means of the Spearman correlation coefficient and multivariate linear regression analysis.

Preoperatively, significant differences were detected between the KC group and the control group in VFQ 25 total and all subscale scores (P < 0.05), except "general health," "color vision," and "peripheral vision" domains. According to the multivariate linear regression analysis, the index of height decentration was the most significant predictor of VFQ 25 total score (b = 0.943; P = 0.016). Postoperatively, significant differences were detected in "mental health" and "dependency" VFQ 25 domains for both the CXL and tCXL groups (P = 0.05). Furthermore, the tCXL group demonstrated significant differences in the "near activities" (P = 0.04), "role limitations" (P = 0.02), and "driving" (P < 0.01) subscale scores.

The researchers concluded that their results suggest that KC exerts a significant impact on KC patients' QOL, even in its early stages with normal best-spectacle-corrected visual acuity. Moreover, both CXL and CXL combined with t-PRK seem to exert a beneficial impact on self-reported QOL, suggesting that they should be applied as soon as possible.

Labiris G, Giarmoukakis A, Sideroudi H, Gkika M, Fanariotis M, Kozobolis V. Impact of Keratoconus, Cross-Linking and Cross-Linking Combined With Photorefractive Keratectomy on Self-Reported Quality of Life. Cornea. 2012 Jan 10. [Epub ahead of print]

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