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Sunday, March 11, 2012  
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Editor's Commentary - Jason J. Nichols, OD, MPH, PhD, FAAO

Almost exactly one year ago, we addressed a potential issue being discussed in the contact lens community—namely, infiltrative keratitis. As one year has passed, we'd like to re-survey you about this important topic. Please respond to our Quick Poll in this issue and we'll report back to you next week comparing the results to those we found in 2011.

New and Improved Features Added to ODLean Consulting Website

The Vision Care Institute, LLC announced a series of improvements to its ODLean Consulting Program Website (www.ODLean.com), including new features and easier navigation.

The ODLean Consulting Program applies lean principles for eyecare practitioners to grow a practice's patient base and manage patient flow for optimal retention, referral and revenue. ODLean offers customized solutions to any-sized eyecare practice that will increase productivity, improve patient experience, and boost profits immediately and sustainably, according to the company.

Visitors to the website are able to learn about ODLean product offerings, read published articles, and view videos and client and patient testimonials. The website connects visitors to the latest findings and trends from ODLean experts on the topics of productivity, marketing and patient experience. In addition, the site provides information about upcoming events and conventions ODLean will be hosting or attending, and features a client portal, which houses business analytics and is accessible to current ODLean customers and alumni.

For more information, visit www.ODLean.com.

Your Feedback Requested

CE Symposium in France? At Contact Lens Spectrum and Optometric Management we're busy planning some exciting and educational events for the future. We'd love to hear your feedback on one particular idea.

Please take a few minutes (likely three minutes or less) to complete a questionnaire. We assure you that the information you provide is strictly confidential, will only be used in statistical form and merged with the responses of your peers.

Please click here to begin the survey.

Thank you for your time and valuable feedback.

B+L Relaunches Site for Presbyopic Patients

Bausch + Lomb (B+L) has relaunched www.GoodbyeReaders.com, an online resource for patients to learn more about vision correction options as they experience the changes that can naturally occur in our eyes as we age. With more than 14,000 unique daily visitors, the newly revised site includes a fun, interactive game to show people how adjusting for nearsightedness and farsightedness can impact their morning. It also gives patient-friendly information about presbyopia and offers an overview of vision correction options available to patients.

The site also features a "doctor finder" application. Eyecare professionals wishing to be added to that network should contact B+L directly.

Lensfindr.com Offers Free Subscriptions

Lensfindr, LLC announces free subscriptions for all eyecare professionals effective immediately. The web based software program allows contact lens clinicians and staff to quickly search and select specific soft contact lens information for their patients.

The robust soft lens database allows a customized search with up to 13 variables. The site also features other useful contact lens information including a manufacturer's directory, solution charts, rigid gas permeable lens information, contact lens products, and news updates.

Lensfindr, LLC was founded by Charles R. Putrino II, OD. To subscribe visit www.lensfindr.com.

AOS Awards Scholarship

The American Optometric Society (AOS) awarded a $1,000 scholarship to Taya Grilli, a senior at the Illinois College of Optometry, at the AOS 3rd Annual Meeting. Grilli is the second recipient of the "Harvey" Award, named after one of the profession's most distinguished optometrists and humanitarians, Dr. Harvey Yamamoto.

The scholarship is open to graduating students from Schools or Colleges of Optometry in the U.S. and Puerto Rico. Applicants submit an essay written on a preselected topic. The winner is presented with $1,000 and a one-year membership in the American Optometric Society, and is recognized at the Annual AOS Meeting.

X-Cel Adds Flexlens Toric to Monthly Replacement Schedule

X-Cel Contacts, a Walman Company, recently announced the addition of the Flexlens toric design to its monthly replacement schedule in their Flexlens product line.

Flexlens custom soft lenses are made to order in hydrogel and silicone hydrogel materials, using the latest manufacturing technology to give doctors the ability to fit a wide range of patients. Order fulfillment time on any Flexlens' product, whether standard or special parameters, is 1-2 working days with a no risk warranty.

For additional information, contact X-Cel Contacts at 800-241-9312.

Stevens-Johnson Syndrome
By Edward Boshnick, OD, Miami, FL

This 16 year-old Asian girl developed Stevens-Johnson syndrome several years before visiting our office from oral antibiotic medications. She is wearing a gas permeable scleral lens which provides her with 20/80 VA. Her other eye is extremely scarred and neovascularized and cannot be helped by surgery or with any type of lens.

We thank Dr. Boshnick for his image and 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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Fitting Newer Materials

In his Materials & Designs column in February 12 issue of Contact Lenses Today, Dr. Watanabe stated that lab consultants recommend that the Definitive material be fit with steeper base curves than traditional HEMA-based hydrogel materials.

The fact of the matter is that HEMA material significantly dehydrates in vivo and therefore has to be fit considerably flatter in order to achieve a proper alignment and accurate vision correction. Since the newer SiHy materials do not dehydrate nearly as much, they should be fit with a shorter base curve but reach a similar alignment as older materials. So the fit of a SiHy is not steeper, as many think, only the in vitro base curve is different and thus creates a similar fit to a proper HEMA or etafilcon fit.

Many colleagues are hesitant to use a "steeper" base curve due to the rule to fit as flat as possible, and strangely enough the industry is very persistent in producing state-of-the-art contact lenses in designs and base curves that were used with the old materials.

Hans Kloes, OD
Beverwijk, Netherlands

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Opinions on Monovision vs. Multifocals

In last week's editorial, I asked for feedback from eyecare practitioners regarding their opinion about fitting multifocals vs. monovision, noting that about 1/3 of practitioners still offer patients monovision as the first choice. We wish to thank all of the readers who responded with their thoughts. Although we cannot print all of the comments, we will be sharing some over this and next week.
Jason J. Nichols, OD, MPH, PhD, FAAO

Monovision is a poor choice for early presbyopia. There is too much neural confusion over which eye should be doing what. Most early presbyopes can still read at or near 20/40 and get confused about what should be happening. On the other hand, low add multifocal contacts offer very good far and near vision and it is easier to "stair step" them through the higher adds when needed.
Keith Ditto, OD
Fort Worth, Texas

You really struck a cord on this issue. After having researched, authored papers, consulted and fit soft multifocals for over 30 years I am astounded how often I still hear from patients whose ECPs inform them that monovision is the better option, multifocal contact lenses really don't work and are also very expensive. Meanwhile I am compelled to go through the none too pleasant task of explaining to the patient why they can no longer comfortably drive at night and/or have such a tough time backing the car out of the garage!

In a nutshell I have come to the sad conclusion that somewhere along the educational stream the boat was missed. The young ECPs graduating today seem more interested in the diagnosing and treatment side of the eyecare profession rather than specialized contact lens fitting.
Jane S. Buckland, FNAO, FCLSA(H), NCLE(AC)
Stuart, FL

In my opinion, there are advantages to monovision over multifocal contact lenses. Multifocal contact lens parameters can be manipulated in many ways to get a desired result, but trying options to give the patient optimum vision may take a great deal of time. Busy patients don't like to spend this time and want an immediate result. It is important to understand the patient's expectations, and more than likely each time something else is tried the patient rapidly loses confidence in the optometrist. In my opinion, this impression is detrimental. This hardly happens with monovision, especially if the system is carefully explained and then demonstrated.

My approach is as follows. I insist all my monovision patients have a set of multifocal spectacles. I prefer to fit 1-day lenses to this group and dispense an extra box of the distance prescription for the non-dominant eye in conjunction with readers. To me this provides more options and far better uncompromised vision and corneal physiology.

Many multifocal contact lenses adopt a modified monovision principle, especially for elderly presbyopes. They possibly give better stereopsis (although I have my doubts) and perhaps better intermediate vision. Having said all this, I do fit multifocal contact lenses, however nothing beats keeping it simple. There is far less chair time spent fitting monovision, often for a similar or better result.
Benjamin Liss, OD
South Africa

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Loretta B. Szczotka-Flynn, OD, PhD, MS, FAAO

Confocal Microscopy in Contact Lens Wearers

As confocal microscopy becomes more common for the detection of corneal disease in research and clinical practice, it is also becoming more common in contact lens research. A confocal microscope is a fascinating instrument that allows in vivo imaging of micro-slices of the cornea from the front to the back. It is possible to image one particular layer such as the epithelium, endothelium, or sub-basal nerve plexus. Prior to implementing rigorous studies using such instrumentation, its use should be validated and standardized for use in contact lens wearers. Two such articles have been recently published. Sindt and coworkers have examined whether fluorescein staining affects the confocal images; they found fluorescein staining did not interfere with laser confocal microscopy of corneal epithelium, sub-basal nerves, or dendritic immune cells.

Chan and coworkers examined whether confocal images could be accurately acquired over a worn soft contact lens. They found that contact lenses did not affect the thickness measurements and the use of a soft lens buffered the cornea during measurements which was effective in eliminating corneal dehydration, preventing staining, and enhancing epithelial image brightness.

Look for more work to be done with confocal microscopy in contact lens wearers. From these preliminary reports, the presence of fluorescein staining will not affect the images which are enhanced with the use of a contact lens worn during the procedure.

Sindt CW, Critser DB, Grout TK, Kern JR. Effects of fluorescein staining on laser in vivo confocal microscopy images of the cornea. J Ophthalmol. 2012;2012:541974. Epub 2012 Jan 26.

Chan KY, Cheung SW, Cho P. Nidek ConfoScan 4 (Z-Ring) Measurements Over Soft Contact Lenses. Eye Contact Lens. 2012 Mar;38(2):80-5.
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Brien Holden, PhD, DSc, OAM, FAAO

The Future Engine of the Contact Lens World

The number of contact lens wearers in the world today is said to be over 125 million, but really there are no hard numbers — partly because the number of wearers in China is not well documented. Estimates range from 15 to 25 million wearers in China with over a third casual wearers of "cosmetic tinted lenses." And these are no ordinary change-iris-color lenses but a kaleidoscope catalogue of amazing hues and designs. The Chinese FDA has recently announced concern and stated that it will ramp up restrictions and regulations on such lenses. But there are forces afoot that will make China not only the biggest economy in the world (estimated to take over from the U.S. as number 1 between 2016 to 2020), but also the biggest contact lens market in the world. My fearless prediction is 100 million wearers in China alone by 2025 — based on two immensely important factors; the growth in personal income and the 700 million Chinese myopes.
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Ronald K. Watanabe, OD, FAAO

A New One-Day for Astigmatism

Vistakon has launched a new toric daily disposable contact lens (DDCL), the 1-Day Acuvue Moist for Astigmatism. It is made of the same etafilcon A with Lacreon Technology that has been very successful as a spherical daily disposable contact lens (DDCL) for a number of years, and the same Accelerated Stabilization Design that has worked well in the Advance and Oasys designs. This lens also has a wide parameter range, as far as DDCLs are concerned. For minus sphere powers up to -9.00 D, cylinder powers are available up to -1.75 DC in axes from 160° to 20° and 60° to 120° in 10° steps, and in -2.25 DC at axes 20°, 90°, 160° and 180°. Plus powers up to +4.00 D are available up to -1.75 DC in 6 cylinder axes (20°, 70°, 90°, 110°, 160° and 180°).

This new lens becomes the third toric DDCL, joining Alcon/Ciba's Focus Dailies Toric and Coopervision's Clearsight 1-Day Toric. The Acuvue lens has the widest parameter range, but all three are excellent options for astigmatic DDCL candidates.
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Corneal Changes Following Short-Term Rigid Contact Lens Wear

The aim of this cross-over study from Australia was to investigate the changes in corneal thickness, anterior and posterior corneal topography, corneal refractive power and ocular wavefront aberrations, following the short term use of rigid contact lenses.

Fourteen participants wore four different types of contact lenses (RGP lenses of 9.5mm and 10.5mm diameter, and for comparison, a PMMA lens of 9.5mm diameter and a soft silicone hydrogel lens) on four different days for a period of 8 hours on each day. Measures were collected before and after contact lens wear and additionally on a baseline day.

Anterior corneal curvature generally showed a flattening with both of the RGP lenses and a steepening with the PMMA lens. A significant negative correlation was found between the change in corneal swelling and central and peripheral posterior corneal curvature (all p</=0.001). RGP contact lenses caused a significant decrease in corneal refractive power (hyperopic shift) of approximately 0.5D. The PMMA contact lenses caused the greatest corneal swelling in both the central (27.92+/-15.49mum, p<0.001) and peripheral (17.78+/-12.11mum, p=0.001) corneal regions, a significant flattening of the posterior cornea and an increase in ocular aberrations (all p

The researchers concluded that the corneal swelling associated with RGP lenses was relatively minor, but there was slight central corneal flattening and a clinically significant hyperopic change in corneal refractive power after the first day of lens wear. The PMMA contact lenses resulted in significant corneal swelling and reduced optical performance of the cornea.

Tyagi G, Collins MJ, Read SA, Davis BA. Corneal changes following short-term rigid contact lens wear. Cont Lens Anterior Eye. 2012 Feb 21. [Epub ahead of print]
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