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Sunday, April 15, 2012  
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Last week's question:
Are lipid emulsion based artificial tears effective in treating meibomian gland dysfunction?

 A. Very effective

 B. Moderately effective

 C. Not effective

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

Multifocal contact lenses have been around for a number of years, but it's important to revisit some significant facts about this modality given the changing age demographic of the market. In the United States, the U.S. Census Bureau indicates that there were about 97 million people over the age of 45 in 2000, while that number has grown to 121 million in 2010 (http://www.census.gov/prod/cen2010/briefs/c2010br-03.pdf). While eyecare practitioners in the U.S. fit more multifocals compared with monovision, the actual number of multifocal fits is relatively low. We know from studies (Situ 2003, Richdale, 2006) that about 7 out of 10 patients actually prefer multifocals when given the choice. With all of the great new technologies in multifocal designs, take the time to be more proactive in fitting this modality. Your patients and practice will benefit from it.

Situ P, Du Toit R, Fonn D, Simpson T. Successful Monovision Contact Lens Wearers Refitted with Bifocal Contact Lenses. Eye Contact Lens, 2003 Jul;29(3):181-4.
Richdale K, Mitchell GL, Zadnik K. Comparison of Multifocal and Monovision Soft Contact Lens Corrections in Patients With Low-Astigmatic Presbyopia. Optom Vis Sci. 2006 May;83(5):266-73.

Optometric Historical Society to Honor Dr. Irvin Borish

Each year the Optometric Historical Society holds a Reminisce-IN honoring optometry's heritage and history. This year the meeting will be held during Optometry's Meeting in Chicago at 3:00 PM on Thursday, June 28. The meeting will honor the life and contributions of Dr. Irvin Borish, considered by many as the father of modern optometry. Borish passed away at the age of 99 on March 3, 2012.

The tribute to Dr. Borish will be led by his long time friend, Dr. Alden N. Haffner, President Emeritus of SUNY, College of Optometry. Dr Borish was a member of the founding committee of the School of Optometry at Indiana University. He authored the definitive reference text on clinical optometry and was named the most influential optometrist of the 20th century.

Those attending the AOA are invited to this tribute to one of the great men of modern optometry. The program will focus on Borish's many substantial achievements and attendees will be asked to relate stories about this great man.

Vistakon Launches the 2012 Acuvue 1-Day Teen-Focused Contest

Vistakon Division of Johnson & Johnson Vision Care, Inc. revealed the 2012 celebrity ensemble for this year's "Acuvue 1-Day Contest." Celebrity mentors include: pop star Demi Lovato, musician Joe Jonas, television star Tyler Blackburn, actress Meaghan Martin and world champion sprinter Allyson Felix. The contest, now in its second year, will give five winners the chance to meet and be mentored for a day by one of the five teen icons.

The five lucky winners will also receive a second trip to Los Angeles to attend a teen event, and a one-year supply of 1-Day Acuvue Moist contact lenses. To enter, now through June 7, 2012, contestants should go to the Acuvue channel on YouTube, www.youtube.com/acuvue, and upload a 30 to 60 second video showcasing what they hope to achieve one day, how they find the confidence to pursue their dreams and why they should be chosen for this mentorship opportunity. Contestants also will be able to view other entries and vote for their favorite to win one of five First Prizes — $1,000 each to put towards their dream.

Official Rules can be found at www.YouTube.com/Acuvue.

PBA Elects McClellan to National Board of Directors

Prevent Blindness America (PBA) announced that Brette McClellan, Vice President, Health Policy Government Affairs of Alcon, has been elected to its National Board of Directors.

At Alcon, McClellan leads the development and communication of Alcon's policy positions pertaining to regulations and legislation that impact the ability of drug and device companies to develop and market products for eye care. She also oversees the market access function within Alcon, which seeks fair and adequate payment for technologies used to improve or save vision.

McClellan has previously volunteered for PBA by helping to orchestrate two Congressional Vision Caucus (CVC) Capitol Hill events hosted jointly by AdvaMed's Ophthalmic Sector and PBA.

For more information about Prevent Blindness America, visit www.preventblindness.org.

Traumatic Lesion
By William Townsend, OD, FAAO

The linear lesion seen in this patient resulted from a very hot steel fragment passing across the surface of the cornea. In effect, the epithelium was totally destroyed in the affected areas. Crucial prognostic indicators included: charring of the tissue, penetration of the burn into Bowman's layer and stroma, and loss of large areas of corneal epithelium.

For more on this patient see http://www.clspectrum.com/articleviewer.aspx?articleID=102030

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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Guest Columnist: Ashley Wallace-Tucker, OD, FAAO; Kelly K. Nichols, OD, MPH, PhD, FAAO

Are GP lenses a better contact lens option for the dry patient?

It is commonly known that approximately 50% of all contact lens wearers suffer from dry eye. The vast majority of recent research has been focused on soft contact lens-related dry eye because this modality dominates the market. However, some believe that rigid gas permeable (GP) lens wearers have less symptoms of dry eye.

Gas permeable lenses may, in fact, provide better contact lens success when compared to soft lenses for two reasons: oxygen transmission (Dk/t) and tear exchange. Oxygen transmissibility is an essential property for maintaining corneal integrity and some believe it may prevent or reduce dry eye, yet research supporting this concept is limited. Although silicone hydrogel lenses provide excellent oxygen transmission, research has shown that a GP lens with a Dk/t of 90 is equivalent to a silicone hydrogel lens with a Dk/t of 125.1 Inadequate tear exchange has been shown to result in increased risk of infection and inflammation and decreased oxygen delivery making it another potential factor in contact lens dry eye.2 Gas permeable lenses can exchange up to 20% of the tear volume per blink whereas soft lenses can exchange only approximately 1% of the tear volume per blink.2,3

Although we are unaware of definitive published research on whether or not gas permeable contact lenses are superior to silicone hydrogel lenses for dry eye patients, we need to consider them as a viable option for our patients. In addition, large diameter scleral type lenses are recommended for moderate to severe recalcitrant dry eye.

1. Ichijima H, Cavanagh HD. How rigid gas permeable lenses Ssupply more oxygen to the cornea than silicone hydrogels: a new model. Eye Contact Lens 2007; 33 (5):216-223.
2. McNamara et al. Tear mixing under a soft contact lens: effects of lens diameter. Am J of Ophthalmol, 101 (1999), pp. 659–665.
3. Bennett ES, Ghormley NR. Rigid extended wear: an overview. Int. Contact Lens Clin 1987; 14 (8): 319-332.

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Brien Holden, PhD, DSc, OAM, FAAO

Heroes and Villains

I've been involved with the contact lens industry for over 40 years, as student, academic, educator, researcher, collaborator, inventor and implementer.

I have worked with some wonderful people and I've experienced the great and the not-so-great—the heroes and villains.

There are many unsung heroes: Adrian Hunter (the 'instigator' and deliverer of the silicone hydrogel lens—so far a $20 billion product); a whole bunch of folk who invented RGPs; Otto Wichterle, of course, who created 250 million CL wearers (including dropouts). Those that toiled for peroxide and relatively trouble-free lens care systems and the Danes and Hank Green the forerunner of Vistakon, the Mike Sealys and Geoff Galleys of the world who developed molding of soft lenses. And you have to hand it to the most enduring technological partnership in the industry—Tony Martin and John Heaton at Vistakon—who have driven Vistakon's development and retention of the number one market share spot for what seems like 100 years between them.

Although some would consider me from time to time something of a villain, I've also experienced a fair share of them myself. I've been told not to publish scientific insights about problems, to which I explained that as healthcare professionals we have an obligation to inform and say something when health and safety are at stake. Through the years, our teams have developed intellectual property, which lead to financial royalties to fund more research, education and blindness prevention. That said, we've experienced our share of disagreements when it comes time to pay royalties on the work we've done, but we've had unsung heroes step in and do the right thing and the villains step in and prevent our just rewards.

Overall though, there are some great people in our industry, who have OVERCOME all sorts of obstacles to bring us to the level of contact lens use that we have today. To get to the next level, the best of the older generation and the new generation need to take innovation to a new level in our field. We need to defeat our nemesis, end-of-day discomfort, and to realize the potential of myopia control—but one thing is for sure, we won't get there without some new heroes, especially from industry.

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Susan J. Gromacki, OD, MS, FAAO

Hand-Washing: The Consequences

In my last column, I brought attention to the importance of hand-washing prior to contact lens handling and presented the CDC's recommended techniques. Today I will discuss the consequences of poor hand hygiene.

Two publications this month in Contact Lens and Anterior Eye provide excellent information on this topic. The first found that poor (or no) hand-washing resulted in increased lipid deposits on contact lenses.1 This can adversely affect contact lens comfort, fit, wearing time, and visual acuity—not to mention attract microbial contamination to the contact lens surface.

A second review article addresses all aspects of hand hygiene with regards to contact lens care.2 The paper states that poor hand-washing results in increased bacterial bioburden on the lens and/or eye. This potentially contributes to dry eye and contact lens discomfort, resulting in discontinuation of lens wear in some patients. There may also be inflammatory responses to bioburden, including palpebral and bulbar conjunctival injection and corneal inflammatory events. Ultimately, less frequent hand-washing is a risk factor for microbial keratitis. Good hand hygiene, meanwhile, removes hand lotion, makeup, and other oils, which can make lenses uncomfortable or blurry. So, remember to discuss this important issue with you patients—it could extend their longevity in contact lenses.

1. Campbell D, Mann A, Hunt O, Santos LJ. The significance of hand wash compliance on the transfer of dermal lipids in contact lens wear. Cont Lens Ant Eye. 2012 Apr;35(2):71-6; quiz 96-7. Epub 2011 Dec 16.
2. McMonnies CW. Hand hygiene prior to contact lens handling is problematical. Cont Lens Ant Eye. 2012 Apr;35(2):65-70. Epub 2011 Dec 24

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A New System, the LipiFlow, for the Treatment of MGD

These researchers wanted to evaluate the safety and effectiveness of the LipiFlow System compared to the iHeat Warm Compress (WC) for adults with meibomian gland dysfunction (MGD).

This was a non-significant risk, prospective, open-label, randomized, crossover multicenter clinical trial. One hundred thirty-nine subjects were randomized between LipiFlow (n=69) and WC control (n=70). Subjects in the LipiFlow group received a 12-minute LipiFlow treatment and were reexamined at 1 day, 2 weeks and 4 weeks. Control subjects received a 5-minute iHeat treatment with instructions to perform the same treatment daily for 2 weeks. At 2 weeks, they crossed over (LipiFlow Crossover) and received the LipiFlow treatment. Effectiveness parameters evaluated included: meibomian gland (MG) assessment, tear break-up time (TBUT) and dry eye symptoms. Safety parameters included: adverse events, ocular health exam, ocular surface staining, intraocular pressure, visual acuity and discomfort.

LipiFlow resulted in significant improvement (P < 0.05) in MG secretion at 2 and 4 weeks (mean +/- standard deviation at baseline = 6.3 +/- 3.5; 2 weeks = 14.3 +/- 8.7; 4 weeks = 16.7 +/- 8.7); and TBUT at 2 and 4 weeks: (at baseline = 5.5 +/- 2.9; 2 weeks = 6.9 +/- 5.0; 4 weeks = 7.4 +/-5.5). There was no significant change in MG secretion or TBUT in the control group. LipiFlow resulted in a greater significant reduction in dry eye symptoms than the iHeat WC. The crossover group demonstrated similar significant improvement 2 weeks post-treatment with the LipiFlow. There was no significant difference between groups in the incidence of non-serious, device-related adverse events.

The researchers concluded that the LipiFlow System was significantly more effective than iHeat WC. These results support its safety and effectiveness in the treatment of MGD and dry eye symptoms.

Lane SS, Dubiner HB, Epstein RJ, et al. A New System, the LipiFlow, for the Treatment of Meibomian Gland Dysfunction. Cornea 2012;31:396-404.

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