clinical pearls for the contact lens practice

Transcription

10/10/2010
CLINICAL PEARLS FOR
THE CONTACT LENS PRACTICE
Michael DePaolis, OD, FAAO
DePaolis & Ryan, OD, PC
University of Rochester Medical Center
FINANCIAL DISCLOSURE STATEMENT
Missouri Optometric Association
October 16, 2010
Visionary Eye Associates
University of Rochester Medical Center
[email protected]
Clinical Investigator, Advisory Panel, Consultant
Alcon
Allergan
AMO
Bausch & Lomb
Ciba Vision
Cooper Vision
Paragon Visio Sciences
SynergEyes
Vistakon
Optometric Editor, PRIMARY CARE OPTOMETRY NEWS
Independent Board of Director, RevitalVision
SPECIALTY DISPOSABLE CONTACT LENSES
CURRENT DESIGN OPTIONS
 Multifocal Lenses
 Toric Soft Lenses
 Silicone Hydrogel Lenses
DISPOSABLE MULTIFOCAL & BIFOCAL LENSES
CURRENT OPTIONS
“I don‟t think the trick is staying young,
I think the trick is aging well.”
- Thomas Perls, MD
Director, New England Centenarian Study
 Therapeutic Bandage Lenses
CURRENT OPTIONS
 Is it time for multifocals to replace monovision ?
 What are our current multifocal and bifocal options?
 What clinical pearls are there for each design ?
 What role do higher order aberrations play ?
CURRENT OPTIONS
IS IT TIME FOR MULTIFOCALS TO REPLACE MONOVISION?
Situ, etal Eye & Cont Lens 29(3):2003
N = 50 monovision wearers refit with Acuvue bifocals
At 6 months …
 68% Preferred Acuvue vs 25% preferring monovision
 High contrast distance VA – same between two modalities
 Low contrast distance VA – monovision better
 High & low contrast intermediate VA – Acuvue better
 Stereopsis – Acuvue better
 Subjective ratings – Acuvue better
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CURRENT OPTIONS
CURRENT OPTIONS
IS IT TIME FOR MULTIFOCALS TO REPLACE MONOVISION?
FreshLook progressive multifocal (Wesley - Jessen)
Center near – aspheric midperiphery – annular distance design
Benjamin, WJ CL Spectrum 22(7):2007
N = 46 Prebyopic patients
(14 new, 12 previous drop-outs, 20 existing lens wearers)
Proclear multifocal vs Proclear monovision
 70% Preferred the multifocal
 76% of new wearers preferred the multifocal
 High & low contrast distance VA – same between modalities
 High & low contrast near VA – same between modalities
 Stereoacuity & visual tasking – same between modalities
 Subjective ratings important !!
CURRENT OPTIONS
N = 68 Patients
Overall success ~51%
 There was no statistically significant difference between the success
group and the „failure‟ group with respect to
Comfort
Handling
Centration
Movement
However ….
CURRENT OPTIONS
FreshLook progressive multifocal lens (Wesley-Jessen)
 Distance VA (Bailey-Lovie)
FreshLook progressive multifocal lens (Wesley Jessen)
Successful : 57.18 (20/23) & Failure : 52.61 (20/28)
 Near VA (Bailey-Lovie)
What did we learn ???
Successful : 57.33 (20/36) & Failure : 52.09 (20/46)
Subjective Distance Clarity Rating (1->10)
Successful : 7.85 & Failure : 6.06
 Subjective Near Clarity Rating (1->10)
Successful : 7.55 & Failure : 4.82
% of successful patients as a function of pupil size :
 3 mm -> 61.9%
 4 mm -> 56.7%
 5 mm -> 18.8%
DISPOSABLE BIFOCAL CONTACT LENSES
PRESCRIBING GUIDELINES


•Listen to what patients tell you …
subjective visual reports are important !
•There is a functional limit to what patients can accept …
snellen near VA of 20/40 isn‟t good enough !
•Know the strength (and limitations) of each design ….
pupil size can be critical !
DISPOSABLE BIFOCAL CONTACT LENSES
CURRENT OPTIONS
 Acuvue Oasys for Presbyopia
How can I improve distance vision ?
change distance by 0.25D in D eye, then ND eye
reduce add power in D eye
single vision contact lens in D eye
 Focus Daily Progressive
 Air Optix Aqua Multifocal
How can I improve near vision ?
change add by 0.50D in ND eye, then D eye
increase ND eye distance Rx by +0.50D
single vision „near‟ contact lens in ND eye
 SofLens Multifocal
 PureVision Multifocal
 Frequency 55 Multifocal -> Proclear Multifocal
 Biofinity Multifocal
 C-vue Multifocal
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ACUVUE OASYS for PRESBYOPIA
CURRENT OPTIONS
Acuvue Oasys for Presbyopia
Senofilcon A
84/143
Low, Medium, High Add profiles
Stereoprecision Technology
•Stereo Precision Select
Clinically Tested, Proprietary
lens selection tool
No more guess work for first
fit or follow up, if required
Adhere to prescribing guidelines
N = 206 patients
74% successfully fit within two visits
Successful fits reported acceptable vision 83% of the time
Target presbyopes < 2D add, current wearers, motivated
ACUVUE BIFOCAL CONTACT LENS
 DePaolis M: Wilmer Eye Inst Cornea & Contact Lens Update 4/99.
Successful Acuvue bifocal patients …
50% bilateral equal adds / 33% unequal adds / 17% modified monovision
 Rigel, etal: Optometry Today 7/98.
Successful Acuvue bifocal patients …
51% bilateral equal adds / 32% unequal adds / 17% modified monovision
Used in combination with
refined patient targeting
Result = 70-80% success
in 2 visits.
© Johnson & Johnson Vision Care Inc. 2009
JJVC, data on file.
CURRENT OPTIONS
Air Optix Aqua Multifocal
 Lotrafilcon B with Aqua Moisture System
 86 / 140
 Lo, Med, Hi add profiles
 Precision Transition Lens Design (Center near aspheric)
 Lin, etal Opt & Vis Sci 80(12s):2003
20 Non-presbyopic patients fit with Acuvue Bifocal vs Acuvue 1 Day
Bifocal associated with loss of low contrast distance VA and increased
glare, halos, and ghosting (with increased add)
≤+1.00D
LO ADD
+1.25D to +2.00D
MED ADD
>+2.00D
HI ADD
Guillon, etal CLAO 28(2):2002
45 patients – Acuvue bifocal vs Progressives
Acuvue bifocal statistically better distance and near VA
Determine Initial Lens ADD Design
If near vision inadequate …
• Using the CIBA VISION® Fitting Guide, select an initial lens
1.
Increase distance Rx in non-dominant eye by +050D
2.
Follow the following chart
Allow initial lens to equilbrate
®
®
Confirm adequate fit
Check distance and near
vision binocularly
Use loose lenses to overrefract without monocular
occlusion
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CURRENT OPTIONS
If distance vision vision inadequate …
1.
Increase distance Rx by -025D
2.
Reduce the add in the dominant eye
®
Proclear Multifocal
Omafilcon A
Dominant eye – center “D” (2.3mm)
Nondominant eye – center “N” (1.7mm)
5mm overall optic zone
Add powers : +1.00 / +1.50 / +2.00 / +2.50D
Prescribing guidelines
 “D” profile on dominant eye
 “N” profile on non-dominant eye
 Equilibrate 15 minutes
PROCLEAR MULTIFOCAL LENS
PROCLEAR MULTIFOCAL LENS
Iravani N CL Spec 17(12s):2002
N = 572 presbyopes
31% bifocal lenses
23% monovision lenses
13% single vision lenses
110 eye care practices
Frequency 55 multifocal prescribed
Clinical impressions …
 Lens handles well
 Fits wide range of corneal topographies
 Very good visual results
 Bilateral „D‟ or „N‟ lenses occasionally necessary
Design soon available in comfilcon A (Biofinity) material
92% of patients – distance vision 20/25 or better
71% of patients – near vision J1
95% of patients satisfied with lens comfort
CURRENT OPTIONS
SofLens Multifocal
 Polymacon
 Low add (up to +1.50D)
 High add (over +1.50D)
 8.5 & 8.8 mm BC / 14.5 mm D
 Spherical back surface
PureVision Multifocal
 Balafilcon A
 Low & High Add
 8.6 mm BC / 14.0 mm D
 Aspheric back surface
BAUSCH & LOMB SOFLENS MULTIFOCAL

Vertex adjust distance spherical Rx

Emerging presbyopes (up to +1.50 add)
Low add ou, then …
High add in non-dominant eye

Mature presbyopes (add over +1.50D)
Low add dominant eye / high add non-dominant eye, then ..
High add ou
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CURRENT OPTIONS
Tran, etal Opt & Vis Sci 80(12S):2003.
SOFLENS MULTIFOCAL LENS
Clinical impressions
N = 22 Successful Unilens C-Vue wearers
Compared final lens parameters with fitting guide
 Handles very well
Fitting guide was …
 Fits wide range of corneal topograhies
 A good predictor of distance Rx for both eyes
 A poor predictor of near Rx for either eye
 Very good visual results
 Avoid overminus or underplus
 A good predictor of base curve (80% of time)
8.8 mm BC < 43.00 D flat keratometry < 8.5 mm BC
PUREVISION MULTIFOCAL LENS
 Mixed add powers work well
CURRENT OPTIONS
PureVision clinical features
Balafilcon A (36% H20) DK/t ~ 110
8.6 / 14.0 Center near aspheric design
Low add & high add
Ares, etal Opt & Vis Sci: 82(12) 2005.
What about higher order aberrations ?
Martin & Roorda Opt & Vis Sci 80(12):2003.
N = 16 Patients
Wavefront analysis with & without bifocal contacts
SV CL
Bifocal CL



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Bifocals decreased visual benefits at distance
Bifocals increased visual benefits at near
Provided bifocal effect or increased depth in focus
Outcomes related to individual patient aberrations
SA Multifocal CL
CURRENT OPTIONS
CURRENT OPTIONS
What about gas permeable contact lenses?
WHAT ABOUT HIGHER ORDER ABERRATIONS?
Rajagopalan , etal Optom & Vis Sci 83(8):2006.
Peyre, etal J Fr Ophthal 28(6):2005.
N = 30 Nonpresbyopic Patients
SLMF-high & low / Progressives / Acuvue +2.00 / Proclear +2.00 D & N
Zywave with & without contacts at various pupil sizes



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All designs increased HOA profile with spherical aberration most
Center near designs -> increase (-) SA
Center distance designs -> increase (+) SA
Annular designs increased overall HOA profile by greatest amount
N = 32 Patients (42 – 65 yoa)
GP monovision / GP Essentials / Acuvue Bifocal / PAL Spectacles
High & Low Contrast VA / Contrast Sensitivity / BAT / Near Task Test


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
High & Low Contrast VA: PAL = GP Essentials >> Acuvue
Contrast Sensitivity: GP Essential > Acuvue = Monovision
BAT: GP Essential > Acuvue > Monovision
Near Task Test: GP Essentials = PAL > Monovision > Acuvue
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TORIC SOFT CONTACT LENSES
CONTROVERSIES & CONSIDERATIONS
 Does corneal topography play a role ?
 Is empirical fitting acceptable ?
 Is rotational assessment important ?
 Should we undercorrect cylinder ?
 Have silicone hydrogels become the new standard ?
TOPOGRAPHIC CONSIDERATION
TOPOGRAPHIC CONSIDERATION
Does corneal topography play a role ?
Does corneal topography play a role ?
DePaolis, Aquavella, & Schwartz CLAO Mtg Jan 1990.
Szczotka, Reddy, Roberts Opt & Vis Sci 76(12s):1999.
Summary …
Both back & front surface torics
fit acceptably
Snellen VA similar
 Corneal topography proved valuable
in identifying patient preference
 N = 139 eye empirically fit
 89/139 (64%) eyes enjoyed 1st lens success
 Neither keratometry or asphericity proved valuable in predicting success
 First lens success increases with …
Type I (spherical) corneas
Type II (central astigmatism > peripheral astigmatism) corneas
Type III (central astigmatism = peripheral astigmatism) corneas
 First lens success unlikely with …
Type IV (peripheral astigmatism > central astigmatism) corneas
Type V (irregular peripheral astigmatism) corneas
Is empirical fitting acceptable ?
Empirical fitting based upon keratometry, refraction, & HVID (?)
 Englehart, etal CL Spec 11(12):42, 1996.
N = 128 eyes fit empirically with Cooper Preference toric
100% acceptable fit / 90% achieved 20/20 / 1.25 lenses per eye
 Young, Hunt, & Covey Opt & Vis Sci 79(1):11,2002.
Lens rotation as a function of eyelid topography
If outer canthi is higher -> lens rotates temporally
If inner canthi is higher -> lens rotates nasally
Is rotational assessment important ?
Lawson Cont Lens Spec 8(8):1993
Case presentation:
Contact lens Rx -200-100x180 with 20 degrees rotation left
Over-refraction +075-125x40
Order without rotational compensation : -162-237x16
Order with rotational compensation: -200-150x22
Rotational compensation important when …
cylinder > 1.00D and rotation > 10 degrees
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120%
Should we underprescribe
cylinder ?
100%
97.3%
81.1%
80%
Comstock & Potvin
Intl AAO Mtg April 2000.
67.6%
60%
40%
N = 38 Eyes (Cyl < 1.00D)
% Achieving 20/20 or Better
•Spectacles = 100%
•Toric SCL = 97%
•Spherical SCL = 81%
21.2%
20%
0%
Equal to or better than 20/20
SofLens66 Toric
Equal to or better than 20/15
Spherical Lens
% Achieving 20/15 or Better
•Spectacles = 82%
•Toric SCL = 68%
•Spherical SCL = 21%
Kollbaum & Bradley CLS 20(3): 2005
N = 14 eyes with low astigmatism (-0.75 +/- 0.87D)
Hartmann-shack measurement of mean residual astigmatism
 Biomedic toric -> - 0.02D
 Choice AB asphere -> - 0.74D
 Frequency 55 Asphere -> -0.64D
 High definition AC Asphere -> - 0.60D
Patel, etal Am Acad Opt Poster Dec 2004
N = 133 eyes with < 1.75D astigmatism
Frequency 55 Asphere (N = 84) vs Sphere (N = 49)
 Asphere Mean Astigmatism Correction = 48.73%
 Sphere Mean Astigmatism Correction = 20.69%
 Asphere Mean Astigmatism Correction As f(x) of Type
Against the rule = 66.25%
Oblique = 63.15%
With the rule = 31.63%
What to do with the „low cylinder‟ patient ??
Extreme H2O 54% Toric LC (hydrogel vision)
 54% water hioxifilcon D (GMA-hydrogel group 2 material)
 Cast molded back surface, prism ballast lens
 Daily wear / six pack / replacement q 1 month




8.6 / 14.2
Sphere power: plano to -6.00
Cylinder power: -0.65
Cylinder axis 15 -> 180 degrees
 90% successful fit with first trial lens (Urs Businger, OD, FAAO)
HYBRID LENS TECHNOLOGIES
SYNERGEYES DUETTE
Have silicone hydrogels become the new standard ?
 Rotational & visual performance
 Lens-to-lens consistency
 Overall patient satisfaction




Bausch & Lomb: SofLens 66 -> Purevision
Cooper: Vertex, Frequency 55, -> Proclear -> Biofinity & Avaira
Ciba: Focus -> AirOptix Aqua for astigmatism
Vistakon: Acuvue Advance -> Oasys for astigmatism
Pence CL Spectrum Vol 23 (1):2008
 N = 125 eyes fit Acuvue Advance & N = 175 eyes fit PureVision
 Both designs 90+% of lenses rotated < 10 degrees
 Acuvue slight nasal rotation / PureVision slight temporal rotation
SYNERGEYES DUETTE
Flex2O silicone hydrogel skirt:
 84 DK
 Low modulus
 HealthyEyes™ surface treatment
Proprietary MaxVu RGP center:




130 DK
High modulus flexure resistant edge lift (up to 6D of astigmatism)
Class II UV blocker: >80% of UVA & >95% of UVB
Low wetting angle
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DUETTE vs SYNERGEYES A
SYNERGEYES DUETTE
Who is a good candidate ?
 Patients w/ myopia or hyperopia with or without astigmatism
 Soft toric wearers desiring more consistent vision and improved
acuity
 RGP wearers looking for improved comfort
 Active patients (athletes)
 RGP portion never touches cornea
 Junction lift area corresponds to peripheral curve area of an RGP,
with a slightly more modest lift
 Prolate asphericity of Duette RGP coupled with reverse geometry
of skirt will most often produce an ideal lens-to-cornea alignment
when the selected base curve is ~1D steeper than flat K.
Who is Duette not meant for?
 Keratoconus or PMD
 Post refractive surgery with irregular astigmatism
 Corneal injuries or scars
IDEAL DUETTE FIT
SYNERGEYES DUETTE
Central Clearance:
Thin NaFl Layer Observed
What are our prescribing objectives ?
 Alignment fit with RGP vaulted over the cornea
 Soft skirt landing to create thin lacrimal lake
How do we accomplish this ?
 Initial base curve selection from nomogram
 Fit adjustments controlled by skirt curve


Skirt too flat -> central bearing and adherence
Skirt too steep -> focal junction bearing and discomfort
Pattern of ideal fit exhibits central clearance with thin band of slightly
more peripheral clearance
.
SILICONE HYDROGEL CONTACT LENSES
CLINICAL CONSIDERATIONS
Is continuous wear something patients really want?
What are our concerns about safety?
How is silicone hydrogel technology better?
What are some of the non-continuous wear applications for
silicone hydrogels?
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Is continuous wear something that patients want ?
Nichols, etal Opt Vis Sci 77(12):2000.
N = 48 Patients
Randomized cross-over clinical trial
Disposable EWSCL (AV2) vs Daily disposable (AV 1-Day)
 64.6% of patients preferred EWSCL
 135.4% of patients preferred daily disposable
What are our concerns ?
Infection with loss of
Vision (2 lines BCVA)
•Gimbel, etal Ophth 105(10):1998.
1000 LASIK EYES
INCIDENCE- 0.1%
•Schein, etal Ophth 12(2)2005.
3.6 in 10,000 Si-Hy CWSCL
Holden, etal CL Spec 13(5s):14,1999.
30 Night Continuous Wear Study
 Pre-study: 66% seriously considering laser refractive surgery
 Post-study: 32% seriously considering laser refractive surgery
Why are we concerned ?
Why are we concerned ?
Holden, Tan, Sack Adv Exp Med Biol 350: 427, 1994.
Nichols & King-Smith Cornea 22(6):2003.
Closed eye tear film
results in increased:
Closed eye post-lens tear
film thickness:
Total tear protein
Secretory IgA
Serum albumin
Complement &
Baseline = 2.0u
plasminogen
Activated pmn‟s
30 minutes closed eye = <1.0u
15 minutes closed eye = 1.20u
How is silicone hydrogel technology better? Chou CL Spec 22(6):2008.
WHAT ARE OUR CONCERNS?
 PureVision (B&L) Balafilcon A (36%) DK = 99 1.1MPa PO
Landage , etal Invest Oph & Vis Sci 44:1843,2003.
 Night & Day (Ciba) Lotrafilcon A (24%) DK = 140 1.4MPa
Corneal “homeostasis”
Limbal stem cells -> migratory basal cells
-> wing cells -> surface (squamous) cells
PT
 Acuvue Advance (J&J) Galyfilcon A (47%) DK = 60 0.4MPa IWA
 O2 optix / Air optix (Ciba) Lotrafilcon B (33%) DK = 110
1.2MPa PT
O/N wear dimishes cell shedding
 Acuvue Oasys (J&J) Senofilcon A (38%) DK = 103
Paradoxical epithelial thinning
 Biofinity (Cooper) Comfilcon A (48%) DK = 128 0.75MPa
 Avaira (Cooper) Enflicon A (46%) Dk = 100
0.50MPa
0.73MPa IWA
Wet
Wet
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How is silicone hydrogel technology better?
 1ST generation

Hydrophilic & silicone phases are distinct (TRIS)
LENS
Purevision
H20
36%
DK/t
110
MODULUS
1.50
FRICTION COEFF
22
Surface treated – plasma or plasma oxidation
Night & Day / O2Optix / Purevision
Aqua Night & Day
24%
175
1.52
47
2ND
Air Optix
33%
138
1.00
6
Acuvue Advance
47%
86
0.43
17
Acuvue Oasys
38%
147
0.72
3
Biofinity
48%
160
0.75
-
generation
Silicone based, hydrophilic, & macromer technology
No surface treatment – internal wetting monomer (PVP)
Acuvue Advance & Oasys
 3RD generation
Silicone macromers
No surface treatment
Biofinity / Avaira
Biomaterials Research Unit, Aston University, Birmingham, UK
What about lipid deposition ?
Jones, etal Eye & Cont Lens 29(1S): 2003
Lysozyme uptake
 Night & Day = 5 ug / lens
 PureVision = 10 ug / lens
 Acuvue = 1,000 ug / lens
Suwala, etal Eye & Cont Lens 33(3):2007
In vitro hen egg lysozyme uptake
•Acuvue 2 = 1800 ug / lens
•Proclear = 68 ug / lens
•Advance, Oasys, O2Optix, Purevision ~ 6 ug / lens
•Night & Day = 2 ug / lens
•Lysozyme activity highly variable and lens dependent
Carney, etal Invest Ophth & Vis Sci 49(1): 2008
In vitro adsorption of cholesterol (CH) and polar lipid (PE)
CH > PE adsorption for all lens types for all time points (1 – 20 days)
 Cholesterol (CH) adsorption
 O2Optix = 3 ug / lens
 Oasys = 23 ug / lens PureVision = 24 ug / lens
 Polar Lipid (PE) adsorption
 Night & Day = 0.4 ug / lens & O2Optix 1.5 ug / lens
 Oasys = 4.9 ug / lens & Advance = 5.1 ug / lens
SHOULD WE RUB & RINSE ??
How is silicone hydrogel technology better ?
 Corneal edema
 Corneal neovascularization
 Papillary conjunctivitis
 Infiltrative keratitis
 Infectious keratitis
How are we measuring corneal oxygenation ?
 Oxygen transmission (Dk/t)
 Oxygen flux (Dk/t x oxygen pressure gradient)
 EOP (oxygen debt)
What are we monitoring ?
DK/t for current contact lenses
 Acuvue 2 (J&J) = 31
 Purevision (B&L) = 110
 Aqua Night & Day (Ciba) = 175
 Acuvue Advance (J&J) = 85
 Air Optix (Ciba) = 138
 Acuvue Oasys (J&J) = 147
 Biofinity (Cooper) = 160
 Avaira (Cooper) = 125
 Striate keratopathy
 Epithelial microcyst
 Corneal neovascularization




Epithelial
Epithelial
Epithelial
Epithelial
cell morphology
thickness
desquamation
bacterial binding
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How is silicone hydrogel lens technology better?
DK/t required for edema free daily wear ? ~25
DK/t required for edema free continuous wear ~90
Holden,Mertz ?89
Harvitt, Bonano 87
LaHood,
Sweeney,
& Holden
Dk/t = 125
Keay, etal Opt Vis Sci 77(11):2000.
Microcyst response study
12 mth study of Low Dk vs High Dk
Results:
 No microcyst in high Dk
 Increased microcyst over time in low Dk
 Low Dk -> high Dk eliminates microcysts
Microcyst Treatment
 Immediate refit with si-hy lenses
 Expect increases before improvements – f/u 1 month
WJ Benjamin, OD, PhD, etal
Clinical Case: 50YOM
How is silicone hydrogel lens technology better?
History:
Acuvue 2 monovision
CW x 2 months
Cc: „my Rx needs fine tuned‟
Exam:
VA c SCL OD 20/30+ & OS J3+
SLE – mild epithelial microcystic edema OU
MRx OD -5.00 -1.25 x 10 = 20/20- & OS -4.00 -1.50 x 157 = 20/30+
Dx: Corneal Warpage Tx: Acuvue Oasys 84 -500 OD & -300 OS
1 month f/u:
MRx OD -5.00 -0.50 x 10 = 20/20 & MR OS -4.50 -0.75 x 175 = 20/20-
Mean Limbal Hyperemia
What about neovascularization and hyperemia ?
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



Corneal Edema
Corneal Neovascularization
Papillary Conjunctivitis
Infiltrative Keratitis
Infectious Keratitis
Chalmers, etal Optom & Vis Sci 82:549,2005.
Prevalence of …
•Neovascularization in low DK/t hydrogels: 18% DW & 24% EW
•Limbal redness in low DK/t hydrogels: 31% DW & 35% EW
How is silicone hydrogel lens technology better ?
50
 Corneal neovascularization can be
40
multifactorial
30
LDK
p=0.000
 Discontinue overnight wear until
20
vessels “ghost” *
10
p=NS
HDK
0
 Resume overnight wear with silicone
hydrogel lenses
Base1 M2 M3 M4 M5 M6 M7 M8 M9 M
Dumbleton C (1999): British Contact Lens Association Conference, Birmingham
 Monitor for other etiologies
* Sweeney, etal Eye & Cont 29(1s):2003.
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

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
 Grant & Amos CL Spec 14(6):1999.
Patient subjective & objective evaluations
Lotrafilcon
Tefilcon
Corneal edema
Corneal neovascularization
Papillary conjunctivitis
Infiltrative keratitis
Infectious keratitis
6%
21%
Awareness
Tarsal abnormality
9%
31%
 Porazinski & Donshik CLAO J 25(3):7,1999.
N = 47 patient retrospective (Replace q1day -> 12 weeks)
Overall 21.3% developed GPC
Replacement <4 weeks -> 4.5% GPC
Replacement >4 weeks -> 36% GPC
Risk factors: Allergies
Non-factors: age, sex, lens type, and daily wear time
Is CLPC the „demon‟ in the closet?
CLPC management
 Sczotka, etal ARVO April 2005
 Temporary d/c contact lenses or refit into daily disposables
Meta analysis
Si-Hy complications
22 studies & 12,000+ eyes
CLPC ~ 5% annual incidence
 Stern, etal Opt & Vis Sci 81(6):2004
6 nite vs 30 nite CW study
3 year duration
N = 154 patients
CLPC #1 reason for discontinuation





Corneal edema
 Irrigate & cool compress
 Antihistamine-mast cell or steroid gtt*
 Refit contact lens
* Friedlaender & Howes Am J Oph 123:455, 1997.
Chalmers, Roseman CLAO J 22: 30, 1996.
2324 patient encounters
Prevalence of infiltrates
2.6 % in extended wear
1.4% in daily wear
Holden, etal In Sweeney (ed):
Silicone Hydrogels.
Butterworth Heinemann 2000.
Annualized incidence of EW related infiltrates
Asymptomatic infiltrative keratitis (AIK) ~ 1.5%
 Symptomatic infiltrative keratitis (IK) ~ 1.7%
Contact lens related acute red eye (CLARE) ~ 1.4%
Contact lens peripheral ulcer (CLPU) ~ 0.8%
12
10/10/2010
Nilsson CLAO 27(3):2001.
N = 353 patients in Purevision for 30 nite wear
N = 151 patients in Purevision for 7 nite wear
Annual incidence of corneal infiltrates
4.6% in 30 nite cohort / 2.3% in 7 nite cohort
McNally, et al Eye & Cont Lens 29(1s):2003.
N = 658 patients in 30 nite continuous wear with Night & Day
33 patients (5%) experienced infiltrative keratitis
42% episoded occurred in 1st month
Who is at risk?
Patients under 29 years of age
Smokers
Are there predictors of who is at risk for infiltrates?
Szczotka, etal ARVO 2006.
N = 317 Patients @ 19 investigator sites
Lotrafilcon A cw up to 30 nights
Infiltrate episodes:
yr 1 = 16, yr 2 = 7, yr 3 = 4
 Probability of remaining infiltrate free:
94% in yr 1, 92% in yr 2, 90% in yr 3
Limbal redness & corneal staining predictive of infiltrative events
History in CLARE or CLPU
Corneal infiltrates can signal mechanical, toxic, immunogenic, or infectious
stress
Discontinue contact lens wear and stage treatment
(Monitor -> steroid/antibiotic gtt -> antibiotic gtt)
Refit with silicone hydrogel lenses or daily disposables





Corneal edema
Oxidative disinfection ?? / Replacement compliance
Morgan, etal Br J Ophth 89(4):2005.
RELATIVE RISK OF CONTACT LENS RELATED MICROBIAL KERATITIS
12 month, prospective, hospital based study
Non-severe keratitis (NSK) vs severe keratitis (SK)
Population based controls (per 10,000 patient years)
Daily wear gpcl -> 2.9
Daily wear daily disposables -> 4.9
Daily wear soft lenses -> 6.4
Extended wear soft lenses -> 96.4
Extended wear silicone hydrogels -> 19.8
CONTACT LENS COMPLICATIONS
MICROBIAL KERATITIS
Silicone hydrogel microbial keratitis
Dart, etal Ophthalmology 115(10):2008
Case control study
367 presumed cases of microbial keratitis
 1069 hospital controls & 639 population controls
Relative risk for developing microbial keratitis (Soft PRP as referent)
 gpcls 0.16x
 daily disposables 1.56x
 Overnight wear lens 5.42x
 No difference between silicone hydrogels and other soft lenses
 Vision loss less likely to occur in daily disposable continuous wear
13
10/10/2010
CONTACT LENS COMPLICATIONS
MICROBIAL KERATITIS
Silicone hydrogel microbial keratitis
Stapleton, etal Ophthalmology 115(10):2008
 12 month prospective population surveillance study in Australia
 285 cases of microbial keratitis and 1798 controls
 Annualized incidence of microbial keratitis (per 10,000 wearers)
 Gas permeable – 1.2
 Daily wear soft – 1.9
 Occasional overnight – 2.2
 Daily disposable – 2.0
 Occasional overnight (DD) – 4.2
 Overnight wear soft lenses – 19.5
 Overnight wear silicone hydrogels – 25.4
WHAT ABOUT CORNEAL STAINING ?
Snyder & Nash ICLC 11(11):1994
 Corneal staining in 75% of all
contact lens wearing visits
 Corneal staining in 37.5% of
all non-lens wearing visits
“While the incidence of staining in the subject
group was 100% and the control group 75%,
none of the staining was judged
severe enough to affect patient
management.”
DO SILICONE HYDROGELS WORK FOR DRY EYE?
Caffery, B Siliconehydrogels.org November 2003
Improved oxygen transmission -> better innervation
Higher modulus -> better mobility
Less water -> Less dehydration
Improved surface -> Less protein
Sickenberger, W Siliconehydrogels.org February 2004
N = 30 patients with dry eye (97% sx) -> refit to Si-Hy with 3 month f/u
% able to wear lenses >12 hrs qd: 25% - > 65%
Computer users reported ave wt increase of 2 h qd
Clinical data supports claims of saftey and efficacy …
Patient selection is important
 No smokers
 No history of CLARE
 No ocular surface disease
 No young males (?)
 No swimming
Choo, etal Optom & Vis Sci 82(2):2005.
N = 15 subjects
Purevision vs Acuvue 2
30 minutes swimming
Increased bacterial burden
 Colonization similar between materials
 Staph epidermidis most common isolate
WHAT ABOUT CORNEAL STAINING ?
Jones, etal Con Lens & Ant Eye 20(1):1997
 Increased incidence of staining in Group II and silicone hydrogel lens
wearers using Polyhexamethylene biguanide (PHMB) solutions
 N-vinyl pyrolidone (NVP) binds to PHMB adsorbed onto lens surface
 www.staininggrid.org ???
 IER Matrix Study
Carnt, etal CL Spec 22(9):2007
Use professional discretion
What about Daily Disposables?
 Bausch & Lomb Daily Disposable
 59% water Hilafilcon B (FDA II)
 Aspheric Optics
 Poloxamine based solution
 Ciba Vision Dailies AquaComfort Plus
 69% water Nelfilcon A
 PEG & HPMC based solution
 Cooper Vision Proclear 1-Day
 60% water Omafilcon A
 Aspheric Optics
 J&J 1-Day Acuvue Moist
Riley, etal Eye & Cont Lens 32(6):2006.
N = 1092 habitual contact lens wearers with 23% c/o dryness
75% of those refit with Oasys reported improved dryness
 58% water Etafilcon A
 UV Block
 Lacreon based solution
14
10/10/2010
Therapeutic Bandage Contact Lenses
Questions for consideration
6. Patients with bullous keratopathy are at increased risk of
developing microbial keratitis with each of the following
risk factors, except:
a.
b.
c.
d.
e.
Increased corneal bullae size
Bandage contact lens use
Male gender
Chronic steroid gtt use
All of the above are risk factors
Therapeutic Bandage Contact Lenses
Questions for consideration
THERAPEUTIC BANDAGE CONTACT LENSES
CLINICAL INDICATIONS
Luchs, etal Ophth 104(5):1997




N = 918 Bullous Keratopathy Patients
4.7% developed ulcerative keratitis
Streptococcus pneumoniae most common
Prophylactic antibiotic conferred no
protective
Risk Factors For Infectious Keratitis?
 Steroid use
 Bandage lens use
 Increased bullae
THERAPEUTIC BANDAGE CONTACT LENSES
CLINICAL INDICATIONS
Persistent epithelial defect / recurrent corneal erosion
7. In treating a recurrent corneal erosion, the appropriate
order of therapeutic strategies should include:
a.
b.
c.
d.
e.
stromal micropuncture, bandage lens, doxycycline
bandage lens, doxycycline, stromal micropuncture
doxycycline, stromal micropuncture, bandage lens
stromal micropuncture, doxycycline, bandage lens
doxycycline, bandage lens, stromal micropuncture
 Reduces pain
 Accelerate
healing ?
 Adjunct
prophylactic
antibiotics
 Additional considertions:
Is it trauma or dystrophy induced?
Is doxycycline, tarsorraphy, or amniotic membrane indicated ?
Is stromal puncture, diamond burr debridement, or ptk indicated ?
CLINICAL PEARLS FOR THE
CONTACT LENS PRACTICE
THANK YOU FOR ATTENDING !!
Visionary Eye Associates
University of Rochester
Medical Center
[email protected]
15

clinical pearls for the contact lens practice

Transcription

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