The Importance of UV Protection:

A ROUNDTABLE DISCUSSION

Peter Bergenske, OD, Jan Bergmanson, OD, PhD, FC Optom, Glenda Secor, OD,Joseph Shovlin, OD,Jack Yager, OD
JUNE 1998

Would you place UV protection high on a scale of important considerations in contact lens practice? Contact Lens Spectrum editor Dr. Joe Barr gathered this group of prominent clinicians and researchers to contemplate the issue.

With managed care looming over your practice, chair time is more valuable than ever before. Now that you have to be more judicious about how you spend time with your patients, is it worth your while and theirs to talk about protecting their eyes from the dangers of ultraviolet radiation (UVR)? What role does UVR play in the development of ocular conditions such as pterygium, endothelial polymegethism and cataract, and what role should UV-blocking contact lenses play in your practice? Questions like these were the topic of this recent roundtable discussion.

Clinical Manifestations of UVR

Dr. Shovlin: Increased life expectancy, increased outdoor activities and decreased ozone thickness all contribute to an increase in our lifetime dose of UVR today, so I think we can safely assume increased ocular morbidity in one form or another.

Dr. Bergmanson: Current observations suggest that the ozone layer will get worse before it gets better. We're on the right track, but chlorofluorocarbons aren't the only thing that can damage the ozone. While we'll probably have to wait to see significant ozone layer improvement, we're well advised to continue to advise our patients on preventative care for their eyes and skin.

Ninety percent of all skin cancers appear in the head and neck region, so we should remember to look at the face, head, eyelids and adnexa of our patients. We should be suspicious anytime a pigmented or unpigmented bump has a recent history. Classic signs of lid cancer are abnormal vasculature and a loss of the normal lid contour of the lid margin. The crystalline lens and the cornea are the primary UVR filters of the eye. High-intensity, short wavelength (blue) visible light can damage retinal receptor cells and that UVR is a risk factor in cataract formation.

Dr. Shovlin: The periocular skin is particularly vulnerable to the deleterious effects of high energy. Lid cancers can assume various clinical presentations. We should be especially suspicious of lesions associated with loss of lashes along the lid margin.

Dr. Bergmanson: Being outside for only 30 minutes on a summer day in New York can give you a UVR keratitis. UVR keratitis is often painful because it damages the epithelium where the majority of the corneal nerve fibers are, but it may also present with mild symptoms such as a sand-in-the-eye feeling.

Dr. Bergenske: You'd think that clinically, we'd see more occurrences of UVR keratitis than we do.

Dr. Bergmanson: Maybe there are more occurrences but we just don't recognize them. In the past, we've only focused on the full-blown cataract -- the end result. We should look for more subtle signs.

Dr. Secor: So even if patients are out for an hour at lunchtime, they might heal up when they go back indoors. That means you're not going to see the acute cases of photokeratitis; you're only going to see the full-blown cases.

Dr. Bergmanson: There are three corneal conditions that we know that have an association to UVR exposure. Photokeratitis is an acute response and climatic droplet keratopathy is the more chronic response. John Schoessler and Greg Good conducted a study which indicated that polymegethism in a clinical population could be related to chronic UVR exposure. Now we have enough studies to say that pterygium clearly has a strong association with UVR exposure. Coroneo and colleagues offer an explanation for why pterygium formation is so much more common on the nasal conjunctiva. Incident light entering the temporal side of the cornea in a tangential direction will travel across the anterior chamber and become focused on the nasal side. Our noses prevent this from happening on the temporal side. Except for wrap-around designs, no sunglasses cover this range.

Dr. Barr: Besides damage to superficial cells, does damage also involve basal stem cells?

Dr. Bergmanson: Relatively modest energies will provide full thickness epithelial damage. In chronic studies, cortical cataract is associated with UVR. Perhaps we should monitor the condition of the lens by measuring the amplitude of accommodation. Premature presbyopia could be a sign of a higher lifetime UVR exposure. Cornea and crystalline lens should definitely be protected from UVR.

Protective Options

Dr. Bergmanson: There are good UVR filters available in ophthalmic lenses and sunglasses, and now we have the contact lens option. The classic approaches such as wearing wide-brimmed hats and limiting outdoor activities are also helpful. While the spectacle lens does not offer a complete protection of the eye, a good soft contact lens will cover important parts of the conjunctiva, the entire cornea and the intraocular components. But not every UVR filter is the same. The UVR band is divided into three ranges -- UVA, UVB, UVC. If you look at Vistakon's Acuvue UV-absorbing lens, you'll see a window in the UVC range, but this is not a concern as long as there's an ozone layer to block UVC (Fig. 1). The lens looks good in the UVB range, with practically 100 percent absorption up to 380nm. UVR-blocking capability in hydrogels is a function of lens thickness, so the FDA requires that manufacturers measure the thinnest lens.

Dr. Bergenske: The amount of UVR transmitted is not equal across the surface of the contact lens. The thinnest part of a minus lens is right over the pupil, so you're going to have the highest transmission right there.

Dr. Bergmanson: Remember too, that RGP lenses, being smaller than soft lenses, are not going to offer the same level of protection.

Dr. Shovlin: We should be mindful that non-prescription options remain a valuable tool. Some important recommendations include wearing sunscreen with an SPF of 15 or greater on the skin and limiting outdoor exposure from 10:00a.m. to 3:00p.m. when the sun is most intense, especially when you're near the equator and in high-altitude environments.

UV Protection in Every Lens?

Dr. Barr: Do we all agree that we would like to have UVR absorber in every contact lens?

Dr. Secor: There hasn't been any indication of a problem with having it there, so it certainly is a benefit. There's no additional cost to me and I haven't had to add additional cost to the patient, so there's no reason not to.

Dr. Shovlin: Whether UVR toxicity is the leading cause for lens opacity isn't really the issue with the science available today. Even if we're not convinced that we can delay onset with the use of blocking agents and perhaps free radical scavengers, why not do it? At the 1997 American Academy of Optometry in San Antonio, Texas, I couldn't help but notice the spate of papers on UVR blocking lenses which showed no adverse effect on oxygen transmission, fit, comfort or deposition characteristics of these lenses.

Dr. Bergenske: If all things are not equal, you would tend to choose the non UVR-blocking product first if it has other advantages. All things being equal, of course, you would choose the UVR-blocking lens. If you were offered the exact same lens with and without UVR-blocker, why would you ever take it without the blocker? I guess I'm not convinced that a UVR-blocker is necessary, but I don't see any reason not to use it if all other things are equal.

Plano UV-Blocking Lenses

Dr. Bergenske: Many outdoor enthusiasts don't require any correction. Do you think they should be wearing plano lenses with UVR absorber?

Dr. Barr: Does this parallel the old issue concerning the ethics of prescribing plano cosmetic tinted lenses to people?

Dr. Bergenske: With plano cosmetic lenses, there is zero benefit and some risk. But is the amount of protection we're providing patients with plano UV-blocking lenses greater than the amount of risk we're creating by having them wear contact lenses? If you accept the hypothesis that UVR increases the risk of many significant pathologies, you have to conclude that everyone who is outdoors should wear UVR-blocking lenses.

Dr. Barr: Many doctors are unwilling to prescribe them because it takes so long for adverse effects to develop. From their perspective, the short-term acute risks outweigh the long-term benefits.

Indoor UV Risk

Dr. Barr: We've said that it's a good idea to stay indoors between certain hours of the day to avoid exposure to UVR. Does that mean there's no UVR risk indoors?

Dr. Bergmanson: In general, UVR intensities indoors are below threshold and are not considered a significant risk. Certain environments like television studios and showroom windows that use high-pressure mercury vapor lights emit significant dosages. Incandescent and fluorescent lights are generally not a hazard. Computers? Not even close.

Dr. Barr: If you're going to spend the rest of your working life under a fluorescent light -- perhaps a third or one-half of your lifetime -- is that something worth protecting yourself from?

Dr. Bergmanson: Obviously, all UVR exposure adds up, so perhaps we should factor the indoor exposure plus the outdoor exposure in the overall equation. That's the great thing about a contact lens -- unlike the sunglass wearer, the contact lens wearer always has his protection on.

When UV Protection is a Must

Dr. Barr: Of the ocular diseases associated with UVR, which ones concern you enough to discuss UVR protection with your patients?

Dr. Secor: Pterygium and cortical cataracts. If I picked up an early sign, I'd probably be more likely to indicate to the patient that there are things that we can do to potentially prevent progression of certain conditions.

Dr. Yager: I would first explain basal cell and squamous cell carcinoma and how that relates to the thinning of the ozone. These hazards have far more serious outcomes than pterygium and cataract.

Dr. Shovlin: I'm most concerned about periocular cutaneous cancers and intraocular melanoma. A case-control study that investigated factors in patients who acquired intraocular melanoma (Tucker, Shields, Hartge et al.) found that inhabitants of southern states had a risk of 2.7 times greater than inhabitants of northern states. Subjects with brown eyes were more protected than those with blue eyes, but neither complexion nor hair color were important risk factors for melanoma in this study. Patients with the condition were more likely to have spent time outdoors in the garden, to have sun-bathed, to have used sunlamps, and to have rarely worn hats, visors or sunglasses while in the sun.

Dr. Yager: One thing we didn't discuss was the increased transmission of UVR in children. I think it's an important issue because we're gauging all of our decisions on what we've seen in the past 20 years, but the next 20 may be worse.

Dr. Shovlin: Crystalline lenses of children are partially transparent to UVA, but long-term exposure is difficult to address. So I still think they need to be included in the high-risk group along with older individuals, aphakes, lightly pigmented individuals and those on photosensitizing medications like tetracycline and allopurinal. Another interesting group includes those who have UVR chromophores in their IOLs from the 1980s but have had significant Yag laser pitting of their IOLs, or those who've had such a lens in their eye for 40 to 50 years.

Dr. Bergenske: The tissues surrounding the eye are at risk for the cancers and we need to be concerned about that.

Talking to Patients

Dr. Barr: Do we agree that most doctors most of the time don't discuss the adverse effects of UVR unless their patients ask? Because most of the complications are chronic, do most doctors feel that they don't have to worry about it now?

Dr. Secor: I agree, but I don't think we're avoiding the issue. I think practitioners just aren't aware of it and don't feel it's critical enough to discuss. The media has certainly brought the issue of UVR protection into my routine patient discussions more often now because patients are bringing it up. I think it's the industry directing the professional, but patients are becoming a lot more knowledgeable.

Dr. Bergenske: Let's say you have a patient who has a -1.00D cylinder. He could wear a toric lens and see maybe a line or two better, or he could wear a lens that has a UVR absorber in a spherical equivalent, but there are no UVR-absorbing toric lenses. I think most of us would choose to put him in a toric contact lens for the better vision. We would see the immediate result as being more beneficial to the patient.

Dr. Barr: What if the patient is a fisherman or a snow ski instructor?

Dr. Bergenske: In those situations, you might change your decision. On the other hand, skiers and lifeguards wear sunglasses anyway.

Dr. Secor: It goes back to vacation, vocation and lifestyle, as well as whether or not they already have a pterygium or other conditions that might influence your recommendation.

Dr. Bergenske: The other issue I have a problem with is the idea of "selling" sunglasses or UVR absorbers to people by scaring them.

Dr. Barr: A psychologist who wrote a book on compliance said that the best methods to ensure compliance are education, re-education, more re-education and having a good relationship with patients. Those things are far more valuable than scare tactics.

Dr. Secor: We use scare tactics mostly when we talk about ulcers or over-wear of extended wear lenses. If you cry wolf too many times, your patients are not going to listen to you. You have to decide which battles you're going to fight.

Dr. Bergenske: Maybe we'd be doing our patients a bigger favor by giving them a lecture on putting sunscreen on their nose than by taking the time to talk about UVR potential harm to their eyes and why they should have UVR-absorbing lenses.

Dr. Bergmanson: I don't think that informing patients about what we know about the ocular consequences of too much UVR is a scare tactic. We're providing information and we're educating. We have very solid evidence on cornea and cataract toxicity of UVR, and there are people who we are definitely going to serve well by giving them a UVR education, which shouldn't be limited to the eye.

Dr. Barr: Let's take the doctor out of the equation. What can we have our staff do and what can we do even in the reception area to educate people about this? What would be really effective in terms of staff and reception area brochure education?

Dr. Secor: Brochures that have UVR information are already available from several companies.

Dr. Shovlin: The AOA also has a nice piece entitled "Protect Your Eyes From UV Radiation," which has a checklist to assess risk factors.

Dr. Bergmanson: When patients ask about UVR, our dispensing staff has a whole set of statements on this issue, and they tell patients that we're going to give them a complimentary UVR filter on their spectacle lenses.

Dr. Bergenske: That's a great idea. I can't imagine that anybody ever turns you down when you offer to give them something free. I have always had trouble "selling" ultraviolet protection because patients can't see it and it doesn't make them feel any better.

Dr. Shovlin: Until we resolve some of the controversies regarding the effects of UVR on the eye, some clinicians will feel awkward promoting lens features that they believe have no scientific basis. But in this age of wellness, alternatives to medicine are attractive, and I've never found it difficult to tout the benefits of minimizing UVR exposure. As eyecare practitioners, we need to spend ample time educating our patients. It's what brings them back.

Dr. Secor: I agree that it's important for us to share information with our patients. I think my level of knowledge or awareness has been brought up a notch. Industry has taken us to the water hole and whether or not we drink is up to us. CLS

This roundtable was sponsored by Vistakon, a division of Johnson & Johnson Products, Inc.

Dr. Bergenske practices in Madison, Wisc.

Dr. Bergmanson is a professor of optometry and director of the Laser Laboratory and the Anatomy and Pathology Laboratory at the University of Houston.

Dr. Secor practices in Huntingdon Beach, Calif.

Dr. Shovlin is director of the Contact Lens Service at the Northeastern Eye Institute, Scranton, Pa.

Dr. Yager practices in Orlando, Fla.