GSLS MEETING

Global Specialty Lens Symposium Report

Research and education highlights from this first global meeting on specialty contact lens fitting.

By L. Gina Sorbara, OD, MSc, FAAO, Dipl C&CL

Dr. Sorbara is an associate professor at the University of Waterloo in Ontario, Canada. She is actively involved in research at the Centre for Contact Lens Research at the University of Waterloo. Her current research interests are in specialty contact lens designs, corneal topography, fluorophotometry and clinical trials involving new lens materials, etc.

The 2009 Global Specialty Lens Symposium (GSLS) took place from Jan. 15 to 18 in Las Vegas. It was presented by Contact Lens Spectrum and the Health Care Conference Group.

This conference hosted more than 320 attendees and presented not only the latest developments in keratoconus and irregular astigmatism, as last year's Global Keratoconus Congress did, but also other specialty contact lens topics such as contact lenses for pediatric and adolescent patients, myopia management with orthokeratology and other methods, large-diameter corneal and scleral lenses for irregular astigmatism and advanced keratoconus, managing presbyopia, custom soft lens applications, the latest on lens care and compliance and, finally, reimbursement issues for contact lenses. This diverse educational program was orchestrated by the GSLS planning committee that included Jason Nichols, OD, MPH, PhD, FAAO; Craig Norman, FCLSA; Patrick Caroline, FAAO; Eef van der Worp, BOptom, PhD, FAAO, FIACLE; and Ed Bennett, OD, MSEd, FAAO.

The meeting also included a number of breakout sessions with hands-on workshops (live patient participation, Figure 1), free paper sessions, poster displays and expert panel discussions. There were also informative industry-sponsored breakfast seminars updating us on the latest manufacturing and product developments.

Here I will summarize the information presented at the general sessions of this exciting symposium.

Figure 1. Some Breakout Sessions from the GSLS meeting featured hands-on workshops with patients.

Contact Lenses for Pediatric and Adolescent Patients

Jeff Walline, OD, PhD, initiated the symposium with a review of results of the Contact Lens In Pediatrics (CLIP) study. He made comparisons between children and teens, indicating that there were no differences in biomicroscopy signs except at three months where the teen group exhibited more conjunctival staining. He reported that some children needed more time for application and removal instruction — three months later compared to teens, considering that children recalled less — but on average there is very little difference. You can predict difficulties with fitting based somewhat on levels of motivation and parent enthusiasm. With a less enthusiastic parent, more anxiety was noted. Overall satisfaction ratings indicated that because of an increase in activity levels, greater ease during activities and increased satisfaction with appearance for both teens and children, practitioners should not use age as a criterion to decide whether to fit a patient with contact lenses. Instead consider patients' motivation, maturity and other factors.

Dr. Walline also discussed the Adolescent and Child Health Initiative to Encourage Vision Empowerment (ACHIEVE) study that looked at the option of daily disposables for pediatric and teen patients. These results will publish later this year.

Marjorie Rah, OD, PhD, gave us valuable tips from her clinical experience in interacting with pediatric patients and their parents, reminding us "what if they were your child?" She advised attendees to talk to young patients first; encourage them to ask questions and be sure to ask them questions, especially if their parents are non-wearers; ask what they will be doing and where they will be while wearing their lenses; compare your and the parents' perceived level of maturity of each child; check children's level of hygiene, check their fingernails, ask how often they brush their teeth, etc. She offered some helpful fitting tips including to spend only 45 minutes for application and removal training because any longer will result in frustration, no swimming or showering while wearing lenses unless they're daily disposable and will be discarded, providing written instructions that both parents and children sign and using CDs or other materials to reinforce these instructions.

Louise Sclafani, OD, FAAO, discussed the medical uses of contact lenses in infants. These include bandage lenses for extreme dryness from lid problems; occluder lenses for iris coloboma or other trauma and for amblyopia training; and for congenital cataracts once removed. She used a video to demonstrate her techniques in examining an infant, using magnifying lenses, a hand-held topographer and penlight fixation for three seconds as an acuity measure. She also demonstrated retinoscopy with the use of a lens bar and the use of patching therapy.

Dr. Sclafani further discussed using silicone lenses, GP lenses and silicone hydrogel lenses with small diameters and steep base curve radii in treating aphakic patients. Finally, Dr. Sclafani emphasized that it's always a good idea to have a spare lens available in the office or sent home with the patient to quickly replace lost or broken lenses.

Myopia Management with Contact Lenses

Dr. Walline reviewed the history of myopia correction, from the very anecdotal Bates method of palming to modern corrections that include the work on peripheral retinal vision (by Earl L. Smith, III, OD, PhD). Dr. Walline reviewed the literature on the use of bifocal spectacle lenses for myopia control, concluding that this method was ineffective, as well as the literature on under-correction with single vision lenses, which actually caused an increase in myopia. Though muscarinic antagonistic drugs such as cyclopentolate, atropine and pirenzepine can be used to slow myopia, you must weigh the consequences of their use. The use of alignment-fitted GP lenses did not demonstrate a reduction in myopia progression, and orthokeratology resulted in only a small amount of myopia reduction with minimal change in axial length according to studies by Cho and Walline. Dr. Walline concluded that perhaps focusing the image onto the peripheral retina by the addition of plus power in the periphery of a contact lens may help discourage the growth of the peripheral retina with age (and emmetropization).

S. Barry Eiden, OD, FAAO, updated us on the year-one (of five) results of the Stabilizing Myopia by Accelerated Reshaping Technique (SMART) study that evaluates the use of corneal reshaping lenses compared to the use of monthly silicone hydrogel lenses for the stabilization of myopia in children from 8 to 14 years of age. Only 20 percent of patients dropped out in the test group primarily because of comfort issues in the first week of wear. The soft lens group had an 18 percent dropout rate, but unlike the test group, most soft lens dropouts occurred later in the study and primarily because of lack of interest or loss to follow up. Considering issues of safety, there was a significant difference in central and inferior staining in the ortho-k group. Researchers also noted inferior staining in the soft lens group, but with one eye only. Notable events at this stage were bulbar and limbal hyperemia (grade 2 or higher), infiltrative keratitis in the soft lens group only (two eyes) and corneal staining not warranting disruption of lens wear. At the one-year point, the change in "best sphere" (= sph. eqv.) for the control group was significantly more myopic than for the test group (p<0.0001), although the soft lens group had an increase in myopia of only 0.37D. There was no significant change in astigmatism values, axial length and vitreous chamber depth over the one-year period with either group.

Nick Despotidis, OD, spoke of his extensive experience in the field of orthokeratology. He quoted a study in Australia demonstrating an environmental link to myopia; that is, children who played outside for two-to-three hours per day demonstrated a slower progression of myopia compared to children who were mainly indoors. Dr. Despotidis presented some of his cases using ortho-k lenses in which he found a progression rate of –0.09D per year as opposed to spectacle-wearing children for whom the rate was –0.50D per year.

Keratoconus and Irregular Astigmatism

Tim McMahon, OD, FAAO, brought us up to date on corneal thinning disorders, which have a prevalence of approximately 230 in 100,000. They are 96 percent bilateral and have no racial predilection. The pathophysiology includes breaks in Bowman's membrane, loss of stromal collagen and questionable endothelial involvement. There appears to be a reduced protein content in the cornea with an increase in degradative enzymes and a decrease in the inhibiting enzymes. Researchers have found that this process secondarily leads to an increase in inflammatory markers and whorl keratopathy. Dr. McMahon also spoke of the genetic findings derived from the Collaborative Longitudinal Evaluation of Keratoconus (CLEK) study, as well as twin studies that tell us that keratoconus is a complex disorder with a mix of genetic and non-genetic factors.

Patrick Caroline discussed the use of videokeratography in fitting contact lenses for keratoconus patients. He noted that their aspheric corneas have high rates of flattening, or e-values. Consider aspheric lenses, those with either a spherical center and aspheric periphery or biaspheric lenses, to successfully fit these patients. His goal in fitting is to align the contact lens along the superior flatter portion of the cornea and to clear the apex of the cone. He noted that with three-point touch, the three o'clock and nine o'clock areas of touch may not be at three o'clock and nine o'clock, but at the axis of the flattest meridian. He demonstrated that the simulated fluorescein patterns obtainable with the Medmont (Precision Technology Services) corneal topographer matched the on-eye fluorescein patterns very well. Patrick Caroline also discussed semi-scleral lens fitting for keratoconus and other irregular cornea conditions (Figure 2).

Figure 2. A semi-scleral lens fitted on a keratoconic cornea.

Randy Kojima discussed the differences between centered and oval cones. The Medmont topographer can easily demonstrate the profile views of each of these conditions with the contact lens. The advantage is, with the use of a rotational bar across the surface of the contact lens, you can see where there are areas of clearance and touch in any meridian.

Large Corneal and Scleral Lens Designs for Keratoconus — Part 1

Michael Baertschi, MSOptom, MME, defined corneal lenses as lenses with overall diameters <10.5mm, intralimbal lenses as those with diameters between 10.6mm and 11.8mm (Figure 3) and sclerallimbal lenses as having diameters ranging from 11.9mm to 12.5mm. He stated that three-point touch fitting relationships typically result in too much touch. His fitting approach is thus to achieve apical clearance, but the lens may be unstable if there is a small area of midperipheral touch. If that is the case, an alignment fit using a quadrant-specific lens in which each quadrant matches the differing eccentricity values that the keratoconic cornea has in each meridian would be the best option.

Figure 3. An intra-limbal lens design.

Michael Baertschi also updated us on methods of performing keratoplasty, either penetrating or lamellar. A Scheimpflug camera such as the Pentacam (Oculus Inc.) can easily help you visualize tilted grafts. He suggests using reverse geometry lenses (Falco) to reduce the amount of lateral decentration that may occur with such grafts.

Langis Michaud, OD, FAAO, discussed some clinical pearls based on his two-year experience with the MSD (Blanchard Contact Lens) and the Jupiter (Medlens Innovations/Essilor) semi-scleral lenses. His approach is to start steep (based on the advancement of the cone), make sure the bowl of the lens is completely filled with solution and then add fluorescein before application. Next, wait 15-to-20 minutes and allow the lens to settle and come down onto the cornea. If you see a central bubble or midperipheral bearing, then systematically flatten the base curve or reduce the sag of the lens until the pattern and bubbles improve. Use the optic section to visualize the amount of central clearance that you have and to ensure that you have no areas of harsh touch. Next, examine the midperiphery of the lens once the central pattern demonstrates good minimal clearance, and see if a good pool of fluorescein forms over the corneal-limbal junction. Do not accept large bubbles in this area; they may cause desiccation under the lens. Tiny bubbles are acceptable and are usually due to poor application technique. Reduce the clearance of just the midperiphery of the lens if necessary to reduce large bubble formation.

Christine Sindt, OD, FAAO, reviewed complications that could occur in fitting corneo-scleral, mini-scleral and semi-scleral lenses and her clinical pearls on how to reduce or avoid them. If central bubbles are present, then reduce the sag; if peripheral bubbles are present, try a thicker solution on lens application instead of saline. Corneal abrasions may be due to application and removal; a (DMV) plunger can be used to break the suction inferiorly first, then the lens may more easily slip out. Corneal erosions may result from tilted grafts or rubbing over sutures where the lens is too flat in that area. Diffuse staining may be due to "toxic swamp" from preservatives in solutions; non-preserved solutions should be used. Flexure may result from a reduced center thickness and excessive clearance; you should then increase the center thickness. In smaller (14mm to 15mm) designs, a lens that is too steep may also cause an impression ring on the conjunctiva that can be observed after lens removal. In this case, flatten the peripheral zone of the lens and reduce the excessive clearance. If the lens periphery impinges on the conjunctival vessels at the limbal area, then steepening the peripheral curves will lift the lens up and over the corneallimbal junction. Limbal edema may also be present where the conjunctiva appears raised; Dr. Sindt suggested increasing the junction thickness to reduce the flexure and flatten the peripheral curves. For focal vascular impingement such as with a toric sclera or pinguecula (Figure 4), she suggested that you flatten peripheral curves, use a toric periphery or add pinguecula notches. She also indicated that fenestrations may be useful for lens removal for smaller lens designs, but, with larger lenses, if the fenestration lies over the conjunctiva, the conjunctival tissue may be drawn up into the hole. In this case, order the lens without fenestrations. Finally, Dr. Sindt spoke of mucin under the lens, especially in post-surgical cases, where the mucin causes lens adherence and deposits on the lens surface. Using Progent (Menicon) or other lens cleaners, along with polishing the lens, will help maintain a more wettable surface.

Figure 4. Impingement of pinguecula with a scleral contact lens.

Large Corneal and Scleral Lens Designs for Keratoconus — Part 2

Eef van der Worp, BOptom, PhD, FAAO, FIACLE, discussed the anatomy of the sclera and the differences in the nasal and temporal regions due to differences in the insertion of the recti muscles and temporal offset of the center of curvature. He discussed the Smith technique of using the biomicroscope and a measuring eyepiece to measure the depth of the anterior segment as an indirect measure of corneal sag.

Dr. van der Worp introduced optical coherence tomography (OCT) techniques that help us visualize the limbal-scleral zones better and help us measure corneal sag at various chord lengths more directly. He spoke of European developments in the area of toric scleral lenses (Visser et al) and indicated how stable these lenses are for correcting residual astigmatism.

Finally, Dr. van der Worp offered tips on the ideal fit for scleral lenses including central clearance of 0.2mm to 0.3mm, 0.1mm of limbal clearance, an area of bearing that's spread out tangentially over the scleral zone, and no trapped air bubbles.

L. Gina Sorbara, OD, MSc, FAAO, gave a brief talk on measuring corneal sag at a 15mm chord and the nasal and temporal angles at that same point. Forty eyes of average patients were measured using the Visante OCT to gather normal information about corneal shape, along with topography readings and horizontal visible iris diameters (HVIDs). For average patients, the corneal sag ranged from 3.6mm to 3.9mm, the horizontal keratometry readings ranged from 42.00D to 45.00D, the HVIDs ranged from 11.1mm to 12.5mm and the nasal (not significantly different from the temporal) angle ranged from 37 degrees to 41 degrees.

Greg Gemoules, OD, used the Visante OCT to measure corneal sags taken at 11 different chord lengths to help in fitting scleral lenses. Using the eccentricity values from corneal topography measurements, he converted the sag measurements to radius of curvature measurements. He sent these measurements of the mapped cornea to a GP manufacturing laboratory where lenses were empirically designed. He provided some case examples in which he fitted these lenses successfully with less lens changes than normally needed.

Managing Presbyopia with Contact Lenses

Dr. Bennett started off the presbyopia fitting session with some demographics on the presbyopic population and the opportunity and potential for multifocal and bifocal fitting. He reviewed monovision, pointing out its limitations, and discussed some recently published articles demonstrating increased success rates with multifocal and bifocal designs and increased patient preference for these lenses when given a choice versus monovision. He discussed some new GP lens materials and designs. High-refractive index GP materials benefit presbyopic patients because lenses can be made 12-to-15 percent thinner and with 20-to-30 percent less mass in high-index materials, allowing for higher add powers and thinner designs. Also, adding anterior aspheric surfaces on back-surface aspheric lens designs can provide, on average, an additional +0.62D of add power. These advancements, along with wavefront technology, bring presbyopia correction with GP lenses to the forefront. Plasma treatment of GP lenses also allows for improved initial comfort while the patient is adapting to lens wear.

Tom Quinn, OD, MS, FAAO, spoke about bridging the gap between great product development and poor lens usage. He described for us the ideal candidates for multifocal lenses: women who have diverse activities including working, playing with their children and exercising. He reminded us to question their hobbies and the lighting conditions under which they are most likely to wear their lenses.

Baby boomers, Dr. Quinn suggested, "know what they want and deserve it." He offered some practice management tips about external communication to patients (which can include newsletters, displays and questionnaires asking about patient interest in contact lenses) and internal communication (where you show your enthusiasm while setting proper expectations). He emphasized displaying confidence and knowledge about the products available and conviction that multifocals can improve their quality of life.

To improve your success, Dr. Quinn suggested that you start with low-add patients with 3.00D or less of refractive error and <0.75D cylinder. Use the "sandwich approach," in which you first say something positive such as, "these lenses will meet most of your needs," then the "meat" of the message, such as, "they may not work for all of your needs," and finally end with the positive, "but you will see…"

In assessing the performance of these lenses, Dr. Quinn suggested that you give patients sufficient settling time (at least 10 minutes), let them do the talking and tell you how the lenses are, ask open-ended questions and keep the lights up in the room over the patient and have less light on the chart. For checking vision he recommended that you use a near chart of most commonly used text sizes (J5) and take binocular acuities, use loose lenses to over-refract, and then take monocular acuities. He suggested some problem-solving pearls such as adding minus power over the dominant eye for poor distance vision and/or reducing the add in that eye if possible and/or switching lenses in case you have the incorrect dominant eye.

Presbyopia Fitting Strategies With Soft and Hybrid Lens Designs Dr. Eiden discussed the use of hybrid lenses for correcting presbyopia. He discussed the SynergEyes Multifocal (SynergEyes, Inc.) lens, which has a 100-Dk GP center and a 27-percent water content skirt with a center-near design. He recommended fitting the lens with apical clearance (0.15mm steeper than K) to enhance lens movement, since a too-flat lens will tighten with time. To assess the fit he suggested applying high-molecular-weight fluorescein and waiting before evaluating the pattern. Ideally there should be apical clearance centrally and alignment in the midperiphery and periphery of the lens (Figure 5). The lens is available in two near zone diameters, 1.9mm and 2.2mm, so modified monovision may be used if a problem occurs with the distance vision. The smaller segment size could be used for the distance eye. Asymmetric zone sizes or add powers could also be used to enhance intermediate vision. Perfect centration, lens movement and little flexure are needed to ensure success.

Figure 5. Desirable fluorescein pattern for a hybrid contact lens.

Michael Gzik, FCLSA, discussed the quality of vision with soft multifocal and bifocal lenses. He began by discussing aspheric lens designs in which as the eccentricity value of the lens increases, so too does the add power, and the back optic zone usually decreases in diameter. He stated that centration with aspheric lenses is critical, which can be affected when the geometric center of the lens and the pupil center are not coincident. Aspheric lenses will typically be successful when they center over the visual axis. Otherwise, changing the base curve or increasing the lens diameter may improve the fit. He also reminded us that regular replacement of these lenses is necessary along with adequate cleaning procedures and lubricants to diminish dryness and lens deposits.

Walter Choate, OD, FAAO, emphasized that you should address any lid and dry eye issues first to increase your success. He pointed out some causes of visual failure including uncorrected cylinder, poor centration, product variability (lathing), manufacturing limitations (molding) and poor optical quality when hydrating the lens due to uneven linear expansion from the dry to the wet state.

Dr. Choate also discussed the hybrid center-near multifocal lens including issues of distance blur that may be related to cylindrical over-refraction due to decentration and/or flexure. Also, discomfort can result because of tear film abnormalities and junctional staining from a steep skirt on the lens. For improving distance acuity he suggested fitting each eye with the smaller near zone lens. He recommended peroxide systems and lubricants to help with discomfort.

Presbyopia Fitting Strategies with GP Lenses Dr. Bennett gave us some clinical pearls for fitting presbyopes with aspheric and translating GP lenses. He suggested starting with a back-surface aspheric lens fitted initially 1.00D to 1.50D steeper than K, ensuring that there is limited lens movement and steepening the lens if it decenters inferiorly. Use trial lens over-refraction and refine the vision, considering that any 0.25D change is often significant to presbyopes. To obtain additional add power over +1.50D, some lens designs provide additional add power on the front surface of the lens. Higher adds are also available with front-surface aspheric designs and with translating lens designs.

Translating lenses rest on or near the lower lid and are stabilized with prism and sometimes with truncation. The segment line should sit at or slightly below the lower edge of the pupil and translate upwards in down gaze (Figure 6). Dr. Bennett offered these simple problem-solving strategies: if the segment is rotated too much, then flatten the base curve radius; if the segment is too high, then increase the prism amount; if there is no lens translation, then either flatten the base curve radius or peripheral curve radius to increase the axial edge lift.

Figure 6. A translating GP lens needs to move up on downgaze.

Stephen Byrnes, OD, FAAO, discussed an empirical approach to GP multifocal fitting in which the empirically designed lenses become your initial trial lenses. First determine the keratometry values, HVID, distance power, add power, e-value, palpebral aperture height, topographic maps, pupil size in normal and dim light and the lid position over the cornea. You would then select the laboratory to send this information to, know the lens design and where the add is situated (front or back surface, spherical or aspheric), determine who are the consultants and, finally, learn what the warranty policies are. Dr. Byrnes then gave some examples and demonstrated how refractive topographic maps can determine the powers of the zones on the lens front surface and where they lie relative to the pupil.

Roxanna Potter, OD, described how specialty lens fitting increased the profitability in her practice. She differentiated between specialty fits and specialty lenses, saying that you should charge for specialty fits, not based on the lens type, i.e. even a spherical soft lens may have complications and risks depending on the wear modality and the type of patient for whom it is prescribed. She has a "specialty lens" day in her practice and enrolls patients for that particular day of the week. She advocated that you should be at the cutting edge, offer staff incentives to promote the special day and schedule telephone calls for follow-up interviews with patients into your appointment book.

Custom Soft Lens Applications

Silke Lohrengel, Dipl. Ing. (FH) Augenoptik, started this session by reminding us that one size does not fit all. She asked us to consider individual patients' keratometry values, HVID, e-values and corneal sag. She also showed us photographic profiles of the corneal-limbal and scleral area of the ocular surface and differentiated flat profiles from steep profiles. Having an understanding of the topography of this area will help reduce limbal epithelial hypertrophy due to poor alignment between the lens and the eye. Proper alignment of a custom soft lens in this area will promote tear exchange. She also demonstrated that if you examine the lower lid as a patient blinks and see that it moves nasally and upward, for example, then you could adjust the axis of a custom toric lens according to this angle.

Mark André also discussed fitting soft custom lenses to match the corneal sagittal depth. He indicated that the HVID is the largest contributor to the lens diameter and contributes to the corneal sag. Two corneas of equal apical radius of curvature will have different sags if the HVID is different (the smaller HVID will have the smaller sag). He also reminded us that two corneas of equal apical radius of curvature will have different sags if the e-values (rate of flattening) are different (the higher e-value will have a higher sag). Taking the HVID into consideration, he then suggested that a soft lens should have 1mm of coverage around the limbus, so that the lens diameter is equal to the HVID plus 2.0mm. In selecting the apical radius, he uses what he called the "effective K," which is an adjustment of the central K depending on the HVID. If the cornea is larger than 11.8mm (an average value for HVID), then for every 0.2mm larger, add 1.00D to the flat K reading; for example, if the flat K = 41.00D and the HVID = 12.00mm, then assume that the effective K = 42.00D and vice versa if the cornea is smaller than 11.8mm. Using this effective K would result in fitting a steep cornea that has a small HVID much flatter than you normally would, because of the reduced sag of that cornea compared to one of equal radius and a larger HVID. He continued with examples of soft lenses fit for irregular corneas due to post-refractive procedures and others.

Neil Pence, OD, FAAO, discussed silicone hydrogel custom lens designs. The difficulty with custom lens designs using silicone hydrogel materials is the lathing process. Improvements in manufacturing have started to overcome these difficulties. Dr. Pence discussed the O₂Optix Custom (CIBA Vision) lens, which is currently available in three diameters and a variety of base curve radii that are chosen based on the HVID. Other custom silicone hydrogel designs are on the horizon, to be available possibly later this year.

Lens Care and Compliance Panel

Michael A. Ward, MMSc, FAAO, spoke about contact lens-associated microbial keratitis. What we have learned from the recent outbreaks of Fusarium solani keratitis and Acanthamoeba keratitis associated with two recalled multipurpose solutions is that digital cleaning of lenses is the single most important step in reducing the colonization of microbes on contact lenses; risk of keratitis increases with overnight use of lenses; showering, swimming and hot tub use while wearing lenses all contribute to keratitis; tap water use, not cleaning/replacing the contact lens case regularly and especially not using fresh solution on a daily basis, but rather topping off, are culprits in promoting microbe colonization.

Susan Gromacki, OD, MS, FAAO, reviewed the current Food and Drug Administration (FDA) standards for testing care products. She outlined the stand-alone testing that is performed on the care solution itself and the regimen test in which microbes are added to a contact lens, then the care system is used on that lens according to the package instructions and a measurement of remaining colony forming units is taken. FDA recommendations that are under consideration include no topping off, eliminating no-rub labeling of solutions, no contact with water for any contact lens, frequent lens case replacement, and instituting a "discard" date after opening a bottle of solution. A joint meeting of the FDA and interested ophthalmic associations occurred in late January 2009 to discuss more "real world" testing requirements for the approval of new care systems.

Tim Edrington, OD, MS, FAAO, discussed some recommendations for patient instructions and follow up relating to compliance. He reviewed the "how to's" of hand washing, rubbing lenses to remove microorganisms and biofilm, and rinsing lenses to reduce lipids, mucin and cosmetics. He also advocated avoidance of tap water, no topping off and no use of generic care systems. He emphasized that replacement schedules must be followed and that part-time wearers should use daily disposable lenses to reduce lens storage times; otherwise patients should redisinfect lenses after 24 hours of storage. In-office education is necessary, and the importance of follow-up care should be reinforced. Dr. Edrington advised asking patients to demonstrate how they handle and manage the care of their lenses so you can correct any discrepancies and show patients the importance of those steps.

Contact Lens Reimbursement

Clarke Newman, OD, FAAO, and Carla Mack, OD, MBA, FAAO, reviewed the definition of medically necessary contact lenses, stating that such lenses are prescribed for patients who have an illness, injury or disease that has a symptom, impairment or functional limitation. The treatment must follow the current standard of care and not be simply for cosmetic or convenience purposes. They then presented the various billing codes and gave examples of how to apply them for both a medically necessary and a cosmetic contact lens case, emphasizing the terminology of "initial dispensing fees" rather than "fitting fees." CLS