2016 GSLS HIGHLIGHTS

Highlights from the 2016 Global Specialty Lens Symposium

The latest findings on scleral lenses, myopia control, custom soft lenses, developing technologies, and more.

By Edward S. Bennett, OD, MSEd, FAAO; Lisa Starcher; & Jason J. Nichols, OD, MPH, PhD, FAAO

As we reported in the February News Spectrum, the 2016 Global Specialty Lens Symposium (GSLS), presented by Contact Lens Spectrum (CLS) and the PentaVision Conference Group, was held Jan. 21 to 24 in Las Vegas. It was attended by a record number of almost 1,000 participants, including well over 600 eyecare practitioners. Including the pre-conference tracks, breakout sessions, and seminars, attendees had more than 110 presentations from which to choose, almost all exclusively pertaining to specialty contact lenses.

General Overview

The four-hour preconference tracks are always very popular. This year’s pre-conference program included presentations on fitting and troubleshooting scleral lenses from experts representing the Scleral Lens Education Society; myopia control management today from international experts from the American Academy of Orthokeratology and Myopia Control; building your specialty contact lens practice, including ICD-10 billing and coding for medically indicated contact lenses (Clarke Newman, OD, FAAO) and developing a specialty contact lens practice (Carmen Castellano, OD, FAAO); and keratoconus diagnosis and management using both contact lens and surgical options.

In addition to the many continuing education breakout sessions, a number of general sessions covered contemporary topics of interest to almost everyone. Scleral lenses predominated, with sessions pertaining to their applications for both dry eye patients and for healthy eyes; information was also presented to provide a better understanding of scleral shape to optimize lens design and fitting. Other sessions focused on new technologies, contemporary methods for myopia control, new developments in correcting presbyopia with contact lenses, controversies in soft contact lens fitting, and new technologies in tear analysis for contact lens wearers, among others. A number of free papers provided current clinical research in specialty contact lenses.

There were a record 100+ scientific posters displayed, with awards given in the scientific and clinical case report categories (Figure 1) (details on the winning posters were announced in the February News Spectrum). Our annual photo contest featured nearly 50 entries in two categories: contact lens and cornea/conjunctiva/lids. The winning photos, which appear on this month’s cover, include:

Figure 1. Poster award recipients (from left to right): Roxana Hemmati, OD; Maria Walker, OD, MS; Bruce Morgan, OD, FAAO; and Beth Kinoshita, OD, FAAO.

• First Place: Dark Side of ICD by Antonio Calossi, Dip Optom, FIAO, FBCLA, FIACLE

• Second Place: Intrastromal Corneal Hemorrhage by Robert M. Kelly, OD

• Third Place: Optic Section of the Eye with Protruded, Iatrogenic Corneal Scar (After LASIK) Wearing Vaulted Hybrid Lens by Halina Manczak, MD, PhD

Another great tradition of the GSLS is the Global Specialty Lens Symposium Award of Excellence, which this year honored worldwide contact lens textbook authors (Figure 2). In addition, Program Chair Craig Norman, FCLSA, was honored by CLS Publisher Roger Zimmer and GSLS Education Program Committee members Jason Nichols, OD, MPH, PhD, FAAO; Edward Bennett, OD, MSEd, FAAO; Eef van der Worp, BOptom, PhD, FAAO; and Patrick Caroline, FAAO, on the 10th anniversary of this global conference (Figure 3); beginning as the Global Keratoconus Congress in January 2007, it quickly expanded into the GSLS, which was Craig’s vision and quickly became the largest annual meeting specifically pertaining to contact lenses in the United States.

Figure 2. GSLS Award of Excellence recipients (left to right): Anthony J. Phillips, MPhil, FBOA; Gerald E. Lowther, OD, PhD, FAAO; Linda Baker (accepting for Robert Mandell, OD, PhD, FAAO); and Edward S. Bennett, OD, MSEd, FAAO.

Figure 3. (left to right) CLS Editor-in-Chief and GSLS Planning Committee Member Dr. Jason Nichols, PentaVision/GSLS Conference Manager Maureen Trusky, GSLS Photographer Ursula Lotzkat, and Craig Norman, FCLSA, who was honored for 10 years of chairing the GSLS Education Committee.

New Developments in Contact Lenses

The meeting kicked off with its traditional “State of the Industry” presentation featuring CLS Editor-in-Chief Dr. Jason Nichols and CLS Clinical Features Editor Dr. Ed Bennett. Dr. Nichols reported that there are presently about 41 million contact lens wearers in the United States and that the soft lens market is approximately a $2.7 billion industry. He noted several trends in his presentation; in particular, there continues to be growth in the daily disposable and multifocal categories. Dr. Nichols’ presentation included a special tribute to Professor Brien Holden, who passed away in July 2015.

Dr. Bennett presented trends in the specialty lens market, but he first started by presenting a staggering statistic that in 2014, 50% of lenses in the cosmetic segment (colored lenses) were purchased illegally. This figure decreased markedly in 2015, in part due to efforts from the American Optometric Association’s (AOA) Contact Lens and Cornea Section to identify both the sites and the vendors that were selling lenses illegally, with the AOA legal department following up on these sites. The AOA has established an e-mail address to report suspected illegal sales as well as adverse events from illegal contact lenses: stopillegalCLs@aoa.org.

Dr. Bennett noted tremendous growth in the specialty lens market, in particular with scleral contact lenses. He discussed improvements in manufacturing (lathing) and plasma treatment that are resulting in significantly improved and customized lenses for patients.

Also of note is the continued growth in myopia control with contact lenses—nearly a quarter of practitioners now report using contact lens myopia control in practice (Nichols, 2016). Dr. Bennett noted that most practitioners are using soft multifocal designs almost as much as orthokeratology designs for myopia control.

Joe Barr, OD, MS, FAAO, moderated a session that featured an overview of new and emerging technologies in contact lens designs. These included concepts such as health-status monitoring contact lenses, contact lenses with dynamic controls for light and power, and other unique designs. Joe Rappon, OD, MS, FAAO, and Jeffrey Linhardt, PhD, presented more specifically on the status of the Novartis-Google glucose monitoring contact lens for diabetes. This lens could have a tremendous impact on diabetes management and care, given that it would provide continued monitoring of glucose over the course of a day.

How to Optimize Success and Change Lives with Scleral Lenses

As in every recent GSLS, more courses were devoted to scleral lenses than to any other topic. Manufacturer breakout sessions helped ECPs learn how to fit and troubleshoot specific designs, while continuing education courses emphasized troubleshooting, applications in healthy eyes (i.e., presbyopia and astigmatism), and coding and billing.

A very popular general session pertained to the use of scleral lenses in ocular surface disease. Symposium moderator Patrick Caroline said what every experienced scleral lens fitter already knows: “There is divine intervention under these lenses…nothing short of miracles occur once patients are placed into scleral lenses. Get accustomed to seeing patients cry due to the immediate relief they obtain from these lenses.” Greg DeNaeyer, OD, FAAO, agreed, stating: “It’s not all about increasing their comfort; it’s about giving these patients their lives back.”

Following are the scleral lens indications discussed in this general session.

1. Ocular Surface Disease Scleral lenses can and perhaps should be used more often to successfully manage many dry eye patients (Figure 4). The benefits include:

Figure 4. The effects of scleral lens wear on ocular surface disease.
COURTESY OF PATRICK CAROLINE, FAAO

• Continuous hydration/fluid interface

• Protection from both evaporation and the effect of the eyelids

• Promotion of healing of epithelial defects common in dry eye (Figure 5)

Figure 5. The healing progression of a persistent epithelial defect with scleral lens wear.
COURTESY OF PATRICK CAROLINE, FAAO, & MICHELLE LEE, OD

• Quality of vision

When fitting pathological dry eye patients with scleral lenses, two other factors to consider are to fit a slightly larger vault than average (i.e., 300 microns) to ensure good lubrication and to fit larger scleral lenses (i.e., 18+ mm), which ensures complete corneal vault and maximizes the area of protection for patients while also providing a wider area of protection to the anterior ocular surface.

Graft-Versus-Host Disease (GVHD) Dr. DeNaeyer discussed this topic and reminded everyone that patients who have ocular GVHD have disabling dryness that severely reduces their quality of life and limits their activities of daily living. Punctate erosions can be a source of pain, photophobia, and decreased vision, and they can also result in persistent epithelial defects, all of which put patients at greater risk for infection. Scleral lenses provide ocular GVHD patients with protection from the atmosphere and the eyelids; they can also help restore desiccated tissue because the fluid reservoir of the scleral lens continuously bathes the anterior ocular surface, and the therapeutic healing effects of the corneal surface epithelium after weeks or months of scleral lens wear may result in visual improvement (Figure 6).

Figure 6. A case example of a GVHD patient who has severe punctate erosions (A); same patient with a properly fit scleral contact lens achieving 20/20 vision (B).
COURTESY OF GREG DENAEYER, OD, FAAO

Exposure Keratitis Lynette Johns, OD, FAAO, conveyed to the audience that when you apply scleral lenses to the eyes of patients who have exposure keratitis, you know within seconds that their discomfort will be resolved and that their lives will be changed forever. Scleral lenses are therapeutic for these patients because they provide constant surface lubrication. In these cases, it is important to ask patients whether they have undergone blepharoplastic surgery, as this can result in the lids not closing completely with resultant dry eye symptoms. Sometimes patients do not mention this as they don’t consider it surgery, so it is best to phrase it as: “Have you had your lids done?”

Due to the resultant exposure keratopathy, scleral lenses can also play a crucial role in surface rehabilitation with those who have experienced severe periorbital burns.

Limbal Stem Cell Deficiency Muriel Schornack, OD, FAAO, communicated that scleral lenses may be useful in managing limbal stem cell deficiency that is not responsive to standard medical therapy. In some cases, scleral lens therapy may allow patients to avoid more aggressive surgical intervention.

Severe Dry Eye Esther-Simone Visser, MSc, discussed scleral lens application in other forms of severe dry eye, including Sjögren’s Syndrome, rheumatoid disorders, neurotrophic keratopathy, vernal keratopathy/atopic keratoconjunctivitis, post-irradiation etiologies, and symblepharon. In addition to the aforementioned benefits (i.e, hydration, protection, and vision), she feels that the stability of the fit is a major benefit of scleral lenses. To optimize scleral alignment, she uses back-surface toric designs in 98% of her scleral lens fits.

In a study comparing a small cohort of dry eye patients wearing scleral designs versus a much larger group of non-dry eye scleral lens wearers (i.e., primarily irregular cornea patients), she found that the overall satisfaction, comfort, and wearing time was slightly lower with the dry eye patients, and they were much more likely to take their lenses out during the day for a short duration and then reapply them. However, overall the difference was small, and the dry eye patients actually rated the quality of vision higher (Visser et al, 2007).

2. Scleral Lens Troubleshooting The ocular surface disease panel also discussed important troubleshooting areas, including tear reservoir debris and front-surface deposits.

Tear Reservoir Debris Tear reservoir debris is not uncommon, notably with lenses that have either excessive central clearance or spherical, non-toric back-surface haptics. Reducing apical clearance will reduce limbal clearance, which can reduce/prevent debris from being drawn into the chamber.

More important is the use of back-surface toric haptics. As the scleral shape can be much different from the corneal shape, with this differential increasing as you move peripheral to the limbus (Kinoshita et al, 2016), the use of spherical back-surface designs can result in peripheral gaps that can lead to discomfort, bubbles, and debris. Back-surface toric haptics can improve lens apposition/alignment and decrease potential gaps between the lens and the eye that allow debris to enter under the lens. Visser (Visser et al, 2006; Visser et al, 2007) has found that switching patients from spherical back-surface to toric haptics can increase comfort and wearing time and can improve overall satisfaction.

Tear reservoir debris may also be reduced by the introduction of solutions specifically formulated for filling scleral lenses. One such solution, LacriPure, was launched at the GSLS by Menicon. Sodium chloride inhalation solution, which is in common use today for filling scleral lenses, has none of the components (i.e., electrolytes, calcium, proteins) to help nourish the ocular surface, which may be a factor in tear reservoir debris.

Front-Surface Deposits To help reduce front-surface deposits on scleral lenses, a hydrogen peroxide system may be beneficial for nightly cleaning and disinfection. Using an extra-strength cleaner is also beneficial, and cleaning can be supplemented with liquid enzyme use. Scleral lenses should be plasma treated for optimum surface wettability, and they may have to be plasma treated again later by the laboratory.

The lenses can be removed midday for cleaning and reapplication; however, if that becomes a common inconvenience, patients can also use a protein-removing eye drop or even use a cotton swab soaked in saline or a conditioner to wipe away deposits from the front surface of the lens.

3. Scleral Shape Evaluation and Impact on Fitting Matt Lampa, OD, FAAO, presented the results of three studies performed at the Pacific University College of Optometry pertaining to scleral shape (Kinoshita et al, 2016; Morrison et al, 2016; Ritzmann et al, 2016). They found that scleral asymmetry increases at the more asymmetrical limbus, and the asymmetry increases as you progress further onto the sclera. Therefore, small scleral lens designs of 14.5mm or less can be rotationally symmetric; scleral lens designs larger than 14.5mm may require a toric haptic and/or a quadrant-specific design with less elevation nasally and greater elevation temporally.

Dr. DeNaeyer provided the valuable information that diagnostic fitting of scleral lenses may become an extinct approach. Diagnostic fitting is currently used because sclerals are manufactured in GP materials and there previously wasn’t a way to measure the ocular surface beyond the cornea. The diagnostic fitting process relies on estimates—it starts by literally guessing the first lens—and it really is more art than science.

The development of corneo-scleral topography will finally allow practitioners to accurately measure the entire anterior ocular surface, including the sclera. A three-dimensional model can then be used to create a custom contact lens design, including for both soft and scleral lenses. Corneo-scleral topography shows the sagittal depth of the eye at any chord diameter. It also enables the generation of elevation maps for both the cornea and sclera—which is much more useful for fitting large-diameter corneal GPs, soft lenses, and scleral lenses.

Given that the aforementioned Pacific University studies conducted using corneo-scleral topography confirm the asymmetry of the sclera, this supports the argument of avoiding spherical back-surface lenses in many cases to minimize the problems of edge lift, discomfort, and debris.

4. Scleral Lenses in Current Ophthalmic Practice Evaluation (SCOPE) Muriel Schornack, OD, FAAO, reported on the initial results of the SCOPE study, which we first reported in the February issue of Contact Lens Spectrum (Bennett and Kramer, 2016). No less than 989 eyecare practitioners (ECPs) from more than 40 countries responded to this survey. Of these, 723 had performed more than five scleral lens fits; a total of 84,000 scleral lens fits was represented from this group. Of these patients, 74.2% were fit into scleral lenses due to corneal irregularity, 16.1% were due to ocular surface disease, and 9.7% were fit into scleral lenses due to refractive error.

For filling the lenses, 60.2% provided some of their patients with single-use vials (i.e., sodium chloride inhalation solution), 57.4% recommended Unisol 4 (Alcon, now discontinued), 32.9% recommended preservative-free artificial tears, 6.3% recommended Sensitive Eyes (Bausch + Lomb) saline, and 4.1% recommended a multipurpose solution. The mean wearing time was 11.8 hours, and 23.2% recommended for patients to periodically remove the lenses during the day most or all of the time.

SCOPE II will address the cross-sectional report on specific patients. For any ECPs who would like to participate, you can send an email from your preferred address to schornack.muriel@mayo.edu.

The Future of Myopia Management

A highlight of the GSLS was a spirited debate among a panel of expects regarding what method of myopia control works best and should be recommended to prospective patients. Moderated by Jeff Walline, OD, PhD, FAAO, the panel included Helen Swarbrick, PhD, FAAO; Don Mutti, OD, PhD, FAAO; and David Berntsen, OD, PhD, FAAO. Several relevant topics were discussed, including the following:

1. Presentation to Parents Now that we know that there are multiple types of contact lenses that can exhibit some myopia control, it is the professional responsibility of ECPs to proactively raise this topic with all parents of young children who either are myopic or appear prone to developing myopia. It was also recommended to present the different options to the parent(s) and to be willing to refer them to someone else who will use one of these modalities if you are unwilling to do so. Parents also need to understand that these methods slow—but do not stop—myopia progression.

2. When Do You Begin Myopia Management? Quite often, myopia control is initiated around the age of 7 or 8. However, it depends upon when patients initially develop myopia. For children who are prone to becoming myopic (i.e., perhaps both parents are myopic), and knowing that the fastest growth toward myopia often occurs in the year before children become myopic and in the year that they become myopic, myopia management can be initiated as soon as they enter myopia. Trying to persuade children to wear multifocal soft lenses during the day when they are not yet myopic, or the compliance issue of having children wear orthokeratology lenses overnight when they still experience good vision during the day, makes it difficult to initiate these management methods until children become ametropic.

3. When Do You Stop Myopia Control? It can be argued that myopia control can be discontinued once the eye is fully mature and elongation has stopped; typically, this stabilization has occurred by the late teens. However, there is the possibility that a rebound effect could occur once treatment is stopped, so there is a risk-benefit ratio to consider. Therefore, if teens are satisfied in their myopia control method, it can be argued to not take them out of it.

4. Soft Multifocals or Overnight Orthokeratology? This is, of course, the million dollar question. Dr. Berntsen argued for the benefits of soft multifocal contact lenses. These designs are effective at delivering a peripheral plus power effect that results in a very good myopic shift in the retinal periphery regardless of the degree of myopia. There can be some variance, however, between specific soft multifocal designs; Dr. Berntsen reported success with the Biofinity D design from CooperVision (Berntsen and Kramer, 2013). Likewise, although the risk of microbial keratitis does not appear to be any higher with overnight orthokeratology compared to with soft lenses worn for extended wear (Bullimore et al, 2013), this is a factor to be considered.

Dr. Swarbrick argued the benefits of overnight orthokeratology. Although overall the myopia control effect appears to be similar between soft multifocal lenses and overnight orthokeratology, she noted that there is much more variance with soft multifocals. In addition, the visual freedom of not having to wear a correction during the day is a benefit, making overnight orthokeratology a preferable option for individuals involved in sports—notably swimming—and other outdoor activities. The soft multifocal design that shows the greatest promise, the Brien Holden Vision Institute design (Holden, 2015), has never been commercially developed to date.

Likewise, Dr. Mutti reported on the Bifocal Lenses in Nearsighted Kids (BLINK) study, a multicenter National Eye Institute (NEI) study with investigators at The Ohio State University College of Optometry and the University of Houston College of Optometry looking at the effect of commercially available soft bifocal lenses on the progression of myopia. It is his estimation that we are about three to five years away from knowing how effective soft bifocals are at controlling myopia. In the meantime, the best plan could be to simply present both options to parents and let them make the decision.

5. What about Atropine? Atropine 1.0% is effective in slowing the progression of myopia by exerting anti-muscarinic biochemical effects on the sclera or retina, and it has a low dropout rate (Chua et al, 2006). However, its numerous side effects include photophobia, blur, ocular allergy, ocular discomfort, headache, dry mouth, and dry eye (Kennedy, 1995). Therefore, the use of a lower percentage of atropine may be a better solution; in fact, atropine 0.01% has minimal side effects compared to atropine at 0.1% and 0.5%, and it exhibits efficacy in controlling myopia progression (Chia et al, 2012). Further study is needed to determine whether combining 0.01% atropine with myopia control contact lenses could result in an additive effect without complications.

6. Does Outdoor Time Slow Myopia Progression? Dr. Mutti reviewed the results of the Collaborative Longitudinal Evaluation of Ethnicity and Refractive Error (CLEERE) study (Jones-Jordan et al, 2014). The study reported that more time outdoors lowers the probability of onset, potentially by a large amount. In addition, emmetropic children who have two myopic parents and spent the lowest amount of time outside (five hours or less per week) had about a 60% chance of becoming myopic. However, the probability of becoming myopic was reduced to 20% for emmetropic children who had two myopic parents and spent 14 hours per week or more outside. The study concluded that, although more time outdoors does reduce the risk of onset, it does not affect the rate of progression. More studies are needed.

Contact Lens Correction of Presbyopia

Several new developments related to correcting presbyopia with contact lenses were presented at this year’s GSLS.

1. Will Scleral Lenses Be a Viable Alternative for Presbyopes? Noted scleral lens expert Jason Jedlicka, OD, FAAO, addressed this very timely topic. He emphasized that scleral lenses are a viable option because many patients have astigmatism that is not as easy for them to tolerate compared to when they were pre-presbyopic. In addition, the lack of accommodation impacts vision at all distances, and the dry eyes and discomfort that come with increasing age can be better managed with scleral lenses.

Current soft lens options for correcting presbyopia are not optimal for correcting astigmatism. Corneal GP lenses—while they can often correct the astigmatism well—are not always well tolerated by patients, and they are not a great option for part-time users. In addition, many corneal GP options are not customizable, meaning that practitioners have a limited ability to adjust add zones and powers to individual patients. Also, dry eye is more difficult to address with standard soft and GP lens options.

In theory, scleral multifocals can provide comfort and therapeutic benefits for dry eyes; sharp, stable acuity, including good distance vision, good near acuity, and good intermediate acuity; numerous parameters; and the ability to correct all refractive errors including astigmatism. The potential shortcomings include: 1) Visual aberrations due to decentration; 2) Fogging/debris/lens surface dryness, which can impact vision; 3) simultaneous vision-induced blur; 4) Expense. Decentration may also be a problem, although performing topography over a soft multifocal may give some indication as to how a scleral multifocal may center. It is evident that scleral multifocals have great potential as a viable option for many presbyopes desiring contact lens wear.

2. New Developments Tom Quinn, OD, MS, FAAO, and Doug Benoit, OD, FAAO, addressed current clinical applications with soft, hybrid, corneal GP, and scleral multifocal designs. When monovision and contact lens multifocals are compared, patients tend to prefer multifocals (Woods et al, 2015). Likewise, contact lens multifocals perform better compared to monovision in “real world” situations such as night driving and viewing a television or computer screen (Woods et al, 2009).

Pete Kollbaum, OD, PhD, FAAO, presented extended depth of focus strategies for correcting presbyopia. Of the possible strategies, the one that he most recommended was to induce aberration of the same sign as the eye into the lens, which minimizes the amount of “wanted” aberration needed in a lens and reduces the level of “unwanted” aberration due to decentration. Ultimately, adaptable designs that more closely mimic the natural accommodation system may help solve these problems.

Free Papers

A number of exceptional free papers were presented at this year’s GSLS. Three of these papers are highlighted here.

1. “Novel Therapeutic Contact Lenses with Controlled and Extended Release for Glaucoma Therapy” Liana Wuchte, Doctoral Fellow for Mark Byrne, PhD, FAIMBE, presented their research on this topic, which is an area of interest to many. Despite their popularity, eye drops are extremely poor drug vehicles for ocular treatment, with between 1% to 7% of the applied drug productively absorbed and the rest lost to systemic circulation (Saettone, 2002).

With challenges that include very little retention, under-administration, over-administration, and non-administration of the drug, their goal became taking dosing out of patients’ hands. Using the approach termed “macromolecular memory,” they engineered the architecture of the lens during synthesis to specifically interact with the drug of choice using functional monomers. Memory sites that are formed within the polymer structure hold the drug within the therapeutic lens. In addition, as the drug moves through the lens, it passes through other memory sites that can interact with and hold the drug, which allows for consistent delivery of drug concentration over a longer period of time. In their first study using rabbits, they found their lenses to be 100 times more effective and efficient as a drug delivery device (Tieppo et al, 2012).

More recently, their primary objective has been to develop silicone hydrogel contact lenses with controllable and sustained release of latanoprost. They have currently produced drug-releasing lenses in all modalities (daily wear, extended wear, continuous wear) and have found that silicone hydrogel extended wear lenses are capable of releasing latanoprost for up to five days. They are also developing lenses that have controlled release rates specific to needed drug concentrations in the eye. The future is potentially exciting for these novel lenses to be used for glaucoma medication administration and possibly for controlled release of other medications.

2. “The Infant Aphakia Treatment Study Contact Lens Experience to Age 5 Years” Buddy Russell, FCLSA, COMT, presented the results of this study, in which 57 infants from 1 to 6 months of age were randomized to contact lens wear and were compared to 57 infants corrected via intraocular lens (IOL) implantation (Russell et al, 2012). Of the lens-wearing infants, 42 eyes were fit with silicone elastomer (SE) lenses, 12 eyes were fit with GP lenses, and three eyes wore both lens types. At age 5, the results showed that for SE patients, 28 wore their lenses on a continuous wear schedule (seven to 21 nights), six wore their lenses on a daily wear basis, and three alternated between daily and continuous wear (wear schedule not documented for five patients) (Lambert et al, 2014; Hartmann et al, 2014). Thirty-three percent (33%) of the patients wearing GP lenses achieved 20/40 or better vision compared to 20% wearing SE lenses.

Compared to IOLs, 13 achieved 20/20 to better than 20/40 vision in the contact lens group; six achieved this in IOLs. There were 13 adverse events in seven contact lens-wearing patients: 12 with SE and overnight wear (eight bacterial infections, two corneal ulcers, two abrasions), one with GP lenses (broken lens on eye). By age 5 there were twice as many adverse events with the IOL group (N = 79) than with the contact lens-wearing group (N=39).

It was concluded that “when operating on an infant younger than 7 months of age with a unilateral cataract, we recommend leaving the eye aphakic and focusing the eye with a contact lens. Primary IOL implantation should be reserved for those infants where, in the opinion of the surgeon, the cost and handling of a contact lens would be so burdensome as to result in significant periods of uncorrected aphakia,” (Lambert et al, 2014).

3. “The Effect of Toric versus Spherical Contact Lenses on Subjective Vision and Lens Fit Complexity in Astigmatic Patients” With the knowledge that many ECPs are fitting low-to-moderate astigmatic patients into spherical soft lenses, Dr. Berntsen reported on work from The Ocular Surface Institute at the University of Houston comparing spherical versus toric lenses. Patients were current soft lens wearers who had between –0.75D to –1.75D of refractive cylinder; they were fitted with a spherical soft contact lens and a toric soft contact lens on different days in random order for at least five days before follow up.

The results found that there was no difference in the number of lenses required to achieve a successful fit. Both the high-contrast and the low-contrast visual acuity were significantly better with toric versus spherical lenses at both fitting and follow-up visits (about one line better on the chart); subjective vision was also rated better on two different standardized scales. The results of this study further support the use of toric lenses, even in patients who have low-to-moderate astigmatism.

CE Breakout Sessions

The GSLS offered a number of one-hour CE breakout sessions on a variety of topics from which attendees could choose. Three are highlighted here.

1. “Cosmetic Tinted Contact Lenses for Normal, Damaged, and Disfigured Eyes” Stephanie Ramdass, OD, MS, FAAO, provided a brief historical overview of colored contact lenses, beginning with the first known mention of tinted lenses in the 1939 movie “Miracles for Sale” and moving through the timeline to the technology in use in colored lenses today. She also discussed current market trends showing the disconnect between the low percentage of colored lens prescribing versus the high consumer interest in colored contact lenses (Allaboutvision.com, 35,472 page views for colored contact lenses in August 2015). She made the point that the interest is there, so if patients can’t get colored lenses from their eyecare providers, they’re going to try to get them from somewhere else.

Dr. Ramdass explained how pigments are incorporated into contact lenses, why it is more difficult for some materials to hold a pigment compared to others, and how developments in lens pigments led to the first silicone hydrogel colored lenses. She also discussed manufacturing processes, including pad printing, molding, reactive dyes and catalysts, and custom hand painting.

Different indications for colored lenses included for cosmetic, prosthetic, color deficiency, fashion, and sports applications. She presented several cases of patients fitted with colored lenses, both medically necessary and not medically necessary, and how to take patients through the fitting process.

Dr. Ramdass concluded with the risks associated with wearing colored contact lenses, especially when patients obtain them outside of an eyecare practitioner’s office, and how important patient education is in this regard.

2. “Treating the Eye with Autologous and Allogeneic Serum Administration” Dr. Newman discussed the indications and the logistics of using autologous and allogeneic serum (AS) as a treatment of ocular surface diseases. He explained that the evidence base supports that AS is therapeutic in a wide range of inflammatory conditions. However, before practitioners can begin prescribing it for patients, some research and preparatory work is required to learn the science and to get set up for the process of obtaining AS.

Dr. Newman also cautioned against overselling AS to patients. While AS contains many components that are beneficial to the ocular surface, there can also be other, sometimes patient-specific components that would lead it to not work as desired. So patients need to have managed expectations and proper documentation of the treatment as well as possible alternatives.

Dr. Newman’s presentation contained many practical pearls and helpful Do’s and Don’ts related to implementing AS into practice. He noted that AS does not have to be discarded every day, but will keep for up to six months. He discussed the nuts and bolts of the process of obtaining AS. Dr. Newman provided tips for how to identify and communicate with the phlebotomy lab and compounding pharmacy (or a compounding pharmacy that offers phlebotomy services, which is the best situation), including what certifications they need and what to include on the order forms. He also discussed what to tell patients before you start, what to include in written instructions to patients, and the importance of obtaining informed consent and following up with patients.

3. Indications, Lens Designs and Fitting Methods for Customized Soft Lenses This presentation by Dr. Lampa discussed how to recognize when the commodity one-size-fits-all soft lens modalities will fail and when to consider looking beyond what you would find in the typical diagnostic fitting set for parameters such as lens diameter, base curve radius, and lens power (sphere, cylinder, and axis). This is mostly required when the refractive status of the patient is beyond the confines of the diagnostic fitting set from a power standpoint (vertexed to the plane of the cornea) and/or the corneal diameter and/or corneal curvature necessitates a base curve and/or diameter beyond that found in the typical diagnostic fitting set. In addition, the center thickness may also need to be adjusted; for instance, irregular astigmatism may necessitate increased lens central thickness, which can help to mask irregularity by converting the irregular surface to more “regular” astigmatism, and incorporating cylinder to attempt to mimic visual results seen in more traditional GP contact lens options in patients who have irregular astigmatism.

Dr. Lampa discussed corneal anatomical features and how they relate to corneal sagittal height, custom soft contact lens parameter availability, how to manage patients through the fitting process, how to order custom soft lenses, and assessing and troubleshooting the fit.

Conclusion

The 2016 Global Specialty Lens Symposium was record-setting, not only in attendance, but also in the number of course options on every conceivable type of specialty contact lens. The next GSLS will take place Jan. 19 to 22, 2017 at the Rio All-Suite Hotel and Casino in Las Vegas. CLS

For references, please visit www.clspectrum.com/references and click on document #245.