The 2017 Global Specialty Lens Symposium (GSLS), which took place from Jan. 26 to 29 in Las Vegas, once again demonstrated that each year it continues to build on its previous years’ success. With a record 730 eyecare practitioners and more than 1,000 total attendees, the GSLS continues to be the biggest contact lens educational event in the United States and one of the largest in the world.

This year’s program featured a total of 82 hours of education, including continuing education courses, theme-based general sessions, free papers on the most up-to-date specialty contact lens research, and industry-sponsored sessions pertaining to specific lens designs, instrumentation, and other new developments. The GSLS focuses on the successful management of ocular conditions using today’s specialty contact lenses. Many of the current hot topics in specialty contact lenses were included in this year’s program, with scleral lenses once again being the most popular: there were no less than 27 courses/presentations on scleral lenses, 14 pertaining to myopia control, 10 on non-scleral lens management of irregular corneas, seven on presbyopia contact lens management, and six related to building your practice with specialty contact lenses. As in previous years, the program was developed by the GSLS Education Planning Committee chaired by Craig W. Norman and including Jason J. Nichols, OD, MPH, PhD; Edward S. Bennett, OD, MSEd; Eef van der Worp, BOptom, PhD; and Patrick J. Caroline.

Pre-Conference Tracks Each year, the first morning features the always-popular Pre-Conference program in which attendees can choose courses from among four four-hour tracks. The tracks in this year’s Pre-Conference program included: 1) Myopia Management in 2017 (presented by the American Academy of Orthokeratology and Myopia Control), 2) Building Your Specialty Contact Lens Practice (presented by Optometric Management), 3) Contemporary Concepts in the Diagnosis and Management of Keratoconus and Corneal Ectasia (presented by the International Keratoconus Academy), and 4) How Do I Use Scleral Lenses in my Practice? (presented by the Scleral Lens Education Society).

Posters and Photo Contest The GSLS is also a very popular meeting for clinical and scientific poster presentations. This year, no less than 101 posters were on display. As at past meetings, awards were presented to the first and second place finishers in each of three clinical and research-based categories (Figures 1 and 2).

In addition, a photo contest was held with more than 30 photos submitted to be considered for awards in the categories of 1) Cornea, Conjunctiva, Lids; 2) Contact Lens, and 3) Instrumentation (Figure 3). The winning photos are displayed on the cover of this issue. Table 1 lists all of the award recipients.

SCLERAL LENSES 2017

The scleral lens general session (this year’s was titled “Scleral Lenses: What Do We Do When the Fit Is Not as Expected?”) moderated by Patrick Caroline is always a highlight of the meeting, and this year was no exception. Scott Read, BAppSc(Optom), PhD, from Queensland Institute of Technology in Brisbane, Australia led off this session and provided recent results from a short-term study performed by his colleagues pertaining to morphological and corneal changes from short-term mini-scleral lens wear (Vincent et al, 2014; Alonso-Caneiro et al, 2016). Subjects were fit into a 16.5mm overall diameter scleral lens manufactured in a 100-Dk lens material with an approximate clearance of 44 microns measured by optical coherence tomography (OCT). Once dispensed, the lenses were worn for three hours. They found that, even after short-term wear, there was a significant compression of the anterior eye tissue, with the greatest effects superiorly and at the approximate area where the landing zone is located. Conjunctival/episcleral change—as opposed to scleral change—accounted for approximately 70% of the tissue compressions, which reached as much as 80 microns superiorly. About 50% recovery occurred three hours post-removal. It was concluded that the superior change was possibly due to the interaction among the upper eyelid, the lens, and the cornea and that this should be monitored in scleral lens wearers.

Jason Jedlicka, OD, addressed the important topic of post-lens tear fogging (Figures 4 and 5). He quoted Maria Walker, OD, MS, whose work showed that individuals who had post-lens tear fogging had a significantly elevated level of lipids in their tear film (Walker, 2014). It is also evident that the debris responsible for creating this turbidity within the chamber fluid comes either through, or directly from, the perilimbal conjunctival tissue. It appears to be a problem that increases over time and forces patients to remove, clean, and reapply lenses during the day to temporarily relieve the symptoms. This, of course, is inconvenient for scleral wearers. It is possible that lens movement and the subsequent tear exchange may, in fact, cause the problem. Dr. Jedlicka proposed a three-step plan to minimize post-lens fogging:

1. Optimize the fitting relationship. In particular, optimize the peripheral alignment of the lens to the sclera. Fluorescein instillation may show excessive fluorescein peripherally in one meridian and seal-off in the other meridian. Optimizing the landing zone alignment should solve the problem. To accomplish this, Dr. Jedlicka uses a toric haptic in 80% to 90% of his scleral fits today (Patrick Caroline commented that he uses toric haptics in 95% of his fits). A scleral topographer would be beneficial in determining whether or not to use toric haptics.
   The fit should be optimized to result in less movement. Lens movement to bring in oxygenated tears may not only be unnecessary with hyper-Dk scleral lenses, but also may induce or exacerbate the post-tear lens debris problem. Tear exchange with sclerals can actually pull in byproducts and cause other issues. It may contribute to the so-called “toxic swamp” behind the lens.
   Finally, reducing the central lens vault can also potentially reduce the problem. The wearer would have less “foggy” fluid to view through, and a lower vault would also further help reduce lens movement.
2. Improve ocular health. Specifically, addressing the issue of meibomian gland dysfunction (MGD) is important to improve the quality of the lipid secretions from the eye and lids. Turbidity in the tear film may occur because lipid-to-lipid interactions are 72% stronger for patients who have MGD than for age-matched normals. (Borchman et al, 2011).
3. Finally, adding a viscous agent in the bowl of the lens prior to application can also be beneficial in minimizing midday fogging.

Melissa Barnett, OD, discussed options for optimizing the lens surface and minimizing deposit/non-wetting-related issues. This can result from ocular surface disease (i.e., ocular rosacea, filamentary keratitis, MGD), as excessive lipids in the tear film may deposit onto the lens to create a foggy, hydrophobic surface. There can be external causes as well, including poor plunger hygiene, using oil-based rather than water-based makeup, using hand soaps that have moisturizing agents such as lanolin, applying makeup to the inside of the eyelid margin, and applying creams and makeup before lens application rather than after. Changing patients to a hydrogen peroxide regimen and adding an extra-strength cleaner can also be beneficial.

Surface treatments and coatings can be beneficial. Plasma treatment has become very popular in recent years to minimize poor initial surface wettability. It effectively removes from the lens surface all residues that result from the manufacturing process. It is a treatment—not a coating—that improves initial on-eye wettability and comfort. A new method of improving lens surface wettability is a permanent polyethylene glycol (PEG) polymer surface coating that encapsulates the lens to improve surface wettability, lubricity, and surface water retention. It was approved by the U.S. Food and Drug Administration (FDA) for both soft and GP lenses in late 2016. Dr. Maria Walker recently performed a study in which 18 subjects, all habitual scleral lens wearers, compared end-of-day comfort with a Hydra-PEG (Tangible Science) coating versus no lens surface coating (Walker and Redfern, 2016). The Hydra-PEG-coated lenses were rated significantly better for end-of-day comfort. In addition, 13 of the 18 subjects preferred the Hydra-PEG-coated lenses, four had no preference, and only one preferred the untreated lens.

Muriel Schornack, OD, reviewed the Scleral Lenses in Current Ophthalmic Practice Evaluation (SCOPE) eyecare practitioner (ECP) scleral survey studies. SCOPE 1 included responses from 989 ECPs, which represented a total of no less than 84,375 lens fits. Among the patients fit, 74% exhibited corneal irregularity, 16% had ocular surface disease, and 10% were fit to correct refractive error (i.e., astigmatism, presbyopia). Complications were relatively rare, with 610 (0.72%) experiencing lens care and handling issues, 171 (0.2%) having conjunctival complications, 975 (1.2%) having corneal complications, and only 70 (0.08%) having experienced microbial keratitis.

SCOPE 2 has recently been initiated. This study is evaluating patient outcomes of scleral treatment. Scleral lens fitters are asked to describe the experience of a single scleral lens patient. The preliminary results show that scleral lens wearers average 12.7 hours of daily lens wear, with 28% experiencing midday fogging. If you would like to participate in this survey, you can contact Ellen Shorter, OD, at eperry1@gmail.com.

SCOPE 3 was initiated at the GSLS with the purpose of defining consensus on scleral lens fitting parameters. If you would like to participate, you can contact Jennifer Fogt, OD, at fogt.78@osu.edu.

MYOPIA CONTROL

Kate Gifford, BAppSc(Optom), moderated an informative session on the popular topic of myopia control. She discussed some useful in-office tools for parents of young myopic children as well as for ECPs. Specifically, the Clinical Myopia Profile is an excellent resource for parents of myopic or emerging myopic children. It discusses the risk of a child being myopic based on environmental factors including time spent outdoors and time devoted to close work. If a young person is already myopic, it provides the available myopia control options and their effectiveness in slowing down myopia. Finally, it provides a clinical management pathway that results in recommended management options (Figure 6). Kate Gifford also discussed "My Kid’s Vision," which is a free online tool that helps parents assess and manage myopia risks for their kids. It is available at www.mykidsvision.org .

Associate Professor Scott Read reported on his seminal research pertaining to the effect of outdoor illumination on myopia (Read et al, 2015). A total of 101 children, ages 10 to 15, 41 of whom were myopes and 61 who were non-myopes, were evaluated four times over an 18-month period. Objective measures of light exposure and physical activity were monitored. They found that greater daily light exposure was associated with slower eye growth and that the so-called “outdoor effect” in myopia is primarily driven by bright light exposure outdoors. Their findings suggested that bright light exposure for less than 60 minutes per day is a risk factor for faster eye growth in childhood. Likewise, increasing outdoor light exposure by 60 to 90 minutes per day is likely to have an impact on slowing eye growth. Therefore, children—in particular, those who are at risk—should be encouraged to spend greater time outdoors to reduce risks of myopia development and progression.

Bret Andre, MS, discussed the current status of FDA clearance of contact lenses for myopia control. He reported that, like extended wear contact lenses, both overnight orthokeratology and soft lenses for myopia control are in the Class III, Significant Risk category. In a recent FDA Workshop on Sept. 30, 2016, experts discussed what it would take for FDA clearance of myopia control lenses. In particular, what questions would need to be answered and what criteria would need to be established in a long-term study to evaluate myopia control. According to Bret Andre, it was decided that such a study would need to be four years in length (three years treatment and one year regression) with children from 7 to 12 years of age. The experimental group would need to have approximately 225 subjects, and the control group would need to have approximately 175 subjects. Therefore, whether it is an overnight orthokeratology design or a multifocal soft lens, it was predicted that initial FDA clearance may be a five- to seven-year process.

CONTACT LENSES OF THE FUTURE

Craig Norman moderated the always fascinating session on “New Technologies in Contact Lenses,” in which we get a glimpse of what the contact lens landscape will look like in the next five to 10 years and beyond.

Jerome Legerton, OD, MS, MBA, talked about the many different applications for which contact lenses are being developed. He noted that a number of trends and technological developments are converging that are helping to make new applications for contact lenses a reality: miniaturization that allows electronic components to be put into contact lenses; precision metrology and manufacturing that allow for enhanced control of optical path; consumer appetite for mobile information and entertainment; peripheral or implanted sensors and sending units to monitor human anatomy and physiology; micro-electro mechanical systems for supplying power that are now small and inexpensive enough to be used in contact lenses; and developments in microfluidics and nanotechnology. These trends and technological advances are driving the development of contact lenses for biological sensing, drug delivery, myopia control and other refractive error regulation, photonics and molecular biology, innovative ways to correct presbyopia, low vision correction, and as wearable displays. With the ability to incorporate light into contact lenses, there is even the possibility to regulate circadian rhythms, manage seasonal affective disorder, and expose the eyes of children to more light for possible myopia prevention.

Dr. Legerton also discussed why contact lenses are well suited for these applications. He said that the eye is “the light of the body.” It is close to the central nervous system, the cornea is transparent, the tear film communicates body chemistry, and the aqueous and crystalline lens also communicate, so the eye is a good place to have sensors to pick up that information. Dr. Legerton said that first-generation sensing lenses are like Trojan horses; they are the first ones to break into this technology, but behind them is a family of lenses that have broader sensing capabilities and can perhaps administer medication in response. Perhaps the highest level of interest in future contact lens designs is for drug delivery, according to Dr. Legerton.

Contact lenses that serve as wearable displays provide a wide field of view without being bulky or unstylish, so they can serve as a better delivery device compared to eyewear devices. Contact lenses can also work as a virtual reality device by themselves or in conjunction with an eyewear display. In addition, Dr. Legerton said that the speed at which we can process information is evolving with the way that information is delivered. Contact lenses could serve as wearable information, making a more efficient conduit for people to get information compared to current means, such as mobile phones.

There are some challenges with these future developments. The lenses will need to have a level of comfort that’s acceptable for the public to embrace them. In addition, there are considerations as to how the added components affect oxygen transmissibility, how the lenses are to be cleaned, and whether the lenses can be surface treated—many new problems that need solutions before these lenses can be clinically viable. Stay tuned for a full feature article on future contact lenses by Dr. Legerton that will appear in the August issue.

MANAGING PRESBYOPIA

Presbyopia can be a difficult condition to manage with contact lenses. But with the number of presbyopes continually growing and so few of them in contact lenses, presbyopes represent a tremendous opportunity for practice growth. So how can you get more of your presbyopic patients into contact lenses successfully? The session “Presbyopia and Contact Lenses—Can We Overcome the Challenges?” covered this topic.

James Wolffsohn, FCOptom, MBA, PhD, from Aston University in Birmingham, United Kingdom discussed “Opportunities for Specialty Contact Lenses in the Multifocal Market.” He noted that there are a number of special considerations for multifocal contact lenses: centration, pupil size, aging ocular optics, ocular comfort, and ocular physiology. While mass-produced multifocal lenses are improving in their designs and their ability to meet these considerations, specialty lenses offer the additional benefits of more diverse designs and the ability to personalize the lens to each patient’s optical and ocular needs. Specialty lenses can also simulate the optics of multifocal intraocular lenses.

Stephanie Woo, OD, gave a lecture packed with practical clinical information titled “Clinical Pearls in Fitting and Evaluating Multifocal Lenses.” From identifying good candidates to the fitting, troubleshooting, and follow up, Dr. Woo covered every step of the multifocal fitting process for both soft and GP lenses and how practitioners can maximize their success. She also noted that because most patient do not even know that multifocal contact lenses exist, it is important for practitioners to be proactive about presenting and discussing the option to appropriate patients.

Dr. Woo indicated that good candidates include emerging presbyopes, especially those who are already wearing contact lenses; those who want to decrease their dependency on glasses even if they don’t have perfect vision; patients interested in part-time wear; and hyperopic patients. She advised attendees to steer clear of patients who have high visual expectations and those who are not willing to wear glasses ever with their contact lenses. Dr. Woo recommended using the fitting guides with soft multifocals and ordering GP corneal or hybrid multifocals empirically, then checking fit and vision in-office and educating patients before sending them out to wear the lenses in their normal environments. She also discussed troubleshooting tips and how to decide when it’s time to pull the plug on an unsuccessful fit.

Craig Norman discussed scleral multifocal lenses, which have been gaining in popularity and are now available from most scleral lens manufacturers for both regular and irregular corneas. The design and fitting of presbyopic sclerals are similar to soft multifocals. Since scleral lenses have limited on-eye movement, they are available in simultaneous multifocal designs, primarily center-near although they can be fabricated as center-distance as well.

He also discussed findings from a study that his colleagues at the Vision Research Institute of Ferris State University’s Michigan College of Optometry carried out in which they fit patients who have normal corneas with scleral lenses. The results indicated that most patients were satisfied with vision and comfort, but found application/removal and lens care to be the greatest deterrents to their wear.

THE FUTURE OF SOFT LENS FITTING

Eef van der Worp, BOptom, PhD, moderated a session on “Survival of the Fitting: Moving Beyond Base Curve with Soft Lenses.” Interestingly, despite all material, replacement frequency, and contact lens care improvements in recent years, the soft lens dropout rate is still high. In fact, the contact lens penetration in developed markets is very flat: as many wearers drop out of lens wear as there are new fits.

Because of this, interest has been growing in recent years regarding the fitting and evaluation of standard hydrogel contact lenses. It may be time to see whether we can do things differently—to potentially change or alter our approach in the way that we fit and evaluate soft lenses going forward. Everyone needs be united in this effort, though; industry, research, schools, and practitioners need to see the limitations—and embrace the future potential—to make a difference.

Dropout Replacing soft lenses once a day (daily disposables) is most likely the ultimate replacement frequency. Replacing lenses more than once a day resulted in no improvement in comfort, according to a study by Papas et al (2014). A recent paper by Sulley et al (2017) showed that 12 months after the lens fit, the retention (the amount of people still in contact lenses) was 74%. Of the dropouts, 25% discontinued during the first month, 47% within 60 days. Interestingly, for 71% of dropouts, no alternative lens or management strategy had been tried. Also of interest, there was a wide variation among sites: between 40% to 100%. In other words, some practices managed to keep all patients in lenses, while others had huge dropout rates—so how practitioners manage contact lens patients makes a difference.

Currently, ECPs try to find eyes that best conform to the limited arsenal of soft lenses available. We individually and meticulously measure the precise power that the eye needs in daily practice. So, why not measure the ocular surface individually as well, to best match the shape of the eye? The question is: How do we do this?

Upgrading Keratometry Keratometry values are relatively useless when it comes to soft lens fitting. There is very little correlation between K values and how a lens behaves on the eye. There is also very little correlation between the central curvature and the shape of the peripheral cornea and sclera due to the wide variation in rates of corneal flattening across the population.

Elevation, sagittal height, tangent angles, and microns seem to be becoming the new standard in soft lens fitting. The average sagittal height of the ocular surface from a clinical perspective can be assumed to be 3,750 microns for a normal eye over a 15mm horizontal chord (900 micron range) (van der Worp and Hulscher, 2015). Associate Professor Scott Read delivered a full overview on this in his lecture “New Technology, Ocular Surface Shape, and Ocular Parameters.” He also noted in one of his lectures that the amount of unwanted corneal change beneath a soft lens (e.g., corneal warpage) may potentially be used to determine the quality of the fit going forward—although much work is required in that sense.

Beyond Base Curve So much for the ocular surface shape, what about the contact lens shape? Base curve values on soft lens packages are of symbolic value only. Substantial differences in sagittal height exist between different commercially available lenses, but the total range of the lenses available is limited. The average sagittal height of a soft lens must be somewhat higher than that of the ocular surface to generate “grip” for an acceptable lens fit; if both have the same sagittal height, excessive lens movement causes discomfort.

Soft lens fitting has evolved to an almost “one-size-fits-all” approach. After years of investment in better lens materials and replacement frequency of soft lenses, it now may be time to get back to lens design and to respecting the shape of the ocular surface better with soft lenses. Finding better standard lenses for any given eye, or creating customized soft lenses, may prove to be instrumental for the future of soft lens fitting.

In his lecture “How Do We Best Fit Soft Lenses?” Professor James Wolffsohn discussed different ways to look at soft lens wear and evaluation. He found that lens movement on-eye typically is not in the 1mm range as generally thought in the past, but is closer to 0.2mm to 0.3mm. He also found that lens substitution (replacing one lens with another based on just the values on the package) will not provide comparable performance on-eye. In other words, lenses should not be substituted based solely on their listed parameters, and detailed assessment of lens fit is essential for safe contact lens wear.

WHAT’S NEW IN DRY EYE?

Dave Kading, OD, and Andrew Pucker, OD, PhD, presented a discussion on “What’s New, What’s Different: A Clinical and Research Perspective of Dry Eye and Contact Lens Wear.” They recommended that dry eye exams should be standardized and that attendees should develop a regular exam protocol for dry eye diagnosis. Because you can’t trust just signs and you can trust just symptoms when it comes to diagnosing dry eye, they recommended that the protocol should cover both: at least one questionnaire about symptoms and a set battery of graded tests that covers the primary ocular structures and is ordered from most to least invasive. Furthermore, they stated that the testing protocol should allow for differentiation between evaporative and aqueous deficient dry eye and that a balance must be struck between the number of tests and the amount of information needed to make an informed diagnosis.

The tests that Drs. Kading and Pucker consider the most valuable and that should be performed on all patients include a dry eye questionnaire such as the Ocular Surface Disease Index (OSDI) or the Standard Patient Evaluation of Eye Dryness (SPEED) survey, blink assessment, lissamine green staining, a consistent method for evaluating meibomian gland expression, and a device to measure levels of matrix metalloproteinase-9. In addition, they said that if you plan to have a dry eye practice and to diagnose/manage a lot of dry eye cases, then a meibographer may be worth considering.

For contact lens wearers, they recommended that ECPs assume that all lens wearers have dry eye/lens discomfort even if they are asymptomatic. In addition, ECPs should consider the least invasive lens options, such as part-time wear, daily disposables, and preservative-free solutions, when possible and treat patients based on their progression rather than their current state. In other words, if a patient is worse now compared to a year ago, then anticipate that he will continue to advance.

SCIENTIFIC PAPERS

Excellent clinical research papers have always been an important component of the GSLS, and this year’s was no exception. Dr. Vogt reviewed the results of her study, which had the purpose of determining whether independently varying the sagittal depth of four concentric zones of a scleral lens can provide greater control and optimal fit without over complicating the fitting process. Twenty-two current scleral lens wearers were refit into test lenses that were determined using the assistance of a corneal-scleral topographer and a newly developed and yet-to-be introduced calculator. The calculator can assist in determining whether less or more clearance is needed in any region including the periphery and, therefore, help in making needed lens parameter changes. Of the 21 subjects who completed the study, 15 preferred the test lenses, four had no preference, and two preferred their habitual lenses.

Boris Severinsky, OD, compared several types of lenses fit to patients who had undergone corneal cross-linking (CXL). Sixty-eight eyes of 53 patients who had undergone CXL (93% epi-off) were fit into either a 17mm overall diameter silicone hydrogel soft mini-scleral (30 eyes), a hybrid design (24 eyes), or a GP scleral (14 eyes). On average, the soft lenses were fit 2.5 months after CXL; the hybrids were fit 4.3 months afterward, and the scleral lenses were fit 4.7 months afterward. The subjects were followed for approximately six months after being fit into contact lenses. Eight subjects dropped out, five in the soft lens group (three had persistent non-wetting; two had poor visual acuity), three in the hybrid group (two with epithelial insult; one due to extreme corneal flattening), and none in the scleral group. The hybrid group had a total of 14 corneal complications, as compared to three with the soft lens group and one with the scleral group. It was concluded that you should wait, at minimum, four to six weeks after CXL before initiating contact lens fitting and to initiate the process with custom soft mini-scleral lenses. You should then allow three to four months for further corneal changes and then refit patients into GP scleral lenses.

Michael Lipson, OD, reported on a three-year retrospective study of young people and myopia change with overnight orthokeratology. He evaluated the results of 194 eyes of 97 subjects. The mean age at the start of wear was 10.4 years. At the end of three years, 65% of the subjects experienced little to no change in axial length (< 0.50mm), 20.1% showed a moderate change in axial length (0.50mm to 1.0mm), and 14.4% showed a significant increase in axial length (> 1.0mm). The youngest subjects exhibited the greatest change in axial length, although still significantly less compared to spectacle-wearing young myopes. Overall, it was concluded that overnight orthokeratology is effective in controlling myopia progression.

Jim Schwiegerling, PhD, gave a fascinating presentation that provided attendees with a glimpse into the future of what can be used to realistically assess vision with multifocal designs and how these images can be used to optimize lens design. His efforts were devoted to creating realistic three-dimensional (3D) scenes and incorporating the multifocal designs into the simulations. He showed that realistic 3D scenes can be created by using multiple depth planes and occlusion; different presbyopic treatments can be compared to determine the capabilities and limitations of each. This can be expanded in the future and can be useful in optimizing vision through multifocal lens designs.

LOOKING FOR MORE?

This article discusses only a portion of the many educational highlights from the 2017 GSLS. You can find PDFs of this year’s educational sessions and clinical posters at www.gslsymposium.com .

Next year’s GSLS will take place from Jan. 25 to 28 at the Tropicana Hotel and Casino in Las Vegas. CLS

For references, please visit www.clspectrum.com/references and click on document #257.