The 2020 Global Specialty Lens Symposium (GSLS), which took place from Jan. 22 to 25 at the Tropicana in Las Vegas, demonstrated once again that interest and enthusiasm for specialty contact lenses continues to thrive and grow. Presented by Contact Lens Spectrum, this year’s meeting was the largest yet, welcoming more than 1,200 total participants including nearly 800 attendees, 52 speakers, and 64 exhibiting companies from 33 countries.

The educational program offered nearly 50 continuing education (CE) sessions with CE credit hours available from Council on Optometric Practitioner Education (COPE), National Contact Lens Examiners (NCLE), and the Florida Board of Optometry. Attendees also had learning opportunities during preconference activities, sponsored non-CE breakfast and breakout sessions, and a record number of posters. The GSLS Program Committee is chaired by Jason J. Nichols, OD, MPH, PhD, and includes Edward Bennett, OD, MSEd; Patrick Caroline; Karen DeLoss, OD; and Eef van der Worp, BOptom, PhD.

PRECONFERENCE HIGHLIGHTS

There was excitement about specialty lenses at the Tropicana before the GSLS even got started. Kicking off the Preconference activities was the International Forum for Scleral Lens Research (IFSLR). Featuring presentations by global scleral lens experts on such hot topics as oxygen delivery to the cornea during scleral lens wear, the post-lens tear reservoir, scleral shape, and scleral fitting, the IFSLR concluded with an interactive discussion in which audience members had the opportunity to both ask and answer questions. More detailed coverage of this event will appear in a future issue.

New this year were two Preconference Workshops. “Scleral Lenses: Taking it to the Next Level” was presented by Matt Kauffman, OD; Dan Fuller, OD; Karen Lee, OD; Pam Satjawatcharaphong, OD; and Maria Walker, OD, MS. It included everything from a basic introduction to scleral lenses and scleral lens terminology to an overview of the fitting process, how to evaluate the lens fit, handling and application/removal tools, scleral topography, scleral shape patterns, customizing the lens periphery, midday fogging, and wavefront optics. Several scleral lens fits were evaluated on-eye during the workshop (Figure 1), and polling software allowed audience members to share their thoughts. A few important takeaway points were to evaluate scleral lens fits from the center out; if the central clearance is too high, it will affect other aspects of the fit, so fixing the sagittal height can often resolve other issues; and, if limbal clearance looks too low, wait until follow up to see whether the eye has a response before making a change.

The Dry Eye Workshop was presented by Lyndon Jones, PhD, DSc, FCOptom; Karen Walsh, BSc(Hons), PGDip, MCOptom; and James Wolffsohn, FCOptom, MBA, PhD. Dr. Walsh reviewed the Tear Film & Ocular Surface Society Dry Eye Workshop II definition and classification of dry eye. Then, Dr. Wolffsohn differentiated between ocular surface disease and dry eye. Specifically, he detailed triaging questions, risk factors, and diagnostic questionnaires. Dr. Walsh explained that practitioners should perform dry eye tests in a certain order—after history, next is tear film, then diagnostic dyes, and then lids. Then, both Dr. Walsh and Dr. Wolffsohn discussed and demonstrated various diagnostic and imaging devices that can be used when assessing a patient’s ocular surface. The workshop ended with Dr. Jones discussing the treatment algorithm for the evaporative components of dry eye disease and demonstrating several devices that are used to clean and treat the eyelids and lid margins.

As in previous years, attendees also had the opportunity to mix and match sessions among five Preconference Program tracks: GP Lens (co-hosted by the Gas Permeable Lens Institute), Myopia (co-hosted by Contact Lens Spectrum), Practice Management (co-hosted by Optometric Management), Irregular Cornea (co-hosted by Contact Lens Spectrum), and Scleral Lenses (co-hosted by the Scleral Lens Education Society).

GSLS AWARDS

A record 127 scientific posters were accepted for the 2020 GSLS. The two poster categories were research and clinical (predominantly case report), and the top three from each category were honored (Figure 2). Likewise, almost 60 photos were submitted as part of the annual GSLS photo contest. Table 1 lists the winning poster titles and authors as well as the winning photos. The three winning photos also appear on the cover of this issue.

Table 1.

SCIENTIFIC POSTER & PHOTO AWARDS
RESEARCH CATEGORY POSTERS
FIRST PLACE: José Vega, Paul Chamberlain, and Baskar Arumugam – Comparison of Myopia Progression in New and Established Myopia Control Treatment (MiSight® 1 day) Groups SECOND PLACE: Andrew Pucker, Gerald McGwin Jr., Quentin X. Franklin, Alanna Nattis, and Chris Lievens – Contact Lens Discomfort Decreases Visual Quality of Life THIRD PLACE: Yueren Wang and Daniel G. Fuller – Safety and Efficacy of Scleral Lenses for Keratoconus
CLINICAL CATEGORY POSTERS
FIRST PLACE: Rosa Yang, Catherine Wright, and Luigina Sorbara – Special Considerations in Managing a Patient with Penetrating Trauma Using Gas Permeable Contact Lens SECOND PLACE: Trevor Fosso – Scleral contact lens correction of varying irregular astigmatism during corneal regeneration THIRD PLACE: Jennifer Liao, Stephanie Ramdass, and Allan R. Slomovic – Rising Over the Rebound
PHOTO CONTEST WINNERS
FIRST PLACE: Marco Sergio Tovaglia, When a Lens Is not Enough SECOND PLACE: Bita Asghari, Pellucid’s Peak THIRD PLACE: Vakishan Nadarajah, Friendly Neighborhood Spidey Lens

A highlight of the GSLS every year is the presentation of the GSLS Award of Excellence. Initiated in 2013, this award is given to distinguished clinicians, scholars, and/or scientists to recognize their lifelong achievements in the field of contact lenses, especially as they relate to specialty contact lenses. The 2020 honoree is Joseph T. Barr, OD, MS (Figure 3). A graduate of The Ohio State University College of Optometry (TOSUCO), he was one of the first individuals to complete the school’s prestigious Master of Science in Physiological Optics and Fellowship in Contact Lenses. He served as a faculty member and administrator at TOSUCO while also serving extensively in industry, first with Dow Corning and as Bausch + Lomb Vision Care Vice-President of Global Clinical Affairs.

Dr. Barr is renowned for his clinical research, which has resulted in numerous peer-reviewed publications and scholarly presentations. Most important, Dr. Barr and his colleague, Dr. Karla Zadnik, were principal investigators of the Collaborative Longitudinal Evaluation of Keratoconus, an eight-year multicenter study evaluating the etiology, demographics, and progression of this condition.

In addition to the GSLS Award of Excellence, Dr. Barr has received—among his many honors—the highest awards given by the American Optometric Association Contact Lens & Cornea Section (the Donald R. Korb Award), the American Academy of Optometry Section on Cornea, Contact Lenses and Refractive Technologies (Max Schapero Memorial Award), and the Contact Lens Manufacturers Association (Josef Dallos Award). Of course, for 20 years he was the editor of Contact Lens Spectrum while also serving as the founding editor of Contact Lenses Today. He is also a beloved mentor to many of today’s leaders in contact lenses.

MYOPIA

One of the hottest topics at the 2020 GSLS was myopia and its management. This is not surprising given the well-known global increase of the condition and scientific evidence showing that its progression can be slowed. In fact, we feel that this topic is so important that, during the opening session, Dr. Nichols announced The Global Myopia Symposium (GMS), which will take place just prior to the 2021 GSLS. Brought to you by Contact Lens Spectrum, the GMS program committee will include Kate Gifford, PhD, BAppSc(Optom)Hons; Dr. Nichols; Dr. Lyndon Jones; Shalu Pal, OD; and Jeff Walline, OD, PhD.

The opening general session of the GSLS was on Clinical Controversies in Myopia Management. You can find a full write up of this popular session as a feature article starting on p. 30 of this issue.

The general session “A 2020 Vision of Myopia and Its Management” was moderated by Dr. Bennett and featured panelists Don Mutti, OD, PhD; Earl Smith, OD, PhD; and Dr. Walline. It was presented in a debate format in which one of the panelists debated one side of nine different myopia-related topics. The panelists may not have been in agreement with the side that they were defending.

The first topic was whether myopia is a disease. Dr. Smith argued that it is not a disease but an adaptation. He stated that the vision-dependent mechanisms that regulate refractive development are designed to optimize refractive error for our environment. In this respect, myopia is a logical adaptation to our modern habitual viewing experience, in which children spend much less time outdoors and much more time viewing electronic screens. Dr. Mutti countered that myopia matches the Oxford English Dictionary definition of a disease. He also noted that each additional diopter increases risk of myopic maculopathy by 67%, but reducing myopia by each diopter reduces this risk by 40%.

The spirited debates continued with a look into which form of myopia control to use, in which Dr. Mutti argued in favor of optical means (primarily soft bifocals), and Dr. Walline argued in favor of pharmaceutical approaches (atropine). Next, the question of how to decide what form of myopia control to use was presented. Dr. Walline argued that patients should prescribed a modality that both fits their lifestyle and that they will continue to use through the age of expected progression, while Dr. Smith countered that treatment should be based on scientific protocols, pointing out that multifocal soft contact lenses, for example, may be a better choice for low myopes.

Other topics that were debated included whether U.S. Food and Drug Administration approval changes how the panelists practice (Dr. Mutti stated that the judgement of licensed healthcare providers should rule, Dr. Walline stated that practitioners owe it to their patients to prioritize the lens with the most evidence); when to start myopia control (before myopia onset, upon myopia diagnosis, or when progression is too fast); whether to change treatments if progression is too fast with treatment; whether to measure axial length for myopia control; when myopia control can be stopped (Dr. Walline argued that if vision, fit, and comfort are good, why stop and switch to something else? Plus, in soft multifocals, the transition to presbyopia will be easier if the multifocal treatment is continued through a patient’s lifetime); and whether myopia control works for adults (there are no studies on this and there are not likely to be, but Dr. Smith pointed out that the mechanisms that regulate ocular growth are still active well into adult life).

One of the Free Papers presented at this year’s meeting was on the topic of “Combined atropine with orthokeratology (AOK) for myopia control: 1-year results,” presented by Qi Tan, MSc. This controlled single-masked clinical trial randomized subjects to one of two treatment groups: 1) AOK (nightly 0.01% atropine combined with orthokeratology [ortho-k]), and 2) OK (ortho-k alone). Axial elongation was significantly slowed in the AOK group (versus ortho-k) in the first six months, but there was no difference in progression in the second six months. In the AOK group only, this change in the first six months was accompanied by a significant moderate negative correlation between axial elongation and photopic pupil size, which was not present from the six- to 12-month visit. It was postulated that the enhanced effect of the combination could result from an enlarged photopic pupil size, increased exposure of relative myopic peripheral defocus on the retina, and/or elevated total high-order aberrations in ortho-k-treated eyes.

Jacinto Santodomingo-Rubido, PhD, MSc, OD, continued his long-term evaluation of ortho-k subjects in his free paper titled: “Eleven years of orthokeratology contact lens wear for reducing myopia progression in children.” Measurements of axial length, corneal topography, and cycloplegic refraction were taken at six-month intervals for the first two years of the study and then after seven and 11 years of ortho-k. A reduced axial elongation of the eye in comparison to a control group was equal to an average of 36%. The effect appears to peak after two years, with the efficacy reducing over time, and axial length and myopia stabilization of children occurring as they enter their teenage years. These results provide support of the long-term efficacy of orthokeratology in reducing myopia progression in children.

SCLERAL LENSES

Scleral lenses often take center stage in the specialty lens arena, both for their life-changing benefits and for their known and unknown complications.

The “State of Scleral Lenses,” general session featured a panel of experts including Patrick Caroline (moderator), Gonzalo Carracedo, PhD; Greg DeNaeyer, OD; Lynette Johns, OD; Stephen Vincent, BAppSc(Optom)Hons; and Dr. Wolffsohn.

Dr. Carracedo looked at how a scleral lens changes the ocular surface. He noted that, through hydraulic forces similar to that with ortho-k lenses, sclerals cause flattening in the superior-nasal quadrant of the eye, which can be seen by comparing topographic images before and one hour after wear. He also noted that some patients experience some edema with scleral lens wear.

Dr. Carracedo also reviewed studies showing that scleral lens wear causes an increase in corneal density and dendritic cells. There is no difference in goblet cell density in keratoconus patients, but there is a significant difference in goblet cell density in post-laser-assisted in-situ keratomileusis (LASIK) patients. However, there is not a significant difference in mucin production in post-LASIK or keratoconus patients.

Next, Dr. DeNaeyer examined scleral shape. He noted that the sclera is non-rotationally symmetric, more irregular toward periphery, and has a tangential slope moving out from the cornea. He noted that there are four possible scleral shapes: 6% are spherical, 30% are toric, and 65% are asymmetric (quadrant-specific or free-form custom). He then explained that scleral toricity cannot be predicted from corneal topography and that quadrant-specific or free-form designs, as opposed to toric landing zones, are needed to get the best fit on asymmetrical scleral surfaces.

Next, Dr. Wolffsohn looked at the effect of scleral lens oxygen permeability on corneal physiology. He explained that as materials have gotten better and allow more oxygen through, scleral lens wear is less concerning. He noted that scleral lenses with a Dk of 100 or above had an effect on swelling, but those with a Dk of less than 88 caused greater swelling. Dk also had a slight effect on comfort; sclerals with a Dk of 200 were reported as the most comfortable. Additionally, corneal thickness increased with all materials > 100Dk.

Professor Vincent then looked at sclerals and oxygen. He noted that thickness profiles vary across the lens for different designs. Clearance also impacts oxygen delivery. Theoretically, excessive clearance reduces oxygen delivery, but clinically, he has seen success with high clearance.

Dr. Johns looked at the possibility of using scleral lenses as a drug delivery modality. She noted that it seems ideal because of the fluid reservoir and limited tear exchange. She gave examples of medications with which drug delivery has been proposed, such as moxifloxacin, bevacizumab, and others. Dr. Johns said that patients would wear lenses on an extended schedule, but they should check every day for any issues. Patients should have two lenses so that a clean lens is worn while the other is disinfecting.

Finally, Pat Caroline discussed the effect of scleral lenses on intraocular pressure (IOP). He shared scleral lens research that was previously published in Contact Lens Spectrum in which scleral lens wearers typically experience a 5 mmHg increase in IOP.1 It is important to consider that the study used a best-case lens wear scenario—normal, young, healthy eyes in an eight-hour study. But, what about aging eyes? Or eyes that are post-ocular surgery or that have active ocular pathology? What are the long-term ramifications of 12- to 16-hour wear followed by post-removal and sleep when the IOP is potentially its greatest?

He concluded by saying that patients need to earn the right to wear sclerals only after they have failed in corneal GP lenses.

NEUROPATHIC PAIN

Dr. Johns moderated a fascinating session with panelists Dr. DeLoss and Deborah Jacobs, MD, on “Ocular Pain: Why Scleral Lenses May Fail.” Dr. Jacobs began with a discussion of the neuroscience of pain. She explained that with neuropathic pain, there is a disconnect between what the nerve fibers sense and where those signals are modulated, with the result that there’s no signal from the nerve fibers, but the brain is sensing pain. She suggested that one way to diagnose this is to have patients rate their ocular surface pain on a 1-10 scale, then instill a drop of anesthetic without telling patients what it is. If after 10 minutes the pain is at the same level, then the problem is likely neuropathic. She said that it is important to not characterize such conditions as psychiatric problems but as nerve problems. Dr. Jacobs noted that therapeutic goals are to reduce signaling and to provide local support and shielding (steroid, cyclosporine, local suppression of inflammation). Cognitive behavioral therapy is useful, strategies are more important compared to a specific treatment, and neurologists who have an interest in headaches may be most helpful.

Dr. DeLoss described how to take these patients through the process of scleral lens fitting. She recommended emphasizing that the goal is to explore options and to then set realistic expectations. During the consult, leave no stone unturned—take a full ocular history, find out when it started, past treatments, and what currently provides relief. For the diagnostic fitting, exhaust all options, try different diameters, and document everything about the fit. Ask patients for feedback. If they don’t provide any, consider leaving the room and coming back to ask. Dr. DeLoss also explained that patients need to know that scleral lenses should not be considered as a final option. She also noted that some patients succeeded with scleral lens wear with the use of some medications such as gabapentin and pregabalin.

CARE OF SPECIALTY LENSES

Louise Sclafani, OD, and Loretta Szczotka-Flynn, OD, PhD, presented on the timely topic of “‘Bugs All Around,’ A New Era in Standards for Contact Lens Practice.” They are certainly well qualified to address this topic, as they are part of a working group from the American Academy of Optometry (AAO) Section on Cornea, Contact Lenses and Refractive Technologies and the American Optometric Association (AOA) Contact Lens & Cornea Section, which also included Christine Sindt, OD; Dr. Bennett; Melissa Barnett, OD; and Carol Lakkis, BSOptom, PhD, who developed a disinfection protocol for diagnostic lenses. These recommended disinfection standards are detailed in full in the Online Exclusive article “Caring for Specialty Lenses in 2020” by Kelsy R. Steele, OD, which appears with the online edition of this issue and is part of the April Digital Edition of Contact Lens Spectrum.

Gloria Chiu, OD, presented a free paper on “Microbiological evaluation of opened saline bottles and hygiene habits of patients wearing scleral lenses.” The overall rate of microbial contamination of saline samples was 63%, with a total of 20 different microorganisms identified. A survey conducted as part of the study indicated that more than 88% of patients practice some form of risky care behavior that may increase the risk of saline bottle contamination. Therefore, it was recommended that scleral lens patients exercise caution when using multidose preservative-free saline.

CE BREAKOUTS

The 2020 GSLS featured a number of CE breakout sessions on a broad range of specialty lens topics including multifocal contact lens fitting, visual rehabilitation for keratoconus, orthokeratology fitting, amniotic membranes, and many more.

Myopia Management The CE breakout titled “Myopia Management: What to do when the Unexpected Happens” was presented by Kevin Chan, OD, MS. During the presentation, he discussed case studies of children who have myopia. He used the cases to help practitioners understand that sometimes common and evidence-based strategies need to be tailored or combined with other treatments to achieve maximum effectiveness. One big take-away from the session was the fact that orthokeratology (ortho-k) is not the best option for all young progressive myopes because there is a limit to the parameters.

Matthew Martin, OD, and Caroline Cauchi, OD, presented “OrthoK Cruise Control: Get your Fitting up to Speed,” a clinical and practical session on managing young myopes through the process of ortho-k for myopia control. They began by discussing the care protocol for ortho-k lenses, which includes surfactant cleaner, digital rubbing for 10 seconds (not too hard or there might be warpage), rinse with preservative-free (PF) saline or multipurpose solution (MPS) (but never with tap water), and place the lenses in hydrogen peroxide (H₂O₂) for 6+ hours. The lenses should be filled at application with PF saline or PF drops; one pearl that they provided was to use the saline that has been converted from the H₂O₂ during the neutralization process. Drs. Martin and Cauchi recommended teaching patients to apply and remove lenses both with a plunger and without one in the event that they ever find themselves in need of handling a lens and there are no plungers available.

For follow-up visits, they recommended a schedule of day 1 (or possibly 2), one week, one month, three months, and every six months thereafter. Drs. Martin and Cauchi discussed what to ask patients at the follow-up visits (wearing time, problems with application and removal, how long is the vision good) as well as what data to collect and how to analyze it. They showed what an optimal fit should look like; an optimal pattern shows central bearing with an annulus of tear reservoir, midperipheral bearing, some edge lift, and good centration. They noted that the amount of edge lift can really affect the treatment. Drs. Martin and Cauchi continued with a discussion of the different types of topography maps and how each can provide information about the fit, noting that ortho-k cannot be done without a topographer because practitioners need to know what change has occurred.

Following this was a detailed discussion of what the post-fitting maps look like in cases of non-optimal fits and how to troubleshoot lens parameter changes based on the post-fitting maps. A few additional pearls that they provided are that the lens diameter should be 95% of the cornea, the epithelial iron rings that can form with ortho-k treatment are benign and of no concern, and at follow-up visits you should have patients say how they are caring for their lenses so that you can correct them as they tell you.

Multifocal Lenses Shalu Pal, OD, and Melissa Barnett, OD, presented an informative CE breakout session titled “Multifocal Contact Lens Fitting: The Importance of Communication to Win Patients Over.” Dr. Barnett explained that practitioners need to be active listeners and should acknowledge their patients’ emotions. Asking open-ended questions will help them determine why their patients are interested in contact lenses. She noted that not every contact lens wearer will be a full-time wearer. Dr. Pal agreed that the practitioners’ focus is to help their patients achieve their goals by determining what they did or did not like about their lenses. For example, do they want an immediate fix to their vision issues, to feel young and free, or to not be limited at any range?

Dr. Barnett noted that she starts to have conversations about presbyopia with patients when they are in their 20s, because many of their parents are dealing with it. There are many basic questions that patients often have. How is the adaptation different between multifocal spectacles and multifocal contact lenses? What is simultaneous vision, and how does my brain turn off the images that I don’t want? Dr. Barnett discusses all options even if patients aren’t interested in any of them right now. While they may never be interested in the lenses for themselves, they might think that multifocals would be good for a friend.

Dr. Pal says that her presbyopia conversations are also happening earlier because many of her patients are suffering from computer vision syndrome. She stated that we should stop talking about age; rather, presbyopia is a factor of how we live our lives.

When fitting multifocal lenses, practitioners should start by getting an accurate refraction (no more plus or minus than necessary), then determine eye dominance and the lens modality (daily disposable, two-week, or monthly). After applying the lenses, it is important to let them settle before checking patients’ visual acuity. If the lens isn’t providing adequate vision, determine whether this is due to alignment issues or to eye anatomy. Practitioners can troubleshoot the visual issues by using fitting guides, performing a binocular distance over-refraction, or through custom soft multifocals.

Finally, Drs. Barnett and Pal mentioned that practitioners want to ensure that they don’t lose patients to follow up. They emphasized the importance of communicating with patients before they leave. In addition, practitioners should touch base with their patients to find out what worked and what didn’t.

Specialty Lenses for Children In “The Magic of Specialty Contact Lenses in Children,” Jennifer Fogt, OD, MS, discussed the importance of visual development from a very young age and how contact lenses can help provide kids with good vision. Various pediatric vision issues include amblyopia due to deprivation that can occur from infantile cataract, persistent hyperplastic vitreous (PHPV), corneal scar due to infection or to a birth injury, strabismus or trauma; or amblyopia due to refractive conditions such as high uncorrected refractive error and anisometropia.

Contact lens options for correcting the resulting aphakia after surgical removal of cataracts/PHPV include silicone elastomer lenses, GP lenses, or soft custom hydrogel or silicone hydrogel lenses. Dr. Fogt said that some practitioners use an intraocular lens (IOL), even right after birth; but, because their eyes are growing, this could cause problems for young patients. She noted that infants younger than 7 months of age who have a unilateral cataract should be left aphakic and treated with contact lenses.

Silicone elastomer lenses are successful because patients can sleep while wearing them, but typically parents have more problems with application and removal. Dr. Fogt prefers GP lenses because of their available customization and the fact that they are easier for parents to handle. She noted that she has fit corneal GPs on kids but has never needed sclerals.

When fitting children with specialty lenses, start with keratometry and/or trial lens evaluation. The key, according to Dr. Fogt, is to have a lens that centers well and stays in the eye (i.e., you don’t want it to pop out) and that has the right refractive power.

Talk directly to the infant/child and explain everything as it happens. Also, giving children things to hold and watch can prevent them from worrying and keep them distracted. Practitioners should only restrain children as a last resort. Most infants do well on a parent’s lap. Alternatively, you could have the child strapped into his or her stroller or car seat. This allows practitioners to do everything that they need to while still making it a happy event for the child.

For infants who have aphakia, add 3.00D of plus power so that their vision is at the near point, because that is where their world is at that age. It’s important to explain to parents that the first lens may not be the final lens and that this process often takes several visits/lenses before reaching perfection. Dr. Fogt tells parents that “We are going to be best friends.”

At dispense, use fluorescein to evaluate the fit. Practitioners can avoid drops by adding fluorescein to the bowl of the lens before application. Additionally, teach the parents, grandparents, babysitters, etc., application and removal as well as cleaning. It’s important to not only demonstrate it for the caregivers but to have them perform it as well. Follow up with patients at one week and one month. At those visits, assess the fit and Rx power with retinoscopy, address parent questions, and don’t forget to praise them.

At around 2 years of age, practitioners should change their strategy for children who have aphakia. At that time, the contact lens power should be used to correct distance vision, and bifocal spectacles should be worn over the lenses.

For children who have a scarred or irregular cornea due to an infection or birth-related trauma, corneal GP lenses work well. If anisometropia is left untreated, it can cause amblyopia. Dr. Fogt noted that amblyopia can develop quickly depending on age; therefore, practitioners must begin occlusion therapy in conjunction with lens fitting. Age shouldn’t be the one factor that determines of what they are capable.

For children who are in need of myopia control, practitioners should present all options. But don’t force them, says Dr. Fogt. It is best to manage parent expectations regarding contact lenses for myopia control from the very beginning by explaining that it will take multiple visits and by providing information about all risks and benefits. She emphasized that the health of the eye is more important than anything, and it is the patient’s specific eyeballs that will dictate the best treatment. Contact lens options for myopia control include orthokeratology and center-distance multifocal soft lenses.

Finally, for children who do not have a medical need for contact lenses, consider maturity, hygiene, and motivation (from the child, not necessarily from the parent). Children may desire contact lenses to more easily participate in sports, dance, or because they have cosmetic/psychological reasons. While many parents are skeptical of contact lens wear, advise them to ask their child who in his or her class has them. Inform parents that wearing contact lenses does not mean not wearing spectacles. Dr. Fogt advises using artificial tears in the office and provides children with some to take home to use for “practice” so that practitioners can get an idea of their capabilities and motivation.

Keratoconus Management John D. Gelles, OD, presented the CE breakout “Contact Lenses for Visual Rehabilitation in Keratoconus.” He began by providing background information on keratoconus and traditional management strategies, noting that there has been a paradigm shift in keratoconus management with corneal cross-linking in that practitioners now intervene earlier in an effort to stop progression and therefore prevent advanced disease.

Dr. Gelles explained that higher-order aberrations (HOAs) increase in severity and have a greater effect on vision in keratoconus patients. Contact lens wear can significantly reduce these HOAs. He stated that the main goals of contact lens wear for keratoconus were corneal health, comfort, and vision, in that order. He then reviewed each type of vision correction option and explained for which patients which option would be most preferable.

He started with spectacles and standard soft lenses. While not usually the first type of vision correction that comes to mind for keratoconus, he advised to not discount them because they are successful for some patients. Standard soft lenses can be considered for patients who can wear spherical lenses or toric lenses with a cylinder less than –2.25D. A lens with a higher sagittal depth should be used if possible, and for toric lenses rotational stability is key.

Custom soft lenses were recommended when the refractive cylinder is greater than –2.25D and the best-corrected spectacle visual acuity (BCSVA) is 20/30. This lens type is also good for patients who do not want to wear or are intolerant to GP lenses. Look for light central touch after settling. Thicker soft lenses for keratoconus create pseudo rigidity to help mask corneal irregularity. These lenses change the anterior surface profile to a more regular shape.

Corneal GP lenses can be used once patients have a BCSVA of 20/40 or worse. These lenses provide good visual acuity, but Dr. Gelles advised to avoid poor pressure distribution (bearing), because poor fitting relationships with these lenses lead to complications.

A typical case for hybrid lenses is when the BCSVA is 20/40^–. Dr. Gelles recommended instructing patients to place the lens on the eye as gently as possible, because forceful application of hybrids can cause complications. He also advised to make sure that the lens does not dig into the cornea and conjunctiva.

A typical case for piggyback lens systems is when the BCSVA is 20/50 and the cone is relatively centered. There are two fitting methods. The first is to fit a soft lens to alter the underlying corneal shape and then fit the GP lens over this new shape. Plus-powered soft lenses will artificially steepen the cornea (make it more prolate), whereas minus-powered soft lenses will artificially flatten the cornea (make it more oblate). You can use this to change the effective anterior surface curvature. The second method is to fit the corneal GP first and then fit a low-power and low-modulus soft lens under it just to serve as a cushion.

Scleral lenses should be considered when the BCSVA is 20/80 and there is dramatic corneal asymmetry. Dr. Gelles said that sclerals should be fit with corneal clearance and haptic alignment.

Dr. Gelles noted that certain patients fail in certain lenses and that all lens types were unsuccessful in some patients. Corneal GP lenses are often the most replaced lens type, but they are also the most commonly used. Scleral lenses don’t usually fail because of corneal irregularity but because of complex scleral geometry and handling issues.

Dr. Gelles concluded with a discussion of surgical options and noted that topography-guided photorefractive keratectomy can improve BCSVA by three lines and is a powerful procedure for keratoconus treatment.

Amniotic Membranes Greg Caldwell, OD, discussed “Amniotic Membranes for Contact Lens Complications and Anterior Segment Pathology.” He discussed the distinction between wound regeneration and wound repair. With regeneration, the cells/tissues are reproduced, and there is no scar; with repair, the end result is scar tissue. Scarring correlates directly with inflammation, so he noted that if inflammation is controlled, it will reduce scarring.

Dr. Caldwell discussed the differences between cryopreserved amniotic membranes and dehydrated amniotic membranes. Cryopreserved membranes have heavy chain hyaluronic acid and pentraxin 3, which help with scarless healing and are approved by the U.S. Food & Drug Administration (FDA) for wound healing. Dehydrated membranes have low-chain hyaluronic acid, which may be proinflammatory. Because of this, dehydrated membranes are approved only for would coverage and are contraindicated for some conditions such as infectious keratitis. Conversely, cryopreserved membranes are contraindicated for eyes that have glaucoma drainage devices or filtering blebs (because of the PMMA ring) and also for patients who have certain allergies (such as cipro or amphotericin B).

One use for cryopreserved membranes that Dr. Caldwell mentioned was stem cell burnout. This is a limbal disease in which hazy, poor-quality epithelium is being produced by exhausted stem cells. It often results from patients overwearing their lenses—such as using monthly lenses but replacing them every four months—and using multipurpose solution. A cryopreserved amniotic membrane can help reboot and heal the traumatized limbal stem cells. Dr. Caldwell recommended using it on day 1 along with medications and to use it for at least three days, but after five days he switches to a more passive healing method such as a bandage contact lens.

Dr. Caldwell also discussed how each type of membrane is acquired, processed, and supplied as well as how to apply each type of membrane.

ELEVATE YOUR KNOWLEDGE

We hope that you’ll join us next year at the inaugural GMS on Jan. 20, 2021 and for the 2021 GSLS from Jan. 20 to 23. CLS

REFERENCES

1. Caroline P, André M. Does IOP Increase During Scleral Lens Wear? Contact Lens Spectrum. 2019 Sep;34:52.