The year 2020 held great expectations for eyecare professionals as we prepared to celebrate a much-anticipated “Year for 20/20 Vision” with fun, positive messaging to highlight the importance of preserving vision and preventing ocular disease. Instead, we found ourselves pivoting to quickly learn strategies to keep our practices viable while safely caring for patients during a pandemic.
The COVID-19 crisis has emphasized the role of eyecare professionals as essential healthcare providers and the importance of delivering medical eye care while implementing new safety standards. Each year, the American Optometric Association (AOA) Contact Lens & Cornea Section council members reflect on controversial issues involving contact lens and anterior segment care. When it came to providing interesting topics to debate, 2020 certainly did not disappoint!
Currently, 58,000 eyecare professionals—40,000 optometrists and 18,000 ophthalmologists—are licensed to perform comprehensive eye examinations in the United States1 and to deliver much-needed primary eye care to patients. This article will take a deep dive into how these primary care practitioners, mostly optometrists, approach myopia management, contact lens fitting, and dry eye treatment, exploring some of the controversies surrounding these areas of care. We discuss key opportunities to better provide care for our patients, and we suggest protocols and efficiencies to help practices thrive.
CONTROVERSY 1: IS MYOPIA MANAGEMENT SPECIALTY CARE OR PRIMARY CARE?
The myopia epidemic has been well established, and the call to action to treat myopia as early as possible has been a hot topic for several years. Patients over the age of 50 who are myopic are particularly susceptible to devastating vision loss from cataracts, glaucoma, myopic maculopathy, and retinal detachment. Thus, all eyecare providers are in a position to not only identify and treat myopia but also to educate patients about the associated risks.
Researchers have found that reducing the amount of myopia progression by only 1.00D can reduce the risk of visual impairment by 20%, of glaucoma by 20%, and of myopic maculopathy by 40%.2 Knowing that the number of patients who have myopia continues to increase and that effective treatments exist to reduce the progression of this disease begs the question: Should myopia management be considered a specialty service or part of primary care?
As a Specialty Service Many of the arguments supporting myopia management as a routine service focus on myopia’s prevalence. Once considered a benign refractive error, myopia has emerged as a public health issue. Studies show that an estimated 1.5 billion people were affected by myopia in 2010, and that number is expected to approach 5 billion by 2050.3 Despite these statistics, some eyecare professionals maintain that myopia management is a specialty service that requires a level of attention that cannot be provided in all offices.
Current prescribing options for managing myopia (most off-label) include spectacles, multifocal soft contact lenses, atropine therapy, and orthokeratology.4-7 Regardless of the method chosen, an effective myopia management plan requires a commitment to long-term evaluation of progression and, equally important, the ability to make quick treatment adjustments. To do this effectively, adequate instrumentation is required. This is a major reason why many providers consider myopia management a specialty service. Cycloplegic refractions, axial length measurements, and topography tend to not be commonplace in every practice; yet, they are necessary to adequately monitor myopia progression.
Providing specialty services also requires continued education. Office staff should understand the basics of myopia so that they can explain the various treatment options to patients. Many specialty service clinics also have trained technicians on staff, which is extremely helpful in examining patients and collecting the data required for a specific treatment. Practitioners also must stay current with the newest methods and treatment options as reported in the literature. A practice that does not focus on myopia management as a specialty may not be able to devote the time and attention to the required education.
As Primary Care Managing myopia as a refractive error is a basic service provided by all practitioners in the primary care setting. Managing myopia as a disease, however, is not so common in the eyecare community. Nevertheless, our understanding of myopia has changed, and it can be argued that our approach needs to change as well.
While managing myopia as a disease used to be relegated to the specialty realm, we now have many options that are well within the scope of a general practitioner. If you know how to fit a distance-center multifocal soft contact lens, you have the skills to prescribe these lenses to children for myopia management. Studies have shown that soft lens wear is just as safe for children as for adults.8 We have several distance-center multifocal contact lens options in reusable and daily disposable modalities, including a lens recently approved by the U.S. Food and Drug Administration for slowing the progression of myopia in children.
If you know how to write a prescription, measure accommodative function, and measure pupil size, then you have the skills to prescribe low-dose atropine therapy. Atropine has been known to reduce myopia progression since the 1800s, and although we are still learning about its mechanism of action, this treatment has been proven safe and effective for years.9,10
Orthokeratology (ortho-k) is well within the skill set of most practitioners who have a topographer. Orthokeratology should not be initiated without the proper knowledge, but industry partners who produce ortho-k lenses make it easy and efficient for practitioners to undergo training to perfect this skill and to use the technology to manage myopia.
As the prevalence of myopia continues to rise, and—more importantly—as the risk for visual impairment related to untreated myopia increases into adulthood, our best hope to curtail this epidemic is to incorporate myopia management into the primary care setting. With new treatments, including spectacle lenses, on the horizon, practitioners cannot afford to leave the fight against this epidemic in the specialty realm.
CONTROVERSY 2: CONTACT LENS DISINFECTION/EMPIRICAL VERSUS DIAGNOSTIC FITTING
Proper contact lens disinfection is essential for all who wear or fit reusable lenses, and it is of utmost concern to practitioners who employ diagnostic lenses from specialty fitting sets. In 2019, well before the emergence of COVID-19, the American Academy of Optometry and the AOA joined forces to update disinfection protocols for improved guidelines. This collaboration produced a white paper and a concise flow chart for all clinicians to utilize.11
There’s nothing like a global pandemic to shine a spotlight on the need for thorough, effective sanitizing measures. During this time of heightened awareness of pathogen transmission, the importance of adhering to proper standards for contact lens disinfection is paramount. Considering the demands of disinfection protocols, should clinical practices turn to empirical fitting rather than using in-office diagnostic lenses?
We know from the literature and from clinical experience that both empirical fitting and diagnostic lens fitting can be effective for many types of contact lenses. Functionally, empirical fitting provides the first lens as a custom diagnostic lens.12
In a comparative study of empirical fitting of soft toric and GP toric lenses to correct moderate-to-severe refractive astigmatism, researchers found no significant difference in vision between spectacles and the empirically calculated lenses.13 Another study compared empirical and diagnostic fitting methods to select the soft toric contact lens cylinder axis. In four out of five of the designs tested, diagnostic fitting did not improve cylinder axis selection compared to empirical fitting.14
Our primary concern in this discussion relates to the utilization of reusable diagnostic, or trial, lenses on a routine basis, particularly in specialty contact lens practices where practitioners commonly apply one or more lenses during a diagnostic fitting. These lenses must be disinfected prior to storage and use on another patient to avoid transferring pathogens. While pathogens may be introduced into the system by patients, they also may be transferred by practitioners or staff during handling and storage. Pathogens can cause acute or chronic infection that can lead to significant temporary or permanent ocular morbidity, including vision loss.
According to the new “Guidelines for Handling of Multipatient Contact Lenses in the Clinical Setting,” contact lenses are divided into three categories for disinfection purposes:11
- Soft lenses (hydrogels), including silicone hydrogels and hydroxyethyl methacrylate (HEMA) hydrogels
- GP lenses, including corneal and scleral lenses
- Hybrid lenses (composite) that have a GP center with a hydrogel periphery
All contact lenses should be rubbed with a daily surfactant cleaner according to the manufacturer’s instructions to clean—not disinfect—the contact lenses. After cleaning, diagnostic lenses should be soaked in non-neutralized, ophthalmic grade, 3% hydrogen peroxide solution for a minimum of three hours.11 GP lenses should then be rinsed with sterile saline or multipurpose solution and then stored dry in a disinfected case. Soft and hybrid lenses should be transferred to a neutralizing case filled with fresh hydrogen peroxide solution, neutralized per manufacturer instructions, rinsed with MPS, and then stored in a disinfected case with MPS.
The 2018 International Organization for Standardization (ISO) standards suggest documenting each contact lens disinfection and maintaining a record for each diagnostic fitting set.15 The record should include the reference number for each lens, the patient reference for each lens, date(s) of use, date(s) of disinfection, method of disinfection, and the person who performed disinfection. This record could be helpful if an infection was present during a fitting to alert practitioners fitting subsequent patients of potential risks of infection from the contaminated lens.
These new guidelines create a burden for practitioners and their staff when fitting lenses diagnostically. A significant amount of staff time is needed to disinfect each lens properly and to maintain a record. With empirical fitting, staff time can be conserved for other tasks within the practice; however, instrumentation to facilitate empirical fitting, such as scleral topographers, is expensive and may be cost-prohibitive for some practices. Consequently, some practitioners continue to rely on diagnostic fitting.
For individual practitioners, the discussion regarding empirical fitting versus diagnostic fitting will depend on the frequency of lens fitting, skills, staff resources, protocols, equipment availability, and patient demographics.
CONTROVERSY 3: DOES CATARACT SURGERY CAUSE DRY EYE?
Cataract surgery is the most frequently performed elective surgery in the United States, with more than 3 million procedures performed every year.16 Baby Boomers, who range in age from 57 to 75 years old, are currently the largest generation at risk for visually significant cataracts.17 Most aging Boomers in the United States have evolved with technology and remain active, whether they’re extending or changing careers, retiring early, traveling, or pursuing new interests.18-20 Considering their active lifestyles, meeting their demands for visual performance is paramount for successful outcomes.
We know that dry eye can significantly affect quality of vision. Does cataract surgery cause dry eye, or is it important to diagnose and treat dry eye prior to surgery?
Cataract Surgery Does Not Cause Dry Eye While cataracts can develop at any age, most patients presenting for cataract surgery are over 60 years of age.21 Population studies show that dry eye is highly prevalent in this age group.22,23 In addition to population studies, two studies have looked specifically at patients presenting for preoperative evaluations for cataract surgery. The Prospective Health Assessment of Cataract Patients’ Ocular Surface (PHACO) study showed that 75% of patients presenting for cataract surgery had corneal staining.24 Another study of this population found that 85% of asymptomatic patients had at least one objective sign of ocular surface dysfunction.25 This is particularly alarming, as a healthy ocular surface is essential for accurate measurements to select an appropriate intraocular lens (IOL).26
In 2019, the American Society of Cataract and Refractive Surgery (ASCRS) presented a new algorithm for preoperative evaluation of the ocular surface, acknowledging the critical importance that the ocular surface plays in the accuracy of IOL calculations, visual performance, and the risk of endophthalmitis.27 This algorithm emphasizes the importance of assessing the ocular surface and aggressively treating disease, not only before surgery but specifically before final IOL calculations. The guidelines are grounded in the Tear Film & Ocular Surface Society (TFOS) Dry Eye Workshop II (DEWS II) evaluation and treatment, with goals to optimize outcomes and to minimize complications.28,29 Therefore, we should embrace these recommendations before referring patients for surgical consultation.
We can identify patients who have ocular surface disease (OSD) ahead of surgery. Our first step is as simple as asking. The use of a standardized survey can quickly identify patients who need further testing. The ASCRS algorithm recommends beginning with an osmolarity screening, which is also supported by TFOS. Increased and asymmetric osmolarity suggests concentrated tears, which can result from evaporative dry eye or aqueous deficient dry eye. Additional testing, such as meibography, matrix metalloproteinase-9 measurement, and slit lamp examination, can help us better identify the problem to be addressed.
Next, we must intervene and follow the guidelines provided by DEWS II and Milner et al30 to rehabilitate these ocular surfaces and restore a good refracting surface. This involves reducing inflammation and eliminating biofilm, Demodex, and microbiota.26-30
By improving our patients’ ocular surfaces preoperatively, we enhance their prospects for excellent outcomes with cataract or even with refractive surgery, and we minimize the risk of complications. There now are many tools to help these patients, ranging from pharmaceuticals to lid cleansing and beyond.
Cataract Surgery Causes Dry Eye Cataract surgery is an important procedure to optimize vision for appropriate candidates; however, as with any surgery, the advantages of the procedure have to outweigh the risks and potential disadvantages of the procedure.
One disadvantage of cataract surgery is the increased incidence of postoperative dry eye. In one study, researchers found that 32% of patients experienced dry eye symptoms six months after cataract surgery.31 Because the prevalence of dry eye increases with age and cataract surgery is typically performed on older patients, these patients are at greater risk of dry eye.32 Compromised ocular surface functionality prior to cataract surgery may predispose patients to greater risk for dry eye after surgery.
Cataract surgery-induced dry eye is multifactorial and associated with topical anesthetics, exposure desiccation, possible light toxicity from the operating microscope, nerve transection, elevated inflammatory factors, goblet cell loss, and meibomian gland dysfunction.33 Some of the dry eye manifestations post-cataract surgery are present for up to three months after surgery, and some eyes continue to manifest characteristics of the disease long after that.31
With the increased stress that cataract surgery places on the ocular surface postoperatively, we must identify OSD prior to cataract surgery and treat the condition to optimize surgical outcomes and to mitigate the potential for iatrogenic dry eye. Often, patients who have cataracts don’t notice the visual instability associated with dry eye. They may have become accustomed to having uncomfortable eyes. Cataract surgery provides an incredible opportunity for our patients to reestablish functional vision. Therefore, it is critical that we provide a healthy ocular surface to promote the best clinical outcomes by identifying and treating those who have underlying OSD.
KEY LEARNINGS TO ENHANCE PATIENT CARE
Eye care’s much anticipated year of 2020 presented unique challenges that forced us to view many aspects of patient care in a different light. If we embrace increasing our scope of care by including young myopes, implementing new efficiencies in contact lens fitting, and identifying and treating the dry eye issues of our cataract patients, 2021 will be remembered as the year that we overcame unprecedented challenges to improve patient outcomes while keeping our practices thriving. CLS
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- Bullimore M. Current Research: Efficacy of Myopia Control. CooperVision Brilliant Futures Myopia Management Program. January 8, 2020, Miami, FL.
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- Walline JJ, Lindsley K, Vedula SS, Cotter SA, Mutti DO, Twelker JD. Interventions to slow progression of myopia in children. Cochrane Database Syst Rev. 2011 Dec 7:CD004916.
- Li S-M, Kang M-T, Wu S-S, et al. Studies using concentric ring bifocal and peripheral add multifocal contact lenses to slow myopia progression in school-aged children: a meta-analysis. Ophthalmic Physiol Opt. 2017 Jan;37:51-59.
- Ganesan P, Wildsoet CF. Pharmaceutical intervention for myopia control. Expert Rev Ophthalmol. 2010 Dec;5:759-787.
- Swarbrick HA, Alharbi A, Watt K, Lum E, Kang P. Myopia control during orthokeratology lens wear in children using a novel study design. Ophthalmology. 2015 Mar;122:620-630.
- Bullimore MA. The safety of soft contact lenses in children. Optom Vis Sci. 2017 Jun;94:638-646.
- Donders FC. On the Anomalies of Accommodation and Refraction of the Eye. London: New Sydenham Society. 1864.
- Joachimsen L, Böhringer D, Gross NJ, et al. A pilot study on the efficacy and safety of 0.01% atropine in German schoolchildren with progressive myopia. Ophthalmol Ther. 2019 Sep;8:427-433.
- Sindt C, Bennett E, Szczotka-Flynn L, Sclafani L, Barnett M; American Academy of Optometry (AAO) Section on Cornea, Contact Lenses & Refractive Technologies, and The American Optometric Association (AOA) Contact Lens and Cornea Section. Technical Report: Guidelines for Handling of Multipatient Contact Lenses in the Clinical Setting. Optom Vis Sci. 2020 Aug;97:544-548.
- Silbert JA. GPs: are you making good use of diagnostic fitting sets? Rev Cornea Contact Lenses. 2015 Sep:16,17,20.
- Michaud L, Barriault C, Dionne A, Karwatsky P. Empirical fitting of soft or rigid gas-permeable contact lenses for the correction of moderate to severe refractive astigmatism: a comparative study. Optometry. 2009 Jul;80:375-383.
- Tan J, Back A, Papas E, et al. Comparison of empirical versus diagnostic fitting of disposable soft toric lenses. Poster presented at: American Academy of Optometry meeting. December 12-15, 2002, San Diego, CA. Available at: https://www.aaopt.org/detail/knowledge-base-article/performance-standards-toric-soft-contact-lenses . Accessed Nov. 18, 2020.
- International Organization for Standardization (ISO). Ophthalmic Optics—Contact Lenses—Hygienic Management of Multipatient Use Trial Contact Lenses; ISO 19979:2018. Geneva, Switzerland: ISO; 2018.
- iData Research. Over 3.8 Million Cataract Surgeries Performed Every Year. April 4, 2018. Available at: https://idataresearch.com/over-3-8-million-cataract-surgeries-performed-every-year . Accessed Nov. 19, 2020.
- National Eye Institute. 2010 age-specific prevalence rates for cataract by age, gender, and race/ethnicity. Available at: https://www.nei.nih.gov/learn-about-eye-health/resources-for-health-educators/eye-health-data-and-statistics/cataract-data-and-statistics/cataract-tables . Accessed Nov. 18, 2020.
- Vogels EA. Millennials stand out for their technology use, but older generations also embrace digital life. Pew Research Center. September 9, 2019. Available at: https://www.pewresearch.org/fact-tank/2019/09/09/us-generations-technology-use/ . Accessed Nov. 18, 2020.
- Fry R. Baby Boomers are staying in the labor force at rates not seen in generations for people their age. Pew Research Center. July 24, 2019. Available at: https://www.pewresearch.org/fact-tank/2019/07/24/baby-boomers-us-labor-force . Accessed Nov. 18, 2020.
- Hymowitz C. Baby Boomers try to stay in the generational mix as they age. Bloomberg Businessweek. September 19, 2019. Available at: https://www.bloomberg.com/news/articles/2019-09-19/baby-boomers-are-staying-in-the-workforce-longer . Accessed Nov. 18, 2020.
- Kauh CY, Blachley TS, Lichter PR, Lee PP, Stein JD. Geographic variation in the rate and timing of cataract surgery among US communities. JAMA Ophthalmol. 2016 Mar;134:267-276.
- Malet F, Le Goff M, Colin J, et al. Dry eye disease in French elderly subjects: the Alienor Study. Acta Ophthalmol (Copenh). 2014 Sep;92:e429-e436.
- Ferrero A, Alassane S, Binquet C, et al. Dry eye disease in the elderly in a French population-based study (the Montrachet study: Maculopathy, Optic Nerve, nuTRition, neurovAsCular and HEarT diseases): Prevalence and associated factors. Ocul Surf. 2018 Jan;16:112-119.
- Trattler WB, Majmudar PA, Donnenfeld ED, McDonald MB, Stonecipher KG, Goldberg DF. The Prospective Health Assessment of Cataract Patients’ Ocular Surface (PHACO) study: the effect of dry eye. Clin Ophthalmol. 2017 Aug;11:1423-1430.
- Gupta PK, Drinkwater OJ, VanDusen KW, Brissette AR, Starr CE. Prevalence of ocular surface dysfunction in patients presenting for cataract surgery evaluation. J Cataract Refract Surg. 2018 Sep;44:1090-1096.
- Owen J. Measurements matter in cataract surgery, the new refractive procedure. Optometry Times. 2019 Jul;11:19.
- Starr CE, Gupta PK, Farid M, et al. An algorithm for the preoperative diagnosis and treatment of ocular surface disorders. J Cataract Refract Surg. 2019 May;45:669-684.
- Wolffsohn JS, Arita R, Chalmers R, et al. TFOS DEWS II Diagnostic Methodology report. Ocul Surf. 2017 Jul;15:539-574.
- Jones L, Downie LE, Korb D, et al. TFOS DEWS II Management and Therapy Report. Ocul Surf. 2017 Jul;15:575-628.
- Milner MS, Beckman KA, Luchs JI, et al. Dysfunctional tear syndrome: dry eye disease and associated tear film disorders – new strategies for diagnosis and treatment. Curr Opin Ophthalmol. 2017 Jan;27 (Suppl 1):3-47.
- Iglesias E, Sajnani R, Levitt RC, Sarantopoulos CD, Galor A. Epidemiology of persistent dry eye-like symptoms after cataract surgery. Cornea. 2018 Jul;37:893-898.
- Stapleton F, Alves M, Bunya VY, et al. TFOS DEWS II Epidemiology Report. Ocul Surf. 2017 Jul;15:334-365.
- Gomes JAP, Azar DT, Baudouin C, et al. TFOS DEWS II iatrogenic report. Ocul Surf. 2017 Jul;15:511-515.