Lids & Lensesis significant. Biofinity Energys™ contact lenses feature a revolutionary Digital...

MMWR Alerts • Drug-Eluting Contact Lenses • Refractive Surgery Controversies • Branding

Lids & LensesHow eyelid disease can compromise contact lens wear, and what to do about it.

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OCTOBER 2016

RCCLRCCLREVIEW OF CORNEA & CONTACT LENSES

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Welcome to the new comfort zone_

* Among patients who use digital devices at least 4 hours per day at least 5 days per week and self-report symptoms of eye fatigue at least once per week.

1 After 1 week of wear; data on file.

2 The Vision Council. Eyes overexposed: the digital device dilemma: 2016 digital eye strain report.

©2016 CooperVision 9033O BC 7/16

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Review of Cornea & Contact Lenses | October 2016

departments features

contents

24CE — How Lid MalpositionCan Compromise Contact Lens Wear

Keep these conditions in mind to prevent or rectify potential obstacles to a successful fi t.

By Steven Turpin, MS,

and Leonid Skorin Jr., OD, DO, MS

News Review4US Refractive Surgeons Now Ready

to SMILE; Microbiota Protects

Against P. aeruginosa Infections

My Perspective 6MMWR and Contact Lens Alerts

By Joseph P. Shovlin, OD

Brand Yourself, and They Will Come

By Gary Gerber, OD

Out of the Box38

12Beat the Blepharitis BluesTo understand and treat this common lid condition, make sure you’re clear on its many diff erent presentations.By Abby Gillogly Harsch, OD, Nicole

Stout, OD, and Nathan Lighthizer, OD

16

20

30

The Chicken-and-Egg Problem of MGD and Contact Lens Wear Which came fi rst, the dysfunction or the discomfort? Researchers aren’t sure, but clinicians need to manage them simultaneously.By Arthur B. Epstein, OD

Lids, Friction andContact Lens WearDoes a relatively new phenomenon help explain contact lens discomfort?By Sruthi Srinivasan, PhD, BSOptom,

FAAO

How Would You Handle These Refractive Surgery Controversies?Despite the procedure’s popularity, some issues still remain. How should you address them?By Aaron McNulty, OD, and

Ian McWherter, OD

Put a Lid on CL Discomfort

By Mile Brujic, OD, andJason R. Miller, OD, MBA

Practice Progress10

Is a Sustained Medication Delivery

System on the Horizon?

By Elyse L. Chaglasian, OD, andTammy Than, MS, OD

Pharma Science & Practice8

Don’t Forget to Check the Lids

By Robert Ensley, OD, andHeidi Miller, OD

The GP Experts36

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4 REVIEW OF CORNEA & CONTACT LENSES | OCTOBER 2016

News Review

US Refractive Surgeons Now

Ready to SMILE

IN BRIEF

■ Conjunctival chemosis may be a mark-er to help clinicians predict Pseudomo-nas aeruginosa as the bacterial agent responsible for certain corneal ulcers, new research suggests. A masked review looked at 62 infective corneal ulcers and found 14 of 16 cases of P. aerugino-sa–related corneal ulcers presented with conjunctival chemosis, compared with only six of the remaining 46 cases caused by other organisms.1 Whether or not che-mosis was present predicted or excluded P. aeruginosa with roughly 87% accuracy, the researchers conclude.1

1. Michael KB, Rotchford A, Ramaesh K. Conjunctival chemosis as a specifi c feature of Pseudomonas aeruginosa corneal ulcers. Cornea. 2016;35(9):1182-4.

■ A new study sheds light on the impact environmental conditions have on tear infl ammatory mediators in contact lens wearers.1 Fifty-four CL wearers were exposed to two environmental condi-tions: standard (50% relative humidity) or adverse (5% relative humidity). The researchers analyzed changes in concen-tration of: epidermal growth factor (EGF); interleukin (IL)-1 receptor antagonist, IL-1β, IL-2, IL-4, IL-6 and IL-8; tumor necrosis factor α; monocyte chemoattractant protein-1; and matrix metalloproteinase (MMP)-9. Under standard conditions, EGF increased signifi cantly while IL-1β and IL-2 decreased signifi cantly. Under adverse conditions, IL-6 increased signifi cantly. During CL wear, secretion of several in-fl ammatory mediators varies, depending on the type of CL and the environmental conditions at play, the study concludes.1 1. Martín-Montañez V, Enríquez-de-Salamanca A, López-de la Rosa A, et al. Eff ect of environ-mental conditions on the concentration of tear infl ammatory mediators during contact lens wear. Cornea. 2016;35(9):1192-8.

■ Researchers recently evaluated the effi cacy and safety of transcutaneous electrical stimulation for symptoms and clinical signs of dry eye. The study included 27 patients with dry eye who underwent transcutaneous electrostim-ulation, wherein electrodes were placed onto the periorbital region of both eyes in addition to manual stimulation with a hand-piece conductor.1 Results showed the Ocular Surface Disease Index improved from 43.0±19.2 at baseline to 25.3±22.1 at the completion of treatment.1 These improvements were maintained at six- and 12-month follow-up evaluations. As the study suggests it improves dry eye without adverse eff ects, transcutaneous electrical stimulation shows potential to widen the scope of treatment options for dry eye.1. Pedrotti E, Bosello F, Fasolo A, et al. Transcu-taneous periorbital electrical stimulation in the treatment of dry eye. Br J Opthalmol. September 4, 2016. [Epub ahead of print].

A new refractive surgery option, Zeiss’s VisuMax small incision lenticule extraction (SMILE)

procedure, recently received FDA approval. The SMILE procedure in-volves the creation of a disc-shaped lenticule in the stroma using a fem-tosecond laser, which the surgeon removes through a small incision—obviating both the creation of a fl ap and use of an excimer laser needed for LASIK.

“Since there is no fl ap, there are no fl ap related issues. There is also vastly less interruption of nerve fi bers so one would anticipate less dry eye,” says John F. Doane, MD, of Discover Vision Centers in Kansas City, MO, a clinical inves-tigator for Zeiss. “The refractive results are essentially the same. Interestingly, since the surgery is done in a vacuum—i.e., the corneal stroma that is not exposed to the atmosphere—the procedure is dose independent. We are just as predict-able with a -1D as we are with a -10D, which is unique to all prior corneal refractive procedures.”

A recent study examined the fi ve-year results of the fi rst 56 eyes treat-ed with SMILE for myopia in 2008-2009 using the 200kHz VisuMax.1 Researchers found a mean regres-sion of −0.48D over fi ve years, which is at least as good as the data of other procedures, they noted—the mean regression for LASIK is 0.63D to 0.97D after six to seven years.2,3 They conclude SMILE is an effective, stable and safe procedure for myopia and myopic astigmatism treatment.1 They also note that la-ser technology advances—the newly approved procedure uses a 500kHz

femtosecond laser—translates into better outcomes, and newer studies report refractive outcomes superior to the 2008-2009 results.4,5

The FDA’s approval came on the heels of a study demonstrating posi-tive visual acuity and refractive pre-dictability outcomes for 336 eyes treated with the SMILE procedure, according to a Zeiss press release.6 The study found participants had stable vision six months post-pro-cedure, and all but one subject had uncorrected visual acuity of 20/40 or better; 88% had uncorrected visual acuity of 20/20 or better.

The SMILE procedure is indicat-ed for the reduction or elimination of myopia of -1.00 D to -8.00D, with ≤ -0.50D cylinder and MRSE -8.25D in patients at least 22 years old with documented stable refrac-tion over the past year, Zeiss says.

“If worldwide acceptance fore-shadows what will occur in the United States, we can expect quick uptake of the SMILE procedure,” Dr. Doane suggests. Over half a million procedures have been per-formed worldwide, Zeiss says.

1. Blum M, Täubig K, Gruhn C, et al. Five-year results of small incision lenticule extraction (ReLEx SMILE). Br J Ophthalmol. 2016;100:1192–5.2. Zalentein WN, Tervo TM, Holopainen JM. Sev-en-year follow-up of LASIK for myopia. J Refract Surg. 2009;25:312–8.3. Sekundo W, Bönike K, Mattausch P, et al. Six-year follow-up of laser in situ keratomileusis for moderate and extreme myopia using a fi rst-generation excimer laser and microkeratome. J Cataract Refract Surg. 2003;29:1152–8.4. Ivarsen A, Asp S, Hjortdal J. Safety and complica-tions of more than 1500 small-incision lenticule ex-traction procedures. Ophthalmology. 2014;121:822–8.5. Blum M, Kunert KS, Gille A, et al. LASIK for myopia using the Zeiss VisuMax femtosecond Laser and MEL 80 Excimer Laser. J Refract Surg. 2009;25:350–6.6. Zeiss. Zeiss receives US FDA Approval for VisuMax SMILE vision correction procedure, the latest advancement in laser eye surgery. Press Release. September 14, 2016. Available at www.zeiss.com/meditec/en_de/media-news/press-releases/us-fda-approval-visumax-smile-vision-correc-tion-procedure-in-laser-eye-surgery.html.

004_RCCL1016_News.indd 4004_RCCL1016_News.indd 4 9/29/16 6:20 PM9/29/16 6:20 PM

REVIEW OF CORNEA & CONTACT LENSES | OCTOBER 2016 5

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EDITORIAL REVIEW BOARD

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Michael A. Ward, FCLSA

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RCCLRCCLREVIEW OF CORNEA & CONTACT LENSES

Ocular microbiota plays a role in protecting against Pseudomonas aeruginosa–induced

infections, a recent study suggests. The reasons for the common association between contact lens wear and P. aeruginosa–induced keratitis have been unclear. While the existence of ocular microbiota is not news, there has been a dearth of functional analyses to probe the signifi cance of its role in ocular immunity.

CL wearers, according to recent genomics-based approaches, harbor altered ocular commen-sal communities compared with non-lens wearers. This has given rise to important questions regard-ing the nature of contamination and the frequency of keratitis. More specifi cally, is this increased frequency of contaminated lens-in-duced keratitis a result of species deriving from the skin, or does ocular microbiota exert immune functions that are required for oc-ular health? Researchers found the presence of microbiota in healthy subjects served to strengthen the ocular immune barrier, resulting from microbiota’s role in increasing concentrations of immune effectors in the tear fi lm.

Using Swiss Webster mice—which are typically resistant to P. aeruginsa-induced keratitis but become susceptible alongside a lack of microbiota—researchers demon-strated that commensal bacteria at the ocular surface serve to deliver regulatory signals regarding the scale of neutrophil recruitment during infection, according to a study in PLoS Pathology.

They posit that these events may result from coagulase neg-ative Staphylococcus, a frequent gram-positive commensal. Further, the authors note that, in addition to the impact of ocular microbiota, gut microbiota may play a signif-icant role in regulating the pool of mature neutrophils and their activation state. In fact, protective immunity was found to be depen-dent on both eye and gut microbio-ta, “with the eye microbiota having a moderate, but signifi cant impact on the resistance to infection,” the study says. This work is the fi rst to demonstrate microbiota as a regu-latory agent regarding susceptibility to P. aeruginosa-induced keratitis. This previously unappreciated role of microbiota will hopefully help push forward more research to broaden the understanding of vul-nerability and treatment regarding infections of the ocular surface. RCCL

Kugadas A, Christiansen SH, Sankaranarayanan S, et al. Impact of microbiota on resistance to ocular pseudomonas aeruginosa-induced keratitis. PLoS Pathog. 12(9): e1005855.

Microbiota Protects Against

P. aeruginosa Infections

Advertiser Index

Alcon ..................................Cover 3

Bausch + Lomb .................. Page 7

CooperVision ....................Cover 2

Menicon ............................. Cover 4

Pseudomonas ulcers could be more

likely in patients with compromised

ocular microbiota, a new study says.

Photo: C

hristine Sindt, O

D

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By Joseph P. Shovlin, OD

My Perspective


MMWR and Contact Lens AlertsTimely information on these issues is at our fi ngertips, thanks to the CDC.

Often referred to as the “voice of the CDC,” the Morbidity and Mortality Weekly Report (MMWR) is

the agency’s vehicle for providing objective and useful information and recommendations. Readership is primarily comprised of physicians and other health care providers, epidemiologists and scientists.1

CLs IN THE NEWS

Recently, contact lens-related adverse events—specifi cally con-tact lens-associated corneal infec-tion—have received much attention in these reports. Two memorable reports related to unexpected non-bacterial clusters prompted voluntary manufacturer recalls. The fi rst highlighted concerns with a resurgence of Fusarium infections associated with the use of Bausch + Lomb’s ReNu with MoistureLoc. The second discussed an unusu-ally high geographical uptick in Acanthamoeba keratitis in patients using Advanced Medical Optics’ Complete Moisture Plus.

Fusarium infections received focused attention when the CDC received multistate cluster reports in 2005-2006.2 A similar report surfaced in 2007 when Chicago eye care providers relayed fears of a resurgence of Acanthamoebakeratitis in lens wearers using a specifi c multipurpose disinfection solution.3 In both cases, MMWR dispatches provided helpful lens care tips for the public to help minimize risk. Further, the reports included management updates for clini-cians suspecting possible infection. Commonality between the Fusarium

and Acanthamoeba concerns showed concurrent outbreaks in contact lens users from two differ-ent non-bacterial sources using two separate multipurpose solutions. Research showed the solutions had insuffi cient antimicrobial effi cacy against specifi c organisms, result-ing in safety concerns.2,3 Although the attack rate was low, getting the message out quickly was crucial due to signifi cant morbidity rates—espe-cially in cases of delayed diagnosis.

LATEST DEVELOPMENTS

The most recent MMWR dispatch, based on a decade of national lens wear data, includes a policy state-ment for prevention and treatment following an epidemiologic report on contact lens-related corneal infections. Researchers tracked data from 2005-2015, looking at trends and impacts to public health. The authors analyzed 1,075 medical device reports (MDRs) containing the terms ulcer or keratitis received by the FDA.4 Contact lens manu-facturers were responsible for 86% of the reports, while 14% were submitted by eye care providers. The MDRs contain device-related safety information to help develop benefi t/risk assessments. The FDA uses these reports to monitor device performance in a post-approval surveillance fashion.4

Notably, 3.1% of cases reported were associated with decorative or cosmetic contact lens use, and 1.5% involve lenses obtained from unapproved sources without a valid prescription (i.e., fl ea market or costume shop). Twenty-fi ve patients (2.3%) required hospitalization. The majority of reports refl ected

recurrent (often daily) offi ce visits, frequent administration of topi-cal eye drops and missed work or school during the acute phase of in-fection.4 The reports further identify several modifi able risks, including overnight wear (11.3%), over-wear beyond prescribed periods (7.0%), storing lenses in tap water (0.8%), using expired lenses or products (0.7%) and swimming in contact lenses (0.9%).4 Tragically, approxi-mately 20% of the MDRs describe patients who suffered permanent eye damage, reduced acuity or both. At least 25% had a modifi able risk that could have been prevented.4

STAY UP-TO-DATE

MMWRs alert health care providers to pertinent public health issues and are often successful in minimiz-ing ongoing risks. They are vital tools that help protect the public. Kudos to the entire CDC team for an admirable program, which also includes Contact Lens Health Week each year. I encourage you to visit the CDC’s site, www.cdc.gov/contactlenses, for more infor-mation on this worthy initiative. Practitioners should continue to monitor and report any signifi cant adverse event to the FDA through its Safety Information and Adverse Reporting program at www.fda.gov/medwatch. RCCL

1. Centers for Disease Control and Prevention. About the Morbidity and Mortality Weekly Report (MMWR) Series. Available at www.cdc.gov/mmwr/about.html. Accessed September 20, 2016.2. Centers for Disease Control and Prevention. MMWR, Fusarium keratitis-multiple states, 2006. MMWR Morb Mortal Wkly Rep. 2006;55(14):400-1.3. Centers for Disease Control and Prevention. Acanthamoeba keratitis multiple states, 2005–2007. MMWR Morb Mortal Wkly Rep. 2007;56:532–4.4. Centers for Disease Control and Prevention. Contact lens related corneal infections-United States, 2005-2015. MMWR Morb Mortal Wkly Rep. 2016;65(32);817-20.

006_RCCL1016_MP.indd 6006_RCCL1016_MP.indd 6 9/29/16 5:30 PM9/29/16 5:30 PM

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By Elyse L. Chaglasian, OD, and Tammy Than, MS, OD

Pharma Science & Practice

Lowering a patient’s in-traocular pressure (IOP) is critical for glaucoma management—but it’s also one of the most

challenging aspects of a patient’s care. Topical glaucoma medica-tions, the go-to treatment option for most practitioners, come with a host of potential issues, the biggest being patient noncompliance, due to physical diffi culty with drop ad-ministration, fi nancial constraints and side effects such as burning and hyperemia.

Alternatively, what if patients only had to put contact lenses in to deliver their daily glaucoma medication? Results of a study re-cently published in Ophthalmologysuggest this could be the future of glaucoma management.

Investigators from Massa chusetts Eye and Ear Infi rmary encapsulated a latanoprost-polymer fi lm into a hydrogel lens to create latano-prost-eluting low-dose (97g) and high-dose (149g) contact lenses—CLLO and ClHI. They then studied the effects of these lenses in glau-comatous eyes of four cynamolgus monkeys (induced by argon laser trabeculoplasty) and compared it with treatment using traditional 0.005% latanoprost ophthalmic solution.

The low-dose CL was worn con-tinuously for seven days, followed by a three-week hiatus in treat-ment as a washout period. Topical treatment was then administered for another fi ve days, followed by

another three-week break. Finally, the high-dose CL was worn continuously for seven days. The study was powered to only detect large differences in IOP re-duction between treatment groups.

IOP measurements performed with a pneu-matonometer before, during and after treatment revealed the sustained delivery of medication was at least as effective as the use of daily latanoprost ophthalmic solution, and at some time points showed a statistically signifi cant difference in reduction. For example, CLHI

reduced IOP by as much as 34% on day three, compared to the 10% seen with the topical treatment. On the last day the difference was 32% vs. 21%. Researchers were surprised by this fi nding in par-ticular, given that topical 0.005% latanoprost ophthalmic solution is considered the optimal treatment option for IOP reduction.

In addition, the latanoprost-elut-ing contact lenses provided relative-ly steady IOP reduction throughout the study—a key difference from topical treatment, which resulted in more variation in IOP reduction during diurnal measurements. For example, CLHI lowered IOP by -10.5±1.4mm HG on day three, -11.1±4mm Hg on day fi ve and -10.0±2.5mm Hg on day eight. In contrast, treatment with daily

eye drops on the fi fth day showed a reduction of -3.0±0.4mm Hg before drop instillation, a peak of -6.5±0.6mm Hg two hours later and then a decrease to 3.5±0.3mm Hg four hours after that.

MORE TO COME

Constant therapeutic effect, as seen with the drug-eluting contact lens-es, could have signifi cant impact on treatment for patients with glauco-ma. This study comes with limita-tions, however, including the small sample size and minimal ocular safety assessment.

More research is needed to determine the optimal continu-ous-release dose that would be well tolerated by patients and provide maximally effective, the researchers conclude. RCCL

Ciolino JB, Ross AE, Tulsan R, et al. Latano-prost-eluting contact lenses in glaucomatous monkeys. Ophthalmology. 2016 Oct;123(10):2085-92. Epub 2016 Aug 29.

Is a Sustained Medication Delivery System on the Horizon?Research reveals latanoprost-eluting contact lenses may one day replace daily eye drops.

To create the sustained medication delivery

system, researchers added a thin latanoprost-

polymer fi lm within the periphery of a

methafi lcon hydrogel, which was then lathed

into a contact lens.

Photo: A

my R

oss and Lokendra Bengani, M

assachusetts Eye & Ear

008_RCCL1016_PSP.indd 8008_RCCL1016_PSP.indd 8 9/29/16 11:30 AM9/29/16 11:30 AM

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By Mile Brujic, OD, and Jason Miller, OD, MBA

Practice Progress

The biggest risk factor for discontinuing contact lens wear is discomfort.1,2

Certainly, an underlying dry eye can decrease lens

comfort. But contact lens–induced dry eye, or CLIDE, gives name to the individual who has no symptoms of dry eye without contact lenses but is symptomatic during contact lens wear.3 Although CLIDE is not tradi-tionally associated with primary dry eye, contact lens discomfort may be an early symptom of a compromised tear fi lm. Let’s discuss why this oc-curs and how to promote healthier, more comfortable contact lens wear.

THREE STEPS FOR SUCCESS

Here are a few strategies that have worked well in our practice to help optimize the lens wearing experience:

(1) Identify underlying risk factors. Although it is relatively easy to identify obvious eyelid margin diseases such as anterior blepharitis, lid margin irregularities or posterior blepharitis, other clinical entities are much less obvious.

Consider fl oppy eyelid syndrome. The lid tarsus is often irregular, causing eyelids to fl ip easily. It is associated with sleep apnea, which should be discussed with the patient, along with a number of other local symptoms.4 Because of the loose lid apposition, the lids may inadvertent-ly open and possibly evert, often in the evening, causing hyperemia and discomfort.5 Contact lens wear can be diffi cult for these individuals.

Another increasingly prevalent condition is non-obvious meibomian gland dysfunction (MGD). Through a standard exam the lid margin will typically appear normal, but dysfunction can be uncovered in a number of ways.6 The simplest test is to provide pressure to the upper and lower lid margin and assess the meibum expressed. Thickened lipids or lack of secretions indicate produc-tion abnormalities. The meibomian gland evaluator (TearScience) is a specialized instrument that applies a standard force to the lid margin, allowing an evaluation of the quality of meibum expressed.

We can also perform a gross inspection of the glands by having a patient look up and then pulling their lower lids down (Figure 1).

At the slit lamp, lid transillumi-nation can also help us visualize the glands. With the slit beam turned off (a handheld transilluminator provides the only light source), have the patient look up, then place the transilluminator on the lower eyelid and slightly turn the lid down so that the palpebral conjunctiva is visible (Figure 2). Higher-level diagnostic imaging is also available to help bet-ter image the structure of the glands (Figure 3).

(2) Educate patients. Making sure patients understand their condi-tion is just as critical as identifying potential defi ciencies. One of the most powerful educational tools is high-quality imaging, which pro-vides patients a better perspective and actual visualization of their condition. Educating our patients is the fi rst step to ensuring they comply with treatment.

(3) Help maintain, or regain, health. Following identifi cation and education, we must treat the under-lying condition. For individuals with fl oppy eyelid syndrome, for example, it is paramount to decrease infl am-mation and ensure the ocular surface is protected in the evening. This may include an ointment or the use of a Lacrisert (hydroxypropyl cellulose ophthalmic insert, Bausch + Lomb). Additionally, the patient may benefi t from eye shields or taping their eyes shut in the evening. In severe instances, patients may also require eyelid surgery to re-establish normal-cy to the lid/globe interaction.7

CHEMICAL VS. PHYSICAL

While there are many approaches to non-obvious MGD treatment, we believe there are two global strate-gies: chemical and physical improve-ment of meibum production.

Know the signs, symptoms and treatment options for CLIDE and non-obvious MGD.

Put a Lid on CL Discomfort

Fig. 1. Gross observation of the

meibomian glands on the lower lid.

Fig. 2. Transillumination of the

palpebral conjunctiva.

010_RCCL1016_PP.indd 10010_RCCL1016_PP.indd 10 9/29/16 4:20 PM9/29/16 4:20 PM


Chemical. Topical cyclosporine can promote healthier meibum production, and research shows the newly approved Xiidra (lifi tegrast, Shire) improves symptoms of dry eye and may have a role in non-obvious MGD treatment as well.8,9 Topical azithromycin is another option for improving meibum production.10,11

Essential fatty acids (omega-3s and omega-6s) have also been shown to improve meibum secretion.12,13

Additionally, oral doxycycline and oral azithromycin have proven effec-tive in improving meibum produc-tion; although typically used with obvious forms of MGD, they may have a role here as well.13

Physical. Clinicians have come up

with a number of ways to physi-cally soften and evacuate stagnant meibum to allow healthier secre-tions. Traditionally, warm compress-es once or twice a day were recom-mended. Although this can be done with warm, moist washcloths, there are logistical challenges to keeping the washcloths at the appropriate temperature for the intended time period. Many practitioners now recommend commercially available heating pads for at-home treatment.

The Lipifl ow (TearScience) in-of-fi ce treatment applies heat to the pal-pebral conjunctiva while simultane-ously applying pressure through an infl atable air bladder on the anterior surface of the eyelid.14 One study shows a single treatment improved both signs and symptoms in individ-uals with MGD over 12 months.15

MiBoFlo Thermofl o (Mibo Medical) and the MGD 3000 (Ophthalmic Concepts) also heat the eyelid while gently massaging the lids.16,17

SEEING THE UNSEEN

We challenge you to look for non-obvious clinical conditions in

your contact lens wearers. If you discover them, educate patients and provide your best clinical judgment on the appropriate treatment. Your patients will thank you for taking the appropriate steps to improve their wearing experience and provide more comfortable lens wear. RCCL

1. Rueff EM, Varghese RJ, Brack TM, et al. A survey of presbyopic contact lens wearers in a university setting. Optom Vis Sci. 2016;93(8):848-54.2. Nichols JJ, Jones L, Nelson JD, et al., members of the TFOS International Workshop on Contact Lens Discomfort. The TFOS international workshop on contact lens discomfort: introduction. Invest Ophthalmol Vis Sci. 2013;54(11):TFOS1-6.3. Fonn D. Targeting contact lens induced dryness and discomfort: what properties will make lenses more comfortable. Optom Vis Sci. 2007;84(4):279-85.4. Skorin L Jr, Knutson R. Ophthalmic diseases in patients with obstructive sleep apnea. J Am Osteo-path Assoc. 2016;116(8):522-9.5.Mastrota KM. Impact of fl oppy eyelid syndrome in ocular surface and dry eye disease. Optom Vis Sci. 2008;85(9):814-6.6. Blackie CA, Korb DR, Knop E, et al. Nonobvious obstructive meibomian gland dysfunction. Cornea. 2010;29(12):1333-45.7. Pham TT, Perry JD. Floppy eyelid syndrome. Curr Opin Ophthalmol. 2007;18(5):430-3.8. Prabhasawat P, Tesavibul N, Mahawong W. A randomized double-masked study of 0.05% cyclosporine ophthalmic emulsion in the treat-ment of meibomian gland dysfunction. Cornea. 2012;31(12):1386-93.9. Holland EJ, Whitley WO, Sall K, et al. Lifi tegrast clinical effi cacy for treatment of signs and symp-toms of dry eye disease across three randomized controlled trials. Curr Med Res Opin. 2016 Jul 22:1-7. [Epub ahead of print].10. Foulks GN, Borchman D, Yappert M, et al. Topical azithromycin therapy for meibomian gland dysfunction: clinical response and lipid alterations. Cornea. 2010;29(7):781-8.11. Liu Y, Kam WR, Ding J, Sullivan DA. One man’s poison is another man’s meat: using azithromy-cin-induced phospholipidosis to promote ocular surface health. Toxicology. 2014 Jun 5;320:1-5.12. Liu Y, Kam WR, Sullivan DA. Infl uence of omega 3 and 6 fatty acids on human meibomian gland epithelial cells. Cornea. 2016;35(8):1122-6.13. Qiao J, Yan X. Emerging treatment options for meibomian gland dysfunction. Clin Ophthalmol. 2013;7:1797-803.14. Zhao Y, Veerappan A, Yeo S, et al. Clinical trial of thermal pulsation (Lipifl ow) in meibomian gland dysfunction with preteatment meibography. Eye Contact Lens. 2016 Jan 27. [Epub ahead of print].15. Blackie CA, Coleman CA, Holland EJ. The sus-tained eff ect (12 months) of a single-dose vectored thermal pulsation procedure for meibomian gland dysfunction and evaporative dry eye. Clin Ophthal-mol. 2016 Jul 26;10:1385-96.16. Mibo Medical Group. MiBoFlo ThermoFlo Management of Dry Eye. Available at http://mibo-medicalgroup.com.17. Ophthalmic Concepts. MGD 3000. Available at www.ophthalmicconcepts.com.

The signs we use to diagnose dry eye are often late changes in the disease state. Corneal staining, for instance, signifi es an ocular surface not adequately protected by the tear fi lm. If these are the signs that prompt initial treatment, we may be waiting too long before starting.

For comparison, we would never wait to treat glaucoma patients until they become symptomatic. Glaucomatous damage is considered permanent, irreversible vision loss, so we seem to take it more seriously than dry eye, which improves wth treatment. However, this isn’t necessarily the right perspective. We now know there are early signs of damage or decreased functionality within the eyelid well before we see the consequences manifest on the ocular surface.

It is critical to become hyper-observant of the lid to ensure appropriate care and maintenance of the lid margin, ultimately providing a higher quality tear fi lm to help support lens wear.

Look for Signs Early

Fig. 3. Meibography provides greater

detail on meibomian gland status

than clinical examination alone.

Image: D

ave Kading, O

D

010_RCCL1016_PP.indd 11010_RCCL1016_PP.indd 11 9/29/16 4:20 PM9/29/16 4:20 PM


We as optome-trists hear com-plaints of dry, itchy eyes on a weekly basis,

at least. Depending on the physical signs and symptoms that present with these reports, we can head down any of a dozen diagnostic roads—creating a potential man-agement dilemma if we only focus on the dry eye signs and symptoms and fail to identify lid involvement as the true culprit. Blepharitis frequently compromises the ocular surface by creating an unstable tear fi lm prone to evaporation. This can be especially troublesome in our contact lens wearers, and may encourage them to drop out of lens wear if they mistakenly blame the lens itself for a problem that is in fact much more complex.

Fortunately, most eye care practi-tioners (ECPs) have the diagnostic skills to uncover the underlying cause of these complaints. Take the following case, for example:

A 47-year-old male presented to the clinic with a primary complaint that his eyes have been itchy over the past few weeks to months. He revealed upon further questioning that he also had a secondary com-plaint of dry eyes for many years, for which he had been using an off-brand nighttime gel. The patient reported occasional but minimal success with the gel, was not taking any medications that may have been contributory to the case and did not report any signifi cant

medical conditions. His vision was 20/25 OD and 20/20 OS, while slit lamp examination revealed trace superfi cial punctate keratitis (SPK) in the inferior half of the cornea OU, along with grade II conjunc-tival injection OU. Osmolarity test (TearLab) fi ndings were 312mOs-m/L OD and 318mOsm/L OS.

Lid evaluation revealed signs of blepharitis as the likely cause of the patient’s issue (Figures 1-4). The diagnosis may, however, be more complicated than that. Let’s delve into the details of lid margin disease before revisiting this case.

DIFFERENTIATING

THE CONDITION

If a patient presents with generic complaints of ocular discomfort and dryness, many ECPs may be tempted to skip straight to diag-nosis and management of ocular surface disease. Though initiating treatment can improve patient symptomology initially, failing to address any underlying eyelid pathology that may also exist can exacerbate the problem long-term. Blepharitis—infl ammation of the lash follicle, lid margins or meibomian glands—can lead to a build-up of bacterial debris, keratinization of gland orifi ces and alterations of the normal tear com-position. In contact lens wearers, this may result in lens discomfort, decreased wear time and lens wear dropout. Identifying the type of blepharitis present in a patient’s ocular environment is crucial for

choosing the appropriate treatment regimen.

The three major forms of anteri-or blepharitis are staphylococcal, seborrheic, and Demodex blepha-ritis, also known as ocular demodi-cosis. Anterior blepharitis typically presents with symptoms of bilateral itchy, matted and/or crusty lid mar-gins and ocular discomfort, often worse in the morning. Symptoms do not always correlate well with signs, so patients may occasionally present with asymptomatic disease. A careful anterior segment exam can help identify the type of bleph-aritis present.

Staphylococcal (or bacterial) blepharitis is commonly seen in clinical practice. Distinctive features include collarettes at the

ABOUT THE AUTHORS

BEAT the

To understand and treat this common lid condition,make sure you’re clear on its many diff erent presentations.

Dr. Harsch completed a

cornea and contact lens

residency at NSU Oklahoma

College of Optometry. She

is currently in practice at

Nittany Eye Associates in

State College, PA.

Dr. Stout recently completed

a family practice residency

with an emphasis in ocular

disease at NSU Oklahoma

College of Optometry. She

is currently working as a

clinical supervisor at the

University of Waterloo School

of Optometry and Vision Science.

Dr. Lighthizer is the assistant

dean for clinical care services,

director of continuing

education and chief of both

the specialty care clinic

and the electrodiagnostics

clinic at Northeastern State

University (NSU) Oklahoma

College of Optometry.

By Abby Gillogly Harsch, OD, Nicole Stout, OD, and Nathan Lighthizer, OD

012_RCCL1016_Bleph_F1.indd 12012_RCCL1016_Bleph_F1.indd 12 9/29/16 4:17 PM9/29/16 4:17 PM


base of the lashes; those present at the tip of the lash indicate a more chronic condition, as it can take eyelashes about 16 weeks to grow to their typical length. Thickened, telangiectatic lid margins and conjunctival and corneal irritation or infection are also commonly encountered in cases of bacterial blepharitis. Chronic cases can also lead to notched, irregular lid mar-gins that exacerbate the patient’s symptoms of dryness.

Staph. blepharitis is often caused by the normal fl ora present on the eyelid, which is most commonly either Staphylococcus epidermidisor Staphylococcus aureus. In these cases, the clinical signs are con-sidered a result of cell-mediated responses to endotoxins that are produced in response to an over-growth of the bacteria.1

Cases of seborrheic blepharitis tend to occur in an older popula-tion and clinically appear as a mix of dandruff and oily debris with slightly hyperemic upper lids. The term “scurf” has been applied to the scaly debris, with similar debris often seen throughout the patient’s eyebrows. More dermatologic in nature than Staph. blepharitis, this type is less frequently associated with infections or other corneal fi ndings.1

Demodex overpopulation of the lids may also cause blepha-ritis. Two species of Demodexmites have been identifi ed on the lids: Demodex folliculorum and Demodex brevis. The former, D. folliculorum, is primarily found in the eyelash follicles and around the base of the eyelashes and can cause chronic anterior blepharitis, while D. brevis can be found in the sebaceous and meibomian glands and can cause posterior blepharitis. Demodex mites create waste that accumulates as cylindrical dandruff around the base of the eyelashes, a

fi nding that is pathognomonic for a Demodex infestation (Figures 5 and 6).2

Chronic Demodex infestations can result in trichiasis and madaro-sis, the latter of which is more commonly a result of Demodexthan staphylococcal blepharitis.1,3

The mites can physically block the sebaceous ducts and cause hyper-keratinization of the lid margins. Defi nitive diagnosis of a Demodexinfestation can be obtained by epilating a few lashes and ex-amining them for mites under a microscope. Demodex blepharitis is considered by some clinicians to be underdiagnosed; one study reports that 100% of patients over 70 years of age have some amount of infestation.4 Demodexmites may also carry bacteria such as Staphylococcus sp., which can exacerbate the bacterial load on the lids and lashes. Several studies have also found a higher density of Demodex in patients with acne rosacea.1,2

Posterior blepharitis is character-ized by infl ammation and obstruc-tion of the meibomian glands. Signs and symptoms include lid

margin hyperemia, telangiectat-ic vessels along the lid margins, notching of the lid margins and inspissated meibomian gland ori-fi ces. Signs of posterior blepharitis are also evident in the tear fi lm, including the saponifi cation of tear fi lm and also an oily appearance.

Meibomian gland dysfunction (MGD) is the most common cause of posterior blepharitis. If fi rm, mild pressure is applied directly to the lid margins, healthy meibomian gland secretions appear clear and oily, while more turbid secretions with opaque to yellow coloration are abnormal. Presence of acne rosacea may also lead to chronic posterior blepharitis, known as ocular rosacea.5 In some cases, clogged meibomian glands from posterior blepharitis can form a sterile, granulomatous chalazion, which presents as a painless, pal-pable lump in the eyelid. Chalazia may resolve with warm compress-es, systemic tetracycline antibiotics or both; many cases, however, require steroid injection or surgical excision.

There are numerous other anterior segment fi ndings that can

Fig. 1. Exam fi ndings of the right

upper lid. What form of blepharitis

does this patient likely have?

Fig. 3. Lid examination fi ndings of

the left upper lid.

Fig. 2. A closer look at the right

upper eyelashes reveals a clear

sleeve of debris on multiple lashes.

Fig. 4. Further examination of the

lids reveals what condition?



result from blepharitis, such as SPK (particularly in the areas where the lid margins contact the cornea) and bulbar conjunctival hyperemia. A reduced tear break-up time can be a sign of posterior blepharitis resulting from MGD. Marginal corneal infi ltrates and phlyctenules can occur in response to Staph.hypersensitivity in patients with Staph. blepharitis. Corneal pannus and corneal neovascularization are signs of chronic blepharitis and may be indicative of ocular rosa-cea. In cases of untreated chronic blepharitis, irreversible corneal scarring and subsequent vision loss can result.

TREATMENT

These conditions may coexist in many patients. Mainstay therapies for long-term blepharitis include lid hygiene efforts and heat therapy with warm compresses, followed by eyelid massage. Warm compress masks are convenient to use and hold heat longer than a warm, wet washcloth. This is important because it is recommended that the warm compresses remain heated to 45°C and be applied for a mini-mum of four minutes for optimal treatment.6 While baby shampoos can be recommended for lid scrub-bing, certain branded lid scrubs are capable of targeting specifi c types of blepharitis as well. Regardless of the type of scrub recommenda-tion, however, educate the patient that a gentle wipe across the lid margin is ideal, as more vigorous scrubbing can cause lid irritation and increase infl ammation. Patient education should also speak to the chronic nature of the condition and emphasize the need for long-term maintenance of good eyelid and lash care.

Lid and lash hygiene products that contain hypochlorous acid, such as Avenova (NovaBay) and

HypoChlor (OcuSoft), are increas-ingly popular for blepharitis treat-ment. In vivo, hypochlorous acid is produced by neutrophils as part of the body’s natural defense system against infection. Hypochlorous acid is microbicidal, which is why lid hygiene products containing hypochlorous acid are an excellent option to decrease the microbial load on the eyelids and lashes. Furthermore, products containing hypochlorous acid are generally non-antibiotic antimicrobials and do not contribute to the ever-grow-ing issue of antibiotic resistance.7,8

Acute fl are-ups of staphylococcal blepharitis are treated using anti-biotic ointments, such as erythro-mycin or bacitracin, massaged onto the lid margins. The short-term use of a topical antibiotic-steroid combination can also be considered in moderate-to-severe cases that present with concurrent corneal and conjunctival infl ammation.

Seborrheic blepharitis is typically treated with dermatologic forma-tion triamcinolone 0.1% cream or, in the case of patients who may have diffi culties with keeping the ointment out of their eyes, Lotemax (loteprednol, Bausch + Lomb) gel or ointment.

Demodex blepharitis can be treated using in-offi ce 50% tea tree oil applied to the lashes and eye-brows. Tea tree oil lid wipes such as Cliradex (Bio-Tissue) that are indicated for home use can also be recommended. Cliradex contains terpinen-4-ol, the most active ingre-dient of tea tree oil.4,9 In addition to tea tree oil treatment, patients should be directed to discard any current eye makeup and launder all bedding on a high heat setting to avoid reinfection. In-offi ce treat-ments such as BlephEx (RySurg) may be a benefi cial adjunct pro-cedure in the management of all types of blepharitis. It cleans the

lashes of both debris and collarettes and removes any bacterial biofi lm from the lid margins.

Posterior blepharitis necessi-tates the use of warm compresses followed by manual expression or massage, though many more adjunct treatment options have come into play in recent years. Topical azithromycin 1% has proven effective in the treatment of signs and symptoms of MGD; its cost, however, has limited its use in some practices.10 Oral tetracyclines are benefi cial for their anti-infl am-matory properties, including the reduction of MMP-9.11 Studies also show low-dose doxycycline (sub-antimicrobial dose) improves the symptoms of MGD in affected patients with a lower incidence of side effects, resulting in better pa-tient compliance.12 Pregnancy and childhood are contraindications for even the non-antimicrobial doses of tetracyclines. Oral azithromycin also shows promise for improving signs and symptoms of MGD, though further studies are neces-sary to better determine its ideal dosage for success.13

The role of omega-3 and

BEAT THE BLEPHARITIS BLUES

Fig. 5. Demodex organism under low

magnifi cation.

Fig. 6. Highly magnifi ed picture of

the Demodex organism.



omega-6 essential fatty acids in managing posterior blepharitis is ever-evolving. Well known for their anti-infl ammatory properties, omega-3 fatty acids must exist in an adequate ratio, together with pro-infl ammatory omega-6 fatty acids. Omega-3 fatty acid supple-mentation with fi sh oil containing EPA and DHA is commonly rec-ommended for patients with MGD. Research suggests gamma-linolenic acid (GLA), an omega-6 fatty acid, is effective in the management of blepharitis. One study found that dietary supplementation with fi sh oil and black currant seed oil (a known source of GLA) signifi -cantly improved both the signs and symptoms of ocular surface infl ammation and irritation.14

HydroEye (ScienceBased Health) is one example of a supplement that contains both fi sh oil and black currant oil.14-16

In-offi ce warm compress appli-cation followed by manual gland expression behind the slit lamp can be performed using a Mastrota paddle (OcuSoft) or similar instru-ment. MiBoFlo Thermofl o (MiBo Medical Group) and LipiFlow (TearScience) are devices that use thermal energy to soften gland contents for removal. MiBoFlo is applied to the outside of the lid, together with slight pressure applied by the eye care practitioner, to encourage expression of the meibum, while the LipiFlow system applies heat from the palpebral side of the eyelids during application of pulsatile pressure on the outer surface of the lids to promote gland expression.17

REVISITING THE CASE

Ultimately, the patient described at the outset was diagnosed as having multiple forms of blepharitis, with Demodex predominating along with a secondary component of

posterior blepharitis due to MGD. Careful epilation of several lashes and examination of their follicles under the microscope revealed such. The patient was treated with Cliradex pads twice daily for two weeks, then once daily for an additional two weeks. The patient was also instructed to use OcuSoft Lid Scrub Plus Foam once daily in the shower to cleanse his eyelids and lashes indefi nitely. Warm compresses with a lipid-based artifi cial tear were also prescribed QID, and HydroEye fi sh oil soft gels were recommended for long-term supplementation to assist with alleviating further MGD. Multiple follow-up visits over the next three months demonstrated slow but continual improvement of the condition, with near resolution at the three-month follow-up appoint-ment (Figures 7 and 8).

To ensure treatment success, clinicians must focus on the

different forms of anterior and posterior blepharitis when pa-

tients present with ocular surface irritation, dry eyes and decreased contact lens wearing time. With a better understanding of these different forms of blepharitis and their appropriate treatments, eye care practitioners can improve their patients’ quality of life and, consequently, their ocular disease practice. RCCL

1. Gadaria-Rathod N, Fernandez K, Asbell P. Blepharitis. In: Yanoff M, Duker JS, ed. Ophthal-mology, 4th edition. Philadelphia: Elsevier Health Sciences; 2014:177-9. 2. Cheng AMS, Sheha H, Tseng SCG. Recent ad-vances on ocular Demodex infestation. Curr Opin Ophthalmol. 2015;26(4):295-300. 3. Jingbo L, Hosam S, Tseng SC. Pathogenic role of Demodex mites in blepharitis. Curr Opin Aller-gy Clin Immunol. 2010;10(5):505-10. 4. Kemai M, Sümer Z, Toker MI, et al. The prev-alence of Demodex folliculorum in blepharitis patients and the normal population. Ophthal Epidem. 2005;12(4):287-90.5. Nijm LM. Blepharitis. In: Holland EJ, Mannis MJ, Lee WB. Ocular Surface Disease: Cornea, Conjunctiva and Tear Film. Philadelphia: Elsevier; 2013:55-60. 6. Blackie CA, Solomon JD, Greiner JV, et al. Inner eyelid surface temperature as a function of warm compress methodology. Optom Vis Sci. 2008;85:675-83.7. Ono T, Yamashita K, Murayama T, Sato T. Micro-bicidal eff ect of weak acid hypochlorous solution on various microorganisms. Biocontrol Science. 2012;17(3):129-33. 8. Debabov D, Noorbakhsh C, Wang L, et al. Avenova with Neutrox (pure 0.01% HOCl) com-pared with OTC produce (0.02% HOCl). NovaBay Pharmaceuticals:1-5.9. Tighe S, Gao YY, Tseng SC. Terpinen-4-ol is the most active ingredient of tea tree oil to kill mites. Transl Vis Sci Technol. 2013 Nov;2(7):2.10. Optiz DL, Tyler KF. Effi cacy of azithromycin 1% ophthalmic solution for treatment of ocular surface disease from posterior blepharitis. Clin Exp Optom. 2011;94:200-6. 11. Duncan K, Jeng BH. Medical manage-ment of blepharitis. Curr Opin Ophthalmol. 2015;26(4):289–94. 12. Yoo SE, Lee DC, Chang MH. The eff ect of low-dose doxycycline therapy in chronic meibo-mian gland dysfunction. Korean J Ophthalmol. 2005;19:258-63.13. Kashkouli MB, Fazel AJ, Kiavash V, et al. Oral azithromycin versus doxycycline in meibomian gland dysfunction: a randomized double-masked open-label clinical trial. Br J Ophthalmol. 2015;99:199-204. 14. Sheppard JD Jr, Singh R, McClellan AJ, et al. Long-term supplementation with n-6 and n-3 PU-FAs improves moderate-to-severe keratoconjunc-tivitis sicca: a randomized double-blind clinical trial. Cornea. 2013;32(10):1297-304. 15. Horn M, Asbell P, Barry B. Omegas and dry eye: more knowledge, more questions. Optom & Vis Sci. 2015;92(9):948-56.16. Pinna A, Piccinini P, Carta F. Eff ect of oral linoleic and ϒ-linolenic acid on meibomian gland dysfunction. Cornea. 2007:26(3):260-4.17. Lane SS, Dubiner HB, Epstein RJ, et al. A new system, the LipiFlow, for the treatment of meibo-mian gland dysfunction. Cornea. 2012;31:396–404.

Fig. 7. Demodex blepharitis:

Improvement but not complete

resolution at follow up.

Fig. 8. Improvement and near

resolution at the fi nal follow up. Total

resolution can be diffi cult to achieve

and will require long-term chronic

management. Without this, future

fl are-ups are much more likely.



Chicken-and-Egg Problem

Our understanding of the ocular surface has increased dra-matically over the past few years, and

much of the research has highlight-ed the role the eyelids and meibo-mian glands play in supporting a stable tear layer. At the same time, renewed interest in the causative factors for contact lens discomfort and dropout have fueled innovation in contact lens material formula-tion, tear chemistry and environ-mental factors impacting lens wear.

Disagreement abounds regarding the role meibomian gland dysfunc-tion (MGD) and function play in contact lens wear. Contact lenses’ impact on the meibomian glands also remains the subject of ongo-ing debate. This article reviews the literature and explores current thinking regarding contact lenses and meibomian gland function, while examining the broader issues of tear fi lm/contact lens interaction.

UNDERSTANDING THE TEARS

While tears serve numerous well-recognized purposes, their pri-mary functions are refractive and protective. This sometimes causes confusion among patients who assume tears exist only to keep the eyes wet and believe their absence leads to dry eye and discomfort. This can be especially confusing for contact lens wearers who mistake contact lens-related discomfort for ocular dryness.1 Similarly, eye care practitioners are also often

confused regarding the cause of dry eye, which is now increasingly recognized as more of a misnomer than a descriptive diagnosis.

Refl ex tears serve the critical purpose of fl ushing irritants and foreign bodies from the ocular surface before they cause signifi cant damage to the corneal surface. This reduces the potential for abrasion and infection with subsequent loss of vision and function. In contrast, basal tears arising from the accesso-ry glands of Krause and Wolfring, with possible contribution from the lacrimal glands, are structural in nature—an often overlooked property. The tear foundation transforms the naturally hydro-phobic surface into a hydrophilic entity, allowing the tears to remain in place, defying gravity and other extrinsic and intrinsic forces. The majority of tears consist of a visco-elastic gel made up of mucins and other components. This structural layer offers protection and smooth-ing, and likely changes its behavior during different phases of the blink.

The outer layer is derived from the meibomian glands, which express a complex lipid with each blink; however, the function and clinical importance of meibum is not broadly understood. Hydrophobic bonding causes lipid to attract lipid. When suffi cient lipid is present to cover the interpalpebral globe, a co-herent layer stretches over the outer surface of the eye. The tear lipid layer provides signifi cant structure to the tear fi lm.

The interface between this outer, nonpolar lipid layer and the rest of the tears occurs through the interfacial action of phospholipids, which bond polar and nonpolar components, effectively anchoring the outer lipid layer to the mostly aqueous sub-layer below.

MGD

Dry eye has historically been viewed as the result of an aqueous tear defi ciency.2 Normal meibomian gland function has increasingly been recognized as an essential element in the maintenance of ocular surface health and function. Contemporary literature confi rms that MGD is a primary or major contributory factor in nearly 90% of patients complaining of dry eye—which is borne out in clinical practice.3 More recently, research-ers questioned whether dry is more frequently an erroneous description of a disorder driven by abnormal meibomian gland function.4

MGD is defi ned as “a chronic, diffuse abnormality of the meibo-mian glands, commonly character-ized by terminal duct obstruction and/or qualitative/quantitative changes in the glandular secretion. This may result in alteration of the

ABOUT THE AUTHOR

Dr. Epstein is co-founder of

Phoenix Eye Care, where he

heads the Ocular Surface

Disease Center and serves

as the Center’s director of

clinical research.

By Arthur B. Epstein, ODThe

Which came fi rst, the dysfunction or the discomfort?Researchers aren’t sure, but clinicians need to manage them simultaneously.

Chicken-and-Egg Problemof MGD and Contact Lens Wear

016_RCCL1016_ChickvsEgg_F2.indd 16016_RCCL1016_ChickvsEgg_F2.indd 16 9/29/16 11:29 AM9/29/16 11:29 AM


tear fi lm, symptoms of eye irrita-tion, clinically apparent infl amma-tion and ocular surface disease.”5

While the exact causes of MGD remain unclear and are likely multifactorial, healthy meibomian gland function is better understood. Driven by the force of the blink, normal gland expression produces a clear, free fl owing, complex oil. Exiting through orifi ces on the lid margin, meibum intermixes with the tears, resulting in an effective evaporative barrier, decreased surface tension and friction and increased tear stability.

There are a greater number and length of glands in the upper eyelid, likely producing additional meibum compared with the lower lid. The glands are buried deep within the lids and protected by the tarsal plate, subcutaneous fat and overlaid by a robust vascular net. Meibum production occurs in the acini, the grape-like clusters present along the length of the glands and remains relatively constant. However, the amount of meibum delivered by each gland varies over time and tends to decrease with age.

Structural changes with MGD include atrophy, truncation, gland loss (which can be complete, sectoral or segmental) and convo-lution. Dilation of the distal duct, sometimes referred to as tooth sign, refl ects obstruction and is likely caused by back-pressure.

Researchers postulate alterations in normal blink patterns and shifts in dietary intake of essential fatty acids are causal factors in MGD.6,7

Blink frequency and rate of blink completion is reduced during tasks requiring concentration, reading text and especially during computer use.8-10 Likewise, shifts in dietary intake over recent decades have resulted in an imbalance in ome-ga-3 vs. omega-6 free fatty acids. Reduced levels of omega-3 fatty ac-ids have been implicated as factors in the pathophysiology of MGD.

CONTACT LENS WEAR

Researchers fi rst described the association of MGD with contact lens intolerance in 1980.11 They reported obstructive meibomian gland disease due to blockage of the glands by desquamated epithe-lial cells as the cause of dryness and discomfort in intolerant contact lens wearers. Other studies report that a decrease in the number of

functional meibomian glands in contact lens wearers worsens with duration of contact lens wear.12

The association of contact lens wear with MGD still remains somewhat controversial—perhaps because of the complexity and multifactorial nature of MGD and contact lens interaction with the ocular environment. While several studies failed to demonstrate a link between MGD and contact lens wear, a recent report offers compel-ling evidence for the role contact lenses play in predisposing patients to meibomian gland and related lid abnormalities.13-16

Contact lenses can lead to MGD in a variety of ways. Blink rates and meibomian gland function may be affected by lens wear, intense visual tasks and concentration. With rigid lenses, blinking may decrease, resulting in lower amounts of meibomian gland secretions. In soft lens wearers, studies associate decreased tear stability and adverse environmental conditions with increased blinking, which may be an adaptive mechanism resulting in increased meibomian gland lipid production.17,18

Meibomian gland loss is strong-ly correlated with decreased lipid layer thickness and tear instabili-ty.19 Although meibomian glands are mechanically compressed and meibum expressed as a function of the blink, higher-order control is

MGD with telangiectatic vessels and

inspissated meibomian glands.

Frothing due to saponifi cation.

Tear fi lm scans provide non-invasive assessment of tear fi lm break-up time.



likely active in regulating tear lipid and aqueous levels. Decreased tear lipid levels result in tear instability and is likely to reactively prompt increased compensatory meibum and tear secretion in healthy patients.20,21

Typical contact lenses are signifi -cantly thicker than the normal tear fi lm. This disparity causes the tears to essentially stretch to accommo-date the relatively massive thickness of the contact lens, resulting in thinning of the pre- and post-lens tear fi lm and destabilization of the tear structure. This can lead to a cycle of increasing tear insta-bility and compensatory meibum overproduction, eventually taxing gland capability—especially in the presence of MGD or frank gland loss. It is possible, if not likely, that chronically overproducing meibo-mian glands can burn out, lead-ing to damage and overall gland down-regulation and loss.

Uptake and sequestration of lipids by hydrophobic moieties in

contact lens materials can exacer-bate the situation. Silicone hydrogel materials, especially early gener-ation lenses, are known for their propensity to bind lipids onto their surfaces.22 Further, some modern contact lens materials are report-edly formulated to integrate lipids within their structure. While this may improve surface compatibility, it can also result in compensatory up-regulation of lipid production and an eventual adverse impact on meibomian glands.

DIAGNOSIS AND

MANAGEMENT

Regardless of whether contact lens wear causes MGD or MGD causes contact lens discomfort and intoler-ance, comorbidity between the two is highly likely, if not certain. Since the overwhelming majority of dry eye is directly caused by or closely associated with MGD, contact lens wearers experiencing dryness and discomfort should always be evalu-ated for MGD. Prospective con-

tact lens wearers who have MGD should be treated before initiating contact lens wear to help ensure success. Before attributing patient complaints to problems with their contact lenses or solutions, a thor-ough workup is indicated, includ-ing assessment of meibomian gland function and structural integrity.

An experienced clinician can evaluate meibomian gland function with diagnostic expression using either fi ngertip pressure applied to the lids or the Korb Meibomian Gland Evaluator (TearScience). Interferometry can assess meibo-mian gland lipid production as well as track changes during treatment. Because of the sensitivity of inter-ferometry, clinicians must be care-ful when removing contact lenses before testing to avoid interference with lipid layer thickness readings.

Although transillumination of the lid margin can be helpful in evalu-ating gland structure, meibography is superior at documenting MGD-related gland loss and structural

THE CHICKEN-AND-EGG PROBLEM OF MGD AND CONTACT LENS WEAR

BLINK EXERCISES

Blinking Sequence:

CLOSE - PAUSE - PAUSE - OPEN

RELAX

CLOSE - PAUSE - PAUSE - SQUEEZE - OPEN - RELAX

CLOSE OPEN

OPEN - RELAXSQUEEZECLOSE

PAUSE - PAUSE

PAUSE - PAUSE

1. Hold your fi ngers at the corners of your eyes and blink. If you feel anything, you are using your defense muscles that run along the side of your head. Your blinking muscles are above your eyelids.

2. Read the blinking sequence. It is very important to do the pause step to make complete contact between the upper and lower lids (partial blinking is very common in people with dry eyes). When you are doing it correctly, you should feel no movement under your fi ngers.

3. Blinking is very task-dependent. For example, if you spend a lot of time on the computer, you are probably blinking much less frequently and might want to post a copy of the blinking exercises nearby as a friendly reminder. (Other pastimes that decrease blink rate are driving, reading, watching TV, working at your desk, or any concentrated visual task, etc.)

4. Lastly, if you having diffi culty consciously incorporating the blinking exercise into your schedule (i.e. 5X/hour) you might want to think about something you do often in your daily routine, such as answering phone calls, sending emails, drinking sips of water, getting dressed, etc. If you can condition yourself to make a full blink and give a little squeeze every time you perform this action it helps to make complete blinking a habit.

TearScience’s Donald Korb Blink Training app off ers directions to help patients with MGD learn proper blink technique

to mitigate symptoms.



changes. The high-quality images generated by meibography are also a useful educational tool for patients in discussing the disease.

Tear break-up time is an ex-tremely useful measure of tear stability and lipid layer integri-ty. Noninvasive measurements can be performed with lenses in place, which can reveal important information.

Both traditional and con-temporary MGD management approaches may be useful for symptomatic contact lens patients who have MGD. Lid scrubs can be benefi cial in managing symptom-atic contact lens wearers.23 More recently, several studies (including an as yet unpublished multicenter study) have investigated the use of LipiFlow (TearScience) thermal pulsation therapy in contact lens wearers with MGD. Researchers saw signifi cant improvement in MGD scores and patient symptoms after a single treatment.24 Another device that applies heat to reported-ly improve gland expression is the MiBoFlo Thermafl o.

Pure hypochlorous acid applied to the lids in products such as Avenova (Novabay) may be ben-efi cial by triggering antimicrobial activity on lid fl ora overpopula-tion and inhibition of associated lipolysis in the tear fi lm.25 Omega-3

supplements have also proven help-ful in managing MGD.26 A recently published study investigating the role of oral re-esterifi ed omega-3 nutritional supplementation on dry eyes showed signifi cant treatment benefi ts.27

Beyond identifying and man-aging MGD, clinicians must be aware of the role different contact lens materials play in exacerbating lens-related evaporative dry eye. We should prescribe materials that adsorb signifi cant amounts of lipid cautiously. Solutions and lens materials designed to increase surface wettability may help reduce the potential adverse impact of lens wear on MGD.

CLINICIAN TAKEAWAY

A steady increase of patients presenting with dry eye threatens to complicate contact lens man-agement. While changes in visual demands and diet likely play sig-nifi cant roles, awareness of MGD and the resulting tear dysfunction helps the clinician troubleshoot and address patients’ discomfort and dryness. With ever-increasing patient expectations and an aging population, understanding risk fac-tors and appropriate MGD man-agement will become increasingly vital tools in the armamentarium of the successful contact lens fi tter. RCCL

1. Kadence International. Exploring Comfort and Vision Survey. 2012. 2. Murube J. History of the Dry Eye. In: The Dry Eye: A Comprehensive Guide. Lemp MA, Mar-quardt R, eds. Heidelberg, Germany: Springer; 1992:3-34.3. Lemp MA, Crews LA, Bron AJ, et al. Distribution of aqueous-defi cient and evaporative dry eye in a clinic-based patient cohort: a retrospective study. Cornea. 2012;31(5):472-8.4. Korb DR, Blackie CA. “Dry eye” is the wrong diagnosis for millions. Optom Vis Sci. 2015;92(9):e350-4.5. The International Workshop on Meibomian Gland Dysfunction. Invest Ophthalmol Vis Sci. 2011;52(4):1917–2085.6. Shine WE, McCulley JP. Meibomian gland triglyceride fatty acid diff erences in chronic bleph-aritis patients. Cornea. 1996;15(4):340-6.7. Schafer J, Steff en R, Reindel W, Chinn J. Eval-uation of surface water characteristics of novel daily disposable contact lens materials, using

refractive index shifts after wear. Clin Ophthalmol. 2015;9:1973-9.8. Argilés M, Cardona G, Pérez-Cabré E, Rodríguez M. Blink rate and incomplete blinks in six diff erent controlled hard-copy and electronic reading condi-tions. Invest Ophthalmol Vis Sci. 2015;56(11):6679-85.9. Chu CA, Rosenfi eld M, Portello JK. Blink pat-terns: reading from a computer screen versus hard copy. Optom Vis Sci. 2014;91(3):297-302.10. Patel S, Henderson R, Bradley L, et al. Eff ect of visual display unit use on blink rate and tear stabili-ty. Optom Vis Sci. 1991;68:11:888-92.11. Korb DR, Henriquez AS. Meibomian gland dysfunction and contact lens intolerance. J Am Optom Assoc. 1980;51(3):243-51.12. Arita R, Itoh K, Inoue K, et al. Contact lens wear is associated with decrease of meibomian glands. Ophthalmology. 2009;116(3):379-84.13. Ong BL. Relation between contact lens wear and meibomian gland dysfunction. Optom Vis Sci. 1996;73(3):208-10.14. Marren SE. Contact lens wear, use of eye cos-metics, and meibomian gland dysfunction. Optom Vis Sci. 1994;71(1):60-2.15. Pucker AD, Jones-Jordan LA, Li W, et al. Associations with meibomian gland atrophy in daily contact lens wearers. Optom Vis Sci. 2015;92(9):e206-13.16. Machalińska A, Zakrzewska A, Adamek B, et al. Comparison of morphological and functional meibomian gland characteristics between daily contact lens wearers and nonwearers. Cornea. 2015;34(9):1098-104.17. Kojima T, Matsumoto Y, Ibrahim OM, et al. Eff ect of controlled adverse chamber environment exposure on tear functions in silicon hydrogel and hydrogel soft contact lens wearers. Invest Ophthal-mol Vis Sci. 2011;52(12):8811-7.18. Jansen ME, Begley CG, Himebaugh NH, Port NL. Eff ect of contact lens wear and a near task on tear fi lm break-up. Optom Vis Sci. 2010;87(5):350-7.19. Eom Y, Lee JS, Kang SY, et al. Correlation between quantitative measurements of tear fi lm lipid layer thickness and meibomian gland loss in patients with obstructive meibomian gland dys-function and normal controls. Am J Ophthalmol. 2013;155(6):1104-10.20. Arita R, Morishige N, Koh S, et al. Increased tear fl uid production as a compensatory response to meibomian gland loss: a multicenter cross-sec-tional study. Ophthalmology. 2015;122(5):925-33.21. Baudouin C, Messmer EM, Aragona P, et al. Revisiting the vicious circle of dry eye disease: a focus on the pathophysiology of meibomian gland dysfunction. Br J Ophthalmol. 2016;100(3):300-6.22. Nichols JJ. Deposition on silicone hydrogel lenses. Eye Contact Lens. 2013;39(1):20-3.23. Paugh JR, Knapp LL, Martinson JR, et al. Mei-bomian therapy in problematic contact lens wear. Optom Vis Sci. 1990;67(11):803-6.24. American Academy of Optometry. A single lipifl ow treatment increases soft contact lens wearing time and reduces lid wiper epitheliopathy and dry eye symptoms. Available at www.aaopt.org/single-lipifl ow-treatment-increases-soft-con-tact-lens-wearing-time-and-reduces-lid-wiper. Accessed September 15, 2016.25. Epstein A, Pang L, Noorbakhsh C, et al. Com-parison of bacterial lipase activity in the presence of eye lid cleansers. Available at http://novabay.com/wp-content/uploads/2016/07/Epstein-AR-VO-2015-Comparison-of-Bacterial-Lipase-Ac-tivity-in-the-Presence-of-Eye-Lid-Cleansers.pdf. Accessed September 15, 2016.26. Macsai MS. The role of omega-3 dietary sup-plementation in blepharitis and meibomian gland dysfunction (an AOS thesis). Trans Am Ophthalmol Soc. 2008;106:336-56.27. Epitropoulos AT, Donnenfeld ED, Shah ZA, et al. Eff ect of oral re-esterifi ed omega-3 nutri-tional supplementation on dry eyes. Cornea. 2016;35(9):1185-91.

Meibography shows the tooth sign on

the distal upper and lower lid glands.



Although the eye care community has well over 100 years of experience in studying, fi tting

and observing contact lenses, our understanding continues to evolve in the face of new fi ndings and theories. Lid wiper epitheliopathy (LWE), fi rst described in 2002, has since attracted considerable attention among researchers and clinicians in the dry eye world—especially as it challenges conven-tional notions of diagnosis and management.1 And it may underlie some of the factors that degrade the on-eye performance of con-tact lenses and threaten to reduce patient satisfaction.

The lid wiper (LW) region is the portion of the marginal conjunc-tiva of the upper and lower eyelid that acts as a wiping mechanism to spread the tear fi lm over the ocular surface or, if present, a contact lens (CL). LWE describes a disturbance to the epithelium of the lid wiper region and is observed through vital staining of the upper and lower lid margin regions that are in contact with the ocular surface or CL (Figures 1 and 2).

LID MARGIN UP CLOSE

The eyelid margin is divided into three regions: (1) the skin epidermis that extends over the meibomian gland orifi ces, (2) the mucocutaneous junction, which represents the line of Marx, and

(3) the lid wiper region.2 The wiper region in the upper lid is the palpebral marginal conjunctiva in contact with the ocular surface. This area, about 1mm in height, ranges from the crest of the sharp posterior lid border to the sub-tar-sal fold superiorly and from the upper punctum to the lateral can-thus horizontally (Figure 3).1,3 It is wider in the nasal and temporal regions compared with the center of the eyelid.2

The conjunctiva of this region contains goblet cells that secrete soluble mucins onto the surface of the LW. These mucins and other components of the tear fi lm form a hydrated gel between the LW and the ocular surface, providing lubrication and keeping the lid and the ocular surface separated. Impression cytology of the LW re-gion shows the presence of goblet cells, mucins, cell nuclei and vari-ous degrees of pre- and parakera-tinization.4 Researchers also found metabolic activity, compromised cell membranes, nucleic acids and apoptosis in cells stained with calcein AM, ethidium and annexin V dyes.4

UPPER VS. LOWER LWE

The primary hypothesis for the cause of LWE is increased friction between the LW and ocular or CL surface due to inadequate lubrica-tion, leading to infl ammation and epithelial compromise.

Researchers proposed that the lower lid wiper makes blink-relat-

ed movements on a much smaller scale than the upper lid wiper and, as a result, has less opportunity to suffer friction-related damage; any epitheliopathy observed may more likely be due to hyperosmot-ic changes.5 Although the upper eyelid wiper has captured the most attention of researchers—likely due to the large, sweeping movements it makes—the upper lid typically glides over a vast ex-panse of generally well-lubricated ocular surface. In fact, the fric-tional effects that cause LWE may be expressed more explicitly in the lower eyelid than the upper.

Investigators evaluated the prevalence and type of lid mar-gin staining and found that LWE is seen in 25% of a population presenting to an eye clinic.14

Others examined LWE in non-CL wearers, soft CL wearers and

ABOUT THE AUTHOR

Does a relatively new phenomenon help explain contact lens discomfort?

Dr. Srinivasan is a research

assistant professor and a

clinical research manager

at the Centre for Contact

Lens Research (CCLR),

School of Optometry and

Vision Science, University

of Waterloo, Canada. She is

actively involved in various

clinical trials conducted at the CCLR. Dr. Sri-

nivasan graduated from the Elite School of

Optometry, India, obtained her PhD in vision

science from the University of Waterloo in

2008 and did her postdoctoral fellowship

at the Ohio State University College of

Optometry. Dr. Srinivasan is a fellow of the

American Academy of Optometry as well

as a Scientifi c Program Committee member.

She is also a member of the Association for

Research in Vision & Ophthalmology and

the International Society for Contact Lens

Research.

By Sruthi Srinivasan, PhD, BSOptom, FAAOLIDS, FRICTION

and Contact Lens Wear

020_RCCL1016_LidWiper_F3.indd 20020_RCCL1016_LidWiper_F3.indd 20 9/29/16 4:20 PM9/29/16 4:20 PM


rigid CL wearers and found that the prevalence and mean grade of lower LWE was signifi cantly higher than that of upper LWE in non-lens wearers. LWE (both upper and lower) was detected in a higher percentage of CL wearers than in non-lens wearers.15

Researchers examined images of upper eyelid wiper staining of non-CL wearers, including the area of the line of Marx in the measurement of lid wiper staining area.16 They also measured the tarsal length, height and area of the tarsal plate in these subjects, but found none of these measures correlated with the area of lid wiper staining. Another study found no difference in the sever-ity of LWE between current CL wearers, previous CL wearers and non-lens wearers.17

TESTING

Researchers use a variety of staining methods to examine the lid wiper region, including sodium

fl uorescein (NaFl), lissamine green (LG), fl uorescein and rose bengal (RB), fl uorescein and LG and a combination of fl uorescein, LG and RB.1,6 However, lissamine green has been the dye of choice for visualizing LWE over the past three years, likely due to the ease of visualization without any bar-rier fi lter. Researchers have moved away from RB because of its rela-tively greater toxicity profi le.

When NaFl is used to visualize LWE, a Kodak Wratten 12-barrier yellow fi lter (transmitting above 495nm) is employed to enhance the view. The slit lamp beam is set to maximum width and 10mm height, and the potentiometer is set to provide maximum illumi-nation through the Wratten 47 or 47A cobalt blue exciter fi lter.

Clinicians can use both sub-jective and objective/automated techniques to grade the severity of LWE. Subjective grading—the fi rst and most frequently used system—is based on the appear-

ance of the lid wiper following instillation of vital dyes. Severity of LWE is graded for each eye on a scale of 0 to 3 or 0 to 4 on the basis of the horizontal and vertical extent of lid margin staining with NaFl, LG or RB vital stains.7,8

Investigators graded on a 0 to 3 subjective scale (0=none, 1=mild, 2=moderate, and 3=severe, using 0.5 steps).9 Others used LG to grade the severity of LWE in 0.5 steps using a 4-point

simplifi ed pictorial severity grad-ing scale (0=none and 3=severe).10

Research reports the length of the band of staining while grading LWE (Figure 1), and some report more complex patterns of staining including fi mbriated or feathery extensions from the superior margin of the subtarsal fold onto the upper tarsal plate.1,7,11 A recent study of silicone hydrogel CL wearers shows six patterns of upper lid margin staining (in addition to no staining): vertical streaks, short horizontal band, broad horizontal band, speckled appearance, comb-shaped and atypical appearance.11

Due to growing interest in understanding LWE, researchers have developed automated grad-ing methods to assess LWE, but they are mainly used for research purposes. Two recently developed methods of automating grading of LW staining involve digital image capture of the stained lid wiper followed by image anal-ysis.12,13 While these techniques are novel and useful in deter-mining the severity and extent of LWE, they are neither quick nor clinician-friendly.

FRICTION, CL

WEAR AND LWE

Measuring friction under the human eyelid during blinking is complicated. Tear fi lm com-ponents, including proteins and lipids, are attracted within the fi rst few minutes of CL insertion.18

This deposition alters surface properties of the lens material, signifi cantly impacting lid/CL interaction. Studies suggest CL frictional properties may also be associated with LWE and lid parallel conjunctival folds (LIPCOF).19, 20 Thus, measuring the coeffi cient of friction (COF) over CLs has attracted interest

Fig. 1. Lid wiper staining extending from the nasal to

the canthal area of the upper lid margin (Top: sodium

fl uorescein. Bottom: lissamine green.)

Fig. 2. Lid wiper staining extending from the nasal to

the canthal area of the lower lid margin (Top: sodium

fl uorescein. Bottom: lissamine green.)

Photos: Jalaiah V

arikooty, Centre for C

ontact Lens Research



LIDS, FRICTION AND CONTACT LENS WEAR

among researchers. COF can be measured by different techniques such as microtribometry, inclined plane method or atomic force microscopy.21-23 The recent TFOS report on contact lens discomfort indicates that COF is the only CL material property that correlates with discomfort.24

COF values can vary depending on technique and testing condi-tions, and there is no standardized method to assess COF. It is there-fore vital to be cautious when in-terpreting results presented in the literature. Researchers have made signifi cant advances in trying to develop models that mimic on-eye conditions, and further research is warranted in understanding the role of friction, LWE and CL wear.

What we do know for sure is that a lubricious ocular surface is essential to minimize friction. Switching to a lens with high sur-face lubricity may decrease LWE associated with CL wear. Research shows that contact lenses have a wide range of surface lubricity values.21 One study demonstrates that lenses with higher lubricity

values are likely to be more com-fortable.25 However, no studies to date have demonstrated a link between CL surface lubricity and LWE. Other management strate-gies under investigation include altering lens wear modalities, us-ing lubricant drops and improving blinking behavior.

CORRELATION OR

CAUSATION?

Although the relationship between LWE and symptoms of dryness or discomfort in CL wearers has been widely studied, the literature is in-consistent in demonstrating a link between LWE and CL-associated dryness and discomfort. For every publication that has found LWE to be greater in CL wearers, another one has found no differ-ences. These inconsistencies could be due to low sample size, record-ing inconsistencies (time of day, length of lens wear), or insensitive techniques for assessing LWE, comfort or dryness. Any of these factors may have confounded the capacity to detect differences or associations.

Lid wiper epitheliopathy is a condition seen in both contact

lens wearers and non-wearers, as well as asymptomatic and symp-tomatic individuals. Future studies are warranted to understand its cause, nature (i.e., acute or chron-ic), time of development, diurnal variation and long-term effects. RCCL

1. Korb DR, Greiner JV, Herman JP, et al. Lid-wiper epitheliopathy and dry-eye symptoms in contact lens wearers. CLAO J. 2002;28:211-16.2. Knop E, Knop N, Zhivov A, et al. The lid wiper and muco-cutaneous junction anatomy of the hu-man eyelid margins: an in vivo confocal and histo-logical study. Journal of Anatomy. 2011;218:449-61.3. Knop N, Korb DR, Blackie CA, Knop E. The lid wiper contains goblet cells and goblet cell crypts for ocular surface lubrication during the blink. Cornea. 2012;31:668-79.4. Muntz A, van Doorn K, Subbaraman LN, Jones LW. Impression cytology of the lid wiper area. Investig Ophthalmol Vis Sci. 2015;56:ARVO E-Ab-stract 4432.

5. McMonnies CW. An examination of the rela-tionship between ocular surface tear osmolarity compartments and epitheliopathy. The Ocular Surface. 2015;13:110-7.6. Korb DR, Herman JP, Finnemore VM, et al. An evaluation of the effi cacy of fl uorescein, rose bengal, lissamine green, and a new dye mixture for ocular surface staining. Eye & Contact Lens. 2008;34:61-4.7. Korb DR, Herman JP, Greiner JV, et al. Lid wiper epitheliopathy and dry eye symptoms. Eye & Contact Lens. 2005;31:2-8.8. Willis T, Blackie CA, Korb D. Meibomian gland function, lid wiper epitheliopathy, and dry eye symptoms. Ophthalmol Vis Sci. 2011;52:ARVO EAbstract 3740.9. Stahl UG, Delaveris A, Madigan M, Jalbert I. Lid wiper epitheliopathy: exploring the links to com-fort and osmolality in contact lens wear. Contact Lens Ant Eye. 2011:(Suppl. 1):34.10. Jalbert I, Rejab S. Increased numbers of Demodex in contact lens wearers. Optom Vis Sci. 2015;92:671-8.11. Varikooty J, Srinivasan S, Subbaraman L, et al. Variations in observable lid wiper epitheliopathy (LWE) staining patterns in wearers of silicone hydrogel lenses. Contact Lens & Anterior Eye: The Journal of the British Contact Lens Association. 2015;38:471-6.12. Varikooty J, Lay B, Kier N, et al. The relationship between clinical grading and objective image anal-ysis of lid wiper epitheliopathy. Invest Ophthalmol Vis Sci. 2013;54:ARVO E-Abstract 5460.13. Kunnen CK, Lazon De La Jara P, Holden BA, Papas EB. Automated assessment of lid margin lissamine green staining. Invest Ophthalmol Vis Sci. 2014;55:ARVO E-Abstract 1976.14. Guillon M, Maissa C. Assessment of upper and lower lid margin with lissamine green. Optom Vis Sci. 2008;84:E-abstract 80088.15. Shiraishi A, Yamaguchi M, Ohashi Y. Prevalence of upper- and lower-lid-wiper epitheliopathy in contact lens wearers and non-wearers. Eye & Contact Lens. 2014;40:220-4.16. Navascues-Cornago M, Maldonado-Codina C, Gupta R, Morgan PB. Characterization of upper eyelid tarsus and lid wiper dimensions. Eye & Contact Lens. 2016 Sep;42(5):289-94.17. Alghamdi WM, Markoulli M, Holden BA, Papas EB. Impact of duration of contact lens wear on the structure and function of the meibomian glands. Ophthalmic & Physiological Optics. 2016;36:120-31.18. Bontempo AR, Rapp J. Protein and lipid deposition onto hydrophilic contact lenses in vivo. CLAO J. 2001;27:75-80.19. Berry M, Pult H, Purslow C, Murphy PJ. Mucins and ocular signs in symptomatic and asymptomatic contact lens wear. Optom Vis Sci. 2008;85:E930-938.20. Pult H, Purslow C, Berry M, Murphy PJ. Clinical tests for successful contact lens wear: relation-ship and predictive potential. Optom Vis Sci. 2008;85:E924-929.21. Roba M, Duncan EG, Hill GA, et al. Friction measurements on contact lenses in their operating environment. Tribol. 2011;Lett. 44:387-97.22. Tucker RC, Quinter B, Patel D, et al. Qualitative and quantitative lubricity of experimental contact lenses. Invest Ophthalmol Vis Sci. 2012;53:ARVO E-Abstract 6093.23. Kim SH, Marmo C, Somorjai GA. Friction studies of hydrogel contact lenses using AFM: non-crosslinked polymers of low friction at the surface. Biomaterials. 2001;22:3285-94.24. Jones L, Brennan NA, Gonzalez-Meijome J, et al. The TFOS International Workshop on Contact Lens Discomfort: report of the contact lens materials, design, and care subcommittee. Invest Ophthalmol Vis Sci. 2013;54:TFOS37-70.25. Coles CML, Brennan NA. Coeffi cient of friction and soft contact lens comfort. Optom Vis Sci. 2012;88:E-abstract 125603.

Fig. 3. Representation of histology of

the lid wiper region. Vertical width of

the lid wiper region is indicated by

the red line.

Photos: Jalaiah V

arikooty, Centre for C

ontact Lens Research


2016 MEETINGS

CE CONFERENCES

*Approval pending

For faculty & more information, go to www.reviewofoptometry.com/eventscall 877-451-6514, or email [email protected]

SOUTHWEST OPTOMETRIC

GLAUCOMA SYMPOSIUM

November 19, 2016

JW Marriott Houston

5150 Westheimer Road

HOUSTON, TEXAS

Up to6 CE

Credits*

Up to 6 COPE Credits for $125! www.reviewofoptometry.com/SWOGS2016

Please call the hotel directly at 713-961-1500 and identify yourself as a participant of the Southwest Optometric Glaucoma Symposium.

Up to

12 CE

Credits*

MEETINGS CO-CHAIRS:

MURRAY FINGERET, OD ROBERT N. WEINREB, MD

8th Annual

WEST COAST OPTOMETRIC

GLAUCOMA SYMPOSIUM

December 9-10, 2016

Hilton Hotel

21100 Pacifi c Coast Hwy,

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Up to 12 COPE Credits for $275! www.reviewofoptometry.com/WCOGS2016

Please call the hotel directly at 800-822-7873 and identify yourself as a participant of the West Coast Optometric Glaucoma Symposium.

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2016_OGS_SW-WC_HouseAd.indd 12016_OGS_SW-WC_HouseAd.indd 1 9/27/16 3:37 PM9/27/16 3:37 PM


While the cor-nea and sclera are consid-ered critical points to

monitor during the contact lens fi t, the patient’s eyelid anatomy and tear fi lm are also important. Some of the fi rst lenses ever made were designed to prevent corneal exposure in a patient whose eye-lid had been partially destroyed by cancer, highlighting the importance of these parts of the ocular anatomy.1 Approximately 130 years after this fi tting, op-tometrists are still using contact lenses to manage eyelid disor-ders; as such, adequate awareness of the interaction between the contact lens and eyelids for the purpose of preventing additional problems is a skill that eye care practitioners should focus on and keep up to par.

Among other concerns, certain lid issues that can arise may lead to an increased risk of infection due to ocular adnexa dysfunc-tion such as misdirected lashes, abnormal lid anatomy, cranial nerve palsies and blepharitis. These issues and their treatments can further impede contact lens success, resulting in patient dis-comfort and possibly even drop-out from lens wear altogether. This article will primarily focus on the presentation of abnormal lid anatomy and the existing strategies for management of these scenarios.

SURGERY AS A

FIRST-LINE STRATEGY

For patients who present to the clinic with a lid malposition issue, surgery is often considered the fi rst-line treatment to correct their problem. Regardless of the condition, the primary goal of the eye care practitioner is to restore both form and function to the eyelid and relevant perioc-ular structure by addressing the cause of the problem—that is, the undesirable alteration in the patient’s lid anatomy.

Once this is done, the contact lens fi tting process following sur-gery is similar to that of fi tting a patient who has not undergone a procedure, as almost all existing lens modalities can be considered for use. However, if surgery is contraindicated, the procedure’s outcome is not optimal, or the patient simply has additional lid issues (e.g., narrow palpebral fi ssures, excessively tight lids or large lid angles), then certain contact lenses are contraindi-cated for fi tting, limiting practi-tioners to the selection of a lens from options that are considered more lid independent.2

For such patients with subopti-mal eyelid anatomy or function, scleral contact lenses are the best option, as they are generally least infl uenced by lid anatomy. In decreasing order of suitability, sclerals are followed by spherical soft lenses, multifocal and toric soft lenses and, fi nally, corneal

rigid gas permeable lenses (es-pecially translating multifocals), which rely on the wearer’s lids for positioning and movement, making them least suited for use by patients with lid issues.3

Taking into account the level of lid dependency of a lens can increase the chance of lens wear success by patients with more severe lid abnormalities or in lieu of further surgical correction. Below, lid conditions and their treatments for rectifi cation are covered.

PTOSIS

Also known as blepharoptosis, this common lid malady man-ifests from one of a variety of different causes including con-genital developmental malforma-tions, trauma, myasthenia gravis or Horner’s syndrome (Figure 1). Regardless of any underlying etiology, however, the prob-lem most often involves either insuffi cient levator contraction due to incorrect or weak muscle

Mr. Turpin, an optometry

student at Pacifi c University

College of Optometry, plans

to graduate in 2017.

Dr. Skorin practices

ophthalmology at the Mayo

Clinic Health System in

Albert Lea, MN.

ABOUT THE AUTHORS

1 CE Credit (COPE Approval

Pending)

HOW LID MALPOSITIONCAN COMPROMISE

CONTACT LENS WEAR

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insertion into the superior tarsal plate or myogenic issues like those seen in muscular dystro-phy or various nerve conduction problems.4 For example, paresis of the third cranial nerve causes severe ptosis as a result of inner-vation to the levator being lost in some fashion. Ptosis is typically graded based on an assessment of remaining levator function and treated accordingly: mild to moderate ptosis (i.e., greater than 4mm of levator function remaining), for example, is man-aged via the reattachment of the aponeurosis of the levator to the tarsal plate, or by the shortening of the levator above Whitnall’s ligament, which both serve to improve function.

Patients with complex or more severe cases of ptosis (i.e., less than or equal to 4mm of levator function), however, are treated via the insertion of a silicone rod or other suspensory material to enable frontalis suspension. Twenty-fi ve percent of severe ptosis patients who undergo this procedure also end up suffering post-surgery from some form of exposure keratopathy.5 The risk of corneal damage also increases signifi cantly if ocular motility is restricted or if orbicularis function is reduced, so addition-al measures are often taken in order to maintain the integrity of the ocular surface. These include the use of artifi cial tears or lubri-cants in mild cases to therapeutic

scleral lenses in moderate to se-vere cases.6 Increasing the thick-ness of a standard scleral lens can also help with improving the cosmetic appearance of the eye-lids and also prevent the upper lid from covering the pupillary axis; this solution can prevent restriction of the superior visual fi eld if the patient elects to forgo surgery or if the operation itself is contraindicated.7

Specialty scleral contact lenses can also be manufactured with either a shelf for the lid to rest on or props to hold it in place.7,8

However, practitioners should

keep in mind that long-term wear of scleral lenses in this scenario simply masks the lid problem rather than permanent-ly correcting it at the source: in effect, the lenses act as crutches, and so should only be used as temporary measures or if surgery has entirely been ruled out.

If the patient does undergo surgery for the lid condition and wishes to return to soft lens wear afterwards, corneal chang-es resulting from the operation should be kept in mind as these can adversely impact the success of the lens fi t. Pressure from the

Fig. 1. Ptosis of the right upper eyelid in a patient with Horner’s syndrome.

Note the miotic right pupil.

Keep these conditions in mind to prevent or rectify potential obstacles to a successful fi t.By Steven Turpin, MS, and Leonid Skorin Jr., OD, DO, MS

Release Date: October 2016Expiration Date: October 1, 2019Goal Statement: Eyelid anatomy and the tear film are important structures to consider during a contact lens fit. This article addresses abnormal lid anatomy and strategies for managing these scenarios.Faculty/Editorial Board: Steven Turpin, MS, andLeonid Skorin, Jr., OD, DO, MSCredit Statement: COPE approval for 1 hours of continuing education credit

is pending for this course. Check with your state licensing board to see if this counts toward your CE requirements for relicensure.

Joint-Sponsorship Statement: This contin uing education course is joint-sponsored by the Pennsylvania College of Optometry.

Disclosure Statement: Drs. Turpin and Skorin have no financial interest in any products mentioned in this article.



HOW LID MALPOSITION CAN COMPROMISE CONTACT LENS WEAR

uneven upper lid prior to surgery can also cause the superior cor-nea to steepen, altering corneal astigmatic power and axis.9 The superior cornea then fl attens fol-lowing the lid procedure and can infl uence both the refraction and the fi t of the lens.

The eye care practitioner should fully reevaluate all contact lens patients wishing to return to contact lens wear fol-lowing lid surgery to record any changes that might necessitate alterations in lens parameters. Note, gas permeable lens wear is not recommended for patients who have undergone ptosis sur-gery as rigid lens wear is linked to the development of ptosis itself.1

Contact lens-induced ptosis (CLIP), a variation on the previ-ous condition, is a phenomenon that has been observed since the 1980s; however, its exact pathophysiology has yet to be established. An existing hypoth-esis for its onset involves the occurrence of a forced blinking action during which the patient attempts to open their eyes wide enough to remove their con-tact lenses. In this instance, the resulting simultaneous contrac-tions of both the levator and orbicularis oculi are believed to increase traction on the levator aponeurosis, causing its de-hiscence.10 Different theories suggest that it may be the lateral pulling of the eyelid—common during lens removal—that cre-ates high amounts of lid tension followed by repeated hard blinks that then lead to the exertion of high amounts of pressure on the palpebral portion of the upper lid.11

However, regardless of the possible anatomical changes, rigid lens wear can increase a

patient’s risk of developing ptosis 17-fold.1 Those patients who do use gas permeable lenses and exhibit CLIP should cease wear for at least one month to allow for spontaneous resolution. If this does occur, refi tting the patient in soft lenses is often a viable solution, though soft lens wear also does increase the risk for ptosis development up to fi ve times more compared with non-lens wearers.1 If resolution does not occur, surgical interven-tion is indicated, with selection of the technique determined by the amount of remaining leva-tor function as detailed above. Regardless of the cause of ptosis, however, consider a different mo-dality other than gas permeable lenses for wear following resolu-tion of the issue.12

ECTROPION

Present almost exclusively in the lower lid, this condition involves the outward turning of the lid margin (Figure 2). The most common subtype of ectropion, involutional ectropion, results from tissue changes made that increase the laxity of the tarsus or canthal tendons.4 In the case of ectropion, it is also common for the inferior punctum to turn outwards, where it impedes normal tear drainage; as a result, epiphora is a frequent com-plaint among patients with this condition.

Practitioners should keep in mind that just a few simple tests can be used to assess lid laxity: one example, the snap-back test, involves asking the patient to look upwards as their lower lid is pulled down gently. Depending on the lid’s response following release, the condition can be graded as either normal (i.e., the patient’s lid returns to its origi-

nal position quickly); mild (i.e., the lid slowly returns); moderate (i.e., the lid incompletely returns on its own, requiring the patient to blink); or severe (i.e., even with blinking, the lid does not return to its original position).12

Cases of lid laxity can be local-ized to either the medial or later-al canthi or the tarsal portion of the lid, which may infl uence the selection of surgical technique for repair. In most instances of a patient with involutional ectro-pion, a simple tightening of the lateral canthus and performance of a tarsal strip procedure works to solve the problem; however, if malpositioning of the punctum is a concern, a medial spindle pro-cedure may also be necessary.13

For patients in which canthal laxity is not a problem, a pen-tagonal wedge resection of the tarsal portion of the lid is pref-erable to other procedures to fi x the issue.4 Furthermore, in the case of an uncontrolled systemic disease presenting in conjunc-tion with the lid problem (i.e., hypertension, diabetes, vascular disease or cardiac disease) that makes surgery too risky to per-form, a scleral lens can be used to prevent corneal exposure.14,15

Patients with involutional ectropion who wear either soft

Fig. 2. Severe ectropion of the left

inferior lid. Note that the inferior

punctum is also turned out.



or rigid lenses may experience discomfort prior to surgery, both from the lenses riding low and also from a decrease in tear fi lm distribution, which can lead to lens dryness. These issues are generally solved and normal lid function is restored following the appropriate surgical intervention. As mentioned earlier, changes in lid structure—both before and after surgery—signifi cantly af-fect the fi t of rigid corneal lenses; thus, they often require adjust-ments accordingly.

Corneal changes can also take place after lower lid tension is restored, as the increased pres-sure on the inferior cornea can increase the degree of with-the-rule astigmatism that a patient may have, possibly affecting the soft lens fi t or making a toric lens a more appropriate option.16

If a toric soft lens is indicated for the patient, lid procedures can help improve rotational stability by reducing the palpebral fi s-sure.2 Better lid tension has yet to be proven to make any signifi -cant difference in the case of lens stability, however.2,17

Ectropion may also result from damage done to the seventh cranial nerve, either by trauma, surgery or conditions such as

Bell’s palsy. This is subcatego-rized as paralytic ectropion and may be associated with a larger number of possible complica-tions. As such, the reduction or loss of orbicularis oculi function may require a more complex surgical intervention than in the case of involutional ectropion; additionally, induction of artifi -cial ptosis either via a botulinum toxin injection or lid weight can lessen levator activity, temporar-ily protecting the cornea from exposure.18 This way, ocular lubricants and other necessary topical medications can still be instilled as needed. In some cases, treatment may need to go as far as the performance of a tarsorrhaphy procedure (i.e., the suturing of the superior and in-ferior lids together to protect the corneal surface).4 Placement of a scleral contact lens is also once again an option in such cases.

ENTROPION

Many of the physiological changes that result in ectropi-on may also lead to entropion, which is the inward turning of the lid margin (Figure 3). The snap-back test used to assess lid function in the case of ectropion can also be useful here if entro-

pion is sus-pected: practi-tioners should simply look for the lower lid margin turn-ing in instead of outwards. Directing the patient to close their eyes tight-ly can also elic-it an entropic turning in of the lid margin. Ultimately, if

this is the diagnosis, treatments include injections of botulinum toxin made to the orbicularis oc-uli muscle for temporary relief, as the botulinum toxin breaks the involuntary muscle contrac-tion pattern characteristic of spastic entropion.12 A more per-manent solution is for the patient to undergo capsulopalpebral reattachment to the base of the tarsal plate to restore both form and function to the lower lid.

Ensuring corneal protection is imperative for patients suffering from entropion, as the inward turning of the eyelashes can cause epithelial erosion or even corneal ulceration or stromal scarring. If surgery to correct the lid problem cannot be performed promptly, a bandage soft lens can help protect the ocular sur-face. Scleral contact lenses may also help shield the cornea from insult, though they themselves can cause a pseudoentropion if fi t with an insuffi cient diameter.1

Postoperative fi tting issues in patients with resolved entropion are similar to those found in individuals who have undergone ectropion surgery because good lid tension is restored in both cases. Keratometric readings pre-operatively and postoperatively are not usually signifi cantly dif-ferent, though key changes can be found if corneal topography is performed correctly.19

KERATOCONUS AND

FLOPPY EYELID

SYNDROME

Traditionally, the standard for correction of patients with keratoconus has been the use of corneal gas permeable contact lenses. These typically provide patients with optimal vision; however, one consideration that can change the eye care prac-Fig. 3. Severe lid laxity manifesting as entropion.



HOW LID MALPOSITION CAN COMPROMISE CONTACT LENS WEAR

titioner’s treatment strategy is when a keratoconic patient has concurrent fl oppy eyelid syn-drome (FES), which is charac-terized by excessive lid elasticity, especially in the upper eyelid (Figure 4). In one study, 11 out of 60 subjects with FES also exhibited corneal changes that were characteristic of kerato-conus, while other research has found that an underlying con-nective tissue defect may link the two conditions together.20,21

Regardless, however, it can be diffi cult to fi t these patients with corneal gas permeable lenses due to the level of existing lid laxity, so other modalities like scleral, hybrid or keratoconic-specifi c soft lens designs can stand in as suitable alternatives. Such op-tions may provide these patients with good vision without the need to rely on the eyelids for proper lens positioning.

Aside from addressing a patient’s visual needs, eye care practitioners must also ensure the patient’s cornea is protect-ed at night in cases of FES. Spontaneous eversion during sleep is a problem that is com-mon among keratoconic patients

with this condition with irri-tation and damage being made to the ocular surface. It can be treated using ocular lubricants or eye shields worn while sleep-ing; should these fail, however, another option is surgical repair, during which the medial can-thopexy and lateral tarsal strip procedures are combined. This procedure can reduce lid elastic-ity while maintaining both the upper eyelid tarsus and punctal positioning.22

Though it can result in chang-es to the anterior segment,

surgery remains the best option for fi xing eyelid malposition problems. Eye care practitioners should remain aware of the changes associated with eyelid procedures and be willing to make changes in their selection of contact lenses following the procedure. They must also keep in mind that bandage soft or scleral lenses can temporari-ly protect the ocular surface. Though the peak age of occur-rence of many lid problems is long after the peak age of habit-ual contact lens wear, the fi tting principles common to normal

wearers apply to these patients as well. RCCL

1. Efron N. Eyelid ptosis. Contact Lens Compli-cat. 2012;4:47–55.2. Jin W, Jin N, Chen Y, et al. The impact of eyelid and eye contour factors on a toric soft contact lens fi tting in Chinese subjects. Eye Contact Lens. 2014;40:65–70.3. Hom MM, Bruce AS. Rigid Gas Permeable Lens Fitting. 3rd ed. St. Louis: Butterworth Heinemann Elsevier; 2006.4. Dutton JJ, Gayre GS, Proia AD. Diagnostic Atlas of Common Eyelid Diseases. Infroma Healthcare USA Inc.; 2007.5. Van Sorge AJ, Devogelaere T, Sotodeh M, et al. Exposure keratopathy following silicone frontalis suspension in adult neuro- and myo-genic ptosis. Acta Ophthalmol. 2012;90:188–92.6. Grey F, Carley F, Biswas S, Tromans C. Scleral contact lens management of bilateral exposure and neurotrophic keratopathy. Con-tact Lens Anterior Eye. 2012;35:288–91.7. Shah-Desai SD, Aslam SA, Pullum K, et al. Scleral contact lens usage in patients with complex blepharoptosis. Ophthal Plast Recon-str Surg. 2011;27:95–8.8. Lindsay RG, Ezekiel DF. Ptosis prop gas permeable scleral lens fi tting for a patient with ocular myopathy. Clin Exp Optom. 1997:123–6.9. Savino G, Battendieri R, Riso M, et al. Cor-neal topographic changes after eyelid ptosis surgery. Clin Sci. 2016;35:501–5.10. Epstein G, Putterman AM. Acquired blepha-roptosis secondary to contact-lens wear. Am J Ophthalmol. 1981;91:634–9.11. van den Bosch WA, Lemij HG. Blepharopto-sis induced by prolonged hard contact lens wear. Ophthalmology. 1992;99:1759–65.12. Skorin L. A review of entropion and its management. Contact Lens Anterior Eye. 2003;26:95–100.13. Clement CI, O’Donnell BA. Medial canthal tendon repair for moderate to severe tendon laxity. Clin Exp Ophthalmol. 2004;32:170–4.14. DeBacker C. Entropion and Ectropion Re-pair. Medscape 2015.15. van der Worp E, Bornman D, Ferreira DL, et al. Modern scleral contact lenses: A review. Contact Lens Anterior Eye. 2014;37:240–50.16. Detorakis ET, Ioannakis K, Kozobolis VP. Corneal topography in involutional ectropion of the lower eyelid: preoperative and postop-erative evaluation. Cornea. 2005;24:431–4.17. Young G, Hunt C, Covey M. Clinical evalu-ation of factors infl uencing toric soft contact lens fi t. Optom Vis Sci. 2002;79:11–9.18. Alsuhaibani AH. Facial nerve palsy: provid-ing eye comfort and cosmesis. Middle East Afr J Ophthalmol. 2010;17:142–7.19. Monga P, Gupta VP, Dhaliwal U. Clinical evaluation of changes in cornea and tear fi lm after surgery for trachomatous upper lid en-tropion. Eye (Lond). 2008;22:912–7.20. Culbertson WW, Tseng S. Corneal dis-orders in fl oppy eyelid syndrome. Cornea. 1994;13:33–42.21. Ezra DG, Beaconsfi eld M, Collin R. Floppy eyelid syndrome: stretching the limits. Surv Ophthalmol. 2010;55:35–46.22. Compton CJ, Melson AT, Clark JD, et al. Combined medial canthopexy and lateral tarsal strip for fl oppy eyelid syndrome. Am J Otolaryngol. 2016;37:240–4.

Fig. 4. Floppy eyelid syndrome increases the risk of spontaneous eversion of

the upper lid during sleep and subsequent corneal damage.



CE TEST ~ OCTOBER 2016 EXAMINATION ANSWER SHEET

How Lid Malposition Can Compromise Contact Lens Wear

Valid for credit through October 1, 2019

Online: This exam can also be taken online at www.reviewofcontactlenses.com. Upon passing the exam, you can view your results immediately. You can also view your test history at any time from the website.

Directions: Select one answer for each question in the exam and completely darken the appropriate circle. A minimum score of 70% is required to earn credit.

Mail to: Jobson Optometric CE, Canal Street Station, PO Box 488 New York, NY 10013

Payment: Remit $20 with this exam. Make check payable to Jobson Medical Information LLC.

Credit: COPE approval for 1 hour of CE credit is pending for this course.

Sponsorship: Joint-sponsored by the Pennsylvania College of Optometry

Processing: There is an eight-to-10 week processing time for this exam.

Answers to CE exam:

1. A B C D 6. A B C D

2. A B C D 7. A B C D

3. A B C D 8. A B C D

4. A B C D 9. A B C D

5. A B C D 10. A B C D

Evaluation questions (1 = Excellent, 2 = Very Good, 3 = Good, 4 = Fair, 5 = Poor)Rate the effectiveness of how well the activity: 11. Met the goal statement: 1 2 3 4 5

12. Related to your practice needs: 1 2 3 4 5

13. Will help improve patient care: 1 2 3 4 5 14. Avoided commercial bias/influence: 1 2 3 4 5

15. How do you rate the overall quality of the material? 1 2 3 4 5

16. Your knowledge of the subject increased: Greatly Somewhat Little 17. The difficulty of the course was: Complex Appropriate Basic

18. How long did it take to complete this course? _________________________

19. Comments on this course: _________________________________________

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20. Suggested topics for future CE articles: ______________________________

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Identifying information (please print clearly):

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By submitting this answer sheet, I certify that I have read the lesson in its entirety and completed the self-assessment exam personally based on the material present-ed. I have not obtained the answers to this exam by fraudulent or improper means.

Signature: ________________________________________ Date: _____________

Please retain a copy for your records. LESSON 113570, RO-RCCL-1016

1. Eyelid issues that can create ocular adnexa dysfunction and increase risk of

infection among contact lens wearers include all of the following except:

a. Misdirected lashes.b. Giant papillary conjunctivitis.c. Cranial nerve palsies.d. Blepharitis.

2. In patients with suboptimal eyelid anatomy or function, the best contact

lens option is which of the following?

a. Scleral lenses.b. Spherical soft lenses.c. Multifocal or toric soft lenses.d. Corneal rigid gas permeable lenses.

3. Which of the following surgical techniques is used to manage mild to

moderate ptosis (i.e., greater than 4mm of levator function remaining)?

a. Reattachment of the aponeurosis of the levator to the tarsal plate.b. Insertion of a silicone rod or other suspensory material to enable frontalis suspension.c. Shortening of the levator above Whitnall’s ligament.d. Both (a) and (c).

4. Rigid contact lens wear has been shown to increase a patient’s risk of

developing ptosis by what magnitude?

a. 5xb. 8xc. 17xd. 25x

5. In severe ptosis patients who undergo a frontalis suspension procedure,

what is the rate of exposure keratopathy that occurs post-surgery?

a. 7%b. 18%c. 25%d. 100%

6. Tissue changes that increase the laxity of the tarsus and/or canthal tendons

are known to result in:

a. Distichiasis.b. Involutional ectropion.c. Blepharoptosis.d. Lid wiper epitheliopathy.

7. Surgical restoration of lower lid tension to correct ectropion can cause

which of the following corneal changes?

a. Keratoconus.b. Pellucid marginal degeneration.c. With-the-rule astigmatism.d. Against-the-rule astigmatism.

8. One clinical technique that can be used to diagnose entropion is:

a. The snap-back test.b. Directing the patient to open their eyes wide.c. Retroillumination of the eyelid.d. Estimation of palpebral fissure size.

9. A poorly designed scleral contact lens can cause a pseudoentropion if the

design suffers from this flaw:

a. Excessively steep haptics.b. Insufficient diameter.c. Insufficient corneal vault.d. Central thickness >250µm.

10. In a keratoconus patient with concomitant floppy eyelid syndrome, the

corneal surface can be protected from exposure due to spontaneous lid

eversion by which of the following interventions?

a. Collagen crosslinking.b. Ocular lubricants or eye shields worn while sleeping.c. Combined medial canthopexy and lateral tarsal strip procedures. d. Both b and c.



No matter what an eye care practice focuses on, many practitioners likely fi eld questions re-

garding the potential for LASIK treatment. Patients ask for our opinions and recommendations on the procedure’s suitability for them, as many have more than likely read reports of complica-tions in the media and remain wary. So, what should we tell them? Below is a summary of some of the latest data and consensus opinions regarding questions that many of us may face during the perioperative care of a refractive surgery patient.

1POST-LASIK ECTASIA

The fi rst example is bilateral thinning of

the cornea post-procedure, or corneal ectasia, which occurs in some patients with a thin residu-al stromal bed, particularly those with high preoperative myopia, an occurrence that alters the structural integrity of the cornea. Those patients with uncommon corneal shapes pre-procedure are even more at risk of onset.

Take this example: a 31-year-old male presented to the clinic wearing monthly disposable con-tact lenses and expressed interest in LASIK. Corneal topography indicates that he has mild corneal irregularity and inferior steepen-ing. Ultimately, the practitioner suspects that his patient has mild

keratoconus, though his vision corrects to 20/20 with refraction. He exhibits 3D of myopia, 1D of astigmatism and a corneal thickness of 560µm, along with a patient history that reveals refractive stability maintenance over the past fi ve years, suggest-ing he might be a good candidate for LASIK. However, due to his irregular corneal shape, he is at risk for possibly the most con-cerning complication that can follow refractive surgery.

Most individuals who develop post-surgical ectasia suffer from structural and visual distortions, somewhat akin to keratoconus, that are not adequately con-trolled either with spectacles or contact lenses, leaving them with limited options should further adjustment be necessary. To help prevent this problem following surgery, the Ectasia Risk Score System was created to assist with the screening of high-risk patients prior to the procedure.1

The system is based on a series of post-LASIK ectasia cases from 2008, during which several risk factors for the development of the issue were identifi ed. These include:

Abnormal preoperative cor-neal topography. Moderate-to-severe keratoconus is a defi nitive contraindication for refractive surgery due to the severe insta-bility of the cornea’s structural bonds, while even milder corneal irregularities or forme fruste ker-

atoconus can increase the risk of postoperative complications.

Low residual stromal bed (RSB) thickness. Research sug-gests that a minimum of 250µm to 300µm of stromal tissue should be left intact following surgery to help ensure the patient does not develop issues after the procedure. If the RSB is thin-ner than this range, the risk of ectasia is higher.2 Expected RSB thickness can be estimated using the following rule of thumb: the femtosecond fl ap should be made approximately 100µm thick, with the laser removing roughly 15µm of stroma per diopter of myopia to be corrected. As such, the preoperative pachymetry values and the patient’s level of refractive error can be predicted to determine anticipated postop-erative corneal thickness.

Age. Though keratoconus typ-ically presents itself during ado-lescence, some cases can manifest

ABOUT THE AUTHORS

HOW WOULD YOU HANDLE THESE

Refractive Surgery Controversies?Despite the procedure’s popularity, some issues still remain.

How should you address them?

Dr. McNulty is in private

practice at the Louisville Eye

Center in Kentucky, where

he practices comprehensive

optometry with an

emphasis on the fi tting of

contact lenses for irregular

corneas, as well as optometric

laser surgery.

Dr. McWherter is a consultative

optometrist at Bennett

and Bloom Eye Centers

in Louisville, KY, and the

director of research at

the University of Pikeville–

Kentucky College of

Optometry in Pikeville, KY.

By Aaron McNulty, OD, and

Ian McWherter, OD

030_RCCL1016_LasikControversies_F5.indd 30030_RCCL1016_LasikControversies_F5.indd 30 9/29/16 5:31 PM9/29/16 5:31 PM


in adulthood as well. In younger patients with a family history of keratoconus (and thus a higher genetic predisposition towards developing the disease), a prac-titioner might consider delaying LASIK treatment until later in the patient’s life. The creators of the Ectasia Risk Score System hy-pothesized that some of the indi-viduals who ended up developing ectasia following surgery in their study sample did so at a younger age without any other recogniz-able risk factors noted, and may have eventually developed forme fruste or manifest keratoconus, even if LASIK had not been per-formed. As such, LASIK surgery runs the risk of preempting the onset of keratoconus and exacer-bating progression of the disease.

Lower amount of preoperative corneal thickness. This factor is directly related to the presence of low RSB thickness. In cases in which the patient has less total tissue and some is removed, com-plications are more likely.

Higher degree of myopia. This is related to residual stromal bed thickness in that a higher degree of stromal tissue must be removed to allow for the success-ful correction of higher levels of ametropia.

This rating system is not with-out controversy, as some sur-geons fi nd it too simplistic and limiting, especially in its admo-nition against performing LASIK in some younger patients. While imprecise, it does raise valuable points for discussion that should be individualized to each patient in your evaluation.

At fi rst look, it appears that the patient mentioned above should undoubtedly be excluded from refractive surgery due to his corneal topography fi ndings. But another shortcoming of the rat-

ing scale is its reliance on placido disc-based topography systems, which are incapable of demon-strating posterior corneal curva-ture. Today’s corneal tomogra-phy systems, however, can more accurately measure both the an-terior and posterior corneal sur-faces than earlier technologies. Recent data based on modern corneal tomography collected us-ing devices such as the Pentacam (Oculus) or Orbscan (Bausch + Lomb) also suggest that PRK (in-stead of LASIK) could be safely performed on mildly irregular cornea patients, provided that the following conditions hold true: First, the patient’s posterior corneal surface must be normal (underscoring the importance of modern tomography’s ability to image it); second, the cornea must be suffi ciently thick; third, the patient must have good pre-operative best-corrected specta-cle acuity to be considered for PRK.3

In this case, the practitioner should consider obtaining corne-

al tomography to confi rm that he exhibits a normal posterior cor-neal surface; if so, he may in fact be a better candidate for PRK than LASIK (given his mild topo-graphical irregularity). His resid-ual stromal bed thickness can be estimated at 560µm minus about 53µm of stroma (15µm x 3.5D of spherical equivalent myopia lost to ablation), for about 507µm. Since PRK might be recommend-ed for this patient over LASIK, there would be no fl ap thickness to account for, meaning more stromal tissue is left behind. As such, assuming that this patient exhibits a typically regular poste-rior corneal curvature, he may be a candidate for PRK.

The recent FDA approval of corneal crosslinking and the emerging technology of topogra-phy-guided PRK may mean that performing refractive surgery on irregular corneas will become more common. By crosslinking the collagen fi bers and strength-ening the stroma, the corneal ectatic disease process can be

This corneal topography shows minimal anterior corneal elevation and

astigmatism. However, there is a signifi cant posterior elevation, which

suggests early posterior keratoconus. The thinnest area of the cornea also

corresponds to the apex of the posterior elevation. This patient would be a

poor LASIK candidate.



slowed and possibly even halted if the procedure is performed pri-or to refractive surgery; however, further research is necessary to better quantify this effect.

Though the patient here has mild corneal irregularity, it’s worth noting that some cases of ectasia occur in eyes that were topographically regular preoper-atively. So, how do we quantify the ectasia risk in these patients? A recently proposed metric known as percent tissue altered (PTA) may help. It states that during calculation, fl ap thickness (FT) should be added to the abla-tion depth (AD), then divided by the preoperative central corneal thickness (CCT), or PTA = (FT + AD) / CCT.4 The study that gave rise to this equation determined that a PTA higher than 40% was the strongest predictive factor of ectasia risk (more so than age, RSB thickness and total Ectasia Risk Score). Because this study was done using topographically normal eyes, however, a lower threshold may be applicable in the case of mildly irregular corneas.

The risk of post-surgical ecta-sia can never be eliminated, of course, but practitioners can use

simple criteria and metrics such as these to estimate a patient’s risk and help them weigh the options. This counseling can be done in the optometrist’s offi ce as part of a preoperative surgical consultation appointment.

2SMALL PUPIL

Pupil size is another fac-tor to consider prior to

recommending LASIK. Consider the following case:

A 26-year-old female contact lens wearer with good ocular health presents for a consultation with refraction values of -5D in each eye and central corne-al thicknesses of 580µm. The practitioner also notices that the patient’s pupils are 8mm in dim illumination and questions her regarding the presence of glare or halos during contact lens wear, to which the patient responds negatively. She does, however, report some glare while wear-ing her spectacles, and wants to know whether she is a good candidate for LASIK.

Many patients who undergo refractive surgery have reported the presence of postoperative glare and halos, especially in dim illumination. Conventional wisdom tells us that pupils measuring larger than the laser treatment optical zone prior to surgery increase the risk of visual disruption after surgery. In fact, this relationship has served as fodder for many malprac-tice lawsuits—so much so that many practitioners now advise these patients against refractive surgery.

Despite this, however, other recent research has disputed the connection between pupil size and visual disturbances, possibly opening the door for a better understanding. One retrospective

study considered results from nearly 11,000 eyes of patients aged 18 to 40 who had under-gone wavefront-guided LASIK with a 6mm optical zone with mean scotopic pupil diameter be-ing 6.6mm.5 Nearly 27% of these eyes had a pupil diameter of 8mm or larger, yet at six months the researchers observed no cor-relation between pupil diameter and patient-reported outcomes such as satisfaction, presence of night glare or onset of halos.

The dissociation between pupil size and visual disruptions can possibly be explained by a number of factors. First, the typical treatment zone for LASIK increased from 4mm during the procedure’s earlier days to a more pupil-sparing diameter of 6mm today. Furthermore, some newer ablation algorithms de-liver extra pulses to the mid-pe-ripheral cornea in an attempt to decrease spherical aberration.

In this context, how then should we approach a preoper-ative discussion with a patient with larger pupils? Someone with 8mm pupils historically would have been discouraged from undergoing LASIK; nowa-days, perhaps these individuals can simply be counseled that there are confl icting reports in the literature about a higher risk for glare and halos after surgery but that it need not be a contra-indication if they are willing to accept the possibility. However, if the patient is on a systemic medication that causes mydriasis (including tricyclic antidepres-sants and anticholinergics), the risk is defi nitively higher.

In conclusion, this patient should be counseled regarding the theoretical risk and historical association between large pupils and nighttime glare and halos.

HOW WOULD YOU HANDLE THESE REFRACTIVE SURGERY CONTROVERSIES?

This corneal topography shows a

regular LASIK-naïve cornea with

average keratometry reading of

40.62D. Flat postoperative corneas

may increase the risk of aberration-

induced visual disturbances;

therefore presurgical keratometry

readings should be considered.



But she should also be notifi ed that more recent research has found no association between pupil size and visual complaints. Assuming she is otherwise a good candidate for the procedure, her pupil size should not exclude her from LASIK treatment.

3HIGH MYOPIA

Patients with higher de-grees of myopia are also

at risk for suboptimal refractive surgery outcomes. For such patients, several considerations must be accounted for preopera-tively. First and foremost, some may be at greater risk for post-LASIK ectasia, since the correc-tion of higher degrees of myopia entails the removal of more stromal tissue, leading to thin-ner postoperative corneas and higher PTA values. Though PRK is a better option than LASIK to reduce the risk of ectasia, since it results in a thicker residual stro-mal bed, PRK also increases the risk of corneal haze developing in individuals with high myopia.6

LASIK still remains the preferred treatment for high myopes de-spite these issues.

Practitioners should also pay attention to the preoperative keratometry readings of high my-opes—for each diopter reduction in spectacle myopia, the cornea

is fl attened by about 0.75D, with particu-larly excessive fl attening leading to the onset of aber-rations such as spherical aberration or coma. Though well studied in the literature, there’s no consensus on the minimum recommended postoperative keratometry measurements—proposed minimum limits range from 33D to 39D. The topic warrants greater scrutiny and consideration.

In considering, for instance, a 34-year-old lifetime specta-cle wearer who presents for a LASIK consultation, three main variables should be examined to determine her LASIK candidacy. Manifest refraction reveals 7D of myopia in each eye, central corneal thickness is 590µm and keratometry readings are 40D. Additionally, her ocular health is suitable in both eyes. However, her attending practitioner should consider the following:

Postoperative corneal thick-ness. Based on the formula above, it can be estimated that this patient’s post-op RSB thick-ness following LASIK would be: 590µm - 100µm - (15µm x 7D) = 385µm. This results in an adequate post-surgical corneal stromal bed thickness, so she would therefore qualify to under-go LASIK.

Percent tissue ablation. The PTA value for this patient can also be calculated as (100µm + 105µm) / 590µm = 34.7%. Since this result is less than the pro-posed threshold of 40%, she also meets this qualifi cation for the procedure.

THE COURT OF PUBLIC OPINION

Most debates about medical and surgical procedures remain within the professional sphere. Not so with refractive surgery. Our internal discussions and concerns have long since spilled over into the lay media, with Morris Waxler, former FDA chair of ophthalmic devices—and one of today’s most vocal critics of LASIK—speaking on the limitations of the data used as the basis for the treatment’s approval in 1998.10 His recent speeches have led to public disagreements, with his supporters on one side aligned against the FDA and various ophthalmology organizations on the other. As these feuds have been covered by popular media outlets, patients may mention them in the exam room. Regardless of which side a practitioner may stand on for any given issue, it is helpful to be aware of these ongoing conversations so that we can continue to be educators and advocates for all patients who enter the clinic.

This patient demonstrates marked punctate epithelial

staining associated with dry eye syndrome. Aggressive

treatment would be indicated before considering LASIK.



Postoperative keratometry reading. Keeping in mind that 0.75D of corneal fl attening oc-curs per diopter of myopia, her postop K can be calculated to be 40D - (7D x 0.75) = 34.75D. The estimated postsurgical corneal steepness of just under 35D in this patient is within the gray area between acceptable and inadvisable. Counseling this patient that she is a fair candi-date to consider LASIK is war-ranted; however, she should also be made aware of the potential aberration-induced visual distur-bances stemming from her fl at-tened postsurgical corneal shape.

4HYPEROPIC

REGRESSION

Though refractive sur-gery is most commonly used to treat myopia, it is also effective in managing hyperopia; however, patients who underwent PRK may be at risk for hyperopic regression for six months to one year after the procedure.

Consider a 35-year-old male with 3D of hyperopia in each eye who was referred for PRK. Though initially satisfi ed with the results, four months follow-ing the procedure he began to complain of diffi culty viewing computer screens. The attend-ing practitioner found 1.5D of refractive hyperopia present, and the patient requested a surgical enhancement.

A recent study of retreatment to manage hyperopic regres-sion following LASIK or PRK in hyperopic astigmatic eyes found signifi cantly higher levels of hyperopic regression present at six months post-op in eyes treated with PRK vs. LASIK.7

The researchers’ recommenda-tion was to wait at least six to 12 months after the procedure

before considering treatment of hyperopic regression in eyes that had initially undergone PRK.7

So, while LASIK has demon-strated good refractive stability in hyperopic eyes, performance of PRK in hyperopic eyes may raise the potential for hyperopic regression for six months to one year postoperatively. Patients who experience this, including the one mentioned here, should wait until stability is demonstrat-ed so that enhancement efforts can be adequately tailored.

5POST-LASIK

DRY EYE

A 23-year-old female presented to the clinic wear-ing disposable contact lenses and complained of end-of-day dryness while wearing her lenses. She commented that it would be great if she could eliminate the need for contact lens wear with a LASIK procedure. Ocular examination revealed moderate dry eye syndrome and meibo-mian gland dysfunction; as such, though she is an otherwise ex-cellent candidate for LASIK, the ocular surface disease should be treated prior to surgery.

Several studies cite dry eye syndrome as the most common postoperative complication in re-fractive surgery patients, possibly due to disruption of the feedback loop between the cornea and the lacrimal glands during surgery.8,9

For instance, corneal nerves can be severed by the fl ap creation in a LASIK procedure, reducing the capacity for refl ex tearing. Patients who have collagen vas-cular disease may be at a partic-ularly high risk for development of denervation and subsequent dry eye; as such, aggressive treat-ment of even mild cases of dry eye is recommended. This can be

done by the referring optometrist prior to surgery to help the OD and MD alike in counseling the patient about their suitability for surgery.

Since LASIK’s approval by the FDA nearly 20 years ago, the

procedure has improved by leaps and bounds. Today, the rate of postoperative complications is lower than ever. Nevertheless, it remains important for optom-etrists to be aware of current controversies in care and recent advances in pre- and perioper-ative care of refractive surgery patients. Such clinical know-how will enable a more effective con-sultation of patients who may be entertaining the idea of undergo-ing refractive surgery. RCCL

1. Randleman JB, Woodward M, Lynn MJ, Stulting RD. Risk assessment for ectasia after corneal refractive surgery. Ophthalmology. 2008;115:37–50. 2. Santhiago MR, Giacomin NT, Smadja D, Bechara SJ. Ectasia risk factors in refractive sur-gery. Clin Ophthalmol. 2016 Apr 20;10:713-20.3. Alpins N, Stamatelatos G. Customized photoastigmatic refractive keratectomy using combined topographic and refractive data for myopia and astigmatism in eyes with forme fruste and mild keratoconus. J Cataract Refract Surg. 2007;33(4):591 602.4. Santhiago MR, Smadja D, Gomes BF, Mello GR, Monteiro ML, Wilson SE, Randleman JB. Association between the percent tissue altered and post-laser in situ keratomileusis ectasia in eyes with normal preoperative topography. Am J Ophthalmol. 2014 Jul;158(1):87-95.5. Schallhorn S, Brown M, Venter J, et al. The role of the mesopic pupil on patient-reported outcomes in young patients With myopia 1 month after wavefront-guided LASIK. J Refract Surg. 2014;30: 159-165. 6. Pietilä J, Mäkinen P, Pajari T, et al. Eight-year follow-up of photorefractive keratectomy for myopia. J Refract Surg. 2004;20:110-5.7. Frings A, Richard G, Steinberg J, et al. LASIK and PRK in hyperopic astigmatic eyes: is early retreatment advisable? Clin Ophthalmol. 2016 Mar 31;10:565-70. 8. Golas L, Manche EE. Dry eye after laser in situ keratomileusis with femtosecond laser and mechanical keratome. J Cataract Refract Surg. 2011 Aug;37(8):1476-80. 9. Shoja MR, Besharati MR. Dry eye after LASIK for myopia: Incidence and risk factors. Eur J Ophthalmol. 2007 Jan-Feb;17(1):1-6. 10. LASIK Newswire. FDAer Who OK’s LASIK Petitions for Revocation. Available at www.lasiknewswire.com/2011/01/fdaer-who-okd-lasik-petitions-for-revocation.html. Accessed July 18, 2016.

HOW WOULD YOU HANDLE THESE REFRACTIVE SURGERY CONTROVERSIES?


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By Robert Ensley, OD, and Heidi Miller, OD

The GP Experts

When deciding which contact lens modality is the best for a patient, contact

lens specialists always consider curvature of the cornea, contact lens diameter and ocular surface conditions; however, the eyelids are often easily forgotten. The lids are taken into account when evaluating for blepharitis or meibomian gland dysfunction, but they may be an afterthought during a contact lens evaluation. When fi tting GP lens-es—whether corneal, intralimbal or scleral—it is important to evaluate lid position in relation to the cornea. The eyelids play a vital role in how a lens will fi t and what options will be possible when troubleshooting a problem lens fi t or potential design.

POSITIONING CORNEAL GPs

In our approach to fi tting corneal GP lenses, practitioners tend to provide an apical alignment fi t with slight upper lid attachment. In cases where a patient may have extremely taut lids, this may cause the lens to ride higher than average and result in corneal molding due to the pres-sure provided by the superior lid. Modifi cations in overall diameter or base curve of the lens may be neces-sary to bypass these issues. On the contrary, patients with dermatocha-lasis may have the opposite problem in that the lens sits low or decenters due to the narrowed palpebral aperture and reduced elasticity of the skin.1 In these patients, it may be necessary to consider a scleral instead, to prop the lid up and pro-vide better overall centration.

In presbyopic patients, inferior

lid position is important for proper orientation and lens movement. The lid position is also crucial in determining whether an aspheric, concentric or translating design will be successful for the patient. When considering an aspheric lens, the best candidates are those with lower lid margins well above or below the limbus, loose lids that will not support prism ballast or those with steep corneal curvatures.2 As with any multifocal, centration and minimal movement is critical for providing optimal vision with less aberrations at all distances. Good candidates for a concentric or trans-lating design are those with a lower lid margin tangent to or slightly above the lower limbus, a normal-to-large vertical fi ssure width and normal-to-tight lid tension.2 Loose lids will not do well with these lenses, as they limit translation of the lens, preventing the patient from seeing through the full reading add.

LIDS AND SCLERALS

Eyelids also play a role in the way a scleral contact lens fi ts on an eye. Naturally, scleral lenses have a tendency to decenter inferiorly. This can be exacerbated by having tight-er lids or a narrow palpebral aper-ture (Figure 1). When fi tting scleral lenses, hypoxia and corneal edema are two complications practitioners need to watch for closely. A decen-tered lens results in asymmetrical clearance throughout the lens, with the greatest amount of clearance inferiorly (Figure 2). This can lead to a decrease in oxygen permeabil-ity inferiorly, making hypoxia and corneal edema more of a concern.

Even after exhausting trouble-

shooting options such as incorporat-ing toric peripheral landing curves, decreasing overall clearance or decreasing the overall contact lens diameter, sometimes the lens will continue to sit lower than normal because of lid positioning. In situa-tions such as this, practitioners may have to leave the fi t as is, as long as adequate central corneal and limbal clearance is provided. It is import-ant to minimize lens thickness and use the highest Dk lens materials to allow better oxygen transmissibility. It is also crucial to provide closer follow-up care and thorough patient education on symptoms that could indicate hypoxic conditions.

Fitting front surface toric lenses

While always important to lens wear, the eyelids also play a vital role in GP lens success.

Don’t Forget to Check the Lids

Fig. 1. The natural tendency of a

scleral lens to decenter inferiorly

can be exacerbated in patients with

tighter lids or a narrow palpebral

aperture.

Fig. 2. A decentered lens results in

asymmetrical clearance, with the

greatest amount noted inferiorly.

036_RCCL1016_GPE.indd 36036_RCCL1016_GPE.indd 36 9/29/16 6:38 PM9/29/16 6:38 PM


is another instance in which the eyelids can affect a scleral lens fi t. If an overrefraction indicates the need for astigmatic correction, a front surface toric may be needed. To stabilize the lens on the eyes, double slab-off ballasting stabilization can minimize rotation. Unfortunately, eyelids can have an effect on lens ro-tation, making it diffi cult to achieve stabilized vision.3

According to one expert, front toric against-the-rule cylinders will naturally align on axis in eyes that have eyelid margins that oppose each other in the vertical meridian due to the thin zones at 6 and 12. If the eyelids oppose more obliquely, the lens will rotate obliquely.3 This is important when the lens contin-ues to rotate out of position despite toric peripheral landing curves and good centration of the lens.

There are several ways eyelids can affect lens position and fi t. However, it is important to keep in mind the changes gas permeable lenses can have on the eyelids with prolonged lens wear. Research re-ports non-senile blepharoptosis, or drooping of the upper lid, as a com-plication of long-term contact lens wear.4 Ptosis results from dysfunc-tion of either the levator palpebrae superioris or Müller’s muscle, which are responsible for elevation of the eyelids.

Etiologies for ptosis include neurogenic, myogenic, mechanical and aponeurogenic mechanisms. The most common acquired form is aponeurotic, in which disinsertion or dehiscence of the levator aponeu-rosis leads to ptosis.4,5 This form is often associated with age, ocular surgery and contact lens wear.

Patients typically present with mild to moderate ptosis of one or both eyes, good levator function and elevated lid crease.6

There are two main theories for the mechanism behind contact lens–induced ptosis. The fi rst involves the manipulation of the upper eyelid during contact lens removal. The pulling of the eyelid laterally fol-lowed by a harsh blink can lead to thinning of the levator aponeurosis.6 Research shows eyelid irritation and edema from constant interaction with the contact lens edge can lead to a reversible ptosis.7

Figure 3 demonstrates a patient who has worn gas permeable con-tact lenses for over 20 years. Her history consisted of mild keratoco-nus in the right eye and prior radial keratometry surgery in the left.

She has worn lenses that were two different sizes to allow for bet-ter centration and overall alignment on the cornea. As evident in Figure 3, the degree of blepharoptosis is different between the two eyes, with the left eye having a greater degree.

Lid manipulation during insertion and removal along with the amount of lid interaction with the lens could cause the asymmetrical blepharo-ptosis noted.

Ranges vary per study, but pro-longed GP contact lens wear is

the only identifi able cause of ptosis in up to 47% of patients under the age of 50.6,8 Studies also suggested there is an increased risk of blepha-roptosis in soft contact lens wearers compared with non-wearers.9 While the percentage may seem high, the average duration of contact lens wear was 15 years, and not all pa-tients are symptomatic.8 Unless the superior visual fi eld is obstructed, surgical intervention is not typically warranted. RCCL

1. Benjamin WJ, Borish IM. Physiology of aging and its infl uence on the contact lens prescription. J Am Optom Assoc. 1991;62(10):743-753.2. Bennett ES, Weissman BA. Clinical contact lens practice. Philadelphia: Lippincott; 1991.3. van der Worp E SS. A Guide to Scleral Lens Fitting: College of Optometry, Pacifi c University. 2010.4. Friedman NJ, Pineda R. The Massachusetts Eye and Ear Infi rmary Illustrated Manual of Ophthal-mology. 3rd ed. Philadelphia: Elsevier; 2009.5. Watanabe A, Araki B, Noso K, et al. Histopa-thology of blepharoptosis induced by prolonged hard contact lens wear. Am J Ophthalmol. 2006;141(6):1092-6.6. Thean JH, McNab AA. Blepharoptosis in RGP and PMMA hard contact lens wearers. Clin Exp Optom. 2004;87(1):11-4.7. Jupiter D, Karesh J. Ptosis associated with PMMA/rigid gas permeable contact lens wear. CLAO J. 1999;25(3):159-62.8. Kersten RC, de Conciliis C, Kulwin DR. Acquired ptosis in the young and middle-aged adult popu-lation. Ophthalmology. 1995;102(6):924-8.9. Kitazawa T. Hard contact lens wear and the risk of acquired blepharoptosis: a case-control study. Eplasty. 2013;13:e30.

Fig. 3. A long-time GP lens wearer with bilateral blepharoptosis of unequal

magnitude (greater OS vs. OD). Lid manipulation during lens insertion and

removal can contribute to the development of blepharoptosis.

036_RCCL1016_GPE.indd 37036_RCCL1016_GPE.indd 37 9/29/16 6:38 PM9/29/16 6:38 PM

By Gary Gerber, OD

Out of the Box


Brand Yourself, and They Will ComeThis requires work, but is much more valuable to the growth and sustainability of your practice than just about anything else.

A Coca-Cola execu-tive was famously quoted as saying, “If Coca-Cola were to lose all of its pro-

duction-related assets in a disaster, the company would survive. By contrast, if all consumers were to have a sudden lapse of memory and forget everything related to Coca-Cola, the company would go out of business.”

MIND OVER MATTER

How would your practice fare in a similar situation? Which would hurt your business more—a physi-cal disaster of your equipment and inventory or wiping out your pa-tients’ and community’s perception of your brand? How strong is your brand and your brand awareness? Do people really emotionally con-nect with who you are and what you do?

If you think loss of your physical assets would be more devastating than mass memory loss, you’ve got work to do—a lot. While it’s certain-ly not easy to physically rebuild a practice, in the fi nal analysis, as the saying goes, it really is “just stuff.”

Your brand, on other hand, is so much more. It’s who you are or,

more importantly, what patients believe and expect you to be. If that is destroyed, no frame displays, new contact lenses or ultramodern piece of technology can replace it.

It takes work to continually sup-port and protect your brand. This isn’t about reputation management. A strong brand can manage that for you. If you get a bum new iPhone, you expect it to be replaced with no hassle. If it isn’t, and you write a bad review about it, Apple’s existing strong brand will negate your review. You’ll be seen as a whiner, complainer and outlier. Brand management goes beyond getting good Yelp reviews.

MAKE YOUR PRACTICE

MATCH YOUR BRAND

To protect and build your brand, you must clearly articulate what it is—a diffi cult task that often requires professional help.

To start, fi rst think in terms of what you want patients to feel after doing business with you. Or, what do you want a current patient to relay to others about their experi-ence with your practice? Consider these examples of patient reactions: “There were eight other patients in the offi ce. I counted. Yet, I received

undivided attention. I genuinely felt like they cared about me.” Alternatively, it could be, “I felt like they were more concerned about making sure the boxes on the insurance form were all fi lled out than they did about my eyes.” Or, “They just cared about selling me glasses—the ones they wanted to sell me, not ones that I wanted.” These scenarios can help initiate the evolution of your brand.

STAY TRUE TO YOUR BRAND

Take some of the positive attri-butes above and start to build your brand around them. For example: if undivided attention is a key part of your brand message, challenge your staff with the question, “How will you handle a situation where you’re on the phone with one pa-tient, two others are on hold, one patient is waiting at the front desk to pay his bill and a new patient walks in 20 minutes early for her appointment? How can all of those patients experience undivided attention?”

Such situations might lead to responses like, “We have to ensure we have enough staff so that never happens.” If it turns out that really is the best solution, and you are go-ing to be true to your brand, then you must hire more staff. After all, you are either about providing un-divided attention—to every patient every time—or you’re not. Create a sincere brand and practice loyal-ty to it; and, if you have a minor disaster—your topographer keeps shutting off between imaging the right and left eye, for instance— your patients will be forgiving. RCCL

DO PEOPLE REALLY EMOTIONALLY CONNECT WITH WHO YOU ARE AND WHAT

YOU DO?

038_RCCL1016_OTB.indd 38038_RCCL1016_OTB.indd 38 9/29/16 4:17 PM9/29/16 4:17 PM

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