RCCL

REVIEW OF CORNEA
APRIL 2015

& CONTACT LENSES

SPECIAL ISSUE
CONTACT LENS
COMPLICATIONS
Expert advice on diagnosing, treating
and—most of all—preventing problems.
• Bringing Clarity to CLARE

• Is That Corneal Infiltrate Sterile

!
or Infectious? EARN 1 CE CREDIT

• Special Care Keeps

Specialty Lens Wearers Safe

• Five Steps to Increase

Contact Lens Adherence
SAFETY
• Anti-VEGF for Corneal
STRATEGIES
Neovascularization

• Troubleshooting GP Lens Complications

ALSO
• Dry Eye: See It Through Their Eyes
Supplement to

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 contents
Review of Cornea & Contact Lenses | April 2015

departments features

12
Dry Eye:
4 News Review
See It Through Their Eyes
Sclerals May Affect Corneal Nerves; Patient questionnaires quantify the subjective
Age and Astigmatic VA: No Link experience of the disease. Though vital
for research, are they worth using in your
practice?
6 My Perspective By Aliza Martin, Associate Editor
Getting Serious About OSD
By Joseph P. Shovlin, OD

16
Bringing Clarity to CLARE
7 Lens Care Insights Understanding and knowing how to treat
this common contact lens complication can
The Great Silicone Cover-Up
benefit both your patients and your practice.
By Christine W. Sindt, OD
By Lindsay A. Sicks, OD

8 Derail Dropouts
Five Steps to Increase
Contact Lens Adherence

20
Special Care Keeps
By Mile Brujic, OD, and Specialty Lens Wearers Safe
Jason R. Miller, OD, MBA
Contact lens care is a vital step to the
10 Pharma Science & Practice continued safety and health of the contact lens
patient. So how does lens care differ in the
Anti-VEGF in the Anterior Segment case of sclerals and other specialty lenses?
By Elyse L. Chaglasian, OD, By Susan J. Gromacki, OD, MS
and Tammy P. Than, OD, MS

30 GP Expert
Troubleshooting GP Complications

24
By Stephanie L. Woo, OD

32 Corneal Consult
Managing Acute Corneal Hydrops
in Keratoconus
By James Thimons, OD
CE — Is that Corneal Infiltrate
Sterile or Infectious?
34 Out of the Box
Differentiating between the two requires close observation
Are You a Mentalist? and analysis. Here’s a results-oriented approach.
By Gary Gerber, OD By Jeffrey Sonsino, OD, and Shachar Tauber, MD

Cover design by Matt Egger

©iStock.com/Jobsonhealthcare

/ReviewofCorneaAndContactLenses #rcclmag
REVIEW OF CORNEA & CONTACT LENSES | APRIL 2015 3

003_RCCL0415_TOC.indd 3 3/27/15 3:40 PM

 News Review
Sclerals May Affect Corneal Nerves
E
xtended wear of fluid-filled
scleral contact lenses may
change corneal nerve func-
tion in patients with certain diseas-
es, according to research published
in the April 2015 Cornea.1
Researchers measured tear pro-
duction, central corneal sensation,
sub-basal nerve density and tortu-
osity, and stromal nerve thickness
of 20 patients from the Prosthetic
Replacement of the Ocular Surface
Ecosystem (PROSE) treatment
program. Patients were divided
into two groups—distorted cor-
neas (DC) or ocular surface disease
(OSD)—and evaluated before and
after 60 days of wear for a mini-
mum of eight hours per day.
Researchers found basal tear
production significantly decreased
and corneal sensation increased
in patients with DC following
long-term wear of the PROSE
prosthetic device. In contrast, tear
Age and Astigmatic VA: No Link
A
ge has no significant influ-
ence on visual acuity in the
presence of defocus and
astigmatic blur, reports a study
published in the March 2015 Op-
tometry and Vision Science.1
Researchers dilated the right
eyes of 22 participants—12 young
adults and 10 older adults—using
cyclopentolate 1.0%, then pro-
vided each with artificial pupils
mounted on the back of a trial
lens. To evaluate visual acuity,
researchers simulated 13 blur
conditions using five spherical lens
conditions and two cross-spherical
lenses at four negative cylinder
axes. In each instance, partici-
pants were asked to read lines of
decreasing size of high-contrast
letters based on the Bailey-Lovie
4 REVIEW OF CORNEA & CONTACT LENSES | APRIL 2015
004_rccl0415_news.indd 4
production and corneal sensation
did not change in patients with
OSD. This difference, the research-
ers say, may be because patients
with DC have a healthier ocular
surface; thus, the intact lacrimal
functional unit (LFU) “responds
to the constant saline exposure by
reducing the basal tear production
and increasing corneal sensa-
tion, which are possible signs of
improvement in corneal disease.”
In contrast, “patients with OSD
did not have similar alterations in
LFU function possibly because of
ongoing inflammatory processes
disrupting the LFU.”
No significant change in sub-
basal nerve density and tortuosity
or stromal nerve thickness was
observed in either patient group.
1. Wang Y, Kornberg DL, St. Clair RM, et al. Cor-
neal nerve structure and function after long-
term wear of fluid-filled scleral lens. Cornea.
2015 April;34(4):427-32.
chart through the center of the
artificial pupil. Following visual
acuity measurements, aberrations
were also measured.
Researchers found no significant
differences in visual acuity be-
tween the two age groups, dis-
proving their hypothesis regarding
the older group experiencing less
decrease in visual acuity with blur;
accordingly, they reported no need
to test their second hypothesis that
variations between the two age
groups is explained by differences
in higher-order aberrations. How-
ever, they suggested further study
with more participants may yield a
different outcome.
1. Mathur A, Suheimat M, Atchison DA. Pilot
Study: Effect of Age on Visual Acuity with
Defocus and Astigmatism. Optom Vis Sci. 2015
Mar;92(3):267-71.
IN BRIEF
• Corneal crosslinking may acceler-
ate epithelialization and reduce length
and severity of necessary treatment in
moderate bacterial keratitis, according
to a study in the April 2015 Cornea.1
Researchers separated 32 bacterial
keratitis patients into two groups. The
control group was treated using stan-
dard medical therapy (i.e., lubrication,
fortified cefazolin (50mg/mL) every
hour, and systemic doxycycline every 12
hours following loading doses of forti-
fied cefazolin and gentamicin) and the
case group was treated with CXL and
standard medical therapy. No statisti-
cally significant difference was noted
between the two groups one day fol-
lowing treatment, but researchers noted
the epithelial defects and the area of
infiltrates were both smaller in the CXL
group compared to the control group
by day seven following the beginning of
treatment.
1. Bamdad S, Makelhosseini H, Khosravi A. Ultravio-
let A/Riboflavin Collagen Crosslinking for Treat-
ment of Moderate Bacterial Corneal Ulcers. Cornea.
2015 Apr;34(4):402-6.
• Tobramycin can help prevent second-
ary corneal infections in patients wear-
ing therapeutic soft contact lenses, says
new research published in the March
2015 Eye & Contact Lens.1
Researchers cultured 40 therapeutic
soft lenses of patients being treated for
recurrent corneal erosion following a
two-week wearing period. During wear
time, patients were treated four times
per day with topical tobramycin 3% and
topical sodium hyaluronate 0.1%. Upon
culturing, however, nine of the 40 lenses
yielded positive cultures, with Staphy-
lococcus epidermidis identified as the
predominant organism. Methicillin-sen-
sitive coagulase-negative staphylococci,
methicillin-resistant coagulase-negative
staphylococci, Enterobacter gergoviae
and Citrobacter freundii were also
isolated. No clinical signs of infectious
keratitis were found.
1. Park YM, Kwon HJ, Lee JS. Microbiological
Study of Therapeutic Soft Contact Lenses Used in
the Treatment of Recurrent Corneal Erosion Syn-
drome. Eye Contact Lens. 2015 Mar;41(2):84-6.
Advertiser Index
Bausch + Lomb .................... Page 5
CooperVision ......Cover 2, Cover 3
Menicon .............................. Cover 4
3/27/15 4:01 PM
 Advertorial

Bausch + Lomb ULTRA® Contact Lenses

with MoistureSeal® Technology
A real no-brainer for my patients and my practice
by Dean Nolan
OD Private Practice
Lawton, Oklahoma
n my own practice my goal is to provide contact lens patients with the lens that is best for them.
I These days, that means finding a lens that not only offers the best comfort and performance, but also
offers excellent value. In a relatively short time, the recently launched Bausch + Lomb ULTRA® contact
lens has become my “go to” lens in the monthly replacement category.
For many of my patients there’s a kind of “Ah hah” moment on
lens insertion; they find that with Bausch + Lomb ULTRA® contact
lenses they truly don’t feel the lens on their eye. When it comes to
lens selection, I encourage patients not to decide too quickly but
instead to take a couple of days in making up their minds. What
I’m finding is that even patients who have been refit in the last year
or so and are very happy with their current lens typically voice a
desire to go with the Bausch + Lomb ULTRA® contact lenses once
they’ve tried them.
I take time to explain to patients what’s behind the exceptional
comfort and performance that Bausch + Lomb ULTRA® contact
lenses offer, starting with oxygen transmissibility. I explain to patients
that the cornea needs oxygen to stay healthy, particularly for the
long wearing cycles and sustained visual demands of today’s digital
device users. With a Dk/t of 163, the Bausch + Lomb ULTRA®
contact lens has the highest oxygen transmissibility among the
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a low modulus, running counter to the long-held presumption that
are not the absolute best they have ever worn. It’s been over seven
years since we have really had anything new to offer our patients in
monthly replacement contact lenses, so I find it very exciting to be
able to recommend an innovative, best in class lens that represents
a great value.
An important note: the level of innovation Bausch + Lomb ULTRA®
contact lenses bring to the monthly replacement category does not
come with an inherently expensive price tag: they are very affordable
to the patient. Beyond that, a $60 rebate is offered to patients who
order a 4-box annual supply of lenses; in effect, they get the last box
for free, effectively reducing the price per box—pretty exciting for
such a lens.
Comparison chart showing physical properties among leading
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BRAND Dk/t MODULUS WATER ASPHERIC
CONTENT OPTICS

an increase in Dk/t also meant an increase in modulus. In fact, the

Bausch + Lomb ULTRA® contact lens also has the lowest modulus Bausch + Lomb ULTRA®
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163 70 46%
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ACUVUE OASYS 147 73 38%
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Dean Nolan, OD has practiced in his hometown of Lawton, Oklahoma
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College of Optometry in Tahlequah, and is a proud member of the
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 My Perspective
By Joseph P. Shovlin, OD
Getting Serious About OSD
We have made huge strides in understanding dry eye disease, with more on the way.
H
ave you noticed the
new catch phrase,
“wellness of the
ocular surface”? It
heralds a change in
thinking that emphasizes routine
screening and maintenance in all
patients. Indeed, the most impor-
tant part of an initial diagnostic
exam for lens wearers is an accurate
assessment of the ocular surface, as
many contact lens-related problems
can be blamed on an unstable tear
film, lid disease or overall poor
ocular surface health.
Fortunately, we’re now armed
with ways to assess and treat ocular
wellness. When I started in practice
three decades ago, artificial tears
were the mainstay of ocular surface
treatment, and sometimes the only
option for combating an issue. Our
inability to accurately diagnose the
problem was also a major impedi-
ment—for example, until recently
dry eye was mostly attributed solely
to aqueous deficiency. Now, how-
ever, we know that’s not the case.
Dry eye is a complex disease with
many interactions and cascades.
In the last four decades, research-
ers like James McCulley, MD, and
others have refined a classification
scheme based on research data. For
example, his work on lid disease
has led to the reclassification of pos-
terior blepharitis into three broad
categories: hypersecretory MGD
(also called meibomian seborrhea),
hyposecretory MGD (either pri-
mary or obstructive) and turbid hy-
persecretory MGD. Other research
has revealed as many as 50% of all
patients with blepharitis co-present
with dry eye, likely because the
detergent effect on the lipid layer
6 REVIEW OF CORNEA & CONTACT LENSES | APRIL 2015
006_RCCL0415_MP.indd 6
alters epithelial cell membranes,
leading to cell death and inflamma-
tion—a possible contribution to an
aqueous-deficient dry eye.
POINT OF CARE OPTIONS
New in-office testing options have
also changed how we handle this
broad disease category by reducing
diagnosis time, improving patient
education and acting as a metric to
assess treatment effectiveness. In
addition to TearLab’s osmolarity
test, newer procedures include the
following:
• InflammaDry (RPS) provides
an assay of the proteolytic enzyme
matrix metalloproteinase 9 (MMP-
9). A marker for inflammation,
MMP-9 is a measure of epithelial
cell stress and is complementary to
measuring tear osmolarity; its real
value, however, is in identifying risk
and treatable problems that respond
to steroid and immunomodulator
therapy. We know that if the test is
negative for MMP-9, the patient’s
issue is not dry eye-related. The
opposite, however, is not true: a
positive response (i.e., >40ng/mL)
doesn’t serve as confirmation of dry
eye disease since there are many dif-
ferent conditions with an elevated
MMP-9 value.
• The TearScan MicroAssay of-
fers two diagnostic tests: one detects
tear film lactoferrin content to
assess lacrimal gland function and
the other quantifies IgE to gauge
the allergic component of ocular in-
flammation. It has a relatively good
sensitivity in detecting an aqueous-
deficient dry eye.
• One in 10 dry eye patients have
Sjögren’s syndrome. Unfortunately,
detection of conventional or tra-
ditional biomarkers for SS-A (Ro)
and SS-B (La) is only about 70%
sensitive in confirming a diagnosis.
Early diagnosis of Sjögren’s is criti-
cal, as its morbidity is troubling and
its link to lymphoma—including
non-Hodgkins lymphoma—is well
established. Now, other novel bio-
markers such as salivary protein-1,
carbonic anhydrase-6, and parotid
secretory protein, instead offer ex-
tremely sensitive measures of early
Sjögren’s. They can be identified
using the Sjö test from Nicox.
Ongoing R&D involving secreta-
gogues, IL-1 blocking anti-inflam-
matories, LFA-1 antagonists, selec-
tive glucocorticoid receptor agonists
and even androgen modulation
promise more treatment break-
throughs coming down the pike.
In the face of all these new devel-
opments, however, let us not forget
that decades ago our knowledge
and techniques, while crude, still
helped our patients achieve some
symptomatic relief. Assessing the
tear film, looking for debris and
meniscus height, staining the cornea
and conjunctiva and looking for lid
pathology helped shape our diag-
nostic decisions and treatment plans
then, and still have relevance today.
In closing, thank you to our
pioneers for paving the way and
asking the right questions that led
to the products we have today. I’m
certain anyone looking back de-
cades from now will be as equally
amazed at the progress made
combating ocular surface disease,
particularly dry eye disease. We
look forward to the future work
that helps assess the “vital signs” of
ocular wellness that’s sure to come.
Stay tuned! RCCL
3/27/15 3:40 PM
 Lens Care Insights
By Christine W. Sindt, OD

The Great Silicone Cover Up

A new lens surfacing option improves wettability and lubricity. How does it work?

I
t can be argued that the most
frustrating aspect of contact
lens practice isn’t determin-
ing the fit or the power, but
rather dealing with a non-
wetting lens—it decreases clarity
and comfort and affects a patient’s
overall lens wearing experience.
Silicone-based materials are inher-
ently hydrophobic, so any exposed
silicone in a lens has the potential
to be non-wetting. Additionally, in
some patients, excessive lipids in
the tear film may deposit onto the
lens to create a foggy, hydrophobic
surface. This issue can be reduced
by dispensing low-silicone-content
contact lenses; however, such lenses
also impede oxygen transmission,
increasing the chance for corneal
complications. Other solutions in-
clude switching lid hygiene regimens
and the most common method,
treating the lens with plasma.
THE 4th STATE OF MATTER
Plasma—ionized gas with an approxi-
mately equal number of positively
and negatively charged particles—is
neither completely a gas nor a liquid
but has properties similar to both.
It’s created by forming a vacuum in a
A NEWCOMER
Hydra-PEG (Ocu-
lar Dynamics) is a
polyethylene glycol
(PEG)-based poly-
mer mixture that is
covalently (perma-
nently) bonded to
the surface of the Before (left) and after (right) Hydra-PEG treatment.
contact lens, ef-
fectively creating a wetting surface
on the underlying lens material and
separating it from the ocular surface
and tear film. PEG has been used in
ocular lubricants for decades and
is known to improve lens surface
wettability, which improves tear
breakup time, increases lubricity
and reduces protein and lipid depo-
sition. Hydra-PEG can be applied
to hydrogel, silicone hydrogel or GP compatibility.
lenses.
During application, the first step
of lens surface preparation is either
the addition of a functional activa-
tor to the monomer mix or a short
plasma surface treatment. Once
active, the lenses are then soaked
in the Hydra-PEG polymers during
the extraction/hydration step, or the another useful option in most con-
Hydra-PEG polymers are added to
comfort in patients suffering from
contact lens-induced dry eye.8
Note: although it is a permanent
coating, Hydra-PEG has only been
tested out to three months of simu-
lated rubbing/cleaning cycles. Ocu-
lar Dynamics currently recommends
hydrogen peroxide-based cleaners,
but reports it is also in the process
of testing multipurpose solutions for
Thus far, my clinic experience
with this product has been positive:
I have found it creates a wettable,
clear and comfortable surface, even
in the most challenging of condi-
tions, such as lagophthalmos and
significant ocular surface disease. I
anticipate Hydra-PEG will provide
tact lens practices. RCCL

reaction chamber, then refilling with a
low-pressure gas such as oxygen.1
During contact lens treatment,
high-energy oxygen plasma bombards
the lens surface, transferring energy
from the plasma to it. This also cleans
and oxidizes the surface by creating
reactive species (i.e., free radicals, ions,
electrons, short-wavelength photons
and unstable oxygen species) that
react with water, altering the lens
surface to a hydrophilic state. This
effect occurs to depths of several hun-
dred angstroms to 10µm without any
change to the bulk properties of the
lens material. Note that while plasma
treatment is superior to other options,
the hydrophilic result may last for only
a few minutes to several months.1
the blister pack during the autoclave
1. William Hoffman. Personal communication.
process.2 In either case, once the 2008.
active lens is placed in the PEG poly- 2. Ocular Dynamics. Hydra-PEG Manufac-
turing. Available at: www.oculardynamics.
mers, the Hydra-PEG permanently com/#!manufacturing/c11sc. Accessed March 25,
2015.
bonds to the lens surface.
3. Measured via Captive Bubble Contact Angle.
In ex-vivo tests, Hydra-PEG Ocular Dynamics data on file, 2014
was shown to improve wettability, 4. Measured via Water Breakup Time. Ocular
Dynamics data on file, 2014
surface water retention, lubricity 5. Measured via Digital Friction Evaluation. Ocular
and deposit resistance.3-6 These lens Dynamics data on file, 2014
6. Measured via Radiolabeled Lysozyme Deposi-
surface properties have been corre- tion Assay. Ocular Dynamics data on file, 2014
lated with contact lens comfort in a 7. Jones, L. et al. “The TFOS International
number of studies.7 When applied to Workshop on Contact Lens Discomfort: Report
of the Contact Lens Materials, Design, and Care
the Acuvue Oasys lens in a random- Subcommittee”. IOVS, October 2013, Vol. 54
ized controlled trial, Hydra-PEG 8. Caroline, P. “Hydra-PEG: A Solution to Contact
Lens Discomfort?” Poster presented at Global
surfaced lenses demonstrated good Specialty Lens Symposium 2015.

REVIEW OF CORNEA & CONTACT LENSES | APRIL 2015 7

007_RCCL0415_LCI.indd 7 3/27/15 3:41 PM

 Derail Dropouts
By Mile Brujic, OD, and Jason Miller, OD, MBA
Five Steps to Increase
Contact Lens Adherence
Getting patients to comply with lens wear and care guidelines is a well-known battle.
Here are some points to make it a little easier.
R
ecent advances in
contact lens technol-
ogy have given us a
host of new lens op-
tions in the realms of
presbyopic, toric and single vision
designs. Positive improvements
in contact lens care systems also
continue to provide additional
benefits to those who use them.
Together, these developments have
increased our arsenal of options to
re-engage with those contact lens
wearers who may have dropped
out in the past.
However, other reasons for
contact lens drop out still remain.
When a lens wearer abuses their
modality or care system, compli-
cations—although rare—can arise
as a result of non-adherence to
practitioner recommendations, a
common problem across all health
conditions, especially contact lens
care regimens.1 This month, we
share five highly effective ways to
better emphasize the importance
of adherence to your contact lens
patients. By increasing and tailor-
ing our efforts, we improve our
patient’s chances of successfully
wearing contact lenses, which
will ultimately help keep them in
lenses long-term.
Be aware of how your
1. patients are caring for their
lenses. How often do contact lens
wearers walk into our practices
without any idea of which solu-
tion or rewetting drops—if any—
they are using? What about the
8 REVIEW OF CORNEA & CONTACT LENSES | APRIL 2015
008_RCCL0415_DD.indd 8
condition of the patient’s contact
lens case? Certainly, migrating pa-
tients to a daily disposable contact
lens will help eliminate these po-
tential issues, as they obviate the
need for care solutions and lens
cases. However, the patient may
still be using drops that you are
unaware of to alleviate comfort
issues.
So, how do you find out what
exactly your patients are doing to
care for their lenses? The answer
is fairly simple: ask them to bring
in their contact lens case, solu-
tion and any other care products,
as well as any drops they may be
using. Seeing them firsthand gives
us the opportunity to educate
patients on proper lens care if
needed and gives us the opportu-
nity to intervene with appropri-
ate clinical solutions if necessary,
including refitting them into a
daily disposable lens or suggesting
an alternate product.
Educate patients on how
2. to appropriately care for
their lenses. While proper lens
care is common knowledge for
the eye care practitioner, many
patients are not as educated
regarding its importance and influ-
ence. Surprisingly, even the most
seasoned contact lens wearers may
not know how to appropriately
care for their lenses. Try ask-
ing your contact lens patients to
explain their process for applying
and removing their contact lenses.
How do you educate these
patients? Devise a consistent
conversation to have with all
contact lens patients and modify
it according to each patient’s
individual needs. Explaining the
importance of adherence and
correcting patient-specific errors
means they are more likely to
adhere to your guidelines. As an
example, you can say, “I want you
to be able to consistently wear
your contact lenses comfortably
and in a healthy way. This can
best be achieved by following our
recommendations on cleaning and
caring for your contact lenses.”
Next, follow this with the actual
steps necessary to care for the
lenses, and consider a discussion
of a daily disposable lens use.
If the patient has issues or
3. complications, show them.
Sometimes, patients will present
with symptoms caused by contact
lens abuse, such as GPC on the su-
perior tarsal plate from lens over-
wear when deposits occur on the
lens surface and interact with the
lid while blinking.2 This response
leads to the clinically evident giant
papillae and, often, excessive mu-
cus production. In these instances,
contact lens wearers typically seek
symptomatic relief—and deliver-
ing it will likely create a more
compliant lens wearer.3
But what about changes that are
less symptomatic, but still impor-
tant to teach patients about? In
these cases, we often use slit lamp
imaging systems as an educational
3/27/15 3:42 PM

tool. For example, the patient who
is sleeping in hydrogel lenses, but
who is asymptomatic, may have
significant corneal neovascular-
ization that can be imaged and
demonstrated. Or, someone who is
keeping their lenses in for longer
than prescribed who presents with
significant deposits on the lens
surface might benefit from seeing
those deposits up close. In either
case, imaging of these scenarios
helps the patient understand their
condition and hopefully, the need
for more compliant wear.
Give them the tools they
4. need. As practitioners, we
have heard almost every single ex-
cuse in the book for why our pa-
tients are noncompliant with their
replacement schedules. We have
made it a point to make it as easy
as possible for patients to remem-
ber to replace their contact lenses.
So, regardless of the modality, be
sure to give them the best tools
possible to help them remember
their replacement schedule.
Obviously, daily disposable
lenses are the easiest modality
to replace. It’s one of the main
reasons these lenses are associ-
ated with such a high level of
adherence.4 For patients wearing
two-week or monthly disposable
lenses, however, we need to guide
them to select a day or two days,
depending on the modality, as
their designated replacement day.
Depending on your practice,
you may also have the means to
provide patients with contact lens
cases, solution and other accoutre-
ment to help with adherence.
008_RCCL0415_DD.indd 9
RCCL
REVIEW OF CORNEA
& CONTACT LENSES
11 Campus Blvd., Suite 100
Newtown Square, PA 19073
Telephone (610) 492-1000
Fax (610) 492-1049
Editorial inquiries (610) 492-1003
Advertising inquiries (610) 492-1011
E-mail rccl@jobson.com
EDITORIAL STAFF
Don’t assume non-adher-
5.  ence is the reason. A pa-
tient wearing contact lenses who
EDITOR-IN-CHIEF
Jack Persico jpersico@jobson.com
ASSOCIATE EDITOR
Aliza Martin amartin@jobson.com
comes in with a corneal infiltrative CLINICAL EDITOR
Joseph P. Shovlin, OD, jpshovlin@gmail.com
response is often immediately EXECUTIVE EDITOR
Arthur B. Epstein, OD, artepstein@artepstein.com
assumed to be someone who has
ASSOCIATE CLINICAL EDITOR
abused their contact lenses. While Christine W. Sindt, OD, christine-sindt@uiowa.edu
this is often the case, take caution CONSULTING EDITOR
Milton M. Hom, OD, eyemage@mminternet.com
to consider other clinical entities SENIOR ART/PRODUCTION DIRECTOR
Joe Morris jmorris@jhihealth.com
that may present similarly. GRAPHIC DESIGNER
For example, a point-of-care test Matt Egger megger@jhihealth.com
AD PRODUCTION MANAGER
such as AdenoPlus can be used Scott Tobin stobin@jhihealth.com
to rule out adenoviral keratocon- BUSINESS STAFF
junctivitis in a contact lens wearer PUBLISHER
James Henne jhenne@jobson.com
presenting with an acute red eye REGIONAL SALES MANAGER
Michele Barrett mbarrett@jobson.com
and corneal infiltrates.5 Clinically, REGIONAL SALES MANAGER
we will often pigeon-hole these
patients as contact lens abusers
Michael Hoster mhoster@jobson.com
VICE PRESIDENT OPERATIONS
Casey Foster cfoster@jobson.com
when in fact they are contact lens
wearers who simply have another
EDITORIAL BOARD
Mark B. Abelson, MD
etiology responsible for the cause James V. Aquavella, MD
of their red eye.
Edward S. Bennett, OD
Aaron Bronner, OD
It is well understood that adher- Brian Chou, OD
ence in health care is a constant
S. Barry Eiden, OD
Gary Gerber, OD
challenge. But by incorporating Susan Gromacki, OD
these strategies, we can help influ-
Brien Holden, PhD
Bruce Koffler, MD
ence contact lens adherence in a Pete Kollbaum, OD, PhD
positive way, reduce complications
Jeffrey Charles Krohn, OD
Kenneth A. Lebow, OD
and ultimately help those patients Kelly Nichols, OD
who may discontinue lens wear
Robert Ryan, OD
Jack Schaeffer, OD
continue wearing their lenses suc- Kirk Smick, OD
Barry Weissman, OD
cessfully. RCCL
REVIEW BOARD
Kenneth Daniels, OD
1. Claydon BE, Efron N. Non-compliance in con- Desmond Fonn, Dip Optom M Optom
tact lens wear. Ophthalmic Physiol Opt. 1994 Robert M. Grohe, OD
Oct:14(4):356-64.2. Elhers WH, Donshik PC. Patricia Keech, OD
Giant papillary conjunctivitis. Curr Opin Allergy Jerry Legerton, OD
Clin Immunol. 2008 Oct;8(5):445-9. Charles B. Slonim, MD
3. Chigbu D. The management of allergic eye Mary Jo Stiegemeier, OD
diseases in primary eye care. Cont Lens Ante- Loretta B. Szczotka, OD
rior Eye. 2009 Dec;32(6):260-72. Michael A. Ward, FCLSA
4. Dumbleton K, Woods C, Jones L, et al. Pa- Barry M. Weiner, OD
tient and practitioner compliance with silicone
hydrogel and daily disposable lens replacement
in the United States. Eye Contact Lens. 2009
Jul;35(4):164-71.
5. Sambursky R, Trattler W, Tauber S, et al.
Sensitivity and specificity of the AdenoPlus test
for diagnosing adenoviral conjunctivitis. JAMA
Ophthalmol. 2013 Jan;131(1):17-22.
3/27/15 3:42 PM
 Pharma Science & Practice
By Elyse L. Chaglasian, OD, and Tammy Than, MS, OD

Anti-VEGF in the Anterior Segment

Corneal neovascularization from contact lens overwear and other hypoxic events may
respond to this posterior segment therapy.

O
ne of the hallmarks
of the cornea is its
avascular, transpar-
ent nature, which
is a result of the pre-
cise composition and arrangement
of its constituent parts. A variety
of affronts—including infection,
inflammation, ischemia, degen-
eration and loss of the stem cell
barrier—can lead to the loss of this
avascularity in the form of corneal
neovascularization.1,2,
Over 1.4 million patients develop
corneal neovascularization each
year, with up to 12% of cases as-
sociated with subsequent decreased
acuity as immature and abnormal
vessels invade from the limbal
vascular plexus, causing scarring,
edema and inflammation.1,3 This
invasion occurs when the habitually
precise balance between pro- and
anti-angiogenic factors is disturbed
by an excess of pro-angiogenic fac-
tors.4
While a number of constituents
promote new vessel proliferation,
vascular endothelial growth factor
(VEGF) is one of the key regulators
of this process and, as such, has be-
come an important target for medi-
cal therapy.5 Anti-VEGF treatments,
a mainstay of therapy for retinal
conditions, also hold promise for
corneal applications and may play a
particularly auspicious role in graft
survival after penetrating kerato-
plasty.2
A BETTER WAY?
Conventional therapy for corneal
neovascularization includes steroids,
thought to suppress activation and
Vessel encroachment into the cornea in a case of neovascularization due to
hypoxic stress. Might this be a patient who would benefit from anti-VEGF?
migration of macrophages, mast
cells, cytokines and other inflam-
matory cells promoting angio-
genesis.2,6,7 Steroids are also often
used in combination with oral
matrix metalloproteinase (MMP)
inhibitors such as doxycycline in an
effort to regress abnormal corneal
vasculature. These techniques are
limited in efficacy, however, and
lead to well-known side effects of
topical steroids including cataracts
and glaucoma. Nonsteroidal anti-
inflammatory medications, photo-
dynamic therapy, laser photocoagu-
lation, fine needle diathermy and
conjunctival, limbal and amniotic
membrane transplantation have
also been used with varying suc-
cess.2,6
Topical anti-VEGF therapy for
corneal neovascularization has been
investigated off-label using both
bevacizumab and ranibizumab,
which are monoclonal antibodies
against VEGF and traditionally
used for retinal indications.2,8,9
Both target VEGF-A, leading to
inhibition of abnormal blood vessel
formation and decreased vascular
permeability. Bevacizumab has been
used more often in off-label indica-
tions and in studies as a result of
its increased affordability. Bevaci-
zumab was originally approved for
metastatic colorectal cancer, but has
long been used in ophthalmology
for off-label therapy of wet AMD,
proliferative diabetic retinopathy
and iris rubeosis.2,10
Therapy with anti-VEGF medi-
cations has been studied both in
subconjunctival and topical use and
has shown promise in the treatment
of herpetic keratitis, recurrent pte-
rygium, corneal transplant rejection
and Stevens-Johnson syndrome.11
Multiple studies confirm the effec-
tiveness of topical bevacizumab in
reducing corneal neovascularization
in experimental animal models, and
human use has shown significant
reductions in abnormal vascula-
ture, even in patients recalcitrant
to traditional anti-inflammatory
therapies.2,6 Early treatment appears

10 REVIEW OF CORNEA & CONTACT LENSES | APRIL 2015

010_RCCL0415_PSP.indd 10 3/27/15 3:43 PM

 more efficacious in both animal and
human models, with both topical
and subconjunctival therapy.6,12,13
Chronic vascular conditions tend
not to respond as well to therapy as
active or acute angiogenesis.6,12
Clinically, corneal neovasculariza-
tion can be seen after infectious, in-
flammatory and traumatic events.1,2
Inflammatory stress tips the balance
of growth and inhibitory factors
in favor of angiogenesis and leads
to the growth of new, abnormal
vasculature.4 The same can be seen
under hypoxic conditions, such as
contact lens overwear.2 The result-
ing neovascularization may be deep,
stromal or may present as super-
ficial vascular pannus, depending
on the ocular insult.2,14 Deep and
stromal neovascularization may
be associated with interstitial and
disciform changes seen in herpetic
keratitis, while superficial changes
are typically associated with ocular
surface disease.2
Other bacterial, viral, protozoan
and fungal antigens may also induce
a keratitis that can lead to subse-
quent neovascularization. Trauma
(including chemical burns), ischemia
(i.e., limbal stem cell deficiency),
and inflammatory conditions may
also promote the abnormal vascu-
lature.2,11,15 Autoimmune diseases
(e.g., Stevens-Johnson syndrome,
graft rejection and cicatricial
pemphigoid) and corneal degenera-
tions (e.g., pterygium and Terrien’s
marginal degeneration) have further
been implicated in corneal neovas-
cularization.2,11,15 Perhaps the most
widespread application, however,
lies in corneal transplantation,
where recipient neovascularization
before transplantation doubles the
010_RCCL0415_PSP.indd 11
FROM VEGF TO VESSELS
While there are a number of itera-
tions of VEGF found throughout the
human body, VEGF-A is one of the
key regulators of hemangiogenesis in
ocular tissues.2 It is secreted by corneal
epithelial and endothelial cells, vas-
cular endothelial cells and fibroblasts
and microphages found in scar tissue;
importantly, this process is exacer-
bated in inflamed and vascularized
corneas.6 Once released, it promotes
vascular endothelial cell proliferation,
migration and tube formation, and may
also play a secondary role in inflam-
mation.1,6 Circulating VEGF exerts its
influence by binding to tyrosine kinase
receptors, which leads to a signaling
cascade promoting cell division and
proliferation of vessels.2
risk of graft rejection, and where
increases in graft survival after anti-
VEGF therapy have been demon-
strated in animal models.2
GROWTH OPPORTUNITY
Clearly, there is a role for anti-
VEGF therapy in corneal neovascu-
larization, and its potential anterior
segment indications are plentiful.
Areas for further research include
determining the ideal administra-
tion, route, dosage and formulation,
and whether a targeted combina-
tion therapy for multiple growth
factors is necessary to completely
regress vasculature in these patients.
While large, randomized studies
are required to firmly establish
the safety and breadth of corneal
indications, it seems clear that anti-
VEGF therapy will have an increas-
ingly significant role in the manage-
ment of corneal neovascularization
patients moving forward, and that
corneal specialists will have a more
efficacious tool at their disposal
REVIEW OF CORNEA & CONTACT LENSES | APRIL 2015
when treating this potentially blind-
ing condition. RCCL
The authors would like to ac-
knowledge Stephanie Fromstein,
OD, for her invaluable contribu-
tions to this article.
1. Chang JH, Gabison EE, Kato T et al. Corneal
neovascularization. Curr Opin Ophthamol. 2001;
12: 242-249.
2. Chang JH, Garg NG, Lunde E et al. Corneal neo-
vascularization: an anti-VEGF therapy review. Surv
Opthalmol. 2012 ; 57(5): 415-429.
3. Lee P, Wang CC, Adamis AP. Ocular neovascu-
larization: an epidemiologic review. Surv Ophthal-
mol. 1998; 43: 245-269.
4. Kvanta A. Ocular angiogenesis: the role of
growth factors. Acta Opthalmol Scand. 2006.; 84:
282-288.
5. Gan L, Fagerholm P, Palmblad J. Vascular
endothelial growth factor (VEGF) and its receptor
VEGFR-2 I the regulation of corneal neovascu-
larization and wound healing. Acta Ophthalmol
Scand. 2004; 82: 557-563.
6. Papathanassiou M, Theodoropoulou S, Analitis A
et al. Vascular endothelial growth factor inhibitors
for the treatment of corneal neovascularization: a
meta-analysis. Cornea. 2013; 32(4): 435-444.
7. Phillips K, Arffa R, Cintron C et al. Effects of
prednisolone and medroxyprogesterone on cor-
neal wound healing, ulceration and neovasculariza-
tion. Arch Opthalmol. 1983; 101: 640-643.
8. Avila MP, Farah ME, Santos A et al. Three-year
safety and visual acuity results of epimacular
90strontium/90yttrium brachytherapy with beva-
cizumab for the treatment of subfoveal choroidal
neovascularization secondary to age-related
macular degeneration. Retina. 2011; 32(1): 10-18.
9. Krebs I, Lie S, Stolba U et al. Efficacy of intravit-
real bevacizumab (Avastin) therapy for early and
advanced neovascular age-related macular degen-
eration. Acta Opthalmol. 2009; 87: 611-617.
10. Cheng SF, Dastjerdi MH, Okanobo A et al.
Short-term topical bevacizumab in the treatment
of stable corneal neovascularization. Am J Oph-
thalmol. 2012; 154: 940-948.
11. Ambati B. Corneal applications for anti-VEGF
agents. Adv Oc Car. 2011: 24-25.
12. Papathanassiou M, Theodossiadis PG, Liarakos
VS et al. Inhibition of corneal neovascularization by
subconjunctival bevacizumab in an animal model.
Am J Opthalmol. 2008; 145: 424-431.
13. Stephenson M. Anti-VEGF for CNV: questions
remain. Rev Ophthalmol. 2011. Published online
14. Ellenberg D, Azar DT, Hallak JA et al. Novel as-
pects of corneal angiogenic and lymphangiogenic
privilege. Prog Retin Eye Res. 2010; 29: 208-248.
15. Bock F, Konig Y, Kruse F et al. Bevacizumab
(Avastin) eye drops inhibit corneal neovasculariza-
tion. Graefes Arch Clin Exp Ophthalmol. 2008;
246: 281-284.
11
3/27/15 3:43 PM
 DRY EYE:
See It Through
Their Eyes
Patient questionnaires
quantify the subjective
experience of the disease.
Though vital for research,
are they worth using
in your practice?
D
ry eye is easily one
of the most common
diseases worldwide,
encompassing a
wide range of ocular
surface alterations with different
etiologies and pathophysiologies.1,2
In recent years, eye care practi-
tioners have made great advances
in objectively measuring dry eye
with precision, using high-tech
tools to quantify tear osmolar-
ity, inflammatory cytokines and
Sjögren’s biomarkers in addition
to familiar clinical evaluation tools
like the Schirmer’s test and tear film
breakup time. Methods to assign an
objective number or severity score
to dry eye have flourished.
But despite this success, the sub-
jective component of the disease—
how it feels for patients—remains
for the most part poorly document-
ed. Thus, it’s no surprise a number
of patient evaluation questionnaires
exist as part of an ongoing move-
ment to quantify patient symptom-
atology. Dry eye questionnaires are
commonly used in clinical research
to screen participants, grade disease
severity and assess the effects of
treatments. They vary in length,
focus and extent of validation, and
often involve a number of rating
scales that are combined to produce
a total raw score (see “Comparing
Notes,” p. 14).13 So, how does one
determine which to use in a busy
12 REVIEW OF CORNEA & CONTACT LENSES | APRIL 2015
012_RCCL0415_F1ANDF2.indd 12
By Aliza Martin, Associate Editor
clinical practice, especially given
that such questionnaires typically
measure patients against a pre-estab-
lished clinical diagnosis of dry eye?
This article discusses some of the
more popular questionnaires avail-
able and examines their relevance in
the context of evaluating patients in
a clinical practice setting.
EXPERT TESTIMONY
In 2007, the International Dry Eye
WorkShop published a report on
the epidemiology of dry eye, which
evaluated the practicality of a
number of dry eye questionnaires.17
Requirements for consideration
included that the questionnaire had
been used in randomized clini-
cal trials (RCTs) or epidemiologic
studies, had passed psychometric
testing and been deemed suitable
for evaluating general, non-disease
specific dry eye populations.17 Four-
teen questionnaires met the criteria,
including five discussed here.
The committee identified charac-
teristics that designate a question-
naire as suitable for use in epide-
miologic studies and RCTs. First, it
must be able to detect and measure
changes in symptoms with effec-
tive treatment or disease progres-
sion.17 The recall period must also
be specified and the ability to set
a threshold of disease severity as
an inclusion criterion should be
present.17 Additionally, because of
the possibility of dry eye symptoms
worsening over the course of the
day, there must be a single, set time
for administering dry eye examina-
tions and the questionnaire.17
The subcommittee recommended
adding a better definition of clini-
cally meaningful changes in scores
as well as a better concept of the
“worst” symptom and a question
on visual function with respect to
dry eye.17 Also, more research on
the relationship between frequency
and severity of dry eye symptoms as
a means to better identify a clinical-
ly meaningful change in symptoms
is warranted.17
WHAT DO YOU USE?
Granted, dry eye questionnaires are
commonly used in clinical research
as a means to grade disease sever-
ity and assess treatment effects, all
within a controlled environment
with a pre-selected population seg-
ment. But are they useful in clini-
cal practice, where many different
patients present who have not been
pre-sorted and who may fall within
a range of disease severity and treat-
ment types and stages?
A validated questionnaire, says
Arthur B. Epstein, OD, provides
a good starting point to evaluate
the patient’s unique experience
and gather information about the
specifics of the disease. Dr. Epstein
is director of clinical research at
3/27/15 4:28 PM
 of Optometry’s TearWell Advanced MMP-9 testing,” he says. “We can

Photo: Mile Brujic, OD

Dry Eye Treatment Center in Mem- also assess treatment response by
phis, also use the OSDI and SPEED following the patient’s symptomatic
questionnaires for similar purposes. improvement on the questionnaire.”
Because both are validated and
used in the practice together, they DIY EFFORTS
act as a good system of checks and Some practitioners choose to create
balances. “We use the question- their own dry eye questionnaire.
naires to first quantify the patient’s In addition to using the SPEED
symptoms as a finite entity, and questionnaire, Paul M. Karpecki,
then track the patient’s progress as OD, of Koffler Vision Group in
we perform or initiate specific treat- Kentucky, also uses a custom one of
ment regimens,” Dr. Kabat says. his own making (shown below).
Does reliance on dry eye signs, like the “Occasionally, patients are in- “The second is a much more
corneal staining above, overshadow
the role of the patient's symptomatic fluenced by how they feel on a extensive questionnaire about dry
experiences and quality-of-life issues? particular day, and the surveys eye disease that is administered on a
provide a more global view,” adds clipboard when the patient is placed
Phoenix Eye Care and runs a dry Dr. Hauser. “Dry eye care, unlike in the exam lane waiting on the
eye clinic at the practice. He uses many other eye diseases, is driven doctor,” he says. Contrary to the
dry eye questionnaires to evaluate by symptom relief, and the surveys SPEED questionnaire, which is used
every patient who walks in. give a measureable indication of on every patient, the custom form is
“I use questionnaires for docu- improvement.” only used for new patients referred
mentation and especially for prog- The responses from the dry specifically for dry eye disease eval-
ress evaluations,” he says. “While eye questionnaires do have a big uations. “The SPEED questionnaire
both are important, my personal influence on treatment decisions, initiates a potential dry eye patient
bias is to measure outcomes by a re- Dr. Kabat says. “For a severely workup,” says Dr. Karpecki. “The
duction in patients’ symptoms even symptomatic patient, we are more extensive custom questionnaire
more than a reduction in physical apt to initiate aggressive therapy actually predicts potential diseases
signs. Questionnaires provide a even in lieu of significant findings. ranging from anterior blepharitis to
standardized way of assessing how Likewise,
se,, for a patient with less
well the patient is doing and if they symptomology,
m
mology, we might be more
are responding to therapy.” conservative
vattive in our treatment
Dr. Epstein uses both the OSDI algorithm.”
hmm.”
and SPEED questionnaires, and says Eric
each has its own benefits. “SPEED Don-
is quicker, but OSDI provides a nenfeld,,
bit more information. As odd as it MD,
sounds, I haven’t totally settled on ei- a Long
ther, but I make sure we use the same Island oph-
opph-
one we used previously to monitor thalmologist
loggist
change” in a specific patient. who special-
eccial-
Overall, he adds, the usefulness of izes in cata-
catta-
the different dry eye questionnaires ract andd refrac-
r
varies depending on the patient. tive surgery,
geery,
“For example, the CLDEQ is uses OSDI
SDDI and
optimized for lens wearers, and the SPEED to o guide
DEQS focuses more on quality-of- diagnostic
stic testing.
life issues. Some are research tools “All patients
tieents who Dry eye questionnaires can also
be custom-made, such as this one from
and less useful in clinical practice.” have positive
osiitive findings Paul M. Karpecki,
p , OD. To download a copy py
Al Kabat, OD, and Whitney on the questionnaire
ti i of it suitable for use in your practice, look for
Hauser, OD, of Southern College undergo osmolarity and this article at www.reviewofcontactlenses.com.

REVIEW OF CORNEA & CONTACT LENSES | APRIL 2015 13

012_RCCL0415_F1ANDF2.indd 13 3/27/15 3:43 PM

 DRY EYE: SEE IT THROUGH THEIR EYES

Comparing Notes: Selected Dry Eye Evaluation Forms

The options for documenting the patient’s experience of dry eye range from simple one-page
sheets with three key components to a complete soup-to-nuts account of their case history.
Here’s a quick overview of several popular ones. To find links to these forms, snap a picture of
the QR code on the right with your smartphone or visit www.reviewofcontactlenses.com.
• McMonnies Questionnaire. Arguably the first modern dry eye questionnaire, the McMonnies
is comprised of 14 items that focus on established risk factors for dry eye including age, sex, contact lens
wear, medication use and certain systemic and ocular factors.5 The questionnaire was intended to both
determine the presence of dry eye and identify individuals at risk for developing the disease.
Several studies validating the McMonnies questionnaire as a means to screen patients for dry eye disease
exist.6,7 A separate study evaluating the psychometric properties—reliability, validity and accuracy—of it re-
ported poor internal consistency, moderate test-retest reliability and fair concurrent validity and accuracy.8
The McMonnies questionnaire appears on p. 15.
• Dry Eye Questionnaire (DEQ) and Contact Lens Dry Eye Questionnaire (CLDEQ). Both versions of
the DEQ include categorical scales to measure prevalence, frequency, diurnal severity and intrusiveness of
common ocular surface symptoms in a typical date of a one-week recall period. Participants are asked to
indicate “never, infrequent, frequent or constant” with regard to frequency and intensity of comfort, dry-
ness, visual changes, soreness and irritation, grittiness and scratchiness, burning and stinging, foreign body
sensation, light sensitivity and itching.9
The two questionnaires also include questions on the perceived time of day that symptoms worsen, how
much the symptoms affect daily activities, computer use, use of systemic and ocular medications, and
presence of allergies.9 The DEQ has been successfully evaluated for its use in measuring the frequency and
intensity of symptoms of ocular irritation in patients with aqueous tear deficient dry eye.10
• Ocular Surface Disease Index (OSDI). Developed by the Outcomes Research Group at Allergan, the
OSDI questionnaire is a self-administered 12-question scale designed to assess a range of ocular surface
symptoms, their severity and impact on visual function in a one-week recall period.11 Currently, the OSDI is
one of only two validated dry eye questionnaires to include quality-of-life measures for clinical use.12
• Subjective Evaluation of Symptom of Dryness (SESoD). The SESoD is a three-item questionnaire
created by Allergan to evaluate a patient’s perception of ocular discomfort related to dryness. Together
with the DEQ, McMonnies and OSDI, the SESoD has been shown to exhibit unidimensionality—that is, it is
comprised of questions that measure specific metrics simply and linearly to yield straightforward values.13
For example, income is a unidimensional variable; socioeconomic status, which includes income, occupa-
tion and education, is a multidimensional variable.
• Impact of Dry Eye on Everyday Life (IDEEL). The 57-question IDEEL survey from Alcon assesses the
effect of dry eye with respect to three primary modules: dry eye symptom bother, impact on daily life
(comprising impact on daily activities, emotional state and work) and treatment satisfaction (comprising
patient attitude towards treatment effectiveness and treatment-related bother/inconvenience).14 Together
with the OSDI questionnaire, the IDEEL survey comprises a small category of dry eye questionnaires that
include quality-of-life measures for clinical use.12
A psychometric analysis performed as part of a validation study involving 210 subjects—130 with non-
Sjögren's keratoconjunctivitis sicca, 32 with Sjögren's syndrome and 48 controls—found IDEEL to exhibit
good consistency and reliability.14 Strong correlation between IDEEL and the Dry Eye Questionnaire was
also noted.14
• Standard Patient Evaluation of Eye Dryness (SPEED). The SPEED questionnaire is a four-question sur-
vey developed by TearScience to assess frequency and severity of patient dry eye symptoms. In particu-
lar, it monitors diurnal and longer-term symptom changes over the course of three months.15 The SPEED
questionnaire has been shown to exhibit good validity, unidimensionality, objectivity and consistency when
compared with the DEQ, McMonnies questionnaire, OSDI and SESoD.15
• Dry Eye-Related Quality-of-Life Score Questionnaire (DEQS). The DEQS is a 15-item questionnaire
created to assess the presence of dry eye symptoms and their severity, and the effects of these symptoms
on aspects of patients’ everyday lives, including psychological and social aspects.16 A psychometric analysis
found the study had good internal consistency, test-retest reliability, discriminant validity and responsive-
ness to change; thus, the test is valid and reliable for evaluating the multifaceted effect of dry eye disease
on a patient’s daily life.16

14 REVIEW OF CORNEA & CONTACT LENSES | APRIL 2015

012_RCCL0415_F1ANDF2.indd 14 3/27/15 3:43 PM

 McMonnies Dry Eye Questionnaire
Please answer the following by underlining the responses most appropriate to you:
Female / Male 6. Are your eyes dry and irritated the day after drinking
(0) (M1/F3) alcohol?
Age: less than 25 years / 25-45 years / more than 45
years(M2/F6) Not applicable(0) / Yes(4) / No(0) / Sometimes(2)

Currently wearing: no contact lenses / hard contact lenses /
soft contact lenses
1. Have you ever had drops prescribed or other treatment
for dry eyes?
Yes(6) / No(0) / Uncertain(0)
2. Do you ever experience any of the following eye
symptoms?
1. Soreness 2. Scratchiness 3. Dryness
4. Grittiness 5. Burning
3. How often do your eyes have these symptoms?
Never(0) / Sometimes(1) / Often(4) / Constantly(8)
4. Are your eyes unusually sensitive to cigarette smoke,
smog, air conditioning, or central heating?
Yes(4) / No(0) / Sometimes(2)
5. Do your eyes become very red and irritated when
swimming?
Not applicable(0) / Yes(2) / No(0) / Sometimes(1)
7. Do you take: antihistamine tablets(2) or use antihistamine
eye drops(2), diuretics (fluid tablets)(2), sleeping tablets(1),
tranquillizers(1), oral contraceptives(1), medication for
duodenal ulcer(1), digestive problems(1), high blood
pressure(1), antidepressants(1) or ___________________?
(Write in any medication you are taking that is not listed.)
8. Do you suffer from arthritis?
Yes(2) / No(0) / Uncertain(0)
9. Do you experience dryness of the nose, mouth, throat,
chest or vagina?
Never(0)/ Sometimes(1) / Often(2) / Constantly(4)
10. Do you suffer from thyroid abnormality?
Yes(2) / No(0) / Uncertain(0)
11. Are you known to sleep with your eyes partly open?
Yes(2) / No(0) / Sometimes(1)
12. Do you have eye irritation as you wake from sleep?
Yes(2) / No(0) / Sometimes(1)

Scores: Normal (< 10) Marginal dry eye (10 - 20) Pathological dry eye (>20)
From: McMonnies C, Ho A: Patient history in screening for dry eye conditions. J Am Optom Assoc 1987, 58(4):296–301.

dry eye to allergic conjunctivitis. It
also triggers various treatment op-
tions.” Also, its short length allows
patients to feel like they are making
the best use of their time.
Dr. Karpecki created a custom
questionnaire because he felt he
“needed more information and
didn’t want to have to rely on my
memory to ask the right questions
of the patient.” It’s a culmination of
his 20 years’ experience running a
dry eye clinic plus information from
research papers and dry eye studies.
Another option is to adapt an
existing questionnaire or two. John
D. Sheppard, MD, president of Vir-
ginia Eye Consultants, uses both the
OSDI and SPEED questionnaires,
but says “both ask a little less than
we’d like to differentiate the differ-
ent types of ocular surface disease.
We all think about dry eye, which
is ubiquitous, but also extremely
common are MGD and blepharitis
as well as ocular allergy.”
Patients who present at Dr.
Sheppard’s practice take a modified
version of the SPEED questionnaire.
“A good supplemental question to
ask on the SPEED is, ‘Do your eyes
itch?’ Answer choices include: In-
frequently; frequently; all the time;
it’s driving me crazy. Itching is an
important symptom that overlaps
between the three most common
ocular surface conditions but
focuses most on ocular allergy,” Dr.
Sheppard says. “Another question
that seems to help with blepharitis
is, ‘Are your eyelids red?’ with the
same frequency qualifiers. Also,
‘Are your eyes burning?’ Burning
seems to be something that helps
with identifying blepharitis. You
can also ask patients about crusting
and matting on their lids as well.”
THE IDEAL
What might the ideal dry eye
questionnaire look like? Dr. Epstein
says SPEED comes closest. “It’s
free, it’s quick, it’s repeatable and it
should be used consistently with all
dry eye patients. It is also an excel-
lent tool for uncovering dry eye
among patients who are ‘silent suf-
ferers’ and don’t realize they have a
problem that can be effectively—or
more effectively—managed.”
Dr. Kabat agrees about the basic
principles of an ideal questionnaire
and that the SPEED is one such
example, but also offers a more
general set of characteristics. “If
the questionnaire takes more than
three minutes for the patient to
complete, then it is impractical. If
it takes more than one minute to
score, then it is impractical. If it
cannot be administered and scored
by a technician or assistant, then it
is impractical,” he says. “For the
physician, there should be no more
of a time commitment than glanc-
ing at the number and assessing its
value relative to the scale.”
(Continued on p. 19)

REVIEW OF CORNEA & CONTACT LENSES | APRIL 2015 15

012_RCCL0415_F1ANDF2.indd 15 3/27/15 3:43 PM

 Bringing Clarity
TO CLARE
Understanding and knowing how to treat this common contact lens
complication can benefit both your patients and your practice.
By Lindsay A. Sicks, OD
T
he clinical entity
known as contact
lens-induced acute red
eye, or CLARE, is an
inflammatory reaction
of the cornea and conjunctiva
associated with overnight contact
lens wear. It is also commonly
referred to as acute red eye or
tight lens syndrome. Often,
the patient will present to your
practice wearing dark sunglasses
or clutching a box of tissues
in an effort to cope with their
symptoms. While treatment
is relatively straightforward,
episodes of this condition can
recur; thus, our job as clinicians is
not only to treat the condition in
its acute stage, but also to educate
the patient and give them the
tools to return to lens wear in the
healthiest possible manner.
SIGNS AND SYMPTOMS
CLARE is typically character-
ized by sudden onset of unilateral
eye pain, photophobia, epiphora
and ocular irritation. Accom-
panying slit lamp signs include
diffuse conjunctival and limbal
hyperemia, as well as the pres-
ence of multiple corneal epithelial
and subepithelial infiltrates. The
infiltrative reaction is generally
located in the corneal periphery
and mid-periphery; when sodium
fluorescein stain is instilled in the
16 REVIEW OF CORNEA & CONTACT LENSES | APRIL 2015
012_RCCL0415_F1ANDF2.indd 16
eye, the infiltrative areas do not
typically exhibit overlying punc-
tate staining, indicating minimal
epithelial involvement.3,4 In more
severe cases of CLARE, corneal
edema or anterior uveitis may also
be present, although these signs
are not common.1,2 Visual acuity is
usually unaffected.
It is prudent to ask patients
presenting with CLARE symptoms
about any recent illnesses, includ-
ing symptoms of the common
cold such as headache, fatigue and
runny nose. Often, upper respira-
tory tract infections are associated
with gram-negative organisms like
Haemophilus influenza.1,2 One
study found that patients who
were colonized with H. influen-
zae were more than 100 times as
likely to have had a CLARE or
infiltrative response than those
subjects who were not colonized
with this bacterium.5
CASE HISTORY
AND EVALUATION
Typically, the most reliable way
to accurately diagnose CLARE
is with a complete case history
and assessment of the symptoms
mentioned above. By defini-
tion, CLARE is associated with
sleeping while wearing contact
lenses.2,3 This can be anything
from a short afternoon nap to a
full night of extended wear—the
fact that the eye is closed for an
extended period of time is key to
our diagnosis. So, consider asking
all your contact lens patients how
many times per week they sleep or
nap in their lenses as part of your
routine history sequence.
Knowledge of the patient’s
habitual lens type and wearing
schedule may also have some
value in our diagnostic consider-
ations. Conventionally, CLARE
is associated with tight fit or poor
movement of extended-wear, low
oxygen permeability, high water
content hydrogel lenses. However,
note that CLARE can also be
caused by extended wear of sili-
cone hydrogel lenses, which have
significantly risen in market share
in the United States in the last de-
cade.1,6 CLARE has been reported
to occur in 34% of continuous
wear hydrogel lens patients and
less than 1% of silicone hydrogel
extended wear patients.7-9 Re-
ports have also linked CLARE to
ABOUT THE AUTHOR
Dr. Sicks is an assistant
professor at Illinois College
of Optometry in Chicago.
She is involved in the
contact lens didactic
curriculum and also serves
as a clinical attending
physician in the Illinois Eye Institute’s
Cornea Center for Clinical Excellence.
3/27/15 3:44 PM
 extended wear gas permeable (GP)
lenses, high oxygen permeabil-
ity silicone elastomer lenses and
overwear of daily disposable soft
contact lenses.10
In the absence of a lens fit evalu-
ation, history questions regarding
hours per day of lens wear and
difficulty with lens removal at the
end of the day may assist in diag-
nosis. If you are able to assess the
lens on-eye, pay special attention
to lens movement and push-up
test results. Note, however, that
there are reported cases of CLARE
occurring with well-fit contact
lenses showing adequate move-
ment.10,11
cells, and then infiltration of the
injured tissue by polymorpho-
nuclear leukocytes and other cells.
This collection of inflammatory
cells within the cornea forms what
we call an infiltrate. The result is
CLARE and its associated signs
of conjunctival hyperemia and
corneal epithelial and subepithelial
infiltrates.7
DIFFERENTIAL DIAGNOSIS
In a case that may be CLARE or
another corneal infiltrative event
(CIE), the most important element
to consider is whether the pre-
senting condition is infectious or
non-infectious.
moderate to severe pain symptoms
that worsen with lens removal.
Anterior chamber cells and flare
and mucopurulent discharge
are more common in MK than
CLARE and CLPU.3 A positive
bacterial culture or the presence
of tear film exudate can also help
make an MK diagnosis.
CLARE can also appear similar
to conditions like contact lens-
induced peripheral ulcer (CLPU)
and infiltrative keratitis (IK).3
However, while CLARE typically
presents with multiple small focal
and diffuse infiltrates that do not
stain with fluorescein, CLPUs are
characterized as single circular

ETIOLOGY
While the etiology of
CLARE is not completely
understood, it is generally
classified as an inflamma-
tory event of the cornea
and conjunctiva. General
risk factors include wear
of high water content
lenses, wear of tight fitting
lenses and history of a
recent upper respiratory
tract infection.2
One commonly cited
cause of CLARE is coloni-
Acute contact lens-associated red eye presentation in a 28-year-old Indian male.
zation of the lens sur- He noted associated blurry vision, foreign body sensation and photophobia.
face with gram-negative After a 10-day course of tobramycin/dexamethasone suspension QID and
bacteria, specifically H. preservative-free artificial tears every hour for relief, he reported a significant
influenzae, Pseudomonas improvement in symptoms. (Case and photo courtesy of Kelli Theisen, OD.)
aeruginosa and Serratia
marcescens.12 An inflammatory Due to its sight-threatening po- focal infiltrates up to 2mm in
response is triggered by endotox- tential if left untreated, microbial diameter that pick up fluores-
ins released by the breakdown keratitis (MK) should be high on cein stain. IK is associated with
of bacterial cell walls. The con- the list of differentials in any con- Staphylococcal hypersensitivity
dition is worsened in the tight tact lens wearer presenting with a and may occur in one or both eyes
lens environment because of lens red eye. To differentiate MK from showing multiple small infiltrates
dehydration, minimal lens move- other CIEs, look for a discrete with or without corneal staining.
ment, decreased tear exchange and area of fluorescein staining, typi- A careful history and slit lamp
hypoxia.1,7,10,12,13 cally greater than 1mm diameter examination can help guide your
In the inflammatory process, and often located in the central diagnosis.
limbal vasodilation occurs, fol- cornea. There may also be lid The remaining CIEs are cat-
lowed by release of white blood edema, a reactive ptosis, and more egorized as asymptomatic and

REVIEW OF CORNEA & CONTACT LENSES | APRIL 2015 17

012_RCCL0415_F1ANDF2.indd 17 3/27/15 3:44 PM

 BRINGING CLARITY TO CLARE
clinically insignificant.3 Asymp-
tomatic infiltrative keratitis (AIK)
and asymptomatic infiltrates (AI)
are simply differentiated from
CLARE in that they are seen on
physical exam but carry no enter-
ing complaints. Other differentials
to consider include: chlamydial
conjunctivitis, trachoma, adeno-
viral infection, epidemic kera-
toconjunctivitis, Staphylococcal
marginal keratitis, Thygeson's
superficial punctate keratitis and
herpes simplex keratitis.14
TREATMENT AND
MANAGEMENT
Management of CLARE always
begins with discontinuation of
contact lens wear. Beyond that,
the condition is often self-limiting
and may not require therapeutic
intervention—in many cases,
palliative treatment with artificial
tears will suffice. However, we
often prescribe additional thera-
peutic options to promote healing
and improve patient comfort. De-
pending on severity, the infiltrates
can take days to weeks following
cessation of lens wear to heal.
Since many of the signs and
symptoms of CLARE mimic those
of microbial keratitis, it is prudent
to instill sodium fluorescein and
assess the corneal integrity for any
epithelial disruption. Typically,
there is minimal to no epithelial
disruption with CLARE; however,
if there is corneal staining present
in association with an infiltrate,
the diagnosis no longer clear-cut
and the lesion becomes suspicious
for MK. In such cases, conserva-
tive management warrants using
a topical antibiotic for at least the
first 48 hours of treatment. Some
practitioners may prefer to ad-
dress both the inflammation and
risk of infection as quickly as pos-
sible by prescribing a combination
18 REVIEW OF CORNEA & CONTACT LENSES | APRIL 2015
012_RCCL0415_F1ANDF2.indd 18
topical antibiotic/steroid from the
start. Recommended follow-up is
daily until signs of improvement
are shown.
In cases where the photophobia
is particularly symptomatic, or
where there is an accompanying
anterior uveitis component, ap-
plication of a topical cycloplegic
agent is warranted for at least the
first 24 hours. Topical and oral
NSAIDs are also effective adjunct
treatment options to quell the
discomfort. If cells and flare per-
sist, consider addition of a topical
steroid to the regimen.
After complete healing, patients
can resume lens wear using a
fresh lens right out of the vial or
blister pack. Consider changing
lens fit, material, modality and/
or replacement schedule prior
to resuming lens wear to reduce
potential for reoccurrence. For
example, if the habitual lens was
a tight fit, try selecting different
base curve or diameter to im-
prove movement and centration.
If the patient has a history of lens
abuse or overwear, switch them
to a daily disposable lens design
instead. Also, consider refitting
patients into GP lenses—patients
with a history of soft lens com-
plications often adapt well to GP
lenses and appreciate the benefits
they provide.
It is important to note that
recurrence of inflammatory
complications can happen in
50% to 70% of wearers who
resume hydrogel extended wear
after resolution of their initial
episode of CLARE.15 Additionally,
patients who have had a CLARE
episode retain higher levels of lim-
bal injection, bulbar injection and
conjunctival staining afterwards
compared with controls.9 Care-
ful slit lamp examinations and
shorter intervals between contact
lens appointments following a
CLARE episode may be the best
practice to follow based on your
clinical judgment.
Above all, patient educa-
tion plays an important role in
preventing corneal infiltrative
events such as CLARE. Stressing
the importance of appropriate
lens replacement, wear and care
schedules to all of your contact
lens patients can promote better
patient adherence to our recom-
mendations.
Patients should be advised to
stop wearing their lenses while ill
and when lens wear is uncomfort-
able or painful, particularly while
their eyes are closed. For patients
who have had a CLARE episode,
emphasizing the risk of recurrence
as well as a review of symptoms to
look out for may also be helpful.
Be sure to also provide an easy
way for patients to contact your
office in case of an emergent issue
so that they end up in the best
hands possible should another
complication occur. RCCL
Coding for CLARE
Currently, there is no exact
match in ICD-9 nomenclature
for CLARE, and it does not
appear that ICD-10 will have
any additional entries that are
more appropriate. As such,
one should continue to re-
port CLARE using a symptom
code appropriate to the chief
complaint, such as those for
eye pain, redness of the eyes
or epiphora. If there is an ac-
companying corneal infiltrate,
additional codes for central
and peripheral corneal opac-
ity would also be appropri-
ate. Other applicable options
may include anterior uveitis,
viral conjunctivitis or corneal
edema codes, depending on
the case.
3/27/15 3:44 PM
 1. Dumbleton K, Jones L. Extended and Continu-
ous Wear. in Clinical Manual of Contact Lenses. E.
Bennett and V. Henry, Eds. Williams and Wilkins.
2008:410-443.
2. Stapleton F, Keay L, Jalbert I and Cole N. The
epidemiology of contact lens related infiltrates.
Optom Vis Sci. 2007;84(4):257-272.
3. Sweeney DF, Jalbert I, Covey M, et al. Clinical
characterization of corneal infiltrative events
observed with soft contact lens wear. Cornea.
2003;22(5):435-442.
4. Sankaridurg PM, Holden BA, Jalbert I. Adverse
events and infections: which ones and how
many? In e. Sweeney D, Silicone Hydrogels:
Continuous Wear Contact Lenses (pp. 217-274).
Oxford: Butterworth-Heinemann.
5. Sankaridurg PR, Willcox MD, et al. Haemophilus
influenzae adherent to contact lenses associated
with production of acute ocular inflammation. J
DRY EYE: SEE IT THROUGH THEIR EYES
(Continued from p. 15)
Additionally, Dr. Kabat says, it
should assess symptom impact on
lifestyle and provide a metric for
quantifying symptom severity, and
should have the ability to be used
“as a screening tool for all patients
in a practice with interest in dry eye
management, or as part of the data/
history collection in a specialty dry
eye practice.”
The ideal dry eye questionnaire
should also cover certain symptoms.
“Key symptoms must be included
such as blurred or transient blurred
vision, dryness/grittiness, irritation,
burning and watering,” Dr. Kar-
pecki says, and also include severity,
frequency and which eye drops are
currently being used.
Dr. Donnenfeld adds, “We want
to know the patient’s ability to
function at normal tasks.”
Dr. Sheppard envisions the devel-
opment of something more techno-
logically advanced. “I would have a
questionnaire that the patient could
fill out at home in a reproducible
format that we could then plug in
digitally when they walk into the
office with essentially no effort on
the part of the technician,” he says.
“The information would then ap-
pear as a global score on the chart,
012_RCCL0415_F1ANDF2.indd 19
Clin Microbiol. 1996;34(10):2426-2431.
6. Nichols JJ. Annual Report: Contact Lenses
2013. Contact Lens Spectrum;29(January
2014):22-28.
7. Zantos SG, Holden BA. Ocular Changes
Associated with Continuous Wear of Contact
Lenses. The Australian Journal of Optometry.
1978;61(12):418-26.
8. Nilsson, S. Seven-day extended wear and 30-
day continuous wear of high oxygen transmis-
sibility soft silicone hydrogel contact lenses: a
randomized 1-year study of 504 patients. CLAO
J. 2001;27(3):125-36.
9. Stapleton F, Keay L, Jalbert I, Cole N.
Altered Conjunctival Response After Contact
Lens–Related Corneal Inflammation. Cornea.
2003;22(5):443-7.
10. Sankaridurg PM, Vuppala N, Sreedharan A,
et al. Gram negative bacteria and contact lens
with maybe a bar graph read-out
that tells us this is aqueous defi-
ciency, this is lipid deficiency, this is
blepharitis, this is allergy.” Histori-
cal data could then portray the pro-
gression or resolution of important
complaints in one readout, he says.
Ultimately, the choice of which—
if any—dry eye questionnaire
depends on practitioner preference.
But no matter what, “providing
surveys to patients about their
symptoms demonstrates a sense of
empathy for their condition that
many practitioners fail to do,”
Dr. Hauser says. “Often, dry eye
patients feel as if they are relegated
to an afterthought by their doctors.
The patients recognize that their ac-
tivities of daily living have been in-
hibited, if not devastated, by ocular
surface disease, and they appreciate
the attention to their plight.” RCCL
1. Gayton JL. Etiology, prevalence and treat-
ment of dry eye disease. Clin Opthalmol. 2009;
3:405-12. www.ncbi.nlm.nih.gov/pmc/articles/
PMC2720680/
2. Savini G, Prabhawasat P, Kojima T, et al. The
challenge of dry eye diagnosis. Clin Ophthalmol.
2008 Mar;2(1):31-55.
3. Bjerrum KB. Test and symptoms in kerato-
conjunctivitis sicca and their correlation. Acta
Ophthalmol Scand 1996;74:436–41.
4. Hay EM, Pal TB, et al. Weak association between
subjective symptoms of and objective testing for
dry eyes and dry mouth: results from a population
based study. Ann Reum Dis 1998;57:20–4.
REVIEW OF CORNEA & CONTACT LENSES | APRIL 2015
induced acute red eye. Indian J Ophthalmol,
1996;44(1):29-32.
11. Crook, T. Corneal infiltrates with red eye re-
lated to duration of extended wear. J Am Optom
Assoc. 1985;56(9):698-700.
12. Holden BA, La Hood D, Grant T, et al. Gram-
negative bacteria can induce contact lens related
acute red eye (CLARE) responses. CLAO J.
1996;22(1):47-52.
13. Binder PS. The physiologic effects of ex-
tended wear soft contact lenses. Ophthalmology.
1980;87(8):745-9.
14. Robboy MW, Comstock TL, Kalsow CM. Con-
tact Lens-Associated Corneal Infiltrates. CLAO J
2003;29(3):146-54.
15. Sweeney DF, Grant T, Chong MS, et al. Recur-
rence of acute inflammatory conditions with
hydrogel extended wear. Invest Opthalmol Vis
Sc 34:S1008.
5. McMonnies CW. Key questions in a dry eye his-
tory. J Am Otpom Assoc. 1986 Jul;57(7):512-7.
6. McMonnies CW, Ho A. Patient history in screen-
ing for dry eye conditions. J Am Optom Assoc.
1987;58:296-301.
7. McMonnies CW, Ho A. Responses to a dry eye
questionnaire from a normal population. J Am
Optom Assoc. 1987:58:588-591.
8. Nichols KK, Nichols JJ, Mitchell GL. The reli-
ability and validity of McMonnies Dry Eye Index.
Cornea. 2004 May;23(4):365-71.
9. Begley C, Chalmers RL, Mitchell GL et al. Char-
acterization of Ocular Surface Symptoms from
Optometric Practices in North America. Cornea
2001;20(6):610-18.
10. Begley CG, Caffery B, Chalmers RL, et al. Use of
the Dry Eye Questionnaire to Measure Symptoms
of Ocular Irritation in Patients with Aqueous Tear
Deficient Dry Eye. Cornea 2002;21(7):664-70.
11. Walt JG, Rowe MM, Stern KL. Evaluating the
functional impact of dry eye: the Ocular Surface
Disease Index [abstract]. Drug Inf J. 1997;31:1436.
12. Grubbs JR Jr, Tolleson-Rinehart S, Huynh K, Da-
vis RM. A review of quality of life measures in dry
eye questionnaires. Cornea. 2014 Feb;33(2):215-8.
13. Simpson TL, Situ P, Jones LW, et al.. Dry eye
symptoms assessed by four questionnaires. Op-
tom Vis Sci. 2008;85:692–699.
14. Espindle D, Simpson T, Nelson J, et al. Develop-
ment and validation of the impact of dry eye on
everyday life (IDEEL) questionnaire, a patient-
reported outcomes (PRO) measure for the assess-
ment of the burden of dry eye on patients. Health
Qual Life Outcomes. 2011 Dec 8;9:111.
15. Ngo W, Situ P, Keir N, et al. Psychometric
properties and validation of the Standard Patient
Evaluation of Eye Dryness questionnaire. Cornea.
2013;32(9):1204-10.
16. Sakane Y, Yamaguchi M, Yokoi N, et al. Devel-
opment and validation of the Dry Eye-Related
Quality-of-Life Score questionnaire. JAMA Oph-
thalmol 2013 Oct:131(10):1331-8.
17. The Epidemiology of Dry Eye Disease: Report
of the Epidemiology Subcommittee of the Inter-
national Dry Eye WorkShop (2007). The Ocular
Surface. April 2007;5(2):93-107.
19
3/27/15 3:44 PM
 SPECIAL CARE
Keeps Specialty
Lens Wearers
Contact lens care is a vital

Safe
step to the continued safety
and health of the contact lens
patient. So how does lens care
differ in the case of sclerals
and other specialty lenses?
By Susan J. Gromacki, OD, MS

W
e and our

Photo: Greg DeNaeyer, OD

patients are
fortunate
to live in an
age where
we have a variety of contact lens
options designed to improve
vision and comfort, and promote
ocular surface health. These
specialty lenses are truly different
and, as such, require special care.

SCLERAL CONTACT LENSES

Currently, scleral gas permeable
(GP) contact lenses represent the
fastest growing segment of the
specialty contact lens industry.1
Already invaluable for treating
patients with keratoconus and
other corneal irregularities, scleral
lenses are now also being worn
by healthy patients who require
simple refractive correction.
Inherently larger than corneal
GP lenses, sclerals are designed to
vault the cornea and rest on the
sclera. As such, they must be filled
with solution prior to application
to prevent air bubbles from form-
ing underneath the lens (Figure 1),
which can compromise comfort,
vision and corneal health (i.e.,
compression of the epithelium
Fig. 1. Scleral contact lens with insertion bubble.
and differential oxygen levels). In
order to prevent this solution from
spilling during application, patients
should be instructed to keep their
head down, parallel to the ground.
In this position, the patient should
open both eyelids wide (scleral
lenses average about 16.0mm in
diameter), gently place the lens on
the conjunctiva and then close the
eyelids.2
ABOUT THE AUTHOR
Dr. Gromacki is a Fellow of
the American Academy of
Optometry and a Diplomate
in the Cornea, Contact Lens,
and Refractive Technologies
section. She has written
extensively and lectured
internationally on the topics of cornea and
contact lenses and serves as the Director of the
Contact Lens Service at a subspecialty group
practice in Maryland.

20 REVIEW OF CORNEA & CONTACT LENSES | APRIL 2015

020_RCCL0415_F3.indd 20 3/27/15 3:44 PM

 Note a scleral lens’s thickness
(approximately 0.3mm), diameter
and depth can affect its center of
gravity, making it more difficult to
balance the lens on one finger com-
pared with a soft or corneal GP
lens. As such, a number of methods
may be utilized to assist in holding
the lens for proper insertion:
• The “tripod method.” After
forming a tripod with the thumb,
index finger and middle finger, rest
the lens in the center of the three
digits for application.
• A large DMV or suction cup.
As a recommendation, cut a small
slice off the bottom or order the
suction cup fenestrated so that it
will be easier to remove from the
lens following placement on the
ocular surface.
• A #8 O-ring. Available from
GP lens manufacturers or at many
hardware stores. Before applica-
tion, place the ring on the tip of the
index finger and place the lens on
top of the ring.3
• Ezi Scleral Lens Applicator (Q-
Case). A ring-like device equipped
with a bowl on which to balance
the scleral lens during application.
• See Green Lens Inserter
(Dalsey Adaptives). A device
equipped with a permanent stand-
ing suction cup and green light to
Fig. 2. The See Green Lens Inserter with stand
(Dalsey Adaptives).
020_RCCL0415_F3.indd 21
help focus the patient’s gaze during
application (Figure 2). According
to the manufacturer, the device is
particularly suited for patients who
struggle with manual dexterity, are
monocular and cannot see the lens,
or need to hold their eyelids.4
FILLING THE LENS
Scleral lenses provide minimal tear
exchange, meaning the solution
placed in the bowl of the lens prior
to application remains in direct
contact with the cornea during
most of the lens-wearing day; thus,
it is critical to use a nonpreserved
solution to prevent preservatives
from inducing allergic or hypersen-
sitivity reactions.5,6
Scleral lenses are commonly
filled with unit-dose sodium chlo-
ride 0.9% inhalation/irrigation
solution, which can be obtained in
3mm or 5mm vials from a phar-
macy or online. Note that although
it is a non-prescription item, some
pharmacies may still require a pre-
scription. I provide a preprinted,
signed medical prescription to all
of my scleral lens patients. This has
two benefits: it tells the pharma-
cist that the solution is for scleral
contact lenses (thus saving us both
a phone call) and it increases the
likelihood that the patient’s medi-
cal insurance will cover
the expense.5,6
Scleral patients suf-
fering from dry eye
and those whose lenses
exhibit areas of touch
or minimal clearance
may benefit from fill-
ing their lenses with
unit-dose artificial tears
instead, which provide
extra lubrication and
corneal protection.
Keep in mind, how-
ever, that only the clear
brands, not the milky
REVIEW OF CORNEA & CONTACT LENSES | APRIL 2015
Enzymatic Cleaners
Patients wearing GP, soft or
hybrid lenses who are prone
to heavy protein deposition
can use an enzymatic cleaner
once per week or more.
or viscous ones, will work without
compromising visual clarity. Also,
try to avoid formulations with HP-
GUAR; while a fantastic wetting
agent, it has the potential to gel
underneath the lens.7
Manufacturers are also increas-
ingly recommending against use
of larger (e.g., 4 oz.) bottles of non-
preserved saline because they often
contain buffers, which can con-
tribute to debris or mucin buildup
underneath the lens.8,9 Patients
are also less likely to comply with
discarding a larger bottle should it
become contaminated.
Note that all of the options cur-
rently available for filling scleral
lenses are considered off-label by
the US Food and Drug Administra-
tion. That being said, research may
one day produce a solution that is
more biocompatible and similar to
the tear film, but for now, unit-
dose nonpreserved saline is the best
option we have at this time.5,6
CLEANING SCLERAL LENSES
Scleral contact lenses are simply
large GP lenses, so any solutions
approved to clean and disinfect
corneal GP lenses can be used for
scleral lenses. However, because
there is less tear flow under the
edge of a scleral lens compared
with a corneal GP lens, additional
care should be taken to ensure that
the lens surface is both clean and
free of pathogens. I recommend
a separate daily cleaner for all
scleral lenses, regardless of whether
they’re plasma-treated or not.
21
3/27/15 3:45 PM
 SPECIAL CARE KEEPS SPECIALTY LENS WEARERS SAFE

Examples of daily cleaners suit- recommendation to rinse with a GP multipurpose solution such as
able for GP lenses include: Boston saline, rather than tap water, to re- Boston Simplus Multi-Action Solu-
Cleaner (Bausch + Lomb), Boston move all cleaner from the lens, due tion (Bausch + Lomb), Menicon
Advance Cleaner (Bausch + Lomb), to the fact that all water contains Unique pH (Menicon), Optifree
Optifree Daily Cleaner (Alcon), some levels of bacteria, fungi and GP (Alcon), or Optimum C/D/S
or Optimum by Lobob ‘Extra amoebae.11 (Lobob). In addition, the Menicon
Strength Cleaner’ (Lobob). The lat- Lens disinfection should be Deluxe Care System (with Progent)
ter, or an isopropyl alcohol-based performed with a GP condition- is now approved for home use.
cleaner approved for GP lenses, ing/disinfection solution such as Many scleral lens fitters advise
may be preferable for cleaning high Boston Advance Comfort Formula sensitive patients to rinse the lens
Dk materials, which may scratch Conditioning Solution (Bausch + with nonpreserved saline prior to
more easily with more abrasive Lomb) or Boston Conditioning application. While this removes
cleaners. I also follow the FDA’s Solution (Bausch + Lomb) or with any residual solution—including
its preservatives—left over from
the disinfection process, it can also
Generic Solutions, Specific Problems diminish wettability. Hydrogen
According to a recent study, the main determinant (38%) of which peroxide solutions like PeroxiClear
type of contact lenses were fitted and purchased was price.14 If lens (Bausch + Lomb) or Clear Care
price has such an effect on the final selection when the doctor is (Alcon) are good preservative-
the primary decision-maker, imagine its considerable impact when free alternatives; however, these
patients are making purchasing decisions on their own, such as solutions are FDA-approved for
when selecting a solution. GP lenses only if they are digitally
Every year or so, a retailer entertains bids on which company will rubbed prior to disinfection. If
produce and package its private-label solution. When the contract necessary, larger cases that accom-
expires, the formulation may likely change. Because a retailer modate diameters up to 30mm can
generally accepts the lowest bidder, companies typically do not be obtained from online stores like
place their premium solutions in generic bottles. So, because the Dry Eye Shop. The catalytic
expiration dates are typically 18 to 36 months into the future, there neutralization disc is not included
could be two different chemical formulations residing in two of with purchase, however, so one
the same bottles sitting side-by-side on the store shelf. Likewise, a
needs to be transferred from the
retailer can label two bottles of the same formulation differently—
smaller case prior to use.12
each to mimic popular brands.15,16
The bottom line: older formulations were the state-of-the art 10
HYBRID LENSES
or 15 years ago, and most work well for most patients. But since
Hybrid contact lenses are com-
then, we have learned more about material/solution interaction;
prised of a GP center surrounded
the private label solution may not be what’s most compatible
by a hydrophilic skirt. Examples
for the patient.17,18 Research has also demonstrated a statistically
include the Duette and Ultra-
higher rate of such ocular complications with patients who use
Health (SynergEyes). Manufacturer
private label compared with name-brand solutions.19
guidelines advise patients who
Additionally, FDA recommended in 2010 that all multipurpose
wear these lenses to digitally rub
solutions carry “rub and rinse” instructions, and the care systems
the lens, front and back, with a
launched since then have complied. However, some mass retail-
daily cleaner approved for silicone
ers’ packages still contain the words “no rub.” It has been common
knowledge for several years that a cleaner lens is a healthier lens,
hydrogel soft lenses, then rinse off
and research has proven that digitally rubbing a lens is more effec-
the cleaner with nonpreserved sa-
tive than not at removing the deposits that can lead to inflamma-
line. For disinfection, manufacturer
tion or infection.20 guidelines recommend Clear Care
We have made great advances in solutions over the past few (Alcon), BioTrue (Bausch + Lomb),
years—including improved cleaning and disinfection, less toxicity, Renu fresh (Bausch + Lomb) or
and increased comfort and wettability—and the patient who buys Complete Easy Rub (Abbott Medi-
generic isn't benefiting from that technology.16 cal Optics). It should be noted that
UltraHealth, due to its vaulted

22 REVIEW OF CORNEA & CONTACT LENSES | APRIL 2015

020_RCCL0415_F3.indd 22 3/27/15 3:45 PM


Fig. 3. Acceptable NovaKone (Alden Optical) fit on a keratoconic eye,
enhanced with high molecular weight fluorescein.
design, needs to be filled with non-
preserved saline or artificial tears
prior to insertion, then inserted
with the head kept down similar to
inserting a scleral lens.
For keratoconus patients who
wear the KC and ClearKone
(SynergEyes) hybrid lenses, preser-
vative-based care systems should
be avoided. Hybrid lens manufac-
turer guidelines recommend Clear
Care or Oxysept Ultracare (Abbott
Medical Optics).
For all hybrid lenses, a digital
rubbing step is required, as they
have a six-month replacement
schedule. Since they contain a soft
skirt, gas permeable solutions are
contraindicated.
SOFT LENSES FOR
KERATOCONUS
There are now excellent soft con-
tact lens designs used specifically
to treat keratoconus. Because these
lenses are custom-produced and
last up to three months, a digital
rubbing step is typically recom-
mended. (Of specific note, Bausch
+ Lomb recommends rubbing its
KeraSoft IC lens in between the
fingers, rather than in the palm of
the hand.13)
020_RCCL0415_F3.indd 23
Because soft lenses for kera-
toconus tend to be thicker than
disposable soft contact lenses, most
manufacturers recommend using
nonpreserved disinfectants because
of the potential for absorption
into the lens matrix. Alden Optical
recommends hydrogen peroxide
systems for its NovaKone lens
(Figure 3), while Bausch + Lomb
recommends use of either multi-
purpose or hydrogen peroxide
with its KeraSoft IC. However, if
multipurpose solution is used, B+L
suggests rinsing it off with sterile
rinsing solution prior to applica-
tion.13
CONCLUSION
The fitting of scleral and other
specialty contact lenses requires
great diligence and attention to de-
tail on the part of the practitioner.
However, even the best scleral lens
fit can be compromised by poor
lens care on the part of the patient.
This part of the equation is just as
critical to contact lens success.
For further information on con-
tact lens care, please consult each
lens and/or material manufacturer
for its specific care recommenda-
tions. RCCL
REVIEW OF CORNEA & CONTACT LENSES | APRIL 2015
1. Nichols, J. 2014 annual report: Contact lenses
2014. Contact Lens Spectrum. 2015;30(1):22-
27.
2. Gromacki SJ. Handling and care of scleral
GP contact lenses, Part 1. Contact Lens Spec-
trum. 2011;27(10):27.
3. Gromacki SJ. Scleral GP contact lens inser-
tion, removal, and care. [Webinar.] Gas Perme-
able Lens Institute, March 2014. Available at:
www.gpli.info/videos/webinar-2014-03.htm.
4. Dalsey Adaptives. The See-Green Lens In-
serter. Available at: www.dalseyadaptives.com.
Accessed February 2015.
5. Gromacki SJ. Handling and care of scleral
GP contact lenses, Part 2. Contact Lens Spec-
trum. 2012;27(1):19.
6. Gromacki SJ. Scleral GP lens preparation:
The latest standard of care. Contact Lens
Spectrum. 2013;28(11):25.
7. Smythe M. Personal communication, April
10, 2014.
8. Imavasu M, Hori Y, Cavanagh HD. Effects of
multipurpose contact lens care solutions and
their ingredients on membrane-associated
mucins of human corneal epithelial cells. Eye
Contact Lens. 2010 Nov;36(3):361-6.
9. Gorbet MB, Tanti NC, Jones L, Sheardown
H. Corneal epithelial cell biocompatibility to
silicone hydrogel and conventional hydrogel
contact lens packing solutions. Mol Vis 2010
Feb 19;16:272-82.
10. US Food and Drug Administration. Medical
Devices. Available at: www.fda.gov/Medi-
calDevices/ProductsandMedicalProcedures/
HomeHealthandConsumer/ConsumerProducts/
ContactLenses/. Accessed February 2015.
11. Ward M. General Session #9: Contact Lens
Care. Lecture at The Global Specialty Lens
Symposium, January 24, 2015; Las Vegas,
Nevada.
12. The Dry Eye Shop. Lens Cases. Available
at: www.dryeyeshop.com/lens-cases-c95.aspx.
Accessed February 2015.
13. A&R Optical. Patient Instruction/Wearer’s
Guide for Intelliwave3/KeraSoft IC. Available
at: www.artoptical.com/files/documents/
resources/Intelliwave_Patient_Instruction_-_
Efrofilcon_A_1.pdf. Accessed February 2015.
14. Ichijima H, Shimamoto S, Ariwaka Y, et al.
Compliance study of contact lens wearing in
Japan, part 1: Internet survey of actual circum-
stances of lens use. Eye & CL 2014;40(3):169-
174.
15. Ferris State University. Private Label Lens
Care Guide. Available at: www.ferris.edu/
HTMLS/colleges/michopt/vision-research-
institute/PDFs/contact-lens-solutions.pdf.
Accessed February 2015.
16. Gromacki SJ. The truth about generics.
Contact Lens Spectrum. 2005;20(12):24.
17. Green JA, Phillips KS, Hitchins VM, et al.
Material Properties That Predict Preservative
Uptake for Silicone Hydrogel Contact Lenses.
Eye Contact Lens. 2012 Nov;38(6):350-357.
18. Andrasko G, Ryen K. Corneal staining and
comfort observed with traditional and silicone
hydrogel lenses with multipurpose solution
combinations. Optom. 2008; 79: 444-454.
19. Forister JY, Forister EF, Yeung KK, et al.
Prevalence of contact lens-related complica-
tions: UCLA contact lens study. Eye Contact
Lens. 2009;35(4):174-80.
20. Schnider C: Clinical performance and effect
of care regimen on surface deposition of galy-
filcon A contact lenses. [Electronic abstract
055102.] Optom Vis Sci. 2005; 82.
23
3/27/15 3:45 PM
 1 CE
Credit
(COPE Approval
Pending)
IS THAT CORNEAL
INFILTRATE STERILE
OR INFECTIOUS? Differentiating between the two requires close observation and analysis.
D
oes this sound famil-
iar? “Doctor, I don’t
understand what’s
wrong. I have been
wearing my contact
lenses overnight for years and this
has never happened before.” Upon
close examination, you note the
presence of small, grayish aggre-
gates in the corneal epithelium. The
diagnosis? Corneal infiltrates. But
how do you tell if they are sterile or
infectious—harmless, or a potential
serious problem?
As practitioners, we have seen
any number of contact lens-related
complications walk through our
doors. Corneal infiltrates and ulcers
are two such examples that have
long been an unfortunate reality of
patient care. In the 19th century,
treatment of corneal ulcers included
chemical cauterization with silver
nitrate. While we’ve come a long
way since those days in the care we
provide, when such adverse events
occur, differentiating infectious and
sterile infiltrates is still no easy task.
BREAKING IT DOWN
Corneal infiltrates result from the
penetration of white blood cells
into the corneal tissue as part of
the body’s inflammatory response
24 REVIEW OF CORNEA & CONTACT LENSES | APRIL 2015
024_RCCL0415_F4_CE.indd 24
Here’s a results-oriented approach.
By Jeffrey Sonsino, OD, and Shachar Tauber, MD
to the presence of bacterial tox-
ins, enzymes and byproducts.1-4 A
corneal ulcer, by comparison, is an
epithelial defect with underlying
inflammation (which typically leads
to necrosis of corneal tissue).
Infiltrates and ulcers are similar
in that they both involve disruption
of the corneal epithelium; indeed, a
staining infiltrate may be the begin-
ning of a corneal ulcer. The differ-
ence, however, is that while corneal
infiltrates are not sight-threatening,
corneal ulcers involve active tissue
damage caused either by infectious
or non-infectious etiologies. Infec-
tious ulcers are caused by fungus,
virus, or parasites like Acantham-
oeba) or, most commonly, bacteria.5
Alternately, noninfectious ulcers
result from autoimmunity, neuro-
trophic keratitis, allergy (e.g., shield
ulcers), inflammation from blepha-
ritis or chemical burns, or idiopath-
ic conditions (e.g., Mooren’s ulcer).
In the case of microbial insult,
the damage typically results in an
excavation of the corneal stroma,
which triggers an anterior chamber
response of flare with or without
cells (Figures 1, 2 and 3). For this
reason, the terms microbial keratitis
and bacterial ulcer are sometimes
used interchangeably.
Four subtypes of contact lens-
related corneal infiltrates exist:
microbial keratitis, contact lens-
induced peripheral ulcer (CLPU),
contact lens-induced acute red eye
(CLARE) and infiltrative keratitis.
While the etiology of these subtypes
is multifactorial, research shows
significant overlap between their
clinical presentations, suggesting it
is not possible to clinically differ-
entiate between them; rather, they
should be considered as stages of a
single disease spectrum.6
ABOUT THE AUTHORS
Dr. Sonsino is a partner in a
specialty contact lens and
anterior segment practice
in Nashville, Tenn. He is a
diplomate in the cornea,
contact lens, and refrac-
tive therapies section of
the AAO, a council member
of the cornea and contact lens section
of the AOA, a fellow of the Scleral Lens
Education Society and an advisory board
member of the GPLI. Dr. Sonsino is board-
certified by the ABO.
Dr. Tauber is an ophthal-
mologist at Mercy Clinic Eye
Specialists and Surgery
Center. He is a fellow of
the American Academy
of Ophthalmology and a
member of the American
Society of Cataract and Re-
fractive Surgery and International Ocular
Surface Society.
3/27/15 4:02 PM

Fig. 1. Slit beam evaluation of a corneal ulcer. Deviation of the beam shows
corneal excavation.
THE “TWO CORNEAS”
When determining whether the cor-
neal infiltrate is infectious or sterile,
one helpful method is to divide the
cornea into two distinct regions.
Consider that the central cornea
encompasses the 6mm of the
cornea apex whereas the peripheral
cornea is a 2mm to 4mm dough-
nut, with the limbus as its posterior
border.
Based upon the close approxima-
tion of the peripheral cornea to the
limbus (with its preponderance of
stem cells and vascularity), investi-
gators believe the immune response
to be more active in this region
of the cornea. Quantification of
the nerve fibers shows a densely
innervated cornea and a five to six
times lower innervated peripheral
cornea.7 Higher mitotic activity
has also been demonstrated in the
peripheral cornea.8
These observations indicate the
two distinct regions of the cornea
have key anatomic, physiologic and
pathologic differences, allowing for
the generalization that infiltrates
in the periphery of the cornea are
non-infectious while infiltrates in
the central 6mm of the cornea may
have an infectious etiology.9
024_RCCL0415_F4_CE.indd 25
ALWAYS TAKE NOTES
As with any medical concern that
presents to the clinic, careful his-
tory taking can lead the eye care
practitioner to identify the proper
diagnosis and resultant treatment
that gives the patient the best pos-
sible outcome with the least risk.
• Contact lenses. Contact lens
use is one identified risk factor for
the development of corneal infil-
trates, as evidence shows continu-
ous wear of contact lenses increases
the risk of ocular complications.
However, it is not the primary
cause of corneal infiltrates; rather,
it is simply one of several contribu-
tors. Other risk factors for corneal
infiltrate development in con-
tinuous wear contact lens patients
include age (i.e., between 18 and
Release Date: April 2015
Expiration Date: April 1, 2018
Goal Statement: This course reviews the eti-
ology, contributing factors and clinical pre-
sentations of sterile and infectious corneal
infiltrates. Key points in ocular examination
and treatment will also be discussed.
Faculty/Editorial Board:
Jeffrey Sonsino, OD, and Shachar Tauber, MD
Credit Statement: COPE approval for 1 hour
of continuing education credit is pending
for this course. Check with your state licens-
ing board to see if this counts toward your
REVIEW OF CORNEA & CONTACT LENSES | APRIL 2015
29 years) and a history of smoking,
corneal scarring, contact lens acute
red eye or corneal infiltrates.10
Of the different corneal infiltrate
types, microbial keratitis is the most
severe complication of contact lens
wear. In the 1980s and 1990s, risk
of microbial keratitis was found
to be four cases per 10,000 lens
wearers per year for daily wear and
20 cases per 10,000 wearers per
year for extended wear.11,12 Pseudo-
monas aeruginosa has been identi-
fied as the most common bacterial
source of microbial keratitis in
contact lens wearers.13
• Corneal trauma. Risk of micro-
bial keratitis also increases any time
there is a history of corneal trauma
or foreign body presence due to the
possibility of incomplete removal.
This is especially true when the
foreign body is vegetative matter,
which is more likely to be con-
taminated by pathogens. Corneal
trauma may also include iatrogenic
etiologies, such as retained or bro-
ken sutures in penetrating kerato-
plasty patients.
• History of surgery. Because
anterior segment surgery compro-
mises epithelial barrier function,
any corneal surgery carries a risk
of resultant infiltrative keratitis and
infectious ulcer. In particular, infil-
trative keratitis is associated with
astigmatic keratectomy, penetrating
keratoplasty, DSAEK, pterygium
removal, trabeculectomy, LASIK
CE requirements for relicensure.
Joint-Sponsorship Statement: This contin-
uing education course is joint-sponsored
by the Pennsylvania College of Optometry.
Disclosure Statement: Dr. Sonsino con-
sults for SynergEyes, Bausch + Lomb,
Alcon, Visionary Optics and Optovue, has
received grant support from Visioneering,
and owns stock in LVR Technology.
Dr. Tauber consults for AMO and Allergan,
has received grant support from the
Department of Defense, and owns stock in
Calhoun Vision and Ocugenics.
25
3/27/15 4:02 PM
 IS THAT CORNEAL INFILTRATE STERILE OR INFECTIOUS?
Fig. 2. Sodium fluorescein evaluation of a corneal ulcer. The hyperfluorescence
is attributed to staining of the mucous plug.
and cataract surgery.14-17 It is not
clear if the relative risk is greater
with regards to a particular corneal
surgery.
• Ocular surface disease. Sterile
peripheral (i.e., marginal) corneal
infiltrates may result from a com-
promised ocular surface. Staphlo-
coccal blooms in the lids spill bacte-
rial byproducts onto the cornea,
which triggers a hypersensitivity
reaction that is theorized to lead
to infiltrates.18,19 Often small and
multiple in nature, these infiltrates
are typically positioned roughly
1mm from the limbus. Marginal
infiltrates may be asymptomatic, or
may be accompanied by conjuncti-
val injection. Pathogenesis includes
bacterial, allergic or autoimmune
etiologies.
In the case of severe blepharitis
and meibomian gland dysfunction
(MGD), the bacterial blooms within
the meibomian glands can produce
a hypersensitivity reaction, leading
to peripheral, non-staining subepi-
thelial infiltrates (SEIs). The body
responds to the to antigen presented
by this presence of Staphlococcal
bacteria in the lids by recruiting
white blood cells to the area as part
of an antibody response. For this
reason, the SEIs associated with
26 REVIEW OF CORNEA & CONTACT LENSES | APRIL 2015
024_RCCL0415_F4_CE.indd 26
Staphlococcal marginal keratitis are
typically in the 2 o’clock and 10
o’clock regions and the 4 o’clock
and 8 o’clock regions, contiguous
with the upper and lower lids.
Similarly, ocular rosacea can
lead to MGD. However, with
severe rosacea, potential outcomes
include marginal infiltrates, chronic
conjunctivitis, sterile ulceration,
corneal neovascularization and
corneal scarring (Figures 4 and 5).
It is also critical to rule out herpes
simplex keratitis (HSK), which
may resemble the infiltrates seen in
Staphlococcal marginal keratitis.
HSK lesions, however, are typically
harder to treat and appear with
deeper stromal inflammation.20
• Allergic conjunctivitis. All
eye care practitioners are familiar
with the signs and symptoms of
Fig. 3. Contact lens-related microbial
keratitis. Ulcer filled with mucous
plug.
seasonal allergic conjunctivitis,
atopic conjunctivitis and papillary
conjunctivitis. Perhaps less com-
monly encountered, however, is
a variant of allergic conjunctivitis
found most often in young boys.
Vernal conjunctivitis is a severe
bilateral condition characterized
by photophobia, chemosis, sticky
discharge, eosinophils at the limbus
(i.e., Horner-Trantas dots) and
shield ulcers.21 Secondary bacterial
keratitis typically results from 10%
of shield ulcers.22
• Medications. Contamination
of ocular medications has been
implicated in numerous case studies
of corneal ulceration; the pathogen
may originate in topical medication
dropper tips or within the medica-
tions themselves.23,24
LOOK FOR THE SIGNS
The next step after collecting a
complete patient history is to con-
duct an ocular examination, which
can help determine whether an
infiltrate is sterile or infectious. The
following are all key elements of a
physical examination that can help
with proper diagnosis:
• Does the patient report symp-
toms of pain, photophobia or loss
of vision? What about corneal sen-
sation? Pain out of proportion with
the signs points to Acanthamoeba,
while loss of corneal sensation (i.e.,
lack of pain upon history or with
the corneal wisp test) signals HSK.
• Do you observe blepharitis,
nasolacrimal duct obstruction,
poor or incomplete blink or lag-
ophthalmos, entropion/ectropion
or conjunctival injection? Is the
conjunctival injection localized or
diffuse? How about circumlimbal?
Be sure to grade the injection (i.e.,
1-4+). What about corneal foreign
bodies?
• Is there discharge and, if so,
what are its characteristics?
3/27/15 4:02 PM

Fig. 4. Severe ocular rosacea. Visible on the lid is tyalosis, scalloped lid
margin and telangiectasia, which signals severe inflammation within the
meibomian glands.
• What is the location, depth and
size of the infiltrate(s)? Do you ob-
serve stromal loss?
• Is there visible loss of corneal
endothelium? What about plaque
or pigment on the endothelium?
• What is the status of the patient’s
corneal graft, if they have one?
• Do you observe any stromal
haze and edema?
• Do you observe anterior cham-
ber reaction, cells/flare or hypopyon?
• Are there vitreous cells present?
Note, a corneal ulcer will rarely
lead to endophthalmitis with vitre-
ous cells present.
THE CULTURAL REVOLUTION
In the last 20 years, a major shift
in thought regarding the need to
obtain corneal material to identify
offending organisms and deter-
mine sensitivity to antibiotics has
occurred. Today, broad-spectrum
fluoroquinolones are readily avail-
able as the primary treatment for
a corneal infiltrate believed to be
infectious. Thus, the majority of
community-acquired cases of bacte-
rial keratitis are typically resolved
with empiric therapy and managed
without smears or cultures.
024_RCCL0415_F4_CE.indd 27
However, such tests are indicated
in certain cases, including those that
involve a corneal infiltrate that is
central, large and extends to the mid
to deep stroma, particularly with
significant thinning of the cornea or
scleral extension; those chronic in
nature or unresponsive to broad-
spectrum antibiotics; and those that
present with atypical clinical fea-
tures suggestive of fungal, amoebic
or mycobacterial keratitis.25 Smears
and cultures may also be helpful
in cases with an unusual history,
such as trauma caused by vegetable
matter or if the patient wore contact
lenses while in a hot tub.25
Additional specialized studies can
help identify atypical organisms, for
example in sight-threatening or se-
vere keratitis of suspected microbial
origin.25 However, the American
Academy of Ophthalmology—not-
ing that the hypopyon that occurs
in eyes with bacterial keratitis is
usually sterile—recommends aque-
ous or vitreous taps should not be
performed unless there is a high
suspicion of microbial endophthal-
mitis, such as following an intra-
ocular surgery, perforating trauma
or sepsis.25
REVIEW OF CORNEA & CONTACT LENSES | APRIL 2015
When obtaining corneal mate-
rial, proper technique is critical
to identify the causative organism
and select the proper antibiotic,
antiviral, antifungal or antiproto-
zoal medications. The process of
obtaining corneal material should
first involve the instillation of a
topical anesthetic agent (note that
tetracaine should be avoided due to
its antimicrobial effect) followed by
the use of a heat-sterilized platinum
spatula, blade, jeweler’s forceps
or other similar sterile instrument
to obtain scrapings of material
from the advancing borders of the
infected area of the cornea. Culture
yield may be improved by avoiding
anesthetics with preservatives.
A thiol or thioglycollate broth-
moistened dacron/calcium alginate
or sterile cotton swab can also be
used to obtain material.25 However,
solid as well as liquid plating media
is always recommended.26 If treat-
ment is refractory and cultures do
not yield results, it is advisable to
halt antibiotics in order to isolate
the exact pathogen for further
treatment. It is also important to
consider culturing contact lenses,
contact lens cases and contact lens
solutions if appropriate and avail-
able.
TREATMENT OPTIONS
Topical antibiotics are the first-line
therapy for suspected or culture-
proven bacterial keratitis; however,
the selection depends on severity. A
peripheral infiltrate associated with
lid margin disease may be appro-
priately managed with inexpensive
early fluoroquinolones such as
ofloxacin, ciprofloxacin, azithro-
mycin or a polymixin-bacitracin
ointment, while central or more
aggressive infiltrates warrant use of
fourth-generation fluoroquinolones
such as gatifloxacin, moxifloxacin
or levofloxacin.
27
3/27/15 4:02 PM
 IS THAT CORNEAL INFILTRATE STERILE OR INFECTIOUS?
Fig. 5. Corneal scarring with severe
ocular rosacea.
For more serious keratitis, the use
of besifloxacin has recently been
advocated. This new fluoroquino-
lone has high MIC values for many
common ophthalmic pathogens
and a unique compound containing
polycarbophil, edetate disodium
dihydrate and sodium chloride,
which allows for greater ocular
surface contact time. Additionally,
its position as the only ophthalmic
fluoroquinolone not used systemi-
cally makes it unique by reducing
the risk of antibiotic resistance.
In severe situations with risk for
perforation, failure to respond to
monotherapy or central aggressive
ulcers with the potential for vision
loss, the use of combination forti-
fied-antibiotic therapy should be
considered. This should be formu-
lated by a compounding pharmacy
that is a member of the Pharmacy
Compounding Accreditation Board.
Note that methicillin-resistant
Staphylococcus aureus (MRSA)
has been isolated with increasing
frequency from patients with bacte-
rial keratitis. Fluoroquinolones are
generally poorly effective against
MRSA ocular isolates; however,
vancomycin has demonstrated some
success.27 In cases of severe ulcer,
consider more complete coverage
with combination therapy.28
Systemic antibiotics are rarely
needed, but may be considered in
severe cases where the infectious
process has moved to adjacent tis-
sues (e.g., the sclera) or when there
28 REVIEW OF CORNEA & CONTACT LENSES | APRIL 2015
024_RCCL0415_F4_CE.indd 28
is impending or frank perforation
of the cornea. Research shows oral
tetracycline controls the anti-
collagenase activity commonly seen
in necrotizing infections such as
Pseudomonas.29 Systemic therapy
is necessary in gonococcal keratitis
because of the extremely aggressive
nature of this organism (corneal
penetration in 24 hours with inad-
equate treatment). For this reason,
the CDC recommends immediate
hospitalization with IV antibiotics
for adult gonococcal infection.
Treating viral, fungal and amoe-
bic keratitis may be challenging and
is beyond the scope of this article.
Regardless, the eye care provider
who has clinical suspicion or labo-
ratory data supporting any of these
infectious processes should be fluent
in their current treatment options
or have available the appropriate
consultants to offer prompt referral.
Determining whether an infiltrate
is sterile or infectious is not an easy
task for even the best clinicians.
However, with careful history tak-
ing, physical examination, differen-
tial diagnosis and proper treatment,
patients have the best chance of
making the best of a bad situation. RCCL
1. Josephson JE, Caffery BE. Infiltrative keratitis
in hydrogel lens wearers. Int Contact Lens Clin.
1979;6:223–41.
2. Szczotka-Flynn L, Lass JH, Sethi A, et al. Risk
factors for corneal infiltrative events during con-
tinuous wear of silicone hydrogel contact lenses.
Invest Ophthalmol Vis Sci. 2010 Nov;51(11):5421-30.
3. Pearlman E, Johnson A, Adhikary G, et al.
Toll-like receptors at the ocular surface. Ocul Surf.
2008;6:108–16.
4. Sweeney DF, Naduvilath TJ. Are inflammatory
events a marker for an increased risk of microbial
keratitis? Eye Contact Lens. 2007 Nov;33(6 Pt
2):383-7; discussion 399-400.
5. Online Merck Manual. Corneal Ulcer. Available
at: www.merckmanuals.com/professional/eye_
disorders/corneal_disorders/corneal_ulcer.html.
Accessed March 10, 2015.
6. Efron N, Morgan PB. Can subtypes of contact
lens-associated corneal infiltrative events be clini-
cally differentiated? Cornea. 2006 Jun;25(5):540-4.
7. Müller, Vrensen, Pels, et al. Architecture of Hu-
man Corneal Nerves. Invest Ophthalmol Vis Sci.
April 1997;38(5):985-94.
8. Lemp MA, Mathers WD. Corneal Epithelial Cell
Movement in Humans. Eye. 1989;3:438-45.
REVIEW OF CORNEA & CONTACT LENSES | JANUARY 2015
9. Mah FS. Corneal infiltrates merit care: Differ-
entiating sterile and infectious conditions key to
diagnosis, treatment. Ophthalmology Times. 2010
Oct;35(19):42.
10. McNally JJ, Chalmers RL, McKenney CD,
Robirds S. Risk factors for corneal infiltrative
events with 30-night continuous wear of silicone
hydrogel lenses. Eye Contact Lens. 2003 Jan;29(1
Suppl):S153-6; discussion S166, S192-4.
11. Poggio EC, Glynn RJ, Schein OD, et al. The
incidence of ulcerative keratitis among users
of daily-wear and extended-wear soft contact
lenses. N Engl J Med. 1989;321:779–83.
12. Cheng KH, Leung SL, et al. Incidence of
contact-lens-associated microbial keratitis and its
related morbidity. Lancet. 1999;354:181–5.
13. Mondino BJ, Weissman BA, Farb MD, et al.
Corneal ulcers associated with daily-wear and
extended-wear contact lenses. Am J Ophthalmol.
1986;102:58–65.
14. Adrean SD, Cochrane R, Reilly CD, Mannis MJ.
Infectious keratitis after astigmatic keratotomy in
penetrating keratoplasty: review of three cases.
Cornea. 2005 Jul;24(5):626-8.
15. Moon SW, Kim YH, Lee SC, Lee MA, Jin KH. Bi-
lateral peripheral infiltrative keratitis after LASIK.
Korean J Ophthalmol. 2007 Sep;21(3):172-4.
16. Villarrubia A, Cano-Ortiz A. Candida keratitis
after Descemet stripping with automated en-
dothelial keratoplasty. Eur J Ophthalmol. 2014
Nov-Dec;24(6):964-7.
17. Akpek EK, Demetriades AM, Gottsch JD.
Peripheral ulcerative keratitis after clear corneal
cataract extraction(1). J Cataract Refract Surg.
2000 Sep;26(9):1424-7.
18. Mondino BJ. Inflammatory diseases of the
peripheral cornea. Ophthalmol 1998;95:463-12.
19. Mondino BJ, Lahedi AK, Adamu SA. Ocular
immunity to Staphylococcus aureus. Invest Oph-
thalmol Vis Sci 1987;28:560.
20. One Network. Herpes Simplex Virus.
Available at: one.aao.org/focalpointssnip-
petdetail.aspx?id=356f0d13-8853-410f-ac6b-
7ff5e0257800. Accessed March 25, 2015.
21. Bonini S, Coassin M, Aronni S, Lambiase A.
Vernal keratoconjunctivitis. Eye. 2004;18:345–51.
22. Reddy JC, Basu S, Saboo US, et al. Manage-
ment, clinical outcomes, and complications of
shield ulcers in vernal keratoconjunctivitis. Am J
Ophthalmol. 2013 Mar;155(3):550-9.
23. Donzis PB. Corneal ulcer associated with
contamination of aerosol saline spray tip. Am J
Ophthalmol. 1997 Sep;124(3):394-5.
24. Schein OD, Wasson PJ, et al. Microbial keratitis
associated with contaminated ocular medica-
tions. Am J Ophthalmol. 1988 Apr 15;105(4):361-5.
25. American Academy of Ophthalmology
Cornea/External Disease Panel. Bacterial keratitis.
Limited revision. San Francisco (CA): American
Academy of Ophthalmology (AAO); 2011.
26. Bhadange Y, Sharma S, Das S, Sahu SK. Role
of liquid culture media in the laboratory diagnosis
of microbial keratitis. Am J Ophthalmol. 2013
Oct;156(4):745-51
27. Eiferman RA, O'Neill KP, Morrison NA. Meth-
icillin-resistant Staphylococcus aureus corneal
ulcers. Ann Ophthalmol. 1991 Nov;23(11):414-5.)
28. Asbell PA, Colby KA, Deng S, et al. Ocular
TRUST: nationwide antimicrobial susceptibility
patterns in ocular isolates. Am J Ophthalmol
2008;145:951-8.
29. Ralph RA. Tetracyclines and the treatment
of corneal stromal ulceration: a review. Cornea.
2000 May;19(3):274-7.
28
3/27/15 4:02 PM
 CE TEST ~ APRIL 2015 EXAMINATION ANSWER SHEET
Is That Corneal Infiltrate Sterile or Infectious?
1. All of the following are likely symptoms or signs of corneal infection EXCEPT:
Valid for credit through April 1, 2018
a. Pain and photophobia.
b. Discharge and foreign body sensation. Online: This exam can also be taken online at www.reviewofcontactlenses.com.
c. Anterior chamber reaction that includes cell and flare. Upon passing the exam, you can view your results immediately. You can also
d. Lack of debris at the tear menuscus. view your test history at any time from the website.
Directions: Select one answer for each question in the exam and completely
2. There are many reasons to culture corneal ulcers. Which of the following darken the appropriate circle. A minimum score of 70% is required to earn credit.
is NOT one of them? Mail to: Jobson Optometric CE, Canal Street Station, PO Box 488 New York, NY 10013
a. Culturing would be a helpful medico-legal component of your record in case
Payment: Remit $20 with this exam. Make check payable to Jobson Medical
the ulcer doesn’t respond to empiric treatment.
Information LLC.
b. Culturing reveals sensitivities of the organism(s).
c. Because no single agent is generally effective for all infections. Credit: COPE approval for 1 hour of CE credit is pending for this course.
d. Because ineffectively treated organisms are difficult to isolate. Sponsorship: Joint-sponsored by the Pennsylvania College of Optometry
Processing: There is an eight-to-10 week processing time for this exam.
3. Currently, the most effective/complete treatment plan for resistant
bacterial infection is: Answers to CE exam:
a. Vancomycin and ceftazidime. 1. A B C D 6. A B C D
b. Tobramycin. 2. A B C D 7. A B C D
c. Gentamycin and Ocuflox.
3. A B C D 8. A B C D
d. Ocuflox and erythromycin.
4. A B C D 9. A B C D
4. Which of the following statements is true regarding corneal infiltrates? 5. A B C D 10. A B C D
a. Sterile infiltrates are often single in number and are found closer to the visual
Evaluation questions (1 = Excellent, 2 = Very Good, 3 = Good, 4 = Fair, 5 = Poor)
axis.
Rate the effectiveness of how well the activity:
b. Corneal infiltrates at least histologically present in all infections.
c. Large, central infiltrates with overlying stains are probably sterile. 11. Met the goal statement: 1 2 3 4 5
d. Corneal infiltrates associated with microbial keratitis generally produce little 12. Related to your practice needs: 1 2 3 4 5
to no pain and photophobia. 13. Will help improve patient care: 1 2 3 4 5
14. Avoided commercial bias/influence: 1 2 3 4 5
5. The most common cause of perennial allergic conjunctivitis is: 15. How do you rate the overall quality of the material? 1 2 3 4 5
a. Ragweed or tree pollen.
16. Your knowledge of the subject increased: Greatly Somewhat Little
b. Summer grasses.
c. Home allergens, such as dust mites and animal dander. 17. The difficulty of the course was: Complex Appropriate Basic
d. Multipurpose disinfecting solutions used in contact lens care. 18. How long did it take to complete this course? _________________________

6. Which of the following is not true regarding the use of systemic 19. Comments on this course: _________________________________________
antibiotics?
___________________________________________________________________
a. They often provide a more effective dose to the cornea than topicals alone.
b. They have a lower chance of producing an allergic response. 20. Suggested topics for future CE articles: ______________________________
c. They are often ineffective when the infection has scleral extension.
d. Tetracycline may aid in patients with an impending corneal melt. ___________________________________________________________________

7. Risk for infiltrative keratitis is increased with all of the following EXCEPT: Identifying information (please print clearly):
a. Poor compliance/hygiene. First Name
b. Smoking.
c. History of corneal scarring and CLARE. Last Name
d. Age 39 to 40.
Email
8. The incidence rate for microbial keratitis has been estimated to range from
The following is your: Home Address Business Address
what to what per 10,000 extended-wear lens patients per year:
a. 18 to 20. Business Name
b. 4 to 5.
c. 34 to 38. Address
d. 1 to 2.
City State
9. Which of the following is NOT a risk for microbial keratitis?
ZIP
a. Wearing contact lenses overnight.
b. History of corneal trauma or foreign body. Telephone # - -
c. Prior corneal surgery.
d. Daily use of aspirin. Fax # - -

10. Which of the following is true regarding monotherapy use in presumed
microbial keratitis?
a. A fourth-generation fluoroquinolone is probably the best overall option and
can be used alone for deep central ulcers.
b. Besivance is likely the best option for MRSA infections.
c. Monotherapy should be reserved for use in central infiltrates only.
d. Erythromycin is generally the best treatment option pending culture results.
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 111206, RO-RCCL-0415

REVIEW OF CORNEA & CONTACT LENSES | APRIL 2015 29

024_RCCL0415_F4_CE.indd 29 3/27/15 4:02 PM

 The GP Expert
By Stephanie L. Woo, OD
Troubleshooting GP Complications
Many GP lens problems are easily resolved once identified.
C
ontact lenses, whether
rigid or soft, are a
foreign object on the
ocular surface. They
interact with the tear
film, cornea, bulbar conjunctiva
and palpebral conjunctiva; not sur-
prisingly, complications may arise
on any of these ocular structures
as a result of contact. Addition-
ally, the tear film is separated into
a pre- and post- contact lens film
with different thicknesses, which
can initiate a variety of issues.1
3 AND 9 O’CLOCK STAINING
A common complication with
corneal GP lenses is 3 and 9
o’clock staining, which is a result
of epithelial punctate staining of
the peripheral cornea near the edge
of the GP lens.2 These so-called
3 and 9 o’clock areas may not be
adequately resurfaced with tears
after a blink, thus resulting in
small desiccated regions. At first
the staining is mild, but over time
the epithelial defects may become
larger and denser. In severe cases,
those portions of the cornea may
become vascularized and even
form an opacity.
When treating, be sure to check
the edge of the contact lens first.
If you have a modification unit
within the office, you can alter
the edge of the lens to be rounded
or a “plus” shape to help with
edge-cornea interaction.3 If your
patient has a particularly high plus
or high minus lens, be sure to use
lenticular lens designs to improve
the edge of the lens.4
Inferiorly centered GP lenses are
another major cause of 3 and 9
30 REVIEW OF CORNEA & CONTACT LENSES | APRIL 2015
030_RCCL0415_gpe.indd 30
o’clock staining, so improving the
centration of the GP lens is key.3
Additionally, selecting a GP lens
material with good wettability
may help to decrease peripheral
erosion by reducing friction be-
tween the lens and ocular surface.
Artificial tears and gels can also
help increase lubrication, but will
need to be used consistently to
prevent further complications.
If all other modifications fail, tryto track marks, which are both
altering the diameter of the lens.
Smaller diameters may decrease
Fig. 1. Foreign body entrapment under
GP lens shows track marks on the corneal
epithelium.
3 and 9 o’clock staining, though
going larger is also an option. A
scleral lens will resolve the issue
completely because of the fluid
layer between the cornea and the
contact lens, which will act as a
lubricating cushion between the
lens and ocular surface. Switching
the patient to a hydrogel material
may also be an answer.
FOREIGN BODIES
Foreign body tracking—when
dirt, dust or another small object
adheres to the ocular surface and
ends up underneath the lens—can
be an extremely frustrating issue
for both soft and GP lens wears
alike.
Even the smallest foreign body
can result in ocular surface dam-
age, as with every blink, the
trapped object scratches the
delicate epithelium. This can lead
very uncomfortable and potentially
painful for the patient (Figure 1).
Lens edge design plays a
major role regarding foreign
body entrapment; for exam-
ple, if the edge is poorly fin-
ished or has unpolished sec-
ondary curves, this can lead
to more occurrences.5 Thus,
rolling the edge and polish-
ing the secondary curves can
help reduce foreign body
entrapment. Be sure to also
check the edges for chipping,
as it can also increase risk of
foreign body entrapment.5 If
the problem persists, consider
switching to a larger diameter
lens, such as a scleral lens, to
reduce or eliminate this issue.
SPECTACLE BLUR
Every once in a while, a patient
comes in who complains that
when they remove their contacts
and put on their glasses, their
vision is blurred. One reason this
so-called spectacle blur may oc-
cur is from the accumulation of
fluid within the epithelial cells.
When contact lenses are removed,
the swelling of these cells slowly
decreases, and the spectacle blur
3/27/15 3:45 PM
 what to expect usu-
ally eases patients
so they do not get
upset or anxious.
LENS
ADHESION
Lens adhesion is
the most common
complication of
extended wear GP
lenses.7,8 Upon ex-
amination, the lens
will be immobile
with mucous/lipid
deposits present
Fig. 2. Topography of a poorly fitting tangent streak
GP lens caused corneal steepening. underneath. When
fluorescein is in-
usually resolves after an hour.6 stilled, none will be seen under the
Spectacle blur can also result lens, indicating no tear exchange
from changes in corneal curvature or lens movement. When the lens
that is not related to edema. This is removed, an arcuate ring pat-
is due to mechanical molding of
the cornea (resulting from lens
fit) or prolonged metabolic stress.
This issue is particularly common
in patients who wear flat-fitting or
hybrid lenses.
In the case of corneal mold-
ing, when the fit of the contact
lens is poor, the lens reshapes the
cornea, thus resulting in spectacle
blur (Figure 2). Spectacle blur is Fig. 3. Corneal topography after
usually not a large issue, unless discontinuing GP lens wear for
the primary cause is because the several months.
contact lens fit is inappropriate. tern is visible around the edge of
For example, in more extreme the lens.7 Patients usually do not
cases, deep stromal striae or have any complaints with lens
opacification of the cornea can be binding; in fact, they may report
seen, which is indicative of further better comfort (except late in the
potential issues. In most cases, day) because of the decreased lid
however, the cornea will eventually interaction and movement.
remold to a stable shape if the lens If an extended wear patient ex-
is removed (Figure 3).6 Regardless, hibits lens adhesion, changing their
education on spectacle blur and wearing schedule to daily wear
REVIEW OF CORNEA & CONTACT LENSES | APRIL 2015
030_RCCL0415_gpe.indd 31
will likely resolve the issue. During
sleep, the pressure from the eyelids
squeezes out the tear layer under
the GP lens, which results in lens
binding.7 If lens binding occurs
with a daily wear patient, however,
the fit of the lens will need to be
altered. When the lens decenters,
the secondary and peripheral curve
junctions contact the flatter areas
of the cornea.7,8 This, combined
with pressure from the eyelids,
leads to lens adherence. Try alter-
ing the centration and curvature of
the lens to achieve a more centered
fit and check to make sure the
curves are well blended. If normal
modifications do not work, con-
sider switching to an aspheric back
surface design.
Note that another potential
cause of lens adherence is dry eye,
specifically aqueous deficient dry
eye, so it is important to check
your patient for any type of dry
eye during their exam. RCCL
1. Nichols J, King-Smith PE. Thickness of the
pre- and post-contact lens tear film measured
in vivo by interferometry. Invest Ophthalmol Vis
Sci. 2003 Jan;44(1):68-77.
2. Van der worp E, de Brabander J, Swarbrick
HA, Hendrikse F. Evaluation of signs and symp-
toms in 3 and 9 o’clock staining. Optom Vis Sci.
2009 Mar;86(3):260-5.
3. Holden T, Bahr K, Koers D, et al. The ef-
fect of secondary curve liftoff on peripheral
corneal desiccation. Am J Optom Physiol Opt
1987;64:113.
4. Henry VA, Bennett ES, Forrest JM. Clinical
investigation of the Paraperm EW rigid gas
permeable contact lens. Am J Optom & Physiol
Opt 1987;64:313-320.
5. Bennett, E. et al. Clinical Contact Lens Prac-
tice. Lippincott, Williams, and Wilkins. Philadel-
phia, PA. 2005. Pp 351.
6. Bailey SC. Contact lens complications. Op-
tometry Today. June 4 1999.
7. Bennett, E. et al. Clinical Contact Lens Prac-
tice. Lippincott, Williams, and Wilkins. Philadel-
phia, PA. 2005. Pp 346-8.
8. Swarbrick HA, Holden BA. Rigid gas perme-
able lens binding: significance and lens factors.
Am J Optom Physiol Opt. 1987;64(11)815-823.
31
3/27/15 3:45 PM
 Corneal Consult
By James Thimons, OD
Managing Acute Corneal Hydrops
in Keratoconus
Using a structured approach to determine which factors impede healing will lead to
success with these often challenging scenarios.
C
orneal hydrops, an
uncommon complica-
tion seen in patients
with corneal ectatic
disorders, is charac-
terized by the leakage of aqueous
through a tear in Descemet’s mem-
brane, which leads to a rolling of
the edge and subsequent gaping of
the posterior surface of the cornea.
This allows the aqueous fluid to
intrude into the cornea, produc-
ing an acute edematous response,
relative changes in corneal archi-
tecture and clinical symptomatol-
ogy. Patients typically present with
a rapid decrease in visual acuity,
photophobia and pain. There is
also notable localized edema and, in
some instances, visible ectasia in the
areas most compromised.
Corneal hydrops is estimated
to occur in 2% to 3% of patients
with keratoconus, with the major-
ity presenting between ages 20 and
40. While some literature supports
an increased rate of occurrence in
males, there is no notable preva-
lence by race. In most cases, the
location of the hydrops is inferior to
the apex of the cone. When ques-
tioned, patients frequently admit
to significant eye rubbing. In some
instances, severe coughing and/or
heavy lifting have also been associ-
ated with onset of disease. Down’s
syndrome may be a risk as well.
Most cases heal naturally over
a period of several months when
treated using conservative methods,
which include topical cycloplegic
agents, corticosteroids to reduce
32 REVIEW OF CORNEA & CONTACT LENSES | APRIL 2015
010_RCCL0415_CC.indd 32
inflammation and IOP-lowering
drugs. Some patients, however, may
require surgery if corneal edema
persists or resultant corneal scarring
affects visual clarity.
Conservative medical intervention
is usually sufficient to stave off the
more concerning consequences of
perforation, but overall has little im-
pact on visual outcome or duration
of disease. Thus, doctors are turning
to other, more advanced methods of
disease management. Recently, there
has been renewed interest in the use
of intracameral SF6 and C3F8 gases,
which have been shown to lead to
Photo: Edward Boshnick, OD
Fig. 1. Placement of intracameral
C3F8 (non-expansile concentration)
in a different patient than the one
described here. Note: the patient
was instructed to lie flat with their
eyes looking up towards the ceiling,
so that the gas can occlude the
break in the posterior cornea.
faster improvement compared to
more conservative treatments.1,2
Intrastromal venting incisions, used
to delimit the large vacuoles that
occur in some patients, have also
demonstrated some success but are
still relatively experimental. Over-
all, more research is needed on the
efficacy of these and other emerging
treatments.
CASE STUDY
A recent case of corneal hydrops
that presented to my office is em-
blematic of the conventional charac-
teristics of the disease, and serves as
a good example of conservative vs.
more aggressive surgical treatment.
TW, a 42-year-old black female,
was initially seen for a complaint
of progressive change in visual
function relative to longstanding
keratoconus, and a recent history of
possible progression noted by her
current clinician. The consultation
identified significant apical scarring
in her right eye, and notably less
scarring in the left. The best-correct-
ed visual acuity with spectacles was
20/300 OD, which did not improve
on pinhole, and approximately
20/80 OS with minimal pinhole
improvement. Her previous history
was positive for contact lens wear,
although discomfort as well as poor
acuity had decreased the patient’s
wearing activity to a minimal level
over the last six to 12 months.
The remainder of her examina-
tion elements (i.e., intraocular
pressure, lenticular assessment
and posterior pole) were relatively
normal. The patient was advised
that several options were available:
she could forgo intervention at this
time, be fit with a complex hybrid-
type or scleral contact lens with the
hope of achieving better results than
3/27/15 3:42 PM

Photo: Edward Boshnick, OD
Fig. 2. Hydrops resolved.
her current standard hard lens, or
undergo a corneal transplant.
The patient elected to consider
the options and was scheduled
for another appointment in three
months, with plans to return sooner
if a decision was made. Approxi-
mately six weeks after her initial
evaluation, the patient contacted the
on-call service on a weekend and
indicated that she had developed
a notable decrease in vision, along
with severe pain and photophobia.
I saw her on the same day, and
it was evident she had a significant
corneal hydrops and a visible Des-
cemet’s membrane tear. This was
accompanied by notable apical ecta-
sia in the zone of the hydrops. The
presentation of the cornea was 3+/4
edema, focally located over the zone
of the hydrops, which consisted of
epithelial microcystic edema and in-
trastromal cysts and vacuoles. The
diameter of the area was approxi-
mately 4.5mm to 5.0mm. Visual
acuity was hand motion at two feet
with no pinhole improvement.
I discussed treatment options
with the patient, who elected to
010_RCCL0415_CC.indd 33
proceed with conservative therapy,
which included a topical antibiotic
(ciprofloxacin) QID to prevent
infection, one drop of a cycloplegic
(atropine) BID, the use of a hyper-
tonic saline ointment (Muro 128)
QID and an ocular antihyperten-
sive agent to lower pressure and
decrease the posterior forces on the
cornea contributing to architectural
change. The patient was also placed
on topical Durezol QID, and a
bandage lens was inserted—primar-
ily for comfort, but also to prevent
perforation.
The patient was observed over
several weeks and, as is typical
with hydrops, the intrastromal
edema that was present at the initial
episode began to resolve, as did the
photophobia. At the initial three-
day follow-up, the pain had less-
ened significantly with the atropine
and Durezol, and the inflammatory
response present in the cornea
showed a mild decrease. Addition-
ally, the pressure had been reduced
from 16mm Hg to 10mm Hg. The
patient’s bandage lens was removed
in order to view the corneal surface;
upon removal, a decrease in the
microcystic edema was observed
and the stromal vacuoles and clefts
appeared stable. I ordered current
medication levels be maintained,
but decreased the atropine to QD.
At the two-week follow-up, I
reduced the steroids to BID and
stopped the atropine. I continued
the antibiotics but reduced the
dose to BID. The bandage lens was
also removed at two weeks and
the cornea was competent with a
negative Seidel. The patient called
two days after the bandage lens was
REVIEW OF CORNEA & CONTACT LENSES | APRIL 2015
discontinued and indicated that she
had developed a foreign body sensa-
tion, so I reinstituted lens wear. I
maintained her on the antihyper-
tensive agents for approximately
four weeks. Additionally, she used
the hypertonic saline ointment four
times daily throughout the treat-
ment period.
By the fourth week, the patient’s
vision had returned to 20/200
best-corrected in the affected eye.
Additionally, the microcystic edema
had reduced dramatically, and the
stromal edema had begun to dem-
onstrate a coalescence of the vacu-
oles, which were notably present at
the initial clinical assessment.
It should be noted in cases like
this one that therapeutic options
like hybrid or scleral lenses are less
viable because of the scar forma-
tion, which is almost universal in
patients of this type following a
severe hydrops. I discussed the po-
tential for a therapeutic penetrating
keratoplasty as the option of choice,
and TW is actively considering the
possibility once the eye stabilizes. I
anticipate that, given her current,
relatively poor visual rehabilitative
potential and the fact that the other
eye also shows notable keratoconus,
a penetrating keratoplasty would be
a reasonable option to rehabilitate
visual function and give her overall
better visual potential in the years
to come. RCCL
1. Panda A, Aggarwal A, Madhavi P, et al. Manage-
ment of acute corneal hydrops secondary to
keratoconus with intracameral injection of sulfur
hexachloride (SF6). Cornea. 2007;26(9):1067-9.
2. Basu S, Vaddavalli PK, Ramappa M, et al.
Intracameral perfluoropropane gas in the treat-
ment of acute corneal hydrops. Am J Ophthalmol
2011:118(5):934-9.
33
3/27/15 3:42 PM
 Out of the Box
By Gary Gerber, OD
Are You a Mentalist?
Probably not. And neither are your staff members. Clear communication with your team
is key to the success of your practice.
I
f you’ve attended one of
my lectures at a meeting
or trade show, chances are
you’ve probably also seen
me do magic—specifically, a
type known as mentalism. Instead
of pulling a rabbit out of a hat,
mentalists use whatever is in the
imagination of their audiences to
complete their illusions. Mental-
ism is essentially magic of the mind
and frequently deals with predic-
tions about the future. So, here’s a
prediction I’ll make for everyone
reading this article and, since you’re
reading it for the first time and I’m
not standing in front of you, there
is no possible way I could have set
this up in advance!
My prediction is that the
practice-building challenge you
encounter most frequently is—wait
for it—staff management. How’d I
do? (Email me, I’d love to know!)
And, the number one reason why
so many doctors struggle with staff
management is because they aren’t
mentalists. In other words, they
haven’t figured out how to predict
the future! But what’s the connec-
tion between understanding the
future and staff management?
While it’s likely most of us do
not know what our personal
futures hold, chances are many
of us have a good idea regarding
the future of our practice. And,
we have an obligation as practice
leaders and CEOs to communi-
cate this future to our staff. Great
staff management and leadership
involves understanding the long
view and communicating that view
to your staff—something that isn’t
always easy.
34 REVIEW OF CORNEA & CONTACT LENSES | APRIL 2015
034_RCCL0415_otb.indd 34
AVOID MYOPIC LEADERSHIP
Due to the stresses and day-to-day
pressures of running a practice,
many of us succumb to “leader-
ship myopia” and are only able
to focus on what is directly in
front of us at a given moment. As
with all behaviors, staff members
see your acute laser focus on the
“here and now” and assume that
if it’s important to you, it should
be important to them too. The
problem with this thought process
is that big-
picture goals,
practice values “BIG PICTURE GOALS
and your very
reason for be- AND PRACTICE VALUES
ing a practice
can get lost in CAN GET LOST.”
this short-term
view. People are people, and pa-
tients are patients. You’ll always
have acute patient management
issues to deal with. Unless you rou-
tinely set aside uninterrupted time
to discuss with your staff why you
are doing what you do with each
patient on a day-to-day basis, they
will never adopt your long-term
view (i.e., your mentalist’s predic-
tion, if you will) of the future.
Here’s an example: Mr. Late
runs into the office out of breath
and says, “I ran out of contact
lenses and I’m on my way to work.
Can I have one more pair to hold
me over?” As instructed at your
last staff meeting, your staff cor-
rectly checks his record and sees
that his last examination was 16
months ago. Your clinical recom-
mendation is once per year. So,
the staff member says, “I’m sorry,
you’re overdue for your exami-
nation, so we can’t give you any
more lenses.”
Volumes have already been
written about what may or may
not happen next, and putting 10
of us in a room to discuss the best
course of action would make for
a nice fireside chat—or perhaps a
barroom brawl. However, what is
rarely discussed is how to put your
own view of how this situation
should be handled into the minds
of your staff.
What is your long-term, futur-
istic macro goal for your practice
and the micro short-term goal for
this particular patient? The policy
to deal with this individual patient
is already known to every practice
(i.e., either give the patient lenses
or don’t, with any necessary expla-
nations or caveats) but the reason
for doing so, in the context of your
big picture practice vision, is rarely
articulated to staff. In other words,
“Give or don’t give the lenses
because our practice philosophy
and long-term goals are…” is not
usually discussed. This way, your
staff members are able to better
adhere to these long-term goals in
the face of such situations.
So, hone your mentalist skills
and start communicating your
goals and aspirations to your staff.
Your day-to-day operations will
run much smoother. RCCL
3/27/15 4:48 PM
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