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JANUARY/FEBRUARY 2019
CORNEAL
S U R G E RY
REVIEW OF CORNEA ISSUE
& CONTACT LENSES
Discover how long to monitor and treat symptoms before considering surgical interventions, PAGE 16
• GPs: A Reliable Post-PK Option, PAGE 8
• The Art of Corneal Transplantation, PAGE 20
• Post-cataract Surgery Inflammation: A Toxin or a Bug?, PAGE 26
• Transplantation for Limbal Stem Cell Deficiency, PAGE 30
(earn 1 CE credit)
ALSO: new lenses
Also: for 2019 • myopia
Acanthamoeba control
keratitis: CYL advice
A•Disease anterior staphyloma
in• Disguise, p. 36
RCCL2019_Contamac.indd 1 2/5/19 11:14 AM
contents
Review of Cornea & Contact Lenses | January/February 2019
departments features
10
4 News Review New Lenses for a New Year
Highlights in 2019 will include toric
Myopia Research Advances; CLs multifocals, a photochromic contact
and MGD: a Mixed Bag lens and more.
By Jane Cole, contributing editor
7 My Perspective
Perfecting the Art of Practice
By Joseph P. Shovlin, OD
Keratoplasty:
8
36
The GP Experts
A Reliable Post-PK Option
By Robert Ensley, OD,
and Heidi Miller, OD
Corneal Consult
16 When and Why
Discover how long to monitor and
treat symptoms before considering
surgical interventions.
By James Esposito, OD
20
The Art of Corneal
Was it a Failure or Rejection? Transplantation
By Aaron Bronner, OD Optometrists have several options
when it comes to keratoplasties, each
38 Fitting Challenges of which has its own pros, cons and
management guidelines.
Depth Charge By Andrew Steele, OD
By Vivian P. Shibayama, OD
26
Post-cataract Surgery
40 Practice Progress Inflammation: A Toxin
Don’t be Nearsighted About Myopia or a Bug?
By Andrew Fischer, OD, Mile Brujic, OD, Although rare, TASS and
and David Kading, OD endophthalmitis are possible
complications, and clinicians must be
able to recognizing the difference.
42 The Big Picture By Barbara J. Fluder, OD
Singing the Blues
By Christine W. Sindt, OD
30
CE —
Transplantation for
Limbal Stem Cell
Deficiency
When severe disease
calls for surgery, here’s how you can
be prepared for the pre- and post-op
care.
By Cecelia Koetting, OD
Become a Fan on Follow Us on
Facebook Twitter
/ReviewofCorneaAndContactLenses @RCCLmag
REVIEW OF CORNEA & CONTACT LENSES | JANUARY/FEBRUARY 2019 3
News Review
IN BRIEF
■ Researchers recently found that Afri-
Myopia Research Advances
can Americans have five times higher
T
odds of developing infectious uveitis wo recent studies shed more UK, researchers analyzed a subset
and 1.5 higher odds of developing light on the pathogene- of the Twins Early Development
non-infectious uveitis compared with
Caucasians. The study used data from sis of this growing ocular Study, a longitudinal evaluation of
the National Inpatient Sample (NIS) condition: 1,991 subjects recruited at birth
and collected patient’s age, sex, race, between 1994 and 1996. Subjective
median household income, payer status
and ocular complications. Medicare pa- MYOPIA BIOMARKER refraction was obtained from the
tients have double the odds of having A group of European researchers twins’ optometrists, with myopia
complications from infectious uveitis recently found conjunctival ultravi- defined as mean spherical equiva-
compared with those with private
insurance, and Medicaid patients have olet autofluorescence (CUVAF) can lent ≤-0.75 diopters. Mean age of
a 1.7 higher risk. Medicare and Medicaid show clinicians how much time pa- subjects was 16.3 years.2
patients also have twice the odds of tients spend outdoors, and that can The team used a ‘life-course
having complications from non-infec-
tious uveitis compared with those with translate into a myopia monitoring epidemiology’ approach, which
private insurance. tool. They assert their study, pub- considers the influence of gesta-
Chauhan K, Scaife S, Rosenbaum JT. Uveitis lished in Clinical and Experimental tional and early childhood factors
and health disparities: results from the National
Inpatient Sample. Br J Ophthalmol. December 21, Optometry, shows that the smaller on long-term development, to
2018. [Epub ahead of print]. a patient’s area of CUVAF, the more appropriately weight myopia risk
■ A new eye drop shows promise for time they spend outdoors.1 factors during critical periods of eye
reducing corneal scarring after Pseudo- “These findings suggest that growth. Adjusted odds ratios (ORs)
monas aeruginosa infection, compared
with traditional treatment. Developed CUVAF measures are a useful, for myopia were estimated at each
by researchers from the University of non-invasive biomarker of the time life stage.2
Birmingham, the eye drop consists spent outdoors in adults in northern Factors significantly associated
of a fluid gel that includes decorin, a
naturally occurring protein that binds hemisphere populations,” the study with myopia included level of ma-
to collagen in the corneal stroma and reads.1 ternal education (OR 1.33), fertility
regulates cell proliferation, survival and To determine that, the team treatment (OR 0.63), summer birth
differentiation by modulating numerous
growth factors. The drop acts similar to looked at 54 patients (24 with my- (OR 1.93) and hours spent play-
a therapeutic bandage, creating a barri- opia and 30 without) and examined ing computer games (OR 1.03).
er that protects the ocular surface from their CUVAF as well as self-re- In addition, the researchers noted
further damage caused by blinking.
Researchers found the eye drop result- ported sun exposure preferences. associations with socioeconomic
ed in reduced corneal opacity within They also took the patients’ blood status, educational attainment,
16 days. Adding human recombinant samples to assess their vitamin D3 reading enjoyment and certain cog-
decorin helped restore corneal epithelial
integrity with minimal stromal opacity. concentrations. While they found nitive variable (particularly verbal
Hill LJ, Moakes RJA, Vareechon C, et al. Sustained no significant association between cognition) at multiple points over
release of decorin to the surface of the eye
enables scarless corneal regeneration. NPJ Regen
sun exposure preferences or serum the life course.2
Med. 2018;3:23. concentration of vitamin D3 and re- “A greater understanding of
■ Researchers examined the benefits
fractive status, they did find that, in contemporaneous, early life factors
of toric contact lenses vs. sphericals on nearly every case, CUVAF area was associated with myopia risk is
objective measures of visual perfor- negatively associated with myopia.1 urgently required, particularly in
mance for patients with low-to-moder-
ate astigmatism. High- and low-contrast
The researchers concluded that younger-onset myopia,” the au-
visual acuities significantly improved the less cumulative ultraviolet B thors wrote in their study, “as this
with toric lenses compared with spher- exposure from sunlight, the more correlates with higher severity and
ical lenses at both fitting and follow-up.
Electromyography recordings showed
likely patients were to be myopic.1 increased complications in adult
less orbicularis muscle activity, correlat- life.”2
ing with less eyestrain, with toric lenses PHYSIOLOGIC FACTORS
compared with spherical lenses; howev- 1. Kearney S, O’Donoghue L, Pourshahidi L, et al.
er, the difference was only different at
A second study found a mix of en- Conjunctival ultraviolet autofluorescence area, but
vironmental and physiologic factors not intensity, is associated with myopia. Clin Exp
the fitting visit. Optom. 2019;102(1):43-50.
Berntsen DA, Cox SM, Bickle KM, et al. A give rise to myopia, some of them 2. Williams KM, Kraphol E, Yonova-Doing E, et al.
randomized trial to evaluate the effect of toric Early life factors for myopia in the British Twins Ear-
versus spherical contact lenses on vision and quite surprising.2 ly Development Study. Br J Ophthalmol. November
eyestrain. Eye Contact Lens. 2019;45(1)28-33. In a new study conducted in the 6, 2018. [Epub ahead of print].
4 REVIEW OF CORNEA & CONTACT LENSES | JANUARY/FEBRUARY 2019
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CLs and MGD: a Mixed Bag
R
esearch now shows silicone mian glands due to silicone hydrogel
EDITORIAL STAFF
EDITOR-IN-CHIEF
hydrogel contact lens (CL) CL wear, some of which could help
Jack Persico jpersico@jobson.com materials don’t cause cy- clinicians detect early MGD.2
MANAGING EDITOR
Rebecca Hepp rhepp@jobson.com tokine-driven inflammation for Researchers examined 173 eyes
ASSOCIATE EDITOR patients with meibomian gland of 87 soft CL wearers and 103 eyes
Catherine Manthorp cmanthorp@jobson.com
ASSOCIATE EDITOR dysfunction (MGD), but they can of 55 controls, grouping them based
Mark De Leon mdeleon@jobson.com affect morphological and functional on duration of wear: less than three
CLINICAL EDITOR
Joseph P. Shovlin, OD, jpshovlin@gmail.com changes to the meibomian glands. years, between three and seven years
ASSOCIATE CLINICAL EDITOR One study evaluated MGD and more than seven years.2
Christine W. Sindt, OD, christine-sindt@uiowa.edu
EXECUTIVE EDITOR patients who had worn CLs for They found significantly higher
Arthur B. Epstein, OD, artepstein@artepstein.com at least six months and found upper and lower eyelid meiboscores
CONSULTING EDITOR
Milton M. Hom, OD, eyemage@mminternet.com silicone hydrogel CLs didn’t cause in the CL wearers compared with
GRAPHIC DESIGNER cytokine-driven ocular surface controls, as well as higher mean
Ashley Schmouder aschmouder@jobson.com
AD PRODUCTION MANAGER inflammation, but they may impact OSDI scores, corneal staining
Scott Tobin stobin@jhihealth.com tear function, which could still lead scores, percentage of gland loss and
BUSINESS STAFF to symptoms of dry eye disease percentage of thickened and curled
PUBLISHER (DED).1 meibomian glands in the upper and
James Henne jhenne@jobson.com
REGIONAL SALES MANAGER The researchers found the mean lower lids. Both the mean TBUT
Michele Barrett mbarrett@jobson.com cytokine concentrations of CL wear- and meibomian gland expressibility
REGIONAL SALES MANAGER
Michael Hoster mhoster@jobson.com ers were not statistically significant were lower in CL wearers compared
VICE PRESIDENT, OPERATIONS compared with those of healthy with the control groups.2
Casey Foster cfoster@jobson.com
controls. Even the concentrations The study also found duration of
EXECUTIVE STAFF of those with and without MGD wear was important, considering
CEO, INFORMATION SERVICES GROUP
Marc Ferrara mferrara@jhihealth.com didn’t show statistically significant meiboscores were higher in patients
SENIOR VICE PRESIDENT, OPERATIONS variation.1 who wore CLs for more than three
Jeff Levitz jlevitz@jhihealth.com
SENIOR VICE PRESIDENT, According to the research team, years compared with those wear-
HUMAN RESOURCES
Tammy Garcia tgarcia@jhihealth.com
the TBUT and ocular surface stain- ing lenses for less than three years.
VICE PRESIDENT, ing in CL wearers with MGD were The earliest change the researchers
CREATIVE SERVICES & PRODUCTION
Monica Tettamanzi mtettamanzi@jhihealth.com
significantly worse compared with documented was meibomian gland
VICE PRESIDENT, CIRCULATION controls, but they did not correlate thickening in the upper eyelid—be-
Emelda Barea ebarea@jhihealth.com
CORPORATE PRODUCTION MANAGER
with tear cytokine levels, suggest- fore deterioration of meiboscores or
John Caggiano jcaggiano@jhihealth.com ing other factors are to blame for increase in gland dropout, the study
EDITORIAL REVIEW BOARD the symptoms. “The abnormal says. This was the only finding that
Mark B. Abelson, MD interaction between the meibomian had the highest diagnostic ability for
James V. Aquavella, MD
Edward S. Bennett, OD lipids and the contact lens surface MGD, they noted.2 RCCL
Aaron Bronner, OD
Brian Chou, OD
is thought to result in thinning of
1. Yucekul B, Mocan M, Mehmet C, et al. Evaluation
Kenneth Daniels, OD the tear lipid layer, accelerated tear of long-term silicone hydrogel use on ocular surface
S. Barry Eiden, OD inflammation and tear function in patients with
Desmond Fonn, Dip Optom, M Optom evaporation and dewetting as a and without meibomian gland dysfunction. Eye &
Gary Gerber, OD
Robert M. Grohe, OD
result of the increased lens-surface Contact Lens. 2019:45(1):61–6.
2. Uçakhan Ö, Arslanturk-Eren M. The role of soft
Susan Gromacki, OD hydrophobicity,” the report reads. contact lens wear on meibomian gland morphology
Patricia Keech, OD
Bruce Koffler, MD “These changes are likely to be and function. Eye Contact Lens. 2018 December 28,
Pete Kollbaum, OD, PhD 2018. [Epub ahead of print].
Jeffrey Charles Krohn, OD the underlying causes for reduced
Kenneth A. Lebow, OD
Jerry Legerton, OD
TBUT, higher ocular surface staining
Kelly Nichols, OD as well as higher OSDI scores previ- Advertiser Index
Robert Ryan, OD
Jack Schaeffer, OD ously reported in CL wearers.”1 Art Optical...........................Cover 3
Charles B. Slonim, MD
Kirk Smick, OD
A second study recently docu- CooperVision ......................Cover 2
Mary Jo Stiegemeier, OD mented several morphological and
Loretta B. Szczotka, OD Menicon .............................. Cover 4
Michael A. Ward, FCLSA functional changes to the meibo-
Barry M. Weiner, OD
Barry Weissman, OD
REVIEW OF CORNEA & CONTACT LENSES | JANUARY/FEBRUARY 2019 5
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My Perspective
By Joseph P. Shovlin, OD
Perfecting the Art of Practice
These seven steps might help you start off your new year on the right foot.
D
o you have a New know you plan on addressing each practitioners become somewhat
Years’ resolution? I’m concern or complaint to the best of hardened from our daily routine; we
fairly certain some of your ability in the future. see so much pathology and visual
you will have already 3. Assess the patient’s response loss that we run the risk of forget-
made and broken to illness and suffering. We must ting how devastating it can be. Dr.
one for the new year by the time provide a precise diagnosis when- Egnew highlights the need for being
you read this. If so, make a new ever possible. Dr. Egnew says that explicit in your understanding of
one! And if you haven’t yet made patients suffer in ways other than a patient’s problem; in doing so,
a New Year’s resolution, here is a experiencing physical pain. We it actually allows them to be more
suggestion. encounter patients with anterior open in sharing both personal and
I came across a fascinating article and posterior segment anomalies clinically important information.
about a year ago by Thomas Egnew, that may not be painful physically
EdD. It deals directly with what we but cause suffering from visual CHECK IN
do daily in clinical practice—caring compromise. One way to incorporate these skills
for patients. I hope you find the 4. Communicate to foster heal- is to keep a list of patients you’ve
highlights striking enough to make ing. Carl Rogers notes that anyone seen over the past week who might
a new resolution to replace the one who counsels patients needs to benefit from a phone call to check
you didn’t adhere to already, or to display congruence (being authen- on their progress. I’ve done this
add to your list of resolutions. tic), acceptance (valuing the patient for years, and patients are always
even if you don’t agree with their amazed that you have taken the
THE MAGNIFICENT SEVEN actions) and understanding (being time to call and are grateful for
Here are the seven skills for mastery sensitive to what they are experi- your concern. It goes a long way in
of practice that the author refers to encing). However, on occasion, we saying, “I really care about you.” Of
as “the magnificent seven:1 are forced into confrontation. For course, there’s some risk that it may
1. Take a moment to focus before example, “You have thyroid eye get you more than you bargained
you enter the examination room. disease—you must stop smoking!” for, but the pluses seem to always
It’s important to clear your mind 5. Use the power of touch. Of outweigh the minuses.
from the last encounter or recharge course, we do not recommend any- Many of these seven skills may
after the morning’s tribulations. thing that can be misconstrued as seem straightforward and even
Then, it’s time to focus on the next an unwanted gesture, but this article obvious, but I find it always good
patient. As Dr. Egnew stresses, be- recommends a warm handshake. to reflect on how your patients
coming mindful of the details of the If you get the sense that a patient and their families might perceive
next patient outside the consultation is uncomfortable with any touch you. Carefully reflecting on each of
room is a precursor to being mind- because of their cultural or religious these areas should serve us all well
ful inside the examination room. beliefs, avoid it. to be better care providers. I thank
2. Establish a connection with the 6. Laugh a little. “Humor can Dr. Egnew for his seven skills to
patient, develop rapport and agree be helpful in establishing rapport, promote mastery in clinical practice.
on an agenda. This initial interac- relieving anxiety, communicating a I hope you also find them helpful.
tion gives you a chance to connect message that you care, enhancing And if this is one New Year’s reso-
with the patient interpersonally healing and providing an acceptable lution you can adopt—an attempt
and intellectually. Spending a small outlet for any anger and frustra- to master the art of practice—I hope
amount of time socializing and lis- tion.” Gentle self-deprecation also it’s one you keep for the remainder
tening is a worthy investment. Also, has worked well for all of us from of your career. Wishing all a happy
set an agenda. You don’t need to time to time. and healthy New Year! RCCL
address all of their concerns on the 7. Show some empathy. This 1. Egnew TR. The art of medicine: seven skills that pro-
first visit, but be certain that they is seldom practiced, especially as mote mastery. Fam Pract Mangag. 2014;21(4):25-30.
REVIEW OF CORNEA & CONTACT LENSES | JANUARY/FEBURARY 2019 7
The GP Experts
By Robert Ensley, OD, and Heidi Miller, OD
A Reliable Post-PK Option
Scleral lenses are growing in popularity, but GPs have long been a mainstay in managing the
complex corneas of these patients.
S
ince 2005, the annual topography will help
number of penetrat- dictate the proper
ing keratoplasty (PK) contact lens fit.
procedures performed Regular astigmatism
in the United States has two principal me-
has decreased by 56%.1 When ridians perpendicular
transplantation is required, more to each other in a bow-
selective procedures, such as tie pattern. Depending
anterior lamellar keratoplasty and on the power of each
endothelial keratoplasty, have half of the bowtie, reg-
contributed to the reduced need ular astigmatism can
for full-thickness grafts. However, be classified further as
PKs are still performed in cases symmetrical or asym-
of advanced corneal disease or Post-PK, the cornea can take on a steep-to-flat metrical. When the
opacification. pattern where the graft is tilted. cornea is non-uniform
A full-thickness PK replaces all or principal meridians
layers of the cornea with a donor may be minimized, careful observa- are not 90 degrees apart, the astig-
button, typically 7.5mm to 8.5mm tion for signs of hypoxia is critical. matism is considered irregular, with
in diameter, sutured in place to Scleral lenses are made with highly several pattern subtypes.7 Irregular
the host tissue.2 Newer surgical oxygen permeable (DK) materi- astigmatism is the most common
techniques such as using a femto- als, but they must also take into indication for fitting GP lenses
second laser to create the donor account the diffusion of oxygen post-transplantation.8
button have improved postopera- through the post-lens tear layer. If Corneal shape is typically
tive wound stability and reduced excessive hypoxic stress is placed classified into three basic pat-
healing time.3 However, refrac- on the endothelium, corneal edema terns: prolate, oblate and mixed.
tive outcomes are still variable, may occur and increase the risk of Prolate-shaped corneas are steeper
and are largely impacted by the rejection. Smaller-diameter corneal centrally and flatter in the periph-
amount of astigmatism that the GP lenses use the same high DK ery, while oblate-shaped corneas
graft produces. High amounts materials and also benefit from a are flatter centrally and steeper
of astigmatism are not uncom- greater tear exchange beneath the in the periphery. Mixed-shape
mon, with one large cohort study lens. This improves oxygen tension features both prolate and oblate
reporting at least five diopters of and is suggested to play a role in areas of the cornea. Post-PK, the
astigmatism in 20% of grafts.4 the lower risk of microbial keratitis cornea can also take on a steep-
If spectacles do not provide a with GP lenses.5,6 to-flat pattern where the graft is
successful visual outcome, contact tilted, steep on one side and flatter
lenses, specifically gas permeable THE CORNEAL PROFILE towards the other side.7,9
(GP) lenses, may be required for The goal of fitting GP lenses is to
vision rehabilitation. align the lens’s back surface to the FITTING STRATEGY
anterior curvature of the cornea. A well-fit GP lens will minimize
LENS CONSIDERATIONS With a normal cornea, eyelid posi- mechanical trauma to the graft,
Because of their ability to vault tioning and keratometry measure- optimize vision and be comfortable
over the corneal surface, scleral ments are used to select diameter to the patient. Maintaining proper
lenses are becoming an increasingly and base curve. For PK patients, centration and distributing weight
popular lens choice for post PK analyzing astigmatism and corne- equally on the cornea can achieve
patients. While mechanical stress al shape with the aid of corneal these objectives.
8 REVIEW OF CORNEA & CONTACT LENSES | JANUARY/FEBRUARY 201908
In general, larger-diameter in- alignment. If the graft is tilted, a post-surgical corneas. The
tralimbal lenses (10mm to 12mm) GP lens will tend to center over SynergEyes UltraHealth lens is
are preferred because their back the steepest part of the cornea. designed using a hyper DK reverse
optical zone diameter will extend Larger-diameter lenses help with geometry GP lens and a high DK
beyond the graft-host junction.9,10 centration, although in these cases SiHy skirt. The GP lens vaults over
If small-diameter lenses must be scleral lenses may indeed be the the cornea with minimal touch
used, care must be taken to avoid preferred choice. and the soft skirt maintains centra-
heavy bearing, especially on the tion with minimal movement.
junction. OTHER OPTIONS
Choosing a back surface design
for the lens is dependent on the
corneal profile. Prolate corneas
Discomfort and decentration can
potentially derail the success of GP
lenses. A piggyback system may
T he versatility of scleral lenses
makes them a popular choice
for the post-PK patient; however,
with regular astigmatism and a be an effective option to correct they are not without risk. If a graft
normal eccentricity can often still both complications. A soft sili- patient cannot tolerate or afford
be fit in a conventional spherical cone hydrogel (SiHy) lens can be a scleral lens, they have options.
lens. If the regular astigmatism is placed under the GP lens to reduce Don’t be afraid to put your GP
2.5D or more, a bitoric design can friction on the cornea. The power fitting skills to the test! RCCL
be fit to avoid lens rocking and ar- profile of the soft lens can help
1. Eye Bank Association of America. 2016 Eye
eas of heavy touch. When the graft manipulate centration. A high my- Banking Statistical Report. restoresight.org/
is steeper, a keratoconic design, opic powered soft lens will act as wp-content/uploads/2017/04/2016_Statistical_
Report-Final-040717.pdf. Accessed December
which typically has a steeper base a carrier for the GP lens to rest on, 23, 2018.
curve and smaller optic zone size, while a high plus lens may “fill in” 2. Richard JM, Paton D, Gasset AR. A Comparison
of penetrating keratoplasty and lamellar kerato-
can be used. Proud grafts that pro- an oblate cornea.10 In a piggyback plasty in the surgical management of keratoco-
trude more from the host cornea design, the soft lens will provide nus. AM J Ophthalmol. 1978;86(6):807-11.
3.Farid M, Pirouzian A, Steinert RF. Femtosec-
may require a quadrant specific only 20% of the total optical ond laser keratoplasty. Int Ophthalomol Clin.
peripheral curve design if there is power of the system.11 Because 2013;53(1):55-64.
excessive edge lift. A reverse ge- oxygen must now diffuse through 4. Kelly TL, Williams KA, Coster DJ. Corneal trans-
plantation for keratoconus: A registry study. Arch
ometry lens, in which one or more two lenses, careful monitoring for Ophthalmol. 2011; 129(6):691-7.
peripheral curves are steeper than corneal hypoxia is warranted. 5. Weissman BA. Corneal oxygen: 2015. CL Spec-
trum. 2015;30:25-29,55.
the optical zone curvature, can Contemporary hybrid lens
6. Fleiszig SM. The pathogenesis of con-
also reduce peripheral edge lift.9 designs are also available for tact lens-related keratitis. Optom Vis Sci.
Reverse geometry lenses 2006;83:E866-73.
7. Karabatsas CH, Cook SD, Sparrow JM. Proosed
are also useful for oblate classification for topographic patterns seen
corneas. A conventional after penetrating keratoplasty. BR J Ophthalmol.
1999;83:403-9
GP would exhibit excessive
8. Wietharn BE, Driebe WT Jr. Fitting contact
central clearance, at risk lenses for visual rehabilitation after penetrat-
for bubble formation, ing keratoplasty. Eye & Contact Lens 2004;
30(1):31–33.
mid-peripheral bearing and 9. Szczotka LB, Lindsay RG. Contact lens fitting
edge lift. Flattening the base following corneal graft surgery. Clin Exp Optom.
2003;86(4):244-9.
curve to match the central
10. Louie DJ, Kawulok E, Kauffman M, Epstein A.
cornea and steepening Postsurgical contact lens fitting. In: Bennett ES,
the peripheral curves Henry VA, eds. Clinical Manual of Contact Lenses.
4th Ed. Philadelphia, PA: Lippincott, Williams &
will better match corneal Wilkins; 2014:578-608.
contour, with a fluorescein A well-fit GP lens will minimize mechanical
11. Woo M, Weissman B. Effective optics of
piggyback soft contact lenses. CL Spectrum.
pattern appearing to be in trauma to the graft. 2011;26(11):50.
REVIEW OF CORNEA & CONTACT LENSES | JANUARY/FEBRUARY 2019 9
New Lenses for a
New Year
Highlights in 2019 will include
toric multifocals, a photochromic
contact lens and more.
By Jane Cole, Contributing Editor
N
ot too long ago, the SUN PROTECTION them from the sun’s brightness
contact lens marketplace For the first time, photochromic without carrying sunglasses has
seemed a bit stagnant. technology is coming to the con- been on patients’ minds for some
Practitioners had a sta- tact lens platform, with a new lens time. Specifically, at least once a
ble line-up of offerings that served under the Transitions banner from month for as long as I have been
patients well, but it was essentially Johnson & Johnson Vision (JJV) in practice, I’ve gotten the ques-
the same product lines year in slated to hit the market in the first tion about photochromic contact
and year out with some incremen- half of this year. Formally named lenses. There is clearly a desire,
tal updates. For 2019, however, Acuvue Oasys with Transitions and I am excited to answer ‘yes’ to
industry has some ambitious new Light Intelligent Technology, the this question several times a year,
ideas to debut. Here, we offer a lens is a two-week reusable prod- and possibly more, as awareness
sneak peek of what’s expected in uct that continuously adapts from increases once the product is
the coming months, and optome- clear to dark and back, according available.”
trists weigh in on how these new to the company. The
lenses might fit into what’s cur- lenses become dark
rently available. in 45 seconds when
“In general, the lenses will be exposed to UV or
a stab at what doctors and pa- HEV light and fade
tients have been asking for over back to clear within
the last several years,” says David 90 seconds in dark-
Anderson, OD, of Miamisburg, er lighting. The lens
Ohio. “We will see toric mul- also provides 100%
tifocals, lenses to treat medical protection against UVB
conditions and lenses that change rays, JJV says. The lens
color like Transitions glasses. For is the result of a joint
the longest time, the lens advanc- partnership between
es have been all health driven, JJV and Transitions
addressing compliance with daily Optical.
disposables or more oxygen with “This lens has been
silicone hydrogel lenses. Now, the long awaited for,” Fig. 1. and Fig. 2. The Acuvue Oasys with
Transitions Light Intelligent Technology lenses
companies are making an effort to says Dr. Anderson. become dark in 45 seconds when exposed to
focus on the cosmetic and medical “The idea of both bright light and fade back to clear within 90
arenas to help solve some needs protecting your eyes seconds in darker lighting, according to the
that patients have had for years.” from UV and shielding company.
10 REVIEW OF CORNEA & CONTACT LENSES | JANUARY/FEBRUARY 2019Mile Brujic, OD, of Bowling an increase in astigmatism as Are CL Developments
Green, Ohio, likens this new lens they age, which alone can cause Meeting ODs’ Needs?
option to a “sunglass contact dropout,” Dr. Anderson adds.
We asked experts from the Centre
lens.” Although it doesn’t provide “This is the first time we’ve for Ocular Research & Education
ocular tissue protection, athletes had access to a toric contact (CORE) at the University of
who may not be able to wear lens that has presbyopia-cor- Waterloo to weigh in on wheth-
sunglasses, for example, will be recting options available in our er the new contact lenses being
able to see comfortably in this office without having to special- developed are bridging doctor and
new lens. “In my mind, that’s the ty order them,” says Dr. Brujic. patient needs.
bigger thing than the actual pro- While a multifocal for astig- At a basic level, contact lenses
tective factors of the potential UV matism has existed for many need to enable patients to see
protection in the lens.” years, it is a custom-fit lens, clearly, with all-day comfort, while
maintaining the health of the
Adds Glenda Secor, OD, of which presents myriad clinical
wearer’s eye, they say. For practi-
Huntington Beach, CA, “This and logistical barriers. “The
tioners, lenses need to be quick and
lens should be great. Patients are process is lengthy because it is a predictable to fit. “Many changes in
anxious to try them.” made-to-order lens,” says Justin contact lens design and technology
Bazan, OD, of Park Slope Eye over the last few years have helped
NEW PRESBYOPIC OPTIONS in Brooklyn, NY. “It can take us move closer to being able to
Last fall, Alcon launched its a couple of weeks just to get provide those basics for a greater
monthly replacement Air Optix the first trial lenses. More times number of patients,” they say.
plus HydraGlyde Multifocal than not, a second or third For example, silicone hydrogel
contact lens, giving the company a trial is needed, adding several materials provide the cornea with
new monthly option to round out weeks to complete the fit. This sufficient oxygen for daily wear,
and, in many cases, adequate
its multifocal product line. The drawn-out process often leads
oxygen for overnight wear also.
HydraGlyde component is said to to frustration and many patients Materials have been engineered to
improve moisture retention and are lost to follow-up.” try and maintain comfort through-
thus contact lens comfort, accord- Also, the fitting process for out the day, and choice of design to
ing to the company. custom lenses is complicated correct astigmatic and presbyopic
Other companies are also plan- and the visual outcome isn’t prescriptions has increased.
ning new multifocal offerings for always satisfactory, Dr. Bazan Yet, there are still improvements
this patient population: says. “For me, the complication to be gained in delivering enhanced
Astigmatism. Bausch + Lomb is stems from numerous add pow- comfort for the many patients who
gearing up to debut a multifocal ers and power designs. It’s rare experience contact lens-related
toric lens, the Ultra Multifocal to get a patient who is happy dryness, they add. “We need to
understand more about the interac-
for Astigmatism. The monthly with their visual outcome.”
tion of contact lenses with both the
replacement silicone hydrogel The forthcoming lens from tear film and contact lens solutions,
lens can correct near or distance B+L may help to resolve these and we would benefit from technol-
vision, astigmatism and presby- issues, Dr. Bazan says. “It com- ogy which enables the incidence of
opia and has an expected release bines technology that has been both microbial keratitis and corneal
of mid-2019. proven successful, it is easy to infiltrative events to be reduced.”
This lens may help patients with fit and will be available on the Acquisitions of instrument and
uncorrected astigmatism stay in spot in an in-office fitting kit. therapeutic device intellectual
contact lenses because they won’t From our spherical presbyopic property by some of the major
need to wear readers over their patients, we have learned that vision care companies over the past
distance vision contacts or rely multifocal contact lenses are the few years demonstrate the focus
that exists in this area, they add. “A
on monovision to help with near preferred way to handle pres-
better understanding of the tear
vision, says Dr. Anderson. “A byopia, and now we are finally film and how it interacts with the
multifocal option to also correct able to offer it to our astigmatic contact lens should lead to new
astigmatism offers an opportunity presbyopic patients.” technology and treatments which
to help more patients as they lose “It will be like fitting a spher- can help maintain, or even enhance,
their near vision, and provides ical multifocal lens, and the ocular surface health,” the CORE
an option as many patients have Ultra material is a comfortable researchers explain.
REVIEW OF CORNEA & CONTACT LENSES | JANUARY/FEBRUARY 2019 11NEW LENSES FOR A NEW YEAR
platform,” Dr. Brujic adds. “This pathway for their innovation. An line extensions added correction
is one I’m excited about.” accommodating contact lens still for astigmatism and presbyopia.
Dynamic refraction. Presbyopic appears to be on Alcon’s product The company also has a non-SiHy
patients may one day have ac- roadmap, too, according to public workhorse lens in the Dailies Aqua
cess to a self-powered smart lens documents. Comfort Plus product line.
designed to dynamically change Though a product launch won’t In 2019 or perhaps 2020, look
focus. The subject of much spec- make it into 2019, clinicians may for the company to add a third
ulation for years, this concept be able to hear more about these category in between those two,
is being pursued by at least two technologies as plans proceed at reportedly to be called Precision1.
companies, Alcon and JJV. Both both companies. Few details are available, but the
have publicly discussed their plans company expects the silicone hy-
to develop a lens that adjusts its A MID-TIER SiHy LENS drogel contact lens to use what it
shape to change the refractive Back in 2011, Alcon planted a flag calls ‘advanced aqueous extraction
index as needed. JJV says it has at the high end of the daily dis- and surface treatment,’ which it
overcome many technical hurdles, posable market with the launch of believes will help the contact lens
including onboard battery tech- its DailiesTotal1 silicone hydrogel compete with other mainstream
nology, and it is working closely (SiHy) lens, using a water gradient silicone hydrogel options currently
with the FDA on the regulatory lens matrix. Subsequent product on the market.
Happy 20th, Silicone Hydrogels!
By Lyndon Jones, PhD, DSc, FCOptom, Jill Woods, BSc (Hons), MCOptom, Karen Walsh, BSc (Hons), MCOptom,
and Doerte Luensmann, PhD, Dipl. Ing.
In 2018, silicone hydrogel (SiHy) contact lenses cele- epithelial microcysts, limbal hyperemia and corneal
brated their 20th birthday. Now that these lenses have neovascularization were significantly reduced. However,
been available for two decades, we at CORE offer a mechanical complications arose from the combination
walk down memory lane. Here is a look at SiHy’s mile- of increased modulus and original base curve designs.
stones and challenges, from balancing properties for These included contact lens induced papillary conjunc-
comfortable daily wear to increased understanding of tivitis, mucin balls, epithelial splits and discomfort.
how the lenses interact with the ocular surface and tear
film, plus a glimpse into the future: ELEMENTARY YEARS: 2004-2009
This was a period of great advancements for SiHy with
INFANT/TODDLER YEARS: 1998-2003 the launch of the first reusable SiHy lens with a daily
Prior to SiHy lenses, frequent replacement soft hydro- wear-only indication. This material, galyfilcon A, had
gel lenses were available, but hypoxia-related compli- a bound internal wetting agent to achieve wettability.
cations existed with full-time daily and extended wear. Further innovation saw the release of comfilcon A, an
The potential benefits of silicone were known, but inherently wettable material. Practitioners had access
researchers and manufacturers faced significant tech- to an increased choice of spherical lenses, along with
nical challenges when incorporating the hydrophobic the addition of toric and multifocal options across a
element into a lens. The first generation of SiHy lenses number of new materials for both extended and daily
were balafilcon A, with a plasma ox- wear. The first daily disposable SiHy
Photo: Jeffrey Sonsino, OD, and Shachar Tauber, MD
idation surface treatment that cre- lens, narafilcon A, was launched in
ated silicate “islands’ on the surface 2008-2009.
of the lens, and lotrafilcon A with Balancing the material properties
a plasma coating. Both required of oxygen transmissibility, modulus,
surface modification to create a coefficient of friction and wetta-
suitably hydrophilic surface. bility was a focus through these
The first years of the SiHy era years to drive increased comfort for
delivered both a leap forward in daily wear. Packaging solutions also
oxygen delivery and some initial received attention, with comfort-en-
Researchers are investigating contact
physiological challenges. Hypoxic lens materials that may reduce the hancing agents added to the blister
responses, such as corneal striae, incidence of microbial keratitis. pack of several SiHy materials.
12 REVIEW OF CORNEA & CONTACT LENSES | JANUARY/FEBRUARY 2019In statements to financial ana- also see an advance that builds professor and university research
lysts, the company said Precision1 upon the Dailies Total1 lens matrix chair, and includes Jill Woods,
“will be a daily disposable, SiHy technology. Investor presentations BSc (Hons), MCOptom, clinical
contact lens intended to compete note a “next generation water research manager and senior clin-
within the mainstream subcatego- gradient” material in the works, ical scientist at CORE; and Karen
ry of the global daily disposable though no release date is specified. Walsh, BSc (Hons), MCOptom,
contact lens market” and it “will CORE clinical scientist.
be engineered for the highest INNOVATION ON Myopia. They predict an
visual clarity of any contact lens in THE HORIZON expansion of myopia control
its class.” Positioned between the Researchers from the Centre for designs, including the MiSight
high-end Dailies Total1 and the Ocular Research & Education (CooperVision) design they have
non-SiHy Dailies Aqua Comfort (CORE) at the School of been working with in clinical tri-
Plus, this new, mid-tier lens could Optometry & Vision Science at the als. This soft lens for myopia con-
strike a balance between perfor- University of Waterloo offer their trol has been available in Canada
mance and cost that helps grow insights on what’s ahead on the for a year and even longer in some
the daily disposable category as a contact lens horizon. This research East Asian and European markets.
mass-market product. team is led by Lyndon Jones, PhD, “It will be interesting to see the im-
Further down the road, we may DSc, FCOptom, CORE director, pact of this lens in the US market
However, adverse reactions still occurred, including tions remain and are the subject of ongoing research.
the potentially sight-threatening complication of micro- Hopefully innovation will result in lenses with reduced
bial keratitis. Additionally, reusable SiHys were found to complication rates and improved all-day comfort.
be two times more likely to result in corneal infiltrative
events compared with hydrogel lenses.1-4 COLLEGE YEARS: 2018 AND BEYOND
Today, researchers are looking into the development of
HIGH SCHOOL: 2010-2017 materials to reduce the incidence of infective (microbial
New research and development resulted in an in- keratitis) and inflammatory (corneal infiltrative) events.
creased understanding of the interaction of SiHys This may involve the addition of antimicrobial coatings
with the tear film. This included establishing protein to contact lens materials. In addition, improving com-
and lipid deposition profiles, and the relevance of the fortable wear times is another goal, and researchers
conformational state of those tear components once are studying the controlled interaction with the tear
adsorbed onto, and absorbed into, the contact lens. film, which would encourage uptake of “good” proteins
Further investigations also explored other variables and lipids while resisting deposition of “bad” tear film
that may impact comfort, such as the effect of contact components. Investigators believe the conformational
lens wear on the ocular inflammatory response and state of deposits is important, with materials ideally
the interactions that occur between SiHy materials and being able to minimize the denaturation of proteins and
contact lens care systems. oxidation of lipids. Further comfort enhancements may
Key milestones during this era included a new lens also involve differential deposition on the front vs. the
material, delefilcon A, with a silicone core and a hydro- back of the lens and the delivery of comfort enhancing
gel-like surface, updated designs from the original 1998 components that could help to stabilize the tear film
lenses, and the emergence of color SiHys. By the end of and enhance wettability.
2017, more than 40 SiHys were available in all prescrip- Although an important area of development, no myo-
tions and modalities, including daily disposables for pia-control designs are available in SiHy materials, but
astigmatism and presbyopia. By 2017, two-thirds of all researchers expect this to change. They also anticipate
soft fits were SiHys, with the greatest use of this mate- innovation for presbyopia with the addition of novel
rial occurring with reusable contact lenses.5 optical designs for multifocal contact lenses.
While understanding SiHy materials and their ocular With 20 years of lens advancements, the future looks
interactions increased during this time, some ques- promising for SiHy lenses.
REVIEW OF CORNEA & CONTACT LENSES | JANUARY/FEBRUARY 2019 13NEW LENSES FOR A NEW YEAR
once it gains the necessary FDA Sensimed’s Triggerfish, a contact
approvals to launch,” the CORE lens designed to evaluate changes
team says. in intraocular pressure, is commer-
Another new soft myopia cially available in Europe and has
control lens that could hit the US FDA clearance.
market in the future is NaturalVue “Biosensing technologies are a
(Visioneering Technologies), which focus for many manufacturers and
was available in some global mar- research institutions,” the CORE
kets in 2018. researchers say. “Parties are ac-
“Given the worldwide recogni- tively exploring the possibilities of
tion of the myopia epidemic, and this technology in a contact lens,
the real sight-threatening pathol- as well as with other ocular and
ogy associated with high myopia, systemic applications, including
the focus on myopia control is detection of cancer markers, blood Fig. 3. Patients with astigmatism now
crucial. We are excited by the rate pressure monitoring, measuring have a monthly replacement silicone
hydrogel lens option in the form of
at which our collective knowledge tear film osmolarity and markers Bausch + Lomb’s new Ultra Multifocal
grows in this area and the fact of dry eye disease.” While biosens- for Astigmatism, which is designed
that optical designs really do seem ing contact lenses are an exciting to provide stable, consistently clear
to have an impact,” CORE says. possibility, most technologies are vision and spherical aberration
“While it is true that there is much still quite a few years away from control in both axes to help reduce
halos and glare.
we don’t understand, this is a fast being commercially available, the
moving area of research, with new CORE team adds. Developers
evidence being generated, and new have several hurdles to overcome through the approval process,
contact lens and spectacle designs before bringing anything to mar- optometrists still hope additional
being tested and released with ket. In November 2018, Verily advances will help to fulfill their
increasing regularity.” (Alphabet) and Alcon announced patient needs.
In addition to these products, that they shelved development of a “A daily disposable toric multi-
the group is aware of alternate diabetes-monitoring contact lens, focal lens is next on my wish list,”
myopia management approaches citing difficulties with obtaining Dr. Anderson says. “I have more
via the use of orthokeratology, consistent measures of glucose than 65% of my patients wearing
pharmaceutical treatments and the levels in tears. daily disposable lenses. The next
future potential of combination Drug delivery. The CORE area needed is the daily toric mul-
therapies that may bring together researchers also see growth in tifocal lens.”
contact lens optical designs and drug-delivering contact lenses to There are still two key areas
drug delivery. treat specific conditions, including where patient needs could be
Light moderation. Light man- glaucoma, inflammation, allergy better met, the CORE team says.
agement will be of interest in and to aid ocular surface healing. “First are the rates of infection
2019, the CORE team says. In One such product in the pipeline and inflammatory events.” Daily
addition to the photochromic is a JJV contact lens that includes disposables are the best way to
lens on the way from JJV, there the medication ketotifen fumarate. minimize risk of these adverse
is much interest around eyestrain This drug-eluting contact lens is events, they say, but reusable con-
from digital device use. designed to help patients with tact lenses could benefit from the
“This has led to modifications to itchy eyes due to ocular allergies, addition of antimicrobial proper-
the optical designs of some contact according to the company. JJV ties to help reduce the incidence of
lenses, targeted to reduce digital says it is on track to bring the these complications. “Secondly, we
eyestrain. It is also possible that product to market within five are striving to minimize dryness/
the digital light management tech- years. discomfort, which remains the
nology offered in certain spectacle main reason for ceasing contact
designs may translate into the CONTACT LENS WISH LISTS lens wear. New technologies that
contact lens market,” they add. Even though several new contact can enhance the comfort of the
Biosensing. A growth in special- lenses are set to launch this year contact lens, such as release of
ty medical lenses is also expected. and others are working their way tear-film type components when
14 REVIEW OF CORNEA & CONTACT LENSES | JANUARY/FEBRUARY 2019Earn up to
NEW
NEWTTECHNOLOGIES
18 CE &T
TREATMENTS IN
20199
Credits* EEye
yyee Care
C rre
Ca
worn, would be welcome,” the
GVCE
REVIEW’S COMMITMENT TO
C O N T I N U I N G E D U C AT I O N
CORE team says.
One example is the Tangible
Hydra-PEG coating (Tangible
Science), which recently gained
FDA approval for use on daily
disposable silicone hydrogel lenses.
This coating is designed to im-
Nashville
prove wettability, increase surface
water retention and lubricity, and
minimize lens deposits. Tangible
Science had previously licensed its
technology for use with Bausch +
Lomb’s rigid gas permeable and
scleral contact lenses.
“We have a standing order with
our gas permeable lenses right
MAY 17-19, 2019
now to put Tangible on every- Join Review’s New Technologies & Treatments in Eye
thing,” Dr. Brujic says. “That’s Care on May 17-19, 2019 in Nashville, TN.
how good it’s actually been.”
This meeting provides up to 18* COPE CE credits
Additionally, while research
continues in the area of myopia
including interactive workshops!**
control, new lens options for GAYLORD OPRYLAND
this patient population would be 2800 Opryland Drive
welcome sooner rather than later,
Nashville, Tennessee 37214
doctors say. “Myopia manage-
ment is a hot topic in optometry,” DISCOUNTED RATE: $209/night†
Dr. Bazan says. “I would like to
PROGRAM CHAIR:
see more contact lens companies
develop options to help with the
myopia epidemic.”
W hile everyone waits for their
contact lens dreams to come
true, ODs are looking forward
Paul M. Karpecki, OD, FAAO
trying several new lenses this year FACULTY:
and sharing them with patients. RCCL Ben Gaddie, OD, FAAO
Jay M. Haynie, OD, FAAO
1. Szczotka-Flynn L, Diaz M. Risk of corneal inflam-
matory events with silicone hydrogel and low dk
hydrogel extended contact lens wear: a meta-anal-
THREE WAYS TO REGISTER
ysis. Optom Vis Sci. 2007;84(4):247-56.
2. Radford CF, Minassian D, Dart JK, et al. Risk
factors for nonulcerative contact lens complica-
tions in an ophthalmic accident and emergency
department: a case-control study. Ophthalmology.
ONLINE: www.reviewsce.com/nashville2019
EMAIL: reviewmeetings@jhihealth.com
2009;116(3):385-92.
3. Chalmers RL, Wagner H, Mitchell GL, et al. Age
and other risk factors for corneal infiltrative and
inflammatory events in young soft contact lens
wearers from the Contact Lens Assessment in
CALL: 866-658-1772
Youth (CLAY) study. Invest Ophthalmol Vis Sci.
2011;52(9):6690-6.
4. Chalmers RL, Keay L, McNally J, Kern J. Multi- Administered by
center case-control study of the role of lens mate-
rials and care products on the development of cor-
neal infiltrates. Optom Vis Sci. 2012;89(3):316-25.
GVCE
REVIEW’S COMMITMENT TO
C O N T I N U I N G E D U C AT I O N
*Approval pending
5. Morgan PB, Woods C, Tranoudis I, et al. In-
ternational contact lens prescribing in 2017. CL Partially supported by an unrestricted
Spectrum. 2018;33(January):28-33. educational grant from
Bausch & Lomb
**Subject to change, separate registration required. See event website for complete details. †Rooms
REVIEW OF CORNEA & CONTACT LENSES | JANUARY/FEBRUARY 2019 15
limited. RGVCE partners with Salus University for those ODs who are licensed in states that require
university credit. Visit www.reviewsce.com/events for any meeting changes or updates.KERATOPLASTY:
WHEN AND WHY
Discover how long to monitor and treat symptoms before considering
surgical interventions.
By James Esposito, OD
S
urgeons perform corneal history and clinical exam are nec- keratoplasty. Questioning a patient
graft surgery for a wide essary before referring patients for on their visual symptoms is a crucial
variety of indications, in- cataract surgery. The next two most first step.
cluding stromal opacifica- common pathologies for corneal • Blurred or variable vision
tion, corneal ectasias and persistent graft surgery are repeat graft surgery associated with corneal edema often
corneal edema due to endothelial after failure and keratoconus.3 has a diurnal nature—worse upon
failure. Worldwide, four-and-a-half Currently, the United States has waking and improved later in the
million individuals have moder- the highest rate of corneal trans- day. This is due to prolonged eyelid
ate to severe vision impairment plants per capita.4 In the 2016 EBAA closure and a relatively hypotonic
secondary to the loss of corneal report, endothelial keratoplasty tear film, which reverses throughout
clarity and more than 200 million (EK) compromised 57% of surgeries the day with greater exposure.
are visually impaired.1 Corneal performed in the United States, and Symptoms of photophobia, glare,
disease is the fifth leading cause of full-thickness penetrating keratoplas- redness, tearing, pain or foreign-
blindness after cataract, uncorrect- ty (PK) was performed in 38% of pa- body sensation are also commonly
ed refractive error, glaucoma and tients.3 Anterior lamellar keratoplasty associated with corneal edema.
macular degeneration.1 Here we (ALK) and deep anterior lamellar • Most conditions associated with
review common graft indications keratoplasty (DALK) procedures corneal edema present gradually
in the United States, clinical pearls accounted for the small portion of over weeks, months or even years.
for a timely and correct diagnosis remaining surgeries. Symptoms may be so gradual at
and recommendations on when to Since EK’s introduction in 1999, times that the patient is able to func-
obtain an initial surgical consult there has been an impressive growth tion surprisingly well and at a much
for keratoplasty. in the number of surgeries and litera- higher level than would be expected
ture publications, supplanting PK as based on a slit-lamp biomicroscopy
COMMON INDICATIONS the mainstay.5,6 In contrast, ALK and exam. Exceptions to this general rule
AND PROCEDURES DALK surgeries were first introduced would be edema caused by acutely
The Eye Bank Association of in 1959, but their popularity has elevated intraocular pressure (IOP),
America’s (EBAA) 2016 report waned, primarily due to the lack of
revealed that the most common indi- properly trained ophthalmic sur- ABOUT THE AUTHOR
cation for any corneal graft surgery geons.7 ALK and DALK also require Dr. Esposito is an
in the US is endothelial cell failure a more prolonged operating room attending provider and
clinical researcher at the
secondary to either Fuchs’ endotheli- time and carry a high risk of perfora- New Mexico Veterans
Administration Health
al dystrophy or cataract surgery [e.g., tion in older patients. Care System Eye
pseudophakic bullous keratopathy Clinic in Albuquerque,
New Mexico. He is an
(PBK)]. Be aware that a significant CASE HISTORY PEARLS adjunct clinical professor
portion of PBK patients also have Many factors come into play when at the University of Houston College
of Optometry, the Pacific University
undiagnosed Fuchs’ endothelial monitoring patients for corneal College of Optometry and the New
dystrophy.2 Therefore, a detailed case edema and considering referral for England College of Optometry.
16 REVIEW OF CORNEA & CONTACT LENSES | JANUARY/FEBRUARY 2019You can also read
