also inside this issue - review of cornea and … of cornea & contact lenses | may 2013 5 jobson...

MAY 2013

Supplement to

May 2013

ALSO INSIDE THIS ISSUEbull A Checklist for Steroid Use in the

Compromised Corneabull Small Wonders Nanotechnology in Practice bull Biocompatibility Buzzword or

Breakthrough

001_rcl0513indd 1 43013 1046 AM

Proprietary HydraGlydereg

Moisture Matrix

REFERENCES 1 Data on fi le Alcon Research Ltd 2 Lally J Ketelson H Borazjani R et al A new lens care solution provides moisture and comfort with todayrsquos CLs Optician 412011 Vol 241 Issue 6296 42 -46 3 Campbell R Kame G Leach N et al Clinical benefi ts of a new multi-purpose disinfecting solution in silicone hydrogel and soft contact lens users Eye amp Contact Lens 201238(2)93-101 4 Davis J Ketelson HA Shows A Meadows DL A lens care solution designed for wetting silicone hydrogel materials Poster presented at ARVO May 2010 Fort Lauderdale FL

ATTACHING ANDFORMING A HYDROPHILIC ENVIRONMENT across the surface of the lens124

CREATING A UNIQUE BARRIER that reduces lipid deposition

and removes protein deposits1-3

PROVIDING MOISTURE from morning till night124

OPTI-FREEreg PureMoistreg MPDS with HydraGlydereg Moisture Matrix

TALK TO YOUR PATIENTS ABOUT THE BENEFITS OF OPTI-FREEreg BRAND PRODUCTS

LEARN MORE AT MYALCONCOM

THIS IS WHY YOU CAN give your patientscomfort that lasts

copy 2012 Novartis 1112 OPM12201JAD

RCCL0313_Alcon Optiindd 1 22513 257 PM

contents

24 A Checklist for Steroid Use in the Compromised CorneaIf you can rule out any contraindications aggressive steroid therapy may help minimize the risk of future complicationsPaul M Karpecki OD

Review of Cornea amp Contact Lenses | May 2013

Departments 4 News Review

7 Editorial2013 ARVO Explores Lens-related Infl ammation and Corneal InfectionJoseph P Shovlin OD

11 Lens Care UpdateAddicted to OxyChristine W Sindt OD

12 Down on the PharmBAK TrackingTammy P Than OD and Elyse L Chaglasian OD

15 Gas-Permeable StrategiesMake the Most of Everybodyrsquos TimeJason Jedlicka OD

16 Derail DropoutsCapitalize on the Astigmatic PresbyopeMile Brujic OD and Jason Miller OD MBA

34 Out of the BoxHow Will Unemployment Impact YouGary Gerber OD

Pharmaceuticals

19 CE mdash A Decision Tree Proper Antibiotic Selection and UseWhen prescribing antibiotics there are several factors you need to consider Here is a guide to help you get startedWilliam Miller OD

28 Small WondersKeep your eye on the latest developments in nanotechnology We may soon have the potential to eliminate many troublesome eye conditionsWilliam Townsend OD

ON THE COVER

REVIEW OF CORNEA amp CONTACT LENSES | MAY 2013 3

32 Biocompatibility Buzzword or BreakthroughItrsquos both Or at least it has the potential to be Herersquos a closer look at the conceptsMark DP Wilcox PhD

ReviewofCorneaAndContactLenses rcclmag

003_rcl0513_tocindd 3 5613 951 AM

VOL 150 No 4

In The News

bull The World Council of Optometry (WCO) presented to Brien Holden PhD its highest honor the Distinguished Service Award which recognizes op-tometrists who have made an outstand-ing contribution to the achievement of WCOrsquos mission to create a world where high quality eye health and vision care is accessible to all

Dr Holden is the founder of the Brien Holden Vision Institute a worldwide multidisciplinary research center and public health organization focused on developing breakthroughs in eye care that can improve the quality of vision for people who suffer from ocular disease Through Dr Holdenrsquos efforts the Institute has invested more than $450 million in the delivery of eye care to people in need over the last 20 years

bull In a paper presented at ARVO 2013 the Mayo Clinicrsquos Sanjay Patel MD and colleagues compared changes in the corneal endothelium after three different keratoplasty techniques Studying outcomes after penetrating keratoplasty deep lamellar endothelial keratoplasty and Descemet-stripping endothelial keratoplasty they found that after three years cell loss was less with the Descemet-stripping procedure

bull GP Specialists rebranded its entire custom made-to-order soft contact lens product line with the name iSight This includes the designs acquired through its purchase of American BioCurve in 2011 The company says it now offers ldquoone of the largest portfolios of made-to-order products in the industryrdquo

bull TrueVision 3D Surgical and i-Optics announced a collaboration that will integrate the latterrsquos Cassini corneal diagnostic device with the formerrsquos Refractive Cataract Toolset surgical guidance system Removing a step in the presurgical cataract work-up can enhance speed and effi ciency they say and blending the technologies will help to optimize patient workfl ow

Doing the Keratoconus Two-Step

News Review

Keratoconus patients might have better refractive outcomes if they undergo a new two-step

surgical approach Medscape reports According to a small study pre-

sented last month at the American Society of Cataract amp Refractive Surgery annual meeting a protocol that pairs small-incision lenticule extraction (SMILE) with collagen crosslinking stabilized irregular corneas for an average of nine months And signifi cantly mean uncorrected visual acuity in the seven study eyes improved from a baseline of 20400 to 2025 at nine months postoperatively The work was done at the Instituto de Oftalmologiacutea Conde de Valenciana in Mexico City

ldquoThe crosslinking is very good for halting progression but re-fractively it doesnrsquot bring much to the patientrdquo coauthor Gabriela Pagano MD told Medscape Medi-

cal News With the combination procedure ldquowersquore bringing patients the possibility of spectacle indepen-dencerdquo The work was selected as Best Paper of the 2013 Refractive Surgery Session

The SMILE procedure for kera-toconus uses a femtosecond laser to cut a lenticule of tissue from the stroma which is removed through a self-sealing incision The pocket created is then infused with ribofl a-vin and the crosslinking procedure proceeds

Because the combined procedure preserves the integrity of Bowmanrsquos layermdashone of the major contribu-tors to corneal strengthmdashldquothis should be better than other corneal refractive proceduresrdquo Dr Pagano told Medscape Pain is minimal and the risk for infection is lower by keeping the corneal epithelium intact she added

Lens Wear So Comfortable Patients Donrsquot Even NoticeIn a 74-subject study of patients newly fi t with 1-Day Acuvue

TruEye (narafi lcon A) lenses contact lens wear was found to have no clinically signifi cant effect on the ocular surface as compared to non-lens wearers across fi ve of six contact lens-related measures associated with eye health Vistakon research shows The lens was also shown to provide high levels of comfort from morning to night comparable to wearing no lenses at all according to the company The fi ndings were published recently in Contact Lens amp Anterior Eye

Comfort scores assessed at the six study visits were equivalent for contact lens wearers and patients who had not previously worn con-tact lenses and remained with spectacle wear for 12 months

After a full year of wear there were no clinically signifi cant differ-ences between contact lens and spectacle wearers for bulbar conjunc-tival hyperemia limbal hyperemia corneal staining neovasculariza-tion and papillary conjunctivitis There was more low-grade ldquotracerdquo conjunctival staining for contact lens wearers than spectacle wearers

4 REVIEW OF CORNEA amp CONTACT LENSES | MAY 2013

Source httpwwwmedscapecomviewarticle803134

004_rcl0513_newsindd 4 5613 546 PM


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CLINICAL EDITORJoseph P Shovlin OD jpshovlingmailcom

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ASSOCIATE CLINICAL EDITORChristine W Sindt OD christine-sindtuiowaedu

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REVIEW BOARDKenneth Daniels ODMichael DePaolis ODDesmond Fonn Dip Optom M OptomRobert M Grohe ODPatricia Keech ODJerry Legerton ODCharles B Slonim MDMary Jo Stiegemeier ODLoretta B Szczotka ODMichael A Ward FCLSABarry M Weiner OD

Advertiser Index

Alcon Laboratories Cover 2 Cover 3Bausch + Lomb Page 6CooperVision Cover 4

Encouraging Data on Myopia ControlA new contact lens design shows noteworthy potential for decreasing

myopic progression based on animal study results published in Investiga-tive Ophthalmology amp Visual Science

The purpose of the randomized masked study was to determine the ef-fect of wearing a new lens with a unique optical design on the development and progression of defocus-induced myopia in newly hatched chickens Ac-cording to the study the lens caused a signifi cant reduction in the develop-ment of defocus-induced myopia over a 14-day wearing period compared to a control lens identical in every aspect except optical design There was also a signifi cant axial length difference with the control group showing increased ocular axial growth as compared to the test design groups

The lens is being developed by Visioneering Technologies of Alpharetta Ga Research was conducted by the Centre for Contact Lens Research at the University of Waterloorsquos School of Optometry amp Vision Science in Canada

This study is the fi rst to report ldquonearly complete inhibition of defocus-induced myopia in chickens compared to control lensesrdquo said lead author Jill Woods MCOptom The lack of signifi cant axial length increase seen ldquoindicates that these lens designs reduced defocused-induced myopia progression through the inhibition of axial elongationrdquo Although further work is needed to determine the exact mechanisms by which the lens de-creases myopia development the potential was signifi cant she added

Visioneering Technologies says its contact lens technology has multiple applications including control of myopic progression as well as multifo-cal vision correction for presbyopia The company expects to introduce a contact lens for presbyopia incorporating its unique technology in early 2014 An intraocular lens using the companyrsquos technology for presbyopia is also under developmentWoods J Guthrie SE Keir N et al ldquoInhibition of defocus-induced myopia in Chickensrdquo Invest Ophthalmol Vis Sci 2013 542662-2668 published ahead of print March 7 2013 doi101167iovs12-10742

An Early Look at the Performance of a New LensWhile the US launch of Alconrsquos new Dailies Total 1 daily disposable

is anticipated later this year research on the delefi lcon A materialrsquos performance is starting to appear A meta-analysis of clinical data pre-sented at ARVO 2013 documented an association between lubricity profi le measured by coeffi cient of friction and subjective reports of comfort in three assessments upon initial insertion overall comfort and end-of-day comfort Each of the three outcomes showed a highly signifi cant association between the respective comfort measure and coeffi cient of friction according to the ARVO abstract (494B0131)

004_rcl0513_newsindd 5 5613 400 PM

Advertorial

Fitting Multifocal Contact Lenses in Patients with PresbyopiaWhy so challenging

Wersquore all familiar with the clinical situation in which one patient needs a particular add power and we chose a particular brand and that patient does great But later the same day we can have another patient with the same add power who is a failure using the same brand What is different about these two patients Their add power need is the same but their distance correction is different one might be a -200 D and the other might be a -600 D You would think that these patients would have a similar result but they often donrsquot

What is the cause of this varied success when fitting multifocal contact lenses The answer may lie within the consistency of the design of the multifocal contact lens and information obtained from power profile measurements that chart the power change from the center to the periphery of the lens help us to understand why Ideally the power profile of a lens will be exactly the same for all lens powers across the available prescription range This consistency of the power profile within each lens affects not only the performance of the distance vision of the lens it also affects the performance of the addition power of the lens1

REFERENCESovi a di to Co i te o o er ro le i lti o al o ta t le e lo al S e ialt e S o i a e a N

a o or orated are trade ar o a o or orated or it a liateAll ot er rod t ra d a e are trade ar o t eir re e tive o er

Power profile consistency across the power range helps ensure that regardless of which power is fit on-eye the practitioner can expect a more predictable fitting experience Many currently marketed multifocal designs contain inconsistencies across the power range and the add power1 So a medium or high add may not perform as I think it should as a result of not knowing what the actual lens add power is or how that add power transitions to distance power I generally expect a high add to have more plus than a medium add but that is not always the case Hence multifocal contact lenses have the potential to provide variable visual outcomes to patients in addition to potentially causing an inconsistent fitting experience or an inability to predict how a lens will perform on-eye from one power to the next This can lead to frustration for patients and practitioners alike

The good news is that the opportunity exists to enhance patient satisfaction and the predictability of lens fitting by improving the power consistency of multifocal contact lenses

S P O N S O R E D B Y

he challenge of fitting multifocal contact lenses for our patients with presbyopia lies in being able to give them distinct near intermediate and

distance vision essentially on demand All of the current multifocal lenses use a simultaneous vision design in which the power for near the power for intermediate and the power for distance vision are each present all the time The brain has to sort it out and pay attention to the power it wants Unfortunately knowing who is going to do well in a multifocal lens and who is not right now seems unpredictable Is it just simultaneous vision that causes the unpredictability or is it something else

T

By Rhonda S Robinson OD

RCCL0513_BL Med Affairsindd 1 5113 258 PM

Editorial By Joseph P Shovlin OD


Each year world-renowned eye care scientists share their research at the Association

for Research in Vision and Oph-thalmology annual conference Valuable information gleaned from the many studies at this yearrsquos meeting (held May 5-9 in Seattle) can aid clinicians in developing best-practice guidelines while rais-ing important questions that will direct future research efforts

Itrsquos always diffi cult sifting through hundreds of abstracts to identify the most useful ones that can translate into immediate clini-cal practice This yearrsquos highlights include risk factors related to lens wear how to prevent infection stemming from lens and storage case contamination disinfection effi cacy and treatment options when disaster strikes

As no single study is likely to provide the defi nitive answer to a research question the fi nd-ings below should be viewed with a perspective that acknowl-edges our full body of literature Nevertheless this yearrsquos crop of abstracts provides many thought-provoking new ideas that will help us move forward

New Information on Risk Factors and Prevention

Inherent in any lens wear is a full range of risks that hopefully can be minimized by addressing identifi able factors responsible for getting an infection How might we best minimize these inherent

risks Several abstracts address these topics Important to any discussion or investigation of infection are geographic differ-ences in pathogens encountered risks to travelers lens storage case contamination and antimicrobial effi cacy of disinfecting solutions

Risk Factors for Contact Lens-related Microbial Keratitis in Singapore (Abstract ID 509B0146)

Elevated risk of microbial keratitis was associated with showering while wear-ing lenses (a three-fold higher risk) while washing and drying hands prior to handling lenses lowered the risk eight-fold Chinese ethnicity also lowered risk seven-fold in this study possibly due to socioeconomic factors Behavioral and innate factors should be investigated further

Travelerrsquos Contact Lens Associated Keratitis (TCLAK) Establishing Preventive and Treatment Guidelines to Close a Gap in Ophthalmic Care (Poster 511B0148)

Though the incidence of lens-associated keratitis is low an increasing number of new cases are identified in travelers due to greater lens use long duration of wear and travel outside the US There appears to be higher morbidity risk due to decreased access to ophthalmic care abroad

The lack of specific recommendations regarding precautions to take while travel-ing internationally is an obvious patient education gap that requires attention The authors designed guidelines that include strict adherence to proper hygiene and care seeking immediate attention if the eye gets red irritated or experiences vision loss and advises patients to not overwear lenses while traveling

Quorum-sensing Molecules in the Preferential Selection of Pseudomonas aeruginosa From Contaminated Contact Lens Cases (Abstract ID 513B0150)

ldquoQuorum-sensingrdquo proteinsgenes were studied to document and correlate their role in the selection of Pseudomonas aeru-ginosa as a preferential corneal pathogen from contaminated contact lens cases according to Bascom Palmer research-ers In 769 of studied lens cases Pseudomonas emerged as the corneal pathogen of all matched controlcornea cultures No proteins recovered correlated with Acanthamoeba species Klebsiella oxytoca or Mycobacterium chelonae

The researchers concluded that the production and expression of quorum-sensing genes and signaling molecules in contact lens case ecosytems may allow for the preferential selection of P aeruginosaas a corneal pathogen Understanding this mechanism in more detail may lead to the development of new solutions to reduce or neutralize this advantage

An Examination of the Effects of Evaporation on Antimicrobial Efficacy of Contact Lens Care Solutions (Abstract ID 5480A0179)

Partial evaporation of multipurpose solutions (MPS) by failing to cap solutions properly may result in loss of antimicrobial efficacy of the solution leading to contact lens-related infections In this study from Abbott Medical Optics evaporation was induced in four MPS products which were then challenged with P aeruginosa Serratia marcescens S aureus Candida albicans and Fusarium solani Test solu-tions were compared at four hours to the non-evaporated solutions

Researchers explore strategies to minimize risk and prevent corneal morbidity in contact lens wearers

2013 ARVO Explores Lens-related Infl ammation and Corneal Infection

007_rccl0513_edindd 7 5613 556 PM

Editorial


This study demonstrated that with partial evaporation up to 4x (simulating the action of not capping a lens case prop-erly) MPS solutions can lose significant disinfection ability More pronounced loss was shown in solutions that failed to meet criteria when non-evaporated Only one MPS tested (an investigational solution) showed full efficacy of disinfection when evaporated at the 4x level

New FDA guidelines could involve evap-oration testing and any loss of efficacy to attempt to reflect real-world conditions

The Evaluation of the Biocidal Efficacy of Multipurpose Solutions Against Mixed Cultures of Pseudomonas aeruginosa With a Variety of Individual Organisms (Abstract ID 521B0158)

This study by investigators at Bausch + Lomb investigated biocidal activity to bet-ter simulate polymicrobial contamination of contact lens cases The organisms used were not the standard five organisms but rather six separate mixtures of organisms that included P aeruginosa and one of the following Candida albicans Candida tropicalis Fusarium solani Fusarium oxysporum Aspsergillus brasiliensis and Aspergillus fumigatus Ten percent organic soil was added for an additional challenge The mixed inoculum was then used to challenge the MPS Four- and six-hour time points were evaluated Results were recorded using log reductions

Results varied according to the MPS used Fungi were recovered more than P aeruginosa Recovery for the four-hour time point ranged from 02 log reduction to gt46 (no microbial recovery observed) The six-hour time point ranged from 00 log reduction to gt46 log reductions

This study demonstrated that MPS have a broad range of in vitro antimicrobial activity against P aeruginosa and fungal

mixtures These results could demonstrate actual use conditions because environ-mental contaminants are frequently mix-tures of organisms

Antimicrobial Activity of Mela-mine or Cathelicidin Bound Contact Lenses (Abstract ID 507B0144)

The development of an antimicrobial contact lens would have the ability to reduce the rate of contact lens-related adverse events This study conducted by Allergan Brien Holden Vision Institute and Bausch + Lomb evaluated two cationic peptides coated on contact lenses for their activity against P aeruginosa and S aureus Minimal inhibitory concentration of two peptides melamine (a synthetic peptide) and cathelicidin (LL37) were measured against strains of P aeruginosaand S aureus

Increasing concentrations of pep-tides were bound covalently to contact lenses Cell death of the bacteria was used to measure the antimicrobial activ-ity compared to the control lenses with no melamine or LL37 Covalently bound LL37 was not active against S aureus melamine on contact lenses had activity against both bacterial types This suggests differing mechanisms of action against gram-negative or gram-positive bacteria by these two cationic peptides

Risk Factors for Microbial Bioburden During Daily Wear of Silicone Hydrogel Contact Lenses (Abstract ID 5479A0178)

This study from Case Western Reserve University University Hospitals Eye Institute-Case Medical Center and Alcon Labs assessed risk factors associated with substantial microbial bioburden of lids cases and silicone hydrogel lenses with daily wear

A total of 218 patients were fit with lotrafilcon A lenses randomized to use

either a preserved MPS or a peroxide care system and followed for one year Lenses lids cases and transport saline were cul-tured at selected visits

Univariate analysis showed that cur-rent or past smokers clerical occupa-tions and solution type were associated with greater risk of microbial bioburden on lenses cases or both Gender age healthcare occupations solution type and other demographic factors were associated with lid bioburden or saline contamination Mulitivariate analysis also showed clerical occupations at significantly greater risk of microbial contamination on lenses and cases

Solution type was associated with microbial bioburden in cases but not lids lenses or transport saline Hydrogren peroxide solution was associated with increased lens case bioburden but not with bioburden of lids lenses and transport saline Case contamination was not a risk factor for corneal inflammatory events in this study

Selenium Covalently Incorporated into the Polymer of Contact Lens Material Inhibits Bacterial Biofilm Formation (Abstract ID 497B0134)

Silver has been used as an antimicrobial agent in contact lens cases but has draw-backs (allergy risk variable antimicrobial effect cost reliance on the agent leaching out of the case) Selenium is a good alter-native to silver it does not have to leach out of the case to be active because it kills by catalytic formation of superoxide radi-cals and is much less expensive

This study investigated the ability of selenium covalently incorporated into the polypropylene polymer of injection-molded contact lens case material to inhibit biofilm formation by different bacteria Polypropylene containing selenium showed over 7 logs (complete) inhibition against

007_rccl0513_edindd 8 5613 556 PM

Editorial


S aureus S maltophilia and P aerugi-nosa and was fully active after soaking in PBS for the equivalent of eight weeks

Updates on Pathogens in Lens-related Infections

Surveillance has identifi ed anti-biotic resistance of ocular patho-gens These ldquobugsrdquo have relevance to lens wearers due to different vectors of exposure Itrsquos important to identify emerging resistance patterns that vary greatly depend-ing on where you practice

Believe it or not wersquore still talk-ing about Acanthamoeba kera-titis Protozoan infection rates have not dropped as expected We must remain vigilant in look-ing for ways to minimize even the rare nonbacterial infections experienced by lens wearers Microbiologic profi les in younger lens wearers are valuable and shared below

Antibiotic Resistance Surveillance of Ocular PathogensmdashFour Years of ARMOR Study Results (Abstract ID 2904B0273)

The ARMOR surveillance study reported Year-4 data on 456 isolates of Streptococcus aureus coagulase-negative staphlococci (CoNS) P aeruginosa and H influenzae from 25 sites that were subjected to susceptibility testing Drug resistance among H influenzae isolates was not observed

Non-susceptibility rates were similar to those of the previous three years Overall resistance rates did not show substantial changes over the four-year study A num-ber of isolates showed resistance to com-monly used ophthalmic antibiotics Among MRSA and MRCoNS isolates multidrug resistance was especially prevalent

Specific findings includebull P aeruginosa isolates were nonsus-

ceptible for ciprofloxacin (91) imipenem (114) tobramycin (45) and polymycin B (45)

bull S pneumoniae isolates were non-susceptible to imipenem (131) penicil-lin (49) chloramphenicol (33) and azithromycin (410)

bull S aureus and CoNS isolates were nonsusceptible to oxacillinmethicillin (373-419) ciprofloxacin (338-366) clindamycin (183-313) azithromycin (588-601) and other antibiotics

bull More than 33 of S aureus and CoNS isolates were resistant to three or more antibiotics

bull Methicillin-resistant isolates of S aureus (MRSA) and CoNS (MRCoNS) were predominantly drug resistant (gt73)

Risk Factors of Severe Acanthamoeba Keratitis (Abstract ID 5435A0134)

Japanese researchers studied risk fac-tors for severe Acanthamoeba keratitis by comparing severe cases to mild ones (ie those with a good prognosis) in a nine-case series

A history of topical steroid use was found in four eyes in the severe group and three in the mild group Mean number of corneal scrapings was 138 in the severe group and 56 in the mild group Kerato-precipitates were present in all eyes in the severe group Also in the severe group S aureus was found in one case by palpebral conjunctiva culture which was resistant to topical antibiotics

They concluded that the use of corti-costeroids and the presence of kerato-precipitates are possible risk factors for severe Acanthamoeba keratitis Attention is also required in patients with comorbidi-ties such as diabetes mellitus and bacterial co-infection

Clinical and Microbiological Profile of Infectious Keratitis in Children (Poster Board B0100)

In this retrospective study of pediatric patients with infectious keratitis in Mexico City 78 of patients showed predisposing factors Ocular trauma including contact lens wear was the most common (25) Factors responsible for visual impairment may be delay in eye care visual axis involvement inadequate adherence to treatment and low positivity of cultures

Pseudomonas aeruginosa isolates were resistant to ceftazidime the first-line drug in gram-negative keratitis Susceptibility to gentamycin was observed Staphylococcus sp showed multiple antibiotic resistance in a majority of cases

Infectious Keratitis in Mexicomdash10-Year Experience in Corneal Scrapes (Poster Board B0091)

Another retrospective study conducted in Mexico City reported the distribution microbiologic trends and antibiotic sensi-tivity patterns of infectious keratitis cases from January 2002 to December 2011 In all 1638 corneal scrapings were taken A pathogen was recovered in 616 samples (38) Bacterial keratitis accounted for 544 of the positive cultures (88)

Results showed a non-significant increase in recovered gram-positive and gram-negative micro-organisms over time An increase in resistance to methicillin in almost half the MSRA and MRCNS islolates was observed In the last five years of the study ceftazidime-resistant P aeuroginosaincreased to nearly 90

Vancomycin-resistant micro-organisms accounted for 99 of all gram-positive isolates while 133 of all bacterial iso-lates were resistant to quinolones For now the authors conclude that this justi-fies quinolones as monotherapy broad-spectrum treatment for bacterial keratitis

007_rccl0513_edindd 9 5613 556 PM

Editorial


The Proctor Experience With Acanthamoeba Keratitis From 1996-2012 (Poster B0105)

This retrospective study described the presentation management and outcomes of Acanthamoeba keratitis (AK) patients in the Bay area before and after an AK epi-demic beginning in 2004-2005

Forty-one patients (42 eyes) demon-strated culture-proven AK From 1996-2004 there were zero to three AK cases From 2005-2011 there were three to six cases This trend is significant (p=0003) The number of microbiology-positive AK cases has increased since 2005 and has not remitted The duration of symptoms in 1996-2004 is not statistically different from 2005-2012 Visual acuity at presenta-tion was not significantly different from pre-2005 and 2005 to present

The number of culture-proven AK cases has not decreased to pre-epidemic levels in the Bay Area Before and after 2005 a median time of four weeks of symptoms prior to diagnosis was endured and patients presented with visual acuity morbidity Even with increased awareness diagnosing AK does not appear to be hap-pening any earlier in its course

Advances in Treatment New therapies are always excit-

ing to share with readers This yearrsquos abstracts look at preclinical evaluations of several new thera-pies for corneal infections includ-ing rare nonbacterial keratitis Ongoing research should help iden-tify new strategies in treating these morbid corneal conditions

Clinical Outcomes and Prognostic Factors Associated With Acanthamoeba Keratitis Treated With Pentamidine Isethionate (Poster Board B0103)

This retrospective Japanese study described the clinical characteristics time of presentation treatment outcomes and prognostic factors on a series of 24 patients and 26 eyes with Acanthamoebakeratitis (AK) treated with pentamidine isethionate

A review of all patients was performed including age gender time to diagnosis use of corticosteroid before diagnosis combination of bacterial of fungal infec-tions diagnostic method initial visual acuity duration of pentamidine isethionate treatment side effects and final visual acu-ity Treatment failure was defined as AK recurrence or needing a therapeutic deep anterior lamellar keratoplasty

The onset of symptoms was greatest in September AK was diagnosed either by typical clinical presentation or by culture Forty-two percent of eyes were diag-nosed previously with herpetic keratitis 58 were treated with corticosteroid eye drops Five eyes had combined bacterial or fungal infections Twenty-two eyes were contact lens wearers Hospital time averaged 269plusmn217 days Visual acuity improved from 141logMARplusmn100logMAR to 019logMARplusmn034logMAR Soft contact lens wearers tended to have a higher risk of infection and failure is likely to be asso-ciated with stromal involvement

Predictors of Outcome in Fungal Keratitis Using Data From the Mycotic Ulcer Treatment Trial (Abstract ID 2900B0269)

The purpose of this study was to deter-mine baseline factors predictive of out-come in fungal keratitis among the Mycotic Ulcer Treatment Trial (MUTT I) Group

MUTT I was a multicenter randomized double-masked NEI-funded clinical trial that compared outcomes in 323 patients with fungal keratitis receiving 5 topical

natamycin or 1 topical voriconazole Significant predictors of worse three-

month visual acuity were worse baseline acuity larger epithelial defect size at presentation and randomization to voricon-azole instead of natamycin in the trial For three-month infiltratescar size significant predictors include larger infiltrate and epi-thelial defect size worse presenting visual acuity and use of topical antifungals prior to trial enrollment Predictors of corneal perforation were worse presentation visual acuity older age and randomization to voriconazole instead of natamycin The predictors of longer time to epithelialize were epitithelial defect size and presenta-tion ulcer depth

Study findings suggest that it is difficult to change the course of an ulcer even with proper treatmentmdashulcer severity at presentation is highly predictive of worse outcomesmdashbut a better understanding of predictive factors may help guide future treatment decisions and management

ConclusionsClinically relevant informa-

tion is not always apparent in high-level research abstracts but ARVO posters and papers are teeming with valuable informa-tion that can be applied to clinical practice Knowing how to reduce risk and prevent morbidity in lens wearers is extremely useful infor-mation Knowing how to identify in a timely fashion and better treat rare devastating infections in lens wear is crucial ARVO has helped us do so year after year

I hope that you have found this yearrsquos review helpful For more information and all the abstracts please visit wwwarvoorgabstracts RCCL

007_rccl0513_edindd 10 5613 557 PM

Lens Care UpdateBy Christine W Sindt OD


A32-year-old male with surgically induced Hornerrsquos syndrome in his right eye

presented with mild hyperemia and irritation He reported that his symptoms have persisted for several years Additionally a previ-ous eye care provider ldquodiagnosedrdquo contact lens overwear although that is a rather nonspecifi c term

The patient reported dosing his right eye with Visine LR (McNeil-PPC) at least 20 times per day on top of his contact lens for the last decade to help control his Horner-induced ptosis Upon examination of the right eye we documented numerous deep-stromal opacities located across the entire cornea as well as diffuse superfi cial punctate epithelial erosions Remarkably he had minimal hyperemia

We diagnosed him with medi-camentosa secondary to chronic topical dosing We instructed him to discontinue Visine LR use Ad-ditionally to treat the underlying ptosis we recommended either

surgical intervention or use of a compounded preservative-free formulation of oxymetazoline

What is MedicamentosaMedicamentosa is a chemical ir-

ritation or a delayed cell-mediated hypersensitivity response of the ocular tissues to topically applied drugs or preservatives It may take weeks months or years for the symptoms of medicamentosa to appear And to further complicate the diagnosis any documented symptoms may in fact be caused by unrelated complicationsndashndashes-pecially in the case of contact lens wearers where there are other ocular surface irritants

While there may be improve-ment of the underlying condition (eg ptosis) ancillary symptoms may develop over time including irritation grittiness stinging burn-ing photophobia conjunctival hyperemia lid swelling and blurred vision Clinically apparent signs of medicamentosa include corneal or conjunctival staining corneal edema pseudodendrites and stro-mal infi ltrates

The differential diagnoses of medicamentosa include contact lens-related staining viral kerato-conjunctivitis dry eye and rosacea

Typically medicamentosa is at-tributed to the preservative agent in an ophthalmic solution Howev-er in some instances the drug itself may cause unwanted effects on the eye that worsen with increased dosing

In our patientrsquos case Visine LR contains oxymetazoline (an alpha- 1 and partial alpha-2 agonist

which serves as a vascular decon-gestant and facilitates ptosis relief) and is preserved with benzalko-nium chloride (BAK)ndashndasha known ocular irritant that causes corneal staining (see ldquoToo much of a good thingrdquo January 2011) In addition however oxymetazoline yields several side effects

The entire class of topical vaso-constrictors (including oxymetazo-line naphazoline and tetrahydro-zoline) has been shown to cause rebound hyperemia after discontin-uation Also while commonly used by dry eye patients these drugs can yield a signifi cant decrease in tear volume and fl ow1 There is at least one published study of corneal opacity development secondary to chronic vasoconstrictor dosing2 In this report the opacities partially resolved with drop discontinuation

When medicamentosa is suspect-ed instruct the patient to discon-tinue the offending medication or switch to a preservative-free for-mulation Keep in mind however that treatment of the underlying condition is still necessary RCCL

1 Goumlbbels MJ Achten C Spitznas M Effect of topically applied oxymetazoline on tear volume and tear flow in humans Graefes Arch Clin Exp Ophthalmol 1991229(2)147-92 Herman DC Bartley GB Corneal opacities secondary to topi-cal naphazoline and antazoline (Albalon-A) Am J Ophth 1987 Jan 15103(1)110-1

This patient developed medicamentosa from chronic long-term oxymetazoline use How should he be managed

Addicted to Oxy

Agents Frequently Associated With Medicamentosa

bull Benzalkonium chloridebull Brimonidinebull Atropinebull Neomycinbull Acyclovirbull Prostaglandin analogs

Medicamentosa may develop in patients who endure long-term exposure to certain topical medications or preservative agents

Phot

o A

ndre

w S

Gur

wood

OD

011_rcl0513_lenscare_MHindd 11 5313 329 PM


Down on the PharmBy Tammy P Than OD MS and Elyse L Chaglasian OD

The concerns over preserva-tives in particular benzalko-nium chloride (BAK) used

in ophthalmic solutions have been well documented1-7

BAK generally is well tolerated with short-term topical therapies (eg an antibiotic for bacte-rial conjunctivitis or a steroid for episcleritis) but glaucoma patients face long-term challenges These patients can be maintained on glaucoma medications for several decades and their treatment plan often involves concurrent use of multiple BAK-containing drops In the end this translates to signifi -cant cumulative exposure to BAK What are the implications

The ResearchWhile most published stud-

ies outline the harmful effects of BAK on the ocular surface some fi ndings are less conclusive and perhaps even contradictory8 Since much of the data available is lab-based or preclinical and uses non-human models making the application to clinical practice can be challenging

In 2010 Robert Noecker MD and Kimberly Miller MD pub-lished a summary of the BAK literature and its effects on the ocular surfacendashndashin particular as it pertains to glaucoma medications They found the majority of the literature says BAK has an adverse effect on the ocular surface and recommended that practitioners should consider nonndashBAK-contain-ing glaucoma medications to avoid these potential reactions9

It has been noted that one

shortcoming in many past clinical evaluations is the failure to include a control group Sudipta Ghosh DO and colleagues recently com-pared the prevalence of symptoms and signs of ocular surface disease (OSD) in glaucoma patients vs a control group Symptoms of OSD were found to be common in both populations However signs of ocular surface disease including fl uorescein staining of the conjunc-tiva and cornea were more preva-lent in the glaucoma group (703 vs 33)10 Reduced tear fi lm break-up time and the presence of ocular surface staining were more likely with each additional glau-coma medication used

While 942 of the study used drops containing preservatives the authors did not compare the effects of different preservatives10 Howev-er approximately 78 of ophthal-mic pharmaceuticals contain BAK leading to the conclusion that this preservative could be implicated as a contributing factor to the signs of OSD in the above study11

In a meta-analysis of seven prospective clinical trials Stefan Trocme MD and colleagues failed to demonstrate signifi cant ocular toxicity in patients treated with latanoprost or timolol both containing BAK They concluded that when BAK is used in the con-centration available in glaucoma medications (0004 to 002) patients do not experience corneal toxicity12

Charles Tressler MD Richard Beatty MD and Michael Lemp MD determined that dilution of BAK occurs quickly from a normal

tear fi lm despite a BAK concentra-tion of 002 (the highest con-centration currently available in a glaucoma medication) upon instil-lation it is reduced to 00025 in 30 seconds and to 000056 in three minutes13 Therefore corneal exposure time to any clinically signifi cant concentration of BAK is very short-lived It should be noted that the dilution would be less rapid in patients with dry eye a common coexisting condition in glaucoma patients13

Glaucoma patients who are also contact lens wearers face an ad-ditional challenge The residence time the ophthalmic drop is in contact with the ocular surface increases If BAK is irritating the effects will be exacerbated in con-tact lens wearers who opt to instill their medications while wearing their lenses despite warnings from eye care practitioners

Therapeutic Optionsbull BAK-free options are now

available in all classes of contem-porary glaucoma medications (see Table 1) except the topical carbonic anhydrase inhibitors that include Trusopt (dorzolamide 2 Merck) and Azopt (brinzo-lamide 1 Alcon)mdashpreserved with 00075 and 001 BAK respectively It should be noted that pilocarpine and Pilopine gel (pilocarpine hydrochloride Alcon) contain BAK as well

bull Beta-blockers although not typically used as initial treat-ment still play a signifi cant role in glaucoma management due to their reasonable cost and 20 to 25

BAK TrackingWhen prescribing medication to patients on multiple BAK-containing drops consider a preservative-free option when appropriate

012_rcl0513_dotpindd 12 5313 312 PM

Down on the Pharm


effi cacy in reducing IOP14 Timop-tic XE (timolol maleate Valeant Pharmaceuticals) is formulated as a gel-forming solution as such it has a longer residence time than a solu-tion in a once-daily drop Both the branded and the generic (Timolol GFS Falcon Pharmaceuticals) are preserved with benzododecinium bromide (BDD) which provides a multiuse container of a non-BAK containing beta-blocker However BDD and BAK are both quaternary ammonium surfactants and may have properties too similar to make BDD a feasible alternative for patients intolerant to BAK

bull Timoptic in Ocudose (timolol maleate Aton Pharma) is available in 025 and 05 concentrations and is preservative-free Available

in prepackaged individual unit doses contained within a foil pack the 60 vials are meant to last for one month with BID dosing and the vials are to be used within one month of opening the foil pack

bull Brimonidine an alpha-agonist is a well-tolerated medication that is typically prescribed twice daily when used as additive therapy The branded drug Alphagan P (brimonidine tartrate ophthalmic solution 01 or 015 Allergan) is preserved with Purite which is an oxychloro complex classifi ed as a ldquodisappearing preservationrdquo that dissociates to water and sodium and chloride ions once exposed to light Note that the generic solutions contain either 015 of 02 of brimonidine and are

preserved with BAK bull Due to a signifi cant incidence

of allergic reactions and tachy-phylaxis Iopidine (apraclonidine Alcon) is typically used only for in-offi ce application The 1 concentration is packaged only in single-unit vials of 01ml each which contain 001 BAK

bull When monotherapy fails to suffi ciently lower IOP combina-tions are often attractive options Cosopt (Merck) contains 05 timolol maleate and 2 dorzol-amide it is available in a preser-vative-free formulation Typically used twice a day this medication is available in a package of 60 single-unit vials Each foil pack contains 15 vials Per the manufacturer once a foil pack is opened unused

Table 1 Commercially Available BAK-Free Topical Ocular Hypertensive MedicationsTrade Name Active Ingredient Preservative Contact Lens Wear (Per Drug

Labeling)Packaging

Alphagan P Brimonidine Purite Not addressed 5 10 or 15 mL

Cosopt PF Timolol maleate 05 Dorzolamide 2

None Not addressed 60 SUV (in foil packs) One pack = 15 SUV (02 mL each)

Timoptic in Ocudose Timolol maleate 025 or 05

None Not addressed 60 SUV One pack = 60 SUV (02 mL each)

Timolol GFS Timolol maleate 025 or 05

Benzododecinium bromide

ldquoHas not been studied in patients wearing contact lensesrdquo

25 or 5 mL

Timoptic XE Timolol maleate 025 or 05



5 mL

Travatan Z Travoprost 0004

sofZia Remove lens before instilling wait 15 minutes before reinserting lens

25 or 5 mL bottle

Zioptan Tafluprost 00015

None Not addressed 30 or 90 SUV (in foil packs) One pack = 10 SUV (03 mL each)

SUV = single unit vial

012_rcl0513_dotpindd 13 5313 312 PM

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Sign up for a sneak peek today

Visit wwwreviewofcontactlensescom

to subscribe to ourmonthly e-newsletter


single-unit vials should be discarded within 15 daysbull Due to excellent effi cacy and tolerability pros-

taglandins are often included in the management of patients with glaucoma and ocular hypertension Travatan Z (travoprost 0004 Alcon) contains sof-Zia an ionic-buffered system containing boric acid propylene glycol sorbitol and zinc chloride These compounds break up into non-toxic ingredients when exposed to the ocular surface

Zioptan (tafl uprost 00015 Merck) was ap-proved in February 2012 and is the fi rst preservative-free prostaglandin available in the US The foil pouches contain 10 single-use vials used once daily with labeling that indicates the need to discard any vials within an opened foil pouch after 28 days Car-tons of 30- or 90-unit vials are available

Should additional preservative-free medications be required or if a patient needs a specifi c therapeutic agent not commercially available in a BAK-free formulation consider a compounding pharmacy

Remember that not all patients require BAK-free options However when patients use multiple drops they are increasing their daily concentration of BAKmdashso for contact lens wearers patients with existing OSD or those with a known BAK sensitiv-ity consider avoiding the preservative Fortunately within the past year there have been several new drug approvals to give us many BAK-free glaucoma op-tions to help manage our glaucoma patients RCCL

1 Kusano M Uematsu M Kumagami T et al Evaluation of acute corneal barrier change induced by topically applied preservatives using corneal transepithelial electric resistance in vivo Cornea 2010 Jan29(1)80-5 2 McCarey B Edelhauser H In vivo corneal epithelial permeability following treatment with prostaglandin analogues with or without benzalkonium chloride J Ocul Pharmacol Ther 2007 Oct23(5)445-51 3 Ammar DA Noekcer RJ Kahook MY Effects of benzalkonium chloride-preserved polyquad-preserved and sofZia-preserved topical glaucoma medications on human ocular epithelial cells Adv Ther 2010 Nov27(11)837-45 4 Whitson JT Cavanagh HD Lakshman N Petroll WM Assessment of corneal epithelial integrity after acute exposure to ocular hypotensive agents preserved with and without benzalkonium chloride Adv Ther 2006 Sep-Oct23(5)663-71 5 Kahook MY Noecker R Quantitative analysis of conjunctival goblet cells after chronic applica-tion of topical drops Adv Ther 2008 Aug25(8)743-51 6 Yamazaki S Nanno M Kimura T et al Effects of switching to sofZia-preserved travoprost in patients who presented with superficial punctate keratopathy while under treatment with latano-prost Jpn J Ophthalmol 2010 Jan54(1)7-14 7 Leung EW Medeiros FA Weinreb RN Prevalence of ocular surface disease in glaucoma patients J Glaucoma 2008 Aug17(5)350-5

Additional references at wwwreviewofcontactlensescom

012_rcl0513_dotpindd 14 5313 312 PM

Gas-Permeable Strategies By Jason Jedlicka OD


Make the Most of Everybodyrsquos TimeGP lab consultations are a valuable resource for practitioners Here are some ways to maximize the value of these appointments

Whether it is getting started with a new fi t or trying to improve a

current one GP lab consultants are an invaluable part of fi tting GP lenses successfully Many of us however do not take advantage of these consultation options as often or as effectively as we could In this monthrsquos column I spoke with Dan Bell president and lead consultant of Corneal Design Corporation in Gaithersburg Md to discuss how consultants view their interactions with contact lens fi tters and to ask for suggestions on how to maxi-mize the time and effectiveness of this communication

Consultation Etiquettebull Do not have a staff member fi ll

your shoes First and perhaps most importantly Mr Bell made it clear that consultations should involve the individual doing the fi tting not a staff person When the individual who is calling into a consultation is not the one who has fi rst-hand knowledge of the patient (eg seen the lens fi t discussed complications and knows the lens fi t history) you do not get the most out of a consultantrsquos time

I had incorrectly assumed that in most cases the fi tter was the one asking for a consultation But Mr Bell said that in almost half the cases it is a staff person who calls to order the lens through consultation on behalf of the practitioner responsible for the fi tting Instead ask your offi ce staff only to order lenses that do not require consultation

through customer service Do not ask someone in consultation to work with a staff member who may not be prepared to answer questions based on patient interac-tion and as such provide the infor-mation needed to optimize the fi t

bull Be thorough in your assess-ment If you anticipate the need for consultation be sure to collect all data that may be crucial to consul-tation including keratometry over-refraction or fl uorescein evalua-tions of the lens fi t When looking at a lens Mr Bell suggested not only to look at the fl uorescein pat-tern but also to take note of how the lid interacts with the lens and what it looks like as the patient blinks and moves his or her eye

bull Come prepared Mr Bell said to collect all paperwork includ-ing your patientrsquos chart and complete the necessary testing prior to scheduling a consulta-tion Also be sure to inform your lab consultant about any potential complication(s) with the lens fi t Dry eye thyroid disease preg-nancy estrogen use and systemic medication use for conditions like high blood pressure or allergies are all important factors when trying to determine why a patient is strug-gling with lens wear or noticing

changes in vision Similarly images of diagnostic

tests (eg corneal topography) or photos of patientsrsquo eyes with or without lenses can be very useful to consultants Make sure that the images are high resolution and in color so they can be accurately interpreted Also be sure to scan and email topographies rather than sending a fax

bull Plan your schedule accord-ingly Block out an appropriate amount of time when you schedule your call with the lab consultant Take the time to learn the specifi ca-tions materials and design of the lens you are discussing how the consultant is planning to alter the parameters and why these changes may improve the patientrsquos experi-ence The more you understand about how lab technicians can change a lens and why they are doing so the less likely you are to need future consultationsndashndashand the more likely you are to take better advantage of the service

Fitting guides are wonderful tools and experience is priceless But your lab consultant is also a crucial component of the GP lens fi tting process He or she is there to help make lens fi ttings easier and more predictable Whether it is

recommending the best design for a particular patientrsquos needs helping to improve a fi t that is not working as well as it could or giving you the latest information on a lens designrsquos intricacies your lab consultant should be a resource that you call on routinely RCCL

( )Look at the fluorescein pattern but also take note of how the lid interacts with the lens and what it looks like as the patient blinks

and moves his or her eye

015_rcl0513_gpsindd 15 5313 312 PM

Derail Dropouts By Mile Brujic OD and Jason Miller OD MBA


Capitalize on the Astigmatic PresbyopeThe newer multifocal designs can help give you an advantage in the presbyopic community

As eye care practitioners there are some facts we always know to be true

These include the trifecta First new fi ts generate revenue Second specialized contact lens fi ttings can improve loyalty and set your services apart from the competi-tion And third the contact lens industry has developed new and innovative productsmdasheg multi-focal lensesmdashwhich help us offer our patients greater visual freedom by minimizing dependence on glasses

While there are several ways to help defi ne a practice consider your strength in delivering new technology and become the local expert on a particular specializa-tion For example astigmatic presbyopes are patients who likely have been told that they cannot wear contact lenses andor only have been offered monovi-sion prescriptions We know that monovision lenses can be successful in some situations But in com-parison the newer mul-tifocal lenses improve both vision and depth perception

By fi tting specialized contact lenses your practice will become synonymous with cutting-edge expertise and you will likely see better patient reten-tion and an increase in word-of-mouth patient referrals And despite worries about excessive chair time specialty

contact lens fi tting typically yields higher gross margins too

The Patient ResponseA decade ago a Review of

Optometry survey found a nearly even split between eye care profes-sionals who fi t monovision vs multifocal contact lenses1 Since then signifi cant improvements in multifocal technology have resulted in a noticeable shift in presbyopic fi tting trends

In a May 2006 study 76 of patients reported that they pre-ferred multifocal over monovision lenses2 In July 2007 another study replicated those results and found a 31 ratio of patient prefer-ence for multifocal over monovi-sion lenses3 The researchers also further demonstrated the added advantage of multifocal contact lenses in the improvement of vari-ous visual measurements includ-ing contrast sensitivity and depth

perception When successfully fi t with multifocals patients can en-joy improved binocular vision vs monovision and improved periph-eral vision vs spectacles

The technological advances in multifocal designs make the adjustment period relatively quick and easy Patients also gain the ability to have an intermedi-ate focus which is particularly important for those with a high add Keep in mind however that there are some patients who will be unsuccessful in multifocal de-signs and may be better served by monovision

Office VisitsTake the time to identify your

patientsrsquo occupations hobbies and daily visual requirements This information will help you prop-erly identify their visual needs and discuss reasonable expectations in advance of the fi tting By taking

a few extra steps to customize the multifo-cal lens fi tting to the individual patientrsquos daily visual tasks you likely will derail contact lens dropouts and inevitably gain the respect of presby-opic patientsndashndashwho will in turn serve as ambassadors for your practice

Keep in mind that presbyopic patients tend to command more time and energymdashincluding increased chair staff

When fitting hybrid contact lenses make sure to check for bubbles after insertion Their presence will hinder vision and comfort

016_rcl0513_Derailindd 16 5313 325 PM

Derail Dropouts


and doctor time Therefore it is important to understand how to properly bill and code for these patients Develop your protocol ahead of time so everyone is on board when these patients come in for their visit For example do you need a corneal topography at every follow-up appointment for a particular specialty fi t Which fi tting sets are most important to keep in the offi ce By planning ahead you will be appropriately compensated for your time and expertise

Understand the Technologybull Soft multifocals The soft

multifocal toric market is the newest area of growth These lenses combine the toric technol-ogy used to correct astigmatism with the most advanced soft multifocal lenses This fi tting process is two-fold First fi t the toric correction and adjust for any rotation or instability Second customize the multifo-cal to the patientrsquos specifi c visual demands

Remember to discuss appro-priate visual expectations the associated fees and the importance of follow-up care Review how these lenses can provide clear distance and near vision for a vast majority of visual tasks Try not to bog down the conversation by going into too much detail on the technical aspects of the lens such as design Instead focus on the expected timeline

Note One of the major keys to success in fi tting presbyopes with soft multifocal lenses is correct-

ing the underlying low astigma-tism We know that uncorrected astigmatism results in distorted or blurred vision as well as decreased ldquocrispnessrdquo in visual acuity It can cause headaches and eye fatigue We also know that there is some loss of visual clarity with soft multifocal contact lenses If we try to mask that cylinder the overall loss adds up and the success rates decrease We can help eliminate some of that by fi rst correcting even low amounts of astigmatism If there is any doubt demonstrate the cylinder in the phoropter and listen to the response

bull RGP multifocals For pres-byopes RGPs often can provide a greater range of clear vision which enables the eye care profes-sional to maximize both distance and near vision for their patients RGPs also have the unique ability to mask irregularities of a compro-mised or irregular corneal surface

For some patients RGPs are the only effective way to achieve the best visual function Patients will most often have diffi culties when excessive movement exists so monitor the fi t closely

bull Hybrids The hybrid platform is an excellent example of how material science can help even those with unique visual needs wear contact lenses successfully The only commercially avail-able hybrid lens for this use is the SynergEyes lens which provides increased oxygen delivery to the cornea through the soft and rigid gas-permeable portions of the lens There were no previous high-Dk hybrid lenses on the market due to the diffi culty in bonding hydro-philic skirts to this materials4

Certainly we will always have patients who are intolerant of any

lens design But for patients who would benefi t from the optics that an RGP delivers and cannot wear the lenses because of issues of discomfort hybrid lens technologies should be con-sidered The soft skirt surround-ing the RGP will lessen the lens awareness

Be comfortable and profi cient as you work to satisfy the needs of your presbyopic patients The

newer multifocal designs provide good optics and comfort Take advantage of this opportunity and grow your practice through your expertise RCCL

1 Eisenberg J Monovision vs multifocal which would you choose Rev Optom 2003 Dec Available at httprevoptomcomindexasppage=2_1061htm Accessed May 20132 Richdale K Mitchell GL Zadnik K Comparison of multifocal and monovision soft contact lens corrections in patients with low-astigmatic presbyopia Optom Vis Sci 2006 May83(5)266-733 Benjamin WJ Comparing multifocals and monovision CL Spectrum 2007 Jul Available at wwwclspectrumcomarticleaspxarticle=100637 Accessed April 20134 Chou B Rigid optics with soft lens comfort CL Spec-trum 2006 Jul Available at wwwclspectrumcomarticleaspxarticle=13066 Accessed April 2013

( )One of the major keys to success in fitting presbyopes with soft multifocal lenses is

correcting the underlying low astigmatism


Whatrsquos The SolutionBy Christopher W Lievens OD MS and Crystal Brimer OD

copy 2013 Novartis 313 OPM13020AE

Sponsored b y

Man is a junkie for news Most of us absorb knowledge so quick-

lymdashby scanning web pages and blogsmdashthat we rarely if ever stop and listen to a remarkable story When the world of optometry as we knew it was altered in 2006 and 2007 suddenly our peers were being interviewed by big media about Acanthamoeba and fungal keratitis

We were concerned by the real-ization that although patients were presenting without classic symp-tomatology they were ultimately being diagnosed with sight-threat-ening pathologies due to the use of certain contact lens multipurpose solutions (MPS) and non-compli-ance Reports of poor compliance behaviors and hygiene gave us great concern1-4 We instructed patients to use specifi c products for contact lens disinfection Before long the issue subsidedmdashas did our universal drive for emphasizing lens care

Six years later we are still caring for the same patient base with very complex ocular surface needs But today we now have new informa-tion As a result the FDA con-ducted independent research studies and has recently published their fi ndings5

FDA FindingsThe goal was to examine disin-

fection effi cacy of a PHMB and POLYQUADregALDOXreg preserved solution in the presence of a contact lens The FDA specifi cally ques-tioned what the soft contact lens

itself does to alter disinfection of commonly used products during storage in the lens case

PHMB is a commonly used preservative in MPS brand-name products and many generic formu-lations A single PHMB formulation was challenged with Staphyloccoc-cus aureus and Fusarium solani Six silicone hydrogels and two conven-tional hydrogel lenses were added to the solution and subsequently challenged with the microbes during a six- 12- 24- 72- or 168-hour soak6

The FDA found that over time some lens materials can signifi cantly reduce the PHMB concentration and the MPS microbial activity against Staph6

In the F solani study seven of the eight lens materials signifi cantly reduced the MPSrsquos ability to kill this microorganism and failed to consis-tently obtain a one-log reduction of F solani after only a six-hour soak7

In fact three of the lens materials induced more than a 50 of label reduction of PHMB concentrations after only six hours of soaking7

After a soak of 24 hours or more three had lost all or almost all fungicidal activity7 Several authors have indicated that MPS formula-tions have diminished antimicrobial activity after soaking with lenses9-11

With the aforementioned ap-proach the FDA conducted a study challenging an MPS contain-ing polyquaternium-1 0001 (POLYQUADreg disinfectant) and myristamidopropyl dimethylamine 0005 (ALDOXreg) in its activity

against Staph after being used to store seven different soft contact lenses8 Unlike the PHMB solution tested the POLYQUADreg ALDOXreg

disinfectant concentration in the lens cases was reduced only very slightly over time8 The presence of the lenses did not adversely affect the biocidal activity of the solution and in some cases the effi cacy was signifi cantly better8

Manufacturers introduced one-step MPS to afford our patients fewer procedures to follow and thereby enhance compliance6 The FDA results highlight the need to carefully evaluate all MPS for their disinfectant potential in the presence of different contact lens materials8

The FDA and others have reminded us that solutionlens in-teractions can have an impact on a contact lens wearerrsquos experience

This news is worthy of our atten-tion and our immediate response

1 Chang DC Grant GB OrsquoDonnell K et al Multistate outbreak of Fusarium keratitis associated with use of a contact lens solution JAMA 2006 Aug 23296(8)953-632 Joslin CE Tu EY Shoff ME et al The association of contact lens solution use and Acanthamoeba keratitis Am J Ophthalmol 2007 Aug144(2)169-803 de Oliveira PR Temporini-Nastari ER Ruiz Alves M et al Self-evaluation of contact lens wearing and care by college students and health care workers Eye Contact Lens 2003 Jul29(3)164-7Additional references at wwwreviewofcontactlensescom4 Donshik PC Ehlers WH Anderson LD et al Strategies to better engage educate and empower patient compliance and safe lens wear compliance what we know what we do not know and what we need to know Eye Contact Lens 2007 Nov33430-35 Eydelman MB Tarver ME Kiang T et al The Food and Drug Administrationrsquos role in establishing and maintaining safeguards for contact lenses and contact lens care products Eye Contact Lens 2012 Nov38(6)346-96 Shoff ME Lucas AD Brown JN et al The effects of contact lens materials on a multipurpose contact lens solution disinfection activity against Staphylococcus aureus Eye Contact Lens 2012 Nov38(6)368-73


Lessons Learned from Past Headlines

CONTINUING EDUCATION


Because antibiotics are one of the more frequently used medication classes in any

office clinicians sometimes rely on well-established prescribing pat-terns without full consideration of alternative approaches or special considerations Prudent prescribing requires knowledge of indications and contraindications for use side effects and formulary or price com-parisons All of this information helps you select the appropriate antibiotic for your patient

Remember that individual choic-es for antibiotic therapy and any additional medications will depend on the particular patient severity of the condition and each practitio-

nerrsquos overall management strategy A patientrsquos systemic allergy profile and current medications may also limit antibiotic selection

Specific actions and side effects of each antibiotic can be found in the individual drugrsquos package insert Physicianrsquos Desk Reference various textbooks or through a consultation with the pharmacist1-3

This article will present a decision tree for therapy guidance includ-ing general directions and caveats concerning therapeutic choices for antibiotics

Prescribing Antibiotics There are a few overarching

principles to guide a practitioner

in starting antibiotic therapy First you should give the antibiotic at sufficient dosing to eradicate the particular insulting microbe Low dosing or insufficient concentra-tions (minimum inhibitory concen-tration MIC50 and MIC90) of an antibiotic can be one of the causes of resistant strains of microbes4-6

This is typically only advisable when a drug is being used for its anti-inflammatory profile rather than its antimicrobial effect7

Tailoring the chosen antibiotic to the suspected microbersquos sensitivity profile is another principle that is

When prescribing antibiotics there are several factors you need to consider Here is a guide to help you get startedBy William Miller OD MS PhD

Release Date May 2013Expiration Date May 1 2016Goal Statement This article discusses the factors that influence antibiotic selec-tion in anterior segment disease FacultyEditorial Board William Miller OD MS PhDCredit Statement COPE approval for 1 hour of CE credit is pending for this course Check with your local state

licensing board to see if this counts toward your CE requirements for relicen-sureJoint-Sponsorship Statement This continuing education course is joint-sponsored by the Pennsylvania College of OptometryDisclosure Statement Dr Miller has no financial relationship to disclose

William Miller OD MS PhD is Associate Professor University of Houston College of Optometry and

Chair of Clinical Sciences Department He is a Fellow of the American Academy of Optometry and member of the European Academy of Optom-etry and Optics He serves on the Editorial Review Board of Eye and Contact Lenses

A Decision Tree Proper Antibiotic Selection and Use

019_rcl0513CEantiindd 19 5313 335 PM



often forgotten As we have learned from resistance data treatment should be sufficient to the task (hit it hard) for the minimum duration to cure the infection

Lastly in cases of microbe-derived inflammation you should start with the most conservative treatment regimen necessary to accomplish the task of eradicating the microbe

Eyelid Disease Treating and managing blephari-

tis and meibomian gland dysfunc-tion (MGD) is typically initiated after or during the application of conservative therapies such as warm compresses and eyelid hygiene When first-line conserva-tive therapy is insufficient or the blepharitis or MGD is recalcitrant consider antibiotic therapy Inad-equate treatment is based on the continued presence of signs and symptoms of the eyelid disease

For antimicrobial intervention the go-to choice is topical oint-ment Favorite antibiotic oint-ments include erythromycin and bacitracin prescribed every night at bedtime for up to a month after which the patient is re-evaluated for possible continuation maintenance dosing or effective control using lid hygiene

However with the evolution of novel more viscous carriers at least one other medication may be appropriate at this stage of therapymdashthe macrolide antibiotic Azasite (azithromycin 1 Inspire Pharmaceuticals) Although used off-label for this purpose the effec-tiveness of Azasite in the treatment of eyelid disease can be traced to its the viscous carrier Durasite (polycarbophil) which increases the medicationrsquos retention time and allows for more contact on the eye-lid margin

How does it work Upon

contact with a mucosal surface a gel is formed that is released in a sustained fashion providing a unique delivery model for use in blepharitis and MGD As compared to other antibiotic ointments Aza-site provides minimal obscuration of vision has anti-inflammatory properties that serve as an adjunc-tive therapy and is relatively easy to apply8 Remember to counsel your patient on out-of-pocket costs and third-party plan coverage9-12

Azasite is administered BID for two to three days then QD for the remainder of the month The patient should apply the drop to a closed eyelid and massage the medi-cation into the base of the eyelash-es Azasite can be used in patients age one or older while erythro-mycin is approved for patients as young as two months of age

Finally MGD has also been treated orally with low-dose tetra-cycline drugs such as doxycycline and minocycline Usual therapy would consist of prescribing either 50mg to 100mg per day for several weeks followed by titrating the dosage down for maintenance ther-apy Be sure to warn patients about sun exposure and do not prescribe low-dose tetracycline to pregnant women and children under the age of eight

Bacterial Conjunctivitis Most current topical ophthal-

mic antibiotics are explicitly FDA approved for bacterial conjunctivi-tis Because most therapy is started empirically it is sensible to use a broad-spectrum antibiotic Consid-ering the disease process is mostly self-limited and has a low visual morbidity there may be no need to prescribe newer-generation antibi-otics as a first-line treatment They can be warranted as a second-line treatment strategy for recalcitrant cases or hyperacute situations

Commonly used antibiotics for bacterial conjunctivitis include

bull Polytrim (polymyxin Btri- methoprim Allergan) QID for seven to 10 days

bull Tobrex (tobramycin Alcon) QID for seven to 10 days

bull Vigamox (moxifloxacin 05 Alcon) TID for four to seven days

bull Zymar (gatifloxacin Allergan) Q2H for two days and QID for day three to seven

bull Besivance (besifloxacin Bausch + Lomb) TID for seven days

bull Azasite BID for two days and QD for five days

Besivance and Azasite the new-est antibiotics on the market offer certain unique attributes As an ophthalmic-only medication Besiv-ance does not have a systemic coun-terpart to increase the possibility of resistance And Azasite through the Durasite carrier increases the reten-tion time on the ocular surface In a five-day study Azasite showed a significant improvement in clinical resolution and bacterial eradication vs placebo13 In another trial Aza-site was found to be as effective as tobramycin with rapid symptom-atic resolution14

In cases of bacterial conjuncti-vitis having the preservative-free optionmdashVigamox and Moxeza (moxifloxacin 05 Alcon)mdashwould control untoward effects on the cornea by preservatives Other

1 Typical peripheral ulcer as seen with sodium fluorescein presumed to be caused by staphylococcal infection



factors to consider when choosing the appropriate topical antibiotic include formulary and third party treatment protocols as well as the need for multiple antibiotics

Finally ointments can be used in patients who have difficulty instill-ing drops (eg children would be prescribed QID for seven days) and when overnight coverage is needed in severe cases Recommendations include ciprofloxacin tobramycin bacitracin and polymyxin Bbacitracin

Corneal Abrasion In most cases the selection of a

topical antibiotic is not as critical because the application is meant to provide prophylaxis against bacterial infection However if sus-picion is heightened select a more potent topical antibiotic Increased suspicion may relate to the health or immune status of the patient Concomitant ocular infection such as blepharitis or MGD could pre-dispose the patient to an increased risk of corneal infection in a com-promised corneal barrier

Short-term use (fewer than two days) is generally sufficient given that most abrasions will heal in that period of time If healing is pro-longed the patient should continue to instill antibiotic drops Dosing may vary from four times a day to once an hour depending on the size and depth of the abrasion You

may need to choose an antibiotic that can be used concurrently with contact lens wear in which case a QD or BID dosing may be more convenient for the patient to avoid preservative uptake into the contact lens

Because we are talking about short-term use there is less of a concern over resistance Remember to select an antibiotic that is least toxic to the newly regenerating cor-neal epithelium Therapeutic recom-mendations include Polytrim or any of the fluoroquinolones (except the newest generation) The antibiotic may need to be altered or the treat-ment period extended if suspicions arise concerning likelihood of infec-tion There may be occasions when an antibioticsteroid medication needs to be added to address the overall pathogenesis of the disease process In these cases remember to take all normal precautions regard-ing topical steroid use including monitoring intraocular pressure and keeping the treatment protocol within a brief timeframe

Microbial Keratitis The most commonly associated

risk factor for microbial keratitis is contact lens wear followed by ocu-lar surface disease ocular trauma and ocular surgery15 Pseudomonas aeruginosa is the most commonly isolated organism followed by the Staphylococcus species and other gram positive microbes15

Iquix (15 levofloxacin Vis-takon) is the only FDA-approved antibiotic with a label indication for microbial keratitis However standard of care and sufficient peer-reviewed research suggests that you have other options as well includ-ing the entire class of fluoroquino-lones16-20 Moderate to severe cases may respond to fourth-generation fluoroquinolones which have been shown to have equivalent clinical

activity18192122 Dosing regimens depend on disease severity

Because many mild cases of marginal keratitis are due to staphy-lococci they can be treated using topical fluoroquinolonesmdashPoly-trim tobramycin or gentamicin23-25

Typical dosing should follow a QID regimen even when the condition is mild More aggressive therapy can be initiated when the condition is not responding to therapy or begins to worsen For marginal keratitis most practitioners may also opt for a topical steroid or antibioticsteroid in cases that are immune-mediated and not likely infectious

Cases of frank bacterial keratitis often are initially managed empiri-cally with resultant cultures per-formed when the keratitis appears recalcitrant or is located centrally or paracentrally Other factors that may indicate the need for culturing include corneal depth and or thin-ning presence of satellite lesions interaction with vegetative mate-rial featherrough infiltrative bor-ders and recent care in a hospital environment A typical treatment regimen includes instillation of a fluoroquinolone every 15 to 30 minutes for six to eight hours then every hour until the patient begins to show improvement Dosing is then titrated based on signs and symptoms until the offending bacte-rial organism is removed

Severe central and paracentral cases of bacterial keratitis can be treated quite successfully with the new generation of fluoroquino-lonesmdashMoxeza and Zymaxid Also consider fortified antibiotics such as vancomycin (25mgml to 50mgml) which can be combined with tobramycingentamicin (9mgml to 14mgml) or ceftazidime (50mgml)17

No published studies have inves-tigated the effectiveness of Moxeza and Zymaxid in bacterial keratitis

2 The same ulcer as in figure 1 viewed with white light




treatment At least one study found Moxeza to have a greater con-junctival tissue concentration than Vigamox which might shed light on its enhanced penetration into ocular tissue26

Utmost care and judicious pre-scribing as well as prudent follow-up care are necessary to prevent ocular morbidity In some cases you may want to consult with a corneal specialist depending upon the practitionerrsquos experience and training on severe forms of bacterial keratitis

Prophylaxis and Postoperative Refractive Surgery

As in corneal abrasion treatment the goal in postoperative refrac-tive surgery is to prevent the onset of bacterial infection Therefore a broad-spectrum antibiotic that is nontoxic to the healing cornea is preferred The patient will likely be administered the antibiotic short-term and other topical drops such as corticosteroids will accompany the treatment

Refractive surgeons will make individual recommendations and those will most likely include fluoroquinolone choices such as Vigamox QID for one week and Besivance TID for seven days2728 Although not approved for postop-erative refractive surgery patients some surgeons are also opting for Zymaxid or Moxeza BID or QID for six to seven days

Keep in mind that a recent ASCRS alert advised against the use of Besivance Moxeza and azithro-mycin among other medications pre- or intraoperatively in refractive surgery because the drugs contain vehicles to enhance retention on the ocular surface and can potentially be sequestered beneath a LASIK flap or bandage contact lens such as in the case of photorefractive keratectomy (PRK) This could

lead to flap displacement or diffuse lamellar keratitis in LASIK cases and decreased epithelial healing in PRK29 The alert also mentioned select topical steroids and tear supplements that contain similar vehicles to enhance retention time

Individual antibiotic choices vary based on the prescribing doctor and the above is meant to serve as a guide to aid in decision-making Note In cases of suspected MRSA or MRSE the Ocular TRUST study found that likely the best choices are trimethoprim with polymyxin B gentamicin tobramycin and van-comycin30 RCCL

1 Physiciansrsquo Desk Reference vol 67 Montvale NJ PDR Network 20132 Bartlett JD Jaanus SD Clinical Ocular Pharmacology 5th ed Philadelphia Elsevier Health Sciences 20073 Autry JC Ocular Therapeutics Handbook 3rd ed Philadel-phia Wolters KluwerLippincott Williams amp Wilkins 20114 Block SL Hedrick J Tyler R et al Increasing bacterial resis-tance in pediatric acute conjunctivitis (1997-1998) Antimicrob Agents Chemother 2000 Jun 44(6)1650-45 McDonald M Blondeau JM Emerging antibiotic resistance in ocular infections and the role of fluoroquinolones J Cataract Refract Surg 2010 Sep36(9)1588-986 Dave SB Toma HS Kim SJ Ophthalmic antibiotic use and mutidrug-resistant staphylococcus epidermidis a controlled longitudinal study Ophthalmol 2011 Oct118(10)2035-407 Geerling G Tauber J Baudouin C et al The international workshop on meibmonian gland dysfunction report of the subcommittee on management and treatment of meibomian gland dysfunction Invest Ophthalmol Vis Sci 2011 Mar 3052(4)2050-648 Luchs J Azithromycin in DuraSite for the treatment of blepharitis Clin Ophthalmol 20104681-89 Veldman P Colby K Current evidence for topical azithromy-cin 1 ophthalmic solution in the treatment of blepharitis and blepharitis-associated ocular dryness Int Ophthalmol Clin 2011 Fall51(4)43-5210 Luchs J Efficacy of topical azithromycin ophthalmic solution 1 in the treatment of posterior blepharitis Adv Ther 2008 Sep25(9)858-7011 Foulks GN Borchman D Yappert M et al Topical azithromycin therapy for meibomian gland dysfunction clinical response and lipid alterations Cornea 2010 Jul29(7)781-812 Haque RM Torkildsen GL Brubaker K et al Multicenter open-label study evaluating the efficacy of azithromycin oph-thalmic solution 1 on the signs and symptoms of subjects with blepharitis Cornea 2010 Aug29(8)871-713 Abelson MB Heller W Shapiro AM et al Clinical cure of bacterial conjunctivitis with azithromycin 1 vehicle-controlled double-masked clinical trial Am J Ophthalmol 2008 Jun145(6)959-6514 Chochereau I Meddeb-Querani A Khairallah M et al 3-day treatment with azithromycin 15 eye drops versus 7-day treat-ment with tobramycin 03 for purulent bacterial conjunctivitis multicentre randomised and controlled trial in adults and chil-dren Br J Ophthalmol 2007 Apr91(4)465-915 Green M Apel A Stapleton F Risk factors and causitive organisms in microbial keratitis Cornea 2008 Jan27(1)22-716 Willcox MD Management and treatment of contact lens-related Pseudomonas keratitis Clin Ophthalmol 20126919-24

17 Wong RL Gangwani RA Yu LW Lai JS New treatments for bacterial keratitis J Ophthalmol 201220121-718 Constantinou M Daniell M Snibson GR Vu HT Taylor HR Clinical efficacy of moxifloxacin in the treatment of bacte-rial keratitis A randomized clinical trial Ophthalmol 2007 Sep114(9)1622-919 Shah VM Tandon R Satpathy G et al Randomized clinical study for comparative evaluation of fourth-generation fluoroqui-nolones with the combination of fortified antibiotics in the treat-ment of bacterial corneal ulcers Cornea 2010 Jul29(7)751-720 Schaefer F Bruttin O Zografos L Guex-Crosier Y Bacterial keratitis a prospective clinical and microbiological study Br J Ophthalmol 2001 Jul85(7)842-721 Parmar P Salman A Kalavathy CM et al Comparison of topical gatifloxacin 03 and ciprofloxacin 03 for the treatment of bacterial keratitis Am J Ophthalmol 2006 Feb141(2)282-622 Scoper SV Review of third- and fourth-generation fluoro-quinolones in ophthalmology in -vitro and in-vivo efficacy Adv Ther 2008 Oct25(10)979-9423 Ficker L Seal D Wright P Staphylococcal infection and the limbus study of the cell-mediated immune response Eye 19893190-324 Chung G Phlyctenular keratoconjunctivitis and marginal staphylococcal keratitis In Cornea Fundamentals Diagnosis and Management Vol 1 3rd ed Krachmer JH Mannis MJ Holland EJ ed Philadelphia Mosby Elsevier 201125 Holden BA Reddy MK Sankaridurg PR et al Contact lens-induced peripheral ulcers with extended wear of disposable hydrogel lenses histopathologic observations on the nature and type of corneal infiltrate Cornea 1999 Sep18(5)538-4326 Lindstrom R Lane S Cottinham A et al Conjunctival con-centrations of a new ophthalmic solution formulation of moxi-floxacin 05 in cataract surgery patients J Ocul Pharmacol Ther 2010 Dec26(6)591-527 Nielsen SA McDonald MB Majmudar PA Safety of besi-floxacin ophthalmic suspension 06 in refractive surgery a retrospective chart review of post-LASIK patients Clin Ophthal-mol 20137149-5628 Charma DP Sharma S Wilkins MR Microbial keratitis after corneal laser refractive surgery Future Microbiol 2011 Jul6(7)819-3129 Attention medical alert for LASIK and PRK ASCRS Avail-able at httpascrsorgPress-Releasesattention-medication-alert-lasik-and-prk Accessed April 201330 Asbell PA Colby KA Deng S et al Ocular TRUST nation-wide antimicrobial susceptability patterns in ocular isolates Am J Ophthalmol 2008 Jun145(6)951-8

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1 Which fundamental principle should guide a practitionerrsquos use of topical antibiotic for ocular surface infections

a Use medication with the lowest efficacyb Intermittent use is preferablec Sufficient concentration (MIC90) should be used d None of the above

2 Which agent has been used as a vehicle to increase the retention time of Azasite

a Polycarbophil b Polyvinyl alcoholc Petrolatumd Carboxymethylcellulose

3 When treating blepharitis with Azasite what is the indicated dosing frequency

a QDb BID c TIDd QID

4 Which topical antibiotic does NOT have a systemic equivalent

a Vigamoxb Ciloxanc Besivance d Azasite

5 What is the most common organism found in an otherwise healthy patient with microbial keratitis

a Streptococcusb Listeriac Pseudomonas aeruginosa d Methicillin-resistant Staphylococcus aureus

6 Which agent is FDA-approved for the treatment of microbial keratitis

a Iquix b Ciloxanc Besivanced Zymaxid

7 An indication for corneal culturing includesa Marginal infiltrate placementb Pinpoint ulcerationc Satellite lesions d Infiltrates with intact overlying epithlium

8 Contemporary topical antibiotics with specialized vehicles in post-LASIK patients may cause

a Epithelial ingrowthb Diffuse lamellar keratitis c Transient light sensitivity syndromed Central islands

9 Which topical antibiotic contains a vehicle that increases drug retention time on the ocular surface

a Vigamoxb Ciloxanc Iquixd Moxeza

10 According to results from the Ocular TRUST study which topical antibiotic might be the best choice to combat MRSA

a Tobramycinb Ciloxanc Iquixd Ocuflox

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Lesson 109180 RO-RCCL-0513



Have you noticed corneal disease patients who pres-ent with a rise in intraocular

pressure developing cataracts and secondary infections As you may have guessed these are all potential adverse effects of corticosteroid use in the treatment and management of corneal disease However in my experience I more frequently see complications due to the withholding of a corticosteroid in corneal disease when it should have been prescribed Such undue caution can result in cor-neal neovascularization prolonged infiltrative keratitis uncontrolled uveitis persistent patient symptoms and even corneal scarring In a num-ber of these cases the patient was left with only one optionmdashcorneal transplant That said I add the cave-at that practitioners must always be cautious in the use of corticosteroids and instruct patients to use them appropriately so as to minimize any risks

Aside from prescriptions related to surgical care optometry writes more prescriptions for certain steroids such as Lotemax (loteprednol 05 Bausch + Lomb) than any other medical profession So while we are comfortable with the use of corti-costeroids it can be helpful to have a refresher course on the dorsquos and donrsquots of proper use

CorticosteroidsWhen incorporating steroids into

your treatment plan there are three potential concerns IOP elevation (which could lead to glaucoma) secondary infections due to the immunosuppressive nature of corti-costeroids and the formation of pos-terior subcapsular cataracts

Newer versions of these agentsmdashester-based steroidsmdashhave signifi-cantly reduced complication rates One recent multicenter study com-paring dexamethasone to ketone-free loteprednol found half as many cases

If you can rule out contraindications aggressive steroid therapy may help minimize the risk of future complicationsBy Paul M Karpecki OD

Dr Karpecki works in the corneal servic-es and heads the clinical

research department at the Koffler Vision Group in Lexington Ky

A Checklist for Steroid Use Compromised Cornea

in the

023_rcl0513steroidsindd 24 5313 340 PM


of significant IOP elevation with loteprednol1 These findings were comparable to previous analyses2

Ketones can form a Schiff base which is a precursor to cataract development the absence of a ketone in loteprednol precludes this from occurring3 However decreasing the risk of IOP eleva-tion with an ester-based steroid does not eliminate the risk of sig-nificant IOP elevationndashndashespecially with long-term use4

Donrsquotsbull Donrsquot write refills This is

perhaps more of a personal prefer-ence but I strongly recommend that you do not allow refillsndashndashespe-cially on the first prescription for a corticosteroid Often the comfort perceived by a patient using topical steroids can lead them to continue the therapy long-term

If a patient is prescribed multiple refills they may no longer experi-ence any symptoms and choose not to return to the office without awareness that their intraocular pressure may be elevated If you do not write a refill the patient is forced to return to your office for an IOP check before he or she can receive another prescription

Similarly a compromised cornea might preclude the use of cortico-steroids such as in the presence of an abrasion Once the epithelium is breached there is an increased risk of potential infection Suppressing the immune system with corticoste-roids in an already present trauma situation where the epithelium has been debrided could lead to a potential secondary infection

bull Donrsquot forget the well-known infectious keratitis contraindica-tions This includes the presence of epithelial herpes simplex keratitis (whether it be dendritic geograph-ic marginal ulcer or any epithelial form) Simply put patients diag-

nosed with HSV keratitis in the presence of corneal staining should not be prescribed corticosteroids Other infectious conditions that could worsen under the presence of a corticosteroid include fungal keratitis mycobacterium and even bacterial keratitis (especially in the early stages)

The Steroids for Corneal Ulcers Trial (SCUT) found that use of corticosteroids in addition to anti-biotics for the treatment of bacte-rial ulcers did not help or hinder healing or complication rates5 In fact more severe bacterial keratitis patients in the SCUT appeared to have a better outcome if cortico-steroids were used after the second day and throughout the long-term follow-up6

It is best to avoid steroids during the early acute phase of a bacte-rial keratitis typically this would mean the first two days for gram-positive bacterial infection and possibly 72 hours for gram-neg-ative rods such as Pseudomonas aeruginosa

I would also advise against using corticosteroids when treating a bacterial corneal ulcer unless a

48- to 72-hour window (depend-ing on the cultured pathogen) has passed and improvement is noted in the clinical picture Positive signs include significant epitheli-alization progress and a pathogen identified via culture that is shown to be susceptible to the drugs being applied If all of these are met cor-ticosteroids could indeed decrease the level of inflammation and pre-vent corneal scarring in a bacterial keratitis

bull Donrsquot forget to take a detailed patient history Avoid corticoste-roid use on a compromised cornea in patients with uncontrolled sys-temic diseases (such as arthritis or lupus) when either an infiltrate or corneal thinning is noted Unless the systemic disease control is well noted a corticosteroid could lead to increased breakdown of the epithelium because the patientrsquos systemic disease is causing further corneal damage

In other words a corticosteroid might be contraindicated in a patient presenting with rheumatoid arthritis and a corneal melt which is an indication of poorly con-trolled rheumatoid arthritis A bet-ter choice of treatment would be systemic immunosuppression via a rheumatologist

bull Donrsquot mix steroids and con-tact lenses There is some debate as to whether a corticosteroid should be applied on top of a contact lens I believe that the absorption of medication into a contact lens can alter the effects of the drug on the cornea due to increased contact time (because the lens acts as a drug reservoir) This could lead to prolonged steroid exposure and potentially increase the individualrsquos risk of complications

In the giant papillary conjuncti-vitis trials patients were adminis-tered loteprednol drops on top of a contact lens7 Even though there Corneal neovascularization

Corneal edema



were no corneal complications (eg infection) the results showed that these patients had a signifi-cantly higher incidence of IOP rise vs studies where a contact lens was not involved Therefore it can be assumed that the safety related to IOP rise of even an ester-based corticosteroid is somewhat lost if the drug resides within the contact lens throughout the day It should also be mentioned that there were no secondary infections reported in any of the patients who received corticosteroid drops directly on the contact lens during clinical trial7

Dosbull Do use corticosteroids in a

timely manner When a cortico-steroid is warranted withholding it could lead to even greater com-plications such as scarring or neo-vascularization We have very few medications on the market that are angiotensivemdashie can prevent cor-neal vascularization as well as give comprehensive inflammation sup-pression For that reason if cor-neal neovascularization is present and encroaching the visual axis it is critical that aggressive corticoste-roid therapy be used

Likewise infiltrative or inflam-matory corneal events require the use of aggressive corticosteroids However if a contact lens periph-eral infiltrate is noted because the cornea is compromised it would be more prudent for a practitioner to use a steroidantibiotic combina-tion agent as opposed to simply

pure corticosteroids Inflammatory conditions tend to be closer to the limbus and often have epithelial defects or staining that is much smaller than the actual infiltratersquos size

bull Do look for critical signs Always be cautious of the potential signs of an infectious keratitis in the presence of an infiltrate This typically can be found in patients with significant symptoms such as acute onset pain and photophobia a very red eye 360deg in the conjunc-tiva decreased vision and the pres-ence of discharge

The critical signs of a bacterial keratitis include lid edema an epi-thelial defect over an infiltrate with significant staining and an ante-rior chamber reaction If the signs are more indicative of a chronic inflammatory event use steroids readily and aggressively via a com-bination steroidantibiotic drop to help the patient with pain and inflammation

bull Do pick the right delivery method Because we have so many options and delivery forms of corticosteroids ranging from sus-pensions to emulsions to gels and ointments it is wise to become familiar with all of the different options and how to use them when the appropriate patient presents

For example the addition of an overnight steroid ung to daily drops can dramatically improve the level of inflammation when treating iritis An overnight corti-costeroid ointment can also help patients with morning symptoms andor significant meibomian gland dysfunction

Since resuspension requires 20-30 bottle shakes try to select medications that do not require resuspension Three corticoste-roid formulations on the market todaymdashLotemax gel Lotemax ointment and Durezol (diflupred-

nate 005 Alcon)mdashreport com-plete uniformity in each drop This is critical when treating significant inflammation where an inappropri-ate amount of drug can result in iritis uveitis or non-infectious infil-trative keratitis

Prescribing steroids is essential to successful clinical practice and good patient outcomes When a patient with a compromised cornea presents doctors must use cau-tion to determine if corticosteroids could cause harm Clinicians must look for key signsmdasheverything from infectious keratitis to epitheli-al defects and even active systemic diseasemdashto determine if a cortico-steroid is contraindicated If not contraindicated aggressive steroid therapy is warranted and may pre-vent serious complications RCCL

1 Chen M Gong L Sun X A multicenter randomized parallel-group clinical trial comparing the safety and effi-cacy of loteprednol etabonate 05tobramycin 03 with dexamethasone 01tobramycin 03 in the treatment of Chinese patients with blepharokeratoconjunctivitis Curr Med Res Opin 2012 Mar28(3)385-942 Holland EJ Bartlett JD Paterno MR et al Effects of loteprednoltobramycin versus dexamethasonetobramycin on intraocular pressure in healthy volunteers Cornea 2008 Jan27(1)50-53 Comstock TL Decory HH Advances in corticosteroid therapy for ocular inflammation loteprednol etabonate Int J Inflam 2012 [Epub 2012 Mar 28]4 Raipal RK Digby D DrsquoAversa G Intraocular pressure eleva-tions with loteprednol etabonate a retrospective chart review J Ocul Pharmacol Ther 2011 Jun27(3)305-85 Srinivasan M Mascarenhas J Rajaraman R et al Cortico-steroids for bacterial keratitis the Steroids for Corneal Ulcers Trial (SCUT) Arch Ophthalmol 2012 Feb130(2)143-506 McClintic SM Srinivasan M Mascarenhas J et al Improvement in corneal scarring following bacterial keratitis Eye (Lond) 2013 Mar27(3)443-67 Bartlett JD Howes JF Ghormley NR Safety and efficacy of loteprednol etabonate for treatment of papillae in contact lens-associated giant papillary conjunctivitis Curr Eye Res 1993 Apr12(4)313-21

Corneal scarring Severe vernal keratoconjunctivitis


027_rcl0513_RCCL_webadindd 1 43013 1045 AM


Imagine a world where the physi-cal characteristics of a material change as it becomes smaller

or where submicroscopic surgical instruments can be used to repair damaged nerves12 This may sound like a scene out of a science fiction movie but it is our reality today More so this technology provides an excellent opportunity to diagnose and treat disease at the molecular level What are we talking about It is the world of nanoscience nano-technology and nanomedicine3

A Nano ApproachLetrsquos start by defining the key

players bull Nanoscience refers to the ldquofun-

damental study of phenomena and the manipulation of matter at the atomic molecular and supramo-lecular level where properties differ significantly from those at a larger scalerdquo4

bull Nanotechnology denotes ldquothe design characterization production and application of structures devices and systems that have novel physical chemical and biological properties by controlling shape and size at the nanometer scalerdquo4

bull Nanomedicine encompasses a broad range of technologies It is defined as ldquothe science and technol-ogy of diagnosing treating and pre-venting disease and traumatic injury of relieving pain and of preserving

and improving human health and using nanoscale structured materials biotechnology genetic engineering and eventually complex machine sys-tems and nanorobotsrdquo5

Derived from the Greek word nano or dwarf a nanometer is one billionth (10-9) of a meter6 Concep-tualizing something that minute can be challenging so contemplate this A nanometer is proportional to a meter in the same way that a marble is comparative to the earth6 To fur-ther put that into perspective the diameter of a double strand of DNA is around 2nm6 Using nanotechnol-ogy we can now manufacture par-ticles no larger than a viral particle or bacterium

Nanoparticles typically are defined as clusters of atoms that range in size from 1nm to 100nm (some objects up to 200nm may still fall under this definition)36 The properties of a material in nanoscale may differ dramatically from the properties it exhibits as larger particles For example in both the ldquoconventionalrdquo scale (eg a can) or in the ldquomicrordquo scale (eg powder) aluminum pos-sesses the same basic qualities How-ever as a nanoparticle aluminum can spontaneously burst into flames1

Implications for the EyeNanotechology offers great prom-

ise in health care The particles are roughly the same sizendashndashor in some

William Townsend OD is a graduate of the Universi-

ty of Houston College of Optometry and practices in a multi-location set-ting He is Distinguished Visiting Clinician in Residence an adjunct professor at the Univer-sity of Houston College of Optometry and the current president of the Ocular Surface Society of Optometry

Keep your eye on the latest developments in nanotechnology We may soon have the potential to eliminate many troublesome eye conditionsBy William Townsend OD

Small Wonders

028_rcl0513nanoindd 28 5313 337 PM


cases smaller thanndashndashthe infec-tious agents that cause disease For example a virus is roughly 100nm in diameter while bacteria are about 10 times as large Nanopar-ticles are also similar in size to basic physiologic molecules found in nature A glucose molecule is approximately 1nm in diameter and an antibody is roughly 10nm in size3

The eye in particular may be a very viable site for nanotherapy The lipophilic corneal epithelium hydrophilic stroma of the cornea and sclera conjunctival lymphat-ics and blood-eye barrier often make it difficult for molecules to be absorbed into the eye7 Topical administration is usually the pre-ferred means of delivering a medi-cation to the eye but because of the factors previously mentioned it may be an inconsistent or ineffi-cient means of conveying molecules into the eye Typically less than 5 of a topically applied dose reaches the anterior ocular tissues7

Incorporating a therapeutic mole-cule into a nanoparticle may allow better targeting of specific tissues or organs using a significantly lower concentration of drug

Medications successfully for-mulated from nanoparticles theo-retically would have the potential to deliver adequate intraocular concentrations of a drug to the anterior and posterior eye at lower surface concentrations7 This is partially due their small size and the type of structures they form

Drug DeliveryOur understanding of glau-

coma has increased exponentially over the past two decades Still the reduction of intraocular pres-sure continues to be the primary method of treating this condition Unfortunately current therapy is not free of complications or

side effects which can negatively impact a patientrsquos quality of life8

Treatment itself also may be unsuccessful especially when you consider that patients may forget to take their medications andor not be able to pay for the costly doses In addition preservatives in glaucoma medications can nega-tively affect the ocular surface to the point of surgical intervention9

Consider the benefits of incorpo-rating nanomolecules into ocular tension-lowering medications Jayaganesh Natarajan PhD and colleagues fabricated latanoprost-loaded egg-phosphatidylcholine (EggPC) liposomes each with an approximate diameter of 109nm Following a single subconjunctival injection of the liposome formula-tion they monitored the clinical status of the eyes and recorded the intraocular pressure They noted sustained release of latanoprost with 60 of the drug discharged after 14 days The intraocular pres-sure-lowering effect was still main-tained after 90 days and there was a significantly greater mean IOP reduction in the eyes treated with

subconjunctival injection of the liposome formulation vs the eyes treated daily with topical latano-prost solution10

bull Liposomes are nanoscale spherical vesicles that can be pro-duced from natural phospholipids and cholesterol (see figure 1) Their structure forms when phospho-lipids are combined with water the immediate result is a bilayered sphere One end of each molecule is water soluble while the opposite end is water insoluble This config-uration allows for delivery of both lipophilic drug molecules incorpo-rated into the bilayer and water-soluble drugs that are trapped inside the liposomal cavity

bull Micelles are lipid molecules arranged in a spherical form in aqueous solutions (see figure 2)11

Their configuration resembles that of liposomes and results from the amphipathic nature of fatty acids (eg they contain both a hydro-phobic and hydrophilic [polar] end groups) In water the polar end faces toward the outer surface of the micelle11 Micelles offer dis-tinct advantages over conventional delivery because of their small size reduced toxicity ability to solubi-lize drugs and targetability12

Several studies have evaluated the feasibility of micelles as car-riers for ophthalmic medications When applied topically onto the eye cyclosporin A (CsA) physically entrapped into micelles displayed a prolonged residence time13 Topi-cal ketorolac physically entrapped into micelles was compared to the administration of the conventional aqueous preparation corneal pen-etration of the micelle preparation was significantly higher than the conventional aqueous suspension and demonstrated higher inflam-matory activity14 These studies suggest that micelles also may prove to be an excellent alternative

1 In this simple liposome structure hydrophilic heads (purple spheres) orient to the outside surfaces and the lipophilic tails (blue lines) orient toward the inside Hydrophilic medications (red spheres) are trapped in the aqueous-filled central cavity

028_rcl0513nanoindd 29 5313 337 PM


to conventional ophthalmic prepa-rations

Severe uveitis is a potentially blinding disease that is often treated with triamcinolone ace-tonide (TA) Because TA is a water-insoluble corticosteroid it is typically delivered by subtenon subconjunctival or intravitreal injection15 Intravitreal steroid injection may cause complications including cataract formation reti-nal detachment hemorrhage and intraocular pressure elevation In a study using a rabbit model of uve-itis Mariacutea Rodriacuteguez-Blanco and colleagues compared intravitreal TA suspension to topical TA in nanoparticles (TA-NP) and topical prednisolone acetate (PA) suspen-sion16 There was no statistical sig-nificance in the anti-inflammatory effect between the intravitreal TA and the topical TA-NP and both were significantly more effective than topical PA in reducing inflam-mation15 While this is an animal-based study it demonstrates that topical NP provides a pharmaceuti-cal benefit comparable to intravit-real injections of the conventional form of the drug

Antimicrobial EfficiencyThe recent increase in antibi-

otic-resistant bacteria is an issue of great concern to health care providers This phenomenon has been attributed to several fac-tors including overprescribing of antibiotics17 One plausible means of circumventing this problem is through the use of nanoparticle carriers of antibiotics By modify-ing materials at the atomic level nano-sized organic and inorganic particles can be generated for even-tual use in health care18

The capability of nanoparticles to kill bacteria largely is a simple matter of size Bacterial cell size is in the micrometric range (500nm

to 5000nm) Bacterial outer cel-lular membranes have pores in the nanometer range (5nm to 50nm) Because nanoparticles can be smaller in size than bacterial pores they can actually cross cell membranes One example of this is the use of nano-sized molecules containing metal oxides19

Ameer Azam PhD and col-leagues evaluated the antimicrobial efficacy of nano-sized particles of zinc oxide 18nm (ZnO) cop-per oxide 22nm (CuO) and fer-rous oxide 28nm (Fe2O3) The nanoparticles were synthesized by gel-combustion method and their antibacterial activities were tested against two gram-positive bacte-rial strains (S aureus and Bacillus subtilis) and two gram-negative bacterial strains (Pseudomonas aeruginosa and E coli)19 The results revealed that ZnO and CuO nanoparticles had excellent antibacterial activity against both gram-positive and gram-negative bacteria The evidence generally indicates that the smaller the size of the nanoparticle the more active it is against bacteria For example ZnO was 75 more effective than

Fe2O3 and 28 more effective than CuO against E coli19

Justin T Seil PhD and Thomas J Webster PhD confirmed the significant antibacterial effect of ZnO They reported that after just eight hours of exposure to ZnO nanoparticles there was in excess of a four-log reduction in Staphy-lococcus aureus When they added ultrasound to the nanoparticle regimen they noted an additional 76 reduction in the number of viable colony-forming units20

The size and unique attributes of the eye make it an excellent subject for nanotechnology The applica-tions discussed in this article rep-resent just a small fraction of the research and technology already completed and under development We are learning that the potential applications of nanotechnology within eye care are almost limitless and nanotechnology may eradicate some of the conditions and ill-nesses that steal our vision shorten our lives or reduce our quality of life RCCL

1 Kahn J Nanorsquos big future National Geographic 2006 June98-1192 Freitas RA Jr Nanotechnology nanomedicine and nanosur-gery Int J Surg 20053(4)243-6 3 Filipponi L Sutherland D NANOYOU Teachers training kit in nanoscience and nanotechnology 2010 Jan Avail-able at httpnanoyoueuattachments052_NANOYOU20Overview20of20training20kit_20for20websitepdf Accessed April 20134 Mette Ebbesen M Jensen TG Nanomedicine techniques potentials and ethical implications J Biomed Biotechnol 2006 Nov 30515165 Patil M Mehta DS Guvva S Future impact of nanotechnol-ogy on medicine and dentistry J Indian Soc Periodontol 2008 May-Aug12(2)34-406 Photocatalyst nanotechnology Green Earth Nano Science Inc Available at wwwgreenearthnanosciencecomnanotech-nologyphp Accessed April 20137 Vadlapudi AD Mitra AK Nanomicelles an emerg-ing platform for drug deliver to the eye Ther Deliv 2013 Jan4(1)1-38 Nordmann JP Auzanneau N Ricard S Berdeaux G Vision related quality of life and topical glaucoma treatment side effects Health Qual Life Outcomes 2003 Dec 101759 Pavici -Astalos J Lacmanovi -Loncar V Petric-VickoviI et al Eye drops preservative as the cause of corneal band keratopathy in long-term pilocarpine hydrochloride treatment Acta Clin Croat 2012 Mar51(1)107-1110 Natarajan JV Ang M Darwitan A et al Nanomedicine for glaucoma liposomes provide sustained release of latanoprost in the eye Int J Nanomedicine 20127123-131Additional references at wwwreviewofcontactlensescom

2 In this simple micelle structure hydro-philic heads (green spheres) orient to the outside surface and the lipophilic tails (blue lines) orient toward the inside The medication molecules (red spheres) attach to the lipophilic tails

028_rcl0513nanoindd 30 5313 338 PM


T hese days practitioners con-stantly hear and see the word ldquobiocompatibilityrdquo Whether

related to a new contact lens or solu-tion it is certainly the buzzword among researchers and manufac-turers This article will review the literature on clinical testing to bet-ter understand the concepts as they relate to lens materials

Defining the TermsBiocompatibility is traditionally

defined as a medical device free of toxic or injurious effects on biologi-cal systems or the extent to which a foreign material fails to elicit an immune or other response in the recipient Eye care practitioners may want to take this a step further to include the concept of mimicking a part of the body (eg the ocular surface) where a device such as a contact lens is placed That is to say a biocompatible product would have

some property whether inherent in the contact lens polymer or added to the lens after polymerization that is similar to the cornea or components of the tear film

Omafilcon AWhile many lenses might be

described as biocompatible omafil-con A (Proclear CooperVision) was one of the first polymers touted to mimic the ocular surface Omafilcon A is a 62 water content material composed of 2-hydroxyethylmeth-acrylate (HEMA) and 2-methacry-loyloxyethyl phosphorylcholine (PC) polymers crosslinked with ethylene-glycol dimethacrylate PC is similar to phospholipids (eg phosphatidyl-choline) which are molecules found naturally in human cell membranes (figures 1a and 1b)

Due to their zwitterionic nature (eg they contain both positive and negative charges) these molecules

Itrsquos both Or at least it has the potential to be Herersquos a closer look at the conceptsBy Mark DP Willcox PhD

Biocompatibility Buzzword or

Breakthrough

Professor Willcox is a fellow of the BCLA and AAO and

president of the ISCLR He has specialized in ocular microbiology contact lenses tear film biochemistry and cor-neal immunology His research has examined the interactions of the normal microbiota of the eye with contact lenses and the effect of contact lenses on the tear film

031_rcl0513bio_MHindd 31 5313 343 PM


can bond hydrogen with water Therefore they attract and sur-round themselves with water molecules This property is why daily disposable manufacturers claim that omafilcon A lenses stay ldquomoist and comfortable even after 12 hours of wearrdquo

According to the manufac-turer omafilcon A lenses are the only contact lenses cleared by the FDA to ldquoprovide improved comfort for contact lens wearers who experience mild discomfort or symptoms relating to dry-ness during lens wearrdquo1 Studies have shown a reduced likelihood of omafilcon A lenses to dehy-drate on-eye2-5 Despite increased tear film evaporation rates and decreased tear film break-up times (TFBUTs) omafilcon A lenses have been shown to be relatively sparing of the pre-lens tear film lipid layer structure6 Omafilcon A lenses show improved symptoms of dryness and discomfortndashndashas well as improved fluorescein and lis-samine green stainingndashndashcompared to habitual lenses in some studies (although others conflict)37-9

Delefilcon AA lens material containing

phosphatidylcholine is the new-est technology on the market The delefilcon A lens (Alcon) is a silicone-containing hydrogel described as possessing a water gradi-entmdashfrom 33 water at core to gt80 water at surface which is only 6microm thick The manufacturer claims that the 80 water content closely mimics that of the cornea In addition this lens

is packaged in phosphate-buffered saline solution containing approxi-mately 03 of polymeric wetting agentsmdashcopolymers of polyamido-amine and poly(acrylamide-acrylic acid) The material is sold for sin-gle use daily disposable lens wear

The published literature on the new delefilcon A material is limited but research is beginning to show an association between its lubricity profile and subjective reports of comfort10 It is known to have a low contact angle hyster-esis which implies better surface wettability (at least in the labo-ratory) Other physicochemical and biochemical factors beyond wettability also influence ocular response to lens wear and will require study11 It will be interest-ing to see if the reports of good clinical performance of the omafil-con A lens which contains phos-phorylcholinemdashchemically similar

to the phosphatidylcholine in delefilcon Amdashare replicated for this lens type

Nelfilcon AAnother lens material

described as biocompatible is nelfilcon A (Alcon) a polymer of polyvinyl alcohol partially acetalized with N-formylmethyl acrylamide and with a 69 water content The packag-ing contains the moisturizing

agents hydroxypropyl methylcel-lulose (HPMC) polyethylene gly-col (PEG) and polyvinyl alcohol (PVA) The manufacturer calls PVA (figure 2) a comfort enhancer that gives the lens ldquooutstandingrdquo hydrophilic properties such as a very low contact angle (which provides better moisture coverage) PVA is also described an agent that helps to stabilize the tear film and that works in synergy with the other agents to continuously lubri-cate the lens for improved comfort

HPMC is claimed to optimize the viscosity of the packaging solu-tion to provide superior comfort upon insertion The manufacturer states that the eyersquos natural blink-ing action releases PVA from the lens and it and the other moistur-izing agents are gradually released over a 20-hour period Further-more this release is associated

with ldquobuilt-in single-day com-pliancerdquo

Prior to the release of this lens PVA was used in ocular drops and shown to improve TFBUT If used at a con-centration of 14 (wv) PVA improved

1a Chemical structure of phosphorylcholine

1b Chemical structure of phosphatidylcholine

031_rcl0513bio_MHindd 32 5313 343 PM


TFBUT by 189 times and if used at 10 (wV) TFBUT was improved by 716 times12 Nelfilcon A lenses with Aqua Release (extra PVA eluting from lenses) provided increased comfortable wearing time and ocular comfort compared to other daily disposable lenses1314

Peterson and associates showed a slight improvement in non-invasive break-up time (NIBUT) of tears on the lens surface for the nelfilcon A containing Aqua Release com-pared to original nelfilcon A lenses although this did not reach signifi-cance13 However another study indicated a significant enhance-ment in NIBUT with the nelfilcon A Aqua Release lenses15

Nesofilcon ANesofilcon A (Bausch + Lomb)

a hydrophilic copolymer of 2-hydroxyethyl methacrylate and N-vinyl pyrrolidone is sold as a daily disposable lens This lens is marketed as one that ldquomatches the moisture level of your eyes to bring you comfortable vision all day longrdquo and that the concept was ldquoinspired by the biology of your eyesrdquo This ldquobioinspiredrdquo material exhibits an outer lens surface that is designed to mimic the tear filmrsquos lipid layer in an effort to prevent dehydration and maintain con-sistent optics The manufacturer points to its water content of 78 (the same as that of the cornea) as a factor that will ldquosupport incred-ible comfortrdquo The lipid layer mimicry is provided by the N-vinyl pyrrolidone moiety (figure 3)

The vinyl moiety has the abil-ity to interact with lipids such as phospholipids found in the tear film layer and plasma membranes

As yet there are no peer- reviewed studies on the biocom-patibility of nesofilcon A lenses However N-vinyl pyrrolidone (NVP) and its polymeric form

polyvinyl pyrrolidone (PVP) have been used in many different lenses over the years such as senofilcon A (which uses PVP) or vifilcon A (containing NVP) However whether the improvements in symptoms or clinical performance with senofilcon A lenses is due to the presence of the vinyl pyr-rolidone or other factors such as lens design is not known16 Recent evidence suggests that the presence of PVP in narafilcon A lenses is not associated with improved clinical performance in terms of dryness and corneal staining17

Contact lenses generally are bio-compatible with the ocular surface in the sense that they are not toxic and are generally well tolerated by the ocular tissue The development of materials that are attempting to mimic specific aspects of the ocular surfacemdashbe that the water content of the cornea or a structuring of the tear film or the lipid layer of the tear filmmdashis exciting It seems the days are gone when it was thought that to be biocompatible the lens should have no interac-tions with the eye

It will be interesting to see whether the claims of lenses with surface water content similar to the cornea translate into improved clinical performance and bio-compatibility with the cornea

Past experience with high water HEMA-based lenses showed equivocal results for dryness symptoms during wear and dry-ness symptoms in relation to lens dehydration31819 Perhaps the new generation of high water content lenses or high water content lens surfaces do not dehydrate as much or as rapidly on-eye I eagerly await results of clinical trials with these new lenses RCCL

1 httpcoopervisioncomcontact-lensesproclear-comfort-able-contacts Accessed 16th March 20132 Hall B Jones S Young G Coleman S The on-eye dehydration of proclear compatibles lenses CLAO 1999 Oct25(4)233-73 Fonn D Situ P Simpson T Hydrogel lens dehydration and subjective comfort and dryness ratings in symptomatic and asymptomatic contact lens wearers Optom Vis Sci 1999 Oct76(10)700-44 Young G Bowers R Hall B Port M Clinical comparison of Omafilcon A with four control materials CLAO 1997 Oct23(4)249-585 Young G Bowers R Hall B Port M Six month clinical evaluation of a biomimetic hydrogel contact lens CLAO 1997 Oct23(4)226-366 Thai LC Tomlinson A Doane MG Effect of contact lens materials on tear physiology Optom Vis Sci 2004 Mar81(3)194-2047 Riley C Chalmers RL Pence N The impact of lens choice in the relief of contact lens related symptoms and ocular sur-face findings Cont Lens Anterior Eye 2005 Mar28(1)13-98 Lemp MA Caffery B Lebow K et al Omafilcon A (Proclear) soft contact lenses in a dry eye population CLAO 1999 Jan25(1)40-79 Fonn D Dumbleton K Dryness and discomfort with silicone hydrogel contact lenses Eye Contact Lens 2003 Jan29(1 Suppl)S101-410 Kern JR Rappon J Bauman E Vaughn B Assessment of the relationship between contact lens coefficient of friction and subject lens comfort ARVO 2013 abstract B013111 Tighe BJ A decade of silicone hydrogel development surface properties mechanical properties and ocular compat-ibility Eye Contact Lens 2013 Jan39(1)4-1212 Bartlett JD Jaanus SD Clinical ocular pharmacology 5th ed St Louis Mo Butterworth-HeinemannElsevier 2008xvi 79313 Peterson RC Wolffsohn JS Nick J et al Clinical performance of daily disposable soft contact lenses using sustained release technology Cont Lens Anterior Eye 2006 Jul29(3)127-3414 Wolffsohn JS Hunt OA Chowdhury A Objective clinical performance of lsquocomfort-enhancedrsquo daily disposable soft con-tact lenses Contact Lens Anterior Eye 20103388-9215 Golebiowski B Phillips B Willcox M Improved non-invasive tear break-up time with nelfilcon A daily disposable soft contact lenses with added PVA Presented at the 30th conference of the British Contact Lens Association 200616 Spyridon M Hickson-Curran S Hunt C Young G Eye sensitivity in soft contact lens wearers Optom Vis Sci 2012 Dec89(12)1682-9017 Diec J Lazon de la Jara P Willcox M Holden BA The clinical performance of lenses disposed of daily can vary con-siderably Eye Contact Lens 2012 Sep38(5)313-818 Pritchard N Fonn D Dehydration lens movement and dryness ratings of hydrogel contact lenses Ophthalmic Physiol Optics 1995 Jul15(4)281-619 Efron N Brennan NA Bruce AS et al Dehydration of hydrogel lenses under normal wearing conditions CLAO 1987 MayJun13(3)152-6

2 3 Left Chemical structure of PVA (ldquonrdquo indicates repeating units of this basic structure to form the polymer)Right Chemical structure of N-vinyl-pyrrolidone

031_rcl0513bio_MHindd 33 5313 343 PM

Out of the Box By Gary Gerber OD


We rarely hear the argu-ment that high unem-ployment (or a weak

economy) is good for your prac-ticersquos bottom line After all reason suggests that if your patients donrsquot have a job they will likely either avoid coming to your practice en-tirely or be especially thrifty when they do But have you considered how unemployment affects your current staff and how that in turn impacts your practice

The rate of unemployment is improving but at a snailrsquos pace Updates about the status of our economy still headline the daily news and the lingering impact remains at the forefront of our minds Regardless of whether your staffi ng situation is good bad or neutral the constant reminder of the large number of unemployed in our country can be a help or hindrance to your practice Letrsquos look at both sides of the equation

The PositivesHigh unemployment rates can

mean at least theoretically that more people are out of work and looking for jobs If your current satisfaction with your staff is less than ideal now might be a good time to try to improve your team With more people in the job appli-cant pool you should have more qualifi ed candidates and increased opportunities to fi nd the best fi t for your practice Be selective and take your time ensuring your next hire is a great fi t

Some positions we need to fi ll require highly skilled employees but I would suggest that you focus

on fi lling the vacancies that do not require specialization Keep in mind that someone who has been out of work for a while may accept lower pay andor a lesser skilled job When the economy turns or they fi nd a better-suited position therersquos a chance they will move on However because nobody can predict such timelines or other extenuating factors Irsquod consider that a risk worth taking

The NegativesOn the other side of the equa-

tion if a current employee is not happy with his or her position they might hesitate to leave for fear of not fi nding another job Someone who isnrsquot enthusiastic about their position or is perhaps burned out due to a hectic sched-ule is a drain on your practicersquos productivity and profi ts

On a related note itrsquos typical for marginally happy staff mem-bers to begin looking around for other opportunities while working for you This may lead to subpar job performance While personal web surfi ng on the clock should never be permitted if you do see this happening be on the lookout for an unhappy employee and be prepared to replace him or her as needed

Remember that staff training should be routine regardless of the economy and unemployment numbers A well-trained staff increases employee loyalty to your practice and reduces subpar performance that may lead you to turnover

Note Staff members frequently report that they left a practice because they were never properly trained and as a result the expec-tations of the owner were never clearly communicated

While high unemployment rates certainly arenrsquot something to cele-brate there is a silver lining From a patient-spending perspective high unemployment may be bad for your practicersquos fi nances But use this opportunity to strengthen your team and even this economy can be a boon to your practice RCCL

How Will Unemployment Impact YouEven in a weak economy there are ways every practice can build and grow

( )With more people in the job applicant pool you

should have more qualified candidates and increased

opportunities

ReviewofCorneaAndContactLenses

rcclmag

FIND US ONLINE

Visitwwwreviewofcontactlensescom

to subscribe

RECEIVE OURE-NEWSLETTER

034_rcl0513_otbindd 34 5313 344 PM

MORE POWERFOR GREATER SUCCESS

Alcon off ers the DAILIESreg family of daily disposable contact lenses and the AIR OPTIXreg family of monthly replacement lenses Multiple studies have shown that daily disposable and monthly replacement contact lenswearers are more compliant than those who wear 2-week lenses234 Compliant patients also return for more eye examinations1

Compliant Patients Come In For More Eye Exams1

Alcon Can Help Bring Patients Back

Read more about this latest study and see how Alcon can boost your practice at myalconcompower-of-oneCompliance with Manufacturer-Recommended Replacement Frequency (MRRF)

References 1 Dumbleton KA Richter D Jones LW Compliance with lens replacement and the interval between eye examinations Optom Vis Sci 201289 (E-abstract 120059) 2 Dumbleton K Woods C Jones L et al Patient and practitioner compliance with silicone hydrogel and daily disposable lens replacement in the United States Eye amp Contact Lens 200935(4)164-171 3 Yeung KK Forister JFY Forister EF et al Compliance with soft contact lens replacement schedules and associated contact lensndashrelated ocular complications The UCLA Contact Lens Study Optometry 2010 81(11)598-607 4 Dumbleton K Woods C Jones L et al Comfort and Vision with Silicone Hydrogel Lenses Eff ect of Compliance Optom Vis Sci 201087(6)421-425

See product instructions for complete wear care and safety information

copy 2012 Novartis 812 POW12060JAD

RCCL0513_Alcon Oneindd 1 5113 253 PM

copy 2013 CooperVision Inc

Treat your patients to the exceptional comfort of Proclearreg 1 daythe only 1- day lens material cleared by the FDA for the claim ldquoMay provide improved comfort for contact lens wearers who experience mild discomfort or symptoms relating to dryness during lens wearrdquo

One-of-a-kind comfort for your patients

RCCL0513_Coopervisionindd 1 5113 256 PM

COVER

TOC

News Review

Editorial

Lens Care Update

Down on the Pharm

Gas-Permeable Strategies

Derail Dropouts

CE mdash A Decision Tree Proper Antibiotic Selection and Use

A Checklist for Steroid Use in the Compromised Cornea

Small Wonders

Biocompatibility Buzzword or Breakthrough

Out of the Box

Proprietary HydraGlydereg

Moisture Matrix

REFERENCES 1 Data on fi le Alcon Research Ltd 2 Lally J Ketelson H Borazjani R et al A new lens care solution provides moisture and comfort with todayrsquos CLs Optician 412011 Vol 241 Issue 6296 42 -46 3 Campbell R Kame G Leach N et al Clinical benefi ts of a new multi-purpose disinfecting solution in silicone hydrogel and soft contact lens users Eye amp Contact Lens 201238(2)93-101 4 Davis J Ketelson HA Shows A Meadows DL A lens care solution designed for wetting silicone hydrogel materials Poster presented at ARVO May 2010 Fort Lauderdale FL

ATTACHING ANDFORMING A HYDROPHILIC ENVIRONMENT across the surface of the lens124

CREATING A UNIQUE BARRIER that reduces lipid deposition

and removes protein deposits1-3

PROVIDING MOISTURE from morning till night124

OPTI-FREEreg PureMoistreg MPDS with HydraGlydereg Moisture Matrix

TALK TO YOUR PATIENTS ABOUT THE BENEFITS OF OPTI-FREEreg BRAND PRODUCTS

LEARN MORE AT MYALCONCOM

THIS IS WHY YOU CAN give your patientscomfort that lasts

copy 2012 Novartis 1112 OPM12201JAD

RCCL0313_Alcon Optiindd 1 22513 257 PM

contents










Pharmaceuticals



ON THE COVER




003_rcl0513_tocindd 3 5613 951 AM

VOL 150 No 4

In The News







News Review














004_rcl0513_newsindd 4 5613 546 PM



















Advertiser Index










004_rcl0513_newsindd 5 5613 400 PM

Advertorial











T
























007_rccl0513_edindd 7 5613 556 PM

Editorial





















007_rccl0513_edindd 8 5613 556 PM

Editorial


























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Editorial





















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Addicted to Oxy




Phot

o A

ndre

w S

Gur

wood

OD





















012_rcl0513_dotpindd 12 5313 312 PM

Down on the Pharm










Labeling)Packaging









25 or 5 mL




5 mL



25 or 5 mL bottle




012_rcl0513_dotpindd 13 5313 312 PM













012_rcl0513_dotpindd 14 5313 312 PM



















015_rcl0513_gpsindd 15 5313 312 PM




















Derail Dropouts





















Sponsored b y


















































































































































1 SS - -


2 - 3

First Name

Last Name

Email


Business Name

Address

City State

ZIP

Telephone - -

Fax - -


Signature Date














in the



















Corneal edema



































Small Wonders

028_rcl0513nanoindd 28 5313 337 PM

















028_rcl0513nanoindd 29 5313 337 PM














028_rcl0513nanoindd 30 5313 338 PM












Breakthrough



031_rcl0513bio_MHindd 31 5313 343 PM

















031_rcl0513bio_MHindd 32 5313 343 PM














031_rcl0513bio_MHindd 33 5313 343 PM



















opportunities


rcclmag

FIND US ONLINE


to subscribe


034_rcl0513_otbindd 34 5313 344 PM














COVER

TOC

News Review

Editorial

Lens Care Update

Down on the Pharm


Derail Dropouts



Small Wonders


Out of the Box

contents










Pharmaceuticals



ON THE COVER




003_rcl0513_tocindd 3 5613 951 AM

VOL 150 No 4

In The News







News Review














004_rcl0513_newsindd 4 5613 546 PM



















Advertiser Index










004_rcl0513_newsindd 5 5613 400 PM

Advertorial











T
























007_rccl0513_edindd 7 5613 556 PM

Editorial





















007_rccl0513_edindd 8 5613 556 PM

Editorial


























007_rccl0513_edindd 9 5613 556 PM

Editorial





















007_rccl0513_edindd 10 5613 557 PM



















Addicted to Oxy




Phot

o A

ndre

w S

Gur

wood

OD





















012_rcl0513_dotpindd 12 5313 312 PM

Down on the Pharm










Labeling)Packaging









25 or 5 mL




5 mL



25 or 5 mL bottle




012_rcl0513_dotpindd 13 5313 312 PM













012_rcl0513_dotpindd 14 5313 312 PM



















015_rcl0513_gpsindd 15 5313 312 PM




















Derail Dropouts





















Sponsored b y


















































































































































1 SS - -


2 - 3

First Name

Last Name

Email


Business Name

Address

City State

ZIP

Telephone - -

Fax - -


Signature Date














in the



















Corneal edema



































Small Wonders

028_rcl0513nanoindd 28 5313 337 PM

















028_rcl0513nanoindd 29 5313 337 PM














028_rcl0513nanoindd 30 5313 338 PM












Breakthrough



031_rcl0513bio_MHindd 31 5313 343 PM

















031_rcl0513bio_MHindd 32 5313 343 PM














031_rcl0513bio_MHindd 33 5313 343 PM



















opportunities


rcclmag

FIND US ONLINE


to subscribe


034_rcl0513_otbindd 34 5313 344 PM














COVER

TOC

News Review

Editorial

Lens Care Update

Down on the Pharm


Derail Dropouts



Small Wonders


Out of the Box

VOL 150 No 4

In The News







News Review














004_rcl0513_newsindd 4 5613 546 PM



















Advertiser Index










004_rcl0513_newsindd 5 5613 400 PM

Advertorial











T
























007_rccl0513_edindd 7 5613 556 PM

Editorial





















007_rccl0513_edindd 8 5613 556 PM

Editorial


























007_rccl0513_edindd 9 5613 556 PM

Editorial





















007_rccl0513_edindd 10 5613 557 PM



















Addicted to Oxy




Phot

o A

ndre

w S

Gur

wood

OD





















012_rcl0513_dotpindd 12 5313 312 PM

Down on the Pharm










Labeling)Packaging









25 or 5 mL




5 mL



25 or 5 mL bottle




012_rcl0513_dotpindd 13 5313 312 PM













012_rcl0513_dotpindd 14 5313 312 PM



















015_rcl0513_gpsindd 15 5313 312 PM




















Derail Dropouts





















Sponsored b y


















































































































































1 SS - -


2 - 3

First Name

Last Name

Email


Business Name

Address

City State

ZIP

Telephone - -

Fax - -


Signature Date














in the



















Corneal edema



































Small Wonders

028_rcl0513nanoindd 28 5313 337 PM

















028_rcl0513nanoindd 29 5313 337 PM














028_rcl0513nanoindd 30 5313 338 PM












Breakthrough



031_rcl0513bio_MHindd 31 5313 343 PM

















031_rcl0513bio_MHindd 32 5313 343 PM














031_rcl0513bio_MHindd 33 5313 343 PM



















opportunities


rcclmag

FIND US ONLINE


to subscribe


034_rcl0513_otbindd 34 5313 344 PM














COVER

TOC

News Review

Editorial

Lens Care Update

Down on the Pharm


Derail Dropouts



Small Wonders


Out of the Box



















Advertiser Index










004_rcl0513_newsindd 5 5613 400 PM

Advertorial











T
























007_rccl0513_edindd 7 5613 556 PM

Editorial





















007_rccl0513_edindd 8 5613 556 PM

Editorial


























007_rccl0513_edindd 9 5613 556 PM

Editorial





















007_rccl0513_edindd 10 5613 557 PM



















Addicted to Oxy




Phot

o A

ndre

w S

Gur

wood

OD





















012_rcl0513_dotpindd 12 5313 312 PM

Down on the Pharm










Labeling)Packaging









25 or 5 mL




5 mL



25 or 5 mL bottle




012_rcl0513_dotpindd 13 5313 312 PM













012_rcl0513_dotpindd 14 5313 312 PM



















015_rcl0513_gpsindd 15 5313 312 PM




















Derail Dropouts





















Sponsored b y


















































































































































1 SS - -


2 - 3

First Name

Last Name

Email


Business Name

Address

City State

ZIP

Telephone - -

Fax - -


Signature Date














in the



















Corneal edema



































Small Wonders

028_rcl0513nanoindd 28 5313 337 PM

















028_rcl0513nanoindd 29 5313 337 PM














028_rcl0513nanoindd 30 5313 338 PM












Breakthrough



031_rcl0513bio_MHindd 31 5313 343 PM

















031_rcl0513bio_MHindd 32 5313 343 PM














031_rcl0513bio_MHindd 33 5313 343 PM



















opportunities


rcclmag

FIND US ONLINE


to subscribe


034_rcl0513_otbindd 34 5313 344 PM














COVER

TOC

News Review

Editorial

Lens Care Update

Down on the Pharm


Derail Dropouts



Small Wonders


Out of the Box

Advertorial











T
























007_rccl0513_edindd 7 5613 556 PM

Editorial





















007_rccl0513_edindd 8 5613 556 PM

Editorial


























007_rccl0513_edindd 9 5613 556 PM

Editorial





















007_rccl0513_edindd 10 5613 557 PM



















Addicted to Oxy




Phot

o A

ndre

w S

Gur

wood

OD





















012_rcl0513_dotpindd 12 5313 312 PM

Down on the Pharm










Labeling)Packaging









25 or 5 mL




5 mL



25 or 5 mL bottle




012_rcl0513_dotpindd 13 5313 312 PM













012_rcl0513_dotpindd 14 5313 312 PM



















015_rcl0513_gpsindd 15 5313 312 PM




















Derail Dropouts





















Sponsored b y


















































































































































1 SS - -


2 - 3

First Name

Last Name

Email


Business Name

Address

City State

ZIP

Telephone - -

Fax - -


Signature Date














in the



















Corneal edema



































Small Wonders

028_rcl0513nanoindd 28 5313 337 PM

















028_rcl0513nanoindd 29 5313 337 PM














028_rcl0513nanoindd 30 5313 338 PM












Breakthrough



031_rcl0513bio_MHindd 31 5313 343 PM

















031_rcl0513bio_MHindd 32 5313 343 PM














031_rcl0513bio_MHindd 33 5313 343 PM



















opportunities


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FIND US ONLINE


to subscribe


034_rcl0513_otbindd 34 5313 344 PM














COVER

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Editorial

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Down on the Pharm


Derail Dropouts



Small Wonders


Out of the Box






















007_rccl0513_edindd 7 5613 556 PM

Editorial





















007_rccl0513_edindd 8 5613 556 PM

Editorial


























007_rccl0513_edindd 9 5613 556 PM

Editorial





















007_rccl0513_edindd 10 5613 557 PM



















Addicted to Oxy




Phot

o A

ndre

w S

Gur

wood

OD





















012_rcl0513_dotpindd 12 5313 312 PM

Down on the Pharm










Labeling)Packaging









25 or 5 mL




5 mL



25 or 5 mL bottle




012_rcl0513_dotpindd 13 5313 312 PM













012_rcl0513_dotpindd 14 5313 312 PM



















015_rcl0513_gpsindd 15 5313 312 PM




















Derail Dropouts





















Sponsored b y


















































































































































1 SS - -


2 - 3

First Name

Last Name

Email


Business Name

Address

City State

ZIP

Telephone - -

Fax - -


Signature Date














in the



















Corneal edema



































Small Wonders

028_rcl0513nanoindd 28 5313 337 PM

















028_rcl0513nanoindd 29 5313 337 PM














028_rcl0513nanoindd 30 5313 338 PM












Breakthrough



031_rcl0513bio_MHindd 31 5313 343 PM

















031_rcl0513bio_MHindd 32 5313 343 PM














031_rcl0513bio_MHindd 33 5313 343 PM



















opportunities


rcclmag

FIND US ONLINE


to subscribe


034_rcl0513_otbindd 34 5313 344 PM














COVER

TOC

News Review

Editorial

Lens Care Update

Down on the Pharm


Derail Dropouts



Small Wonders


Out of the Box

Editorial





















007_rccl0513_edindd 8 5613 556 PM

Editorial


























007_rccl0513_edindd 9 5613 556 PM

Editorial





















007_rccl0513_edindd 10 5613 557 PM



















Addicted to Oxy




Phot

o A

ndre

w S

Gur

wood

OD





















012_rcl0513_dotpindd 12 5313 312 PM

Down on the Pharm










Labeling)Packaging









25 or 5 mL




5 mL



25 or 5 mL bottle




012_rcl0513_dotpindd 13 5313 312 PM













012_rcl0513_dotpindd 14 5313 312 PM



















015_rcl0513_gpsindd 15 5313 312 PM




















Derail Dropouts





















Sponsored b y


















































































































































1 SS - -


2 - 3

First Name

Last Name

Email


Business Name

Address

City State

ZIP

Telephone - -

Fax - -


Signature Date














in the



















Corneal edema



































Small Wonders

028_rcl0513nanoindd 28 5313 337 PM

















028_rcl0513nanoindd 29 5313 337 PM














028_rcl0513nanoindd 30 5313 338 PM












Breakthrough



031_rcl0513bio_MHindd 31 5313 343 PM

















031_rcl0513bio_MHindd 32 5313 343 PM














031_rcl0513bio_MHindd 33 5313 343 PM



















opportunities


rcclmag

FIND US ONLINE


to subscribe


034_rcl0513_otbindd 34 5313 344 PM














COVER

TOC

News Review

Editorial

Lens Care Update

Down on the Pharm


Derail Dropouts



Small Wonders


Out of the Box

Editorial


























007_rccl0513_edindd 9 5613 556 PM

Editorial





















007_rccl0513_edindd 10 5613 557 PM



















Addicted to Oxy




Phot

o A

ndre

w S

Gur

wood

OD





















012_rcl0513_dotpindd 12 5313 312 PM

Down on the Pharm










Labeling)Packaging









25 or 5 mL




5 mL



25 or 5 mL bottle




012_rcl0513_dotpindd 13 5313 312 PM













012_rcl0513_dotpindd 14 5313 312 PM



















015_rcl0513_gpsindd 15 5313 312 PM




















Derail Dropouts





















Sponsored b y


















































































































































1 SS - -


2 - 3

First Name

Last Name

Email


Business Name

Address

City State

ZIP

Telephone - -

Fax - -


Signature Date














in the



















Corneal edema



































Small Wonders

028_rcl0513nanoindd 28 5313 337 PM

















028_rcl0513nanoindd 29 5313 337 PM














028_rcl0513nanoindd 30 5313 338 PM












Breakthrough



031_rcl0513bio_MHindd 31 5313 343 PM

















031_rcl0513bio_MHindd 32 5313 343 PM














031_rcl0513bio_MHindd 33 5313 343 PM



















opportunities


rcclmag

FIND US ONLINE


to subscribe


034_rcl0513_otbindd 34 5313 344 PM














COVER

TOC

News Review

Editorial

Lens Care Update

Down on the Pharm


Derail Dropouts



Small Wonders


Out of the Box

Editorial





















007_rccl0513_edindd 10 5613 557 PM



















Addicted to Oxy




Phot

o A

ndre

w S

Gur

wood

OD





















012_rcl0513_dotpindd 12 5313 312 PM

Down on the Pharm










Labeling)Packaging









25 or 5 mL




5 mL



25 or 5 mL bottle




012_rcl0513_dotpindd 13 5313 312 PM













012_rcl0513_dotpindd 14 5313 312 PM



















015_rcl0513_gpsindd 15 5313 312 PM




















Derail Dropouts





















Sponsored b y


















































































































































1 SS - -


2 - 3

First Name

Last Name

Email


Business Name

Address

City State

ZIP

Telephone - -

Fax - -


Signature Date














in the



















Corneal edema



































Small Wonders

028_rcl0513nanoindd 28 5313 337 PM

















028_rcl0513nanoindd 29 5313 337 PM














028_rcl0513nanoindd 30 5313 338 PM












Breakthrough



031_rcl0513bio_MHindd 31 5313 343 PM

















031_rcl0513bio_MHindd 32 5313 343 PM














031_rcl0513bio_MHindd 33 5313 343 PM



















opportunities


rcclmag

FIND US ONLINE


to subscribe


034_rcl0513_otbindd 34 5313 344 PM














COVER

TOC

News Review

Editorial

Lens Care Update

Down on the Pharm


Derail Dropouts



Small Wonders


Out of the Box



















Addicted to Oxy




Phot

o A

ndre

w S

Gur

wood

OD





















012_rcl0513_dotpindd 12 5313 312 PM

Down on the Pharm










Labeling)Packaging









25 or 5 mL




5 mL



25 or 5 mL bottle




012_rcl0513_dotpindd 13 5313 312 PM













012_rcl0513_dotpindd 14 5313 312 PM



















015_rcl0513_gpsindd 15 5313 312 PM




















Derail Dropouts





















Sponsored b y


















































































































































1 SS - -


2 - 3

First Name

Last Name

Email


Business Name

Address

City State

ZIP

Telephone - -

Fax - -


Signature Date














in the



















Corneal edema



































Small Wonders

028_rcl0513nanoindd 28 5313 337 PM

















028_rcl0513nanoindd 29 5313 337 PM














028_rcl0513nanoindd 30 5313 338 PM












Breakthrough



031_rcl0513bio_MHindd 31 5313 343 PM

















031_rcl0513bio_MHindd 32 5313 343 PM














031_rcl0513bio_MHindd 33 5313 343 PM



















opportunities


rcclmag

FIND US ONLINE


to subscribe


034_rcl0513_otbindd 34 5313 344 PM














COVER

TOC

News Review

Editorial

Lens Care Update

Down on the Pharm


Derail Dropouts



Small Wonders


Out of the Box




















012_rcl0513_dotpindd 12 5313 312 PM

Down on the Pharm










Labeling)Packaging









25 or 5 mL




5 mL



25 or 5 mL bottle




012_rcl0513_dotpindd 13 5313 312 PM













012_rcl0513_dotpindd 14 5313 312 PM



















015_rcl0513_gpsindd 15 5313 312 PM




















Derail Dropouts





















Sponsored b y


















































































































































1 SS - -


2 - 3

First Name

Last Name

Email


Business Name

Address

City State

ZIP

Telephone - -

Fax - -


Signature Date














in the



















Corneal edema



































Small Wonders

028_rcl0513nanoindd 28 5313 337 PM

















028_rcl0513nanoindd 29 5313 337 PM














028_rcl0513nanoindd 30 5313 338 PM












Breakthrough



031_rcl0513bio_MHindd 31 5313 343 PM

















031_rcl0513bio_MHindd 32 5313 343 PM














031_rcl0513bio_MHindd 33 5313 343 PM



















opportunities


rcclmag

FIND US ONLINE


to subscribe


034_rcl0513_otbindd 34 5313 344 PM














COVER

TOC

News Review

Editorial

Lens Care Update

Down on the Pharm


Derail Dropouts



Small Wonders


Out of the Box

Down on the Pharm










Labeling)Packaging









25 or 5 mL




5 mL



25 or 5 mL bottle




012_rcl0513_dotpindd 13 5313 312 PM













012_rcl0513_dotpindd 14 5313 312 PM



















015_rcl0513_gpsindd 15 5313 312 PM




















Derail Dropouts





















Sponsored b y


















































































































































1 SS - -


2 - 3

First Name

Last Name

Email


Business Name

Address

City State

ZIP

Telephone - -

Fax - -


Signature Date














in the



















Corneal edema



































Small Wonders

028_rcl0513nanoindd 28 5313 337 PM

















028_rcl0513nanoindd 29 5313 337 PM














028_rcl0513nanoindd 30 5313 338 PM












Breakthrough



031_rcl0513bio_MHindd 31 5313 343 PM

















031_rcl0513bio_MHindd 32 5313 343 PM














031_rcl0513bio_MHindd 33 5313 343 PM



















opportunities


rcclmag

FIND US ONLINE


to subscribe


034_rcl0513_otbindd 34 5313 344 PM














COVER

TOC

News Review

Editorial

Lens Care Update

Down on the Pharm


Derail Dropouts



Small Wonders


Out of the Box













012_rcl0513_dotpindd 14 5313 312 PM



















015_rcl0513_gpsindd 15 5313 312 PM




















Derail Dropouts





















Sponsored b y


















































































































































1 SS - -


2 - 3

First Name

Last Name

Email


Business Name

Address

City State

ZIP

Telephone - -

Fax - -


Signature Date














in the



















Corneal edema



































Small Wonders

028_rcl0513nanoindd 28 5313 337 PM

















028_rcl0513nanoindd 29 5313 337 PM














028_rcl0513nanoindd 30 5313 338 PM












Breakthrough



031_rcl0513bio_MHindd 31 5313 343 PM

















031_rcl0513bio_MHindd 32 5313 343 PM














031_rcl0513bio_MHindd 33 5313 343 PM



















opportunities


rcclmag

FIND US ONLINE


to subscribe


034_rcl0513_otbindd 34 5313 344 PM














COVER

TOC

News Review

Editorial

Lens Care Update

Down on the Pharm


Derail Dropouts



Small Wonders


Out of the Box



















015_rcl0513_gpsindd 15 5313 312 PM




















Derail Dropouts





















Sponsored b y


















































































































































1 SS - -


2 - 3

First Name

Last Name

Email


Business Name

Address

City State

ZIP

Telephone - -

Fax - -


Signature Date














in the



















Corneal edema



































Small Wonders

028_rcl0513nanoindd 28 5313 337 PM

















028_rcl0513nanoindd 29 5313 337 PM














028_rcl0513nanoindd 30 5313 338 PM












Breakthrough



031_rcl0513bio_MHindd 31 5313 343 PM

















031_rcl0513bio_MHindd 32 5313 343 PM














031_rcl0513bio_MHindd 33 5313 343 PM



















opportunities


rcclmag

FIND US ONLINE


to subscribe


034_rcl0513_otbindd 34 5313 344 PM














COVER

TOC

News Review

Editorial

Lens Care Update

Down on the Pharm


Derail Dropouts



Small Wonders


Out of the Box




















Derail Dropouts





















Sponsored b y


















































































































































1 SS - -


2 - 3

First Name

Last Name

Email


Business Name

Address

City State

ZIP

Telephone - -

Fax - -


Signature Date














in the



















Corneal edema



































Small Wonders

028_rcl0513nanoindd 28 5313 337 PM

















028_rcl0513nanoindd 29 5313 337 PM














028_rcl0513nanoindd 30 5313 338 PM












Breakthrough



031_rcl0513bio_MHindd 31 5313 343 PM

















031_rcl0513bio_MHindd 32 5313 343 PM














031_rcl0513bio_MHindd 33 5313 343 PM



















opportunities


rcclmag

FIND US ONLINE


to subscribe


034_rcl0513_otbindd 34 5313 344 PM














COVER

TOC

News Review

Editorial

Lens Care Update

Down on the Pharm


Derail Dropouts



Small Wonders


Out of the Box



Sponsored b y


















































































































































1 SS - -


2 - 3

First Name

Last Name

Email


Business Name

Address

City State

ZIP

Telephone - -

Fax - -


Signature Date














in the



















Corneal edema



































Small Wonders

028_rcl0513nanoindd 28 5313 337 PM

















028_rcl0513nanoindd 29 5313 337 PM














028_rcl0513nanoindd 30 5313 338 PM












Breakthrough



031_rcl0513bio_MHindd 31 5313 343 PM

















031_rcl0513bio_MHindd 32 5313 343 PM














031_rcl0513bio_MHindd 33 5313 343 PM



















opportunities


rcclmag

FIND US ONLINE


to subscribe


034_rcl0513_otbindd 34 5313 344 PM














COVER

TOC

News Review

Editorial

Lens Care Update

Down on the Pharm


Derail Dropouts



Small Wonders


Out of the Box





























































































































1 SS - -


2 - 3

First Name

Last Name

Email


Business Name

Address

City State

ZIP

Telephone - -

Fax - -


Signature Date














in the



















Corneal edema



































Small Wonders

028_rcl0513nanoindd 28 5313 337 PM

















028_rcl0513nanoindd 29 5313 337 PM














028_rcl0513nanoindd 30 5313 338 PM












Breakthrough



031_rcl0513bio_MHindd 31 5313 343 PM

















031_rcl0513bio_MHindd 32 5313 343 PM














031_rcl0513bio_MHindd 33 5313 343 PM



















opportunities


rcclmag

FIND US ONLINE


to subscribe


034_rcl0513_otbindd 34 5313 344 PM














COVER

TOC

News Review

Editorial

Lens Care Update

Down on the Pharm


Derail Dropouts



Small Wonders


Out of the Box












in the



















Corneal edema



































Small Wonders

028_rcl0513nanoindd 28 5313 337 PM

















028_rcl0513nanoindd 29 5313 337 PM














028_rcl0513nanoindd 30 5313 338 PM












Breakthrough



031_rcl0513bio_MHindd 31 5313 343 PM

















031_rcl0513bio_MHindd 32 5313 343 PM














031_rcl0513bio_MHindd 33 5313 343 PM



















opportunities


rcclmag

FIND US ONLINE


to subscribe


034_rcl0513_otbindd 34 5313 344 PM














COVER

TOC

News Review

Editorial

Lens Care Update

Down on the Pharm


Derail Dropouts



Small Wonders


Out of the Box


















Corneal edema



































Small Wonders

028_rcl0513nanoindd 28 5313 337 PM

















028_rcl0513nanoindd 29 5313 337 PM














028_rcl0513nanoindd 30 5313 338 PM












Breakthrough



031_rcl0513bio_MHindd 31 5313 343 PM

















031_rcl0513bio_MHindd 32 5313 343 PM














031_rcl0513bio_MHindd 33 5313 343 PM



















opportunities


rcclmag

FIND US ONLINE


to subscribe


034_rcl0513_otbindd 34 5313 344 PM














COVER

TOC

News Review

Editorial

Lens Care Update

Down on the Pharm


Derail Dropouts



Small Wonders


Out of the Box


































Small Wonders

028_rcl0513nanoindd 28 5313 337 PM

















028_rcl0513nanoindd 29 5313 337 PM














028_rcl0513nanoindd 30 5313 338 PM












Breakthrough



031_rcl0513bio_MHindd 31 5313 343 PM

















031_rcl0513bio_MHindd 32 5313 343 PM














031_rcl0513bio_MHindd 33 5313 343 PM



















opportunities


rcclmag

FIND US ONLINE


to subscribe


034_rcl0513_otbindd 34 5313 344 PM














COVER

TOC

News Review

Editorial

Lens Care Update

Down on the Pharm


Derail Dropouts



Small Wonders


Out of the Box

















028_rcl0513nanoindd 29 5313 337 PM














028_rcl0513nanoindd 30 5313 338 PM












Breakthrough



031_rcl0513bio_MHindd 31 5313 343 PM

















031_rcl0513bio_MHindd 32 5313 343 PM














031_rcl0513bio_MHindd 33 5313 343 PM



















opportunities


rcclmag

FIND US ONLINE


to subscribe


034_rcl0513_otbindd 34 5313 344 PM














COVER

TOC

News Review

Editorial

Lens Care Update

Down on the Pharm


Derail Dropouts



Small Wonders


Out of the Box














028_rcl0513nanoindd 30 5313 338 PM












Breakthrough



031_rcl0513bio_MHindd 31 5313 343 PM

















031_rcl0513bio_MHindd 32 5313 343 PM














031_rcl0513bio_MHindd 33 5313 343 PM



















opportunities


rcclmag

FIND US ONLINE


to subscribe


034_rcl0513_otbindd 34 5313 344 PM














COVER

TOC

News Review

Editorial

Lens Care Update

Down on the Pharm


Derail Dropouts



Small Wonders


Out of the Box












Breakthrough



031_rcl0513bio_MHindd 31 5313 343 PM

















031_rcl0513bio_MHindd 32 5313 343 PM














031_rcl0513bio_MHindd 33 5313 343 PM



















opportunities


rcclmag

FIND US ONLINE


to subscribe


034_rcl0513_otbindd 34 5313 344 PM














COVER

TOC

News Review

Editorial

Lens Care Update

Down on the Pharm


Derail Dropouts



Small Wonders


Out of the Box

















031_rcl0513bio_MHindd 32 5313 343 PM














031_rcl0513bio_MHindd 33 5313 343 PM



















opportunities


rcclmag

FIND US ONLINE


to subscribe


034_rcl0513_otbindd 34 5313 344 PM














COVER

TOC

News Review

Editorial

Lens Care Update

Down on the Pharm


Derail Dropouts



Small Wonders


Out of the Box














031_rcl0513bio_MHindd 33 5313 343 PM



















opportunities


rcclmag

FIND US ONLINE


to subscribe


034_rcl0513_otbindd 34 5313 344 PM














COVER

TOC

News Review

Editorial

Lens Care Update

Down on the Pharm


Derail Dropouts



Small Wonders


Out of the Box



















opportunities


rcclmag

FIND US ONLINE


to subscribe


034_rcl0513_otbindd 34 5313 344 PM














COVER

TOC

News Review

Editorial

Lens Care Update

Down on the Pharm


Derail Dropouts



Small Wonders


Out of the Box














COVER

TOC

News Review

Editorial

Lens Care Update

Down on the Pharm


Derail Dropouts



Small Wonders


Out of the Box

also inside this issue - review of cornea and … of cornea & contact lenses | may 2013 5 jobson...

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