Conjunctival UV autofluorescence - prevalence and risk factors

Purpose: Autofluorescence of ultraviolet (UV) light has been shown to occur in localised areas of the bulbar conjunctiva, which map to active cellular changes due to UV and environmental exposure. This study examined the presence of conjunctival UV autofluorescence in eye care practitioners (ECPs) across Europe and the Middle East and its associated risk factors. Method: Images were captured of 307 ECPs right eyes in the Czech Republic, Germany, Greece, Kuwait, Netherlands, Sweden, Switzerland, United Arab Emirates and the United Kingdom using a Nikon D100 camera and dual flash units through UV filters. UV autofluorescence was outlined using ImageJ software and the nasal and temporal area quantified. Subjects were required to complete a questionnaire on their demographics and lifestyle including general exposure to UV and refractive correction. Results: Average age of the subjects was 38.5±12.2 years (range 19-68) and 39.7% were male. Sixty-two percent of eyes had some conjunctival damage as indicated by UV autofluorescence. The average area of damage was higher (p=0.005) nasally (2.95±4.52mm2) than temporally (2.19±4.17mm2). The area of UV damage was not related to age (r=0.03, p=0.674), gender (p=0.194), self-reported sun exposure lifestyle (p>0.05), geographical location (p=0174), sunglasses use (p>0.05) or UV-blocking contact lens use (p>0.05), although it was higher in those wearing contact lenses with minimal UV-blocking and no spectacles (p=0.015). The area of UV damage was also less nasally in those who wore contact lenses and spectacles compared to those with no refractive correction use (p=0.011 nasal; p=0.958 temporal). Conclusion: UV conjunctival damage is common even in Europe, Kuwait and UAE, and among ECPs. The area of damage appears to be linked with the use of refractive correction, with greater damage nasally than temporally which may be explained by the peripheral light focusing effect.

Editorial

This time of year we look back at the year that has passed and make plans for the next year. I like to reflect on things that I have learnt and people that I have met, especially those who facilitated that learning. In 2009 I went to various conferences, The BCLA conference in Manchester, The Romanian Optical Society meeting in Brasov, Transylvania (where the university is actually on Vlad Tepes Street), The European Council for Optometry and Optics (ECOO) in Brno, Czech Republic, The American Academy of Optometry (AAO) in Orlando USA, The International Association of Contact Lens Educators (IACLE) meeting in Tianjin China and finally The Vereinigung Deutscher Contactlinsen-Spezialisten (VDCO) meeting in Jena. All were interesting places and thoroughly all were enjoyable conferences with their own highlights but I wanted to focus on Jena and one person I met there and his inspirational search for knowledge and the contributions he made in the field of contact lenses. Jena itself is a fascinating place and should be on the ‘must visit’ list of anyone involved in eye care. It is the birth place of Carl Zeiss of course and where he started his company. It is also the birth place of Ernst Abbe (physicist and optometrist and expert lens maker), and Otto Schott (chemist and technologist who made high quality glass. There are many road signs bearing witness to these famous pioneers. The optical museum is worth spending a few hours looking around too. I was invited to speak at the VDCO at the kind invitation from colleagues at the Jena School of Optometry, Professor Wolfgang Sickenberger and Professor Sebastian Marx. At this meeting I met 87-year-old Willi KAUE who was being awarded the Adolf Wilhelm Müller-Welt prize by the VDCO for contribution to contact lenses over his 60-year career. At the age of 15 Willi Kaue took up an apprenticeship to become an Optician in Germany in 1937. At this time he first heard about the scleral glass lenses made by the Carl Zeiss Company in Jena. This started his lifelong fascination which was to become his passion but not yet his career. During the war he was enlisted into military service but immediately after was back to his former career. In 1950 Willi corrected his own 3.5 dioptres of myopia with a plastic scleral lens. His fascination strengthened as for the first time he himself could experience a wider field of view than his spectacles gave him, less aberrations and less retinal minification. He also appreciated the fact that contact lenses did not cause pressure on the nose or ears and did not slide down his nose plus remained optically centred with his eye movements. He decided that form now on he would make fitting contact lenses his career. He travelled to London to learn more about contact lenses and how to fit them but initially did not find many willing teachers and to start with became largely self-taught. He wanted to know how to make scleral lenses. So far he only knew that pulverized polymethyl methacrylate (PMMA) was pressed and moulded. In 1951 he met Berlin optician Otto Marzock. He made his only scleral lenses from using military PMMA windshields. His process involved lathe cutting the lenses and resulted in lenses that were thinner than moulded ones. Willi developed a manufacturing method, using a rotary diamond drill, starting form the outer edge and towards the centre at a constant cut speed. This enabled him to make more reproducible lenses and in less time. His enthusiasm in the field was clear from the travels he made in the pursuit of advancement - travelling around Europe, South America, North America and Asia. In 1963 he visited George Nissel in Hemel Hempstead, England. Constantly thriving towards innovations Willi came across the new Naturalens from the USA made from HEMA at a congress in Marseille in 1969. Amongst his contributions to the field, was his own technique of fitting ocular prosthetics, using an alginate impression of the orbit. I was fortunate enough to have dinner with Willi Kaue and learnt more about his fascinating career through the patient interpreting skills of Hilmar Bussacker (the 2008 winner of the same award and the 2007 winner of the European Federation of the Contact Lens and IOL Industries Award). I look forward to 2010 with eager anticipation as to what I may learn and who I might meet!!! Copyright © 2009 British Contact Lens Association. Published by Elsevier Ltd. All rights reserved.

Optical quality and visual performance with customised soft contact lenses for keratoconus

Purpose: This study investigated how aberration-controlling, customised soft contact lenses corrected higher-order ocular aberrations and visual performance in keratoconic patients compared to other forms of refractive correction (spectacles and rigid gas-permeable lenses). Methods: Twenty-two patients (16 rigid gas-permeable contact lens wearers and six spectacle wearers) were fitted with standard toric soft lenses and customised lenses (designed to correct 3rd-order coma aberrations). In the rigid gas-permeable lens-wearing patients, ocular aberrations were measured without lenses, with the patient's habitual lenses and with the study lenses (Hartmann-Shack aberrometry). In the spectacle-wearing patients, ocular aberrations were measured both with and without the study lenses. LogMAR visual acuity (high-contrast and low-contrast) was evaluated with the patient wearing their habitual correction (of either spectacles or rigid gas-permeable contact lenses) and with the study lenses. Results: In the contact lens wearers, the habitual rigid gas-permeable lenses and customised lenses provided significant reductions in 3rd-order coma root-mean-square (RMS) error, 3rd-order RMS and higher-order RMS error (p ≤ 0.004). In the spectacle wearers, the standard toric lenses and customised lenses significantly reduced 3rd-order RMS and higher-order RMS errors (p ≤ 0.005). The spectacle wearers showed no significant differences in visual performance measured between their habitual spectacles and the study lenses. However, in the contact lens wearers, the habitual rigid gas-permeable lenses and standard toric lenses provided significantly better high-contrast acuities compared to the customised lenses (p ≤ 0.006). Conclusions: The customised lenses provided substantial reductions in ocular aberrations in these keratoconic patients; however, the poor visual performances achieved with these lenses are most likely to be due to small, on-eye lens decentrations. © 2014 The College of Optometrists.

Visual performance and optical quality with soft lenses in keratoconus patients

Purpose: To assess visual performance and ocular aberrations in keratoconic patients using toric soft contact lenses (SCL), rigid-gas-permeable (RGP) contact lenses and spectacle lens correction. Methods: Twenty-two keratoconus patients (16 RGP lens wearers and six spectacle wearers) were fitted with toric SCL. Ocular aberrations were measured with and without the patient's habitual RGP lenses and with the SCL in place. In the spectacle wearers, aberrations were measured with and without the SCL. Visual performance (high- and low-contrast visual acuity) was evaluated with the patient's habitual correction and with the SCL. Results: In the RGP lens wearers both the habitual lenses and the toric SCL significantly reduced coma, trefoil, 3rd-order, 4th-order cylinder and higher-order root-mean-square (RMS) aberrations (p≤0.015). In the spectacle wearers the toric SCL significantly reduced coma, 3rd-order and higher-order RMS aberrations (p≤0.01). The patients' habitual RGP lenses gave better low-contrast acuity (p≤0.006) compared to the toric SCL; however, no significant difference was found between lens types for high-contrast acuity (p=0.10). In the spectacle wearers no significant differences in visual performance measurements were found between the patients' spectacles and the toric SCL (p≥0.06). Conclusion: The results show that RGP lenses provided superior visual performances and greater reduction of 3rd-order aberrations compared to toric SCL in this group of keratoconic patients. In the spectacle-wearing group, visual performance with the toric SCL was found to be comparable to that measured with spectacles. Nevertheless, with the exception of spherical aberration, the toric SCL were successful in significantly reducing uncorrected higher-order aberrations. Ophthalmic & Physiological Optics © 2012 The College of Optometrists.

Determining which factors influence the optimum multifocal contact lens correction for presbyopia

Presbyopia is a consequence of ageing and is therefore increasing inprevalence due to an increase in the ageing population. Of the many methods available to manage presbyopia, the use of contact lenses is indeed a tried and tested reversible option for those wishing to be spectacle free. Contact lens options to correct presbyopia include multifocal contact lenses and monovision.Several options have been available for many years with available guides to help choose multifocal contact lenses. However there is no comprehensive way to help the practitioner selecting the best option for an individual. An examination of the simplest way of predicting the most suitable multifocal lens for a patient will only enhance and add to the current evidence available. The purpose of the study was to determine the current use of presbyopic correction modalities in an optometric practice population in the UK and to evaluate and compare the optical performance of four silicone hydrogel soft multifocal contact lenses and to compare multifocal performance with contact lens monovision. The presbyopic practice cohort principal forms of refractive correction were distance spectacles (with near and intermediate vision providedby a variety of other forms of correction), varifocal spectacles and unaided distance with reading spectacles, with few patients wearing contact lenses as their primary correction modality. The results of the multifocal contact lens randomised controlled trial showed that there were only minor differences in corneal physiology between the lens options. Visual acuity differences were observed for distance targets, but only for low contrast letters and under mesopic lighting conditions. At closer distances between 20cm and 67cm, the defocus curves demonstrated that there were significant differences in acuity between lens designs (p < 0.001) and there was an interaction between the lens design and the level of defocus (p < 0.001). None of the lenses showed a clear near addition, perhaps due to their more aspheric rather than zoned design. As expected, stereoacuity was reduced with monovision compared with the multifocal contact lens designs, although there were some differences between the multifocal lens designs (p < 0.05). Reading speed did not differ between lens designs (F = 1.082, p = 0.368), whereas there was a significant difference in critical print size (F = 7.543, p < 0.001). Glare was quantified with a novel halometer and halo size was found to significantly differ between lenses(F = 4.101, p = 0.004). The rating of iPhone image clarity was significantly different between presbyopic corrections (p = 0.002) as was the Near Acuity Visual Questionnaire (NAVQ) rating of near performance (F = 3.730, p = 0.007).The pupil size did not alter with contact lens design (F = 1.614, p = 0.175), but was larger in the dominant eye (F = 5.489, p = 0.025). Pupil decentration relative to the optical axis did not alter with contact lens design (F = 0.777, p =0.542), but was also greater in the dominant eye (F = 9.917, p = 0.003). It was interesting to note that there was no difference in spherical aberrations induced between the contact lens designs (p > 0.05), with eye dominance (p > 0.05) oroptical component (ocular, corneal or internal: p > 0.05). In terms of subjective patient lens preference, 10 patients preferred monovision,12 Biofinity multifocal lens, 7 Purevision 2 for Presbyopia, 4 AirOptix multifocal and 2 Oasys multifocal contact lenses. However, there were no differences in demographic factors relating to lifestyle or personality, or physiological characteristics such as pupil size or ocular aberrations as measured at baseline,which would allow a practitioner to identify which lens modality the patient would prefer. In terms of the performance of patients with their preferred lens, it emerged that Biofinity multifocal lens preferring patients had a better high contrast acuity under photopic conditions, maintained their reading speed at smaller print sizes and subjectively rated iPhone clarity as better with this lens compared with the other lens designs trialled. Patients who preferred monovision had a lower acuity across a range of distances and a larger area of glare than those patients preferring other lens designs that was unexplained by the clinical metrics measured. However, it seemed that a complex interaction of aberrations may drive lens preference. New clinical tests or more diverse lens designs which may allow practitioners to prescribe patients the presbyopic contact lens option that will work best for them first time remains a hope for the future.

Global trends in myopia management attitudes and strategies in clinical practice

PURPOSE: Myopia is a global public health issue; however, no information exists as to how potential myopia retardation strategies are being adopted globally. METHODS: A self-administrated, internet-based questionnaire was distributed in six languages, through professional bodies to eye care practitioners globally. The questions examined: awareness of increasing myopia prevalence, perceived efficacy and adoption of available strategies, and reasons for not adopting specific strategies. RESULTS: Of the 971 respondents, concern was higher (median 9/10) in Asia than in any other continent (7/10, p<0.001) and they considered themselves more active in implementing myopia control strategies (8/10) than Australasia and Europe (7/10), with North (4/10) and South America (5/10) being least proactive (p<0.001). Orthokeratology was perceived to be the most effective method of myopia control, followed by increased time outdoors and pharmaceutical approaches, with under-correction and single vision spectacles felt to be the least effective (p<0.05). Although significant intra-regional differences existed, overall most practitioners 67.5 (±37.8)% prescribed single vision spectacles or contact lenses as the primary mode of correction for myopic patients. The main justifications for their reluctance to prescribe alternatives to single vision refractive corrections were increased cost (35.6%), inadequate information (33.3%) and the unpredictability of outcomes (28.2%). CONCLUSIONS: Regardless of practitioners' awareness of the efficacy of myopia control techniques, the vast majority still prescribe single vision interventions to young myopes. In view of the increasing prevalence of myopia and existing evidence for interventions to slow myopia progression, clear guidelines for myopia management need to be established.

Editorial

The year so far has been a slow start for many businesses, but at least we have not seen the collapse of as many businesses that we were seeing around two years ago. We are, however, still well and truly in the midst of a global recession. Interest rates are still at an all time low, UK house prices seem to be showing little signs of increase (except in London where everyone still seems to want to live!) and for the ardent shopper there are bargains to be had everywhere. It seems strange that prices on the high street do not seem to have increased in over ten years. Mobile phones, DVD players even furniture seems to be cheaper than they used to be. Whist much of this is down to cheaper manufacturing and the rest could probably be explained by competition within the market place. Does this mean that quality suffered too? Now that we live in a world when if a television is not working it is thrown away and replaced. There was a time when you would take it to some odd looking man that your father would know who could fix it for you. (I remember our local television fix-it man, with his thick rimmed bifocal spectacles and a poor comb-over; he had cardboard boxes full of resistors and electrical wires on the floor of his front room that smelt of soldering irons!) Is this consumerism at an extreme or has this move to disposability made us a better society? Before you think these are just ramblings there is a point to this. According to latest global figures of contact lens sales the vast majority of contact lenses fitted around the world are daily, fortnightly or monthly disposable hydrogel lenses. Certainly in the UK over 90% of lenses are disposable (with daily disposables being the most popular, having a market share of over 50%). This begs the question – is this a good thing? Maybe more importantly, do our patients benefit? I think it is worth reminding ourselves why we went down the disposability route with contact lenses in the first place, and unlike electrical goods it was not just so we did not have to take them for repair! There are the obvious advantages of overcoming problems of breakage and tearing of lenses and the lens deterioration with age. The lenses are less likely to be contaminated and the disinfection is either easier or not required at all (in the case of daily disposable lenses). Probably the landmark paper in the field was the work more commonly known as the ‘Gothenburg Study’. The paper, entitled ‘Strategies for minimizing the Ocular Effects of Extended Contact Lens Wear’ published in the American Journal of Optometry in 1987 (volume 64, pages 781-789) by Holden, B.A., Swarbrick, H.A., Sweeney, D.F., Ho, A., Efron, N., Vannas, A., Nilsson, K.T. They suggested that contact lens induced ocular effects were minimised by: •More frequently removed contact lenses •More regularly replaced contact lenses •A lens that was more mobile on the eye (to allow better removal of debris) •Better flow of oxygen through the lens All of these issues seem to be solved with disposability, except the oxygen issue which has been solved with the advent of silicone hydrogel materials. Newer issues have arisen and most can be solved in practice by the eye care practitioner. The emphasis now seems to be on making lenses more comfortable. The problems of contact lens related dry eyes symptoms seem to be ever present and maybe this would explain why in the UK we have a pretty constant contact lens wearing population of just over three million but every year we have over a million dropouts! That means we must be attracting a million new wearers every year (well done to the marketing departments!) but we are also losing a million wearers every year. We certainly are not losing them all to the refractive surgery clinics. We know that almost anyone can now wear a contact lens and we know that some lenses will solve problems of sharper vision, some will aid comfort, and some will be useful for patients with dry eyes. So if we still have so many dropouts then we must be doing something wrong! I think the take home message has to be ‘must try harder’! I must end with an apology for two errors in my editorial of issue 1 earlier this year. Firstly there was a typo in the first sentence; I meant to state that it was 40 years not 30 years since the first commercial soft lens was available in the UK. The second error was one that I was unaware of until colleagues Geoff Wilson (Birmingham, UK) and Tim Bowden (London, UK) wrote to me to explain that soft lenses were actually available in the UK before 1971 (please see their ‘Letters to the Editor’ in this issue). I am grateful to both of them for correcting the mistake.

Fitting an MSD (Mini Scleral Design) rigid contact lens in advanced keratoconus with INTACS

Keratoconus is a bilateral degenerative disease characterized by a non-inflammatory, progressive central corneal ectasia (typically asymmetric) and decreased vision. In its early stages it may be managed with spectacles and soft contact lenses but more commonly it is managed with rigid contact lenses. In advanced stages, when contact lenses can no longer be fit, have become intolerable, or corneal damage is severe, a penetrating keratoplasty is commonly performed. Alternative surgical techniques, such as the use of intra-stromal corneal ring segments (INTACS) have been developed to try and improve the fit of rigid contact lenses in keratoconic patients and avoid penetrating keratoplasties. This case report follows through the fitting of rigid contact lenses in an advanced keratoconic cornea after an INTACS procedure and discusses clinical findings, treatment options, and the use of mini-scleral and scleral lens designs as they relate to the challenges encountered in managing such a patient. Mini-scleral and scleral lenses are relatively easy to fit, and can be of benefit to many patients, including advanced keratoconic patients, post-INTAC patients and post-penetrating keratoplasty patients. © 2011 British Contact Lens Association.

An update on the characteristics of patients attending the Kooyong Low Vision Clinic

BACKGROUND: Since 1972, the Australian College of Optometry has worked in partnership with Vision Australia to provide multidisciplinary low-vision care at the Kooyong Low Vision Clinic. In 1999, Wolffsohn and Cochrane reported on the demographic characteristics of patients attending Kooyong. Sixteen years on, the aim of this study is to review the demographics of the Kooyong patient cohort and prescribing patterns. METHODS: Records of all new patients (n = 155) attending the Kooyong Low Vision Clinic for optometry services between April and September 2012 were retrospectively reviewed. RESULTS: Median age was 84.3 years (range 7.7 to 98.1 years) with 59 per cent female. The majority of patients presented with late-onset degenerative pathology, 49 per cent with a primary diagnosis of age-related macular degeneration. Many (47.1 per cent) lived with their families. Mean distance visual acuity was 0.57 ± 0.47 logMAR or approximately 6/24. The median spectacle-corrected near visual acuity was N8 (range N3 to worse than N80). Fifty patients (32.3 per cent) were prescribed new spectacles, 51 (32.9 per cent) low vision aids and five (8.3 per cent) were prescribed electronic magnification devices. Almost two-thirds (63.9 per cent) were referred for occupational therapy management and 12.3 per cent for orientation and mobility services. CONCLUSIONS: The profile of patients presenting for low-vision services at Kooyong is broadly similar to that identified in 1999. Outcomes appear to be similar, aside from an expected increase in electronic devices and technological solutions; however, the nature of services is changing, as treatments for ocular diseases advance and assistive technology develops and becomes more accessible. Alongside the aging population and age-related ocular disease being the predominant cause of low vision in Australia, the health-funding landscape is becoming more restrictive. The challenge for the future will be to provide timely, high-quality care in an economically efficient model.

Exploring business models to provide a foundation for enhanced eye care services in high street optometric practice

High street optometric practices are for-profit businesses. They mostly provide sight testing and eye examination services and sell optical products, such as spectacles and contact lenses. The sight testing services are often sold at a vastly reduced price and profits are generated primarily through high margin spectacle sales, in a loss leading strategy. Published literature highlights weaknesses in this strategy as it forms a barrier to widening the scope of services provided within optometric practices. This includes specialist non-refraction based services, such as shared care. In addition this business strategy discourages investment in advanced diagnostic equipment and higher professional qualifications. The aim of this thesis was to develop a greater understanding of the traditional loss-leading strategy. The thesis also aimed to assess the plausibility of alternative business models to support the development of specialist non-refraction services within high street optometric practice. This research was based on a single independent optometric practice that specialises in advanced retinal imaging and offers a broad range of shared care services. Specialist non-refraction based services were found to be poor generators of spectacle sales likely due to patient needs and presenting concerns. Alternative business strategies to support these services included charging more realistic professional fees via cost-based pricing and monthly payment plans. These strategies enabled specialist services to be more self-sustainable with less reliance on cross-subsidy from spectacle sales. Furthermore, improving operational efficiency can increase stand-alone profits for specialist services.Practice managers may be reluctant to increase professional fees due to market pressures and confidence. However, this thesis found that patients were accepting of increased professional fees. Practice managers can implement alternative business models to enhance eye care provision in high street optometric practices. These alternative business models also improve revenues and profits generated via clinical services and improve patient loyalty.

Long-term efficacy of orthokeratology contact lens wear in controlling the progression of childhood myopia

Purpose: The primary outcome of this study is to compare the axial length growth of white European myopic children wearing orthokeratology contact lenses (OK) to a control group (CT) over a 7-year period. Methods: Subjects 6–12 years of age with myopia −0.75 to −4.00DS and astigmatism ≤1.00DC were prospectively allocated OK or distance single-vision spectacles (SV) correction. Measurements of axial length (Zeiss IOLMaster), corneal topography, and cycloplegic refraction were taken at 6-month intervals over a 2-year period. Subjects were invited to return to the clinic approximately 5 years later (i.e., 7 years after the beginning of the study) for assessment of their ocular refractive and biometric components. The CT consisted of 4 SV and 12 subjects who switched from SV to soft contact lens wear after the initial 2 years of SV lens wear. Changes in axial length relative to baseline over a 7-year period were compared between groups. Results: Fourteen and 16 subjects from the OK and CT groups, respectively, were examined 6.7 ± 0.5 years after the beginning of the study. Statistically significant changes in the axial length were found over time and between groups (both p <0.001), but not for the time*group interaction (p = 0.125). The change in the axial length for the OK group was 22% (p = 0.328), 42% (p = 0.007), 40% (p = 0.020), 41% (p = 0.013), and 33% (p = 0.062) lower than the CT group following 6, 12, 18, 24, and 84 months of lens wear, respectively. Conclusion: A trend toward a reduction in the rate of axial elongation of the order of 33% was found in the OK group in comparison to the CT group following 7 years of lens wear.