New And Innovative Uses for Contact Lenses New And Innovative

5/23/2014
New And Innovative Uses for
Contact Lenses
New And Innovative Uses for
Contact Lenses
David Kading, OD, FAAO
David Kading, OD, FAAO
Seattle, WA
drdave@specialtyeye.com
Disclosure
•
The speaker has no financial or proprietary
interest in any of the products that are
mentioned
•
Co-Owner Optometric Insights with Dr. Mile
Brujic
•
The speaker have received honoraria for
consulting, performing research, speaking
and/or writing from: Alcon Laboratories,
Allergan, Art Optical, Bausch & Lomb,
Biotissue, Contamac, Cooper Vision, Ciba
Vision, Medlens Innovations, Nicox,
Paragon, SynergEyes, RPS Detectors,
Unilens, Valeant, Valley Contax, Vistakon,
and The Vision Care Institute
Seattle, WA
drdave@specialtyeye.com
New and Innovative Uses for
Contact Lenses
My Grandpa
Color Me Bad
Ill take a
regular Kone
Soften Things Up
IOP YO YOU KNOW
ME
Biggerestist
Put some Sugar
On it
Accommodate Yourself
Control Yourself
Plug in Your CL
OCT is for October,
right?
SynergEy
1
5/23/2014
New and Innovative Uses for
Contact Lenses
New and Innovative Uses for
Contact Lenses
My
Grandpa
Color Me
Bad
Ill take a
regular
Kone
SynergEy
My
Grandpa
Color Me
Bad
Ill take a
regular
Kone
SynergEy
Soften
Things Up
IOP YO YOU
KNOW ME
Biggerestist
Put some
Sugar On it
Soften
Things Up
IOP YO YOU
KNOW ME
Biggerestist
Put some
Sugar On it
Accommodate
Yourself
Control
Yourself
Plug in Your
CL
OCT is for
October, right?
Accommodate
Yourself
Control
Yourself
Plug in Your
CL
OCT is for
October, right?
New And Innovative Uses for
Contact Lenses
David L. Kading, OD, FAAO
David Kading, OD, FAAO
Seattle, WA
Doctorkading@gmail.com
Seattle, WA
2
5/23/2014
MEDICATIONS
AND
CONTACT
LENSES
Contact Lens Jewelry
Jewelry suspended from
contact lenses
Dutch Designer: Eric
Klarenbeek
3
5/23/2014
Gold Plated, Diamond-Encrusted Lenses
$15,000
Boston Scleral Lenses
18 diamonds
Diabetes and Contact Lenses
Nano-Particles react with Blood
Sugar and change the color of the
Lens
4
5/23/2014
Eye pod: This contact lens (top) uses a circular strain gauge to detect changes in the diameter of the eye, an
important factor in patients with glaucoma. The tiny microelectromechanical systems chip (bottom), made by
ST Electronics, reads data from the strain gauge and wirelessly transmits the information to an external
receiver. Credit: Sensimed
•
Glaucoma Test in a Contact LensThe first continuous monitoring system for glaucoma hits the European market.By Lauren GravitzWEDNESDAY, MARCH 31,
2010 E-mail Audio » Print Favorite Share »Glaucoma is the second most common cause of blindness, and without constant vigilance it can prove a very
difficult disease to manage. But a Swiss biotech company has developed a monitoring system that allows physicians to keep track of their patients' symptoms
over 24 hours. Sensimed's "Triggerfish" system consists of a contact lens with embedded sensors that can pick up subtle physical changes in a patient's eye,
and then wirelessly transmit that data to a receiver worn around his neck.Eye pod: This contact lens (top) uses a circular strain gauge to detect changes in the
diameter of the eye, an important factor in patients with glaucoma. The tiny microelectromechanical systems chip (bottom), made by ST Electronics, reads
data from the strain gauge and wirelessly transmits the information to an external receiver. Credit: SensimedDespite decades of study, researchers still only
poorly understand the causes of glaucoma, a group of diseases in which deterioration of the optic nerve can eventually lead to blindness. But controlling one
symptom in particular--high intraocular pressure, which is caused by too much liquid inside the eye--appears to help prevent disease progression."Nowadays,
glaucoma specialists live in the dark," says Kaweh Mansouri, an ophthalmologist who has been using the Sensimed system in his clinic at the University
Hospital, Geneva. "We only get a few chances to see the patient and measure intraocular pressure, and we know this is a major drawback of how we diagnose
and treat glaucoma."Current methods for glaucoma diagnosis and monitoring are usually limited to single snapshots in time, taken at a visit to the eye doctor
during daytime, when pressure tends to be at its lowest. But glaucoma specialists believe that one of the main contributors to disease progression is frequent
changes in pressure over the course of a day, or high peaks during the night--something that, in the most serious cases, requires frequent measurement
during an overnight hospitalization. The Sensimed device, the first of its kind on the market, provides constant readings for a fraction of the price of a hospital
stay. The company received safety approval for Triggerfish in Europe last year, and is hoping for U.S. Food and Drug Administration approval by late 2011.
Ultimately, Sensimed believes it may be possible to use Triggerfish to detect glaucoma at earlier stages in people with a family history of the disease or other
risk factors. If a high-risk patient has a relatively normal daytime pressure, says company president and CEO Jean-MarcWismer, he might benefit from a preventative 24hour monitoring session every once in a while. "We would like to be able to diagnose glaucoma earlier, before it actually causes damage that affects vision."This may be a
bit premature, says Andrew Iwach, the executive director of the Glaucoma Center of San Francisco. "Some patients have high intraocular pressure, but their optic nerve
tends to do fine. Others have lower pressure, but still have a major impact on their optic nerve," says Iwach, who's also spokesperson for the American Academy of
Ophthalmology. The problem, experts say, is that increased intraocular pressure is the only symptom of glaucoma that is treatable and can slow or stop disease
progression.However, both Iwach and Stanford ophthalmology professor Kuldev Singh believe that continuous monitoring of intraocular pressure is something the field
desperately needs, and note that there are multiple groups working toward such a goal. But while the new device will likely have a major benefit in understanding
individual patients' treatments, Singh says, it also provides an important opportunity to better understand the disease. "The idea of a continuous measurement device for
eye pressure is a very, very good one," he says. "I think the most important use for it is to better study the relationship between eye pressure and glaucoma
progression.""From a scientific standpoint, this type of technology will be groundbreaking in letting us understand the relationship between eye pressure and glaucoma,
and how treatments work over a 24-hour period," says Singh, who is also chair of the Glaucoma Research Foundation's board of directors.To date, the device has only
been used clinically in about 80 patients--the holdup, says Mansouri, is price: It's not yet reimbursed by the Swiss health care system. Prices should drop, however, as
reimbursement increases and production scales up.
5
5/23/2014
OPD Scan
• Auto Refraction
• Wave Front Analysis
• Topography
Aberrations
Sphere/Cylinder accounts
for about 80% of all
aberrations
Approximately 20% of
reduced vision is due to
Higher Order Aberration
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5/23/2014
Visual Consequences
•
•
•
•
•
•
Monocular Diplopia
“Ghost” images
Asthenopia
Polyopia
Photophobia
Halos around lights
www.medicalvision.com
Alcon
7
5/23/2014
Aberration control lenses
Irregular Astigmatism Regular
8
5/23/2014
WATERCONTENT/Dk
Definitive
• 56 YOM
• Glasses Wearer: referred for CL Fitting
• Trialed and Failed GPs in the past due to vision
issues
• MR:
OD: - 11.50 – 3.75 X 006
20/25-
•
OS: - 10.75 – 4.50 X 175
20/25+
Keratoconus
Soft KCN Lens Designs
Super Nova HydroKone
•
•
•
•
•
Base Curves: 4.10 to 9.30
Diameters: 12.0 to 17.0
Power: +50.00 to -75.00 D
Cylinder: -0.25 to -50.00 D
8.0mm central aspheric thick zone
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5/23/2014
Custom SCL’s for KC
8.6/6.8
Soft-K
8.6/6.9
20/20-2
NovaKone
Novel new soft lens for keratoconus
• Excellent Visual Outcomes
• A higher level of comfort than
most RGP or hybrids can
deliver
• Simplified Fitting Approach
20/20-1
KeraSoft® IC Design
• Designed to fit all
stages of keratoconus
and other irregular
corneas
• Front surface
asphere/aspheric toric
• Adjustable periphery fits
any corneal shape
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5/23/2014
Patient: LB Age: 41 F
Patient: LB
History:
Bilateral LASIK in 1999. Significant symptoms of poor VA, halos and
glare at night.
MR: OD 0.00 -0.75 x 025
OS +0.50 -0.50 x 010
K’s:
20/50
20/50
OD 38.12 @ 026 / 38.87 @ 116
OS 36.37 @ 006 / 37.25 @ 096
Mark Andre, FAAO
Mark Andre, FAAO
Patient: LB
Custom Reverse
Geometry SCL With
Black Iris
Base Curve: 9.70 / 8.60
Power: Plano
Diameter: 14.5 mm
Design: Black occluder
lens with a clear pupil
Mark Andre, FAAO
VA: 20/20 OD / OS
Mark Andre, FAAO
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5/23/2014
Reverse Geometry Design
•
•
•
Refractive Surgery
– RK
– PRK
– LASIK
Penetrating Keratoplasty
– Sunken Grafts
Oblate corneal shape
– Post trauma
– Post infection
Myopia
8 YOF
MR:
OD:-2.00-0.50X172
In Americans
ages 12 to 54, the
OS:-2.25-0.25X008
Prescription increased by 0.50
prevalence over
of last
myopia
increased 66%
year and has been
increasing by 0.50 to 0.75 over
between
1970 and 2000
last 3 years
Mom: “Is there anything that we
can do so that she doesn’t end
up like her father (-4.50), he is
SO blind.”
Corneal Reshaping
• Corneal Reshaping
• Orthokeratology
• Vision Shaping
Treatment (VST)
• Corneal Refractive
Therapy (CRT)
www.paragoncrt.com
www.beretainer.com
lid
www.dreimlens.com
kl
12
5/23/2014
Myopia Control: % Change
Corneal Reshaping
Myopia Control: Corneal Reshaping
What Does This Mean ???
CR
Control
Change
Cho
0.15
0.27
44%
Walline
0.11
0.26
58%
Annual Axial Growth
The fovea DOES NOT
play the dominate role in
refractive development.
Instead peripheral retinal
image plays the MAJOR
role in determining overall
eye growth.
Earl Smith OD PhD
University of Houston
13
5/23/2014
The “Image Shell” Post OK
Corneal Reshaping
Negative Curvature of Field
Multifocal Soft Contact Lenses for
Myopia Control
Thomas Aller OD San Bruno CA
Abstract from International Myopia
Conference Queensland Australia 2008
Control
John Phillips OD PhD New Zealand
MiSight
Manufactured by Cooper Vision
Distributed in Hong Kong, China
MF SCL
Refractive Error (D.)
-0.75 +/- 0.50
0.10 +/- 0.36
Axial Length (mm.)
0.24 +/- 0.17
0.05 +/- 0.14
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5/23/2014
Take Home
•
•
•
•
Communicate with Parent
Tell Kids to go OUTSIDE
Discuss Current FDA approvals – NONE
Consider doing SOMETHING
– CRT
– MF Soft Lenses
• (Distance Center +2.00 Add or higher)
The Problem
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5/23/2014
Iris Abnormalities
Iris Abnormalities
Color Deficiencies / Sports Enhancement
16
5/23/2014
Hybrid Lenses
Saturn
Softperm
SynergEyes
???
ClearKone/UltraHealth
17
5/23/2014
11 Different Vaults – 4 Skirts
• Vaults: 50µ-550µ
 Skirts: 8.7 flat 2, 8.4 flat, 8.1med, 7.9 steep
• Powers: +10.00 to -20.00
Vault Determination
Ideal fit = 100 to 150µ above the apex of the cornea
Start with a 250µ lens and a 8.4 Flat Skirt
Use NaFl and wait 3-4 minutes
Note: if you see immediate touch, no need to wait 3
minutes.
YouPooling
will see =either
clearance (pooling)
or touch
(bearing)
Clearance
Bearing
= Touch
Variable Parameters Increase Patient Candidates
Fixed Lift Curve
Variable Lift Curve
250µ and Below
300µ and Above
Reverse geometry, vaulted lens design clears
vast majority of ectasias.
18
5/23/2014
OCT of UltraHealth
Duette™ Platform Technical Details
Latest Hybrid Lens
Advancement
OCT Photo of Duette Junction
SynergEyes Duette
19
5/23/2014
Empirical Ordering
Made possible through:
•
•
•
The consistent centration of the lens enabling alignment fitting for all
patients
The ability to calculate the power needs
The ability to deliver a much improved first lens experience to the
wearer
Benefits of empirical ordering:
•
No investment in fitting sets
•
Reduces number of fitting visits
•
Virtually eliminates fitting changes due to physical fit
– Slight power changes are the most common reason for exchange
Indications for Piggybacking
Piggyback Design
•
•
•
•
•
•
•
•
Keratoconus
Pellucid Marginal Degeneration
Post – PKP
Trauma
RK
Unilateral Correction
High Ametropia when
Increasing Lens Thickness
Post - Refractive Surgery
•
•
•
•
•
•
•
•
Prosthetics
Cosmetic Color Lenses but
have Astigmatism
Lens Decentration
Maintaining Corneal Integrity
Adaptation to GP
End of Day Comfort
Enhancing Patient Overall
Comfort
????
20
5/23/2014
Anterior Curvature of
Myopic vs. Hyperopic SCL’s
Myopic Piggyback Soft Lenses
No Lens
44.00 D
Hyperopic SCL
Myopic SCL
-0.25
-3.00
-6.00
43.50 D
41.25 D
38.75 D
Pacific University
Pacific University
Hyperopic Piggyback Soft Lens
Higher Powers
No Lens
44.00
44.00 D
+0.25
+3.00
44.12 D.
45.62 D.
No Lens
+6.00
38.75
-6.00
47.75
+6.00
47.75 D.
Pacific University
Pacific University
21
5/23/2014
No Lens Wear
-0.25 D. Night & Day
No Lens Wear
-0.25 D. Night & Day
Central
Cornea
39.75 D
44.2 D
+6.00 D. Night & Day
Pacific University
+6.00 D. Night & Day 44.25D
Pacific University
Piggyback System
• 49 YOM
• Hx of penetrating
trauma
• (28 years ago)
OD: 20/15
OS: 20/200
FW is now a
Tree Trimmer
REVENGE
Hab VA
Culprit
Pacific University
22
5/23/2014
Piggyback System
Piggyback System
• With Piggyback
system
– Durasoft 3 custom
prosthetic lens
– High Plus GP
• OS: 20/25
• Patient's Response
Piggyback Lenses
Soft Lenses of Choice
• Improve patient comfort
• Protect epithelium (important for damaged corneas)
• Manage peripheral RGP complications
• To provide an improved fitting surface
David L, Kading, OD FAAO, FCLSA
Specialty Eyecare Group
specialtyeye com
drdave@specialtyeye com
425 821 8900
23
5/23/2014
Presbyopia
• By 2014 there will be 90 Million
Presbyopes
Amplitude of Accommodation
3.50 Diopters
40 Years
24
5/23/2014
Leaders
Gas Permeable Multifocals
Gas Permeable Multifocals
Introducing Anterior Asphericity
25
5/23/2014
The Multifocal Success!
The “OK” Multifocal Experience!
26
5/23/2014
27
5/23/2014
Compliance:
A Battle we can win?
Things aren’t always what they seem
THINGS ARE NOT AS THEY APPEAR…
•
•
•
•
TruEye
Acuvue Oasys
Hydraclear
Extreme H2O
•
•
•
•
•
Optifree Replenish
BioTrue
Moisture Plus
Acuvue Moist
Aqua Release
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5/23/2014
Pillars of CL Success
Between 50-75% of your contact lens
patients are not doing what you tell them to!
Face and Hands
Role of Hand Washing
29
5/23/2014
Microorganisms on Lenses After
Handling
A Case for the Case
CL Case Replacement
• Contact Lens Case
Contamination
– 70% of contact lens
cases are contaminated
– Bacteria shows up
about 7 days after case
replacement
• Exopolysaccharide Glycoalyx
Biofilm
Dumbleton Contact Lens & Anterior Eye 2010; 34: 216-22
30
5/23/2014
Solutions or Problems?
How many of you recommend a specific
solution for your patients?
94%
What is the #1 reason that you prescribe a
specific solution?
66% due to solution/material compatibility
What percentage of your patients do you
believe are compliant with your
recommendations?
OD’s believe that 69% of patients are
compliant with recommendations
31
5/23/2014
Compliance with Lens
Replacement
Most European countries have adopted DD and 1 month over 2 week
In US 2wk lenses are majority
Eye & Contact Lens 2009; 4: 164-171
OVS 2002; 79: 259
Optician 2007; 234: 20-25
CL Specturm 2009; 24: 28-32
Compliance with Lens Replacement
2 Week wearer wore lenses on average 27 days (10-124) (2.6X MRRF)
1 Month wearers wore lenses on average 47 days (10-365) (1.5X MRRF)
Dumbleton Eye & Contact Lens 2009; 4: 164-171
Dumbleton Contact Lens & Anterior Eye 2010; 34: 216-22
Effect of Compliance:
SyHy 1 month and 2 week
• Lens Compliance:
– Better end of day Comfort
– Better Vision
– Better end of day Comfort at end of lens cycle
– Better Vision at end of lens cycle
Dumbleton Optom Vis Sci 2010;87:6
What is the #1 reason for
non-compliance?
• #1: Forgot when to replace
• #2: Save money
Dumbleton Contact Lens & Anterior Eye 2010; 34: 216-22
32
5/23/2014
Reminder System
Improve Compliance
53% believed a reminder system would be helpful
• Sample One Solution with a Strong
Recommendation/Prescription
• Prescribe Lens and Case Replacement
• Review
patients KNOW
yearly WHY!
ANDCleaning
LET THEwith
PATIENTS
Dumbleton Eye & Contact Lens 2009; 4: 164-17
Keratoconus
33
5/23/2014
Keratoconus
=
•
•
•
•
Male = Female
Bilateral (2-7% unilateral)
1:2000
Worldwide
Visual Consequences
•
•
•
•
•
•
Monocular Diplopia
“Ghost” images
Asthenopia
Polyopia
Photophobia
Halos around lights
www.medicalvision.com
Alcon
Keratoconus
Kone Kinds
34
5/23/2014
Traditional KC Lens Fitting
What is more important K-values or Sag/E-Value?
Base Curve Based
Randy Kojima FAAO
Modern Keratoconus Fitting
Eccentricity/Sagittal Depth Focused
Modern RGP Keratoconic Fitting
– Bi-surface Aspheric
– Balanced Zone Design
– BC radius varied to achieve fit
– Periphery fits Non-Ectatic Area
35
5/23/2014
Bi-Aspheric
Initial Lens Selection
Effect of Peripheral Curve
1 Step Steeper
3 Steps Steeper
36
5/23/2014
Advanced Keratoconus
K’s 65.50 @ 108 / 71.50 @ 18
5.15 @ 108 / 4.70 @ 18
Apical Radius
4.30 mm
78.50 D
?
K’s 65.50 @ 108 / 71.50 @ 18
5.15 @ 108 / 4.70 @ 18
Apical Radius
4.30 mm
78.50 D
7.67 mm
44.00 D
3.55 mm 35.50 D. Flatter than Apical Radius
Reverse Geometry Lens
Designs for Keratoconus
7 Vaults
Base Curve:
Power:
Di
t
1 to 7
44.00 (7.67 mm)
-4.00 D.
11 0
37
5/23/2014
Apical Radius:
50.00 D 6.70mm
Vault 3
Vault 1
Vault 2
PK 8/2007
• 29 YOM
• Noted 3-4 years ago that VA wasn’t as
good
• Most tasks are difficult: OS>OD
• Reports Eye Rubbing
• No change to RX last year, but Glasses
don’t work
38
5/23/2014
Right
Left
??NOW WHAT??
30.0 Diopters
81.0 Diopters
39
5/23/2014
Reports
• Best Vision I have had in a Decade!
• My softball team is wondering what
happened to me!
• My wife doesn’t have to always drive at
night!
• My parents, who feel guilty about my KCN,
are so happy to hear I can see!
Scleral Lenses 2014
Scleral Lens Zones of Interest
Zone 1
Zone 2
Zone 3
40
5/23/2014
Lens Evaluation
Evaluating Depth on Eye
Dark Band is CL
41
5/23/2014
A New Approach to
Sclerals
The System
21 Lens fitting set with B+L solutions, wratten filter and fitting guide
OCT What is it good for?
42
5/23/2014
Corneal Evaluation
Print Out
72 microns
136 microns
416 microns
646 microns
43
5/23/2014
Tear Debris
Ideal Sagittal Depth
44
5/23/2014
Standard
Edge
Design
Limbal Clearance
1 Step Steeper Edge
1 Step Flatter Edge
45
5/23/2014
Surgery, Why Not?
Penetrating Keratoplasty
– 84% achieve > 20/40
– 40% at least 20/20
– 85% anisometropia, regular or irregular astigmatism
– Fowler fit 87% of referred patients
– 85% achieving > 20/30
– Risks: steep or flat grafts infection, rejection, high
astigmatism, glaucoma, ect. …
Transplant Highlights
Transplant Highlights
David L, Kading, OD FAAO, FCLSA
Specialty Eyecare Group
specialtyeye.com
drdave@specialtyeye.com
425.821.8900
David L, Kading, OD FAAO, FCLSA
Specialty Eyecare Group
specialtyeye.com
drdave@specialtyeye.com
425.821.8900
46
5/23/2014
- Primary Goal: to make patients tolerant to CL
- Does not slow the progression of KCN
- Does not always improve vision and may make it worse
Changed Lives
Changed Lives
• Lasik/Ectasia/Graft/Rejection/Regraft
•
•
OD: -18.50-2.00X010 VA:20/60
OS: -17.00-4.25X166 VA:20/60
47
5/23/2014
Something went wrong…
Asha
48